a.
Operational Error: An
occurrence attributable to an element of the air traffic system in
which:
(1)
Less than the applicable
separation minima results between two or more aircraft, or between an
aircraft and terrain or obstacles (e.g., operations below minimum
vectoring altitude (MVA); equipment / personnel on runways), as
required by FAA Order 7110.65 or other national directive; or
(2)
An aircraft lands or
departs on a runway closed to aircraft operations after receiving air
traffic authorization.
(3)
An aircraft lands or
departs on a runway closed to aircraft operations, at an uncontrolled
airport and it was determined that a NOTAM regarding the runway
closure was not issued to the pilot as required.
b.
Operational Deviation: An
occurrence attributable to an element of the air traffic system in
which applicable separation minima as referenced in paragraph 5-1-1a,
Operational Error was maintained, but:
(1)
Less than the applicable
separation minima existed between an aircraft and adjacent airspace
without prior approval; or
(2)
An aircraft penetrated
airspace that was delegated to another position of operation or
another facility without prior coordination and approval; or
(3)
An aircraft penetrated
airspace that was delegated to another position of operation or
another facility at an altitude or route contrary to the altitude or
route requested and approved in direct coordination or as specified in
a letter of agreement (LOA), pre-coordination, or internal procedure;
or
(4)
An aircraft is either
positioned and/or routed contrary to that which was coordinated
individually or; as specified in a LOA/directive between positions of
operation in either the same or a different facility; or
NOTE:
This
does not apply to inter/intra-facility traffic management initiatives.
(5)
An aircraft, vehicle,
equipment, or personnel encroached upon a landing area that was
delegated to another position of operation without prior coordination
and approval.
c.
Technical Violation:
Operational errors that are classified as low severity and all
operational deviations. Operational
errors that cannot be reviewed by radar data or a playback tool will
be initially classified as a low severity, if all indications are that
at least 80% separation minima was maintained.
See Chapter 6, Severity Index.
d.
Operational Duties: Duties
that require an employee to issue or relay an ATC clearance or
instruction; make a control decision that will affect coordination;
perform a strip marking function or update computer generated
information that may be used by an AT controller to make a control
decision; or supervise these duties.
e.
Operational
Error/Operational Deviation Steering Committee: As established by
Memorandum of Understanding (MOU) to address national quality
assurance issues contained within this order and other matters
including, but not limited to, trend analysis, program effectiveness,
compliance, and ongoing positive efforts.
The committee meets as necessary to review and address quality
assurance matters. The steering committee is comprised of two
representatives from NATCA and two representatives from AAT-20.
f.
Controlled Event: An
operational error where the AT employee was aware of the impending
conflict and takes corrective action to increase the separation.
g.
Uncontrolled Event: An
operational error where the AT employee was unaware of the conflict,
takes no corrective action and/or became aware of the conflict but did
not have enough time to effectively mitigate the loss of separation.
h.
Severity Index: A method
to determine the gravity, or degree that the separation standard was
violated, for operational errors that occur in-flight.
i.
OE Causal Factors: The Air
Traffic Evaluations and Investigations Staff, AAT-20, in coordination
with the Office of Aerospace Medicine’s Human Resources Research
Division, AAM-500, analyzes, FAA Form 7210-3, Final Operational
Error/Deviation Reports to compile statistics and determine trends
regarding the causal factors for OE/D’s.
Based
on that analytical information and as a quality assurance initiative
to further reduce the potential for OE/D’s system-wide, AAT-20 has
identified certain checklist items that, when rated as problematic
during evaluations, indicate that the facility’s potential for
experiencing an OE/D is increased.
a.
In order to maintain an effective Air Traffic System, it is
imperative that we identify all deficiencies within our system and
take appropriate corrective actions necessary to fix any associated
problems. Operational
errors and deviations are reported for just that reason, so those
problems (either systemic or individual) can be corrected to enhance
system integrity. The identification of operational errors and
deviations without fear of reprisal is an absolute requirement and is
the responsibility of all of us who work within our system.
b.
Accordingly, it remains Air Traffic Policy that any employee
who is aware of any occurrence that may be an operational error,
deviation, or air traffic incident (as defined in paragraph 4-1-1,
Definitions), immediately report the occurrence to any available
supervisor, controller-in-charge (CIC) or management official.
c.
