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unaware.
Issue Number 10 15
Table 3 — Incident Resolution
Based on 172 Citations from 172 Reports (Categories are Mutually Exclusive)
Event Resolution Categories Citations Citations Percent
Controller Actions 68 39.6%
Controller Intervened 52
Controller Issued New Clearance 16
Flight Crew Action 84 48.8%
No Action Taken / Anomaly Accepted 26
No Action Taken / Detected After the Fact 23
Flight Returned to Original Clearance / Course 14
No Action Taken / Insufficient Time 13
Flight Crew Overcame Equipment Problem 4
Flight Crew Became Reoriented 3
Avoidance Maneuvers / Evasive Action 1
Unspecified 20 11.6%
Not Resolved / Unable / Other 17
Other 3
TOTALS 172 172 100%
Summing Up
Crossing restriction
altitude deviations occur
more often on STARs than
SIDs, but traffic separation
was known to be compromised
in only a small
portion of these events.
Aircraft configuration or
type did not appear to
play a role in these incidents.
Most deviations
were altitude undershoots.
An altitude undershoot on
a STAR may indicate a
flight crew’s failure to
adequately plan for the
STAR, or their distraction
from effectively monitoring
the descent.
In instances of altitude
overshoots, the flight crew
or ATC often detected the
error before the altitude deviation
occurred; however,
climb or descent rates may
have been sufficiently
high to preclude recovery
before a deviation occurred.
Crossing restriction
altitude deviations occurred more
often when the crossing altitude was
assigned by ATC.
It is good practice to advise ATC of
any altitude change, specifically the
altitude being vacated and the destination
altitude, and to confirm with ATC
the point of anticipated or expected
initiation of descent.
Flight crews anticipating or experiencing
difficulty adhering to crossing
restriction requirements should advise
ATC as soon as practical.
Cockpit workload was commonly
cited as a contributing factor in
altitude deviations on STARs. Therefore,
flight crews may wish to complete
checklists early (mid-cruise or
before descent), and review STAR
charts before descent initiation. _
End Notes
1 Ralph E. Thomas and Loren J.
Rosenthal, Probability Distributions of
Altitude Deviations (NASA Contractor
Report 166339), Ames
Research Center: Moffett Field,
California, p. 32.
2 Don George, One Zero Ways to Bust an
Altitude, ASRS Directline Issue No. 2, 1991.
16 Issue Number 10
The 1996 Nall Report, published by
the Aircraft Owners and Pilots Association
(AOPA) Air Safety Foundation,
further focused our attention on dual
instruction.2 Although flight instruction,
overall, is one of the safest
operations in General Aviation,
according to 1995 accident statistics,
there was a notable concentration of
fatalities and accidents during dual
instruction: the only fatal go-around
accident, four of the five fatal maneuvering
accidents, and five out of seven
non-fatal maneuvering accidents
occurred during dual instruction.3 This
cluster of accidents and fatalities in dual
flight instruction raised the question of
whether problematic communications,
both inside and outside the aircraft,
might have played a role.
A final motivation for this study
was research by NASA and others
which has shown that in shared
decision-making situations similar to
those that occur in GA dual flight
instruction, there is often a failure of
individuals to take responsibility for
actions, including communications.
At the 1995 OSU Symposium, Prince
and Stout presented the results of
interviews with professional aviators
from the military, air carriers, and GA.
They reported that 30 percent of the
GA instructors surveyed stated that
Communications-related Incidents in
General Aviation Dual Flight Training
by Kamil Etem and Marcia Patten
they trained students to perform
independently, as single pilots, and
believed their task as flight instructor
was to encourage independence, not
team awareness.4 An exaggerated
emphasis on pilot independence
during training arguably may exclude
development of sound cross-cockpit
communications procedures, and
impair communications awareness
and effectiveness.
Defining the Task
Our research goal was to examine a
representative set of ASRS reports
referencing communications-related
　
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