Near-Misses Lessons for Aviation Safety Managers

Aviation is one of the safest modes of transportation, yet the margin for error remains razor-thin. In 2023, the Federal Aviation Administration (FAA) recorded 503 significant air traffic control lapses, a 65% increase from the previous year, despite only a 4% rise in air traffic (New York Times).

These incidents, known as near-misses, are events where an accident was narrowly avoided—perhaps by

• a pilot’s quick decision,
• an air traffic controller’s alertness, or
• sheer luck.

For aviation safety managers, near-misses are not just close calls; they are critical opportunities to enhance safety by identifying hazards and addressing risks before they lead to catastrophe. This article explores what near-misses can teach us, drawing on real-world examples, data, and the unique challenges of regions like Alaska, to provide actionable insights for safety professionals.

The Value of Near-Miss Reporting in Aviation SMS

Defining Near-Misses

A near-miss in aviation is an unplanned event that could have resulted in an accident but did not, often due to timely intervention or fortunate circumstances. Examples include

• runway incursions, where aircraft come dangerously close on the ground, or
• near mid-air collisions (NMACs), where planes breach safe separation distances in the sky.

The FAA defines an NMAC as an incident where aircraft come within 500 feet of each other, posing a collision risk (ASIAS NMACS). Unlike accidents, near-misses allow the industry to analyze failures without loss of life or property.

Why Near-Misses Are Crucial

Near-misses are invaluable because they expose vulnerabilities in the aviation system—be it human error, technological gaps, or procedural flaws—without the devastating consequences of an accident. As noted in a safety analysis, “The chain of events that lead to a near miss are the same chain of events that lead up to an accident, especially at the underlying cause” (AviationKnowledge). By studying these events, safety managers can implement preventive measures, reducing the likelihood of future incidents.

The Role of Safety Reporting Systems

The Aviation Safety Reporting System (ASRS), established in 1976 after the tragic TWA Flight 514 crash, is a cornerstone of near-miss reporting in the United States. Operated by NASA to ensure neutrality, ASRS allows pilots, air traffic controllers, and other aviation professionals to submit confidential reports without fear of disciplinary action (ASRS).

This immunity encourages transparency, capturing thousands of incidents annually that might otherwise go unreported. For instance, a 2016 incident where a Delta jet aborted takeoff in Atlanta to avoid another aircraft was documented through ASRS, leading to procedural reviews (The Atlantic). The FAA’s cooperative safety reporting program further supports this by inviting reports on near mid-air collisions and other safety discrepancies, ensuring comprehensive data collection (FAA AIP).

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Analyzing Near-Misses for Safety Improvement

Investigation by Regulatory Bodies

The FAA and the National Transportation Safety Board (NTSB) play pivotal roles in investigating near-misses. The FAA follows up on all reported events, even those where no collision was imminent, to evaluate safety risks (FAA Close Calls). The NTSB conducts detailed investigations for significant incidents, producing reports that identify causal factors and recommend corrective actions. These investigations often lead to changes in regulations, training, or technology, as seen in numerous case studies.

Data Analysis and Trends

Analyzing near-miss data helps identify patterns and root causes. For example, FAA data showed 1,115 runway incursions in the 12 months ending May 31, 2024, ranging from minor to serious close calls (Newsweek). A 2023 analysis revealed that 60% of runway incursions were due to pilot deviations, 20% to operational incidents, and 20% to vehicle or pedestrian deviations (FAA Runway Safety). Such insights allow safety managers to target specific areas for improvement, such as pilot training or air traffic control procedures.

Integration Into Safety Management Systems (SMS)

Safety Management Systems (SMS) are systematic approaches to managing safety, incorporating

• organizational structures,
• policies, and
• procedures.

Near-miss reporting is a key component of SMS, feeding into the safety assurance process to identify hazards proactively. By integrating near-miss data into aviation SMS implementations, organizations can conduct risk assessments, implement corrective actions, and monitor effectiveness. This approach aligns with the FAA’s goal of achieving zero serious close calls by examining technical and human factors (FAA Close Calls).

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Case Study: Austin-Bergstrom Near-Miss Incident

Incident Overview

On February 4, 2023, a FedEx cargo plane and a Southwest Airlines jet came within 100 feet of each other at Austin-Bergstrom International Airport in Texas. The incident occurred in low-visibility conditions, with both aircraft cleared for the same runway due to a series of errors. The FedEx plane was on final approach, while the Southwest jet was preparing for takeoff, leading to a critical runway incursion (NTSB Report).

