Number 258
February 2001
The Experience-Procedures Feedback Loop
Procedures are a means of communicating the wisdom of experience in a standardized form to operators. But procedures may need to be revised when incidents and accidents demonstrate their weaknesses. This continuous reinforcement loop between experience and procedures is one of the most important safety tools in aviation. A Captain’s report to ASRS describes the dangerous situation that developed for a Lear-60 crew when a procedural oversight by maintenance was amplified by a flight crew oversight during pre-flight. I…proceeded to accomplish the transition level checklist. When doing this a visual check of the oxygen pressure gauge as well as checking the crew oxygen mask is required. I did this and did not receive a positive flow of oxygen to my mask. The co-pilot checked his and again received no oxygen pressure. Thus we requested a lower altitude which was given to us. I asked the co-pilot if he had performed the pre-flight check which required him to test both crew member oxygen masks. He said he thought he had, but it was obvious he had not… The reason for this was that he was distracted by ground crew who were bringing beverages and ice to the aircraft. This Lear 60 has a nose compartment oxygen system… In [this]…system the oxygen indicator will read the oxygen bottle pressure, even if the valve is turned off and the crew masks are tested. When I boarded the aircraft to prepare for takeoff, I looked at the oxygen indicator and it showed a normal oxygen level…I, however, did not test my mask on the ground. I believe each crew flying…should know where their oxygen system is located and its operational characteristics… It is now company policy for both crew members to check the crew oxygen masks [during pre-flight]. It appears the maintenance technician who serviced the oxygen did not open the shutoff valve after servicing the bottle. The flight crew did not check the oxygen masks for flow until 18,000 feet MSL – a potentially lethal situation had they not detected the problem in time.
s Upon arrival, I…checked our aircraft’s flight log to make
sure that the previous day’s maintenance work was done properly and signed off correctly... After determining that the…paperwork was correct, I went out to assist the co-pilot [with pre-flight checks]… This was a position leg with no passengers on board the aircraft. The discrepancy was that our oxygen system needed to be topped off to remain in the required limits. When the mechanic fills the oxygen system [he] must turn off the oxygen flow to the crew and the passenger masks. Then after the oxygen is topped off, the mechanic opens the valve and once again passenger oxygen [is] available to passengers and crew… I asked my co-pilot if the pre-flight had been accomplished. He stated that it was and we prepared to leave. After takeoff we were cleared to 18,000 feet. Upon reaching 18,000 feet,
The Tie That Binds
A First Officer reports an unusual event involving what air crews commonly refer to as a “crotch strap” – a part of the seat harness that passes between the legs and snaps into the seatbelt portion of the harness. This same type of restraint is called a “submarine strap” in car racing because it keeps the driver’s body from “submarining” under the panel during a crash. Here’s what happened: for 2-3 minutes. He took the flight controls and felt the same rubbing or stiffness of the elevator and immediately said we are going back… Normal approach and landing and taxi into blocks [were made]… The next day one of our assistant Chief Pilots informed the Captain and me that…[my] crotch seatbelt was found in the floor in the slot where the yoke sits… Having never worn the crotch belt (between the legs of the 5-point harness) and having had numerous check rides, line checks, simulator supports on type rides, and having never been corrected to the contrary, and having never witnessed our own Captains using this part of the harness, I thought it was optional. I must confess I had tried it on before but did not use it because of the discomfort… A different assistant Chief Pilot suggested I should start wearing the belt, which I do [now]. The unused belt was only part of the problem here. The control column seal in this older aircraft (DC-8) was apparently not maintained properly, allowing the unused belt strap to become caught in the base of the column.
