CALLBACK From the NASA Aviation Safety Reporting System
 Issue 531 April 2024 

Other Points of View

O wad some Power the giftie gie us
To see oursels as ithers see us!
It wad frae mony a blunder free us,…
  – Robert Burns.

I often wonder how professionals in one aviation working group, particularly pilots, are generally perceived by those of another group and how much cross-knowledge exists between groups that work closely to operate the mission and maximize safety. Aviation professionals in one working group are often separated, or siloed, from those of another and do not realize regulations and compliance required of the other groups. Quantitatively, pilots submit approximately 75 percent of ASRS reports currently received. Qualitatively, professionals from other aviation disciplines submit equally valuable incident reports, but from different vantages than pilots. Their knowledge, experience, and perceptions of an event can vary significantly from a pilot’s assessment.

This month, CALLBACK looks at incidents reported mainly by aviation professionals other than pilots. Examine vantages and perceptions of each through the eyes of both. Then, holding safety supreme, it may behoove us all to heed Mr. Burns’ poetic proverb, consider some self-examination, and appreciate our colleagues’ contributions to our mission.

Part 121 – B767 Flap Change

From a Maintenance Technician’s report:

A lockout tagout was performed for a flap change. Gear pin installation was required for the lockout. A coworker installed the gear pins, and I documented all lockout tagouts for the flap change. [After the change], the lockout for the flap change needed to be reversed. My coworker removed the gear pins. I witnessed him returning gear pins to where they go in the cockpit. I did not verify how many he had. I looked at the main gear and nose gear to verify no flags remained. I did not see flags on the main or nose gear. I signed off the reversal of the lockout for the flap change, which included gear pins being removed and signed off. [On a later date], I was notified of an air turnback for that aircraft…for the main landing gear not retracting. I notified my coworker of this, and he said he was not aware there were 5 gear pins on the 767, and he only removed 3. He also said he did not see flags for other gear pins. The gear pins were missed by the mechanic who departed the aircraft as well as the pilot who did the walkaround. My assumption is that storms in the area [when the aircraft flew] possibly blew gear pin flags to positions where they were not visible.

Part 91 – Cessna 188 Elevator Cables

From the Maintenance Technician’s report:

During the annual inspection of the Cessna 188, I removed a clevis bolt that secures the upper and lower elevator control cables to the control stick. I found the bolt to be excessively worn, so the cables remained detached while a replacement bolt was on order. When the new clevis bolt arrived, I installed it into the control stick, securing only the upper cable. After installation, I moved the control stick to actuate the elevator, and it seemed to work properly, because the attached cable moved the elevator up, and gravity pulled the elevator back down. Flight control freedom of movement was also checked by two other A&P mechanics and the pilot before the flight. The lower elevator control cable is routed from the control stick through a tube and then down around a pulley. When the problem was discovered, the lower cable end was hidden inside the tube. I believe the hidden cable is one factor that led to my mistake. Another factor is my failure to request a secondary maintenance check. The problem was initially discovered by the pilot just after takeoff.… After landing, a flight control inspection revealed a very loose elevator cable under the pilot seat.… The inspector followed the cable forward to find the end inside the tube, but not connected to the control stick as it should be. I then installed the lower cable along with the upper cable to the control stick with the clevis bolt. No other discrepancies were found during the post flight inspection.

From the pilot’s report:

Upon preflight inspection of the exterior and interior of the airplane, no discrepancies were discovered. All surface controls moved freely. Upon engine run-up while performing the Pre-takeoff Checklist, all flight controls moved freely and in the correct manner. On takeoff, I recognized the stall warning horn and an abnormal pitch up after rotation. I immediately provided full forward pressure on the stick and received no response. I proceeded to reduce power and add full forward trim, which lowered the nose of the aircraft. It became clear that the plane did not have elevator control. I proceeded to keep the engine in normal operating range, trim full forward, and circle back to the runway I had departed. I landed with…flaps and full aft trim (to flare), leaving the stick full forward. The landing was uneventful. I taxied over to Maintenance. Upon inspection of the aircraft, an elevator cable, which [should have been] connected at the base of the stick, was not connected. This cable and pulley are only visible when panels and other coverings are removed.

