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.

Monday, November 19, 2012

CALLBACK 394 - November 2012


CALLBACK From the NASA Aviation Safety Reporting System
Issue 394
November 2012
Adverse Weather Planning and Tactics - Two Perspectives
According to the FAA General Aviation Pilot’s Guide to Preflight Planning, Weather Self-Briefings, and Weather Decision Making1, many pilots who hear about a weather-related accident think, “I would never have tried to fly in those conditions.” But interviews with pilots who survived weather-related accidents indicate that they thought the same thing— until they found themselves in weather conditions they did not expect and could not safely handle.

This CALLBACK presents weather-related ASRS incident reports along with corresponding National Transportation Safety Board (NTSB) accident reports involving the same type of aircraft in similar weather conditions.

The ASRS reports offer a first-hand account of what were often narrow escapes from adverse weather conditions. The NTSB reports are second-hand accounts about pilots who were not as fortunate in their weather encounters. The ASRS incidents are often seen as precursors to the accidents reported by the NTSB.

Three of the many lessons that can be learned from the ASRS reports are: 1) review and know the procedures for dealing with adverse weather in your aircraft, 2) avoid adverse weather if possible and, 3) have an escape plan in the event of an unexpected encounter with dangerous weather.

Failure to learn the lessons presented here can lead to an ASRS incident report if you are lucky or an NTSB accident report if you are not. But, smart pilots remember the old axiom: You start with a bag full of luck and an empty bag of experience. The trick is to fill the bag of experience before you empty the bag of luck.
Event #1
Aircraft: PA-32 with weather data link capability
Situation: Entry into an area of rapidly building thunderstorms
ASRS Report #1
“I Came Close to Being a Statistic”
Even with good preflight planning and onboard weather data link capability, it took the help of ATC to successfully extricate this PA-32 Pilot from an area of fast-building thunderstorms. The all-too-close encounter highlights a critical factor about the timeliness of NEXRAD (Next-Generation Radar) weather data.
While in cruise flight, it became necessary to deviate due to existing and building thunderstorms. ATC had advised me of the largest storm which I had visually…. I was also using XM downloaded NEXRAD weather information. When the NEXRAD data indicated it was safe to turn more northerly, I advised ATC that I was starting my turn…. I went IMC momentarily and when I broke out there was a large buildup at my twelve o’clock position. The main storm was still off to my right. I could see several breaks around the buildup and requested a climb to 10,000 feet in an attempt to remain visual on the buildup. I was unable to do so and encountered IMC. While IMC, I flew into a fast building area of weather that was joining up with the known cell to my right. I advised ATC of my dilemma and was very surprised to see how quickly the cell was developing. ATC vectored me through the safest part of it. I was using every method from my training— turning the autopilot off, slowing, and keeping the wings level. At one time, with climb power, I was descending at 1,500 feet per minute.

I eventually exited the weather and looked out my right rear window to see the huge storm that was developing behind me. ATC advised that it had completely closed up. Only then did the NEXRAD downloaded weather update to reflect the actual conditions that existed.

A meteorologist friend assisted me in downloading archived radar images that showed how fast these air mass cells/thunderstorms were developing and how I came close to being a statistic. I knew not to use the NEXRAD for storm penetration prevention, but did so in error. I am very lucky that the outcome was good…. The delay of the [NEXRAD] update with the speed of the buildup of these air mass thunderstorms resulted in an inaccurate pictorial that I was using to determine my route of flight.
NTSB Report #1
This NTSB report details how another PA-32 Pilot apparently relied on outdated NEXRAD weather information in an attempt to escape an area of rapidly developing thunderstorms.
The airplane was on a cross-country flight in level cruise at about 8,000 feet MSL when the pilot flew into an area of heavy rain showers. The pilot informed an Air Traffic Controller that he was diverting around an area of thunderstorms. The pilot last reported that he was in “bad” weather and was going to try to get out of it. Following that transmission, radio and radar contact was lost. A witness on the ground heard a sound resembling an explosion….

The main wreckage consisted of the entire airplane except for the left wing, vertical stabilizer, rudder, and the right wing tip fuel tank. Those components were located about 200 feet north-northeast of the main wreckage. An examination of the left wing spar showed that the wing failed in positive overload. A weather study of conditions in the area at the time of the accident indicated the potential for heavy rain showers, thunderstorms, wind in excess of 45 knots, clear air turbulence, and low-level wind shear…. The pilot had a global positioning system (GPS) unit with a current subscription for Next-Generation Radar (NEXRAD).

