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Hartzell Engine Technologies Announces the Availability of FAA Certified South Wind Replacement Cabin Heaters

Tue, 01/31/2017 - 09:18

Montgomery, AL, (January 31, 2017)  — Mike Disbrow, president of Hartzell Engine Technologies (HET), announced today that as a result of its asset purchase of C&D Associates in 2016,

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Categories: News, US

CALLBACK 444 - January 2017

Thu, 01/12/2017 - 10:18
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Issue 444 January 2017 Extensive and accurate communications are imperative in aviation operations. Whether conducting an airline operation or a general aviation equivalent, communications occur in various ways through many channels. Communications must be efficient and explicit between Pilots, Air Traffic Controllers, Dispatchers, Maintenance Technicians, Relay Services, Ramp Services, Flight Attendants, Passengers, Customer Services, and Command and Control Authorities.

An old aviator’s maxim wisely bids one to “aviate, navigate, and communicate.” Effective communications may preclude a multitude of aviation problems or even restore success from imminent failure, while poor or no communications can quickly steer a desirable outcome toward potential disaster. As Mark Twain once said, “The difference between the right word and the almost right word is the difference between lightning and the lightning bug.” We might all benefit if we strive to better our communications with the same commitment as the effort expended to resolve personal weight and balance issues that emerge each January.

In this issue, CALLBACK examines reports that reveal communication deficiencies during aviation operations. In these reported incidents, the resulting circumstances yield important lessons where ambiguity is unacceptable and may have serious consequences. An Air Carrier’s Premature Pushback“The single biggest problem in communication is the illusion that it has taken place.” - George Bernard Shaw.■ At the same time we were cleared to push, we received a [third] message for inaccurate weights. I told the push crew that we needed to get new weights before we pushed. We got new weights and loaded them into the FMC. When cleared to push, I released the brakes and said, “Brakes released, cleared to push, disconnect abeam gate XX.” We started moving, but no verbal response was heard from the push crew. After trying to contact [the push crew] on the headset, the aircraft stopped. I still thought we had a communication problem. One of the wing walkers got on the headset and told us there was no one in the tug. From Defect to Conflict and Complexity“The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through.” - Sydney J. Harris. ■ [The airport] was running an east operation, and we were on approach for Runway XX. We were given vectors to turn north for the base leg and 3,000 feet. I had spotted the preceding aircraft, as well as the aircraft on approach for Runway YY. Approach called us and issued a right turn to a heading of 070. I sensed everything went quiet because usually there is a bit more with that clearance, so I looked at [the] radio and realized that Communication Radio 1 was transmitting. We had a stuck microphone, yet as I scanned all the switches, none were in the [Radio Transmit (R/T)] position. The First Officer (FO) and I both [realized the condition] at the same time, and [we] began checking our switches more thoroughly. The FO was the Pilot Flying (PF), and as we were converging with traffic from the adjacent runway, coupled with a small delay caused by our becoming aware of the malfunction, he elected to disengage the autopilot to expedite the turn back toward our localizer. Additionally, because we had strayed and it appeared that the adjacent aircraft had started a descent based on our TCAS, [the FO] started a shallow descent as well.

Once we established a heading back toward our approach course and were no longer in unsafe proximity of the Runway YY approach course, we leveled off. To make matters worse during this situation, we didn’t realize for a few moments that he and I couldn’t hear one another over the crew intercom, and the FO is hearing impaired. We were both talking, thinking the other person could hear, and at one point, he asked me to take the controls so he could investigate his headphone jacks, but I didn’t hear him. Nothing came of that because he was only a moment in doing so, but under a different set of circumstances there could have been very different results. I didn’t think there was a procedure in the QRH for our situation and felt that what little time I had to correct this problem without it escalating into an even bigger problem was best spent trying to [troubleshoot] a couple of things I knew of from basic system knowledge. I isolated the [communication radios] by selecting EMERG on both [audio control panels], and it solved the problem. Although the FO could not hear ATC or me, I was able reestablish communication with the Approach Controller and obtain proper clearances. As we crossed the outer marker, ATC issued a low altitude alert as a result of the descent maneuver we performed earlier. We had leveled off at 2,200 feet, and ATC advised us that the minimum altitude at the outer marker was 2,700 feet. We established the aircraft on the glideslope and continued to a normal landing. The FO’s [communication radios] came back somewhere along the approach but went back out during taxi in. We reported to ground control that we were having problems with the radios, and we were extra vigilant during taxi in.

The biggest threat was losing communication with ATC at a very critical phase of the approach, in very congested and busy airspace.… The nature of this malfunction didn’t allow a determination of the full scope of debilitation immediately; it became a huge distraction when coupled with the tight constraints of the operating environment. The idea of flying in such busy, complex airspace without [communication, and thereby] imperiling one’s own aircraft as well as others, caused extreme pressure to correct the issue. Impaired Crew Communications“Communication usually fails – except by chance. If communication can fail – it will. If communication cannot fail, it nevertheless, usually does fail.” – Osmo A. Wiio.■ The first attempt to land…was unsuccessful due to fog, and the flight returned to [the departure airport]. The flight then changed Captains and was re-dispatched…. The [second] Captain was on his second day of being [assigned involuntary flying] and [had been] pulled off his deadhead aircraft home to [fly this] turn…. He was understandably upset and was having problems hearing the First Officer (FO) through the [communications system], since there was no HOT MIC function on this [aircraft]. Unfortunately this was not identified until the return trip. The Captain missed several CRM calls from the FO on climbout, and the FO assumed it was due to his emotional state, but it was also due to the [communications system issue]. Upon approach to [the airport], Approach Control vectored the flight to a position north of [the airport] and asked if they had the field in sight. [The destination] recently had a snow and frost event, and the Crew was having problems identifying the field. Everything looked white. The Captain responded that they had it; the FO concurred and began to maneuver for landing. At approximately 1,300 feet AGL, both pilots noted that the runway did not line up with the navaids and verbalized, “This doesn’t look right.” At that time, [the] Tower informed the Crew that they were lined up on the wrong airfield. A go-around was conducted, the flight maneuvered for the proper airfield, and [we] landed uneventfully.

The HOT MIC function should be installed on all aircraft. A Numerical Near Miss“Precision of communication is important, more important than ever, in our era of hair trigger balances, when a false or misunderstood word may create as much disaster as a sudden thoughtless act.” - James Thurber. ■ Upon my landing flare on Runway 17 at CVO, I noticed a single engine, low wing plane off to the left side of the runway, heading toward me. The plane had moved off to the left of the runway and was flying above the taxiway at about 100 feet AGL.

It was my third landing at CVO on Runway 17 that day, and I had communicated with other planes on 123.075, all of which were using Runway 17. During my [last] left downwind, I did see a plane to the west of the airport above traffic pattern altitude, but I didn’t hear any calls on CTAF and thought [the plane] was transitioning through the airspace. So I was a little shocked to see it buzz past me as I landed. I was able to complete the landing without incident. I do know that the sectional shows CTAF at CVO as 123.0, but the frequency is 123.075, so maybe they were reporting on this frequency, but I don’t know. Dispatch Isolation“The more elaborate our means of communication, the less we communicate.” - Joseph Priestley. ■ As I was building the release for this flight, I was getting an error that [indicated] the drift-down alternates could not be calculated because of an error. [A fellow Dispatcher] told me to file it and make sure that the drift-down information was on the release. I filed it and checked the release, but the [drift-down] information was missing. After I corrected this issue, I called [the associated ARTCC] to pull the flight strip, sent the corrected [flight plan], sent an ACARS message to the crew, and then called Ops to pass the information to the crew to print the new [flight plan]. While the flight was enroute, I got a message from the crew that the route given to them by ATC was not matching what was on the release. I sent [the crew] the corrected flight summary, the drift-down information, and the weather for [their] escape airport. I then did a pen and ink for the new flight plan. The Captain said he was not notified by the gate agent and did not receive [my] ACARS [message].