Employees’ shall verbally provide the preliminary
information, of which they have knowledge, when requested by the
supervisor, controller-in-charge (CIC) or management official to make
an initial determination as to whether an investigation is warranted.
This phase is meant only to determine the need of an
investigation and is not investigatory. Therefore, Union representation is not required at this time.
The
initial investigation is intended to be fact finding in nature.
It has been designed to determine what occurred in the system,
to ensure corrective action is initiated to maintain system integrity,
and to report significant events to higher levels of management.
NOTE:
There are occasions when it is appropriate for higher levels of
management to require further review of a suspected incident, and this
further review may result in the discovery of an incident not
previously identified.
The
operations supervisor or the controller-in-charge when a supervisor is
not available, with ATM concurrence, shall determine the validity of
suspected OE/OD's and, if valid, shall ensure the following is
accomplished:
NOTE:
Other facility personnel shall assist the operations supervisor and/or
controller-in-charge in gathering data to conduct the initial
investigation, whenever feasible.
a.
When information indicates that an OE/OD may have occurred in
another facility, promptly advise that facility's operational
supervisor-in-charge.
b.
Provide relief to any
employee who appears to be involved in the incident from all
operational duties as promptly as operational and staffing conditions
permit. This action is intended to allow employees’ an opportunity
to review the voice recordings and prepare draft statements while the
circumstances are fresh in their minds.
The relief of an employee from operational duty also provides
the employee the opportunity to participate in the preliminary
investigation. Initial
written statements should be completed prior to initial AAT-200
notification.
NOTE:
It may be necessary for involved employees’
participating in suspected OE/OD investigations to remain in the
facility beyond their scheduled shift in order to complete their
statement, be interviewed, and participate in the initial
investigation.
c.
Gather flight progress
strips, weather data, and other pertinent information. If another
facility is involved, that facility shall provide the reporting
facility's supervisor with all the pertinent data necessary for the
timely completion of the preliminary report.
d.
Review voice recordings;
denote the difference in the system times and, as soon as feasible;
prepare a cassette re-recording from the original to be used as a
working tape.
e.
Review available radar
data; denote the difference in the system times, e.g., National Track
Analysis Program (NTAP), or Continuous Data Recording (CDR) data, etc.
See Appendix 1, Radar Data Processing.
f.
Review appropriate
computer data and denote the difference in the system times;
(1)
Data Analysis Reduction
Tool (DART).
(2)
Airport Movement Area
Safety System (AMASS).
(3)
Tower Data Link Services (TDLS).
(4)
Pre-departure Clearance (PDC).
(5)
User Request Evaluation
Tool (URET).
(6)
Core Capability Limited
Deployment (CCLD).
(7)
Controller Pilot Data Link
Communications (CPDLC) messages.
(8)
Operational and
Supportability Improvement System (OASIS) or Model 1.
EXAMPLE-
DART
printouts will indicate a chronological sequence of textual CPDLC
transactions. Individual CPDLC messages are stored in the Data Link
Applications Processor (DLAP) temporary file as a binary encoded
message and can be printed out in a text format for review.
NOTE:
Most of these new systems retain data on their
individual hard drives, which are automatically deleted after 15 days.
It is the ATM’s responsibility to advise Airways Facilities, in a
timely manner, so they may extract this data onto a
storable/retainable electronic media. The pertinent data shall then be
retained with the required incident file.
g.
Conduct preliminary
interviews with involved employees’.
Efforts should be made to complete these interview(s) prior to
the initial AAT-200 notification.
h.
Notify the ATM of the OE/OD.
i.
Ensure that FAA Form
7210-2, Preliminary Operational Error/Deviation Investigation, is
completed.
NOTE:
When
writing the summary, be as clear and concise as possible using who,
what, when, where, and how, to describe the entire events.
Instructions for completing FAA Form 7210-2 are contained in Appendix
2 and shall include pertinent actions of the pilot(s) and air traffic
control leading up to the event and any subsequent action.
j.
Notify AAT-200 and the ATD
through ROC/WOC by telephone within 3 hours from the time the
occurrence is first reported or suspected with the following
information/data:
NOTE:
The intent of the time limit is not to
preclude a continuation of the preliminary investigation.
