ASRS reporters describe incidents or mistakes that came about as a result
of their own actions or inactions. Although pilots take final responsibility
for the safe operation of the aircraft, they can sometimes trace a key
link in the error chain back to some "significant other."
In our first report, a corporate helicopter experienced a mechanical malfunction
due to foreign object damage.
- While enroute
from XYZ, the #1 engine oil temp began to rise. I started to return
to XYZ; however, it became obvious that the oil temp was climbing too
quickly to continue. The engine was shut down when the oil temp exceeded
limits, [and the flight diverted to nearby ABC].
I had completed a thorough preflight, as had a company mechanic. [On
postflight], a white diaper used by the cleaning personnel was found
in the oil cooler blower. The aircraft is white and the diaper could
be easily missed. Cleaning crews are not aviation personnel and do not
understand the importance of keeping track of rags.
Management, pilots, and mechanics
all need to communicate to non-aviation personnel how essential it is
that no foreign objects are left in or near an aircraft.
A Real Tail-Dragger
Weight and balance determination
is often the result of input from a number of people, including the pilot,
the baggage handler, the gate agent, and even the passengers. In the following
report from a commuter airline First Officer, all the people involved
and the aircraft were ultimately at the mercy of an airline operational
- On the flight
from ABC to XYZ [and continuing to JFK International Airport], I planned
(per company policy) to use normal baggage weight, which is 23.5 lb.
per bag. But almost all the passengers were on their way to JFK. When
you fly to JFK, you are supposed to use international baggage weights
of 35 lb. So from ABC to XYZ, we're supposed to use 23.5 lb., then on
the leg to JFK, the bags automatically go up to 35 lb. I think this
is a terrible policy.
Upon landing at XYZ, we touched down and, unexpectedly, the nose came
abruptly off the ground. We added power as well as pushing forward on
the yoke, [and] proceeded normally to the gate. Upon visual inspection
of the tail, I saw scratches on the tail section. At that point, we
requested all the bags to be weighed. The average weight was 44.5 lb.
At that weight, we were so far aft center of gravity that we should
not have even been able to leave ABC.
The only way to ensure proper
weight and balance is to weigh each bag before loading it onto the aircraft.
However, this may not always be a realistic option. Some pilots have brought
this problem to the attention of company management. They report that,
in some cases, company policies on baggage weight estimates have been
changed to reflect more realistic figures.
Back Seat Interference
A General Aviation pilot navigating
by normally reliable VOR receivers wandered off-course, and discovered
that an unexpected culprit was the cause of the navigation discrepancy.
- After departing
VFR, I picked up an IFR flight plan, and was given a clearance. Abeam
one intersection, Approach advised that I was 7 miles south of course
and provided a heading to reintercept. I began course correction and
configured the Loran for course guidance. On further comparison, it
was determined that both VOR receivers were suspect as they both indicated
8 degrees off. This prompted a query of the two passengers, children
ages 7 and 12, after which it was found that both were using portable
tape players. Both units were turned off, and the VOR receivers returned
to normal operation.
Air carrier aircraft are not
the only ones susceptible to the effects of portable electronic equipment.
Small aircraft, too, can experience interference with potentially serious
results, particularly in IMC conditions.
Watch Your Step!
In the next report, departing
passengers inadvertently left the pilot with a surprise to remember them
- After dropping
off the load of skydivers, I was cleared to descend into Class B airspace.
[Descending], I experienced an engine failure. I notified ATC that I
had an engine failure. They cleared me to the municipal airport. I began
the restart checklist to restart the aircraft. As I checked the fuel
selector knob, I noticed that it had been bumped into the OFF position
by one of the skydivers. I placed the knob into the BOTH position and
regained power to the airplane.
The lesson I learned is that a safety guard is needed on the fuel selector
knobs if you are carrying skydivers. The owner agreed, and has placed
one on this aircraft.
Another lesson learned by all
these reporters is the potential impact of "significant others."
Air Traffic Controllers must
often carry out their duties in less-than-ideal conditions, and also come
to the aid of pilots who find themselves in less-than-ideal conditions.
In a report from a Center controller, a non-IFR-rated General Aviation
pilot took advantage of ATC's expertise and got some badly-needed help.
