GENERAL INFORMATION

NARRATIVE

[O] On June 23, 1998, about 1601 eastern daylight time, a Piper PA-31 Navajo, N711LD, and Grayhawk 06, a Navy Grumman E-2, were involved in an air traffic control (ATC) operational error, which occurred about 20 miles southwest of Bradford, Pennsylvania. Both airplanes were operating on instrument flight rules (IFR) flight plans under control of the Federal Aviation Administration's (FAA) Cleveland Air Route Traffic Control Center (ARTCC) Bradford sector. Grayhawk 06 was northbound, en route from Norfolk, Virginia, to Wellsville, New York, and N711LD was westbound, en route from Elmira, New York, to Akron, Ohio. The two airplanes passed within 2 miles horizontally and 100 feet vertically. [Recommendations] A-00-27. Establish a formal method for air traffic control personnel to report instances in which sectors become overloaded (similar to the Unsatisfactory Condition Report process), so that the circumstances causing or permitting overloading can be identified and addressed. [Responses] FAA LTR DTD: 6/9/00 FAA Order 7210.3, Facility Operation and Administration, paragraph 17-7-5, provides very specific guidance concerning recurring sector loading issues. The Unsatisfactory Condition Report form is the appropriate means for reporting equipment problems with the monitor alert parameter equipment. The FAA's Director, Air Traffic Service, sent a memorandum to regional air traffic division managers on May 17, 2000, reminding them of the responsibility to ensure compliance with this procedure. I have enclosed a copy of the memorandum for the Board's information. A sector overloading situation would most likely result from "no notice ground stops" and/or "no notice holding situations" and would require follow-up activities to preclude repeat circumstances. Consequently, to preclude a problem with sector loading, the FAA expanded the Quality Assurance Reporting requirements to investigate all "no notice ground stops" and/or "no notice holding situations." I believe that the FAA has addressed the full intent of this safety recommendation, and I consider the FAA's action to be completed. NTSB LTR DTD: 10/24/00 The FAA states that FAA Order 7210.3, "Facility Operation and Administration," paragraph 17-7-5, provides very specific guidance concerning recurring sector loading issues. The FAA further states that the Unsatisfactory Condition Report form is the appropriate means for reporting problems with MAP equipment. The FAA's Director, Air Traffic Service, sent a memorandum to regional air traffic division managers on May 17, 2000, reminding them of their responsibility to ensure compliance with this procedure. The FAA indicates that a sector overloading situation would most likely result from "no notice ground stops" and/or "no notice holding situations" and would require follow-up activities to preclude repeat circumstances. To preclude a problem with sector loading, the FAA indicates that it expanded the Quality Assurance Reporting requirements to investigate all "no notice ground stops" and/or "no notice holding situations." The Safety Board is aware of the procedures outlined in FAA Order 7210.3 relating to the analysis of recurring sector loading issues. However, these procedures do not meet the intent of this recommendation, which is to provide a specific means for controllers to identify and report situations in which a sector is subjected to excessive demand or in which other circumstances bring into question the effectiveness of traffic management procedures. The incident at the Cleveland ARTCC Bradford sector described in the recommendation letter is an example of the type of situation that would be eligible for reporting under this recommendation. That incident did not result from no-notice holding or ground stops and, absent the reported operational error and an anonymous call regarding the surrounding circumstances, it may otherwise never have been investigated. The Safety Board is aware of other situations in which severe weather or other disruptions to normal operations resulted in traffic situations that warranted concern, even though these disruptions to normal operations did not qualify as "recurrent events." The Unsatisfactory Condition Report analogy was not chosen lightly: the Safety Board believes that a specific and tracked means of identifying and correcting serious operational issues is just as important as a specific and tracked means of identifying and correcting serious equipment issues. If a traffic situation similar to a recurring issue already under investigation were reported through such a method, the report could be closed by referencing the ongoing analysis process. However, reports of transient overloading events may also provide important insights into problems within the ATC system, especially in light of increased demands for less structure and greater operational flexibility. The Board believes that the additional feedback provided by such reports would be beneficial to the analysis of system operations and should be implemented as soon as possible. Pending notification of the establishment of a formal method for ATC personnel to report transient overloading events, Safety