The captain of the 767 tilted an ear toward his cockpit speaker. The controller was calling their flight number. The first officer was flying the airplane.
“Transglobal 63, cross two-zero miles south of XRAY intersection at flight level two-five-zero.”
The captain was about to read back the clearance, but was interrupted by another airline checking in on the frequency. And still another airplane interrupted with a request for a ride report.
An electronic chime sounded in the cockpit, illuminating a blue flight attendant call light on the overhead panel. The first officer nodded at the captain and then unclipped the intercom handset from the back of the center pedestal. The first officer put the handset to his ear.
When the radio was silent for a brief moment, the captain keyed his mic switch and responded to the controller’s instruction. “Transglobal 63, roger, cross two-five miles south of XRAY at two-zero-zero.”
The captain hears a “roger.” He pauses for a moment and considers verifying the clearance. He dismisses the idea when the controller wastes no time issuing a heading instruction to another airline.
After the first officer snaps the handset back into the holder, the captain relays the altitude crossing clearance. The first officer repeats the clearance and then presses the appropriate flight director mode control buttons. Twenty-thousand feet is set in the altitude selector. The autopilot begins a descent.
Descending through an altitude of 24,500 feet, the captain hears their call sign again. The controller’s voice has a stern and irate tone.
“Transglobal 63, climb immediately back to 25,000! You were instructed to cross two-zero south of XRAY at flight level two-five-zero!”
The captain’s stomach begins to sink. In an instant he realizes the mistake. He had transposed the altitude crossing for the distance. The first officer has disconnected the autopilot and is pulling back on the control wheel while pushing the power levers forward. He is biting his lip. Both men have lost the color in their face.
One month later, the pilots receive a letter of inquiry from the FAA indicating a potential violation. When the hearing is complete, both the captain and the first officer receive a two-month certificate suspension. Because the cockpit voice recorder transcript revealed a questionable conversation unrelated to the safety of flight, the Transglobal Airlines HR department terminates the pilots’ employment despite the fact that the sterile period had not been violated. The controller receives a written warning for not taking the time to verify that the captain’s readback was correct.
Nightmare? Although I have created this drastic scenario, it is not far from the truth. The error could have been committed by any professional flight crew. But analyze the situation for a moment. Who was at fault? The captain? The first officer? The controller? The busy environment inside and outside the cockpit? Does it really matter?
Would you consider me insane if I said that finding fault isn’t important? Would you consider me insane if I said that assigning blame and administering discipline isn’t important either? Would you consider me insane if I said that the most important objective is actually to prevent the error from ever occurring again?
In this scenario, discipline accomplishes nothing toward preventing future occurrences. Airline pilots are their own worst enemy. It is punishment enough for us to realize that we made a mistake.
This is not to say that accountability for mistakes is unjustified. It is. However, the pilot, the airline and the flying public are best served by a system that corrects mistakes through training and education.
Such a system is already in place. It is called Aviation Safety Action Program (ASAP). My airline originated the program in 1994. It was developed by one of our pilots. Other airlines adopted it. The FAA agreed to the program utilizing a memorandum of understanding with each individual carrier. The system has a proven track record of success.
Then why was ASAP terminated at my airline and two other airlines? (One of those airlines has recently restored its program.) The reason for termination is based on one principle: Trust. Ironically enough, the fundamental principle that formed the basis for the ASAP system has been violated in the eyes of the people that contribute the most to its success: Airline pilots.
How does ASAP operate? A little background might be helpful. In 1975, the FAA and the NTSB agreed that the aviation community might benefit from collecting data on FAR deviations and safety issues. The data would help to recognize potential threatening trends. To encourage participation self-disclosed FAR or safety deviations were granted anonymity and immunity from certificate action as long as the violation was not intentional, willful or criminal. The get-out-of-jail-free card was available only if the pilot had not been found in violation of another FAR within the last five years. And the pilot had to file the report within 10 days of the event.
This program is called Aviation Safety Reporting System (ASRS), and is administered by NASA who acts as an unbiased third party. The program is still in effect today. The drawback for the airlines is that the ASRS data is not accessible because the NASA report is confidential. Potential hazards in policy, procedure or aircraft systems can’t be fixed without specific information from these reports.
Back in the early ’90s, USAir was experiencing a rash of altitude busts. As a fix for the problem, the airline devised a point and shoot program. It was simple. The nonflying pilot set the next assigned altitude in the altitude window and then pointed at the number. The flying pilot verbally acknowledged the altitude.
The frequency of USAir’s altitude deviations began to diminish. Many airlines, including mine, adopted the point and shoot program procedure. But the procedure may never have been considered if a reporting system for USAir’s altitude deviations hadn’t been created. With the reporting system, the FAA agreed to grant immunity from certificate action for any crew that self-disclosed an altitude bust. The objective was to determine the root cause of the problem. The USAir flight department made their airline that much safer. Unfortunately, the reporting system stopped at altitude problems.
Enter ASAP. Using the same reporting concept, ASAP includes all types of safety-related issues. Under ASAP the FAA will not pursue certificate action against a pilot that self-discloses a potential FAR deviation in an ASAP report that is filed within 24 hours of the event. An airline manager has the responsibility of ensuring that the report is de-identified and also sent to NASA as part of the ASRS program within the 10-day window.
In order for the report to be accepted into the system, the event cannot involve an intentional disregard for safety or security. The event cannot involve criminal activity, drugs, substance abuse or intentional falsification. And finally, the reporter must comply with the corrective action of the event review team (ERT).
