4-1-1. DEFINITIONS

There are several types of incidents that adversely affect the capabilities of air traffic control (ATC) facilities to provide safe, orderly, and expeditious movement of air traffic:

a.        The following incidents are defined and FAA Order 8020.11 provides for their reporting procedures:

(1)     Aircraft Accident – an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and until such time as all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage.

(2)    Near Midair Collision (NMAC) – an incident associated with the operation of an aircraft in which the possibility of collision occurs as a result of proximity of less than 500 feet to another aircraft, or a report is received from a pilot or flight crewmember stating that a collision hazard existed between two or more aircraft.

(a)     Workload permitting, notify any member of a flight-crew receiving air traffic control services who expresses concern about the proximity of another aircraft to contact facility representatives.  Use the following phraseology, “(aircraft identification) advise you contact (facility) at (telephone number)”.

(b)     Upon receiving any telephone call from a flight crewmember that expresses concern about the proximity of another aircraft, the supervisor/controller-in-charge shall ask the caller if he/she desires to file a formal near midair collision report.  All such calls shall be taken on a recorded line, if available.

(3)     Pilot Deviation – the actions of a pilot that result in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance.

(a)     When it appears that the actions of a pilot constitute a possible pilot deviation, notify the pilot, workload permitting, using the following phraseology “(aircraft identification) possible pilot deviation, advise you contact (facility) at (telephone number)”.

NOTE:
These classifications include TCAS RA, spill outs and controlled airspace intrusions that result in a loss of separation.

(4)     Vehicle and Pedestrian Deviation – any entry or movement on the airport movement area by a vehicle operator or pedestrian that has not been authorized by air traffic control (includes surface incidents involving aircraft operated by non-pilots, such as mechanics).

b.        The following definitions are for incidents whose reporting procedures are provided for by this chapter:

(1)     Emergency – a distress or urgent situation that requires special handling of an aircraft by air traffic (AT); includes giving priority that may result in delays to other aircraft.

(2)     Flight Assist - when in-flight assistance is provided to an aircraft in a potentially dangerous situation.

(3)     Military Facility Deviation - an operational error or operational deviation that involves delegated AT responsibilities performed by a military facility, including all Authorization for Interceptor Operations (AFIO) deviations.

NOTE:
This classification does not include instances when approved separation minima are used between military aircraft that are less than those used by the FAA.

(4)     Spill Out - an excursion of an IFR or VFR military aircraft, or a civil aircraft contracted to the military, including remotely operated aircraft, from the exterior boundary of Special Use Airspace (SUA) allocated to military using agencies into other controlled airspace without coordination or prior approval. SUA includes Altitude Reservations (ALTRV); ATC Assigned Airspace (ATCAA); Military Operations Areas (MOA); Military Training Routes (MTR); Prohibited, Restricted, and Warning Areas.

(5)     Surface Incident (SI) - any event where unauthorized or unapproved movement occurs within the movement area associated with the operation of an aircraft that affects or could affect the safety of flight.

NOTE:
Surface incidents result from Pilot Deviations, Operational Errors, Vehicle or Pedestrian Deviations, or Operational Deviations.

(6)     Runway Incursion - any occurrence at an airport involving an aircraft, vehicle, person, or object on the ground that creates a collision hazard or results in a loss of separation with an aircraft.  The occurrence may involve a pilot taking off, intending to take off, landing, or intending to land.

NOTE:
Runway incursions result from one of three types of airport surface incidents: pilot deviations, operational errors, and vehicle or pedestrian deviations.

c.        Operational Errors and Operational Deviations (OE/OD) are defined and their reporting procedures provided for in Chapter 5.

4-1-2.  GENERAL HANDLING PROCEDURES

In addition to any procedures provided for by other FAA orders and other sections of this document, the following procedures shall be applied to all air traffic incidents addressed in paragraph 4-1-1, Definitions:

a.        Compiling Information. The facility first learning of or primarily involved in an incident shall obtain and complete a summary of the pertinent data immediately upon learning of the incident, or as soon thereafter as duties permit, to meet the reporting time requirements for the particular incident.  A reference to this incident shall be logged on FAA Form 7230-4, Daily Record of Facility Operation as a Quality Assurance Review (QAR), as outlined in paragraph 4-1-3, Quality Assurance Review.

b.        Incidents Involving More Than One Facility.

(1)     The ATM's of the involved facilities shall cooperate in the investigation and the preparation of the final report.

