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, August 19, 2014

CALLBACK 415 - August 2014


CALLBACK From the NASA Aviation Safety Reporting System
Issue 415
August 2014
The Go-Around Decision - What Would You Have Done?
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 the event up to the decision point. You may then use your own judgment to determine the 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 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 and discussion related to the type of incidents that were reported.

The following reports all involve a situation in which the pilots had a choice between landing or going around to run an Abnormal checklist. In these, as well as most other irregular situations, an assessment of the problem and associated factors can help integrate the use of checklists with other adaptive problem solving techniques. Immediately going into the “Light on—Start checklist” mode may cause a pilot or flight crew to overlook other important elements of the situation. As one of the human factors researchers at NASA Ames said, “Checklists should not be used as a replacement for common sense. The first item on every Abnormal or Emergency checklist should be ‘Brain...…Engage’.”
The First Half of the Story
Situation # 1  B757 Captain’s Report
It was a visual approach. We had an ATC speed request of 180 knots to the Final Approach Fix and then slowed and selected Flaps 30 under 168 knots. Flaps went to the 20 position and then we got the TE and LE Disagree caution lights. We were on glideslope, on the VASIs, and in a position to land with the appropriate airspeed.

On an ILS approach we received a TE FLAP Disagree light and EICAS while configuring for final landing with the runway in sight.

Runway was in sight on final at approximately 1,400 feet AGL. Flying Pilot called for Flaps 30, Landing checklist. I selected Flaps 30 and noticed an EICAS message “Trailing Edge Flaps.” The flaps remained at 25 with the flap handle selected to 30. I asked the Flying Pilot if he noticed any “roll” in one direction or the other? He said, “No.” I then selected the flap handle back to 25 and informed him of the Trailing Edge Flaps EICAS message. At this point we were at 1,000 feet AGL and stable on final.

The Captain was the Pilot Flying and I was Pilot Monitoring. While configuring for landing, the Captain noticed the forward amber LE FLAPS TRANSIT light illuminated and called it out. I looked up at the overhead LE Devices Indicator and saw that the number one Slat Full Extend light was not illuminated green. I notified the Captain of this. We were descending via the glideslope on the visual with gear down and Flaps 15, somewhere between 2,000 feet and 1,000 feet AGL.

I stated that we will need to go around and work out the problem. The Captain indicated that he had been in this situation before and we were fine to land.

On approach at approximately 2,500 feet, we selected Thermal Anti-Ice (TAI) for the engines as we began to enter icing conditions (a cloud deck from approximately 2,500 feet to 800 feet). This was the first time during the flight that we used the TAI. The Number Two engine TAI showed a disagreement indication, a bright light on the overhead panel and a yellow indication on the engine instruments. We cycled the TAI several times to no avail. Fuel available was approximately 6,900 lbs. There was at least a 200-300 mile flight to find non-icing conditions.
The Rest of the Story

The Reporter's Action:
I elected to land with Flaps 20. I had the First Officer confirm the airspeed for Flaps 20. We landed on centerline, on speed, and in the landing touchdown zone. Approach was stabilized.

The Reporter's Action:
We elected to discontinue our approach to run the TE FLAP Disagree checklist. ATC provided vectors while we configured the plane for a Flaps 20 approach as the checklist directed. We coordinated with ATC for the ILS to a runway with more favorable winds. This took much longer than anticipated with the final result being a VOR approach at the last minute. We set up for the new approach, but did not see the runway at minimums and had to again go missed approach. By this point our fuel state was becoming a greater concern than the non-standard configuration for landing so we requested immediate vectors back to the ILS Runway XX as the winds were once again favorable for that approach. We ended up breaking out early and were able to then fly a Flaps 20 landing in visual conditions.

The Reporter's Action:
I elected to land rather than go around in order to run the QRH checklist since the flaps were at 25 with no noticeable roll. Once on the ground we attempted to retract the flaps but they remained at 25. I’m not really sure if the flaps would have retracted if we had attempted a go-around.

