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  3. NTSB A-83-038
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NTSB · Safety Recommendation

Safety Recommendation A-83-038

Recommendation

THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INSTITUTE AIR TRAFFIC CONTROL DIRECTIVES AND PROCEDURES TO REQUIRE, WHEN THE ASSIGNED FIRST-LINE SUPERVISOR IS OCCUPIED WORKING A CONTROL POSITION, THAT THERE IS APPROPRIATE AND ADEQUATE DIRECT SUPERVISION TO ENSURE THE DETECTION AND REPORTING OF ALL CONTROLLER ERRORS OR DEVIATIONS, THE DETECTION AND MONITORING OF FATIGUE AND/OR STRESS, AND THE CONTROL OF EACH CONTROLLER'S WORKLOAD. (Supersedes Safety Recommendation A-81-147)

Safety Issue and Context

THE NATIONAL TRANSPORTATION SAFETY BOARD HAS COMPLETED ITS FOLLOWUP INVESTIGATION OF THE NATION'S AIR TRAFFIC CONTROL (ATC) SYSTEM. THE INVESTIGATION, WHICH WAS INITIATED ON SEPTEMBER 20, 1982, EXAMINED THE OPERATION OF THE ATC SYSTEM FROM AUGUST 3, 1981, TO DECEMBER 31, 1982. THE INVESTIGATION INCLUDED THE SURVEY OF 51 ATC FACILITIES, DURING WHICH ABOUT 350 CONTROLLERS AND OTHER ATC FACILITY STAFF AND MANAGERS WERE INTERVIEWED. THE BOARD'S INVESTIGATORS OBSERVED THE OPERATION OF THE ATC SYSTEM FROM WITHIN THE FACILITIES, WHILE RIDING IN THE COCKPITS OF COMMERCIAL AIRLINERS, AND WHILE FLYING GENERAL AVIATION AIRCRAFT WITHIN THE SYSTEM.

QUESTIONNAIRES REGARDING THE ATC SYSTEM AND STRESS AND FATIGUE WERE SENT TO RANDOMLY SELECTED CONTROLLERS WHO WORKED AT THE FACILITIES SURVEYED. ADDITIONALLY, QUESTIONAIRES WERE SENT TO SCHEDULED AIRLINE USERS OF THE ATC SYSTEM AND WERE DISTRIBTED TO PILOTS OF NONSCHEDULE AIRCRAFT SOLICITING THEIR VIEWS ON THE EFFICIENCY AND SAFETY OF THE ATC SYSTEM. THE BOARD'S INVESTIGATORS ALSO VISITED 20 FLIGHT SERVICE STATIONS (FSS) WHERE THE MANAGERS AND SPECIALISTS WERE INTERVIEWED.

Response History

January 26, 1989 · NTSB Correspondence · FAA

Safety Recommendation A-83-38 concerns the institution of ATC directives and procedures to require, when the assigned first-line supervisor is occupied working a control position, that there is appropriate and adequate direct supervision to ensure the detection and reporting of all controller errors or deviations, the detection and monitoring of fatigue and/or stress, and the control of each controller's workload. We note that two separate issues are addressed.

The first is "...appropriate... direct supervision to ensure the detection and reporting of all controller errors or deviations, the detection and monitoring of fatigue and/or stress, and the control of each controller's workload." The changes to FAA Handbook 7210.3H, Facility Operations and Administration, paragraph 241, address the chain of command for watch supervision. However, the changes are inadequate in that the "controller-in-charge" who is acting as watch supervisor may also be assigned "specialist duties in addition to those associated with watch supervision," with no limits on either function. Additionally, the change may lead

to confusion by giving the one person up to three titles (controller-in-charge, watch supervisor, and area supervisor). It also raises questions, such as "How do the individual specialists know who is the acting supervisor at any given time, especially with the first-line supervisor able to occupy or vacate a control position at any time?" and "How does the next person in the chain of command know when he or she is the acting supervisor?" The changes to paragraph 241 make it clear to all ATC specialists what the chain of command is, but do not make clear how the chain operates.

The second issue of this safety recommendation is "...adequate direct supervision...". The statement "...to the extent practicable, avoid scheduling supervisors for non-operational duties during periods of known heavy traffic" which has been added to the FAA Handbook (para. 242) does not address whether adequate supervision exists, as required by the safety recommendation. This is further diluted by having a "controller-in-charge" who may have full operational duties as both a supervisor and controller, at the same time.

