Say Again? #26: It's the Little Things
There are a lot of big things that can kill you in aviation, and we've heard them all: T-storms, ice, marginal VFR, and runway incursions, to name a few. Sometimes insidious little things can cause even more trouble for pilots and controllers, because we haven't heard about them. AVweb's Don Brown relates a few of those in this month's Say Again column.
Did you ever notice it's always the little things that jump up and bite you? We all worry and obsess about the big things. We know not to fly into thunderstorms. We know to stay away from icing. There's nothing wrong with focusing on the big things. It's made aviation one of the safest forms of transportation on the planet.
As an industry, we've done a good job of publicizing the big errors made in aviation. Of course, we really don't have any choice about the matter. The big failures in aviation tend to be rather spectacular. The media covers them in depth. Grieving relatives get on TV and demand answers. The pressure is on to "do something."
But what about the little things? If you've ever read an accident report you'll notice that invariably it's a bunch of little things that added up to cause an accident. Are you paying attention to the little things? More important, are you studying the little things that are going wrong in today's environment?
Let's try a few and see if any sound familiar. I saw an incident a while back that sparked the idea behind this column. I was just plugging in and receiving my briefing from the controller working the sector. In case you've never seen one given or never heard one accidentally broadcast on the frequency it goes like this:
"Status: HKY is runway 24, VFR. CLT is south, 15 MIT. The SVH localizer is out of service. The SPA radials are still unusable like they have been for months. VFR approaches to all your airports ...
"Weather: Good VFR throughout the sector, no deviations, no ride complaints ...
"Traffic: N12345 is on a visual approach to HKY talking to the tower ..."
"Atlanta Center Bizjet123 is airborne climbing to six thousand."
It's a rare day controllers get through a position relief briefing without being interrupted.
"Bizjet123, Atlanta Center roger, I'll pick you up on radar shortly."
Who's On Second?
Now keep in mind, I'm not working the sector yet. I'm just standing there getting the briefing. I see the controller has a data tag at UKF for Bizjet123. But what I can't figure out is who the code is that's just off SVH. The reason it caught my eye is there's also traffic about six miles away from SVH at 4,000. It's an IFR code off SVH. If it really is an IFR, it's going to be tight between the SVH departure and the one at 4,000.
"Bizjet123, Atlanta, I still don't see you, say altitude leaving."
"Bizjet123 is out of four for six."
The controller is looking at UKF and I'm looking at the strips to see if I can find the code at SVH. I find the code, scan left on the strip to find the call sign and it's Bizjet123. Huh???
Blinded By the Light
About this time the other controller notices the code at SVH. So many light bulbs were going off at the same time it was blinding.
"Bizjet123 turn left heading 250 for traffic."
What the %$#@! is going on?
Well, it's just one of those "little things." Bizjet123 was filed out of SVH but the controller thought they were coming out of UKF. So the controller cleared Bizjet123 "from the UKF airport to the XYZ airport via ..." I guess you could call that a big mistake on the controller's part. The strip said SVH was the departure airport. But remember how I'm always saying this is a system? What could have prevented this mistake from becoming an even bigger mistake?
If the pilot had heard "Cleared from the UKF airport," he would have questioned the clearance. Did the controller use that phraseology? Probably. The bigger question for you, the pilot, is are you really listening? Think back to the last time you got a clearance out of an uncontrolled airport. Did you really listen to where you were being cleared "from"? Did you read it back that way (cleared from) or did you just read back what you thought was important?
One more thing before I drop this one. Think about what would have happened if the pilot had requested clearance through FSS. Controllers are trained to listen critically. Can you imagine what the FSS specialist would have said if he'd requested the clearance on Bizjet123 from SVH and the controller cleared the aircraft from UKF? That would have been one more step in the system that could have prevented the error. But we routinely skip that step. Why? Expediency. All together now class: Safe, Orderly and then we get to Expeditious.
So, getting back to one of the themes I want to highlight in this article, how many of you have ever heard about an instance like this? It's certainly not the first time it has happened. If you haven't ever heard about it before does it make you the least bit curious as to why you haven't?
