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Safety Recommendation Details

Safety Recommendation A-16-051
Details
Synopsis: On July 7, 2015, about 1101 eastern daylight time, a Cessna 150M, N3601V, and a Lockheed Martin F-16CM, operated by the US Air Force, collided in midair near Moncks Corner, South Carolina.1 The private pilot and passenger aboard the Cessna died, and the Cessna was destroyed during the collision. The damaged F-16 continued to fly for about 2 1/2 minutes, during which the pilot activated the airplane’s ejection system. The F-16 pilot landed safely using a parachute and incurred minor injuries, and the F-16 was destroyed after its subsequent collision with terrain and postimpact fire. Visual meteorological conditions (VMC) prevailed at the time of the accident. No flight plan was filed for the Cessna, which departed from Berkeley County Airport (MKS), Moncks Corner, South Carolina, about 1057, and was destined for Grand Strand Airport, North Myrtle Beach, South Carolina. The personal flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The F-16 was operating on an instrument flight rules flight plan and had departed from Shaw Air Force Base, Sumter, South Carolina, about 1020.
Recommendation: TO FEDERAL AVIATION ADMINISTRATION, MIDWEST AIR TRAFFIC CONTROL, ROBINSON AVIATION, AND SERCO, INC.: Include the July 7, 2015, and August 16, 2015, midair collisions as examples in your instructor-led initial and recurrent training for air traffic controllers on controller judgment, vigilance, and/or safety awareness.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Aviation
Location: Moncks Corner, SC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ERA15MA259AB
Accident Reports:
Report #: ASR-16-06
Accident Date: 7/7/2015
Issue Date: 11/15/2016
Date Closed:
Addressee(s) and Addressee Status: FAA (Open Acceptable Alternate Response)
Midwest Air Traffic Control Service, Inc. (Closed - Acceptable Action)
Robinson Aviation, Inc. (Closed - Acceptable Action)
Serco, Inc. (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/17/2018
Response: We note that in January 2017, you conducted instructor-led training on the components of a healthy occupational safety culture; however, we do not understand how this training is relevant to our recommendations, as we do not believe that the safety issues in the Moncks Corner and San Diego accidents were related to occupational safety culture. We further note that, in July 2017, you delivered web-based training on emergencies that you believe uses events similar to those in the Moncks Corner and San Diego accidents, and you also provided recurrent, instructor-led threat and error management training to controllers. Finally, as of December 31, 2017, all controllers have completed this training, and it is now mandatory for all future controllers. As a result, you believe that you have addressed these safety recommendations and consider your actions complete. The threat and error management training and web-based training you described may be alternatives that satisfy these recommendations if the events used as case studies are substantially similar to those that occurred in the Moncks Corner and San Diego accidents, and if the training discusses issues similar to the ones we found during our investigations. In an attempt to evaluate whether the events that you used were equivalent alternatives, we contacted your staff on March 9, 2018, for details and asked that we be allowed to take the web-based training. Your staff replied that, although they believe that the training modules cover incidents similar to the Moncks Corner and San Diego events, they were not able to share any further details nor provide us with access to the web-based training. Without adequate information to evaluate whether your alternative satisfies the recommendations, we would likely classify them “Closed—Unacceptable Action”; however, because you believe that you have developed and completed the training recommended for controllers, we ask that you reconsider your staff’s determination that they cannot share information with us about the alternative events that you used, and allow us to evaluate the web based training that you developed. We cannot close these recommendations until we can review the alternative events and training you used, although they may represent an acceptable alternate action. Please provide us with the information needed to make this determination. Pending our receiving that information and determining that the events are similar and the training that you developed covers the issues in these accidents, Safety Recommendations A-16-51 and 52 are classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 2/23/2018
Response: -From Daniel K. Elwell, Acting Administrator: In January 2017, the Federal Aviation Administration (FAA) conducted instructor-led training on components of a healthy occupational safety culture and discussed the indicators, risks, and hazards associated with an unhealthy safety culture. In July 2017, the FAA delivered a I-hour Web-based training module dedicated to emergencies that covered events similar to the July 7, 2015, and August 16, 2015, collisions as mentioned by the Board. Additionally, threat and error management (the practice of applying controller judgement, vigilance, and safety awareness) was delivered to our controllers as part of the July 2017 instructor-led recurrent training. The FAA has required that all future controllers complete this mandatory training with current controllers having completed the training as of December 31, 2017. Based on the actions noted above, I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 3/13/2017
Response: We agree that the ongoing activities described in your letter will address these recommendations. The intent of these recommendations was not to initiate any new programs; rather, we believe the two midair accidents represent good case studies to use in existing initial and recurrent air traffic controller training. Pending completion of actions to satisfy Safety Recommendations A 16-51 and -52, they are classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/25/2017
Response: -From Michael P. Huerta, Administrator: Many of the causal factors leading to these events have already been included in training and awareness campaigns since September 2014. Additionally, operational and procedural deficiencies identified through Mandatory Occurrence Reports and validated by Quality Assurance are being addressed through the Air Traffic Organization's Top 5 Program, which is a list of high-priority hazards that the Federal Aviation Administration (FAA) commits to assessing and mitigating on a continuing basis every fiscal year. While the FAA believes that controller judgment and vigilance is important to midair collision prevention and the overall safety of the National Airspace System. We believe these ongoing initiatives will address the concerns in these recommendations. I will keep the Board informed of the progress of these recommendations and provide an update by December 2017.

