Originally Posted by
Del Prado
I haven’t read the full report, was that the published conclusion?
Sorry, I don’t want to dig you out on every post Aterpster but I wonder if cheap shots and ?made up? rumours really advance the exchange of information here and flight safety in general.
Not sure about which "cheap shots and rumors" are you talking about, but this was the conclusion:
The incident was caused by the air traffic controller assigning the pilots a left turn instead of the required right turn after departure which placed the aircraft in an unsafe proximity with terrain and obstructions. Contributing to the incident was the air traffic controller's inadequate recovery technique during the development of the incident.
And the report found issues only with the ATC, and no issues with the pilots:
Personnel issues:
Incorrect action selection - ATC personnel (Cause)
Interpretation/understanding - ATC personnel (Factor)
Total instruct/training recvd - ATC personnel
Lack of action - ATC personnel
Experience/qualifications - ATC personnel
If you want a clearer picture you should really read the entire report:
https://app.ntsb.gov/pdfgenerator/Re...Final&IType=IA
And the associated documents:
https://dms.ntsb.gov/pubdms/search/d...361&mkey=94560
And then maybe draw your own conclusion, if you don't trust NTSB's conclusion.
In my opinion, after I reviewed the GPWS data, the pilots initially followed the controller instructions to the letter. She told them to go left, they went left. She told them to go right, they went right. She told them to stop climbing, they stopped climbing. She told them to go left again, they went left again. She told them to climb, they climbed.
Unfortunately the controller assumed they were not following her instructions and/or not understanding her, and lost her temper. They only stopped following her instructions when they became extremely confusing, like telling them to go southbound when they were heading north, without specifying a left or right turn. They even asked her to clarify if she meant left or right. She seems to have missed that, didn't answer, and kept telling them to go southbound, still without specifying a turn direction, left of right.
Towards the end of the incident she finally started telling them to climb, after another controller yelled at her to watch the MVAs, but at no point there was a "expedite climb" from her. And she only asked them to climb to 7000, when the MVA for that mountain was 7800. It seems she didn't realize how close they were to terrain.
At some point the pilots realized they would have to do something themselves, and they chose a random turn direction, to the right, without waiting further confirmation. The only problem is that they were already very close to the terrain when they did that. The final piece that saved the day was the GPWS system telling them to pull up during that right turn, to which the pilots reacted immediately.
Also, there is no evidence the pilots had any issues understanding English as it was initially discussed here. I was doubting that was a factor in this incident, as their readbacks didn't have any errors and were very prompt, and to me their English sounded quite good, but I'm not a native English speaker.
Now, maybe there are things that the pilots could have done better, for example questioning the controller more, and having a better awareness of the terrain around them, but I think overall they didn't make any major mistakes.
As to the controller, not sure what to say. Anyone can make mistakes. Her losing her temper and using "expletives" was probably not ideal, but we all have bad days. It was an unusual situation, with traffic departing in the opposite direction that night due to weather, which happens very rarely. From her interview, she felt overloaded. And the aircraft entered an area she wasn't trained for.
She was alone at that point, her colleague was on a break and asked her to call him back if the departures change direction, which would things more challenging, but for some reason she didn't call him back to help.
What really surprised me was her work schedule. From her interview:
On the day of the incident, she had worked a 0545 to 1345 shift followed by an overtime mid-shift starting 8 hours later at 2200 to 0600 the following morning. Ms. Hocutt left work the afternoon prior to the incident; she could not recall exactly what she did, but, said she would normally eat and go to sleep around 1800 and wake up around 2100 to 2110. She lived within 20 minutes of the facility.
That means about 16 hours of work within a 24 hour interval. And only around 3 hours of sleep in the same interval. The incident occurred at around 01:20, 3 hours and 20 minutes into her second shift. To me, this kind of schedule sounds crazy. I'm not sure what work time limits there are for traffic controllers, but as a random comparison I took a look at the limits for truck drivers. My intuition is that driving a truck is less challenging than being an ATC, but I may be wrong.
In any case, this is one of the limits for truck drivers:
14-Hour Driving Window This window is usually thought of as a “daily” limit even though it is not based on a 24-hour period. You are allowed a period of 14 consecutive hours in which to drive up to 11 hours after being off duty for 10 or more consecutive hours. The 14-consecutive-hour driving window begins when you start any kind of work. Once you have reached the end of this 14-consecutive-hour period, you cannot drive again until you have been off duty for another 10 consecutive hours, or the equivalent of at least 10 consecutive hours off duty.
That regulation makes it impossible to drive more than 14 hours within a 24 hour interval, for example 11 hours driving + 10 hours break + 3 hours driving = 24 hours. This controller was planning to work for about 16 hours within a 24 hour interval. I think whatever regulations allow that should be reviewed, because it sounds excessive, and fatigue is probably one of the factors contributing to her poor performance during that incident.