ISSUE NO.

10 DECEMBER 1998
The Aviation Safety Reporting System is a cooperative program established by the Federal Aviation

Administration’s Office of the Assistant Administrator for System Safety, and administered by NASA

Cockpit Interruptions and Distractions

by Key Dismukes, Grant Young, and Robert Sumwalt

…Page 4
10 Crossing Restriction Altitude Deviations
on SIDs and STARs
by Jeanne McElhatton, Paul Buchanan, and Charles Drew

16 Communications-related Incidents in
General Aviation Dual Flight Training
by Kamil Etem and Marcia Patten

23 ASRS Services on the Internet

An Introduction to Issue Number 10 December 1998

H
ere is Issue Number Ten of ASRS Directline. We have presented a summary of two of ASRS’s research
efforts—Crossing Restriction Altitude Deviations on SIDs and STARs, and Communications-Related Incidents
in General Aviation Dual Flight Training. Both studies were presented at the Ohio State University Sym­
posium on Aviation Psychology in 1997.
Another excellent article, Cockpit Interruptions and Distractions, is one of the best reviews of these types of
problems we have seen—it may be an effective tool in your training syllabus or perhaps something you might
wish to incorporate in your operational procedures.
Users are encouraged to reproduce and redistribute any of the articles and information contained within
ASRS Directline. We DO ask that you give credit to the ASRS, Directline, and the authors. We also request that
you send us two copies of any publication or other material that makes use of Directline articles or information.
Here are the articles for Issue Number Ten:

Cockpit Interruptions and Distractions

Effective Management Requires a Careful Balancing Act
by Key Dismukes, Grant Young, and Robert Sumwalt

4
Distraction is a commonly cited contributor

to incidents in ASRS reports. This excellent ar­

ticle examines common sources, results, and manage­
Communications-related Incidents
in General Aviation Dual Flight Training
by Kamil Etem and Marcia Patten
ment strategies for cockpit interruptions and distrac­
tions.
Crossing Restriction Altitude Deviations
16 Kamil and Marcia took a hard look at
communications issues as they relate to
General Aviation dual flight training, but don’t ne­
on SIDs and STARs glect this article just because you are flying an air car­
by Jeanne McElhatton, Paul Buchanan, and Charles Drew rier aircraft—there is plenty to learn from the experi­
ences of these GA pilots.
10 ASRS receives more reports of altitude
deviations than any other problem. A
significant number of these involve crossing restric­
ASRS Services on the Internet

tion deviations on Standard Instrument Departures

and Standard Terminal Arrival Routes. Read along to
23 ASRS’s Web Site saw significant growth
in 1997. New features have been added,
and even more good things are planned for coming
find out the why and how of these types of problems. years. Check this out to see what our Internet site can
do for you.

We hope you enjoy this issue of ASRS Directline. _

Charles Drew—ASRS Directline Executive Editor.

ASRS on the World Wide Web

http://olias.arc.nasa.gov/asrs

Issue Number 10 3
 1

by Key Dismukes, Ph.D., NASA Ames Research Center

Grant Young, Ph.D., New Mexico State University
Captain Robert Sumwalt, Battelle2

M
anaging several tasks concurrently is an everyday part of cockpit opera­
tions. For the most part, crews handle concurrent task demands effi­
ciently, yet crew preoccupation with one task to the detriment of other
tasks is one of the more common forms of error in the cockpit. Most pilots are fa­
miliar with the December 1972 L-1011 crash that occurred when the crew became
preoccupied with a landing gear light malfunction and failed to notice that some­
one had inadvertently bumped off the autopilot. More recently, a DC-9 landed
gear-up…when the crew, preoccupied with an unstabilized approach, failed to
recognize that the gear was not down because they had not switched the hydrau­
lic pumps to high.

NASA has recently begun a research

project to study why crews are vulner­
able to these sorts of errors. As part of
this project we reviewed NTSB reports
of accidents attributed to crew error. Thirty-four different types of com­
We concluded that nearly half of these peting activities distracted or preoccu­
accidents involved lapses of attention pied the pilots. Ninety percent of
associated with interruptions, distrac­ these activities fell into one of four
tions, or preoccupation with one task broad categories: (1) communication
to the exclusion of another task. We (e.g., discussion among crew or radio
have also analyzed 107 ASRS reports communication), (2) head-down work
involving competing tasks; we present (e.g., programming the FMS or review­
here some of our conclusions from ing approach plates), (3) searching for
this review. The 107 ASRS reports VMC traffic, or (4) responding to
involved 21 different types of routine abnormal situations. We will discuss
tasks crews neglected at a critical examples from each category and
moment while attending to another suggest preventive actions crews can
task. Sixty-nine percent of the ne­ take to reduce their vulnerability to
glected tasks involved either failure to these and similar situations. Our
monitor the current status or position suggestions are not perfect fixes, but
of the aircraft, or failure to monitor we hope they will be useful. It is likely
the actions of the pilot who was flying that research will ultimately provide
or taxiing. more powerful solutions.

4 Issue Number 10
 Category 1
However, the danger is that the crew
Communication
may become preoccupied with the Task Management
✍ "Copilot was a new hire and new in
type; first line flight out of training IOE.
conversation and may not notice cues
that should alert them to perform W hy do activities as
routine as conversa­
tion sometimes interfere with
Copilot was hand-flying the aircraft on other tasks. (The accompanying
sidebar explores the nature of interfer­ monitoring or controlling the
CIVET arrival to LAX. I was talking to
ence between competing tasks.) aircraft? Cognitive research
him about the arrival and overloaded
Special care is required to avoid indicates that people are able
him. As we approached 12,000 feet (our
distraction when others enter the to perform two tasks concur­
next assigned altitude) he did not level off
cockpit, because they may not recog­ rently only in limited circum­
even under direction from me. We de­
nize when the pilots are silently stances, even if they are skill­
scended 400 feet low before he could re­
involved in monitoring, visual search, ful in performing each task
cover. I did not realize that the speed
or problem-solving. separately.
brakes were extended, which contributed
Broadly speaking, hu­
to the slow altitude recovery." (# 360761)
mans have two cognitive sys­
In this example, the Captain was tems with which they per­
attempting to help the new First Category 2

form tasks; one involves con­

Officer, but the combination of flying Head-Down Work

scious control, the other is an

the airplane and listening to the ✍ “…Snowing at YYZ. Taxiing to runway automatic system that oper­
Captain was too much for the new 6R for departure. Instructions were taxi to ates largely outside of con­
pilot. Tellingly, the act of talking taxiway B, to taxiway D, to runway scious control.* The con­
distracted the Captain himself from 6R.…as First Officer I was busy with check­ scious system is slow and
adequately monitoring the status of lists [and] new takeoff data. When I looked effortful, and it basically per­
the aircraft. up, we were not on taxiway D but taxiway forms one operation at a
Thirty-one of these incidents W…ATC said stop….” (# 397607) time, in sequence. Learning a
involved altitude deviations or failure In a review of airline accidents new task typically requires con­
to make a crossing restriction.3 In 17 attributed primarily to crew error over scious processing, which is
of these 31 incidents (and 68 of the a 12-year period,4 the NTSB concluded why learning to drive a car or
total 107 incidents) the crews reported that failure to monitor and/or chal­ fly an airplane at first seems
being distracted by some form of lenge the Pilot Flying contributed to overwhelming: the multiple
communication, most commonly 31 of the 37 accidents. In 35 of the demands of the task exceed
discussion between the pilots, or ASRS incidents we studied, the Pilot conscious capacity. Automated
between a pilot and a flight attendant. Not Flying reported that preoccupa­ cognitive processes develop as
Most, although not all, of these tion with other duties prevented we acquire skill; these pro­
discussions were pertinent to the monitoring the other pilot closely cesses are specific to each task,
flight. However, in many cases the enough to catch in time an error being they operate rapidly and flu­
discussion could have been deferred. made in flying or taxiing. In 13 of idly, and they require little ef­
We later discuss how crews can sched­ these 35 incidents (and 22 of the total fort or attention.
ule activities to reduce their vulner­ 107 incidents), the Pilot Not Flying Many real-world tasks re­
ability to distraction. was preoccupied with some form of quire a mixture of automatic
Research studies have shown that head-down work, most commonly and conscious processing. A
crews who communicate well tend to paperwork or programming the FMS. skillful driver in a familiar car
perform better overall than those who Monitoring the Pilot who is flying on a familiar road can per­
do not. But conversation has a poten­ or taxiing is a particularly challenging form largely on automatic,
tial downside because it demands a responsibility for several reasons. leaving enough conscious
substantial amount of attention to Much of the time the monitoring pilot capacity to carry on a con­
interpret what the other person is has other tasks to perform. Monitor­ versation. However, if the au­
saying, to generate appropriate re­ ing the other pilot is much more tomatic system is allowed to
sponses, to hold those responses in complex than monitoring altitude operate without any con­
memory until it is one’s own time to capture because the other pilot is scious supervision, it is vul­
speak, and then to utter those re­ performing a range of activities that nerable to certain types of
sponses. One might assume that it is vary in content and time course. Thus, error, especially a type of er­
easy to suspend conversation when­ it is sometimes difficult for the moni­ ror called habit capture. For
ever other tasks must be performed. toring pilot to integrate other activi-

