Number 201
March 1996
Significant Others
Most ASRS reporters describe incidents or mistakes that came about as a result of their own actions or inactions. Although pilots take final responsibility for the safe operation of the aircraft, they can sometimes trace a key link in the error chain back to some “significant other.” In our first report, a corporate helicopter experienced a mechanical malfunction due to foreign object damage. The only way to ensure proper weight and balance is to weigh each bag before loading it onto the aircraft. However, this may not always be a realistic option. Some pilots have brought this problem to the attention of company management. They report that, in some cases, company policies on baggage weight estimates have been changed to reflect more realistic figures.
■ While enroute from XYZ, the #1 engine oil temp began to rise. I started to return to XYZ; however, it became obvious that the oil temp was climbing too quickly to continue. The engine was shut down when the oil temp exceeded limits, [and the flight diverted to nearby ABC].
I had completed a thorough preflight, as had a company mechanic. [On postflight], a white diaper used by the cleaning personnel was found in the oil cooler blower. The aircraft is white and the diaper could be easily missed. Cleaning crews are not aviation personnel and do not understand the importance of keeping track of rags. Management, pilots, mechanics—all need to communicate to non-aviation personnel how essential it is that no foreign objects are left in or near an aircraft.
Back Seat Interference
A General Aviation pilot navigating by normally reliable VOR receivers wandered off-course, and discovered that an unexpected culprit was the cause of the navigation discrepancy.
■ After departing VFR, I picked up an IFR flight plan,
and was given a clearance. Abeam one intersection, Approach advised that I was 7 miles south of course and provided a heading to reintercept. I began course correction and configured the Loran for course guidance. On further comparison, it was determined that both VOR receivers were suspect as they both indicated 8 degrees off. This prompted a query of the two passengers, children ages 7 and 12, after which it was found that both were using portable tape players. Both units were turned off, and the VOR receivers returned to normal operation. Air carrier aircraft are not the only ones susceptible to the effects of portable electronic equipment. Small aircraft, too, can experience interference with potentially serious results, particularly in IMC conditions.
A Real Tail-Dragger
Weight and balance determination is often the result of input from a number of people, including the pilot, the baggage handler, the gate agent, and even the passengers. In the following report from a commuter airline First Officer, all the people involved—and the aircraft—were ultimately at the mercy of an airline operational policy.
Watch Your Step!
In the next report, departing passengers inadvertently left the pilot with a surprise to remember them by.
■ On the flight from ABC to XYZ [and continuing to JFK International Airport], I planned (per company policy) to use normal baggage weight, which is 23.5 lb. per bag. But almost all the passengers were on their way to JFK. When you fly to JFK, you are supposed to use international baggage weights of 35 lb. So from ABC to XYZ, we’re supposed to use 23.5 lb., then on the leg to JFK, the bags automatically go up to 35 lb. I think this is a terrible policy.
Upon landing at XYZ, we touched down, and unexpectedly, the nose came abruptly off the ground. We added power as well as pushing forward on the yoke, [and] proceeded normally to the gate. Upon visual inspection of the tail, I saw scratches on the tail section. At that point, we requested all the bags to be weighed. The average weight was 44.5 lb. At that weight, we were so far aft center of gravity that we should not have even been able to leave ABC.
■ After dropping off the load of skydivers, I was cleared to
descend into Class B airspace. [Descending], I experienced an engine failure. I notified ATC that I had an engine failure. They cleared me to the municipal airport. I began the restart checklist to restart the aircraft. As I checked the fuel selector knob, I noticed that it had been bumped into the OFF position by one of the skydivers. I placed the knob into the BOTH position and regained power to the airplane. The lesson I learned is that a safety guard is needed on the fuel selector knobs if you are carrying skydivers. The owner agreed, and has placed one on this aircraft. Another lesson learned by all these reporters is the potential impact of “significant others.”
ASRS Recently Issued Alerts On...
