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.

Monday, December 21, 2015

CALLBACK 431 - December 2015


CALLBACK From the NASA Aviation Safety Reporting System
Issue 431
December 2015
The Ostrich and the Eagle - Two Approaches to Taxiing
F.O. Ostrich keeps his head down a lot,
Doing his First Officer stuff.
But this puts the ol’ Captain on the spot,
When one set of eyes isn’t enough.
F.O. Eagle has a whole different plan,
To stay alert and in the loop.
He won’t be caught with his head in the sand,
When it’s time to fly the coop.
There’s a time ’n place for looking down,
To input this and check on that.
But taxiing’s the time for looking ’round,
Not for typing or checklist chat.
Distractions, including the use of electronic tablets, inputting Flight Management Computer data, sending or receiving ACARS messages, and running checklists while on the move, can all jeopardize safe ground operations. A heads-down First Officer compromises the situational awareness that safe taxi operations demand. Add an unfamiliar airport, new procedures, complicated taxi instructions, confusing signage, or congested frequencies, and the opportunities for embarrassing or dangerous mistakes increase dramatically.
Taxiing in the Real World
Aviation requires some degree of multi-tasking, but never at the expense of vigilance. With the First Officer heads down during taxi, this B737 Crew had a nighttime near miss.
In preparation for taxi at night we decided to run the Before Takeoff Checklist before moving the aircraft due to the busy environment. Our intent was to mitigate the threats that this checklist imposes, knowing full well that we may have to re-run it if the runway gets changed. Upon taxi out, the runway was changed and I went heads down to do everything I needed to do and run the Before Takeoff Checklist while the Captain taxied slowly toward the new runway. We elected to wait for my heads down time until we were on a relatively straight taxiway. While I was heads down, another aircraft cut across in front of us and was momentarily blocked from the Captain’s view by the windshield post. I was unable to assist and warn the Captain of the crossing aircraft because I did not see it as I was too busy… Since implementation of the new checklist I have felt … extremely uncomfortable with my lack of situational awareness while taxiing. This near miss on a taxiway is just one example of the potential dangers of this much heads down time while taxiing in the real world.
When Focus is Diverted, Errors Result
A B737 Captain reported on expectation bias resulting in a taxiway incursion while his First Officer was heads down.
I briefed the anticipated taxi. I identified and briefed the threat of taxiing without our final [numbers]. We began to taxi … and we received the final weights. The First Officer verbalized “heads down” as he input the numbers. We received error messages in the performance data … and simultaneously were given [new taxi] instructions. We both had our attention focused on resolving the weight and balance issue, and I taxied on the anticipated route I had briefed [initially]. I had heard what I anticipated hearing because my attention was diverted.

I am left feeling completely out of the loop regarding takeoff performance … because I am not able to review the information while I taxi. [Running the] checklist … while I am taxiing and listening to ATC does not give me an adequate picture of the takeoff performance nor am I able to verify that the correct entries have been made. The safest operation has both pilots focusing on one task at a time (not necessarily the same task) and when that focus is diverted, errors may result.
Right Runway, Wrong Flap Setting
There are several critical components to check before takeoff. This B737 Captain reported how changes during taxi interrupted those checks and resulted in an incorrect flap setting.
The flaps were set incorrectly for takeoff. I had a new First Officer who was getting used to normal cockpit duties and flows and we were given a last-minute runway and ATIS change during taxi out. We discussed the changes, reviewed the [performance] changes, programmed the FMS, reviewed the departure instructions, and were given an immediate takeoff clearance.

We ran the Before Takeoff Checklist and I ran a [mnemonic] check …, but failed to set the parking brake and rerun the Before Taxi Checklist… and therefore missed reselecting the flaps. We proceeded with our takeoff with a flap setting for the previous runway selection.

As Captain, I knew the new First Officer was burdened with a lot of last-minute changes and [I] should have set the parking brake to allow time to complete the previous checklist and rerun the Before Taxi Checklist, which are my normal triggers for checking flap settings on the [performance computer].
I Feel the Need… the Need for V-Speeds
Distractions that come late in the taxi or on the runway leave little time for catching or correcting mistakes. An A321 First Officer shared this lesson on delayed distractions.
The Takeoff Checklist had been completed “Down to the Line.” As we accomplished the “Below the Line” portion of the checklist, we realized that the wrong runway was loaded. When we were cleared for takeoff, I changed the runway, but was distracted by a company message and attempted to review and clear it. I can’t remember if I had the Performance page up or not when we got the ENG THR LEVERS NOT SET. I advised the Captain to set TOGA and we continued the takeoff. Above 80 knots, we realized that the V-speeds were not displayed on the Primary Flight Display so I called them out. The remainder of the takeoff and climb out proceeded uneventfully.

