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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.
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.
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.
Safe Landings - December 2011
Fly The Airplane
A review of recent ASRS reports indicates that failure to follow one of the most basic tenets of flight continues to be a concern when pilots are faced with distractions or abnormal situations. Since the consequences associated with not flying the airplane can be serious, this month’s
Safe Landings revisits the problem and re-emphasizes a lesson as old as powered flight: Fly the airplane; everything else is secondary.
Note that the phrase, “FLY THE AIRPLANE” appears in all-caps in each of the following reports. The emphasis is not an editorial addition, but rather reflects the importance each reporter placed on that admonition.
Safe Landings - November 2011
Upside Down and Backwards
One of several versions of the origin of “Murphy’s Law” contends that the Law’s namesake was Captain Ed Murphy, an engineer at Edwards Air Force Base in 1949. Frustration with a transducer which was malfunctioning due to an error in wiring caused him to remark that—if there was any way that something could be done wrong, it would be.
Recent ASRS reports indicate that Captain Murphy’s Law was in full effect when several aircraft components managed to get installed upside down or backwards.
Pernicious Panel Placement
An aircraft Mode Selector Panel that “looks the same” whether right side up or upside down, and that can be readily installed either way, is a good example of a problematic design. Confronted with an inverted panel, this Cessna 560 Captain found out what happens when the wrong button is in the right place.
Safe Landings - October 2011
See and Avoid
The number of midair collisions in the United States has averaged 30 per year since 1978.1 These accidents primarily involve General Aviation aircraft, but Air Carrier, Corporate and other operators are by no means immune from potentially serious airborne conflicts.
In the preceding 12-month period, more than 4,000 in-flight traffic conflicts were reported to NASA ASRS. Of these, 235 met the ASRS criteria (within 500 feet) for a Near Midair Collision (NMAC). Nearly half of these NMACs involved Air Carrier, Corporate and Air Taxi operations.
Technological advances such as the Traffic Collision Avoidance System (TCAS) and Conflict Alert (CA) have enhanced the ability of pilots and controllers respectively to resolve airborne conflicts before they become critical, but the following ASRS reports show that the “see and avoid” principle remains a crucial aspect of collision avoidance in visual conditions.
Safe Landings - September 2011
Safe Landings - August 2011
Safe Landings - July 2011
What Would You Have Done?
This month we present an incident that required quick decisions on the part of the ASRS reporter. How did our reporter do? You be the judge. In “the first half of the story,” we report an excerpt followed by several plausible action choices. Next, you will find “the rest of the story,” the actions actually taken by the reporter to resolve his situation. This incident will give you a chance to draw on your own operating experience to anticipate what you would have done in the same situation.
The First Half of the Story
“My Climb Would Not Safely Increase”
Safe Landings - June 2011
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.
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.
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.
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.