When ASRS Analysts screen safety incident reports, they can tag certain ones for their relevance to upcoming CALLBACK
topics. Other reports can be tagged for the Editor’s “Miscellaneous”
file simply because they are “interesting.” A year-end review of the
Miscellaneous file found several reports that fit into the “DOH!”
(“Different Or Humorous!”) category and are worth sharing.
No
matter what our level of experience, there is an important lesson to be
learned from these reports. No one is immune to error and, while some of
these mistakes may seem rather improbable, those who think, “It could
never happen to me” may be setting themselves up for embarrassment or
worse. Wise aviation professionals recognize that we are all just a
brief mental lapse away from one of those memorable moments we’d like to
forget. Or, as a pilot stated in the first sentence of a recent report,
“After years of reading incident reports and thinking, ‘How could a
pilot do something so stupid?’ now I understand. I have met the moron
and he is ME!”
Not a Good Friday
Obviously,
mistakes attributable to lack of experience tend to happen earlier in
our flying careers. One of the factors often affecting newer pilots is a
tendency to focus so intently on one thing that their sense of the “big
picture” is lost. An integral part of the big picture is what some old
timers refer to as “headwork” or common sense. This B99 pilot may have
been a little too focused on the mechanics of a checklist to step back
mentally and question whether it fit the situation.
■
Enroute … I started to perform my required “Weekly Checks” Checklist,
going through item by item. The checklist calls for the weekly
fire-test; the first item is to pull both fire handles. As I pulled them
I noticed a sudden loss of performance on both engines. My gauges
indicated that both of them flamed out. I pushed the handles back and
started to troubleshoot. I determined that my right engine was still
operational. Meanwhile, the aircraft was losing altitude but it was
under control. I advised ATC about my situation and they told me there
was an airport ten miles away along my route.… Being a new pilot on this
airplane, under these circumstances I decided the best course of action
was to secure the inoperative engine and land as soon as possible.
Having my right engine operational, I was able to stabilize the airplane
and started my VFR descent. I completed my Emergency Checklist and then
performed a safe single engine landing.
I am a new pilot on
this airplane, having just completed my upgrade training one week ago.
During the flight training, this part of the checklist was never
mentioned and the checklist was not available in the training aircraft.
On the checklist, the fire test appears to be among the inflight test
items. This situation was the result of me following the checklist that I
believed I was supposed to perform. Had I received the proper training,
I am sure this situation could have been avoided.
Push the “Right” Pedal
The
more this Maule M7 Pilot corrected a left yaw with right rudder, the
more trouble he had controlling the aircraft. When you think you’re
doing the right thing, but get the wrong result, it’s time to do some
troubleshooting.
■
I was flying … at 11,000 feet on an IFR flight plan. My autopilot
disconnected and revealed an out-of-trim condition which caused the
aircraft to yaw to the left. I had stretched my right leg to the right
of the cockpit for comfort. When the aircraft yawed, I instinctively
pressed my right foot on the rudder pedal. This caused the aircraft to
yaw even more to the left, requiring full right aileron to keep from
rolling inverted. I turned the autopilot off and released the rudder
trim with no effect. I also reduced power and lowered the nose to get
better control, advising ATC that I was turning and descending with a
flight control problem. ATC advised me that [an airport] was ahead about
ten miles.… As I continued to troubleshoot, I noticed that my right
foot was pressing on the copilot left rudder pedal instead of the pilot
right rudder pedal. As soon as I got my foot on the correct rudder
pedal, I was able to control the aircraft and advised ATC. I continued
the flight.
Climb to Increase Airspeed (?!)
A
regular pattern of observation that includes all of the essential
flight instruments is the essence of a good instrument scan. To some
extent, the scan starts on the takeoff roll and, as this ERJ-145 Pilot
learned, fixation on one instrument can disrupt the scan and lead to an
embarrassing sequence of events.
■
On the takeoff roll, after calling out, “Thrust set,” I scanned the
EICAS engine indications, and then I fixated on the altimeter, confusing
it with the airspeed indicator. When the numbers on the altimeter dial
did not increase during the takeoff roll, I mistakenly believed it was a
stuck airspeed indication and called for an aborted takeoff. The
Captain aborted the takeoff and we taxied to a location where we could
talk to maintenance. As I was explaining to the Captain what I had seen,
I realized my mistake. I had confused the Altimeter indication with the
Airspeed. There were no problems with the aircraft and we completed the
flight safely.