There was a breakdown of communication. The gate agent did not notify the crew to print the new [flight plan], and the crew did not receive the ACARS message. The next time I [will] directly call the Captain and follow up to ensure that they have the correct [flight plan]. Check Out
ASRS Safety Topics!ASRS Database Report Sets each consist of 50 de-identified ASRS Database records relevant to topics of interest to the aviation community. View/Download Report Sets »CALLBACK Issue 444 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS Search ASRS Database ASRS Homepage Special Studies
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more » November 2016 Report Intake: Air Carrier/Air Taxi Pilots 4,154 General Aviation Pilots 1,191 Controllers 504 Flight Attendants 435 Military/Other 250 Dispatchers 236 Mechanics 138 TOTAL 6,908 ASRS Alerts Issued: Subject No. of Alerts ATC Equipment or Procedure 2 Hazard to Flight 1 TOTAL 3 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 444


NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

January/February 2017 FAA Safety Briefing

Thu, 01/05/2017 - 11:22

 The January/February 2017 issue of

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Categories: FAA/CAA, News, US

Is a mechanic or maintenance facility responsible for maintaining my aircraft in an airworthy condition?

Tue, 12/20/2016 - 14:14

 Nuts, Bolts, and Electrons: Airworthiness Directives— GA maintenance i

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Categories: FAA/CAA, News, US

CALLBACK 441 - October 2016

Fri, 12/16/2016 - 09:28
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Issue 441 October 2016 Once again CALLBACK offers the reader a chance to “interact” with the information given in a selection of ASRS reports. In “The First Half of the Story” you will find report excerpts describing an event up to a decision point. You may then use your own judgment to determine possible courses of action and make a decision regarding the best way to resolve the situation.

The selected ASRS reports may not give all the information you want, and you may not be experienced in the type of aircraft involved, but each incident should give you a chance to exercise your aviation decision-making skills. In “The Rest of the Story…” you will find the actions actually taken by reporters in response to each situation. Bear in mind that their decisions may not necessarily represent the best course of action. Our intent is to stimulate thought, discussion, and training related to the type of incidents that were reported. The First Half of the StorySituation # 1  C150 Pilot’s Report■ My mission for the day was to fly to look at an airplane I was considering purchasing. Another pilot, who had a VFR only Cessna 150, [offered] his airplane for the flight. The weather was forecast to be marginal VFR with some IFR along the route [and] ceilings of 800 to 1,000 feet, becoming broken to clear as the day progressed. The weather was forecast to be bad the following day, so I “had” to take the flight that day. To complicate issues, I needed to…pick my son up from school that evening.

I was paying close attention to the weather enroute.… A couple stations near our destination [were] reporting marginal VFR broken conditions, and an airport near the destination was VFR. It took me another hour to realize that the VFR airport report was 4 hours old and was not being updated by ADS-B. I had received a weather brief earlier that day, and I supplemented it with my iPad, but my weather program was not updating. I was still on the 4 hour old weather at our departure time.

This plane literally had no equipment. We had a handheld transceiver and [a] portable, [ADS-B capable] GPS unit. We could get 5 miles of range out of the handheld on a good day. At least [we had] an attitude indicator. All the areas within range of our fuel supply were reporting anywhere from low IFR to 1,000 feet overcast ceilings and 5 miles visibility. We were now 2 hours into the flight, and I was waiting for the ADS-B to refresh. What Would You Have Done?
Situation #2  LR-24 Pilot’s Report
■ We were departing a small…airport when a light twin landed [with a] gear malfunction [that] resulted in a belly landing. [That] aircraft came to rest in a position leaving approximately 4,000 feet of runway unobstructed.

At [that] time, we had only started the number 2 engine and were sitting on the FBO ramp, having not moved from our initial parked position.… I began to deplane so I could offer assistance to the disabled aircraft.… The Captain stopped me and told me to sit down.… I objected, but [he] told me that he was keeping our schedule. He proceeded to taxi, and I had to stop him from blocking the path for an emergency vehicle. After the fire truck passed, several airport officials, two of whom were in uniform, crossed their arms over their heads and attempted to stop [our] taxi. I brought this to the Captain’s attention,…but he proceeded to start the number 1 engine on the taxi roll, disregarding any checklist. Multiple aircraft on the approach to the airport reported, via UNICOM, that they were diverting because of the fouled runway.
What Would You Have Done?
Situation #3  B767 Captain’s Report
■ [Enroute to our destination], the crew noticed a fuel imbalance situation developing between the left and right main tanks with approximately 2,700 pounds remaining in the center tank. The left main fuel tank had approximately 40,000 pounds and the right had approximately 38,000 pounds with the “FUEL CONFIG” light illuminated. The crew balanced the fuel between tanks, [but also] noticed that the fuel quantity in the center tank was increasing slightly. The QRH was consulted. Nothing there seemed to apply to this situation. We relayed all the information up to that point to the Maintenance Representative.… The rate of transfer from the right main tank to the center was approximately 3,100 pounds per hour. At that point we were informed by the Maintenance Representative that once the main tanks reached the halfway point in their burn (about 20,000 pounds per tank), the fuel transfer from the right tank to the center would cease.
What Would You Have Done?
Situation #4  CRJ-200 Captain’s Report
■ After leveling off at FL310, the number 1 engine power could not be reduced. The thrust lever was completely unresponsive. After trying to troubleshoot the problem, we both looked in the QRH and decided that the only checklist for our situation was, “Thrust Lever Jammed.”… We called Maintenance on the radio to see if they might have a suggestion, [but they had no advice for our predicament].
What Would You Have Done?The Rest of the Story
Situation #1  C150 Pilot’s Report
The Reporter's Action:■ We continued another half hour.… At this point, the left fuel gauge was bouncing off “E.” We did find an airport at the very edge of our fuel supply that was reporting 1,000 foot broken ceilings, and [we] set course for it.… I…[chose] an airport well away from a major city that was reporting good visibility below the clouds and (reasonably) high ceilings. I dialed up an RNAV approach on my handheld, switched to UNICOM (figuring I could break things off if I heard another plane on the approach), and into the soup we went. We broke out of the clouds right at 1,000 feet, landed safely, and had 3 gallons of fuel remaining.… We waited a couple hours on the ground for conditions to improve, then continued to our destination. Lesson for the day: nothing, and I mean nothing, is worth taking a chance like that.
First Half of Situation #2
Situation #2  LR-24 Pilot’s Report
The Reporter's Action:■ As the Captain entered the runway, I brought it to his attention that we needed 3,600 feet of runway according to the performance data for the airplane to safely take off. I questioned the wisdom of taking off on approximately 4,000 feet of runway with a disabled aircraft with passengers and emergency crews still in close proximity. The Captain turned around with about 25 [feet of] clearance to the fire truck, and, over my objection, he initiated a takeoff.
First Half of Situation #3
Situation #3  B767 Captain's Report
The Reporter's Action:■ I elected to continue the flight expecting to land [at our planned destination] with approximately 18,000 pounds in the center and approximately 8,000 pounds in each main tank. We put together a plan to divert to several locations as the situation developed. We then spent time figuring out various scenarios to determine the options for safety, weather, maintenance, passenger servicing, etc. We climbed to FL380 as soon as ATC allowed it, [achieving] slightly better range and enroute weather avoidance. As we approached [one of the diversion locations], it became clear that [we] would not reach [our original destination] safely. We declared an emergency and elected to divert to [this newly chosen location]. At that point the fuel tanks had about 16,000 pounds in each main tank and approximately 18,000 to 19,000 pounds in the center. By the time we reached [this diversion airport], the main tanks were down to approximately 5,500 pounds, [with] the center at 35,000 pounds and climbing. We were given direct [to a fix] for the ILS. Not feeling comfortable with the distance from the end of the runway, we called, “Field in sight,” and headed directly toward the end of the runway.… I felt [that] the [threat] of losing one or both engines was a real possibility. I was determined to get to a 3-mile final with at least 2,000 feet to 2,500 feet of altitude in case of a dual engine failure. Once we were close enough to the field we flew through final to gain spacing, and…were in the slot by 500 feet. [We] landed without incident [with] approximately 2,500 pounds in the left and 2,000 pounds in the right tank as we crossed the threshold.
First Half of Situation #4
Situation #4  CRJ-200 Captain's Report
The Reporter's Action:■ We told the Flight Attendant we were going to shut down the engine and that it would be a normal landing. We checked the weather [at] nearby alternates to see if conditions were any better than [they were at our] destination, but they were worse. We declared an emergency, got vectors to run the checklists, made the announcement to the passengers, and landed with no further problems…. The flight crew did exactly as we were trained, and it resulted in a successful conclusion. At no time were we in any doubt about what we were doing and what the results would be. Check Out
ASRS Safety Topics!ASRS Database Report Sets each consist of 50 de-identified ASRS Database records relevant to topics of interest to the aviation community. View/Download Report Sets »CALLBACK Issue 441 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS Search ASRS Database ASRS Homepage Special Studies
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more » August 2016 Report Intake: Air Carrier/Air Taxi Pilots 5,279 General Aviation Pilots 1,229 Controllers 659 Flight Attendants 604 Military/Other 313 Mechanics 217 Dispatchers 168 TOTAL 8,469 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 5 ATC Equipment or Procedure 1 Other 1 TOTAL 7 NOTE TO READERS:  ■ or ■ Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 441




NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

CALLBACK 442 - November 2016

Fri, 12/16/2016 - 09:27
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Issue 442 November 2016 The perennial perils of winter weather are upon us once again. Seasonal weather, consisting of low temperatures and visibilities, freezing rain, ice, drizzle, snow, and fog, brings many additional challenges to flight operations. Hazards exist everywhere, and may not be clearly evident. Degrading conditions, changing schedules, unpredictable situations, complex procedures, ambiguity, confusion, task saturation, and fatigue can all increase the seasonal risk.

The FAA has taken many safety related actions to improve the safety of aircraft that encounter icing conditions on the ground and in flight.1 Carriers and crews are equally invested. De-icing and anti-icing procedures are routinely modified each year and get dusted off with the same regularity. Strict discipline, adherence to procedures, keen vigilance, and superior situational awareness are all integral to safe operations, and occasionally, some ingenuity is necessary to avert an incident. The ability to perceive and act on potentially imperceptible threats can be critical.

This month, CALLBACK examines reported incidents attesting to the wide range of hazards associated with icy winter weather. We look predominantly at events stemming from air carrier de-icing operations, but the hazards are equally pertinent to all aviators. Carbs and CaloriesThis General Aviation pilot departed on an IFR flight in instrument conditions. He suspected that carburetor icing resulted in a partial power loss and an unplanned landing.■ [We] departed on an IFR flight plan to our home base with four souls on board.… The takeoff was normal, in rain, [with] low visibility and ceiling. [I was]…cleared to 7,000 feet. All [was] normal until approaching 5,000 feet when [the] engine was not developing climb power. [I] turned on the carb heat with no noticeable change, then turned it off after four to five minutes. [I] turned on [the] electric fuel pump, changed tanks, and adjusted the mixture, [all] with no change. I did not check the magnetos. [I] was able to hold altitude at this time but [with] little or no climb. I told ATC that we had a problem and wanted to return. He replied that the weather had deteriorated at [our departure, but another airport] had better conditions and was closer. I accepted that recommendation, and he began vectoring us [for the] ILS.… I turned on the carb heat again, but engine power continued to worsen. I couldn’t hold altitude or airspeed, [and the] controller advised [us that] he didn’t show any roads or fields near our position. I broke out at about 400 feet AGL and landed in a farmer’s plowed and very muddy field. [There were] no injuries, and no damage occurred to the plane. No cause has been determined at this time, but I think carburetor ice could be a likely reason. Perhaps I missed signs and should’ve turned it on earlier or left it on longer, or perhaps the carb heat didn’t work as designed. The De-Icing Communications VacuumA Captain’s attempts to communicate were apparently unsuccessful, and his message was not “heard.” As a result, a ground employee got a surprise when he approached this A321 to begin de-icing procedures. The threat might have been mitigated had the Captain’s message been “received.”■ [We were] dispatched with an inoperative APU due to APU inlet icing while operating in freezing rain. [We] proceeded to the de-ice pad and contacted Snowman on the assigned frequency. [We explained] our APU problem and notified them four to six times that we had both engines running.… [We were] informed, as we entered [the de-ice] pad, to shut down the number 1 engine for de-ice and anti-ice fluid application. As we [set] the parking brakes and prepared to shut down the engine, Snowman informed us that de-ice personnel had approached the aircraft too soon and had [a] headset sucked into the number 1 engine. After ensuring [that the] employee was safe and unharmed, we contacted ATC, Operations, Maintenance, and Ramp, and returned to the gate.Specifications More like GuidelinesThis air carrier Captain had his aircraft treated with Types I and IV de-icing and anti-icing fluids. He was then perplexed when the Type IV fluid did not perform as specified.■ [We] requested de-ice and anti-ice fluid treatment after pushback.… Station personnel sprayed the aircraft with Type I and Type IV fluids.… After being sprayed and commencing taxi to the runway, ATC advised us of a ground stop to our destination, so we returned to the gate. While sitting at the gate for some time, the First Officer and I both noticed snow accumulating on top of both wings after only approximately 45 minutes since the commencement of the application of the Type IV fluid. We pointed out the snow accumulation to the station personnel…to make sure that they understood that the Type IV fluid was not holding up to the minimum holdover time. After our release by ATC, we had the aircraft de-iced and anti-iced again in the same manner and departed without delay to our destination.

The First Officer and I both reviewed the holdover tables for the Clariant fluid, making sure that we were looking at the proper table and reading it correctly. I don’t know why the Type IV fluid underperformed its holdover time. Missed Trim and Mis-TrimmedThis B737 crew experienced considerable difficulty getting their aircraft properly de-iced before departure. The de-icing procedures produced distractions that resulted in an abnormal configuration for takeoff.■ [The] first push was on time. A significant delay occurred waiting for [our] first de-ice attempt.… A cabin check was made, and frozen precipitation was observed on the cabin side of both engine nacelles.… We were deiced a second time. We did another cabin check, but the aircraft still had frozen precipitation in the same locations. Because of the extended ground time, we taxied back to the gate.… We spoke with the Supervisor at the gate, [who]… said that an experienced crew would do the [next] de-icing procedure. They also requested that we trim the aircraft full nose down…to de-ice. As our procedure calls to de-ice in the green band, we had the [trim] as far forward as possible, but remaining in the green [band]. This did result in having to note the trim setting not being [set to] the proper [value] in the Before Push Checklist. We…mentioned the need to reset the trim after de-icing. This time, we decided to do a cabin check at the point of de-icing.… Once again, we did not have a clean aircraft. Another call was made to Ops to de-ice again. Engines were shut down and we again described the location of the snow and contamination.… This fourth and final de-ice procedure was conducted with radio communication directly with the de-ice truck. They did a double check of each problem area and stated that they could see there was no contamination. The Captain did a cabin check and confirmed [that we now had] a clean aircraft.

Post de-icing checklists were done, and we were finally at [the runway].… We were cleared by Tower for takeoff and I taxied slowly onto the runway due to the ice and snow present and fair braking reports by other aircraft. After lining up and confirming the runway, I gave control of the thrust levers to the First Officer. As he advanced the thrust levers, we got a takeoff warning horn. I took control of the aircraft and quickly determined…that the trim, although it looked in the front edge of the green, was clearly not at the [correct] takeoff setting and was the source of the horn. We told Tower we needed to clear the runway. Better Late Than NeverThis B737 Captain was distracted with his wing anti-ice configuration during takeoff. The result was unintentional, but a significant deviation to the takeoff procedure occurred.From the Captain's report:■ [It was a] flaps 1 takeoff on compacted snow. [I] began the takeoff roll with engine heat and wing anti-ice on. After the “V1” call, [I] became distracted by the [wing] anti-ice configuration, causing [me] to miss the…“Rotate” call. [I] rotated approximately 35 to 40 knots late.From the First Officer's report:■ The Captain became distracted by the [wing] anti-ice on configuration right at the point I was making the “Rotate” call, requesting that I turn the wing anti-ice off. (The Wing Anti-Ice Switch was in the ON position with the blue valve position lights illuminated, indicating [the valves] had closed as designed.) I repeated the “Rotate” call two more times in quick succession, and the [Captain] rotated late. Sliding into HomeAn A320 Captain encountered a snow covered ramp while parking his aircraft at the gate. Normal precautions and procedures proved ineffective, so he reverted to his instincts to bring the aircraft to a stop.■ [As we approached] the gate, there were no personnel to guide us in. The taxi-in line was covered in snow. After a few minutes, rampers appeared in tugs and on foot. The ramp was slippery as indicated by a ramper falling down…. The tugs were sliding as well. We waited a few more minutes to be marshalled in. Finally the marshallers showed up, and we proceeded into the gate indicating 1 knot on the ground speed readout. I was purposely very cautious on the taxi in. We were given the [normal] stop signal, and [I] set the brakes. The aircraft continued to slide forward even though the brakes were set. The residual thrust at idle was enough to move the aircraft on the ramp under these conditions. The aircraft was not going to hit anything or anyone, but I was helpless at this point. I indicated to the marshaller to get the chocks in. He didn’t have any!!! I turned on the yellow pump and decided to shut down the engines in hopes [that] the loss of the residual thrust would help. It did. The aircraft stopped sliding. What a helpless feeling.… We were lucky that nothing was touched or damaged. Fortunately the jetway was very far away from its normal position.1 https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=10398
The ASRS Database is a rich source of information for policy development, research, training, and more. Search ASRS Database »CALLBACK Issue 442 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS View ASRS Report Sets ASRS Homepage Special Studies
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more » September 2016 Report Intake: Air Carrier/Air Taxi Pilots 4,335 General Aviation Pilots 1,183 Controllers 616 Flight Attendants 422 Military/Other 265 Mechanics 211 Dispatchers 111 TOTAL 7,143 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 12 Airport Facility or Procedure 3 ATC Equipment or Procedure 2 Company Policy 1 Other 1 TOTAL 19 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 442

