CALLBACK 25 Years Masthead

Number 298
July 2004
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Dear Readers:

As the NASA Aviation Safety Reporting System looks forward to its 30th Anniversary in 2006, this month marks an interim milestone, the 25th Anniversary of the Monthly Safety Bulletin, CALLBACK.

Since its inception, the Aviation Safety Reporting System has received and analyzed more than 600,000 reports from pilots, air traffic controllers, flight attendants, maintenance personnel, and others. ASRS data is used to:

1. Identify aviation system deficiencies for correction by appropriate authorities.

2. Support aviation system policy, planning, and improvements.

3. Contribute to aviation human factors safety research.

An additional use for ASRS data was envisioned in 1979 when the ASRS Advisory Subcommittee—an industry/government group established to function in an advisory role—recommended that NASA develop a means of increasing the visibility of the program and sharing information obtained through the ASRS with the aviation community. In response, the late Captain Rex Hardy, a decorated Naval Aviator and corporate test pilot, created the monthly safety bulletin, CALLBACK. Rex's vision of a short, readable, and informal format to present the ASRS "lessons learned" was an immediate success.

With his insight, talent, and determination, CALLBACK evolved into a widely recognized, award-winning publication. When Rex Hardy retired after producing the first 100 issues, the very capable and talented Dr. Rowena Morrison was able to step in and carry on the intent and spirit of Rex's creation for the next 174 issues. Perhaps this recent letter from a reader offers the best tribute to the efforts of all the people at ASRS who have contributed to 25 successful years of CALLBACK.

...I congratulate the ASRS staff for continually producing one of the finest aviation safety tools in the industry.

I love the low tech, high concept approach to "CALLBACK." (i.e., one-page, print on both sides, full use of page space, monochrome print, no fluff graphics). The quality is in your editing - nice use of themes, narratives always to the point without scolding. The slick magazines have similar products...[and] serve a useful purpose, to be sure. But it is only "CALLBACK" which makes my spine tingle and butterflies fly in my stomach when I think, "That could have been ME," as I read the narratives each month.

Please know the widespread appreciation we in the piloting community feel for your fine work. "CALLBACK" is a great return for what I am sure is a miserly amount of tax funding. Some other agencies could take a lesson from you folks." (excerpted from a CALLBACK reader's letter of 5/26/2004)

We appreciate the kind words, but we also recognize that it is the generous input from people who are willing to share their observations and lessons learned that constitutes the heart of CALLBACK. The entire aviation community is indebted to each and every person who takes the time to submit a report to ASRS.

The safety analysts who perform in-depth reviews of ASRS reports write a personal note on each form's return receipt. On behalf of the entire NASA/ASRS staff, CALLBACK would like to echo that sentiment, "Thank you for your Report!"

...Don Purdy, Editor

25 Years of Aviation Wisdom

25 YearsMany ASRS reports conclude with a statement of the lesson (or lessons) learned by the reporter. Here are 25 important lessons culled from the collective wisdom of the reports submitted to NASA's Aviation Safety Reporting System over the past 25 years.

Taking the time to share a lesson learned through a report to the ASRS is a good thing and, as mentioned earlier, we appreciate all of the submissions. By heeding the advice offered below, however, you may avoid a mishap and we may not have reason to hear from you. That's a good thing too.

1. ...I learned that it is better to divert early than to press on in deteriorating conditions hoping for a positive outcome. No one should attempt to "scud run" in marginal VFR conditions as I did (with a near disastrous result).

2. ...Even though I have been flying for a number of years, I learned a valuable lesson about how fast weather can close in and how stupid it is to "assume" that the weather will clear.

3. ...For every flight I make now, IFR or VFR, outside air temperature and icing forecasts will receive very close attention. I will never again fail to scrutinize approaching IMC for icing. It is an insidious trap.

4. ...Not knowing if the other aircraft was being provided advisories shouldn't have been a factor. It's always, "see and avoid" out there.

5. ...They say a good approach leads to a good landing. Early recognition of a bad setup will enable a go-around and prevent getting "into the hole" where few options remain.

6. ...No matter how familiar the other guy says he is with the airport, monitor, monitor, monitor.

7. ...From now on I'll visually check the fuel myself and I'll keep track of the fuel I'm using in flight.

8. ...Here is what I learned: 1) To the extent possible, always get prepared on the ground, not while in the air. 2) Don't let external pressures like time make you do something you haven't thoroughly prepared for.

9. ...I was making a rushed approach to land. I have learned that when I am rushed is when I really need to take the time for the checklist.

10. ...I guess the lesson to be learned is not to let personnel (station, refueling, etc.) or situations rush and distract you in your normal duties. Sometimes inattention to the small details will cause as many problems as the large ones.

11. ... In a real-life emergency, the work load and noise can be more distracting than the simulator can emulate. Don't get distracted from the first priority - fly the airplane! Concentration is key.

12. ...Post-flight concentration may have dropped after a successful landing in poor conditions. As they say, "The flight's not over until the aircraft is stopped and the engine is shut down."

13. ...I was counting on the autoflight system to fly the departure as it was supposed to and got a little lax. Lesson learned! Always back it up and don't relax. Garbage in, garbage out. If the route isn't in there or it drops out, you're not going to fly what you're thinking you'll fly.

14. ...In retrospect, doing a go-around to troubleshoot the problem wasn't too smart. We had a perfectly good runway right in front of us.

15. ...Any time an aircraft is damaged, don't fly it until it can be proven that all necessary actions have been taken to return the aircraft to an airworthy condition.

16. ...I blame the mistake on simple overconfidence. Experience, it seems, is no replacement for doing one's homework.

17. ...Line check airmen can make mistakes.

18. ...I could have done a better job of communicating. It must be difficult enough to be a controller in these situations, let alone a mind reader. The old saying goes, "Aviate, navigate, communicate." And, as I just learned, communicate clearly. Leave the guesswork on the ground.

19. ...I learned, that if ever there is a doubt, not only as to what ATC said, but also what they meant, I should become absolutely clear of ATC's instructions, especially before taxiing onto an active runway.

20. ...I assumed that the traffic situation would work out. I learned a valuable lesson for controllers: "Never assume anything."

21. ...It has been my experience that transmissions shouldn't be made to aircraft during the takeoff roll unless absolutely necessary.

22. ...Looking back on it, I learned two things: 1. Take the time necessary to do the work right even if there is pressure to get the plane out. 2. Always check the part number, no matter who says it's the right part.

23. ... Always carefully check the MEL book when deferring an item and also check for special procedures. Special procedures may not be listed on the MEL placard.

24. ...I pointed out to the gate agent that Federal Aviation Regulations specifically prohibit boarding a passenger who appears to be intoxicated. Never let anyone talk you into it. The situation never gets better. It only gets worse.

25. ...The timely and accurate flow of information from the cabin to the cockpit was vital in resolving the situation. Lesson learned: CRM (Crew Resource Management) works!

ASRS Recently Issued Alerts On...
 Mexican airport arrival routing
 A320 vertical stabilizer spar crack
 Western U.S. airport departure procedure
 B757-200 engine surge bleed kiss seal failure
 Southern U.S. airport ramp security deficiency

June 2004 Report Intake
 Air Carrier/Air Taxi Pilots
 General Aviation Pilots