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, December 20, 2017

CALLBACK 455 - December 2017


CALLBACK From the NASA Aviation Safety Reporting System
Issue 455
December 2017
Small Odds and Interesting Ends
NASA’s Aviation Safety Reporting System (ASRS) is a voluntary, confidential, and non-punitive reporting system for aviation safety that has served the aviation community since 1976. It is a successful and trusted program, forged from a cooperative effort between the FAA, NASA, and the aviation community. ASRS receives, processes, and analyzes voluntarily submitted reports from pilots, air traffic controllers, flight attendants, maintenance personnel, dispatchers, ground personnel, and others regarding actual or potential hazards to safe aviation operations. The program’s output currently includes aviation safety alert messages issued to appropriate agencies, research studies and special papers on various subjects, a searchable database with direct access to de-identified reports, and CALLBACK. The latter four are publicly available on the ASRS website.1

Value added to aviation safety stems from two important protections that the ASRS program offers to reporters. Confidentiality and limited immunity from FAA enforcement actions are afforded. Naturally, participation has consistently grown, and the result is the richness found in greater breadth and depth of reported incidents, lessons learned, and aviation wisdom. ASRS’s intake is robust, currently averaging 261 reports per calendar day and projected to exceed 95,000 in 2017.

With intake of that magnitude, ASRS receives reports on every conceivable topic related to aviation operations. This month we have reserved a few of the more unusual and light-hearted, but still important, incidents to share. Enjoy these “Odds and Ends” as we conclude another successful year.
Now You See it, Now You Don’t
A Bonanza Pilot became distracted and confused when he perceived the runway edge and centerline lights cycling on and off while ATC assured him that they were on steady.
I was transiting the final approach path of…Runway 16R and observed the runway edge and center line lights cycle on and off…at a rate of approximately 1 per second. It was very similar to the rate of a blinking traffic light at a 4-way vehicle stop. The [3-blade] propeller speed was 2,400 RPM. This was observed through the entire front windscreen and at least part of the pilot side window. I queried ATC about the reason for the runway lights blinking and was told that they were not blinking. It was not immediately obvious what was causing this, but I did later speculate that it may have been caused by looking through the propeller arc.

The next day [during] IFR training while on the VOR DME Rwy 16R approach, we observed the runway edge and center line lights cycle on and off…at a rate slightly faster than 1 per second. The propeller speed was 2,500 RPM. I then varied the propeller speed and found that at 2,700 RPM, the lights were observed strobing at a fairly high rate, and at 2,000 RPM the blinking rate slowed to less than once per second. This was observed through the entire approach that terminated at the Missed Approach Point (MAP). The flight instructor was also surprised and mentioned that he had not seen this before, but he also doesn’t spend much time behind a 3-blade propeller arc.

I would speculate that the Pulse Width Modulation (PWM) dimming system of the LED runway lights was phasing with my propeller, causing the observed effect. I would also speculate that the effect would…significantly differ at other LED dimming settings…and behind a 2-blade propeller.

I found the effect to be entirely confusing and distracting, and would not want to make a landing in such conditions.
Snakes on a Plane
A Large Transport Captain receiving a line check experienced a peculiar problem during the pre-departure phase of flight. He may have speculated whether the rest of the flight would be as “snake bitten” as the idiom implies.
Well within hearing distance of the passengers, the Gate Agent said, “Captain, I am required to inform you that while cleaning the cockpit, the cleaning crew saw a snake under the Captain’s pedals. The snake got away and they have not been able to find it. I am required to tell you this.”

At this time the [international pre-departure] inspection was complete, and I was allowed on the aircraft. I found two mechanics in the flight deck. I was informed that they had not been able to find the snake and they were not able to say with certainty what species of snake it was. The logbook had not been annotated with a write up, so I placed a write up in the logbook. I was also getting a line check on this flight. The Check Airman told me that his father was deathly afraid of snakes and suggested that some passengers on the flight may suffer with the same condition.