T

NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

CALLBACK 443 - December 2016

Fri, 12/16/2016 - 09:27
Share or Problem viewing / mobile device: CLICK HERE
Issue 443 December 2016 Controller Pilot Data Link Communication Departure Clearance Services (CPDLC-DCL) is one segment of the Future Air Navigation System (FANS) that has been recently implemented in the contiguous 48 states at local Tower Data Link Service (TDLS) equipped facilities to deliver departure clearances and revised departure clearances prior to takeoff.

As any new system is implemented, some “bugs” may be expected, and CPDLC-DCL is no exception. ASRS is receiving reports suggesting that crews are experiencing problems while using CPDLC-DCL for its intended objective. The problems that are experienced point to sources from system architecture, to precise meanings of specific words and formats used in the CPDLC-DCL syntax, to basic interpretation and understanding of the CPDLC-DCL information protocols and operational procedures.

This month, CALLBACK shares reported incidents of complications that arose from the crews’ use of CPDLC-DCL to obtain departure clearances and revised departure clearances. While CPDLC-DCL offers many improvements and advantages over voice and Pre-Departure Clearance (PDC), some issues remain as we transition to this new system. As these examples may hint, ideas will emanate from the cockpit and formal solutions will be devised.Cautious Pilot Distrusts Link
CommunicationsThis Air Carrier Crew clarified an initial question they had about a revised departure clearance. Curiosity over the revised SID and transition that had not been “properly” LOADED resulted in a route portion that was manually loaded but not included in the clearance.■ During preflight, we received a revised clearance via CPDLC. The change was from the TRALR6.DVC to the STAAV6.DVC. I verified [the] clearance and received a full route clearance over the radio. When the LOAD feature was selected in CPDLC, the new revised route did not LOAD into the ROUTE page properly. It still showed [the] TRALR6.DVC, but now it had a discontinuity. At this point, I had to load the route manually. When I did load the STAAV SIX, however, I failed to select the DVC transition, [so the FMC] now had point STAAV direct to LAA in the LEGS page. When we did the route verification later, during the preflight, we both failed to detect the missing transition that included the points TRALR, NICLE, and DVC.

This went unnoticed until passing point STAAV on the departure. That is when ATC queried us if we were headed to point TRALR. We indicated to ATC that we were direct LAA. He re-cleared us to TRALR to resume the departure. There was nothing significant to report for the rest of the flight. Complications Perceiving Data Link
ChangesAfter using CPDLC to obtain their clearance, this Air Carrier Crew saw no indications that their clearance had been revised. It appeared the same as the filed route, so they did not LOAD it. ATC soon called them off course. ■ Prior to departing SNA we loaded the FMC using normal procedures.… We received a ready prompt but did not get a clearance. Shortly before push we still had not received a CPDLC clearance, so we requested a clearance via PDC. We got a PDC reply message stating to use CPDLC, and simultaneously a clearance was uploaded to the FMC ATC page. The clearance showed our departure and transition as filed, as well as the altitude restrictions, expected altitude, squawk, and departure frequencies as we expected to see. The ATC page did not state that it was a revised clearance or route. All obvious indications were [that] our clearance was unchanged from the filed route. A LOAD prompt and ACCEPT prompt were shown. We ACCEPTED the clearance, but because we had already loaded the flight plan, we did not LOAD the flight plan sent via CPDLC.

We departed as normal. Once airborne passing 10,000 feet, we received an ACARS flight progress print out that showed our originally filed course. After passing TRM, ATC stated they showed us off course. They gave us a revised route clearance.… There was no print out of our clearance to reference, and since the CPDLC did not display the full route clearance, we had difficulty tracking down whether or not there was actually a change to our originally filed route. We were able to find a LOAD prompt on page 3 of the ATC clearance page. When we selected LOAD, a new route was LOADED to the FMC, which was different from our originally filed route. We discovered our route had, in fact, been changed via CPDLC. We erased the change since we already had a new route assigned by ATC airborne and continued uneventfully to [our destination]. Complex Presentation — Desired
Learning CumbersomeNon-intuitive wording and convoluted clearance procedures coupled with incomplete systems knowledge caused this Crew to misinterpret the message that their clearance had been revised. The result was another call off course.■ We received our departure clearance via CPDLC. During my preflight, I loaded the FMC with the route we were given on our release paperwork (PORTT THREE DEPARTURE). Our release had the following FMS route: KEWR BIGGY PTW J48 BYRDD J230 SAAME STEVY HVQ UNCKL MAUDD4 KSDF. When it came time to log on to the CPDLC, the Captain and I received the following [departure clearance]: CLEARED ROUTE CLEARANCE ORIGIN: KEWR DEST:KSDF ARRIVAL: DARBY 5.UNCKL +LOAD NEW RTE TO KSDF+ EWR2, CLB VIA SID EXC MAINT 2500FT EXPECT FL340 10 MIN AFT DP, DPFRQ 119.2 SQUAWK 1534, CTC GROUND 121.8 FOR TAXI.

When we saw that this was a change, I manually changed the SID to the NEWARK TWO off of Runway 22R. I did not select the LOAD prompt as I did not see any other change to our clearance. I believed our clearance was now the NEWARK TWO (flown in LNAV), and our first fix was still BIGGY then PTW, etc. The Captain and I agreed on this. I printed the CPDLC clearance, folded it, and laid it on the center console.

After takeoff, we were handed off to Departure Control. He cleared us to fly directly to a fix which neither the Captain nor I saw on our route. He said, “Don't you have the PARKE J6” on your routing. We said, “Negative, we have BIGGY PTW J48.” He then just told us to fly a heading. He came back a short time after that and told us to fly directly to LRP and join J6 and expect a further clearance later. He did come back shortly thereafter, and told us to fly J6 to UNCKL, then the arrival.…We obviously knew we had been expecting something different than the Controller had been, so I picked up the "printed" copy of the CPDLC clearance we had received, and on it was also the following: PARKE J6 UNCKL Note that this was NOT on the original CPDLC clearance we looked at on the FMC. I don't know if it had been truncated off due to space, or it had been inadvertently left off or what, but we both went back and looked and noticed this. That was why we thought the only change to our clearance was to the NEWARK TWO, [while keeping] the same fixes as we originally had on our paperwork (i.e. BIGGY PTW J48).

