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Multiple ram air scoop icing incidents involving the MD-80
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
April 1995 Report Intake
Air Carrier Pilots 1643
General Aviation Pilots 701
Controllers 60
Cabin/Mechanics/Military/Other 40
TOTAL 2444
The Whole Crew, and Nothing But The Crew
The concept once known as Cockpit Resource Management
is now referred to as Crew Resource Management (CRM),
with an emphasis on the ideas that everyone involved with
the aircraft is part of the team, and no one is a mere observer.
Still, CRM skills sometimes get overlooked. This
Part 135 commuter Captain on a round-robin night flight
experienced two failures of CRM practices during one flight.
■ I have been extremely pleased with the CRM training I
have received. I have tried to incorporate such lessons into
my briefings with my crew and consider myself a very approachable
Captain. Even so, I experienced a total breakdown
of communication...Twice in one night my crew withheld
information I needed to do my job, for no good reason.
During a low visibility approach, my First Officer apparently
became disoriented after breaking out of the clouds and assuming
visual control of the aircraft for landing. However,
he never said a word about it until after we had made a
rather firm landing. He stayed quiet and took a chance that
could have resulted in much worse conclusions than a hard
landing.
After shutting down, I inspected the exterior of the
airplane...everything OK. The passengers were boarded, and
we returned to XYZ without further incident.
When the flight attendant got off the airplane, she said she
was suffering from a headache because she had hit her head
against the bulkhead during the [previous hard] landing.
She had said nothing then because she was in a hurry to get
home.
In the next report, the usual CRM efforts of the flight and
cabin crews were complicated by the Passenger Service
Agent (PSA) at the gate, as well as the behind-the-scenes
team members (dispatch and load control). Add an
electronic information display, and confusion–with lack of
CRM–reigns:
■ A final load and weight of 106,300 lbs. was sent to the
aircraft via ACARS prior to push. I questioned this because
by my math we should have weighed 107,800 lbs. Just prior
to push...107,300 lbs. appeared, which was closer to what I
expected. The PSA re-opened the door...and put on [four
more passengers]. Because of opening the door, all previous
data dumped from the ACARS. After a call to dispatch for a
takeoff alternate due to deteriorating weather, a call was
made to load control to ask for a new weight for takeoff.
They said it appeared we were over weight [max. takeoff
weight=108,000 lbs.], but moments later, we received a new
weight of 107,600 lbs.
Just after lift-off, we received two ACARS messages that we
were over weight, and should return to the gate.
Who’s Flying the Aircraft?
A three-person crew, inbound on an ILS, found themselves
having a little trouble getting it all together for the final
approach. The First Officer overshot the localizer, then
discovered that the Captain had dialed in the wrong ILS
frequency. All of this led to two offers by ATC to execute a
go-around. The First Officer and Second Officer agreed, but
the Captain declined, insisting that the approach could be
salvaged. Finally, someone made a decision, as the Second
Officer reports:
■ The First Officer said he was going around, and called for
climb power. He did not remove his hand from the throttles,
nor did he push the throttles to a climb power setting. I then
pushed the throttles full forward with the First Officer’s hand
still on them, and called for gear up. The Captain told ATC
we were going around...The pilots flying were late and
indecisive in initiating a go-around.
CRM principles worked in this case (eventually!), but could
have worked even better in all these reports if the whole
crew had accepted the principles from the start.
SOP or SOL?
SOPs (Standard Operating Procedures) can be a useful form
of communication among crew members, especially when
radio contact is not available. Deviation from SOPs by anyone
can leave a pilot-in-command SOL (Sure Outta Luck).
An ASRS report describes an incident that led to an
adrenalin rush for all concerned.
■ [This airport] has a light system for parking. The red
light coming on is the signal to stop the aircraft. When the
　
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