Issue Number 258 |
February
2001
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P.O. Box 189, Moffett Field, CA 94035-0189 |
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Procedures are a means of communicating the wisdom of experience in a standardized form to operators. But procedures may need to be revised when incidents and accidents demonstrate their weaknesses. This continuous reinforcement loop between experience and procedures is one of the most important safety tools in aviation.
A Captains report to ASRS describes the dangerous situation that developed for a Lear-60 crew when a procedural oversight by maintenance was amplified by a flight crew oversight during pre-flight.
It appears the maintenance technician who serviced the oxygen did not open the shutoff valve after servicing the bottle. The flight crew did not check the oxygen masks for flow until 18,000 feet MSL a potentially lethal situation had they not detected the problem in time.
The unused belt was only part of the problem here. The control column seal in this older aircraft (DC-8) was apparently not maintained properly, allowing the unused belt strap to become caught in the base of the column.
Flight crews of multi-engine aircraft experiencing engine or system failures during flight often can proceed to destination without making a precautionary landing. The decision to do so is generally safe because of system redundancies, well-honed crew coordination procedures, and other factors. But when an engine failure occurs over water, safety margins can quickly shrink, as highlighted by this First Officers report.
The First Officer implies that the Captains decision was questionable, but the Captain may have had motivations other than those noted for continuing to the company base. The closest airport during an emergency may not always be the most "suitable" because of weather, crew familiarity with the airport, runway length, and other important considerations.
Hurry-up pressures are evident in this report from a flight crew that ignored safe operating procedures in a rush to take off:
As Will Rogers said, "If youre riding ahead of the herd, take a look back every now and then to make sure its still there."
A helicopter pilot with passengers bound for a casino depended too heavily on ATC for a steer to an alternate airport. That gamble not only didnt pay off, but led to an upsetting reception for all involved:
Our reporter was intent on getting his passengers to the gaming tables and didnt adequately prepare for arrival in the area. The ATC assistance offered may have been less than optimal, but the final responsibility for navigation belonged to the pilot not to ATC.
ASRS Recently Issued Alerts On... |
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False warnings of smoke in a CL65 cargo hold |
B737-200 uncommanded yaw during takeoff roll |
Non-compliance with DC9 radome repair procedures |
Multiple reports of false GPWS / EGPWS terrain warnings |
Late arrival clearances and runway changes at an airport |
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Air Carrier/Air Taxi Pilots
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2,051
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General
Aviation Pilots
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566
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Controllers
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56
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Cabin/Mechanics/Military/Other
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166
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TOTAL
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2,839
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