Issue Number 10 5
 ties with monitoring because he or she In 16 incidents crews failed to turn
example, if we intend to take cannot entirely anticipate the actions as directed by ATC on the SID or STAR
a different route home from of the other pilot. Furthermore, they were following. The crews re­
work, we are prone to miss serious errors by the pilot who is ported various activities competing for
our turnoff and continue our flying or taxiing do not happen their attention; in three cases the
habitual route if we do not frequently, so it is very tempting for activity was searching for traffic called
consciously supervise our the pilot who is not flying to let out by ATC or TCAS. Altogether, crews
driving. Also, if we encounter monitoring wane in periods of high reported searching for traffic as a
a section of road that is diffi­ workload. competing activity in 11 of the 107
cult to navigate, we find that Periods of head-down activity, such incidents. Searching for traffic takes
we cannot continue the con­ as programming the FMS, are espe­ the pilot’s eyes away from monitoring
versation without risking er­ cially vulnerable because the monitor­ aircraft position and status, and also
rors in the driving, the con­ ing pilot’s eyes are diverted from other demands substantial mental attention.
versation, or both. This is be­ tasks. Also, activities such as program­ If the conflict is close the urgency may
cause the automatic pro­ ming, doing paperwork, or reviewing further narrow the focus of attention.
cesses are not adequate to approach plates, demand such high One of the insidious traps of inter­
handle the unpredictable as­ levels of attention that attempting to ruptions is that their effects some­
pects of the driving task. perform these tasks simultaneously times linger after the interruption. For
Conscious control is re­ with other tasks substantially increases example, descending through 4500
quired in four situations: i) the risk of error in one task or the feet, a crew might be instructed to
when the task is novel, ii) other (see sidebar). Some FMC entries report passing through 3000 feet.
when the task is perceived to involving one or two keystrokes can They might then respond to and
be critical, difficult, or dan­ be performed quickly and may be quickly resolve a traffic alert, but
gerous, iii) when an auto­ interleaved with other cockpit tasks. forget the instruction to report by the
matic process must be over­ However, attempting to perform time they reach 3000 feet. In this
ridden to prevent habit cap­ longer programming tasks, such as hypothetical example, searching for
ture, or iv) to choose among adding waypoints or inserting ap­ traffic preempts the reporting instruc­
competing activities. The re­ proaches during busy segments of tion from the crew’s conscious aware­
quired mixture of automatic flight, can be problematic. It is not ness. The instruction presumably is
and conscious processing possible for the Pilot Not Flying to still stored in memory in an inactive
varies among tasks, and the reliably monitor the Pilot Flying or the form, and if reminded, the crew
mixture may vary with the aircraft status during longer program­ probably will recognize that they were
moment to moment de­ ming tasks, and it is difficult to sus­ given the instruction. However,
mands of a given task. Con­ pend the programming in midstream lacking such a reminder and being
versation, for example, gen­ without losing one’s place. preoccupied with other activities, they
erally requires a substantial do not remember to contact ATC as
amount of conscious pro­ they pass through 3000 feet.
cessing because it involves
Category 3

novelty; we do not know

Searching for VMC Traffic

what the other person is go­

ing to say and we have to ✍ "PRADO 5 Departure. Cleared to Category 4
climb (and) received TCASII TA (which) Responding to Abnormal Situations
formulate unique responses
appropriate to the discus­ upgraded to an RA, monitor vertical ✍ "Large areas of thunderstorms; we
sion. In contrast, an experi­ speed. While searching for the traffic we had to deviate considerably. Several
enced pilot can manually fly went past the NIKKL intersection...for the (equipment malfunctions) in short
a familiar aircraft in a largely turn to the TRM transition. We had dis­ period...then cabin pressure started climb­
automatic fashion. However, cussed the departure before takeoff; spe­ ing slowly in cruise (FL290).
certain subtasks embedded cial procedures, combined with many step Troubleshooting...to no avail. Requested
in the act of flying manually climb altitudes in a short/time/distance, immediate descent. Descending through
require conscious attention. made this a more demanding departure FL180, both crew members forgot to reset
For example, leveling off at than most. Next time on difficult depar­ altimeters, putting us 300 feet low at
an assigned altitude requires tures I will use autopilot sooner...will try FL130. To prevent this from occurring
consciously monitoring the to be more vigilant in dense traffic areas." again during any abnormal, I will: 1) del­
(# 403598) egate tasks; have one person focus on fly­