I contacted Dispatch and discussed with them that I was uncomfortable taking the aircraft with an unknown reptile condition.… The possibility [existed] that a snake could expose itself in flight, or worse on the approach, come out from under the rudder pedals. Dispatch agreed with my position. The Gate Agent then asked to board the aircraft. I said, “No,” as we might be changing aircraft. I then contacted the Chief Pilot. I explained the situation and told him I was uncomfortable flying the aircraft without determining what the condition of the snake was. I had specifically asked if the cleaning crew had really seen a snake. I was informed yes, that they had tried to vacuum it up, and it had slithered away. The Chief Pilot agreed with me and told me he would have a new aircraft for us in five minutes. We were assigned the aircraft at the gate next door.

…When I returned [to the airport], I asked a Gate Agent what had happened to the “snake airplane.” I was told that the aircraft was left in service, and the next Captain had been asked to sign some type of form stating he was informed that the snake had not been found.
Up, Close, and Personal
While attempting to mitigate a known, visible hazard, an Air Taxi Captain took special care to clear his wingtips while taxiing for takeoff. A surprise loomed ahead just as he thought that the threat had subsided.
Taxiing out for the first flight out of ZZZ, weed whacking was taking place on the south side of the taxiway. Watching to make sure my wing cleared two men mowing [around] a taxi light, I looked forward to continue the taxi. An instant later I heard a “thump.” I then pulled off the taxiway onto the inner ramp area and shut down, assuming I’d hit one of the dogs that run around the airport grounds on a regular basis. I was shocked to find a man, face down, on the side of the taxiway. His coworkers surrounded him and helped him to his feet. He was standing erect and steady. He knew his name and the date. Apparently [he was] not injured badly. I attended to my two revenue passengers and returned the aircraft to the main ramp. I secured the aircraft and called [the Operations Center]. An ambulance was summoned for the injured worker. Our ramp agent was a non-revenue passenger on the flight and took pictures of the scene. He stated that none of the workers was wearing a high visibility vest, which I also observed. They seldom have in the past.

This has been a recurring problem at ZZZ since I first came here. The operation is never [published in the] NOTAMs [for] an uncontrolled airfield. The pilots just have to see and avoid people and animals at all times. I don’t think the person that collided with my wingtip was one of the men I was watching. I think he must have been stooped down in the grass. The only option to [improve the] safety of the situation would be to stop completely until, hopefully, the workers moved well clear of the taxiway. This is one of…many operational deficiencies that we, the pilots, have to deal with at ZZZ on a daily basis.
Corrigan Conquers Again
An RV-7 Pilot was planning ahead for the weather he observed prior to departure. The weather, distractions, and personal stress influenced his situational awareness and decision-making during the takeoff.
I was cleared to depart on Runway 27L from [midfield at] intersection C. However, I lined up and departed from Runway 9R.… No traffic control conflict occurred. I turned on course and coordinated with ATC immediately while airborne.

I had delayed my departure due to weather [that was] 5 miles east…and just north of the airport on my route.… Information Juliet was: “340/04 10SM 9,500 OVC 23/22 29.99, Departing Runway 27L, Runways 9L/27R closed, Runways 5/23 closed.” My mind clued in on [Runway] 09 for departure. In fact I even set my heading bug to 090. Somehow while worried mostly about the weather, I mentally pictured departing Runway 9R at [taxiway] C. I am not sure how I made that mistake, as the only 9 listed was the closed runway.… My focus was not on the runway as it should have been, but mostly on the weather.

Contributing factors were:
1.Weather.
2. No other airport traffic before my departure. (I was looking as I arrived at the airport and completed my preflight and final weather checks).
3. Airport construction. For a Runway 27 departure, typical taxi routing would alleviate any confusion.
4. ATIS listing the closed runway with 9 listed first.
5. Quicker than expected takeoff clearance.
I do fly for a living.… I will be incorporating the runway verification procedure we use on the jet aircraft at my company into my GA flying from now on. Sadly, I didn’t make that procedural change in my GA flying.
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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 »
October 2017
Report Intake:
Air Carrier/Air Taxi Pilots 4,897
General Aviation Pilots 1,407
Controllers 544
Flight Attendants 411
Military/Other 320
Dispatchers 233
Mechanics 200
TOTAL 8,012
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 4
Airport Facility or Procedure 4
ATC Equipment or Procedure 6
Other 1
TOTAL 15
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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 455



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

CALLBACK 454 - November 2017


CALLBACK From the NASA Aviation Safety Reporting System
Issue 454
November 2017
Weather – You're Prepared or Not
The arrival of winter weather brings an assortment of phenomena which manifest themselves in many predictable aviation hazards. Commercial and General Aviation are similarly affected. Winter storms, turbulence, low ceilings and visibilities, fog, freezing rain, ice, snow, and slippery surfaces all demand special attention. With increased workload, concentration becomes more fragmented, and situational awareness can suffer. Crews may exhibit more susceptibility to common or uncommon winter threats.