NTSB Findings

The NTSB investigation identified several contributing factors:

• Lack of Surface Detection Equipment: Austin-Bergstrom lacked Airport Surface Detection Equipment (ASDE-X), hindering the controller’s ability to track the Southwest aircraft.

• Controller Expectation Bias: The controller assumed the Southwest jet would depart before the FedEx plane arrived, influenced by prior patterns and low situational awareness in foggy conditions (visibility as low as 1/8 mile).

• Communication Lapses: The Southwest crew did not inform the controller of a 19-second engine run-up, reducing separation to 150-170 feet at the closest point.

• Training Deficiencies: The controller had no recent training on low-visibility operations or the airport’s Surface Movement Guidance and Control System (SMGCS) plan.

• Cockpit Voice Recorder (CVR) Limitations: The 2-hour CVRs were overwritten, limiting the investigation’s ability to capture critical communications.

Lessons Learned and Recommendations

The NTSB issued seven new safety recommendations to the FAA, including:

• Implementing surface detection equipment at Part 139 airports without ASDE-X.
• Requiring controllers to receive annual training on low-visibility operations.
• Amending the Aeronautical Information Manual to ensure pilots communicate runway delays.
• Mandating 25-hour CVRs to preserve critical data (NTSB Report).

These lessons underscore the importance of technology, training, and communication in preventing runway incursions. For safety managers, this case highlights the need to advocate for advanced equipment and ensure robust training programs.

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Near-Misses in Challenging Environments: The Case of Alaska

Unique Aviation Challenges in Alaska

Alaska’s aviation environment is uniquely demanding. Over 80% of its communities are accessible only by air, making aviation a lifeline for transporting people, cargo, and mail (CDC Aviation). Challenges include:

• Harsh Weather: Rapidly changing conditions, such as fog, snow, and high winds, increase risks.
• Rugged Terrain: Mountains and remote areas complicate navigation and emergency responses.
• Small Airports: Many have unpaved, poorly lit runways, heightening operational risks.
• Limited Infrastructure: Much of Alaska is uncontrolled airspace, with limited weather and traffic information (ProPublica).

From 1990 to 2015, Alaska accounted for over one-third of U.S. commuter and air taxi accidents, despite its small population, highlighting the heightened risks (CDC Aviation).

Importance of Near-Miss Reporting

In such high-risk environments, near-miss reporting is critical for identifying and mitigating hazards. For example, a near-miss involving a pilot navigating through unexpected fog could reveal gaps in weather forecasting or pilot training. By analyzing these incidents, safety managers can develop targeted solutions, such as improved weather data or enhanced instrument flight training. The FAA emphasizes that “Reporting hazards helps prevent additional injuries and increases safety” (FAA Incident Reporting).

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FAA Initiatives in Alaska

The FAA’s Don Young Alaska Aviation Safety Initiative (DYAASI) addresses these challenges through:

• Weather Data Improvements: Installing weather observing systems at airports to enhance forecasting.
• Expanded ADS-B Coverage: Increasing satellite-based air traffic control to improve situational awareness.
• Navigation Charting: Updating charts to reflect Alaska’s complex terrain (FAA Alaska).

These initiatives demonstrate how near-miss data can inform broader safety strategies, particularly in regions with unique operational demands.

Case Example: Alaskan Context

While specific near-miss incidents in Alaska from 2023-2025 are less documented, the state’s high accident rate underscores the need for robust reporting. For instance, controlled flight into terrain (CFIT) is a leading cause of fatal crashes in Alaska, often preceded by near-misses where pilots narrowly avoid obstacles (CDC Aviation). Safety managers can use near-miss reports to enhance CFIT prevention training, ensuring pilots are better equipped to handle Alaska’s terrain.

Conclusion

Near-misses are powerful tools for aviation safety managers, offering insights into systemic risks without the tragic outcomes of accidents.

Through systems like ASRS, the industry captures critical data that drives improvements in procedures, technology, and training. The Austin-Bergstrom incident illustrates how near-misses can lead to concrete recommendations, such as advanced surface detection equipment and enhanced training.

In challenging environments like Alaska, where aviation is a lifeline, near-miss reporting is even more vital to address unique risks like weather and terrain. By fostering a culture of reporting and integrating near-miss analysis into Safety Management Systems, aviation safety managers can proactively prevent accidents, ensuring that flying remains one of the safest modes of transportation. As the FAA notes, “Safety is not a static destination; it is the relentless pursuit that requires continuous improvement” (FAA Close Calls).

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