CALLBACK 421 - February 2015

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Issue 421 February 2015 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 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 Story Situation # 1  C172 Pilot’s Report ■ The weather briefing advised my route was VFR and forecast to be so until around 0300 local time…. Enroute the weather quickly deteriorated. I noticed larger cumulonimbus clouds forming around me and a thick cloud deck forming in front of me. I opted to drop my altitude to 3,500 feet to maintain VFR cloud clearance and duck below it. Once the weather opened up I decided to climb to 5,000 feet to get a better look at what was going on around me. I saw that the weather was worse than I thought. It was solid IMC everywhere and deteriorating rapidly…. I started checking different enroute weather services to get a picture of what was going on. At this point I had 1.3 hours of fuel left and realized that any airport within range was heavy IMC…. I decided to continue towards [my home airport]…. I maintained 1,000 feet above the cloud deck for some form of traffic separation, but could not see the ground as it was a solid [layer]. Shortly after, both NAV 1 and NAV 2 failed, but DME was still operational. I then attempted to call Center for vectors and help, but to no avail. It appeared my radio could receive but not transmit. I then attempted to navigate via my iPad, but the battery died shortly after. At this point the weather had gotten so poor that flying through clouds became unavoidable. I was in complete IMC. I executed an emergency 180 using my turn coordinator and my stopwatch and held that heading for a few minutes. Realizing it wasn’t improving, I decided to climb to get above the deck once again for traffic separation. I climbed for approximately 20 minutes and popped out above the deck at 10,000 feet. It was solid overcast as far as the eye could see…. At this point, I was very disoriented as to where I was, and had no way to call for help. What Would You Have Done? Situation #2  PA28 Pilot’s Report ■ When the throttle was retarded from full power to cruise after a practice power-off stall recovery maneuver was completed, the throttle cable broke causing the engine to run at full power. I took control from the student while bringing the [throttle] to idle to confirm we couldn’t run at any less power. The power continued to read between 2,500 and 2,700 RPM (redline for the prop). I declared an emergency with [the TRACON], whom I was already using for radar services, and diverted to [a nearby airport] with a longer runway than our home base. At this point it became apparent I could not maintain level flight without over-speeding the propeller. What Would You Have Done? Situation #3  CRJ900 Captain’s Report ■ While descending…we entered IMC and icing conditions. We turned on our cowl and wing anti-ice. Shortly thereafter the EICAS indicated a master warning immediately followed by an Anti-Ice Duct Fail message. We then received Left and Right Wing Anti-Ice Fail messages. The First Officer and I complied with the appropriate QRH items and informed Approach that we were having issues with our icing system and requested an expedited ILS…and a lower altitude. Shortly thereafter we were out of icing conditions and decided an emergency did not need to be declared…. We landed, taxied to the gate and contacted Dispatch to initiate a write-up with Maintenance. We taxied out to a run-up area with Contract Maintenance to do several tests on the system…. Although the system checked out on the ground, the First Officer and I agreed that it still might not be safe. The reasons were several. The conditions within 150 miles were calling for icing from 3000 to 23,000 feet. Since we were limited to FL250 due to single pack operations, this was a serious consideration. It was also night time and a considerable portion of the flight would be over mountainous/remote terrain. While on the ground the aircraft experienced an Ice Detect 2 Fail status message. Simply resetting the system and having the message(s) disappear from the EICAS did not inspire confidence to depart under these conditions. During a conference call with the company we explained our rationale. We fully understood this would inconvenience holiday passengers and that some might not understand why we did not depart in a plane that was legally signed off. Ultimately we were told that it was solely our decision. What Would You Have Done? The Rest of the Story Situation #1  C172 Pilot’s Report The Reporter's Action: ■ Using my DME, I determined where I was relative to the tuned VOR/DME by flying different headings and observing the DME’s reaction. On my sectional chart I drew a line straight from the VOR, and determined I was roughly six miles south of [the departure airport]. I then turned direct north and held this heading for 10 more minutes to get far north of the field where I knew there were no obstacles while descending from 10,000 down to 2,000. Once [my passenger’s] cell phone got signal, I pulled up a computerized satellite map and used that to line myself up with the runway coming from the north. I maintained a slow but steady descent as I continued essentially a poor man’s GPS approach. I broke through the clouds at roughly 1,200 feet AGL and landed. First Half of Situation #2 Situation #2  PA28 Pilot’s Report The Reporter's Action: ■ I allowed the aircraft to stay in a slow climb, eventually ending up near the airport at [3,500 feet AGL]. While on a very high