The FAA is attempting to reduce the risk of runway overrun accidents and incidents due to runway contamination caused by weather.1 In October 2016, the FAA implemented Takeoff and Landing Performance Assessment (TALPA) procedures that include new tools such as the Runway Condition Assessment Matrix (RCAM). After just one season, TALPA has produced significant improvements to operational safety. A TALPA Stakeholders Feedback Review2 was held in July 2017, and recommendations from this review are targeted to become procedural changes.

This month CALLBACK shares reported incidents spawned by typical winter weather. Even if you are not familiar with TALPA procedures, we encourage you to learn more, connect your dots, and glean the lessons in these reports.
The Winter Wing Ding
A Learjet Captain anticipated and experienced icing conditions during his descent. As a precaution, he turned on the nacelle heat, but he had not bargained for the surprise he received during the landing.
Descending through FL180, I turned on the nacelle heaters, but did not turn on the wing and stab heat, as I anticipated a short descent through a shallow cloud layer to temperatures above freezing. The approach proceeded normally.… The aircraft entered the cloud tops at approximately 1,500 feet MSL and exited the bases at approximately 900 feet MSL. There were no indications of ice accumulation on the normal reference area during descent. During the landing flare (less than 10 feet AGL), as the flying pilot applied right aileron to counteract the right crosswind, the left wing abruptly dropped. I immediately took the controls, applying full right aileron as the left main landing gear contacted the runway, followed closely by deployment of spoilers, thrust reversers, and brakes to return the aircraft to the runway centerline.

Upon exiting the aircraft, I observed a small amount (less than 1/4 inch) of rough, rapidly melting ice on the leading edges of the wings. Inspection revealed that the trailing edge of the left wingtip had contacted the runway surface, causing abrasion to the contact area. I believe the combination of the small amount of ice, aileron deflection, and mechanical turbulence from buildings on the upwind side of the runway caused the left wing to stall at a higher than normal airspeed, resulting in the uncommanded left roll. Contributing factors include my failure to turn on the wing and stab heat prior to entering the cloud layer.
Ever Present Proverbial Pitot Heat
This SR22 pilot experienced aircraft icing while IFR in IMC. He kept the wings, propeller, and windshield clear of ice, but the routine associated with his VMC habits caused another problem.
I was on an IFR flight plan.… We had been in and out of the clouds picking up light rime ice.… Occasional use of the aircraft’s ice protection system was easily keeping the wings, propeller, and windshield clear of ice buildups.… We were initially above the clouds at 10,000 feet, but soon realized we would again be in the clouds. Center gave us a climb to 11,000 feet MSL where we remained in IMC. The Controller reported another aircraft ahead of us was in VMC at 13,000 feet MSL and offered a climb to 13,000 feet MSL.

As I considered the options of climbing to 13,000 feet (we had supplemental oxygen on board), I first noted significant ice accumulating on the windshield and wings, and then the airspeed began to fluctuate and suddenly dropped to 60 knots on the Primary Flight Display (PFD). I immediately recognized a Pitot-Static System failure, disconnected the autopilot, and began hand flying using the attitude indicator and standby instruments as primary references. I also immediately noted that, although the Ice-Protection Switch was on, the Pitot Heat Switch was in the OFF position. I turned on the pitot heat, selected alternate static air, and advised Center. The Center Controller cleared me for a descent to 8,000 feet, which I initiated slowly using only the attitude indicator as a reference. Within 2 minutes the airspeed indicator and altimeter began indicating normally.… We broke out into VMC at approximately 8,000 feet MSL.… The rest of the trip was uneventful, and a safe landing was completed.

