CALLBACK From the NASA Aviation Safety Reporting System
 Number 362   February 2010

Unusual Attitude

Everyone who obtains a pilot’s license receives training in how to recover from unusual attitudes—potential loss-of-control situations in which there is an excessive aircraft bank or pitch angle. But reporters to ASRS sometimes note that “unusual attitude” can convey another meaning that occasionally surfaces in ASRS reports—a state of mind that can lead to safety consequences for others.

This month we offer a cross-section of incident reports that illustrate reporters’ concerns for communication, professionalism, and courtesy. These narratives are a reminder that positive attitudes and thoughtful actions can go a long way toward making flying safer for everyone.

conversation bubbles 1) ...What are you doing this weekend? 2) ?Gobbledygook

Brevity and clarity are the heart of effective radio communications. In the words of the AIM, “Jargon, chatter, and ‘CB’ slang have no place in ATC communications.” (AIM 4-2-1-c) A report from a C172 flight instructor expressed annoyance with nonsense talk on a frequency.

indication of report narrative Air-to-air frequency 122.750 is widely used in [this] area for position reports (or other flight safety related calls) by aircraft doing airwork and/or transiting the area. The frequency is at times very busy and you need to pay close attention to all aircraft calls, especially when flight instructing at the same time.

Unfortunately, the frequency has become more and more misused for general small talk and plain nonsense by certain pilots. The topics can be anything from ‘Hey Jim, what are you going to do this weekend?’ to ‘I am doing 146 knots up here, what’s your speed down there?’…usually followed by lengthy private conversations. This is extremely annoying and contributes nothing to safety. It is frustrating, too, when you try to instruct on top of this garble.

Today I tried to step in one of these ‘conversations’ with a position report. This was immediately followed by ‘You were mashed out, can you say again’ from one of the pilots making this nonsense conversation.

The Pilot/Mechanic Disconnect

A B737 Captain pleaded with Maintenance Technicians to follow established procedures.

indication of report narrative Upon doing external preflight inspection, I noticed several Mechanics working on the aircraft. They were changing a tire. I asked them if they had posted the sign alerting pilots that maintenance was being performed and not to touch controls. I told them that my First Officer was in the flight deck (we were doing a scheduled aircraft change) and I had not noticed the sign and he was probably about to perform preflight duties. They said they had not posted the sign, but that ‘…he can do anything he wants except turn on hydraulics or mess with the parking brake.’ I tried to convey to them the risk they had just incurred by not following procedures, but they seemed to shrug it off. We (the pilots) had no warning at all that they were down there, and very well could have turned on a hydraulic pump for any of many reasons, including to keep the wheel [yoke] steady in windy conditions.

Please, please, please advise all Mechanics of the importance of following the procedure of displaying the card in the flight deck while they are working on the airplane. Indifference and complacency can maim and kill.

Out of Sight. Out of Mind?

The pilot of a C-172 dropped Foreign Object Debris (FOD) on a runway but neglected to inform the Tower in a timely way, subsequently endangering other aircraft.

indication of report narrative Upon initial climb for takeoff from runway 16L, I saw the cowl plugs eject from the cowling, [and] I realized that I had forgotten to remove the cowl plugs. One plug was stuck in the cowling, while the rope connecting the two plugs dangled the other half on top of the cowling. I informed Tower of my situation and asked to return to the airport. They cleared me to remain in the pattern…As I was turning base, the rope holding the two cowl plugs together broke and the remainder of the cowling flew and got lodged in the right wing. I proceeded for a normal landing, and as I was in the flare, the lack of airspeed let the cowl plugs drop onto the runway from the wing. Tower cleared me from the runway…I contacted Ground and was given instructions to taxi to the ramp…I shut down the engine and did a thorough inspection of the cowling. I only found little pieces of foam from the cowling but the majority of it seemed to be ‘lost’…I spent about 20-30 minutes to make sure there wasn’t any debris in the engine. I contacted Ground for my squawk and taxi clearance. I was concerned about the remainder of my cowling and kept a visual lookout for it. After not seeing it on the taxiway, I contacted Tower for takeoff clearance. Tower cleared me for takeoff on Runway 16L. As I was doing my takeoff roll, I saw the cowl plugs sitting on the right side of the centerline close to the 500-foot marker. I informed Tower that the cowl plugs were sitting on the runway. I was told they were aware of the situation and other airplanes had already reported it….

A Rodent's What?

An air carrier crew following a STAR descent profile received a terse and unusual instruction from ATC.

Rodent/mouse with question markindication of report narrative [We were] cleared to descend on the arrival, [our] altitude approximately 24,000 feet, STAR calls to be at or above FL200 at ABCDE. Center directed us to expedite descent through FL200. If we did we would have been through 20,000 feet well before ABCDE. I responded that we were restricted to at or above FL200 at ABCDE. The controller said, ‘I don’t give a rat’s you-know-what, I got a photo mission at your 11 o’clock FL200 I’m not talking to, and an F-16 climbing to your 1 o’clock. Descend and maintain FL190.’ I responded, ‘understand cancel clearance to descend via the STAR, cleared to descend to and maintain FL190, expediting.’