6 Issue Number 10
ing the airplane while the other trouble­
shoots and state clearly who will do altimeter to read the num­
what, 2) strictly adhere to company pro­ bers and to match the cur­
cedures." (# 404306) rent altitude with the as­
signed altitude the pilot is
In 13 incidents crews failed to reset
holding in memory.
their altimeters when passing through
The framework outlined
the transition altitude (18,000 feet
above allows some general
MSL in the United States and Canada).
conclusions about the cir­
It is especially easy to forget to reset
cumstances under which two
altimeters if this action is not linked
tasks may be performed con­
in pilots’ minds to other actions. (For
currently. A task requiring a
this reason some pilots make resetting
high degree of conscious
altimeters part of a cluster of action
processing, FMS program­
items they routinely perform together,
ming, for example, cannot
e.g., making a passenger announce­
be performed concurrently
ment and turning on the seat belt
with other tasks without risk­
sign. Some companies make resetting
ing error. Two tasks that are
altimeters part of the descent check­
largely automated can be
list.) In principle, the problem is
performed together reliably if
similar to that of monitoring for Two of the crews reporting to ASRS
they are regularly practiced
altitude level-off, except more vulner­ thought that they forgot to reset their
in conjunction, for example,
able to error. In air carrier operations altimeters stated they were preoccu­
flying the aircraft manually
the crew is normally aided with pied with an abnormal situation.
and intercepting the local­
altitude level-off by altitude alerting Altogether, abnormals were a factor in
izer. We are less certain how
devices and by the formal procedure 19 of the 107 incidents. Ironically, it
well individuals can combine
of making a thousand-foot call, seems that one of the biggest hazards
two tasks, each of which in­
confirmed by both pilots, before of abnormals is becoming distracted
volves a mixture of conscious
reaching the assigned altitude. from other cockpit duties. Abnormals
and automatic processing,
easily preempt crews’ attention for
for example, searching for
several reasons. Recognizing the
traffic while monitoring for
cockpit warning indicators, identify­
altitude capture. We suspect
ing the nature of the problem, and
that pilots can learn to inte­
choosing the correct procedure require
grate two tasks of this sort
considerable attention. Crews have
and achieve reliable perfor­
much less opportunity to practice
mance, but only if they regu­
abnormal procedures than normal
larly practice the two tasks in
procedures, so choosing and running
conjunction. This, however,
the appropriate checklists requires
is speculation, and requires
more effort and greater concentration
experimental research for
of mental resources than running
validation. _
normal checklists. Also, in situations
perceived to be urgent or threatening,
the normal human response is to * Norman, D. J. and Shallice,
narrow the focus of attention, which T. (1986). Attention to ac­
unfortunately tends to diminish mental tion: willed and automatic
flexibility and reduce ability to analyze control of behavior. In R. J.
and resolve non-routine situations. Deardin, G. E. Schwartz, and
D. Shaprio (Eds), Conscious­
ness and Self-Regulation, Ad­
vances in Research and
Theory (pp 1-18). New York:
Plenum.
Abnormals = Distractions
Issue Number 10 7
 Strategies for Reducing Vulnerability to Interruptions and Distractions
We suggest several lines of defense against the types of crew errors described
above. These are not perfect, but in combination they should, in our opinion,
reduce crews’ vulnerability to error.
(1) Recognize that conversation is a (3) Schedule/reschedule activities to
powerful distracter. minimize conflicts, especially
Unless a conversation is extremely during critical junctures.
urgent, it should be suspended When approaching or crossing an
momentarily as the aircraft ap­ active runway, both pilots should
proaches an altitude or route suspend all activities that are not
transition, such as altitude level-off related to taxiing, such as FMS
or a SID turn. In high workload programming and company radio
situations, conversation should be calls, until the aircraft has either
kept brief and to the point. Even in stopped short of the runway or
low workload situations, crew safely crossed it. Crews can reduce
should suspend discussion fre­ their workload during descent by
quently to scan the status of the performing some tasks while still at
aircraft and their situation. This cruise, for example, obtaining ATIS,
requires considerable discipline briefing the anticipated instrument
because it goes against the natural approach, and inserting the ap­
flow of conversation, which usually proach into the FMS (for aircraft so
is fluid and continuous. equipped). Also, it may be useful
for companies to review their
(2) Recognize that head-down tasks
operating practices for optimal
greatly reduce one’s ability to
placement of procedural items. For
monitor the other pilot and the
instance, could some items on the
status of the aircraft.
Before Takeoff Checklist be moved
If possible, reschedule head-down
to the Before Start Checklist, since
tasks to low workload periods.
the latter is performed during a
Announce that you are going head-
period that usually has lower
down. In some situations it may be
workload?
useful to go to a lower level of
(4) When two tasks must be per­
automation to avoid having one
formed concurrently, set up a
crew member remain head-down
scan and avoid letting attention
too long. For example, if ATC
linger too long on either task.
requests a speed change when
In some situations pilots must
cockpit workload is high, the crew
perform two tasks concurrently, for
may set the speed in the Mode
example, searching for traffic while
Control Panel instead of the FMS.
flying the airplane. With practice,
An FMS entry might be made later,
pilots can develop the habit of not
when workload permits. Also, some
letting their attention linger long
airlines have a policy that FMS
on one task, but rather switch
entries should be commanded by
attention back and forth every few
the Pilot Flying and implemented
seconds between tasks. This is
by the Pilot Not Flying. This
somewhat analogous to an instru­
approach minimizes the amount of
ment scan, and like an instrument
attention the Pilot Flying must
scan it requires discipline and
divert from monitoring the aircraft.
practice, for our natural tendency is
to fixate on one task until it is
complete. Pilots should be aware

8 Issue Number 10
 that some tasks, such as building
an approach in the FMC, do not
lend themselves to time-sharing
with other tasks without an in­
creased chance of error.
(5) Treat interruptions as red flags.
Knowing that we are all vulnerable
to preoccupation with interruptive
tasks can help reduce that vulner­
ability. Many pilots, when inter­
rupted while running a checklist,
place a thumb on the last item
performed to remind them that the
checklist was suspended; it may be
possible to use similar techniques
for other interrupted cockpit tasks.
One of us has developed a personal
technique using the mnemonic
“Interruptions Always Distract” for
a three-step process: (1) Identify
the Interruption when it occurs, End Notes
(2) Ask, “What was I doing before I 1
was interrupted” immediately after We thank ASRS staff members who
assisted in this study.: Dr. Rowena
the interruption, (3) Decide what
Morrison and Mr. Vince Mellone helped
action to take to get back on track. design the search strategy for reports;
Perhaps another mnemonic for this Mr. Bob Wright screened reports; Capt.
could be “Identify-Ask-Decide.” Bill Richards made callbacks to reporters
(6) Explicitly assign Pilot Flying and and consulted with NASA on selected
Pilot Not Flying responsibilities, incidents; Capt. Charles Drew reviewed
especially in abnormal situations. the paper; and Dr. Rowena Morrison
The Pilot Flying should be dedi­ reviewed and edited the paper.
cated to monitoring and control­ 2
Captain Sumwalt is employed by a
ling the aircraft. The Pilot Flying major U.S. air carrier, and has served as
must firmly fix in mind that he or an ASRS research consultant since 1993.
she must concentrate on the He has also published a number of
primary responsibility of flying the articles on pilot error and human
airplane. This approach does not factors issues in professional aviation
publications.
prevent each pilot from having to
3
perform concurrent tasks at times, The relative frequencies of different
but it does insure that someone is types of neglected activity reported
flying the airplane and it guards probably do not reflect the relative
against both pilots getting pulled frequencies actually occurring in line
operations. Pilots may be more likely to
into trying to solve problems. _
report incidents observable to ATC, for
example, altitude deviations, than to
report incidents not observable outside
the cockpit, for example, omitting a
checklist item.
4
National Transportation Safety Board
(1994). A review of flightcrew-involved
major accidents of U.S. air carriers, 1978
through 1990. Safety study NTSB/SS-94­
01. Washington, D.C.: NTSB.

Issue Number 10 9
Crossing Restriction
Altitude Deviations
on SIDs and STARs
by Jeanne McElhatton, Paul Buchanan, and Charles Drew

T
“ he FMS was programmed for [a] Runway 8 arrival. [The] flight attendant
came forward. I…started reprogramming the FMS for a Runway 26 arrival
and the new crossing restriction. After I had completed this, I noticed that
the FMS was not in VNAV—we had overflown the descent point. I made every
effort but crossed 6,000 feet high.” (# 298266)

A History of Ups and Downs

Throughout 21 years of operation by (STARs). SIDs and STARs are published
the Aviation Safety Reporting System instrument routings whose primary
(ASRS), approximately 35 percent of purpose is to simplify ATC’s clearance
all incidents reported to the ASRS have delivery procedures.
been altitude deviations. Previous Altitude crossing restrictions associ­
ASRS reviews of altitude errors have ated with SIDs and STARs may be pub­
identified multiple contributing fac­ lished on navigation charts or
tors for these events. A 1982 ASRS assigned by ATC. Crossing restrictions
study, Probability Distributions of Alti­ exist for two primary purposes: 1) to
tude Deviations, found that altitude de­ provide vertical separation from traffic
viations reported to ASRS were on different routings that cross the
exponentially distributed with a mean same fix, and 2) to contain traffic verti­
of 1,080 feet, and that deviations from cally within a given ATC controller’s
ATC-assigned altitudes were equally sector in cases where other sectors
likely to occur above or below the as­ within the same facility, or sectors in
1
signed altitude. Another ASRS review another facility, are layered above and
of altitude deviation problems, One below. ATC-assigned crossing restric­
Zero Ways to Bust an Altitude,2 looked tions (as opposed to published crossing
at the percentage of altitude devia­ altitudes) may be temporary require­
tions by altitude pairing, (i.e., confus­ ments imposed to meet
ing one altitude for another) and changing operational conditions, in­
found that 35% of all paired devia­ cluding facilitating traffic hand-offs to
tions occur at 10,000 and 11,000. another sector. Pilot compliance with
More recently, ASRS analysts have SID and STAR altitude assignments is
noted that approximately 15 to 20 important, for if a controller permits
percent of the altitude deviations re­ traffic penetration of another sector
ported to ASRS involve crossing re­ either laterally or vertically without
striction errors on Standard prior coordination and approval from
Instrument Departures (SIDs) and the controller in that sector, an opera­
Standard Terminal Arrival Routes tional deviation results.

