CALLBACK 455 - December 2017

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Issue 455 December 2017 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. 1. https://asrs.arc.nasa.gov 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 455 Download PDF & Print View HTML ASRS Online Resources CALLBACK Previous Issues Report to ASRS Search ASRS Database ASRS Homepage Special Studies 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 » 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 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

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Issue 454 November 2017 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. 1. https://www.faa.gov/news/updates/?newsId=88369 2. https://www.faa.gov/about/initiatives/talpa/update_meeting_July_2017/     media/TALPA-Update-Meeting-2017-Stakeholder-Feedback-w-Notes.pdf 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 Special Studies 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 » 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 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