ASRS CALLBACK includes excerpts from ASRS incident reports with supporting commentary. In addition, CALLBACK may contain summaries of ASRS research studies and related aviation safety information. CALLBACK is one of the ASRS's most effective tools for improving the quality of human performance in the National Aviation System (NAS) at the grass roots level.

Tuesday, December 13, 2011

CALLBACK 383 - December 2011

CALLBACK From the NASA Aviation Safety Reporting System
Issue 383
December 2011
When Practice Emergencies Go Bad
Before the advent of state-of-the-art simulators, practicing emergency situations in the aircraft was standard procedure. It is still the procedure used in much of General Aviation and, for the most part, works well in preparing for the unexpected. However, as this month’s reports dealing with simulated engine failures show, precautions have to be taken to prevent training scenarios from leading to real mishaps.

A Traveler's Shortcoming

This student pilot’s use of the first-person singular (I) throughout the description of this incident in an AA-5 Traveler seems to indicate that the instructor was not inclined to intervene. This can be a good training technique, but only up to a point. In this case the point was about 100 feet short of the runway.

While cruising at 2,500 feet, my instructor pulled the power to idle, applied carburetor heat and told me that I had just lost engine power. I pitched for best glide and performed a flow check for a restart. I then decided to head for [a nearby airport]…. I made a radio call and entered the pattern on a 45-degree downwind at pattern altitude for Runway 28. I added 10 degrees of flaps on downwind also. I then made a radio call to turn left base for Runway 28, made the turn and added flaps to 20 degrees. I then made the radio call for final which was to be a full stop and made the turn. I added full flaps shortly after making the turn to final. It was looking like it was going to be close for making the touchdown point. On short final I decided to add some power just to be sure I was going to make the runway. At about half throttle the main wheels came in contact with the deep snow on the ground and then the nose wheel came down. The nose wheel folded over when it hit a snowmobile track which resulted in a propeller strike. I skidded to a stop about 100 feet short of the runway.

The main contributing factors for not making the runway were: 1. I did not add full throttle and added throttle too late…. 2. The point of touchdown is about 15 feet higher than the approach end of the runway. With the snow, the perception of contour may have been distorted and hindered my judgment of height.

"The horn, the horn, the lusty horn,
Is not a thing to laugh to scorn."

— William Shakespeare

In the following report, a C182 pilot performed a simulated engine failure while undergoing a practical examination. It appears that both the examiner and the examinee were so engrossed in the simulated emergency that they both tuned BEEEEP out BEEEEP the BEEEEP gear BEEEEP warning BEEEEP horn.

At roughly 1,900 feet over [the airport], a simulated engine failure was initiated by the Examiner. I immediately pulled the carburetor heat on, pitched for best glide and started a right turn to land on Runway 36. While circling to land, I went through the engine troubleshooting procedures and made a simulated emergency call over the CTAF (Common Traffic Advisory Frequency). At this point we were on final. The aircraft was high, so I put in full flaps and initiated a forward slip to dissipate altitude. The aircraft landed long with the gear up. As soon as I realized that the gear was not down, I secured the engine (mixture— idle cutoff, fuel selector— off, master— off, ignition switch— off).

At no point during the maneuver did I hear any indication from the Examiner that the gear was not down or that I should initiate a go around. I believe that causal factors in this incident were nervousness and stress associated with the practical examination as well as a poorly executed power-off approach resulting in distraction on final.

A number of actions on my part could have prevented this incident. The most obvious and sure method of prevention would have been to put the gear down immediately after the simulated engine failure. This would have solved the problem at its root. Additionally, during the course of the maneuver, a number of factors led to my inability to recognize that the gear was not down. I failed to complete a GUMP check (Gas on fullest tank, Undercarriage [gear] down, Mixture full rich, Prop full forward) on final. Additionally, better execution of the power-off approach would have allowed adequate time and altitude to utilize the checklist. Since we were high on final, my concentration was on getting the aircraft down (using full flaps and a forward slip) rather than verifying that the aircraft was configured for landing. Additionally, it is my opinion that nerves and stress associated with the practical examination led to my inability to recognize the gear warning horn. Finally, I should have initiated a go-around maneuver as soon as I realized that we were going to land long.

