NTSB · Safety Recommendation
Safety Recommendation A-88-090
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Establish an independent national division that would be responsible for the quality assurance of the air traffic control system and that would report directly to the administrator of the Federal Aviation Administration. (Superseded by A-89-41 and A-89-90)
Safety Issue and Context
THE NATIONAL TRANSPORTATION SAFETY BOARD BELIEVES THAT RUNWAY INCURSIONS AND NEAR-MIDAIR COLLISIONS, WITH THEIR ASSOCIATED POTENTIAL FOR A CATASTROPHIC COLLISION, REPRESENT TWO OF THE MOST SERIOUS PROBLEMS INVOLVING THE SAFETY OF COMMERCIAL AVIATION OPERATIONS IN THE UNITED STATES TODAY. IN THE PAST 2 YEARS AND TO DATE DURING 1988, THERE HAS BEEN A SIGNIFICANT NUMBER OF AIR TRAFFIC CONTROLLER OPERATIONAL ERRORS AT THE CHICAGO O'HARE INTERNATIONAL AIRPORT (O'HARE) THAT RESULTED IN NEAR COLLISIONS BETWEEN AIR CARRIER, CORPORATE, AND GENERAL AVIATION AIRPLANES DURING GROUND OPERATIONS ON THE AIRPORT AND DURING DEPARTURE AND ARRIVAL PHASES OF FLIGHT.
THE SAFETY BOARD REMAINS CONCERNED THAT, ALTHOUGH THE FEDERAL AVIATION ADMINISTRATION (FAA) HAS IMPLEMENTED PROCEDURAL AND OPERATIONAL CHANGES AND OTHER CORRECTIVE ACTIONS AT O'HARE, THESE EFFORTS HAVE NOT PREVENTED THE CONTINUING OCCURRENCE OF THESE INCIDENTS. THE SAFETY BOARD IS AWARE THAT ON AUGUST 8, 1988, THE FAA'S OFFICE OF AVIATION SAFETY INITIATED A SYSTEMS SAFETY AND EFFICIENCY REVIEW OF THE O'HARE AIRPORT WITH A VIEW TOWARD MAKING APPROPRIATE IMPROVEMENTS IN THE O'HARE AIRPORT AND ITS OPERATION. THE SAFETY BOARD BELIEVES THAT IT IS IMPORTANT FOR THE FAA TO HAVE THE RESULTS OF THE SAFETY BOARD'S SPECIAL INVESTIGATION INITIATED ON JUNE 9, 1988.
Response History
July 12, 1989 · NTSB Correspondence · FAA
Thank you for the FAA's May 1, 1989, response to the National Transportation Safety Board's Safety Recommendation A-88-90. This recommendation stemmed from the Safety Board's special investigation of operational errors at the Chicago O'Hare International Airport. We recommended that the FAA establish an independent national division that would be responsible for the quality assurance of the air traffic control (ATC) system and that would report directly to the Administrator of the FAA. We note that the Associate Administrator for Aviation Safety, who reports directly to the Administrator, will provide oversight of ATC quality assurance. In
addition, his office will identify problem areas and develop recommendations for improvements to the national airspace system.
On May 23, 1989, the Safety Board issued 11 safety recommendations to the FAA following its special investigation of the Coast Terminal Radar Approach Control at El Toro, Marine Corps Air Station, California. One of the Safety Recommendations, A-89-41, addressed the need for an independent quality assurance and safety oversight function within the Office of Aviation Safety and for adequate staff and funding of this new organization so that it can properly monitor the ATC system and ensure that operational and managerial shortcomings are identified and corrected. Since Recommendation A-89-41 encompasses the action that was proposed in Safety
Recommendation A-88-90, we are classifying the latter as "Closed--Superseded."
July 7, 1989 · NTSB Correspondence · FAA
The Safety Board was disappointed with the FAA response to Safety Recommendation A- 88-90. The Safety Board believes that the quality assurance function and responsibility would be more effective and objective were it located, organizationally, outside the air traffic service and reported directly to the Administrator. The Safety Board was encouraged, therefore, when its staff received a briefing from the Associate Administrator of Aviation Safety and his Deputy on March 7, 1989, concerning proposed organizational changes in the Office of Aviation Safety. Safety Board staff members were advised that the intent of these changes is
to provide enhanced quality assurance and safety oversight to FAA's major program offices, including air traffic, and also to be responsive to Recommendation A-88-90. While these proposed changes have been tentatively approved by the Acting Administrator, we understand that staffing and funding for the expanded organization is still under review.
Safety Recommendation A-88-90 has been classified as "Open--Acceptable Action" pending receipt and review of the FAA's final reorganization plan for the Office of Aviation Safety and its associated staffing and functional responsibilities.
May 1, 1989 · Recipient Response · FAA
"--THE FAA'S QUALITY ASSURANCE/EVALUATION/APPRAISAL PROCESS HAS UNDERGONE AN EXTENSIVE REVIEW. THE ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY, WHO REPORTS DIRECTLY TO THE ADMINISTRATOR, HAS BEEN GIVEN AN ESSENTIAL ROLE IN THE EVALUATION AND COMPLIANCE ACTIVITY. THIS OFFICE WILL PROVIDE OVERSIGHT OF AIR TRAFFIC QUALITY ASSURANCE BY, AMONG OTHER THINGS, INDEPENDENTLY ANALYZING AIR TRAFFIC EVALUATION REPORTS. IN ADDITION, THIS OFFICE WILL CONDUCT FULL-SCALE EVALUATIONS OF THE MAJOR PROGRAM AREAS AND INDEPENDENT, INTERDISCIPLINARY SAFETY AND EFFICIENCY REVIEWS. THESE REVIEWS WILL IDENTIFY PROBLEM AREAS AND DEVELOP RECOMMENDATIONS FOR IMPROVEMENTS TO THE NATIONAL AIRSPACE SYSTEM.
December 8, 1988 · Recipient Response · FAA
TODAY THE SECRETARY OF DOT SIGNED CHANGES TO DOT ORDER 1100.62B AND FAA ORDER 1100.2C REMOVING THE AIR TRAFFIC QUALITY ASSURANCE FUNCTION FROM THE ASSOCIATE ADMINISTRATOR FOR AIR TRAFFIC AND TRANSFERRING IT TO A NEWLY CREATED OFFICE OF QUALITY ASSURANCE UNDER THE ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY.
November 4, 1988 · Recipient Response · FAA
"THE FAA HAS ESTABLISHED THE OFFICE OF AIR TRAFFIC EVALUATIONS AND ANALYSIS UNDER THE ASSOCIATE ADMINISTRATOR FOR AIR TRAFFIC TO PERFORM THE OVERALL QUALITY ASSURANCE FUNCTION OF THE AIR TRAFFIC CONTROL SYSTEM. THIS OFFICE IS, BY DESIGN, SEPARATE FROM OTHER ELEMENTS OF THE AIR TRAFFIC ORGANIZATION TO ENSURE THE CREATION OF AN INDEPENDENT BODY TO ENSURE AN UNBIASSED EVALUATION AND QUALITY ASSURANCE FUNCTION. THE ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY ALSO REPORTS DIRECTLY TO THE ADMINISTRATOR. I AM CONFIDENT THAT THE PROGRAMS OUTLINED ENSURE THE HIGHEST STANDARDS OF EVALUATION, ANALYSIS, AND QUALITY ASSURANCE OF THE AIR TRAFFIC CONTROL SYSTEM.
I BELIEVE THAT THE FAA'S ACTIONS MEET THE FULL INTENT OF THIS SAFETY RECOMMENDATION."