Advertisements


 

Thursday
Nov082018

Safe Landings: Non-Towered Airport Incidents 

The non-towered airport environment can introduce some curious threats that are not usually prevalent in towered airport operations. A non-towered airport environment exists at an airport without a tower or at an airport with a tower that is closed while the airport remains open. In either case, similar threats can exist but may be especially subtle in the latter, particularly if a pilot is unaccustomed to using non-towered airport procedures. 

In the non-towered environment, pilots rely on rules, regulations, radios, communications, and common sense to ensure safety. Deviating from these precepts invites near misses, ground conflicts, opposite direction traffic, and unannounced aircraft movements, all of which have been reported to ASRS. Peculiar threats to aircraft on the ground have been reported, and easy or unrestricted access to active runways and taxiways has led to incidents as well. 

This month, Callback shares reports of incidents that occurred during non-towered airport operations. Significant threats and hazards are revealed, while lessons learned suggest increased awareness and strict compliance with regulations and procedures. 

A Tale of Two Takeoffs 

After taking all the usual precautions at a non-towered airport, this private pilot began the takeoff roll. The reporter perceived an unexpected object ahead, which was quickly identified and became a significant threat. 

• [It was a] beautiful, crisp, sunny day, and the wind was light. I monitored CTAF during startup and ground flight checks, but I did not hear any traffic. The hangars and ramp area are at the Runway 32 [approach] end, and there is no taxiway parallel to the runway, so with the light crosswind, I setup to depart on Runway 32. While holding at Runway 32, I transmitted on the radio my intention to take off on Runway 32 and depart the pattern to the southwest. When about 300 feet down the runway on takeoff roll, I noticed a large white object at the far end of the runway that looked unusual, but I could not discern its shape… The runway is…3,500 feet [in length] plus approximately 300 feet of displaced threshold. Since the departure end terminates adjacent a busy road, my first thought was that a large semi-trailer had parked on the side of the road. As I was about to rotate approximately 700 feet down the runway, I saw the aircraft rolling toward me on Runway 14. [The plane] was still on the ground, so I elected to continue the rotation, climbed, and banked to the right. The other aircraft broke ground very nearly the same time as I had, climbed, and banked to his right. We passed about 100 feet laterally! At that point, I made several calls on the radio, but there was no reply. The other aircraft appeared to be some kind of low wing aircraft. Either the other aircraft was NORDO (unlikely), or using the wrong frequency (unlikely since there is only one frequency at that field), or simply did not use the radio… If I had been flying a more conventional airplane, I would have had a longer ground roll, and both airplanes would have been on the runway at rotation speeds – a head on collision on the narrow runway pavement! 

If the other aircraft had been burning its landing light when I taxied into takeoff position, I would have seen that and clearly identified the object as an airplane and subsequently taxied off the runway… “Burn the light” just made my departure checklist… If the other aircraft had been required to use the radio, then this near miss would likely have been avoided. It is ironic that my antique aircraft has a radio, yet the much newer aircraft pilot felt that radio traffic wasn’t important… I think it’s time for the FAA to require radio use at all uncontrolled public use airports, no exceptions. 

Flyer Beware at Non-Towered Airports 

This private pilot was well established in the traffic pattern. The reporter was perplexed when procedures employed by a departing business jet resulted in a dangerous situation. 

• METAR and ATIS were reporting winds calm… In accordance with the SFRA (Special Flight Rules Area) flight plan that I filed, I was conducting left closed pattern work, departing and landing on Runway 17. As part of my startup check, I confirmed by radio check that I was operating on…CTAF, and during my pattern work, I heard and communicated with other departing aircraft… Multiple aircraft departed Runway 17 immediately before and after I began my pattern work. 

I was in my fourth approach for landing, having reported on CTAF that I was on left downwind and then left base for Runway 17, when a business jet announced departure from Runway 35. I immediately announced that I was turning final for Runway 17. At the beginning of my left turn to final at approximately 800 feet MSL, I saw the business jet accelerating on Runway 35 and lift off the ground.

I took immediate evasive action by turning further left and inside the departing business jet, judging that a right hand turn would put me closer to the departing aircraft and blind to his location. After the business jet passed, I crossed the runway at 800 feet and announced entering left upwind for Runway 17. I attempted a single communication with the departing business jet pilot but did not call his tail number, and I do not know if he heard any CTAF calls during his departure. Hearing no other aircraft in the pattern at that point, I climbed to pattern altitude and completed…three additional landings.

I do not know whether the business jet pilot failed to sufficiently monitor the ATIS and CTAF frequency to understand that Runway 17 was the active runway, or whether he judged that he could make the more convenient northern departure before I began my final approach. In either event, he created a dangerous near miss.

Unexpected Runway Clutter 

This general aviation pilot began a normal takeoff from a non-towered airport. When the passenger identified a hazard that the pilot had not perceived, safety had already been compromised, and all involved incurred significant risk.

