Number 297
June 2004
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

What Would You Have Done...

Aircraft Skywriting a ?In light of the amount of positive feedback generated by Callback #285, the same "interactive" format is utilized in this issue. Readers are once again encouraged to consider an appropriate course of action for a given situation. The actions that were actually taken by the reporters of these incidents are found on the reverse of this Callback issue.

Bear in mind that the reported action may or may not represent the best response to the situation. Our intent is to stimulate thinking, discussion, and training related to the type of incidents that were reported.

Situation #1: Last Minute Cancellation

This Falcon 50 flight crew had to make a high speed decision.

  • ...Runway 24 was being used for arrivals and departures.... We had not yet reached the hold short line when the tower controller said, "Taxi into position and hold Runway 24. Traffic cleared to land Runway 24 on downwind. Be ready for an immediate takeoff." I saw an aircraft on a rather close-in downwind-to-base turn.... Prior to being aligned with the runway, the tower controller issued us an immediate takeoff clearance.... I called, "80 knots cross-checked." The flying pilot called, "My yoke." I said, "Your yoke." At some point after this, the tower controller said, "Falcon XXX, takeoff clearance canceled." We were close to V1 (96 knots)...

What would you have done? See the Reporter's Action



Situation #2: Intermittent Engine Vibration

A pilot and instructor in a PA28 performed touch-and-go landings with an engine that ran fine... most of the time.

  • I departed ... with an instructor for a BFR (Biennial Flight Review) and currency work. ... After a normal run up and uneventful takeoff, we flew 40 miles to ZZZ1 airport.... We did a touch-and-go on Runway 17. On climb out the engine ran rough with some vibration. The engine smoothed out when we reduced the manifold pressure to 23 inches and the propeller to 2300 RPM. It ran smooth to ZZZ2 field where we did a touch-and-go. Again, the engine ran rough on climb, but smoothed out once we reduced power to 23 inches and 2300 RPM. The instructor asked if I wanted to do another touch-and-go at ZZZ2...

What would you have done? See the Reporter's Action



Situation #3: Open Door Policy

As these BE55 pilots learned, go/no go policies should be decided before, rather than during, takeoff.

  • The right forward door popped open just after rotation (approximately 90 knots) on Runway 6 (4,000 feet long)...

What would you have done? See the Reporter's Action



Situation #4: Between the Clouds and the Trees

With only trees below and no radio or navigation systems, this PA32 pilot's prospects looked bleak.

  • [I was] proceeding IFR from FL to AR. After passing [County] VOR, I lost all electrical power. All instruments (navigational, radio, etc.) were inoperative. Proceeding at 8,000 feet, the alternator was not charging and the battery was discharging. I descended in order to attempt to land VFR as soon as possible. I tried broadcasting once on 121.5 in the blind and squawked 7700. I found a hole and descended through the overcast that was about 2,000-3,000 feet thick. I leveled off below the overcast which was now solid at 1000 feet. I was over a forest...

What would you have done? See the Reporter's Action



Situation #5: When the Traffic Gets Out of Line

A busy approach controller, faced with a flight crew deviating from their assigned heading, had to make some quick decisions to sort out the traffic.

  • I was working an extremely busy arrival period vectoring to Runway 27R with a final approximately 25 miles long. Aircraft X was on an ILS approach. At seven miles, Aircraft X received a TCAS climb for unknown VFR traffic. I... gave Aircraft X... a right turn to 030 degrees for re-sequencing. Shortly thereafter, I turned him right to a heading of 080 degrees and worked on making a hole for him on final.... Aircraft X was about 10 miles northeast of [the airport].... There was a commuter on an eight mile final talking to the tower, and an A320 (Aircraft Y), on a 13 mile final (on my frequency and cleared for an ILS approach.). I had made a hole for Aircraft X behind Aircraft Y.... As I went to issue the traffic and sequence to Aircraft X, I saw that they had turned base leg.... To verify, I asked Aircraft X if they had, in fact, turned base. Realizing their error, they said they were turning back to a 080 degree heading...

As the controller, what would you have done? See the Reporter's Action



Situation #6: Conspicuous Consumption

This B757-200 crew was faced with a fuel imbalance that appeared to be increasing.

