Number 221
November 1997
Maintaining Safe Aircraft
Since ASRS introduced incident reporting forms for maintenance personnel in the spring of 1997, we have received over 150 reports from mechanics, and continue to hear from flight crews about maintenance-related incidents. Following are some examples, beginning with a report from an air carrier mechanic:
Half-Full or Half-Empty?
Optimists and pessimists alike can appreciate the difficulties a commuter Captain confronted due to a halfcup of water:
s The First Officer handed his nearly-empty cup of water
to the Flight Attendant (FA), and requested a refill. The FA dropped it on the center console. Very little water spilled and we immediately cleaned it up. A few minutes later, the cabin altitude began to fluctuate—climbing and descending. We initiated a descent to below 10,000 feet. While descending, the passenger oxygen masks deployed. The flight continued to our destination without incident. Even though everything turned out all right, it can never be emphasized enough: be very cautious with liquids around electronic components.
s [As part of routine maintenance requiring an engine
run to check for leaks], I assisted by pulling some of the gear safety pins…then proceeded to perform a quick inspection of the nose gear area. From my vantage point in front of the gear, I did not notice the nose gear pin still installed. Another mechanic provides the rest of the story:
s At the beginning of the next night’s shift, I was briefed that the aircraft had returned to the airport because the nose landing gear wouldn’t retract. The mechanics found the nose gear safety pin still installed. The safety pin was removed, and the aircraft was once again dispatched.
One reason the mechanics may have failed to notice the safety pins is that the “remove before flight” flags attached to the pins are often rolled up and tucked out of the way to enable good visibility of the work area. Flags can also blow up into the wheel well and become caught there. Solution: make certain those flags keep flying until the aircraft is released back to the flight line.
The Big Sky
A recent ASRS report reminds us that the “big sky” isn’t as big as we may think. A parachute-jump plane pilot explains in an ASRS report:
s After takeoff, I told Center that we were 4-1/2
minutes until jumpers away, and I confirmed that there was no traffic in the area. At 12,000 feet, I made an announcement on CTAF that jumpers would be jumping in two minutes. At one minute away from jumpers exiting the aircraft, a spotter checked one last time for hazardous traffic. I made one final announcement on CTAF that jumping would be in progress for the next 10 minutes. After landing, I was told that an aircraft hit a skydiver’s open canopy at about 2,000 feet, just seconds after the chute deployed. The most outboard cell of the chute had a one-foot tear in it, confirming the event. The skydiver was not hurt, nor was the chute damaged enough for a cutaway. The pilot of the other aircraft knew he was near the drop zone. He also heard the two-minute call on the CTAF, but continued flying circles near the area. It is possible that he was distracted while circling and sightseeing. The pilot of the other aircraft was legal to be occupying the airspace at the same time as the jumpers. However, careful see-and-avoid practice by the pilot might have prevented this near-tragedy.
Static Display
Flying the flags might have prevented another return-toland incident, as reported by a corporate Captain:
s Early morning departure from a dark ramp; I did not
finish my walk-around inspection, as I was interrupted by a passenger arriving early. I never resumed my normal routine. On takeoff, I heard the First Officer call, “You’ve got no airspeed.” I then called, “Say your airspeed.” Came the reply, “I’ve got no airspeed either.” By that time, we had considerable speed, and…I elected to continue takeoff. Airborne, I got the “ADC [Air Data Computer] failure” light. We decided to dump fuel and return to base. The aircraft had been inspected and washed the day before, and tape had been left on the static ports and pitot tubes. I had not seen it in the dark, and my pre-flight had been interrupted. No excuse! It was CAVU this time, but what if it had been 200 feet and half-mile visibility?! A “remove before flight” flag or long strip of “caution” tape attached to the tape covering the static ports and pitot tubeswould have provided a visual warning to ground and flight crews. ASRS Recently Issued Alerts On...
Uncommanded 20-degree roll in a B737-300 A spoiler cable incorrectly installed on a DC9-10 Parachute jumping activity over a Nevada STAR Unpronounceable computer-generated navaid fix names SF340 cargo fire detection system false alarms above FL180
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://olias.arc.nasa.gov/asrs
September 1997 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1974 759 84 63
TOTAL
2880
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_221.pdf
November 1997
Maintaining Safe Aircraft
Since ASRS introduced incident reporting forms for maintenance personnel in the spring of 1997, we have received over 150 reports from mechanics, and continue to hear from flight crews about maintenance-related incidents. Following are some examples, beginning with a report from an air carrier mechanic:
Half-Full or Half-Empty?