Based on the above comments and on the lack of timeliness, the Safety Board has classified Safety Recommendation A-83-38 as

Read Recommendation

Recommendation Facts

Status
Closed - Unacceptable Action
Issued
May 19, 1983
Priority
CLASS II
Recipient
FAA
Adopted
May 12, 1983
Closed
January 26, 1989
Related Investigation
DCA83SI001
Related Report
SIR-83-01
"Closed--Unacceptable Action."
However, we continue to believe that the above ambiguities in the revision to FAA Handbook 7210.3H should be resolved.
June 15, 1988 · Recipient Response · FAA

THE FAA HAS REVISED FAA HANDBOOK 7210.3H, FACILITY OPERATIONS AND ADMINISTRATION, TO ADD PARAGRAPH 242, AREA SUPERVISION. THIS NEW PROCEDURE REQUIRES THAT MANAGERS AVOID SCHEDULING SUPERVISORS FOR NONOPERATIONAL DUTIES DURING PERIODS OF KNOWN HEAVY TRAFFIC. ADDITIONALLY, PARAGRAPH 241, DESIGNATING WATCH SUPERVISION COVERAGE,ADDRESS SPECIALISTS ARE ON DUTY AND NO SUPERVISORY PERSONNEL ARE AVAILABLE. I (T. ALLAN MCARTOR) HAVE ENCLOSED A COPY OF THESE PARAGRAPHS FOR THE BOARD'S INFORMATION.

May 6, 1986 · NTSB Correspondence · FAA

From the special investigation report Runway Incursions at Controlled Airports in the United States (NTSB/SIR-86/01). The Board published this report on 5/6/1986. As a result of its special investigation of runway incursions at controlled airports in the United States, the National Transportation Safety Board reiterates Safety Recommendation A-83-38, A-84-98, A-85-16, and A-85-33.

January 15, 1986 · NTSB Correspondence · FAA

Safety Recommendation A-83-038 was reiterated in the standalone greensheet issuing safety recommendations A-86-7 through -12 on January 15, 1986.

At 1722 eastern daylight time on September 24, 1985, the captain of an Eastern Airlines Boeing 727 (B-727) rejected a takeoff on runway 36 at Washington National Airport (DCA) when he observed a Bell 206-Ll helicopter depart the north helicopter pad in a direction that would cross the B-7271s projected takeoff path. The B-727 came to rest on the grass overrun off the end of runway 36, approximately 130 feet from the Potomac River. There was no damage to the aircraft or injuries to the passengers or crew during the rejected takeoff.

The National Transportation Safety Board's preliminary investigation of this incident disclosed that the B-727 was cleared for takeoff by the tower local controller while, about the same time, the Bell 206 was cleared for takeoff by another controller who was staffing the helicopter control position. The Bell 206 pilot, who had access to a Special Military Helicopter VFR Route Chart, had requested a departure via "Route 1 to Greenbelt."

The Bell 206 pilot interpreted the controller's subsequent takeoff clearance as authorization to proceed to the east by the most direct route to intersect "Route 1 to Greenbelt." The flightpath for this route crosses runway 36. During his takeoff, the pilot observed the Eastern B-727 on takeoff roll, and he also maneuvered to avoid crossing runway 36. He subsequently returned to the north helicopter pad without damage to the helicopter or injury to persons on board.

In a post-incident interview, the helicopter controller stated that she normally would direct a pilot requesting this departure to proceed northwest to join Route 1 at the Memorial Bridge and that she thought she had issued these instructions to the Bell 206. A helicopter flying from the north helicopter pad to the northwest would not interfere or pass over airplanes departing runway 36.

'Ille recorded tower communication, however, showed that the controller transmitted the winos, altimeter, and takeoff clearance information without amplifying departure instructions. 1be helicopter controller stated that she had not coordinated the Bell 206 departure with the local controller because she expected the helicopter to depart northwest, causing no traffic conflict. Further, she stated that even without specific departure clearance instructions, she would have expected the departure helicopter to remain clear of runway 36.

'Ille tower cab supervisor, however, stated that he would assume that the helicopter would cross runway 36 during a "Route 1 to Greenbelt" departure unless given specific instructions to the contrary. The controller who worked ground control during the incident stated that although he would have given distinct departure instructions to the helicopter pilot, he would not have expected the helicopter to cross an active runway even without instruction.

The “Route 1 to Greenbelt” departure is not a standard routing published for use by civilian helicopter operators. The routing is, however, depicted on the Special Military Helicopter VFR Route Chart published by the U.S. Department of Defense (DOD). This DOD route chart is intended for use by military helicopters. However, DCA has letters of agreement with local helicopter users concerning procedures and operation to and from the airport and through the Washington terminal control area (TCA). These letters of agreement are with the local police, military, Federal Aviation Administration (FAA), and some civilian helicopter operators.

They establish responsibilities and describe procedures for helicopter operations under the provisions of Special Visual Flight Rules clearances and for general operations within the Washington TCA. They also describe the use of various routes and altitudes published on the DOD Special Military Helicopter VFR Route Chart. Helicopter operators with letters of agreement with DCA are given copies of the Special Military Helicopter VFR Route Chart. Transient helicopter operators are not assumed to possess this chart, although some, including the helicopter pilot involved in this incident, have obtained copies.