Bad Vibrations
Traffic
and weather distractions after takeoff disrupted an A320 Flight Crew’s
normal procedures to the point where the obvious became obscure. As the
Captain noted, their experience level led them directly to
troubleshooting. You can’t know too much about aviation, but sometimes
you can “overthink” a simple problem.
■
We were focused on avoiding thunderstorms in the departure corridor.
Immediately after takeoff we requested a right turn from Departure. We
also remained vigilant of the [reported traffic]. There was now another
concentrated area of weather directly ahead. I was trying to break into
the congested Departure frequency for a turn on course, which would
provide adequate weather clearance. This took a couple minutes and
dominated our attention.
I noticed a slight airframe rumbling,
but thought it might be the landing lights which were still extended.
Once we were given the turn on course and accelerated to 250 knots, we
both started to focus on the increasing noise and vibration. I raised
the landing lights with very little improvement. We completely
concentrated on things that might be wrong with the airplane and
searched through numerous system ECAM pages for answers. Everything
appeared normal and all symbols were green (including the large green
landing gear DOWN and LOCKED symbols which were as we always see them…
on the ground. But the gear doors I concentrated on were in fact UP and
green), so we started hypothesizing about abnormal things that might be
wrong with the jet. Things like a missing engine cowl, flap track
fairings, gear doors open, flight controls out of position. We continued
north as we attempted troubleshooting and began to think about
diverting. We asked the Lead Flight Attendant to take a look at the
wings, etc. and report back any anomalies. He found nothing unusual. I
asked the First Officer to keep the speed back at 210 knots and to level
off at 15,000 feet to remain in a safe speed and altitude range in case
something was extended and to protect the airframe. I attempted a radio
patch through Dispatch to include Maintenance. The reception was poor
and we never spoke with Maintenance. We decided to continue
communications through ACARS.
Enough troubleshooting time had
passed that I decided we needed to get the plane on the ground safely. I
instructed the First Officer to coordinate landing at the divert
airport while I briefed the Lead Flight Attendant and then performed the
Airframe Vibration Checklist.... As the First Officer flew the visual
approach he called for “Gear Down, Landing Checklist.” It then became
immediately clear that our “problem” was that the landing gear had never
been retracted. We continued to a landing without incident since there
was not enough time to verify adequate fuel to continue to [our
destination].
I attribute this error to saturation with weather
and traffic avoidance on departure followed by a lack of performing
normal climb out procedures for the same reason.… When we were handed
off to Departure we focused intently on clearing traffic and weather on a
very congested frequency. Obviously, I did not raise the gear and after
raising the flaps we had already completed our 90-degree right turn and
were headed toward the thunderstorm area directly ahead. My attention
was primarily on trying to break into the busy Departure Control
frequency for an immediate clearance north away from the weather. This
dominated our attention and I believe I never accomplished the After
Takeoff Checklist since it’s simply so out of sequence climbing out of
approximately five or six thousand feet.
Between us, [the First
Officer and I] have around 30,000 flight hours, and about eight years’
experience each in the Airbus. I believe this is an important
contributing factor since I have never experienced even a delayed gear
retraction on takeoff. It’s such an unusual thing that we simply didn’t
consider it. As we scrolled through ECAM system pages and other
troubleshooting attempts/hypotheses, we never considered such a simple
error. Our experience level led us directly to troubleshooting a problem
rather than looking for the obvious solution. It’s the most
embarrassing event of my flying career.
This flight encountered a
confluence of operational challenges as well as human factors issues
which resulted in a sub-par performance. It’s not like we lacked
understanding of landing gear panel or ECAM symbols. I simply allowed my
focus on weather and aircraft avoidance to lead to my neglect of
basics. I failed to raise the landing gear and perform the After Takeoff
Checklist properly since we were so far past the normal flight sequence
to accomplish it while concentrating on immediate safety of flight
procedures.… I am glad the company allowed us to continue the flight
since I personally wanted to get back in the saddle and put this behind
us.
|
The ASRS Database is a rich source of information for policy development, research, training, and more.
CALLBACK Issue 432
ASRS Online Resources
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 »
November 2015
Report Intake:
|
Air Carrier/Air Taxi Pilots
|
4,591
|
General Aviation Pilots
|
1,047
|
Flight Attendants
|
507
|
Controllers
|
434
|
Military/Other
|
252
|
Dispatchers
|
206
|
Mechanics
|
171
|
TOTAL
|
7,208
|
|
Requests 
Search ASRS Database »
