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Callback: What’s All The Flap About?
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..
Safe Landings: The Pursuit and Presumption of Balance
Weight and balance has been a critical issue in aircraft operations since the beginning of aviation. Loading errors can go unnoticed and have potential to cause great harm. Clerical mistakes that account for cargo weight and location can be subtle and equally costly.
This month’s CALLBACK examines several reports that highlight weight and balance errors. In the following accounts, all the aircraft unknowingly departed with uncertain centers of gravity and most departed with an inaccurate gross weight that was assumed correct. Many of the mistakes were not discovered until the aircraft was airborne and some, not until the aircraft landed. Other similarities included unknown cargo weights and freight that was loaded in improper locations. These mistakes might have been prevented. The ASRS report excerpts reiterate the need for attentiveness and accuracy in every aspect of weight and balance procedures.
The first three reports describe incidents where cargo was loaded in the wrong location on the aircraft. The remaining accounts detail various other errors that were experienced in Air Carrier Operations.
The Usual Suspects
Cargo loaded into the wrong compartment and closeout paperwork that did not specify its location allowed this B737 Flight Crew to launch with an inaccurate Center of Gravity (CG) that was not discovered until after the aircraft landed.
Safe Landings: January 2015
“The Airplane was still in a Descent with Full Power”
Faced with little IFR experience, poor CRM, and airframe icing, the pilots of a Rockwell 112 were lucky to break out into conditions that would allow the ice to dissipate. Among the lessons this incident highlights are the need for an adverse weather “escape plan,” and the value of building actual instrument time with a qualified instructor until proficiency is attained.
• Sunset was imminent, this area of the country was new to me, and the more things changed for the worse, the more interest I had in parking the airplane and just spending the night in a hotel.
Always leave an out. The area over the airport…was in IMC. Ordinarily this would not have been an issue. The AWOS indicated a 1,500-foot ceiling. Things were going smoothly then at 6,000 feet, with no control input to cause a descent rate of more than 500 feet per minute, my VFR rated passenger told me that we were descending (I could see that and was trying to process why we were descending). He further stated that I needed to “fly the airplane.” Then he took the controls and pulled back on the yoke. The attitude indicator shifted to a very sharp indication of a left turn. The descent rate increased to about 1,500 feet per minute. I could not over power this person. I told him, “The airplane was flying a minute ago; let the airplane continue to fly.” He let go of the controls. I reiterated that announcing, “Your airplane/my airplane” prior to manipulating any controls was a requirement when flying with me.
Safe Landings: October 2014
Fuel Management Errors
Fuel management errors continue to account for a significant percentage of the General Aviation forced landing incidents reported to ASRS. However, since fuel exhaustion and fuel starvation events often result in significant aircraft damage and personal injury, an even greater number of fuel management errors result in NTSB accident reports.
The following ASRS reports offer sobering lessons from pilots who have “been there, done that” and, fortunately, survived to share their experiences. Top off your fuel management wisdom by learning from these fuel management mishaps.
In a Position to Fail
This Twin Piper pilot learned that “close” is not good enough when it comes to positioning fuel tank selector switches.
■ While flying solo on an IFR flight plan in a rental Twin Piper approximately 20 nautical miles to the east of my destination, I was cleared to descend from 8,000 feet to 6,000 feet. At this time, I was in IMC with light rain. As part of routine pre-landing checks, I switched both left and right tanks from Auxiliary to Main. As I was reaching 6,000 feet, the right engine started to run rough for a few seconds and subsequently failed. Since I was in the landing phase of the flight, there was no time to complete the “cause check” procedure. When ATC asked me to maintain altitude, I responded, “Unable” and explained that I was on one engine only. At this time, I was in VMC. I squawked 7700, declared an emergency, and requested vectors to the nearest airport. ATC vectored me to a nearby field, advised that I could land on any runway, and switched me to Tower frequency. Tower immediately cleared me to land. I maintained a safe airspeed, lowered the landing gear and flaps, and landed uneventfully. The next day, I found that although the fuel selector had been set to the Main position, the engine was still drawing fuel from the auxiliary tank, which had eventually emptied and led the engine to fail due to fuel starvation. Apparently, the fuel selector valve had not been positioned completely in its detent position (close, but had not “clicked”). This incident was a good lesson learned, and I have become more alert and diligent to ensure the fuel selector valves are properly positioned when using them to switch between tanks.
Safe Landings - June 2014
Message from the Editor: Though these incidents are all airline related, the systems involved are now also used in GA and could cause accidents.
Autoflight control modes generally involve interrelated functions of the Flight Management System (FMS), the flight director, the autopilot and autothrottles. The mode logic controlling the combined input of these systems can be very complex. Despite focus on design improvements and training emphasis on flight management modes, ASRS continues to receive a significant number of incident reports on mode related errors. While they usually result in minor “altitude busts” or crossing restrictions not met, mode errors can also lead to more serious outcomes including Controlled Flight Toward Terrain (CFTT).
Safe Landings - April 2014
Safe Landings - March 2014
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 the event up to the decision point. You may then use your own judgment to determine the 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 Cessna 210 Pilot’s Report
■ I was on an IFR flight plan…in cruise at 8,000 feet. The autopilot stopped operating. While I was troubleshooting the problem, I noticed that the battery charge was low and falling rapidly. I attempted to notify Approach of the problem and believe that they understood that I…was about to lose communications…. I started turning off some electrical systems in an attempt to save battery power while troubleshooting the alternator. It did not come back online and I turned off the battery to conserve what power remained. I attempted to make radio contact with a hand-held radio, but either its transmissions were too weak or its battery was too low….