The GPS unit owner’s manual states that NEXRAD weather data should be used for “long-range planning purposes only,” and should not be used to “penetrate hazardous weather” as the NEXRAD data is not real-time.

On June 19, 2012, the NTSB issued a Safety Alert to warn pilots using in-cockpit flight information services broadcasts (FIS-B) and satellite weather display systems that the NEXRAD “age indicator” can be misleading. The actual NEXRAD data can be as much as 20 minutes older than the age indication on the display in the cockpit. If misinterpreted, this difference in time can present potentially serious safety hazards to aircraft operating in the vicinity of fast-moving and quickly developing weather systems.

The NTSB determines the probable cause(s) of this accident to be: The pilot’s inadvertent encounter with severe weather, which resulted in the airplane’s left wing failing in positive overload. Contributing to the accident was the pilot’s reliance on outdated weather information that he received on his in-cockpit Next-Generation Radar (NEXRAD).
Event #2
Aircraft: PA-28
Situation: Icing conditions
ASRS Report #2
“I Just Didn’t Appreciate How Fast Ice Could Form”
The Pilot who submitted this ASRS report planned to avoid icing and flew a PA-28 that was equipped with dual GPS, satellite weather, and electronic approach plates. What the Pilot did not include in his planning was an understanding of how rapidly ice can build up and how, without adequate training, complex equipment can become a distraction.
I checked the weather via the internet prior to departing…filed an IFR flight plan, and checked in with Center a few minutes into the flight…. At about 2,800 feet, I entered cloud bases. My autopilot wasn’t holding heading and I was distracted with this problem. About this time I noticed ice was rapidly forming on the temperature probe. I [told] ATC about my flight conditions and explained that I better land. ATC helped me select an airport and gave me a vector.

I had only been in icing conditions a couple minutes and was alarmed at the rate the ice was forming. I have never had much experience with ice, always successfully avoiding it. Now I was getting set up on an unplanned approach, dealing with rapid ice formation, wanting to use the autopilot to decrease workload but wary of it. ATC advised me that I should climb to avoid a tower. I was aware of the tower because it was depicted clearly on my terrain database.

Now I was getting a strong vibration from the prop; it was accumulating ice. ATC advised that I needed to climb for the tower, but I asked if I couldn’t stay lower. The Controller gave me 3,200 feet and a vector of 180 degrees to avoid the tower…. I was unnerved by all of this and was very happy to have ATC’s help with setting up for the approach….

One other distraction was that with my dual GPS, satellite weather, and electronic approach plates, it messed up my scan and made it almost harder. I was very glad to have a paper approach plate. The one thing I did right is that I immediately realized my error and asked for ATC’s help to land as soon as possible. I just didn’t appreciate how fast ice could form and while part of my flight planning was to keep me out of ice by staying under the clouds, I didn’t have enough margin for error or unexpected weather. I need more hood time with an instructor, training with my electronics and how to use them…. In most situations you are trying to use all the information available, but if you haven’t trained your scan to include these devices they can be distracting. I’ve learned an important lesson.
NTSB Report #2
In its report on a PA-28 involved in an accident, the NTSB cited icing conditions and improper in-flight planning as probable causes.
An instrument flight plan was filed by the pilot, inflight, with Denver Air Route Traffic Control Center (ARTCC). The airplane was handed off to the Kansas City ARTCC. No radio contact was established between the airplane and Kansas City ARTCC. Denver ARTCC’s last reported radar contact with the airplane was at 4,500 feet MSL…. Denver ARTCC heard someone say, “We’re going down.” The airplane was located by…Sheriff’s deputies…. Weather stations…were reporting overcast ceiling, visibility from 1/2 to 3 miles with light rain, and temperatures and dew points at 32 degrees F. An examination of the wreckage revealed no anomalies. The NTSB determines the probable cause(s) of this accident to be: Inadvertent stall. Factors relating to this accident were the pilot’s inadvertent flight into known adverse weather conditions, the icing conditions, and improper in-flight planning by the pilot.
Event #3
Aircraft: C182
Situation: Carburetor icing
ASRS Report #3
“The Engine Stopped Running”
A C182 Pilot learned that severe carburetor ice can form even though no airframe icing is seen. The Pilot was lucky to break out of the clouds and restart the engine.
We were at 12,000 feet on an instrument flight plan in communication with Approach. The Controller directed us to descend and maintain 9,000 feet. Flight conditions were IMC, -4 degrees C, and no airframe icing was being encountered. We reduced throttle in order to descend and within a few seconds of reducing throttle, the engine stopped running. After completing the Engine Failure Checklist, with no success, we declared an emergency with Approach…. We continued on our present heading with the intent of making an emergency landing at a nearby CTAF airport…. Upon further discussion with the Controller, however, we elected to head for a nearby Class D airport…. As we descended (still in IMC) we were able to restart the engine…. We continued to descend towards the airport and broke out of the clouds into VMC at approximately 4,800 feet….

