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
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 »
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
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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

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