The controller’s unprofessionalism goes without saying. But more importantly, there was an urgent situation developing and the controller didn’t know how to handle it in a timely manner.

Ramp Rashness

As the air carrier industry has come under severe economic pressures in recent years, ASRS has received increased reporting of ramp incidents. The theme of many such reports is that ramp crews may not be trained to the standard of safe operating procedures previously in effect. Here’s a report from a B757 crew that, because of questionnable procedures by ramp personnel, narrowly averted a potential inflight hazard.

indication of report narrative After pushback was complete and marshaller disconnected headset, there was incorrect verbiage from the pushback crew. Notification of the bypass pin being removed was not received either visually or verbally. The pushback crew was ordered to return to the aircraft to re-establish communication with the cockpit. Proper notification of the bypass pin was received and we were waved off. Shortly after we were released and commenced the taxi out, ramp personnel rapidly approached the aircraft and directed us to stop. A ramp vehicle also approached and two minutes later we were given the ‘all clear’ and resumed taxi away from the gate. We called Operations to find out what had occurred. We were told that a lavatory service door was open. Had we not called the pushback crew back for the bypass pin confirmation, we would have departed with the lavatory service door open….

The high incidence of improper pushback procedures is the norm at this airport. There seems to be a casual attitude about the importance of complying exactly with the procedure and verbiage. The number of these occurrences were far less when pushbacks were conducted by trained Maintenance personnel.

The Limits of Indifference

Some air carrier reports to ASRS call it “pencil-whipping,” and others “pilot-pushing,” but by whatever name, non-standard Maintenance practices challenge crews to follow up when they are uncomfortable. A First Officer describes one such situation in which a Maintenance Supervisor exerted pressure on both the flight crew and Maintenance Technicians to ignore a potential flight hazard.

indication of report narrative Upon arrival for flight, the Captain and I started our pre-flight of the aircraft. Captain found his (forward) windshield delaminated. He asked me to give Maintenance a call to come and check out the windshield. Two Maintenance personnel arrived and found that Pilot looking at delaminated window and with question markthe delaminated window was one inch out of limits. The Maintenance crew then radioed in to their Supervisor to advise him that the windshield was out of limits. The Captain and I heard the Supervisor call back and say, ‘Sign it off.’ The Maintenance crew member said, ‘It is out of limits and I am not going to sign it off.’ The Supervisor then said, ‘Are you scared?’ The Maintenance crew member then said, ‘I am not scared, it is out of limits and I’m not signing it off! If you want it signed off, you have to sign it off.’

About three minutes later, we see a Supervisor come to the stairs of the jetway and walk straight to the logbook and sign it off without even looking at the delamination on the window. Then the Supervisor walks into the aircraft and looks at the window, pushes on it, turns around and says, ‘Your window is just fine.’ I made a comment to the Captain I can’t believe what he just did, he signed it off without even looking at it and not even measuring the delamination of the window….

Inflight, Captain saw that there was a scratch in front of the delamination on the window…Once we got back, we wrote up the scratch…and also requested the delamination be re-inspected. Maintenance met us at the aircraft and inspected the aircraft and found that it was out of limits and grounded the aircraft.

Runway Roulette

In coming months, CALLBACK will devote an entire issue to non-Towered airport incidents. In the meantime, the report of a Beech 35 pilot describes an all-too-common event at a non-Towered field.

indication of report narrative I was departing a non-Towered airport. Having announced my intent on the CTAF to enter Runway 31 for departure, I taxied into position and did a short final check…and began the takeoff roll. While accelerating at full power, I heard a transmission that an airplane intended to enter Runway 13 for departure. I could see a yellow airplane in the run-up area for 13, and immediately radioed that I was on takeoff on 31. The yellow airplane taxied onto the runway and I radioed again, but he kept coming, so I immediately aborted the takeoff. I estimate that I was at around 50 knots at the time. I managed to slow the aircraft enough to get off the runway at the mid-field taxiway. The yellow aircraft continued the takeoff roll and made a steep climbing turn to the left, which appeared to be an evasive maneuver. A C172 on base to Runway 31…transmitted concern that there was someone taking off opposite direction. A radio transmission, which I believe came from the yellow airplane, was something like ‘traffic not a factor.’

The cause of the incident was the yellow airplane choosing to depart in the opposite direction of traffic using the single runway, in failing to monitor or hear or heed my transmissions, and in taxiing onto and departing on a runway in use despite repeated warnings on the radio. Had the incursion happened only a few seconds later, the outcome might have been very different.

 
ASRS Alerts Issued in December 2009
Subject of Alert
No. of Alerts
Aircraft or aircraft equipment
9
Airport facility or procedure
4
ATC equipment or procedure
4
TOTAL
17
 
December 2009 Report Intake
 Air Carrier/Air Taxi Pilots
2,982
 General Aviation Pilots
776
 Controllers
563
 Cabin/Mechanics/Military/Other
385
 TOTAL
4,706

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