It is clear that this engine failure incident was caused by severe carburetor ice— just below the freezing level, in clouds, with visible ice crystals. Although the ice crystals were not of the type that created airframe ice (no airframe ice was reported in our area), it was ideal for causing carburetor ice, which built up more rapidly than we were able to clear using carburetor heat.
NTSB Report #3
An NTSB report recounts how another C182 Pilot experienced carburetor icing, but was unable to restart the engine and wound up losing his airplane in a tree.
The pilot received a weather briefing from FSS the evening before departure and a friend at the destination told him that the area had been free of fog for the last several days. Upon descent to 1,500 feet at the destination, he could not spot the airport due to a fog layer. He decided to divert to his alternate. After turning toward the alternate airport, the engine began to run roughly. The pilot was unable to remedy the power loss by applying carburetor heat, switching fuel tanks, leaning the mixture, and checking the magnetos in the both position. As he turned back toward his original destination airport, the engine continued to run rough and he was unable to arrest the airplane’s descent. He was just above the fog layer, saw the runway through the fog, and turned back to the runway. During the turn, he went into the fog and the airplane collided with treetops and lodged in branches. The occupants noticed fire in the floorboard area, exited through the pilot’s door, and jumped to the ground. The fuselage was consumed by fire….

The NTSB determines the probable cause(s) of this accident to be: A loss of engine power due to carburetor icing and the pilot’s failure to use carburetor heat in conditions conducive to icing.
CALLBACK Issue 394
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September 2012
Report Intake:
Air Carrier/Air Taxi Pilots 3,510
General Aviation Pilots 1,045
Controllers 683
Cabin 224
Mechanics 165
Dispatcher 82
Military/Other 17
TOTAL 5,726
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 7
Airport Facility or Procedure 4
ATC Equipment or Procedure 4
TOTAL 15
Special Studies
Wake Vortex Encounter 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 »
Meteorlogical and Aeronautical Information Services Data Link and Application 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 »
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 394
Forward to a Friend!


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

Tuesday, October 16, 2012

CALLBACK 393 - October 2012


CALLBACK From the NASA Aviation Safety Reporting System
Issue 393
October 2012
When Autopilots Go Bad
The three “loss of aircraft control” events in this CALLBACK share a common factor— an autopilot malfunction. Thankfully, they also share a common result in that the pilots involved were able to recover from the resulting loss of control.

According to the FAA1, loss of control (LOC) has accounted for more than 1,100 GA accidents in the last decade. That statistic alone should be incentive to heed the “lessons learned” in the following reports.
"A Serious Attitude Issue"
Having experienced a similar autopilot failure in another aircraft, this Mooney M20 pilot quickly recognized the problem, but still had a “struggle” to regain control.
There was no ground reference because the layer below was around 4,000 feet and no sky reference because of a high layer…. I was looking out the pilot window inspecting for ice when I noticed a slight change in the engine speed. The engine instruments read normal, then I noticed a precession on the [horizon indicator]. Just as I noticed this, the autopilot kicked off and the plane shot up hard and fast…. I instantly knew what had happened because I’ve owned another Mooney that had an autopilot failure and runaway trim. The plane was in a climbing, unusual attitude. Center called me inquiring about my altitude…and asked if I needed help….

