1. Presented to: Sun n Fun, Lakeland, FL By: FAASTeam Program Manager, Eastern Region, Karen Arendt Date: April 2009 Federal Aviation Administration Reducing Pilot Deviations This presentation is adapted from multiple sources including Air Traffic, Flight Standards and FAASTeam. We have provided it to safety professionals for education and awareness.

2. 2 Federal Aviation Administration Reducing Pilot Deviations May 2009 Agenda Introduction Why are we here Review of Data Review of Action Items

3. 3 Federal Aviation Administration Reducing Pilot Deviations May 2009 News Report – Call to Action

4. 4 Federal Aviation Administration Reducing Pilot Deviations May 2009 A Pilot Deviation…. “ is an action of a pilot that results in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance”. Security-related airspace violations are but a part of this system, which also includes incidents such as runway incursions and near misses.

5. 5 Federal Aviation Administration Reducing Pilot Deviations May 2009 Pilot Deviation Reduction Requires Partnership Aircraft Operations FAA-ATC (Controllers) (Security- related policy) (Pilots) DHS

6. 6 Federal Aviation Administration Reducing Pilot Deviations May 2009 Types of Airspace Special Use Airspace (SUA) –Prohibited, Restricted, MOA, Alert, Controlled Firing Area (CFA) Temporary Flight Restrictions (TFR) DC Special Flight Rules Area & Flight Restricted Zone (SFRA & FRZ)

7. 7 Federal Aviation Administration Reducing Pilot Deviations May 2009 System Operations Security Temporary Flight Restrictions (TFR) A TFR is an area of airspace (defined both laterally and vertically) which has been temporarily or partially closed to non-participatory aircraft for a specified period of time. Flight restrictions may be requested in response to the aviation safety needs for the separation of aircraft for disaster type occurrences.

8. 8 Federal Aviation Administration Reducing Pilot Deviations May 2009 System Operations Security FAA TFR Considerations Nature of event (Security/Disaster) Existing airspace (Class B, Borders) Credible threat intelligence Aviation commerce TFR’s are not restricted to circles, polygons ; racetracks are also an option. In addition cutouts may be provided to allow access to otherwise closed airports

9. 9 Federal Aviation Administration Reducing Pilot Deviations May 2009 System Operations Security Temporary Flight Restrictions (TFR) Title 14: Aeronautics and Space PART 91 – GENERAL OPERATING AND FLIGHT RULES § 91.141 Flight restrictions in the proximity of the Presidential and other parties. No person may operate an aircraft over or in the vicinity of any area to be visited or traveled by the President, the Vice President, or other public figures contrary to the restrictions established by the Administrator and published in a Notice to Airmen (NOTAM). Title 14: Aeronautics and Space PART 99 – SECURITY CONTROL OF AIR TRAFFIC § 99.7 Special security instructions. Each person operating an aircraft in an ADIZ or Defense Area must, in addition to the applicable rules of this part, comply with special security instructions issued by the Administrator in the interest of national security, pursuant to agreement between the FAA and the Department of Defense, or between the FAA and a U.S. Federal security or intelligence agency.

10. 10 Federal Aviation Administration Reducing Pilot Deviations May 2009 Typical Presidential TFR Issued to Protect the President, Vice President, or other public figures (14 CFR Section 91.141) TFR’s for the President generally have 2 rings. 10NM and 30NM with separate rules for each. Occasionally there may be multiple inner and outer rings to accommodate movement.

11. 11 Federal Aviation Administration Reducing Pilot Deviations May 2009 DC SFRA / FRZ

12. 12 Federal Aviation Administration Reducing Pilot Deviations May 2009 Number of US ADIZ Breaches - 2001 to 2007-

13. 13 Federal Aviation Administration Reducing Pilot Deviations May 2009 Airspace Deviations by Airport (DC SFRA)

14. 14 Federal Aviation Administration Reducing Pilot Deviations May 2009 Airspace Deviations by State

15. 15 Federal Aviation Administration Reducing Pilot Deviations May 2009 Trend per 100,000 operations

16. 16 Federal Aviation Administration Reducing Pilot Deviations May 2009 Accident Rates – per 100,000 hours

17. 17 Federal Aviation Administration Reducing Pilot Deviations May 2009 Where’s the balance….? Congressional Research Service Report – Library of Congress, September 2005

