Number 293
February 2004
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Award Winning Lessons

ASRS Awards in MarqueeA certain percentage of the reports submitted to the Aviation Safety Reporting System deal with inadvertent mistakes. While the related error analysis provides valuable material for the "Don't do it this way" school of aviation safety, ASRS also receives many reports that deal with the positive aspects of aviation mishaps. In the following incidents, various abnormal situations were handled with noteworthy competence and skill. All of the aviation professionals involved are to be commended for their contributions to the "Do it this way" school of aviation safety.

These reports were selected as the best examples among recent incidents that document the value of communication, teamwork, and training when things go wrong.

And the Winners Are...Captain Oscar Award

Best Performance in a Supporting "Role"

Being well prepared for their roles enabled this B757 cabin crew to make a major contribution to the success of a dramatic flight despite the foul and noxious setting.

  • At FL330...we had a foul, noxious odor in the cockpit.... The flight attendants also had a burning, sulfur-like odor in the cabin. They quickly checked to be sure that the odor was not coming from the ovens or from someone smoking in the lavatories. The odor was overpowering, so the decision was made to divert into ZZZ. ATC was notified. The First Officer flew the airplane while I ran the checklists. The time from the first smell to touchdown was approximately 12 minutes. While in the descent, I informed the flight attendants that we might need to do an emergency evacuation and to prepare the cabin. After landing...the smell was getting stronger so I gave the order to evacuate. Our flight attendants did an outstanding job. I talked with the passengers at the emergency wing exits and they were well briefed and understood what they had to do perfectly. The aircraft was evacuated in excellent time, with only minor injuries. Our flight attendants were calm, professional, and completely in charge of the situation....

(The fumes came from an overheated wire bundle that supplied current to the L2 cockpit window for in-flight heating. Apparently the circuit breakers had not opened to cut the current from the errant power source. —Ed.)

Best Performance in a Takeoff "Role"Captain Oscar Award

The Captain of this B767 may have had the leading role, but the "behind the scenes" efforts of the controllers and flight attendants deserve equal praise in the smooth handling of this incident.

  • Pushback and start-up were normal.... During takeoff, just after calling out VR, the right engine began compressor stalling. EGT reached a maximum of 710 degrees Centigrade and power diminished. We climbed to 1,000 feet AGL and ran the abnormal procedures. Engine indications were back within limits so it was decided to leave the engine running in idle until after landing. Landing weight was 311,800 lbs. and maximum landing weight is 295,000 lbs. Auto brakes were selected at level "4." The Captain did an outstanding job getting the aircraft smoothly on the ground.... [There were] no injuries to passengers or crew. The communication between the cockpit crew and all others involved was superb. Kudos to the tower, departure, approach, and ground controllers. The flight attendants were great at keeping us informed about what aircraft conditions they could see and feel and how the passengers were holding up.

Best Performance Based on Audience Reaction

Captain Oscar AwardThe professionalism of the entire crew of this B767 ensured that the passengers remained calm and confident all the way to the end of a rather lengthy production.

  • A passenger came up to the galley and said that he smelled something burning. As I went into the first class cabin there was a strong smell of smoke.... I turned off all power to the entertainment and power port systems. When I entered the cockpit, the Captain and First Officer had donned oxygen masks and smoke goggles and smoke was pouring out of the instrument panel. At this point the Captain was far too busy to communicate with me, other than to acknowledge that they were working on the problem. It was at least ten minutes before the Captain and I were able to discuss the situation. During that time the flight attendants did a great job of dealing with a possible crisis with no real answers.... When the Captain and I could talk, it was determined that he felt that the source of the smoke and electrical smell had been contained, but that we should make an emergency landing. The crew had turned off all extra power needed in the cabins, there was no way to dissipate the smell and haze, and our nearest airport was one and one-half hours away.... The flight attendants remained calm and kept reassuring the passengers that the situation was contained and that we would land safely. We had no lights in the cabin, galleys, or lavatories, no power in the galleys, and of course we had the smell and haze created by the electrical problem. The passengers did not overreact, and no one panicked. I attribute this to the fact that the flight attendants were visible, spent time with each and every passenger, and that the Captain made many announcements to reassure the passengers.... The Captain made a beautiful landing and the relief everyone felt being on the ground was expressed by applause. The Captain and First Officer did an outstanding job. The lines of communication were definitely open. Their confidence, expertise, and leadership skills influenced how the rest of the crew reacted to a potentially dangerous situation.

