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NTSB Report: ATC Needs Better Emergency Training



 
 
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Old September 7th 16, 01:32 PM posted to rec.aviation.piloting
Larry Dighera
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Posts: 3,780
Default NTSB Report: ATC Needs Better Emergency Training

http://www.avweb.com/avwebflash/news...-226902-1.html
NTSB Report: ATC Needs Better Emergency Training
By Mary Grady

Air traffic controllers need better training in how to assist aircraft in
distress, the NTSB says in a report
http://ntsb.gov/investigations/AccidentReports/Pages/ASR1604.aspx released
this week. The safety recommendation is based on an analysis of five general
aviation accidents, from 2012 to 2015, in which seven people were killed. In
each case, the pilot was communicating with ATC but the controller either
failed to provide adequate assistance or instructed the pilot to take actions
that made the situation worse, according to the NTSB. The FAA should develop a
required national training program to ensure that all controllers have training
that is “current and relevant,” the NTSB said, and includes lessons learned
from recent events.

In one fatal incident, in North Carolina in December 2012, a private pilot
flying a Piper PA-28-160 in IMC had difficulty controlling the airplane and
advised ATC that he was “no gyro.” The controller “did not understand that the
loss of these primary flight instruments would make it extremely difficult for
the pilot to maintain the correct attitude,” the NTSB said. The pilot asked to
be cleared to an alternate airport with visual meteorological conditions.
However, the controller instead prompted the pilot to leave VMC and attempt
another approach into IMC, during which the pilot lost control of the airplane
and crashed. The NTSB determined that contributing to the accident, in part,
was “the inadequate assistance provided by FAA ATC personnel, and the
inadequate recurrent training of FAA ATC personnel in recognizing and
responding to in-flight emergency situations.”
--------------------------------------------------------------------

http://ntsb.gov/investigations/Accid...s/ASR1604.aspx

Safety Recommendation Report: Emergency Training for Air Traffic Controllers
Executive Summary

?The National Transportation Safety Board (NTSB) is providing the following
information to urge the Federal Aviation Administration (FAA) to take action on
the safety recommendations in this report. These recommendations address
emergency identification and response training for air traffic controllers and
are derived from our investigations of five accidents. As a result of these
investigations, the NTSB is issuing two safety recommendations to the FAA.


Probable Cause

Accident Location: Multiple , Multiple
Accident Date:
Accident ID: ERA15FA099, ERA14FA192, ERA13FA105, ERA13FA088, ERA12LA500

Date Adopted: 9/25/2016
NTSB Number: ASR1604
NTIS Number:
Related Report
ASR1604 http://ntsb.gov/investigations/Accid...ts/ASR1604.pdf

ASR-16-004
National Transportation Safety Board
Washington, D.C. 20594
Safety Recommendation Report
Emergency Training for Air Traffic Controllers
Accident Numbers: ERA15FA099, ERA14FA192, ERA13FA105, ERA13FA088,
and ERA12LA500
Operator/Flight Number: Multiple
Aircraft and Registration: Multiple
Location: Multiple
Date: 2012 through 2015
Adopted: August 25, 2016

The National Transportation Safety Board (NTSB) is providing the following
information to urge the Federal Aviation Administration (FAA) to take action on
the safety recommendations in this report. These recommendations address
emergency identification and response training for air traffic controllers and
are derived from our investigations of five accidents. As a result of
these investigations, the NTSB is issuing two safety recommendations to the
FAA.

