CALLBACK From the NASA Aviation Safety Reporting System
 Issue 403   August 2013
What Would You Have Done?

This “interactive” issue of CALLBACK presents one General Aviation and three Air Carrier reports. In “The First Half of the Story” you will find report excerpts describing the event up to a decision point. You may then use your own judgment to determine the possible courses of action and make a decision regarding the best way to resolve the situation.

The selected ASRS reports may not give all the information you want and you may not be experienced in the type of aircraft involved, but each incident should give you a chance to exercise your aviation decision-making skills. In “The Rest of the Story…” you will find the actions actually taken by reporters in response to each situation. Bear in mind that their decisions may not necessarily represent the best course of action. Our intent is to stimulate thought, discussion, and training related to the type of incidents that were reported.

The First Half of the Story

Situation #1  SR22 Pilot's Report

[In cruise] our Number One alternator failed. We tried to bring it back online without success. Since we still had Number Two alternator and had run the checklist with appropriate equipment shutdowns, we elected to continue the flight. We were on an IFR flight plan, but we were in VMC the entire route…. We were given instructions direct to [destination] and a descent from 9,000 to 5,000 feet. At approximately 7,500 feet ATC asked us to confirm our altitude. They were showing 10,800 feet. They asked us to shut off the transponder altitude encoding at that time. A few minutes later we noticed the battery was down to 24 volts from 28 and that alternator Number Two appeared not to be charging the battery any longer. A few minutes later ATC instructions became unclear and unreadable. We realized what was happening and at that time the battery failed completely despite not getting a failure light on alternator Number Two.

What Would You Have Done?

Situation #2  B777 Captain's Report

After departure…we were advised to re-contact [ATC] in regard to tire fragments found on our departure runway. We…were told that tire fragments had been found and that airport personnel thought they could have come from our aircraft. In the course of conversations with the different agencies involved we also heard that the fragments found were too small to be identified with our particular aircraft. What the ground crews had found indicated that the entire tire had been “exhausted.”

We immediately initiated a synoptics check of our aircraft, keying on the FUEL and GEAR pages. The LANDING GEAR page indicated that all tire pressures and temperatures were normal with no notable variations. In addition, there were no abnormalities in the fuel system or any other system in the synoptic pages reviewed. There were no EICAS messages received. We contacted our Operations and relayed all of the information. We received a reply stating that, 1) the original call from [the departure airport] was made to all aircraft departing within a certain time frame (not just ours) and, 2) Maintenance Control found no abnormalities in their system monitors of our aircraft.

What Would You Have Done?

Situation #3  Air Carrier Captain's Report

[We were] in a normal descent, cleared to 7,000 feet. Upon reaching 7,000, we asked for lower. There was no answer. We troubleshot the radios, but were unable to establish communication with Center. The aircraft was 22 miles out [from destination] and we needed to descend to make the approach. Weather precluded operations north of the field. The Tower was closed.

What Would You Have Done?

Situation #4  CRJ900 Captain's Report

Before departing...the First Officer and I discussed the Flaps 20 required for Runway 19R. The First Officer even highlighted it on the TOLD (Takeoff and Landing Data) card. We were given a flow time which would give us about 10 minutes from pushback. We went through the After Start Check while I was listening to Ground move an aircraft behind us. I was thinking with our flow time we would need to be moved. During this time I believe we both agreed to the normal Flaps 8. We were then given the short taxi instruction. We began a Taxi Check and…a moment later we were cleared onto the runway. Still thinking we had at least a couple of minutes, we accepted the clearance and tried to get confirmation that the Flight Attendants were ready. While entering the runway, we were cleared for takeoff. I told Tower that we were waiting for the Flight Attendants and would need another minute. He cancelled our takeoff clearance and had us hold in position. We had finished the Taxi Check and were now trying to get the Takeoff Check done. We were quickly given a new takeoff clearance and advised that traffic was on final. We let ourselves be rushed and missed the flap setting again.

During the takeoff roll, in the high speed segment, the First Officer announced that the flaps were not set to 20.

What Would You Have Done?

The Rest of the Story

Situation #1  SR22 Pilot's Report
The Reporter's Action:

We squawked 7600 and, due to the time of day and anticipated congestion into [destination], I elected to maintain VMC conditions and divert west to an uncontrolled field…. I broke off the IFR clearance once we lost radio contact (and our entire electrical system) as I thought it the safest and most prudent decision to avoid potential conflicts with other aircraft and a landing at [destination] which is an extremely busy airport during rush hour.

We continued the flight VMC and entered a long downwind after a quick overflight of the airport to view any possible traffic and wind conditions. We landed without any electrical equipment or flaps as they are fully electrical in this aircraft.

We spoke with ATC via telephone immediately after landing to advise what had happened.

First Half of Situation #2

Situation #2  B777 Captain's Report
The Reporter's Action:

We continued the flight. Repeated checks enroute verified that there were no indications of tire damage or loss of pressure and no fuel problems. The landing…was totally uneventful as was taxi to the ramp. However, after exiting the aircraft, we saw maintenance personnel clustered around the right main gear assembly. The Number 12 tire, although still fully inflated, had suffered a separation of the entire tread belt. Resulting damage was evident on the trailing edge of the wing flap and an access panel on the underside of the right wing. In addition, there were numerous rubber scuff markings on the entire area.

First Half of Situation #3

Situation #3  Air Carrier Captain's Report
The Reporter's Action:

We squawked 7600 and complied with lost communication procedures.... We continued to the Initial Approach Fix, descended to 3,000 feet, switched to CTAF frequency and made normal radio calls. At approximately two miles out on the ILS, Tower queried us, although they were not yet open, and said that Center’s radio was inoperative. They said that they could hear us and asked if we were squawking 7600… We continued the approach to landing. I asked if there were any problems with what we did and Tower said that Center told him that we did exactly what they expected.

First Half of Situation #4

Situation #4 CRJ900 Captain's Report
The Reporter's Action:

My first reaction when I looked up from the airspeed was to abort, however when I saw what little runway was left at the high speed we were traveling, I felt a rejected takeoff would be more dangerous and decided to continue while adding the flaps. We rotated normally and climb out was normal.

I feel this was a perfect storm of events that led us to err. In the future, if I sense we are being rushed, I will advise ATC how much time we will need to be ready well in advance of being on the runway. Also to prevent this in the future I will touch the flap lever while looking at the TOLD card.

 
ASRS Alerts Issued in June 2013
Subject of Alert No. of Alerts
Aircraft or Aircraft Equipment 2
Airport Facility or Procedure 1
ATC Equipment or Procedure 3
TOTAL 6
 
June 2013 Report Intake
Air Carrier/Air Taxi Pilots 3,909
General Aviation Pilots 1,076
Controllers 792
Flight Attendants 287
Dispatchers 233
Military/Other 138
Mechanics 127
TOTAL 6,562
NOTE TO READERS:   or  Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS

A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
Issue 403