Contributing factors to this confusing situation are numerous. I now know that I am supposed to select the LOAD prompt when we have a change to our routing.… The method we are transitioning into with respect to getting our clearances via CPDLC is very confusing. The wording… on the FMC is not intuitive, and the overall procedure…is very convoluted.… We now receive our clearances in several different ways, at different airports, and in different airplanes, [which] all lead to a higher chance of mistakes. Complicated Process Destines Lowered CognizanceThis CPDLC message arrived at precisely the wrong time. The Crew’s attention was diverted, and their situational awareness suffered as they attempted to eliminate the confusion generated when they could not quickly resolve the revised clearance CPDLC message. ■ We were taxiing out of a very congested, weather-impacted, JFK airport the other day. The ground frequency was non-stop due to long taxi routes because of 20 mile in-trail spacing for departing aircraft in all directions. A CPDLC message [reading] “THIS IS A REVISED CLEARANCE” appeared with no other information. No revised route [was] included. [We] spent [the] next 5 to 10 minutes heads down, while taxiing, trying to figure out what was happening, in addition to eventually calling Clearance Delivery on the radio, and Dispatch. [There was] no place to pull out of [the] way due to long taxiways with no exits. And, we were getting automatic ACARS messages [that we] must be airborne in 15 minutes due to [the] 9 hour flight time restriction. A simple printout of the revised clearance would have resolved the issue in a few moments and would have been much more intuitive.…

The current system of having an ATC clearance, current or revised, stored on multiple, disjointed pages of the ACARS or FMS display is confusing and causes excessive heads down time while taxiing. It will cause a gross navigational error,…is a defective system, and is going to harm someone. Common Precautions Demystify Link
ConfusionThis Air Carrier Crew noticed an ambiguity in their departure clearance. Although the syntax was confusing, Clearance “cleared up” their misunderstanding.■ The First Officer loaded [the filed route] into the FMC before requesting a CPDLC clearance. The clearance came back, “CLEARED ROUTE CLEARANCE. FREE TEXT. POM9.GMN. FREE TEXT CLB VIA SID EXC MAINT 14000FT.” The First Officer noticed a LOAD prompt, and [saw that] the new route [read], “DIRECT GMN DIRECT RGOOD RGOOD.EMZOH3.SKIZM.” Because we were now confused, we called Clearance to see if we were now filed direct to GMN, but they cleared up our confusion. We were still on the POM9.GMN. Check Out
ASRS Safety Topics!ASRS Database Report Sets each consist of 50 de-identified ASRS Database records relevant to topics of interest to the aviation community. View/Download Report Sets »CALLBACK Issue 443 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS Search ASRS Database ASRS Homepage Special Studies
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more »
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report » October 2016 Report Intake: Air Carrier/Air Taxi Pilots 4,368 General Aviation Pilots 1,255 Controllers 498 Flight Attendants 404 Military/Other 336 Mechanics 205 Dispatchers 159 TOTAL 7,225 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 5 Airport Facility or Procedure 5 ATC Equipment or Procedure 1 Hazard to Flight 1 TOTAL 12 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 443

T

NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

CALLBACK 440 - September 2016

Fri, 12/16/2016 - 09:26
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Issue 440 September 2016 In modern day aircraft, automation is a reality that facilitates procedures and allows precision never before achieved in flight operations. Thorough systems knowledge and keen management skills are required to operate the automation effectively. To that end, the aviation community has proactively educated itself, honed its skills, and created new paradigms. Many improvements have been made, but pilots are human and automation is complex.

Automation can clearly improve flight safety, but may also spawn new opportunities to err. Automation errors may occur in almost any flight regime. Operational programming errors are common. Errors suggesting a lack of knowledge or understanding are less frequently reported. ASRS often receives reports suggesting that aircrews believe their automation is accomplishing a desired task when, in actuality, it is not. As aircrews rely more exclusively on automation, a tendency can arise to place more trust in it than may be prudent. Perhaps the most interesting of the complex automation phenomena reported are of the human factors type. They are central to the complicated relationships existing between situational awareness, judgment, and automation management that quicken the human vulnerability to become lulled into a false sense of security and think that, “the automation has it.”

This month, CALLBACK looks at a small sample of incidents that describe reduced awareness, dependency, overreliance, and management errors that occur with automation. You can see how the incidents developed and can project how they may have concluded had the errors not been discovered.How Low Should You Go?This B737 aircrew programmed their automation correctly, but they deviated from standard operating procedure in one important detail that wasn’t of “immediate concern.” Soon thereafter, the distraction of a beautiful day and overreliance on their automation resulted in a significant altitude error.From the Captain's report:■ We were cleared to descend via the arrival landing south. As the Pilot Monitoring (PM), I set the lowest altitude on that STAR, which was 6,000 feet, and…then accidentally abrogated my PM duties by not stating, “I’ll set the next lowest altitude of FL220,” as we approached [the altitude restricted fix] in Level Change pitch mode. Already high on the profile and well above crossing restrictions, it wasn’t of immediate concern, but [it was] completely improper procedure on my part. Instead of correcting that, I passed the radios to the First Officer as I took to the [public address (PA) system] to offer a good-bye to our customers.

[After I finished] with the PA, I reported, “Back on number 1 radio,” to the First Officer, who had switched us to Approach but had not yet checked in. I…checked in and reported, “Descending via the…arrival.” I did not refer to the Primary Flight Display (PFD) to check what pitch mode we were in, but the Controller said, “Climb and maintain 10,000 feet.” We were on a STAR, and this was such an unusual call.… I said, “Say again,” and the Controller unemotionally repeated, “Climb and maintain 10,000 feet.” We complied immediately. By that time I saw that the bottom [altitude] window of the next fix showed 10,000. The Controller then asked, “Why were you down at 6,000 feet?” I said, “My bust,” as there was no excuse for this performance.

I had been relying on the VNAV automation instead of the old fashioned, “Set the next lowest altitude,” which forces both pilots [to be] situationally aware with respect to the profile. I was allured by the pure beauty of a clear Spring day and was obviously much less aware than I needed to be. From the First Officer's report:■ The Captain set 6,000 feet into the MCP altitude window, and we both verified it against the bottom altitude of the arrival.… The Captain [reported to Approach Control] that we were descending via the arrival. At this point I simply was not looking at our displays and a very short time later, we were told to climb to 10,000 feet from our current altitude of 6,000 feet.… I knew right away that we never got back into VNAV path for protection. Teetering on the ApproachA Gulfstream Captain, experiencing strong winds during an approach, became fixated on the automation’s correction. He then lost sight of his own situation and the airport.■ During the arrival into Teterboro, we were cleared for the ILS to Runway 6. The Pilot in Command (PIC) let the autopilot drift left of the center line and [I told him] that the airport was in sight at one o’clock. The PIC’s comment was, “Look at how much correction this thing is putting in.” We continued to drift left. I told him again that the center line was to the right and that the airport was in sight. The PIC turned right and started to descend. Then he said that he had lost sight of the [airport]. I told him that the airport was at eleven o’clock and that he was way too low for where we were. I [pointed out] the towers south of [the airport] to him twice. He then said he had them and asked where the stadium was. At this time the tower came on the frequency and gave us a low altitude alert. The airport was at our ten o’clock position, but at this point, I lost sight of the airport and told the PIC to go around. At that point, we both picked up the airport visually and landed without further incident.

The trip was extremely rough and had been for the preceding 20 minutes. The wind at 4,000 feet was out of the northwest at 65 knots. The [reported] landing wind was from 330 [degrees] at 19 [knots, gusting to] 25 [knots]. This [is] a classic example of how automation dependency can cause a very experienced pilot to lose track of situational awareness and ignore the basics of flying the aircraft. A Descending STARA Gulfstream aircrew was given two runway changes during the arrival, and the automation did not quite lead them down the correct vertical path. ■ The FMS was programmed with the arrival, and VNAV was selected. All seemed well as we descended to, and crossed, HOMRR at 16,000 feet and 250 knots. However, the next fix, VNNOM, required crossing between 11,000 feet and 10,000 feet. VNNOM is 4.1 nautical miles from HOMRR. Crossing HOMRR at 16,000 feet, we realized that it was almost impossible to lose 5,000 to 6,000 feet in 4.1 nautical miles. At this point I clicked off the automation and pointed the nose down, achieving a descent rate of better than 6,000 feet per minute. Our airspeed increased to 280 knots, and we crossed VNNOM high and fast.

The STAR called for crossing HOMRR at or below 16,000 feet, and the FMS should have been in a position to make the next subsequent fix. Obviously we could have done a better job monitoring the situation.… We made, programmed, and verified two runway and approach changes during this descent prior to HOMRR. In fact, the first change went from a landing east flow to a landing west flow. This could actually explain why the FMS logic chose 16,000 feet at HOMRR instead of lower.… Landing east on the EAGUL FIVE requires crossing [the next fix] immediately past HOMRR between 15,000 feet and 14,000 feet.

