Number 272
April 2002
“TERRAIN, TERRAIN – Pull Up!”
A Minimum Safe Altitude (MSA) is defined by 14 CFR Part 91.119(a) as “an altitude allowing, if a power unit fails, an emergency landing without undue hazard to persons or property on the surface.” The minimum altitudes depicted on approach charts provide at least 1,000 feet of obstacle clearance for emergency use within a specified distance from the navigation facility upon which a procedure is based. As a First Officer discovered, a night approach into an airport located in mountainous terrain requires good crew coordination and compliance with charted altitude minimums: Further, while I saw the mountains on the right, I failed to verbalize anything to the Captain because I assumed he was lining up on the runway and we would pass well left of them. These mountains rise to 4,687 feet and have no light or beacon on top. At night, with good visibility, it is hard to judge their position.
1 Controller, 3 Emergencies
An instrument-rated General Aviation pilot encountered unforecast IMC and a lower ceiling than he felt confident handling under IFR flight. Unfortunately, this emergency was not the only one being handled by ATC.
s Approach Control cleared us for visual approach
approximately 30 nm northwest of the field. We were descending to 6,500 feet on the [STAR] when we received clearance for visual… The Approach controller directed us to “contact Tower 11 miles northwest.” I looked down, set in the localizer frequency for the ILS and Tower frequency in VHF#1 [radio], but did not select Tower… While I was looking down, the Captain selected 4,500 feet in the altitude alerter, and I did not notice that this was well below the MSA of 5800 feet… Around 15 nm…I selected Tower. Shortly thereafter we received an EGPWS alert for terrain. I noticed the black shapes of terrain approximately 3 miles right of us and the Captain started a climb out of 5,200 feet to 5,500 feet. Tower contacted us…when Approach Control notified them that he had a low altitude alert on us. I failed to provide proper back-up by not noticing the new altitude in the alerter, or noting that it was below MSA. I also switched the VHF to Tower prior to 11 miles, which prevented us from hearing Approach Control’s warning,
s After receiving a standard weather briefing with 2
updates, I filed IFR. Conditions were VFR and all Traffic Advisory Frequencies were calling for VFR. [Reported conditions] prior to departure were 4,700 feet broken and 5 miles [visibility]. Unfortunately…during climb I encountered IMC at 900 feet and immediately contacted the Tower to return to the airport. I then heard another pilot who departed just before me call in to report severe icing and spatial disorientation. The controller issued me a heading to turn to and I turned in the opposite direction, which took me over the airport. At this time a third plane declared an emergency due to icing and was inbound. I was also [encountering] icing, light and clear, as the controller vectored me out to the north and up to MSA. I flew [a VOR] approach to an uneventful landing on Runway 28L. The weather occurrence was not forecast and lasted only a short time. My personal minimums are 2,000 feet and 5 miles. My overflight of Runway 28 caused great problems for the controller and he told me that. All 3 pilots with problems landed uneventfully. My ILS antennas had 2 inches of ice.
Wanted GPWS: Gear Pin Warning System
A maintenance technician reports to ASRS that creative substitutes for maintenance manual procedures may cause their own set of problems:
s Aircraft X came in for overnight maintenance
(routine). One deferral on the aircraft was a faulty Ground Proximity Warning System (GPWS). While troubleshooting the system per the maintenance manual, one step was to install gear pins. Not having any in the immediate area I chose to use my 6-1/4 inch drive ratchet extension for the nose gear down
lock pin. After all the troubleshooting and testing… I returned the GPWS back to airworthy condition and released the aircraft back to service, failing to remove the 6-inch extension from the nose gear down lock assembly. Unfortunately, the aircraft was unable to retract the nose gear after takeoff, thus returning back to the airfield… Contributing factors to this event: poor choice in not following maintenance manual procedures.
ASRS Recently Issued Alerts On…
An ATC clearance-related runway conflict EMB145 pitch trim failure during initial climb A severe runway conflict involving a B767 and A321 CL-65 frozen aileron stabilizer trim incident at FL240 DHC8-100 aileron control wheel disconnect on landing
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/
February 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 1856 678 28 97 2659
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_272.pdf
April 2002
“TERRAIN, TERRAIN – Pull Up!”
