CALLBACK From the NASA Aviation Safety Reporting System

It Could Never Happen to Me!

When ASRS Analysts screen safety incident reports, they can tag certain ones for their relevance to upcoming CALLBACK topics. Other reports can be tagged for the Editor’s “Miscellaneous” file simply because they are “interesting.” A year-end review of the Miscellaneous file found several reports that fit into the “DOH!” (“Different Or Humorous!”) category and are worth sharing.

No matter what our level of experience, there is an important lesson to be learned from these reports. No one is immune to error and, while some of these mistakes may seem rather improbable, those who think, “It could never happen to me” may be setting themselves up for embarrassment or worse. Wise aviation professionals recognize that we are all just a brief mental lapse away from one of those memorable moments we’d like to forget. Or, as a pilot stated in the first sentence of a recent report, “After years of reading incident reports and thinking, ‘How could a pilot do something so stupid?’ now I understand. I have met the moron and he is ME!”

Not a Good Friday

Obviously, mistakes attributable to lack of experience tend to happen earlier in our flying careers. One of the factors often affecting newer pilots is a tendency to focus so intently on one thing that their sense of the “big picture” is lost. An integral part of the big picture is what some old timers refer to as “headwork” or common sense. This B99 pilot may have been a little too focused on the mechanics of a checklist to step back mentally and question whether it fit the situation.

Enroute … I started to perform my required “Weekly Checks” Checklist, going through item by item. The checklist calls for the weekly fire-test; the first item is to pull both fire handles. As I pulled them I noticed a sudden loss of performance on both engines. My gauges indicated that both of them flamed out. I pushed the handles back and started to troubleshoot. I determined that my right engine was still operational. Meanwhile, the aircraft was losing altitude but it was under control. I advised ATC about my situation and they told me there was an airport ten miles away along my route.… Being a new pilot on this airplane, under these circumstances I decided the best course of action was to secure the inoperative engine and land as soon as possible. Having my right engine operational, I was able to stabilize the airplane and started my VFR descent. I completed my Emergency Checklist and then performed a safe single engine landing.

I am a new pilot on this airplane, having just completed my upgrade training one week ago. During the flight training, this part of the checklist was never mentioned and the checklist was not available in the training aircraft. On the checklist, the fire test appears to be among the inflight test items. This situation was the result of me following the checklist that I believed I was supposed to perform. Had I received the proper training, I am sure this situation could have been avoided.

Push the “Right” Pedal

The more this Maule M7 Pilot corrected a left yaw with right rudder, the more trouble he had controlling the aircraft. When you think you’re doing the right thing, but get the wrong result, it’s time to do some troubleshooting.

I was flying … at 11,000 feet on an IFR flight plan. My autopilot disconnected and revealed an out-of-trim condition which caused the aircraft to yaw to the left. I had stretched my right leg to the right of the cockpit for comfort. When the aircraft yawed, I instinctively pressed my right foot on the rudder pedal. This caused the aircraft to yaw even more to the left, requiring full right aileron to keep from rolling inverted. I turned the autopilot off and released the rudder trim with no effect. I also reduced power and lowered the nose to get better control, advising ATC that I was turning and descending with a flight control problem. ATC advised me that [an airport] was ahead about ten miles.… As I continued to troubleshoot, I noticed that my right foot was pressing on the copilot left rudder pedal instead of the pilot right rudder pedal. As soon as I got my foot on the correct rudder pedal, I was able to control the aircraft and advised ATC. I continued the flight.

Climb to Increase Airspeed (?!)

A regular pattern of observation that includes all of the essential flight instruments is the essence of a good instrument scan. To some extent, the scan starts on the takeoff roll and, as this ERJ-145 Pilot learned, fixation on one instrument can disrupt the scan and lead to an embarrassing sequence of events.

On the takeoff roll, after calling out, “Thrust set,” I scanned the EICAS engine indications, and then I fixated on the altimeter, confusing it with the airspeed indicator. When the numbers on the altimeter dial did not increase during the takeoff roll, I mistakenly believed it was a stuck airspeed indication and called for an aborted takeoff. The Captain aborted the takeoff and we taxied to a location where we could talk to maintenance. As I was explaining to the Captain what I had seen, I realized my mistake. I had confused the Altimeter indication with the Airspeed. There were no problems with the aircraft and we completed the flight safely.