From: NTSB
To: Midwest Air Traffic Control Service, Inc.
Date: 7/12/2018
Response: We note that you have included the July 7, 2015, and August 16, 2015, midair collisions as examples in your initial and recurrent training for controllers. Accordingly, Safety Recommendation A-16-51 is classified CLOSED--ACCEPTABLE ACTION.

From: Midwest Air Traffic Control Service, Inc.
To: NTSB
Date: 6/12/2017
Response: -From Shane L. Cordes, President and CEO: As requested by the NTSB Chairman, I have included our actions and any implementations in regards to mid-air collisions that occurred at Brown Field, San Diego, CA on 7/7/2015 and within Charleston (CHS) Approach Control airspace on 8/16/2015. Midwest ATC took the following actions: • Midwest ATC assigned our Internal Air Traffic Bulletin as Initial Training for all newly hired controllers. The initial training for controllers includes a face to face briefing for all new hires on the July 7, 2015 and August 16, 2015 midair collision examples provided by the NTSB. • The July 7, 2015 and August 16, 2015 midair collision examples provided by the NTSB have been implemented into Midwest ATC’s Annual Recurrent Training and assigned to the January Monthly Training Curriculum. Midwest will continue to monitor our performance in the coming months as part of our rigorous Quality Control Program. If we find evidence of non-compliance at any facility, we will immediately initiate corrective action plans.

From: NTSB
To: Midwest Air Traffic Control Service, Inc.
Date: 5/23/2017
Response: We do not consider the actions that you described in your letter to be responsive to this recommendation. We issued this recommendation to ensure that all controllers, both at Federal Aviation Administration facilities and at federal contract towers, are aware of the need for controller judgment, vigilance, or safety awareness training and briefings. We believe that the information provided by the developing chain of events in these accidents provides an ideal opportunity to impart a lesson to the controller workforce on judgment, and we encourage you to incorporate these accidents as examples in your instructor-led initial and recurrent training. Pending completion of this action, Safety Recommendation A-16-51 remains classified OPEN--AWAIT RESPONSE.

From: Midwest Air Traffic Control Service, Inc.
To: NTSB
Date: 2/28/2017
Response: -From Shane L. Cordes, President and CEO: As requested by the NTSB Chairman, I have included our actions and any implementations in regards to mid-air collisions that occurred at Brown Field, San Diego, CA on 7/7/2015 and within Charleston (CHS) Approach Control airspace on 8/16/2015. Midwest ATC professionals were briefed on the findings including controllers failing to maintain situational awareness. Additionally, all employees were extensively briefed on actions that led to controller performance in one event as a contributory factor and controller performance in the other event as the primary cause of the accident. Midwest ATC took the following actions: • Conducted a review of Quality Control Operational Skill Assessments (QC-OSA) between January 1, 2016 and December 31, 2016. • Conducted a review of Mandatory Occurrence Reports (MOR) that were filed between January 1, 2016 and December 31, 2016. • Conducted a review of all Quality Control Operational Skills Assessment (QC OSAs) and Internal/External Compliance Verification (ECV/ICV) findings regarding IFR/VFR conflicts and safety alerts Conducted Situational Awareness Briefings that included: • IFR releases. • Relaying headings and routes from approach control/center. • Updating, then reviewing the SIA board. • Use of runway memory aids. • Scanning the runway/taxiway environments. • Listening to read backs. Finally, Midwest FCT Air Traffic Managers along with Midwest Corporate Managers have taken the following actions: • QC OSAs were conducted at each facility in January 2017 with the emphasis item for Traffic Advisories and Safety Alerts. • Midwest ATC has instituted internal Air Traffic Bulletins, which focus on safety related areas. Midwest will continue to monitor our performance in the coming months as part of our rigorous Quality Control Program. If we find evidence of non-compliance at any facility, we will immediately initiate corrective action plans.