Keeping It Unreal

When faced with a real engine failure, performing the Engine Secure Checklist reduces the chance of a fire on landing. However, actually performing the steps in the Engine Secure Checklist when the engine failure is not real can lead to a real problem.

While I was instructing a student in simulated forced landings, the student went through an Engine Secure Checklist. At some point during the descent, the student turned off the fuel selector without verbalizing his actions. Because the aircraft has a fuel selector handle that points in opposite directions in the ON and OFF positions, I mistakenly thought the fuel selector handle was in the ON position. At approximately 500 feet AGL, the go-around was initiated and the engine quit. I took control and successfully made a forced landing on a dirt road without incident. This could have been prevented by ensuring that students only verbalize the secure flow check and do not actually move the fuel selector, mixture and magnetos to off.

Bogged Down

Activating carburetor heat and periodically clearing the engine are two procedures that should be used when simulating an engine failure in a light aircraft. The instructor who submitted this report failed to use either procedure and ended up in a sticky situation.

I was conducting a VFR training flight. At 6,000 feet MSL, I gave the student a simulated engine failure. At approximately 200 feet over an open field, with the landing assured, I asked the student to recover the aircraft. Upon applying full power, the engine began sputtering and ran very rough and was not developing full power. I announced that I had control of the aircraft, verified full throttle and placed the carburetor heat on. At this point the aircraft had descended through 50 feet AGL and was still sputtering and developing 50 percent power at best. It was apparent that the aircraft was going to touch down.

I performed a soft field landing, but the aircraft immediately bogged down on the soft mud and came to a stop. I secured the aircraft and called for assistance on my cell phone. Even though I was communicating with ATC, it was my judgment that there was no need to declare an emergency.

In order to prevent a recurrence of this situation, I will ensure that carburetor heat is on and occasionally clear the engine by momentarily increasing the RPM during the simulated engine out, best glide portion of the procedure.

Another One Bites the... Mud

Even when carburetor heat is used and the engine is cleared, it is still possible to wind up in the mud if recovery from a simulated engine failure is initiated too late. aircraft with wheels in mud

I was practicing an emergency engine out procedure. I pulled the throttle to idle to simulate a lost engine, maintained flight attitude for best glide, put the carburetor heat on, mixture rich, fuel pump on and switched the fuel tanks. I then started looking for a field to aim for. I periodically cleared the engine and continued with my procedures, checked the primer and simulated restarting the engine.

Heading toward the field, I entered on a left downwind setting myself up to land northward. I simulated transmitting a Mayday call of my situation and position. I turned final with full flaps. I kept gliding down to ensure that I would make the field if indeed my engine had failed. By the time I applied full power to go around, I was too low and the mains touched the ground. I had no intention of touching down. My altitude judgment was in error. The ground was very soft and muddy and I could feel the mud grabbing hold of the tires and slowing the aircraft down. I pulled the yoke full back and kept in full power in an attempt to get back off, but it was no use. The mud kept slowing the aircraft down and forced the nose down. When the nose gear hit, it buried itself in the mud along with half the prop blade, bringing the aircraft to a full stop. Luckily the plane had slowed up enough before the nose gear hit. If I were going any faster, the aircraft would have flipped over.