• I was ready for takeoff on Runway 22 and looked to make sure the landing traffic had cleared the runway. When it was exiting, I called, “Aircraft X taking off 22, straight out.” After I started my takeoff roll, my passenger said, “People on runway,” and I noticed them about midfield crossing from north (right) to south (left), about half way across [the runway]. I realized that I was too fast to abort my takeoff and that continuing my takeoff was safer. I moved to the right side of the runway, and then after liftoff, I went further to the right. The people still were on the left side of the runway, almost off it, when I passed by them. I estimate that I went diagonally over them about 300 or 400 feet.

How to have prevented [this] incident? Pause again before takeoff to make sure the runway is clear. Post signs and…have people monitoring pedestrians on the airport to make sure they don’t get near or cross the runway. It was open house that day and good weather… Some pilots had to park airplanes on the south side [of the runway]… There were three or four of us waiting in line for takeoff, and the people crossing the runway should have seen that… They should…have waited for everyone to takeoff or asked for a golf cart to take them around the airport to their airplane. 

A Perfect Aviation Storm 

With their IFR clearance, a light turbojet jet crew opted to fly a published obstacle departure procedure from a non-towered airport. Uncommunicated intentions, perceptions, and expectations resulted in an undesirable situation.

From the Captain’s Report:

• We were departing [from]…an uncontrolled airport. The copilot received the clearance, “[via FIX] as filed, maintain 7,000.” We decided to do the obstacle departure [procedure], as we thought that was what ATC expected. We departed Runway 30. On climbout prior to contacting departure, we flew through a large group of parachutists at about 6,500 feet. After contacting Departure, they gave us an immediate turn. Departure asked if we saw the parachutists, and we replied that we did. Departure asked us why we didn’t go directly to [FIX], and we replied that we were on the obstacle departure… ATC knew of parachute activity in the area. [We] knew we were planning the obstacle departure [procedure], but that was not communicated to ATC.

From the First Officer’s Report:

• …I advised [the Captain] that there is a published obstacle departure procedure (ODP) for Runway 30. Due to higher temperatures, elevation, and rising terrain I felt it would be safer to follow the ODP… During this time I was on the phone with…TRACON since I could not reach them on the radio… The ATC controller very quickly read off, “Cleared via [FIX] then as filed, climb and maintain 7,000,”… I advised the PIC of our clearance, and we went over the ODP. We departed Runway 30 and made a last call on…CTAF. I contacted…Departure…and checked in. Once we reached about 6,000 feet, I noticed and called out skydivers at 11 o’clock high. The PIC leveled the aircraft at 6,500 feet… We had already checked in with…Departure, but were not advised of any skydiving activities. After leveling off, ATC advised us to turn right to a heading of 120… Once we were clear of all skydivers we continued our turn to a heading of 120. We advised ATC of the skydivers, and ATC advised us that, due to skydivers, we had been issued [FIX] as our first fix. We were never given any notice or caution prior to this… In addition, we reviewed all NOTAMs, and there was nothing mentioned other than occasional skydiving in the area northwest of the field… Nothing was mentioned by [TRACON] when I called for our clearance, and [I] even advised him that we would be departing Runway 30… Lastly, there was no communication on…CTAF about jumpers.

 

Wednesday
Nov222017

Safe Landings: Re-Sourcing Crew Management  

The application of team management concepts in the flight deck environment was initially known as cockpit resource management. As techniques and training evolved to include Flight Attendants, maintenance personnel, and others, the new phrase “Crew Resource Management” (CRM) was adopted. CRM, simply put, is “the ability for the crew…to manage all available resources effectively to ensure that the outcome of the flight is successful.”1 Those resources are numerous. Their management involves employing and honing those processes that consistently produce the best possible decisions. Advisory Circular 120-51E, Crew Resource Management Training, suggests that CRM training focus on “situation awareness, communication skills, teamwork, task allocation, and decision making within a comprehensive framework of standard operating procedures (SOP).”2

Aircrews frequently experience circumstances that require expert CRM skills to manage situations and ensure their successful outcomes. Effective CRM has proved to be a valuable tool to mitigate risk and should be practiced on every flight. This month CALLBACK shares ASRS reported incidents that exemplify both effective CRM and CRM that appears to be absent or ineffective. 

Who Has the Aircraft? 

A B737 Captain had briefed and instituted his non-standard method to transfer aircraft control when the FO performed takeoffs. When he did not employ his own technique, confusion was evident and aircraft control was questionable. 

[As we were] pushing back in Albuquerque, ATC switched the airport around from Runway 26 to Runway 8. The Captain and I ran the appropriate checklist and proceeded to taxi. I was the Pilot Flying (PF) [for this leg]. The Captain stated previously that he likes to spool the engines up and transfer controls while the aircraft is moving.

Once cleared for takeoff, the Captain spooled the [engines]. I was expecting him to transfer controls. I monitored him spool them up to takeoff power. While he was accelerating, my comment was, “I’m not flying the aircraft. You have the controls.” He seemed confused briefly, and we took off with the Captain in full control without incident. The Captain needs to [abandon] the habit of transferring thrust levers to the First Officer while moving. It’s a bad habit. It can be confusing if one of the crewmembers is saturated. Under no circumstance should transfer of thrust levers and aircraft happen while saturated in the takeoff phase while moving. 