From: NTSB
To: Robinson Aviation, Inc.
Date: 4/15/2019
Response: We note that you have included the July 7, 2015, and August 16, 2015, midair collisions as examples in your initial and recurrent training for controllers. Accordingly, Safety Recommendation A-16-51 is classified CLOSED--ACCEPTABLE ACTION.

From: Robinson Aviation, Inc.
To: NTSB
Date: 1/22/2019
Response: -From Keren Williams McLendon, President and CEO: This is a follow-up to our letter dated September 21, 2018. We created training around NTSB reports WPR15MA243AB and ERA 15MA259AB and inserted it into our yearly refresher training schedule. This training was accomplished in December 2018. It covers the importance of proper phraseology, including the need to use the key words "immediately" and "safety alert" when the situation warrants. Emphasis is on the need for controllers to remain vigilant when, in their judgement, aircraft are in close proximity to each other, and to continue traffic calls using proper phraseology until the conflict has been resolved . The training covers priority of duties, with the separation of aircraft and safety alerts being the highest priority. Vigilance and awareness are emphasized in the need for clear, "textbook" phraseology, verifying pilots are complying with instructions, assuming aircraft will not get each other in sight, the importance of using the correct call sign in a situation requiring immediate action, and the need for on-the- job instructors to maintain situational awareness at all times. In addition to this yearly training, we continue to utilize the FAA's recurrent training program for air traffic control specialists. As such, FAA analyzes safety data and develops specialized training, which is delivered in six month cycles. Modules specifically designed for tower controllers are delivered during each session. We appreciate your input and suggestions. If you have any questions, please do not hesitate to let us know.

From: NTSB
To: Robinson Aviation, Inc.
Date: 11/27/2018
Response: We note that you plan to develop annual refresher training that will focus on these two midair collisions and address traffic advisories, safety alerts, priority of duties, and the need for proper phraseology. Although we believe that these are important topics to include in your training program, we point out that the intent of this recommendation is to ensure that controllers receive training that addresses controller judgement, vigilance, and safety awareness. Pending the implementation of training that addresses these topics, Safety Recommendation A-16-51 is classified OPEN--ACCEPTABLE RESPONSE.

From: Robinson Aviation, Inc.
To: NTSB
Date: 9/24/2018
Response: -From Keren Williams McLendon, President and CEO: Immediately upon receipt of your recommendations, RVA incorporated briefings for all tower personnel on the contents of NTSB reports WPR15MA243AB and ERAl 5MA259AB. All air traffic control specialists were briefed as part of their December 2016 training requirements. We utilize the FAA' s recurrent training program for air traffic control specialists. As such, FAA analyzes safety data and develops specialized training delivered in six-month cycles. Modules specifically designed for tower controllers are delivered each session. Most recently we completed training on basic radar service to VFR aircraft, visual approaches, and terminal teamwork. When FAA develops training following specific safety events, we ensure our controllers receive the required training. In addition, we will create annual refresher training around the two events, focusing on traffic advisories, safety alerts, priority of duties, and the need for proper phraseology. Based on our current training schedule, this will be scheduled annually, beginning in December. I hope you find this reply satisfactory. If you need anything else, please do not hesitate to contact me.

From: NTSB
To: Robinson Aviation, Inc.
Date: 9/6/2018
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We normally expect actions to address our recommendations to be completed within 3 to 5 years, and we have yet to hear from you regarding your progress toward addressing these recommendations. We would appreciate receiving a response within 90 days indicating any actions you have taken or plan to take to implement the recommendations; until then, they retain their current classification of OPEN--AWAIT RESPONSE. Please update us at correspondence@ntsb.gov regarding your actions to address Safety Recommendations A 16 51 and -52, and do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: Robinson Aviation, Inc.
Date: 11/15/2016
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. We are providing the following information to urge Robinson Aviation to take action on the safety recommendations being issued in this letter. On November 14, 2016, we adopted our accident reports concerning the July 7, 2015, and August 16, 2015, midair collisions and our safety recommendation report concerning educating controllers on these midair collisions. Additional information about the two accidents and the findings that led to our recommendations may be found, respectively, in the reports of the investigations (ERA15MA259A/B and WPR15MA243A/B) and the safety recommendation report (ASR-16-006), all of which can be accessed at our Aviation Information Resources web page. As a result of these investigations, we issued the following two new recommendations to Robinson Aviation (and also to the Federal Aviation Administration, Midwest Air Traffic Control, and Serco): Chairman HART, Vice Chairman DINH-ZARR, and Member WEENER concurred in these recommendations. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate receiving a response from you within 90 days detailing the actions you have taken or intend to take to implement them. When replying, please refer to the safety recommendations by number.

