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.

Friday, December 16, 2016

CALLBACK 441 - October 2016


CALLBACK From the NASA Aviation Safety Reporting System
Issue 441
October 2016
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 an event up to a decision point. You may then use your own judgment to determine 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  C150 Pilot’s Report
My mission for the day was to fly to look at an airplane I was considering purchasing. Another pilot, who had a VFR only Cessna 150, [offered] his airplane for the flight. The weather was forecast to be marginal VFR with some IFR along the route [and] ceilings of 800 to 1,000 feet, becoming broken to clear as the day progressed. The weather was forecast to be bad the following day, so I “had” to take the flight that day. To complicate issues, I needed to…pick my son up from school that evening.

I was paying close attention to the weather enroute.… A couple stations near our destination [were] reporting marginal VFR broken conditions, and an airport near the destination was VFR. It took me another hour to realize that the VFR airport report was 4 hours old and was not being updated by ADS-B. I had received a weather brief earlier that day, and I supplemented it with my iPad, but my weather program was not updating. I was still on the 4 hour old weather at our departure time.

This plane literally had no equipment. We had a handheld transceiver and [a] portable, [ADS-B capable] GPS unit. We could get 5 miles of range out of the handheld on a good day. At least [we had] an attitude indicator. All the areas within range of our fuel supply were reporting anywhere from low IFR to 1,000 feet overcast ceilings and 5 miles visibility. We were now 2 hours into the flight, and I was waiting for the ADS-B to refresh.


We were departing a small…airport when a light twin landed [with a] gear malfunction [that] resulted in a belly landing. [That] aircraft came to rest in a position leaving approximately 4,000 feet of runway unobstructed.

At [that] time, we had only started the number 2 engine and were sitting on the FBO ramp, having not moved from our initial parked position.… I began to deplane so I could offer assistance to the disabled aircraft.… The Captain stopped me and told me to sit down.… I objected, but [he] told me that he was keeping our schedule. He proceeded to taxi, and I had to stop him from blocking the path for an emergency vehicle. After the fire truck passed, several airport officials, two of whom were in uniform, crossed their arms over their heads and attempted to stop [our] taxi. I brought this to the Captain’s attention,…but he proceeded to start the number 1 engine on the taxi roll, disregarding any checklist. Multiple aircraft on the approach to the airport reported, via UNICOM, that they were diverting because of the fouled runway.



[Enroute to our destination], the crew noticed a fuel imbalance situation developing between the left and right main tanks with approximately 2,700 pounds remaining in the center tank. The left main fuel tank had approximately 40,000 pounds and the right had approximately 38,000 pounds with the “FUEL CONFIG” light illuminated. The crew balanced the fuel between tanks, [but also] noticed that the fuel quantity in the center tank was increasing slightly. The QRH was consulted. Nothing there seemed to apply to this situation. We relayed all the information up to that point to the Maintenance Representative.… The rate of transfer from the right main tank to the center was approximately 3,100 pounds per hour. At that point we were informed by the Maintenance Representative that once the main tanks reached the halfway point in their burn (about 20,000 pounds per tank), the fuel transfer from the right tank to the center would cease.




The Rest of the Story


We continued another half hour.… At this point, the left fuel gauge was bouncing off “E.” We did find an airport at the very edge of our fuel supply that was reporting 1,000 foot broken ceilings, and [we] set course for it.… I…[chose] an airport well away from a major city that was reporting good visibility below the clouds and (reasonably) high ceilings. I dialed up an RNAV approach on my handheld, switched to UNICOM (figuring I could break things off if I heard another plane on the approach), and into the soup we went. We broke out of the clouds right at 1,000 feet, landed safely, and had 3 gallons of fuel remaining.… We waited a couple hours on the ground for conditions to improve, then continued to our destination. Lesson for the day: nothing, and I mean nothing, is worth taking a chance like that.



As the Captain entered the runway, I brought it to his attention that we needed 3,600 feet of runway according to the performance data for the airplane to safely take off. I questioned the wisdom of taking off on approximately 4,000 feet of runway with a disabled aircraft with passengers and emergency crews still in close proximity. The Captain turned around with about 25 [feet of] clearance to the fire truck, and, over my objection, he initiated a takeoff.



I elected to continue the flight expecting to land [at our planned destination] with approximately 18,000 pounds in the center and approximately 8,000 pounds in each main tank. We put together a plan to divert to several locations as the situation developed. We then spent time figuring out various scenarios to determine the options for safety, weather, maintenance, passenger servicing, etc. We climbed to FL380 as soon as ATC allowed it, [achieving] slightly better range and enroute weather avoidance. As we approached [one of the diversion locations], it became clear that [we] would not reach [our original destination] safely. We declared an emergency and elected to divert to [this newly chosen location]. At that point the fuel tanks had about 16,000 pounds in each main tank and approximately 18,000 to 19,000 pounds in the center. By the time we reached [this diversion airport], the main tanks were down to approximately 5,500 pounds, [with] the center at 35,000 pounds and climbing. We were given direct [to a fix] for the ILS. Not feeling comfortable with the distance from the end of the runway, we called, “Field in sight,” and headed directly toward the end of the runway.… I felt [that] the [threat] of losing one or both engines was a real possibility. I was determined to get to a 3-mile final with at least 2,000 feet to 2,500 feet of altitude in case of a dual engine failure. Once we were close enough to the field we flew through final to gain spacing, and…were in the slot by 500 feet. [We] landed without incident [with] approximately 2,500 pounds in the left and 2,000 pounds in the right tank as we crossed the threshold.

