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the Controller’s capability to have an awareness of the situation.
Controller workload, poor radar return of transponder signals,
and lack of aircraft transponders, can all reduce the Controller’s
ability to have this awareness. In this incident, the Controller
apparently had no knowledge of a second aircraft until the callout
from the reporter.
Finally, the AIM and the FARs both state that the job of safely
flying the aircraft remains with the pilot. As the Controller
observed, it was the pilot’s responsibility to practice the see-andavoid
concept and to maintain separation.
ASRS Recently Issued Alerts On...
NOTAM procedures for tethered balloon operations
Reported transmission gaps in an RCO below FL170
Failure of a backup battery system at San Juan CERAP
Uncommanded yawing during a Fokker F-28 ferry flight
A BA-31 emergency attributed to a chafed hydraulic line
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
July 1995 Report Intake
Air Carrier Pilots 2028
General Aviation Pilots 817
Controllers 100
Cabin/Mechanics/Military/Other 24
TOTAL 2969
ASRS Research “Snapshots”
Editor’s note: In April 1995, ASRS presented several
research papers at The Ohio State University’s Eighth International
Aviation Psychology Symposium. Brief summaries of four papers
are presented below.
❶ Airport Ramp Safety and Crew Performance
Issues
This study examined 182 Part 121 and Part 135 ramp
operations incident reports from the Aviation Safety Reporting
System (ASRS) database, to determine the areas of operations in
which damage is most likely to occur, the types of damage that
occur, and the role of flight and ground crew performance errors
in ramp incidents.
It was found that ramp damage incidents occurred more often
during aircraft arrivals than during departures. The damage
incidents occurred most frequently at the gate stop area (within
20 feet of the nose wheel parking line); next most frequently at
the gate entry/exit areas, where taxi lines lead into and out of
the gate area; and least frequently on the ramp fringe areas.
Damage most frequently occurred to ground equipment (in 64%
of the incidents). In more than one third of the damage
incidents, there was only one ground crew member available to
attend the aircraft. Pilot reporters attributed error to ground
crew personnel in more than half the incidents, but also faulted
themselves almost as frequently. The authors offer suggestions
relevant to both airline management and flight crews for
preventing ramp incidents.
❷ Flight Crew Performance During Aircraft
Malfunctions
Past research has shown that a large number of aircraft
accidents attributed to human error began with an aircraft
malfunction. Several of these accidents were caused by the flight
crew’s fixation on the malfunction, which resulted in their loss of
overall situational awareness. The objectives of this study were
to develop a better understanding of the factors that can affect
performance when flight crews are faced with inflight
malfunctions, and to offer recommendations designed to improve
crew performance during these conditions.
The study examined 230 reports in NASA’s Aviation Safety
Reporting System (ASRS) database. Each report was placed into
one of two categories, based on the severity of the malfunction.
Report analysis was conducted to extract information regarding
crew procedural issues, communications, workload
management, situational awareness, and safety problems. A
comparison of these factors across malfunction types was then
performed. This comparison revealed significant differences in
the ways that crews dealt with serious malfunctions compared to
less serious malfunctions. These differences may be due to crew
perception of the malfunction severity, as well as training. The
authors offer recommendations for improving crew performance
when faced with inflight aircraft malfunctions.
❸ The Use of ASRS Incident Reports in AQP
(Advanced Qualification Program) Training
The FAA’s Advanced Qualification Program (AQP) is a recent
approach to flight crew training that can be customized to an air
carrier’s unique operational needs. The goal of AQP is to
introduce real-world conditions into training situations that
require trainees to apply a range of technical and flight
management skills. AQP emphasizes the use of scenario-based
training in Line Oriented Flight Training (LOFTS), ground
　
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