CALLBACK Issue 383
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October 2011
Report Intake:
Air Carrier/Air Taxi Pilots 2,787
General Aviation Pilots 965
Controllers 639
Cabin 348
Mechanics 155
Dispatcher 39
Military/Other 12
TOTAL 4,945
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or aircraft equipment 11
Airport facility or procedure 8
ATC equipment or procedure 7
Company policies 2
TOTAL 28
Special Studies
Wake Vortex Encounter Study
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 »
Meteorlogical and Aeronautical Information Services Data Link and Application Study
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 »
Subscribe to CALLBACK for FREE!
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NOTE TO READERS: Indicates an ASRS report narrative [ ] Indicates clarification made by ASRS

A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 383



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

Monday, November 21, 2011

CALLBACK 382 - November 2011

CALLBACK From the NASA Aviation Safety Reporting System
Issue 382
November 2011
Fly the Airplane!
A review of recent ASRS reports indicates that failure to follow one of the most basic tenets of flight continues to be a concern when pilots are faced with distractions or abnormal situations. Since the consequences associated with not flying the airplane can be serious, this month’s CALLBACK revisits the problem and re-emphasizes a lesson as old as powered flight: Fly the airplane; everything else is secondary.

Note that the phrase, “FLY THE AIRPLANE” appears in all-caps in each of the following reports. The emphasis is not an editorial addition, but rather reflects the importance each reporter placed on that admonition.

A Flying Lesson

Two Cessna 205 pilots flying in IMC and experiencing communication problems were fortunate that one of them recognized the importance of actually flying the aircraft.

We were in a well-equipped C205 with a thorough annual completed a few weeks earlier.... The ceilings were lowering quickly as lines of widely spread thunderstorms moved through the area. We had satellite weather and weather radar on board so we had updated information even though I did a thorough weather brief. We figured we’d be in front of the line of weather as long as we were airborne early.

Our release time was 20 minutes later than hoped for. Satellite weather still showed, “Waiting for data.” We launched and within a minute were in IMC. The left seat pilot wasn’t doing a very good job of keeping wings level. I pointed to the attitude indicator…and decided that I’d only interfere if bank angle exceeded 15 degrees or so. I tried calling Center— nothing. We were at 3,500 feet (and cleared to 5,000). We should have had contact by now.

I tried Approach—nothing; Tower— nothing. [There was] lots of activity on the [weather radar]; we needed to deviate soon.... I saw that we were in a 30-degree bank and said, “Let’s turn on the autopilot while I figure out this communication problem.”

I fiddled with the radios, tried different frequencies— still nothing. I looked at the attitude indicator and saw a steep descending turn. I switched off the autopilot, grabbed the yoke and tried to figure out why the autopilot didn’t correct the bank angle. Then I heard a voice in my head, “FLY THE AIRPLANE!” I leveled the wings and arrested the descent.

.... Lessons learned? Make sure you can hear some transmissions before taking off into IMC. The autopilot cannot be relied on to reduce pilot load when there are system problems. A handheld GPS device with independent battery and approaches is a lifesaver. Practice for emergencies. They don’t happen when you are expecting them. And, most importantly, FLY THE AIRPLANE.

Attention Deficit

When autoflight systems are involved, “flying” the airplane may shift to a role of closely monitoring the flight path. This MD80 Captain’s report confirms how easy it is to miss an important step in setting up the autoflight system and emphasizes how important it is to continue flying the airplane.

We were cleared to cross an intersection at 12,000 feet and then descend via the [Arrival]. VNAV was selected with an assigned 250 knot speed in the descent. 8,000 feet was the selected altitude in the window for the VNAV descent. Center then issued a clearance to fly normal speed until the intersection. I wanted to pick up speed, but knew that I would have to get below the depicted descent path in order to slow for the 250 knot restriction. So, without saying anything to the First Officer, I de-selected VNAV and selected Vertical Descent on the Mode Control Panel (MCP) while de-selecting the autothrottle. I descended below the descent path and accelerated to about 275 knots and held that speed as we continued the descent towards the intersection. I did not remember to place 12,000 feet in the altitude window.

We noticed ice on the wings so I turned on the wing anti-ice and watched as the ice melted off the wings. As I turned off the wing anti-ice, the First Officer pointed out that I was not leveling off at 12,000 feet per the intersection restriction. I was surprised that I missed seeing us descending through our altitude and climbed the aircraft back to 12,000 feet.

