Issue Number 282
March 2003
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Safety in the Cabin

B737 seating configuration

Flight Attendants are an integral part of the aircraft crew and their primary responsibilities are safety-related. The "sealed" cockpit environment has increased the reliance upon Flight Attendants for the transfer of vital information to the pilots and for their independent resolution of cabin incidents.

These recent reports to ASRS demonstrate the variety of situations Flight Attendants are called upon to handle.

MRE: Meals, Ready to (H)eat

Quick action by an MD-80 Cabin Crew dampened a passenger's unauthorized attempt to heat and eat.

  • The #4 Flight Attendant was the first person to detect a burning plastic smell... I walked up a few rows and then noticed the same smell she was describing. We immediately called the cockpit and then checked out the galley area and lavatories. While I stayed in the aft portion of the cabin, the #4 Flight Attendant went out to pick up trash and to see if the smell was apparent throughout the cabin. In the aft part of plane we all smelled it and then noticed smoke coming from the trash bag that the #4 Flight Attendant had just brought back... Smoke was coming from an airsickness bag. We carefully opened it slightly and noticed a Styrofoam cup and a military, Meals, Ready to Eat (MRE) heating bag. A military passenger told another Flight Attendant that he was using it to cook the food he brought on board. We dumped the MRE heating device into a lavatory sink full of cold water, covered it with ice, and then locked the lavatory. It was still hot one and one-half hours later on landing. The passenger said he had done this before on other flights...

Commotion Control

Passenger behavior during an emergency is directly related to the actions and directions of the cabin crew. In the following ASRS reports, the Cabin Crew's training, demeanor, and clear communications prevented bad situations from getting worse.

  • ...The Captain declared an emergency [due to a main battery overheat and smoke in the cabin]. We had 20 minutes to prepare the cabin for emergency landing [and] accomplished the checklist in 10 minutes... While I gathered the crew to inform them of the emergency, etc., a few of our coach passengers could see that we were no longer continuing to [our destination] and started a wave of panic and grabbing of life vests. We contained [the panic] and I elected to make a second PA to make sure they knew how to operate the vest and, more importantly, when not to... We landed without incident.

  • ... Passenger Call lights started going off all around a passenger who was strapped in his seat and flailing his arms and legs all over. The food on the tray went flying everywhere. I was the first Flight Attendant there and assumed that the passenger was having a seizure. I restrained his arms, so he wouldn't keep hitting the person next to him. The man had lucid moments and...asked for help. The Captain was notified. The passenger was offered oxygen and water and was reseated in the rear of the plane... I thought that he might have a medical problem other than seizures and determined that he had not taken his lithium for a mental disorder. We made an emergency landing and were met by medical personnel.

The Flight Crew was very quick to respond without question to our request to land and trusted the Flight Attendants' decisions. All crew members worked well as a team!

Bad Vibrations

Cabin Crews often provide information that helps to clarify or confirm a problem that the Flight Crew is already working. In this next report, however, a Flight Attendant alerted the Captain to a problem that would not have become apparent in the cockpit until the situation became much worse.

  • While the #2 Flight Attendant and I were working the beverage cart, we heard a loud bang and felt a vibration. I notified the Captain...and then saw a cabin window that appeared to be slightly cracked. On closer inspection, I noticed that it was cracked all the way up and the outer panel was bulging away from the aircraft... I notified the Captain of the severity of the window problem. We had only enough empty seats to move passengers seated two rows forward and two rows aft of the cracked window... The beverage service was stopped and we prepared the cabin for landing... The Captain had to slowly decompress the cabin when he got down to 10,000 feet. His descent was very slow due to the fragility of the window... After mechanics inspected the window, they agreed that we were very lucky that the flight ended without incident.

Cabin Crews often provide information that helps to clarify or confirm a problem that the Flight Crew is already working. In this next report, however, a Flight Attendant alerted the Captain to a problem that would not have become apparent in the cockpit until the situation became much worse.

Hitting the Spot
Aircraft making a spot landing
Distractions are a common factor in flying. Usually they are overcome by concentrating on the task at hand or through the use of checklists. But, as this pilot and his instructor learned, when fixation and fatigue team up with a distraction, costly mistakes can result.

