CALLBACK Masthead

Number 288
September 2003
 
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Nobody Is Perfect? Title

Reports to ASRS often confirm the popular wisdom, "Nobody is perfect." However, in the following reports it would appear that "Nobody" is not perfect. Things can go wrong when Nobody takes over.

"Nobody Was Flying"Invisible Pilot

In this report, Nobody did a little sight-seeing and then headed for the golf course... with two pilots along for the ride.

  • This was a test flight and proficiency check after a condition inspection. A pilot-rated A&P mechanic was in the back seat (two-place, tandem). When I was finished with the test maneuvers, I asked the other pilot if he wanted to fly. I misunderstood him and relinquished control. The airplane flew a random sight-seeing track, but then descended to approximately 500 feet AGL over a golf course. I asked the other pilot to climb. He replied that he thought I was flying. Nobody was flying.

Nobody's "Got It"

Taking advantage of poor cockpit communication is one of the most common ways for Nobody to take control.

  • As I was attempting to dial in the ATIS, I was having trouble clearing the current frequency on the radio and [my passenger] said he would fly the airplane while I tuned the radio. After entering the frequency, the ATIS came on and I said, "Got it." As I continued to listen to the ATIS, I noticed that we had begun a shallow, descending turn to the right. The airplane began to pick up speed and I told [my passenger] that we were getting a little fast. There was a stand of trees coming up quickly and I said, "We need to pull up." He pulled the plane out of the shallow dive.... We had a long discussion afterward and it was clear that he misunderstood "got it" to mean that I had control of the airplane. We each thought that the other was flying when actually nobody was flying the plane. We agreed that we would be more certain of cockpit communications in the future.

Pilots Get Relief - Nobody Takes Over

While this B757 crew was busy playing musical chairs, at least the autopilot stayed on the job. Nobody was at the controls.

  • During cruise flight, I needed to leave my seat and go to the forward lavatory.... I exited the cockpit as a flight attendant entered to secure the cockpit door behind me, per company policy. [When I returned], I cleared the area and knocked on the cockpit door for re-entry. Instead of the flight attendant opening the door, I was very surprised to see the First Officer at the cockpit door. We passed each other as he let me in and exited to use the facility himself. I knew instantly that nobody was "flying" the plane (of course, the autopilot was on and we were in level flight). I quickly jumped into my seat. Nobody was at the controls for maybe 5-10 seconds.... In his zest to be efficient and minimize the opening of the cockpit door (for security reasons), the First Officer forgot he was leaving the airplane unattended when he got up to let me in and himself out.... To make matters worse, when the First Officer opened the cockpit door, we were both in the doorway at the same time in view of the first class passengers. Additionally, since the flight attendant had apparently retreated momentarily to the Captain's seat to let the First Officer get by her (the jump seat was folded up), she may have been perceived by passengers to be "at the controls" when the door was opened. This was an embarrassing and misleading situation.

Nobody Busts an Altitude

This Falcon 50 crew learned that Nobody takes over when both pilots are busy doing other things.

  • After receiving a clearance to FL280, we left our assigned altitude. During the descent, we were doing some HF radio checks, and forgot to arm the altitude select mode on the flight director. As a result, we descended through our altitude.... We promptly returned to FL280.

    As a crew, we are very diligent and disciplined about altitude assignments. But in this case, because our attention was diverted from the task at hand, we flew through our assigned altitude. It was that classic trap: both crew members distracted by something and nobody flying the airplane.

Safety Is Everbody's Concern, Especially When Nobody Is Around


Air Traffic Controller at Radar ScopeNobody Coordinates Traffic

In this report, a busy air traffic controller was expecting some assistance, but Nobody provided it.

  • As an MD11 leveled at 12,000 feet, the conflict alert activated with traffic to the southwest of him climbing northeast. The tag (radar display of an aircraft's tracking and flight information), which showed the traffic climbing out of 11,700 feet, switched to an "M" tag (a tag which indicated that an approach sector took the handoff). Nobody coordinated with me to allow this VFR Beech Jet to climb through my airspace. By the time the conflict alert activated, there was nothing I could do. Somehow the aircraft was radar identified, allowed to climb, and handed off to another sector without approval, or traffic issued.... I don't know if the VFR aircraft had the MD11 in sight.... I was focused mainly on the aircraft on my tags and not as much on the other tagged and untagged aircraft on my scope.

Nobody Does the Documentation

As reported by an A320 maintenance technician, when Nobody documents a job, trouble follows.

  • I gave clearance to close the #1 and #2 engine fan cowls. I did not know that the deactivation pins for the reversers were still installed. Nobody had documented that the pins were installed as required by our maintenance procedures. On the test flight the reversers did not deploy. The job card for removing these pins had been accomplished prior to the first test flight the day before, however the pins were reinstalled without documentation. Our policy for clearance to close the cowls does not include looking for deactivated engine components.

Nobody Knew There Was a Problem

This maintenance crew should have informed their supervisor rather than let an aircraft depart with a known problem.

  • The aircraft went to the run-up area for an engine run, and was towed back to the hangar pad. The gear doors were up and locked at this time. A tug then took the aircraft to the gate where the ramp crew said they saw the nose landing gear door droop. After two attempts to push the gear door up at the gate, they told nobody about the problem and left the aircraft. On takeoff, the nose landing gear door departed the aircraft causing an air turn back....

Nobody Answers, but Everybody WinsPerson Being Resuscitated

Things don't always have to go wrong when Nobody is around. In this case, a cabin crew's training and teamwork prevailed when Nobody answered the call for a doctor.

  • While at the gate, the Purser made a PA announcement for a physician. Nobody responded so I went forward. In the First Class section, a passenger was on the floor in the aisle. The Purser was performing compressions, Flight Attendant #3 was monitoring the Automated External Defibrillator (AED), and a passenger was operating the resuscitator bag. I put on gloves, replaced the Purser and the Purser took over the resuscitator. We performed Cardio-Pulmonary Resuscitation (CPR) until paramedics took over....

 

ASRS Recently Issued Alerts On...

Eastern airport STARS radar problem

B737 series nose gear tire incompatibility

Southern airport runway surface conditions

SA227 nose wheel steering loss on takeoff

CL65 uncommanded flight spoiler activation

August 2003 Report Intake
 Air Carrier/Air Taxi Pilots
1,969
 General Aviation Pilots
822
 Controllers
45
 Cabin/Mechanics/Military/Other
107
 TOTAL
2,943