In hindsight I realized that I traditionally do not turn on the pitot heat because most of my personal flying is VFR.… I will now…always turn on the pitot heat before takeoff, regardless of the flight conditions.
Clear and Present Danger
This BAe125 crew encountered widespread winter weather and elected to divert. Weather and aircraft consumables reduced their number of options and influenced decisions which could have had a much worse outcome.
The entire New York City area was forecast for moderate to severe icing conditions, snow, and low visibility. Numerous PIREPs reported the presence of such icing conditions, which were further confirmed by an amber ICE DETECT light indication. We elected to divert to Morristown, NJ, which was reporting 2 miles visibility, adequate ceilings, and moderate snow.… At the time we began receiving vectors, the amber ANTI-ICE LOW QUANTITY annunciator illuminated, indicating that we had approximately 30 minutes of ice protection remaining.

We were cleared for the approach and configured normally.… Upon reaching the MDA, I continued searching for the runway. The runway came into view, and I called, “Runway in sight, 12 o’clock.”… It became clear to me that we did not have the required visibility for the approach and that we did not have the ability to achieve a normal rate of descent to a normal landing.… I called for a go-around, and the pilot flying responded something like, “I think I’ve got it, yeah, I’ve got it,” and continued the approach. He immediately retarded the thrust levers to idle and called for full flaps. We immediately began an excessive descent rate and received ground proximity warnings that said, “SINK RATE, SINK RATE, PULL UP,” and continued…until just before touchdown. We landed just about halfway down a snow covered runway that was 5,998 feet in length. The braking action was good and we stopped…on the runway. The next several aircraft behind us were not able to land…and diverted to an alternate.
Low Visibility White Out Taxi
After a successful approach and landing in traditional winter weather, this Large Transport Captain was surprised by an unexpected stop while taxiing to the gate.
After landing, on the taxi-in, we turned westbound on the taxiway. Since it was snowing fairly hard and the wind was blowing, we made sure to identify the yellow centerline and confirmed it by noting the blue taxi lights to our right. Almost abeam [the turn point] to the gate, the right engine shut down. We stopped and requested a tug. When the snow let up, we determined that we were stuck on a snowdrift that had blown onto the taxiway.
Icing the Puck
This Large Transport crew planned extensively for their approach and landing. The approach and touchdown were executed well, but procedures they used during the landing rollout were not as successful.
Weather at our arrival time was forecast to have blowing snow, 2 SM visibility, winds gusting up to 24 knots out of the northwest, and ceilings between 800 and 1,500 feet. ATIS advertised arrivals to Runways 28C, 28R, and 4R at various times enroute.… We planned a primary approach to Runway 4R and pulled landing data for Runways 28C and 28R in case of further changes. ATIS advertised braking action of 5-5-5 for Runway 4R. The landing data calculation produced a 7,000 foot stopping distance for good braking action with Autobrakes 3 and flaps 30. Stopping distance declined to 6,500 feet for Autobrakes 4. We discussed both braking options. The Captain initially chose Autobrakes 4 while I favored Autobrakes 3. He ultimately chose Autobrakes 3.

ATIS called the winds 340/23G29, which drove a target speed of 151 knots. Tower verified the same winds at initial check-in.… The landing was smooth and uneventful.

The Captain used full reverse thrust and stowed the reversers passing 80 knots. He called 3,000 feet runway remaining at the appropriate location and seemed to have complete control of the aircraft. At that point, he asked me to disengage the autobrakes. I noted the airspeed decelerating through 70 knots and stowed the speed brakes in order to disengage the autobrakes. I expected the Captain to use manual braking at that point to ensure control of the aircraft as we decelerated to taxi speed. The aircraft did not decelerate like I expected between 3,000 and 1,000 feet remaining. At that point, I could see the end of the runway approaching rapidly and told the Captain that he needed to come left to exit the runway. That was when I realized that he was trying to stop the aircraft and bring it left without success.

The runway end identifier and taxiway lights came up quickly, and we slid right as the right main gear departed the prepared surface. It took me a brief period of time to realize that the main gear had departed the prepared surface. I called…Tower to tell them that we had departed the runway and would not be able to clear Runway 4R. After our situation was clarified with Tower, I started the APU and shut down Number 2 Engine.
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 454
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 Search ASRS Database
 ASRS Homepage
Subscribe to CALLBACK for FREE!
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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 »
September 2017
Report Intake:
Air Carrier/Air Taxi Pilots 4,157
General Aviation Pilots 1,256
Controllers 515
Flight Attendants 335
Military/Other 302
Mechanics 188
Dispatchers 129
TOTAL 6,882
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 1
ATC Equipment or Procedure 1
TOTAL 2
Subscribe to CALLBACK for FREE!
Forward to a Friend
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 454