(2)     If circumstances prevent collaboration, the facility most involved shall prepare the final report and provide a copy to the other.

(3)     Do not submit individual reports on the same incident.

(4)     When facility or regional boundaries overlap, send a copy of the final report to each ATD involved.

(5)     When an incident occurs and it is suspected that other facilities may have provided services (flight plan, pilot briefing, radio contact, etc.), transmit a priority FF message on Service B to all facilities as follows (text only): "Advise whether any services provided (aircraft identification) today (or specify date). Negative replies requested."

(a)     Limit the reply to the message reference, the aircraft identification, the services provided, and the time and the date the records will be forwarded.

EXAMPLE-
(text only): Reference message from your office (RUMES) (date-time) N1235M. Pilot briefed 1410, VFR flight plan filed. Records will be mailed (date).

(b)     After interviewing the employee involved, if necessary, prepare a narrative summary of the interview and attach facsimile copies of the pertinent records.

NOTE:
FSS's are responsible for the immediate delivery of the request message (either by telephone or hand delivery) to addressees in their flight planning area.

c.        Telegraphic Notification. Any incident that warrants telegraphic notification will require adherence to the following procedures:

(1)     The message shall be a numbered operational priority message.

(2)     No part of the message shall exceed twenty lines, as that will cause an incomplete message to be relayed.

(3)     The originating facility shall obtain and record an acknowledgment from each addressee.

d.        Post-Incident Coordination. As part of the initial process for handling accidents or serious incidents, it is imperative that facilities remain aware of the potential personal impact to involved individuals and to any special needs or requests that may develop as a result.  To that end, the ATD must ensure that appropriate regional counterparts are kept abreast of developing information so that they may participate in subsequent decisions affecting facility personnel.

(1)     ATM's shall, following a major aircraft accident or serious incident; contact the regional ATD and provide an assessment of the personal affect on facility personnel.  Additionally, any proposed personnel action that results from the incident shall be coordinated with the appropriate regional offices.

(2)     ATD Managers shall ensure that subsequent coordination is accomplished as necessary with the Aviation Medical Division, Human Resource Management Division, as well as the Assistant Chief Counsel.  Employee Assistance Program Coordinators or Contractors should also be alerted to the potential need of their services.  Additionally, any proposed personnel action that results from the incident shall be coordinated with AAT-20 before initiation.

e.        Coordination with Regional Counsel.  Incidents resulting in personal injury or property damage may result in a lawsuit.  In such event, the files and records relating to the investigation and any actions taken may be subject to disclosure to the attorneys for the litigants and produced in court.  Therefore, coordinate follow-up actions with the Regional Counsel.  The purpose of this action is not to minimize or restrict actions but to provide assurance that the findings upon which the action is taken contain no misleading language resulting in possible liability to the agency or the individual.

4-1-3. QUALITY ASSURANCE REVIEW (QAR)

For the ATC system to be effective, it is essential that all system deficiencies be identified and corrected.  Serious system deficiencies may be involved in air traffic incidents that fall outside of the definitions and corrective procedures for OE/OD's.  QAR's provide an opportunity for the identification, investigation, and resolution through corrective training of these identified deficiencies.

a.        Conduct a QAR for all of the following when air traffic control services are involved:

(1)     Aircraft accidents.

(2)     Air traffic incidents other than OE/OD's.

NOTE:
QAR's are not required for incidents preliminarily identified as OE/OD's. As such reviews would be redundant to OE/OD investigative/corrective procedures (see Chapter 5 AT OE/OD Investigation and Reporting).

(3)     Traffic Alert and Collision Avoidance System (TCAS) Resolution Advisory (RA) Reports.

(4)     Operational Error Detection Program (OEDP) alert.

(5)     Other miscellaneous incidents or reports that involve a loss of separation.

(6)     Public inquiries regarding air traffic control services provided during a specific operation; e.g. flight crewmember, passenger, or media inquiries.

(7)     Interfacility traffic management initiatives that cause “NO NOTICE GROUND STOPS” or “NO NOTICE AIRBORNE HOLDING”.

NOTE:
Both the initiating and receiving facilities shall conduct a review of these interfacility initiatives.  The review shall include the causes and the effects of these initiatives.

b.        Determine in a QAR whether employee performance, procedures, and/or equipment may have contributed to, increased the severity of, or unreasonably failed to mitigate the initiating incident.

