ATSAP Briefing Sheet

Please post throughout your facility, and utilize the subject and
lessons learned during crew briefings as a method to raise
awareness within the workforce.
May 7, 2010

Sometimes the "holes in the Swiss cheese"

When Factors Align align. Aircraft ABC123 was handed off to
Sector B by approach control. Before
communications are established, the Sector B Controller inputs an interim altitude of 170 and
flashes the aircraft to Sector A intending to wait for converging traffic at 160 to pass before
issuing the climb. ABC123 then checks on “ABC123 climbing XYZ..DEF./. leveled at 10000ft (normal ops)
with Sector A, rather than Sector B, leveling and was not on my frequency. I called approach control asking
at 100. Sector A saw the interim altitude of them to "switch the ABC" and they said they already had. I had
put an interim altitude of 17000 in the data block before talking
170 and asked the pilot "Verify climbing to to ABC123 and flashed the data block to Sector A. ABC123
170?" The pilot took that as a clearance and was NORDO then appeared on Sector A's frequency (I don't
simply stated, "Roger, leaving 100 for 170." know how) and Sector A climbed the ABC in the face of Air-
craft 2 that I was vectoring behind the ABC for his climb. Con-
Sector B was not anticipating the climb and trol was not given to Sector A for a climb and when I asked
still had the converging traffic at 160. As Sector A they said ABC123 reported climbing to 17000 (I did
shown in these narratives, a quick response, not give him that clearance)."
coordination and awareness by the involved
"ABC123 checked on at 10,000ft, showing 17,000ft in the in-
controllers mitigated the potential safety terim altitude XYZ direct DEF. Asked ABC123 to verify climbing
issue. Most of us have probably experienced to 17,000ft, pilot advised out of 10,000ft for 17,000ft. R-side
Sector A cleared ABC123 to FL230. Meanwhile. Aircraft 2 was
similar events, and need to remember that
at 16,000ft at first showed descending to 12,000ft direct
“roger” means “ok” not “affirmative.” If the MNOPQ, but then changed by Sector B to interim 16,000ft.
pilot response doesn’t seem to match the Sector B says they never talked to ABC123 and asked R-side
Sector A if he was climbing and asked to expedite climb. This
question, be aware that you may have a
was done with plenty of separation."
communication problem on your hands.
“ABC123 called on "leveling at 100" The datablock showed climbing to 170 out of Sector B. I stated "verify climbing to
170." ABC123 replied, "Roger, leaving 100 for 170." I climbed him to 230. Sector B called and asked if I climbed
ABC123, I said affirmative. Aircraft 2 was direct MNOPQ descending to 160, Sector B had Aircraft 2 on frequency and
control. Sector B called back and said they never spoke to ABC123 and did not climb him to 170. I then expedited the
climb thru 160, ABC123 replied leaving 160."

Weekly Statistics for Watch Item

April 26th to May 3rd
Eligible Facilities
Eligible Employees
Total Submitted Reports
Reports Filed this Week
234 Although a lot of emphasis is
15000+
placed on the “Narrative” section,
it is important to take the time to
15275
fill out all tabs like the “Causal and
210 Contributory” factors.

By submitting your reports, you contribute important safety information that will help the 1
ATO identify negative trends, safety issues, and procedural deficiencies.
 ATSAP Briefing Sheet
Question: Can you help me understand who has to report and when?
ANSWER:
The wording in N JO 7210.741 paragraph 9-1-2e is a little confusing, but this is what it
means.
 It doesn’t matter what position you are working, ALL eligible employees (those at
facilities in the program) may ALWAYS file an ATSAP in order to report ANY air traffic
safety event or problem, whether experienced or observed.
 If you are “self reporting” an event, i.e. you are the one directly involved in the event,
then ATSAP meets your obligation to report to management.
 If you are acting in a management role, i.e. as an FLM/CIC and you observe a Sole
Source Event as described in the MOU, then you may STILL file an ATSAP report, and
it STILL meets your obligation to report, but you may also report it through QA, which
we encourage.
• If you are acting in a management role, just like above (here is where it’s different) and
you are informed of an event, it is no longer Sole Source, and you MUST report it via
the QA process. You may still file an ATSAP report, but it no longer satisfies your obli-
gation to report.

ATSAP Positives
Issue: Several ATSAP reports identified a safety issue with wind instruments at an
Air Traffic Control Tower (ATCT). The facility had made requests for an upgrade
for over two years. The request’s continued to get replaced by other projects that
were believed to be of a higher priority. There were some changes made to the exist-
ing instruments in an attempt to remedy the issue, but to no avail. At one point, Tech-
nical Operations replaced the hard wire connecting the sensor and the display with a
wireless connection. However, the wind readout did not display the wind and instead, displayed "service error,"
which caused the system to become unreliable.
Potential Hazard: Disruption in situational awareness and operational oversight.
Positive: The Event Review Committee (ERC) issued a Corrective Action Request (CAR) to expedite a fix to the Sur-
face Advisory Weather System (SAWS). The Air Traffic Organization’s (ATO) Terminal Weather Group allocated
the release of a SAWS unit and it's scheduled for installation in the near future.

Event: An En Route controller cleared an aircraft to descend to 2500 feet which s/he believed was the Minimum Safe
Altitude (MSA) for the particular area. The Minimum Safe Altitude Warning (MSAW) alerted at 2900 feet. The
overhead charts depicted 2500 feet as the MSA. The controller was not aware that the MSA had been raised to 2900
feet a week earlier.
Potential Hazard: Inadequate terrain clearance.
Positive: The ERC communicated the issue and the charts were updated accordingly.

By submitting your reports, you contribute important safety information that will help the 2
ATO identify negative trends, safety issues, and procedural deficiencies.