Recommendation A-00-27 is classified "Open Unacceptable Response." FAA LTR DTD: 3/2/01 The FAA believes that FAA Order 7210.3, Facility Operation and Administration, paragraph 17-7-5, provides very specific guidance concerning recurring sector loading issues. Chapter 17 provides extensive guidance for the identification, reporting (tactical and strategic), mitigation, tracking, and review of sector overloading issues. Additionally, air traffic control operational supervisors have the responsibility to evaluate and document an air traffic control specialist's performance--maintaining safety is the highest priority. The operational supervisors are also required to evaluate and supervise air traffic operations in order to initiate the appropriate action(s) to prevent sector/air traffic control specialist overloading. I believe that the FAA has addressed the full intent of this safety recommendation, and I consider the FAA's action to be completed. NTSB LTR DTD: 7/25/01 The FAA reports that FAA Order 7210.3, "Facility Operation and Administration," paragraph 17-7-5, provides very specific guidance concerning recurring sector loading issues, and that chapter 17 provides extensive guidance for the identification, reporting (tactical and strategic), mitigation, tracking, and review of sector overloading issues. Additionally, the FAA states that ATC operational supervisors have the responsibility to evaluate and document an ATC specialist's performance and to evaluate and supervise ATC operations to initiate the appropriate action(s) that will prevent sector/ATC specialist overloading. The Safety Board disagrees with the FAA's assertion that chapter 17 of Order 7210.3 already contains procedures that address the intent of Safety Recommendation A-00-27. The FAA's response refers specifically to paragraph 17-7-5. The Board notes that this paragraph refers to the elevation to higher-level management of recurring sector loading issues, rather than individual cases that may result from transient events, such as weather reroutes, traffic management failures, or unexpected holding. Because of the reference to "the elevation of a recurring sector loading issue," paragraph 17-7-5 appears to followup on paragraph 17-7-4, "Analysis Requirements," which addresses the analysis of alerts generated by the ETMS Monitor Alert function and requires only minimal analysis of events that do not appear to be recurring or part of a pattern. The Board notes that the sector overload that prompted this recommendation was not recurrent and was not detected by ETMS. Therefore, procedures contained in these two paragraphs would not apply. The Board also notes that the type of situation subject to the reporting process proposed by this safety recommendation could result from the failure of ETMS to provide a timely alert. The lack of an alert might fail to initiate the existing analysis process, resulting in little or no examination of the circumstances permitting sector overloading. On March 14, 2001, Safety Board staff met informally with staff from the FAA's Air Traffic Division to discuss this recommendation. In this meeting, the FAA staff cited workload concerns as a result of processing the reports and again asserted that the process contained in FAA Order 7210.3 for analyzing recurrent alerts is also applied to incidents of the type cited in the recommendation letter. Although the Board recognizes that processing overload reports will represent some increase in workload, the data obtained may reduce the risk of operational errors and deviations by identifying operational problems and traffic management deficiencies within the ATC system. Further, a significant increase in workload caused by processing overload reports indicates a problem that the FAA needs to recognize and correct. During the meeting, Safety Board staff also asked whether the FAA could supply documentation of examples where the analysis process contained in Order 7210.3 had been used to report, analyze, track, and correct circumstances leading to transient incidents similar to the one described in the recommendation letter. FAA staff responded that no such documentation existed. Since the goal of this recommendation is the establishment of a reporting process that achieves those objectives, the Board disagrees with the FAA that current procedures are sufficient to fulfill the intent of this recommendation. If the current process were equivalent to the recommended process, such documentation would be complete and readily available. The FAA states that operational supervisors are required to evaluate and document ATC specialist performance and to supervise air traffic operations in order to prevent sector and controller overloading. The Safety Board notes that the FAA has been reducing the number of operational supervisors available to perform these duties. In addition, supervisory failure to perform these duties properly might be the cause of an overload report from the affected controllers. Discovering the reasons for such a failure would be valuable and a useful consequence of the reporting process proposed in this recommendation. The Safety Board asks the FAA to reconsider its response to this recommendation. The