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NTSB · Safety Recommendation

Safety Recommendation A-16-018

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Develop, in collaboration with your internal offices that investigate aviation accidents and incidents and also organizations familiar with the challenges facing pilots confronting an emergency situation, and require recurrent national training for air traffic controllers, including scenario-based training, to instruct them on identifying and responding to emergency situations to include the following: (1) recognizing emergencies, (2) determining what help is needed, and

(3) taking actions that help pilots safely resolve the situation.

Safety Issue and Context

On January 13, 2015, about 2058 eastern standard time (EST), a Cessna 152, N757ZM, crashed into shallow water at a public beach in New Smyrna Beach, Florida. The commercial pilot died, and the airplane was substantially damaged by impact forces. A review of air traffic control (ATC) data indicated that the pilot had requested assistance from ATC, telling the controller that she could not continue flight under visual flight rules (VFR) and that she wanted to land; night instrument meteorological conditions (IMC) prevailed at the time.

FAA Order 7110.65, Air Traffic Control, states that air traffic controllers providing assistance to VFR pilots having difficulty flying in IMC should ask if the pilot is qualified for instrument flight rules (IFR) flight. For pilots not requesting an IFR clearance or not qualified for IFR, controllers should provide airports where visual meteorological conditions (VMC) are reported, provide other available pertinent weather information, and ask if the pilot chooses to conduct VFR flight to such an airport.

Response History

May 16, 2024 · NTSB Correspondence · FAA

You previously informed us that air traffic facilities must develop a written annual refresher training plan to ensure that course materials, visual aids, and scenarios are properly developed, maintained, tailored to meet identified requirements, and to update previously taught knowledge and skills. In addition, in 2020, you published Order JO 3120.4R, “Air Traffic Technical Training,” which uses classroom discussion and high-fidelity scenario-based simulation exercises to reinforce the skills and procedures necessary to identify and respond to emergency situations.

Although we considered these actions responsive to these recommendations, we requested the standards and guidance used for administering this training and information about the training topics, such as how they are selected and when they are updated.

We note that Order JO 3120.4R outlines standards and guidance for delivering recurrent training. We also note that the training topics change every year and are derived from data collected through various FAA safety reporting systems, such as the Air Traffic Safety Action Program, and significant events. In addition, the training is delivered twice per calendar year and includes 4 hours of web-based training and 4 hours of instructor-led training.

Based on the additional information that you provided, we believe the training that you developed satisfies the intent of Safety Recommendations A-16-18 and -19, which are classified CLOSED-- ACCEPTABLE ACTION.

August 29, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The standards and guidance for the delivery of recurrent training are taken from Federal Aviation Administration (FAA) Order JO 3120.4R, Air Traffic Technical Training, Chapter 4, Training Requirements for Air Traffic Control Specialists, Section 5, Proficiency Training, published on October 30, 2020.

Although not specifically mentioned in this order, the selection of topics, such as emergencies, for each round of recurrent training is derived from data collected through various FAA safety reporting systems, including the Air Traffic Safety Action Program, Risk Analysis Process, Mandatory Occurrence Reports, Electronic Occurrence Reports, Quality Assurance assessments, and significant events. This data-driven approach guarantees the recurrent training curricula remain current, mitigating evolving risks throughout the national airspace system.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
September 1, 2016
Priority
CLASS II
Recipient
FAA
Adopted
August 25, 2016
Closed
May 16, 2024
Related Investigation
ERA15FA099
Related Report
ASR-16-04

Additionally, the FAA solicits facility training best practices and conducts an annual review with stakeholder participation no later than July 1 of each year. This guarantees continuous revision on guidance, effectiveness, and technical accuracy; evaluation of air traffic technical training, coursework/curriculum development, review, and maintenance; and the oversight of national and FAA Academy-delivered courses. The recurrent training development teams consist of subject matter experts from across the FAA, including field facilities management and bargaining unit employees.

We actively seek collaboration with industry stakeholders, such as airline representatives, general aviation, and human performance scientists, to develop accurate and relevant recurrent training.

To ensure compliance with FAA training directives and goals, the refresher training is different every year, covering an array of topics such as Air Traffic Control (ATC) basics, contingency plans, emergencies, equipment, fatigue awareness, operations, oceanic procedures, procedures, professional skills, recovery in ATC operations, safety, safety alerts, and lost aircraft orientation.

The course content is updated and delivered twice per calendar year, currently delivered every January and July. Each training course typically consists of four hours of web-based training and four hours of instructor-led training. The following list describes recent instructor-led recurrent training objectives and topics:

April 2019: Objective: Emergencies – Identify Emergency Procedures • Engine failure • Hypoxia • Identify controller responsibilities in emergency situations • Identify Team Resource Management duties related to emergency situations • Recognize emergency situations • Recognize how to assist pilots in distress • Visual Flight Rules into Instrument Meteorological Conditions

April 2022: Objective: Emergencies • Electrical system failure • Identify controller responsibilities in emergency situations • Identify emergency procedures • Identify emergency situations • Identify how to assist pilots in distress • Pitot-static system failure • Thunderstorm encounters

January 2023: Objective: Back to Basics • Describe the impact of drift on fundamental ATC processes and procedures • Icing emergencies • Identify controller best practices

Data analysis is underway for the selection of the upcoming January 2024 topics.

As shown above, recurrent training on emergencies, best practices for controllers, and insight into the types of assistance required by pilots during emergencies has taken place several times since 2019. These are also prospective topics for future rounds of recurrent training.