V-speeds and Flex Temperature are deleted when a new runway is loaded into the FMS and the new numbers need to be confirmed or manually loaded. I would have caught this had I not been distracted by the company message.
Outside (the) Loop
Threat and error management is becoming more widely adopted as a systems approach to aviation safety. A report from a B737 First Officer points out how distractions make it difficult “to stay in the loop” and watch for threats while taxiing.
The new [procedure] is very difficult to execute while keeping any sort of situational awareness outside the cockpit. We elected not to do any single engine taxiing due to the high workload. On several occasions I was heads down for so long … that I was not aware of where we were taxiing…. It gets very busy trying to … load the [FMC] and get the takeoff data all while trying to stay in the loop…. As a First Officer who normally likes to be able to … scan the situation for potential threats, I find that it is not possible with the new procedure.
Texting While Tugging
A Regional Jet Captain reported on a texting event outside the airplane that resulted in a close call on the ramp.
We were cleared to enter on the left side of the ramp and taxi to the gate. I looked to the left and noticed several vehicles yielding to us. I called, “Clear left” and then noticed an object moving from the right in my peripheral vision. I saw a tug pulling two baggage carts and the operator of the vehicle texting on a cell phone and heading at a fast speed directly toward us. I slammed on the brakes bringing the aircraft to a stop with the nose just over the ramp entrance. The driver just happened to look up and slammed on the brakes making a hard right turn back into the ramp and missed hitting us by about 15 feet. Had I not stopped…, he would have struck the nose of the aircraft.
Cell Phone Tower Conversation
Dealing with distractions is not a problem limited to flight crews. An Air Traffic Controller reported how aircraft monitoring technology overcame the self-induced distractions that affected a group of Tower Controllers.
A B737 landed and was instructed to turn right to join the parallel taxiway and to contact Ramp Control. Without visually scanning, the Controller assumed the aircraft had turned off at the first intersection, but he hadn’t. The Controller then cleared the DHC8 for takeoff and … shortly thereafter the Airport Surface Detection Equipment issued the alarm, “Warning. Runway occupied.” The Controller instructed the DHC8 pilot to abort the takeoff. The pilot complied and turned off the runway approximately 2,500 short of the intersection where the B737 ultimately cleared. At the time there were four other positions staffed including an Area Supervisor/Controller-in-Charge position and no one saw this event developing on the main runway even though it was not busy at the time. I believe this happened due to distractions in the work area, most notably, extraneous conversations and the heads down use of cell phones while working.
Two Ostriches Are Not Better Than One
Heads down mishaps are not limited to ground operations. Dealing with last minute approach changes, this B737 crew had four eyes focused inside when one eagle-eyed glance outside could have prevented a go-around.
Because both of us were heads down frantically trying to resolve the last minute approach change, we failed to see that it was VFR and we could have just requested a visual approach.…
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Special Studies
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 »
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 »
October 2015
Report Intake:
Air Carrier/Air Taxi Pilots 4,795
General Aviation Pilots 1,124
Controllers 477
Flight Attendants 416
Military/Other 325
Dispatchers 144
Mechanics 142
TOTAL 7,423
ASRS Alerts Issued:
Subject of Alert No. of Alerts
Aircraft or Aircraft Equipment 3
ATC Equipment or Procedure 2
TOTAL 5
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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 431


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

CALLBACK 430 - November 2015


CALLBACK From the NASA Aviation Safety Reporting System
Issue 430
November 2015
ATC Low Altitude Alerts
Controller issued Low Altitude alerts are created by either the Minimum Safe Altitude Warning (MSAW) or the Low Altitude Alert System (LAAS). The systems are similar as far as pilots are concerned, although MSAW has some predictive capabilities. The alerts are intended for IFR aircraft but may be requested by VFR aircraft, and are designed “as a controller aid in detecting potentially unsafe aircraft proximity to terrain or obstructions.” The alerts generally result in the controller issuing a “Check your altitude” call and often include an altimeter setting and altitude reference (MDA, MVA, etc.). Nuisance false alarms can be generated as the computer cannot predict a pilot’s intentions and delays in Mode C updating can delay a timely warning.

