CALLBACK From the NASA Aviation Safety Reporting System

CALLBACK - 35 Years of Wisdom... and Wit

Dear Readers:

July 2014 marks another proud milestone for the Aviation Safety Reporting System, the 35th anniversary of CALLBACK.

Captain Rex Hardy, a decorated Naval Aviator and corporate test pilot, created the monthly safety bulletin, CALLBACK in 1979. 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 230 more issues.

Perhaps this letter from a reader offers the best tribute to the efforts of all the people at ASRS who have contributed to 35 successful years of CALLBACK.

“I congratulate the ASRS staff for continually producing one of the finest aviation safety tools in the industry. 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.”
– J.U.

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 every person who takes the time to submit a report to ASRS.

– Don Purdy, Editor

Many ASRS reports include a statement about the lesson (or lessons) learned by the reporter. Rather than the usual report narratives, this anniversary issue of CALLBACK presents several important lessons culled from reports submitted to NASA’s Aviation Safety Reporting System.

Taking the time to share a lesson learned is a good thing and, as mentioned earlier, we appreciate all of the reports submitted to ASRS. By heeding the advice offered below, however, you may avoid an error or incident.

Words of Wisdom from 35 Years of CALLBACK

— Time Pressure —

  • My first mistake came from reacting much too quickly. Take your time. Run the checklist when appropriate. Verify important switches with the other pilot before you move them.
  • To the extent possible, always get prepared on the ground, not while in the air. Don’t let external pressures make you rush to do something without being thoroughly prepared.
  • 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.

— Automation —

  • I have learned a valuable lesson about my responsibility to make timely inputs to the aircraft when I realize that the automation isn’t doing what I expect it to do.
  • Aircraft are machines subject to malfunction and we pilots who operate them are humans subject to human error. As a pilot who plans on remaining on the line, I have learned a valuable lesson— monitor the autoflight system like a hawk.
  • I must keep in mind that the buttons on the Flight Guidance Controller are myth and what displays on the PFD (Primary Flight Display) is truth. In other words, I can’t rely on the aircraft to do what I command by simply pressing a button. I must verify that the plane is doing what I command by seeing what is displayed on the PFD.
  • I was counting on the autoflight system to fly the departure as it was supposed to and I got a little lax. Lesson learned! 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.

— Fuel —

  • We thought we had a pretty good handle on our fuel state. Another minute or two of fuel and we would have made it safely to the airfield.
  • From now on I’ll visually check the fuel myself and I’ll keep track of the fuel I’m using in flight.
  • Next time I’ll make sure I have enough fuel for the unexpected and I hope others might be able to do the same without learning the hard way.

— Weather —

  • 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. Never again.
  • 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.

— Miscellaneous —

  • Not knowing if the other aircraft was being provided advisories shouldn’t have been a factor. It’s always, “see and avoid” out there.
  • 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.
  • Always have Plan B ready in case something goes wrong—because it will.
  • Line check airmen can make mistakes.
  • Never get distracted from the first priority— fly the airplane!
  • 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.
  • I blame the mistake on simple overconfidence. Experience, it seems, is no replacement for doing one’s homework.
  • 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 about ATC’s instructions, especially before taxiing onto an active runway.
  • It has been my experience that radio transmissions shouldn’t be made to aircraft during the takeoff roll unless absolutely necessary.
  • 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.
  • 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!

Once in a while a spelling error, an unusual situation, or a witty comment from a reporter can add a little spice to the thousands of reports screened by ASRS analysts every month. Here are a few examples:

  • I no longer believe my problem was fuel exhaustion, but possibly carb ice. This was the first carbonated airplane I had ever flown.
  • No APU or ground power was available so we did a crossbreed start.
  • Event: Bird strike on Captain’s forward windscreen.
    Cause: Bird was apparently texting.
  • It was very dark in the ramp area and the pilot didn’t have any lights on the airplane. His left wing struck a sign that said, “This is not a taxiway.”
  • Tower said, “[Callsign] turn left and cross Runway 24L and contact ground on the other side.” I informed him that we were unable to comply as we were still on final.
  • The Captain rounded out a bit late, touched down, and skipped back into the air. He was also tired and, not realizing we were airborne again, he pulled the speed brake lever. This time we knew we were on the ground.
ASRS Alerts Issued in May 2014
Subject of Alert No. of Alerts
Airport Facility or Procedure 6
ATC Equipment or Procedure 1
May 2014 Report Intake
Air Carrier/Air Taxi Pilots 5,086
General Aviation Pilots 1,134
Controllers 746
Flight Attendants 493
Mechanics 245
Dispatchers 125
Military/Other 125
TOTAL 7,954
   Indicates an ASRS report narrative
[  ]  Indicates clarification made by ASRS
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
Issue 414