The Crosscheck: Tools To Manage Risks
If you are a Part 135 operator and haven’t yet ventured into the Safety Management System (SMS) world, there are some old but useful tools you can use to help you manage risk. The Aviation System Reporting System (ASRS) and the Near Midair Collision System (NMACS) have been around a long time, but they don’t get much use by corporate and business operators. In fact, the NMAC system doesn’t get much use by anybody.
The ASRS was conceived in 1975 as a way for pilots and airlines to share hazard information and provide limited immunity to pilots for reporting safety issues and potential violations. It was the forerunner to the aviation safety action programs (ASAP) run by airlines and commercial operators. ASRS analysts include experienced pilots, air traffic controllers and mechanics who assess each report, identify hazards and flag the information for action. FAA offices may be alerted if appropriate. A drawback to some ASRS reports is that they are marred by complaining, self justification and defensiveness, so it’s important when submitting a report to write objectively, not just find fault.
The NMACS was established in the 1980s to allow pilots to notify ATC when they’ve had a very close encounter with another aircraft. FAA staff investigate the event and determine if it had the potential to cause an accident. NMACS reports are a bit difficult to make, because they are made immediately after the event, when the pilot is still busy coping with the problem. Estimation of separation distances and identification of the other aircraft can be difficult, and ATC probably won’t file a report unless the pilot says “I want to file a near midair collision report.” The FAA thinks NMACS are vastly underreported.
The key to the usefulness of these two systems is honest, accurate and timely reporting, and establishing a feedback loop that leads to safety improvements. You have to use them to get their benefit.
I took a look at ASRS and NMACS data for Ketchikan, Alaska, a place that has seen more than its share of accidents, including a recent midair collision. Not all ASRS reports show up in the public queries, but there are enough to get a sense of the issues. Of the 46 reports (40 ASRS, 8 NMACS) available in the two databases, only 13 had been filed in the last 10 years. Of those 13, only 7 pertained to traffic conflicts. Twenty-five had been filed by the crews of airliners. The participation of Part 135 operators has been sporadic at best.
Despite this dearth of reporting, there have been some fairly hair-raising cases. Some involve aircraft conducting IFR approaches in IMC or hazy conditions and coming close to VFR aircraft crossing or flying parallel to their approach path. Two DHC-2 Beavers flying at 200 ft AGL under an overcast passed within 100 ft of one another. An airliner went nose to nose with a C-208 at 1,000 ft on approach. A DHC-2 Beaver had a near collision with a tour boat on takeoff. In 2018, an airliner on a GPS approach got multiple TCAS resolution advisories (RAs) from a sling-loaded helicopter he could never see. Imagine how much would have been learned if all the Part 135 operators in Ketchikan had been using these reporting systems regularly. They might have been able to avoid some of their accidents.
You can start by looking at the reports in your area of operation from these two databases to get an idea of the kinds of hazards you may encounter. Then you have to start encouraging your pilots and staff to begin making these reports when appropriate, not only to obtain possible immunity from enforcement, but to begin the process of searching for risk. Third, you have to think about what changes you need to make to reduce the risk of these hazards bringing harm to your operation. Along with this, the FAA may start to consider improving airports and ATC services in your area. If your people aren’t telling you about these reports, maybe you should think about what kind of safety culture you have.
Once you’ve built in the habit of having people make safety reports and you start responding to the risks you’ve found, you’ve begun to change people’s mindset and you’re starting to be systematic. At this point, you’re doing much of what SMS does. You don’t have to wait for SMS to do these things. You can use what you have now.
Editor's Note: This BCA safety column, called The Crosscheck, by Roger Cox explores the interaction between regulators/investigators and pilots/operators. Send your comments to [email protected].