However, it is intended to ensure that AAT-200 is aware of
reported or suspected events within 3 hours of occurrence. If you are
unable to meet the 3-hour requirement an extension shall be requested
from AAT-200.
(1)
A completed FAA Form
7210-2.
(2)
En-route; a reduced copy
of the NTAP with LST 5 text data shall be faxed to AAT-200.
(3)
Terminal; a copy of the
CDR plot with the associated separation data shall be faxed to
AAT-200.
NOTE:
Once AAT-200 receives this official report of
the OE, the AAT-200 specialist will issue a preliminary severity
classification in accordance with Chapter 6, Severity Index for return
to duty purposes.
k.
If an employee is believed
to be primary or contributory:
(1)
For an operational
error/deviation initially classified as low severity by AAT-200, the
employee shall be returned to operational duty in accordance with
paragraph 5-1-9b, Return to Operational Duty.
(a)
In cases where AAT-200
cannot complete a preliminary severity classification within one hour
of official notification to AAT-200, and initial indications are that
at least 80% of the separation minima was maintained, the employee
shall be returned to operational duty as stated above,
(b)
In the event the
classification later indicates a moderate or high severity, a
controller may be required to complete skill enhancement training, if
such training is appropriate.
(2)
For operational errors
classified as moderate or high severity and if the employees’
overall documented performance history warrants, he/she shall not be
assigned to operational duties until the provisions of paragraph
5-1-9, Return to Operational Duty, are met.
l.
If the preliminary
investigation reveals that certain employees’ first believed to be
primary/contributory were not, they may be returned to duty without
further action. If these
employees’ have knowledge of the events, obtain their views and
recommendations.
m.
If an operational
supervisor, by virtue of performing supervisory duties,
or a controller while performing CIC duties, is believed to be
primary/contributory to a suspected OE/OD, that employee shall not be
assigned supervisory/CIC duties until the provisions of paragraph
5-1-9, Return to Operational Duty, are met.
n.
When the initial
investigation results in a determination of a non-occurrence, retain
for 45 days, all data used in the investigation process.
For example, pilot/controller statements, record of
conversations, original NTAP and CDR plot(s) in an approved electronic
format, used in a determination of a non-occurrence, as well as any
other pertinent data not otherwise required to be retained. 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.
a.
During a single
event where multiple losses of standard separation are reported/discovered, and
are determined to be the result of employee actions or inaction, each
instance of a loss of separation shall be reported individually by
completing a separate FAA Form 7210-2 and FAA Form 7210-3.
Each form should describe the individual loss of separation,
including a reference, if necessary for clarity, to the other related
incidents.
b.
When a singular failure of
a employee to ensure separation between two aircraft (or an aircraft
and terrain) that subsequently creates a chain reaction of additional
losses of separation between other pairs of aircraft or terrain, the
multiple losses of separation shall be considered as a single event
only for return to operational duty purposes, performance skill
checks, and training actions/plans.
If combined, these actions and/or documentation shall be based
on the higher of severity classification assigned.
c.
The individual separation
losses may be combined as one event for the purposes of entries onto
FAA Form 3120-1, Section VI.
a.
Fact Finding. The
investigation of an OE/OD must entail an in-depth inquiry into all
causal factors. The following should be considered for a comprehensive
investigation:
(1)
Facility procedures.
(2)
Facility training.
(3)
Facility supervision.
(4)
Equipment.
(5)
Control environment.
(6)
External factors.
(7)
Controller action vs.
inaction.
(8)
Airspace configuration.
(9)
Traffic
flow/volume/initiatives.
(10)
Pilot actions, including
the consequence of any Traffic Alert and Collision Avoidance System (TCAS)
event.
(11)
Route of flight or taxi
route, as appropriate.
(12)
Weather.
(13)
Position configuration.
(14)
Coordination procedures.
(15)
Airport environment:
(a)
Runway markings.
(b)
Ramp use.
(c)
Areas of poor visibility
(blind spots, fog).
(d)
Runway configuration.
(e)
Airport Congestion.
(f)
Surface Conditions (rain,
ice, snow)
(16)
Human
factors.