Optimists and pessimists alike can appreciate the difficulties a commuter Captain confronted due to a halfcup of water:
s The First Officer handed his nearly-empty cup of water
to the Flight Attendant (FA), and requested a refill. The FA dropped it on the center console. Very little water spilled and we immediately cleaned it up. A few minutes later, the cabin altitude began to fluctuate—climbing and descending. We initiated a descent to below 10,000 feet. While descending, the passenger oxygen masks deployed. The flight continued to our destination without incident. Even though everything turned out all right, it can never be emphasized enough: be very cautious with liquids around electronic components.
s [As part of routine maintenance requiring an engine
run to check for leaks], I assisted by pulling some of the gear safety pins…then proceeded to perform a quick inspection of the nose gear area. From my vantage point in front of the gear, I did not notice the nose gear pin still installed. Another mechanic provides the rest of the story:
s At the beginning of the next night’s shift, I was briefed that the aircraft had returned to the airport because the nose landing gear wouldn’t retract. The mechanics found the nose gear safety pin still installed. The safety pin was removed, and the aircraft was once again dispatched.
One reason the mechanics may have failed to notice the safety pins is that the “remove before flight” flags attached to the pins are often rolled up and tucked out of the way to enable good visibility of the work area. Flags can also blow up into the wheel well and become caught there. Solution: make certain those flags keep flying until the aircraft is released back to the flight line.
The Big Sky
A recent ASRS report reminds us that the “big sky” isn’t as big as we may think. A parachute-jump plane pilot explains in an ASRS report:
s After takeoff, I told Center that we were 4-1/2
minutes until jumpers away, and I confirmed that there was no traffic in the area. At 12,000 feet, I made an announcement on CTAF that jumpers would be jumping in two minutes. At one minute away from jumpers exiting the aircraft, a spotter checked one last time for hazardous traffic. I made one final announcement on CTAF that jumping would be in progress for the next 10 minutes. After landing, I was told that an aircraft hit a skydiver’s open canopy at about 2,000 feet, just seconds after the chute deployed. The most outboard cell of the chute had a one-foot tear in it, confirming the event. The skydiver was not hurt, nor was the chute damaged enough for a cutaway. The pilot of the other aircraft knew he was near the drop zone. He also heard the two-minute call on the CTAF, but continued flying circles near the area. It is possible that he was distracted while circling and sightseeing. The pilot of the other aircraft was legal to be occupying the airspace at the same time as the jumpers. However, careful see-and-avoid practice by the pilot might have prevented this near-tragedy.
Static Display
Flying the flags might have prevented another return-toland incident, as reported by a corporate Captain:
s Early morning departure from a dark ramp; I did not
finish my walk-around inspection, as I was interrupted by a passenger arriving early. I never resumed my normal routine. On takeoff, I heard the First Officer call, “You’ve got no airspeed.” I then called, “Say your airspeed.” Came the reply, “I’ve got no airspeed either.” By that time, we had considerable speed, and…I elected to continue takeoff. Airborne, I got the “ADC [Air Data Computer] failure” light. We decided to dump fuel and return to base. The aircraft had been inspected and washed the day before, and tape had been left on the static ports and pitot tubes. I had not seen it in the dark, and my pre-flight had been interrupted. No excuse! It was CAVU this time, but what if it had been 200 feet and half-mile visibility?! A “remove before flight” flag or long strip of “caution” tape attached to the tape covering the static ports and pitot tubeswould have provided a visual warning to ground and flight crews. ASRS Recently Issued Alerts On...
Uncommanded 20-degree roll in a B737-300 A spoiler cable incorrectly installed on a DC9-10 Parachute jumping activity over a Nevada STAR Unpronounceable computer-generated navaid fix names SF340 cargo fire detection system false alarms above FL180
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://olias.arc.nasa.gov/asrs
September 1997 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1974 759 84 63
TOTAL
2880
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_221.pdf
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