Say Again? #65: Lost Perspective

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Say Again?

This is the problem with being a safety rep: After a while, your perspective changes on things. Sometimes, it seems like every thing. Take this story from a recent edition of AVweb, for instance:
NTSB Finding Reassessed -- Case To Reopen, Decades After ... When a Piedmont Airlines 727 and a Cessna 310 collided over North Carolina in July 1967, all 82 people on both aircraft died in the crash, and the pilot of the Cessna was blamed ....
I don't know how many controllers at Atlanta Center have even heard of this accident, but I have, and it bothers me still.

Bearer of Bad News

Safety reps live and breathe bad news. Nobody ever comes up to us and says, "Things are perfect. We don't need to change a thing." Most of the conversations start with, "If we don't fix this, somebody is going to die." I hope you don't have to hear that even once a week. I hear it every day.

If you followed the links in that article above, it sent you to a story done by the Spartanburg Herald-Journal and you could learn even more about the accident. Although I've known about the accident for a really long time (since my first instructor at Atlanta Center told me about it), there's always something new to learn. For instance, I didn't know it was the NTSB's first major investigation.

Accidents of this nature tend to make an impression on the controller culture, at least in the short term. Without going into the details of this particular accident, the reason my first instructor told me about it was because of the role of the air traffic controller in the accident. But I really have to wonder about the long term changes that were made -- or even reversed -- as folks forget the history of why some procedures are in place (or never learn it in the first place).

Old Bad News

Two of the other "biggies" at Atlanta Center were the Southern 242 crash and the Bruno's crash.

Many of you might remember the Southern 242 crash in New Hope, Ga. A Southern Airways DC-9 penetrated a severe thunderstorm and both engines quit. The aircraft made a forced landing on Highway 92 and clipped some obstructions before sliding into a convenience store.

The crash spurred the aviation industry into better training on severe weather ... for everyone: dispatchers, pilots and controllers. The company dispatch system was cited with failing to adequately brief the crew. The crew was thought to have misread their weather radar -- mistaking the worst part of the storm for a hole -- due to attenuation. The accident also spurred the FAA to ask the National Weather Service for help. The NTSB recommended the FAA improve the weather information available to controllers. That was the beginning of the Center Weather Service Units.

It all sounds well and good. Lessons learned. But you don't have to look very far to find recent aviation accidents that mention thunderstorms. Bruce Landsberg's shop over at the AOPA Air Safety Foundation recently put out a briefing (54 Kb Adobe PDF file) on the rise in general aviation accidents involving thunderstorms. And in a move that really leaves you scratching your head, the FAA and National Weather Service are cutting out the Center Weather Service Units.

Bad VFR

Unlike the Southern 242 crash, most people don't remember the Bruno's crash in Rome, Ga. On December 11, 1991, a BE400 (Beechjet) belonging to Bruno's Inc. (a Birmingham, Ala. based grocery chain) departed Rome for Huntsville, Ala. The captain elected to depart VFR despite a ceiling of 1,000 ft. overcast. The visibility was 10 miles.

After departing Rome, the flight attempted to obtain an IFR clearance from Atlanta Center. They were told to "maintain VFR" and that there would be a delay in obtaining a clearance. There were two aircraft inbound to Rome, both either in or exiting a holding pattern for an approach to Rome -- below radar coverage. In just under four minutes, the Beechjet slammed into Lavender Mountain. The aircraft was destroyed and all nine people on board perished.

As usual, several lessons emerged from this accident and not all were even related to aviation. Bruno's, founded in 1932, lost several key executives in the crash -- including its two co-founders. Its stock price plummeted by almost half by 1993. While there were certainly other factors involved, losing so many key people couldn't have helped. That made some people think long and hard about how they transport their key executives. It made the NTSB think about who was in charge of safety at the smaller corporate flight departments, and they wrote:

