Monday, March 10, 2008
Don Brown History Lesson -- March 10
Twenty years ago today -- March 10, 1988 -- was a noteworthy day for me. Oddly, it will take more time to explain it than it did for the most significant event of the day to occur. I hope it will provide you with a frame of reference to understand the significance of today’s (or tomorrow’s) events. But first, I must set the stage.
I was hired by the FAA in November of 1981 -- just over 3 months after the PATCO strike of 1981. The strike was one of the most significant crises the FAA every faced. After attending the FAA Academy and suffering through the accelerated training program (much like the training today) I was certified to work all the positions in my Area in August of 1984. In short, by 1988 I was still a relatively new controller, having less than 4 years experience after I finished training.
Despite such a short period of time, I had already become disillusioned with the FAA. The petty and vindictive management, the bureaucratic inertia and the lax safety culture. By the summer of 1987, I and many other controllers had already banded together and formed the National Air Traffic Controllers Association -- a new union for controllers.
From the FAA Historical Chronology, 1926-1996...
”Jun 19, 1987: The Federal Labor Relations Authority certified the National Air Traffic Controllers Association (NATCA) as the exclusive representative of all GS-2152 series terminal and center controllers whose primary duty was separation of aircraft. The controllers had voted for representation by a margin of 7,494 to 3,275, using mail ballots sent to them on May 6. The Authority had announced the outcome on Jun 11. (See Jul 2, 1982, and May 1, 1989.)“
It is hard to overstate the significance of that brief time span. In slightly less than 6 years, a brand new group of very young people had banded together to form a union during the decidedly anti-union Reagan Administration. That one fact speaks volume about the culture of FAA management that -- in large part -- still exists today.
Within that larger context, I had already developed a deep interest in the safety aspects of air traffic control. I personally looked at NATCA as a vehicle that allowed me to speak out in public about the safety problems I saw within the FAA. I had been filling out numerous Radar Trouble Report forms (an official FAA form) on a problem with a radar site in my Area called Maiden. Little did I realize -- or even imagine -- how important those forms were to become.
Concurrently, the FAA -- in their never-ending quest to reinvent the wheel -- was busy implementing an airspace redesign program called the Expanded East Coast Plan. See if the following FAA history entry doesn’t sound just like today’s airspace redesign program.
From the FAA Historical Chronology, 1926-1996...
”Feb 12, 1987: FAA initiated Phase 1 of the Expanded East Coast Plan (EECP) to help increase the capacity of the National Airspace System (see Aug 21, 1986). The plan had been originally intended to relieve traffic congestion in the New York and Washington, D.C., areas through the more effective use of airspace, but was expanded to cover the airspace from Maine to Florida and west to Chicago. The EECP: created new departure and arrival routes; established separate paths and altitudes for jets and slower propeller aircraft; set up new city-pair routes; and used new traffic management techniques to increase airport departure flows and reduce holding procedures. The agency initiated Phase II of plan on Nov 19. That phase involved a realignment of the northwest departure quadrant from the New York Metropolitan area. The agency also increased the number of westbound high-altitude, routes from one to four to expedite traffic flows to Chicago, Detroit, and the west coast. The final phase of the EECP, implemented on Mar 10, 1988, was designed to improve traffic flow from the New York area to the northeast, and involved changes affecting the airspace in New England, New York, Philadelphia, Baltimore, and Washington, D.C. (See Aug 25, 1988.)“
It’s important to note that the plan itself wasn’t a bad plan. It was the implementation of the plan that was the problem. The FAA was changing all the routes into the New York and Washington areas and wasn’t providing any meaningful training to the controllers. As I said at the time, it was like changing the names of every street in town -- making some one way, closing others and paving a few new ones -- overnight. And controllers were the ones that were supposed to make it all work the next morning.
Our concerns were so grave that NATCA managed to arrange a meeting with the Secretary of Transportation -- James Burnley at the time -- through the office of Congressman Guy Molinari. I was volunteered to represent the Atlanta Center local of NATCA at the meeting. The meeting was absolutely brutal. Here we were, a bunch of mostly-young controllers in a brand new union, meeting with the Secretary and the top brass of the FAA. Secretary Burnley ran the meeting and left no doubt that he thought we were wasting his time. Unbelievably to me, he was even blatantly rude to the Congressman.
Towards the end of the meeting -- after the Secretary had threatened to throw us out -- I and another controller from Boston Center (Bill McGowan) got to present our safety concerns. I mentioned the problems we already had along Atlanta Center’s boundary with Washington Center and pointed to the enroute holding patterns near Greensboro, NC as evidence of how difficult the traffic in this area was already. That difficulty would be exacerbated by controllers being unfamiliar with the new routes. The controllers needed better training. They needed to work with the newly designed airspace in the simulation lab. I also mentioned something to the effect of, “We’ll be lucky if we don’t kill somebody without better training.”
It was a lucky -- but an educated and sincere -- guess. On the very first day of the Expanded East Coast Plan -- March 10th -- this event occurred just west of Greensboro, NC.
