Issue Number 241					July 1999
			A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System P.O. Box 189, Moffett Field, CA 94035-0189

In the midst of preparing this summer’s issues, we realized that July 1999 marks a proud milestone for both the ASRS and this publication—CALLBACK’s 20th anniversary.

More than two decades ago, the ASRS Advisory Committee—an industry/government group charged with oversight of the ASRS—reviewed the results of a survey that showed a large proportion of the flying population lacked knowledge of the ASRS and its immunity features. ASRS was "aviation’s best-kept secret." The Committee took steps to fill this awareness gap by directing NASA to develop a means of regular communication with potential users of the ASRS.

In the summer of 1979, the first issue of CALLBACK was cobbled together with scissors and transparent tape by Captain Rex Hardy, the founding Editor (as well as writer, circulation manager, and entire staff). Helping Rex type up that first issue was Dr. Charles ("Charlie") Billings, an experienced researcher who had conducted much of NASA’s earlier human-factors research and was NASA’s then commander-in-chief of the ASRS.

Charlie Billings took on a formidable bureaucratic challenge and risk in approving those first monthly bulletins—which some of his NASA colleagues considered shockingly casual for what was unquestionably a government publication.

The "casual" nature of these monthly bulletins was largely due to Rex, a decorated Naval aviator and corporate test pilot who had the working pilot’s distaste for well-intentioned but dull exhortations on safety. He had decided that ASRS’s new safety bulletin would be short, readable, and informal.

Rex christened the new publication CALLBACK. Issue No. 1, in July 1979, explained the title:

"CALLBACK? That’s a code term used at ASRS when a contact is initiated with someone who has sent in a report. The idea is to establish a dialogue in the interest of aviation safety...Safety is a serious subject, but we hope you will find this bulletin interesting, instructive, and even—sometimes—entertaining..."

Rex kept that promise to his readers for 100 issues, until his retirement as Editor in 1987. His editorial credo, upheld by others in the years since, has helped CALLBACK reach into every corner of the aviation community to educate, inform, and inspire potential users to submit their incident experiences to ASRS. Along the way, CALLBACK has gathered four major aviation industry awards for publication excellence.

Now some 20 years and 430,000 ASRS incident reports later, we invite you to enjoy some of our personal favorites from Rex Hardy’s first 100 CALLBACKs. And to Rex and Charlie, both now retired but as productive as ever, a resounding Thanks from the troops—for your vision, originality, and courage. We all owe you a lot.

...Rowena Morrison, Editor

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Look Mom—No Hands!

We borrow from England’s Flight Safety Focus a tale about an airline in the process of installing Autoland equipment in its fleet. Test report:

• Log entry from pilot: "Autoland carried out. The aircraft landed very firmly and well to left of centerline. Most unsatisfactory."
  
  Engineer’s entry: "Autoland not fitted to this aircraft..." (May 1983, #47)

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Nuggets

These odds and ends have been extracted from otherwise routine ASRS reports. They may instruct, edify, or amaze readers. The [first], from a report of a minor mishap, comes, obviously, from a Captain who changes into his uniform in a phone booth:

• This was my first error since I started flying in 1968. (August 1984, #62)
  
  
• Moral: Know Exactly where you are—not About where you are. (February 1984, #56)
  
  
• Keep your coffee on the floor! (November 1984, #65)
  
  
• Whoever designed this departure procedure must moonlight as a video game designer. Case in point: Turns before transition–6; altitude restrictions–5; intersections–8; total–(19 opportunities [for error])! (November 1985, #77)
  
  
• After 16 years of conditioning, maybe I’m no better than Pavlov’s dog (February 1987, #92)

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• I had been playing "Space Invaders" for about two straight hours when I and an inexperienced co-pilot were launched to find a man believed to be injured who was lost in dense underbrush. After we got to the search pattern only 100 to 200 feet above the ridgeline we were searching, I started "seeing" (imagining) the Space Invaders descending down the windscreen. I gave the helicopter to my co-pilot, who continued the search at a higher, safer altitude. It took me about two minutes to de-program the Space Invaders out of my vision.
  
  Why did this happen? Two hours of self-induced strong visual programming plus mental exhaustion from a normal day and intense game "arcade fever" combined to catch me off guard in a quiet moment in the cockpit...The knowledge that I was dangerously close to "granitus" and a well-developed ability to concentrate on the instruments and facts pulled us out of that situation. Needless to say, I don’t spend that extended a time period in the arcade anymore! (June 1984, #60)

Cost of Flying

Our cousins in England operate a Confidential Incident Reporting Program modeled closely on ASRS. Their equivalent to CALLBACK is called FEEDBACK and contains, as you might suppose material much like that found in our own bulletin, with due allowance for language and geographic differences. Now and then FEEDBACK borrows from CALLBACK and vice versa. Here, with grateful acknowledgement, is a versa:

• Controller asked widebody for an orbit. The Captain replied, "Do you realize it costs 500 dollars every time we turn this aircraft through 180 degrees?" The unperturbed controller simply responded, "Well, give me a 1000 dollar turn, then." (December 1984, #66)

• As an air traffic controller my job depends totally on communication. I try diligently to issue safe, effective clearances... I never try to over-control and penalize the users. I try to maintain a safe, efficient, and positively-controlled flow of traffic. This is often not very easy to do. There are entirely too many pilots who don’t acknowledge clearances. We must all strive to maintain a vigilant listening watch, give complete readbacks, and use FULL callsigns. I expect use of standard rate turns, descents and climbs. If you need something different, ask for it. Let’s all be professionals, communicate, and comply. Give me your best and I promise I’ll give you mine. (April 1985, #70)

Just One Little Letter

By failing to note an inconspicuous "N" on their release form, a flight crew jeopardized the welfare of crew and passengers by flying too close to the mountain tops.

• Cleared as filed at 12,000 feet. We flew V121. On descent Center asked us to clarify our routing. Checking, we were filed for V121N, not V121. Minimum Enroute Altitude for V121 is 13,000 feet, terrain clearance altitude is 12,000 feet. The problem was caused by folding the flight release and covering the "N" part of "V121N." (March 1987, #93)

Culture Shock

[Ed. Note: "Ladies" in the story that follows refers to the seatbelt sign in the aircraft lavatory.] Airline pilots traditionally spent their entire careers flying for the same carrier. Trends in the industry have changed this: many flight crew are now wearing different uniforms, and their aircraft now carry different logos. A new hazard is appearing in some ASRS reports.

• Passing through 10,000 feet on descent the Captain, acting as the non-flying pilot, said, "ladies, legal, lights, and liquids" which at the time were new terms to me. In an effort to learn, I asked what was meant by that. The Captain, a former XYZ airline pilot, explained that these were words used by the XYZ airline pilots to crew members to remember at 10,000 feet to turn on the seatbelt sign, reduce airspeed to less than 250 knots, turn on the lights for recognition, and make sure the hydraulic pumps and fuel boost pumps are turned on. While both of us were distracted by the explanation we descended to 8300 feet. We immediately climbed....
  
  I believe the problem arose because of a mixture of airline cultures. I was trained by pilots with ABC airline background. Even though we are all supposed to fly per SOP procedures and checklists, there are differences between training and flying the line... (October 1997, #100)

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From CALLBACK’s Correspondence

Dietary Notes

CALLBACK’s editor has eaten crow (and plenty of humble pie) before; now he’s in for another helping. A reader takes us to task for referring to the part of the airplane that goes over the fence last as its "tailfeathers." "Very unprofessional," says our correspondent. We should endeavor to be more serious. As a reminder, we have given ourselves a healthy kick in the empennage. (April 1980, #10)