Accidents
January 13, 2015, New Smyrna Beach, Florida
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.1 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,

1 More information about this accident, NTSB case number ERA15FA099, can be
found in the Aviation Accident Database at www.ntsb.gov.
2
provide other available pertinent weather information, and ask if the pilot
chooses to conduct VFR flight to such an airport.2

Not adhering to this guidance, air traffic controllers from the New Smyrna
Beach ATC tower and Daytona Beach International Airport, Daytona Beach,
Florida, vectored the pilot toward New Smyrna Beach Airport, an airport that
was also under IMC. The pilot was unable to visually acquire that airport and
eventually crashed while maneuvering. Airports west of the accident site
reported VMC, but the air traffic controllers did not attempt to obtain that
information or nearby pilot reports of flight conditions at a higher altitude.
The NTSB determined that contributing to the outcome of the accident was the
controller’s failure to follow published guidance for providing assistance to
VFR pilots having difficulty flying in instrument conditions.

April 11, 2014, Hugheston, West Virginia
On April 11, 2014, about 1653 eastern daylight time (EDT), a Piper
PA-32RT-300T, N39965, impacted trees and terrain near Hugheston, West Virginia.
The commercial pilot and the sole passenger died, and the airplane was
destroyed. Daytime IMC prevailed, and an IFR flight plan was filed.3 An air
traffic controller advised the pilot of moderate to extreme precipitation
and indicated that the pilot should navigate around the weather. While the
pilot was attempting to navigate around the weather, the controller observed
significant altitude deviations of more than 3,000 ft, airspeed fluctuations
from about 80 to 170 knots, and erratic turns, and repeatedly asked the pilot
over the next 15 minutes if he needed assistance. Despite these observations
and the pilot sounding confused and distressed on the frequency, both the
controller and the controller’s supervisor failed to recognize or handle the
flight as an emergency. The NTSB determined that the probable cause of this
accident was “the pilot’s loss of airplane control while operating in [IFR]
conditions.”

January 4, 2013, Palm Coast, Florida
On January 4, 2013, about 1419 EST, a Beechcraft H35, N375B, experienced a loss
of engine power and struck a house while on approach to Flagler County Airport,
Palm Coast, Florida. The private pilot and two passengers died, and the
airplane was destroyed. IMC prevailed, and an en route IFR clearance was
obtained.4 While in cruise flight, the pilot contacted ATC, reported propeller
vibrations and an oil pressure problem, and requested assistance; however,
despite the fact that the airplane had lost total power, the pilot did not
clearly indicate this fact to ATC. The air traffic controller did not question
the pilot further and treated the airplane as if it had at least partial power.
Although the failure occurred almost directly over an airport, the air traffic
controller vectored the airplane away from the airport, and the airplane

2 If these actions are not feasible or declined by the pilot, the controller
should provide radar assistance to the pilot if the pilot declares an
emergency, or if the pilot refuses to declare an emergency and the controller
has determined the exact nature of the radar services the pilot desires.
3 More information about this accident, NTSB case number ERA14FA192, can be
found in the Aviation Accident Database at www.ntsb.gov.
4 More information about this accident, NTSB case number ERA13FA105, can be
found in the Aviation Accident Database at www.ntsb.gov.
3

crashed about 1 mile short of the runway. The NTSB determined that
“contributing to the accident was the pilot’s failure to clearly state that the
aircraft had lost all power and the air traffic controllers’ incomplete
understanding of the emergency, which resulted in the controllers
vectoring the airplane too far from the airport to reach the runway.”

December 16, 2012, Parkton, North Carolina
On December 16, 2012, about 1532 EST, a Piper PA-28-160, N5714W, crashed into a
wooded area near Parkton, North Carolina. The private pilot died, and the
airplane sustained substantial damage. IMC prevailed at the time of the
accident, and an IFR flight plan was filed.5 While conducting an instrument
approach, the instrument-rated pilot began experiencing directional control
issues with the airplane and eventually advised ATC that he was “no gyro.”6
The air traffic controller did not understand that the loss of these primary
flight instruments would make it extremely difficult for the pilot to maintain
the correct attitude and that the pilot would need to reach VMC to control the
airplane and land safely.7 The pilot asked ATC if he could proceed to the filed
alternate airport, which was in VMC; however, the controller instead prompted
the pilot to leave VMC and attempt another approach into IMC, during which the
pilot lost control of the airplane and crashed. The NTSB determined that
contributing to the accident, in part, was “the inadequate assistance provided
by FAA ATC personnel, and the inadequate recurrent training of FAA ATC
personnel in recognizing and responding to in-flight emergency situations.”

