I had a few friends go to work in the chief-pilot office at my last airline, and they claimed that 5 percent of the pilot group created 95 percent of the problems. I’m pretty sure that’s true clear across the aviation industry, and likely within general aviation as well. My key to flying under the radar is to stay diligent, to keep my screw-ups small — and, when I do mess up, to readily confess and demonstrate that I’ve learned from it.
For most nonairline pilots, “fessing up” might include filing a report through the Nasa-administered Aviation Safety Reporting System. ASRS gives participating pilots a “get-out-of-jail-free card” for most unintentional mistakes, and in exchange, gives the FAA insight into GA pilots’ problem areas. Ultimately, it allows them to design a better system for us to operate within.
At the airlines, we have a similar but more robust system called the Aviation Safety Action Program (ASAP). Pilots who disclose honest mistakes within a reasonable time frame are protected from career-threatening FAA certificate action. A panel composed of an airline safety specialist, an FAA inspector and a pilot-union representative considers each de-identified case and has fairly broad powers to require safety improvements, including corrective training for the reporting pilots. It also has the power to exclude a report if it decides the crew willfully disobeyed procedures or regulations, and the FAA can still pursue certificate action if it’s not a sole-source event (e.g., if the FAA already knew about the incident from ATC records or eyewitnesses). However, the fact that the program requires pilot-union cooperation generally keeps all parties acting in good faith, with a few highly publicized exceptions that were quickly rectified.
This has resulted in most airline pilots “buying in” to ASAP. Most will very willingly submit ASAP reports for events big and small — sometimes quite small, to the exasperation of
program administrators. In my opinion, ASAP has done more to improve airline safety than any other program since the adoption of crew resource management (CRM). A version of ASAP has even been extended to air traffic controllers, and has helped create a more proactive safety culture there than the old punitive “three deals and you’re out” system.
My airline career coincided with the adoption of ASAP at the regional airlines, so I’ve been filing ASAP reports going on 15 years now — sometimes for my own screw-ups, sometimes for lurking potential “gotchas” I’ve noticed, sometimes when the aircraft did something wacko. I submitted more ASAPS on the Mcdonnell Douglas MD-80 than any other aircraft I’ve flown, most for that last reason. Meanwhile, I’ve filed but a single ASAP report in the nearly two years I’ve been flying the Boeing 757/767 — but it was a doozy. I even made our fleet’s monthly safety newsletter! The headline: Gross Navigational Error. That certainly sounds foreboding, doesn’t it?
My “gross navigational error” occurred over the frigid wastes of the North Atlantic Ocean, and was, in fact, a rather small deviation that never would have been noticed or reported in the “bad old days” of scratchy HF position reports and nonradar controllers moving paper chits across plotting tables. Which is to say, a mere 15 years ago. The amazingly busy North Atlantic tracks went straight from being one of the most antiquated chunks of controlled airspace in the world to one of the most modern — and most monitored. The change is instructive to GA pilots as we face the advent of ADS-B here at home.
These days, most airliners crossing the Atlantic are equipped with ADS-C (automatic dependent surveillance-contract). Unlike ADS-B, which transmits aircraft data to specialized ground receiving stations, ADS-C transmits the same information across existing datalink networks. Over remote areas, these networks operate via HF radio or (more typically) satcom. The second half of the system is the controller-pilot datalink communications (CPDLC) system, which allows text communication with ATC over those same datalink networks. So those scratchy voice position reports have been replaced by automated uplinks that transmit a vastly greater amount of data, all of it dead-on accurate, and the few other communications required are usually done via text message. It’s a system that is increasingly used in Europe, where frequencies in congested ATC sectors have fallen strangely quiet, as well as some developing nations that lack expensive radar coverage but can now afford ADS-C and CPDLC.
