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Monday
May162011

Safe Landings - May 2011

It has been said that the only voluntary act in aviation is the decision to take-off.  Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.

In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others.  These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs.  Additionally, NASA distributes an electronic publication, “CALLBACK,” which contains selected, de-identified, reports on a free subscription basis.  In Flight USA is proud to reprint selected reports, exerted from “CALLBACK,” for our readers to read, study, occasional laugh at and always, learn from.  Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.

Motor Skills: Getting Off to a Good Start

A motor skill is a learned sequence of movements that combine to produce a smooth, efficient action. This month’s we look into another type of motor skill- the skill required to produce a smooth, efficient (and safe) aircraft engine start.

Lesson One: Know Your Crew

This pilot was familiar with the proper procedures for hand-propping, but despite a conscientious effort, one critical assumption led to a nose-to-nose encounter. One should also note that training was an issue in this event.  Anyone sitting behind the controls of an airplane, alone, with the engine running, should be ready and capable of flying that plane.

• I was going to fly a 65 HP taildragger with no electrical system and no starting system. It requires the pilot to hand-prop the engine and either requires the aircraft to be tied down or a person to hold the brakes…. [I] instructed the passenger how to hold the brakes and how to pull the throttle to idle after engine start. Both holding the brakes and pulling the throttle to idle had been practiced. The passenger was in the rear seat, with the seatbelt fastened. After hand propping the engine, I noticed what sounded like an increase in engine rpm and the aircraft started to move forward rapidly. I got out of the way of the moving aircraft and around to the door. I was halfway inside the aircraft getting the engine to idle while telling the passenger to push the brakes when the aircraft struck a parked Cessna. The aircraft hit nose-to-nose…. The aircraft had traveled approximately 25 yards across the tarmac. [There was] prop and cowling damage…and both passenger and pilot were unhurt.

I had incorrectly assumed that the passenger would be able to hold the brakes after engine start and I placed too much confidence in the abilities of a non-pilot…. The very act of hand-propping an aircraft is dangerous and I will never again pull the prop through without the aircraft being tied down…. Even 65 HP is enough to overpower the person starting the engine.

Lesson Two: What “Should Have” Been Done

Resorting to hand-propping due to a faulty battery could lead to the aircraft taxiing on its own for about 100 feet before being stopped by a collision.

• The aircraft was pulled from the tie-down spot and turned 90-degrees for starting and taxi to the hangar. Due to a weak battery the aircraft did not start. The wheels were chocked for hand-propping and the throttle was cracked open. When the engine started, it revved up to approximately 1,800 RPM and then the aircraft rolled over the chocks and proceeded ahead about 100 feet where it contacted a parked aircraft. There was minor damage to both aircraft, but no injuries beyond a scraped knee when [I] scrambled from the rotating prop and fell under the wing. The chocks were insufficient to hold the airplane past a certain engine RPM.

The brakes should have been set. The tail should have been secured as well. The throttle setting should have been lower. A second pilot in the cockpit holding the brakes and controlling the throttle would have been best.

While it is possible to find any number of published recommendations and checklists for solo hand-propping, it remains an extremely dangerous practice. The best procedure is to follow the Federal Aviation Administration’s advice found in the Airplane Flying Handbook (FAA-H-8083-3) which states in part: “An engine should not be hand-propped unless two people, both familiar with the airplane and hand-propping techniques, are available to perform the procedure…. The procedure should never be attempted alone.”

Wednesday
Apr132011

Safe Landings - April 2011

It has been said that the only voluntary act in aviation is the decision to take-off.  Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.

In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others.  These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs.  Additionally, NASA distributes an electronic publication, CALLBACK, which contains selected, de-identified, reports on a free subscription basis.  In Flight USA is proud to reprint selected reports, exerted from CALLBACK, for our readers to read, study, occasional laugh at and always, learn from.  Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.

Preventable Fuel Management Errors: Fuel Exhaustion

Miscalculation: Determining fuel remaining based on assumed fuel burned figures and on gauges that are assumed to be correct is a dangerous gamble. This Piper Navajo pilot learned that physical verification of the fuel onboard is the best way to prevent miscalculations.

The aircraft started to run out of fuel on the midfield downwind position as a result of a fuel miscalculation that I had made. At the first indication of fuel exhaustion, I commenced a descending right turn to the runway and notified Tower of my situation. I was cleared to land and did so without incident. During the turnoff onto a taxiway, the right engine quit running….

To the best of my knowledge, the origin of my fuel miscalculation was during a flight…on the previous day…. Based on [the flight time] and the chart our company uses for fuel consumption on the Navajos, I calculated that I departed on this flight with 25 gallons of fuel which should have yielded 38 minutes of flight time. [The flight was] approximately 10-15 minutes. When making fuel calculations with this table, it is my personal habit to err on the side of caution, and I often make it a point to add several gallons to whatever number is given so that there is a bit of a “cushion.” Although the numbers on paper indicated that the aircraft had 25 gallons of fuel, I was certain that there was a bit more. I was quite alarmed when both engines started to sputter on the midfield downwind leg.