The Reporter's Action:
The approach was continued to a landing.
From the Captain’s report on the same incident:
I elected to continue, carry a higher speed and land the aircraft. After landing, the First Officer was questioning my decision and looked in the QRH. According to the QRH we should have gone around and come back with Flaps 15 for landing. I made the call to land and not to go back into the overcast. A Mechanic met the aircraft and found the number one slat was extending; however, we were not getting the indication.
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June 2014
Report Intake:
Air Carrier/Air Taxi Pilots 5,100
General Aviation Pilots 1,223
Controllers 787
Flight Attendants 507
Mechanics 215
Military/Other 140
Dispatchers 122
TOTAL 8,094
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 9
Airport Facility or Procedure 1
ATC Equipment or Procedure 2
TOTAL 12
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 » Read the Interim Report »
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NOTE TO READERS or  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 415



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

CALLBACK 414 - July 2014


CALLBACK From the NASA Aviation Safety Reporting System
Issue 414
July 2014
35 Years of Wisdom... and Wit
Dear Readers:
July 2014 marks another proud milestone for the Aviation Safety Reporting System, the 35th anniversary of CALLBACK.
Captain Rex Hardy, a decorated Naval Aviator and corporate test pilot, created the monthly safety bulletin, CALLBACK in 1979. Rex’s vision of a short, readable, and informal format to present the ASRS “lessons learned” was an immediate success. With his insight, talent, and determination, CALLBACK evolved into a widely recognized, award-winning publication. When Rex Hardy retired after producing the first 100 issues, the very capable and talented Dr. Rowena Morrison was able to step in and carry on the intent and spirit of Rex’s creation for 230 more issues.
Perhaps this letter from a reader offers the best tribute to the efforts of all the people at ASRS who have contributed to 35 successful years of CALLBACK.
“I congratulate the ASRS staff for continually producing one of the finest aviation safety tools in the industry. The quality is in your editing— nice use of themes, narratives always to the point without scolding. The slick magazines have similar products…[and] serve a useful purpose, to be sure. But it is only “Callback” which makes my spine tingle and butterflies fly in my stomach when I think, “That could have been ME,” as I read the narratives each month.

Please know the widespread appreciation we in the piloting community feel for your fine work. “Callback” is a great return for what I am sure is a miserly amount of tax funding. Some other agencies could take a lesson from you folks.”
– J.U.
We appreciate the kind words, but we also recognize that it is the generous input from people who are willing to share their observations and lessons learned that constitutes the heart of CALLBACK. The entire aviation community is indebted to every person who takes the time to submit a report to ASRS.
– Don Purdy, Editor
Many ASRS reports include a statement about the lesson (or lessons) learned by the reporter. Rather than the usual report narratives, this anniversary issue of CALLBACK presents several important lessons culled from reports submitted to NASA’s Aviation Safety Reporting System.

Taking the time to share a lesson learned is a good thing and, as mentioned earlier, we appreciate all of the reports submitted to ASRS. By heeding the advice offered below, however, you may avoid an error or incident.