I believe the FAA has effectively addressed Safety Recommendations A-16-18 and -19 and consider our actions complete.

February 27, 2023 · NTSB Correspondence · FAA

We note that you continue to work with government and industry stakeholders in aviation safety to develop best practices and checklists for assisting pilots experiencing problems. You also reported that air traffic facilities must develop a written annual refresher training plan to ensure that course materials, visual aids, and scenarios are properly developed, maintained, and tailored to meet identified requirements, and to update previously taught knowledge and skills.

In addition, we note that, in 2020, you published Order JO 3120.4R, “Air Traffic Technical Training,” which uses classroom discussion and high-fidelity scenario-based simulation exercises to reinforce the skills and procedures necessary to identify and respond to emergency situations.

We have reviewed Order 3120.4R and, although it includes course modules that describe scenario-based simulation exercises that pertain to emergencies, the order does not mention the National Recurrent Training on Emergencies course, which is the course you developed in response to these recommendations and began delivering to controllers in 2019. Order 3120.4R prescribes instructions, standards, and guidance for administering air traffic technical training. Because it does not include the National Recurrent Training on Emergencies course, we would like to: • review the standards and guidance used for administering this course.

• know if the course is updated annually with lessons learned from recent events throughout the NAS. • review the best practices and checklists that have been developed to assist pilots experiencing problems.

Pending our review of this additional information, Safety Recommendations A-16-18 and -19 remain classified OPEN-- ACCEPTABLE RESPONSE.

June 15, 2022 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues to work collaboratively with other government and industry aviation safety stakeholders to ensure best practices to assist pilots experiencing emergencies, problems, or hazards, including but not limited to, the hazardous conditions listed in the recommendations. We have set up risk-mitigation strategies to handle emergencies and a process was established to follow up on their effectiveness throughout the system lifecycle.

In collaboration with the National Air Traffic Controllers Association, we continue to address these recommendations through web-based and instructor-led recurrent training. Since our last update, the FAA’s Air Traffic Organization began delivering instructor-led training on emergencies in April 2019. This training helps develop skills to include early identification, mitigation, and management of risk.

Additionally, we published FAA Order JO 3120.4R, Air Traffic Technical Training, on October 30, 2020. This order aims to reinforce skills in emergency procedures through classroom discussion and high-fidelity scenario-based simulation exercises. Air traffic facilities must develop a written annual refresher training plan ensuring that course materials, visual aids, and scenarios are properly developed, maintained, tailored to meet identified requirements, and update previously taught knowledge and skills.

I believe that the FAA has effectively addressed Safety Recommendations A-16-18 and -19 and consider our actions complete, as the subject of emergencies is adequately covered in all stages of training.

July 31, 2020 · NTSB Correspondence · FAA

We note that you have developed national recurrent training that addresses the emergency scenarios outlined in Safety Recommendation A-16-18, and that air traffic controllers received this training in April 2019. We also note that the FAA’s Air Traffic Organization plans to continue its work with government and industry stakeholders in aviation safety to revise this training in the future, with best practices and checklists for assisting pilots experiencing problems.

Although we believe your actions are responsive to both of these recommendations, you did not indicate whether any of the training is scenario-based. We point out that, to fully satisfy these recommendations, the training should be updated annually with lessons learned from recent events throughout the NAS. We also request that you provide a copy of the training that was given to controllers in April 2019. Pending our review of this additional information, Safety Recommendations A-16-18 and -19 remain classified OPEN--ACCEPTABLE RESPONSE.

March 19, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: Subject matter experts from the Federal Aviation Administration's (FAA) Air Traffic Organization (A TO) and Flight Standards Service met with representatives from the National Air Traffic Controllers Association and General Aviation Joint Steering Committee to review a training project addressed in this recommendation. The group recommended national recurrent training, delivered in a combined web-based and instructor-led discussion format, as the most effective way to train air traffic controllers. The FAA developed and delivered National Recurrent Training on Emergencies in April 2019. This training focused on the following topics:

• Identifying emergency procedures; • Recognizing emergency situations; • Recognizing the procedures for providing assistance to pilots in distress; • Identifying the procedures for controlling aircraft in emergencies; and • Identifying Team Resource Management duties related to emergency situations.

March 13, 2017 · NTSB Correspondence · FAA

We note that you plan to convene a cross-organizational workgroup of subject experts from the National Air Traffic Controllers Association, the FAA’s Flight Standards Service and Air Traffic Organization, and the General Aviation Joint Steering Committee to review the technical content of the emergency response training for controllers. Pending our review of the workgroup’s analysis and its recommended improvements to ensure that controllers are equipped to help pilots in emergency situations, Safety Recommendations A-16-18 and -19 are classified OPEN--ACCEPTABLE RESPONSE.

November 22, 2016 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) is reviewing curricula to seek opportunities for technical updates or other improvements that will adequately address the identified issues. We are currently planning to convene a cross-organizational workgroup of subject experts from the National Air Traffic Controllers Association, the FAA' s Flight Standards Service and Air Traffic Organization, and the General Aviation Joint Steering Committee to collaboratively review the data and provide technical content and for additional recommendations to address these issues.

We hope to identify several opportunities to enhance qualification training and proficiency training throughout the organization.

Additionally, we believe the use of the recurrent training methodology may or may not be the best approach to addressing this matter. We will know better once the curricula reviews are completed and the workgroup has been convened to analyze the technical material. We plan to first identify all courses suitable for improvements by December 2016 and to convene the first cross-organizational workgroup by March 2017.

I will keep the Board informed of the progress of these recommendations and provide an update by October 2017.