NTSB Identification: ATL88IA108A.
The docket is stored on NTSB microfiche number 36207.
Scheduled 14 CFR Part 121: Air Carrier operation of CONTINENTAL AIRLINES (D.B.A. TEXAS INT'L AIRLINES, INC. )
Incident occurred Thursday, March 10, 1988 in GREENSBORO, NC
Probable Cause Approval Date: 7/18/1990
Aircraft: BOEING 737, registration: N13331
Injuries: 159 Uninjured.
CONTINENTAL FLT 458 (BOEING 737, N13331) WAS FLYING NE AT FL370 AS CONTINENTAL FLT 703 (BOEING 737, N432PE) WAS FLYING FM THE OPPOSITE DRCTN AT FL350. BOTH FLTS WERE ON THE SAME FREQ, BEING CTLD BY ATLANTA ARTCC (SECTOR 47) CTLR, WHO HAD JUST COME ON DUTY. IN PREPARATION FOR HANDOFF TO SECTOR 33, FLT 458 WAS TOLD TO DSCND TO FL 350; FURTHER DSCNT OF FLT 458 WAS INTENDED AS SOON AS IT WAS CLR OF A 3RD ACFT AT FL330. THE RELIEVED SECTOR 47 CTLR HAD AGREED WITH THE SECTOR 33 CTLR THAT SECTOR 33 WOULD GIVE FLT 458 A VECTOR SO IT COULD BE FURTHER DSCNDD. BASED ON AN ASSUMPTION OF WHAT WAS TO BE DONE, THE SECTOR 47 CTLR HANDED OFF FLT 458 TO SECTOR 33. DRG THIS TIME FRAME, THE SECTOR 33 CTLR WAS ALSO RELIEVED & FLT 458 WAS NOT VECTORED FOR ABT 3 MIN. SEEING A POTENTIAL CONFLICT, THE CTLRS TURNED THEIR RESPECTIVE FLTS, BUT BOTH WERE TURNED TOWARD THE NW (FLT 458 TO THE LEFT & FLT 703 TO THE RGT). AS BOTH ACFT WERE TURNING, THEY CONTD TO CONVERGE. SUBSEQUENTLY, THE CONFLICT ALERT SOUNDED & THE ACFT PASSED EACH OTHER AT THE SAME ALT WITH ABT .6 MI SEPN.
The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
CREW/GROUP COORDINATION..INADEQUATE..ATC PERSONNEL(ARTCC)
RADAR SEPARATION..NOT MAINTAINED..ATC PERSONNEL(ARTCC)
There was no “ABT .6 MI SEPN” (about point 6 miles separation) to it. They “about” hit.
Adding to the confusion of the airplanes maneuvering to meet the new restrictions that were part of the Expanded East Coast Plan, was the fact that the Maiden radar site lost track of one of the aircraft in the middle of the event. It was the same problem I had been documenting on those Radar Trouble Report forms I mentioned earlier. It came out in the following investigation that my supervisor had been throwing the reports away. Unfortunately for him, I had made copies. That didn’t prevent his boss from trying to cover for him.
It is my sincere wish that you not focus on the personalities involved in this incident but instead, focus on the processes of the system. The Radar Trouble Report forms are there so that the people using the equipment (the controllers) can inform management and the problem can be fixed. Locking away the forms and even failing to educate the controllers to the existence of the forms subverts the processes that make the system work. As does a supervisor that intentionally thwarts the process and a manager that covers for him.
A bad supervisor isn’t unheard of. Neither is a manager covering for one. That is the reason other processes have been built into the system. A union gives employees added protection and encourages them to speak up about problems. Unions provide the resources individuals cannot attain by themselves -- the ability to speak to the Press without retribution -- the ability to attract the interest of a Congressman. A Congressman who -- by another intentionally designed process -- can command the attention of a Cabinet member. Or even the President himself.
As this incident points out, all of these processes can fail. It almost cost 159 people their lives on this day, 20 years ago. This event didn’t make the evening news. It certainly didn’t make the history books. The majority of these events never do. Pay attention to the ones that do manage to make it into the headlines.
When you read yesterday’s headlines -- or today’s or tomorrow's -- I hope you will take the time to read between the lines and try to fill in the gaps. Were the controllers properly trained ? Were the positions adequately staffed.? Is there a good first-line supervisor in place with adequate resources or is he overwhelmed ? Are the second-line managers competent or are they just petty and vindictive ? How about upper management ? Are they focused on their duties or are they distracted by that six-figure salary industry has dangled in front of them ?
Think of the political appointees running your government. Are they competent ? Or are they just checking a box on their resume ? How about your Congressmen ? Are they providing the needed oversight ?
Every single process in this system -- every check and balance -- is important. If you fly, you are betting your life that at least some of them work.
(Note: You can read a more detailed version of this story in one of my AVweb articles entitled, “Maiden and Me.” There are a few more details in Say Again? #61: It's Here!)
March 10, 2008