10 Issue Number 10
 No previous ASRS review of SID-
and STAR-related altitude deviations
has been conducted. Thus we under­
took this review to determine the
causes and contributors to altitude de­
viations that occur during SID and
STAR procedures, and to compare the
results of this analysis with selected
findings of the 1982 ASRS study.
Finally, altitude crossing restriction
Looking at Reports errors were detected by ATC and the
The objective of this review was to cat­ flight crew in approximately equal
egorize the types (i.e., undershoot or proportions: 53 percent were detected
overshoot) and frequency of crossing by flight crews, and 41 percent by ATC
restriction altitude deviations, and to controllers.
determine the types of human perfor­
ATC-Assigned vs.
mance errors that contribute to cross­
Charted Requirement
ing restriction altitude deviations.
Where the required crossing restric­
Additionally, we looked at how and by
tion altitude was assigned by ATC, the
whom these deviations are detected and
flight failed to meet a crossing restric­
corrected, and compared the number of
tion on a SID or a STAR in 66 percent
deviations for traditional versus glass
of events, while in 34 percent of
cockpit technology aircraft.
events the crossing restriction was a
Reports selected for review in this
charted requirement. The preponder­
study involved Part 121 or 135 aircraft
ance of incidents in which ATC
in scheduled or non-scheduled air car­
assigned the crossing restriction
rier operations conducting Standard
altitude may be attributable to dimin­
Instrument Departure (SID) or Stan­
ished time for climb or descent plan­
dard Terminal Arrival Route (STAR)
ning and to breakdowns of communi­
procedures under Instrument Rules,
cations.
where the flight failed to level at or
The following report excerpt dem­
cross a specified crossing restriction al­
onstrates a communication problem:
titude as instructed by ATC or as re­
quired by a published procedure. Two ✍ “We had assumed that while in radar
hundred full-form records, from De­ contact…we could safely descend to the
cember 1988 through February 1996, cleared level of Flight Level 70—appar­
were extracted from the ASRS Data­ ently Santiago Approach intended for us
base and reviewed. Of these, 172 met to observe the arrival procedure altitude
the criteria for inclusion in this study. restrictions, even though they had us in
A five-page coding form was devel­ radar contact and had cleared us to de­
oped to extract pertinent information scend to Flight Level 70. We both feel
from the data set. that this incident was in part due to com­
munications misunderstanding.”
What Doesn’t Matter
(# 294836)
Of the 172 air carrier reports in the
study, 159 involved turbojet aircraft And now for one that illustrates the
and 13 involved turboprop aircraft. problems of reduced time for descent
We found no evidence that the day of planning:
the week, time of day, aircraft type or ✍ “ATC deviated from the expected
configuration, or weather factors CIVET 1 Arrival. [We received an] un­
played a role in these altitude devia­ usual crossing restriction not normally
tions. Similarly, it did not intuitively used or expected during an approach into
appear that crossing restriction alti­ LAX. Too many short-notice clearances
tude deviations were more likely to issued, with very little time between each
occur at any given ATC facility. of them.” (# 304840)

Issue Number 10 11
 Deviations Up—Going Down altitude. In 17 percent of events the
Only 23 percent of altitude deviation error was discovered after passing the
events in the data set occurred on required altitude.
occurred on SIDs (climb), while a full In those events where the error was
77 percent occurred on STARs (in discovered at or before the required
descent). One possible explanation for crossing altitude, climb or descent
this variation may be workload: in the rates may have been sufficiently high
descent (STAR) phase of flight, flight to preclude recovery before the devia­
crews have a large number of tasks tion occurred.
and issues to contend with, including How Much Did We Miss By?
obtaining ATIS, adjusting or planning 1. Point of Detection: The magnitude
for changing weather conditions, of the altitude deviation at the
conducting company communica­ point of detection averaged 2,400
tions, confirming gate assignments, feet, with a median of 1,500 feet.
planning for terminal procedures and
2. Point of Maximum Excursion: The
runway configurations, traffic watch,
altitude deviation magnitudes at the
configuring the aircraft, or alerting
point of maximum excursion were
and communicating with cabin crew.
examined using methods employed
✍ “Number 1 Flight Attendant came by the 1982 ASRS study, and were
into the cockpit asking for gate connec­ found to be exponentially distrib­
tions and giving a cabin write-up. Man­ uted, with a mean deviation of
aged to get distracted and forgot to reset approximately 2,500 feet. The mean
altimeters to the proper setting below for crossing restriction deviations at
18,000 feet.” (# 306840) point of maximum excursion was
It is also possible that on STARs there substantially larger (approximately
is greater ambiguity about ATC expecta­ 1,400 feet greater) than the mean
tions, that is, when or where ATC expects for undifferentiated altitude devia­
the flight to initiate descent. tions (1,080 feet) reported in the
Undershoots and Overshoots 1982 ASRS study on altitude devia­
A majority of altitude deviations—75 tions. The median for the point of
percent—were altitude undershoots maximum excursion was 1,500 feet.
(failure to reach the assigned alti­ Controller Actions
tude—usually on descent). This ATC did not intervene, or was not
indicates that flight crews may have required to intervene in order to avoid
been late in planning or execution of airborne conflict in 43 percent of
the procedure. incidents in the data set. (This sup­
✍ “The Captain began programming ports the research team’s subjective
the FMC when we should have started assessments of incident severity.) In 60
down to Flight Level 190. Afterwards, the percent of incidents (100 of 168), the
Captain commented that he always tells flight continued the climb or descent,
new copilots to begin the descent before with ATC concurrence.
programming the FMC if there is any ✍ “We were given descent clearance from
doubt as to meeting the crossing [restric­ Flight Level 230 to 13,000 feet by ATC, on
tion], and he was upset that he had tried the MINEE 1 Arrival (MCA). We read back
to program the FMC first.” (# 112925) ‘Descending out of Flight Level 230 for
13,000 feet’ and dialed 13,000 feet in the
Point of Detection
altitude select and began the descent. ATC
In over half of all events in the data
then told us to contact Approach. We
set (51 percent), the error was detected
checked in with Approach and stated we
before reaching the required or speci­
were descending to 13,000 feet. As we
fied altitude. In 28 percent of events,
passed through 14,700 feet, Approach
the error was discovered at the re­
asked us if we were level at 15,000 feet, we
quired or specified crossing restriction
replied ‘Negative, we are descending

12 Issue Number 10
through 14,700 feet for 13,000 feet.’ We
also said we would stop the descent and
return to 15,000 feet, if necessary. Ap­ Table 1 — Human Errors
proach replied, ‘No, descend and maintain, Based on 233 Citations from 171 of 172 Reports
13,000 feet.’ We then advised them we Human Errors Citations Percent
were given 13,000 feet by ATC and had
checked in with him stating we were de­ Exercised poor judgment 43 25.1
scending to 13,000 feet. Approach then
said 13,000 feet was O.K.” (# 297750) Neglected to cross-check data 42 24.6

