Anonymous reports of close calls in the air and on the ground are meant to prevent calamities

by Kevin Crowe and Kelly Thornton | inewsource

A commercial airline pilot en route to San Diego International Airport looked out a window at 10,800 feet and saw a Navy jet coming right at him.

“The captain quickly pulled up on the control column to avoid hitting the (Lockheed) S-3 (Viking),” the pilot wrote in a federal aviation report. “He turned his head to the right, which made me look out of my window on the right. And the window was full of the S3. He appeared to be less than 100 feet below us. We were pretty much shook up and just leveled off for a minute.”

Pilots, air traffic controllers, flight crew members and aircraft maintenance workers have filed hundreds of anonymous reports like this about near mid-air collisions, miscommunication, pilot fatigue, equipment failures and other mishaps that occurred in San Diego County airspace or on runways from 1988 through 2009.

inewsource, an independent reporting center based at San Diego State University, delved into these reports and found at least 45 accounts by pilots in San Diego skies since 2000 who said they had to bank, dive or climb – sometimes violently – to avoid colliding with aircraft or terrain that in some cases came as close as 30 to 500 feet.

Crashes make the news and are investigated by transportation safety authorities. But reports of these close calls – ones that don’t result in injury, death or major damage – give a rare glimpse into what goes on behind-the-scenes in the aviation world. These incidents range from the serious to the mundane.

The state of California represented the most reports to NASA with 48,344 in the last decade. Texas was second with 34,898 reports.

Since 1988, 867 of the public reports related to San Diego County airspace and airports. Of those, 478 occurred in and around San Diego International Airport. Since 2000, there were 271 reports relating to airports in San Diego, of those 142 related to San Diego International Airport.

In the local reports, one pilot said he could hear another plane’s engines as it passed within 400 feet overhead at 15,000 feet; another said his commercial jet nearly struck a fuel truck on a runway but managed to stop with two feet to spare as frightened passengers alerted him; another said he was forced to bank low over a crowded beach to avoid a high-flying parasail being towed by a boat.

The stories are recorded in a complex database kept by NASA, which runs the nation’s space program and has no investigative or disciplinary authority. NASA is considered neutral territory where pilots and others can disclose mishaps voluntarily, anonymously and usually with impunity. The purpose is to highlight safety concerns; the hope is that the information can prevent future mistakes and disasters.

NASA is “in a wonderful position to be a clearinghouse of information and see patterns…to head off problems, ” said John King, a pilot, instructor and co-owner of King Schools Inc. near Montgomery Field. He said he incorporates what he learns from NASA’s monthly safety roundup into his teaching.

Members of the aviation community – including NASA officials – cautioned that the reports, while valuable for identifying problems before they turn into calamities, are not statistically reliable because they are voluntary, subjective and sometimes difficult to verify.

But while some downplay the significance of NASA’s Aviation Safety Reporting System, or ASRS, others said the often long, meticulously detailed stories likely represent just a fraction of what is really going on.

Linda Connell, director of NASA’s program said the information is valuable. “We believe that the real power of ASRS lies in the report narratives.”

San Diego’s airspace is a freeway in the sky, shared by commercial, military and corporate jets down to two-seat recreational planes and gliders.

At San Diego International Airport, the busiest single-runway commercial service airport in the country, there were about 190,000 departures and arrivals carrying 16.9 million passengers in 2010. There were 486,253 takeoffs and landings at the county’s eight airports, the largest of which are Gillespie Field in El Cajon and McClellan Palomar in Carlsbad.

Add to that the 185,506 operations at Montgomery Field and 91,025 at Brown Field, the approximately 4,800 at Oceanside Municipal Airport, plus a conservatively estimated 350,000 operations at the region’s military airports at Camp Pendleton, Miramar Marine Corps Air Station and Naval Air Station North Island.

That’s more than 1.3 million a year, or about 3,582 a day.

About 170 accidents have been investigated by the National Transportation Safety Board in San Diego County since 2000, including 36 involving fatalities.

NASA officials estimate they receive about 50,000 reports a year nationally – a number that has increased 48 percent in the last decade, from 34,263 in 2001 to 50,902 in 2010. NASA analysts triage each report and focus on the more troubling ones, which are then coded and entered into a public database. They contain no information that could identify the reporting party. Officials said the public reports account for about 20 percent of the total.