(17)
Compare the system time of
any pertinent equipment.
(18)
Staffing levels and/or
position assignments based on proficiency vs. complexity/volume.
(19)
Radar Data (see Appendix
1, Radar Data Processing).
b.
Interviews. Certain
information, which is necessary to complete FAA Forms 7210-2 and
7210-3, must be obtained from the employees’ involved. Since many
employees’ in the facility, e.g., controllers, air traffic
assistants, and supervisors may be knowledgeable of, or a party to the
incident, interviews with all possibly involved personnel shall be
held. It is imperative that these interviews be conducted in an
atmosphere of shared concern as to the events leading to and
surrounding the incident. When an interview is conducted, the
following shall apply:
(1)
As appropriate the
Interview Statement shall be read or given to an employee before
conducting an interview (see Appendix 9, Interview Statement).
(2)
An employee who is a
member of a bargaining unit may elect to have a union representative
present during the interview, in accordance with the applicable
negotiated agreement.
(3)
An employee who is
interviewed shall be afforded the opportunity to submit written
comments and recommendations to the ATM within 5-calendar days of the
interview. The comments shall include the employees’ name, position
function, and location of employment. The employees’ signature shall
be affixed to the end of the statement and dated. Recommendations
should concern corrective actions that can be undertaken to preclude a
similar occurrence.
(4)
Interviews shall be
conducted by supervisory personnel, designated IIC's or the ATM.
Investigative team members, other than the involved employees’, may
participate in the interviews.
(5)
Every effort shall be made
to conduct interviews during the employees’ regularly assigned shift
and within the employees’ assigned facility.
c.
Voice Recordings.
(1)
Two certified cassette
re-recordings, one marked "Original" and the other marked
"Copy", shall be made from the original voice recording that
shall include the time track, when available both tapes shall be
retained in the OE/OD file. Certification and labeling of these
cassettes shall be in accordance with FAA Order 8020.11. Include all
communications for a period of 5 minutes before initial contact to 5
minutes after the last contact with each position involved in the OE/OD.
When re-recordings are made from digital voice recording system (DVRS)
equipment, this period will be from the call file immediately
proceeding and immediately after the 5 minute before and after
requirement.
(2)
If the above period
exceeds 30 minutes, the ATD manager may approve, for the specific OE/OD,
limiting the recording to that period pertinent to the incident.
a.
The ATM of the facility
whose personnel were responsible for the separation of the aircraft
involved, regardless of where the OE/OD occurred, shall:
(1)
Ensure that OE/OD
investigations are conducted in accordance with any negotiated
agreements between the FAA and pertinent labor organizations.
(2)
When the Preliminary OE/OD
Investigation Report indicates that another facility(s) is involved in
the occurrence, as soon as feasible confer with other ATM(s) to
determine the scope of the other facility's investigative effort and
how long it will take. This includes gathering data and completing Parts I and II of
FAA Form 7210-3, Final Operational Error/Deviation Report. If the
reporting ATM and the other ATM cannot concur in any phase of their
respective investigations, their differences shall be reported to the
ATD for a resolution.
(3)
Designate the
Investigator-In-Charge (IIC). The IIC may be designated on a
rotational or permanent basis. Supervisory
personnel or facility staff shall perform the IIC function.
If the only facility officer is the ATM, and there are no
assigned supervisors, the ATM performs the IIC functions.
(4)
Designate a team to assist
the IIC in the investigation of each OE/OD.
The ATM shall determine the size and composition of the team,
but shall as a minimum afford:
(a)
A Union designated
representative reasonable opportunity to participate as a member of
the investigative team.
(b)
Employees’ believed to
be primary/contributory to the event reasonable opportunity to
participate in the investigative process, except during the interview
of other employees’.
(5)
Ensure FAA Form 7210-3 is
completed. Instructions for completing FAA Form 7210-3 are contained
in Appendix 4.
b.
The ATM of any other
involved facility shall be responsible for providing the reporting
facility with information and assistance as required. This may require
an investigation on the same scale as the reporting facility, in which
case the ATM shall have the same responsibilities as defined under
paragraph 5-1-3, Initial Investigations. The ATM of any other involved
facility shall also be responsible for retaining all pertinent
original data until notified of release by AAT-20.
c.