Words of Wisdom from 35 Years of CALLBACK
— Time Pressure —
  • My first mistake came from reacting much too quickly. Take your time. Run the checklist when appropriate. Verify important switches with the other pilot before you move them.
  • To the extent possible, always get prepared on the ground, not while in the air. Don’t let external pressures make you rush to do something without being thoroughly prepared.
  • I was making a rushed approach to land. I have learned that when I am rushed is when I really need to take the time for the checklist.
— Automation —
  • I have learned a valuable lesson about my responsibility to make timely inputs to the aircraft when I realize that the automation isn’t doing what I expect it to do.
  • Aircraft are machines subject to malfunction and we pilots who operate them are humans subject to human error. As a pilot who plans on remaining on the line, I have learned a valuable lesson— monitor the autoflight system like a hawk.
  • I must keep in mind that the buttons on the Flight Guidance Controller are myth and what displays on the PFD (Primary Flight Display) is truth. In other words, I can’t rely on the aircraft to do what I command by simply pressing a button. I must verify that the plane is doing what I command by seeing what is displayed on the PFD.
  • I was counting on the autoflight system to fly the departure as it was supposed to and I got a little lax. Lesson learned! Garbage in, garbage out. If the route isn’t in there or it drops out, you’re not going to fly what you’re thinking you’ll fly.
— Fuel —
  • We thought we had a pretty good handle on our fuel state. Another minute or two of fuel and we would have made it safely to the airfield.
  • From now on I’ll visually check the fuel myself and I’ll keep track of the fuel I’m using in flight.
  • Next time I’ll make sure I have enough fuel for the unexpected and I hope others might be able to do the same without learning the hard way.
— Weather —
  • I learned that it is better to divert early than to press on in deteriorating conditions hoping for a positive outcome. No one should attempt to “scud run” in marginal VFR conditions as I did— with a near disastrous result. Never again.
  • Even though I have been flying for a number of years, I learned a valuable lesson about how fast weather can close in and how stupid it is to “assume” that the weather will clear.
— Miscellaneous —
  • Not knowing if the other aircraft was being provided advisories shouldn’t have been a factor. It’s always, “see and avoid” out there.
  • They say a good approach leads to a good landing. Early recognition of a bad setup will enable a go-around and prevent getting “into the hole” where few options remain.
  • Always have Plan B ready in case something goes wrong—because it will.
  • Line check airmen can make mistakes.
  • Never get distracted from the first priority— fly the airplane!
  • In retrospect, doing a go-around to troubleshoot the problem wasn’t too smart. We had a perfectly good runway right in front of us.
  • I blame the mistake on simple overconfidence. Experience, it seems, is no replacement for doing one’s homework.
  • I learned that if ever there is a doubt, not only as to what ATC said, but also what they meant, I should become absolutely clear about ATC’s instructions, especially before taxiing onto an active runway.
  • It has been my experience that radio transmissions shouldn’t be made to aircraft during the takeoff roll unless absolutely necessary.
  • Looking back on it, I learned two things: 1. Take the time necessary to do the work right even if there is pressure to get the plane out. 2. Always check the part number, no matter who says it’s the right part.
  • The timely and accurate flow of information from the cabin to the cockpit was vital in resolving the situation. Lesson learned: CRM (Crew Resource Management) works!
Once in a while a spelling error, an unusual situation, or a witty comment from a reporter can add a little spice to the thousands of reports screened by ASRS analysts every month. Here are a few examples:
  • I no longer believe my problem was fuel exhaustion, but possibly carb ice. This was the first carbonated airplane I had ever flown.
  • No APU or ground power was available so we did a crossbreed start.
  • Event: Bird strike on Captain’s forward windscreen.
    Cause: Bird was apparently texting.
  • It was very dark in the ramp area and the pilot didn’t have any lights on the airplane. His left wing struck a sign that said, “This is not a taxiway.”
  • Tower said, “[Callsign] turn left and cross Runway 24L and contact ground on the other side.” I informed him that we were unable to comply as we were still on final.
  • The Captain rounded out a bit late, touched down, and skipped back into the air. He was also tired and, not realizing we were airborne again, he pulled the speed brake lever. This time we knew we were on the ground.
ASRS Database Online
The ASRS Database is a rich source of information for policy development, research, training, and more.
 Search ASRS Database »
CALLBACK Issue 414
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 View ASRS Report Sets
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Contact the Editor
Special Studies
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 »
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 » Read the Interim Report »
May 2014
Report Intake:
Air Carrier/Air Taxi Pilots 5,086
General Aviation Pilots 1,134
Controllers 746
Flight Attendants 493
Mechanics 245
Dispatchers 125
Military/Other 125
TOTAL 7,954
ASRS Alerts Issued:
Subject No. of Alerts
Airport Facility or Procedure 6
ATC Equipment or Procedure 1
TOTAL 7
Subscribe to CALLBACK for FREE!
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NOTE TO READERS:  [   ]  Indicates clarification made by ASRS
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 414



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

Wednesday, June 18, 2014

CALLBACK 413 - June 2014


CALLBACK From the NASA Aviation Safety Reporting System
Issue 413
June 2014
Experimental Emergencies
Experimental Amateur-Built aircraft (aircraft limited to recreational, non-commercial purposes and which must have at least 51 percent of their assembly completed by an amateur builder) represent about 10 percent of the U.S. General Aviation fleet. However, according to a 2012 study by the NTSB, Experimental Amateur-Built (EAB) aircraft accounted for approximately 15% of the total and 21% of the fatal U.S. general aviation (GA) accidents.

