From DALPA Central Air Safety Committee:
“No Problem” May Be a Big Problem!
There have been at least six events since ASAP was reinstituted in which a crew decided not to file ASAP reports based on a casual assurance of “no problem” from ATC (via either the radio or in response to a telephone call), and a Pilot Deviation (PD) was subsequently filed against them. In each case, the crew was informed of the PD after the ASAP reporting window was closed. Below are summaries of some of these events.
Event 1: A 757 crew was departing ATL on an RNAV SID, fully coupled and automated as recommended. On climbout, they experienced an autopilot failure and the aircraft started to roll away from the SID track. The Pilot Flying (PF) disconnected the malfunctioning autopilot and took control of the aircraft, and after what was described as a few seconds of assessment, manually turned back toward the SID track. The PF then attempted to re-engage the autopilot, which again resulted in a roll away from the track, so he again disconnected and turned back in the proper direction. As the crew was correcting to course, ATC queried them regarding their situation, notified them they were off track, and directed them back toward course. Upon landing, the Captain phoned ATC, spoke with ATL tower and departure personnel, and was told there had been no loss of separation, and it was not a problem. The crew then decided there was no reason or need to file ASAP reports. Two days later (and outside the ASAP reporting window), a PD was filed against the crew.
Event 2: A crew landed in ATL and was directed by tower to cross the inboard runway, join Taxiway M, and contact ground. The Ground Control frequency was busy, so while the captain monitored ground waiting for a break, the first officer called Ramp Control, and the aircraft was cleared into the ramp. The aircraft was on Taxiway M directly outside of Ramp 3, no traffic was coming in either direction on Taxiway L, and the crew elected to proceed into the ramp. A PD was subsequently filed against this crew. This crew also failed to recognize the potential violation, and did not submit ASAP reports until several days later when told a PD had been filed.
Event 3: A crew was at altitude one quiet night, monitoring Center and Guard frequencies, when they received an ACARS message from dispatch to contact Center on another frequency. There had been approximately 30 minutes of no communications. No apparent attempt was made to raise the crew on Guard or to have another aircraft on frequency try to call them. A PD was filed against this crew for failure to maintain communications. The crew never even considered the need to file ASAP reports until informed later that a PD had been filed.
The FAA has recently implemented revised internal processes with regard to operational errors and pilot deviations. These changes were part of an effort by the FAA to increase emphasis on Voluntary Safety Programs and on positive utilization of safety information.
Local ATC controllers are now required to report all “occurrences,” and their supervisors must now complete Mandatory Occurrence Reports (MORs). This information is forwarded upstream to a regional Quality Assurance “Clearing House,” reviewed, and in many cases the decision made at that level as to whether or not a PD will be filed. The Air Traffic Controller you work with may be totally unaware of the eventual outcome of your occurrence. Good intentions aside, this new process, at least initially, appears to be driving up the number of PDs filed by the FAA. More specifically, it appears to be driving up the number of PDs filed against Delta pilots who are totally unaware or unsuspecting that there has even been a deviation.
While it is still too early in the process to draw firm conclusions, the first 30 days of the new FAA procedures, when compared to the previous 30 days, show an increase of 40 percent in total Pilot Deviations filed against Delta flight crews (21 vs. 15).
Since March 1, the number of deviations filed has gone down dramatically. It is not clear if this is due to the change in process, fewer pilot errors, or merely a reduction in backlog of paperwork at the FAA QA clearing house.
Additionally, the test period of the Terminal Analysis and Review Program (TARP) is nearing completion, and the system is scheduled to become operational sometime in May 2012. TARP is an automated system, which measures aircraft position against separation standards—vertical, lateral, and angular divergence. The TARP system generates an alert when an aircraft approaches the limits of the required separation, and subsequently generates an Electronic Occurrence Report (EOR). An EOR is forwarded to the same regional QA clearing house as an MOR and can result in a pilot deviation without the Controller saying a word to the crew.
Language in the ASAP MOU describing the timeliness requirements for non-sole source ASAP reports references whether the crew “knew or should have known” that the possible deviation occurred. We still strongly encourage all pilots to file ASAPs whenever anything which could possibly be categorized as a violation occurs. In each of the examples above, the FAA could attempt to argue that every pilot should know getting off the track on an RNAV, crossing a taxiway without clearance, or not communicating with ATC is a potential violation.
Finally, for several months now, ATC has made a practice of filing PDs against crews who deviate from ATL RNAV SID tracks even slightly; autopilot disconnects, turbulence avoidance, or nav system limitations notwithstanding. There is active debate among the parties regarding the navigation accuracy standard on these SIDs, the reference for that standard, and the accuracy and scale of the Departure Control radar depictions. ATL ATC has informally agreed to review their standards/procedures and revisit the manner in which they are policing RNAV departures. However, the message and best practice for our pilots is not affected by the outcome of that debate and review. Any divergence from the SID track which could possibly be construed as a deviation on RNAV SIDs, whether in ATL or elsewhere, and warrants ASAP reports from all cockpit crewmembers.
Your ALPA safety team will continue to work hard to address these issues. For the line pilot, the message is simple: Any safety-related event, any slight deviation from clearance, even if not noted by ATC, should be documented via ASAP. Filing a NASA report should also always be considered. Again, if in doubt, file. If you have doubt, and that doubt is somehow dispelled later, file anyway! Do not let assurances from ATC convince you that an ASAP report is somehow unnecessary. As always, if you have questions about an event you have been involved in on the line call 800 USA ALPA and ask to speak to a safety representative or call the ALPA Intl’s 24 Safety Accident/Incident Hotline at 202 797 4180 (if outside the US you must use the US country code of 001 or 011). For any non-time critical safety related problem call the ALPA Engineering and Air Safety Department at 1 800 424 2470 (US and Canada).
