Number 277
October 2002
Some “Thoughts” on Safety
An ASRS report that appears in CALLBACK is meant to stimulate thinking about aviation safety. The following reports offer a few thoughts that might prompt us to think twice when that ‘little voice’ says, “Something’s not right” said both transmissions were, “Cleared to land Runway 18L.” [I] don’t know what to say. I just kept thinking Runway 18R In another “I thought he said” incident, a Tower controller might have helped the involved pilot avoid a wrong runway landing by mentioning a change of runway assignments in the clearance.
“He Thought I Said…”
A misunderstanding leads to an unexpected reconfiguration, a look of consternation, an unplanned deceleration, an embarrassing interrogation, and a resolve to improve communication.
s At ten miles out, I [gave] my
position…[and] was told to enter a right pattern to Runway 28. I was also told to report the river, which is about three miles out. I reported the river where I was told to continue to Runway 28 and enter a right downwind. When I got abeam Runway 20, I was cleared to land Runway 20. I didn’t catch the difference in the two runways. I was told twice to report Runway 28 and when told Runway 20, I thought he said Runway 28. I landed on Runway 28… The controller asked why I landed on Runway 28 instead of Runway 20. I responded that I didn’t realize that I had made that mistake.
s We were assigned FL 240 with clearance to cross INTXN
at 10,000 feet and 250 knots. At approximately 78 DME, Center asked if we were going to be able to get down by INTXN. The First Officer had started the descent [checklist] and was responding to an ATC query. I stated (to the First Officer), “We’re down,” as I had already started the descent. The First Officer extended the landing gear at 23,000 feet and 300+ knots. He thought I said, “Gear down.” We attempted to raise the gear, but were unsuccessful until we slowed below 250 knots. The First Officer informed ATC that we were temporarily unable to maintain the assigned speed of 310 knots. ATC asked if there was a problem...then vectored us off track and then back to the Arrival. During the vector, the gear retracted normally and we resumed [our] assigned speed. From the First Officer’s report: While I was starting to run the descent checklist, I noticed that we were a little high for our descent to INTXN… Because we were high, ATC had told us to expedite our descent, and I heard the Captain say, “Gear down.” I quickly lowered the gear handle. After I had put the handle down I realized that could not have been what the Captain had asked for – and the look on his face confirmed it… Upon reflection…I realize that I should not react so fast to an order that is not a normal procedure. If I had questioned the order first, then the Captain could have cleared up my misunderstanding. CRM works if you use it.
“You are where your thoughts have brought you.” – James Allen
The pilot in our next report makes three references to “thinking” about where he is going, but doesn’t appear to be “hearing” any directions until the First Officer says, “Stop!”
s Tower told us to hold short of Runway 19L. The First
Officer acknowledged the call from Tower and confirmed the “Hold short of Runway 19L [clearance]. I, however, ” was thinking Runway 19R. We proceeded on Taxiway L toward Runway 19L, but since I was thinking Runway 19R, I crossed the hold short line for Runway 19L. The First Officer rightly called for the “hold short,” and I was still thinking (erroneously) to hold short of Runway 19R. The First Officer, recognizing that we weren’t actually stopping, said, “Stop!” At that point, I quickly applied the brakes and stopped the aircraft about 20 feet beyond the hold short line. A light aircraft (a C172, I think) on final went around, seeing that we had crossed the hold short line. Tower then cleared us into “position and hold” on Runway 19R. Lessons learned: 1) Confirm with the First Officer the actual taxi/hold short instructions. 2) Check final approach corridor for traffic. 3) Call out simple commands like, “Stop now” that don’t require further thought.
“I Thought He Said…”
A B757 pilot shows that even when we think we are paying attention, the thinking process can be shortcircuited by a preconceived notion.
s Approach said, “Expect Runway 18R.” On short final I
thought I heard, “Cleared to land Runway 18R.” I asked [Tower to] confirm clearance to land. Again, I thought he said, “Cleared to land Runway 18R.” After landing, Tower
ASRS Recently Issued Alerts On…
BE55 landing gear incident B777 main battery overheat A fuel contamination incident An approach frequency charting error Oceanic Area Control Center clearance lead time incident
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/
August-September 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 4209 1499 116 286 6110
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_277.pdf
October 2002
Some “Thoughts” on Safety
An ASRS report that appears in CALLBACK is meant to stimulate thinking about aviation safety. The following reports offer a few thoughts that might prompt us to think twice when that ‘little voice’ says, “Something’s not right” said both transmissions were, “Cleared to land Runway 18L.” [I] don’t know what to say. I just kept thinking Runway 18R In another “I thought he said” incident, a Tower controller might have helped the involved pilot avoid a wrong runway landing by mentioning a change of runway assignments in the clearance.