As a result of this incident, I made it a point to review the fuel logs for all flights made several days prior and have come to the conclusion that the error was made sometime during this period. In the end, the lesson learned…. if you cannot physically see or touch fuel in the tanks, you cannot make assumptions.

Misidentification and  Misreading

With two nearly identical aircraft on the field, refueling the correct plane becomes a concern. Unfortunately, by misreading a fuel sight gauge, this pilot “confirmed” a case of mistaken identity.

I flew a new LSA (Light-Sport Aircraft) for display at [an airshow]. The sister ship to the one I was flying was already there. They are almost identical aircraft and both aircraft arrived with more than two hours of fuel remaining. Company plans required another pilot to take the aircraft I had flown (Aircraft #1)… and to leave the other aircraft (Aircraft #2) at the show with me. I placed a fuel order with the intention of fueling Aircraft #2, but they fueled Aircraft #1 instead…. I witnessed the refueling of Aircraft #1, but misidentified it as Aircraft #2.

The following morning, I reset the EMS (Engine Monitoring System) fuel counter to “FULL.” The location of the fuselage fuel filler does not allow for a visual inspection and the fuel sight tube, located behind the seats, is difficult to read (clear fuel in a clear tube). When full, the fuel level is out of sight. I looked at the top of the tube for confirmation and, anticipating a full fuel indication, I misread no visible fuel as an indication of a full tank. I did not inspect the lower portion of the tube that was probably reading a partial fuel situation.

…Nearing [my destination], the engine gave signs of fuel exhaustion so I requested assistance from Approach who vectored me to an uneventful landing.

After refueling… I departed and landed at my next stop where I spent the night thinking about what I had done wrong and how very lucky I was.


Monday
Mar142011

Safe Landings - March 2011

It has been said that the only voluntary act in aviation is the decision to take-off.  Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.

In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others.  These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs.  Additionally, NASA distributes an electronic publication, CALLBACK, which contains selected, de-identified, reports on a free subscription basis.  In Flight USA is proud to reprint selected reports, exerted from CALLBACK, for our readers to read, study, occasional laugh at and always, learn from.  Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.

Listen To Your Little Voice

ASRS report narratives frequently contain references to a “little voice” that offers timely advice. The voice, of course, resides within the mind of the reporter and is usually the voice of experience or sometimes just the “vocalization” of a gut feeling. While it is possible to get through some situations despite what a little voice is telling us, the following reports show that the voice usually has something important to say.

“…Then That Little Voice…Started Shouting”

Poor visibility and unfamiliarity with the GPS navigation equipment contributed to a Piper Cherokee pilot’s approach to the wrong airport. It took the emphatic interruption of a little voice to get the reporter to climb, confess and communicate.

• I skipped getting a weather briefing. [The flight] should have taken no more than 30 minutes. Smoke and haze filled the sky and the visibility was probably made worse by a nearby forest fire. I flew…to the coast, then eastward. When ready to call Tower to request landing clearance, I checked the GPS to get the distance. The GPS was displaying the satellite page…. I flipped through the GPS pages looking in vain for navigation information and returned to the satellite page. I backtracked and dialed in the VOR…then called for landing clearance. The VOR needle wandered and I told Tower that I was having problems with my navigation equipment, but I declined the offer of additional assistance. I couldn’t think of anything to ask for.

Descending to pattern altitude, I peered into the [partially obscured] sky, keeping the beachfront to my left, looking for the smoke stack and runways at the water’s edge. It seemed to take forever. The GPS did not give me ground speed or any navigation information. Since I thought that the GPS automatically switches from the satellite page to a navigation page on startup, I decided that the signal quality was not good enough to switch….

Finally, two crossing runways appeared to my left, but it didn’t look quite right. I told Tower that the runways were in sight and asked whether he could see me just off-shore. I was cleared for Runway 24 and started looking for the numbers. Tower asked me for a position report, leading me to believe that he didn’t see me. I was looking straight at the Tower and he should have been able to see me.

When a runway numbered “2” became visible, I was trying to figure out how to get to Runway 24. Then that little voice that lives somewhere in the back of my brain started shouting, “There should not be a Runway 2 at this airport.” At the same time, Tower was again asking me for a position report. I was looking down the departure end of a runway at an unknown field at pattern altitude.

