Excerpts from the NASA ASRS

One of my students last semester (thanks, Ronney!) turned me on the “Callback” publication from the NASA Aviation Safety Reporting System. These are almost all first person stories written as case studies of errors and accidents or near accidents. There aren’t so many that it falls under my list of neat databases, but it certainly is interesting reading.

I’ve collected a few below to give a taste of the stories that are included. These are just the top level descriptions – click through to read the first person accounts.

From Issue 381 Upside Down and Backwards

  1. “An aircraft Mode Selector Panel that “looks the same” whether right side up or upside down, and that can be readily installed either way, is a good example of a problematic design. Confronted with an inverted panel, this Cessna 560 Captain found out what happens when the wrong button is in the right place. “
  2. “Without detailed instructions and clear notation, nearly symmetrical parts can be installed incorrectly. Faced with the replacement of such a part, this CRJ 700 Maintenance Technician wound up with a case of component “misorientation.”

From Issue 383 When Practice Emergencies Go Bad

  1. “…a C182 pilot performed a simulated engine failure while undergoing a practical examination. It appears that both the examiner and the examinee were so engrossed in the simulated emergency that they both tuned BEEEEP out BEEEEP the BEEEEP gear BEEEEP warning BEEEEP horn.”
  2. “When faced with a real engine failure, performing the Engine Secure Checklist reduces the chance of a fire on landing. However, actually performing the steps in the Engine Secure Checklist when the engine failure is not real can lead to a real problem.”

From Issue 382 Fly the Airplane!

  1. “A review of recent ASRS reports indicates that failure to follow one of the most basic tenets of flight continues to be a concern when pilots are faced with distractions or abnormal situations.”

From Issue 376 The Fixation Factor

  1. “The ability to maintain the “big picture” while completing individual, discrete tasks is one of the most critical aspects of working in the aviation environment. Preoccupation with one particular task can degrade the ability to detect other important information. This month’s CALLBACK looks at examples of how fixation adversely affects overall task management.”
  2. “Advanced navigation equipment can provide a wealth of readily available information, but as this Cirrus SR20 pilot learned, sometimes too much information can be a distraction.”

From Issue 375 Motor Skills: Getting Off to a Good Start

  1. “The Captain of an air carrier jet experienced a very hot start when distractions and failure to follow normal flow patterns altered the engine start sequence.”
  2. “This pilot was familiar with the proper procedures for hand-propping, but despite a conscientious effort, one critical assumption led to a nose-to-nose encounter.”

Photo credit smartjunco @ Flickr