downwind I contacted Tower, was cleared to land, and elected at that time to pull the mixture back to begin the descent for landing. I briefed the student on how I planned to land, using the mixture to add “bursts” of power if necessary, and asked him to turn off the fuel and mags on my command. The glide went well. I had the student secure the [engine] once I was sure we’d make the runway and it was an uneventful touchdown. First Half of Situation #3 Situation #3  CRJ900 Captain's Report The Reporter's Action: ■ We elected to do it the next day during daylight and vastly better weather. During the flight we had a master warning immediately followed by an Anti-Ice Duct Fail. This caused our wing anti-ice protection to turn off. We quickly exited icing conditions. All QRH items were complied with and maintenance was given a heads-up via ACARS. 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 421 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 » December 2014 Report Intake: Air Carrier/Air Taxi Pilots 5,167 General Aviation Pilots 1,061 Controllers 543 Flight Attendants 450 Military/Other 220 Mechanics 188 Dispatchers 125 TOTAL 7,754 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 4 ATC Equipment or Procedure 5 Other 3 TOTAL 12 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 421

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CALLBACK 420 - January 2015

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Issue 420 January 2015 By definition, a ground loop is the rotation of a fixed-wing aircraft in the horizontal plane while on the ground. It is predominantly associated with aircraft that have conventional landing gear (taildraggers) due to the center of gravity being located aft of the main gear. If horizontal rotation is all that happens, the ground loop may only affect the landing gear or cause a runway excursion. Unfortunately, aerodynamic forces can cause the advancing wing to rise, which may then cause the other wingtip to contact the surface. A ground loop that progresses to this stage may result in extensive airframe and engine damage and even personal injury. While often caused by an unfavorable wind component or adverse runway conditions, ground loops may be caused entirely by pilot error. To avoid a ground loop, the pilot must respond to any directional change immediately while sufficient control authority is available to counteract the unwanted movement. In order to respond quickly enough, taildragger pilots have to anticipate the need for corrective control input. This means keeping ground loop countermeasures in mind whenever the aircraft is moving. To reinforce the need for taildragger pilots to keep the nose ahead of the tail, this month’s CALLBACK looks at three ground “oops!” incidents. Note that while these reports emphasize the particular need for vigilance in training scenarios, the basic techniques noted apply to all taildragger operations. Errant Cub Strikes PAPI This J3 Cub instructor’s observation that, “we were comfortably in control right up to the point when it became clear…we were going to depart the runway” emphasizes the need for constant vigilance in a taildragger. ■ I was…flying from the front seat. An ATP rated pilot was the student for tailwheel training, flying from the rear seat. We did two landings and takeoffs from a small grass field several miles from our home airport. The day was clear with very light winds, essentially calm. We returned to our airport for our final landing. The student had done well with his earlier landings and I felt comfortable having him make this landing also. I briefed that a pavement landing was more challenging than grass and required even more precise directional control…. We had previously discussed the center of mass location relative to the main gear and how that causes a ground loop tendency in tailwheel aircraft if the aircraft is not aligned with the direction of travel or is drifting at the time of touchdown. The approach and final approach segment were flown precisely on speed and on glide path. As we neared touchdown and were into the landing flare, I noticed that the airplane began drifting very slightly to the right. It was my impression that the degree of drift and the alignment of the aircraft for landing were within safe limits and therefore I continued to monitor the landing, letting the student maintain full control. After we touched down, just at stall with the stick full aft, the aircraft began to turn gradually left. I began to assist the student on the flight controls and then said, “I have it” as the rate of turn increased. Despite full right rudder and brake, the turn developed into a progressive swerve to the left. I do not recall if I added left aileron. I noticed a small amount of power still on and I took this out. We left the runway between the runway lights and continued to roll onto the grass. The radius of the turn tightened and I began to see the PAPI lights to our left…. As the turn continued, we went past the first three lights and slowed, but the radius of the turn tightened despite all control inputs. We struck the fourth PAPI light. We were moving so slowly at the time of impact that there was no discernible force felt by us. I checked the brakes, bungees, and tailwheel. All seemed to be intact and functional. I initially wondered if there could have been a mechanical problem because the degree of side movement seemed to be in an acceptable range at touchdown and I was surprised by the ground loop. We did subsequently note that the