The IIC is responsible for
conducting a complete investigation and shall be the final authority
for the findings and recommendations to be submitted to the ATM. In
addition the IIC shall:
(1)
Ensure that all pertinent
data has been collected and documented in Part I of FAA Form 7210-3
and distributed to the ATM.
(2)
When other facilities are
involved, ascertain the scope of their investigation and coordinate
the exchange of data and assistance as required.
(3)
Assign duties to team
members.
(4)
Ensure that interviews
conducted are done in accordance with paragraph 5-1-5b,
Interviews.
d.
The IIC Investigative Team
shall:
(1)
Assist the IIC by
performing and completing all assigned tasks.
(2)
Remain under the
supervision and jurisdiction of the IIC until relieved by the IIC or
ATM.
a.
After preliminary
notification procedures are completed, a review of the data may
indicate a reclassification of the incident to one of the following:
(1)
Pilot deviation.
(2)
Military facility
deviation.
(3)
From an operational
deviation to an operational error.
(4)
From an operational error
to an operational deviation.
(5)
No occurrence.
b.
If a reclassification is
determined to be appropriate, the ATM shall:
(1)
Complete FAA Form 7210-5,
Operational Error/Deviation Reclassification Report.
NOTE:
If a reclassification is from an operational deviation to an
operational error or from an operational error to an operational
deviation, then reclassify the original incident to a "No
Occurrence" and indicate in the supporting documentation the new
OE/OD report number.
(2)
Forward FAA Form 7210-5,
Operational Error/Deviation Reclassification Report along with the
rationale and all necessary supporting documentation, including voice
tapes and radar data, to the ATD for review.
c.
The ATD shall conduct an
initial review of all requests for reclassification. Those they believe have merit shall be reviewed jointly
between the ATD and AAT-200. Should
the ATD and AAT-200 not agree with the resolution of any request,
AAT-20 is the authority to make a final determination.
Once AAT-200 verbal approval is obtained, the ATD shall submit
FAA Form 7210-5, Operational Error/Deviation Reclassification Report,
for all reclassification requests to AAT-20.
d.
Facilities shall retain
all original forms and supporting investigative data for a period of 2
1/2 years.
a.
Performance based action
of surface errors, MVA/Obstruction errors, and oceanic/non-radar
errors shall be handled in accordance with paragraph 5-1-9c, Return to
Operational Duty.
b.
When radar data
does not exist and all indications are that
less than 80% of the separation minima was maintained, performance
based action shall be handled in accordance with paragraph 5-1-9c,
Return to Operational Duty.
c.
When radar data
does not exist and all indications are that
at least 80% of the separation minima was maintained, performance
based action shall be handled in accordance with paragraph 5-1-9b,
Return to Operational Duty.
d.
No controller will be
decertified or required to complete remedial training for any
operational error(s) classified as a low severity and/or any
operational deviation(s). However,
skill enhancement training may be administered in accordance with
paragraph 5-1-12, Skill Enhancement Training, for errors classified as
low severity and are uncontrolled.
e.
The number and types of
error(s) shall not be the sole determining factor for
performance-based actions. Performance
based actions shall be based on overall documented performance
history.
f.
The revocation or
suspension of control tower operator certificate and facility ratings
shall not be used for addressing performance deficiencies.
g.
Decertification shall not
be based solely on involvement in the OE but rather the employee's
overall performance history. Operational position decertification and
remedial training shall only be used in cases where an employees’
documented performance history warrants such action.
The employees’ supervisor, with ATM concurrence,
determines whether to decertify.
Decertification may be on one, multiple, or all positions as
appropriate for the documented performance deficiencies.
EXAMPLE-
The employee has been determined to be primary
in two operational errors within the last 2 1/2 years. The
employees’ first-line supervisor has had three documented
performance discussions (including a TTD) within the past year
outlining needed performance improvement with a training plan.
(1)
Determine the appropriate
actions and training necessary to return the employee fully to duty in
consideration of performance deficiencies identified in the above
review.
(2)
If the decision is not to
decertify then skill enhancement training may be administered in
accordance with paragraph 5-1-12, Skill Enhancement Training.