18. 18 Federal Aviation Administration Reducing Pilot Deviations May 2009 The Evolution of Safety Thinking TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS TODAY 1950s1970s1990s 2000s

19. 19 Federal Aviation Administration Reducing Pilot Deviations May 2009 Cost of doing business – General Aviation Increase in security measures –Physical Barriers –Regulations and Fines –Alerts & Warnings –Education & Training GA Operations ProtectionProduction “So where do we go from here”

20. 20 Federal Aviation Administration Reducing Pilot Deviations May 2009 Pilot Deviations Challenge 675,000 GA pilots 221,000 Registered Aircraft 18,000 Airports Technology has its limitations Causes – Crucial Information not reaching pilots Source: * FAA Runway Safety Fact Sheet

21. 21 Federal Aviation Administration Reducing Pilot Deviations May 2009 Recent (ASRS) Pilot Reports September 2005; 500-hour pilot files flight plan enters IMC during climb through FL100. At completion of flight pilot recognizes cockpit distraction caused him to lose situational awareness. Pilot cancels flight plan and recognizes error in judgment. April 2006 enroute from Cancun, Mexico to Mobile, AL the pilot is told to call Eglin AFB upon landing. The military was tracking him offshore to U.S. Airspace and alleges he did not file a DVFR flight plan and he should have been on a discrete code. Anniston, TX Sector controller requested he squawk 1200.

22. 22 Federal Aviation Administration Reducing Pilot Deviations May 2009 Recent (ASRS) Pilot Reports May 2006, a pilot checked all NOTAMS for a flight in a Hughes 500 helicopter from Lancaster to Chester County, NJ. The BUF FSS briefer told the pilot the FAA had cancelled all TFRs. On arrival in the PHL area, ATC told the pilot to land immediately as he had violated the TFR. The pilot landed and after a call to the FSS discovered that the TFR in question was reinstated 45- minutes after his initial call.

23. 23 Federal Aviation Administration Reducing Pilot Deviations May 2009 Recent (ASRS) Pilot Reports Pilot receives a NOTAM briefing but arrives in briefed area earlier than planned. He attempts to call FSS to no avail. He was announced as traffic in the TFR by the controller the pilot contacted. The pilot asserts he had no knowledge of the TFR, by FSS briefing or Air Traffic control sector prior to handoff.

24. 24 Federal Aviation Administration Reducing Pilot Deviations May 2009 Types of Errors (Active Failures) Perception Errors –“I didn’t see it,” or “I didn’t notice the difference…” Memory Lapses –“I forgot to do it…” Slips –“I didn’t mean to do that…” Wrong Assumption –“I assumed that the situation was different…” Alan Hobbs, ATSB (2008)

25. 25 Federal Aviation Administration Reducing Pilot Deviations May 2009 Errors (cont.) Technical Misunderstandings –“I tried to do it right but I didn’t understand what I had to do…” Procedure Violations –“ Nobody follows that procedure here….” –“We can’t get the job done if we do all that…” Alan Hobbs, ATSB (2008)

26. 26 Federal Aviation Administration Reducing Pilot Deviations May 2009 Organizational Accidents Organizational processes Latent conditions Workplace conditions Defenses Active failures

27. 27 Federal Aviation Administration Reducing Pilot Deviations May 2009 Recognizing Risk in the Workplace

28. 28 Federal Aviation Administration Reducing Pilot Deviations May 2009 Risk Mitigation & Reduction Click Space Above for Video

29. 29 Federal Aviation Administration Reducing Pilot Deviations May 2009 Safety Management Strategies Reactive (Past) Reactive (Past) Responds to events that have already happened, such as incidents and accidents Responds to events that have already happened, such as incidents and accidents Proactive (Present) Proactive (Present) Actively seeks the identification of hazardous conditions through flight risk tools Actively seeks the identification of hazardous conditions through flight risk tools Predictive (Future) Predictive (Future) Analyzes system processes and environment to identify potential future problems Analyzes system processes and environment to identify potential future problems

30. 30 Federal Aviation Administration Reducing Pilot Deviations May 2009 Major Airports within the ADIZ/FRZ

31. 31 Federal Aviation Administration Reducing Pilot Deviations May 2009 Tipton Army Airfield (FME)

32. 32 Federal Aviation Administration Reducing Pilot Deviations May 2009 Fatal Accident – Tipton Army Airfield Controller: "N9130-November, you are squawking 1200, is that correct?" Pilot: "Roger that." Controller: "You are violating the ADIZ. You need to land at Tipton immediately and I'll have them give you a phone number for air defense." Pilot: "Landing at Tipton Immediately. 30- November." Controller: "30-November, I'm too busy to give you that phone number. Maybe you'll get away. Just turn it off and land and call us on the phone for your clearance." Pilot: "Roger."