August 11, 2012, Effingham, South Carolina
On August 11, 2012, about 1310 EDT, a Beechcraft V35B, N11JK, performed a
forced landing near Effingham, South Carolina. The private pilot and the
passenger were uninjured; the airplane was substantially damaged.8 While en
route, an air traffic controller provided the pilot with information on an area
of moderate to extreme precipitation along the route of flight. The airplane
continued toward the extreme precipitation, and the controller provided no
further weather updates to the pilot despite numerous flight deviation requests
by air carriers to avoid the same area. The pilot entered the area and
encountered severe turbulence that caused a loss of control. During the upset,
the pilot reported to the controller that the airplane’s “AHRS” (attitude
and heading reference system) had failed, but the controller did not know what
that meant.9 The pilot managed to regain control and land the damaged airplane
in a field. The controller failed to recognize the possible consequences of the
pilot’s continued flight into severe weather that was

5 More information about this accident, NTSB case number ERA13FA088, can be
found in the Aviation Accident Database at www.ntsb.gov.
6 Specifically, when the pilot indicated that he was “no gyro,” he was likely
referring to the inoperative state of the gyroscopic flight instruments
consisting of the attitude indicator and directional gyro or heading indicator.
7 Without these primary flight instruments, the pilot was flying “partial
panel” and was required to maintain control of the airplane by referencing the
electrically operated turn coordinator and airspeed indicator. Unaffected
flight instruments consisting of the altimeter and vertical speed indicator
were still available.
8 More information about this accident, NTSB case number ERA12LA500, can be
found in the Aviation Accident Database at www.ntsb.gov.
9 AHRS was the primary instrument to help the pilot keep control of the
airplane. The controller did not know
that the loss of AHRS would affect the pilot’s ability to maintain control of
the airplane in IMC.
4

being avoided by all of the other traffic in his sector and did not understand
the reported loss of attitude information. Although the NTSB determined that
the probable cause of the accident, in part, was “the pilot’s failure to avoid
an encounter with known adverse weather conditions,” the controller could have
helped the pilot sooner by identifying the need to vector the pilot around
the adverse weather.

Discussion
FAA Order 7110.65, Air Traffic Control, chapter 10, provides general guidance
about how air traffic controllers should handle emergencies. Although pilots
may not always specifically declare an emergency, as in the accidents above,
paragraph 10-1-1, “Emergency Determinations,” includes the following:

d. Because of the infinite variety of possible emergency situations,
specific procedures cannot be prescribed. However, when you believe an
emergency exists or is imminent, select and pursue a course of action which
appears to be most appropriate under the circumstances and which most nearly
conforms to the instructions in this manual.

In addition, paragraph 10-1-2, “Obtaining Information,” indicates that
controllers should “[o]btain enough information to handle the emergency
intelligently. Base your decision as to what type of assistance is needed on
information and requests received from the pilot because he/she is authorized
by 14 CFR [Code of Federal Regulations] Part 91 to determine a course of
action.” However, this guidance provides no context or details that would help
controllers recognize an emergency situation, ask appropriate questions to
fully understand the problem, and participate fully with the pilot to identify
and follow a course of action that leads to a safe resolution.