The NTSB also noted that EAB aircraft accidents usually happen very early in the airplane’s life, often on the first flight and frequently involve engine failure or loss of power.

The first two reports in this month’s CALLBACK deal with aircraft fuel issues that led to loss of engine power in the initial flight testing phases. Two additional EAB aircraft reports remind us that unexpected things can happen in any type aircraft after many trouble-free hours. A successful outcome relies in large part on the pilot being ready for anything— no matter how unusual the emergency.
“Two Miles Short”
This Pilot of an EAB aircraft learned the hard way that, although an engine issue was a major concern, proper fuel planning should always be a priority.
Aircraft was being flown under Part 91 on a Special Airworthiness Certificate for Experimental (Amateur-Built) aircraft. The purpose of the flight was to conduct Phase I flight limitations issued for this aircraft. Two miles short of the intended landing field (the airfield specified as home base in the aircraft’s Phase I operating limitations) the engine stopped due to fuel starvation. I landed uneventfully in a field. There was no damage to the aircraft or to property on the ground. I refueled and, with the permission of the farmer who owns the field, took off to return to base.
At the time of the flight, the aircraft had flown fewer than five of the Phase I flight hours. As the aircraft had experienced cylinder-head cooling issues, most flight time to date had focused on getting the cylinder head temperatures within limits. This flight was meant to test a new, enlarged cooling baffle that had been installed for that purpose. Because of the need to address the cooling issues, I had not yet had time to perform the planned test flights to verify expected fuel flow, nor to cross-check expected fuel-quantity indications (as shown on the ground with the aircraft in flight attitude) with the actual indications airborne. As a result, actual fuel quantity was less than expected. When I realized that, about twenty miles from base, I immediately began my return to home field; the fuel supply ran out just outside of glide range.

Test flights to determine actual fuel flow and to crosscheck airborne fuel quantity indications are planned. The information derived will provide planning data that will prevent a recurrence of this incident.
Crossed Fuel Lines
The Pilot of another EAB aircraft was also performing initial flight testing when fuel starvation resulted in an off-field landing. Rather than a misjudgment of the fuel available, the culprit in this case was a fuel plumbing issue. There was no mention of selecting the other tank after the engine stopped or of correlating fuel usage with tank selection prior to the loss of power.
I departed on a local flight to do some air work checking engine cooling, magnetic heading calibration, autopilot operation, and VOR operation. We proceeded on course to a nearby airport at 2,500 feet MSL and then maneuvered over the airport at 3,000 feet performing standard rate turns…. We then exercised the autopilot operation for altitude hold, vertical speed control, and bank command. After several circuits over the airport, we started to return to my departure airport after approximately 45 minutes of flight time.

After listening to automated weather, I contacted Approach and proceeded inbound for landing. About 15 NM from the airport, I noted that the fuel pressure indication was flashing and the value read approximately 3.0 PSI (6-7 PSI is normal). The electric fuel pump was ON, but I cycled the switch in an attempt to restore fuel pressure, to no avail. The Fuel Tank Selector switch (Electric) had been set on the right tank since takeoff. The right tank contained approximately nine gallons and the left tank had five gallons.

The engine eventually stopped. I declared an emergency and looked for a field to set the airplane down. I set the mixture full rich and attempted a start but, as I recall, I did not get the prop to even turn over. At one point in the descent, the aircraft got a little slow on airspeed (~75 knots) and started to roll right (heavy wing) while a left turn was being commanded. I kept the left turn in, increased airspeed, and eventually the aircraft rolled left for the desired field. I set up to land into the wind.

