ASAP Annual Safety Overview
2024 ASAP Safety Overview
2024 marked a busy year for Air Charter Safety Foundation with 888 submitted events from 281 active participants. Several key trends are changing the way safety is managed, implemented, and improved. Regulatory updates and technological advances are driving new practices and initiatives. Aircraft are becoming more automated with advancements in avionics, autopilot and automatic collision avoidance systems. Improvements in simulator technology offer more realistic training scenarios. Operators are increasingly adopting Safety Management Systems that focus on proactive safety management, ensuring that safety is embedded into every aspect of operations.
Members are actively placing stronger emphasis on fostering a culture of safety. This includes encouraging open reporting of safety concerns by all employees and ensuring that data is transparently analyzed to drive improvements. FAA continues to encourage a just culture with a focus on learning from mistakes, identifying root causes, and applying corrective actions when necessary.
Fatigue Management and Navigating Geopolitical Challenges
Airlines are adopting stronger scheduling practices, increasing awareness of the dangers of fatigue, and using technology to track and mitigate fatigue risks. Geopolitical instability in certain regions has had mixed effects on business aviation, increasing volume of reports related to GPS spoofing/jamming. Operators are taking proactive measures and are training pilots how deal with these anomalies.
Advancing Human Factors and Crew Resource Management
The industry continues to place emphasis on human factors, with a focus on improving crew resource management. Training programs are evolving to address issues like stress management, decision-making under pressure, and communication strategies within the cockpit. This helps to reduce pilot error, which remains one of the leading causes of incident reports.
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Leveraging Big Data for Enhanced Safety Systems
The use of big data analytics is expanding to improve safety management systems. By collecting and analyzing flight data, operators can identify patterns of behavior that could indicate safety risks. This data can be used to refine training programs, update maintenance schedules, and predict failures before they occur, ultimately reducing incidents and improving operational safety.
A NOTE ON DATA
Events from two years ago refer to those submitted between October 1, 2022, and September 30, 2023, while last year covers October 1, 2023, to September 30, 2024. The data is organized this way for FAA reporting purposes.
Events from two years ago refer to those submitted between October 1, 2022, and September 30, 2023, while last year covers October 1, 2023, to September 30, 2024. The data is organized this way for FAA reporting purposes.
ACSF Primary Types of Events
5 Most Common Types of Member Events
Primary Event Type
# of Events
2 Yrs Ago
# of Events
Last Year
% Change
Altitude Deviation
262
262
0.0%
Traffic Proximity Event
251
213
-17.8%
Coordination Comm. Issue
198
167
-17.4%
Aircraft Mechanical Issues – Airframe
117
131
10.7%
Altitude deviation
Example Corrective Actions
| Title | Description | Action For |
|---|---|---|
| Training Completion | Remedial training was completed for both pilots, with an emphasis on crossing restrictions. | Employee |
| Avionics Upgrade | Garmin upgrades will be installed in the aircraft involved to enable altitude selection. | Company |
| Simulator Training | Training programs will include event scenarios in simulator training. | Company |
| Updated Communication Process | The operator updated SOPs for the arrival brief checklist, emphasizing crossing and speed restrictions. | Company |
| Addition to Recurrent Training (FAA Recommendation) | The FAA recommended exploring online training to address this issue. There have been prior events regarding international operations. The FAA would like to see training distributed to the pilot group. | Company |
| Crew Counselling | The company will follow up with the SIC to ensure familiarity with the aircraft and SOPs, review the fatigue policy, and emphasize calling fatigue earlier. This event will carry over for a follow-up report from the counseling session, and past training records will be reviewed to identify any longer-term performance issues. | Employee |
| Lessons Learned | The crew has been debriefed and counseled on automation. The event was discussed during the pilot safety meeting. A "lessons learned" memo will be sent regarding automation procedures and adherence to SOPs. | Employee & Company |
| Notice to Pilots | All events were resolved with a "read and acknowledge" directive and were added to the agenda for review at the next Pilot Safety Meeting (a mandatory meeting conducted in person or through an LMS). | Employee & Company |
Traffic Proximity Event
Example Corrective Actions
| Corrective Action | Supporting Comments | Action For |
|---|---|---|
| Notice to Pilots | Company plan to send out read and initial through their SMS portal after ERC. | Company |
| Notice to Pilots | The issue is being tracked by the company - process in place to remove high-risk uncontrolled airports from company locations. Notice was sent to the pilot group via a company safety update. | Company |
