ASRS CALLBACK includes excerpts from ASRS incident reports with supporting commentary. In addition, CALLBACK may contain summaries of ASRS research studies and related aviation safety information. CALLBACK is one of the ASRS's most effective tools for improving the quality of human performance in the National Aviation System (NAS) at the grass roots level.

Thursday, July 16, 2015

CALLBACK 426 - July 2015

CALLBACK From the NASA Aviation Safety Reporting System
Issue 426
July 2015
NOTAM Issues
Time-critical aeronautical information which is either of a temporary nature or not sufficiently known in advance to permit publication on aeronautical charts or in other operational publications receives immediate dissemination via the National NOTAM (Notice to Airmen) System. Federal Air Regulations require that all pilots must check NOTAMs before every flight.

In accordance with Public Law 112-153 (also known as the Pilot’s Bill of Rights), The Federal Aviation Administration (FAA) established a NOTAM Improvement Panel to assist in making needed enhancements to the NOTAM program. The Panel is working to increase standardized digital NOTAMs that can be more easily filtered, sorted, and prioritized. This should result in a significant reduction in the volume of NOTAMs pilots must currently review and allow pilots to focus only on those NOTAMs relevant to their flight.

The ASRS reports in this CALLBACK highlight the latter NOTAM issue— the large number of NOTAMs that must be reviewed by Pilots and Controllers.
One Among Dozens
While this Beech 36 Pilot took responsibility for missing an important NOTAM, he discovered that finding a relevant Notice in a stack of NOTAMs can be like finding a needle in a haystack.
I was on an IFR flight plan, in the clouds, nearing the airport. My plane was equipped with an IFR-certified GPS system. I had planned the flight carefully (I thought) and had reviewed all necessary information and NOTAMs for the flight.

I was being handled by Center. The Controller asked which approach I wanted. Given that the ceiling was reported 2,500 broken, but variable and just below the 3,300 transition altitude, I told him that I wanted the VOR approach. He cleared me direct to the VOR at 3,300 feet and cleared me for the approach.

I had been navigating using the GPS system in my plane and continued to use it to go direct to the VOR. I tried tuning in the VOR, but did not get a good signal. I told ATC that I was not receiving the VOR. He told me that he did not have any NOTAMs showing that the VOR was out of service so I continued to use the GPS to navigate to the VOR, thinking that since the VOR was low powered I was just not yet getting a good signal.

Another plane behind me asked for the VOR approach, then reported that he was not receiving the VOR either and asked for a different approach. I began to be concerned, but I knew that I could substitute my IFR-certified GPS for an out-of-service VOR legally, but I could not use it for navigation from the Final Approach Fix.

I continued to navigate using my GPS system and broke out of the clouds into VFR conditions just before reaching the VOR. I started to descend VFR, turning back toward the airport…. I cancelled IFR before having to navigate the final approach course from the VOR.

As it turns out, the VOR had been NOTAM’d out-of-service and I had missed this NOTAM in the dozens that had to be reviewed. ATC apparently also missed it because the Controller told me that he did not have any NOTAMs for the VOR. The other plane behind me also missed the NOTAM because he asked for the VOR approach.

I should have been more careful in my review of the NOTAMs. Having said that, the FAA is working on fixing the NOTAM system. As it stands now, pilots and controllers are supposed to review pages and pages of NOTAMS, many of which are basically unreadable. Two Pilots and the Controller not knowing about the NOTAM testifies to problems with the NOTAM system as it is today. Nonetheless, I should have seen the NOTAM and requested a different approach. I will be more careful in the future.
TFR Trespass
Inadvertent entries into TFRs (Temporary Flight Restrictions) constitute a large percentage of the airspace violations reported to ASRS. In the case of this aerial photographer, there may have been a problem with the promulgation of the NOTAM by the issuing authority or it may have been missed in a “long list” of NOTAMs that had to be checked.
The purpose of the flight was to photograph [an area] that had recently been the site of an accident…. Prior to departing, I obtained a preflight briefing using the computer service at my home FBO. This service displays a list of NOTAMs for a route of flight. I reviewed the list and did not see any mention of a TFR. I also use a service from XM which transmits real time TFR information via satellite for display on my GPS moving map. I thought I had the TFR base covered.