From: NTSB
To: Serco, Inc.
Date: 11/27/2018
Response: We note that, in February 2017, you required all controllers to watch the recording of our Board meeting about this accident, and the facility training programs and employee certification checklists at all Serco tower facilities now also require new controllers to watch the recording and, during annual proficiency training, to review the presentations from this meeting. We also note that, to verify that these changes have been implemented at all Serco tower facilities, you have included them as special emphasis items in your external compliance verification audit checklist. In addition, we are pleased to learn that traffic management boards have been successfully implemented at all of your facilities. Your actions satisfy the intent of Safety Recommendations A-16-51 and -52, which are classified CLOSED--ACCEPTABLE ACTION.

From: Serco, Inc.
To: NTSB
Date: 9/28/2018
Response: -From David Dacquino, Chairman and Chief Executive Officer: I am replying to your letter dated September 12, 2018, requesting an update on Serco's actions in response to your Issuance of Safety Recommendations A-16-51 and -52. We have taken the following actions: 1. During the month of February 2017, all Serco Air Traffic Control personnel were required to view the video of the NTSB's hearing covering the July 7, 2015, accident near Moncks Corner, South Carolina and the August 16, 2015, accident near Brown Field Municipal Airport, San Diego, California. 2. The Facility Training Programs at all of our Air Traffic Control Towers (ATCT) were amended to include the requirement for all newly hired employees to view the same video of the hearing as part of their initial certification training. This requirement was also added to each facility's Employee Certification Checklist. 3. The Facility Training Programs at all of our ATCT's were also amended to include the requirement for all air traffic control personnel to review the slide presentations used during the hearing as part of their annually proficiency training. 4. The above requirements were added to our External Compliance Verification Audit Checklist as Special Emphasis Items until February 2019. This ensures that our program-level safety staff will physically verify implementation of the above requirements at all of our ATCT's. We have taken additional steps to address the causal factors identified in the subject aircraft accidents. Prior to August 2015, Serco had placed Traffic Management Boards (TMB) in about 20% of our ATCT's. We have subsequently placed them in every facility. The TMB is a magnetic dry-erase board with a graphical overlay of the airport and other aids. The TMB is used to assist the Local Controller with tracking aircraft identities, sequencing aircraft, and meeting FAA tower memory aid requirements. TMB "chips" are magnetic strips which can be written on with dry-erase markers. They are colored according to their function or purpose and are used to represent aircraft, vehicles, personnel or the status of a movement area. This system has taken the place of memory pads, enhanced controller situational awareness and proven to be less of a distraction for controllers whose attention must be focused outside of the windows the majority of the time. We take seriously the safety sensitive work our air traffic controllers perform daily and public trust that has been bestowed upon our organization. It is our desire to partner with government and industry to ensure we are providing the absolute best services possible to the flying public. If Serco can be of any assistance to the NTSB, please do not hesitate to call upon us.

From: NTSB
To: Serco, Inc.
Date: 9/12/2018
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We normally expect actions to address our recommendations to be completed within 3 to 5 years, and we have yet to hear from you regarding your progress toward addressing these recommendations. We would appreciate receiving a response within 90 days indicating any actions you have taken or plan to take to implement the recommendations; until then, they retain their current classification of OPEN--AWAIT RESPONSE. Please update us at correspondence@ntsb.gov regarding your actions to address Safety Recommendations A 16 51 and -52, and do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: Serco, Inc.
Date: 11/15/2016
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. We are providing the following information to urge Serco to take action on the safety recommendations being issued in this letter. On November 14, 2016, we adopted our accident reports concerning the July 7, 2015, and August 16, 2015, midair collisions and our safety recommendation report concerning educating controllers on these midair collisions. Additional information about the two accidents and the findings that led to our recommendations may be found, respectively, in the reports of the investigations (ERA15MA259A/B and WPR15MA243A/B) and the safety recommendation report (ASR-16-006), all of which can be accessed at our Aviation Information Resources web page. As a result of these investigations, we issued the following two new recommendations to Serco (and also to the Federal Aviation Administration, Midwest Air Traffic Control, and Robinson Aviation). Chairman HART, Vice Chairman DINH-ZARR, and Member WEENER concurred in these recommendations. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate receiving a response from you within 90 days detailing the actions you have taken or intend to take to implement them. When replying, please refer to the safety recommendations by number.