Although the helicopter traffic arriving, departing, or overflying DCA represents only a small percentage of the total daily operational count, 1/ the circumstances of this incident exemplify safety issues regarding the general operation of helicopters at busy airports. Additionally, the investigation of the incident has prompted some specific concerns regarding the administration of the controller training program at the DCA facility.

The Safety Board found that at the time of the incident, all standard control tower positions were staffed with qualified personnel. Before the strike of the Professional Air Traffic Controllers Organization on August 3, 1981, the average number of controllers scheduled for work during a 1500-2300 shift at DCA ranged from 20 to 25. On September 24, 1985, there were 23 air traffic controllers scheduled to work the 1500-2300 shift during which the incident occurred. Two controllers scheduled to work were granted 8 hours of sick leave. One controller was approved for 8 hours of annual leave.

Also, one controller worked from 1500-1900 and took 4 hours annual leave from 1900-2300, and one controller worked from 1800-2300 and took 3 hours annual leave from 1500-1800. In summary, at the time of the incident (1722) there were 19 controllers on duty including 10 full performance controllers (3 of whom were supervisors), 4 controllers certified through departure radar y, 3 certified through local control, 1 certified through ground control, and 1 controller certified at flight data and clearance delivery positions. Thus, of the 19 controllers on duty, only 2 were not qualified to work all positions in the tower cab.

At the time of the incident, 3 controllers were on an authorized break from duty--all 3 were certified to work all tower cab positions.

At DCA, in addition to the supervisor positions, with the maximum number of positions staffed there are 6 control positions in the tower and 8 control positions in the Terminal Radar Approach Control Facility (TRACON). This maximum number is only filled during peak activity. At other times, positions are combined. At the time of the incident, 13 positions were staffed (the LC position was staffed by 2 controllers: a developmental controller and the supervisor administering on-the-job training) and two of the arrival radar positions in the TRACON were combined. Normally, at DCA, two supervisors are on duty in the TRACON and one in the tower cab.

At the time of the incident, one of the TRACON supervisors was staffing an arrival radar position.

The local control position at DCA is responsible for the control of both fixed-wing and helicopter traffic during normal traffic activity. However, during peak traffic periods, the helicopter control position is activated and staffed by another certified local controller to reduce the workload of the local controller. At the time of the incident, the helicopter control position, with specific responsibilities for helicopter operations, was staffed by a developmental controller who was certified through the departure radar position. The tower cab supervisor was responsible for local control while he administered on-the-job-training (OJT) to a developmental controller working the LC position.

The supervisor did not designate a controller-in-charge even though sufficient staff were available to assist in the tower.

The safety issue raised when a regular first-line supervisor is working a control position or is absent from his duties has been the subject of previous Safety Board recommendations addressed to the FAA. On October 14, 1981, during its special investigation of the air traffic control system in the United States, the Safety Board issued Safety Recomm

October 1, 1985 · NTSB Correspondence · FAA

In that there are on-going Safety Board accident investigations and a special study on runway incursions that address this subject further, the Safety Board wishes to withhold further comment at this time. The Safety Board's evaluation of the FAA response to A-83-38 will be made available to the FAA when pertinent information has been developed as a result of these activities.

April 18, 1985 · Recipient Response · FAA

FAA LTR: WE BELIEVE THE GENERAL NOTICE THAT WILL BE ISSUED BEFORE MAY 1, 1985, REGARDING THIS RECOMMENDATION, AND SAFETY RECOMMENDATION A-84-117 WILL SATISFY THE BOARD'S CONCERN "THAT MORE POSITIVE ACTION IS REQUIRED BY THE FAA TO ASSURE THAT FIRST-LINE SUPERVISION IS AVAILABLE TO MONITOR CONTROLLER PERFORMANCE AT PEAK TIME."

November 9, 1984 · NTSB Correspondence · FAA

In its letter, the FAA stated that it had issued General Notice (GENOT) RWA 3/59 concerning the assignment of first-line supervisors to control positions. The principal point of this GENOT was: "When only one supervisor or manager on duty in an area of operation elects to work an operational position involving direct control of air traffic, a controller in charge shall be designated and readily available to provide assistance or coordination." The Safety Board notes that the substance of this GENOT met the intent of Safety Recommendation A-83-38. However, the FAA subsequently rescinded this GENOT since it proved to be impractical because of staffing limitations.

The FAA indicated, however, that it was moving as fast as possible to remove first-line supervisors from controller assignments so they might be used in a supervisory capacity during periods of high volume traffic activity. The FAA also assured the Board that it would make supervisors available, at facilities where staffed, during high traffic operations.

