Case Studies of Narrative Safety Reporting Programs

Review case studies from operators in their own words that highlight best practices and lessons learned from actual implementations of narrative safety reporting programs.

• Hold Short Line
• FMS Data Entry Issue
• Near Midair Collision With Glider
• Bird Strike
• Altitude Deviation
• Rejected Takeoff
• Aborted Takeoff
• Heading/Course Deviation
• Missed Crossing Restriction – CRM With New Hire SIC
• Go-around at Non-towered Airport
• Duty Time Issue for Medevac Operations
• ASAP, FOQA and ASIAS Use by a Large Part 135 Operator

Hold Short Line

Result: Increased Level of Safety; ASAP “Violation Protection”

All four of the company aircraft were being ferried (crew only) to KXXX to be in place for the transport of company leadership the following day. Because of its location near a major city, KXXX has an uncomfortably small FBO ramp and very high level of activity; however, we all know the airport and FBO very well, operating through there at least several times per month.

The aircraft were launched 15 minutes apart to give the FBO time to park us on their ramp. We were the third aircraft to land, but, due to ATC routing, we landed only a few minutes behind our second aircraft (#2). The taxi route to the FBO requires the crossing of an active runway with the FBO ramp immediately on the other side. We were both on Ground frequency and #2 had just received clearance to cross that runway to the ramp as we cleared the active runway and turned onto the same taxiway behind him.

Our clearance was to hold short of the runway #2 just crossed. After acknowledging the hold short and hearing the pilot in command (PIC) repeat that back to me I, as the pilot monitoring (PM), announced I was going to the FBO frequency to coordinate our parking. As the PF taxied slowly towards the runway and I was talking on the radio, we were both intently watching the progress of #2 on the ramp across the runway trying to anticipate our own parking location. Being cleared directly across or being told to hold short at this intersection occur with equal frequency, I completely forgot about the hold short clearance, and so our movement forward seemed normal to me. As we approached the runway, I suddenly felt the PF abruptly bring the aircraft to a stop and ask me if we were told to hold short. I said “Yes.” At that point, we realized our nose was beyond the hold short line and witnessed a light GA aircraft go around in front of us. Our distraction and familiarity caused a runway incursion.

We clarified our clearance with Ground to hold short and that we were physically short of the runway. We were subsequently cleared to cross the runway to the ramp. After we parked, I called the Tower to discuss the event. It was a cordial call and we both better understood what happened. While they didn’t feel it was necessary, I mentioned I was going to file an ASAP report. I also filed a NASA report and an internal SMS report, and thoroughly explained things to our ASAP Gatekeeper.

A few weeks later I received a call from the local (KXXX) FAA inspector to discuss the event. He came across it as part of a routine audit in his FSDO. I stated we were a member of the ASAP program, which he was unaware of, since we fall under a different FSDO. After thoroughly discussing the sequence of events, he asked for a written report – since he was not privy to the original ASAP report – and my suggestions to prevent a recurrence. I recommended the following:

• Thoroughly brief the incident to our pilots at our next quarterly pilot meeting. Since we routinely operate through this airport and FBO, the distraction and familiarity I fell prey to could happen to any one of us.
• Change our SOPs to explicitly disallow any other duties/activities by either pilot as a runway is approached until either the aircraft is stopped short (hold short clearance) or completely across (cleared across clearance).
• Consider designating this runway/taxiway intersection as a “Hotspot” on the taxi diagram. The narrative should state that the visual volume of activity on the FBO ramp can cause distraction as the runway is approached.

The inspector accepted my report and, to close out the incident, requested a signed training roster from the briefing I presented at our pilot meeting.

The ASAP program directly increased the level of safety at this airport (at least in our department) and avoided a violation on my otherwise clear, 41-year flying record.

FMS Data Entry Issue

Result: ASAP “Violation Protection”

We were eastbound from Europe to the U.S. and had just crossed 20 West using CPDLC and ADS-C with Shanwick.

