Number 237
March 1999
Incidents Involving
Flight Towards Terrain
Analysis of a recent controlled flight into terrain (CFIT) accident revealed that the flight crew errors could be grouped into those that involved a failure of group interaction skills, and those that involved individual errors in thinking, planning, recognizing, preparing, or remembering (FSF Flight Safety Digest, May-June 1998). An air carrier Check Airman’s report to ASRS provides examples of both error types–even though the aircraft involved was equipped with the latest terrain-avoidance technology: Unfortunately, I failed to arrest the descent at 3,800 feet, and we were called by the Tower upon reaching approximately 3,300 feet [and] advised that the Tower was receiving a low altitude alert. We were advised to climb immediately, which we did… I am constantly preaching to everyone that rules 1 through 10 are “fly the airplane first,” and I simply failed to follow my own rules. I should have…allowed the Captain to work out the problems. Fortunately, [this airport] is an excellent ATC facility. They quickly caught our altitude and gave us an immediate climb…Our rate of descent was greater than 2,500 feet per minute which allowed for very little deviation time. Flight crew distraction is a factor in many accidents. Our reporter’s analysis is accurate. In addition, pilots must be trained to recognize when they are rushed, distracted, and susceptible to error.
s Late night training flight…We were going out [to] make a 180 degree turn and land. The aircraft is equipped with an Enhanced Ground Proximity Warning System [EGPWS]. It was on, and showed some terrain in the green band at the 12 o’clock position. I vectored the student on a modified procedure turn. I put my head down to get the VREF numbers and heard the ground proximity warning, “Caution, terrain.” I took over the controls and performed our escape maneuver and gave the jet back to the student. The student allowed the jet to descend again while my head was down. Again the ground proximity [warning] went off. I did our escape maneuver again and flew the airplane to the final approach course and let the student land.
There were only 3 of us on board. Another student was in the jump seat. I asked them if they saw the terrain on the enhanced display and they said yes. They thought I would tell them when to turn. I told them to fly the jet first regardless of who is in the left seat (I’m a Check Airman). I should not have looked away while in that phase of flight with new students unfamiliar with the area. Enhanced GPWS is a second-generation terrain avoidance system that is much prized by pilots. But it’s no substitute for proper training, clear communications among crew, and a primary focus on flying the airplane.
Spin City
A pilot practicing aerobatics over a private pasture learned why air show performers don’t attempt some maneuvers:
s I was using a base of 1,500 feet AGL while I performed
advanced aerobatic maneuvers. I had worked all night the night before and was somewhat tired. I had misjudged a couple of maneuvers…and realizing this, added 200 feet to my base…I entered a hovering maneuver at 1,700 feet AGL. I pulled the nose up to a 60 degree or so angle with full power and used the rudder to keep it straight…A popular air show performer performs this maneuver and then rudders the aircraft in a small turning circle to the right. I have done this maneuver many times. This time, I decided to do a left-hand turn. There is a reason the popular air show performer turns right. The aircraft suddenly broke into a left-hand flat spin. I pulled the power, put in full right rudder and released the stick…The rudder had no effectiveness. I pushed the stick all the way forward which only resulted in a cross-over spin to inverted. By this time, I was getting very low. It finally came out of the spin at about a 45 degree inverted nose-down angle. Due to my lack of altitude, I continued a delicate, buffeting 45 degree push to level inverted. I only had 100-200 feet before I became a statistic. I figure that I lost 1,500 feet in only 4 rotations. Some botched maneuvers require more than the 1,500 feet minimum mandated by the FAA. That altitude is the bottom, and I need at least double that for any new maneuvers. I am sure my lack of sleep affected my judgment, and I feel that I am lucky to have survived… We’re also glad that our reporter survived his ordeal and was willing to share this experience with others. January 1999 Report Intake
Air Carrier/Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 2035 523 57 178
Rules One Through Ten
The flight crew of a Turbo Commander rediscovered a basic flying rule while trying to troubleshoot a problem on an IFR approach over mountainous terrain. The First Officer (the flying pilot) reports:
s After passing the VOR, we were descended to 10,000 feet and given a vector towards the final approach…We were traveling at approximately 230 knots. During this process the directional gyro on my side of the cockpit failed and the Captain was trying to diagnose the problem. At about this time, we were advised to descend and maintain 3,800 feet, which is the MVA [Minimum Vectoring Altitude] for that sector. Our descent was delayed somewhat so we were descending fairly rapidly while trying to diagnose the directional gyro problem and join the localizer.
ASRS Recently Issued Alerts On...