The ERT is comprised of only three people: an FAA representative, an airline representative and a pilot’s union representative. These individuals meet in person or on the phone on a regular basis. They review each event’s circumstances on a case by case basis. Collectively, they decide on a course of action that will best suit the objective of preventing future occurrences. The course of action can include training for the individual pilot or pilots involved. Changing airline policy, procedure or airplane systems is another possible solution. In addition, a safety enhancement change to the FAA and/or NTSB can be recommended. The ERT’s decision may involve a combination of all three options.
The reported event is concluded by one of the following: (1) an FAA letter of correction, (2) an FAA warning, (3) an FAA letter of no action, (4) an ERT response, (5) a referral to a traditional departmental reporting system. The FAA letter of correction remains in the pilot’s file for two years and then is expunged. The FAA warning of no action remains in the pilot’s file for 30 days and then is expunged. The remaining documentation options do not involve an FAA file. In the majority of circumstances, reports are concluded with a brief response from the ERT.
But what if the ERT can’t agree on a solution? That’s the beauty of the ASAP system. The team members must reach a unanimous consensus or the entire program is terminated. Because all parties recognize the inherent value of ASAP, this forces a compromise even if team members are not in complete agreement. Since 1994, I am not aware of the program ever being terminated as a result of a unanimous consensus issue. That makes a statement about the commitment to ASAP from all parties.
So why has the program been terminated at my airline? Simply stated, the controversy involves semantics. And the semantics all stem from the principle of trust. Trust is the foundation that supports the ASAP building. Without trust the building collapses.
One of the major precepts of the ASAP agreement is the fact that reports cannot be used as a basis for company discipline. I spoke with a high-ranking officer in my union regarding this subject. I also spoke with a high-ranking manager in my airline hierarchy. Both are knowledgeable. Both are articulate. Both are airline pilots. Both agree that over the course of time, the perception of trust has deteriorated to a dangerous level.
My union officer cited specific examples of ASAP reports that were used for company discipline. He cited other instances that appeared contrary to fairness. Not having been privy to the circumstances, I could only accept his statement as true.
The company manager did not deny the circumstances. Although the two men disagreed on who was to blame regarding the predicament, they were in complete agreement that the ASAP system has to be restored.
What are the specific issues? It gets complicated. One issue involves sole-source reporting and non-sole-source reporting.
A sole-source reported event is an occurrence that would never have been discovered had a pilot not disclosed his or her mistake. For instance, suppose a crew struck a baggage loader with an engine nacelle while taxiing to the gate, causing minimal damage. The captain misinterpreted the information he read regarding the automatic parking system, believing it scanned for obstacles during the guidance process. The crew files an ASAP report. So far, the event is a sole-source occurrence. However, damage has to be reported by the appropriate company department. The event would now become a non-sole-source report. Would this fact allow the company an opportunity to begin a discipline process? The union says, ‘No.’
At ASAP renewal time, the breakdown of trust prompted the union to request clarifications to portions of the original memorandum of understanding. Another issue materialized. The airline wanted the right to discipline pilots who filed ASAP reports that involved “reckless” operations. The union refuses to give the company an opportunity to label its members as reckless. This is where the concept of “Just Culture” enters the picture. What is Just Culture?
Suffice it to say that Just Culture involves a well-defined discipline process. By theory, the process is supposed to be fair and equitable in its treatment of employees. My airline management endorses Just Culture. It wishes to employ the process as part of the ASAP memorandum of understanding. The union is not fond of attaching an entire process to another contractual document. The fear is that the process can be modified by the company outside of the contract.
The union is willing to compromise, however. Rather than using the word ‘reckless’ it will accept the precise Just Culture definition, which is, “a behavioral choice to consciously disregard a substantial and unjustifiable risk.” This definition aligns with the original intent of excluding ASAP reported events that are intentional.
Controversy also surrounds the unanimous consensus requirement of the ERT. It seems that the airline has indicated a desire to allow for a majority vote regarding corrective action. This, of course, negates the incentive to reach a collective decision because not doing so, on even a single event, shuts down the entire ASAP program for the airline.
Some of you may remember the mid-air collision between a newly purchased corporate Embraer Legacy jet and Brazil’s low-cost airline. Tragically, the airliner had no survivors, but the crew and passengers of the Embraer were able to land their crippled airplane in a harrowing few minutes of raw pilot skills. Although the facts indicate that the corporate jet was adhering to the rules, the Brazilian government still wants to prosecute the pilots in a criminal trial even though it is apparent to most experts that their military air traffic control system is in desperate need of modernization. I know from firsthand knowledge that despite the hotel accommodations, for all practical purposes, Brazil imprisoned the crew for many anxious days by not allowing them unencumbered access to leave the premises, let alone the country. If you think that the criminal prosecution scenario is not possible in the United States, think again. Is blame going to fix the cause of that tragedy?
Now what? For the moment, the ASAP negotiation is at a stalemate. After two and a half years, our regular contract negotiation is also at a stalemate. The two should be independent of each other. But the frustration level makes it almost impossible to separate.
ASAP has developed into a system that is vital to the complicated environment airlines operate in. It should not be a negotiation. The system worked before. There is no reason why it can’t work again.
Until trust can be restored on both sides of the bargaining table, ASAP will not exist for my company. My fellow airline pilots have lost a valuable tool. Worse yet, the flying public has lost an essential safety net. Perhaps when this column goes to print, my words will be ancient history. Until then, I’ll be filing a NASA report.