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

Tuesday, October 17, 2017

CALLBACK 453 - October 2017


CALLBACK From the NASA Aviation Safety Reporting System
Issue 453
October 2017
Re-sourcing Crew Management
The application of team management concepts in the flight deck environment was initially known as cockpit resource management. As techniques and training evolved to include Flight Attendants, maintenance personnel, and others, the new phrase “Crew Resource Management” (CRM) was adopted. CRM, simply put, is “the ability for the crew…to manage all available resources effectively to ensure that the outcome of the flight is successful.”1 Those resources are numerous. Their management involves employing and honing those processes that consistently produce the best possible decisions. Advisory Circular 120-51E, CREW RESOURCE MANAGEMENT TRAINING, suggests that CRM training focus on “situation awareness, communication skills, teamwork, task allocation, and decisionmaking within a comprehensive framework of standard operating procedures (SOP).”2

Aircrews frequently experience circumstances that require expert CRM skills to manage situations and ensure their successful outcomes. Effective CRM has proved to be a valuable tool to mitigate risk and should be practiced on every flight. This month CALLBACK shares ASRS reported incidents that exemplify both effective CRM and CRM that appears to be absent or ineffective.
Who Has the Aircraft?
A B737 Captain had briefed and instituted his non-standard method to transfer aircraft control when the FO performed takeoffs. When he did not employ his own technique, confusion was evident and aircraft control was questionable.
[As we were] pushing back in Albuquerque, ATC switched the airport around from Runway 26 to Runway 8. The Captain and I ran the appropriate checklist and proceeded to taxi…. I was the Pilot Flying (PF) [for this leg]. The Captain stated previously that he likes to spool the engines up and transfer controls while the aircraft is moving.

Once cleared for takeoff, the Captain spooled the [engines]. I was expecting him to transfer controls. I monitored him spool them up to takeoff power. While he was accelerating, my comment was, “I’m not flying the aircraft. You have the controls.” He seemed confused briefly, and we took off with the Captain in full control without incident. The Captain needs to [abandon] the habit of transferring thrust levers to the First Officer while moving. It’s a bad habit. It can be confusing if one of the crew members is saturated.… Under no circumstance should transfer of thrust levers and aircraft happen while saturated in the takeoff phase while moving.
Freedom of Speech
This Captain received uncommon, simultaneous inputs from two unexpected sources. An accident may have been averted when the Heavy Transport crew exercised simple, effective CRM in a critical situation and high workload environment.
This was a night takeoff,…and it was the FO’s first flying leg of Initial Operating Experience (IOE). Two Relief Pilots were assigned for the flight. We were cleared onto the runway…after a B737 [had landed]. The FO taxied onto the runway for takeoff. Once aligned for takeoff, I took control of the throttles. At this point I thought we were cleared for takeoff, but apparently we were not. I advanced the power to 70% and pressed TOGA. At about that same time, a Relief Pilot alerted the flying pilots that the other plane that had just landed was cleared to [back-taxi]…on the runway, and the Tower alerted us to hold our position. I disconnected the autothrottles and immediately brought them to idle. [Our speed was] approximately 30 knots, and we had used up approximately 200 to 400 feet of runway. The back-taxiing B737 exited the runway.

Looking back, somehow the clearance to take off or the non-clearance was lost in the translation. The Controllers in ZZZZ most often use non-standard phraseology with an accent not easily understood.… Higher than normal workloads [existed] due to a new hire first leg, and the flight was late and had been delayed from the previous day. I had assumed situational awareness with the airport and runway environment. Generally in past practice, ZZZZ holds the landing traffic in the holding bay after landing and does not have two airplanes on the runway at the same time. What “saved” the situation was good CRM and situational awareness by the Relief Pilots.
Finishing Strong
This MD80 crew finished the last leg of their trip, but distractions degraded the performance of their duties. Unmanaged threats had contributed to the misperception that the job was done when it was clearly incomplete.
From the Captain's report:
The landing was uneventful, and we were given an expedited crossing of the departure runway. We accomplished the after landing checklist, but due to the expedited crossing, I wasn’t sure if the First Officer started the APU (which had been consistent/standard practice so far in the trip). We were cleared to enter the ramp, and I consciously elected to leave both engines running (which was contrary to my standard practice during the trip). As we turned to pull into the gate,…an unmarked van cut across our path. We saw him coming, so no immediate stop was necessary.… At the gate,…we pulled to a stop normally, parked the brakes, and I believe I commanded, “Shut down engines.” The FO believes he heard, “Shut down the left engine” (which had been the standard command throughout the trip). He shut down the left engine. The right engine continued to run and we finished the Parking Checklist and departed the cockpit.

