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.

Wednesday, May 13, 2015

CALLBACK 424 - May 2015


CALLBACK From the NASA Aviation Safety Reporting System
Issue 424
May 2015
Maintenance Matters
Charles Taylor, the “first aviation mechanic in powered flight,” is credited with designing and building the engine for the Wright brothers’ aircraft. The Charles Taylor Master Mechanic Award is presented by the FAA to recognize the lifetime accomplishments of senior aviation mechanics who have worked for a period of 50 years in aviation maintenance.

While recipients of the Award have demonstrated extraordinary knowledge, skill and integrity throughout their careers, it is doubtful that any of them would say they were perfect. More likely, they would be the first to say that errors are always possible; that the idea is to learn from your own or others’ mistakes; that errors need to be recognized and corrected before an aircraft takes flight.

The Aircraft Maintenance Technicians (AMTs) who submitted the following reports all learned valuable lessons and, by sharing them, contributed to improved maintenance practices. Whether or not any of them go on to win professional awards for their work, their contributions to aviation safety definitely embody the spirit of the Charles Taylor Award.
Excessive Force
A landing gear bushing was significantly over-torqued when three AMTs, a Lead Technician, and a Shift Supervisor all misinterpreted a torque setting.
I was assigned to work on securing an A320 right main landing gear Side Stay Bushing. I was directed by my Lead Mechanic to work with [two other AMTs]…. We briefly went over the paperwork for this phase and Lead showed us the torque was 500 foot-pounds…. I set the tooling in place, put the nut and locking tab washer in place, spun it down by hand, and then engaged the tooling to begin the final torqueing of the retaining nut. [The other AMTs] read that the final torque setting was 500 foot-pounds and that the initial torque setting was 440 foot-pounds. The torque wrench was set to 440 foot-pounds, shown to our inspector, and then attached to the tooling. Once the initial torque was reached, we (myself and our Inspector) checked the tab lock positions and it was necessary to advance the position of the retaining nut by close to 1/4 inch to align the lock tab. Once we reached 500 foot-pounds, the tab lock was still not aligned. The Inspector instructed us to back the collar off and then reapply the minimum torque of 440 foot-pounds and recheck the tab lock position. We continued this through four break/reset sequences with no better luck.

We went to the incoming midnight Supervisor and explained the dilemma. He took the paperwork and briefly perused it and then said that we should turn the issue over to the incoming crew. We turned the paperwork over to [the midnight shift Lead] and explained the problem we were having. He left with the paperwork and returned approximately 15 minutes later to show me that he read that the torque was to be no more than 500 INCH-pounds. The paperwork had “500 lbf. in” in the text. Because of this misinterpretation, the applied torque was 12 times greater than was intended in the operation.

There is a difference between the way Boeing and Airbus present this information. Boeing uses “lb-ft” for foot-pounds and “lb-in” for inch-pounds. Airbus references foot-pounds with “LBF.FT” and inch pounds with “LBF.IN”. I believe that “LBF.IN” is very confusing and led to our mistake in applying the improper torque for the job. Perhaps “LB.IN”, or spelling out “foot-pounds” or “inch-pounds” would be clearer.
An Array of Assumptions
When you assume that you have the right parts and you assume they are going on the correct engine, what could go wrong? Verification of the paperwork associated with the job could have saved a lot of time, labor and embarrassment in this wrong engine, wrong parts incident.
I started my service on [a B737 aircraft]…#1 engine. Another AMT was to start the fuel nozzle replacement. After I completed my service, I noticed the #2 engine cowlings were opened up so I assumed that must be the engine getting the fuel nozzles…. When the nozzles arrived, one AMT took the left side of the engine and another took the right side and they began removing the fuel nozzles to replace them. I was the third person so I was handing tools to them and getting whatever they needed….

After the Inspector had checked the engine for safety and security, I closed the #2 engine cowlings. It wasn’t until the next day that I was informed that the nozzles were the wrong part number and the work was supposed to have been done on the #1 engine. I had never looked at any of the paperwork to verify the part numbers or which engine we were supposed to work on.
Reversed Rocker Arms
It is understandable to assume that an engine would be properly assembled when received from an overhaul facility. This AMT learned, however, that it is best not to make any assumptions when it comes to aircraft maintenance.
The PA-28 aircraft was flying fine and compression on the two new cylinders was good. After approximately 10 hours of flight time, the pilot reported that the engine was making a knocking noise and elected to land.

