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Archive for the ‘Threat and Error Management’ Category

Free Runway Safety Card from FAASTeam

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FAA Runway Safety Program Approach Chart For Pilots
Notice Number: NOTC1099

The FAA Runway Safety Program has made available through FAASTeam the following information card, which will fit in your approach plate book. To see or print the information card please use the web link below:

To obtain copies of the above card, please contact your local FAASTeam Program Manager. For more information on who is your FAASTeam Program Manager and Runway Safety information, please go to Taxi (and Takepff/Land) Smart


Written by Clark

January 23, 2008 at 7:29 am

In-Close Approach Change (ICAC) Events

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If you are flying into an airport, consider the hazards involved with changing your planned runway in a dynamic environment. Make sure you are familiar with the new runway information, check navaids, and be ready for a new taxi plan. If you’re not ready, build time by asking for vectors while you get set up or going around. Please yourself first, this is not the time to rush.


From NASA’s Aviation Safety Reporting System

Issue 335

November 2007

Air Carrier In-Close Approach Change (ICAC) Events

At the request of NASA Ames Research Center’s Human Systems Integration Division in early 2007, ASRS performed a review of ASRS Database reports referencing In-Close Approach Changes (ICAC) – also termed Late Runway Change and Change in Runway. The ASRS Database reports spanned the time period of January 1996 to the present. Three hundred thirteen (313) relevant air carrier pilot-reported ICAC events were identified.

For the purposes of this analysis, an In-Close Approach Change Event is defined as one in which an ATC directed change from an originally assigned arrival, approach, or runway assignment results in an incident. Examples of these incidents are unstabilized approaches, track or heading deviations, speed deviations, controlled flight toward terrain (CFTT), loss of separation or airborne conflicts, wake vortex encounters, loss of aircraft control, breakdown in crew coordination, and other safety concerns cited by reporters.

Go directly to CALLBACK

HTML Version – View CALLBACK Issue 335 in html…

PDF Version – Download PDF of CALLBACK Issue 335…
[Note: To print PDF to 8.5 x 11 page, select the “Shrink oversized
pages to paper size” option in Print dialogue box]


If you don’t already get Callback electronically, sign up at ASRS

Fly Smart


Written by Clark

January 17, 2008 at 3:06 pm

AOPA ASF Seminar Top 5 Mistakes Pilots Make

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I went to the AOPA Air Safety seminar “Top Five Mistakes” in Ft Worth last night, hosted by Tarrant County College. It was a great turnout, almost 400 attendees. Pat Shaub of Eagle Training Solutions gave a great brief.

From the AOPA Air Safety Website

“Top 5 Mistakes Pilots Make

It’s sad but true: In an average year, three quarters of all accidents are caused by pilot error. And the mistakes that lead to those accidents? For the most part, they’re the same ones pilots have been making for decades.

ASF’s latest seminar takes new aim at those old mistakes. We’ve identified the most common fatal errors pilots make and put together a show that’s full of practical tips for avoiding them. From steering clear of weather to maneuvering safely and much more, if you’re looking to minimize your chances of being involved in a fatal accident, you’ll definitely want to attend this seminar!”

The Top Five Mistakes occurred while managing the following:

5. Fuel (8%)

4. Descent and Approach (10%)

3. Takeoff and Climb (13%)

2. Weather (14%)

1. Maneuvering Flight (33%)

What we can do now is couple this seminar information with focused pilot proficiency training. The new Wings program applies special emphasis to incident and accident causal factor areas of operation. These areas should be addressed when flying with a flight instructor.

The AOPA Air Safety Foundation’s safety seminars qualify for the safety seminar portion of the FAA WINGS program. Did we mention in addition to becoming a better pilot we can save money too? Learn more about the AOPA Accident Forgiveness and Deductible Enhancement for AIG Aircraft Insurance policyholders.

Fly Smart


Written by Clark

January 15, 2008 at 9:39 pm

FAA moves to extend runway safety requirements to all certified airports

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Wednesday January 9, 2008 ATW

US FAA yesterday proposed extending the requirement that the US’s 75 largest airports make enhancements to taxiway centerline markings to all 567 certificated airports as part of its ongoing effort to mitigate the risk of runway incursions.

The agency also is recommending “regular recurrent driver training for all persons with access to the movement area and ramp areas at certificated airports.” Acting Administrator Bobby Sturgell said the nation’s largest airports have heeded FAA’s runway safety “call to action” (ATWOnline, Oct. 23, 2007) and that yesterday’s proposals are intended to extend the safety improvements to smaller facilities.

The 75 largest airports are required to upgrade runway centerline markings by June 30. “Most have already completed the work,” FAA said. Of the 567 certificated airports, more than 300 “are in some stage of voluntarily adopting the standard.” The agency added that 385 airports now “require recurrent training for nonairport employees such as Fixed-Based Operators or airline mechanics” operating vehicles on runways and said such training should be a requirement for all certified airports. Interested parties have until Feb. 26 to comment on yesterday’s proposals.