Runway visibility obstruction at a Minnesota airport MU-2 cockpit smoke attributed to failed cockpit heat valve Inadequate taxiway signage/markings at a Wisconsin airport Three incidents of electrical smoke and fumes in BE-1900Ds Confusing charting of a holding pattern for a Canadian airport
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
TOTAL
2793
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_237.pdf
March 1999
Incidents Involving
Flight Towards Terrain
Analysis of a recent controlled flight into terrain (CFIT) accident revealed that the flight crew errors could be grouped into those that involved a failure of group interaction skills, and those that involved individual errors in thinking, planning, recognizing, preparing, or remembering (FSF Flight Safety Digest, May-June 1998). An air carrier Check Airman’s report to ASRS provides examples of both error types–even though the aircraft involved was equipped with the latest terrain-avoidance technology: Unfortunately, I failed to arrest the descent at 3,800 feet, and we were called by the Tower upon reaching approximately 3,300 feet [and] advised that the Tower was receiving a low altitude alert. We were advised to climb immediately, which we did… I am constantly preaching to everyone that rules 1 through 10 are “fly the airplane first,” and I simply failed to follow my own rules. I should have…allowed the Captain to work out the problems. Fortunately, [this airport] is an excellent ATC facility. They quickly caught our altitude and gave us an immediate climb…Our rate of descent was greater than 2,500 feet per minute which allowed for very little deviation time. Flight crew distraction is a factor in many accidents. Our reporter’s analysis is accurate. In addition, pilots must be trained to recognize when they are rushed, distracted, and susceptible to error.
s Late night training flight…We were going out [to] make a 180 degree turn and land. The aircraft is equipped with an Enhanced Ground Proximity Warning System [EGPWS]. It was on, and showed some terrain in the green band at the 12 o’clock position. I vectored the student on a modified procedure turn. I put my head down to get the VREF numbers and heard the ground proximity warning, “Caution, terrain.” I took over the controls and performed our escape maneuver and gave the jet back to the student. The student allowed the jet to descend again while my head was down. Again the ground proximity [warning] went off. I did our escape maneuver again and flew the airplane to the final approach course and let the student land.
There were only 3 of us on board. Another student was in the jump seat. I asked them if they saw the terrain on the enhanced display and they said yes. They thought I would tell them when to turn. I told them to fly the jet first regardless of who is in the left seat (I’m a Check Airman). I should not have looked away while in that phase of flight with new students unfamiliar with the area. Enhanced GPWS is a second-generation terrain avoidance system that is much prized by pilots. But it’s no substitute for proper training, clear communications among crew, and a primary focus on flying the airplane.
Spin City
A pilot practicing aerobatics over a private pasture learned why air show performers don’t attempt some maneuvers:
s I was using a base of 1,500 feet AGL while I performed
advanced aerobatic maneuvers. I had worked all night the night before and was somewhat tired. I had misjudged a couple of maneuvers…and realizing this, added 200 feet to my base…I entered a hovering maneuver at 1,700 feet AGL. I pulled the nose up to a 60 degree or so angle with full power and used the rudder to keep it straight…A popular air show performer performs this maneuver and then rudders the aircraft in a small turning circle to the right. I have done this maneuver many times. This time, I decided to do a left-hand turn. There is a reason the popular air show performer turns right. The aircraft suddenly broke into a left-hand flat spin. I pulled the power, put in full right rudder and released the stick…The rudder had no effectiveness. I pushed the stick all the way forward which only resulted in a cross-over spin to inverted. By this time, I was getting very low. It finally came out of the spin at about a 45 degree inverted nose-down angle. Due to my lack of altitude, I continued a delicate, buffeting 45 degree push to level inverted. I only had 100-200 feet before I became a statistic. I figure that I lost 1,500 feet in only 4 rotations. Some botched maneuvers require more than the 1,500 feet minimum mandated by the FAA. That altitude is the bottom, and I need at least double that for any new maneuvers. I am sure my lack of sleep affected my judgment, and I feel that I am lucky to have survived… We’re also glad that our reporter survived his ordeal and was willing to share this experience with others. January 1999 Report Intake
Air Carrier/Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 2035 523 57 178
Rules One Through Ten
The flight crew of a Turbo Commander rediscovered a basic flying rule while trying to troubleshoot a problem on an IFR approach over mountainous terrain. The First Officer (the flying pilot) reports:
s After passing the VOR, we were descended to 10,000 feet and given a vector towards the final approach…We were traveling at approximately 230 knots. During this process the directional gyro on my side of the cockpit failed and the Captain was trying to diagnose the problem. At about this time, we were advised to descend and maintain 3,800 feet, which is the MVA [Minimum Vectoring Altitude] for that sector. Our descent was delayed somewhat so we were descending fairly rapidly while trying to diagnose the directional gyro problem and join the localizer.
ASRS Recently Issued Alerts On...
Runway visibility obstruction at a Minnesota airport MU-2 cockpit smoke attributed to failed cockpit heat valve Inadequate taxiway signage/markings at a Wisconsin airport Three incidents of electrical smoke and fumes in BE-1900Ds Confusing charting of a holding pattern for a Canadian airport
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
TOTAL
2793
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_237.pdf
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