Freedom of Speech

This Captain received uncommon, simultaneous inputs from two unexpected sources. An accident may have been averted when the Heavy Transport crew exercised simple, effective CRM in a critical situation and high workload environment.

This was a night takeoff and it was the FO’s first flying leg of Initial Operating Experience (IOE). Two Relief Pilots were assigned for the flight. We were cleared onto the runway…after a B737 [had landed]. The FO taxied onto the runway for takeoff. Once aligned for takeoff, I took control of the throttles. At this point I thought we were cleared for takeoff, but apparently we were not. I advanced the power to 70% and pressed TOGA. At about that same time, a Relief Pilot alerted the flying pilots that the other plane that had just landed was cleared to [back-taxi]…on the runway, and the Tower alerted us to hold our position. I disconnected the auto-throttles and immediately brought them to idle. [Our speed was] approximately 30 knots, and we had used up approximately 200 to 400 feet of runway. The back-taxiing B737 exited the runway.

 

Looking back, somehow the clearance to take off or the non-clearance was lost in the translation. The Controllers in ZZZZ most often use non-standard phraseology with an accent not easily understood. Higher than normal workloads [existed] due to a new hire first leg, and the flight was late and had been delayed from the previous day. I had assumed situational awareness with the airport and runway environment. Generally in past practice, ZZZZ holds the landing traffic in the holding bay after landing and does not have two airplanes on the runway at the same time. What “saved” the situation was good CRM and situational awareness by the Relief Pilots. 

Finishing Strong

This MD80 crew finished the last leg of their trip, but distractions degraded the performance of their duties. Unmanaged threats had contributed to the misperception that the job was done when it was clearly incomplete.

From the Captain’s report:

The landing was uneventful, and we were given an expedited crossing of the departure runway. We accomplished the after landing checklist, but due to the expedited crossing, I wasn’t sure if the First Officer started the APU (which had been consistent/standard practice so far in the trip). We were cleared to enter the ramp, and I consciously elected to leave both engines running (which was contrary to my standard practice during the trip). As we turned to pull into the gate, an unmarked van cut across our path. We saw him coming, so no immediate stop was necessary. At the gate, we pulled to a stop normally, parked the brakes, and I believe I commanded, “Shut down engines.” The FO believes he heard, “Shut down the left engine” (which had been the standard command throughout the trip). He shut down the left engine. The right engine continued to run and we finished the Parking Checklist and departed the cockpit.

 

Minutes later…I received a page…requesting that I return to the gate. I returned to find the right engine running. I immediately shut off the fuel lever. No damage or injuries occurred. The aircraft was chocked and the brakes parked. In my estimation, there are three distinct contributing factors in this event. 

1. Complacency when reading the checklist. I assumed items had been accomplished and felt no need to follow up the response with a tactile and visual check. 

2. Complacency when relying on past actions as a predictor of future actions. We had done things the same way each leg, therefore we would continue to do them the same way on every leg. 

3. Distractions. The expedited crossing to the ramp side of the runway, compressed time frame for completing the after landing checklists, and vehicular traffic all led to this event.… These issues…still keep happening. Strict, unyielding adherence to policy and procedures is a must. No one is perfect, and that is why policies and procedures exist. An event like this WILL happen if you allow yourself to become too comfortable.

From the First Officer’s report:

We arrived at the gate, and the parking brake was parked. The Captain remarked, “Shut down the Number 1 Engine, Parking Checklist.” I read the checklist as the Captain responded. At the end of the checklist, I exited the aircraft. I had walked about 10 gates down from the aircraft…when I heard an announcement asking the flight crew inbound from our flight to please return to the gate. No one was there when I returned. About 5 minutes later the agent walked up…and told me that one of the engines had been left running. She let me on the jet bridge and the Captain was walking off the aircraft.

 

I believe this problem came about because of a pattern we developed during all our flights. I started the APU…after landing, and…about two to three minutes [later], would shut down the Number 2 Engine at the Captain’s request. We did this every flight. After landing on this flight, it got very busy. When…at the gate, the Captain called for me to shut down the Number 1 Engine, I didn’t think about the Number 2 Engine still running. I read the checklist and listened to the Captain’s responses. I should have been double checking him, but I didn’t. This has never happened to me. I’m just grateful that no one was hurt. 

Here, Here! and Hear, Hear!

This Dash 8 crew experienced a flight control problem that required extensive coordination. Thorough, effective CRM contributed to the orderly sequencing of their decisions and to the successful completion of their flight.

We had to deice prior to takeoff, and we checked all flight control movements twice before we took off. At the beginning of the cruise portion of the flight, the…Master Caution Annunciators…and two amber Caution [lights] illuminated: ROLL SPLR INBD HYD (Spoiler Inboard Hydraulics) and ROLL SPLR OUTBD HYD (Spoiler Outboard Hydraulics). We completed the associated Spoiler Failure Checklist, including confirming that all spoilers [indicated] retracted at the PFCS (Primary Flight Control System) indicator. The Pilot Flying, the Captain, continued to hand fly the aircraft (as our autopilot was [inoperative] for all legs). We evaluated all facts, discussed all of our options, and [advised Center of our flight control situation]. We informed them that we were not requiring any assistance (upon landing or elsewhere).

