CALLBACK 263



Issue Number 263		July 2001
	A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System P.O. Box 189, Moffett Field, CA 94035-0189

"Kick the Tires and Light the Fires" — Not The colorful lingo of military aviation has found a permanent niche in the civil aviation vernacular, including that often-quoted favorite, "Kick the tires and light the fires!" This expression originally meant to bypass or severely limit the time required for physical inspection of an aircraft prior to flight. Currently, it means, "Let's get this aircraft pre-flighted and out of here!" Regardless of which interpretation is applied, the result can spell trouble for pilots who follow the advice too literally. I took another pilot to airport ABC to ferry an aircraft to my home field. Due to winds, I elected not to fly my taildragger and borrowed another tri-gear aircraft. The VFR flight to ABC was uneventful with my fellow pilot navigating. I had never been to ABC before, which is a very busy Class B area. Upon departure [from ABC] in high winds and turbulence throwing me around in the cockpit, I quickly became disoriented. [Not] having... my navigator did not help. I could not recognize landmarks... on my Terminal Area Chart. I estimated my position, staying low to clear the Class B [airspace]. Once I confirmed my position I realized I was probably in the 1500-foot ring and my altitude was 1900 feet MSL. I quickly dove to 1400 feet. I continued at 1400 feet until well clear of that portion of Class B. I failed to have a clear plan in mind when departing ABC for heading and altitude. Because I was in unfamiliar territory in a borrowed aircraft and turbulence was throwing me all over the sky, I was a bit overwhelmed. I am an experienced pilot and learned a great [lesson] from this experience. That is ? work up a plan with an alternate [plan] and stick to [them]. Don't just "kick the tires and light the fires"!

Pay Your Toll To the Towbar Troll I arrived at the airport, pre-flighted the airplane in the hangar, attached a towbar to the nose wheel and pulled the airplane onto the ramp with my vehicle. Disconnected the towbar from my vehicle and pulled around the side of the plane to put my flight bag into the plane. Put the vehicle in the hangar, closed the hangar door. I called FSS to obtain my IFR clearance. I jumped into the airplane, taxied to the runway, and departed into 200 sky obscured and 1/2 mile visibility. After rotation I heard a thump. Concerned that my landing gear may have hit a small animal (fox, etc.) I did not retract the gear. I continued to my destination, which was VFR with its services. Approximately 20 minutes prior to arrival, I remembered the towbar and advised the Tower of my situation and requested CFR services as a precaution. The landing was uneventful, with a 1/4-inch dent the only damage to the airplane. Events leading to this occurrence were: Early morning departure; Using my vehicle to pull the airplane out (normally I tow by hand); Attention devoted to departure into IMC conditions. Suggestions: Attaching a towbar requires that at the very least, action be corrected to... complete pre-flight.

A Note on ASRS Report Submission ASRS has received several recent reports submitted by air carrier crew members that include a sentence like this: "I am submitting this report on behalf on myself and the First Officer, with his permission." [ASRS emphasis] ASRS program users should be aware that only the individual whose name appears on the report identification strip (ID strip) is eligible for the FAA immunity provisions associated with ASRS participation. Two individuals cannot receive immunity from submission of the same ASRS report form. Only the person who submits the report is eligible for immunity, assuming that other important conditions such as timely receipt of the report and inadvertent nature of the incident are met. There is another reason for each person involved in an incident to submit his or own report. Multiple reports of the same incident provide a richer, fuller picture of what happened, and are of special interest to many requesters of ASRS data. FAA Advisory Circular 00-46D outlines all the ASRS program provisions, and is available from the IMMUNITY POLICY page on this site.

Notes from the Galley Most air carriers have policies that prohibit cockpit crews from eating the same entree. These policies are a safeguard against an entire flight crew being incapacitated by food poisoning. An incident recently reported to the ASRS points to the need for care in serving cockpit beverages, as well. While parked at the gate waiting for departure time, my First Officer and myself asked for a glass of orange juice. The Chief Purser brought us each a glass of orange juice and after taking a sip, we discovered that both glasses of orange juice were mixed with champagne. I asked the Chief Purser where he got the glasses from and he said he took them from a tray in the cabin. We were both very disturbed by this, so I called the duty Flight Manager to inform him of this incident. We were told to pack our bags and leave the aircraft, we were no longer legal to fly... The flight was delayed over an hour and a half while another crew was found to fly the aircraft. I was very glad that this incident happened while parked at the gate rather than in flight, but I am very concerned that it happened at all. I feel that the cabin crew need to review their procedures for handling cockpit beverages (as well as food items) so that this problem does not happen again.

