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  3. NTSB A-15-010
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NTSB · Safety Recommendation

Safety Recommendation A-15-010

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another airport based on an observed (and possibly incorrect) trajectory.

Safety Issue and Context

The National Transportation Safety Board (NTSB) urges the Federal Aviation Administration (FAA) to take action on the safety recommendations issued in this letter. These recommendations address the issuance of landing clearances with multiple airports in the vicinity and minimum safe altitude warning (MSAW) software limitations. The recommendations are derived from our investigations of wrong airport landing events. As a result of these investigations, we have issued two safety recommendations, both of which are addressed to the FAA. Information supporting these recommendations is discussed below.

Response History

March 3, 2025 · NTSB Correspondence · FAA

On August 2, 2024, former FAA Administrator Michael G. Whitaker informed us that the agency is continuing the work described in its previous letter regarding Safety Recommendations A-15-9 and -10. We look forward to receiving your next update.

August 2, 2024 · Recipient Response · FAA

Michael G. Whitaker, Administrator: The ARV software enhancement has been delivered to the government and has completed the Operational Test and Evaluation phase. The ARV software will address the wrong airport landing issue, not the MSAW software. ARV software key-site testing has been successfully completed at the Lincoln Tower/Omaha Terminal Radar Approach Control Facility.

The ARV software enhancement was found nationally operationally suitable for use on November 2, 2023. We anticipate the continued deployment of the R10 Release Drop 1, containing the ARV software enhancement, to the remaining sites by following the current deployment processes.

I believe the FAA has effectively addressed Safety Recommendations A-15-9 and -10 and consider our actions complete.

August 15, 2023 · NTSB Correspondence · FAA

We note that you continue to finalize the implementation of the Standard Terminal Automation Replacement System (STARS) R10 Software Release 1, which was delayed due to COVID-19. We continue to believe this STARS enhancement will reduce the possibility of wrong airport landings and will represent an acceptable alternate solution to both recommendations. Pending this enhancement being fully implemented and controllers having received training on it, Safety Recommendations A-15-9 and -10 remain classified OPEN-- ACCEPTABLE ALTERNATE RESPONSE.

January 9, 2023 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: As stated in our previous response, the Federal Aviation Administration (FAA) continues to finalize the implementation of the Standard Terminal Automation Replacement System (known as STARS) R10 Software Release 1. This software enhancement will change the data block color, display a wrong airport indicator as “WA” in line 0 of the data block, and sound an aural alarm when an aircraft track is headed toward the wrong airport.

Due to continued delays associated with COVID-19, the software implementation at key sites is now expected to be completed by the third quarter of Fiscal Year 2023.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-15-9 and -10 and anticipate providing an update by December 31, 2023.

September 13, 2022 · NTSB Correspondence · FAA

We note that you are finalizing the implementation of the Standard Terminal Automation Replacement System (STARS) R10 Software Release 1, which will change the data block color, display a Wrong Airport indicator as “WA” in line 0 of the data block, and sound an aural alarm when an aircraft track is headed toward the wrong airport. You reported that the FAA delayed implementing this enhancement until the first quarter of fiscal year 2022 due to required COVID-19 quarantine procedures.

We continue to believe this STARS enhancement will reduce the possibility of wrong airport landings and that, once the enhancement is fully implemented and controllers have received training on it, it will represent an acceptable alternate solution to both of these recommendations. Pending the completion of these actions, Safety Recommendations A-15-9 and -10 remain classified OPEN-- ACCEPTABLE ALTERNATE RESPONSE.

February 1, 2022 · Recipient Response · FAA

-From Steve Dickson, Administrator: As indicated in our previous response, the Federal Aviation Administration (FAA) determined that the procedural guidance contained in FAA Order JO 7110.65, Air Traffic Control, was sufficient and did not require modification. The FAA is continuing to finalize the implementation of the Standard Terminal Automation Replacement System (STARS) R10 Software Release 1. This software enhancement will change the data block color, display a Wrong Airport indicator as “WA” in line 0 of the data block, and sound an aural alarm when an aircraft track is headed toward the wrong airport.

