Some of the most difficult
judgment calls in aviation occur on the ground, before a flight. Pressured
by schedule, passengers, and other considerations, pilots may be tempted
to suspend the good judgment they have gained from experience and training
to undertake questionable or unsafe flights. We hear from several pilots
who explain to ASRS why they regretted not taking a stand for safety.
From a new-hire corporate
First Officer:
- The Captain
[who was] also Chief Pilot...would not put on more fuel at my request.
We both were aware of the forecast conditions at our destination,
and were both also aware that these conditions required additional
fuel to be added to remain within legal IFR reserve fuel minimums.
However, the Captain was still unwilling to purchase the fuel.…
I am new with this company and was afraid to make waves with my boss
as he has a poor record with pilot personnel. I should have made a
stand and deplaned the aircraft, but did not. We landed with about
35 minutes of fuel at our destination after shooting an ILS to 500
feet and 1-1/4 mile visibility.…
I made contact with his superiors and informed [them] of the event.
They assured me that they would stand behind me in all situations
of this nature... and also informed me that this will not happen again...
I have learned that I should and will take whatever actions [are]
necessary to avoid putting my certificate...the passengers’ safety
or the aircraft in jeopardy
The next incident, recounted
by the pilot of a high-performance single-engine aircraft, made white-knuckle
flyers out of several veteran pilots. It occurred just after a routine
passenger pick-up at an airport in the West whose elevation is almost
4,000 feet AGL.
- The incident
began at [an] airport on [the] lake. I was part of a group of five
similar airplanes there to pick up a group of river rafters... The
load I was given was five men, two of them quite large, and quite
a lot of baggage. There were no scales in the plane so there was no
way to know exactly what the load was. However, it was clear that
it came very close to max weight. I refused some of the bags and put
them aboard another plane. I loaded up the passengers and proceeded
to depart. The takeoff was normal and although I could feel the weight
of the plane, it did climb out normally.
The weather was hot with high winds and turbulence as is usual for
this location. There were also updrafts and downdrafts. On climb-out
I flew into one of these downdrafts and the plane began to sink. I
was flying over the river which has steep canyon walls. In this downdraft
I could not climb out of the canyon. I knew that eventually the downdraft
would abate and I could climb out, but my passengers were beginning
to panic. Two of them were pilots themselves. The passenger sitting
behind me took the initiative without my orders to open the pilot-side
door and throw out all the bags into the river below, a load of perhaps
150 pounds. I did not resist this move as to do so may have increased
their panic. Eventually the downdraft abated and the plane climbed
out of the canyon and up to a safe altitude, then landed safely.
In retrospect I believe there are a number of ways the incident could
have been avoided. I could have been more conservative on the load
and refused more bags…. I was over-confident about the capabilities
of the plane. Also, unconsciously I was relying on the judgment of
two of the other pilots present.… Both of these pilots had much
more experience at this location than I did. I could also have...allowed
for the possibility of downdrafts.
It’s possible that the
open aircraft door and resultant drag worsened the downdraft situation.
Our reporter might have prevented the passenger panic and subsequent
baggage barrage by briefing on the local flight conditions prior to
departure.
And
from a pilot who was persuaded by a company salesman to bend weight-and-balance
rules to sew up a sale:
- The salesman,
myself, and the [new aircraft] owner were flying [on a long cross-country].
With 3 people and full fuel this aircraft is approximately 50 pounds
over gross takeoff weight. We departed with an additional 8 bags and
one set of golf clubs, which clearly put us over gross weight. I know
better, but rationalizing the salesman’s statement, "I fly
with 5 people and full fuel...and it is fine," I proceeded...
When I had the plane at approximately 400 feet AGL I ran out of nose-down
elevator trim. I called Tower and requested that we come around to
land... This was my first experience outside of the college training
environment which consists of good habit patterns and flying by the
book. Unfortunately, I did not follow good judgment. Upon my return,
I told the salesman he needed to get someone else.
