From: jcmorris@mwunix.mitre.org (Joe Morris)
Subject: ASRS CALLBACK # 162 (November, 1992)
Keywords: ASRS CALLBACK
Organization: The MITRE Corporation
Date: Thu, 24 Dec 1992 15:22:16 GMT


                     C   A   L   L   B   A   C   K

              From NASA's Aviation Safety Reporting System

     Number 162                                      November 1992

[This material is transcribed from the monthly safety bulletin _CALLBACK_
 as published by the ASRS office at Moffett Field.  It may include only
 a subset of the articles in the ASRS publication, and within a transcribed
 article I may exercise a mild editor's pencil for style or brevity.  Where
 appropriate I've marked edited material with /[ comments ]/; material in
 normal [brackets] was bracketed in the original text.]

DIALING DILLIES

Pay telephones (airfones) are being installed in increasing numbers for
passenger use on commercial aircraft.  A recent ASRS report highlights
one airfone use that we're sure aircraft operators never anticipated:

*** After takeoff crew noted...no transponder received on left or right
    by ATC and TCAS was inoperative.  While passing upwards through FL240
    right pack trip "off" light illuminated, but reset was impossible
    using irregular checklist.  This meant loss of pressurization capacity.
    At FL300 loss of second pack was indicated by the left pack "off"
    light -- also not resettable.  Captain directed First Officer to use
    oxygen masks and initiated emergency descent.  ATC cleared aircraft to
    FL240, then 15,000 feet, then 10,000 feet enroute back to airport.
    Cabin pressurization reached 9500 feet but cabin oxygen masks never
    actuated...

    This flight was in sunny, dry conditions with no loss of controls or
    engines...[Crew later discovered that] a passenger in first class used
    airfone to call 911, Highway Patrol, and report aircraft out of control
    and in danger of hitting a mountain.  In fact, aircraft was never in
    danger of hitting anything, and except for initial pushover of nose
    and actuation of speed bake to begin descent, operations were mostly
    normal.

/[explanation of 911 for international readers]/

Some days you just can't win.


FREEWAY FLASH

Another phone concern was submitted by a Flight Service Station (FSS)
specialist:

*** Pilot called for weather briefing from a car phone.  Call was lost,
    after several breakups.  Given the weather and NOTAMS, I don't see
    how he could copy the information while driving on the turnpike in the
    morning rush hour even if the connection had been perfect.  This
    practice could even create a road hazard.  In any case, the pilot
    couldn't possibly give the weather brief the attention it deserves...

Our reporter is right: pilots need to provide adequate off-road copying
and "pondering time" for weather forecasts and briefings in their pre-
flight planning.  Those other freeway drivers will be grateful, along
with FSS.


PROGRAMMING NOTES

Behind-schedule operations and catch-up procedures in the cockpit are
factors in many flight crew errors reported to ASRS, including errors
that occur during multiple programming chores.  As the following ASRS
report illustrates, there are times when a few extra minutes at the
gate -- and better Crew Resource Management (CRM) techniques -- might
prevent later unwanted events.

*** After completing preflight procedures and before starting checklist,
    power was removed from aircraft accidentally by ground crew while
    APU was still in the start phase.  This caused a delay in the
    electric power shift and dumped most FMD and ACARS [Automatic
    Communications and Recording System] data which had been previously
    loaded.  We then reloaded and rechecked all FMC inputs, causing
    a 10-minute departure delay.

    During taxi out we completed the remaining checklists but failed
    to notice the power shift had changed takeoff altitude [alerter]
    limit from 5,000 to 10,000.  When doing autopilot flight director
    system (AFDS) panel check I called out...10,000 feet, but this
    did not register as incorrect, as I assumed co-pilot had reset
    new altitude.  At the same time co-pilot was distracted trying
    to reload dumped ACARS data prior to takeoff.

    After takeoff, I wa unable to contact Departure Control due to four
    conflicting calls by other aircraft.  When I finally got through...
    I was asked why we were going to 10,000...


GENERAL AVIATION WEATHER INCIDENTS

        by Betty Hicks

---------
Editor's note: Betty Hicks is an ASRS Research Consultant who has logged
more than 6,000 hours as a pilot and flight instructor in various single-
and twin-engine aircraft.  She is also an advanced ground instructor and
FAA Written Test Examiner.  This is Part 1 of a two-part article by Ms.
Hicks.
---------

*** I have never seen rime collect as fast as it was doing that day.  I
    could not hold (altitude), let alone climb.

*** We departed VFR. But there were darker clouds ahead.  Stormscope
    indications caused me to request an IFR clearance prior to hitting
    any weather.  We flew into the leading edge of a thunderstorm cell
    at 4,000 feet MSL, hit a severe updraft of 2,000 FPM, and settled
    out at 4,700 to 4,800 feet.

