The
approaching holiday season will bring hoards of passengers to airports,
and a blizzard of flights to domestic and foreign destinations. Air crews
will want to heed the experiences with aircraft and ramp security offered
by several ASRS reporters. Our first reporter, an air carrier Captain,
describes what happened at a foreign location when the passenger and bag
count didnt match:
- After completion
of the preflight checklist and cabin door closure, the relief crew
Captain, who had been at the boarding door greeting passengers, returned
to the flight deck. He informed me that a clerical error had been
made in the passenger-to-bag match and that he had chosen to close
the main cabin boarding door. I expected that we would get a call
on the radio or via ACARS if there was an actual mismatch between
passengers and their bags. As we waited at the end of the runway for
our takeoff clearance (about 45 minutes), one of the relief crew members
commented that the bag match must be OK since we hadnt been
advised of any problems via radio. I concurred, thinking that the
arrangement had been for Ground Operations to call if there was true
mismatch. It appears that I was mistaken, as the Station manager states
that a positive bag match was not accomplished.
I believe the problem was caused by a modification of the normal chain
of events. While the bag match is an extremely important check, it
is not on our preflight checklist, because the boarding agent does
not close the last cabin door until the bag match is complete. Since
we check doors closed on our Before Start checklist, we have assurance
that bags and passengers match before we start engines. What I failed
to realize, however, is that if anyone other than the boarding agent
closes the door, our normal checkpoint for the bag match is lost.
I suspect that cultural behavior differences may also have contributed
to this problem.
It now seems highly unrealistic to expect a
respectful [foreign] employee to radio a Captain to argue about his
bag match decision...and to direct a return to the gate... I am convinced
that I must become directly involved in all unusual events and discussions
pertaining to aircraft ground operations and to solicit input from
all involved personnel.
Another incident reported
to ASRS points to the value of clear communication between the cabin
crew and flight deck when passengers are observed behaving strangelywhether
or not they have yet created problems.
- At FL330
had momentary [warning] message Door Left Aft Cabin, meaning
door 2L was not fully latched. Message cleared itself, then reappeared.
(Got message a total of 4 times.) Contacted purser to have her ensure
no one was tampering with door. She said there was a female passenger
who had been acting very strangely since leaving [airport]. Purser
was sent to check, and to latch door. Passenger had been seen in the
aft galley area near the door. Through an interpreter...passenger
admitted to having attempted to open door. [Crew] found 2 [company]
pass-riders and had them sit with/watch over passenger for remainder
of flight. Contacted company and asked for flight to be met by the
FBI. I emphasized that the passenger was at least unstable...and clearly
should not get on our [next] flight.
This event clearly highlighted the advantages of a large infrastructure
and excellent communications available at my...airline.
Late-boarding, panicky passengers
are a headache for every gate agentand a potential security problem,
too. The moral of this Captains story: "Always question if
in doubt; some passengers will do anything to catch a flight."
- Pushback
had just started. The ground crew (pushback crew) asked me if I would
take another passenger. I said sure, OK. They started to pull me back
to the gate, when I noticed a passenger run up the jetway stairs from
the ramp onto the jetway... Was this one of our employees to be able
to come from the ramp? About the time I questioned who this person
was, the Station Manager was telling the pushback crew not to come
back and continue pushing the aircraft.
A new agent in the jetway and the passenger were waving us to come
back in. This created some confusion. But since the security of this
passenger was questionable, we left him and continued on our way.
On follow-up, I found that this passenger had been arrested for breach
of security to get access onto our ramp. He had darted down another
jetway onto the ramp in an attempt to catch our flight. The new agent
had not recognized what happened and was trying to help this passenger.
The Station Manager and my own question about security kept us from
violating a very serious security situation.
ASRS
is receiving more and improved information from maintenance personnel
since the issuance of customized reporting forms for this community
in 1997. From "creative" repairs to troubling trends, here
are highlights from some recent maintenance reports.