At the time of the operational error on May 9, 1984, at Philipsburg, Pennsylvania, the assigned first-line supervisor was not available at the control sector because he had been directed to attend a meeting with other facility staff members. A supervisor who normally was assigned to a different control area was given the responsibility for supervising the sector where the operational error occurred. When the assigned supervisor returned from his meeting, he noted that the control sector was extremely busy and he immediately assigned additional controller personnel to assist the radar controller. However, shortly after this, the volume

of traffic in the sector was near the point of saturation and the operational error occurred. The Safety Board believes that the absence of the assigned first-line supervisor, during a period of known peak traffic, contributed to the development of the operational error.

The Safety Board believes that the circumstances of the Philipsburg operational error illustrate the importance of having a first-line supervisor, who is qualified and familiar with the control position, assigned and available even during periods of regular traffic activity. In addition, the lack of qualified first-line supervision during the Philipsburg incident has convinced the Safety Board that more positive action is required by the FAA to assure that first-line supervision is available to monitor controller performance at peak time. The Safety Board has concluded that the FAA's actions are not sufficient to satisfy the intent of Safety Recommendation A-83-38.

Therefore, Safety Recommendation A-83-38 has been classified as "Open--Unacceptable Action" and the Safety Board requests that the FAA take further action to address this issue.

August 24, 1983 · Recipient Response · FAA

FAA LETTER: THIS RECOMMENDATION IS SIMILAR TO SAFETY RECOMMENDATION A-81-147 WHICH HAS BEEN CLASSIFIED AS "OPEN--ACCEPTABLE ACTION." WE RESPONDED TO SAFETY RECOMMENDATION A-81-147 BY PUBLISHING GENERAL NOTICE (GENOT) RWA 3/59. THE GENOT READ AS FOLLOWS: "WHEN ONLY ONE SUPERVISOR OR MANAGER ON DUTY IN AN AREA OF OPERATION ELECTS TO WORK AN OPERATIONAL POSITION INVOLVING DIRECT CONTROL OF AIR TRAFFIC, A CONTROLLER IN CHARGE SHALL BE DESIGNED AND READILY AVAILABLE TO PROVIDE ASSISTANCE OR COORDINATION." THE CONTENT OF THE GENOT WAS THE PRELIMINARY STEP TO ITS INCORPORATION INTO FAA ORDER 7210.3F, FACILITY OPERATION AND ADMINISTRATION HANDBOOK.

HOWEVER, THE GENOT WAS RESCINDED AS IT PROVED TO BE IMPRACTICAL BECAUSE OF STAFFING RESTRAINTS AND THE LACK OF NEED FOR SUPERVISORS AT SOME FACILITIES. AT FACILITIES WHERE FIRSTLINE SUPERVISORS ARE EMPLOYED, THEY ARE NORMALLY AVAILABLE TO SUPERVISE CONTROLLERS TO THE GREATEST EXTENT POSSIBLE. IT IS A LONGSTANDING PRACTICE THAT, WHERE SUPERVISOR POSITIONS ARE STAFFED, THEY NOT WORK A CONTROL POSITION DURING VOLUME TRAFFIC CONDITIONS BUT RATHER BE AVAILABLE TO SUPERVISE OPERATIONS. DUE TO PERSONNEL SHORTAGES FOLLOWING THE STRIKE THIS PRACTICE WAS NOT POSSIBLE, AS IT WAS ESSENTIAL THAT SUPERVISORS WORK A CONTROL POSITION TO PROVIDE POSITION COVERAGE.

THIS MAY STILL BE TRUE TO A LESSER EXTENT TODAY; HOWEVER, WE ARE MOVING AS RAPIDLY AS POSSIBLE TO REMOVE SUPERVISORS FROM CONTROLLER POSITION COVERAGE SO THEY MAY DEVOTE FULL TIME TO SUPERVISORY DUTIES DURING VOLUME TRAFFIC CONDITIONS. WE INTEND TO HAVE SUPERVISORS, AT FACILITIES WHERE STAFFED, CONTINUOUSLY AVAILABLE DURING VOLUME TRAFFIC OPERATIONS. WE BELIEVE THIS IS RESPONSIVE TO THE NEED AND ROLE OF THE FIRSTLINE SUPERVISOR. THE BOARD DOES NOT ACKNOWLEDGE THE FACT THAT AT MANY VISUAL FLIGHT RULE TOWERS WE DO NOT HAVE A REQUIREMENT FOR SUPERVISORS, AND NOT ALL SHIFTS AT FACILITIES WITH SUPERVISORS ARE STAFFED, E.G., MIDNIGHT STAFF, ETC.

AS A FOLLOWN-ON, WE PLAN TO LOOK AT THE POSSIBILITY OF IMPLEMENTING THE ESSENCE OF THIS RECOMMENDATION ON A SELECTIVE BASIS WHERE POSSIBLE.