Advanced and Traditional Cockpits Delayed implementing procedure 41 24.0

There were slightly more (61 percent)
Misunderstood clearance 35 20.5
advanced cockpit (EFIS and/or NAV
control) than traditional cockpit Other (unspecified) 32 18.7
aircraft in the data set. This compares
to 51 percent advanced cockpit versus Forgot clearance 15 8.8
49 percent traditional cockpit air
Did not read, or mis-read chart 14 8.2
carrier aircraft in the entire ASRS
database for the same time period. Not stated or ambiguous 9 5.3
It was expected that advanced cock­
pit aircraft would be more likely to be Did not hear clearance 1 0.6
involved in crossing restriction alti­
Looked at wrong chart 1 0.6
tude deviations due to the greater
complexity in programming descents TOTALS 233 136.4%
and descent crossing fixes. While we
did see this pattern, the difference in Note: Multiple citations are possible in this category, thus the total
numbers between advanced and tradi­ number of citations exceeds the number of reports.
tional cockpit aircraft was not large.
Human Performance Errors thought he would be able to make the re­
Reporters of incidents in this data set striction.” (# 315639)
referenced human errors as shown in
Flight crews failing to cross-check
Table 1.
data typically resulted in use of the
An example of poor judgment is
wrong waypoint:
flight crew failure or reluctance to use
speed brakes to meet descent profile ✍ “Inbound to SLC at Flight Level 310.
requirements: We were cleared the OGDEN 5 Arrival
with a descent clearance to cross BEARR
✍ “Flight plan called for a (SIE CAMRN (25 nm NW Ogden VOR) at 17,000 feet.
2) STAR to JFK. ATC instructed us to
STAR path tracks outbound Burley VOR
cross CAMRN at 11,000 feet, 250 knots.
117 degree radial to Ogden VOR 302 de­
At 19,000 feet, I told Captain we would
gree radial, then radar vectors. The STAR
not make restriction unless he used speed
depicts the Ogden VOR very close to the
brake to increase rate of descent. He re­
Salt Lake City VOR. I (Captain) was fly­
sponded there would be no problem. I in­
ing the aircraft outbound on the Burley
formed him I would tell ATC we were un­
VOR radial, First Officer had switched
able to comply with restriction. ATC
his VOR to Salt Lake City for distance to
responded, ‘give us the altitude first and
the field. However, he did not verbally
then the airspeed.’ We crossed CAMRN at
announce that he had switched to SLC—I
13,000 feet and 290 knots. We were
thought he was on Ogden. Because of un­
handed off to Approach for a normal con­
familiarity with arrival (only second time
tinuation of flight to JFK with no com­
into SLC), I switched over to SLC VOR
ments made to us by ZNY or Approach
inbound (should have been Ogden). We
Control reference the CAMRN crossing.
discussed the fact the outbound and in­
The Captain’s comment to me was that
bound radials did not match up but nei-
he did not like using the speed brake and

Issue Number 10 13
 ther of us discovered my mistake. I there­ SID and STAR Charts
fore tracked off course and, because [I In 88 percent of reports, there were no
was] looking at the wrong DME, started complaints about chart graphic
the descent too late to make the crossing depiction or procedures. There were,
restriction.” (# 300912) however, some complaints regarding
chart text narratives, specifically that
Cockpit Workload
the font size was small, and that text
Reporters cited cockpit workload on
blocks were sometimes not placed
SIDs and STARs as a factor in 44
sufficiently close to the appropriate
percent of reports. The most com­
area of the graphic depiction. In one
monly noted workload issues are
event, the flight crew of a turbojet
shown in Table 2.
transport followed instructions spe­
✍ “I tried unsuccessfully to enter the cific to turboprop aircraft, thus deviat­
restriction in the FMS. After three at­ ing from an altitude requirement.
tempts, the Captain tried unsuccessfully
Event Resolution
and tried to explain why it wouldn’t take.
Table 3 provides event resolution
Meanwhile, no descent was started…we
information:
are flying an airplane, not a computer.
My focus on the FMS got in the way of Incident Severity
doing a very simple descent profile. I will In more than 95 percent of incidents
be focusing on flying first, programming in the data set, the analysts’ subjective
second.” (# 259889) assessment was that there was mini­
mal impact on flight safety or effi­
ciency. While there was no direct
evidence of loss of separation in the
majority of these events, there may
have been implications for ATC, such
as sector penetration, of which the
pilot reporters in this study were
unaware.

Table 2 — Cockpit Workload Issues

Based on 97 Citations from 171 of 172 Reports

Workload Issues Citations Percent

FMS Programming (automation issues) 18 24.0%

High quantity radio communication with ATC 17 22.7%

Lack of planning on the part of the flight crew that led to

17 22.7%
time-compression (such as cabin attendant in cockpit)
Other (misread altimeter, company com, etc.) 15 20.0%
Flight attendant call or cockpit-cabin interphone
12 16.0%
communication
A change in clearance 10 13.3%

Weather factors 8 10.7%

TOTALS 97 129.4%
Note: Multiple citations are possible in this category, thus the total number
of citations exceeds the number of reports.

14 Issue Number 10
Summing Up
Crossing restriction Table 3 — Incident Resolution
altitude deviations occur Based on 172 Citations from 172 Reports (Categories are Mutually Exclusive)
more often on STARs than
SIDs, but traffic separation Event Resolution Categories Citations Citations Percent
was known to be compro­
mised in only a small Controller Actions 68 39.6%
portion of these events. Controller Intervened 52
Aircraft configuration or
type did not appear to Controller Issued New Clearance 16
play a role in these inci­
Flight Crew Action 84 48.8%
dents. Most deviations
were altitude undershoots. No Action Taken / Anomaly Accepted 26
An altitude undershoot on
a STAR may indicate a No Action Taken / Detected After the Fact 23
flight crew’s failure to Flight Returned to Original Clearance / Course 14
adequately plan for the
STAR, or their distraction No Action Taken / Insufficient Time 13
from effectively monitor­ Flight Crew Overcame Equipment Problem 4
ing the descent.
In instances of altitude Flight Crew Became Reoriented 3
overshoots, the flight crew
Avoidance Maneuvers / Evasive Action 1
or ATC often detected the
error before the altitude de­ Unspecified 20 11.6%
viation occurred; however,
climb or descent rates may Not Resolved / Unable / Other 17
have been sufficiently Other 3
high to preclude recovery
before a deviation oc­ TOTALS 172 172 100%
curred. Crossing restric­
tion altitude deviations occurred more
often when the crossing altitude was
assigned by ATC.
It is good practice to advise ATC of
any altitude change, specifically the
altitude being vacated and the destina­
tion altitude, and to confirm with ATC
the point of anticipated or expected
initiation of descent.
Flight crews anticipating or experi­
encing difficulty adhering to crossing
restriction requirements should advise
ATC as soon as practical. End Notes
Cockpit workload was commonly 1
Ralph E. Thomas and Loren J.
cited as a contributing factor in Rosenthal, Probability Distributions of
altitude deviations on STARs. There­ Altitude Deviations (NASA Con­
fore, flight crews may wish to com­ tractor Report 166339), Ames
plete checklists early (mid-cruise or Research Center: Moffett Field,
before descent), and review STAR California, p. 32.
charts before descent initiation. _ 2 Don George, One Zero Ways to Bust an

Altitude, ASRS Directline Issue No. 2, 1991.

Issue Number 10 15
Communications-related Incidents in
General Aviation Dual Flight Training
by Kamil Etem and Marcia Patten

A
recent survey of the Aviation Safety Reporting System (ASRS) database
on incidents involving General Aviation (GA) aircraft revealed that one
third of the GA incidents were associated with communications diffi­
culties. These problems included failure to comply with ATC clearances, com­
munications equipment malfunctions, and poor radio technique. The results
of this survey suggested to our research team that GA communications issues
were an appropriate topic for further ASRS research. We were also aware that
past ASRS research has not focused on this subject.1

The 1996 Nall Report, published by they trained students to perform

the Aircraft Owners and Pilots Associa­ independently, as single pilots, and
tion (AOPA) Air Safety Foundation, believed their task as flight instructor
further focused our attention on dual was to encourage independence, not
instruction.2 Although flight instruc­ team awareness.4 An exaggerated
tion, overall, is one of the safest emphasis on pilot independence
operations in General Aviation, during training arguably may exclude
according to 1995 accident statistics, development of sound cross-cockpit
there was a notable concentration of communications procedures, and
fatalities and accidents during dual impair communications awareness
instruction: the only fatal go-around and effectiveness.
accident, four of the five fatal maneu­
Defining the Task
vering accidents, and five out of seven
Our research goal was to examine a
non-fatal maneuvering accidents
representative set of ASRS reports
occurred during dual instruction.3 This
referencing communications-related
cluster of accidents and fatalities in dual
incidents that occurred during GA
flight instruction raised the question of
dual instruction, with the following
whether problematic communications,
specific objectives:
both inside and outside the aircraft,
might have played a role. • To identify the airspace, location,
A final motivation for this study and operational context in which
was research by NASA and others GA dual instruction communica­
which has shown that in shared tions incidents occurred (external
decision-making situations similar to factors);
those that occur in GA dual flight
• To determine the nature of prob­
instruction, there is often a failure of
lematic communications interac­
individuals to take responsibility for
tions that occurred (or did not
actions, including communications.
occur) in the cockpit between
At the 1995 OSU Symposium, Prince
instructor and trainee (internal
and Stout presented the results of
factors);
interviews with professional aviators
from the military, air carriers, and GA. • To identify contributing communi­
They reported that 30 percent of the cations equipment and operational
GA instructors surveyed stated that factors;