(3)
If the decision is made to
decertify the employee the following actions and training, as a
minimum, shall be taken:
(a)
A
corrective action/recertification plan shall be developed in
accordance with FAA Order 3120.4.
(b)
This
plan shall include, as a minimum, remedial training, which addresses
all identified performance issues.
(c)
Prior to
communicating the above determinations and plans to the employee, the
supervisor shall brief the ATM on the issues associated with the OE
and obtain the ATM's concurrence for the action plans developed.
(d)
Accomplish
recertification in accordance with FAA Order 3120.4 for the position(s)
that the employee has been decertified.
(e)
Upon
satisfactory completion of the performance skill check, the employee
shall be returned to duty; or
(f)
If the
employee fails to successfully complete the performance skill check,
then the employee shall remain decertified and the provisions of FAA
Order 3120.4 applied.
h.
When
either an operations supervisor (OS) or a controller while performing
supervisory/CIC duties, is identified as primary/contributory to an OE/OD,
operations CIC duties shall be suspended.
Approval from the ATD shall be required before an OS/CIC is
authorized to resume supervisory/CIC duties.
a.
The ATM shall remain
involved in the post error process, in consultation with the ATD,
including a review of the supervisors' determinations made under this
paragraph to ensure complete and consistent handling of all incidents.
b.
For all operational errors
initially classified as a low severity and/or all operational
deviations:
(1)
The employee(s) determined
to be primary/contributory to the error/deviation shall be returned to
operational duties as soon as the preliminary investigation activities
are completed.
(2)
No post OE/OD performance
skill check will be completed on any operational position associated
with this return to duty, nor will a 30-day follow-up performance
skill check be conducted relating to this error/deviation.
(3)
The employees’
supervisor or designee shall complete the following as soon as
feasible after the employee has returned to operational duty:
(a)
Conduct an in-depth review
with the employee of the their role. This review shall include as a
minimum:
1.
The events leading up to
and surrounding the incident.
2.
The procedure or the
separation standard involved.
3.
Available computer, radar
data and voice recording of the incident via SATORI/RAPTOR playback.
4.
The training record,
including all applicable technical training discussions (TTD’s).
c.
For all operational errors
initially classified as moderate, or high severity, as well as all
surface, MVA/Obstruction, oceanic/non-radar errors or at those
facilities where radar data is not available and less
than 80% of the separation minima was maintained:
(1)
Employee(s) determined to
be primary/contributory to an operational error and if the
employees’ performance warrants, shall not be assigned to
operational duties until the employees’ supervisor or designee shall
take the following action:
(a)
Conduct an in-depth review
of the employees’ role in the OE. This review shall include as a
minimum:
1.
The events leading up to
and surrounding the incident.
2.
The employees’
statement.
3.
The procedure or the
separation standard involved.
4.
Available computer, radar
data and voice recording of the incident via SATORI/RAPTOR playback.
5.
The training record,
including all applicable technical training discussions (TTD's).
6.
Verification of currency
on the position of operation.
7.
Employee involvement in
previous OE/ODs during the past 2 1/2 years.
(b)
Conduct performance based
action in accordance with paragraph 5-1-8g, Performance Based Action.
(c)
Conduct performance skill
check(s) for those positions on which the employee(s) will be allowed
to return to operational duty while training is being provided. This skill check may be accomplished on individual or
multiple positions at the discretion of the ATM.
If the employee fails to successfully complete the performance
skill check, then the employee shall be decertified and the provisions
of FAA Order 3120.4 applied.
EXAMPLE-
If an employee was removed from operational duties on the radar
departure position, but is to be returned to duty in the tower cab
while completing some skill enhancement training for the departure
position, a performance skill check(s) would be required in the tower
cab function, so as not to unduly delay the return to duty.
(d)
As soon as possible after
the employee has returned to operational duty, the employees’
supervisor or designee shall conduct a performance discussion to
include:
1.
The results and
recommendations from the IIC/investigative team and/or the facility OE
review board.
2.
Any deficiencies in the
employees’ performance identified during the investigation of the OE.
