Issue Number 225
March 1998
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

"Aircraft Rock and Roll"

ASRS receives many reports of fuel mismanagement and fuel exhaustion, common causes of engine failures and forced landings. Less common is fuel contamination, which can come as a surprise, even after a pilot takes the precautionary measures of a thorough pre-flight and ground run-up. A general aviation pilot reports on the hazards of hidden water, and speculates on whether wing-rocking might have prevented the problem.

Any rocking of wings should come early in the pre-flight, so that the water and contaminants have plenty of time to settle in the sumps before the sumps are drained. Many flight schools make this standard procedure.

Next, an air carrier Captain reports that both the ground crew and the flight crew failed to detect a different sort of fuel-related problem. In this case, improper defueling procedure was the cause of the incident.

Leaving the defuel valve open prevents closing of the defueling door, and impairs the crew's ability to control fuel transfer. Diligent use of checklists--by both the ground crew and the flight crew--can help prevent this situation. The ground crew's checklist should include an item to check the security of the defuel valve and door. The flight crew's checklist usually provides more than one opportunity to review proper fuel distribution. This is particularly important after any type of fuel transfer operation.

"If The Shoe Fits" I set out to brush up on cross-wind taxi/takeoff/landing procedures. On the second landing, while in the flare, my left shoe fell off while applying left rudder. The shoe landed in front of the left rudder pedal and heel brake. The right crosswind started to pivot the aircraft to the right, and I discovered the shoe blocked access to the left rudder pedal and brake. Without left rudder capability, I was unable to prevent the aircraft from turning right into the wind. The aircraft departed the runway to the right onto a level grass area. I finally kicked the shoe free of the pedals and braked to a stop with one shoe off, one shoe on. Taxied back to the ramp and shut down for a thorough inspection. No damage to aircraft or airport property.

Despite nearly 20 years experience, I was unable to overcome the effects on an errant shoe on a crosswind landing. In the future, I will pay more attention to the fit of my shoes before commencing flight.

Of Arms and "Legs" Onboard

Last month we shared some ASRS reports describing the difficulties encountered by cabin crew members. This month we add two sobering reports about passengers authorized to carry firearms onboard the aircraft. In the first report, the Captain was apparently the last to know of the presence of armed passengers onboard.

The FA solicitously asked the two passengers in Row 4 if their legs were OK. They were.

At some air carriers, policy requires that when an armed passenger is admitted to the aircraft, the Passenger Service Representative come to the cockpit to inform the flight crew of the location of the passenger. When more than one armed passenger is on board, the Captain also makes sure that the armed individuals are privately introduced to each other, so that neither will be startled by the sight of another weapon-carrying passenger.

Another crew was first surprised, then very concerned about a firearm left unattended. The First Officer reports:

"Cleared to Land...Almost"

Landing without a clearance incidents don't usually result in dire consequences, but the potential for a hazardous situation certainly exists. An air carrier Captain attributes his failure to obtain a landing clearance to a typical scenario--cockpit workload and instructions for a delayed frequency change.

To ensure that Tower has been contacted, some pilots have developed a habit of always checking that they are on Tower frequency at a fixed point in the Approach, such as at the outer marker or after completing the landing checklist. If the pilots have reached that pre-determined point without receiving instructions to change to Tower frequency, they can make the request to Approach Control. Whatever memory techniques are employed to prevent landing without a clearance, each requires discipline on the pilot's part to be effective.

Distraction is another commonly-reported cause of failure to obtain a landing clearance. A general aviation flight instructor, returning home after a pleasant afternoon's VFR flight, succumbed to the distraction of a non-essential task and missed an essential frequency change.

ASRS Recently Issued Alerts On...
Inadequate taxiway lighting at an Alabama airport
In-flight separation of B-757 wing-skin leading edge
In-flight engine nacelle panel separation on a BE1900
False TCAS II alerts attributed to a failed electrical bus
Smoke alarm activation due to deicing fluid in cargo door seals
January 1998 Report Intake
 Air Carrier Pilots 1,999
 General Aviation Pilots 633
 Controllers 85
 Cabin/Mechanics/Military/Other 70
 TOTAL 2,787