EXAMPLE-
[1] In review of a pilot deviation resulting in a runway incursion, determine whether a local controller's scanning of movement areas was adequate

[2] In review of an aircraft accident, determine whether an in-flight specialist's weather briefing to the involved pilot was adequate.

[3] Determine whether a controller's radar vectors resulted in an instrument approach intercept inside the final approach fix.

c.        The ATM shall designate the personnel responsible for the conduct of QAR's. This designation may be made on a permanent, or ad hoc basis.

d.        Conduct the QAR in sufficient detail so as to assess the system performance with reasonable accuracy. The detail of a QAR may range from simply discussing the situation with the involved employees, to a full investigation that may include reviewing recorded radar data and voice communications from the incident (see paragraph 5-1-5a, Investigative Process, Fact Finding, for investigative sources to consider).

e.        The result of a QAR that involves an employee shall be communicated to the affected employee as soon as practical, normally the employees’ next assigned shift and forwarded to the employees’ first-level supervisor for review.

f.         Accomplish appropriate corrective training for all identified employee technical proficiency deficiencies. Training shall be administered in accordance with FAA Order 3120.4.

NOTE:
In cases of serious technical performance deficiencies, appropriate training may include decertification and remedial training if documented performance history warrants.

g.       Communicate the conclusions of the QAR, including those finding no employee performance deficiency, to the ATM.

h.       Record notification of the QAR initiating incident and conclusion of its review on FAA Form 7230-4, Daily Record of Facility Operation, in accordance with FAA Order 7210.3.

i.         Notify AAT-200 through the Regional Operations Center (ROC), along with the ATD and the Washington Operations Center (WOC) within 3 hours of any occurrence that results in less than standard separation.

NOTE:
When reporting operational errors/deviations, follow the reporting procedures in paragraph 5-1-3, Initial Investigations.

j.         Notify the ATD through the ROC within 3 hours of the occurrence of all surface pilot deviations, vehicle runway deviations, “NO NOTICE GROUND STOPS”, “NO NOTICE AIRBORNE HOLDING”, and any other safety related incidents, regardless of whether standard separation was lost.  This requirement is supplemental to the requirements contained in FAA Order 8020.11.

k.       Retain all suspected air traffic incidents (listed above) and supporting data that are investigated and determined to be a non-occurrence for 45 days.

NOTE:
Retain all supporting documentation including; certified re-recordings of the pertinent voice tapes, employee statements, and NTAP/CDR data in electronic format used to determine the event was a non-occurrence. Facilities that determine the event was a non-occurrence based on a printed NTAP or CDR Plot (i.e. significant target jump) shall retain both the original paper printout and an electronic copy.

4-1-4. EMERGENCIES

a.        When appropriate, make emergency notification using FAA Form 8020-3, Facility Accident/Incident Notification Record.

b.        Compile the information and document on FAA Form 7230-4, Daily Record of Facility Operation, the events, the notifications, and the termination of the emergency.

c.        Notify AAT-200, the ATD, and the appropriate FSDO through the ROC/WOC whenever:

(1)     The aircraft involved is an air carrier, a commuter, or an air taxi; or

(2)     The aircraft is carrying members of Congress or prominent persons; or

(3)     The emergency is or may become newsworthy by coming to the attention of the public or the news media.

d.        Prepare FAA Form 8020-11, Incident Report in accordance with FAA Order 8020.11.  For significant emergencies (e.g., involving air carriers, air taxis, or prominent persons), immediately notify AAT-200, ATD ROC/WOC by telephone, and forward a preliminary report within 3 hours.

4-1-5. FLIGHT ASSISTS

a.        Report instances where a pilot is provided in-flight assistance to the appropriate FSDO through the ROC within 3 hours of the occurrence. Obtain the information required to complete FAA Form 7230-6, Flight Assist Report, and include the pilot's name and address if obtainable. Instructions for completing FAA Form 7230-6, Flight Assist Report are contained in Appendix 7 Instructions for FAA Form 7230-6, Flight Assist Report.

b.        When another pilot helps in providing flight assistance, obtain the assisting pilot's name and address, via telephone, and include in Item 16 of FAA Form 7230-6, Flight Assist Report.

c.        Prepare FAA Form 7230-6, Flight Assist Report within 10 administrative days of the occurrence and include the following:

(1)     The pilot's name and address, if obtainable, in Item 16.

(2)     If the assistance was of an outstanding nature, enter the word "Outstanding" at the top center of the form.