The maintenance facility removed the rocker box cover on the suspect cylinder and found that the rocker arms were reversed causing a misalignment. The cylinders were received from the overhaul facility and placed on the aircraft. I should have checked to make sure the correct part number was on the correct side. I assumed that they were.
Misconnections
A Maintenance Inspector’s report reiterates the need for careful review and inspection in any maintenance procedure, but especially when manpower issues, workload, and time pressure are added to the process.
I was the Inspector on the shift and two other Mechanics and I were finishing up the rigging and final checks after a scheduled engine change on a DHC-8 aircraft…. On top of this we had a spare [aircraft] being worked, which suddenly had to go out. The Lead was busy with other duties on the engine change, so I was also working on closing out the package and making sure all the paperwork was correct on the spare. When it came time to close the cowlings, I helped lift the lower cowl while the Mechanics secured it and hooked up the connectors, hoses, and jumpers. We “ops checked” the deice light and bypass door function. I inspected the lower cowling deck and internal area of the intake for FOD and cleanliness and we closed the cowling.

We found out the next day that the deice supply hose was connected to the oil cooler drain valve, which can be done since they are adjacent to each other and look similar.

The intake deice boot and one boot on the wing were found to be inoperative on the first flight of the day. The event occurred simply because we were in a hurry to get the engine change done, get the aircraft ready for an evaluation flight for another maintenance issue, and trying also to get the spare aircraft finished up to go out.

Slow down and take the time to review what you have just done even when you are rushed by time constraints, lack of manpower, and a heavy workload.
CRJ-700 Unplugged
Among other things, experienced Mechanics rely on good communication and careful attention to Job Card procedures in order to overcome adverse factors such as time pressure, stress, and fatigue. In the following incident, inexperience and poor communication exacerbated the other adverse factors confronting two AMTs. Both of them overlooked Job Card procedures that could have prevented this costly CRJ-700 oil leak.
I was about to service an aircraft with [engine] oil when the Crew Lead asked me to help a co-worker in the Deferral Action of a hydraulic Shut-Off Valve (SOV). I approached my fellow Mechanic, asking what needed to be done. The Mechanic told me to take off the hydraulic pump from the #1 engine while he took the parts necessary for the deferral out of the Fly Away kit. The Mechanic instructed me to install the Blank-Off Plate in the mount [on the Engine Accessory Case] where the hydraulic pump was installed and to secure it along with the Cannon plug. After I installed this plate and capped the [hydraulic] quick disconnect outlets, I asked if any further assistance was needed….

With four minutes left before clock-out time, the other Mechanic approached me asking to sign a Job Card for the task. I signed the blocks required, but failed to see the part where it mentioned that a Spline Plug was to be installed before the Blank-Off Plate. The error was discovered when the aircraft had to make an emergency landing due to [engine oil] leakage.

This was a lack of communication between co-workers. I assisted my co-worker by following his instructions. I failed to pay the necessary attention to the Job Card when filling [out] the [sign-off] blocks. Lack of knowledge and experience was also a factor. I’ve been employed for several months in this company and have never worked on the engine section of the CRJ-700 aircraft. Also the other Mechanic explained to me that he has never performed this procedure either. Stress and fatigue may also have been factors because it was at the end of the night and my co-worker said the plane had to be at the gate in a half-hour….

An Engine Run/Leak Check was performed after the job was completed; however the required High Power Run was not accomplished.

[I recommend] better communication between mechanics when working as a team, especially if one joins another in the middle of the task. Pay more attention to Job Cards, especially when completing them under stress.
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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 »
March 2015
Report Intake:
Air Carrier/Air Taxi Pilots 5,354
General Aviation Pilots 1,234
Controllers 556
Flight Attendants 525
Military/Other 305
Mechanics 228
Dispatchers 138
TOTAL 8,340
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 12
Airport Facility or Procedure 26
ATC Equipment or Procedure 12
Maintenance Procedure 1
Company Policy 2
TOTAL 53
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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 424


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

CALLBACK 423 - April 2015


CALLBACK From the NASA Aviation Safety Reporting System
Issue 423
April 2015
Autothrottle Speed Control Issues
The term autothrottle (automatic throttle) refers to the thrust control function of the automated Flight Management System (FMS) found on most larger commercial aircraft. Generally speaking, autothrottle systems operate by adjusting the fuel flow to the engines in response to a set of desired parameters compared to actual flight data input. These parameters may be set manually by the pilot or determined automatically by the FMS which instructs the autothrottle to increase or decrease thrust to maintain the desired vertical flight profile and/or airspeed.

