True Confessions

ASRS is a voluntary, confidential and nonpunitive incident-reporting system funded by the FAA and administered by NASA. It was created shortly after the crash of TWA Flight 514 into a Virginia mountain on December 1, 1974. The TWA flight crew misunderstood an ATC clearance and descended too soon on an approach into Washington Dulles International Airport. Six weeks earlier, a United Airlines flight crew had experienced an identical misunderstanding and narrowly missed hitting the same mountain. The United crew realized their mistake after landing and reported it to their company, but because a national incident-reporting system didn't exist, the TWA pilots weren't aware of the danger.

Today, according to the ASRS website (asrs.arc.nasa.gov), "The ASRS acts on the information these reports contain. It identifies system deficiencies and issues, alerting messages to persons in a position to correct them." Reports or information filed with ASRS can't be used in enforcement actions unless the information concerns accidents (instead of "incidents"), criminal offenses (such as hijacking, bomb threats and drug running) or a lack of qualification or competence.

As defined in 49 CFR 830.2, an "aircraft accident" is an occurrence associated with the operation of an aircraft in which any person suffers death or serious injury, or in which the aircraft receives "substantial damage." An "incident" is an occurrence other than an accident that affects or could affect aircraft operations safety. Events excluded from the definition of "substantial damage" that may qualify as "incidents" suitable for ASRS reports include the failure of one engine, bent fairings or cowlings, ground damage to propeller blades, and damage to landing gear, wheels, tires, flaps, brakes or wingtips.

ASRS maintains online database report sets on topics of interest to the aviation community. These include altitude deviations, bird strikes, icing incidents, fuel-management issues, weather encounters, nontowered-airport incidents, penetration of prohibited airspace, pilot/controller communications and runway incursions.

As a result of aircraft-separation incidents caused by misunderstood altitude clearances, controllers have recently been instructed to get altitude readbacks from pilots, who were previously permitted to simply acknowledge altitude clearances with responses such as "wilco," "roger" and "affirmative." This new requirement is directed at controllers, but is likely an indication that pilots also need to pay closer attention to altitude clearances.

Generally, if an alleged violation wasn't deliberate, the pilot hasn't had an adjudicated violation in five years and a report was submitted within 10 days of the event, then filing an ASRS report is considered to be "indicative of a constructive attitude." That is, a civil penalty or certificate suspension won't be imposed if the FAA later determines a violation occurred based upon information from another source.

Forms can be downloaded online, and reports can be filed electronically or by mail to ASRS. People filing reports are given a verification code for online filings, and the identification strip from paper filings is returned with a time-and-date stamp as proof that the report was filed. ASRS removes identifying data before entering the reports into a database available to researchers and the public. Of the 45,603 reports filed with ASRS in 2007, 10,531 were GA reports.

Caps Off!
In Scottsdale, Ariz., in May 2006, a flight instructor and two flight-instructor candidates decided to top off a Piper PA28 Cherokee so they wouldn't have to refuel later at another airport. In his report, the instructor explained that "subconsciously, in an effort to save time, I believe I left the fuel caps partially open, in the expectation that the fuel truck would shortly arrive." The instructor was distracted by a discussion, and he decided to depart without the extra fuel because 30 minutes had elapsed since the truck had been called.

Shortly after takeoff, an instructor candidate in the back noted that a fuel cap wasn't secure. The pilot returned to the airport; both fuel caps fell off as the plane entered the traffic pattern. The instructor filed a report because of his concern that when the fuel caps fell, "they would have developed significant energy by the time they reached the surface [and] the airport is located in a densely populated area."

More often, loose fuel caps create another problem. After conversing with another pilot while refueling his Cessna 180 Skywagon in July 2007, a pilot reported that he failed to adequately secure the fuel caps. Two hours and 22 minutes into his subsequent flight, the engine quit. After a safe, three-point landing in a hard-packed cucumber field, he discovered that the left fuel cap was off and fuel had siphoned out.

Who's In Control?
You needn't be the strongest pilot aboard an aircraft to be pilot in command, but if you don't have roles clearly spelled out in advance, it may work out that way.

In February 2005, a prospective buyer wanted to fly a Grumman Cheetah to his mechanic for a prepurchase inspection. The owner "allowed him to fly as pilot in command if I flew with him to assist." On departure from the owner's airport, the buyer became disoriented and began a turn in the wrong direction. Later, at the nontowered destination, he entered a downwind for the north runway but announced on the radio that he was downwind for the south runway. The owner corrected the buyer both times.

The buyer's first approach was too fast and too high; he went around. On his next approach, the airspeed fluctuated by as much as 15 knots and the aircraft came within five knots of a stall, according to the owner's report. When the buyer started to pull back on the yoke to avoid landing short, the owner told him to add power. The buyer then ballooned over the numbers, lost control of the airplane and drifted to a grassy area to the side of the runway.

The owner told the buyer to go around. When the buyer didn't respond, the owner added full power and grabbed the controls. The buyer, who was stronger, grabbed the controls back and turned the ignition off. The engine quit, the airplane settled and they slowed to a stop in shrubs (with no injuries). The owner conceded that they should have discussed the positive exchange of controls and handling of possible outcomes before the flight.

In August 2005, an instructor and student doing pattern work at an airport began to enter clouds. The instructor tried to take control of the Cessna 172 to level off, telling the student three times that she had the airplane. Her larger, stronger student apparently froze on the controls; by the time the instructor "wrestled" the plane from him, they "were deep into solid IMC." The instructor climbed to avoid terrain and obstructions, and radioed the tower to report the situation and request vectors. The instructor was able to land safely at the home airport. In the future, the instructor reported, students will be made to understand, "when I say I have the aircraft, it means they must let go."

Turn On, Tune In & Look Out!
A radio isn't required at nontowered airports, but it can be a great safety accessory when used properly. A careful scan outside the cockpit, however, is always essential when conditions permit.

In August 2007, the pilot of a Piper PA38 Tomahawk returned to a nontowered airport in Tracy, Calif., after takeoff to search for an unidentified item believed to have been left behind. After landing, the pilot realized he was sitting on the "lost" item. The engine was restarted and the pretakeoff checklist was run again. The pilot announced a departure on runway 30, rolled onto the runway and accelerated for takeoff. Just after the Tomahawk rotated, a Cessna taking off on runway 7 passed in front from left to right. During the climb out, it was discovered that the Tomahawk's radio wasn't on.

This event was attributed to "being sloppy and hurried in going through the prestart checklist. The ’lost item' got me out of synch, having to turn around and land again," the pilot reported. His flying had mostly been in airplanes where the radios were left on and canceled by the master switch. This was his third flight in the Tomahawk, where the radios were a separate checklist item, he noted.

In April 2007, a Cessna 172 departed Melbourne International Airport in Florida with the radio on. Its ATP/CFI-qualified pilot later decided to make some practice landings at Merritt Island, a nontowered airport. He had checked the NOTAMs for Melbourne before the flight, but not for Merritt Island. Unfortunately, the Merritt Island radio frequency had changed since the most recent printing of the local aeronautical chart. The 172 pilot made calls in the pattern on downwind, base and final---all on the wrong frequency---before landing on runway 29. Only then was a Cessna 152 observed rolling out in the opposite direction. Both aircraft moved to the right and passed each other near the 3,601-foot runway's midpoint. The 152 pilot said he didn't see the 172 until after touchdown because he was practicing an emergency landing.

If you file an ASRS report because you made a mistake, odds are you'll know what it is you need to do to keep from repeating the unsafe event. So do it, and accept the gratitude of those of us who may learn from your "true confessions," just as you may learn from ours.