As the Pilot Monitoring (PM), I noted the position and other flight details for the plotting chart and flight log. The Pilot Flying (PF) stated he was going to use a 1.0 NM offset and I verbally agreed. As he began entering that in the FMS, I looked away to annotate the log and began plotting the position. When I finished in less than one minute), I looked up at my map display and noticed the aircraft was heading away from the cleared track to the right as expected. However, we were approximately 4 NM right of course and continuing away. It appeared the FMS did not capture the offset and turn back to the correct heading. I called this out to the PF, and he immediately selected Heading mode and began a turn back to the cleared route. As we were in the turn, Shanwick sent us a CPDLC message and a SELCAL as they saw us moving away from the cleared course. I established contact on the primary HF, explained what I thought had happened, and told them we were correcting. The maximum distance off course was approximately 6NM.

When we went back to the FMS to reenter the offset, we noticed that it was programmed for a 10 NM offset, not 1.0 NM. The PF remembers entering the “.” when he typed 1.0; however, either it did not register when he pressed the key or it was missed. Regardless, if I had been monitoring and confirming his entry, this error would have been caught. Our high level of experience with North Atlantic crossings (36 years) and familiarity with each other lead to complacency which did not catch this error.

Upon our return, I filed a company SMS report and discussed it with our Gatekeeper. Since we were not in U.S. airspace, I asked if filing an ASAP report was worthwhile or appropriate. He emphatically said “Yes” as the foreign ATS might report the incident to the FAA.

Near Midair Collision With Glider

Result: Reporting to FAA Hotline and Submitted a Chart Change request

ASAP Report: Near mid-air collision on right downwind to VRB Runway 12R. While on an IFR vectors to the northwest at 1500′, we were advised of traffic off our left wing. We never saw that traffic, but instead had a near miss with a co-altitude aircraft (appeared to be a glider) approximately 500′ off our left wing. The aircraft was not squawking. We had no time to maneuver away.

The aircraft was approaching Vero Beach (KVRB) for landing when they had a near midair collision with glider traffic. The New Hibiscus Airpark (X52) is not shown on the IFR charts, but is depicted on the sectional chart for this area.

In response to the event, the operator submitted a report through the online FAA Hotline portal and submitted a charting suggestion to the FAA to increase awareness of the airpark. The ATIS at KVRB has been updated to include the statement “Glider operations in the vicinity of the airport.”

Bird Strike

Result: Maintenance Inspection

ASAP Report: Small flock of birds cut across our takeoff roll at high speed. There was no way to avoid hitting them without further danger to aircraft.

The crew reported the bird strike via ASAP. The aircraft was written up for a maintenance inspection. No action required of the crew by the ERC.

Altitude Deviation

Result: Crew Counseling

ASAP Report: We just completed the NAME Arrival and were getting vector to the approach segment of 19R into KZZZ.

We were given a heading of 300 and 6300′ attitude. We were very busy with traffic, terrain, and getting the aircraft configured. We accidentally set 3600′ in the FMS during the business of everything.
ATC informed us of our attitude at about 5500′; we recovered immediately to 6300′. We proceeded with the approach and arrival without incident.

This was a straightforward mistake due to a busy flight deck and two tired crew members. We followed procedures correctly for setting the perceived correct altitude, but we both misheard the altitude as “3,600 feet” instead of “6,300 feet.” We had two long duty days in a row, and I had not slept well.

As a result of this ASAP report, the crew received coaching on the fatigue policy, which emphasized that it is okay to call out “fatigued” if appropriate. No further action was required of the crew.

Rejected Takeoff

Result: Crew Counseling, Checklist Revision Request

ASAP Report: After completing de-icing procedures, the crew received taxi instructions to the runway. The taxi route involved a back-taxi on the runway.

While turning the aircraft around to line up on the runway, we received our takeoff clearance and Pilot Monitoring verbally ran the lineup checklist and announced all items done.

The PF applied takeoff power and we immediately received a config-error trim warning. The PF brought the throttles to idle to assess the situation, and the aircraft had traveled less than 50 feet down the runway. The trim was reset correctly, and the takeoff was completed.

The crew received counseling on the need to exit the runway after a rejected takeoff to verify aircraft configuration and communicate with the company. Additionally, a request to change the de-ice checklist was made to include “Reset Trim.”

Aborted Takeoff

Result: Checklist Revision

ASAP Report: We were cleared for departure on runway 31 at KZZZ. The Pilot Flying (PF) executed a rolling takeoff, pushing the power levers to the takeoff detent. Within a second of reaching takeoff power, we received a red configuration warning CAS message.

The PF reduced the power to idle and executed an aborted takeoff, slowly rolling out to taxiway C and exiting the runway. I notified the Tower of the aborted takeoff.