 

The Captain talked to Dispatch and Maintenance, while I hand flew the aircraft. The Captain, Dispatch, and I all agreed that ZZZ, with its long runways, was the best place to land. I informed our Flight Attendant that we were planning on a normal, uneventful landing with no delays. ATC issued [our runway], and we executed a visual approach. [We accomplished] a normal landing and taxi. We thanked ATC for all of their help. At the gate, the maintenance write up was completed. The smooth outcome can be attributed to very good CRM exhibited today.

 

Notations:

1. https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/

airplane_handbook/media/airplane_flying_handbook.pdf

2. https://www.faa.gov/documentLibrary/media/Advisory_Circular/

AC120-51e.pdf

 

Monday
Aug072017

Safe Landings: Windshear

The windshear saga in American aviation history reveals a complex and costly past. Windshear has existed for as long as aviators have taken to the skies and is largely responsible for several classic aviation losses. Notable U.S. aviation accidents include Eastern Flight 66 (1975), Pan American Flight 759 (1982), and Delta Flight 191 (1985).

Windshear remained unrecognized for years. It was not clearly understood until swept wing, jet aircraft encountered the phenomenon. Since 1975, windshear has been researched and studied, measured, defined, catalogued, and rightly vilified. Technology has been developed to identify and minimize the threats that it poses. Procedures have been implemented to aid pilots who experience windshear in flight and flight crews invest hours of simulator training practicing windshear escape maneuvers.

Even with progress to date, windshear continues to be a worthy adversary to aviation professionals. It requires respect and wisdom to defeat. Pilots often must make decisions regarding known or anticipated windshear, and the best practice is always avoidance.

This month, CALLBACK shares reported incidents that reveal some means and extremes of windshear experienced in modern aviation. Lessons to be gleaned are ripe, rich, and many.

Teasing a Toronto Tailwind

After encountering windshear that resulted in an unstabilized approach, this A319 Captain elected to continue to a landing. He noted his awareness of the current winds and trends as well as his personal preparedness to go around as reasons for continuing the approach.

After being delayed due to low ceilings in Toronto, we were finally descending…in heavy rain and moderate turbulence with clearance to 7,000 feet MSL. After a third 360 degree turn, we were…transferred to the Final Controller and proceeded inbound for the ILS RWY 05. The last several ATIS [reports] showed winds at approximately 090 to 100 [degrees] at 5 to 10 knots, and the Final Controller mentioned the same with an RVR of 6,000 plus feet for Runway 05. When cleared for the approach, we were at 3,000 feet MSL to intercept the glideslope, and I noticed the winds had picked up to a 50 knot direct tailwind. The First Officer was flying. We were assigned 160 knots and began to configure at approximately 2,000 feet AGL. At 1,500 feet the wind was a 30 knot direct tailwind and we had flaps 3. Indicated airspeed (IAS) had increased at this point [with] thrust at idle to 170-175 knots, prohibiting final flaps just yet. The First Officer did a great job aggressively trying to slow the aircraft, as we were concerned about getting a flaps 3 overspeed. As I knew from the ATIS and the Controllers (Tower now), the winds were to die off very soon to less than 10 knots. [Below] 1,000 feet we were just getting the airspeed to put in final flaps (full) and were finally stabilized and on speed between 500 to 800 feet. The winds were now at the reported 090 [degrees] at 8 knots or so [below] 500 feet. The total wind shift was approximately 90 degrees from direct tailwind to a right crosswind - losing 40 knots [of tailwind] in the space of 1,500 feet or so. The reasons I elected to continue the approach were:

1. We landed uneventfully in the touchdown zone and on speed…after breaking out before minimums.

2.[I saw] a positive trend in the wind.

3.  [I was] prepared for the missed approach (at 500 feet) IF the winds and IAS stayed as they were earlier in the approach.

We landed uneventfully in the touchdown zone and on speed…after breaking out before minimums.

Up and Down into Salt Lake City

While being vectored for an approach, this light twin transport Pilot encountered a vertical windshear that dramatically demonstrated the intensity, danger, and potential traffic conflict that a challenging vertical shear can present.

We had lined up for the ILS RWY 3 at Ogden, but at glideslope intercept, the weather had [deteriorated] to . mile visibility and a 400 foot ceiling. We broke off the approach,… requested an approach to land at Salt Lake City, and were vectored to the ILS RWY 34L. Approximately 10 miles downwind in solid IMC [with the] autopilot and altitude hold on and about to turn base, we hit a downdraft that dropped us approximately 2,000 feet. The horizon ball was all brown, the autopilot and altitude [hold function] were ineffective,

the loss of control set off the master warning system due to lack of fuel (at the time we had 750 pounds per side), and the terrain warning went off. Recovery was accomplished, but with a 2,000 foot gain (assigned altitude [had been] 10,000 feet; at the floor of the incident [the altitude was] approximately 8,000 feet; at the ceiling of the incident [the altitude was] approximately 12,000 feet). I was then routed back to the west and north on vectors for sequencing back to the ILS RWY 34L at Salt Lake City that was shot with a side‑step on final in VFR conditions to Runway 34R.

