December 18, 2010

Close Calls, Narrow Escapes


Thousands of reported air safety lapses on the ground and in the sky, including near mid-air collisions and averted runway wrecks, have led to harrowing close calls at Bay State airports over the past two decades, according to disclosures filed with the National Aeronautics and Space Administration each year.

From Boston’s busy Logan Airport to smaller airfields in Berkshire and Worcester counties; from the skies over Lawrence, Bedford and Cape Cod and out to the village heliports and seaplane ramps on Martha’s Vineyard and Nantucket, the reports recount safety blunders which might have ended tragically were it not for rapid remedial actions taken by flight or ground crews and air traffic controllers.

The reported incidents include communication breakdowns between pilots and airport employees, equipment failures, lack of adequate space on airfields, sudden weather scares and flight crew fatigue, according to an analysis by the New England Center for Investigative Reporting.

In about 500 cases, aircraft was either damaged or pilots had to take evasive or emergency action to prevent accidents or damage to objects on the ground, the NECIR analysis shows.

Federal aviation officials caution that because the information is voluntary and sometimes difficult to verify, it’s impossible to tell from the reports how frequently air travel disaster is foiled. Rather, reports made to NASA’s Aviation Safety Reporting System are used to identify safety problems and address them before an aircraft calamity occurs.

These incidents are only about one-fifth of what is actually reported to NASA annually. Linda Connell, director of NASA’s ASRS database, said that partly due to budget constraints, analysts are only able to focus on reports that could pose a “high hazard.”

“It’s really meant to grab at incidents, close calls and near misses,” said Linda Connell, director of NASA’s ASRS database. “Those kinds of things that we all know are precursors to the more serious events.”

“The value of this data is in lessons learned,” Connell said. “We’re a significant piece of the process that makes aviation so safe."

One chilling pilot dispatch filed in August at Logan Airport alleged hard-to-read runway signage and confusing lighting could have caused planes to collide during takeoff.

“. . . a failure by an aircraft to stop could be catastrophic. BOS has experienced near misses before and it would seem that even temporary flashing lights at the intersecting runways would help,” the pilot wrote.

A November 2009 report from a pilot who misunderstood altitude instructions from the controller and flew dangerously low on approach to Nantucket expressed relief in catching the mistake which could have “turned into a disaster.”

“It seems clear to me now that this was an error of memory, hearback and readback,” the pilot wrote after landing safely. “We were fortunate that it happened over the water with no air traffic in the area.”

In January, a pilot taxiing on the runway at Lawrence Municipal Airport reported coming so close to the propeller of a parked aircraft that paint rubbed off onto the pilot’s plane.

“I immediately took corrective action which required taxiing significantly to the right of the taxiway centerline in order to clear the two aircraft,” the pilot reported to ASRS.

“I realize that the taxiway centerline does not guarantee obstacle clearance and that it is the pilot's responsibility to see and avoid, however, it is my opinion that the clearance between Taxiway E and the north ramp is insufficient and hazardous.”

Other recent reports include:

• a pilot’s complaint that insufficient notice was given from Logan airport about a tall ship in Boston Harbor which could have impeded visibility during a landing

• a truck driving on a runway as the pilot was taking off

• a plane having to return to the airfield because a bird strike made a hole “about the size of a golf ball” in the right wing flap, the records show.


The nearly 2,300 ASRS publicly-available reports filed between 1988 and August, 2010 represent what some air safety experts said could be just a fraction of similar incidents taking place on flights coming in and out of Massachusetts each year. The majority of reports are filed by pilots, ground crew or airport employees like traffic controllers.

“We hear about the ones who come to grief, not necessarily the ones who escape,” said David Kenny, a pilot and manager of Aviation Safety Analysis for the Air Safety Institute in Fredericksburg, MD. “These are pilots who get a good scare.”

Last year, well over a million aircraft traveled the skies above Massachusetts, the most recent Federal Aviation Administration data shows. About 98 aircraft accidents have been investigated by the National Transportation Safety Board since January, 2005, including 12 involving fatalities, NTSB data shows.

But Kenny also warned that the subjective nature of the ASRS system makes it impossible to gauge the full extent of aviation safety hazards that don’t result in injury, death or substantial damage to an aircraft or an object on the ground.

“There is no legal or practical requirement that every close call be reported,” Kenny said. “An episode that gets the attention of one pilot may not get the attention of another.”