It was immediately clear that the reason for the warning was a rudder trim indication that was just outside of the normal range. We corrected the rudder trim position, conferred with each other, and determined that we were still within acceptable brake cooling limits. We returned to runway 31 and executed a normal takeoff and flight.

As a result of a rejected takeoff, the operator changed their “Before Takeoff” checklist. A new line item was added – “Rudder Trim – Check” – to ensure that the crew verifies the rudder trim position to reduce the number of aborted takeoffs.

Heading/Course Deviation

Result: Training Provider Coordination

ASAP Report: The wrong departure transition was entered in the CDU. This mistake was quickly realized after a prompt from ATC and corrected on course.

As a result of several course deviation reports, the operator worked with their training provider to require more focus on the issue during initial and recurrent training events. Additionally, there is a Line-oriented Flight Training (LOFT) scenario where crews receive departure changes and need to manage the event.

Missed Crossing Restriction – CRM With New Hire SIC

Result: New Training Courses Developed

ASAP Report: The aircraft was inbound to KZZZ (an airport without a standard terminal arrival route) and at FL190. The PIC was looking at the approach and re-listening to ATIS – and was therefore distracted.

ATC called for “Direct to FIX, Cross FIX at 11000 feet.” The PIC only heard “direct to FIX” and did not hear the descent. The readback from the SIC was low and blocked out by ATIS.

The PIC watched the SIC enter the waypoint and direct to fix, and a visual confirmation (nod) was given to the SIC.

The PIC started looking at approaches and looked up and saw the SIC entering a crossing into the FMS. The PIC looked up and saw FL190 in the Altitude Selector and looked back at approaches for less than a minute.

The PIC looked up and saw 11,000 in the FMS. The PIC was about to query the SIC when ATC asked, “Are you going to cross FIX at 11000’?” We were approximately 6 miles from the fix.

The PIC quickly asked the SIC if we were given that crossing. The SIC acknowledged that we were; the PIC immediately started an expedited descent to 11,000’ and advised the SIC to tell ATC that we were descending to 11,000’, which he did.

The PIC then mentioned to the SIC that he should have set 11,000’ in the Altitude Select. Passing approximately 14,000’, the controller cleared us down to 1,700’, and asked if we needed some time before a vector towards the Final Approach Fix.

We asked for 5 miles and the controller acknowledged. A few miles later we were given a vector towards Final and a couple of minutes later we were cleared for the visual approach.

After landing (post brief), the crew discussed the importance of good communication when setting the Altitude Select. The setter must set and wait for an acknowledgement, as well as communicate positively any altitude clearance changes. Contributing factors were the PIC’s distraction with ATIS and reviewing approaches, radio masking, and SOP noncompliance in Altitude Select procedures.

As a result of this report, and similar events with low-time, new-hire SICs, the company instituted a new SOP training course through their training provider. The SOP training will ensure new-hire SICs are fully trained on SOPs.

Additionally, the company is developing training for new hires after their initial training at the training provider. The new training is intended to help bridge the gap between initial training and gaining additional experience as they integrate into the operation.

Go-Around at Non-Towered Airport

Result: Follow-up With Safety Department, Refresh of Procedure

ASAP Report: We were on a vector heading for the RNAV XX approach into KZZZ (a non-towered airport).

There was an IFR aircraft departing that ATC was waiting to hear from, before we could start our approach.

ATC gave us a lower altitude and a heading back around that sent us towards the final approach fix on the straight in for the RNAV XX approach.

After hearing from the other aircraft, ATC cleared us for the approach and by that point we had the airport in sight. I had heard another aircraft was inbound after us, so we decided to cancel IFR and proceed VFR to the airport, but following the vertical and lateral path of the approach. ATC appreciates when aircraft can do this, as it frees up the airspace and allows aircraft to either arrive or depart faster.

We were told to switch to CTAF frequency. I called the CTAF airport frequency and stated our position. We observed no other aircraft in the pattern and continued the final approach into KZZZ. As we were descending, we heard AIRLINE 123 call a base leg to final for runway XX without checking if any other aircraft were on approach.

They were above us about 1,000 to 1,500 feet and 1 to 2 miles in front of us. I then made another position report and advised them that we were on final for runway XX and they were above us and should make a left turn back around to enter the traffic pattern behind us.