Board will consider alternative proposals from the FAA for establishing a reliable means of reporting, analyzing, tracking, and correcting circumstances leading to transient overloads of ATC sectors. Pending completion of the recommended action, Safety Recommendation A-00-27 remains classified "Open Unacceptable Response." FAA LTR DTD: 11/13/01 As previously stated, FAA Order 7210.3, Facility Operation and Administration, paragraph 17-7-5, provides very specific guidance concerning recurring sector overloading issues. Chapter 17 provides extensive guidance for the identification, reporting (tactical and strategic), mitigation, tracking, and review of sector overloading issues. Additionally, air traffic control operational supervisors have the responsibility to evaluate and document an air traffic control specialist's performance (maintaining safety is the highest priority). The operational supervisors are also required to evaluate and supervise air traffic operations in order to initiate the appropriate action(s) to prevent sector/air traffic control specialist overloading. The procedures currently in place address the full intent of this safety recommendation, and the FAA does not agree that there is a need to establish a separate formal method for air traffic control personnel to report instances in which sectors become overloaded. I consider the FAA's action to be completed in response to this safety recommendation. NTSB LTR DTD: 6/14/02 The FAA states (1) that the procedures currently in place (FAA Order 7210.3, "Facility Operation and Administration," paragraph 17-7-5) address the full intent of this safety recommendation and (2) that it does not agree that there is a need to establish a separate formal method for ATC personnel to report instances in which sectors become overloaded. Additionally, the FAA notes that ATC operational supervisors are responsible for evaluating and documenting an ATC specialist's performance, evaluating and supervising air traffic operations, and initiating appropriate action(s) to prevent sector/ATC specialist overloading. The Safety Board is disappointed by the FAA's response. In its July 25, 2001, letter to the FAA on this recommendation, the Board stated the following: The Safety Board disagrees with the FAA's assertion that chapter 17 of Order 7210.3 already contains procedures that address the intent of Safety Recommendation A-00-27. The FAA's response refers specifically to paragraph 17-7-5. The Board notes that this paragraph refers to the elevation to higher-level management of recurring sector loading issues, rather than individual cases that may result from transient events, such as weather reroutes, traffic management failures, or unexpected holding. Because of the reference to "the elevation of a recurring sector loading issue," paragraph 17-7-5 appears to followup on paragraph 17-7-4, "Analysis Requirements," which addresses the analysis of alerts generated by the ETMS Monitor Alert function and requires only minimal analysis of events that do not appear to be recurring or part of a pattern. The Board notes that the sector overload that prompted this recommendation was not recurrent and was not detected by ETMS. Therefore, procedures contained in these two paragraphs would not apply. The Board also notes that the type of situation subject to the reporting process proposed by this safety recommendation could result from the failure of ETMS to provide a timely alert. The lack of an alert might fail to initiate the existing analysis process, resulting in little or no examination of the circumstances permitting sector overloading. The Safety Board's July 25, 2001, letter also described a March 14, 2001, informal meeting between Board staff and FAA Air Traffic Division staff to discuss this recommendation. The Board noted the following: During the meeting, Safety Board staff also asked whether the FAA could supply documentation of examples where the analysis process contained in Order 7210.3 had been used to report, analyze, track, and correct circumstances leading to transient incidents similar to the one described in the recommendation letter. FAA staff responded that no such documentation existed. Since the goal of this recommendation is the establishment of a reporting process that achieves those objectives, the Board disagrees with the FAA that current procedures are sufficient to fulfill the intent of this recommendation. If the current process were equivalent to the recommended process, such documentation would be complete and readily available. The FAA has not addressed the point made by the Safety Board that the failure to perform supervisory duties properly might be the cause of an overload report from the affected controllers. Discovering the reasons for such a failure would be valuable and a useful consequence of the reporting process proposed in this recommendation. The FAA states that there is no need to establish a separate formal method for ATC personnel to report instances in which sectors become overloaded and that it plans no further action in response to this recommendation. Consequently, Safety Recommendation A-00-27 is classified "Closed Unacceptable Action." 7

END REPORT