While FAA touts success in reducing the risk of incursions, the US Government Accountability Office issued a report last month casting doubt on claims of progress, concluding that “the rate of runway incursions has not decreased over the last five years” (ATWOnline, Dec. 6, 2007).

by Aaron Karp



Fly Smart


Written by Clark

January 9, 2008 at 2:29 pm

Crosswind Landings

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Crosswind Landings

By: Brad Whitsitt (

Did you know… crosswinds are the number one cause of weather related
General Aviation accidents every year?  The NTSB counted 2684 GA accidents
that were weather related from 1995 through 2001.  25% were due to
crosswinds.  In fact, the top two, Crosswinds and Gusts make up 45% of
weather related accidents.  In comparison, Low Ceilings account for 7% and
Icing just 2% of weather related accidents.

Crosswind accidents are almost never fatal, so they do not get much press.
But, accidents are still traumatic and cost millions in the industry.  Some
in the industry believe that there are many more crosswind accidents than
are reported.  We all know stories of pilots who make trips through grass,
mud, lights, storm drains, fences, etc.  Many of us have made the trip
ourselves after a crosswind landing.  We have all watched crosswind
landings and wondered how some pilots ever make it.

Why are there so many crosswind accidents?  Here are some facts.

Low experience – Many GA pilots have very little crosswind experience.
Think about it.  If you can fly, you are not going to hurt yourself in the
pattern.  Even on final approach, as long as you can maintain speed and not
hit a tree all is well.  But, at the ground, when the aircraft must now
work with the Earth to land in a crosswind, there is a 5 second window to
do the right things.

Look in your own logbook and count the times that you landed with a + 10
knot crosswind component.  Now, multiply that by 5.  This is the number of
seconds of real crosswind experience you have in your flying career!

How can anyone be good any anything when they have only 2 minutes of
experience?  Most new private pilots are very lucky if they have 90 seconds
of experience.

Low Currency – We all know that the FAA requires 3 takeoffs and landings
every 90 days.  But, there is no required currency for the more difficult
crosswind landing.  For many pilots, it has been a year since they had to
land in a crosswind component over 10 knots.

Limited Testing – Most checkrides occur on good weather days.  It is very
unlikely that pilots must demonstrate landing in a +10 knot crosswind
component.  We all know how to talk about crosswinds on our checkride but
can we do it.

Even when checking out in a new aircraft at the local FBO, how many do that
on a windy day.  We probably don’t have to demonstrate crosswind skill to
them either.  During flight reviews, we are likely to do that on a good
weather day too.

My point is that pilots can go a long way through the ratings and not know
how to master crosswinds.
Hard to Practice – Even if you decide that you are going to get good at
crosswinds, you must find the right weather.  The wind must be strong but
not too strong and other conditions can’t interfere like rain, snow, and
clouds.  If you are going to practice on your own, the outcome must be
successful.  You need to practice beyond your comfort zone in order to
learn.  But, you can’t have an accident.  Wow!  What a challenge.

You can get an instructor.  But, then you must schedule a time and you
can’t schedule the conditions.  Even if you want to practice, it can be
hard to match your schedule, the instructor’s schedule and the weather’s

If you get the right weather, look how long it takes to go around the
airport to get 5 seconds of practice on each landing.  Can you land 10
times in an hour?  With an instructor, you can easily spend $150 to get 50
seconds of experience assuming other traffic does not interfere.

Instruction is Weak – Many flight instructors are not that good at
crosswinds themselves.  Many instructors destined for the airlines may have
only 300 hours when they start instructing.  How much crosswind experience
do they have?  3 minutes?  How much crosswind experience do they have from
the right seat?  1 minute?  As a Chief Flight Instructor, I have heard some
very poor crosswind technique offered to students by instructors.
Instruction in the industry is weak.  How many pilots continue to employ
improper technique because they learned it from their instructor?

There is also little incentive for an instructor to risk their tickets to
help entry level pilots get good at crosswinds.  The prevailing idea is to
give a student pilot the basics and let them figure out the rest on their
own ticket.

I was told by an FAA examiner in Chicago that he fails 60% of private pilot
applicants because they have no idea how to handle an airplane in a
crosswind.  He has ways of testing that when it is calm.  Many examiners
are not looking as hard at this issue.  But, he would agree that
instruction in this area is weak.

As I continue to work on crosswind instruction, there are my pilots who
have been flying for 500 hours, let’s say, who do not know exactly what
they are trying to do in a crosswind.  For example, if you believe that you
need to “plant” the airplane at the highest possible speed in a crosswind,
you may do this every time even though it does not work very well.  It is
surprising how many wrong concepts are used all the time.

