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received often and are usually different verbiage to mean
the same thing – usually adding a VOR on the airway that
was not listed on the clearance, but would have been passed
over anyway.
ASRS obtained an actual example of a PDC with a
confusing depiction of revised vs. filed routing. The PDC
was for a Dallas-Fort Worth (DFW) RNAV SID. Here is
A Monthly Safety Bulletin from
The Office of the NASA
Aviation Safety
Reporting System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
March 2009 Report Intake
Air Carrier/Air Taxi Pilots 2681
General Aviation Pilots 1021
Controllers 100
Cabin/Mechanics/Military/Other 450
TOTAL 4252
ASRS Alerts Issued in March 2009
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 4
Airport facility or procedure 3
ATC equipment or procedure 2
Company policies 1
Maintenance procedure 1
TOTAL 11
When to flying pursuits you’re inclined,
Keep procedures and training in mind,
And when soaring the blue,
Heed those instincts and clues
That tell you you’re getting behind.
– Editor
In this month’s CALLBACK, we’ll sample a selection of ASRS
incident reports that describe how some pilots and air crews missed
– or heeded – important clues to flight safety. Our selection includes
general aviation, air carrier, and maintenance incidents.
Clue: A Left-Rolling Tendency
A Cessna 210 pilot suffered temporary engine failure and altitude/
track deviations while recovering. Here is the pilot’s story of how
important flight handling clues were missed.
n …My engine stopped inflight. I believe the cause was that I
forgot to switch the fuel tank selector at the appropriate time and
the right tank ran dry, starving the engine of fuel. During the
incident, I glided below my assigned altitude and had to leave my
assigned heading to look for a suitable place to land, if necessary.
I also made a ‘Mayday’ call to Approach and informed them the
engine had failed. I switched to the (full) left tank and was able to
restart the engine and continue to the destination.
I started the flight with the right tank selected. I intended to switch
tanks approximately 1/2 way to my destination. Apparently, I forgot
to switch tanks, because the selector was still on the right tank
when the engine stopped…My plan to switch tanks at the 1/2 way
point was a poor plan. The logic was if I could make it 1/2 way
on 1 tank, I should have enough fuel in the other tank to complete
the flight. The problem was that it left the plane imbalanced with
hundreds more pounds of fuel in one wing than the other. In the
future, I will switch tanks every 30 minutes.
I missed clues that might have alerted me to the problem. First,
the autopilot failed to hold a heading, and the plane began an
uncommanded turn to the left. I turned off the autopilot and noted
a left-rolling tendency. At first I thought a passenger’s bag was
putting pressure on the co-pilot’s yoke, but moving the bag did
not help. I looked around to see if something had happened to the
airframe but saw nothing unusual. I assumed that the autopilot
had stuck with a bungee pulling to the left. Only after I landed
did I realize that the left-rolling tendency was caused by the
imbalance of fuel….
Cue: “Something Looked Wrong”
Night visual approaches to unfamiliar airports with multiple
runways can be challenging, even for highly experienced pilots. An
air carrier flight crew averted a wrong runway landing when they
heeded cockpit and ATC cues.
n This was a case of a visual approach where we were issued
a visual clearance to enter a left downwind to Runway 21 and
entered a left downwind for Runway 25. We realized at a point in
time, this was the incorrect runway (Runway 25), abandoned the
approach, maneuvered for a right 270 degree turn and flew the
correct approach to the correct Runway 21…Complications were
an unfamiliar airport, at night VMC with multiple aircraft in the
airport environment. There was a helicopter on final for Runway
21, another carrier B737 on a right downwind for Runway 21 and
a C5 inbound.
Cues were the controller telling us we were too wide, the Pilot
Flying asking me if it looked right because something looked
wrong, and the directional gyro not aligning up with the runway we
were flying to. Also, the ILS just did not make sense as it was our
backup. Once I, as the Pilot Monitoring, stated it was not correct,
we broke off from the approach….
　
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