| Updated Communication Process | The company is adding special notes on airports with high volumes of TCAS events. | Company |
| Brief to Pilots | ERC to brief event in pilot meeting - lessons learned. | Company |
| Crew Coaching | Recommend coaching with the crew: when departing Scottsdale, recommend using lower climb rates to reduce deck angle to assist in sighting VFR traffic. | Company & Employee |
| Training Topic | Company to prepare a training document that will be a Read and Acknowledge for the pilot group. This event type will be discussed in the next check rides for the pilot group, specifically clear and concise read backs to radio calls. | Company |
| Safety Meeting | The company is considering an SOP change for airports with parallel runways (VNY in particular). If the aircraft on the parallel is "cleared for the option," we may delay our takeoff to ensure adequate separation. | Company |
| Training | The crew was counseled on the need to follow the TCAS RA commands, even if they think they have the traffic in sight. The traffic they see may not be the traffic that the TCAS system is de-conflicting. | Employee |
Coordination/Communication Issue
Example Corrective Actions
| Corrective Action | Supporting Comments | Action For |
|---|---|---|
| Brief to Pilots | The event was discussed in a management meeting with pilots as lessons learned. | Company |
| Updated Communication Process | Company plans to implement a check-and-balance procedure. Both pilots will be required to check NOTAMs and TFRs, then brief each other. Additionally, pilots will now leave the TFR layer on in the ForeFlight system. | Company |
| Notice to Pilots | Pre-departure brief to be standardized. A memo to the pilot group has been distributed, and this will be included in the next GOM update and training. | Company |
| SOP Update | SOP changes to include a requirement for both crew members to receive and cross-check clearances. | Company |
| Training Completion | The training department conducted retraining with both pilots, emphasizing ATC communication, ground procedures, and taxi procedures. | Employee |
| Updated Communication Process | Operator enrolled in the U.S. Domestic Controller/Pilot Datalink Communication (CPDLC) Program. No issues since. | Company |
| Updated Communication Process | Company to update SOPs, requiring pilots to always monitor 121.5. | Company |
| Updated Communication Process | The company now sends emails to pilots whenever there is a change in stations. A folder with information on these changes is also added to the company iPads. | Company |
| Crew Counseling | ERC had counseling with the crew, who stated the controllers’ instructions were misleading. ERC felt there were errors on both the crew's part and ATC's. Contributing Factors: Crew failed to follow taxi instructions and ATC's loss of situational awareness. ERC will follow up with crew counseling after the meeting. | Company & Employee |
Aircraft Mechanical Issues
Example Corrective Actions
| Corrective Action | Supporting Comments | Action For |
|---|---|---|
| Part Replacement | Maintenance inspection conducted post-flight. Primary Outflow Valve has been replaced. Aircraft is back in service with no recurring issues. | Company |
| Updated SOPs | Pilots have been counseled to inspect the door before closing. The company implemented a new procedure with crew calling chief pilots directly in such events (depressurization). | Employee & Company |
| Notice to Employees | The company reached out to the manufacturer regarding issues. The manufacturer sent guidance for troubleshooting, which was forwarded to pilots and line service technicians. | Company & Employee |
| Aircraft Audit | The company is in the process of auditing all aircraft in the fleet to ensure that proper uniform pitot covers are being used. | Company |
| Updated SOPs | All aircraft were grounded for 24 hours to conduct a fleet check. A 4-blocker was distributed to the company. Wheel installation now requires taking pictures and uploading them to the work packages. | Company |
Flight Diversion/Air-Ground Return
Example Corrective Actions
| Corrective Action | Supporting Comments | Action For |
|---|---|---|
| Brief to Pilots | The operator has briefed the pilot group on proper procedures during a ground run. The company also plans to have this implemented in formal procedures (SOPs, GOM). | Company |
| Addition to Checklists | The company will implement changes to the checklist to have pressurization settings set to "auto." The crew has been counseled, and the event was included in the safety newsletter. | Company |
| Updated Communication Process | The oxygen mask cover was not removed after installation. Maintenance (MX) is introducing a read-and-sign book to provide a means of verification. MX conducted a fleet check for these covers. | Company |
| Manual Revision | The Normal and Expanded Checklist has been revised, approved, and published fleetwide. The revision includes the requirement to check gear pins on every flight (not just the first flight of the day). | Company |
| Training | The event highlighted errors when releasing the aircraft for maintenance check flights. Internal training with employees responsible for releasing the aircraft has been conducted. | Company |