I made several mistakes. The first was that I made an MCP change and did not mention it to the First Officer. Second, I did not remember to place the Altitude Alerter to the next restriction altitude as required when de-selecting VNAV. Third, I allowed myself to be distracted at a critical time when I should have had my attention on flying the aircraft. I need to remember that anytime VNAV is deselected (or any other change), I should announce what action is being taken and immediately reselect the next altitude restriction in the window and… FLY THE AIRPLANE.

"It is possible to fly without motors, but not without knowledge and skill."

— Wilbur Wright

In the following two reports, the pilots of a Cessna 210 and an Experimental Homebuilt both had a loss of oil pressure and were facing imminent engine failure. They had to make some quick assessments to determine the best course of action, but in the process they wisely maintained flying the airplane as their first priority.

We were flying [a Cessna 210] on an IFR departure…and were vectored to 080 degrees then southeast. As I rolled level [there was] a loud bang and heavy shudder of the engine. I turned the boost pump on and manipulated the throttle with no effect. RPM stayed about 1,000-1,200. Oil pressure was zero. We declared an emergency and turned direct to [the airport] and were cleared to land, but we were unable to make it to the airport. We considered the highway, but there was heavy traffic. We located an open field and committed with a good approach and landing. [There was] no damage.

The event confirmed the wisdom of FLYING THE AIRPLANE!

We flew our [Experimental Homebuilt] aircraft at about 2,500 feet and under the Class C airspace. About one hour into the trip, I heard a pop and there was smoke in the cabin. I had to assume that the smoke would only get thicker (though it did not). The EFIS (Electronic Flight Instrument System) was flashing Zero Oil Pressure. I immediately looked for a good spot to put the airplane down. I knew from the GPS that we were not close enough to an airport. So much raced through my mind that I am not sure how to explain it as anything but almost instantaneous. All of the hours training for this came back with multiple instructors’ voices in my head repeating the procedures. I do not think I can emphasize this enough. It really was rote. I did not have to think about it.

An airfield was out; the fields looked small and hilly; there was a road that was about to turn to a straight section directly in front of us. I pulled off the power and lined up on the road…. I started trying to tune the radio to 121.5, but then I heard, “FLY THE AIRPLANE” in my mind as I gave up on the radio. I did not exactly establish best glide as I needed to lose too much altitude. I was in a slight dive…. As we got closer to the road, I saw how close the trees were to my wingtips and how many power lines there seemed to be. We were flying right behind a truck and coming to a set of power lines…. I had put it in my head that I needed to fly as if I would lose the engine at any second, but I thought, “Well, I’ll go over that line and under the next!” I added power and I felt as though I were threading a needle. My foot slipped on the rudder pedal and I glanced down to see a river of shiny black oil on the floor. No time to think about that; FLY THE AIRPLANE! We sailed over the truck and…touched down and started the rollout.

There is an old aviation adage that sums up the lessons in all of this month’s reports and it is just as valid today as when it was first expressed: Aviate; navigate; communicate. In other words, fly the airplane first.

CALLBACK Issue 382
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September 2011
Report Intake:
Air Carrier/Air Taxi Pilots 2,908
General Aviation Pilots 878
Controllers 615
Cabin 329
Mechanics 171
Dispatcher 61
Military/Other 14
TOTAL 4,976
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or aircraft equipment 3
Airport facility or procedure 4
TOTAL 7
Special Studies
Wake Vortex Encounter Study
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 »
Meteorlogical and Aeronautical Information Services Data Link and Application Study
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 »
Subscribe to CALLBACK for FREE!
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Facebook - Like

NOTE TO READERS: Indicates an ASRS report narrative [ ] Indicates clarification made by ASRS

A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 382

Forward to a Friend!