  • The instructor...told me to...execute a spot landing on the second stripe of the runway centerline. Abeam the numbers ...I reached forward to the place where the landing gear switch is found on [my type aircraft], but where the cowl flaps control is located on this type aircraft. I closed the cowl flaps, but before I reached for the landing gear switch, the instructor startled me by switching the radio back to...Approach. He informed Approach that we were remaining in the pattern. I switched back to CTAF and announced our position. I proceeded to "complete" the [landing] check... turned final, and adjusted power to ensure that we would touch down on the designated spot. I fixated on the spot landing target and failed to make my customary recheck of "three green..." Evidently, the instructor distracted himself as well when he made the radio call...because he did not catch my failure to lower the gear abeam the numbers. He also must have fixated on the spot-landing target... The airplane's gear up warning horn was inoperative and did not sound. The prop struck the runway as the belly settled onto the second stripe of the centerline... The sound of metal striking concrete was horrible, but the actual landing was surprisingly soft...

Distraction, fixation, and motor memory confusion all played a roll in this unfortunate incident, but the underlying cause was fatigue. My sleep-deprived mind focused reasonably well on one thing at a time, but was thrown off by a relatively minor distraction... The assumption that I could safely fly dual when I was too tired to fly solo was my basic mistake... If one is too tired to fly solo, one shouldn't take the controls of an airplane period.

Command Decisions

In this report to ASRS, a junior B737 Captain who "knew better" was led astray by voices of experience. The Captain's parenthetical remarks voice a step-by-step critique of the incident.

  • On approach to Runway 31, I let my First Officer get high. When I finally reached for the gear handle, he called for gear down (good decision, but too late). At approximately three miles out, I realized that we might not make it down, so I asked for S-turns (good decision). Tower said he had traffic to the left so I then asked for a right 360- degree turn (excellent decision). My First Officer said that he still thought we could make it. I then told Tower we would continue the approach (bad decision). At 1000 feet we were not within parameters, so I elected to go around (excellent decision). The controller offered Runway 22, so we entered a left downwind (bad idea). We turned base and overshot Runway 22L and were given a vector to Runway 31 where a normal approach and landing was made. Reaching the gate, I made a PA and told the passengers that we had been too high to make a safe landing so we had elected to go around...

This was the second leg of my first Captain trip. It was the first non-flying leg without a check airman. My First Officer was an experienced pilot with twenty years experience flying airliners. I believe that I let his experience influence my decision to continue the approach. I shouldn't have let my First Officer get high and shouldn't have accepted Runway 22L from such a tight downwind. I also should have made the PA while on downwind to Runway 31... In the future I will never let anyone's experience lull me into a decision that I am not comfortable with... A good decision was made to go around, but I never should have had to make that call.

The Maintenance Desk

Several recent ASRS maintenance reports have indicated a recurring problem regarding failure to install B767 wheel spacers. In some instances, it appears that the wheel spacer adheres to the grease on the inboard side of the wheel and is removed with the old assembly. Refer to the B767 Maintenance Manual for wheel spacer installation procedures.
  • ... Installation of the new tire was completed without the spacer ring causing the tire, wheel, and brake assembly to be damaged beyond repair. The men changing this tire failed to use proper procedures in the manual and never checked for the spacer ring.
  • ... I may have inadvertently left the spacers out of the installation of the new tire and wheel assembly. I do not believe that the spacers were originally there. I followed the maintenance manual card which states that there should be a maximum of two to three threads showing. This thread count is maintained even with the spacer missing.
  • ... I conferred with the other mechanic and we both agreed that the tire was installed properly. When the aircraft landed at its next destination, the brake on this wheel assembly overheated and the tire deflated... It was noted that the inboard spacer was missing from the assembly... While I had a copy of the maintenance manual, I referred to it only for torque values. I didn't look for this inboard spacer because I wasn't aware of it.
ASRS Recently Issued Alerts On...

Tower window visibility problem

A300 sharp yaw movement incident

B757-200 fuel sccavenging discrepency

Absence of makers on a closed runway

MD88 E&E compartment water damage

February 2003 Report Intake
 Air Carrier/Air Taxi Pilots
 General Aviation Pilots