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28 août 2009

Collision de l'Hudson: Recommandations du NTSB

En guise de follow up au feuilleton de l'été, voici les premières recommandations du NTSB ... c'est très facile à lire et assez instructif sur l'organisation de la circulation aérienne à New York. La version pdf est en ligne.

On notera toutefois que le BEA américain continue de charger les contrôleurs de KTEB à la fois sur un point règlementaire vis à vis de l'information de vol (la notion de service rendu en fonction de la charge de travail est aussi un débat bien connu chez nous) mais aussi et probablement surtout pour un comportement qualifié de peu professionnel.

Extraits

"After the initial postdeparture traffic call, ATC did not advise the accident airplane pilot of potential conflicts with other aircraft ahead in the Hudson River class B exclusion area. Because the first radar target for the accident helicopter was detected about 1152:27, the helicopter was not yet visible on radar when the TEB local controller issued the frequency change to the airplane’s pilot. Therefore, before the frequency change, the TEB local controller could not have detected the impending conflict between the accident airplane and the accident helicopter or issued a warning to the airplane pilot about the helicopter. However, radar detected other aircraft in the Hudson River class B exclusion area that were potential conflicts at that time. The TEB local controller did not advise the airplane pilot of the other traffic ahead. The pilot of the airplane had requested radar traffic advisories before departure, and was advised of "radar contact" by TEB after departure, indicating that, workload permitting, the service was being provided. According to FAA Order 7110.65, Air Traffic Control, providing traffic advisories to VFR aircraft is an additional service that, as the FAA order states, “is required when the work situation permits.” The TEB local controller's ATC workload was light at the time of the frequency change, so it appears that nothing should have prevented him from providing the service. The EWR tower controller observed the existing traffic in the Hudson River class B exclusion area and called the TEB local controller to ask that he instruct the airplane pilot to turn toward the southwest to resolve the situation. The call overlapped the pilot’s acknowledgment of the radio frequency change instruction from the TEB local controller. The TEB controller did not hear the EWR controller’s instruction clearly and requested that it be repeated. The TEB controller then attempted to contact the airplane, but the pilot did not respond, likely because he had already changed frequencies. The collision occurred about 1 minute after the frequency change and 26 seconds after the TEB local controller's last attempt to contact the pilot."

Le NTSB suggère ici clairement que certes le contrôleur ne pouvait pas faire l'info d'un hélico qu'il ne voyait pas mais que puisqu'il na pas fait l'info de ceux qu'il voyait, il ne l'aurait pas fait non plus pour l'hélico s'il l'avait vu !!!

"The NTSB is concerned with the complacency and inattention to duty evidenced by the actions of the TEB local controller and the supervisor during the events surrounding this accident. The local controller initiated a telephone conversation unrelated to his work about 1150:31, about 2 minutes after he cleared the accident airplane for takeoff. The conversation continued until 1153:13, with the local controller dividing his attention between the telephone conversation and his ATC tasks. The controller was not fully engaged in his duties.
Following the accident, the TEB controller attempted to locate the ATC supervisor on duty, who had left the tower cab for a break, to tell him what had occurred. The supervisor could not be found in the building. The controller attempted to contact the supervisor by cell phone, but there was no response. The supervisor later stated that he had left the premises to run a personal errand. He did not tell the local controller, who was the controller-in-charge in the absence of the supervisor, that he would be leaving the facility. This adversely affected the mandatory and time critical accident notification and reporting process. The supervisor's unannounced absence is also of concern because of the local controller’s inappropriate telephone conversation that likely would not have been permitted if the supervisor had been on duty in the tower cab.

Therefore, the NTSB recommends that the FAA brief all air traffic controllers and supervisors on the ATC performance deficiencies evident in the circumstances of this accident and emphasize the requirement to be attentive and conscientious when performing ATC duties."

Cela a bien sûr induit une réaction immédiate du NATCA :"The NTSB again has rushed to wrongly blame the air traffic controller in this incident. The board inexplicably has also made its recommendations before the FAA task force examining these issues -- which NATCA is participating on - has done its job to make what is already an incredibly safe airspace even safer. The task force is due to release its report next week. So why the rush? But the bottom line here is that the controller is not responsible for contributing to this tragic accident and he did everything he could do. We cannot provide traffic advisories to aircraft we are not talking to, cannot see on radar or are not a factor at all."

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