Attacks from the Back

ASRS has received several reports during the last year of a potential hazard to air carrier flight crews that are repositioning or ferrying aircraft. Because these flights do not carry passengers and the usual cabin crew complement, some pilots forget to secure the cabin. Here’s what can happen when this precaution is neglected:

During landing rollout at 60 knots, a galley cart from the aft galley rolled all the way down the aisle and into the flight deck on our ferry flight. The cart struck the center pedestal preventing damage to any flight instruments.

I, the First Officer, failed to properly secure the aft galley as per our flight handbook. During preparation to start the flight, I did assure that the forward galley was secured. For some reason, I didn't think to check the aft galley. We don't [do] ferry flights very often so it is easy to overlook cabin security during a ferry flight. I am now sure I will always check cabin security on my future ferry flights.

An almost identical situation was experienced by a B737-400 crew on a recent repositioning flight.

...Because we were the only people on board, we kept the cockpit door open. Captain...crossed the threshold of Runway 33 on speed, on course and touched down at the proper touchdown point. Without warning, at about 100 knots there was a loud bang and hissing noise in the cockpit. We continued to stop the airplane on the runway. As the airplane came to a stop we realized the aft center galley cart had traveled through the center aisle of the aircraft, crashing into the center console of the airplane. Several pop cans had been dislodged and were at our feet. Some had burst. None of the cans hit the forward instrument panel...

It's easy to envision even worse damage occurring to cockpit instrumentation and occupants, including jamming of flight controls by loose cans and injury to pilots. Securing the cabin during preflight is the best defense against such incidents.

ETOPS Sign-offs

A maintenance incident reported to ASRS carries a reminder that sign-off requirements for ETOPS (Extended Range Operations) repairs are restrictive – a point that can easily be forgotten.

I am an A&P mechanic for a major international airline. Another mechanic and I were assigned two tasks on a Boeing 767-300ER. Per our company's policies and procedures manual, only those people designated as "ETOPS Qualified" (EQ) may sign off tasks or discrepancies on most systems on the aircraft. A non-EQ mechanic may work under the supervision of an EQ mechanic and the EQ mechanic may sign off the non-qualified mechanic's work. I am not EQ, while the other mechanic is. We had pretty much wrapped up the first task and...I began the second task, which was to replace a bearing tube assembly on an engine...The other mechanic joined me not long after I started to remove and replace the tube, and in fact assisted me with the installation. We completed the replacement per the maintenance manual and leak-checked the line, which was found to be OK for service. Later in the shift the other mechanic made all the required logbook entries for the items we had worked, except for the entry for the tube replacement. He handed the logbook to me so I could enter and clear the item, which I did.

A few days later, I received a memo and copy of the log page from my foreman indicating...I may not have been in compliance with our policies and procedures regarding ETOPS only tasks.... As it turns out, any maintenance done on the engines is considered an ETOPS item, so I was most definitely not in compliance by making the entry for the repair in the logbook. The maintenance performed was OK, as I was being supervised by an EQ mechanic. The sign-off was the problem...

On non-ETOPS aircraft it is common to pass around the logbook for each mechanic to sign off his work. This has become more habit than we thought, [even though] we have all received ETOPS awareness training. Some solutions we have implemented are to post a "read and sign" [notice] reminding everyone of the restrictive nature of ETOPS maintenance. The foreman also intends to meet with the leads and remind them to be more aware of whom they are assigning work to on an ETOPS airplane.

ASRS Recently Issued Alerts On...
Maule M-7 loss of pitch control emergency
Power line hazard to gliders at a Northeast airport
B767 GPWS false warnings during heavy precipitation
Recurring ARTS III computer problems at an ATC facility
ATC "pull alongside" clearance to air carriers on approach

MAY 2001 Report Intake
Air Carrier/Air Taxi Pilots	2,112
General Aviation Pilots	718
Controllers	54
Cabin/Mechanics/Military/Other	192
TOTAL	3,076