On the night in question, I was in the right seat of a Boeing 767-300ER as we coasted out over Newfoundland, Canada, and prepared to enter North Atlantic airspace. The captain was in the bunk on his scheduled break, the relief pilot flying from the left seat. As we turned over our oceanic entry point, the relief pilot entered an offset of 2 miles right of course into our FMS
due to an Airbus A380 ahead and above us, a standard procedure for wake-turbulence avoidance. I agreed that the offset looked correct on our navigation display, and the relief pilot hit the execute button. What neither of us caught was that while the aircraft was already “smart turning” to the next fix, we were still a few tenths of a mile short of passing the current waypoint. Boeing 757s, 767s and 777s have a known bug in which the FMS does some very funky things when executing offsets just before waypoint sequencing. It was a simple mistake on our part, but with serious consequences. The aircraft entered a right turn as though to intercept the offset route, and then continued turning as if it wanted to head for Bermuda!
After a moment’s consternation, the relief pilot punched the heading-select button and got us turning back toward our intended route. Only a few seconds
ding passed before a loud resounded through the cockpit — we were being “paged” by Gander Oceanic Control. We donned our headsets and responded on our HF radio, and they gamely inquired just where the heck we were going. At this point I noticed that the FMS had also completely deleted our next waypoint! I explained that we had suffered an FMS malfunction and were re-entering the correct waypoints and returning to our course. We never got more than a couple of miles off our route but had nonetheless committed the grand pooh-bah of North Atlantic sins. You see, ADS-C doesn’t merely transmit positional information, but also the exact route in our FMS as well as selected autopilot modes. As soon as our FMS contained a route other than our cleared one, we were guilty of a gross navigational error — the actual physical extent of our deviation was irrelevant. Crews at my airline have been dinged for merely entering “reminder waypoints” that didn’t change the aircraft’s actual route at all. Big Brother is very much watching us out there.
Fessing up was easy — all three of us submitted ASAP reports, even the captain who was asleep in the crew-rest module at the time. My report included some of the contributing factors, such as the relatively high workload while approaching the oceanic entry point, my lack of concentration on proper sequencing as we passed the waypoint and my forgetfulness about the embedded FMS bug when approving the route offset. The ASAP committee accepted all three reports without comment, turning a potential violation into a nonjeopardy event. A few weeks later, the flight-safety newsletter highlighted our bugaboo. It wasn’t that we did anything uniquely stupid — quite the opposite, actually. ASAP reports revealed an uptick in similar mistakes, and it had been over a year since the Fms-bug memo had been issued, so our fleet captain concluded that our crews could use a reminder. This neatly illustrates the contribution that ASAP makes to a proactive safety culture.
This incident did get me thinking, however, about potential consequences for the U.S. general aviation fleet as it equips for the adoption of nationwide ADS-B by 2020. Mind you, most ADS-B installations will not transmit nearly as much information as a widebody airliner crossing oceanic airspace, but at a minimum it will transmit exact position, altitude and your aircraft’s N-number. Clip a TFR, brush just inside Class B, fly only 950 feet above a “congested area,” and the feds will possess incontrovertible evidence of your guilt before you even land. The FAA points out that no ADS-B data has ever been used for enforcement action during the Capstone Project in Alaska, but I think we all know that the FAA of Alaska is not the FAA of the lower 48.
I’m not arguing against ADS-B equipage, mind you; that ship has long sailed. But considering that in the future many pilot mistakes will be perfectly recorded and potentially reported, I think it’s time for the FAA to reconsider some of its GA enforcement mechanisms, lest pilots merely switch their ADS-B boxes off whenever they meander too close to the edges of legality. Explicitly prohibiting the use of ADS-B data for enforcement except in egregious cases (where existing radar evidence would be sufficient) would be a good start. In addition, I think the NASA ASRS program should be revamped to more closely align with the proven ASAP system, with a collaborative approach between FAA, industry and pilot advocates, easy zero-risk reporting and an emphasis on training and system fixes over punitive measures. Getting GA pilots to buy into such a system as airline pilots have would be a major boon to flight safety.
What neither of us caught was that while the aircraft was already “smart turning” to the next fix, we were still a few tenths of a mile short of passing the current waypoint.
Most airliners crossing the Atlantic are equipped with ADS- C, while most of GA is starting to equip with ADS- B.