You Should Know by Now – It is very hard for some pilots to admit that they
really need help after they have flown for 5 years and still have not tamed
the crosswind landing.  I just want to encourage you a little.  How can you
do something for only 2 minutes with weak instruction and no testing, that
you last tried a year ago, and expect to be good at it?  Get some help and
really dive into getting good at it.  It sure can be fun and greatly adds
to your safety factor.

Xwind, LLC has created a motion based simulator that places a pilot in a
gusty crosswind forever with no risk.  As a pilot, you can sit there in a
cockpit that rolls, yaws, and moves laterally with no flat computer screens
and you can achieve excellence in crosswind skill instead of just getting
by.  You will see results in the airplane the very next time you fly.

Become a professional!  Check out the training centers at: and
multiply your crosswind experience by 100!

Brad Whitsitt is an Electrical Engineer and Flight Instructor with over
4000 flight hours.  Brad is also the president of Xwind, LLC, a company
dedicated to crosswind landing skill excellence.

Written by Clark

January 3, 2008 at 7:45 pm

ATC Tips for Pilots

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From Aviation Safety Magazine Oct 2007, good advice to fly by…

-Listen for other traffic on frequency before transmitting

-Make your radio call, then be patient for a reply-the controller may be busy coordinating traffic you can’t hear or be on the land line

-Be precise and brief, use standard terminology and be professional.

-Get weather information before calling for clearance, taxi or checking in for approach and landing.

-Read back clearance completely and in order received. Make requests for ammendments before taking off.

-If you file it, be able to fly it.

-ATC can pass along current weather, but they are not forecasters.

-Traffic avoidance isthe pilot’s responsibility, even in IMC.

-Know when you have to ask for altitude changes and when you don’t.

-Follow published procedures when cleared for a transition or approach.

-You determine your level of safety, not the airplane.

Fly Smart


Written by Clark

January 2, 2008 at 3:49 pm

Runway Safety & Communications 101

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“WestJet plane in near-miss at L.A. airport

WestJet Boeing 737 came within 15 metres of colliding with a Northwest Airlines Airbus A320 that was taking off

LOS ANGELES (AP) – A WestJet airliner on a flight from Calgary was involved in a near-miss Thursday with another jet on the tarmac at Los Angeles International Airport, aviation officials said.

The close call happened at about 1 p.m. and appeared to have been the result of mistakes made by both the arriving pilot and a ground traffic controller, said Ian Gregor, a spokesman for the U.S. Federal Aviation Administration.

Officials said the WestJet Boeing 737, which seats up to 132 passengers, came within 15 metres of colliding with a 150-seat Northwest Airlines Airbus A320 that was taking off.

The Northwest jet was travelling about 240 kilometres an hour when the WestJet plane approached its path. The WestJet plane managed to stop just in time to avoid a crash.

No one was hurt, authorities said. An investigation was under way.

Gregor said the arriving pilot switched radio frequencies too early after landing and was unable to receive final directions from the air traffic controller, the Los Angeles Times reported on its web site.

When the WestJet pilot notified the ground traffic controller that the plane was proceeding to its gate, the ground controller cleared him without checking first with the air traffic controller.

Aircraft arriving at the Los Angeles airport must cross the inside runway to reach their gate.

The “runway incursion” was the eighth such incident at LAX this year, matching the total for all of 2006.”

Communications are key for safe operations on the ground. Keep aware of active runways during taxi and assess incursion potential.

Fly Smart


Written by Clark

August 31, 2007 at 6:02 pm

Runway Safety Threat and Error Management

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How to”fly smart” in the airport ground environment? Get a current airport diagram and use it! Here are some tips from FAA SPANS Notice Number: NOTC0932

Line Safety Audits completed by the airlines revealed 23% of errors and 38% of the threats occur before ever leaving the ground.

A crucial part of the flight process is pre-flight planning. Accident analysis reveals that preflight planning is often inadequate or entirely ignored. An important part of this flight process is the obtainment of information for your departure, arrival, and alternate airports. This should include utilizing a current Airport Facility Directory, obtaining current NOTAMs, and having a current Airport Diagram. And not only should we have it, it should be out in plain view and ready for easy reference.

Airports Diagrams are readily available (and FREE!) to download at If you are an aviation nut you must like charts also, especially free charts given to you by Uncle Sam. The Federal Aviation Administration (FAA), National Aeronautical Charting Office (NACO), publishes and distributes United States government civil aeronautical charts and flight information publications. You can now download or order these charts online.

