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of the speeds when spoilers are extended.
Situation #2: An air traffic controller had bad vibes
about a trainee’s instructions to two aircraft – but when
the instructor tried to intervene, miscommunications
prevented a timely resolution.
n I was training a Developmental [controller in training]
on a Radar East sector…The Developmental descended an
MD80 to 3,000 feet about 10 miles northeast of airport on
a heading of 180 degrees. A Cessna 414 departed airport
heading 030 degrees climbing to 4,000 feet. The trainee
told the C414 to climb and maintain 12,000 feet and turn
right to ABCDE intersection (approximately a 060 degree
heading). As I was telling the trainee that this was not
going to work, the C414 asked for a verification of the
assigned vector and altitude. Instead of hearing me, [the
trainee] heard the pilot and verified the climb and vector.
Again I told the trainee this was not going to work and to
correct the situation. The trainee called the C414 and told
the pilot to fly heading 350 degrees and maintain 3,000
feet. The pilot did not respond. Again the trainee called
the C414 with no immediate response. It turns out that
the trainee had transposed the last 2 letters of the C414’s
call sign. I did not realize that [the trainee] had made
this mistake. The trainee advised the MD80 to maintain
4,000 feet and turn left, I do not recall what heading was
assigned. The MD80 pilot acknowledged and complied.
Either before or after the communication with the MD80,
the C414 asked if the previous calls were for them because
the last two letters were transposed. The trainee responded
affirmative and told the C414 to fly heading 350 degrees,
maintain 3,000 feet, traffic stopped at 4,000 feet. The C414
pilot replied ‘turn to 350 degrees, maintain 4,000 feet.’
The trainee told the C414 to maintain 3,000 feet, traffic
alert. The C414 pilot replied ‘Maintain 3,000 feet, traffic in
sight.’ At this point, separation had already been lost….
The error began when the trainee turned and climbed the
C414 directly toward the MD80. In retrospect, I should
have taken over at that point but I wanted the trainee to fix
it. When the trainee twice used the transposed call sign, I
did not catch the mistake and this is what I believe led to
the loss of separation….
Instructor Loss of Focus
Situation #3: In the aviation maintenance environment,
Technicians may be asked to play dual roles, depending
on staffing and availability of resources. A Maintenance
Upgrade Inspector made several inspection errors while
trying to train a new-hire Mechanic.
n I was an Upgrade Inspector (I am an alternate) on
RON [Remain Over Night] shift. I ‘Received’ [verified tire,
make, and wheel half] approximately 100 mixed tires and
brakes tires and brakes that evening…. While Receiving
the tires, one of our new-hire Mechanics asked if I would be
able to help him with a pressurization event he had on his
RON aircraft. I was about halfway through the tires and
had the nose and brakes left to inspect when I went and
helped this Mechanic for about 2 hours with his aircraft.
After that, I returned and continued my inspections work.
I was notified by another Mechanic that several of the nose
tires I had inspected had improper parts tags on them.
Three tires had been inspected by me. I verified the 3 tires
were in fact incorrect and retagged them as they needed to
be. I also rechecked the stack of tires and found no other
discrepancies….
Number 357 September 2009
Aviation
Training
Incidents
Learning to Fly
landing right the first time as we knew a go-around would
not be an option. I was watching his approach carefully to
make sure he was not high or low. The final approach to
landing was fine. However, we both became fixated on the
landing itself. In the process we failed to put the landing
gear down…
My instructor was flying the aircraft and felt responsible.
However, I realize that I did nothing to reduce his
workload. I could have performed a simple GUMPS check
which I normally do even in a fixed gear aircraft.
I believe my lack of action was due to the following factors:
• Lack of confidence and experience in the aircraft
• Little experience with my instructor
• Lack of sleep
• Having a student mentality and depending totally on
my instructor.
Situation #6: A Bonanza 36 pilot receiving recurrent
training in short field procedures assumed (incorrectly) that
if the instructor was not intervening, things must be OK.
　
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