“He Thought I Said…”
A misunderstanding leads to an unexpected reconfiguration, a look of consternation, an unplanned deceleration, an embarrassing interrogation, and a resolve to improve communication.
s At ten miles out, I [gave] my
position…[and] was told to enter a right pattern to Runway 28. I was also told to report the river, which is about three miles out. I reported the river where I was told to continue to Runway 28 and enter a right downwind. When I got abeam Runway 20, I was cleared to land Runway 20. I didn’t catch the difference in the two runways. I was told twice to report Runway 28 and when told Runway 20, I thought he said Runway 28. I landed on Runway 28… The controller asked why I landed on Runway 28 instead of Runway 20. I responded that I didn’t realize that I had made that mistake.
s We were assigned FL 240 with clearance to cross INTXN
at 10,000 feet and 250 knots. At approximately 78 DME, Center asked if we were going to be able to get down by INTXN. The First Officer had started the descent [checklist] and was responding to an ATC query. I stated (to the First Officer), “We’re down,” as I had already started the descent. The First Officer extended the landing gear at 23,000 feet and 300+ knots. He thought I said, “Gear down.” We attempted to raise the gear, but were unsuccessful until we slowed below 250 knots. The First Officer informed ATC that we were temporarily unable to maintain the assigned speed of 310 knots. ATC asked if there was a problem...then vectored us off track and then back to the Arrival. During the vector, the gear retracted normally and we resumed [our] assigned speed. From the First Officer’s report: While I was starting to run the descent checklist, I noticed that we were a little high for our descent to INTXN… Because we were high, ATC had told us to expedite our descent, and I heard the Captain say, “Gear down.” I quickly lowered the gear handle. After I had put the handle down I realized that could not have been what the Captain had asked for – and the look on his face confirmed it… Upon reflection…I realize that I should not react so fast to an order that is not a normal procedure. If I had questioned the order first, then the Captain could have cleared up my misunderstanding. CRM works if you use it.
“You are where your thoughts have brought you.” – James Allen
The pilot in our next report makes three references to “thinking” about where he is going, but doesn’t appear to be “hearing” any directions until the First Officer says, “Stop!”
s Tower told us to hold short of Runway 19L. The First
Officer acknowledged the call from Tower and confirmed the “Hold short of Runway 19L [clearance]. I, however, ” was thinking Runway 19R. We proceeded on Taxiway L toward Runway 19L, but since I was thinking Runway 19R, I crossed the hold short line for Runway 19L. The First Officer rightly called for the “hold short,” and I was still thinking (erroneously) to hold short of Runway 19R. The First Officer, recognizing that we weren’t actually stopping, said, “Stop!” At that point, I quickly applied the brakes and stopped the aircraft about 20 feet beyond the hold short line. A light aircraft (a C172, I think) on final went around, seeing that we had crossed the hold short line. Tower then cleared us into “position and hold” on Runway 19R. Lessons learned: 1) Confirm with the First Officer the actual taxi/hold short instructions. 2) Check final approach corridor for traffic. 3) Call out simple commands like, “Stop now” that don’t require further thought.
“I Thought He Said…”
A B757 pilot shows that even when we think we are paying attention, the thinking process can be shortcircuited by a preconceived notion.
s Approach said, “Expect Runway 18R.” On short final I
thought I heard, “Cleared to land Runway 18R.” I asked [Tower to] confirm clearance to land. Again, I thought he said, “Cleared to land Runway 18R.” After landing, Tower
ASRS Recently Issued Alerts On…
BE55 landing gear incident B777 main battery overheat A fuel contamination incident An approach frequency charting error Oceanic Area Control Center clearance lead time incident
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/
August-September 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 4209 1499 116 286 6110
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_277.pdf
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