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Especially When Nobody Is Around
Nobody Coordinates Traffic
In this report, a busy air traffic controller was expecting
some assistance, but Nobody provided it.
Nobody Does the
Documentation
As reported by an A320 maintenance technician, when
Nobody documents a job, trouble follows.
■ I gave clearance to close the #1 and #2 engine fan
cowls. I did not know that the deactivation pins for the
reversers were still installed. Nobody had documented that
the pins were installed as required by our maintenance
procedures. On the test flight the reversers did not deploy.
The job card for removing these pins had been
accomplished prior to the first test flight the day before,
however the pins were reinstalled without documentation.
Our policy for clearance to close the cowls does not include
looking for deactivated engine components.
Nobody Knew There Was a
Problem
This maintenance crew should have informed their
supervisor rather than let an aircraft depart with a
known problem.
■ The aircraft went to the run-up area for an engine
run, and was towed back to the hangar pad. The gear
doors were up and locked at this time. A tug then took the
aircraft to the gate where the ramp crew said they saw
the nose landing gear door droop. After two attempts to
push the gear door up at the gate, they told nobody about
the problem and left the aircraft. On takeoff, the nose
landing gear door departed the aircraft causing an air
turn back....
Nobody Answers, but
Everybody Wins
Things don’t always have to go wrong when Nobody is
around. In this case, a cabin crew’s training and
teamwork prevailed when Nobody answered the call for a
doctor.
■ While at the gate, the Purser made a PA announcement
for a physician. Nobody responded so I went forward. In
the First Class section, a passenger was on the floor in the
aisle. The Purser was performing compressions, Flight
Attendant #3 was monitoring the Automated External
Defibrillator (AED), and a passenger was operating the
resuscitator bag. I put on gloves, replaced the Purser and
the Purser took over the resuscitator. We performed Cardio-
Pulmonary Resuscitation (CPR) until paramedics took
over....
■ As an MD11 leveled at 12,000 feet, the conflict alert
activated with traffic to the southwest of him climbing
northeast. The tag (radar display of an aircraft’s tracking
and flight information), which showed the traffic climbing
out of 11,700 feet, switched to an “M” tag (a tag which
indicated that an approach sector took the handoff).
Nobody coordinated with me to allow this VFR Beech Jet
to climb through my airspace. By the time the conflict alert
activated, there was nothing I could do. Somehow the
aircraft was radar identified, allowed to climb, and
handed off to another sector without approval, or traffic
issued.... I don’t know if the VFR aircraft had the MD11 in
sight.... I was focused mainly on the aircraft on my tags
and not as much on the other tagged and untagged
aircraft on my scope.
CCAALLLLBBAACCKK From NASA's Aviation Safety Reporting System
Number 289 October 2003
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
September 2003 Report Intake
Air Carrier / Air Taxi Pilots 2114
General Aviation Pilots 781
Controllers 51
Cabin/Mechanics/Military/Other 136
TOTAL 3082
ASRS Recently Issued Alerts On…
B737-300 flight control malfunction
Southern airport landing traffic conflict
CL65 horizontal stablizer trim problem
ATC handling of weather deviation request
MD-80 lavatory serviced with automotive fuel
■ The First Officer handled the radios as we taxied. When
we were cleared for takeoff (First Officer’s leg), I responded
using my boom mic (microphone) and we commenced our
takeoff. Tower made no query as to whether we received the
takeoff clearance (presumably because they saw us on the
roll). As we passed through 2,000 feet, Tower called and
instructed us to turn right to 050 degrees and contact
Departure. I acknowledged…. Tower called again (with a
more urgent tone) with the same instructions, and asked if
we had received their instructions. I then switched to my
hand mic and replied again. Tower repeated the last
instruction in a more urgent tone and also stated, “‘Ident’
if you can hear me or contact Departure.” I looked at the
Com #1 (Captain’s) audio box and noticed that it was set
　
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