Trapping Pilot Errors
There’s an old adage in aviation that says there are two kinds of pilots: “There are those that have, and those that will.” It’s commonly used to explain why some poor schmuck landed gear up. Roughly translated in ecclesiastical, Renaissance prose as: “Beware thouist of majestic confidence and regal arrogance. Thine time of blunder will cometh as surely as wings maketh ye to soar.”
The adage has succeeded in scaring the bejesus out of us into using the GUMP acronym (Gas, Undercarriage, Mixture, Prop), and it’s a reminder that there are opportunities a-plenty for us to make mistakes, gaffs, goofs and errors while aviating or when writing in Shakespearian tongue. Rest assured Mon Capitaine, even we pilots are human and will err.
There’s a similar adage from the religious discipline: But for the grace of God, go I. Both philosophical statements reflect that we make mistakes. Truthfully, we make tons of them. This is especially true in the dynamic environment of aviation. It’s our job to catch, or “trap,” the mistakes before bad things happen.
Even with warning systems designed to prevent such errors, in the United States alone, they still happen to the tune of several gear-up landings each week. I’ve used GUMP on short final my whole life and still use it at the airlines and in the Duke. I really, really don’t want to be one of those that have. We can also use the “those that will” warning to remind ourselves of just how many other “gotchas” are out there, as demonstrated by the following tale about the lucky schmucks at SFO.
And so, this article isn’t about landing gear up. It’s about missing things and how to catch them before we become the one that has.
We See Some Lights
The event was almost an accident; potentially one with the largest number fatalities in U.S. aviation history: more than 1,000. Most likely related to fatigue and confusion rather than professionalism, it happened in the darkness at SFO this past July. The 20,000-hour captain and 10,000-hour FO both missed the problem and were saved from disaster by a pilot on the ground and the tower controller.
Shortly before midnight, an Airbus 320 was cleared to land on 28R in SFO, which has a parallel taxiway, Charlie, to the right (North) of the runway. Runway 28L was dark and unlighted (it did have a lighted “X” at the approach end), which presented the expected appearance of two parallel, lighted runways. Except this time, one was a taxiway.
There were four airplanes full of passengers on taxiway Charlie waiting to take off. The pilot on approach, while hand-flying the airplane, lined up on Charlie instead of 28R. Sensing that something was wrong because he saw airplane lights on “the runway,” he queried the controller asking if they were still cleared to land on 28R:
Airbus: “And, tower, just want to confirm, ah, we see some lights on the runway there. Confirm cleared to land on 28R?”
Tower: “OK, 759. Confirmed cleared to land runway 28R. There’s no one on 28R but you.”
The next voice, most likely one of the pilots on taxiway Charlie, chimed in:
“Where’s this guy going? He’s on the taxiway.”
Tower heard the radio call, figured it out after a couple of seconds and directed a go around adding:
“It looks like you were lined up for Charlie there.”
Preliminary NTSB findings indicated a blind spot in the Airport Surface Surveillance Capability (ASSC) system prevented an automated warning horn from sounding in the tower. At their lowest point of 81 feet, as they passed over the second of four planes on the taxiway, the Airbus was just 26 feet above the top of a 787’s tail. According to an analysis of accidents from 2006 to 2015 by Boeing, about 47 percent of fatalities occur during final approach and landing. This was nearly one of those 47 percent and would have been another landing disaster at SFO. The last one also in the month of July.
In the Part 121 world and a good portion of corporate aviation, we operate with two cockpit crew members. Both are fully qualified to operate the airplane by themselves if necessary. The general public’s misconception is that the second pilot is simply a backup for when the old, gray, senile pilot has a heart attack or chokes on his crew meal.
The truth is, of course, that a two-pilot crew operates very much like the dual, or redundant systems, in an airplane. Not only do we provide a secondary backup, but we load share. Like two electrical busses, two hydraulic systems or two pressurization sources. As it turns out, the load-sharing function is the most used and the one that often times saves our bacon. In single-pilot ops, saving bacon, pancakes or our hiney, is up to us.
Set the Tone
The newest FAA approved terminology for a two-pilot crew is Pilot Flying and Pilot Monitoring (PF and PM). The PF is responsible for the flight path of the aircraft throughout all phases of flight whether accomplished manually or with automation. The PM runs the checklists, the radios, monitors systems, the aircraft flight path and catches things missed by the PF.
Most two-pilot crews trade duties on each leg. Typically, the captain starts the trip and flies the first leg. One rationale for this technique is that the captain can then “set the tone” for how the flight will be operated, how checklists will be managed and the general level of professionalism expected while flying (i.e., no reading the newspaper or playing games on the cellphone).
A quote from former NTSB member Dr. John K. Lauber describes one rational for this technique: “There is a fine line separating a relaxed and easy atmosphere in a cockpit from a lax one where distractions can result in critical failures. Professionalism may be described in knowing the difference between the two.”
If flying with two pilots, the PM has a critical role in all phases of flight, but especially during takeoff and landing. Most of the time, from the final approach inbound, we complete our approach and landing visually. At the airlines and in the Duke, 90 percent of all approaches are a vector to intercept the localizer followed by the ILS. At my carrier, company policy dictates that we use all navaids available for the approach whether day, night, VMC or IMC. It’s an excellent policy.
There have been times when I was grateful for the final approach guidance and runway alignment provided by the avionics. We recently completed a trip that included a landing at SFO and MEX (Mexico City). Both airports have closely spaced runways and often poor visibility, which can increase the likelihood of lining up on the wrong runway. With poor visibility, darkness or unfamiliarity with the airport, it’s not difficult to make a runway alignment error. Use of all tools, including navaids such as the localizer or RNAV course, visual references such as the approach lighting system and PAPI, and timely assistance from the PM will help to avoid becoming “one that has” by lining up, and potentially landing (à la Han Solo) on the wrong surface.
I fly with FO’s that like to hand-fly the jet, and I understand: It’s fun, satisfying and a fine way to keep your crosscheck and hand-eye coordination sharp. But from my left-seat perspective, use of the autopilot allows more diligent monitoring of the aircraft path and systems. And as an airline captain, I have a half-dozen other esoteric “systems” to monitor and manage such as passenger and crew issues as well as the airlines schedule.
Therefore, in addition to the current state of the airplane and the operation, my PIC brain needs to be looking ahead by more than just a few minutes. While en route, practice shifting your focus from 30 minutes, to 15, to one minute and then to the next five seconds, then back out to 30. Perhaps at the
following ratio: 10 percent focus at 30 minutes, 20 percent at 15, 30 percent at one minute and 40 percent on the next five seconds. Naturally, the ratios change as you enter the terminal area. It’s similar to an instrument crosscheck except used for big-picture situational awareness. It will help increase your mental bandwidth, keep your head in the game and your rump out of the ringer.
“To Err With Love.” Sidney Poitier, 1967 (almost)
We need to keep our workload at a manageable level so as to avoid time pressures and distractions that can lead to errors. Our procedures and checklists should be focused on helping us to catch errors of omission and commission. When flying single-pilot, use every resource available on the approach: the autopilot, the localizer, the ILS, the RNAV course, flight director, approach lighting system, landmarks and if available, the PM. If you feel the hairs standing up, if something doesn’t look, feel or sound right, then most likely something is wrong. Perhaps simplistic, but until you find it, keep your speed up and stay away from the ground. And when the airport gets big and your airspeed gets small, verify runway alignment and GUMP. After all Mon Capitaine, to err is human and lest ye take heed, thine time of blunder may cometh on tearful wing.