This is a really poorly designed STAR. Something should be done to warn other aircrews not to fall into the same trap.1The Virtual Green FlashAutomation dependency also exists in the ATC environment. A Center Controller, while using an automated hand-off procedure, “flashed” several aircraft to incorrect sectors. This alert Controller noticed the problem, bypassed the automation, and minimized the airspace violation. ■ I was working Sector XX, R-Side and D-Side combined. Traffic was moderately busy and we had overflights available through the [airspace] which [adds] some complexity. I was flashing several aircraft to Approach to initiate our flash-through procedure. The automation forwarded the handoffs [incorrectly] to Sector YYG instead of YYB. [Initially,] I did not notice that in my scan, and one of the aircraft penetrated [the adjacent sector’s] boundary without a handoff having been completed. I called Sector YYB for the late point-out and redirected the [automated, incorrect] handoff from Sector YYG to YYB. The Controller there took the handoff and flashed it on to Sector ZZ.

This is a repeated problem with YY Approach's automation. I would recommend their automation be forwarded correctly so the appropriate sector sees the handoff flashing at them. More Than Meets the EyeThis B737 aircrew trusted their automation to calculate the descent point, but they did not consider the winds. The situation was compounded as a second problem resulted from the action they took to solve the first.From the First Officer's report:■ [We were] given the crossing restriction 10 [miles] north of HIELY at 13,000 feet. [I] got behind on the descent, asked for relief, and the Controller gave us a heading and a descent to 13,000 feet. [We] entered moderate chop, and I oversped [the aircraft about] 5 knots or so [in the] clean configuration. I was…rushing to comply, and, along with chop, I got behind the aircraft. I need to do a better job cross checking the automation against what the restrictions actually are. I was trusting in the automation too much for when to start my descent.From the Captain's report:■ [Our mistake was] overreliance on the automation for planning the descent. [We should have] double checked that it makes sense with the winds and should have been more aware of speed control when using vertical speed to try to comply with a crossing restriction. 1 The EAGUL FIVE arrival is now the EAGUL SIX arrival, and the altitude restrictions have been changed so that the descent path is much more tenable given a runway change just prior to HOMRR.
The ASRS Database is a rich source of information for policy development, research, training, and more. Search ASRS Database »CALLBACK Issue 440 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS View ASRS Report Sets ASRS Homepage Special Studies
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more » July 2016 Report Intake: Air Carrier/Air Taxi Pilots 4,742 General Aviation Pilots 1,124 Controllers 660 Flight Attendants 543 Military/Other 304 Mechanics 155 Dispatchers 148 TOTAL 7,676 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 440



NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

CALLBACK 439 - August 2016

Fri, 12/16/2016 - 09:25
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Issue 439 August 2016 Airport ramp safety and associated hazards continually appear as common concerns in ASRS reported incidents. Reported ramp events range from routine to remarkable, while the hazards and associated threats may exist almost anywhere. Many hazards are familiar, while others are uncommon. They can be obvious or concealed, and are often unexpected. Unmitigated ramp hazards frequently result in significant property damage or injury to personnel.

The routine tasks and interactions required during ramp operations may combine to produce unique circumstances and peculiar threats. Recognizing the hazards and identifying the threats requires anticipation, attention to detail, and situational awareness to avoid incidents when hazards develop or already exist.

This month CALLBACK features reports taken from a cross section of ramp experiences. These excerpts illustrate a variety of ramp hazards that can be present. They describe the incidents that resulted and applaud the “saves” made by the Flight Crews and Ground Personnel involved. A Dose of Sand and FODThis B737 Crew encountered a ramp hazard that is not uncommon, but got a surprise that grounded the aircraft, in part, because local authorities had altered the airport facility. ■ [Our] aircraft arrived…and a normal exterior inspection was conducted with no abnormalities noted. There was a significant increase in wind strength directly behind the aircraft causing a dust storm.… Shortly after [the storm], a Ramp Agent informed us of…debris in both the intake and exhaust sections of both engines. The debris consisted of dust, sand, and small particles of stone.… The total quantity was estimated between one-fourth and one-half cup in each engine’s exhaust section and about the same…in [each engine’s] intake.

Dispatch and Maintenance Control were consulted and contract maintainers were summoned. Debris was vacuumed out of all sections of the engines and inspections noted no other visible defects. The engines were then [run] at idle power for five minutes with no abnormalities noted from the flight deck engine instruments. Visual inspection of the engines, unfortunately, indicated that additional debris had been expelled from the hot section…during engine spool down. Maintenance Control…grounded the aircraft pending a borescope inspection.… There is certainly a significant cost to this incident.

The airport authority had recently replaced all of the infield grass and areas between the runways and taxiways with a sand and gravel mix.… I am certain this is the material that found its way into the engines. I am astonished more aircraft have not fallen victim to this hazard. Getting Caught Up at WorkThis Lead Ramp Agent, while striving for excellence in the performance of his duties, was surprisingly pulled in another direction. His co-worker likely prevented a serious injury.From the Lead Ramp Agent’s report:■ An Agent who was loading mail with me in the pit saw the lavatory service technician driving his equipment. He thought he was driving under the aircraft. I leaned [out] to see and…that is when my badge caught between the belt and the belt loader ramp and dragged my vest in.

I yelled and the other Agent pushed the emergency stop. Many thanks to the Agent who did what he did to prevent any injury. From the co-worker Ramp Agent’s report:■ [While the flight was being serviced], I was in…the rear cargo hold [working] with the assistance of my Lead Ramp Agent. He…leaned over the end of the belt loader to check on a lavatory service truck that appeared to be under the aircraft fuselage. I heard him yell and turned to see his badge and vest caught between the baggage belt and the roller on the loader, and his face and chest [were] being pulled into the belt. I immediately hit the e-stop button and the belt stopped. Another Ramp Agent ran over…and turned off the belt loader key. We released the Lead's badge lanyard and vest from his neck and the other Agent restarted the belt. [The belt would not reverse, so] we…passed his badge through the same way it was pulled in.Reenergizing EarlyThis CRJ-700 Captain received a surprise after he blocked in and noticed that he was being refueled even before the engines were shut down. ■ The aircraft was operating without an APU due to a MEL [item]. Ground power and air were requested on the in-range call. Upon arrival at our gate, the left engine was shut down and the hand signal was given to the Ground Lead for ground power. The individual acknowledged with a nod. During this time the aircraft beacon was on. After several minutes waiting for ground power, I noticed on the EICAS that the fueler had hooked up to the aircraft. I immediately shut down the aircraft and went to emergency power. I went out to speak with the supervisor.… I explained the importance of stopping an unsafe action and keeping personnel clear of the number 2 engine. Further, I explained how dangerous it was to attempt to fuel an aircraft while an engine is running and with passengers on the aircraft.Missed Communications – Again At the conclusion of his pushback, a B777 Captain received the “clear” signal that was clearly premature. The result was a taxi route that could have been presumed unobstructed, but was actually blocked by the tug.■ After pushback from [the] gate, the tug driver asked me to set brakes. I did. He then told me the towbar was disconnected. I told him to disconnect [his headset]. Within seconds after the towbar was disconnected from the aircraft, but while [the tug] was basically still directly under the nose of the aircraft and in front of the nose landing gear, the marshaller gave me the “all clear” free to taxi signal—even though the tug hadn’t moved! I have written this up time after time and it seems to be getting worse, not better. Someone is going to get killed if SOP is not followed!Unsafe in the Safety ZoneAn Air Carrier Captain took evasive action while turning in to the gate when a ground vehicle ignored the right of way rules and sped through the safety zone.■ [As I was] turning in to [the] gate, a ground operations vehicle crossed directly in front of our aircraft. The vehicle was moving right to left at a high rate of speed…through the safety zone and directly across the lead-in line. To avoid a collision, I aggressively applied maximum wheel brakes, bringing the aircraft to a violent stop. After the vehicle had cleared the safety zone, we taxied in to the gate normally.Bridging the GapThis Air Carrier Crew was actively taking precautions and mitigating risk as they taxied to the gate. Just when they thought the flight was all but over, an unexpected, uncommon, and unnoticed threat abruptly became a reality.■ Light snow [was] obscuring most runway and taxiway markings. I approached the gate at a very slow pace (as the First Officer later described, “slower than a walk”). A Marshaller…was in place and had shoveled or plowed the lead-in line for us. The lead-in line was the only marking clearly visible on the ramp. There was no equipment adjacent to the Safety Zone, no hoses or cables in the Safety Zone, and…the jet bridge appeared to be in the correct location. We…verbalized that the safety zone was clear and I turned on to the lead-in line, continuing the very slow pace.