s Flight departed block late followed by normal Before Takeoff checklist…[This included] elevator control tab check by both Captain and First Officer simultaneously full aft, then full forward, while confirming associated movement of elevator... This was accomplished. No abnormalities noted. As takeoff was initiated Captain called “80 knots.” I accomplished “elevator checks” but noted a somewhat different feel of yoke as if there was a rubbing or stiffness [in] yoke elevator. I checked the elevator two more times feeling the same stiffness, but having elevator authority I elected to continue the takeoff as we were approaching V [speeds] rapidly. On climbout I asked the Captain to take the flight controls after we had been ‘cleaned up’ and cleared on course
ASRS Recently Issued Alerts On…
False warnings of smoke in a CL65 cargo hold B737-200 uncommanded yaw during takeoff roll Non-compliance with DC9 radome repair procedures Multiple reports of false GPWS / EGPWS terrain warnings Late arrival clearances and runway changes at an 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://asrs.arc.nasa.gov/
December 2000 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2051 566 56 166 2839
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_258.pdf
February 2001
The Experience-Procedures Feedback Loop
Procedures are a means of communicating the wisdom of experience in a standardized form to operators. But procedures may need to be revised when incidents and accidents demonstrate their weaknesses. This continuous reinforcement loop between experience and procedures is one of the most important safety tools in aviation. A Captain’s report to ASRS describes the dangerous situation that developed for a Lear-60 crew when a procedural oversight by maintenance was amplified by a flight crew oversight during pre-flight. I…proceeded to accomplish the transition level checklist. When doing this a visual check of the oxygen pressure gauge as well as checking the crew oxygen mask is required. I did this and did not receive a positive flow of oxygen to my mask. The co-pilot checked his and again received no oxygen pressure. Thus we requested a lower altitude which was given to us. I asked the co-pilot if he had performed the pre-flight check which required him to test both crew member oxygen masks. He said he thought he had, but it was obvious he had not… The reason for this was that he was distracted by ground crew who were bringing beverages and ice to the aircraft. This Lear 60 has a nose compartment oxygen system… In [this]…system the oxygen indicator will read the oxygen bottle pressure, even if the valve is turned off and the crew masks are tested. When I boarded the aircraft to prepare for takeoff, I looked at the oxygen indicator and it showed a normal oxygen level…I, however, did not test my mask on the ground. I believe each crew flying…should know where their oxygen system is located and its operational characteristics… It is now company policy for both crew members to check the crew oxygen masks [during pre-flight]. It appears the maintenance technician who serviced the oxygen did not open the shutoff valve after servicing the bottle. The flight crew did not check the oxygen masks for flow until 18,000 feet MSL – a potentially lethal situation had they not detected the problem in time.
s Upon arrival, I…checked our aircraft’s flight log to make
sure that the previous day’s maintenance work was done properly and signed off correctly... After determining that the…paperwork was correct, I went out to assist the co-pilot [with pre-flight checks]… This was a position leg with no passengers on board the aircraft. The discrepancy was that our oxygen system needed to be topped off to remain in the required limits. When the mechanic fills the oxygen system [he] must turn off the oxygen flow to the crew and the passenger masks. Then after the oxygen is topped off, the mechanic opens the valve and once again passenger oxygen [is] available to passengers and crew… I asked my co-pilot if the pre-flight had been accomplished. He stated that it was and we prepared to leave. After takeoff we were cleared to 18,000 feet. Upon reaching 18,000 feet,
The Tie That Binds
A First Officer reports an unusual event involving what air crews commonly refer to as a “crotch strap” – a part of the seat harness that passes between the legs and snaps into the seatbelt portion of the harness. This same type of restraint is called a “submarine strap” in car racing because it keeps the driver’s body from “submarining” under the panel during a crash. Here’s what happened: for 2-3 minutes. He took the flight controls and felt the same rubbing or stiffness of the elevator and immediately said we are going back… Normal approach and landing and taxi into blocks [were made]… The next day one of our assistant Chief Pilots informed the Captain and me that…[my] crotch seatbelt was found in the floor in the slot where the yoke sits… Having never worn the crotch belt (between the legs of the 5-point harness) and having had numerous check rides, line checks, simulator supports on type rides, and having never been corrected to the contrary, and having never witnessed our own Captains using this part of the harness, I thought it was optional. I must confess I had tried it on before but did not use it because of the discomfort… A different assistant Chief Pilot suggested I should start wearing the belt, which I do [now]. The unused belt was only part of the problem here. The control column seal in this older aircraft (DC-8) was apparently not maintained properly, allowing the unused belt strap to become caught in the base of the column.
s Flight departed block late followed by normal Before Takeoff checklist…[This included] elevator control tab check by both Captain and First Officer simultaneously full aft, then full forward, while confirming associated movement of elevator... This was accomplished. No abnormalities noted. As takeoff was initiated Captain called “80 knots.” I accomplished “elevator checks” but noted a somewhat different feel of yoke as if there was a rubbing or stiffness [in] yoke elevator. I checked the elevator two more times feeling the same stiffness, but having elevator authority I elected to continue the takeoff as we were approaching V [speeds] rapidly. On climbout I asked the Captain to take the flight controls after we had been ‘cleaned up’ and cleared on course
ASRS Recently Issued Alerts On…
False warnings of smoke in a CL65 cargo hold B737-200 uncommanded yaw during takeoff roll Non-compliance with DC9 radome repair procedures Multiple reports of false GPWS / EGPWS terrain warnings Late arrival clearances and runway changes at an 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://asrs.arc.nasa.gov/
December 2000 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2051 566 56 166 2839
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_258.pdf
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