I decided that I needed to ignore Center for now and concentrate on recovering the plane which was now in a dive. I neutralized the trim, then referenced the directional gyro and stopped the turn and finally pulled gently out of the dive. When the plane was recovered, I could see a few house lights straight down…so I descended to VMC to organize myself. Just at that time someone called my tail number and asked my position and altitude. I responded that I was at 1,500 feet, but said nothing about my position because I hadn’t reset my GPS or looked at my position. The relay pilot called again and said that Center was concerned about my low altitude and wanted me to climb up to 2,400 feet. When I climbed I went IMC and I could tell I had a serious case of vertigo which felt unsafe so I descended again to VMC. Several more calls were made from Center through relay pilots and then Center made it to my frequency asking that I climb again. I felt frustrated that I was repeatedly asked to do this, but I made a decision that I was going to stay visual because I had decent forward visibility, ground reference, and I was safe. Having ground reference also made my vertigo subside….

[Ed note: The reporter was able to continue on to the original destination (but then had to contend with an emergency gear extension procedure) and concluded the report with the following remarks about unusual attitude recovery.]

Something that probably helped with the runaway trim and unusual attitude was recent training for a tailwheel endorsement that included slow flight and unusual attitude recovery training. After this event I’m quite sure I’m going to keep a routine of going out under the hood with an instructor and practicing recovery techniques. That’s very inexpensive insurance.
Experimental Excitement
This loss of control event, presented from an Air Traffic Controller’s perspective, highlights the team effort that helped to ensure a successful outcome for the pilot of an Experimental/Homebuilt.
I accepted a hand-off from South Departure, a VFR Experimental at 10,500 feet. Since the aircraft was close to my boundary and about 18 miles from the next sector’s boundary, I initiated a hand-off to the next sector. After a few minutes, I heard the South Departure Controller trying to contact the Experimental. I looked at the tag and noticed that it was no longer displaying an altitude read out…. The tag was still being tracked because I had it in hand-off status. I took the hand-off back to see if it was a radar tracking issue…. The South Departure Controller tried to get a nearby Air Carrier to reach the pilot with no luck. I used Guard frequency to try to raise him. A few seconds later we saw the 7700 code pop up and the emergency sound from the STARS (Standard Terminal Automated Replacement System) display alert. I attempted again to reach the pilot on Guard and had him “ident.” After seeing the “ident,” I had him switch to my frequency. I tried to reach him with no luck and also asked a near by VFR aircraft if he was able to hear him respond. The pilot could not hear him. I tried again and this time got a response from the pilot. He, with very heavy breathing, said that he had an emergency and, “Everything is OK now.” I asked his altitude and he replied 4,200 feet. After a few more routine questions I gave him a squawk and asked if he was squawking altitude. He replied that there may have been some damage to other equipment. I asked what kind of damage he had experienced and what caused the damage (bird strike or something else). He replied that it was an autopilot issue with a slipped trim wheel. I asked his intentions. He replied that he wanted to go to ZZZ…. As he was about to leave my airspace, I noticed that he was almost twenty degrees off course. I corrected his heading and gave a briefing to the Class B Tower Controller regarding his situation….

I was informed that the pilot landed safely and that the autopilot was giving him trouble so he disabled it only to find that the trim wheel had slipped and pushed the aircraft into a nose dive. He was experiencing negative and positive G’s that were making it difficult for the pilot and his passenger to regain control. He finally did at around 4,000 feet. He had hit his head on the canopy and broke his headset and some other equipment. He also noticed that one of the latches to the canopy was bent so he was holding it shut during the flight….

Team work was the key here. The use of Guard, other pilots, and situational awareness helped in determining the location of the aircraft and the correct method of getting the pilot calm and under control.
"Whole Lotta Shakin' Goin' On"
The pilot of an unidentified Experimental aircraft had his hands full when a new, integrated autopilot malfunctioned. As Dave learned with the Hal 90002, it is best to cut off all power to a system that starts to develop “a mind of its own.”
A stand-alone autopilot had been removed and replaced with the new fully integrated unit. Everything had been bench tested and checked out…. I was returning to [home base]. Weather was VMC, however I filed IFR to expedite leaving the [busy metropolitan] area. The autopilot functioned OK upon leveling at 10,000 feet, however it was “hunting for heading.” As I started my descent, the autopilot developed a mind of its own, [and] was searching for the altitude that I had pre-set in the EFIS (Electronic Flight Information System) which was driving the new autopilot. The servos were “pulsating” the control stick and I could not stop it. I slowed my descent and airspeed to try to diagnose the problem. I decided to divert to [a nearby airport] as I knew there were facilities there in the event I developed further problems. I contacted Approach and they cleared me to 7,000 feet on a heading to the airport. The autopilot would not level at 7,000 and deviated about 500 feet low as I fought the stick to stop the oscillations. Then it zoomed up to about 7,300 feet. The stick was fighting me and during the button pushing while trying to control the autopilot, I somehow lost contact with Approach Control…. I finally managed to get the autopilot off, called Approach again and they cleared me for the visual.