Even though there are excellent Terrain Awareness and Warning Systems (TAWS) and Ground Proximity Warning Systems (GPWS) in many aircraft, the ATC alert systems provide a useful backup for pilots.

The following ASRS reports show the benefit of having the controllers keeping an eye on a pilot’s altitude.
Flying Straight Toward Trouble
Before they could resolve an ambiguous clearance, two C172 Pilots were “alerted” about their proximity to terrain. Misunderstandings between Pilots and Controllers are problematic. In the approach or departure environment they can be critical.
We were climbing via a published departure. At around 3,000 feet we contacted Departure Control who gave us a new altimeter setting and then proceeded with the following clearance: “Fly straight out; climb and maintain 9,000 feet.” Our altitude was approximately 3,800 feet and we were still heading westerly toward terrain, not yet established on the outbound radial. The student noted that it was strange for ATC to vector us close to terrain while we were this low. A moment later, ATC gave us a Low Altitude alert and suggested a right turn to 090. Then ATC mentioned a possible deviation and gave us a number to call.

There was confusion about what the ATC clearance actually meant. The clearance “Fly straight out” was filled with ambiguity (we were still flying westerly and not heading northwest on the published procedure radial). The clearance was perceived as a vector for the climb. Before we had a chance to request clarification, the Low Altitude alert was issued.
Help on a Hazy Day
One CRJ Pilot and two Controllers share three perspectives on an approach to the wrong airport. A timely ATC Low Altitude alert cleared up the confusion on a hazy day.
ATC Front Line Manager Report:
Aircraft X was handed off to Approach at 12,000 feet. The Controller issued the landing information and told the aircraft to expect the Visual Approach to RWY 17 at [their destination airport]. The Controller then informed the aircraft that the airport was at 12 o’clock, 18 miles. The pilot stated that it was hazy, then reported the airport in sight. The Controller cleared him for a Visual Approach Runway 17 and to contact the Tower.

A little while later the Low Altitude alert went off and the Controller noticed Aircraft X turning final to [the wrong airport] and was observed at 3,400 feet MSL with a field elevation of 3,062 feet. The Tower issued a 300 heading and a climb to 6,000 feet.

I asked the Controller if he had advised that [the nearby airport] was at 1 o’clock and 10 miles and [the destination airport] was at 12 o’clock and 18 miles and he said he had not. We have two airports that are located ten miles from each other.
Approach Controller Report:
I was the Approach Controller and cleared Aircraft X for a visual approach to Runway 17 and switched them to the Tower frequency. Aircraft X began to maneuver and appeared to be attempting to land at [a nearby airport], which lies 12 miles southeast of [the intended destination]. I called the Tower and the Tower had Aircraft X on frequency. The Tower issued a heading to Aircraft X to land at the correct airport.
Pilot Report:
I was the Pilot Flying. Normal In-Range checklist was completed, including a briefing of the intended runway and type of approach (visual backed-up by the ILS Runway 17). ATC cleared us from cruise altitude down to 13,000 feet and subsequently down to 10,000 feet. We both agreed we had the airport in sight at approximately 12 o’clock and approximately 8 miles (based on my recollection of visually identifying the airport and confirming it with the Multi-Function Display). ATC then cleared us to land.