tailwheel springs and linkages were somewhat loose. I have made thousands of tailwheel landings and felt this time that we were comfortably in control right up to the point when it became clear the swerve was increasing and we were going to depart the runway. I have to conclude this was mostly pilot error for not fully recognizing that lateral limits had been exceeded, perhaps exacerbated by a somewhat loose tailwheel steering linkage. “Never Relax Your Vigilance” The type of aircraft was not given in this report, but the lessons given are good for any taildragger. Also, the importance of not overestimating a student pilot’s ability is good advice for instructors in any type aircraft. ■ This was the first flight of a tailwheel endorsement for a previously endorsed pilot who had lost his documentation. He had approximately 100 hours of tailwheel time…. Two hours of ground school was accomplished covering tailwheel aircraft and model specific characteristics. The start and taxi, including control positioning, was normal. The takeoff was somewhat erratic in that the control yoke was “pumped” slightly; rudder control was erratic, but satisfactory. Slow flight at various flap settings and stalls were accomplished. On the first pattern, downwind to final was satisfactory, but he elected to use 30 flaps instead of 40. As the flare was initiated, he “pumped” the yoke initially, but quickly established a proper attitude. As the aircraft touched down he relaxed back pressure and over-controlled the rudder causing a minor heading change. He then reversed the rudder, adding back pressure and causing the aircraft to become airborne and change direction. At this point I commanded him to hold the yoke with a nose up attitude and center the rudder; however he relaxed back pressure, allowing the aircraft to touch down. His rudder input at this time was excessive (push and hold rather than the quick inputs required for a taildragger). I took control of the aircraft (at this time we were very slow), but I could not override his rudder input in a timely manner. The aircraft did a slow ground loop, exiting the runway. It was more of a quick turn than a classic ground loop. I reentered the runway and taxied back to the ramp to perform an inspection. There was nothing wrong with the aircraft or tail wheel assembly. I have around 5,000 hours of instructor time with no incidents/accidents and have trained many pilots, but I committed a cardinal sin in having higher expectations for this pilot than warranted based upon his experience. Could this have caused me to relax my vigilance? It probably did…. When the student started pumping the yoke at the initial round-out I should have taken the aircraft and performed a go-around. I also did not demo the first landing which is usually my method of operation. This event reiterated the fact that a demo is also appropriate for someone who has never flown a particular model and [I should] never fail to take timely control of the aircraft even though someone has extensive experience. Never relax your vigilance. Wayward WACO Even a very experienced instructor pilot may not be able to overcome a student pilot’s error when it involves a critical action at a critical time. The situation is aggravated in an aircraft such as this WACO where the instructor was unable to see, and possibly anticipate, the student pilot’s actions. ■ The objective of the flight was to practice takeoffs and landings on a paved runway which is more difficult and challenging than operations from a turf runway in a vintage aircraft of this type…. The decision was made to practice at a nearby field where there is a 150-foot-wide runway. A key point in technique that had been stressed…was not to touch the brakes until the tail wheel was on the ground when making a wheel landing. Moreover one should not try to force the tail down once on the ground in the wheel landing attitude, but rather let the tail come down on its own, maintaining directional control with the rudder only; no brakes during this phase of the landing roll out. The point had been previously stressed and understood by the student that forcing the tail down (pulling it down with the stick) prematurely was a good way to induce a ground loop because this action would dramatically increase the angle of attack on the wing when it still had enough speed remaining to generate some lift and enough lift, if helped along by any crosswind, to cause the aircraft to yaw and thereby cause the downwind wing to hit the ground and begin a ground loop event. Application of brakes while the tail was still flying could also cause enough adverse yaw to induce a ground loop or even worse, flip the aircraft over. Conditions at the time were ideal. Wind was less than five knots. When the airplane touched down on the main wheels, directional control was good and it was tracking straight. Then it began to yaw to the right as speed decreased and the tail began to lower. This is a critical time where the pilot flying needs to immediately arrest the yaw with opposite rudder even if aggressive opposite rudder is necessary, but no brakes. Instead the student hit the left brake fairly hard. Now the right yaw, which was only about 10 degrees, suddenly became a sharp yaw to the left at about 45 degrees. At this point the airplane was headed off the runway onto the grass and it struck a runway light where it departed the runway. The critical error was that the student stomped on the left brake when the aircraft began to yaw to the right while the tail was still flying. This is an antique aircraft. The instructor pilot sits in the front cockpit. The instructor cannot see what the flying pilot is doing with his feet or how he has them positioned on the rudder pedals. 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 420 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 » November 2014 Report Intake: Air Carrier/Air Taxi Pilots 4,458 General Aviation Pilots 1,090 Controllers 509 Flight Attendants 386 Military/Other 246 Mechanics 201 Dispatchers 118 TOTAL 7,008 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 10 Airport Facility or Procedure 13 ATC Equipment or Procedure 7 Other 1 TOTAL 31 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 420