- While reviewing
aircraft log book, noted discrepancies with Item #54, an interim repair.
Inspected First Officer clear view window and noted toilet paper had
been used with sealant around half the First Officer window. This
is the interim repair and deferral for follow-up maintenance.
ASRSs resident maintenance
guru tells us there are several approved methods in the maintenance
manual for interim repair of cockpit window pressure leaks. None include
toilet paper in the materials required.
A
study of return-land incidents to be published later this fall in ASRS's
Directline publication found that more than one third of the study incidents
involved pre-departure errors by ground personnel and flight crews, or
pre-existing equipment problems. The next maintenance report highlights
a typical cause of a return-land event:
- I was servicing
all three engines and serviced #1 last as it was the last one shut
down... I was thinking about returning the oxygen cart that was needed
for servicing the aircraft. Because I was distracted by that thought,
I forgot to secure the oil cap. Because the door on the cowl was down,
I thought I had capped the tank and secured the door. I then returned
the oxygen cart with the flatbed. Six minutes later the next aircraft
came into the gate. Approximately 15 minutes later I went to service
all engines on that aircraft. I then saw the oil cap and contacted
the lead [mechanic], who contacted Maintenance Control.
ASRS has recently
received a rash of maintenance reports describing technicians
failures to install spacers (a type of washer) when changing wheel assemblies.
The absence of this small part causes excessive bearing wear and tire
"wobble." In some of these incidents it appears that the spacers
themselves are hitchhikersin grease:
- During
inspection found right nose tire worn to limits. While removing wheel
assembly from axle, spacer or washer that fits between axle nut and
outer wheel bearing 'stuck to' removed wheel assembly. The rebuilt
Color wheel assembly was installed w Color ithout spacer. The removed
wheel assembly was rolled to stores shipping area, then trucked to
wheel shop where it [spacer] was discovered still affixed to the bearing.
Line maintenance was notified and aircraft was taken out of service
to reinstall this part.
Contributing factors to this situation may be the type of grease (adhesiveness)
which had been changed a while ago and/or the grease seal which grips
and forms a tight seal around the edge of the spacer.
Use of work cards, which
provide step-by-step instructions for routine parts installations, can
help technicians detect when spacers have gone AWOL.
This excellent report from
a CFI involved in a loss-of-separation incident at an uncontrolled field
describes some of the crew coordination issues at stakeand potential
hazardswhen two CFIs fly together.
- This was
a training flight where I, the pilot flying, was getting checked out
in a new aircraft...by another CFI. While I was doing the flying,
the pilot not flying was handling all the electronics. We were both
looking out for other traffic and making radio calls.
Unable to get a response from UNICOM we decided to land on Runway
22... On taxi back there was a fair amount of chatter on the UNICOM
and the pilot not flying turned the volume down on the radio. We performed
our before take-off check and looked for traffic on final, base, and
downwind for Runway 22. We did not turn the volume up on the radio
(some takeoff check) nor did we announce our departure.
While on the takeoff roll, the pilot not flying suddenly grabbed the
controls, only to release them again allowing me to continue the takeoff,
but pointed out [another aircraft] on short final for Runway 10! We
were well past the intersection prior to his touchdown, but this was
just a little too close.
There were a number of factors leading up to this incident. First
and foremost, the concept of "See and Avoid" was not practiced.
Unlike what I teach my students, we only checked the pattern we were
using and did not accomplish a 360 to check the whole area... Nor
did we have the radio volume turned up. This was another factor. There
is no excuse for not monitoring UNICOM or announcing our intentions.
Probably the most important factor, I feel, was the delineation of
who actually was PIC and who was to do what. Though I was "sole
manipulator of the controls," I assumed the role of student and
expected/relied on the other CFI to assume all responsibility..
I feel, that when two CFIs are flying together the responsibilities
HAVE to be spelled out so that there are no assumptions, second guessing,
missed items/procedures and missed traffic
It is truly scary when two CFIs fly together.