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Number 302
November 2004
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Weather ReportsRain Cloud

With the approach of winter, weather becomes a more prominent factor in aviation incidents and accidents. The following reports offer timely lessons regarding light aircraft encounters with Instrument Meteorological Conditions (IMC). Were it not for the able assistance of Air Traffic Controllers, the pilots who submitted these reports might not have been around to share their lessons.

"I lost sight of the ground."

By continuing into deteriorating weather, this C172 pilot made a poor decision that got him into trouble. Fortunately, he then made a wise decision to contact a controller who was able to help get him out of trouble.

I got a [weather] briefing...and departed in clear skies with unrestricted visibility.... I got within 10 miles of [destination airport] when things got worse and began to happen fast. I lost sight of the ground and descended to 1,000 feet MSL. I saw trees and antennas and decided to climb into the clouds and reverse direction. I got very disoriented and began losing control of the plane. I called approach control and asked for help. They vectored me back to VFR conditions. They did a great job keeping me calm, on course, and in level flight. They vectored me to an airport where I found a hole in the fog and landed safely. I was very shook up at what had happened because of my poor decision not to turn back sooner. I felt like I was within seconds of losing my life.... I've heard and read stories of what can happen and how fast. To experience it was a valuable lesson....

"That's not very much ice."

Flying into icing conditions in a light aircraft with no anti-icing or deicing capability is a gamble. It is a bit like betting your life on one pull of a slot machine lever - there is only a slight chance that you'll win.

I obtained a weather briefing two hours before the flight. The forecast was clear, One hour [from destination] the skies became cloudy.... [I] called ATC, received an IFR clearance, and climbed to 9,000 feet in the clear.... I entered clouds about 25 miles from [destination] VOR. I started picking up ice, but did not react. I looked out and thought, "That's not very much ice." The airplane started to slow down and I could not maintain altitude. I realized I was close to a stall...and the aircraft was handling poorly. I finally advised ATC about the ice and not being able to maintain altitude. ATC gave me a turn toward lower terrain and also toward an airport. The airplane continued to descend. [I] broke out of the clouds and ATC vectored me to the airport. I landed without incident. I could not have flown even a few miles farther. What strikes me is that I continued to fly into danger, hoping I could complete the approach. It was in my head that I had to follow ATC's instructions and I waited for ATC to direct me out. It was like I was lulled into taking no action. An incoming airliner's report of icing triggered me to report icing on my aircraft.

"I am in the clouds and need help."

A case of "get-homeitis" and an inadequate contingency plan for avoiding flight into IMC combined to put this pilot into a desperate situation. Once again, an Air Traffic Controller's assistance helped to prevent an accident.

Conditions were getting worse by the minute.... There were scattered thunderstorms throughout the area. This prompted me to hurry my preflight and departure. I was also trying to get to a meeting scheduled for later that afternoon.... I thought that if I could get about one mile from the end of the runway, I could make the determination of whether or not I would be able to make the flight home. If conditions were not favorable to continue, I would do a 90/270-degree turn back and land. Immediately after takeoff (1/2 mile and 300 feet), I was in the clouds. This was not what I had planned and fear and panic set in. Next came spatial disorientation. Unknowingly, I put the plane in a hard bank to the left and a very steep climb. Nothing was making sense to me and the next thing I remember was seeing...the VSI pegged off scale (greater than 2000 foot per minute descent). I broke through the clouds long enough to see the ground coming up, which is a view I had never seen before and hope never to see again.... I thought of how stupid I was to get into this mess.... I pulled up hard. I remember doing this several times in the next few minutes of trying to stabilize the aircraft. The oscillations became less severe as I regained control of the aircraft.... My mind was not able to digest the tremendous amount of data it was receiving and I was trying to hang on by a thread.... My first [radio] transmission was, "[Approach] this is XXX and I am in trouble. I am in the clouds and need help. I need a vector to get out." [Approach] responded by giving me a squawk code and then a heading and altitude.... I was able to climb, but my heading was all over the place. [Approach] then said that I should be out of the clouds in about three or four miles. About 20 seconds later, I saw an opening to go down through the clouds and I took it.