If
the employee involved in the OE/OD is the ATM, the ATD manager may
waive the requirements in paragraph 5-1-9, Return to Operational Duty,
temporarily. This waiver shall not exceed 2 weeks, pending the arrival
of an ATD designee. Upon arrival, the ATD designee shall serve as the
employees’ certifying official for the purpose of complying with
paragraph 5-1-9, Return to Operational Duty, and 5-1-11, Follow-up
Performance Skill Check.
The
employees’ first line supervisor or designee of an employee found to
be primary/contributory to an OE of moderate or high severity, as well
as all surface errors, MVA/Obstruction errors, and oceanic/non-radar
errors shall conduct, as a minimum, a follow-up performance skill
check of the employee, within 30 days from the date of return to
operational duty. The skill check shall be conducted on a position in
the control function involved in the OE.
The subsequent technical training discussion (TTD) shall review
all training that was administered as a result of the OE and shall be
documented in accordance paragraph 3-1-4, Documentation.
NOTE:
There
is no performance skill check or 30-day follow-up performance skill
check required with any operational error classified as a low severity
or operational deviation.
a.
Skill enhancement training
is designed to increase the proficiency of a specialist in a skill on
a position on which the specialist is certified. Based on the circumstances unique to a specific error, skill
enhancement training need not always be accomplished prior to an
employee continuing operational duties.
Skill enhancement training shall be based upon the factors
identified during the investigation of the operational error.
b.
For employees’
identified as either primary or contributory to an operational error
classified as low severity, skill enhancement training may be
appropriate only if the operational error has been classified as
uncontrolled.
c.
Based on the employee(s)
performance skill enhancement training may be required for
employees’ identified as either primary or contributory to an
operational error classified as moderate or high severity.
The
ATM shall:
a.
Analyze the data submitted
by the IIC in Part I of the FAA Form 7210-3 to determine:
(1)
The classification of the
occurrence; i.e., operational error, operational deviation, pilot
deviation, or no occurrence. If it is determined that an OE/OD can be
reclassified, the ATM shall request that the incident be reclassified
in accordance with paragraph 5-1-7, Reclassification.
(2)
The categorization of the
OE/OD; i.e., ATCS, manager/supervisor/other personnel, procedural,
equipment, or any combination thereof.
(3)
The causal factors of the
OE/OD.
(4)
The recommendations and
corrective actions to be taken to prevent a recurrence of the OE/OD.
b.
Provide copies of Part I
and Part II to each employee involved and the Principal Union
Representative, before completing Part II, Item 69, Facility Manager's
Recommendations and Corrective Actions.
Employees’ may submit comments or recommendations in writing
to the ATM within 5-calendar days of receipt.
The comments shall include the employees’ name, position
function, and location of employment, signature and date.
Recommendations should concern corrective actions that can be
undertaken to preclude a similar occurrence. The ATM shall consider
these comments in his/her deliberations before completing Facility
Manager's Recommendations and Corrective Actions and shall append the
employees’ comments to Part II.
c.
Complete Part II of the
FAA Form 7210-3 and submit two copies of Parts I and II and all
attachments (including employee and union statements) to the ATD, and
one copy each to other ATMs and ATDs as required, within 30
administrative workdays of the date the occurrence was reported.
d.
When an employee(s) of
another facility is involved in an OE/OD, ensure that the employees’
supervisor, through that facility ATM, is provided sufficient
documentation to determine the appropriate corrective action.
e.
Provide involved
employee(s) with a copy of the complete report after receipt of Part
III from the ATD.
f.
Retain the original report
in the facility files.
g.
Establish a method of
follow-up to evaluate the effectiveness of the local
recommendations/actions that result from the investigation.
When an employees’
performance has been determined to contribute to an OE/OD, the
following shall be entered into the employees’ FAA Form 3120-1:
a.
The causal factors as determined by the ATM shall be fully
transcribed and endorsed by the employees’ first-line supervisor on
a separate page in Section VI. This page shall be used for any further
reference to the OE/OD and shall indicate the facility's name, the OE/OD
report number, and the removal date for the page.
b.
Any associated training,
remedial and/or skill enhancement shall be logged, in accordance with
FAA Order 3120.4, without reference to the OE/OD.
c.
Any associated position
performance skill checks, including all follow-up performance skill
checks (e.g., 30-day) shall be logged in accordance with FAA Order
3120.4, without reference to the OE.
d.
