CALLBACK From the NASA Aviation Safety Reporting System
 Issue 530 March 2024 

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 or situation up to a point where a specific decision must be made, an immediate action must be taken, or a non-normal condition 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.

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 these reported incidents.

The First Half of the Story

Part 91 – A Night Sky Nightmare An M-20 Pilot’s Report
Flying…on an IFR flight plan last night, it was overcast at 12,000 feet and very dark.… I had descended from 8,000 feet and was level at 3,000 feet. I was heading 290 degrees getting vectors for the ILS approach.… Approach told me to turn left to 250 degrees. During the turn, I noticed bright lights ahead and at first, thought it was an airplane very close above me at 12 o’clock flying in the opposite direction.… I ducked my neck down and tilted my head back to look up 45 degrees out the windscreen to look directly at the lights. Immediately, I thought I was flying with a very nose high, pitch up attitude and immediately realized [the lights] were not an airplane! I must have pushed on the yoke to get the nose down. I turned my head left to look out the side window hoping to make sense of what I was seeing, but the pitch blackness with only a couple lights was of no help. I immediately looked at my G5 [attitude indicator], and what I saw made my head spin! For a split second I questioned whether my G5 had malfunctioned.

What Would You Have Done?

Part 91 – A Non-Towered Tale A Turbo Skylane Pilot’s Report
It was a routine takeoff on [Runway] XX, the 6th one today. I made the usual call, “ZZZ traffic, callsign, departing XX.” This was later verified by another person on the ground monitoring the advisory [frequency]. I turned onto the runway, started the takeoff roll, lifted off, and saw landing lights on a light twin on final approach to [the opposing runway]. They had made no calls at all on advisory, which was also confirmed by the listener on the ground. I hoped for a second that the twin was just making a low approach and saw us, but they continued [their] approach.

What Would You Have Done?

Part 121 – Hidden Power for Cabin Devices A B737 Captain’s Report
A customer had to check a bag due to lack of overhead space. The customer admitted to a flight attendant that…a lithium-ion battery was in the bag.

What Would You Have Done?


Part 121 – A Close Approach A Commercial Fixed Wing Captain’s Report
While flying…to SFO, we planned and briefed the BDEGA Arrival to be followed by the charted visual for [Runway] 28L. Upon checking in with NORCAL, we were assigned a heading of 100 [degrees] off of CORKK for the charted visual to [Runway] 28R. We changed the localizer frequency, reprogrammed the FMS, and briefed the new approach. We flew a right downwind and were vectored for a right base. ATC pointed out traffic that would merge for [Runway] 28L. We were assigned 160 knots. The ATIS was reporting winds of approximately 260/25G34. With our weight and the wind additive, the Vref was 149, and target [airspeed] was 164. ATC was advised that 164 was our slowest speed. We configured gear down, flaps 15 on base and slowed. ATC gave us another vector to join the localizer course. We had tuned [the localizer], but had not planned on using it, since [ATC] was [assigning] the charted visuals. We armed the localizer and continued while configuring for landing. We intercepted the localizer course and were cleared for the approach. The [other] aircraft was intercepting their localizer for [Runway] 28L. At about that time, we got a Traffic Advisory (TA) from the merging aircraft. I looked to find it visually. It was under our wing turning left, left wing down. At that same time, we got a Resolution Advisory (RA) to “LEVEL OFF, LEVEL OFF!”

What Would You Have Done?


The Rest of the Story

Part 91 – A Night Sky Nightmare
Thank God all my training kicked in, and I immediately disregarded the thought that my G5 was broken. At that moment, I realized I was experiencing overwhelming spacial disorientation. So, I focused on using the attitude indicator to get wings level and control the airspeed. I was in a bank of approximately standard rate. I leveled the wings first. I did not notice the horizon, so I did not immediately perceive my pitch attitude. After getting wings level, I…focused on the airspeed. The airspeed indicator was moving fast…and the numbers were increasing! I do not remember whether or not I reduced power. Before this happened, power was set at about 1,700 rpm, and I had been flying at 135 mph. Now airspeed was passing through 190 mph fast! I immediately pulled back on the yoke to reduce the airspeed and recover the airplane.… The horizon came back into view, I stopped the descent, added power, and began to climb. As I started to climb, the Controller came on the radio and stated, “Aircraft X, I got an altitude alert. Check your altitude.” I could hear the Controller's alarm going off. I didn’t try to communicate. I only focused on completing the recovery and controlling the airplane. I had gotten 400 feet or more off my assigned altitude. Although it felt like slow motion, this all occurred in a time span of less than 10 seconds. I got back to 3,000 feet and a heading of 250 degrees.… After a minute of silence, the Controller gave me a vector to intercept and cleared me for the approach. I’ve thought a lot about what happened last night and realize that a slight disorientation accelerated rapidly into extreme disorientation.… My head movements in the cockpit trying to figure things out were counterproductive and actually were a significant contributing factor to the magnitude of my disorientation.

First Half of Situation #2

Part 91 – A Non-Towered Tale
I pulled power, pitched down, called, “ZZZ, aborting takeoff.” I was able to set the plane down and exit the runway as the twin continued the approach. About that time, the twin pilot called, “Going around,” and tried to claim that he had made appropriate calls and that I had not. I suspect that the twin pilot did not turn on…landing lights until I had already taken off. Approaching against the rest of the traffic with…low light under the overcast, a white airplane would not be very visible without those lights.

First Half of Situation #3

Part 121 – Hidden Power for Cabin Devices
I initiated the process of having the bag removed. I asked the passenger where the batteries were, initially thinking that we could remove them, put the bag back on, then depart. The customer told me that [it was unknown] where anything was in the bag because the customer hadn’t packed it.… This raised a red flag with me. The customer and the bag were removed.…I’m curious how many of these batteries are flying around in…cargo compartments. Every toothbrush has a lithium battery. We run out of overhead space all the time. These bags are going into the cargo compartments with these lithium batteries inside. Flight Operations Manual (FOM) guidance on this doesn’t seem to exist.

First Half of Situation #4

Part 121 – A Close Approach
I had already had the autopilot and autothrottle off to hand-fly the approach. We started the go-around response to the RA. As we were bringing the flaps up, the RA changed to “CLIMB – CLIMB NOW!” We continued with the escape maneuver and climbed to approximately 3,400 feet MSL. ATC assigned us 3,000 feet after we finished the RA response. We complied and subsequently flew another approach to an uneventful landing. During the RA response, the RA aircraft symbol showed the [other] aircraft at -100 feet. I visually looked, and it was jarring how close the aircraft had come to us. It was under our wing, and I can confirm the 100 feet separation. If I had selected the TCAS to TA only, we could have…descended down on top of him and been involved in a mid-air collision.
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ASRS Alerts Issued in January 2024
Subject of Alert No. of Alerts
Aircraft or Aircraft Equipment 6
Airport Facility or Procedure 5
ATC Equipment or Procedure 1
January 2024 Report Intake
Air Carrier/Air Taxi Pilots 7,756
Flight Attendants 3,105
General Aviation Pilots 1,453
Military/Other 601
Dispatchers 406
Controllers 371
Mechanics 293
TOTAL 13,985
and   Indicate an ASRS report narrative
[  ]  Indicates clarification made by ASRS
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A Monthly Safety Newsletter from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
Issue 530