They said ATC left them high, so they would have to do s-turns in order to descend and land. I advised them again of our location and they should make a left turn and re-enter. Our TCAS alerted us of the traffic, which we had in sight, and by this point I realized he did not care that we were below him and already established and stabilized and he was going to do s-turns on top of us to make the landing. We slowed down and executed a go-around behind him and re-entered the traffic pattern for a safe landing.

As a result of this report, the company reached out to the airline’s safety manager. A meeting was held with the airline’s chief pilot and safety manager to discuss the event. The airline sent a “must-read” email to their pilot group reminding them of the non-towered airport procedures.

Duty Time Issue for Medevac Operations

Result: Duty Time Calculator Revised

An ASAP report was submitted for a medevac operation where the time needed to transfer the patient from ground transportation to the aircraft resulted in additional unexpected crew duty time. This additional transfer time was not accounted for by the operator’s duty time calculator.

As a result of this report, the operator conducted an audit of different types of medevac patients to identify patients that required extra transfer time. The operator added a new category of patient to their duty time calculator, with additional transfer time built in, to help eliminate exceedances of duty time.

ASAP, FOQA and ASIAS Use by a Large Part 135 Operator

We routinely publish deidentified ASAP reports, so other peers can learn from these events. When appropriate, we reinforce the appropriate SOP or threat and error management (TEM) concept that would have helped the crew prevent the issue in the report. We also publish the latest Safety Performance Indicator (SPI) tracking.

We track our rates relative to the FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) GA ASAP rates for the same categories and phase of flight.

Our safety performance metrics are based on the ASIAS industry rates. We use ASAP reporting for most of the SPIs, except in unstable approaches because nobody ever self-reports on those in ASIAS it seems.

We are building cross-talk and cross-communication about safety risk by getting our maintenance teams and flight coordination team more comfortable with ASAP report submittal as a safe vehicle for reporting near misses and events.

We brief our aviation executive every quarter on our SPI performance relative to ASIAS rates and of course have our own targets. The ASIAS data provides a reference frame. While ASAP is somewhat subjective in nature, it is based on reporting, and, without a full FOQA program, we have to continue to return value to the employees in respect for their reporting.

Our monthly reporting has roughly doubled (from 25 to 50 reports per month) based on the shift to publishing deidentified reports. Only 20 of the roughly 700 reports we received last year were based on pilots’ fear of a pilot deviation being filed against them.

We see ASAP reports submitted for about 4% of flights and about 17% of the pilots reporting. We do not have what some call ‘over-reporting’ by a single individual.

Through ASAP reporting our aviation executive sees us:

• sharing TCAS reports to try and address the airspace issue
• talking with various tower operators about issues
• working with flight schools at airports where pilot training interferes with jet traffic
• addressing process issues relative to fatigue and flight scheduling

Every six months we hold a corporate safety review board with the executive team and the FAA. We discuss trends; safety risk management activity; root cause investigation results and subsequent changes; and safety assurance from IEP, ASAP, safety hazard reporting and FOQA. We also review the safety promotion activity and discuss the open items

An improvement we will make this year is to discuss the value created by the safety activity we undertake with safety risk management. We preemptively use hazard analysis and Lean Kaizen-type activity to assess changes for processes, programs and procedures. We require the executive VPs and Division VPs to report on the safety activity in their divisions/departments.

The feedback from the corporate safety review board is positive all the way around, as everyone develops a continuum of understanding about where our risk is, what we are doing about it, and how we rate relative to others.

Ground Safety Reports

We implemented tracking of ground damage incidents and steps taken to reduce the likelihood of future occurrence, then tracked how well the changes performed with the vendors that supported the carrier (a large Part 121 air carrier).

We were able to determine if the actions taken had the desired impact, or if we needed to do more to find and address all the contributing factors. We would track the change in rates from the point of implementation.

The best practices were shared at quarterly meetings with all vendors. We used feedback from vendors on things that contributed to communication breakdowns or confusion on an SOP so we could address the gap.

All these items helped reduce incident occurrence rates and improve operating efficiency.

ASAP and FOQA Together

At a previous employer that had full FOQA, we used the data and ASAP reports to develop videos on the risks of a particular airport arrival. The crews could access and watch the videos anytime. We sent a message to the flight deck before top of descent reminding them of airports characterized by unstable arrivals/approaches. Our unstable approach rate dropped by 73% over a period of six months.