Hawaii air incident reports reveal more human than mechanical error

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With the Boeing 737 Max 8 and Max 9 models grounded, we wanted to know what kinds of problems pilots on Hawaii flights have encountered? Always Investigating found pilots have flagged several mechanical glitches serious enough to report to the Federal Aviation Administration — and not just on 737s. The vast majority of reportable incidents, however, involve human error, airport congestion, and flight control staffing.

Among the FAA’s many layers of safety protocol is a process for voluntarilyy reporting, including writing up incidents on the Aviation Safety Reporting System. Always Investigating reviewed all postings since the Max models came out to see what kinds of issues Hawaii pilots had with the 737 Max or any other airplane.

We found that out of 129 postings since 2016, 5 flagged mechanical problems on passenger planes. Here are some narratives written by pilots themselves:

“We felt a kick. It happened a second and then a third time. The aircraft controls were doing something that was not normal.” That was on an unspecified plane model.

A 737 pilot noted, “multiple errors during taxi,” wrong weight, and a pitch incident resulting in a scraped tail.

On another 737, an extensive maintenance delay as followed by sudden-onset turbulence when none was forecast.

Autopilot kicked off on an Airbus and its instruments were hard to read.

Weak wi-fi was reported to be undermining real-time weather information on a 787, and the pilot wronte: “It has been about over a year since we were old the wi-fi issue on the 787 would be attended to and in the meantime, not to write it up in the logbook.”

An FAA spokesperson said, “The FAA reviews the reports and cross-references them with other data sources to identify possible risk areas for further investigation.”

Possible risk areas include things reported far more often than mechanical glitches: human error in the air or at flight control, risks from congestion at peak periods, staffing issues and fatigue at the towers.

A flight controller wrote up a near mid-air collision between incoming planes, calling it a “catastrophic event that was about to happen. This was a pilot deviation.”

And a pilot blamed ground control when two planes came too close for comfort at touchdown saying, “We would have been in direct conflict with the aircraft landing. ATC failed to sequence traffic.”

The FAA points out those are examples of their training, safety systems and backups working, saying “Our system is laced with so many layers of redundancy that one problem alone does not result in an accident.”

But some aviation professionals say it could be a matter of time, feeling stretched to the limit in the Hawaii sectors, first by congestion at busy airports.

A controller writes, “Almost daily the controllers are telling them to hold planes, slow them or keep them out. This results in an extremely dangerous and complex ATC.”

Another says, “Today was the worst I have ever seen… The sector should not be working as much airspace as they do.”

Concerns about staffing levels in the face of a huge workload is straining workers at the control towers, tales of 6-day work weeks and being on-position hours at a time, controlling sectors that are often combined, or controllers working multiple roles on the same shift.

One incident report states, “I was working CIC and arrival radar combined because of low staffing.”

Another incident write-up says, “I was working cab and controller-in-charge combined. What the hell happened and why did everything break down so rapidly?”

But it’s the narratives from separate close-call incidents that are most unnerving.

A tower worker writes, “A catastrophic event almost occurred where 3 planes almost had a mid-air. We are short staffed, yet-again. I was trembling after the incident.”

“I don’t want to see another event like that occur before our management decides to de-combine the sectors during busy periods.”

  

In another incident a controller writes, “I blame the short staffing at the HCF. I am fatigued, as are my coworkers.

  

“Fatigue is playing a factor in our day-to-day operations.  I fear a catastrophic incident could potentially happen.”

  

The FAA points out that while these are first-person anecdotes, that “they describe safety issues as perceived by the reporting party, and the FAA greatly values these reports,” adding “the U.S. commercial aviation system is experiencing the safest period in world transportation history.”

The FAA tells KHON2 they have a targeted staffing level of 83 controllers for Honolulu and have 88 on board, but the air traffic control workers union – the National Air Traffic Controllers Association – said in a statement they “are at a 30-year low of fully certified air traffic controllers nationwide and, as we have warned for several years, capacity would need to be reduced when there is not enough staffing to ensure the safety of all flights.”

NATCA says there are only 61 fully certified controllers for the Honolulu Control Facility area, stating “This is 22 below the facility’s targeted number for full staffing of fully certified controllers and reflects the fact that this is an understaffed facility, very much like others around the country which is why we have called it a staffing crisis.”

NATCA says the headcount of 88 that the FAA provided includes trainees who can only work certain amounts of traffic on their own or work alongside an on-the-job trainer, and should not be counted as part of an analysis of proper staffing for a facility in handling the day-to-day traffic loads.

The state Department of Transportation said in a statement: “Air Traffic Controllers are federal employees and HDOT does not manage their staffing schedules. As always, safety is atop priority and we will work with our partners in the federal government to continue safe and efficient operations.”

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