I began maneuvering the aircraft for a downwind leg, while continuing to configure the aircraft for landing. After turning from base to final, the Pilot Monitoring notified me that the LOC had not captured and called for a go-around. As I called for TOGA and Flaps 8, my scan moved to the top of the PFD and I noticed that the Flight Mode Annunciator did not change to LOC. I caught a glimpse of the number on the runway and noticed it was “18.”Around this time, ATC queried us as to our intentions and status. It quickly became evident that we had mistaken a nearby airport for our destination airport.
Following the Wrong Bug
Rushing to catch up after a late runway change, this C208 Pilot mistakenly flew a “Vertical Speed” approach until alerted by ATC. Thorough familiarization with the aircraft’s instrumentation in a training environment is the best way to ensure interception of the “real glideslope” in actual instrument conditions.
I was being vectored for the ILS 5R and everything was set up for Runway 5R. While turning base, the preceding aircraft had a problem and was delaying on the runway. ATC advised me to descend from 4,000 feet to 3,000 feet and expect the Runway 5L ILS. I started the descent to 3,000 feet and rushed to change and set up the approach to Runway 5L. I was given a late turn to intercept and overshot the localizer. That was followed by a turn to 080 to intercept and maintain 3,000 feet until established, cleared for the approach, and switch to Tower frequency. I corrected back to intercept the localizer, checked in with Tower and was cleared to land. Intercepting the localizer I was now good to descend to 2,500 feet and was still above 3,000 feet descending. I mistook what I later identified as the VSI bug (that was about -450 fpm) as indicating that I was slightly above glideslope and continued the descent. I broke out about the same time that Tower said, “Low altitude alert. Check your altitude.” I stopped the descent and could see that I was lower than the glideslope and that the field was much farther ahead. Tower asked me to confirm altitude at 1,780 feet, which I did. I then noticed the green diamond bug had appeared and I realized that I had mistaken the VSI bug for the glideslope indicator. I maintained altitude at 1,780 feet and joined the real glideslope and landed.

When they gave the late change to Runway 5L, I should have asked for a box around until I had everything set up. My acceptance of this clearance left me rushing to catch up, leading to mistakes.
“We Were Too Low”
A Regional Jet Captain, confident in the abilities of the Co-Captain, was lulled into accepting an improper altitude. A timely alert from ATC awakened the Crew to their altitude vs. position error.
We were flying as Co-Captains. My role was Pilot-in-Command (PIC) and I was the Non Flying Pilot. The weather was marginal VFR. ATC was using the RNAV GPS to the left runway and the ILS to the right runway. We were assigned the RNAV GPS approach to the left.

Throughout our flight, I was privately admiring the proficiency, professionalism and airmanship of my Co-Captain. As we approached the Initial Fix, the Second-in-Command (SIC) called for the Minimum Descent Altitude (MDA) instead of the Final Approach Fix (FAF) altitude. Since we were in visual conditions, I set the MDA in the altitude preselect without question. I do remember thinking, “He’s going to mentally adjust the descent rate for the Final Approach Fix.”

I then proceeded to observe the visual conditions outside the airplane, especially noting the surface winds and the whitecaps on the ocean surface, and updated the SIC on my observations.

We received the 1,000 foot callout from the radar altimeter and then the Gear Warning horn. We noted that as being out of the ordinary and lowered the gear. Shortly thereafter, we received a Low Altitude alert from the Tower. I advised the SIC that we were too low, at the MDA [approximately 350 feet AGL], and just approaching the FAF. We continued for an otherwise uneventful landing.
Too Low, Too Soon
In another example of a timely Low Altitude alert, an EMB 500 crew was in a hurry to get home at the end of a long day.
While on an RNAV GPS approach at night, the Captain and I became disoriented and started to descend to the MDA prior to the FAF. We thought we had already passed the FAF but in reality we had only passed the intersection before the FAF. Four miles from the FAF, Tower notified us of a Low Altitude alert and advised us to climb immediately…. The published altitude for that segment of the approach was 2,000 feet and we had descended to 1,400 feet.

I am most grateful for the safeguards placed within the ATC system. I was safe within legal duty and rest limits, [but] the long duty day... allowed me to slip into a near-lethal combination of get-home-itis and complacency.
ASRS Database Online
The ASRS Database is a rich source of information for policy development, research, training, and more.
 Search ASRS Database »
CALLBACK Issue 430
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 View ASRS Report Sets
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Contact the Editor
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 »
September 2015
Report Intake:
Air Carrier/Air Taxi Pilots 4,540
General Aviation Pilots 1,216
Flight Attendants 457
Controllers 368
Military/Other 342
Dispatchers 162
Mechanics 139
TOTAL 7,224
ASRS Alerts Issued:
Calendar Year No. of Alerts
2012 217
2013 173
2014 159
2015* 107
TOTAL 656
*Data through August 2015
Subscribe to CALLBACK for FREE!
Contact the Editor
Facebook
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LinkedIn
Facebook - Like
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 430



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

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