Upon return to my home base, ATC told me to call. They said I had violated a TFR that was described in a NOTAM and centered on the exact spot we were photographing. It was a one-mile radius around the area up to 3,000 feet. Either the FAA, the website, and/or XM did not properly disseminate the TFR information or I somehow simply missed the NOTAM in the long list that the web service displays. The solution, for me, is to not rely on technology, but to call Flight Service and talk to a human.
Airport Closed— Who Knew?
Acting on information from a Pilot regarding an airport closure, this TRACON Controller attempted to track down why the relevant NOTAM was not at hand. In addition to local problems with tracking and dissemination, the Controller noted that it is a cumbersome process to decipher numerous pages of complex NOTAMs.
While I was serving as the Supervisor in the…TRACON, my Sector Controller asked me if I knew anything about ZZZ being closed. I stated that I did not. The Sector Controller said that he had Aircraft X inbound, but the pilot was questioning the status of the airport because according to him, there was a NOTAM showing it closed…and the current AWOS broadcast also said the airport was closed. I quickly checked the current FAA NOTAMs on the website, but there were none indicating the airport was closed. I then called the…Airport Manager and…asked the person who answered the phone if the airport was open and they said, “Yes.” I told my Sector Controller that there were no NOTAMs showing the airport closure and the person at the airport said the airport was open. So, the Controller cleared the aircraft for the approach and approved the frequency change. Shortly thereafter, Aircraft X went around claiming that there were men and equipment on the runway and diverted to [a nearby airport]. I called the secondary number listed [for ZZZ]. I asked [this person] about the status of the airport. He said that there were men working on the lights, but assured me they were clear of the safety area and the airport was therefore open. But, he said he was at [a different airport] so he asked me to stand by while he called out there. He returned to say that the men and equipment were now clearing the runway, turning the lights on, and the airport should be open in about 20 minutes. I said that I had just talked to someone over there who said the airport was open. He said that number transfers to [a nearby airport] after hours so that person must have thought I was inquiring about that airport.

I asked Aircraft X to call the TRACON so I could explain what had happened. He was very polite and did not seem concerned about the whole thing. After researching a little more, I discovered that the morning FLM (Front Line Manager), whom I had relieved earlier, had printed out the Satellite NOTAMs and stapled them to the daily staffing sheet. It included a NOTAM about ZZZ being closed, but there was no mention of it in the position relief briefing nor on our IDS (Information Display System).

There is clearly a flaw in our tracking/dissemination of NOTAMs. The NOTAMs for a 40-mile radius of [local international airport] created 19 pages. Some supervisors review these at the beginning of the shift and enter them into the IDS. Others simply print them out and staple them to the daily staffing sheet. Most of the NOTAMs we receive are unimportant, but obviously some are critical. However, deciphering 19 pages of ridiculously hard-to-read NOTAMs is cumbersome at best.

Our Position Relief Checklist includes NOTAMs, but they aren’t briefed unless it’s something significant. Additionally, we get NOTAMs sometimes via fax, sometimes via Flight Service Station, and via the internet. It’s a system that is filled with flaws and risks.
Interred Information
An Air Traffic Controller noted that Pilots not adhering to an arrival speed restriction that was NOTAM’d, but not yet published on the arrival chart was “a common occurrence.” The fact that the NOTAM was “buried” in about 40 others for the airport was apparently a factor in so many Pilots missing the information.
The RNAV arrival into ZZZ from the southwest corner has a NOTAM for turbojet pilots to descend via Mach number until intercepting 280 knots Indicated Airspeed (IAS). When asked, Aircraft X said he was at 300 knots. I asked if Aircraft X was aware of the 280 knot restriction and he said that I had not issued it, so he was not flying at 280 knots. I explained the speed restriction was in the NOTAMs and the Pilot then explained to me that he was not required to reduce his speed until [FIX]. I read the NOTAM requirement to the Pilot and asked him to reduce to published speed. Upon frequency change to Approach Control, the Pilot again explained that he was not required to reduce speed.

This is a common occurrence with Pilots on this arrival and creates a hazard to flight safety as it causes unnecessary frequency congestion while aircraft traffic is increasing. Pilots have complained that the NOTAM is buried in a list of about 40 NOTAMs for the airport, however that should not negate responsibility to comply with the speed requirement.
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Special Studies
Wake Vortex Encounter Study
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more »
Meteorlogical and Aeronautical Information Services Data Link and Application Study
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
May 2015
Report Intake:
Air Carrier/Air Taxi Pilots 4,956
General Aviation Pilots 1,090
Controllers 528
Flight Attendants 496
Military/Other 292
Dispatchers 224
Mechanics 207
TOTAL 7,793
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 6
Airport Facility or Procedure 1
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NOTE TO READERS:     Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS
A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 426

NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189

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