Safe Landings - January 2014
Safe Landings - November 2013
Safe Landings - October 2013
Automation Issues
As autoflight system managers, Flight Crews are responsible for entering correct information into the flight management system, selecting the appropriate flight mode and monitoring the aircraft’s compliance with the desired flight path. As pilots, Flight Crews must maintain situational awareness, stay ahead of the aircraft, use good judgment, make sound decisions based upon training and experience, and do whatever is necessary (within the constraints of good airmanship) to put the airplane where it is supposed to be. These responsibilities apply not only to air carrier and corporate crews, but with the growing use of automation, to general aviation pilots as well.
This CALLBACK presents a few recent reports in which Air Carrier Flight Crews and a General Aviation Pilot share some lessons learned regarding automation issues
Safe Landings - July 2013
Safe Landings - June 2013
It has been said that the only voluntary act in aviation is the decision to take-off. Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.
In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others. These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs. Additionally, NASA distributes an electronic publication, CALLBACK, which contains selected, de-identified, reports on a free subscription basis. In Flight USA is proud to reprint selected reports, exerted from CALLBACK, for our readers to read, study, occasionally laugh at, and always learn from. Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.
Weather and Aeronautical Information Services and Data Link Issues
In cooperation with the Federal Aviation Administration (FAA), the Aviation Safety Reporting System (ASRS) initiated a study of meteorological (MET) and aeronautical information services (AIS) received via data link. The purpose of the study was to analyze information from users of data link technologies as reported in ASRS incident reports. Qualitative assessments of available records provided valuable insight on data link user interface and actual cockpit experiences related to data link weather or AIS information. The preliminary findings in the Study included:
Safe Landings - May 2013
Gear Up Landings – Getting a Handle on the Problem
Over the past five years, ASRS has received an average of 60 gear up landing reports per year. Gear up landings rarely meet the damage or injury requirements for a National Transportation Safety Board (NTSB) report or investigation and they are seldom reflected in general aviation safety statistics. Nevertheless, no pilot wants to experience a gear up landing. There is always the potential for a serious outcome and the repair costs associated with any gear up landing can be substantial. To avoid the risks and costs associated with gear up landings, pilots can get a handle on the lessons offered in these ASRS reports.
Scrape and Go Landing
A malfunctioning gauge, failure to use a checklist and the absence of a gear warning horn were all factors in this blade-bending low approach.
Safe Landings - April 2013
Safe Landings - March 2013
Safe Landings - February 2013
Safe Landings - January 2013
It’s a Blast But It’s Not Fun
During takeoff and some taxi maneuvers, the high thrust levels of modern jet engines can produce exhaust wakes that present a significant hazard to other aircraft operating on or near the airport surface. The jet blast incidents presented in this CALLBACK highlight the need for both Pilots and Air Traffic Controllers to be aware of the circumstances where this hazard can occur and take measures to avoid jet blast or prevent it.
The three events below deal with aircraft versus aircraft scenarios that occurred in the runway environment. Jet blast (or prop wash) can also occur in the ramp area where it poses a risk to vehicles and ground personnel as well.
While most general aviation pilots think of wake turbulence and jet blast as being issues that primarily concern pilots of small planes, it should be noted that even “big on big” can have problems. A little Cessna 150 can receive the same surprise some of these pilots did when caught by the surprise of a Barron in the middle of a high power run up. Don’t count on the tower to prevent prop and jet blast from being a problem. As the PIC, this is your job.
Safe Landings - December 2012
Adverse Weather Planning and Tactics
Two Perspectives
According to the FAA General Aviation Pilot’s Guide to Preflight Planning, Weather Self-Briefings, and Weather Decision Making, many pilots who hear about a weather-related accident think, “I would never have tried to fly in those conditions.” But interviews with pilots who survived weather-related accidents indicate that they thought the same thing — until they found themselves in weather conditions they did not expect and could not safely handle. This CALLBACK presents weather-related ASRS incident reports along with corresponding National Transportation Safety Board (NTSB) accident reports involving the same type of aircraft in similar weather conditions. The ASRS reports offer a first-hand account of what were often narrow escapes from adverse weather conditions. The NTSB reports are second-hand accounts about pilots who were not as fortunate in their weather encounters. The ASRS incidents are often seen as precursors to the accidents reported by the NTSB.
Three of the many lessons that can be learned from the ASRS reports are: 1) review and know the procedures for dealing with adverse weather in your aircraft, 2) avoid adverse weather if possible and, 3) have an escape plan in the event of an unexpected encounter with dangerous weather. Failure to learn the lessons presented here can lead to an ASRS incident report if you are lucky or an NTSB accident report if you are not. But, smart pilots remember the old axiom: You start with a bag full of luck and an empty bag of experience. The trick is to fill the bag of experience before you empty the bag of luck.
Safe Landings - November 2012
Safe Landings - August 2012
What Would You Have Done?
This “interactive” issue of CALLBACK, deals with two situations that involve General Aviation Pilots’ encounters with weather. In “The First Half of the Story” you will find report excerpts describing the situation up to the decision point. It is up to the reader to determine the possible courses of action and make a decision (preferably within the same time frame that was available to the reporter). 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.