*** I was VFR between two cloud layers.  I was just off the coast when
    layers of clouds started to merge.  Instead of doing a 180 degree turn,
    I contacted Approach and filed an instrument flight plan.  From that
    time on I was IMC.  I did not have enroute maps.  I did not have
    approach charts for [my destination] XYZ, but XYZ was VFR that day.
    Except for my descent from altitude without clearance, at no time did
    I deviate from any headings or instructions.  I am currently an
    instrument student.

These general aviation pilots, among many in like situations, survived
to submit weather-related incidnet reports to the Aviation Safety
Reporting System (ASRS).  During the same time period covered by these
reports, other pilots became ensnared by meteorological phenomena,
but their encounters with weather were fatal.

A DISMAL SAFETY PROBLEM.  Year after year, weather is indicted in almost
40% of general aviation fatal accidents.  Year after year, air safety
organizations, videotape producers, FAA Accident Prevention Specialists,
and aviation writers inundate the general aviation community with how-to's
of coexisting with atmospheric phenomena.  Perhaps that is why the
weather-encounter fatalities are held to less than half of the dismal
totals.

Weather-related incident reports submitted to ASRS account for only 4% of
the total database incidents.  Yet almost half (48%) of these weather-
related reports are submitted by general aviation pilots, who represent
one third of all ASRS reporters.

To learn more about the types and causes of general aviation weather
incidents, we selected a study sample of 146 reports from the ASRS
database for the period 1986 to 1991.  Our search procedure ensured that
the reports were randomly selected and representative of a cross-section
of pilot qualifications and flight experience.

Because we were interested in identifying any significant relationships
between flight plan types, and associated types and causes of weather
incidents, we also divided the study reports into two main sections for
analysis: 1) incidents involving IFR flight plans (76 report); 2) incidents
involving VFR flight plans, or no flight plan (70 reports).  Here are some
of our findings:

FRACTURED FARS.  Of the 146 ASRS reports examined, 104 involved one or more
violations of Federal Aviation Regulations (FARs), including busted VFR
mimimums, illegal airspace penetration, altitude and course deviations,
maintenance and recency of experience oversights, and communications
deficiencies.  Of these categories, the "winner" was FAR 91.155, "Basic
VFR Weather Minimums", with 22 violations confessed.  Close behind were
FARs 91.131 and 91.179, "Terminal Control Areas" and "IFR Crusing Altitude
or Flight Level", respectively.  Each logged 19 violations.

"At that altitude I should have been using oxygen," admitted one pilot,
trapped attempting to top buildups, "although I did not notice any
ill effects."  The latter phrase did not exonerate /[sic]/ him from
adherence to FAR 91.211, "Supplemental Oxygen".

REPORTER QUALIFICATIONS.  We had expected instrument-rated pilots to be
less predisposed to weather-related safety incidents and related
violations of FARs than their non-IFR counterparts.  This expectation
for the study set proved false.  One hundred twenty-six of the 146
reporter pilots were instrument-rated.

WEATHER ENCOUNTERS ON IFR FLIGHT PLANS.  "I probably should not have
been there," recalled one remorseful IFR pilot, whose single-engine
aircraft was transformed into a barely-flying ice cube.  "It was my
first instrument flight after receiving my ticket," wrote another,
whose first was almost his last, as he flew into an area of level 3
convective activity.

Of the 76 incidents that occurred on IFR flight plans, 31 involved
*moderate to severe icing* in clouds and precipitation, with rapid
structural icing buildups in many of those instances.  Nineteen
incidents involved encounters with *thunderstorms*.  *Turbulence*
associated with wind or mountain wave conditions was third, with 13
reports.  These conditions collectively accounted for more than
three-fourths of the IFR flight plan weather encounters.  Somewhat
predictably, those "in the clouds" weather encounters were distinctly
different from the "away from clouds" group of weather encounters.

WEATHER ENCOUNTERS IN VFR/NON FLIGHT PLANS.  Of the 70 reports that
involved VFR flight plans, or no flight plan, 21 incidents occurred on
VFR flight plans, one on a SVFR flight, and 48 on no flight plan.  The
prevailing weather condition reported was *low ceilings and/or visibilities*,
with 27 reports.  *Lowering ceilings and merging layers* was the next
most frequent weather situation encountered, with 18 reports.  These
conditions collectively accounted for almost two-thirds of the weather
encounters in this group of reports.  Thunderstorm encounters were
infrequent in this group of incidents, with only four encounters reported.

--------
Next month: Part 2 discusses underlying causes of general aviation
weather incidents reported to ASRS: pilots' poroblems with the weather
data delivery system; passive acceptance of weather information; and
deficienct knowledge of ATC regulations and procedures.
--------

September 1992 report intake:

  Air carrier pilots . . . . . . . . .  1708
  General Aviation pilots  . . . . . .   684
  Controllers  . . . . . . . . . . . .    82
  Cabin/Mechanics/Military/Other . . .     4

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