Reducing Pilot Deviations

Presented to: Sun n Fun, Lakeland, FL

By: FAASTeam Program Manager, Eastern Region, Karen Arendt

Date: April 2009

Federal AviationAdministration

Reducing Pilot Deviations

This presentation is adapted from multiple sources including Air Traffic, Flight Standards and FAASTeam. We have provided it to safety professionals for education and awareness.

2Federal AviationAdministration

Reducing Pilot DeviationsMay 2009

Agenda

• Introduction• Why are we here• Review of Data• Review of Action Items



News Report – Call to Action



A Pilot Deviation….

“is an action of a pilot that results in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance”.

• Security-related airspace violations are but a part of this system, which also includes incidents such as runway incursions and near misses.



Pilot Deviation Reduction Requires Partnership

AircraftOperations

FAA-ATC

(Controllers)(Security-related policy)

(Pilots)

DHS



Types of Airspace

• Special Use Airspace (SUA)– Prohibited, Restricted, MOA, Alert, Controlled Firing

Area (CFA)

• Temporary Flight Restrictions (TFR)• DC Special Flight Rules Area & Flight

Restricted Zone (SFRA & FRZ)



System Operations SecurityTemporary Flight Restrictions (TFR)

•A TFR is an area of airspace (defined both laterally and vertically) which has been temporarily or partially closed to non-participatory aircraft for a specified period of time.

•Flight restrictions may be requested in response to the aviation safety needs for the separation of aircraft for disaster type occurrences.



System Operations SecurityFAA TFR Considerations

• Nature of event (Security/Disaster)• Existing airspace (Class B, Borders)• Credible threat intelligence• Aviation commerce• TFR’s are not restricted to circles, polygons ; racetracks are also

an option. In addition cutouts may be provided to allow access to otherwise closed airports



System Operations SecurityTemporary Flight Restrictions (TFR)

Title 14: Aeronautics and SpacePART 91 – GENERAL OPERATING AND FLIGHT RULES

§ 91.141 Flight restrictions in the proximity of the Presidential and other parties.

No person may operate an aircraft over or in the vicinity of any area to be visited or traveled by the President, the Vice President, or other public figures contrary to the restrictions established by the Administrator and published in a Notice to Airmen (NOTAM).Title 14: Aeronautics and SpacePART 99 – SECURITY CONTROL OF AIR TRAFFIC

§ 99.7 Special security instructions.

Each person operating an aircraft in an ADIZ or Defense Area must, in addition to the applicable rules of this part, comply with special security instructions issued by the Administrator in the interest of national security, pursuant to agreement between the FAA and the Department of Defense, or between the FAA and a U.S. Federal security or intelligence agency.



Typical Presidential TFR

• Issued to Protect the President, Vice President, or other public figures (14 CFR Section 91.141)

• TFR’s for the President generally have 2 rings. 10NM and 30NM with separate rules for each.

• Occasionally there may be multiple inner and outer rings to accommodate movement.



DC SFRA / FRZ



Number of US ADIZ Breaches-2001 to 2007-



Airspace Deviations by Airport (DC SFRA)

22

11

8

27

54

78

5

13

57

12

46

32

11

3

30

15

13

5

11

25

55

127

18

14

60

20

40

24

13

11

34

21

0 20 40 60 80 100 120 140

WINCHESTER

WARRENTON

QUANTICO

MARTIN STATE

MANASSAS

LEESBURG

INDIAN HEAD

HAGERSTOWN

GAITHERSBURG

FREEWAY

FREDERICK

FORT MEADE

EASTON

COLLEGE PARK

BAY BRIDGE

ANNAPOLIS

DEST

ORIGIN



Airspace Deviations by State Percentage by State

DCA-FRZ-ADIZ

MD

NY

PA

P56

ME

VA

MA

NJ

CT

NC

NH

WV

RI

DE

P40

UNK

VT



0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2003 2004 2005 2006

OperationalErrors

PilotDeviations

Trend per 100,000 operationsTrend per 100,000 operations



Accident Rates – per 100,000 hoursAccident Rates – per 100,000 hours

0

1

2

3

4

5

6

7

8

2003 2004 2005 2006

Air Carrier

Air Taxi

Commuter

GA



Where’s the balance….? Congressional Research

Service Report – Library of Congress, September 2005



The Evolution of Safety Thinking

HUMAN FACTORS

TOD

AY

1950s 1970s 1990s 2000s



Cost of doing business – General Aviation

• Increase in security measures

– Physical Barriers– Regulations and Fines– Alerts & Warnings– Education & Training

GA Operations

Protection Production

“So where do we go from here”



Pilot Deviations Challenge

• 675,000 GA pilots

• 221,000 Registered Aircraft

• 18,000 Airports • Technology has its

limitations

• Causes – Crucial Information not reaching pilots

Source: * FAA Runway Safety Fact Sheet



Recent (ASRS) Pilot Reports

• September 2005; 500-hour pilot files flight plan enters IMC during climb through FL100. At completion of flight pilot recognizes cockpit distraction caused him to lose situational awareness. Pilot cancels flight plan and recognizes error in judgment.