Because the guidance contained in FAA Order 7110.65 is general, scenario-based
training is critical to provide controllers with specific examples to help them
identify unstated emergencies and handle aircraft in the safest manner
possible. Current FAA training on emergency handling is formulaic, based on the
general guidelines described above in FAA Order 7110.65, and does not
necessarily incorporate lessons learned from actual events on a national level.
Although the FAA’s training guidance for controllers does not mention emergency
training for specific situations or use real-life scenarios as examples, it
does indicate that “each facility” must maintain an annual refresher training
plan that includes training on “unusual situations” and instructs that
“training on emergency situations should be based on real-life incidents and
aircraft accidents, stressing a lessons-learned approach.”10 As part of the
local refresher training, 2 hours of evidence-based simulation training must
occur; however, because this training is specific to each facility and
therefore developed on a local level and not a national level, the training is
largely dependent on the equipment and manpower available in each

10 The FAA’s training guidance for controllers is contained in Joint Order
(JO) 3120.4N, Air Traffic Technical Training. Chapter 4, “Training Requirements
for Air Traffic Control Specialists,” references recurrent
“collaboratively-developed national safety training” and includes topics of
“Safety Culture” and “Threat and Error Management.”
5

facility.11 The NTSB notes that controllers have indicated in interviews that
the quality of local refresher training can vary widely; a national ATC
training program including specific, real-life emergency situations would
ensure consistency throughout the country.

On September 24, 2001, the NTSB issued Safety Recommendations A-01-35 through
-40 regarding inadequate air traffic controller response to and awareness of
emergency situations.12 Specifically, Safety Recommendation A-01-36 asked the
FAA to do the following:

Develop and ensure that air traffic controllers receive academic and
simulator training that teaches controllers to quickly recognize and
aggressively respond to potential distress and emergency situations in
which pilots may require air traffic control (ATC) assistance, including
but not limited to (1) recognition of situations in which visual flight
rules aircraft may be encountering instrument meteorological conditions;
(2) an understanding of common aircraft system failures that may require
ATC assistance or special handling; and (3) the application of specific
techniques for assisting pilots that encounter such weather difficulties
and aircraft system failures. Further, this training should be based on
actual accidents or incidents, include a comprehensive review of successful
flight assists and the techniques used, and be reviewed annually to ensure
that the training materials remain current and effective.

To address this recommendation, the FAA developed, distributed, revised, and
redistributed computer-based instruction (CBI) course 57098, “Recognizing and
Responding to Aircraft Emergencies,” which all controllers were required to
take.13 The FAA also revised Order JO 3120.4, Air Traffic Technical Training,
so that it directs that facilities’ annual refresher training includes relevant
real-life scenarios; addresses unusual situations and weather conditions
affecting flight, such as VFR aircraft that encounter IMC; and uses simulators,
if available, for at least 2 hours of training. On June 21, 2012, the NTSB
classified Safety Recommendation A-01-36 “Closed—Acceptable Action.”

The NTSB is concerned that, despite the FAA’s actions in response to
Safety Recommendation A-01-36, the air traffic controllers we interviewed in
the investigations described above did not provide effective emergency
assistance or protect against the deterioration of problems into emergencies.
During the course of the investigations, NTSB investigators noted
inconsistencies in air traffic controller training and examined the training
that the controllers received to determine if the training was effective.

11 FAA Order JO 3120.4N defines evidence-based training as “training based on
an analysis of safety data.”
12 The safety recommendation letter can be found by accessing the Safety
Recommendations link at www.ntsb.gov.
13 The revised course discusses the potential domino effects of common
in-flight mechanical problems; introduces a scenario of a VFR aircraft
encountering IMC; explains a front-line manager’s role in handling an
emergency; and contains an example based on the October 14, 2004, crash of
Pinnacle Airlines flight 3701 near Jefferson City, Missouri.
6

Although NTSB investigators were not able to review the specific simulations
that the controllers received because they are not recorded, the investigations
did review the existing/current simulations and determined that the development
of evidence-based simulations is handled individually by each ATC facility. The
training review suggested that the effectiveness of the evidence-based
simulation training depended on the ability of the local training specialist
to develop simulations and CBIs that benefited controllers and that the
controllers could recall. Accordingly, while the FAA is providing the training
recommended in A-01-36, the NTSB’s review of the training conducted in these
accident investigations indicates that it is not consistent and that no
effective mechanism exists “to ensure that the training materials remain
current and effective,” as recommended.