Shearing Situational Awareness

This Air Carrier Captain accomplished a successful windshear recovery while on final approach. He was surprised by the quickly changing environment and challenged by his diminished awareness as a result.

We were on final for Runway 8R in Houston and encountered windshear.… Tower started calling an approach wind loss of 20 knots that increased to 25 knots at a 3 mile final. The Copilot and I were discussing what constituted a microburst alert, which was 30 knots, so we elected to continue the approach. We were in moderate turbulence and the wind was currently a right quartering tailwind which would switch to a left crosswind on the runway. I asked the Copilot to increase our target speed to plus 20, which he did, and as we approached the outer marker, we were fully configured and on speed. At approximately 1,400 feet AGL, we received a “MONITOR RADAR DISPLAY.” I saw that the indication was ahead of us to the right of our course. Since we were still stable and fully configured [with the] autopilot and autothrottles on, we elected to continue.

Shortly we received the call, “GO AROUND, WINDSHEAR AHEAD.” I initiated the go-around and asked for flaps 15 and gear up. Very shortly after this, we received the call, “WINDSHEAR, WINDSHEAR, WINDSHEAR.” At that point I pushed the throttles to the stops, verified the spoilers were stowed, and selected Takeoff Go-Around (TOGA) again. The First Officer called ATC and said we were going around. I was so focused on flying the plane with regards to Radio Altimeter (RA) and trend, and verifying I was doing everything correctly, I did not hear what ATC replied back to us. Adding to the workload and task saturation was the plane on Runway 8L, which also went around, and then the two planes behind us on Runways 8L and 8R also went around.

The Copilot advised that ATC said to level off at 2,000 feet as we were passing through 2,000 feet with a high climb rate. I still had “WINDSHEAR” displayed on my ADI, and I told him I was not going to level off. He then had to try to talk to ATC again to get a new altitude. They gave us 3,000 feet. We were climbing rapidly, and I brought the throttles back to level off at 3,000 feet, but overshot it to approximately 3,200 feet and descended back to 3,000 feet. The landing gear horn immediately began to sound when I pulled the power back since we still had flaps 15. I made sure we were above flaps 15 retraction speed, and we completed a normal go-around at that point to clean maneuvering speed.

Everything happened so fast. ATC should not give a level off altitude of 2,000 feet since I now know it is possible to still be in windshear…at that altitude. If I were to fly this approach again, I would elect to abort the approach and wait for tower to stop calling a 20-25 knot loss at a 3 mile final.… We thought that since the planes ahead of us were landing, we would be able to [as well]. Obviously there is always a first flight that cannot land, and on this day, that was us.

The Final Authority – 14 CFR 91.3

This heavy transport Captain perceived a subtle suggestion to take off when weather that may have presented a windshear hazard was nearby. He exercised his authority with seasoned wisdom and sound judgment when he opted not to leverage the safety of his aircraft or crew.

As we were taxiing west on Runway 27, we could see a radar return of a strong storm which was depicted red on our screen. The storm was directly west of the…airport and appeared to be moving east toward us. As we turned south on Taxiway N, we could only see part of the storm to our right on the radar display. When we switched frequencies to Tower, we heard that there was windshear on a two mile final for our runway. As we approached the runway, we advised Tower that we would not take off. Tower reminded us that the windshear was two miles in the opposite direction from where we would be heading. It seemed like the cell was directly over the field at that time, possibly centered a little north.… The FOM guides us not to get within 5 miles of a cell below FL200. Tower instructed us to taxi out of the way so that several other aircraft could take off while we waited a few minutes for the storm to pass.

I feel that Tower was more concerned about getting airplanes on their way than waiting a few minutes until it was safe. I also think [there is an] air carrier culture pressure to get the job done even if there is an increased risk.

When one aircraft decides it is not safe to take off, perhaps Tower should inform the following aircraft that might not have been on frequency to get the same information. Although several aircraft took off away from the storm, they faced the possibility of getting a decreasing performance

Wednesday
Jan252017

Safe Landings: Controller Pilot Data Link Communications 

Controller Pilot Data Link Communication Departure Clearance Services (CPDLC-DCL) is one segment of the Future Air Navigation System (FANS) that has been recently implemented in the contiguous 48 states at local Tower Data Link Service (TDLS) equipped facilities to deliver departure clearances and revised departure clearances prior to takeoff.

As any new system is implemented, some “bugs” may be expected, and CPDLC-DCL is no exception. ASRS is receiving reports suggesting that crews are experiencing problems while using CPDLC-DCL for its intended objective. The problems that are experienced point to sources from system architecture, to precise meanings of specific words and formats used in the CPDLC-DCL syntax, to basic interpretation and understanding of the CPDLC-DCL information protocols and operational procedures.

This month, CALLBACK shares reported incidents of complications that arose from the crews’ use of CPDLC-DCL to obtain departure clearances and revised departure clearances. While CPDLC-DCL offers many improvements and advantages over voice and Pre-Departure Clearance (PDC), some issues remain as we transition to this new system. As these examples may hint, ideas will emanate from the cockpit and formal solutions will be devised.