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Special Studies
Meteorlogical and Aeronautical Information Services Data Link and Application Study
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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 »
August 2016
Report Intake:
Air Carrier/Air Taxi Pilots 5,279
General Aviation Pilots 1,229
Controllers 659
Flight Attendants 604
Military/Other 313
Mechanics 217
Dispatchers 168
TOTAL 8,469
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 5
ATC Equipment or Procedure 1
Other 1
TOTAL 7
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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 441





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

CALLBACK 442 - November 2016


CALLBACK From the NASA Aviation Safety Reporting System
Issue 442
November 2016
De-Icing with Winter Hazards
The perennial perils of winter weather are upon us once again. Seasonal weather, consisting of low temperatures and visibilities, freezing rain, ice, drizzle, snow, and fog, brings many additional challenges to flight operations. Hazards exist everywhere, and may not be clearly evident. Degrading conditions, changing schedules, unpredictable situations, complex procedures, ambiguity, confusion, task saturation, and fatigue can all increase the seasonal risk.

The FAA has taken many safety related actions to improve the safety of aircraft that encounter icing conditions on the ground and in flight.1 Carriers and crews are equally invested. De-icing and anti-icing procedures are routinely modified each year and get dusted off with the same regularity. Strict discipline, adherence to procedures, keen vigilance, and superior situational awareness are all integral to safe operations, and occasionally, some ingenuity is necessary to avert an incident. The ability to perceive and act on potentially imperceptible threats can be critical.

This month, CALLBACK examines reported incidents attesting to the wide range of hazards associated with icy winter weather. We look predominantly at events stemming from air carrier de-icing operations, but the hazards are equally pertinent to all aviators.
Carbs and Calories
This General Aviation pilot departed on an IFR flight in instrument conditions. He suspected that carburetor icing resulted in a partial power loss and an unplanned landing.
[We] departed on an IFR flight plan to our home base with four souls on board.… The takeoff was normal, in rain, [with] low visibility and ceiling. [I was]…cleared to 7,000 feet. All [was] normal until approaching 5,000 feet when [the] engine was not developing climb power. [I] turned on the carb heat with no noticeable change, then turned it off after four to five minutes. [I] turned on [the] electric fuel pump, changed tanks, and adjusted the mixture, [all] with no change. I did not check the magnetos. [I] was able to hold altitude at this time but [with] little or no climb. I told ATC that we had a problem and wanted to return. He replied that the weather had deteriorated at [our departure, but another airport] had better conditions and was closer. I accepted that recommendation, and he began vectoring us [for the] ILS.… I turned on the carb heat again, but engine power continued to worsen. I couldn’t hold altitude or airspeed, [and the] controller advised [us that] he didn’t show any roads or fields near our position. I broke out at about 400 feet AGL and landed in a farmer’s plowed and very muddy field. [There were] no injuries, and no damage occurred to the plane. No cause has been determined at this time, but I think carburetor ice could be a likely reason. Perhaps I missed signs and should’ve turned it on earlier or left it on longer, or perhaps the carb heat didn’t work as designed.
The De-Icing Communications Vacuum
A Captain’s attempts to communicate were apparently unsuccessful, and his message was not “heard.” As a result, a ground employee got a surprise when he approached this A321 to begin de-icing procedures. The threat might have been mitigated had the Captain’s message been “received.”
[We were] dispatched with an inoperative APU due to APU inlet icing while operating in freezing rain. [We] proceeded to the de-ice pad and contacted Snowman on the assigned frequency. [We explained] our APU problem and notified them four to six times that we had both engines running.… [We were] informed, as we entered [the de-ice] pad, to shut down the number 1 engine for de-ice and anti-ice fluid application. As we [set] the parking brakes and prepared to shut down the engine, Snowman informed us that de-ice personnel had approached the aircraft too soon and had [a] headset sucked into the number 1 engine. After ensuring [that the] employee was safe and unharmed, we contacted ATC, Operations, Maintenance, and Ramp, and returned to the gate.
Specifications More like Guidelines
This air carrier Captain had his aircraft treated with Types I and IV de-icing and anti-icing fluids. He was then perplexed when the Type IV fluid did not perform as specified.
[We] requested de-ice and anti-ice fluid treatment after pushback.… Station personnel sprayed the aircraft with Type I and Type IV fluids.… After being sprayed and commencing taxi to the runway, ATC advised us of a ground stop to our destination, so we returned to the gate. While sitting at the gate for some time, the First Officer and I both noticed snow accumulating on top of both wings after only approximately 45 minutes since the commencement of the application of the Type IV fluid. We pointed out the snow accumulation to the station personnel…to make sure that they understood that the Type IV fluid was not holding up to the minimum holdover time. After our release by ATC, we had the aircraft de-iced and anti-iced again in the same manner and departed without delay to our destination.