For example, in the New Smyrna Beach, Florida, accident, the air traffic
controllers interviewed did not recall receiving the evidence-based simulation
training on emergencies as required by FAA Order JO 3120.4. In the Hugheston,
West Virginia, accident, the controllers believed the emergency handling
training that they received as part of the annual refresher training was
redundant, and they could not remember specifics of the training. In the Palm
Coast, Florida, accident, the air traffic controller did not apply the required
provisions of FAA Order 7110.65, paragraphs 10-1-1 and 10-1-2. Effective
emergency handling training would have reinforced the need to “obtain enough
information to handle the emergency intelligently.” In the Parkton, North
Carolina, accident, the air traffic controller did not obtain enough
information to handle the emergency effectively and did not understand the
implications of the airplane’s failed gyro, a common aircraft system failure
that may require ATC assistance or special handling. In postaccident
interviews, the air traffic controller could not recall any specific
information about the refresher training involving emergencies, unusual
situations, or aircraft systems. Finally, in the Effingham, South Carolina,
accident, more assertive actions by the controller, such as reiterating the
precipitation hazard to the pilot, rerouting the flight, and understanding the
implications of losing AHRS, could have reduced the likelihood of an accident.

One of the specific items included in Safety Recommendation A-01-36 was an
understanding of common aircraft system failures that may require ATC
assistance or special handling. The gyro failure in the Parkton, North
Carolina, accident and the AHRS failure in the Effingham, South Carolina,
accident involved important airplane systems whose failures likely put pilots
into distress and in need of ATC assistance. However, our investigation of
these accidents indicated that the emergency response training the controllers
received did not adequately prepare them to understand these systems and the
safety implications of their failures, as envisioned in the recommendation.

On June 26, 2011, the FAA indicated in response to Safety Recommendation
A-01-36 that, while CBI course 57098 is a refresher course, annual refresher
training in the areas highlighted in the recommendation is accomplished through
training developed locally by the ATC facilities. Since updating the CBI course
annually could be a lengthy and time-consuming process, the FAA believed the
annual event-based training developed by the individual ATC facilities was a
more effective and efficient way to address annual recurrent training needs.
However, for many of the training scenarios, the same resources to update the
training annually would be required at each facility; the NTSB notes that
sharing resources or using a single resource at the national level would be the
most efficient way to address these common training 7

needs. Specific, locally developed training could then supplement the
standardized training common to multiple facilities. While each emergency has
its unique circumstances, the NTSB has identified recurrent groups of
emergencies with common characteristics that can be used as learning
experiences, including the following:

(1) power loss and fuel emergencies,
(2) control difficulties,
(3) impaired navigational capability,
(4) loss of flight instruments,
(5) encounters with hazardous meteorological conditions,
(6) VFR flight into IMC, and
(7) pilot medical issues.

A situation encountered by a controller in one facility can occur elsewhere;
however, currently, there is no assurance that other facilities will be advised
about such an event, much less learn anything from it. In addition, national
training on specific, real-life examples could help satisfy the FAA’s
requirement in Order JO 3120.4 for refresher training based on real-life
aircraft incidents and accidents.

The NTSB concludes that, based on the accidents discussed above, the current
training provided to air traffic controllers is not effective in preparing them
to provide appropriate assistance to aircraft in distress.14 The NTSB further
concludes that recurrent national training for controllers specifically
addressing the identification of common emergencies such as those listed above,
illustrated with current, real-life examples, and explaining how best to help
pilots facing such events would ensure that controllers are well equipped to
help pilots in emergency situations.