Once the EFIS shut the autopilot off, everything returned pretty much to normal. The remaining approach and landing were uneventful except that my body was shaking.

In retrospect, when the first issues developed, I should have canceled IFR and continued VFR. I tried the master “Off” switch as well as the “Off” switch on the stick, to no avail. As a result, I wasted valuable time as I was caught off guard by the events. ATC was very professional…. Inasmuch as it was VMC, I probably should have pulled the circuit breaker on the EFIS (which drives the autopilot), but I was hesitant to as I would have lost all navigation functions.

I have developed a habit of always flying the plane by myself for at least an hour after it comes out of maintenance before ever letting anyone else fly with me. This event strengthened my reasoning for doing that.
CALLBACK Issue 393
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August 2012
Report Intake:
Air Carrier/Air Taxi Pilots 4,389
General Aviation Pilots 1,298
Controllers 833
Cabin 295
Mechanics 212
Dispatcher 153
Military/Other 31
TOTAL 7,211
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 10
Airport Facility or Procedure 4
ATC Equipment or Procedure 5
TOTAL 19
Special Studies
Wake Vortex Encounter 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 »
Meteorlogical and Aeronautical Information Services Data Link and Application 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 »
Subscribe to CALLBACK for FREE!
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Contact the Editor
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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 393
Forward to a Friend!


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

Monday, September 10, 2012

CALLBACK 392 - September 2012


CALLBACK From the NASA Aviation Safety Reporting System
Issue 392
September 2012
Texting While Taxiing
The pilot who submitted the first report in this issue of CALLBACK has the honor of being the inspiration for this month’s theme. The reporter’s concept of equating electronic tablet usage during taxi to phone texting while driving, led to a search for similar events in the ASRS Database. A surprising number of such incidents, often resulting in taxiway or runway incursions, were found. Granted, taxiways are not as crowded as roads and highways, but “texting” on a laptop, tablet, FMC, or ACARS while taxiing can still lead to embarrassing and potentially dangerous consequences.
An Embarrassing Lesson
Taxiing and flying an airplane will always involve some degree of multi-tasking, but this C172 pilot learned an embarrassing lesson when the “heads-down” usage of an electronic tablet conflicted with the “heads-up” requirements of safe taxiing.
We were cleared by Ground to taxi on the outer ramp area to Taxiway Bravo to Runway 22 and hold short. It’s a “no-brainer” taxi route and there were no other aircraft taxiing out. I was with another pilot and was showing him the information I had available on my iPad with ForeFlight. I was showing how I had the enroute charts for our trip and then went to the checklists, also on the iPad. I was definitely multi-tasking as I taxied and demonstrated the software. I was aware of the runway area approaching but missed the hold short line until Ground said, “[Callsign], stop. Stop!”

I would never dream of texting on my phone while driving, but wasn’t this sort of the same thing? There was no traffic for the runway, but it was still an embarrassing lesson learned.
Texting While Tired
Several factors led this B737 Flight Crew to miss a taxiway turn on the last flight of a long duty day. The First Officer’s report includes a “texting while taxiing” factor that involved inputting data in the FMS.
Ground Control told us to taxi north on Echo and hold short of Echo 11…. The intersections are not in numerical order. Still, that’s no excuse and by the time we recognized the mistake, we had taxied past Echo 11. The Captain immediately stopped the aircraft and notified Ground Control. He also apologized to them. They were very understanding and told us to continue taxiing on Echo to Runway 18C….

It was fairly congested and we missed the Echo 11 sign. I was heads-down as I finished inputting weight and balance in the FMS. It was a fairly high-workload situation at the end of a four-leg, twelve hour day.