How about this one? I've got a C150 who departs HKY (Hickory), Runway 24, with a right turn direct to BZM VOR. That's northeast-bound and basically parallels the final approach course for the ILS 24 to HKY. I've got a Baron, inbound from the southwest, that wants to shoot the ILS. I take the Baron on the south side of the localizer and parallel the C150. The Baron is descending, the C150 is climbing. When they swap out, altitude-wise, I'll be able to turn the Baron toward the localizer.
The first thing to go wrong is that the C150 doesn't have his transponder on.
"Atlanta Center, Cessna 23456 is off HKY, leaving 1,500 climbing to 5,000."
"Cessna 23456, Atlanta Center roger, radar contact, turn your transponder on please."
No big deal. It happens all the time. I'm busy as I can be so it takes me a while to get back to the situation. When I finally do get to take another look and see how I'm doing on the altitude swap all I see is a 1200 code.
"Cessna 23456 Atlanta Center, squawk 5114."
I've been too busy to think about it but it finally dawns on me that this guy is probably training. I try to hold my temper in check and move on to other things. A minute or so later I get another chance to check on the altitude swap and I see that the C150 is only out of 3,000 and climbing. I've got grape vines that climb faster.
"Cessna 23456 can you increase your rate of climb?" Of course not.
"Baron 567, traffic, 9 o'clock, seven miles, northeast-bound leaving 3,200 and climbing. I'll have a turn to the localizer as soon as he's clear."
Again, it's busy, so I have plenty of other things to do. After forever, I look again and the Baron is level at 3,400 and the C150 is leaving 4,400. Finally.
"Baron 567 turn left heading 345."
Anybody see anything wrong? Do you see what's coming? I didn't either.
"Atlanta Center, Cessna 23456."
"Cessna 23456 go ahead."
"Yes sir, when we flew into HKY earlier the controller said our Mode C was off a little. We're leaving 4,000 what do you show?"
After I finished beating my head against the scope I turned the Baron onto the ILS and took a break. I spent my break filling out a NASA Aviation Safety Reporting form.
I swear I'm the only person that has this kind of stuff happen. I'm downright testy about verifying Mode Cs. If you don't give me an altitude report I'm going to drag it out of you. This guy gave me an altitude report but he didn't have his transponder on so there was nothing to verify. The one time I get distracted and forget to verify the Mode C is the one time I get bit.
The reason I know this kind of stuff only happens to me is because I never read about it happening to anyone else. You see, I actually spend time looking for these types of things. It's real simple to do. You go to the NASA ASRS Web site, click on "Publications" and read "Callback." I always make sure to note the tally at the bottom of each issue. For June 2003 issue the tally reads:
May 2003 Report Intake
Air Carrier/Air Taxi Pilots: 1,736
General Aviation Pilots: 719
Maybe I should have been an Air Carrier or Air Taxi pilot. They seem to make plenty of mistakes worth telling others about. Maybe I'd fit in better. Evidently there are only 31 other controllers in the country who made a mistake last month. That's assuming I only filled out one ASRS form last month. I fill out so many it's hard for me to remember.
All sarcasm aside folks, it's not that hard to do. Repeat after me: "I made a mistake." See? That didn't hurt too bad. It only takes about 10 minutes to fill out the form. Once you fill out two or three and get the hang of it you can fill them out inside of five minutes. That's five minutes that might save your ticket. Or somebody's life.
Let's see. Where were we before I started drifting off on all that safety stuff? Oh yeah, the little things. I was working the high side one day when I had a real spooky one. All the en routes to IAH (Houston, Texas) showed up at the same time (like they always do) so I had about a dozen of them check in, one right after the other. Flow Control (in their usual helpful manner) was having us reroute them all down over SJI (Semmes VOR) instead of like they'd filed, over VXV J22 VUZ (Volunteer to Vulcan VORs).
Keep in mind that I'm about a thousand miles from IAH. Getting the in-trail to IAH isn't number-one on the hit parade in my sector, much less rerouting every single one of them. I never can understand how ZDC (Washington Center) can feed them to us all stacked on top of each other but all of a sudden it becomes so all-fired important to get them in-trail when they cross the ZTL (Atlanta Center) boundary. But I digress.
In between working the CLT (Charlotte, N.C.) arrivals and departures, the ATL (Atlanta, Ga.) arrivals and the ORD-CVG-DTW-CLE en routes, I'm rerouting the IAH arrivals.