Inadequate flight idle detent system on EMB-120 Uncommanded full rudder deflection on a Boeing 727-100 Difficulty in identifying a Washington departure intersection Confusion about newly-published STARs for Salt Lake City Dornier 328 window cracks attributed to airframe contraction
A Monthly Safety Bulletin from The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
December 1995 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1545 539 83 27
TOTAL
2194
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_201.pdf
March 1996
Significant Others
Most ASRS reporters describe incidents or mistakes that came about as a result of their own actions or inactions. Although pilots take final responsibility for the safe operation of the aircraft, they can sometimes trace a key link in the error chain back to some “significant other.” In our first report, a corporate helicopter experienced a mechanical malfunction due to foreign object damage. The only way to ensure proper weight and balance is to weigh each bag before loading it onto the aircraft. However, this may not always be a realistic option. Some pilots have brought this problem to the attention of company management. They report that, in some cases, company policies on baggage weight estimates have been changed to reflect more realistic figures.
■ While enroute from XYZ, the #1 engine oil temp began to rise. I started to return to XYZ; however, it became obvious that the oil temp was climbing too quickly to continue. The engine was shut down when the oil temp exceeded limits, [and the flight diverted to nearby ABC].
I had completed a thorough preflight, as had a company mechanic. [On postflight], a white diaper used by the cleaning personnel was found in the oil cooler blower. The aircraft is white and the diaper could be easily missed. Cleaning crews are not aviation personnel and do not understand the importance of keeping track of rags. Management, pilots, mechanics—all need to communicate to non-aviation personnel how essential it is that no foreign objects are left in or near an aircraft.
Back Seat Interference
A General Aviation pilot navigating by normally reliable VOR receivers wandered off-course, and discovered that an unexpected culprit was the cause of the navigation discrepancy.
■ After departing VFR, I picked up an IFR flight plan,
and was given a clearance. Abeam one intersection, Approach advised that I was 7 miles south of course and provided a heading to reintercept. I began course correction and configured the Loran for course guidance. On further comparison, it was determined that both VOR receivers were suspect as they both indicated 8 degrees off. This prompted a query of the two passengers, children ages 7 and 12, after which it was found that both were using portable tape players. Both units were turned off, and the VOR receivers returned to normal operation. Air carrier aircraft are not the only ones susceptible to the effects of portable electronic equipment. Small aircraft, too, can experience interference with potentially serious results, particularly in IMC conditions.
A Real Tail-Dragger
Weight and balance determination is often the result of input from a number of people, including the pilot, the baggage handler, the gate agent, and even the passengers. In the following report from a commuter airline First Officer, all the people involved—and the aircraft—were ultimately at the mercy of an airline operational policy.
Watch Your Step!
In the next report, departing passengers inadvertently left the pilot with a surprise to remember them by.
■ On the flight from ABC to XYZ [and continuing to JFK International Airport], I planned (per company policy) to use normal baggage weight, which is 23.5 lb. per bag. But almost all the passengers were on their way to JFK. When you fly to JFK, you are supposed to use international baggage weights of 35 lb. So from ABC to XYZ, we’re supposed to use 23.5 lb., then on the leg to JFK, the bags automatically go up to 35 lb. I think this is a terrible policy.
Upon landing at XYZ, we touched down, and unexpectedly, the nose came abruptly off the ground. We added power as well as pushing forward on the yoke, [and] proceeded normally to the gate. Upon visual inspection of the tail, I saw scratches on the tail section. At that point, we requested all the bags to be weighed. The average weight was 44.5 lb. At that weight, we were so far aft center of gravity that we should not have even been able to leave ABC.
■ After dropping off the load of skydivers, I was cleared to
descend into Class B airspace. [Descending], I experienced an engine failure. I notified ATC that I had an engine failure. They cleared me to the municipal airport. I began the restart checklist to restart the aircraft. As I checked the fuel selector knob, I noticed that it had been bumped into the OFF position by one of the skydivers. I placed the knob into the BOTH position and regained power to the airplane. The lesson I learned is that a safety guard is needed on the fuel selector knobs if you are carrying skydivers. The owner agreed, and has placed one on this aircraft. Another lesson learned by all these reporters is the potential impact of “significant others.”
ASRS Recently Issued Alerts On...
Inadequate flight idle detent system on EMB-120 Uncommanded full rudder deflection on a Boeing 727-100 Difficulty in identifying a Washington departure intersection Confusion about newly-published STARs for Salt Lake City Dornier 328 window cracks attributed to airframe contraction
A Monthly Safety Bulletin from The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
December 1995 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1545 539 83 27
TOTAL
2194
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_201.pdf
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