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.

Tuesday, October 17, 2017

CALLBACK 452 - September 2017

CALLBACK From the NASA Aviation Safety Reporting System
Issue 452
September 2017
What Would You Have Done?
This month, CALLBACK again 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 point where a decision must be made or some direction must be given. You may then exercise your own judgment to make a decision or determine a possible course of action that would best 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 refine your aviation decision-making skills. In “The Rest of the Story…” you will find the actions that were 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, training, and discussion related to the type of incidents that were reported.
The First Half of the Story
What’s All the Flap?  B737 First Officer’s Report
As the Pilot Flying while maneuvering in the busy terminal area, I didn’t notice that the flap indicator did not match the [flap] handle (2 indicated, 30 selected) until the Captain identified it with the…Before Landing Checklist. We checked the Leading Edge Device [LED] indicator on the overhead panel; the LED’s [indicated] FULL EXTEND. We discussed how the aircraft felt as it was being hand flown. The feel was normal.… The airspeed indicator was normal. The aircraft flew normally in all aspects except for the flap indication. All this occurred approaching the final approach fix..

[The] airport (with a single runway) was undergoing major construction and had no parallel taxiway.… The only exit from the runway was a single narrow taxiway at the [approach] end of Runway 02 leading between some hangars to and from the FBO. [There was] no operating Control Tower, only UNICOM. Before departure I asked…the FBO what the active runway was, and the reply was, “People are taking off on Runway 02 and landing on Runway 20 to avoid a back taxi on a long runway.” Taxiing out to Runway 02 for departure I encountered another…single engine airplane near the runway end taxiing in on a narrow taxiway…, so we talked ourselves past each other on UNICOM. I had apparently not heard the radio call…of a small jet landing on Runway 20, so I started my takeoff roll on Runway 02.… The aircraft that had [just] landed…was at taxi speed. During my takeoff roll, I only saw that aircraft when I was near rotation speed.

The Rest of the Story

The Captain elected to continue to land. We used flaps 15 Vref [speed for the approach] and added 10 knots. Landing was uneventful. The flap indicator moved to match the [flap] handle shortly after clearing the runway during taxi. We notified maintenance on gate arrival.

I thought the best option was to immediately lift off with a slight turn to the right to laterally clear the runway in any case, and that worked. I missed him vertically by 50 feet and laterally by more than 150 feet. Was that the best split-second decision? I thought so - I am an [experienced] pilot. In my opinion, the airport management had made some bad decisions concerning their improvement construction (reconstructing the parallel taxiway), and the airport was dangerous considering their heavy corporate jet traffic. I had not heard the small jet on UNICOM - possibly due to my conversation on UNICOM with the…plane taxiing in (opposite direction) just prior to takeoff. The wind was…light, and Runway 20 was apparently chosen by the jet traffic to, likewise, avoid a back taxi since the only runway exit was at the [departure] end of Runway 20.

I [requested] to level off at FL350, then to descend to FL320. I was the pilot monitoring. I did not [request priority handling] at this time because we received no EICAS messages or alerts telling us of this situation.

After rechecking the engine instruments and conferring with the pilot flying, I made the decision to shut down the engine inflight via the QRH Engine Failure/Shutdown Checklist.… I also made the decision that we would attempt to restart the engine because no limitations or engine parameters or engine vibrations were present or were exceeded. At this time we were about 20 minutes into the flight.… The inflight shutdown checklist was completed, and the engine inflight start checklist was completed. The engine started and accelerated normally,…and all parameters [remained within] limitations.… I contacted Dispatch and Maintenance Control…. After speaking with them and informing them of our situation and what transpired, I made the decision to continue to destination.

[I] told him to stop the descent. We stopped 150 feet below the MDA, continued the approach, and landed. Looking back at the approach, I should have called for a missed approach and received vectors for another approach. The only reason for continuing was…poor judgment or just a bad decision at the time.

[We] requested a 360 degree turn for our descent from the Tower. They approved us to maneuver either left or right as requested, and we initiated a go-around and a 360 degree left turn in VMC conditions. We initiated the go-around above 1,000 feet but descended slightly during the first part of the turn. I directed the FO to climb to 1,000 feet, which he slowly did. I had referenced the approach plate and noticed that the obstacles on the plate in our quadrant were at 487 feet and our climb ensured clearance from them. During the 360 [degree] maneuver, the FO lost sight of the airport, but I had it in sight and talked him through the turn back to the landing runway.

The FO completed the maneuver, but we were, again, not in a position to make a safe landing, as we were not well aligned with the landing runway.… We initiated another go-around, again getting approval to stay with Tower, but we maneuvered in a right hand pattern so the FO could see the runway in the turn. I directed a climb to 1,500 feet for the 579 foot towers west of the field. The FO…had lost sight of the field and wasn’t sure what maneuver we were doing while on downwind.… I had not adequately communicated my intentions for the pattern we were flying. We were maneuvering visually, so I took control of the aircraft and directed the FO to re-sequence the FMC…and extend the centerline. I completed the base and final turns and landed uneventfully on Runway 18.

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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 »
July 2017
Report Intake:
Air Carrier/Air Taxi Pilots 5,224
General Aviation Pilots 1,261
Controllers 622
Flight Attendants 451
Military/Other 345
Mechanics 204
Dispatchers 179
TOTAL 8,286
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 1
ATC Equipment or Procedure 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 452


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