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CALLBACK 419 - December 2014

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Issue 419 December 2014 According to the FAA1 and NTSB2, icing is a cause or contributing factor in aircraft accidents and incidents every year. In-flight icing can degrade aircraft performance and alter controllability. Ultimately, complete loss of control of the aircraft may result. Other hazards associated with icing include: Blockage of pitot tubes and static vents causing errors in pressure instruments such as the altimeter, airspeed indicator, and vertical speed indicator if the associated heating system is not activated or operating properly. Airframe or engine damage caused by ice shedding off of aircraft surfaces or propellers. The following ASRS reports offer lessons on each of the above hazards from pilots who experienced in-flight icing incidents— incidents that came uncomfortably close to being accidents. Carrying an Extra Load After an unexpected “hard bank” resulted in a hard landing, an ERJ145 crew discovered that icing may have been the cause. ■ ATC…descended us to 2,000 feet and vectored us for the approach. We were having a little problem picking up the localizer, however we finally got a strong signal before the FAF and decided to fly the approach…. The Captain called, “Visual” and I said, “Landing.” I tried to turn off the autopilot and had a hard time getting the autopilot warning off. The Captain called, “Speed.” I had gotten slow by about 3-4 knots and we were about 200 feet off the ground. I said, “Correcting” and added power and had no issue from there. We crossed the threshold and I started my crosswind correction and that is when the airplane took a hard bank to the right. The Captain and I did everything we could to get the airplane on the ground. The landing was hard but we decided that the plane was able to taxi in. We asked to hold short of the center runway to collect ourselves, talk to the Flight Attendant, and resume the taxi. “Rudder INOP” displayed on the EICAS during taxi in. We got to the gate and deplaned then started making phone calls to report the rudder and hard landing. After that was done, a ramp agent came up and let us know that there was some limited wing damage. We both went outside to see and it was then that we saw a considerable load of ice built up on all leading edges and engine nacelles. “The Airplane was Still in a Descent with Full Power” Faced with little IFR experience, poor CRM, and airframe icing, the pilots of a Rockwell 112 were lucky to break out into conditions that would allow the ice to dissipate. Among the lessons this incident highlights are the need for an adverse weather “escape plan,” and the value of building actual instrument time with a qualified instructor until proficiency is attained. ■ Sunset was imminent, this area of the country was new to me, and the more things changed for the worse, the more interest I had in parking the airplane and just spending the night in a hotel. Always leave an out. The area over the airport…was in IMC. Ordinarily this would not have been an issue. The AWOS indicated a 1,500 foot ceiling. Things were going smoothly then at 6,000 feet, with no control input to cause a descent rate of over 500 feet per minute, my VFR rated passenger told me that we were descending (I could see that and was trying to process why we were descending). He further stated that I needed to “fly the airplane.” Then he took the controls and pulled back on the yoke. The attitude indicator shifted to a very sharp indication of a left turn. The descent rate increased to about 1,500 feet per minute. I could not over power this person. I told him, “The airplane was flying a minute ago, let the airplane continue to fly.” He let go of the controls. I reiterated that announcing, “Your airplane/My airplane” prior to manipulating any controls was a requirement when flying with me. The airplane was still in a descent with full power after he released the controls. It took a while to discover that we had ice on the wings. We broke out into VMC and ATC asked what my intentions were. I explained that I needed to stay VFR to dissipate the ice and would like the approach into [a nearby airport]. I do not have much experience as an IFR pilot; less than 20 hours in actual IMC. I thought my passenger, with over 50 years of aviation experience, would be an asset in the cockpit. In VMC he is a continuing source of information and a person I respect. But, there is a difference between being IFR rated and VFR rated…. Being diverted 59 miles south due to the iced over runways was already putting me outside of my comfort range. I usually fly in [warmer states]. The majority of my flight instructors had minimal or no experience in actual IMC. I will be signing up for a course