In August 2015, the pilot of a Cessna 310 on approach to Titusville, Florida, lost control of his aircraft during a missed approach from the Runway 36 ILS in heavy rain. The airport was at the time reporting VFR conditions.
The radar controller initially responsible for vectoring the aircraft to the final approach, for some unknown reason, failed to inform the pilot of the weather over the airport. Another controller took the place of the first and completed the final vectoring to the localizer. This controller also did not mention the heavy rain over the airport to the Cessna pilot. In the final accident report, the NTSB learned that the Titusville tower controllers never updated the local weather as conditions worsened and also failed to mention to the pilot that the control tower itself had been struck by lightning shortly before the pilot began his approach.
Why these controllers failed to pass along pireps that could have significantly impacted the flight, including that the pilot might have returned to his departure airport just 30 miles north, is still under investigation. But the failure to share pireps is certainly not just a weakness with the ATC sector, as an NTSB forum held in Washington last June with various pirep user groups and a recent NTSB investigation into weather dissemination discovered.
The board revealed during last year’s forum that, “Between March 2012 and December 2015, the NTSB investigated 16 accidents and incidents that exposed pirep-related areas of concern,” adding that, “The pirep information, if disseminated, would have increased the weather situational awareness of the incident flight crews, which could have helped them avoid the weather hazards and prevent the aircraft-damaging events.” The board cited areas for improvement that can be led by the AOPA, NATCA, the NWS, NAFI & SAFE.
The NTSB yesterday released its report, Improving Pilot Weather Report Submission and Dissemination to Benefit Safety in the National Airspace System, that focused on the two primary categories of pirep deficiencies.
The first looked at submission deficiencies, explaining that pilots are providing relatively few pireps, particularly during good or as-forecasted conditions, and air traffic controllers are not consistently soliciting pireps during weather conditions that mandate such services. Also, the board reminded the audience that pilot assessments of weather conditions are subjective and submitted reports can be inaccurate or incomplete. Under dissemination problems, the board said, ATC, flight service station, or company personnel who handle pireps can introduce delays and errors or even fail to distribute the information.
The board also discovered that procedural inefficiencies or noncompliance, low task prioritization of pirep processing, data-entry errors, problems with data-entry interfaces (including a lack of current automation functions for pireps within Next Generation Air Transportation System [NextGen] platforms), and proprietary practices (in which pireps are not shared to the NAS) have been identified as ongoing issues.
Based on months of study, the NTSB made safety recommendations to the FAA, NWS, National Air Traffic Controllers Association, Aircraft Owners and Pilots Association Air Safety Institute, Aviation Accreditation Board International, National Association of Flight Instructors, Society of Aviation and Flight Educators, and the Cargo Airline Association.
Many of the board’s recommendations focus on education for pilots, flight instructors, Flight Service Station personnel and air traffic controllers to help them better understand the vital role their efforts, or the lack of them, play in accident prevention. The board also spoke to technology’s role for increasing the efficiency of that training, as well as pirep gathering and dissemination.
A review of the NTSB’s recommendations to the FAA included reviewing the process by which federal and contract flight service station specialists receive verbal pilot weather reports. The goal is to simplify procedures to reduce the amount of time the specialists take to gather the necessary information from pilots. To the National Air Traffic Controllers Association, work with the FAA to develop and distribute to all ATC facilities, best practices guidance for the solicitation and dissemination of pilot weather reports based on the type of facility. The NTSB suggested the AOPA update its online pirep course content to include scenario-based training using more real-world examples to illustrate the value of both fair-weather and adverse-weather pireps, explain how meteorologists use pireps to verify and revise aviation weather forecasts and advisory products to improve safety in the National Airspace System.
The board also suggested AOPA provide guidance on how to assess and describe weather phenomena and report their location accurately and to also demonstrate the various ways to submit pireps. Finally, the board suggested the two flight instructor organizations, NAFI and SAFE, encourage members to teach their students, during initial flight training, recurrent flight training, and flight reviews, the importance of pilot weather reports by using as many real-world examples of both fair and adverse weather reports in the creation of sample pireps.
The entire report, as well as all of the Board’s conclusions and recommendations are available online.