16 Issue Number 10
• To suggest strategies for improving
communications management
during GA dual flight instruction.
This research effort was limited to
ASRS incidents involving powered
aircraft with a maximum gross takeoff
weight less than or equal to 14,500
pounds. Incident reports selected for
Findings and Discussion
the study had to directly reference the
presence of a flight instructor onboard External Factors Properties of

who was actively conducting dual Environment for GA Communications ASRS Data

flight instruction or a flight review. Incident Occurrences ASRS data have certain
Although we had no means of A strong pattern emerged from our limitations. Reporters to
identifying database reports in which analysis of the environment in which ASRS may introduce biases
communications (or the lack thereof) dual instruction communications- that result from a greater
between instructor and trainee con­ related incidents occurred: Half or tendency to report serious
tributed to an incident but were not more of the incidents occurred within events than minor ones;
reported, it was possible to retrieve the airport environs and airspace, from organizational and
reports in which communications within 10 nautical miles of the airport, geographic influences; and
factors were explicitly referenced as a at altitudes less than 1,000 feet. from many other factors. All
contributing factor. Therefore a As depicted in Figure 1, almost half of these potential influences
further requirement was that reports of the dual instruction events occurred reduce the confidence that
selected for the study contain specific in Class D airspace, with Class E can be attached to statisti­
references to verbal interactions airspace next in the number of occur­ cal findings based on ASRS
between the flight instructor and rences.5 This concentration of inci­ data. However, the propor­
trainee which contributed to the dents within Class D airspace was not tions of consistently
incident. Examples included directives surprising, as both primary and more reported incidents to ASRS,
or instructions; questions; recognition advanced types of instruction are such as altitude deviations,
or announcements of a problem; airport-centered: primary instruction have been remarkably
predictions or warnings; status reports; involves recurrent landing practice stable over many years.
information acquisition; statements and pattern work, while more ad­ Therefore, users of ASRS
referring to planning or goals; expla­ vanced flight instruction often in­ data may presume that
nations; and non-pertinent conversa­ volves approaches to an airport or incident reports drawn
tions. (See the sidebar on the Proper­ related navigational aid, and takeoff/ from a time interval of
ties of ASRS Data.) landing practice. In slightly over half several or more years will
Initial query of the ASRS database of all events, the incident also oc­ reflect patterns that are
revealed 582 incident occurrences curred within a 10-nautical mile range broadly representative of
from January 1988 through December of the airport (Figure 2) and at altitudes the total universe of
1996 which had the potential to meet less than 1,000 feet AGL (Figure 3). aviation safety incidents of
the scoping criteria for this study. We Consistent with the numbers of that type. _
screened a random sampling of these incidents in the study set that oc­
reports to aid in hypothesis generation curred on or near airports, and at low
and the development and refinement altitudes, communications-related
of a coding instrument. incidents were most prevalent during
A final data set of 200 incidents the approach/descent phases (167
were selected that met the scoping citations, 47 percent) and landing
criteria for the study. Eighty-four phase (103 citations, 29 percent) of
percent of these reports were submit­ flight.6 The concentration of incidents
ted by instructors; sixteen percent in these flight phases is doubtless due
were submitted by trainees. This to the fact that more approaches and
reporter distribution is almost identi­ landings are performed in dual in­
cal to that of the ASRS database for all struction than in other types of GA
GA dual instruction incidents. operations.

Issue Number 10 17
zz y
,
||,yz|
zz
47% ATA/D

18% OCA/E Surface Versus Airborne Communications Incidents

One third of our data set (66 reports) described
47% 13% UCA/G incidents involving aircraft operating on an
airport surface, and conducting external radio
11% TCA/B communications. In our extensive experience as

z| ,_yz|
_yy
|,,
flight instructors, the amount of time spent on
8% ARSA/C
the airport surface in any type of dual instruction
3% Other is generally small–usually 15 percent (or less) of
an instructional period, even in primary instruc­
tion. The occurrence of more GA dual instruction
Figure 1 — Airspace Involved
incidents on the airport surface than expected

,,
suggests that airports may be a problematic
environment for communications-related inci­
dents.7
For both surface and airborne incidents that
24% At Location involved external radio communications, control
tower communications were reported the most
18% 1 - 5 nm frequently. Of the 66 surface-based incidents, 47
(71 percent) cited communications with a control
40% 11% 6 - 10 nm tower. Another 117 reports that involved airborne
operations cited ongoing ATC communications.
7% 11 - 100 nm Of these, 52 incidents (44 percent) cited commu­
nication with towers, 39 incidents (33 percent)
40% Unknown
referenced communication with TRACONs, and
21 incidents (18 percent) cited communications
with UNICOM or Centers. The prevalence of
Figure 2 — Distance from Airport (miles) tower-communication reports in our study set
reinforces the notion that effective management
of instructional communications while monitor­
ing Tower frequencies is crucial to the effective
1% 5,000' and safe conduct of dual training operations,
both while on the surface and airborne.
2% 2,101' - 2,700'
Internal Factors
1% 1,801' - 2,100'
All reports included in our study set were classi­
2% 1,501' - 1,800' fied into broad groupings of verbal communica­
1,201' - 1,500' tion anomalies that occurred within the cockpit.
2%
Drawing on explicit references from the study
4% 901' - 1,200' reports, we classified the types of instructor/
4% 601' - 900' trainee statements, determined whether these
statements were heard by the intended recipient,
7% 301' - 600' and evaluated the timeliness and appropriateness
17 % 1' - 300' of responses these statements elicited. Addition­
ally we sought to identify the equipment, and
62 % On Surface
task or workload-related (operational) factors
which played material roles in the events.
0 10 20 30 40 50 60 70 80
Figure 3 — AGL Altitude Range
(113 of 200 Total Reports)

18 Issue Number 10
Cockpit Communications Anomalies
Figure 4 (right) depicts the three most
frequently occurring combinations of
instructor/trainee verbal interaction
problems. Figure 4 — Cockpit Communications Anomalies
Confusing, erroneous, or misleading
statements were the leading type of Top 3 Combinations of Communications Anomalies
instructor communications anomaly
(30 percent of citations).8 Delayed or • Instructor made confusing or misleading statements
withheld communications by instruc­ and trainee delayed action or acted inappropriately.
tors were the next most frequent
instructor anomaly (16 percent of • Instructor heard but misinterpreted intra-cockpit coms
citations), and a leading cause of and trainee delayed action or acted inappropriately.
delayed or inappropriate actions on
the part of trainees. It is a common • Instructor withheld or delayed comment
technique of flight instructors to allow and trainee delayed action or acted inappropriately.
the trainee to make mistakes in an
attempt to develop independent
actions and observe the trainee’s level
of awareness. However, especially
during IFR operations, or when com­
pliance with an ATC directive is Communications Equipment Factors
doubtful, corrective verbal comments We expected that a number of reports
by the instructor have a significant in the study set would describe prob­
impact on flight safety. lems with onboard communications
Regardless of the type of communi­ equipment that contributed to inci­
cations anomaly displayed by instruc­ dents. One in five reports (21 percent)
tors, the effect on trainees most often did identify such problems. The most
was a delayed or inappropriate verbal frequently reported problems involved
or control response (39 percent of malfunctioning or improperly oper­
citations). Several reports indicated a ated headsets, microphones, and
lack of assertiveness on the trainee’s installed radios. The following
part, and a failure to challenge the instructor’s report illustrates both a
instructor even when the trainee pilot-induced headset problem, and a
believed the instruction was wrong. preoccupation with training that led
The following study report excerpt to complete lack of situational aware­
exemplifies how confusing and vague ness:
communication by both instructor ✍ “We had started flying using head­
and trainee can result in a safety sets, with the radios being monitored
incident: through the headsets. After the first land­
✍ “Instructor said...‘Uh, you can have ing the student stated he would prefer to
control if you, uh, want it.’ I probably re­ continue without the headsets as he
plied ‘OK’ rather than the usual ‘I have didn’t feel comfortable wearing them. I
control.’ I began to pull the nose up said OK. We got involved in doing touch
slowly when I thought I felt my instructor and goes (5) and I failed to notice that we
push forward on the wheel [and] had not heard from Tower during this
relaxed...Nosewheel touched down first time. When I did notice that the speaker
and we bounced...Fortunately we walked button was not in the proper position, I
away...with an undamaged aircraft. made contact with the Tower. They
‘Wishy washy’ coms played a major role (Tower) terminated the flight and I was
in this.” (# 240165) instructed to call the Tower.” (# 290210)