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

Friday, October 14, 2011

CALLBACK 381 - October 2011

CALLBACK From the NASA Aviation Safety Reporting System
Issue 381
October 2011
Upside Down and Backwards
One of several versions of the origin of "Murphy’s Law" contends that the Law’s namesake was Captain Ed Murphy, an engineer at Edwards Air Force Base in 1949. Frustration with a transducer which was malfunctioning due to an error in wiring caused him to remark that—if there was any way that something could be done wrong, it would be.

Recent ASRS reports indicate that Captain Murphy’s Law was in full effect when several aircraft components managed to get installed upside down or backwards.

Pernicious Panel Placement

An aircraft Mode Selector Panel that “looks the same” whether right side up or upside down, and that can be readily installed either way, is a good example of a problematic design. Confronted with an inverted panel, this Cessna 560 Captain found out what happens when the wrong button is in the right place.

During the takeoff roll, the First Officer called for rotation and I pulled back on the yoke and focused my attention on the V-bars. Instead of finding the bars above the horizon as expected, they were on it. I reached up and pushed the upper left Selector Panel button again, but the bars did not spring into place as anticipated. I glanced back at the panel and, for the first time, realized that it had been installed upside down. Looking across, I found the First Officer’s side was upside down as well. We returned to the airport and reported the discrepancy to our company.

Upon reflection, I realized that I’ve become so accustomed to the panel that I may no longer read the writing on the buttons; I just press the place where that button should be. Instead of pressing HDG, I pushed VS on the inverted panel. The faulty installation escaped the attention of two Avionics Technicians, one Quality Control Inspector and, of course, both pilots. The panel looks exactly the same whether right-side up or upside down except for the labels. I find it surprising that it was designed in such a way that it could be installed incorrectly.

Although the aircraft had just come out of maintenance, there seemed no logical reason for giving extra attention to the Mode Selector Panel since none of the maintenance directly involved avionics repair or installation. We later learned that the panels had been removed during the replacement of the nose fans.

If anyone had asked me if I observe the Mode Selector prior to pushing a button, I would have assured them that I do. Since this incident, I’ve come to notice how often I (and I suspect most people) rely on “standard position placement.” The lesson is obvious; be more observant. I also question the wisdom of manufacturing a part that is capable of being installed incorrectly.

The Downside of Upside Down

Without detailed instructions and clear notation, nearly symmetrical parts can be installed incorrectly. Faced with the replacement of such a part, this CRJ 700 Maintenance Technician wound up with a case of component “misorientation.”

The aircraft returned to the field due to the landing gear not retracting. Previously, the nose landing gear torque links had been replaced to fix a nose wheel shimmy problem. While installing the torque links, the lower assembly was installed upside down. The lower torque link assembly looks similar upside down to the way it does right-side up. The Maintenance Manual does not specify anything about the orientation, nor is there any indication on the part itself. I feel that if there had been a specific note that the part is able to be installed upside down, I would have paid closer attention to the orientation. The operational check of the installation did pass, but it does not require a gear swing. A note should be added in the installation task noting that the part is able to be installed incorrectly and that it looks close to the correct installation.*

Bonanza Blunder

In order to mount a Beech 33’s ailerons on the wrong wings, a resourceful paint shop crew had to mount the ailerons upside down and use incorrect hardware. The achievement may have been dubious, but the confirmation of Murphy’s Law was unambiguous.

After the rudder was balanced and reinstalled, I preflighted the aircraft and flew it back from the paint shop to [our base]. The only problem with the flight was that the aircraft wanted to make a shallow left bank when the controls were released.

I looked at this aircraft two days in a row and preflighted it twice. Our Chief of Maintenance walked around it and another Instructor Pilot from the flight school also looked it over and none of us realized that the ailerons were installed incorrectly. A Maintenance Technician noticed that the location of the static wicks was wrong. The wicks were attached to the top surface of both ailerons and should have been mounted on the lower surface. This made it obvious that the ailerons were installed wrong; the left aileron was installed upside down on the right wing and the right aileron was installed on the left wing. Incorrect hardware was also used for the installation. I did not believe you could install the ailerons incorrectly and still be able to control the aircraft properly.*

When All Else Fails...