Lessons
in Situational Awareness
Situational Awareness–or
"SA" as human factors specialists like to call it–is
a term referring to pilots’ ability to "keep the big picture"
in flight operations. This includes awareness of the aircraft’s
location and attitude, its proximity to physical hazards and obstructions,
weather and environmental factors, engine and systems status, task priority
within the cockpit, and many other factors.
Loss of situational awareness
is often associated with poor weather, aircraft emergencies and other
extreme situations. But more insidiously, loss of situational awareness
also occurs in good visual conditions during routine operations. An
air carrier Captain describes a case in point:
- While being
vectored on a downwind leg to Runway 01L, Tower asked if we had the
field in sight, which we did. At that time we were cleared for a visual
approach to Runway 01L and a left turn back to the field was initiated
to result in a final of approximately 6 miles. When approximately
60° from the runway heading, Tower reported traffic (a B-757)
joining a final for runway 01R. While looking for the traffic the
First Officer, who was flying the aircraft, took his eyes off the
field and shallowed his bank... When I realized he was not just squaring
off his final but was going to overshoot the runway I told him he
was going to overshoot and ordered a turn back to our runway. He seemed
disoriented and was slow in responding, resulting in a significant
overshoot approaching the approach corridor for Runway 01R. A TCAS
II-Resolution Advisory resulted with a "monitor vertical speed"
command which was complied with. Tower questioned if we had the traffic
in sight which we answered in the affirmative. We corrected back to
the 01L centerline and landed with no further incident.
In talking to the First Officer after the landing, he indicated that
he lost sight of the runway in the left turn. Also that he never actually
saw the B-757. Although I indicated that I saw the traffic and pointed
it out, the First Officer did not see it, but I assumed he did. I
also assumed that he had the runway in sight, so I was unaware that
he had lost situational awareness.
The lesson to me is to never assume another crew member is seeing
the same thing I am and to work to communicate what I am seeing even
when weather is good and "easy" visual approaches are being
conducted.
We trust this incident taught
the First Officer the importance of communicating clearly with other
crew when he does not have other traffic and the runway in sight.
The
Importance of Homework
Lack of preparation for flight
into marginal conditions can contribute to a loss of situational awareness
that in turn can build to a near-catastrophe. The pilot of a private
jet who was the victim of a critical instrument failure, explains.
- Localized
area of moderate/heavy rain near and over destination airport. Center
controller reported, "it’s only heavy rain, there’s
nothing in it." This was consistent with the pattern of the previous
day or two. Carried out normal VOR approach using Autopilot/Flight
Director. At Missed Approach Point began to climb on autopilot. Encountered
very heavy rain, moderate turbulence. At approximately 700 feet MSL
(250 feet above minimums) ADI failed with loss of all Autopilot/Flight
Director functions. Pilot had difficulty maintaining precise control
over aircraft using backup instruments due to turbulence and loss
of position and altitude guidance.
Contributing factors: 1) backup instruments not set up for missed
approach; 2) pilot did not study and prepare adequately for missed
approach; 3) lack of situational awareness when talking with controller
due to lack of familiarity with nearby landmarks, fixes and waypoints.
Corrective actions: Training should include setting up backup navigation
indicators for approach/missed approach in anticipation of primary
ADI/HSI failure. Pilots need to thoroughly memorize and set up missed
approach [procedure] because an emergency or equipment failure does
not leave time to read it while executing.
Recently
ASRS received a refreshing international flight operations report in which
an ATC instruction was rendered in plain English, understood by the U.S.
crew, and complied with promptly. No apparent problem, one would think–but
read on.
- We were approaching
[airport in England] on a relatively clear morning. We held for about
10 minutes and then made an approach under Approach Control radar
vectors and Tower control. An aircraft in position was cleared for
takeoff and we were cleared to "land after" the departing
aircraft. I decided not to make a go-around. We were stable and landed
after he broke ground. We made a normal roll-out and taxied in. Tower
commented "good job." Later we found out a newspaper called
it a near miss.
Therefore, even though the "land after" clearance works
well over there, in the same situation, I would go around next time.
In this judgment dance between
the pilot and controller, we still don’t know who was leading.
What’s certain is that "land after" is not recognized
by the International Civil Aviation Organization (ICAO) as accepted
ATC terminology.