- I got a
call from ABC Approach about a small aircraft trapped on top of an overcast
with only about 45 minutes of fuel remaining. The pilot thought he was
40 nm northeast of ABC VOR, but Approach couldn't find him on their
radar. The Center Controller expanded the range all the way out and
discovered the aircraft about 40 miles west of XYZ [more than 100 nm
south of ABC VOR-Ed.]. Being familiar with that aircraft, I realized
that this pilot was in danger of losing his life. The pilot did not
have enough fuel to go to an airport with good weather, committing him
to land at XYZ. I told Approach to ask the pilot if he had a working
autopilot on board to turn it on so he could reduce his workload in
keeping the aircraft right side up while in the clouds.
Later, we found out that the pilot had broken out of the overcast and
was proceeding safely to XYZ.
An air carrier Captain, dodging
weather and contending with a cabin pressurization problem, called ATC
for assistance, and was pleased with the quick response.
- We advised
Center we would require an immediate descent. Controller did a great
job, as he understood our situation completely. He moved traffic and
got us a clearance for a lower altitude and towards the airport, without
our even declaring an emergency, which I fully intended to do. ATC provided
us a safe path [around storm cells]. ATC couldn't have performed better.
Perhaps nothing is more heart-stopping
for both pilot and controller than a power failure at a terminal radar
facility. Cool heads prevailed in the following incident, however, and
teamwork with the Center contributed to a happy ending.
- A single
engine aircraft called with a fuel emergency. I gave the aircraft a
heading to the airport and was able to radar identify him [even though
he was at low altitude due to a 700 foot ceiling]. When the aircraft
was about 8 miles from the airport, my radar scope and every other one
in the facility went blank--no ARTS, no primary, nothing. Center was
advised of our outage, and continued to provide position info to me
about the aircraft. The aircraft landed safely. If it had not been for
luck and the cooperation of the Center controller, the situation could
have easily been much worse.
Silence Isn't Golden
Then there are the pilots who
don't talk to ATC. In such cases, ATC often goes the extra mile to ensure
of these pilots and their passengers. In the next report, a Controller
could not contact a GA aircraft, and finally enlisted outside help to
unravel the mystery of the silent pilot.
- The aircraft
was supposed to land at XXX but was passing the airport, and Center
could not raise the aircraft. Transmissions were made over the VOR,
121.5, [and Center, Approach, and Tower] frequencies to no avail. Eventually
a military Beech was launched and it intercepted the aircraft 120 miles
southeast of XXX. Evidently, the Beech awakened the sleeping pilot and
very quickly thereafter, the pilot contacted ATC. The aircraft landed
without incident. I'd say that Beech saved the pilot's life.
Another pilot unknowingly courted
disaster by not communicating with ATC. A quick-thinking Controller came
to the rescue.
- I was working
Approach/Departure Control when I noticed an aircraft as it entered
the corner of a Restricted Areawhich was active for artillery firing.
The VFR aircraft never contacted ATC. As it entered the Restricted Area,
I alerted the Range Control personnel about the intruding aircraft.
The aircraft was halfway through the area before Range Control could
accomplish the cease-fire. Better pilot use of VFR radar services should
prevent such deviations.
In our next example, an air
taxi pilot was talking, but wasn't really communicating. As a result,
the reporting Controller was unable to provide services when they were
- The aircraft
climbed normally, but then the pilot called and said he must return.
He indicated he was in no difficulty, but must return for "more
work." The pilot turned on his own, and canceled IFR. He called
back later requesting vectors to the nearest airport. I vectored him
to XYZ, only five miles from him by this time. I lost radar and communication
with the aircraft about 1.5 miles from XYZ.
The State Police later informed TRACON that the aircraft landed on a
road due to dual engine failure. The pilot never communicated a need
or a problem except the last minute request for "a vector to the
nearest airport." I believe the pilot received quality service,
but deserved more attention. I wish the pilot had shared the info of
his impending problem with me sooner.
ASRS Recently Issued Alerts
- Inadequate flight idle detent
system on EMB-120
- Uncommanded full rudder
deflection on a Boeing 727-100
- Difficulty in identifying
a Washington departure intersection
- Confusion about newly-published
STARs for Salt Lake City
- Dornier 328 window cracks
attributed to airframe contraction
December 1995 Report Intake
- Air Carrier Pilots--1545
- General Aviation Pilots--539