The snowfall had changed to very large flakes.… I checked the braking action and [announced that] braking was “good.” Continuing down the lead-in line, I remained focused on the Marshaller with the snow falling. As we neared the jet bridge…I secured the number 2 engine and verbalized doing so.… Shortly thereafter, we felt a slight thump and the aircraft stopped. I did not notice any jet bridge movement and the Marshaller was still signaling forward taxi.

Something did not seem right. I set the parking brake and opened my sliding window.… As soon as I saw the proximity of the jet bridge to the number 1 engine, I immediately shut down the engine. I then scanned the instruments for any signs of FOD ingestion. All indications were normal. The Marshaller never seemed to realize that we contacted the jet bridge.… There was about an eight by three inch puncture in the top leading edge of the engine inlet.… I realize now that the jet bridge was angled out of the Safety Zone normally but then [had been] extended…into the Safety Zone. In the tradition of CALLBACK’s first editor, Captain Rex Hardy, I will abandon the anonymous editorial “we” for a short note in this, my last hurrah as CALLBACK editor. I have strived to carry on the high standards set first by Rex and then by my predecessor, Dr. Rowena Morrison. Now, after ten years in the dual roles of editor and safety analyst, culminating 50 years in the challenging, sometimes wild, but always wonderful world of military, commercial and private aviation, it is time for me to hang ’em up. The very capable Captain Ned Kintzing has picked up the reins and will carry on the CALLBACK tradition of providing concise, timely and valuable “lessons learned.”

I have always said that CALLBACK is a “community effort” and I would like to thank everyone on the ASRS staff for their insights and assistance in putting the newsletter together each month. I would like to thank you, the readers, for your kind words, for your constructive feedback, and most importantly, for sharing your safety reports with the aviation community.

Thank you and farewell,
Don Purdy
The ASRS Database is a rich source of information for policy development, research, training, and more. Search ASRS Database »CALLBACK Issue 439 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS View ASRS Report Sets ASRS Homepage Special Studies
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more »
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report » June 2016 Report Intake: Air Carrier/Air Taxi Pilots 5,285 General Aviation Pilots 1,230 Controllers 661 Flight Attendants 587 Military/Other 343 Mechanics 196 Dispatchers 156 TOTAL 8,458 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 439



NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189
Categories: News

CALLBACK 438 - July 2016

Fri, 12/16/2016 - 09:24
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Issue 438 July 2016 “Fatigue makes cowards of us all,” said legendary Green Bay Packers coach, Vince Lombardi, as he warned his players about this insidious threat. In similar fashion, fatigue exerts an influence upon aviation operations daily. Many aviation professionals have felt its effects. Many have suffered its consequences. The NTSB 2016 “Most Wanted List” of Transportation Safety Recommendations leads with, “Reduce Fatigue-Related Accidents.” It states, “Human fatigue is a serious issue affecting the safety of the traveling public in all modes of transportation.”1 FAA Advisory Circular 117-3, Fitness for Duty, notes that, “Fatigue is characterized by a general lack of alertness and degradation in mental and physical performance.”2

Fatigue can manifest itself in diverse ways. Fatigue research has documented many of its effects and generally describes it as "a decrease in cognitive ability from sleep loss, circadian disruption, or sleep inertia.”3 Fatigue is rarely the sole or primary factor in an incident or accident, though it is often cited as a factor in ASRS reported incidents.

CALLBACK presents six reports from various aviation professions that either state directly or imply that fatigue was a contributing factor. You can draw your own conclusions as to the role fatigue played in these ASRS reported incidents. Sleep Less in SeattleA routine radio call was a wakeup for this B737 First Officer. ■ After being assigned FL390 and a subsequent frequency change, we discovered during the climb that we had leveled at FL380 for approximately 10 minutes. I was the Pilot Flying, but when we changed Center frequencies, I took the call. When I checked in, I stated our altitude (FL380) and, as is my habit pattern, looked at the Mode Control Panel (MCP) altitude window. It read 39,000 and was different from our current altitude, so I checked in by saying, “Seattle, (call sign) FL380, climbing FL390.” I had not noticed that we had been level at FL380 for approximately 10 minutes. I simply assumed we were still slowly climbing to our cruise altitude.… I looked at the MCP altitude window again. It read 39,000. I told Seattle it looked like we were climbing to FL390 but we were level at FL380. Seattle said to climb to FL390. I affirmed that clearance. The Captain also confirmed the clearance over the radio and we climbed to FL390 without incident.

In retrospect, I realize that I had probably entered FL380 into the FMC on the ground before we had received our new paperwork.… This was the last leg of an extremely taxing four-day trip that would have been illegal prior to FAR 117. I was more tired than I realized.… I cannot over-emphasize the importance of fatigue in situations like this. I didn't realize how tired I was. First Impressions Don’t Always LastA misinterpreted flight instrument led this Air Carrier Pilot into performing a rejected takeoff.■ I was the First Officer and Pilot Flying for this [international] night flight. It was the seventh of eight duty periods and my second of two opportunities in the right seat on this trip. Our preflight preparation was completed for an on time pushback. The weather was VFR, we were heavy at 618,000 pounds, and our first opportunity on the runway resulted in a rejected takeoff.

With the Non Flying Pilot callout of “80 knots,” I recall a quick scan of the Primary Flight Display (PFD), but did not linger to verify 80 [knots] and the green trend line on the PFD speed tape. I believe I instinctively made the inappropriate callout “checked,” but was troubled enough to make at least two quick scans back to the PFD. Regrettably, both times when I glanced down, I saw the right side altitude tape instead of the left side speed tape, and what [registered incorrectly as airspeed] in my mind both times was 40, which was, in reality, the takeoff zone elevation.

Company training kicked in for a perceived malfunction, but I struggled to call it out clearly and precisely. Nevertheless, I communicated the threat and we accomplished the rejected takeoff procedure. When I saw the functioning and decreasing speed tape, my error became clear. There was, in fact, no frozen 40 [knot airspeed] indication. With a safe stop assured…I briefed the Captain on my error.

I have beaten myself up over it, but still can’t pinpoint the root cause. [Was it] fatigue on a long trip or less than usual currency in the seat for me? [Was it] a distraction with the centerline lighting, or was the PFD lighting too low? Nevertheless, vigilance and the commitment to speak up are traits that we have emphasized and I took them to heart. Target Fixation Preoccupation with a minor problem prevented this Regional Jet Crew from perceiving other critical events. From the Captain's report:■ We were maintaining 6,000 feet to join the ILS for Runway 11L. Four miles prior to the Initial Approach Fix I selected Heading Mode and inadvertently hit the transfer button causing the ILS frequency to disappear in the Communications 1 standby box. I was distracted by this and tried to fix it. I was fixated on my [ILS] frequency and did not recognize that the autopilot had disconnected. The Pilot Not Flying asked what was wrong. I [corrected] the frequency error and looked up to see that we were low for the approach and then the Ground Proximity Warning System (GPWS) “Too Low Terrain” alert went off. I applied max thrust and started to climb. ATC also said that they were getting a Low Altitude Alert and suggested the 6,000 foot minimum vectoring altitude in that sector. We climbed back through 6,000 feet, leveled off, intercepted the ILS to Runway 11L, and continued the approach.

