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美国ASRS安全公告CALLBACK cb_269.pdf2页

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Number 269

January 2002

It’s Nice to De-Ice – But Be Careful!
Icing – its presence and possibility – is a staple of winter operations that pilots must reckon with in their pre-flight inspections. According to ASRS reporters, the attempt to remove ice from an aircraft before flight may have consequences just as hazardous as an unexpected encounter with icing while airborne. We illustrate with a First Officer’s report that describes how routine ice-removal procedures went awry. controls and abrupt attitude changes] continued for about 2 to 4 minutes. During that time we flew into clear skies and advised Center we were having trouble controlling pitch on our airplane. Immediately [a lower altitude] was granted, and as we descended into warmer conditions…the pitch controls began to respond normally. The reporter added that because of a warming trend, slush was sliding off the aircraft’s wings and fuselage prior to pushback. Ground crew elected not to de-ice the airplane, but just to sweep the fuselage with brooms. Maintenance inspected the elevators after the incident and found that slush from the top of the fuselage had lodged in the stabilizer elevator gap, causing recurring elevator jams.

s During rotation Runway 25L, lost autothrottles,
Flight Director, and Captain’s airspeed began to decrease. GPWS [Ground Proximity Warning System] began alert, “Terrain, terrain” and “Whoop, Whoop, pull up!” Attempted to stay VFR but unable. Flew vectored ILS to runway 35L. On landing, unable to start APU. During pattern, may have deviated from assigned headings or altitudes. Tower controller outstanding and very helpful. Captain made excellent use of all resources including First Officer, ATC, Flight Attendants, and company. This reporter told ASRS analysts during a callback conversation that the aircraft had spent the night on the ground during a severe ice storm and as a result was de-iced prior to departure. The reporter believed the problem was caused by de-icing fluid in the pitot and static tubes of the #1 system.

ASRS Updates Web Site Reporting Forms
The ASRS web site (http://asrs.arc.nasa.gov) has been updated with new “interactive” Adobe Acrobat versions of the program’s reporting forms. After web site users download a reporting form, they can now fill it out using their computer to enter information. All four ASRS forms have been updated with this new interactive feature. The forms include: • General Form (for pilots, dispatchers, airport personnel, and others) • ATC Form (for Air Traffic Controllers) • Maintenance Form (for aviation maintenance personnel) • Cabin Crew Form (for airline cabin crew members) Important Note: The free (non-commercial) version of the Adobe Acrobat Reader does not allow users to “save” information entered into the forms. Once the forms are filled out using the freeware version of the Acrobat Reader, they must be printed to preserve the information entered. Reporters can print a duplicate copy of the report for their own records at this time, also. Completed forms should be mailed to ASRS at the address given on the form.

The Broom That Didn’t Sweep Clean
The flight crew of a regional passenger jet experienced an equally harrowing aftermath of ice removal. From the Captain’s report to ASRS:

s Our airplane was boarded 20 minutes late because of
heavy sleet, snow and rain... Later, residual slush build-up on the airplane was swept off… Start-up, taxi out for takeoff was normal… Takeoff on Runway 35 was normal. Cleared to climb to 9,000 feet (all anti-ice protection on), everything in the climb was normal. However, when I went to level off, I immediately noticed I couldn’t push the nose over! We were on instruments (OAT -14 degrees Celsius). I noticed about a 1-inch strip of rime ice on the leading edge of the wing. My own past experience told me this was not enough ice to freeze up the controls. I was able to arrest the climb somewhat with use of trim and power, while continuing to free up controls. Then, all of a sudden it [the ice] let loose and an abrupt nose-down attitude resulted… This [sticking

ASRS Recently Issued Alerts On…
MD80 auto spoiler deployment incidents ATC handling of an air carrier on a STAR routing Incidents involving CL65 trailing edge inflight failure Unusual wake turbulence incident involving a EMB-145 Security incidents since the Sept. 11th national emergency

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/

November 2001 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 1721 850 30 103 2704


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