The FAA expected the software enhancement to be installed at key sites by March 2021; however, due to required COVID-19 quarantine procedures, implementation at key sites was rescheduled. The R10 implementation at key sites began in the first quarter of Fiscal Year 2022, and is expected to continue throughout the fiscal year.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-15-9 and -10, and anticipate providing an update by December 31, 2022.

June 22, 2020 · NTSB Correspondence · FAA

We note that you believe the procedural guidance contained in FAA Order JO 7110.65Y, paragraph 7-4-3, is sufficient, and you do not intend to amend the guidance; however, to reinforce this procedure, you created a briefing sheet and a training video that narrates a controller’s actions during an actual attempted wrong airport landing. We note that, in June 2019, you distributed the video and a mandatory face-to-face, “Wrong Airport Landing” briefing document to all FAA Air Traffic Organization operational personnel and management.

We also note that you are in the process of enhancing the Standard Terminal Automation Replacement System (STARS), which will considerably reduce the possibility of wrong airport landings. As part of this enhancement, when an aircraft track is headed to the wrong airport, an aural alarm will sound, the color of the datablock will change, and the datablock will also display “WA” in line 0.

We believe the training video and briefing document, along with the STARS enhancement (including implementation and training), will constitute an acceptable alternate solution to Safety Recommendation A-15-9. We also believe that the STARS enhancement, once completed, represents an acceptable alternate solution to Safety Recommendation A-15-10. Accordingly, pending completion of those actions, Safety Recommendation A-15-9 is classified “Open—Acceptable Alternate Response,” and Safety Recommendation A-15-10 remains classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.

February 18, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: Originally, the NTSB recommended modifying the MSAW software to apply the MSA W parameters for the flight plan destination airpo11 to touchdown, rather than automatically reassigning the flight to another airport based on an observed (and possibly incorrect) trajectory. As previously stated, the FAA does not concur with this recommendation as written based on the fact that there is currently nothing in the design of the MSA W software to address the issue cited in the NTSB report.

Instead, the FAA explored other possible automation enhancement solutions leading to the creation of site rule STARS-0-0116, which is available to the field as part of the set of STARS site rules. The functionality included in STARS-0-0116 is now being implemented in STARS software as part of the R l 0 software release. As stated above, with this functionality, when an aircraft track is headed to the wrong airport (i.e., intruding into a geographic area around the airport), STARS will: • Change the datablock color; • Display "WA'. in line 0 of the datablock; and • Sound an aural alarm.

I believe the FAA has effectively addressed Safety Recommendation A-1 5-9 and consider our actions complete.

I will keep the Board informed of the FAA's progress on Safety Recommendation A-15-10 and anticipate providing an update by May 2021.

November 12, 2015 · NTSB Correspondence · FAA

We note that, although you do not concur with this recommendation because “the current design of the MSAW tool does not contain any element to address” it, you plan to investigate other possible software solutions aside from MSAW that would satisfy Safety Recommendation A-15-10. We continue to believe that, despite this issue with the current MSAW system, a simple and effective revision to the system is to compare the destination airport in the flight plan that the MSAW is using to the adaptation that the MSAW is applying to the aircraft, and to note when they are different. Such a revision would alert controllers to a potential wrong-airport landing.

Other possible software revisions that you identify and implement could also satisfy the recommendation. We request that you describe these alternatives in sufficient detail so that we may determine whether they fully address Safety Recommendation A-15-10. Pending your doing so, and your implementation of an acceptable alternative, Safety Recommendation A 15 10 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

July 31, 2015 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The FAA does not concur with this safety recommendation as written. Both the MSAW Governance Committee Chairman and National Air Traffic Controllers Association representatives verified that the current design of the MSA W tool docs not contain any element to address this Safety Recommendation. However, we plan to investigate possible software solutions aside from MSA W such as flight plan conflict automation. If feasible, potential automation changes would have to be assessed for complexity cost and schedule.

I will keep the Board informed of the progress of these recommendations and provide an update by September 2016.

Read Recommendation

Recommendation Facts

Status
Open Acceptable Alternate Response
Issued
May 4, 2015
Priority
CLASS II
Recipient
FAA
Adopted
April 27, 2015
Related Investigation
DCA14IA037
Related Report
None