• April 2006 enroute from Cancun, Mexico to Mobile, AL the pilot is told to call Eglin AFB upon landing. The military was tracking him offshore to U.S. Airspace and alleges he did not file a DVFR flight plan and he should have been on a discrete code. Anniston, TX Sector controller requested he squawk 1200.




• May 2006, a pilot checked all NOTAMS for a flight in a Hughes 500 helicopter from Lancaster to Chester County, NJ. The BUF FSS briefer told the pilot the FAA had cancelled all TFRs. On arrival in the PHL area, ATC told the pilot to land immediately as he had violated the TFR. The pilot landed and after a call to the FSS discovered that the TFR in question was reinstated 45-minutes after his initial call.




• Pilot receives a NOTAM briefing but arrives in briefed area earlier than planned. He attempts to call FSS to no avail. He was announced as traffic in the TFR by the controller the pilot contacted. The pilot asserts he had no knowledge of the TFR, by FSS briefing or Air Traffic control sector prior to handoff.



Types of Errors (Active Failures)

• Perception Errors– “I didn’t see it,” or “I didn’t notice the difference…”

• Memory Lapses– “I forgot to do it…”

• Slips– “I didn’t mean to do that…”

• Wrong Assumption– “I assumed that the situation was different…”

Alan Hobbs, ATSB (2008)



Errors (cont.)

• Technical Misunderstandings– “I tried to do it right but I didn’t understand

what I had to do…”

• Procedure Violations– “Nobody follows that procedure here….”– “We can’t get the job done if we do all that…”

Alan Hobbs, ATSB (2008)



Organizational AccidentsOrganizational processes

Latentconditions

Workplaceconditions

DefensesActive

failures



Recognizing Risk in the Workplace



Risk Mitigation & Reduction

Click Space Above for Video



Safety Management Strategies

Reactive(Past)

Responds to events that have

already happened, such as

incidents and accidents

Proactive(Present)

Actively seeks the identification of

hazardous conditions

through flight risk tools

Predictive(Future)

Analyzes system

processes and environment to

identify potential future problems



Major Airports within the ADIZ/FRZ



Tipton Army Airfield (FME)



Fatal Accident – Tipton Army Airfield

• Controller: "N9130-November, you are squawking 1200, is that correct?"Pilot: "Roger that."Controller: "You are violating the ADIZ. You need to land at Tipton immediately and I'll have them give you a phone number for air defense."Pilot: "Landing at Tipton Immediately. 30-November."Controller: "30-November, I'm too busy to give you that phone number. Maybe you'll get away. Just turn it off and land and call us on the phone for your clearance."Pilot: "Roger."



12 October 2006-2 Fatalities-

….Contributing to crash pilot’s “self induced” pressure to land. (NTSB Report NYC07FA009)



Leesburg Executive Airport (JYO)Airport Specific Procedures exist for Operating in the Leesburg Maneuvering Area (LMA)



The Leesburg (JYO) Maneuvering Area

•A separate NOTAM (!FDC 8/9460) has been issued to cover the Leesburg Maneuvering Area (JYO).

•The major change in the geographic size of the maneuver area is the realignment of the eastern boundary with the Armel VORTAC, AML 004 /16.6 radial.



Call to Action – Shift to Permanent Airspace

On February 17, 2009 the Administrator designated the Air Defense Identification Zone (ADIZ)– the Special Flight Rules Area (SFRA) defined as ‘National Defense Airspace’.

• Procedures for operating in the SFRA : – File DC SFRA or FRZ Flight Plan– Obtain discrete code– Maintain two-way communications with ATC – Monitor 121.5

The Administrator agreed to require all pilots operating with 60NM of the DCA VOR take online training at FAASafety.gov effective February 9, 2009. This action permitted the FAA to retain the SFRA airspace at 30NMR (outer-ring) and FRZ ca. 15NMR (inner-ring).



Flight Standards Action

• Flight Standards has formed an Enhanced Pilot Deviation Work Group to improve our understanding and response to pilot deviations in order to reduce the numbers, including runway incursions

• This work group involves stakeholders from across AVS and ATO in developing improved inspector training, investigative techniques, data collection and analysis of pilot deviations

• That data will allow us to better understand root causes and design interventions that will reduce future pilot deviations




1) Today!