The reporting system is maintained by the NASA, which runs the nation’s space program, rather than federal aviation agencies, to provide a layer of immunity for people who want to honestly report safety concerns but are fearful of being penalized for violating federal aviation laws and regulations, said Connell.

The FAA and the National Transportation Safety Board have primary enforcement powers for U.S. aviation safety. The FAA also investigates aircraft accidents, along with the other agencies like the National Transportation Safety Board and state and local aviation officials.

“The whole goal is to sever reporting about safety from enforcement or violations of federal air regulations just in the interest of getting people to talk about what’s happening out there in the everyday so we can learn,” Connell said.

Generally, without a deliberate or negligent legal or procedural air safety violation, the person reporting will be immune from punishment like a fine or a pilot’s license revocation, Kenny said.


In more than half of the Massachusetts reports to date, “human factors” is cited as the primary problem for the incident,” - an unsurprising fact for those working in aviation.

“As long as you have a human in there, you’re probably going to make mistakes. It’s like driving a car; you’re going to get distracted,” said Fred Guertin, the manager of the Fitchburg Municipal Airport where an alleged mechanical problem caused a fatal crash last month.

Guertin, a pilot since 1965, said he used the ASRS system to disclose an incident in the early 2000s in which he flew at an altitude not previously agreed to by the air traffic controller.

“The autopilot didn’t capture the altitude. I wasn’t paying close enough attention. I just assumed it was going to do it. The altitude alert started going off,” Guertin said.

Guertin acknowledged the reporting system is partially for “covering your butt” but also has value in improving safety.

“That whole program is intended, I think, to point out errors. How did it happen? It’s to help you identify what caused the infraction so that you can learn from it,” he said.

While pilot error is the problem cited in numerous reports, communication breakdowns happen much more frequently, the NECIR analysis shows.

“There is a likelihood of people not hearing or mishearing calls to them and as a result doing stuff that is unexpected to the controller,” said pilot Ted Lester, president of Associated Pilots, a Bedford-based flying club. “It’s unlikely that one misread or misunderstood report could cause a safety thing but it could be the one key in . . . . the chain of an accident.”

FAA spokeswoman Laura Brown said the agency has made strides in addressing safety problems caused by “low-hanging fruit” such as mechanical or design issues.

“But AT the end of the day, the system involves human beings and is operated by human beings,” Brown said.

Christopher Willenborg, head of the state Department of Transportation’s aeronautics division, said issues such as runway safety and adequate pilot training have required closer scrutiny in the last five years.

“We are always looking for ways to enhance and improve safety,” Willenborg said. “I think as we move forward (these reports) will be something we will look into on a regular basis.”


At Logan Airport in Boston, which is owned and operated by the Massachusetts Port Authority, there have been at least five separate complaints this year from air traffic controllers about a new digitized radar system known as ASDE-X. The system has also been the subject of safety complaints from air traffic controllers around the country in recent years, the ASRS data shows.

In March, an air traffic controller complained about continued false reports issued by the system about obstacles on runways, the report states.

A February report indicates that an aircraft completely disappeared from the radar system as it made its final approach to the runway, while other planes were waiting their turn to land.

“This ASDE-X system is going to cause a horrific's just a matter of WHEN? This is completely UNSAFE,” the report continues.

Massport officials are aware of the complaints and have asked the FAA for vehicle transponders to enable Massport to track their movements at all times, said Massport spokesman Phil Orlandella. Orlandella said ASDE-X, which was implemented at Logan last year, cost $6 million – with the FAA paying $4 million.

“We are definitely concerned. You are talking about accidents and damage to property and lives,” said Massport spokesman Phil Orlandella.

Beth Larson, a spokeswoman for Sensis Corporation, the Syracuse-based company that designed and implements ASDE-X, referred questions to the FAA.

Brown said the ASDE-X system has needed to be adjusted to conform to environmental and other conditions at airports around the country. As of this past October, the system had been installed in 32 major U.S. airports nationwide. The FAA is currently testing vehicle transponders at Logan, Brown said.

“There are no transponders currently operational at Logan,” Brown said.

Matt McClusky, the Boston representative for the National Air Traffic Controllers Association, said in a statement the FAA has made improvements to the system this year.

“The upcoming winter weather will likely create some challenges for the system based on past performance but we will continue to work collaboratively with the FAA to address those challenges," the statement said.

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