Safe Landings

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 decision making 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? 

The windshear saga in American aviation history reveals a complex and costly past. Windshear has existed for as long as aviators have taken to the skies and is largely responsible for several classic aviation losses. Notable U.S. aviation accidents include Eastern Flight 66 (1975), Pan American Flight 759 (1982), and Delta Flight 191 (1985).

Windshear remained unrecognized for years. It was not clearly understood until swept wing, jet aircraft encountered the phenomenon. Since 1975, windshear has been researched and studied, measured, defined, catalogued, and rightly vilified. Technology has been developed to identify and minimize the threats that it poses. Procedures have been implemented to aid pilots who experience windshear in flight and flight crews invest hours of simulator training practicing windshear escape maneuvers.

Even with progress to date, windshear continues to be a worthy adversary to aviation professionals. It requires respect and wisdom to defeat. Pilots often must make decisions regarding known or anticipated windshear, and the best practice is always avoidance.

This month, CALLBACK shares reported incidents that reveal some means and extremes of windshear experienced in modern aviation. Lessons to be gleaned are ripe, rich, and many.

Teasing a Toronto Tailwind

After encountering windshear that resulted in an unstabilized approach, this A319 Captain elected to continue to a landing. He noted his awareness of the current winds and trends as well as his personal preparedness to go around as reasons for continuing the approach.

• After being delayed due to low ceilings in Toronto, we were finally descending…in heavy rain and moderate turbulence with clearance to 7,000 feet MSL. After a third 360 degree turn, we were…transferred to the Final Controller and proceeded inbound for the ILS RWY 05. The last several ATIS [reports] showed winds at approximately 090 to 100 [degrees] at 5 to 10 knots, and the Final Controller mentioned the same with an RVR of 6,000 plus feet for Runway 05. When cleared for the approach, we were at 3,000 feet MSL to intercept the glideslope, and I noticed the winds had picked up to a 50 knot direct tailwind. The First Officer was flying. We were assigned 160 knots and began to configure at approximately 2,000 feet AGL. At 1,500 feet the wind was a 30 knot direct tailwind and we had flaps 3. Indicated airspeed (IAS) had increased at this point [with] thrust at idle to 170-175 knots, prohibiting final flaps just yet. The First Officer did a great job aggressively trying to slow the aircraft, as we were concerned about getting a flaps 3 overspeed. As I knew from the ATIS and the Controllers (Tower now), the winds were to die off very soon to less than 10 knots. [Below] 1,000 feet we were just getting the airspeed to put in final flaps (full) and were finally stabilized and on speed between 500 to 800 feet. The winds were now at the reported 090 [degrees] at 8 knots or so [below] 500 feet. The total wind shift was approximately 90 degrees from direct tailwind to a right crosswind - losing 40 knots [of tailwind] in the space of 1,500 feet or so. The reasons I elected to continue the approach were:

1. We landed uneventfully in the touchdown zone and on speed…after breaking out before minimums.

Controller Pilot Data Link Communication Departure Clearance Services (CPDLC-DCL) is one segment of the Future Air Navigation System (FANS) that has been recently implemented in the contiguous 48 states at local Tower Data Link Service (TDLS) equipped facilities to deliver departure clearances and revised departure clearances prior to takeoff.

As any new system is implemented, some “bugs” may be expected, and CPDLC-DCL is no exception. ASRS is receiving reports suggesting that crews are experiencing problems while using CPDLC-DCL for its intended objective. The problems that are experienced point to sources from system architecture, to precise meanings of specific words and formats used in the CPDLC-DCL syntax, to basic interpretation and understanding of the CPDLC-DCL information protocols and operational procedures.

This month, CALLBACK shares reported incidents of complications that arose from the crews’ use of CPDLC-DCL to obtain departure clearances and revised departure clearances. While CPDLC-DCL offers many improvements and advantages over voice and Pre-Departure Clearance (PDC), some issues remain as we transition to this new system. As these examples may hint, ideas will emanate from the cockpit and formal solutions will be devised.

Cautious Pilot Distrusts Link

Communications 

This Air Carrier Crew clarified an initial question they had about a revised departure clearance. Curiosity over the revised SID and transition that had not been “properly” LOADED resulted in a route portion that was manually loaded but not included in the clearance. 

• During preflight, we received a revised clearance via CPDLC. The change was from the TRALR6.DVC to the STAAV6.DVC. I verified [the] clearance and received a full-route clearance over the radio. When the LOAD feature was selected in CPDLC, the new revised route did not LOAD into the ROUTE page properly. It still showed [the] TRALR6.DVC, but now it had a discontinuity. At this point, I had to load the route manually. When I did load the STAAV SIX, however, I failed to select the DVC transition, [so the FMC] now had point STAAV direct to LAA in the LEGS page. When we did the route verification later, during the preflight, we both failed to detect the missing transition that included the points TRALR, NICLE, and DVC.

This went unnoticed until passing point STAAV on the departure. That is when ATC queried us if we were headed to point TRALR. We indicated to ATC that we were direct LAA. He re-cleared us to TRALR to resume the departure. There was nothing significant to report for the rest of the flight. 

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. 

“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.

Non-Towered Aircraft Operations

At an airport without an operational control tower, sometimes referred to as an “uncontrolled” airport, communication is one of the key elements in maintaining proper aircraft separation. Use of the Common Traffic Advisory Frequency (CTAF) helps to assure the safe, orderly flow of arrival and departure traffic. FAR 91.113 cites basic right-of-way rules and FAR 91.126 establishes traffic-flow rules at non-towered airports. The Aeronautical Information Manual (AIM) and FAA Advisory Circular 90-66A expand on these regulations to define procedures for operations at non-towered airports. Staying visually alert is the final measure of defense against aircraft that may be operating without a radio or without regard to the standard non-towered airport procedures. The following ASRS reports highlight some of the problems commonly associated with non-towered airport operations.

Unexpected Opposition – Two Opposite Runway Takeoff Incidents

A C680 Flight Crew had to abort their takeoff when an aircraft made an unannounced departure on the opposite runway. It is not known if the “other airplane” failed to use a radio or did not have one. For aircraft without a radio installed, the use of a hand-held transceiver is highly recommended at busy non-towered airports.

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.

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).

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….