It is not only important to have a current airport diagram, but to also USE THEM. You should review the airport diagram before taxi while stationary; and then after receiving your taxi clearance, review the diagram again to ensure that you are familiar with the taxi route and any hold short instructions. Red and White signs and markings mean STOP, do not taxi past unless you have been cleared to do so. Use your charts and checklists, and look outside, both on the ground and in the air for other aircraft. Listen for traffic on the radio too, this helps build a mental picture of activity at the field. Just like a railroad crossing, Stop (at least mentally), Look and Listen when approaching all taxiway and runway crossings. ATC can help out and provide progressive taxi instructions when we are unsure of where we are or where we need to go. A few questions up front will save answering a lot of questions later. If there ever is a question, STOP and ASK!

Visit the FAA NACO site to download the entire library of Airport Diagrams and Terminal Procedures…or go to the FBO and pay a lot of money….

You can also check out the award winning online Runway Safety course provided by AOPA. It’s FREE!

One thing that I do is take a yellow highlighter and highlight the area (FBO, Terminal) on the diagram that I am going to. A Nav Log goes a long way on the ground too, so you’re not heads down looking for frequencies while taxiing. When at all possible, do your checklists when stopped, esp if you are single pilot. We also turn on all external lights when crossing an intersecting runway, which is especially effective at night. If you have a TCAS, you can use that on the ground too to build that mental picture of airborne traffic. At a lot of major airports, they now want you to leave your transponder on at all times, so the Airport Movement Area Safety System can electronically see you and keep ATC in the loop.

If you have any special tips and techniques, let’s hear about them.

Fly (and Taxi) Smart


Written by Clark

July 20, 2007 at 9:28 am

Stop, Look and Listen

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From our local FAA Safety Program Manager…

“DOT Says Serious Runway Incursions Still a Danger
The Department of Transportation Office of the Inspector General (IG) said
in a report  released last Thursday that runway incursions remain a
persistent, serious problem, despite the FAA?s efforts to reduce their
frequency. Though the focus of the IG?s study was at Boston Logan, Los
Angeles International, Philadelphia International and Chicago O?Hare
airports, where incursions have recently increased, the results of the
study gave recommendations for system-wide improvements. The study said the
FAA should engage in better information sharing to communicate root causes
of deviations and communicate best practices that have worked to reduce
incursions; focus more on controller human-factor issues and training; and
improve accountability at the national level to ensure runway incursions
remain a top priority. According to the study, runway incursions have
decreased from a high of 407 in fiscal year 2001 to a low of 323 in fiscal
year 2003. Since then, the numbers have remained relatively flat. According
to the IG?s study, the FAA did not comment on how it would address the
concerns noted in the report.”

And my thoughts on the matter….

An open, learning, just reporting culture will be a good start so that rich data can be gathered. then throw in valid risk assessment and a vigorous safety awareness campaign. “Stop. Look. Listen”. Another risk management system that works is “Ask, Assess, Act.”

We need to go beyond who did what, and look at “Why” it happened, and at what level the hazard was generated. Runway Incursions are an area where “Production” goals are outstripping “Protection” mitigations. Time pressure is huge at large airports to increase capacity, and it shouldn’t be. There’s only one thing that can happen when you try to put too much stuff in too small of a bag. There are latent hazards that reside at the Decision/Policy Maker and Line Management level, and they become active failures during the productive activities of controllers, ground vehicle operators and pilots. High ops tempo is always a factor, cognitive task loading leads to increased slips, lapses and mistakes. Invalid assumptions about system performance lead to skewed behaviors, high risk consequences and sub-optimal decisions.

Is the hazard more frequent (percentage wise) at these high capacity airports vs small towered fields? If so, capacity (production) is a risk element that needs to be transferred, eliminated, or mitigated.

Do air traffic controllers have reporting protections similar to those offered by ASAP? When we extend those privileges to everyone, all users of the NAS, then the number of reports will actually go up, which is a sign of a healthy reporting system. Then we will have a better contextual view of the system and be able to focus on “Why”, not “Who”. From there we can develop and implement valid action items and monitor their effectiveness.

Fly Smart


Written by Clark

May 31, 2007 at 11:26 am

Dr Funk’s Words of Wisdom

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I had a chance to talk to Dr Wally Funk on Wednesday and she took me through a crash investigation slide presentation that she delivers at safety seminars. I am working on a preservation project to digitize her slides. What struck me was the similarity of her comments to those of Herb Webber, another local safety rep who I talked to last year. (Herb’s wisdom is posted below).
It is amazing the number of crashes that could be prevented if people would use a checklist properly. Check for fuel. Check for contaminated fuel. Check your prop. Check your electrical system. Check that the CONTROL LOCK is REMOVED before attempting any junior birdman/birdwoman activities! Stay out of box canyons. You get the idea. The system tries to trip you up enough without helping it out.
Be professional, be smart. And as Wally says, “don’t wreck your airplane and yourself.”

Read Dr Funk’s Bio. Hold on to your jaw, because it will drop as you read it!

Fly Smart


Written by Clark

May 9, 2007 at 9:56 pm