Placing a maintenance Job Card upside down may seem like a minor example of Murphy’s Law, but when it leads to a departure from Allen’s Axiom (When all else fails, follow the instructions), the results can be major. In the incident reported by this Maintenance Technician, a large portion of a turbofan engine fell to the hangar floor.

I was assigned to work on an engine with another Mechanic who was under training. We started working on a Job Card to remove the HPC (High Pressure Compressor) from the fan case which we finished and then started working on another Job Card to trunnion the HPC. We followed the Step #1 to Step #3 [procedures]. In Step #3, we installed a fixture plate in front of the HPC. During this installation the other Mechanic was working at the 12:00 o’clock position while I was at the 6:00 o’clock position…. I was sick from a head cold and was wondering if I should talk to my Supervisor or a Safety Representative about this? With these thoughts running through my head, I put the Job Card on the table upside down and walked away for a moment to try to refocus on the job. When I came back, I looked at the Job Card and saw Step #6— to remove the center fixture. The next step (#7) was to trunnion the core, but the eye bolt attached to the front fixture sheared off….

Because I had placed the Job Card upside down from where we had been working, I inadvertently missed the critical Step #4 about handling the HPC safely. As a result the HPC broke off and struck the floor.

Exit Here...Maybe

After an MD-80 had completed several trips, an alert Flight Attendant caught a subtle discrepancy with the overwing exits.

After blocking in, the interphone rang. One of the aft Flight Attendants called to report that she had just noticed that both of the aft overwing escape hatch plug doors “looked backwards” because the arm rests were going the wrong way. I went back and confirmed that this was the case. Except for the arm rests, the doors appeared normal in every way. The signage and wording on the doors were normal.

The aircraft made at least three trips with the reversed doors and maintenance later determined that the doors required substantial effort to open.*

"He Yelled at Me to Stop!"

The problem this Maintenance Technician reported provides a dramatic lesson in the need to verify proper setup before going ahead with a job, especially one involving high-pressure jacks.

I was assigned to work at jack point “E” at the left-hand, inboard side of the B777 wing. At the site, I found that the jack pad [adapter] was already installed and the jack was seated with 4,000 LBS of pressure on it. When all the jacks were in place, my Lead instructed me to start jacking and he left the site to check on the right wing jacking area. I started jacking by increasing the pneumatic pressure to 7,000 LBS. As the jacking process was going on, my fellow Mechanic, who was on the wing dock at the jack point, heard a cracking noise and saw the panel cracking. He yelled at me, “Stop!” I immediately stopped the jacking process. I went up on the left-hand wing dock and found out that the [wing] panel underneath the jack pad was damaged. Afterwards we learned that the day shift had installed the jack pads backwards.

If a little voice in your head says that something doesn’t seem right, pay attention. It could be Captain Murphy warning that you are about to install something upside down or backwards.

*ASRS issued an Alert Bulletin on this issue.

CALLBACK Issue 381
 Download PDF & Print
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ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 Search ASRS Database
 ASRS Homepage
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August 2011
Report Intake:
Air Carrier/Air Taxi Pilots 3,204
General Aviation Pilots 943
Controllers 697
Cabin 553
Mechanics 142
Dispatcher 75
Military/Other 13
TOTAL 5,627
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or aircraft equipment 9
Airport facility or procedure 4
ATC equipment or procedure 2
Company policies 2
Maintenance 1
TOTAL 18
Special Studies
Wake Vortex Encounter Study
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 »
Meteorlogical and Aeronautical Information Services Data Link and Application Study
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 »
Subscribe to CALLBACK for FREE!
Forward to a Friend
Facebook
Share with Twitter
LinkedIn
Facebook - Like

NOTE TO READERS: Indicates an ASRS report narrative [ ] Indicates clarification made by ASRS

A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 381

Forward to a Friend!



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

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