The First Officer and I both reviewed the holdover tables for the Clariant fluid, making sure that we were looking at the proper table and reading it correctly. I don’t know why the Type IV fluid underperformed its holdover time.
Missed Trim and Mis-Trimmed
This B737 crew experienced considerable difficulty getting their aircraft properly de-iced before departure. The de-icing procedures produced distractions that resulted in an abnormal configuration for takeoff.
[The] first push was on time. A significant delay occurred waiting for [our] first de-ice attempt.… A cabin check was made, and frozen precipitation was observed on the cabin side of both engine nacelles.… We were deiced a second time. We did another cabin check, but the aircraft still had frozen precipitation in the same locations. Because of the extended ground time, we taxied back to the gate.… We spoke with the Supervisor at the gate, [who]… said that an experienced crew would do the [next] de-icing procedure. They also requested that we trim the aircraft full nose down…to de-ice. As our procedure calls to de-ice in the green band, we had the [trim] as far forward as possible, but remaining in the green [band]. This did result in having to note the trim setting not being [set to] the proper [value] in the Before Push Checklist. We…mentioned the need to reset the trim after de-icing. This time, we decided to do a cabin check at the point of de-icing.… Once again, we did not have a clean aircraft. Another call was made to Ops to de-ice again. Engines were shut down and we again described the location of the snow and contamination.… This fourth and final de-ice procedure was conducted with radio communication directly with the de-ice truck. They did a double check of each problem area and stated that they could see there was no contamination. The Captain did a cabin check and confirmed [that we now had] a clean aircraft.

Post de-icing checklists were done, and we were finally at [the runway].… We were cleared by Tower for takeoff and I taxied slowly onto the runway due to the ice and snow present and fair braking reports by other aircraft. After lining up and confirming the runway, I gave control of the thrust levers to the First Officer. As he advanced the thrust levers, we got a takeoff warning horn. I took control of the aircraft and quickly determined…that the trim, although it looked in the front edge of the green, was clearly not at the [correct] takeoff setting and was the source of the horn. We told Tower we needed to clear the runway.
Better Late Than Never
This B737 Captain was distracted with his wing anti-ice configuration during takeoff. The result was unintentional, but a significant deviation to the takeoff procedure occurred.
From the Captain's report:
[It was a] flaps 1 takeoff on compacted snow. [I] began the takeoff roll with engine heat and wing anti-ice on. After the “V1” call, [I] became distracted by the [wing] anti-ice configuration, causing [me] to miss the…“Rotate” call. [I] rotated approximately 35 to 40 knots late.
From the First Officer's report:
The Captain became distracted by the [wing] anti-ice on configuration right at the point I was making the “Rotate” call, requesting that I turn the wing anti-ice off. (The Wing Anti-Ice Switch was in the ON position with the blue valve position lights illuminated, indicating [the valves] had closed as designed.) I repeated the “Rotate” call two more times in quick succession, and the [Captain] rotated late.
Sliding into Home
An A320 Captain encountered a snow covered ramp while parking his aircraft at the gate. Normal precautions and procedures proved ineffective, so he reverted to his instincts to bring the aircraft to a stop.
[As we approached] the gate, there were no personnel to guide us in. The taxi-in line was covered in snow. After a few minutes, rampers appeared in tugs and on foot. The ramp was slippery as indicated by a ramper falling down…. The tugs were sliding as well. We waited a few more minutes to be marshalled in. Finally the marshallers showed up, and we proceeded into the gate indicating 1 knot on the ground speed readout. I was purposely very cautious on the taxi in. We were given the [normal] stop signal, and [I] set the brakes. The aircraft continued to slide forward even though the brakes were set. The residual thrust at idle was enough to move the aircraft on the ramp under these conditions. The aircraft was not going to hit anything or anyone, but I was helpless at this point. I indicated to the marshaller to get the chocks in. He didn’t have any!!! I turned on the yellow pump and decided to shut down the engines in hopes [that] the loss of the residual thrust would help. It did. The aircraft stopped sliding. What a helpless feeling.… We were lucky that nothing was touched or damaged. Fortunately the jetway was very far away from its normal position.
ASRS Database Online
The ASRS Database is a rich source of information for policy development, research, training, and more.
 Search ASRS Database »
CALLBACK Issue 442
 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
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 »
September 2016
Report Intake:
Air Carrier/Air Taxi Pilots 4,335
General Aviation Pilots 1,183
Controllers 616
Flight Attendants 422
Military/Other 265
Mechanics 211
Dispatchers 111
TOTAL 7,143
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 12
Airport Facility or Procedure 3
ATC Equipment or Procedure 2
Company Policy 1
Other 1
TOTAL 19
Subscribe to CALLBACK for FREE!
Contact the Editor
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 442


T


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

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