"The Safety Board believes that, to encourage adherence to good operating practices among pilots of corporate-owned or -operated aircraft, and to enhance the ability of first officers of corporate aircraft to participate in the management of the cockpit, the FAA should, in conjunction with professional aviation associations and manufacturers of turbine-powered aircraft, inform corporate aircraft operators of the circumstances of this accident, and encourage them to examine their flight operations to verify that policies and procedures are established to prevent such accidents and to encourage first officers to play an active role in cockpit decision-making."
You'll have to read all of the NTSB's various reports about the accident to read between those lines, so let me give you the summary: Crew resource management is just as important in corporate flight cockpits as it is in airline cockpits, and ground proximity warning systems are necessary for safety.
Continuing from the NTSB:
"The number of accidents of this type, in which an airworthy aircraft is flown into terrain under controlled circumstances in instrument conditions or in darkness, has been reduced in recent years in air transport operations, largely because of the aural warnings of imminent ground collision provided in the cockpits of air carrier airplanes by the currently required ground proximity warning systems (GPWS)."
For controllers, it made us think that departing VFR to pick your clearance up in the air wasn't such a smart idea. But it didn't last. We're like everybody else: Time tends to diminish memories, even the painful ones. As controller staffing kept decreasing, it kept getting easier and easier to encourage pilots to depart VFR and pick up their clearances in the air.

Getting a Clearance

The way the system was designed -- the way it is supposed to work -- the pilot would call FSS, FSS would call us and we'd issue the clearance through FSS. Nobody will argue with the fact that it was (and is) a cumbersome system. Let's look at it a little more closely, though, from a safety perspective.

In the Centers, if the sector is fully staffed, the call from FSS would be answered by the D-side -- the non-radar controller. In that this controller isn't talking on the radio (that's the job of the Radar Controller -- the R-side), he isn't under the same time pressures that the R-side is under. He could be more careful and take his time.

In addition, the non-radar controller can see "further" than the radar controller. And last, but certainly not least, this procedure allows a clearance to be issued without tying up the air traffic control frequency.

Every time I work the early shift in my Area, this happens: Several air carriers want off Asheville airport before the AVL Tower opens. We struggle to issue a clearance to them -- between the vectors and altitude clearances for the inbounds to Charlotte -- when all they'd have to do is call FSS. We usually have a D-side sitting there twiddling his thumbs, able to take a call from the FSS. The D-side could get them out safer (and even faster), but instead we tie up the air traffic control frequency playing Clearance Delivery.

VFR to IFR

I'll admit I'm grateful the airlines don't depart VFR before they get their IFR, but other pilots do try that, and usually it works. On a short-staffed shift, without a D-side, the R-side has to answer the phone call from FSS. He can't talk on the radio while he is on the phone, so he doesn't like getting phone calls from FSS. Therefore, he discourages pilots from calling them.
"Hey Center, we're coming back out in about 15 minutes, can we talk to you on the ground?"
"Uhhh, negative N12345, but if you'll just depart VFR, I'll be able to get you a clearance with no delay."

I'd bet every one of you have heard something like that on the radio. And most of you take us at our word.

It works better than 99% of the time, too. The weather is decent 90% of the rest of the time when it doesn't work, presenting no real danger to the pilot. That is a lot of positive reinforcement of a bad habit. But what happens when it doesn't work andthe weather is bad? Perhaps a better way to approach this is to think of human nature at work: How easy is it to convince yourself that something that has worked (departing VFR) for you dozens and dozens of times will work again?

Deja Vu

That may explain why I found myself working a guy -- VFR at 3,500 and requesting an IFR clearance -- trapped underneath an overcast layer while I had IFR traffic at 4,000. I could clear him at my minimum IFR altitude (MIA) of 3,400 (if there wasn't any traffic) and this guy probably knew that was my minimum altitude. But he didn't know about the traffic at 4,000. It still doesn't sound too bad until he found himself at 3,500 in an area where the MIA was 4,300.

Now I found myself in that one-tenth-of-one-percent situation. The VFR departure didn't work out and the weather isn't decent. Which one of us has lost our perspective? I know what I was thinking when it happened: I was thinking about the Bruno's crash and how we could avoid repeating it.