(3)     If a pilot helps in providing assistance, include their name in Item 16.

(4)     Indicate in Item 16 when an FAA Form 8020-17, Preliminary Pilot Deviation Report, is filed as a result of a flight assist.

(5)     For outstanding flight assists, indicate in item 17 the name of the employee primarily responsible for the assist.  All other names in item 17 will be considered as having provided additional assistance.

d.        Pilot Recognition:

(1)     The ATM shall review the circumstances when a pilot aids in providing flight assistance. If appropriate, write a letter of recognition.  Attach a copy to FAA Form 7230-6, Flight Assist Report.

(2)     When pilot assistance is of an outstanding nature, the ATD shall review the circumstances, and if appropriate, prepare a regional level letter of recognition.

e.        Distribute FAA Form 7230-6, Flight Assist Report as follows, and indicate on the original to whom the copies are routed:

(1)     The original to the facility's files.

(2)     The ATD.

(3)     ATX-400.

(4)     The FSDO.

(5)     Others as determined by the ATD.

f.         Process Annual National and regional Outstanding Flight Assist Award as follows:

1.       Annual National and Regional Outstanding Flight Assist Awards recognize employees whose actions contribute significantly to the safety of aviation. The selection of an outstanding flight assist will be judged on the basis of operational efficiency.  Factors to be considered are the method used, expediency of the assist, circumstances surrounding the flight assist, analytical decision exhibited, timely action, the all-out effort demonstrated, and any other special factors that are appropriate.

2.       Each region may submit three nominations (one per option: en-route, terminal and flight service).

3.       Each nomination is expected to include a narrative statement describing the details of the flight assist, a copy of FAA Form 7230-6, Flight Assist Report, a certified voice recording of the flight assist, and any other documentation relative to the occurrence.

4.       Nominations for the preceding year must be received by the Program Director of Air Traffic Resource Management, ATX-1, by February 15.

NOTE:
An employee is limited to one monetary award for a single contribution. Therefore, it is recommended that regional or facility awards are not made until it is determined that the occurrence does not warrant a national award.

4-1-6.  MILITARY FACILITY DEVIATIONS

a.        The AT facility or representative (ATREP, RADLO, etc.) noting or receiving information about a military facility deviation shall report the occurrence immediately to the respective ATD.

(1)     The report number shall be composed of the letter "M", followed by the last digit of the calendar year, a slant line, and the sequential number of military facility deviations forwarded by the reporting FAA office.  Use a new sequence of numbers beginning January 1 of each year.

(2)     Report the deviation in narrative form by memorandum within 10 administrative days of the occurrence.  Prepare the report as follows:

(a)     Include a chronological summary of the incident.  Details shall be as complete as security considerations and data availability will permit.

(b)     Include a brief statement of the probable cause or causes if the available data is sufficient to make these conclusions.

(c)     Include recommendations, as appropriate, to preclude a recurrence of the event.

b.        Distribute the report as follows:

(1)     Original to the ATD.

(2)     Facility's files.

(3)     AAT-20.

(4)     Military Distribution:

(a)     Designated Regional Office Military representative.

(b)     Send one copy to the facility’s major command (MAJCOM/MACOM). Obtain MAJCOM/MACOM information from the facility or the appropriate regional military representative.

1.      Air Force
HQ AFFSA/XAES
1535 Command Drive
Suite D-309
Andrews AFB, MD 20762 –7002

2.      Army
US Army Aeronautical Services Agency
ATTN: Chief, Airspace Support Division
9325 Gunston Road
Bldg 1466, Suite N-319
Fort Belvoir, VA 22060-5582

3.       Navy/Marine
Chief, Air Traffic Branch
CNO N885F
Navy Department
Washington, DC 20350-2000

4-1-7.  SPILL OUTS

Spill out reporting is a non-punitive program to identify design and/or procedural problems with special use airspace. Facilities shall report all spill outs and forward the following information to AAT-20 through the ATD, ROC, and the WOC with an information copy to Manager, Special Operations Division, ATP-200, via data communications Service B message, within 3 hours of the incident.

a.        If the spill out resulted in a loss of separation or report of a NMAC with another aircraft outside the SUA, report the incident as a pilot deviation and forward the following information to AAT-20 via the Washington Operations Center (WOC) within 3 hours of the incident:

(1)        Reporting facility.

(2)        Date and time (UTC) of the incident.