Captain Oscar AwardBest Performance in a Medical Drama

The combined efforts of an MD88 crew and Air Traffic Controllers demonstrated how conscientious rehearsals lead to great performances under pressure.

  • During descent...the lead flight attendant called the cockpit to advise that an elderly passenger was pale and not feeling well and that she was going to administer oxygen. We discussed our options and decided to ask for any doctor on board to assist us. A doctor came forward and while he was doing an examination, the passenger began to experience chest pains. We were descending through FL200 on the arrival when the flight attendant told us about the chest pains and that they were going to get out the defibrillator. I declared an emergency and asked for priority assistance. I turned the radios and aircraft over to the First Officer and I began coordinating medical assistance for our arrival. Center and approach control did an excellent job getting us into the airport immediately. The doctor on board determined that it would be safe to take the passenger to a gate and have the paramedics ready there, so I advised [ZZZ] of our intentions. I had the First Officer fly at our maximum speed to about 15 miles from the airport. We slowed, configured, and made an uneventful landing. We were able to get to the gate in two to three minutes and our passenger was assisted there. This emergency demonstrated excellent coordination between the cockpit and cabin crew and between Air Traffic Control and the flight crew. All of the training really pays off under these time compressed and stressful situations.

Best Solo Performance

Captain Oscar AwardThe brilliant performance of this C206 pilot was enhanced by the superb direction of equally talented controllers.

  • I experienced electrical output failure of the alternator at 11,000 feet on top of all clouds and in the clear some 150 miles from destination, with 4+ hours fuel on board. Light icing conditions existed in the clouds with low IMC existing below and within a 100 mile radius of my position. I advised Air Traffic Control (ATC), declared an emergency, and presented my plan of action: 1) I requested Center to look for VFR weather within my fuel range. 2) I advised of my flight conditions and announced that I would maintain present heading at 11,000 feet and go off the air for 20 minutes in order to conserve battery power for communication.... [I] set the cockpit up for no-electric, partial panel flight with vacuum driven attitude indicator, magnetic compass, wrist watch fastened to the control yoke, two good flashlights (one two-battery pen light and one "D" cell light). Twenty minutes later, with communications back up, ATC had indeed located VMC at [ZZZ1] and Special VFR 4,000 foot overcast at [ZZZ2]. Both stations had advised Center by telephone that they could provide Airport Surveillance Radar (ASR) assistance for descent. I elected to go to [ZZZ2] and requested to remain at plan a descent pattern that, if necessary, would ensure of the suitability of the weather in the event of complete electrical failure and loss of communications. Center agreed and handed me off early to [ZZZ2] approach control some 60 miles out. Approach was able to let me go off the air and conserve eight more minutes of battery power.... Twenty miles out, approach was able to give me a rapid descent into their airspace, making two ASR heading corrections to keep me free of all clouds on a wide downwind leg for Runway 23 and well clear of the normal traffic flow. The ASR controller accomplished this with only the primary target of my airplane. Once on tower frequency and cleared to land, I [turned on the] navigation and rotating beacon lights. The landing was without incident except that the battery power failed completely on clearing the runway.... This report is respectfully submitted [to confirm that] Resource Management works, and current safety training initiatives in Resource Management are paying off.

Best Short Subject

Captain Oscar AwardThis flight crew's swift and decisive performance was right on the mark. The First Officer's screenplay wasn't bad either.

  • Taking off on Runway 36 in our B757 jet, right close to V1 and, bang, bang, bang; loud noises and vibrations shatter the plan to go flying. The Captain and I throw a school house-perfect abort. CRM rules as we team with the cabin crew and return to the gate with no injury or further incident. The "head wrench" reports that one of our Rolls Royce Rockets sparked and stalled. The End.

Sustained Achievement Award

Mechanic Oscar AwardEvery day the vast majority of flights are conducted without any significant airframe, engine, or equipment malfunctions. Given the complexity of modern aircraft, and often tightly scheduled utilization, this record of availability and reliability is a testament to the dedication, skill, and often overlooked efforts of maintenance technicians. ASRS is proud to acknowledge the backstage maintenance heroes for their tireless efforts to "keep 'em flying."

ASRS Recently Issued Alerts On...

Prisoner transport incident

BD700 oxygen supply hose failures

MD80 escape slide deployment failure

Hughes 500C door latch and hinge failure

Eastern U.S. airport taxiway signage deficiency

January 2004 Report Intake
 Air Carrier/Air Taxi Pilots
 General Aviation Pilots