Cautious Pilot Distrusts Link

Communications 

This Air Carrier Crew clarified an initial question they had about a revised departure clearance. Curiosity over the revised SID and transition that had not been “properly” LOADED resulted in a route portion that was manually loaded but not included in the clearance. 

During preflight, we received a revised clearance via CPDLC. The change was from the TRALR6.DVC to the STAAV6.DVC. I verified [the] clearance and received a full-route clearance over the radio. When the LOAD feature was selected in CPDLC, the new revised route did not LOAD into the ROUTE page properly. It still showed [the] TRALR6.DVC, but now it had a discontinuity. At this point, I had to load the route manually. When I did load the STAAV SIX, however, I failed to select the DVC transition, [so the FMC] now had point STAAV direct to LAA in the LEGS page. When we did the route verification later, during the preflight, we both failed to detect the missing transition that included the points TRALR, NICLE, and DVC.

This went unnoticed until passing point STAAV on the departure. That is when ATC queried us if we were headed to point TRALR. We indicated to ATC that we were direct LAA. He re-cleared us to TRALR to resume the departure. There was nothing significant to report for the rest of the flight. 

Complications Perceiving Data Link  

Changes 

After using CPDLC to obtain their clearance, this Air Carrier Crew saw no indications that their clearance had been revised. It appeared the same as the filed route, so they did not LOAD it. ATC soon called them off course.

Prior to departing SNA, we loaded the FMC using normal procedures… We received a ready prompt but did not get a clearance. Shortly before push, we still had not received a CPDLC clearance, so we requested a clearance via PDC. We got a PDC reply message stating to use CPDLC, and simultaneously a clearance was uploaded to the FMC ATC page. The clearance showed our departure and transition as filed, as well as the altitude restrictions, expected altitude, squawk, and departure frequencies as we expected to see. The ATC page did not state that it was a revised clearance or route. All obvious indications were [that] our clearance was unchanged from the filed route. A LOAD prompt and ACCEPT prompt were shown. We ACCEPTED the clearance, but because we had already loaded the flight plan, we did not LOAD the flight plan sent via CPDLC.

We departed as normal. Once airborne passing 10,000 feet, we received an ACARS flight progress printout that showed our originally filed course. After passing TRM, ATC stated they showed us off course. They gave us a revised route clearance. There was no printout of our clearance to reference, and since the CPDLC did not display the full-route clearance, we had difficulty tracking down whether or not there was actually a change to our originally filed route. We were able to find a LOAD prompt on page three of the ATC clearance page. When we selected LOAD, a new route was LOADED to the FMC, which was different from our originally filed route. We discovered our route had, in fact, been changed via CPDLC. We erased the change since we already had a new route assigned by ATC airborne and continued uneventfully to [our destination].

Complex Presentation — Desired

Learning Cumbersome

Non-intuitive wording and convoluted clearance procedures coupled with incomplete systems knowledge caused this Crew to misinterpret the message that their clearance had been revised. The result was another call off course.

We received our departure clearance via CPDLC. During my preflight, I loaded the FMC with the route we were given on our release paperwork (PORTT THREE DEPARTURE). Our release had the following FMS route: KEWR BIGGY PTW J48 BYRDD J230 SAAME STEVY HVQ UNCKL MAUDD4 KSDF. When it came time to log on to the CPDLC, the Captain and I received the following [departure clearance]: CLEARED ROUTE CLEARANCE ORIGIN: KEWR DEST:KSDF ARRIVAL: DARBY 5.UNCKL +LOAD NEW RTE TO KSDF+ EWR2, CLB VIA SID EXC MAINT 2500FT EXPECT FL340 10 MIN AFT DP, DPFRQ 119.2 SQUAWK 1534, CTC GROUND 121.8 FOR TAXI.

When we saw that this was a change, I manually changed the SID to the NEWARK TWO off of Runway 22R. I did not select the LOAD prompt, as I did not see any other change to our clearance. I believed our clearance was now the NEWARK TWO (flown in LNAV), and our first fix was still BIGGY then PTW, etc. The Captain and I agreed on this. I printed the CPDLC clearance, folded it, and laid it on the center console.

After takeoff, we were handed off to Departure Control. He cleared us to fly directly to a fix, which neither the Captain nor I saw on our route. He said, “Don’t you have the PARKE J6” on your routing? We said, “Negative, we have BIGGY PTW J48.” He then told us to fly a heading. He came back a short time after that and told us to fly directly to LRP and join J6 and expect a further clearance later. He did come back shortly thereafter, and told us to fly J6 to UNCKL, then the arrival.

We obviously knew we had been expecting something different than the Controller had been, so I picked up the “printed” copy of the CPDLC clearance we had received, and on it was also the following: PARKE J6 UNCKL Note that this was NOT on the original CPDLC clearance we looked at on the FMC. I don’t know if it had been truncated off due to space, or it had been inadvertently left off or what, but we both went back and looked and noticed this. That was why we thought the only change to our clearance was to the NEWARK TWO, [while keeping] the same fixes as we originally had on our paperwork (i.e. BIGGY PTW J48).

