Reports reveal close calls in the skies over Washington
February 8, 2011
A pilot and co-pilot operating on three hours’ sleep start taking a wrong turn – right into the path of another aircraft – after lifting off from Boeing Field in Seattle. Quick work by an air traffic controller averts disaster over the state’s largest population center.
A pilot leaves Spokane’s Felts Field in a single-engine Cessna planning to touch down at Thun Field near Puyallup – but instead lands about 10 miles away at McChord Air Force Base, breaching security. Inbound to Spokane, another pilot in a 10-passenger, single-prop Cessna mistakenly lands at Fairchild Air Force Base.
While training near Everett, a student pilot comes within 100 feet of crashing into a plane inbound for a landing. Another student pilot coming into Bremerton barely avoids a midair collision when a small homebuilt aircraft darts in front of him, touches down and then takes off without stopping.
These are just a handful of the heart-stopping scenes portrayed in the words of the pilots, air traffic controllers and others involved in safety breaches in and around Washington airports over a 10-year period. At least twice a week on average from January 2000 to January 2010, a pilot or air traffic controller or other air-safety professional encounters a situation serious enough to contact a national safety-reporting system run by NASA, records show. InvestigateWest and KING 5 examined the reports filed with NASA, which seeks to uncover dangerous patterns before they turn to tragedy.
The results reveal that aircraft in Washington come perilously close to calamity on a surprisingly frequent basis. One of the most serious kinds of close calls, when planes nearly collide in midair, occurred 62 times, an average of about every two months.
Those were the close calls. But sometimes luck runs out. Planes collide.
It happened to Bud Williams when he was flying over Commencement Bay and looked up at the last second to see a blue-and-white plane emerging from the blue-and-white sky.
“I was just going over the (Tacoma) Narrows. There’s a heavy traffic pattern from east to west and I didn’t really expect anybody to come out of the north at me,” Williams said, describing the 2007 incident. “He popped into the windscreen right in front of me in the upper right-hand corner,” Williams said.
Instinctively, Williams pulled back on the controls, avoiding a dead-on hit but smacking into the other plane’s tail. It’s rare enough for anyone to survive a midair collision. Miraculously, Williams and the pilot and passenger of the other plane survived without serious injury.
A mid-air collision in Puget Sound’s busy airways is among pilots’ worst nightmares.
More than half of the nearly 1,000 NASA reports reviewed for this story relate to SeaTac International Airport or nearby Boeing Field. Sixty-four of the reports concern Spokane International Airport or Spokane’s Felts Field.
SeaTac’s proximity to Boeing Field sets up a sometimes problematic situation. In the example March 2003 incident in which the air-traffic controller prevented a collision, the sleep-deprived pilot’s report to NASA started ominously: “We were scrambled from the hotel for a flight…”
As the air taxi carrying an unreported number of passengers made its way from the terminal to the runway, “We became hurried and our (crew resource management) suffered as a result.”
The pilot thought the tower assigned the aircraft to turn right to 180 degrees. The co-pilot didn’t double check. After takeoff, the pilot wondered why he was being instructed to turn toward SeaTac but started in that direction anyway. The crew radioed in that they were turning to 180 degrees, only to be quickly corrected by a controller.
“I was disgusted with our performance since we seemed to do many things contrary to SOPs,” or standard operating procedures, the pilot wrote. “Yes, we were tired and hurried, but that can be no excuse. . . . Thankfully this did not cause a (near-midair collision) or worse.”
He added: “It would have been better to simply refuse the trip since we were still fatigued.”
Pilot fatigue “is a huge problem,” said Terry von Thaden, an air-safety researcher at the University of Illinois Urbana-Champaign who created a special system to measure the safety culture of aviation organizations. “In our research it’s one of the No. 1 things we see.”
Federal rules require flight crews to be off for eight hours between flights – but that doesn’t equate to eight hours sleep. A pilot whose flight arrives at midnight still has to button down the airplane, get to the hotel, sleep, shower, get a meal and get back to the airplane – perhaps as early as 6:30 a.m.
Human error isn’t the only problem. Other times, the problem is system malfunction. Planes just stop working.
That happened to Mike Ellis of Everett, a maintenance supervisor at Paine Field who had to crash-land a vintage Stinson JR(S) in August when the device providing current to the spark plugs failed midflight.
“These engines (on small planes) are glorified lawnmower engines,” Ellis said.
It’s these kinds of incidents that NASA’s Aviation Safety Reporting System was designed to avert. The reports offer a rare front-row view of a surprising number of near-disasters. Yet the 943 incidents recorded from January 2000 through January 2010 are far from the whole picture, as even NASA admits. Nationally, only one in five of the reports received, once screened, is investigated and put into the reports that make up a database reviewed by InvestigateWest, KING 5 and members of the Investigative News Network.
The incidents reported to NASA range from life-threatening close calls to seemingly more mundane matters such as inadequate runway directions signs. But even those runway signs, if they’re bad enough, could send planes smashing into each other on the taxiway.
“This is a system that is trying to learn from everyday events,” said Linda Connell of NASA, director of the program. “This is an opportunity for people to say . . . there were things going on that probably should be looked at.”
