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with the Airworthiness Directive…It was explained to me
that the prop strike that occurred fit this change definition,
and that, therefore, the return flight to the home base was
not in compliance with the Airworthiness Directive…Had I
known of the Airworthiness Directive, I certainly would not
have flown the plane back….
Situation #2: “Don’t Sink, Don’t Sink” (B737
First Officer)
• The Reporter’s Action: Arrest the descent and
begin a climb
n The Captain immediately arrested the descent and then
commenced a climb. We never saw the traffic. We were
360
only 1000 feet AGL and the terrain was rising in front
of us (red on the EFIS screen). The aircraft was able to
climb safely away from the terrain once the climb was
commenced. The Captain called the Tower the next day
and related to me that the Bonanza was on a downwind
and the Tower thought there was adequate separation.
Our B737 apparently thought differently, resulting in
something that should be of concern: an RA commanding
a descent at a low altitude in rising terrain. I have never
had a Resolution Alert at such a low altitude, and I have
never had a Ground Proximity caution resulting from a
TCAS RA maneuver. We could not out-climb the Bonanza,
it was directly in our climb path. Even if we saw it, which
we didn’t, we were in a canyon without room to maneuver
clear, other than descending and passing underneath it at
1,000 feet AGL…We were lucky it was daylight.
Situation #3: “I Discovered a Socket
Rail Missing” (Maintenance Technician)
• The Reporter’s Action: Report the Missing Tool
to a Supervisor
n I notified my Supervisor who immediately checked on the
status of the aircraft. It was on final at [destination]. He
called [the airport] to check the aircraft and the socket rail
was recovered. I should have been more assertive, stuck with
one task at a time and inventoried my toolbox after each
task. If not for the repositioning of the aircraft at the gate, I
still would have had time to discover the missing tool before
flight. I had the right process but not the right sequence.
Situation #4: A Passenger Stuck in the
Lavatory (EMB-145 Captain)
• The Reporter’s Action: Tell the Passenger to Stay
Seated for Landing
n I told the Flight Attendant to have the passenger take
a seat to the best of his ability in the lavatory and had
her prepare for landing. The landing was uneventful and
reaching the gate Maintenance personnel came on board
before any passenger deplaned and were able to open the
lavatory door by releasing the hinge pins. An AML entry
was made.
The First Officer’s report on the same incident added,
“The passenger that was stuck in the bathroom was not
injured [and] seemed to be in good spirits after the event.”
The Rest of the Story: The Reporter’s Actions
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/
November 2009 Report Intake
Air Carrier/Air Taxi Pilots 2599
General Aviation Pilots 873
Controllers 419
Cabin/Mechanics/Military/Other 319
TOTAL 4210
ASRS Alerts Issued in November 2009
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 8
Airport facility or procedure 2
ATC equipment or procedures 2
Company policy 1
TOTAL 13
ASRS incident reports offer useful descriptions of a variety of
aircraft ground and airborne icing hazards. Air carrier reporters
often focus on ground-related issues such as inadequate deicing
procedures, deicing fluid ingestion hazards, and deficient
inspections for snow and ice accumulation. GA reporters are apt
to describe airborne icing events that involve immediate decision
making or controllability issues. Our January 2010 CALLBACK
offers a “slice of ice” from the narratives of ASRS reporters.
Hurry Up and Wait
A B757 flight crew experienced a lengthy flight delay after shortstaffed
Maintenance and Deicing personnel failed to anticipate
needed icing inspections.
n During preflight… the First Officer noticed ice and snow
adhering to airframe, wings, and tail, which had pooled and
refrozen in both engine inlets aft of the fan section. He notified me
(Captain), Station, Maintenance, and Deicing, and after looking at it
myself, we agreed that Maintenance needed to view ice in engines…
Weather was CAVOK and forecast to remain so after severe winter
　
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