Contributing factors to this confusing situation are numerous. I now know that I am supposed to select the LOAD prompt when we have a change to our routing. The method we are transitioning into with respect to getting our clearances via CPDLC is very confusing. The wording… on the FMC is not intuitive, and the overall procedure… is very convoluted. We now receive our clearances in several different ways, at different airports, and in different airplanes, [which] all lead to a higher chance of mistakes.

Complicated Process Destines LoweredCognizance

This CPDLC message arrived at precisely the wrong time. The Crew’s attention was diverted, and their situational awareness suffered as they attempted to eliminate the confusion generated when they could not quickly resolve the revised clearance CPDLC message.

We were taxiing out of a very congested, weather-impacted, JFK airport that day. The ground frequency was non-stop due to long taxi routes because of 20-mile in-trail spacing for departing aircraft in all directions. A CPDLC message [reading] “THIS IS A REVISED CLEARANCE” appeared with no other information. No revised route [was] included. [We] spent [the] next five to 10 minutes heads down, while taxiing, trying to figure out what was happening, in addition to eventually calling Clearance Delivery on the radio, and Dispatch. [There was] no place to pull out of [the] way due to long taxiways with no exits. And, we were getting automatic ACARS messages [that we] must be airborne in 15 minutes due to [the] nine-hour flight time restriction. A simple printout of the revised clearance would have resolved the issue in a few moments and would have been much more intuitive.

The current system of having an ATC clearance, current or revised, stored on multiple, disjointed pages of the ACARS or FMS display is confusing and causes excessive heads-down time while taxiing. It will cause a gross navigational error, is a defective system, and is going to harm someone.

Common Precautions Demystify Link

Confusion

This Air Carrier Crew noticed an ambiguity in their departure clearance. Although the syntax was confusing, Clearance “cleared up” their misunderstanding.

The First Officer loaded [the filed route] into the FMC before requesting a CPDLC clearance. The clearance came back, “CLEARED ROUTE CLEARANCE. FREE TEXT. POM9.GMN. FREE TEXT CLB VIA SID EXC MAINT 14,000FT.” The First Officer noticed a LOAD prompt, and [saw that] the new route [read], “DIRECT GMN DIRECT RGOOD RGOOD.EMZOH3.SKIZM.” Because we were now confused, we called Clearance to see if we were now filed direct to GMN, but they cleared up our confusion. We were still on the POM9.GMN.

Wednesday
Jul272016

Safe Landings: The Pursuit and Presumption of Balance 

Weight and balance has been a critical issue in aircraft operations since the beginning of aviation. Loading errors can go unnoticed and have potential to cause great harm. Clerical mistakes that account for cargo weight and location can be subtle and equally costly.

This month’s CALLBACK examines several reports that highlight weight and balance errors. In the following accounts, all the aircraft unknowingly departed with uncertain centers of gravity and most departed with an inaccurate gross weight that was assumed correct. Many of the mistakes were not discovered until the aircraft was airborne and some, not until the aircraft landed. Other similarities included unknown cargo weights and freight that was loaded in improper locations. These mistakes might have been prevented. The ASRS report excerpts reiterate the need for attentiveness and accuracy in every aspect of weight and balance procedures.

The first three reports describe incidents where cargo was loaded in the wrong location on the aircraft. The remaining accounts detail various other errors that were experienced in Air Carrier Operations. 

The Usual Suspects 

Cargo loaded into the wrong compartment and closeout paperwork that did not specify its location allowed this B737 Flight Crew to launch with an inaccurate Center of Gravity (CG) that was not discovered until after the aircraft landed. 

• The [destination station] Crew Chief came to the cockpit and inquired about how the aircraft handled during our flight… He then informed me that according to his paperwork, all cargo should have been loaded in the aft compartment, but when opened, he found it completely empty. Upon further inspection, he found that all cargo was loaded in the forward compartment. I checked my load planning paperwork and found the plan was for 1,900 pounds of cargo to be loaded in the aft compartment. Closeout paperwork showed 1,100 pounds of cargo with no indication whether forward or aft.

I then called Dispatch and was transferred to Load Planning. They checked the computer and said that all cargo should have been loaded in the aft compartment…, but that was not the case. Actual loading was in the forward compartment.

We had a light load of only 105 souls on board and a light cargo load. The Load Agent ran the numbers with the actual cargo in the forward compartment and found that we were still within safe CG limits. How much [misloaded] cargo weight would it have taken on this aircraft to create an unsafe situation? Would a full load of passengers have helped or hindered the situation? How about fuel burn on a long flight? Is it the Ground Crew’s habit to load cargo in the forward [compartment] on smaller aircraft? Did they fall back on habit or disregard loading documents? 

The load closeout we receive in the cockpit does not show forward or aft cargo weights. It just shows total weight and a breakdown for live animals and restricted articles. Maybe we should receive that information on closeout. Although that would not have helped in this situation since all the “paperwork” was correct.

Trust but Verify

Non-standard operations resulted in freight being placed in the wrong cargo compartment of this B737-800. The Flight Crew was unable to confirm compliance with loading instructions.