33. 33 Federal Aviation Administration Reducing Pilot Deviations May 2009 12 October 2006 -2 Fatalities- ….Contributing to crash pilot’s “self induced” pressure to land. (NTSB Report NYC07FA009)

34. 34 Federal Aviation Administration Reducing Pilot Deviations May 2009 Leesburg Executive Airport (JYO) Airport Specific Procedures exist for Operating in the Leesburg Maneuvering Area (LMA)

35. 35 Federal Aviation Administration Reducing Pilot Deviations May 2009 The Leesburg (JYO) Maneuvering Area A separate NOTAM (!FDC 8/9460) has been issued to cover the Leesburg Maneuvering Area (JYO). The major change in the geographic size of the maneuver area is the realignment of the eastern boundary with the Armel VORTAC, AML 004 /16.6 radial.

36. 36 Federal Aviation Administration Reducing Pilot Deviations May 2009 Call to Action – Shift to Permanent Airspace On February 17, 2009 the Administrator designated the Air Defense Identification Zone (ADIZ)– the Special Flight Rules Area (SFRA) defined as ‘National Defense Airspace’. Procedures for operating in the SFRA : –File DC SFRA or FRZ Flight Plan –Obtain discrete code –Maintain two-way communications with ATC –Monitor 121.5 The Administrator agreed to require all pilots operating with 60NM of the DCA VOR take online training at FAASafety.gov effective February 9, 2009. This action permitted the FAA to retain the SFRA airspace at 30NMR (outer-ring) and FRZ ca. 15NMR (inner-ring).

37. 37 Federal Aviation Administration Reducing Pilot Deviations May 2009 Flight Standards Action Flight Standards has formed an Enhanced Pilot Deviation Work Group to improve our understanding and response to pilot deviations in order to reduce the numbers, including runway incursions This work group involves stakeholders from across AVS and ATO in developing improved inspector training, investigative techniques, data collection and analysis of pilot deviations That data will allow us to better understand root causes and design interventions that will reduce future pilot deviations

38. 38 Federal Aviation Administration Reducing Pilot Deviations May 2009 Flight Standards Action 1)Today! 2)Distribute training materials (DVD) 3)Increase emphasis on PDs through Flight Instructor Refresher Clinics (FIRCs) 4)Initiated development of Aviation Safety Inspector training program(s) - eLMs (electronic Learning Management System) and Academy for string and recurrent training Right Now 7/31/08 Enhanced Awareness:

39. 39 Federal Aviation Administration Reducing Pilot Deviations May 2009 5)Published Notice 8900.48 from AFS-1 to all Managers/Supervisors restating the importance of awareness of PDs 7/31/08 Flight Standards Action Enhanced Awareness (continued):

40. 40 Federal Aviation Administration Reducing Pilot Deviations May 2009

41. 41 Federal Aviation Administration Reducing Pilot Deviations May 2009 Flight Standards Action Redesign “block-18”, of the electronic ATQA 10/31/08 Data Acquisition:

42. 42 Federal Aviation Administration Reducing Pilot Deviations May 2009 Flight Standards Action Data Acquisition: “Box 18” Pull-down Questions

43. 43 Federal Aviation Administration Reducing Pilot Deviations May 2009 Determine Root Cause: Once sufficient data have been collected through the revised FAA Form 8020-18, the FAASTeam will initiate analysis of the acquired data to determine root causes Create Solutions: Once the FAASTeam has determined root causes, a joint effort between Air Traffic, Airports, AFS-800 will lead to programs and procedures designed to reduce or eliminate pilot deviations Flight Standards Action 2009

44. 44 Federal Aviation Administration Reducing Pilot Deviations May 2009 Operator short-term actions Improve pilot training by including particular focus on hazard identification through feedback from airspace users. Provide feedback at safety meetings and hearing sessions: –Search ASRS database –Create internal monitoring and feedback from flight instructors and pilots, renter-pilots, and students –Assign mentor-pilots and FAASTeam Representative at high-risk/high-use airports

45. 45 Federal Aviation Administration Reducing Pilot Deviations May 2009 Operator short-term actions Review Manuals, SOPs and cockpit procedures to identify elements that may contribute to pilot distraction before takeoff and develop a plan to eliminate those elements Enhance training for all-pilots (SBT) Place NOTAMS and current charts in prominent locations Annotate airspace-user concerns and discuss at regular safety-meetings

46. 46 Federal Aviation Administration Reducing Pilot Deviations May 2009 Review of Action Items Has continuous education on the hazards identified in ‘pilot-occurrence’ reports been provided to pilots, renters & CFIs? If so, how many pilots have received it? What steps can be taken to “speed-up” the implementation – or to reach pilots immediately who won’t be back for refresher training for a while?