It is incumbent upon flight crews to be fully aware of the differences in autothrottle function associated with the FMS mode selections available in their particular aircraft make and model. In some systems, the autothrottles will “wake up” in all modes in order to maintain a selected airspeed or a minimum flying speed, but other systems do not have this feature. In the following ASRS reports, airspeed control issues resulted when the autothrottles did not respond as expected due to a more basic “mode” error— the ON vs. OFF “mode.”

Another aspect common to these reports is a delay on the part of one or more of the flight crew in recognizing how the lack of autothrottle response was affecting the aircraft on a very basic level. In an age of flying by “system management,” it is important to remember that, when aircraft performance appears compromised, an immediate evaluation of raw data (airspeed, attitude, altitude, thrust setting, rate of climb or descent, DME, etc.) is the flight crew’s best resource for understanding the energy state of the jet. Raw data is fast, factual and not subject to programming or mode errors. It represents the “real world” in which the jet exists regardless of how “virtually” it is operated.
A Whole Lot of Shaking Going On
A B757-200 experienced a high altitude stall when the autothrottles failed to re-engage after being intentionally disengaged. Beginning with the Captain’s report, the members of the augmented flight crew present three interesting perspectives on the incident.
Captain's Report:
We began to pick up light to moderate chop and I selected Mach .78 in the autothrottle speed window. The airspeed decrease was minimal as I fought the autothrottles to retard, so I clicked them off until Mach .78 was achieved. I put .78 in the FMS cruise page, and selected VNAV on the Mode Control Panel. I then gave my seat to the Relief Pilot. [After] I walked to the aft galley to check on the Flight Attendants and passengers…moderate buffeting began. I [returned] to the cockpit where I observed that we were in a climb at .74 Mach passing 30,500 feet…. We advised ATC of the altitude loss due to turbulence and returned to FL350.

The likely causes include:
1. The autothrottles were not engaged. When I slowed down for the turbulence just before the Relief Pilot was to relieve me, I clicked the autothrottles off, but did not verify they re-engaged in Speed or VNAV mode.

2. Distraction from the seat swap, ATC radio chatter (loud squeal).

3. Late night “fatigue” compounded by 90 minutes of flight in light to moderate chop and thunderstorm deviations. When the vibrations started I thought it was due to another aircraft’s wake vortices. The First Officer thought it was a Mach over-speed buffet or engine vibration. The moderate vibrations during the few minutes of buffeting made reading the panel instruments very difficult. The noise from the autopilot disconnect warning was adding to the stress. Stick shaker was noticed by one pilot, but not the other….

Maintaining aircraft control, analyzing the situation, and taking appropriate action are paramount. Mach recovery is also critical in high altitude recovery. When exchanging seats or aircraft control, verify you have the automation doing what you think you have it doing.

Relief Pilot's Report:
Approximately five minutes [after I took the left seat], the First Officer commented about an abnormal vibration. The vibration went from light, increasing to moderate, to the point that the autopilot disconnected. The First Officer assumed control of airplane. We scanned the flight instruments to ascertain the problem, but continuous buffeting made it impossible. When we realized our speed was slow we maintained wings level, lowered the nose, and made a smooth recovery. Our altitude went from FL350 to approximately FL290…. Late night flying in continuous turbulence can be very fatiguing.

First Officer's Report:
At FL350 I felt a strange vibration through the airframe, and commented to the flying pilot…. I initially scanned the upper and lower EICAS for a possible engine malfunction. In about 10-15 seconds the siren (“wailer”) began. I initially believed it was an over-speed. We began descending. I took control of the airplane, maintained wings level and closed the throttles. The vibration made it difficult to see the flight instruments. I set pitch and thrust for level flight. Upon discovery of very slow speed, I commanded climb thrust and set the nose attitude, accelerated to clean maneuver speed, and began to climb back to assigned altitude.