Issue Number 10 19
 Operational Factors number of ATC-related consequences
In addition to our analysis of cockpit was therefore unexpected. We believe
communications anomalies, we that the high incidence of missed ATC
examined the types of operational clearances in the study set, and report­
factors that were present during dual ers’ failure to comply with various
flight training, and identified the clearance requirements, directly relate
leading combinations of factors to several other patterns observed in
associated with incident occurrence. the data: (1) the concentration of dual
We found that instructor critiques instruction incidents on or near
during ongoing maneuvers were the airports, especially tower-controlled
most frequent operational pattern (27 airports with their demanding com­
percent of citations), closely followed munications requirements; and (2) the
by maneuvers during ongoing com­ operational context in which dual
munications with Tower (26 percent), instruction often occurs, specifically,
and instructor critiques during ongo­ the simultaneous occurrence of
ing Tower communications (20 per­ internal verbal or external radio
cent of citations). The following communications with aircraft maneu­
description of a wrong-runway takeoff vers and demonstrations.
illustrates how an instructor’s percep­ It is clear that dual instruction
tion of task priority may have been places heavy demands on the atten­
distorted by the desire to critique the tion management and communica­
student: tions skills of both instructor and
✍ “We took off on [Runway] 24 instead trainee, and that lapses in concentra­
of 30, as the Tower subsequently in­ tion may result in reduced situational
formed us. As I reviewed the event later, awareness and safety consequences.
with my student and in my own mind, I
realized how I may have added to the un­ Summary and Conclusions
certainty. I was busy pointing out airport
General Aviation flight instruction
markings and critiquing the flight to this
presents an environment with unique
point. The priority should have been com­
external and intracockpit communica­
munications with the Tower and standard
tions requirements. This research
procedure.” (# 137322)
identified key communications factors
that contributed to incidents in the
study set. The research team also
Event Consequences
developed some possible approaches
More than three-fourths of all the GA to resolving the communications
communications incident citations problems identified.
involved some ATC-related infraction
Situation
or violation of FARs. Most often this
Almost half of all communications-
was non-compliance with a clearance
related dual instruction incidents
(51 percent of citations), but more
occurred within, or near, an airport
than a third of all citations also
environs, at an altitude less than 1,000
involved clearance-related ground
feet AGL. Ongoing communications
hazards, such as runway incursions
with Tower were a prominent element
(22 percent) and ground conflicts (10
of both ground and airborne incidents.
percent). Aircraft damage was reported
in 13 percent of citations. Suggestion
Although the study’s report selec­ • In preflight briefings and ground
tion criteria had required that there be instruction, instructors may wish
direct reference to verbal communica­ to raise trainees’ awareness that
tions between instructor and trainee, airport surface operations are
no such requirement existed regarding vulnerable to safety incidents
ATC communications. The large during dual instruction. They

20 Issue Number 10
 should also consider emphasizing
the importance of standard phrase­
ology in communications with
ATC, and the active monitoring of
ATC frequencies—especially Tower
Situation
frequencies.
One in five study reports noted
Situation problems with communications equip­
Trainees often delayed actions or ment that contributed to the incident.
acted inappropriately because instruc­
Suggestion
tors made confusing or misleading
• The detection during preflight of
comments, misinterpreted trainees’
aircraft equipment problems,
comments, or delayed or withheld
especially with “renter installed”
feedback on maneuvers.
communications equipment such
Suggestion as intercoms and push-to-talk
• Our study data suggest the need for switches, can serve as a caution to
additional curriculum and training delay the flight until qualified
to improve the clarity, economy, assistance can be found to ensure
and judgment of priority of verbal normal operation.
communications in dual training,
• Instructors may want to establish
especially for flight instructors.
specific radio usage procedures to
Trainees need to be able to express
ensure that volume levels for ATC
doubt or uncertainty, and also to
communications are louder than
admit mistakes. But it is also
intercom volume levels, and that
helpful for instructors to remember
radio equipment is operating
that every word counts–as well as
normally with periodic equipment
the timing of training-related
tests (i.e., “radio checks”).
critiques. For example, it is more
effective for an instructor to say • To enable quick recognition of
“turn left 90 degrees,” than to ask, external communications problems
“where are you going?” as the (i.e., stuck mike or volume level
aircraft enters controlled airspace misset), an instructor may mini­
without a required clearance. mize intracockpit communications,
especially at controlled airports
• Instructors should consider delay­
during pattern operations.
ing critiques until after tiedown,
whenever possible. This will allow Situation
maximum attention to be given to A large majority of all incidents
other aircraft operations, compli­ involved non-compliance with ATC
ance with taxi clearances, runway clearances, or other ATC-related
and taxiway markings and signs, infractions and violations.
pedestrian activity (at non-tower
Suggestion
fields), and aircraft equipment
• In order to advise ATC and other
operating procedures. Instructors
aircraft of the instructional nature
may make summary notes in-flight
of a flight, the word “trainer” (e.g.,
for use in post-flight debriefings.
Cessna trainer 54321) may be
These notes may be reviewed prior
added to flight plans and radio
to the next lesson’s flight to rein­
broadcasts. The use of “trainer” can
force instructional focus.
also serve as an attention cue that
helps guard against missed clear­
ances and readbacks. ATC already
employs enhanced callsigns with
suffixes such as /R (RNAV) and /H
(Heavy). _

Issue Number 10 21
 References
involves a student or rated pilot
Drew, Charles, A. Scott, and R. who actively handles the aircraft
Matchette. 1993. Delayed Pilot Recog­ controls (usually from the left seat
nition of Lost Communications of the aircraft, except in tandem
Events. In Proceedings of the Seventh configurations), and a certified
International OSU Aviation Psychol­ flight instructor who observes the
ogy Symposium, 318-323. Columbus, trainee’s actions (usually from the
Ohio: The Ohio State University. right seat of the aircraft) and has
the capability of intervening in
Morrison, Rowena, K. Etem, and B. control and communications
Hicks. 1993. General Aviation Landing actions.
Incidents and Accidents: A Review of
3
ASRS and AOPA Research Findings. In The 1996 Nall Report: Accident
Proceedings of the Seventh Interna­ Trends and Factors for 1995, AOPA
tional OSU Aviation Psychology Air Safety Foundation, 1996, 21.
Symposium, 975-980. Columbus, 4
Ohio: The Ohio State University. Carolyn Prince and Renee Stout.
“Situation Awareness From the
The 1996 Nall Report: Accident Trends Team Perspective.” In Proceedings of
and Factors for 1995. 1996. AOPA Air the Eighth International OSU Aviation
Safety Foundation. Psychology Symposium, Columbus,
Ohio: OSU, 1995, 744.
Orasanu, Judith. 1995. Situation
5
Awareness: Its Role in Flight Crew There were a total of 300 airspace
Decision Making. In Proceedings of citations for the 200 incident
the Eighth International OSU Aviation reports in the data set.
Psychology Symposium, 734-739. 6
Columbus, Ohio: The Ohio State There were a total of 356 flight
University. phase citations for the 200 incident
reports in the data set.
Prince, Carolyn and R. Stout. 1995. 7
Situation Awareness From the Team To provide a context for this study
Perspective. In Proceedings of the finding, we searched for statistics on
Eighth International OSU Aviation the numbers of total GA ground
Psychology Symposium, 740-744. operations that occur daily and/or
Columbus, Ohio: The Ohio State annually in the U.S. We discovered
University. that the Boeing Company has done
a study for insurance purposes of
End Notes the amount of time an air carrier
1
aircraft spends on the ground in
ASRS research on General Aviation maintenance. However, we were
issues largely has been confined to unable to find comparable data on
weather-related topics, such as the numbers of GA ground opera­
single-pilot IFR; pilot judgment tions for any time period.
issues; and flight phase-specific
problems such as landing incidents. 8
192 out of 200 reports (96 percent)
2
described one or more communica­
For the purposes of this study, dual tions anomalies that occurred
instruction is considered primary or within the cockpit during flight (as
advanced flight training that opposed to preflight, or post­
tiedown, communications anoma­
lies).