47. 47 Federal Aviation Administration Reducing Pilot Deviations May 2009 Review of Action Items We committed to review feedback from pilots to identify hazards through root cause analysis. Has everyone completed the review of their procedures? Have distractions been identified? Is there a plan for eliminating these distractions? Is the plan being executed? Can we speed up this effort?

48. 48 Federal Aviation Administration Reducing Pilot Deviations May 2009 Common Air Traffic Control Errors resulting in an Pilot Error Forgets to add instructions to “maintain current squawk code” after cancelling IFR flight plan –“Negative Habit Transfer” – Actions that are exceptions to routine leave the Controller vulnerable to error. Distractions, interruptions – Number one enemy of memory

49. 49 Federal Aviation Administration Reducing Pilot Deviations May 2009 Common Pilot Errors resulting in a Pilot Deviation Pilot files an IFR Flight Plan and takes-off intending to obtain the clearance ‘in the air’ –‘Law of Recency, Reinforcement and Repetition’ - pilot applies long-term practices to a new situation. Most common factor cited for losing situational awareness is fatigue, loss of situational awareness, workload management

50. 50 Federal Aviation Administration Reducing Pilot Deviations May 2009 Airspace Structure – NO VFR CORRIDOR

51. 51 Federal Aviation Administration Reducing Pilot Deviations May 2009 Common Pilot Errors resulting in a Pilot Deviation Pilot interprets ‘VFR Corridor’ on chart is available for transit purposes –‘Law of Primacy’ - pilot applies long-term practices to a new situation. Most common factor is how the airspace information is perceived, interpreted and acted-upon by the pilot. The pilot’s understanding should match the airspace design- intent conveyed on the charts.

52. 52 Federal Aviation Administration Reducing Pilot Deviations May 2009 Safety Culture A Safety Culture includes: –Personal dedication and accountability Individual attitudes and behaviors –Shared vision with structures to attain it Organizational processes, methods and metrics –Commitment to improve (resist complacency) Beyond simple adherence to procedures Learning and continuous improvement –Pervasive safety thinking Commitment to excellence Integration of safety into all activities –Climate in which news is quickly and easily communicated –Committed to investing the time and resources to address risk

53. 53 Federal Aviation Administration Reducing Pilot Deviations May 2009 Outreach to Pilots The FAA released a new booklet titled- ‘Risk Management Handbook’ In collaboration with the industry, the FAA created online training course at FAASafety.gov that educates pilots on the Special Flight Rules Area. The course is required for all pilots operating VFR within 60NM of the DCA VOR (FAR 91.161). online training course at FAASafety.gov Every year, the FAA conducts hundreds of safety seminars across the country to encourage safe practices on the nations airspace.

54. 54 Federal Aviation Administration Reducing Pilot Deviations May 2009 Outreach to Pilots A Safety Alert for Operators (SAFO) is an information tool that alerts, educates, and makes recommendations to the aviation community.Safety Alert for Operators An Information for Operators (InFO) message contains valuable information for operators that should help them meet administrative requirements or certain regulatory requirements with relatively low urgency or impact on safety.Information for Operators

55. 55 Federal Aviation Administration Reducing Pilot Deviations May 2009 Outreach to Pilots www.faasafety.gov –‘Navigating the New DC SFRA’ http://airspace.nifc.gov –National Interagency Space – TFR/Laser/Stadium

56. 56 Federal Aviation Administration Reducing Pilot Deviations May 2009 What’s Next Leadership Meeting with Industry/User- groups (FAA/NCRCC/ATC/FSS) Each group should come up with 5 initiatives on how to deal with best practices Review of inFO: –Show Hand Out Check Here HereCheck Here

57. 57 Federal Aviation Administration Reducing Pilot Deviations May 2009 Questions