2) Distribute training materials (DVD)

3) Increase emphasis on PDs through Flight Instructor Refresher Clinics (FIRCs)

4) Initiated development of Aviation Safety Inspector training program(s) - eLMs (electronic Learning Management System) and Academy for string and recurrent training

Right Now

Right Now

Right Now

7/31/08

Enhanced Awareness:



5) Published Notice 8900.48 from AFS-1 to all Managers/Supervisors restating the importance of awareness of PDs

7/31/08

Flight Standards ActionEnhanced Awareness (continued):



Flight Standards ActionRedesign “block-18”, of the electronic ATQA

10/31/08Data Acquisition:



Flight Standards ActionData Acquisition: “Box 18” Pull-down Questions



• Determine Root Cause: Once sufficient data have been collected through the revised FAA Form 8020-18, the FAASTeam will initiate analysis of the acquired data to determine root causes

• Create Solutions: Once the FAASTeam has determined root causes, a joint effort between Air Traffic, Airports, AFS-800 will lead to programs and procedures designed to reduce or eliminate pilot deviations


2009

2009



Operator short-term actions

• Improve pilot training by including particular focus on hazard identification through feedback from airspace users.

• Provide feedback at safety meetings and hearing sessions:– Search ASRS database– Create internal monitoring and feedback from flight

instructors and pilots, renter-pilots, and students– Assign mentor-pilots and FAASTeam

Representative at high-risk/high-use airports



Operator short-term actions

• Review Manuals, SOPs and cockpit procedures to identify elements that may contribute to pilot distraction before takeoff and develop a plan to eliminate those elements

• Enhance training for all-pilots (SBT)• Place NOTAMS and current charts in

prominent locations• Annotate airspace-user concerns and

discuss at regular safety-meetings



Review of Action Items

• Has continuous education on the hazards identified in ‘pilot-occurrence’ reports been provided to pilots, renters & CFIs? If so, how many pilots have received it? What steps can be taken to “speed-up” the implementation – or to reach pilots immediately who won’t be back for refresher training for a while?



Review of Action Items

• We committed to review feedback from pilots to identify hazards through root cause analysis. Has everyone completed the review of their procedures? Have distractions been identified? Is there a plan for eliminating these distractions? Is the plan being executed? Can we speed up this effort?



Common Air Traffic Control Errors resulting in an Pilot Error • Forgets to add instructions to “maintain

current squawk code” after cancelling IFR flight plan

– “Negative Habit Transfer” – Actions that are exceptions to routine leave the Controller vulnerable to error.

• Distractions, interruptions – Number one enemy of memory



Common Pilot Errors resulting in a Pilot Deviation

• Pilot files an IFR Flight Plan and takes-off intending to obtain the clearance ‘in the air’

– ‘Law of Recency, Reinforcement and Repetition’ - pilot applies long-term practices to a new situation.

• Most common factor cited for losing situational awareness is fatigue, loss of situational awareness, workload management



Airspace Structure – NO VFR CORRIDOR



Common Pilot Errors resulting in a Pilot Deviation

• Pilot interprets ‘VFR Corridor’ on chart is available for transit purposes

– ‘Law of Primacy’ - pilot applies long-term practices to a new situation.

• Most common factor is how the airspace information is perceived, interpreted and acted-upon by the pilot. The pilot’s understanding should match the airspace design-intent conveyed on the charts.



Safety CultureA Safety Culture includes:

– Personal dedication and accountability

• Individual attitudes and behaviors

– Shared vision with structures to attain it

• Organizational processes, methods and metrics

– Commitment to improve (resist complacency)

• Beyond simple adherence to procedures

• Learning and continuous improvement

– Pervasive safety thinking

• Commitment to excellence

• Integration of safety into all activities

– Climate in which news is quickly and easily communicated

– Committed to investing the time and resources to address risk



Outreach to Pilots

• The FAA released a new booklet titled- ‘Risk Management Handbook’

• In collaboration with the industry, the FAA created online training course at FAASafety.gov that educates pilots on the Special Flight Rules Area. The course is required for all pilots operating VFR within 60NM of the DCA VOR (FAR 91.161).

• Every year, the FAA conducts hundreds of safety seminars across the country to encourage safe practices on the nations airspace.



Outreach to Pilots

• A Safety Alert for Operators (SAFO) is an information tool that alerts, educates, and makes recommendations to the aviation community.

• An Information for Operators (InFO) message contains valuable information for operators that should help them meet administrative requirements or certain regulatory requirements with relatively low urgency or impact on safety.



Outreach to Pilots

• www.faasafety.gov – ‘Navigating the New DC SFRA’

• http://airspace.nifc.gov– National Interagency Space – TFR/Laser/Stadium



What’s Next• Leadership Meeting with Industry/User-

groups (FAA/NCRCC/ATC/FSS)• Each group should come up with 5

initiatives on how to deal with best practices

• Review of inFO:– Show Hand Out Check Here Here



Questions

Reducing Pilot Deviations

Documents

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