22 Issue Number 10
 ASRS Services

on the INTERNET

T
he ASRS Web Site, started in late 1995, has become increasingly popular with
the aviation community. To the end of September 1998, there have been
*Definitions
435,763 “Hits”1 in 154,904 “User Sessions.”2 The most popular pages, other 1 Hit: An action on a web
than the ASRS Home Page are CALLBACK (ASRS’s award winning Monthly server, such as when a
Safety Bulletin), ASRS Reporting Forms, ASRS Database Information, and ASRS user views a page or
Directline. Since April, 1997, 14,888 NASA Incident Reporting Forms (in PDF3) have downloads a file.
been downloaded by pilots, controllers, maintenance personnel, and cabin crew. 2 User Session: A session
There were 25,114 ASRS Database Report Sets downloaded from February 15 of activity (all hits) for
through the end of September, 1998 (see pages 25 and 26). one user of a web site. A
New Features in 1998 unique user is deter­
Ongoing ........ We will continue to add CALLBACK and ASRS Directline issues in mined by the IP address
HTML4 and PDF format as they are published. or domain name. By
default, a user session is
January 15 .... Selected ASRS Database “Report Sets” were added to the ASRS (considered) terminated
Web Site. We have provided twenty individual sets of reports on when a user falls inactive
various issues of topical interest. Report Sets are available in Rich for more than 30
Text Format5 (RTF). The file size for each Report Set will be minutes.
small, averaging less than 200K, thus download time for users
3 PDF: Adobe’s Portable
will be minimal.
Document Format,
Each Report Set consists of fifty ASRS Database records,
quickly becoming a
preceeded by a note of introduction, caveats on use of ASRS
standard where there is
data, and standard abbreviations and definitions used in ASRS
need to transfer exact
Database records. All Report Sets have been pre-screened to as­
image documents
sure their relevance to the selected topic. The Report Sets will be
between various com­
updated quarterly. New topics will be added—and outdated top­
puter platforms.
ics removed—in response to input from the ASRS user commu­
4 HTML: Hyper Text
nity, and analysis of Web site usage.
Your comments on the usefulness of the “ASRS Database Report Markup Language—the
Sets” feature would be appreciated, and may be directed to common cross-platform
ASRS’s Web Site Administrator at webadmin@olias.arc.nasa.gov language for web
browsers.
5 RTF: Microsoft’s Rich Text
Upcoming Features in 1999 Format, a format which
• Research Products can preserve formatting
ASRS Research Papers will be provided in HTML and PDF. between various applica­
tions, most notably word
• Web Pages
processing packages. RTF
The general appearance and functionality of all ASRS pages will can be read by almost all
be upgraded, and navigation will be made simpler and more word processors, and by
intuitive. many spreadsheet and
• Electronic Report Submission database programs. _
We are planning to introduce a new method for electronic
dissemination, and ultimately submission, of ASRS aviation
safety incident reports.

Issue Number 10 23
 ASRS Web Site Features (December, 1998)

Here is what is available on ASRS’s Web Site:

ASRS Publications
✔ CALLBACK (December, 1994 through present, in HTML and PDF)

✔ ASRS Directline (All Issues, in HTML and PDF)

Operational Issues Bulletins

✔ Operational Issues Bulletin 96-01 (new bulletins will be added as they are
issued—in HTML and PDF)
Reporting Forms (In PDF)
✔ General Reporting Form (for pilots, dispatchers, ground personnel, etc.)
✔ ATC Reporting Form (for controllers)
✔ Maintenance Reporting Form (for mechanics)
✔ Cabin Crew Reporting Form (for flight attendants)
Immunity Policies
✔ Advisory Circular 00-46D
✔ Federal Aviation Regulation (FAR) 91.25
✔ Facility Operations and Administration Handbook (7210.3M), Para. 2-2-9
ASRS Database
✔ ASRS Database Report Sets (in Rich Text Format), including:
• Automated Weather Systems • Multi-Engine Turbojet Aircraft
• Cabin Attendant Reports Upsets Incidents

• Checklist Incidents • Non-Tower Airport Incidents

• Commuter and Corporate Flight • Parachutist / Aircraft Conflicts

Crew Fatigue Reports • Passenger Electronic Devices
• Commuter and GA Icing Incidents • Pilot / Controller
• Controlled Flight Toward Terrain Communications

• CRM Issues • Rotary Wing Aircraft Flight Crew

Reports
• Fuel Management Issues
• Runway Incursions
• Inflight Weather Encounters
• TCAS II Incidents
• Land and Hold Short Operations
• Wake Turbulence Encounters
• Mechanic Reports
✔ Information on the ASRS Database on CD-ROM (available from Aviation
Research Group/U.S.)
✔ Requesting database searches from ASRS
Program Overview (a quick summary of ASRS function and products)
Program Briefing (a slightly more in-depth examination of the ASRS)
Contact ASRS (e-mail addresses for major ASRS programs)

Website: http://olias.arc.nasa.gov/asrs

24 Issue Number 10
 Web Site Usage—Some Interesting Numbers

ASRS Publications
HTML and PDF versions of CALLBACK and ASRS Directline complement the printed versions of these publi­
cations. CALLBACK, posted monthly to the Web Site, is extremely popular—an average of 1,200 users every
month read the most current “online” version.
NASA Aviation Incident Reporting Forms
In April of 1997, ASRS introduced Adobe Acrobat versions of the Reporting Forms. (Users download a PDF
version of the Reporting Form of their choice, a free copy of Adobe Acrobat Reader, and then print, fill out
and mail their completed report.) Here are the downloads for NASA Reporting Forms:
• General (Pilot) Forms ............................ 9,560

• Maintenance (Mechanic) Forms ........... 2,417

• Cabin Crew Forms ................................. 1,566

• ATC (Controller) Forms ......................... 1,345

Total ..................................................... 14,888

Overall Access to the ASRS Web Site

Figure 1 (below) shows both "Hits" and "User Sessions" from December, 1995 though September, 1998. (See
the “Definitions” sidebar on page 23 for an explanation of “Hits” and “User Sessions.”)
ASRS Database Reports Sets
Rich Text Format versions of frequently search requests were introduced in January of 1998. As can be seen
in Table 1 (facing page), these have generated a lot of interest. _

30,000

25,000
� 435,720 Directory “Hits”
� 154,835 “User Sessions”

20,000

15,000

10,000

5,000
Dec-95

Jan-96

Feb-96

Mar-96

Apr-96

May-96

Jun-96

Jul-96
Aug-96
Sep-96
Oct-96
Nov-96
Dec-96
Jan-97
Feb-97
Mar-97
Apr-97
May-97
Jun-97
Jul-97
Aug-97
Sep-97
Oct-97
Nov-97
Dec-97
Jan-98
Feb-98
Mar-98
Apr-98
May-98
Jun-98
Jul-98
Aug-98
Sep-98

Figure 1—ASRS Web Site “Hits” and “User Sessions,” December, 1995 through September, 1998

Issue Number 10 25
26 Issue Number 10