Deja Vu Two

When I returned from a break on the midnight shift the other night I got another "You should have seen this one" story. This controller had an inbound to Asheville and AVL Tower was closed for the night. The pilot -- not wanting to call FSS to cancel once on the ground -- canceled IFR just after being told "radar contact lost" on the final approach course (FAC) to Runway 34. A few seconds later, another pilot -- not wanting to call FSS for a clearance -- showed up on the frequency requesting clearance. Turns out that he'd departed Runway 16 at AVL. Just so you can share in our level of discomfort, the departure procedure for AVL Runway 16 is to fly runway heading direct to the BRA radio beacon -- the same beacon the inbound flew over on the FAC to Runway 34. And, as I alluded to earlier, all this was happening below our radar coverage.

They were both VFR and had to see and avoid each other, but in the end, we had two aircraft navigating towards the same NDB below radar coverage. I don't know how often that can happen and we get away with it.

Deja Vu Three

While I was writing this article, the NTSB sent this press release to my mailbox: "Aircraft Accident Brief; Controlled Flight Into Terrain; Learjet 35A, N30DK; San Diego, California; October 24, 2004."

Let me quote a few things from the report that jumped out at me:

"Night visual meteorological conditions prevailed ...

"The accident flight was the fourth and final leg of a trip that originated the previous day ...

"A review of records from the San Diego Flight Service Station (FSS) revealed that one of the flight crewmembers filed the IFR flight plan to ABQ at 0002 on October 24, 2004 ... The flight crewmember did not request any weather information or an IFR clearance and clearance void time ...

"The cockpit voice recorder (CVR) recording revealed that the captain and the co-pilot listened to the SDM automatic terminal information service (ATIS) recording; however, they listened only to the remarks portion of the recording and did not listen to the weather information ...

"The co-pilot then attempted to contact 'Brown Field Municipal clearance' on the radio frequency, but he received no response. The captain suggested that the co-pilot could try contacting the Tijuana tower. The co-pilot stated he could pick up the flight's clearance in the air but then stated, 'I don't want to do it, but ...' ...

"The co-pilot then tried to contact the San Diego FSS via the remote communications outlet frequency but received no reply. He next tried to contact the Tijuana tower but again received no reply. Afterward, the co-pilot tried to contact the San Diego FSS utilizing a different radio frequency but still received no reply. After the co-pilot's fourth failed attempt to obtain the IFR clearance using the radio, the captain said, 'All right, let's just do VFR' ...

"According to the operator, the flight crew had a cellular telephone and a satellite telephone on board the airplane. The CVR recording revealed no attempt by either crewmember to telephone the FSS for an IFR clearance and clearance void time ...

"He also stated that a Runway 8 departure would place the flight on a heading straight toward ABQ, and the co-pilot agreed with this statement. Neither the captain nor the co-pilot mentioned the mountainous terrain to the east and northeast as a consideration in deciding which runway to use for departure ...

"A review of radar data revealed that the airplane climbed to about 2,300 feet mean sea level (msl) and leveled out, and its flight track remained approximately straight out from the departure runway ...

"At 0024:55, the controller stated the flight was radar identified, and he instructed the flight crew to turn to a heading of 020, maintain VFR, and expect an IFR clearance above 5,000 feet MSL ...

"The airplane wreckage was located about 8 nm east of SDM in a mountainous area southeast of Otay Mountain's highest peak. The initial impact point was at an elevation of 2,256 feet MSL ...

"Previous Accident Near SDM: A review of Safety Board accident data revealed that, on March 16, 1991, at 0143 Pacific standard time, a Hawker Siddeley DH125-1A/522 transport-category turbojet airplane crashed into mountainous terrain about 8 nm northeast of SDM, killing 10 people. The Hawker accident site was located within 1.5 miles of the Learjet accident site." [My emphasis added.]

Lost or Found?

I'll be the first to admit that my perspective has been changed by reading all this gloom and doom for all these years. My perspective really isn't the important one, though. Yours is.

You have to ask yourself if your perspective will allow you to make the right decisions at the right time. The rules allow you to depart VFR and pick up your clearance in the air. It's your perspective that tells you when you shouldn't. The rules allow you to fly during periods of inclement weather. It's up to you to analyze the information available and measure the risks. When you're fatigued, stressed or under pressure to meet a schedule, you have to take those factors into consideration and make sure you don't lose your perspective.

Have a safe flight.

Don Brown
Safety Representative
National Air Traffic Controllers Association


Want to read more from air traffic controller Don Brown? Check out the rest of his columns.