Any associated
recertification shall be logged, in accordance with FAA Order 3120.4,
without reference to the OE.
a.
The OE/OD investigation
file shall:
(1)
Be retained by the
reporting facility for 2 1/2 years
from the date of the occurrence.
(2)
Be identified by a label
(maximum size 3"x5") clearly marked "OPERATIONAL
ERROR" or "OPERATIONAL DEVIATION," the report number,
the incident local date and time, and the local date to be destroyed.
(3)
Contain, as a minimum, the
original FAA Forms 7210-2 and 7210-3, signed employee personnel
statements and/or any similar supporting documents, the two certified
re-recordings marked "Original," and "Copy” in
accordance with paragraph 5-1-5c, all supporting documentation such as
the original NTAP or CDR plot in both printed format and an approved
electronic media, as well as all documentation from the supervisor's
training plan, performance skill checks, and the severity index
chart from AAT-20.
NOTE:
A
facility may elect to store the supporting data, i.e.. two certified
voice re-recordings, and NTAP on a floppy disk in a separate secured
place in lieu of the OE/OD investigation file.
b.
Preliminary and final OE
reports that are classified as low severity and/or OD reports, while
retained for 2 1/2 years, shall be sanitized after 12 months so that
any information, which could lead to the identification of an
employee, either primary or contributory to the OE/OD, has been
removed.
c.
All references to a
specific OE/OD shall be removed from the employees’ FAA Form 3120-1
and returned to the employee 2 1/2 years after the incident. All
references to a specific OE classified as a low severity and/or OD
shall be removed from the employees’ FAA Form 3120-1 and returned to
the employee 12 months after the incident.
a.
AAT-1 shall be responsible
for establishing and maintaining an analytical and investigative
element within the headquarters office of Air Traffic Evaluations and
Investigations Staff, AAT-20, which shall:
(1)
Maintain a central source
of OE/OD data.
(2)
Review all FAA Forms
7210-3, Final Operational Error/Deviation Report, for the purpose of
identifying system wide deficiencies (e.g., human, equipment, and
procedural) and based upon these reviews, initiate recommendations for
corrective actions to reduce the occurrence of OE/ODs.
(3)
Distribute, on a
semi-annual basis, an OE/OD Analysis Report. This report shall, as a
minimum, identify trends concerning deficiencies specified in
paragraph 5-1-14a and be sent to all regions and AT facilities.
(4)
Conduct periodic program
evaluations to determine the effectiveness and efficiency of this
program.
(5)
Maintain liaison with the
regions, facilities, and other headquarters AT offices and services to
provide continuity and follow-up on corrective action recommendations.
(6)
Provide policy
interpretations concerning the administration of this order.
b.
The ATD shall be
responsible for establishing an analysis element within the ATD, which
shall within 10 administrative workdays after receipt of Parts I and
II of FAA Form 7210-3:
(1)
Review Parts I and II and
complete Part III. Completion of Part III ends the investigation
process.
(2)
Send copies of the
completed FAA Form 7210-3, Parts I, II, and III and all attachments,
including employee and union statements, to AAT-20 and the Planning,
Information and Analysis Division, ATX-400.
(3)
Send a copy of Part III to
the appropriate ATM's and other ATD's, when required, and retain the
original in either paper or automated form in the regional files.
(4)
If the above cannot be
completed within the 10-day time period, notify AAT-20 via telephone.
(5)
Review all requests to
reclassify OE/OD's for completeness of data and to ensure their
validity before coordination with AAT-20. Send the approvals in
accordance with paragraph 5-1-7, Reclassification, to AAT-20.
(6)
Establish a follow-up
mechanism to determine if corrective actions contained in FAA Forms
7210-3 are effective and are accomplished in a timely manner. All
corrective actions shall specify a completion deadline.
(7)
Provide regional
assistance to facilities as required.
(8)
Work closely with other
ATDs when an OE/OD may involve facilities in different regions and the
respective ATMs cannot concur in any phase of their investigations. If
30 administrative workdays have passed since the incident and a
decision cannot be reached with the other ATDs, forward all
investigative data to AAT-20 for resolution.
Until a decision is reached, ensure that all recordings, data
and documentation pertaining to the incident are retained.
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