Many of the reports reflect a tension between those piloting the planes and those responsible for their safe journeys. The ranks of San Diego’s air traffic controllers have dwindled as a result of labor strife and retirements, and some union leaders say the result has been a devastating loss of experience and an increase in fatigue and mistakes that is just beginning to improve.

In one, an annoyed pilot wrote that he’d been cleared for landing at San Diego International Airport and had been advised by air traffic control that a police helicopter was in the vicinity but “presented no problem.”

Soon after that, an alarm sounded that a collision was imminent and urged him to “Climb, Climb.” As he quickly pulled the nose of the plane up, the offending helicopter came into view. “Tower advised that the helicopter had us visually and no problem existed. I’m not sure the helicopter had us in sight. If so, an (alarm) should not have been necessary. I can’t believe that an airport with a prior midair (collision) can operate in such a cavalier environment.”

That was a clear reference to the 1978 collision of PSA Flight 182 and a private Cessna 172 over North Park. At the time it was the worst aviation disaster in the nation’s history, and remains the most deadly in the state of California. The death toll was 144.

FAA spokeswoman Laura Brown in Washington, D.C., noted that NASA’s program, while a trendsetter when established in the 1970s, is just one small piece of a bigger data picture the FAA relies upon to evaluate matters of safety. The agency now uses a system that connects 46 safety databases across the industry – including NASA’s. Most of that data is not publicly available.

A Government Accountability Office report in May 2010, however, found the NASA program to be an important part of the FAA’s efforts to identify trends and prevent problems before they become serious. The GAO document said voluntary reporting programs such as NASA’s provide “safety information that would not be discovered 95 percent of the time.”

Several pilots said the NASA system is widely used, mostly to report minor errors rather than near-catastrophic blunders. Pilots make the reports to protect themselves from fines or other disciplinary action, and to keep others from making the same mistakes.

Other key San Diego findings in the NASA reports include:

    • Analysts listed “human factors” as the primary problem for almost two-thirds of the public reports, according to the Institute’s analysis.
    • Since 2000 at San Diego International Airport, 13 aircraft were damaged; five aircraft landed in emergency conditions; one plane was evacuated, 30 resulted in maintenance action and two incidents resulted in injuries.
    • At and around the county’s smaller airports, including McClellan-Palomar, Gillespie and Montgomery, there were 58 reports since 2000. Of those, there were 11 near mid-air collisions reported and 11 runway problems, including skidding off the runway and breaking runway lights, and landing without gear down.

Among NASA reports at smaller airports:

  • The pilot of a Cardinal 177 took off from Gillespie Field in El Cajon and almost ran directly into an approaching Cessna. The pilot taking off said he had been cleared. Air traffic controllers later asked him if he had heard their instructions for him to abort the takeoff so the Cessna could land. He said he did not hear the controllers.
  • A pilot flying a solo personal mission from McClellan-Palomar was informed he deviated from a takeoff clearance and created an airborne conflict with a corporate jet that took off after him. He didn’t realize this until he was told by a controller. The pilot insisted in the report he did nothing wrong.

Airport officials who are responsible for maintaining grounds and runways said the NASA numbers represent a tiny fraction of the number of takeoffs and landings that take place at county airports. For instance, 99 reports made to NASA over 10 years concerning McClellan-Palomar Airport, out of about 200,000 operations there annually, is statistically negligible at .0000495 percent.

“There are issues in these reports that may be considered breaches of safety but not necessarily as significant,” said Peter Drinkwater, director of San Diego County airports, which include Gillespie, McClellan-Palomar, Ramona, Fallbrook, Borrego Valley, Jacumba, Agua Caliente and Ocotillo.

A Near Mid-Air Collision is an incident associated with the operation of an aircraft in which a possibility of a collision occurs as a result of proximity of less than 500 feet to another aircraft, or a report is received from a pilot or flight crew member stating that a collision hazard existed between two or more aircraft. A report does not necessarily involve the violation of regulations or error by the air traffic control system, nor does it necessarily represent an unsafe condition. -FAA

Jim Swain, a former airport tower manager and TRACON controller who is now a consultant for county airports, said he has written reports to NASA as a controller, and reviewed reports as a manager. He said one weakness of the system is the NASA reports are based on one person’s perceptions and don’t include the perspectives of all the parties involved in an incident.

When it comes to identifying safety issues, he said he looks to official reports, such as annual safety reviews by the FAA and records like voice and radar recordings, rather than the one-sided NASA reports.

Some reports from pilots point a finger at air traffic controllers.