  • We noticed approximately 1,000 lbs. of fuel imbalance passing FL180, but decided to wait until level off to address the issue. Level at FL370, we noticed that the right tank was 3,000 lbs. heavier than the left. We checked the fuel used and the total fuel indications on the FMC (Flight Management Computer). As best we could tell, our level off fuel was approximately 3,000 lbs. less than planned.

What would you have done? See the Reporter's Action



Situation #1

Last Minute Cancellaton

  • I believed that we would have been above V1 by the time I called abort and the flying pilot had responded to the instruction. For this reason I called, "Continue. V1." At 112 knots, I called, "Rotate." Just after rotation, the tower again said, "Falcon XXX, takeoff clearance cancelled." We were committed at this point and continued the takeoff. Shortly after, the tower said, "Falcon XXX, turn right 20 degrees." At this time...I saw nothing on TCAS or visually....

    I can't recall hearing what event triggered the tower controller's decision to cancel our takeoff clearance. I can only speculate that it was either an instruction to the aircraft behind us to go around or the pilot's own decision to go around and then the controller's reaction to the go-around.... Regardless of what caused the cancellation, I was forced to make the classic go, no-go decision.

    If I had this takeoff to do over again, I would have questioned the tower controller about the location of the aircraft that was cleared to land... It looked close to me and I should have followed my gut feeling and delayed our lineup until after his arrival. I can only speculate that the tower controller may not have known that the landing aircraft was turning base so close in....

back...Back to Situation 2


Situation #2

Intermittent Engine Vibration

  • I said, "No, this engine has a problem. Let's get it home." We proceeded to [departure field]. I... entered the pattern as number two for landing. When I reduced power, the engine began vibrating, although it maintained power and RPM.... At this point, I should have called the tower to request a priority landing, but didn't.... When we turned to final (a long final due to traffic), the engine began losing power. I called tower [to declare] an emergency and told them we would not make the airport. Tower cleared the area of traffic. The engine regained power and we were able to land on the runway. When we pulled into the ramp area, we observed that the number one cylinder head had come off the engine and lodged halfway through the cowling. Examination showed a normal cylinder with both valves and no internal damage. There was no piston.
back...Back to Situation 3


Situation #3

Open Door Policy

  • The pilot flying reduced power to idle, landed the aircraft, and commenced maximum braking. The reject was initiated with less than 1000 feet of runway remaining. The aircraft departed the end of runway at approximately 20 knots. We taxied back to the ramp and inspected the aircraft. There was no damage to either the landing gear or propellers. A faulty latch on the right door resulted in the door not being fully locked.... The pilot flying thought that he had more runway remaining than he actually had. He stated afterward that he should have continued the takeoff versus rejecting. We both agreed that a door opening on takeoff in this aircraft is not a reject item.
back...Back to Situation 4


Situation #4

Between the Clouds and the Trees

  • I searched until I found a dirt road. The dirt road led to a paved road. The paved road led to Interstate [123].... I followed the Interstate west toward [City].... Finally, I saw a road sign that read, "[City] 21 miles." Shortly thereafter, I sighted [City] International, got a green light from the tower, and landed without further ado.
back...Back to Situation 5


Situation #5

When the Traffic Gets Out of Line

  • I told them, "No. Do not turn back. Continue on the base." I pointed out the B190 traffic at two o'clock and one mile... and cleared them for a visual approach. I then went to Aircraft Y, cancelled their approach clearance and told them to maintain 3,000 feet on the localizer.... The lesson I would like to communicate to pilots is this: we all make mistakes and most of them can be fixed.
back...Back to Situation 6


Situation #6

Conspicuous Consumption

  • The Captain referred to the irregular procedures for the "Fuel Configuration" light. We decided against attempting to balance the fuel due to the uncertainty of the cause of the imbalance (possible fuel leak in the left tank). The fuel indication in the right tank appeared to be stuck at "12.8." We verified the right wing heavy by hand flying the aircraft and using rudder trim to level the wings. Trim required increased from 2.0 units to 4.0 units as the flight progressed due to the increasing imbalance. We were unable to determine if the fuel in the right wing was trapped and unusable. We decided to divert [departure airport] since it was only 60 miles behind us and the weather was clear.... Dispatch and maintenance concurred with the divert decision since the fuel state could not be verified. We requested and received priority handling for an uneventful landing.
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