In the future, we both need to be much more vigilant; not only in reading airport diagrams, but in staying heads-up, slowing down, and realizing that we are prone to mistakes at the end of a long day.
Texting in the Tower
Distraction due to “texting” is not a problem that only affects pilots. This Tower Controller reported that the requirement to be “heads-down” entering flight plan and route information into a Flight Data system can detract from the job of keeping an eye on aircraft and other factors affecting air traffic.
I instructed Air Carrier X to taxi from the terminal ramp to Runway 08 via Taxiways Foxtrot and Mike, and to hold short of Taxiway Juliet (for an aircraft that I knew would be exiting the runway). The pilot of Air Carrier X read back the instructions at the same time that Air Carrier Y was on final reporting birds. While I was typing in the Flight Data Input/Output (FDIO) system, attempting to amend a flight plan, I looked up and observed Aircraft X on Taxiway Foxtrot, on the West side of Runway 17R, facing West. The aircraft had obviously just crossed Runway 17R at Taxiway Foxtrot. I advised the aircraft that he had gone the wrong way; instructed the aircraft to turn around (holding short of the runway), then proceeded with traffic as normal. The pilot made no indication that he knew he had even made a mistake. There was another landing aircraft on about a six mile final.

Maybe there should be more awareness and less complacency on the part of pilots. Just because it’s a low activity time doesn’t mean that the same hazards of collision do not exist…. The same goes for Controllers. Also, amending just one flight plan requires “heads-down” time as does amending routes. This takes away (since we work Local/Ground/Flight Data combined a majority of the time, no matter what the traffic situation is) from the Controller’s ability to spot those pesky “little things” like flocks of geese on final, jets crossing the runway, etc…. Combined positions are a very poor practice, requiring the Local Controller to take his eyes out of the air and away from the runways and aircraft, to perform required duties of two other positions at the same time.
Driver Goes Through a "Stop Sign"
hold short lineThe First Officer of an MD-80 series aircraft was “texting” to accommodate a runway change when the Captain “drove” past the hold short line and onto an active runway.
We were told to taxi to Runway 12…. We had planned on a Runway 8L departure. After clearance was received from ground, we re-briefed a Runway 12 via Papa taxi. When we were both clear on the instructions, we started our taxi on Taxiway Papa. The Captain stated he had the taxi under control down Papa to Runway 12. I then diverted my attention inside the cockpit to change the box to match Runway 12 not 8L. I was “heads-down” when the Captain drove the aircraft onto Runway 12 at Intersection Sierra. Before I realized the situation, it was too late. We crossed the hold line and onto an active runway.

The Captain stated that a lack of proper signs in that area led to the mistake. I have been to that area of the airport and no one has ever made the mistake to veer off Taxiway Papa. That is why I was changing the box early to be more heads-up later in the taxi. Never losing track of your position is the best solution to this event.
Off Road Excursion
An extra pair of eyes on the taxiway might have helped this B767 Captain keep the aircraft “on the road.”
I was taxiing on the ramp area leading up to the taxiway and initiated a right turn to enter onto the taxiway. Halfway through the turn I felt a shudder and side load that did not seem normal. I stopped the airplane and asked the First Officer to contact Tower and Maintenance to tell them of our situation. Maintenance informed me that the right main gear was partially on the taxiway and partially on the grass. After realizing that we were stuck, I informed the passengers and Flight Attendants of the situation as well as Operations.

The First Officer was “heads-down” inputting ACARS data and receiving the load close out when the incident occurred. Lesson learned: two “heads-up” are better than one.
CALLBACK Issue 392
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ASRS Online Resources
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 Report to ASRS
 Search ASRS Database
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Contact the Editor
July 2012
Report Intake:
Air Carrier/Air Taxi Pilots 3,918
General Aviation Pilots 1,359
Controllers 868
Cabin 296
Mechanics 211
Dispatcher 118
Military/Other 19
TOTAL 6,789
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 3
Airport Facility or Procedure 8
ATC Equipment or Procedure 3
TOTAL 14
Special Studies
Wake Vortex Encounter 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 »
Meteorlogical and Aeronautical Information Services Data Link and Application 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 »
Subscribe to CALLBACK for FREE!
Forward to a Friend
Contact the Editor
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 392
Forward to a Friend!



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

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