The day was long with weather in the entire southwest. We flew five legs and were delayed…every leg. An ILS was hampered by fatigue and [selecting] the wrong button on the Communications 1 standby box, followed by fixation on that problem. Fatigue being the cause, a solution is to avoid and recognize it before it hampers safety. From the First Officer's report:■ The uncommon weather conditions, turbulence throughout every flight, and long delays most likely contributed to our being fatigued.… It appears that fatigue and fixation on a communication [switching] problem were the causes. Don’t Put off until Tomorrow What You Can Do TodayAfter a lengthy duty day, this Maintenance Technician accomplished a routine engine oil and filter change on a light aircraft. An in-flight engine failure occurred the next day. ■ I was instructed to meet the aircraft to conduct routine maintenance that consisted of an oil change and an inspection required by an Airworthiness Directive (AD). The aircraft arrived at dusk and I proceeded to drain the oil, remove and replace the oil filter, add new oil, and complete the inspection. Because it was not common company practice to cut open and inspect every oil filter removed from an aircraft, I set the old oil filter aside to drain and did nothing more with it. I had been on duty for twelve hours and was eager to finish the maintenance and go home.

The aircraft departed early the next morning. That afternoon the aircraft experienced a catastrophic engine failure and made a forced landing.

Some weeks later another maintenance technician located and cut open the oil filter that I had removed. Upon inspection, the filter was glittering with ferrous and non-ferrous metal, an obvious indication that the engine was not airworthy and required immediate attention. Had I cut open and inspected the filter the evening it was removed, I would never have signed off the aircraft as airworthy and the incident would have been avoided.

I believe several factors contributed to this occurrence.… A long duty day and consequent fatigue likely inhibited my better judgment to cut and inspect the oil filter. Double Checking the Check ValveA Maintenance Technician improperly installed a bleed check valve on this Regional Jet. The engine failed during the subsequent takeoff roll.■ I was tasked with the functional check of the Number 1 engine low stage bleed check valve. While reinstalling the valve, I accidentally installed it backwards. After it was put back together we [ran] the engine. On the first engine run we had a Bleed-1 Fail message. We reset everything and ran the engine again at power with the APU bleed off. This time no message came into view. We ran the engine a few more times…and didn't receive any abnormal indications.

The next morning the aircraft returned to the gate with a write-up…the number one engine [had] shut down on takeoff roll at thirty percent power. At Maintenance Control’s direction, we returned to the hangar to verify the check valve installation and found that it had been improperly installed.

At the time of re-install I had been up for approximately 18 hours. This is a job I have done before and I am familiar with it. I was tired and installed it incorrectly. I was fatigued and not aware…that I had installed it backwards. Too Tired to Arm Two DoorsThis B757 Flight Attendant cited fatigue in two separate door incidents.■ Due to fatigue, I failed to arm doors 1L and 1R prior to takeoff. I realized once we were in the air that they weren’t armed. My action was to immediately arm the doors. This is the second time due to fatigue I’ve had a door incident. 1. http://www.ntsb.gov/safety/mwl/Pages/mwl1-2016.aspx
2. FAA Advisory Circular 117-3, October 11, 2012, para. 5.b.
3. Dr. Erin Flynn-Evans, Fatigue Countermeasures Group, Human Systems Integration Division, NASA Ames Research Center.
The ASRS Database is a rich source of information for policy development, research, training, and more. Search ASRS Database »CALLBACK Issue 438 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS View ASRS Report Sets ASRS Homepage Special Studies
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more » May 2016 Report Intake: Air Carrier/Air Taxi Pilots 4,861 General Aviation Pilots 1,230 Controllers 611 Flight Attendants 567 Military/Other 362 Dispatchers 238 Mechanics 192 TOTAL 8,061 NOTE TO READERS:   ■  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
Issue 438

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Categories: News

Maintainer Fatigue Risk Management - AC 120-115

Thu, 12/08/2016 - 15:15

We are a nation of sleep-deprived workers. It is estimated that adults attempt to function on 1 to 1.5 hours less sleep than the generally recommended 8 hours per night. Human fatigue costs U.S.

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Categories: FAA/CAA, News, US

FAA National Policy on Additive Manufacturing in Maintenance, Preventive Maintenance, and Alteration

Thu, 12/08/2016 - 09:26

 This notice provides an introduction and awareness regarding the use of Additive Manufacturing (AM) technology in the maintenance, preventive maintenance, and alteration of aircraft, aircraft

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Categories: FAA/CAA, News, US

GE Unveils First Details Of MRO Data Exchange

Wed, 11/23/2016 - 11:42

Initial details of GE Aviation’s plan to leverage its Predix data-collection and analysis platform as a de facto MRO data-exchange pipeline between owners, operators and maintainers include a per-asset pricing model and a partnership with business-process specialists Capgemini.

GE used its annual Minds and Machines conference to publicly launch its Configuration Data Exchange (CDE) offering, as well as a “teaming agreement” with Capgemini.

“The product will include a configuration data standard and data translation capability to move data from one system of record to another via the GE Digital Predix platform,” GE explained.

To read the full story:https://airlineaftermarket.com/ge-unveils-initial-details-of-mro-data-exchange/

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Categories: News, US

FAAST Blast — Week of Nov 14, 2016 – Nov 20, 2016 Biweekly FAA Safety Briefing News Update

Mon, 11/21/2016 - 11:48

FAA Making Progress on New Pilot Medical Qualifications The FAA is working to implement Section 2307 of the FAA Extension, Safety, and Security Act of 2016 (P.L. 114-190), Medical Certification of Certain Small Aircraft Pilots. In the Act, Congress outlined an alternative medical qualification in lieu of holding an FAA medical certificate. The FAA must draft rules to meet the Congressional mandate.

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Categories: FAA/CAA, News, US

You Asked, We Answered! New Nov/Dec 2016 Issue FAA Safety Briefing Now Available

Mon, 11/21/2016 - 09:55

The November/December 2016 issue of FAA Safety Briefing focuses on many of the questions the FAA commonly receives from the public, as well as how to interact more effectively with the agency. Areas of discussion include aviation rulemaking, airman rules and regulations, and pilot resources.

Feature Articles include:

• What is the Federal Register- Why is it Important? PDF P.10

• Out for Comments - Why does it Take So Long to Process a Rule? PDF P.12

• What if the Rule Doesn't Fit? - Exemptions, Waivers, Deviations, and Authorizations PDF P.14

• Who's in Charge? - Logging Pilot in Command Time PDF P.16

• Breaking Bad - What to Do When You See Someone Doing Something Wrong PDF P.20

• Safety in Numbers - Understanding the Parameters for Small UAS Operations PDF P.24

• Why Can't I Uber with my Airplane? - The Legalities of Ridesharing in the Skies PDF P.29

The link to the online edition is:

http://www.faa.gov/news/safety_briefing/.

Produced by the editors, FAA Safety Briefing,

http://www.faa.gov/news/safety_briefing/

Address questions or comments to: SafetyBriefing@faa.gov.

Follow us on Twitter @FAASafetyBrief or https://twitter.com/FAASafetyBrief.

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Categories: FAA/CAA, News, US

You Asked, We Answered! New Nov/Dec 2016 Issue FAA Safety Briefing Now Available

Mon, 11/21/2016 - 09:55

The November/December 2016 issue of FAA Safety Briefing focuses on many of the questions the FAA commonly receives from the public, as well as how to interact more effectively with the agency. Areas of discussion include aviation rulemaking, airman rules and regulations, and pilot resources.

Feature Articles include:

• What is the Federal Register- Why is it Important? PDF P.10

• Out for Comments - Why does it Take So Long to Process a Rule? PDF P.12

• What if the Rule Doesn't Fit? - Exemptions, Waivers, Deviations, and Authorizations PDF P.14

• Who's in Charge? - Logging Pilot in Command Time PDF P.16

• Breaking Bad - What to Do When You See Someone Doing Something Wrong PDF P.20

• Safety in Numbers - Understanding the Parameters for Small UAS Operations PDF P.24

• Why Can't I Uber with my Airplane? - The Legalities of Ridesharing in the Skies PDF P.29

The link to the online edition is:

http://www.faa.gov/news/safety_briefing/.

Produced by the editors, FAA Safety Briefing,

http://www.faa.gov/news/safety_briefing/

Address questions or comments to: SafetyBriefing@faa.gov.

Follow us on Twitter @FAASafetyBrief or https://twitter.com/FAASafetyBrief.

read more

Categories: FAA/CAA, News, US

Critical Aircraft Maintenance Information is Now Everywhere

Fri, 11/04/2016 - 10:18

In the past decade, mobile devices have become an increasingly important part of our lives.

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Categories: News, US

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