"Airliner one twenty three, cleared to Houston via direct Volunteer direct Semmes the Stros One arrival Houston."
One right after another. Of course we have to type every one of them into the computer. I know it's glamorous but you get used to it.
"Atlanta Center, Airliner ten eleven."
No, you can't get direct SJI, and yes, it's for weather.
"Airliner ten eleven, go ahead."
"Reference that reroute you gave us a minute ago, you want us to go over Volunteer and then to Semmes?"
"Airliner ten eleven affirmative."
"Well the previous sector cleared us down J37 to Semmes. Volunteer is about a 60-degree turn for us. Any chance we can just stay on J37?"
What in the blue blazes is this guy talking about? He's 10 miles southwest of PSK just off J22. Volunteer is straight ahead of him about 100 ...
"Airliner ten eleven, say position."
"We're about twenty miles southwest of Spartanburg."
"Airliner ten eleven ident."
"There you go."
I look down about 20 miles southwest of SPA and sure enough there's an ident. That's two sectors away for mine. I pull up the data tag and it's Airliner two eleven. Not 1011 but 211.
"Airliner two eleven, that's two one one, don't change course, stay on your previously assigned routing."
Ten to Two
Holy smokes! Every inbound into ATL is off his right wing (in yet another sector) descending through his altitude. If he'd turned to VXV he'd have cut right across them and we never would have figured it out in time. Somebody key up the music from "The Twilight Zone."
I look up the flight plan and sure enough it's J37 to Semmes.
"Airliner two eleven, that's two one one, verify routing is J37 Semmes Stros One Houston."
"Affirmative Atlanta, two eleven."
"Airliner two eleven, that's two one one contact Atlanta Center one two zero point four two."
"Twenty forty two, we'll see ya."
"Airliner ten eleven, that's one zero one one, Atlanta Center."
"Airliner ten eleven Atlanta, go ahead."
"Airliner ten eleven verify you got the routing Volunteer Semmes and the Stros One?"
"That's affirmative Atlanta, Volunteer Semmes Stros One for Airliner ten eleven."
Still Clueless After All These Years
I still don't have any idea how that happened. The 211 flight shouldn't have ever been on my frequency. It's not that odd for an airplane to be switched to the wrong frequency, so that part doesn't surprise me. The only thing I can figure out is that I assumed the 1011 flight checked in twice (again, not that uncommon) when it was actually the 211 flight that checked in and I just didn't catch the call sign.
How we went through the whole reroute process without me or the pilot (or the other flight) catching the error is just beyond me. How both of them got the routing when I only issued it once (at least I think I did) is unbelievable.
What makes it so spooky is that if he had turned to Volunteer he would have been in another sector in five miles. That's about one minute's flying time. I don't know I'm talking to him. I don't even know he exists. The computer doesn't think I need to know him either. The Conflict Alert wouldn't have displayed on my scope. The sector that was supposed to be working him wouldn't have noticed the turn before he got out of their airspace. The sector that he would have entered would have had less than three minutes to notice him before he got with the ATL arrivals. It gives me the creeps just thinking about it.
Unfortunately I didn't have time to dwell on it. That's the problem with getting controllers to write these things down. We don't have time to analyze them while they're happening. You can't disengage your mind from all the other airplanes you're working long enough to try and replay an incident while it's fresh in your memory.
We could ask for the tapes to be pulled but no one ever does. That really is an unwritten rule. The first time that thought crosses a trainee's mind after something odd happens he'll have five senior controllers tell him, "Don't ever ask for a tape to pulled. Nothing good ever comes of it and it's usually the controller that gets the short end of the stick." That's sad. But that's reality.
That is one reason that the NASA Aviation Safety Reporting System is so important. It's anonymous. It's confidential. It gives you a large degree of immunity. Controller immunity is somewhat limited but it's better than nothing and it does work. It's easy as pie and it's free. You don't even have to pay for the stamp. What else could you want?
It's like any other program though. If you don't use it there's no gain. It's great that you file and get your "get out of jail free" slip, but if you don't take the time to read the reports others file you're not going to learn from their mistakes. That's the whole point of the program., to learn from other's mistakes. You've learned from your mistakes, haven't you? Others can learn from your mistakes, right? You can learn from others. If you can learn to avoid the little things that go wrong you won't have to worry about them turning into big things.
Have a safe flight.