Safe Landings - June 2011

It has been said that the only voluntary act in aviation is the decision to take-off.  Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.

In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others.  These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs.  Additionally, NASA distributes an electronic publication, “CALLBACK,” which contains selected, de-identified, reports on a free subscription basis.  In Flight USA is proud to reprint selected reports, exerted from “CALLBACK,” for our readers to read, study, occasional laugh at and always, learn from.  Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.

The Fixation Factor

The ability to maintain the “big picture” while completing individual, discrete tasks is one of the most critical aspects of working in the aviation environment. Preoccupation with one particular task can degrade the ability to detect other important information.

This month we look at examples of how fixation adversely affects overall task management.

On the Button, Off the Course

Too much attention to an autopilot issue detracted from this General Aviation pilot’s navigation duties and resulted in a frightening lesson.

• … I meant to set 2,800 feet as my minimum altitude to insure avoiding the…Class D ceiling (2,600 feet). I mistakenly set 1,800 feet. It wouldn’t have mattered if I were paying proper attention since I didn’t intend to fly that close to the Class D airspace.

I was head down in the cockpit trying to figure out why a button pushing sequence was not working per the autopilot manual. At some point I realized that I was taking too long over this. When I turned westward I noticed that I was almost over [the] airport at 1,800 feet. [There were] sky divers above and to the north as low as about 2,300 feet and perhaps a half-mile [distant]. This is the most frightening thing that’s ever happened to me in flying. The airspace incursion was the least of it. Had [the direction of] my turn been different, I could have been among the divers with potentially catastrophic results. The cause is obvious – task fixation and a resulting lack of situational awareness that resulted in being where I shouldn’t be and not establishing [radio] contact for any potential warning of the skydiving activity.

It’s not so much that [my] priorities need reordering, it’s actually making my behavior match my mental priorities. Not as easy, but a scare like this is a very effective incentive.

Technically Advanced Violation

Advanced navigation equipment can provide a wealth of readily available information, but as this Cirrus SR20 pilot learned, sometimes too much information can be a distraction.

• I was receiving transition training and [we were]… in cruise with Flight Following services from ATC. We requested permission to transition the Class D airspace at our cruising altitude of 2,500 feet MSL. We then went back to looking at information about our next destination, some 15 miles away, on the MFD (Multi-Function Display) screen. Since we were on the airport detail page, we were not monitoring our position on the map page. Switching back to the map page we realized that we were…in the airspace around [the airport]. Shortly, ATC responded to our request with a denial of clearance into the Class D airspace.

I can now add my name to the list of those who advise against getting fixated on the capabilities and “interesting things to look at” on TAA (Technically Advanced Aircraft) displays… While they are a fantastic benefit for situational awareness, the information they provide must still be monitored wisely by the pilot….

The U.S. Coast Guard’s Team Coordination Training Guide defines Situational Awareness as “the ability to identify, process, and comprehend critical elements of information about what is happening…. Simply put, it is knowing what is going on around you….”

In addition to fixation, there are a number of other human factors that can adversely affect our ability to know and efficiently process “what is going on around” us. In upcoming issues, reporters to ASRS will share their insights on such factors as complacency, overload, confusion, fatigue and distraction.