I could imagine an aircraft on takeoff roll coming straight toward me. My response was an immediate right turn to get away from there. In a 45-degree bank and losing altitude, unusual attitude training kicked in and I got the plane straight and level. Then the 5 “C’s” came to mind: Confess that I’m lost; Climb above the Minimum Safe Altitude; Communicate with the appropriate controlling agency; Conserve fuel; Comply with the Controller’s instructions. I told Tower, “I’m declaring an emergency. I don’t know where I am. I’m lost.”  I climbed back up to 2,800 feet while the Tower contacted Approach Control and got me a [transponder] code. A very professional Controller vectored me to the correct airport.

I have spoken to an instrument instructor and arranged for additional training…. I will be sure to learn more about using the GPS. I did not know that it would not automatically return to a navigation page after acquiring satellites…. I will not skip a weather briefing even for a short flight.

From Feb 2011 ASR Call Back, issue 373



Tuesday
Feb082011

Safe Landings - February 2011

It has been said that the only voluntary act in aviation is the decision to take-off.  Every action after take-off involves the skillful management of risk, the enjoyment of flight and a continuous stream of decisions that result in a safe landing.

In 1974, NASA created the Aviation Safety Reporting System (ASRS) to allow aviation professionals to share experiences in a frank, non-punitive manner. The ASRS structure allows pilots and other aviation professionals to file an anonymous report of an incident, error or occurrence that the contributor feels might be of value to others.  These reports are gathered, analyzed and data based by NASA experts and made available to all interested parties as a tool for creating pro-active aviation safety programs.  Additionally, NASA distributes an electronic publication, “CALLBACK,” which contains selected, de-identified, reports on a free subscription basis.  In Flight USA is proud to reprint selected reports, exerted from “CALLBACK,” for our readers to read, study, occasional laugh at and always, learn from.  Visit http://asrs.arc.nasa.gov/ to learn how you can participate in the ASRS program.

Paperless Flying

The day of the paperless cockpit has dawned, and with that, ASRS is hearing more about incidents involving Electronic Flight Bags (EFBs), as these electronic display systems are known.

EFB displays may be portable (Class 1), attached to a cockpit mounting device (Class 2), or built into the cockpit (Class 3). There is no doubt EFB devices are powerful and versatile. With display screens often the size of a laptop computer or approach plate, EFBs can display a variety of aviation data, including electronic manuals and documents, performance and planning data, moving maps and GPS, logs and checklists, spreadsheets, real-time weather, TCAS, terrain avoidance, email, and even the internet.

But as pilots transition to the use of these electronic marvels, there are challenges to consider. In this ASRS report we take a look at a problem reported to ASRS.

It should be noted that because there is tremendous variability in EFB hardware, software and the way applications are integrated, the example presented, while representative of EFB issues, may not apply to all EFBs. For example, EFBs differ greatly in terms of physical size, location in the cockpit, and whether a one or two-person crew is operating it (them). These and other human factors can greatly influence general usability.

“A Real Gotcha”

A pilot of a light twin on a VFR test flight was using a low altitude airway chart stored in a panel-mounted GPS for orientation and airspace avoidance. The pilot had not looked at a paper sectional chart before departure.

• I decided to intercept the [last leg of route]…to save time. When I made the turn, I realized on both the moving map on my panel GPS as well as the commercial chart software that I had running on a tablet PC as a back-up moving map, that the leg would cut across the southern edge of ZZZ’s Class D airspace. In HDG mode on the autopilot, I proceeded to fly south of ZZZ’s airspace, which on both moving maps was indicated to be a 5 nm radius from the ZZZ airport from the surface to 3,200 MSL. Even though I was at 3,500 MSL, I didn’t want to get near ZZZ’s airspace. I passed approximately 8 nm south of ZZZ airport according to both moving maps.

As I got past ZZZ, for some odd reason I decided to look at my sectional to make sure I was clear of the Class D airspace, and to my horror, I found that what was depicted on both commercial databases was WRONG!

The Class D airspace for ZZZ on the current database is depicted as a 5 nm radius from the ZZZ airport with a top of 3,200 feet MSL. When I look at the current sectional, it is depicted as a 5 nm radius from the surface to 8,000 feet MSL, and a 10 nm ring from 2,000 to 8,000 feet MSL [actually the ZZZ TRSA]. I had unintentionally incurred upon this outer ring by 2 nm and 1,300 feet above the floor. This was the third flight I made in the past week along this similar route! Each time, I relied on the data from three commercial sources along with the airspace depicted in the panel GPS from a commercial chart maker to help me avoid airspace along my route!

 Can you imagine my horror as I write this? The lesson that I learned was that this kind of thing is a real “gotcha.” I relied on electronic charts instead of the good old sectional map and it burned me badly. I will never fly VFR without first referring to the sectional and continually referring to the sectional to make sure it is consistent with the electronic charts…..

Even though this pilot had taken the precaution of using a back-up EFB, both the GPS and EFB databases were inaccurate in that the TRSA was not depicted.



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