ASRS’ CALLBACK is a very useful safety tool for All Aviators

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ASRS Callback

6 Instances of Complacency Contributing to Risk & Teaching Valuable Lessons

ONE OF THE MOST POWERFUL TOOLS IN THE CURRENT RISK MANAGEMENT/ PREVENTATIVE APPROACH OF AVIATION SAFETY IS NASA’S ASRS AND ITS Callback analysis of the information submitted to this deidentified data base. The most recent edition highlighted six instances in which COMPLACENCY contributed to each of these events. The examples are particularly useful since they are not hypotheticals, but real world experiences with compelling lessons:

pilot fuel complacency1.  Fueling Complacency— the experienced pilot flew the particular aircraft and assumed that the fuel switch, as usual, was in the “BOTH” mode. Fuel starvation compelled an early landing and after he landed the plane, he did a self-analysis and found that in his preflighting the aircraft, he failed to notice that the switch was in the Left fuel tank setting. His familiarity with the airplane cause him to be COMPLACENT.

2.  Dueling Complacency— this report was filed by an air traffic controller. The tower was busy and the person handling the runway was told by a ground controller that there was a Bonanza holding short of the departure position. At the same time, there was a Cessna on final for landing.

air traffic controller pilot communication

The controller lazily did not visually check to see whether the Bonanza was properly positioned, in part because there was a heavy shade drawn over the window to cope with the low afternoon sun. The “dueling lack of competency” was attributed to the tower’s assuming that the pilot could read a compass, would read a runway sign depicting which way the runway goes, or ASRS Callback aviation safetywould familiarize himself with an airfield layout. The accident was avoided and the ASRS posting brought home a valuable lesson.

{Hopefully the new Data Comm “texting capabilities” will minimize this risk in the future!}

3.  Automating Complacency— Surprise the man-machine interface can cause complacency as evidenced by this G-V PIC’s report.

asrs pilot aircraft automation

Assigned to an altitude of 14,000’, the sole pilot (the other one was on a potty break during this phase of landing) entered it into the altitude alerter to 14,000 feet and selected VPATH for the vertical mode of operation. After making that computer entry, the pilot attended to other duties. After a while (but before ATC called the deviation to his attention; thus, the ASRS report), the pilot in the cockpit noticed the altitude at 13,500’, turned off the autopilot and assumed manual control correcting back to the assigned altitude. In retrospect, he admitted that “I got complacent…and I believe it was because for so many years of operating this equipment, never had the automation failed to perform as it had been set up. I believed that it would do as always…I allowed myself to occupy my attention with other aspects of the flight. Worse, I allowed this to happen when the other pilot was away from his station. I did not discipline myself to avoid distraction from the primary duty…COMPLACENCY CONTRIBUTED DIRECTLY TO THIS DEVIATION AND…HAS NO PLACE ON THE FLIGHT DECK.”

asrs aviation safety errors

4.  Functional Complacency— a B767-300 First Officer made a simple, but significant erro Making no excuses, he describes how complacency was the most probable culprit.

aircraft center pedestal

In the F/O’s words: “After becoming airborne on our initial takeoff, the Captain called, “Gear up.” Inexplicably, I raised the flap handle instead of the gear handle. Over the next several seconds, the flaps retracted while I confirmed lateral navigation… I screwed up.… No excuses. I have no idea why I reached for the flaps instead of the gear. I have successfully raised the gear—without error—for decades and buckets of hours. Slow down. Don’t rush. Fight complacency. Don’t think it can’t happen to you!”

ASRS Callback procedure complacency

asrs procedural complacency5.  Procedural Complacency— here an Aviation Maintenance Technician’s lack of focus resulted in major damage to a CJ-700 engine; while Fan Blade Pin change, the mechanic left his ratchet inside of the powerplant. Fortunately, a preflight engine test produced major vibration and resulted in the discovery of the missing tool. Here is how the MX person described his error: “Several factors may have contributed to this incident. It was very early in the morning on my first day back to work after three days off. This is a job I have performed often, and OVERCONFIDENCE OR COMPLACENCY may have figured in.

{Perhaps Member Goglia’s Annual Super Bowl MX competition will help foster such focus?}

complacency safety

6.  Combating Complacency— a flight attendant filed this report and it is a thoughtful flagging of an issue for which she was not the culprit. Her point was to remind well-intended dead-heading flight attendants NOT To perform the duties assigned to the crew responsible for the flight and the task.

asrs flight attendant

Her specific admonition: “My intent…is to bring to the attention of the company…an action that should be discouraged and discontinued due to its ability to impact the safety and security of an armed aircraft door…I think a note or bulletin needs to be sent out to each and every flight attendant explaining proper procedures so that complacency does not breed an opportunity for a fatal outcome.

aviation safety human factors

A GA PILOT, A PIC OF A COMMERCIAL FLIGHT, A TOWER CONTROLLER, A FIRST OFFICER, A MECHANIC AND A FLIGHT ATTENDANT PROVIDE A SERIES OF EXCELLENT REAL WORLD EXAMPLES AND ASRS COMBINES THEIR STORIES IN A POWERFUL CALLBACK REPORT. Aside for the need to fight complacency with constant vigilance by all involved in aviation, this edition is a good reminder for those practicing SMS, risk management and safety culture, that subscribing to this NASA publication and MOST IMPORTANTLY USING IT AS A LEARNING TOOL MAKES IMMENSE AVIATION SAFETY SENSE. 

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