CALLBACK From the NASA Aviation Safety Reporting System
 Issue 464 September 2018 

What Would You Have Done?

This month, CALLBACK again offers the reader a chance to “interact” with the information given in a selection of ASRS reports. In “The First Half of the Story,” you will find report excerpts describing an event up to a point where a specific decision must be made, an immediate action must be taken, or a non-normal situation must be actively managed. You may then exercise your own judgment to make a decision, determine a possible course of action, or devise a plan that might best resolve the situation to a successful conclusion.

The selected ASRS reports may not provide 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 refine your aviation judgment and decision-making skills. In “The Rest of the Story…” you will find the actions that were taken by reporters in response to each situation. Bear in mind that their decisions may not necessarily represent the best course of action, and there may not be a “right” answer. Our intent is to stimulate thought, training, and discussion related to the type of incidents that were reported.

The First Half of the Story

Close and Closer Air Carrier Captain’s Report
During the takeoff roll into darkness, an aircraft taxied onto our runway from Taxiway Delta, just past midfield. I noticed it after making the 100 knot callout and about 200 yards away from us, and called it out to the flying pilot.

What Would You Have Done?

Twin Throttle Technique Duchess Instructor’s Report
My student and I were practicing a simulated single engine approach.… We crossed the IAF at 2,000 feet, and then I reduced the left throttle to start the simulation. My student started to practice the emergency procedure: maintain directional control and altitude, full mixture, full props, full power (right throttle), flaps up, gear up, auxiliary pumps on, identify and verify “dead foot dead engine.” He identified the dead engine [as] the left one, so we [set] zero thrust and continued the maneuver. At this time everything was all right. Then we crossed the FAF. My student tried to decrease the manifold pressure of the good engine (right one)…to descend.… Then I realized that the manifold pressure in the right [engine] did not decrease. I took the controls and I canceled the maneuver, putting back the left prop and throttle. When I tried to decrease both throttles, I saw that manifold pressure of the right engine did not decrease.

What Would You Have Done?

Trust but Verify Air Carrier Captain’s Report
We were on a left downwind south of the field at 9,000 feet on a 090 degree heading for vectors for the ILS DME 1 Runway 28 [at Guadalajara, MMGL]. The First Officer was flying. Approach instructed us to turn left to a heading of 340 degrees and descend to 8,200 feet. As the approach was built, I extended off of the 12 DME fix at 8,200 [feet]. I had progress page 2 of 2 up, and we were about 3.5 miles from the course intercept. I am not sure, but I believe we were about 14 DME from the airport.

Approach then said, “Turn left to a heading of 310 and descend and maintain 7,100 feet, on that heading join the localizer, cleared the ILS Runway 28.” This heading took us to just outside the 8 DME fix by about 1 mile. I extended off of the 8 DME [fix] at 7,100 [feet].

It was VFR, I could see the runway, and the First Officer said he had the terrain in sight to the north. We both had the Terrain Awareness and Warning System [TAWS] displays up. Because Approach gave such a precise vector and instructions, I assumed…terrain clearance would not be a factor. Both the First Officer and I had reviewed and discussed the high terrain in the MMGL area on the leg down. As we were being vectored from the south, it appeared the high terrain would be mostly to the north of our heading. The FO was in a slow descent toward 7,100 feet. Out of about approximately 7,200 feet, I heard “CAUTION, TERRAIN,” and then it went immediately to a hard warning of “PULL UP.”

What Would You Have Done?

An Approach to Remember B737 Captain’s Report
On short final, inside the FAF, visual with the runway about 1,700-1,500 feet AGL, I commented, “We need gear down.” The First Officer called, “Gear down, flaps 15.” I got the gear down, armed the speed brakes, and [selected] flaps to 15. I last noticed speed decreasing around 181 [knots]. I was trying to get fully configured by 1,000 [feet] AGL. I called, “Flaps 30,” and moved the handle to 30.… The First Officer saw above 175 knots…and called, “Flaps 25.” I reversed the flap handle to 25.… I saw the airspeed below 175 knots, and the First Officer called, “Flaps 30.” I moved the flaps to 30 and pulled out the checklist. As I ran the checklist, I saw the flaps [indicating] 25. I cycled [the flap lever from] 25 to 30 again, but the flaps locked out. We got a “TOO LOW FLAPS” warning.