A Minimum Safe Altitude (MSA) is defined by 14 CFR Part 91.119(a) as “an altitude allowing, if a power unit fails, an emergency landing without undue hazard to persons or property on the surface.” The minimum altitudes depicted on approach charts provide at least 1,000 feet of obstacle clearance for emergency use within a specified distance from the navigation facility upon which a procedure is based. As a First Officer discovered, a night approach into an airport located in mountainous terrain requires good crew coordination and compliance with charted altitude minimums: Further, while I saw the mountains on the right, I failed to verbalize anything to the Captain because I assumed he was lining up on the runway and we would pass well left of them. These mountains rise to 4,687 feet and have no light or beacon on top. At night, with good visibility, it is hard to judge their position.
1 Controller, 3 Emergencies
An instrument-rated General Aviation pilot encountered unforecast IMC and a lower ceiling than he felt confident handling under IFR flight. Unfortunately, this emergency was not the only one being handled by ATC.
s Approach Control cleared us for visual approach
approximately 30 nm northwest of the field. We were descending to 6,500 feet on the [STAR] when we received clearance for visual… The Approach controller directed us to “contact Tower 11 miles northwest.” I looked down, set in the localizer frequency for the ILS and Tower frequency in VHF#1 [radio], but did not select Tower… While I was looking down, the Captain selected 4,500 feet in the altitude alerter, and I did not notice that this was well below the MSA of 5800 feet… Around 15 nm…I selected Tower. Shortly thereafter we received an EGPWS alert for terrain. I noticed the black shapes of terrain approximately 3 miles right of us and the Captain started a climb out of 5,200 feet to 5,500 feet. Tower contacted us…when Approach Control notified them that he had a low altitude alert on us. I failed to provide proper back-up by not noticing the new altitude in the alerter, or noting that it was below MSA. I also switched the VHF to Tower prior to 11 miles, which prevented us from hearing Approach Control’s warning,
s After receiving a standard weather briefing with 2
updates, I filed IFR. Conditions were VFR and all Traffic Advisory Frequencies were calling for VFR. [Reported conditions] prior to departure were 4,700 feet broken and 5 miles [visibility]. Unfortunately…during climb I encountered IMC at 900 feet and immediately contacted the Tower to return to the airport. I then heard another pilot who departed just before me call in to report severe icing and spatial disorientation. The controller issued me a heading to turn to and I turned in the opposite direction, which took me over the airport. At this time a third plane declared an emergency due to icing and was inbound. I was also [encountering] icing, light and clear, as the controller vectored me out to the north and up to MSA. I flew [a VOR] approach to an uneventful landing on Runway 28L. The weather occurrence was not forecast and lasted only a short time. My personal minimums are 2,000 feet and 5 miles. My overflight of Runway 28 caused great problems for the controller and he told me that. All 3 pilots with problems landed uneventfully. My ILS antennas had 2 inches of ice.
Wanted GPWS: Gear Pin Warning System
A maintenance technician reports to ASRS that creative substitutes for maintenance manual procedures may cause their own set of problems:
s Aircraft X came in for overnight maintenance
(routine). One deferral on the aircraft was a faulty Ground Proximity Warning System (GPWS). While troubleshooting the system per the maintenance manual, one step was to install gear pins. Not having any in the immediate area I chose to use my 6-1/4 inch drive ratchet extension for the nose gear down
lock pin. After all the troubleshooting and testing… I returned the GPWS back to airworthy condition and released the aircraft back to service, failing to remove the 6-inch extension from the nose gear down lock assembly. Unfortunately, the aircraft was unable to retract the nose gear after takeoff, thus returning back to the airfield… Contributing factors to this event: poor choice in not following maintenance manual procedures.
ASRS Recently Issued Alerts On…
An ATC clearance-related runway conflict EMB145 pitch trim failure during initial climb A severe runway conflict involving a B767 and A321 CL-65 frozen aileron stabilizer trim incident at FL240 DHC8-100 aileron control wheel disconnect on landing
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/
February 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 1856 678 28 97 2659
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_272.pdf
自定义标签： 