I now recommend checking fuel pressure values between engine driven pump and electric fuel pump. Monitor fuel quantities to match expected consumption. Consider some sensing means and indication to determine that fuel is being withdrawn from the selected tank. The fuel tank selector valve had been replaced due to what appeared to be a leak from the original valve. The primary concern would be that fuel lines are correctly installed on the proper ports of the selector valve. Testing five days later confirmed that: 1) The fuel valve was powered. 2) When the fuel pump was powered and the right tank (containing approx. 9 gal.) was selected, no fuel was pumped through the line to the carburetor. 3) When the fuel pump was powered and the left tank (empty) was selected, fuel was pumped through the line to the carburetor. The fuel lines had been reversed when the new valve was installed.
“We Were in a Steep Nose Down Attitude”
Luckily, there was a passenger along to “uncover” the Pilot of a pressurized EAB aircraft when a door opened to a world of excitement.
After departing, we were being vectored around traffic during the climb sequence of the flight. Upon receiving clearance to FL230, I noticed the cabin pressure light begin to flash intermittently. I increased the cabin inflow and adjusted the cabin altitude, with only a slight improvement of the annunciator panel. The door lock and door seal lights were in their normal lit configuration at this time. I recycled the door seal to test its integrity. Shortly thereafter, the door flew open, with resultant depressurization.

Cabin contents were flying about the cabin, my headset and glasses departed the plane…. A blanket from the back seat covered my head and face and was pulling my head out of the cabin into the slipstream. My passenger pulled the blanket off my head and I saw we were in a steep nose down attitude. I pulled back power and eased the descent. The plane was very difficult to control at this point.

I elected to try to get the plane under control before considering an attempt at landing. I asked my passenger to place a headset onto my head and I was able to communicate with ATC, informing them that we had lost our door. At some point, the door completely departed the plane, improving the flight characteristics considerably. After slowing down and aggressively trimming, I was able to get back control of the plane and said we would return to the departure airport since the plane was now flyable and the runway environment was familiar….

I asked for permission to change to Tower frequency and requested a downwind approach since it would give me a chance to test the flight characteristics in the landing configuration at pattern altitude. Tower immediately cleared us to land. With flaps and gear down, the plane was more stable, and the landing was uneventful.
“I Probably Should Have Told You…”
Communication problems are often cited as contributing factors in ASRS incident reports. The following report from a Pilot who was instructing the new owner of an EAB aircraft has to be one of the better examples of the consequences of poor communication. There are some things a trainee just shouldn’t keep from the instructor.
I was providing transition training to a Private Pilot who had recently purchased the aircraft. The flight was to be just over two hours long. The evening prior I was with the owner and witnessed him refuel the aircraft with 20 gallons of fuel. I told the owner that there were already six gallons of fuel aboard based on our previous flying, our observed fuel burn of 8.2 GPH, and the fact that we started with full tanks and kept very careful track of fuel burned, added, or removed.

The next morning I arrived at the airport, watched the owner perform the pre-flight and asked him about our fuel state. He told me, “The gas is fine.”

We made an uneventful takeoff, climbed to altitude for a short cross-country trip so he could practice descents and perform traffic pattern work. We departed for a second airport using the same training profile and then headed back home.

Approximately 16 miles from the airport at 2.1 hours into the planned mission, the engine coughed. The owner correctly reacted and switched fuel tanks using the proper procedures. I remarked to him that the event was strange because according to my watch we should have a little over eight gallons of fuel remaining.

At this point the owner said, “Oh.” I asked, “Oh what?” He tells me, “I probably should have told you before, but early this morning before you got to the airport, I drained eight gallons of gas out of the airplane into my gas cans.” The owner told me he had been concerned that we might be too heavy with so much gas on the airplane. He had no explanation for why he did not tell me that he had removed fuel from the airplane.

Concerned that we could experience fuel exhaustion, I opted to make a precautionary landing in a field about 12 miles northwest of the airport. The landing was uneventful. The owner refueled the airplane with the eight gallons he had removed and I flew the aircraft back to the airport.
ASRS Database Online
The ASRS Database is a rich source of information for policy development, research, training, and more.
 Search ASRS Database »
CALLBACK Issue 413
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 View ASRS Report Sets
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Contact the Editor
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 » Read the Interim Report »
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 »
April 2014
Report Intake:
Air Carrier/Air Taxi Pilots 4,195
General Aviation Pilots 1,179
Controllers 708
Flight Attendants 405
Mechanics 195
Dispatchers 128
Military/Other 89
TOTAL 6,899
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 4
Airport Facility or Procedure 3
ATC Equipment or Procedure 9
Hazard to Flight 1
TOTAL 17
Subscribe to CALLBACK for FREE!
Contact the Editor
Facebook
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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 413


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

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