Part 121 – CRJ200 Cabin Teamwork

From a Flight Attendant’s report:

I would like to report an issue on today’s flight.… The Captain…informed me…about a [landing] gear issue. The Captain…explained [the problem] to all the passengers…and apologized, saying that we must return to ZZZ. All the passengers…complied with our crew instructions.… I made my announcements and…apologized one more time for the inconvenience. We made it back to ZZZ in about 10 minutes. When we landed…I had received a call from Management to check on me. I was glad that everything went OK and everyone was calm. The Captain did a great job.

Part 121 – Departure Procedure

From an observant colleague Controller’s report:

I was working CAMRN/LENDY in the JFK area, and we were on the 31s. I noticed a departure come off Runway 31L that was supposed to be on the JFK5 Departure Breezy Point Climb. The climbout is supposed to have the departures go direct to Canarsie (CRI) VOR and then depart that VOR on a 223 [track]. However, Aircraft X did not depart CRI on a 223 [track], but appeared to be going direct Robbinsville (RBV). Before I could say anything, the Departure Controller noticed the pilot’s error and corrected him before he got too deep into LaGuardia’s (LGA) airspace. Luckily, there weren’t any LGA arrivals in conflict with Aircraft X. The Departure Controller did not ask Aircraft X why he turned that way, but it appeared they were going direct RBV. I don’t believe Aircraft X was read the Brasher warning. This keeps happening. I don’t know what to write anymore. Please do something before the Departure Controller is too busy to notice these pilot errors and we have a near miss.

Part 121 – GPS Navigation

From a Dispatcher’s report:

I received a SATCOM call from the Captain, who informed me they were having issues with the left GPS, and it wasn’t functioning properly. The aircraft kept going into DME DME Mode, and his Actual Navigation Performance (ANP) value was going up and was currently at 15 miles. [I] explained to them that the area they were in was a known GPS Jamming area (Bulgaria/Romania/Serbia). The Captain did not believe this was the case and continued his explanation…why he thought it wasn’t jamming and it was, indeed, the GPS unit going out, even though I told him that this same flight a week ago had GPS jamming happen in the same area. I got aircraft [Technicians] involved, and they stated they couldn’t find anything wrong with the GPS. After hearing this, the Captain still wasn’t convinced that it was GPS jamming and kept insisting it was a faulty GPS unit. He then proceeded to say he couldn’t [fly] the Atlantic crossing with an ANP value of 15 and one GPS unit down. I assured him he could, as I was reading from the circle of entry chart. I told him all that is needed since he was on a random route was VHF, VOR, DME, ADF, and Mode C. He didn’t believe me and instructed me to do my research and get back to him before he started the crossing, which was over 2 hours away. He was adamant that if I couldn’t provide him with sufficient information on why he can still do the crossing, he was going to divert.… At this point my relief stepped in, and I briefed him on the situation. He said he would research it.

The crew refused to listen to Dispatch and did not believe Dispatch that they were in a known area for GPS jamming. Train crews to know the signs of GPS jamming and the areas where it happens frequently.

Part 121 – B737 Navigation and Terrain

From an Approach Controller’s report:

[I was] working…arrivals. Gusting winds and wet conditions were causing confusion and distractions. The advertised runway was not acceptable to certain aircraft due to aircraft performance.… On the arrival about 20 miles from the airport, Aircraft X spoke up and said they were too heavy for any runway!? I asked the pilot their intentions, since other aircraft on frequency were asking for Runway XXC. He asked to be broken out [of the arrival sequence] to crunch some numbers. I broke the pilot out with a left turn [heading] 180 and to maintain 3,000 feet. The instruction was well before the…Minimum Vectoring Altitude (MVA) area of 3,300 feet. I went to work other traffic. Aircraft X made a call…asking if it was a right or left turn. I restated it was a left turn. Aircraft X was already in a right turn, then said he would correct to the left, making an even wider turn into the MVA area. I issued a climb to 3,300 feet.

Company A flies a plane that can’t land at ZZZ.… The [airport arrival] rate should be significantly reduced if the primary user of the airport can’t land on the primary runway.

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ASRS Alerts Issued in February 2024
Subject of Alert No. of Alerts
Aircraft or Aircraft Equipment 5
Airport Facility or Procedure 18
ATC Equipment or Procedure 9
Other 2
February 2024 Report Intake
Air Carrier/Air Taxi Pilots 5,215
Flight Attendants 1,714
General Aviation Pilots 1,351
Military/Other 548
Controllers 302
Mechanics 298
Dispatchers 183
TOTAL 9,611
Indicates 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 531