The NTSB believes that when developing the topics covered and the content of
the emergency response training for controllers, the FAA would benefit from
coordinating with the offices within its Air Traffic Organization, Flight
Standards Service, and Accident Investigation and Prevention organizations that
investigate aviation accidents and incidents, and also with organizations
familiar with the challenges facing pilots confronting emergency situations,
such as the Aircraft Owners and Pilots Association and the General Aviation
Joint Steering Committee. These organizations should be consulted to determine
the situations in which pilots would benefit from the assistance of controllers
and the most appropriate and valuable assistance controllers could provide to
resolve the emergency. These organizations can also provide valuable
information on common aircraft system failures and common ways that a pilot
might characterize these failures to a controller. Therefore, the NTSB
recommends that the FAA develop, in collaboration with its 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

14 The NTSB acknowledges that pilots should not hesitate to declare an
emergency to ATC and should be as specific as possible about their situation.
The NTSB has therefore issued a safety alert (SA-055) to heighten pilot
awareness of this issue. This safety alert can be accessed from the NTSB’s
Aviation Information Resources web page.
8

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.

The NTSB also recommends that the FAA, in collaboration with its internal
offices that investigate aviation accidents and incidents and also
organizations familiar with the challenges facing pilots confronting an
emergency situation, annually revise the required training described
in Safety Recommendation A-16-18 at the national level to ensure that the
training is current and relevant and includes lessons learned from recent
events throughout the National Airspace System that address best practices for
helping pilots who are experiencing problems such as (but not limited to) the
following:

(1) partial or total power loss and fuel emergencies;
(2) control difficulties;
(3) impaired navigational capability;
(4) loss of flight instruments or other critical aircraft systems (including
attitude information);
(5) encounters with hazardous meteorological conditions;
(6) inadvertent flight into instrument meteorological conditions by visual
flight rules pilots; and
(7) pilot medical issues, such as hypoxia.

In addition to national training, ATC facilities would continue to provide
training for controllers on issues specific to their geographic areas of
responsibility. NTSB investigators have visited several ATC facilities to
discuss some of these real-life emergency situations with controllers, who
indicated that the examples helped them better understand how to handle such
situations in the future.
9

Recommendations
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. (A-16-18)

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, annually revise the required training
described in Safety Recommendation A-16-18 at the national level to ensure that
the training is current and relevant and includes lessons learned from recent
events throughout the National Airspace System that address best practices for
helping pilots who are experiencing problems such as (but not limited to) the
following:

(1) partial or total power loss and fuel emergencies;
(2) control difficulties;
(3) impaired navigational capability;
(4) loss of flight instruments or other critical aircraft systems (including
attitude information);
(5) encounters with hazardous meteorological conditions;
(6) inadvertent flight into instrument meteorological conditions by visual
flight rules pilots; and
(7) pilot medical issues, such as hypoxia. (A-16-19)
9
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  #2  
Old September 14th 16, 01:41 AM posted to rec.aviation.piloting
[email protected]
external usenet poster
 
Posts: 169
Default NTSB Report: ATC Needs Better Emergency Training

On Wednesday, September 7, 2016 at 7:32:33 AM UTC-5, Larry Dighera wrote:
http://www.avweb.com/avwebflash/news...-226902-1.html
NTSB Report: ATC Needs Better Emergency Training
By Mary Grady

Air traffic controllers need better training in how to assist aircraft in
distress, the NTSB says in a report
http://ntsb.gov/investigations/AccidentReports/Pages/ASR1604.aspx released
this week. The safety recommendation is based on an analysis of five general
aviation accidents, from 2012 to 2015, in which seven people were killed. In
each case, the pilot was communicating with ATC but the controller either
failed to provide adequate assistance or instructed the pilot to take actions
that made the situation worse, according to the NTSB. The FAA should develop a
required national training program to ensure that all controllers have training
that is “current and relevant,” the NTSB said, and includes lessons learned
from recent events.


Sure, when I have a warning light on my CAR I just dial 911 and the operator will guide me to the proper wires to jiggle, NOT. ATC is not the auto club for weekend flyers. At best Cessna et. all should set up emergency customer service operators that a wounded flyer can be patched into via the radio, and PAY for the assistance like Sears Appliance repair.
 




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