• After the parking brake was released for push back, the Ground Crew opened the forward cargo door twice without notifying the Captain. The Captain flew to our destination and other than noting that the aircraft was nose heavy on takeoff, the flight was uneventful. After we parked, the Crew Chief entered the cockpit as the passengers were deplaning. He explained that the cargo had been incorrectly loaded and pointed to his offload report. The report clearly showed that only one bag should have been placed in the forward cargo and the rest should have been in the aft cargo. The Crew Chief reported that the aft cargo was empty and all the bags were in the forward cargo. Obviously this was a very serious issue—one that could have caused aircraft controllability issues, or worse… Pilots should have the same paperwork used to load the aircraft, so we can double check with the load closeout and takeoff performance data and verify proper loading.

The Edge of the Envelope

This CRJ-700 Captain directed that ballast be added to the forward cargo compartment but got a post-flight surprise.

• Due to ACARS weight and balance, I directed the Ramp Lead to move the one and only bag from the aft cargo compartment to the front and to add 500 pounds of ballast to the front cargo compartment. On rotation we noticed a slight nose up pitch tendency but dismissed it as normal for the aft CG limit. On arrival, the First Officer discovered that the 500 pounds of ballast had been placed in the aft cargo compartment.

Late Arrivals

Conflicting load numbers that surfaced during preflight planning remained suspect into the flight, nurtured mistrust, and spawned a weight and balance error for this A319 Flight Crew.

• We received a flow release time from ATC that was 10 minutes from our scheduled push time. At push, we had not received the weights, so I sent an ACARS [message] because I wanted to make sure we had the weights to make our slot time. I received the response that weights were not available because the ramp had not completed the loading document. We continued to taxi to the active runway where we held for 10 minutes waiting for weights and missed our slot time. I called Station Operations, and they said they were talking to Load Planning about the weights. We waited another five minutes and received a Dispatch ACARS message stating our zero fuel weight had gone up 4,000 pounds with new [projected] fuel burn and fuel at touchdown numbers. We acknowledged the increase and accepted the numbers. The weight manifest printed, and it showed our weight below the weight I had used to calculate performance numbers. After we departed, we received another weight manifest with an even lower gross weight and numbers closer to the planned weights on the flight plan. While the numbers we were working with resulted in minimal changes in the CG, there was potential for a very serious error to occur.

Missing from the Manifest

Upon arrival, this Air Carrier Flight Crew noticed three tires being offloaded but had no paperwork or knowledge that they were even onboard during the flight.

From the First Officer’s report:

• The Captain and I, upon receiving the load sheet, asked the Ramp Agent if it was correct. We were told that it was. During the post-flight inspection, I noticed Ground Operations removing three main tires from our [aft] baggage compartment. I did not remember seeing this on the load sheet, so I went back up to the cockpit and took [another] look at the load sheet. To my surprise, there were no tires listed in the baggage compartment. We departed unaware that we had an extra 300 pounds of cargo in the back of the aircraft.

From the Captain’s report:

• During the post-flight walk around, the First Officer noticed that three tires were being removed from the [aft] cargo bin. He asked the Ramp Agent if those were on our flight, and he replied that they were. The First Officer got the cargo load report from the trash, and it showed no cargo [listed] on the airplane other than the standard bags, the heavy checked bag, and the gate claim items. Each tire weighs 100 pounds, so 300 pounds were missing from the cargo load report. We both agreed that missing items on the cargo load report was a safety of flight issue.

Who’s on First?

An ERJ-170 Flight Crew took off with an inaccurate cargo weight. The correct weight would have identified an out-of-balance condition and an exceeding of structural limitations.

• The ramp personnel asked the First Officer during his walk around if we could accommodate… freight weighing a total of approximately 2,000 pounds. He instructed them to wait on loading until he could confirm that the load could be safely accommodated. When the First Officer returned to the ramp, the cargo was already loaded in the aft compartment, and he was told it was approximately 1,000 pounds. When we received the cargo load report, it indicated a total load of 59 standard and five heavy bags in forward cargo and 1,000 pounds of freight loaded in the aft cargo compartment. We ran the reported load, and after reseating four passengers as a result, we received good takeoff performance numbers. After closing the door, the tug driver said they had made a mistake and that we should add one standard bag to the forward compartment and that the actual weight in the rear was 2,200 pounds. I asked twice to clarify these numbers, but I wasn’t confident in his count. We ran new numbers anyway and adjusted the passengers, once again, per the ACARS instruction.

I called Ops before taxiing to confirm the load numbers. The ramp manager told me that the second numbers I had received were, in fact, accurate. Just prior to reaching the runway, we received a message from Dispatch stating to once again add two bags to the forward cargo. After a normal takeoff and being airborne for approximately 30 minutes, Dispatch informed us that the load in the rear cargo compartment was actually 4,000 pounds. The cargo compartment’s weight limitation was exceeded… They [then] informed me that the CG was out of limits and… the decision was made to divert. After a 74,000 pound uneventful landing, Ramp personnel removed and weighed all cargo from both front and rear compartments. The actual contents of both compartments were: 62 standard and four heavy [bags] forward, and 3,600 pounds in the rear compartment.

Copyright © 2009, In Flight Media. All rights reserved.
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.
Creative Commons License

Designed by jbNadler Creative Labs