Bad Vibrations

Traffic and weather distractions after takeoff disrupted an A320 Flight Crew’s normal procedures to the point where the obvious became obscure. As the Captain noted, their experience level led them directly to troubleshooting. You can’t know too much about aviation, but sometimes you can “overthink” a simple problem.

We were focused on avoiding thunderstorms in the departure corridor. Immediately after takeoff we requested a right turn from Departure. We also remained vigilant of the [reported traffic]. There was now another concentrated area of weather directly ahead. I was trying to break into the congested Departure frequency for a turn on course, which would provide adequate weather clearance. This took a couple minutes and dominated our attention.

I noticed a slight airframe rumbling, but thought it might be the landing lights which were still extended. Once we were given the turn on course and accelerated to 250 knots, we both started to focus on the increasing noise and vibration. I raised the landing lights with very little improvement. We completely concentrated on things that might be wrong with the airplane and searched through numerous system ECAM pages for answers. Everything appeared normal and all symbols were green (including the large green landing gear DOWN and LOCKED symbols which were as we always see them… on the ground. But the gear doors I concentrated on were in fact UP and green), so we started hypothesizing about abnormal things that might be wrong with the jet. Things like a missing engine cowl, flap track fairings, gear doors open, flight controls out of position. We continued north as we attempted troubleshooting and began to think about diverting. We asked the Lead Flight Attendant to take a look at the wings, etc. and report back any anomalies. He found nothing unusual. I asked the First Officer to keep the speed back at 210 knots and to level off at 15,000 feet to remain in a safe speed and altitude range in case something was extended and to protect the airframe. I attempted a radio patch through Dispatch to include Maintenance. The reception was poor and we never spoke with Maintenance. We decided to continue communications through ACARS.

Enough troubleshooting time had passed that I decided we needed to get the plane on the ground safely. I instructed the First Officer to coordinate landing at the divert airport while I briefed the Lead Flight Attendant and then performed the Airframe Vibration Checklist.... As the First Officer flew the visual approach he called for “Gear Down, Landing Checklist.” It then became immediately clear that our “problem” was that the landing gear had never been retracted. We continued to a landing without incident since there was not enough time to verify adequate fuel to continue to [our destination].

I attribute this error to saturation with weather and traffic avoidance on departure followed by a lack of performing normal climb out procedures for the same reason.… When we were handed off to Departure we focused intently on clearing traffic and weather on a very congested frequency. Obviously, I did not raise the gear and after raising the flaps we had already completed our 90-degree right turn and were headed toward the thunderstorm area directly ahead. My attention was primarily on trying to break into the busy Departure Control frequency for an immediate clearance north away from the weather. This dominated our attention and I believe I never accomplished the After Takeoff Checklist since it’s simply so out of sequence climbing out of approximately five or six thousand feet.

Between us, [the First Officer and I] have around 30,000 flight hours, and about eight years’ experience each in the Airbus. I believe this is an important contributing factor since I have never experienced even a delayed gear retraction on takeoff. It’s such an unusual thing that we simply didn’t consider it. As we scrolled through ECAM system pages and other troubleshooting attempts/hypotheses, we never considered such a simple error. Our experience level led us directly to troubleshooting a problem rather than looking for the obvious solution. It’s the most embarrassing event of my flying career.

This flight encountered a confluence of operational challenges as well as human factors issues which resulted in a sub-par performance. It’s not like we lacked understanding of landing gear panel or ECAM symbols. I simply allowed my focus on weather and aircraft avoidance to lead to my neglect of basics. I failed to raise the landing gear and perform the After Takeoff Checklist properly since we were so far past the normal flight sequence to accomplish it while concentrating on immediate safety of flight procedures.… I am glad the company allowed us to continue the flight since I personally wanted to get back in the saddle and put this behind us.

November 2015 Report Intake
Air Carrier/Air Taxi Pilots 4,591
General Aviation Pilots 1,047
Flight Attendants 507
Controllers 434
Military/Other 252
Dispatchers 206
Mechanics 171
TOTAL 7,208
   Indicates an ASRS report narrative
[  ]  Indicates clarification made by ASRS

A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
Issue 432