Minutes later…I received a page…requesting that I return to the gate. I returned to find the right engine running. I immediately shut off the fuel lever. No damage or injuries occurred. The aircraft was chocked and the brakes parked. In my estimation, there are three distinct contributing factors in this event.
1. Complacency when reading the checklist. I assumed items had been accomplished and felt no need to follow up the response with a tactile and visual check.
2. Complacency when relying on past actions as a predictor of future actions. We had done things the same way each leg, therefore we would continue to do them the same way on every leg.
3. Distractions. The expedited crossing to the ramp side of the runway, compressed time frame for completing the after landing checklists, and vehicular traffic all led to this event.… These issues…still keep happening. Strict, unyielding adherence to policy and procedures is a must. No one is perfect, and that is why policies and procedures exist. An event like this WILL happen if you allow yourself to become too comfortable.
From the First Officer's report:
We arrived at the gate, and the parking brake was parked. The Captain remarked, “Shut down the Number 1 Engine, Parking Checklist.” I read the checklist as the Captain responded. At the end of the checklist, I exited the aircraft.… I had walked about 10 gates down from the aircraft…when I heard an announcement asking the flight crew inbound from our flight to please return to the gate.… No one was there when I returned.… About 5 minutes later the agent walked up…and told me that one of the engines had been left running. She let me on the jet bridge and the Captain was walking off the aircraft.…

I believe this problem came about because of a pattern we developed during all our flights.… I started the APU…after landing, and…about two to three minutes [later], would shut down the Number 2 Engine at the Captain’s request. We did this every flight. After landing on this flight, it got very busy.… When…at the gate, the Captain called for me to shut down the Number 1 Engine, I didn’t think about the Number 2 Engine still running.… I read the checklist and listened to the Captain’s responses. I should have been double checking him, but I didn’t.… This has never happened to me.…I’m just grateful that no one was hurt….
Here, Here! and Hear, Hear!
This Dash 8 crew experienced a flight control problem that required extensive coordination. Thorough, effective CRM contributed to the orderly sequencing of their decisions and to the successful completion of their flight.
We had to deice prior to takeoff, and we checked all flight control movements twice before we took off. At the beginning of the cruise portion of the flight, the…Master Caution Annunciators…and two amber Caution [lights] illuminated: ROLL SPLR INBD HYD (Spoiler Inboard Hydraulics) and ROLL SPLR OUTBD HYD (Spoiler Outboard Hydraulics). We completed the associated Spoiler Failure Checklist, including confirming that all spoilers [indicated] retracted at the PFCS (Primary Flight Control System) indicator. The Pilot Flying, the Captain, continued to hand fly the aircraft (as our autopilot was [inoperative] for all legs). We evaluated all facts, discussed all of our options, and [advised Center of our flight control situation]. We informed them that we were not requiring any assistance (upon landing or elsewhere).

The Captain talked to Dispatch and Maintenance, while I hand flew the aircraft. The Captain, Dispatch, and I all agreed that ZZZ, with its long runways, was the best place to land. I informed our Flight Attendant that we were planning on a normal, uneventful landing with no delays. ATC issued [our runway], and we executed a visual approach. [We accomplished] a normal landing and taxi. We thanked ATC for all of their help. At the gate, the maintenance write up was completed. The smooth outcome can be attributed to very good CRM exhibited today.
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 453
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 Search ASRS Database
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Forward to a Friend
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 »
August 2017
Report Intake:
Air Carrier/Air Taxi Pilots 5,349
General Aviation Pilots 1,391
Controllers 598
Flight Attendants 516
Military/Other 321
Mechanics 203
Dispatchers 196
TOTAL 8,574
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 2
ATC Equipment or Procedure 1
TOTAL 3
Subscribe to CALLBACK for FREE!
Forward to a Friend
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 453

   



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

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