The circumstances, beginning with the vibration were highly unusual, something I have never seen demonstrated in the simulator. Furthermore, the high altitude recovery following a possible autopilot disconnect, is something that should be demonstrated in the simulator. decision.
Low and Slow
Lack of communication and confusion about the autothrottle status led to a go-around for a B777-200 flight crew.
The autothrottle became disconnected on final several miles from the runway, but this was not recognized until short final. I noticed the IAS at Vref (142 knots) at 200 feet AGL. I asked the Pilot Flying (PF) to add power and realized that the autothrottles were not driving the power. The PF did not respond immediately. I believe he was confused as to why the autothrottle was not responding. The IAS then decreased to approximately five knots below Vref. I again requested more power and brought the First Officer’s attention to the low speed condition more urgently while I began pushing the throttles up myself.

At this point the PF reacted with more thrust and the speed immediately jumped to Vref +5, but then continued to accelerate beyond Vref +10. I felt the approach to be unstable and called for a missed approach at 50-100 AGL. The go-around was completed without contacting the runway.

More attention to cockpit automation was necessary. A later review of the incident revealed that the PF had disconnected the autothrottles at the same time as the autopilot with the intention of hand flying the approach. By utilizing a “double click” of the autothrottle disconnect button, the Autothrottle Off aural warning was prevented from sounding since the system assumed the act was intentional, as it was in this case. Fatigue following a more than 12-hour flight was a factor.
Lower and Slower
An A321 flight crew got into a low energy situation that led to an “ugly landing” when the autothrottles failed to “spool the engines” as expected.
When it was time to start the managed arrival, I pushed the altitude selector button on the Flight Control Unit (FCU). At this point we suffered a Flight Management Guidance Computer (FMGC)1 malfunction which resulted in loss of my map display as well as a minor ECAM and loss of GPS primary positioning on the Captain’s side. This resulted in a transfer of control to the First Officer.

At the 1,000 feet AGL call the First Officer called “stable” and I confirmed that we were on glide path and within a couple of knots on the low side of Vapp. At the 500 foot call I called “stable, REF minus 3 to 4.” Because we were a little slow, I made a conscious decision to watch the airspeed as the A321 tends to be less forgiving if energy gets low. I made a call of “REF minus 5” at some point closer in and another call of “REF minus 8” as we were approaching 50 feet AGL. I was expecting the autothrottle to have spooled the engines by now, but it had not changed the downward trend in airspeed. We landed hard and I was expecting a bounce, but we did not get one.

It was an ugly landing and it unnerved both of us. The weather was not a factor as far as I could tell. It was just an average day with light winds. I cannot remember anything unusual about the gap between Vls and the target speed. It must have looked pretty normal. I do remember looking at the Vapp speed displayed on the First Officer’s MCDU since mine was not working and it showed 144 knots, which seemed about right….

The bottom line is that the airspeed drifted downward below Vapp during the last 500 feet of the approach without the autothrottle spooling up the engines. I had not seen this before. Up until now, I have experienced pretty reliable performance from the autothrottle. Upon later reflection I wondered what a go around would have looked like. We were low on energy. The increase in thrust as well as increase in pitch for the go around would have put the tail of the aircraft very close to the runway surface. I am reasonably sure we would have made contact with the runway, wheels first, during the go around. We need more autothrottle OFF practice so it is more instinctive to intervene and skillfully restore proper energy during an approach. We are losing our ability to hand fly the airplane.
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 423
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 Search ASRS Database
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Contact the Editor
Special Studies
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 »
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 »
February 2015
Report Intake:
Air Carrier/Air Taxi Pilots 4,392
General Aviation Pilots 988
Controllers 517
Flight Attendants 366
Mechanics 210
Military/Other 175
Dispatchers 87
TOTAL 6,735
January/February 2015
Total ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 1
ATC Equipment or Procedure 1
TOTAL 2
Subscribe to CALLBACK for FREE!
Contact the Editor
Facebook
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LinkedIn
Facebook - Like
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 423



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

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