As I look back, it was incredible how fast things went bad.... Why did I ever take off with conditions as bad as they were and getting worse? Why didn't I listen to any of the people I had talked with prior to takeoff that recommended not going? I truly believe in safety first, yet everything I did showed just the opposite.... I have learned a great deal from this event and I hope that those who choose to listen might learn from my story....


Slide Show

Self-inflating escape slides are a valuable asset to the safe and efficient evacuation of commercial aircraft. However, as the following reports show, escape slides can cause embarrassing delays and have the potential to cause Aircraft Emergency Escape Slidesevere injury.

Armed and Dangerous

Just as every firearm should be treated as if it were loaded and ready to fire, aircraft escape slides should always be considered armed and dangerous until their status can be positively verified. Several ASRS reports from maintenance technicians offer some loaded lessons on slide handling.

.... We were now able to arm the door slide, however, when the slide armed, the yellow flag went behind the door handle because we had previously removed the cover/guide in our troubleshooting. At this point the job was complete. We then attempted to put the cover/guide back on, but were unable because the door handle has to be in the up position to reinstall the cover. With the armed flag out of sight, we did not realize that the door was armed and lifted the handle to reinstall the cover/guide. The slide deployed.

A review of the B767 maintenance manual showed that I should have deactivated the slide bottle before performing any maintenance on the slide.

The lavatory service valve was inoperative and it was decided to service the center lavatories with a hose through door 3R. I asked a flight attendant if the door was disarmed and the flight attendant said, "Yes." There was no sign indicating the door status nor any "armed" or "disarmed" flags. I pulled the handle and the slide deployed. I learned the hard way that [B757-200] doors 3L and 3R are always armed.

Even when they are removed from the aircraft, escape slides can continue to present a hazard.

An emergency escape slide was received in the slide shop with the firing cable still connected to the pull tab, that is, in the armed mode.

Emergency slide, serial number xxxxx, was delivered to maintenance for repair. The firing cable attached to the pull handle was in the firing position. The valve safety pin was not installed.

Careless Catering

Lack of communication among ramp personnel can be a recipe for disaster. Fortunately, no one was injured when a catering crew delivered this chef's surprise.

.... The first officer was just about to call ramp control for push clearance when the push crew called saying, "There is a catering truck behind the aircraft." Within a few seconds, a flight attendant called saying that someone had opened a rear door and the slide had partially deployed. I immediately set the brakes.... I discovered that the caterers had driven up to the aircraft without any guidance and had opened door 2L while it was armed.... At no time was any crewmember on the aircraft made aware that catering was coming to the rear of the aircraft.

Lift Here to Deflate Ego

In his eagerness to help secure an exit door, this B757 First Officer seems to have confirmed the old adage, "No good deed goes unpunished."

While parked at the gate and before any passengers had boarded, a flight attendant reported that she thought an over-wing exit was not properly secured. I went back to inspect the exit, and it did not appear to be sealed properly. I then opened the over-wing exit to try to readjust the door. The over-wing slide deployed. I had completely forgotten about the slide deploying automatically. No one was injured. Maintenance responded very quickly to begin fixing my big blunder.... Moral of the story — don't touch anything; call maintenance; think before you act.

When in Doubt, Get a Fifth Opinion

Confusion with another model of their aircraft may have been a factor in this First Officer and cabin crew's misconception about an over-wing escape slide.

During preflight inspection, I noticed a large amount of clear ice on the aircraft surfaces.... I wanted to check the upper wing surfaces for ice from an over-wing exit. Not being able to see clearly through the emergency exit window, I thought that opening the exit door would give me a better view of the amount of ice on the wings. I hesitated for a moment, questioning if the aircraft had over-wing escape slides. I did not notice any placards on the door with pictures of slides and their use in an emergency. I then asked a flight attendant if this aircraft had wing escape slides, and she said, "No." I said, "Are you sure?" She said, "Let me check with the other two flight attendants." They also indicated that the aircraft did not have wing escape slides. I then opened the right wing emergency exit door and the slide deployed.
 
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October 2004 Report Intake
 Air Carrier/Air Taxi Pilots
1,900
 General Aviation Pilots
727
 Controllers
46
 Cabin/Mechanics/Military/Other
154
 TOTAL
2,827