What Would You Have Done?

The Rest of the Story

Close and Closer Air Carrier Captain’s Report
The Reporter's Action
A second later I took control, added Takeoff/Go-around [TO/GA] power, and rotated. I suspect we cleared the aircraft by about 150 feet vertically.

More of the Story from the Controller’s Report:

Aircraft X was departing Runway 4. I was working Clearance Delivery/Controller in Charge [CD/CIC] and monitoring Local Controller-1 [LC-1] as required. As the Aircraft X became airborne, he asked LC-1 “Tower, did you see that?” The LC-1 asked if Aircraft Y, who was supposed to be turning at Taxiway Q, had entered the runway. At that point I looked at Aircraft Y, and the aircraft was moving slowly forward as if they were crossing the runway. However, it was night, and depth perception can be difficult at night. Aircraft X responded to LC-1 by saying yes he did enter the runway, and they had to maneuver to the left to avoid Aircraft Y. The Ground Controller [GC] then told Aircraft Y that they were supposed to be turning on Taxiway Q, but they had missed the turn. Aircraft Y replied, asking if he should turn right on Taxiway N on the other side of Runway 4. GC then explained that there was an aircraft departing and Aircraft Y replied, “Ok, um, obviously we missed it.” The GC then continued taxiing Aircraft Y towards Runway 13R.

First Half of Situation #2

Twin Throttle Technique Duchess Instructor’s Report
The Reporter's Action
I was talking with Tower at this time.… They asked me if I wanted to take Runway 32 or circle for Runway 28. The conditions were VFR, so I canceled the approach and started to align the plane for landing on Runway 28.… My right engine was [operating] with full power due to the throttle level [being] unable to control.… I [flew] with the left…engine at idle…to maintain a safe and stable approach.

On short final when I was sure about my landing and everything was safe with usable runway, I killed both mixtures at the same time and feathered [both] of the engines.… I landed and vacated the runway in the protected area and shutdown the plane.

First Half of Situation #3

Trust but Verify Air Carrier Captain’s Report
The Reporter's Action
The FO turned off the autopilot and began to initiate the Controlled Flight into Terrain (CFIT) recovery maneuver. As soon as he rotated, the warning stopped and he continued to climb to about 7,500 feet – the Minimum Vectoring Altitude (MVA) for this sector. At this point, there was no terrain indicated on the TAWS, and then there were no warnings. The terrain alert was momentary, and we were clear of terrain. We continued the approach at 7,500 feet and landed without event.

There were several underlying factors that contributed to this event: 1. Approach giving very precise instructions on vectors and altitudes for the approach clearance. 2. It was a very clear night, we could see the airport, and there appeared to be no terrain between us and the airport. 3. The First officer stating he had the terrain to the north in sight.

I was aware and reviewed the MVAs for our sector. However, I allowed myself to become misled by assuming Approach had information on terrain clearance that I did not have, based on his instructions. This was a mistake. I should not have accepted a clearance. I will never again accept an altitude below MVA while on a radar vector.

First Half of Situation #4

An Approach to Remember B737 Captain’s Report
The Reporter's Action
The FO suggested the Flap Inhibit Switch. I concurred.… I knew we had a long runway and could safely land.… We landed uneventfully and taxied in.
ASRS Alerts Issued in July 2018
Subject of Alert No. of Alerts
Aircraft or Aircraft Equipment 2
Airport Facility or Procedure 3
ATC Equipment or Procedure 1
July 2018 Report Intake
Air Carrier/Air Taxi Pilots 5,571
General Aviation Pilots 1,608
Flight Attendants 582
Controllers 547
Military/Other 287
Mechanics 209
Dispatchers 166
TOTAL 8,970
and   Indicate an ASRS report narrative
[  ]  Indicates clarification made by ASRS
  • Subscribe to CALLBACK  (Read Policy)

    NASA ASRS only uses your email address for subscription to CALLBACK. NASA ASRS and the third party used for distribution of emails and handling subscriptions will never share or sell your personal information.

    If you have any feedback about this service please contact us.

Receive the FREE monthly newsletter by email!

A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
Issue 464