NASA sifts through the confidential reports, culling the ones that appear to be worth passing on to the airport, airline or whoever needs to know about what’s going wrong. That’s often the Federal Aviation Administration, the body that regulates pilots and employs air traffic controllers.
The FAA said it uses the reports filed with NASA as one of dozens of information sources to guide decisions about air safety. The FAA did not grant an interview for this story but did release a written statement in answer to questions. Near midair collisions are a matter of a pilot’s perception, not a specific distance, the agency wrote.
"Although the value of (near-miss) reports is also limited because they are subjective, we can analyze them to determine if a trend is occurring,” said the statement released by FAA spokesman Ian Gregor in Los Angeles. The FAA also said incidents of pilots landing at the wrong airport are rare, and that the agency takes enforcement action against violators.
The FAA appears to loom large in the minds of many of those filing reports with NASA identifying themselves as having just broken -- or at least skirted -- air-safety regulations. Although their names are withheld from the public record, why would a pilot or controller call the government’s attention to his or her own shortcoming? Because reporting the incident to NASA usually provides immunity from FAA disciplinary action that otherwise could result in loss or suspension of the person’s FAA certificate.
The FAA noted that while the NASA reports are useful, they represent “opinion or perception about an event and do not always include complete information. Because the reports are anonymous, the FAA cannot investigate or validate the data.”
Todd Curtis of Airsafe, a nationally known air-safety expert in Seattle, emphasized that the NASA reports cover only a portion of the air-safety problems occurring.
“Oftentimes you won’t find out about a problem unless there’s some (potential) sanction involved.”
For example, Curtis is particularly knowledgeable about airplanes colliding with birds – a frequent and potentially lethal problem that often doesn’t make it into the reports filed with NASA, Curtis said.
In a report last May, the congressional watchdog Government Accountability Office faulted FAA for failing to use the NASA data and a related system maintained by the airlines to spot national safety trends. Many of the airlines’ reports are forwarded to NASA for inclusion in the space agency’s system, but not all of them are.
Despite the shortcomings, the GAO echoed air-safety experts and concluded that NASA’s system and the related ones maintained by the airlines “are the best source of information for hidden risk in the system.”
Even at smaller airports where fewer close calls are reported, chilling incidents occur.
Take the example in 2008 of the aviation instructor who was teaching a student pilot near Yakima McAllister Field how to set a flight computer and lost track of a nearby airplane. He was jarred back to awareness when a controller called – with crash-avoidance alarms in the control tower raging in the background – and the instructor looked out of cockpit to see another single-engine plane pass just 400 feet overhead.
“Perhaps we missed an instruction from (air-traffic control) or had incorrectly interpreted a direction however there were no urgent calls from (air-traffic control) to instruct us to do anything different. During a time of high work load pilots tend to shed functions that do not seem to be a priority,” the instructor wrote in his report to NASA. “I failed to recognize the danger of the high workload we were under and should (have) reduced our training goals at the moment until the situation had passed.”
About one out of every 40 reports to NASA over the period studied concerned a fuel problem, sometimes a small plane running short on fuel. That’s a problem that’s most common among small private planes, said Terry Asp, a controller at Bellingham Airport.
“It all makes a difference, too, you know, what types of airplanes,” Asp said. “You’re not going to see air carriers, big airliners, go run out of gas. I don’t know that that ever happens.”
So what’s going on with the pilots of the smaller planes?
“I think it’s just like people run out of gas with a car; they just aren’t paying attention or they just thought they could make it and didn’t,” Asp said.
Even members of the public who never fly in small planes need to be wary of safety problems with them, notes Bill Voss, president and CEO of the Flight Safety Foundation, an international organization. Perhaps the most infamous such accident occurred in 1986 over Cerritos, Calif., when an AeroMexico jetliner crashed in midair with a small family-owned Piper aircraft, killing 67 people aboard both aircraft and 15 people on the ground.
Voss said he was not surprised that many of the reports in the system come from larger airports, because that’s where pilots’ shortcomings are mostly likely to be seen by someone else.
“There’s high incentive to report if there’s a sense that someone else might report it,” Voss said.
SeaTac spokesman Perry Cooper said it makes sense that the largest number of reports in the system pertain to SeaTac and Boeing Field, because that’s where the most flights go. And airspace in the region is relatively congested.
“We’re considered the 300-pound gorilla in the airspace world around here,” he said. “Everything gets based on us and what works for us.”
Safety expert von Thaden said the public might be frightened to learn of close calls. As for her assessment of the air-transport system:
“Is it safe? Yes. Does stuff happen every day that you wouldn’t want to know about? Yes.”
Kevin Crowe of The Watchdog Institute and InvestigateWest reporter Will Graff contributed to this report.
This story was edited by Rita Hibbard.
InvestigateWest is a nonprofit investigative journalism center based in Seattle.
This story was reported in partnership with KING 5 TV.
View KING 5 News reporter Jim Forman's report, "Hidden dangers of fying: Unreported Near Misses."
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Photo: John Marshall JHS, 1963. SPSA 108-97.