One pilot said an air traffic controller was too overwhelmed to notice a mid-air collision was about to happen above Mission Valley. Another plane “suddenly appeared at our 12 o’clock to 1 o’clock position…coming right at us.”

“No call was ever received from air traffic control, nor did we ever tell her. Her sector was non-stop chatter, and she was in constant communication with some aircraft. She was extremely busy. I know the other aircraft never saw us. Without evasive action it would have been a fatal incident.”

Many of San Diego’s controllers are working at the busiest air traffic control facility in the world, Southern California TRACON, pronounced TRAY-con, for Terminal Radar Approach Control.

It’s in an unobtrusive beige three-story building with a few antennas protruding from the roof near Miramar Marine Corps Air Station, next to a Holiday Inn Select.

San Diego County controllers working in on-site airport towers direct traffic from the airport to a point five miles away. At that time TRACON takes over for up to roughly 15,000 feet.

TRACON controllers keep close watch on aircraft from north of Burbank to the Mexican border and from Catalina Island to Palm Springs. They track 2.2 million aircraft operations a year, more than in all of Western Europe. Their jurisdiction covers aircraft around Los Angeles, San Diego, Orange County, Burbank and Ontario airports.

NASA narratives reflect some of the issues affecting TRACON controllers.

Staffing levels, which bottomed out in the mid-2000s, are just starting to recover following a bitter labor dispute. There were 261 certified air traffic controllers in 2004, 150 in 2008, and there are 183 now, according to Ron Geyer, union president of Southern California TRACON local.

He said conditions have improved since controllers reached a contract agreement with the FAA in late 2009. More retirements in coming years are expected to create a shortage of veteran controllers, and there are 100 junior controllers in a training process that can take years. Geyer said inexperience jeopardizes safety.

FAA spokeswoman Brown said the agency is on track in its controller hiring goals and disputed there is a shortage. “I don’t think we think we need more air traffic controllers.”

In his June 2008 testimony before the House Transportation and Infrastructure Committee, TRACON facility representative Melvin S. Davis noted a significant increase in operational errors at TRACON resulting from understaffing.

He said the number of controllers correlated directly to the number of operational errors, which were on pace to increase 400 percent, from 10 in 2004 to an estimated 40 in 2008. At the same time, the number of controllers dropped 42 percent from 261 in 2004 to 150 in 2008.

An operational error is when aircraft get closer than 1,000 vertical feet and 3 miles laterally and longitudinally to each other, terrain or obstacles.

“In the last four years the facility has lost over 2000 years of experience, Davis testified. He noted that trainees can’t keep pace with retirements of veterans.

Alexandra Caldwell, spokeswoman for the National Air Traffic Controllers Association, believes the NASA program, as well as a couple other similar ones instituted in the last few years, are improving safety.

“It’s a more safety-minded culture now,” Caldwell said. Controllers, for instance, “are not being penalized for reporting errors. Our controllers feel more comfortable raising the red flag on problems in the system.”
How much should a passenger worry about the stories in the NASA reports?

“Is it safe? Yeah,” said Terry van Thaden, an air-safety researcher at the University of Illinois Urbana-Champaign. “Does stuff happen every day that you don’t want to know about? Yeah. The fact that it works always amazes me.”

inewsource intern Sandy Coronilla contributed to this report.

About the data:

The National Aeronautics and Space Administration (NASA) operates and manages the Aviation Safety Reporting System (ASRS). The mission of the ASRS is to acquire information concerning current and potential deficiencies in the operational performance of the National Aviation System, and to maximize effective use of the information to further aviation safety and system planning. The ASRS has two primary aspects: one deals with the maintenance and operation of a voluntary, confidential incident-reporting program that, by agreement with the Department of Transportation’s Federal Aviation Administration (FAA), complements the FAA’s Aviation Safety Reporting Program (ASRP). The other aspect of the ASRS program deals with research and development using the incident reports to support improvements in the performance and safety of the future aviation system. The ASRS began operations on April 15, 1976.

The ASRS Aviation Incident Database is a generalized database used to track and report on codified aviation safety incident data collected from pilots, air-traffic controllers, cabin crew, mechanics, and others. In 2008, the ASRS received about 50,000 voluntarily submitted reports. All reports go through our rigorous screening and review process. Since March 2001, 100% of reports received had high level information captured and up to 20% of the reports had detailed narrative, coding, and synopsis entered into the ASRS database. -NASA

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