on “icing” in the near future. “The Airspeed Was Decreasing Rapidly and I Began to Worry” ATC helped to get a trio of pilots in a PA32 out of trouble as they dealt with zero IAS, no GPS, and ice on the leading edge of the wings. FAA and NTSB statistics show that accidents often result from similar scenarios, especially when “get-there-itis” is added to the mix. ■ We decided to depart knowing that most of the flight would be VFR, but the last 100 miles would be in marginal conditions. We planned on stopping prior to encountering the marginal conditions…. Once at [the interim stop], we refueled and obtained a telephone weather briefing. For the briefing, I had [one of the other pilots] call the briefer. We spoke about the information the briefer gave him. We were told that the freezing level was at the surface and above. Our understanding was that other aircraft were not having problems with icing, but were experiencing moderate turbulence. At this point my mindset was that icing could happen, but would not be an extreme hazard to us. I spoke with the owner of the airplane, (our passenger) and told him that as soon as we got any accumulation of icing, we would divert to an airport that was along our route. We chose our route with that plan in mind. The preflight was performed by another pilot. Thirty minutes after departure, the weather became marginal and I avoided IMC while we got an IFR clearance from TRACON. We were cleared to climb to 7,000 feet to see if we could find VFR conditions. During the climb, we started to notice icing. We then climbed to 8,000 feet, but we were still IMC so we asked for 6,000 feet. At 6,000 feet, I noticed that the airspeed was decreasing rapidly and I began to worry. For a while I thought we were losing the capability to generate lift due to the icing and by instinct I reacted by reducing the pitch of the aircraft to avoid a stall. At this point the other pilot suggested it was the pitot tube getting clogged by the ice which was the cause of the IAS decrease. I then noticed that our altitude was now 5,300 feet MSL…. While all of this was happening, the pilot beside me was attempting to coordinate with ATC to help us get back down to an airport…. The Controller gave us an Initial Approach Fix and told us to fly direct to that fix. As we were loading the information into the GPS system, we realized that the GPS had lost its signal. With IAS at zero, no GPS, and ice on the leading edge of the wing, we thought it would be best to get vectors to the nearest airport…. Flying at a lower altitude in VMC helped us regain the airspeed indicator and land in visual conditions. The one factor that hurt us the most was “get-there-itis.” I had been asked to help out the owner with the flight since I had more experience than he did. The owner was spending a lot of money for each night at a hotel and wanted to get back soon. I should have been more involved with the preflight and weather briefing and not just taken the other pilot’s word since I am the PIC. I also just assumed that the pitot heat was working since I assumed it was the responsibility of the owner to ensure that the plane was up to date on maintenance. Low Level Ingestion After experiencing a flameout and “vigorous” relight on one of the engines, a BE100 pilot was able to regain control after breaking out of the clouds. There was no mention of how low the airplane descended, but since a “climb to 3000 feet” ensued, this was undoubtedly a chilling lesson on the dangers of engine inlet icing. ■ Before the final turn for the ILS approach, with all deicing equipment on, the right engine seemed to stutter. I assumed it was [the right engine] from the direction that the plane was suddenly going. I corrected with left aileron and rudder. I did not see a decrease in torque with either engine when I looked at the gauges. The engine restarted vigorously and pushed the plane hard left and into a fast descent. I was able to control this just as I broke out of the clouds. I climbed to 3000 feet, stabilized the plane, and made the approach without further incident. After landing, I observed that the inlet to the right engine was clear of ice. The inlet to the left engine was significantly blocked by ice buildup. I suspect that the right engine flamed out, caused by ice breaking loose and entering the engine. The igniters were armed, which restarted the engine. A possible cause is that I did not have the engine inlet heat system on soon enough to avoid ice buildup. I was watching the wings during flight and turned on the engine inlet heat system only after I observed ice on the wings. The icing was encountered at 5000 feet enroute. There was no icing in the immediate vicinity of [the destination airport]. 1 https://www.faasafety.gov/gslac/alc/course_content.aspx?cID=33&s ID=148&preview=true 2 http://www.ntsb.gov/news/speeches/EWeener/Documents/ weener_020111.pdf A NASA course on aircraft icing can be found at: http://aircrafticing.grc.nasa.gov/courses.html 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 419 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 2014 Report Intake: Air Carrier/Air Taxi Pilots 4,757 General Aviation Pilots 1,271 Controllers 635 Flight Attendants 443 Mechanics 218 Military/Other 165 Dispatchers 107 TOTAL 7,596 ASRS Alerts Issued: Subject No. of Alerts Aircraft or Aircraft Equipment 6 Airport Facility or Procedure 4 ATC Equipment or Procedure 6 TOTAL 16 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 419

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