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told them we would not make the airport. Tower cleared
the area of traffic. The engine regained power and we were
able to land on the runway. When we pulled into the ramp
area, we observed that the number one cylinder head had
come off the engine and lodged halfway through the
cowling. Examination showed a normal cylinder with both
valves and no internal damage. There was no piston.
Situation #3
Open Door Policy
The pilot flying reduced power to idle, landed the aircraft,
and commenced maximum braking. The reject was
initiated with less than 1000 feet of runway remaining.
The aircraft departed the end of runway at approximately
20 knots. We taxied back to the ramp and inspected the
aircraft. There was no damage to either the landing gear
or propellers. A faulty latch on the right door resulted in
the door not being fully locked.... The pilot flying thought
that he had more runway remaining than he actually had.
He stated afterward that he should have continued the
takeoff versus rejecting. We both agreed that a door
opening on takeoff in this aircraft is not a reject item.
Situation #4
Between the Clouds and the Trees
I searched until I found a dirt road. The dirt road led to a
paved road. The paved road led to Interstate [123].... I
followed the Interstate west toward [City].... Finally, I saw
a road sign that read, “[City] 21 miles.” Shortly thereafter,
I sighted [City] International, got a green light from the
tower, and landed without further ado.
Situation #5
When the Traffic Gets Out of Line
I told them, “No. Do not turn back. Continue on the base.”
I pointed out the B190 traffic at two o’clock and one mile...
and cleared them for a visual approach. I then went to
Aircraft Y, cancelled their approach clearance and told
them to maintain 3,000 feet on the localizer.... The lesson I
would like to communicate to pilots is this: we all make
mistakes and most of them can be fixed.
Situation #6
Conspicuous Consumption
The Captain referred to the irregular procedures for the
“Fuel Configuration” light. We decided against attempting
to balance the fuel due to the uncertainty of the cause of
the imbalance (possible fuel leak in the left tank). The fuel
indication in the right tank appeared to be stuck at “12.8.”
We verified the right wing heavy by hand flying the
aircraft and using rudder trim to level the wings. Trim
required increased from 2.0 units to 4.0 units as the flight
progressed due to the increasing imbalance. We were
unable to determine if the fuel in the right wing was
trapped and unusable. We decided to divert [departure
airport] since it was only 60 miles behind us and the
weather was clear.... Dispatch and maintenance concurred
with the divert decision since the fuel state could not be
verified. We requested and received priority handling for
an uneventful landing.
Number 298 July 2004
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/
ASRS Recently Issued Alerts On… June 2004 Report Intake
Air Carrier / Air Taxi Pilots 2550
General Aviation Pilots 832
Controllers 63
Cabin/Mechanics/Military/Other 115
TOTAL 3560
Mexican airport arrival routing
A320 vertical stabilizer spar cracks
Western U.S. airport departure procedure
B757-200 engine surge bleed kiss seal failure
Southern U.S. airport ramp security deficiency
Dear Readers:
As the NASA Aviation Safety Reporting System looks forward to its 30th Anniversary in 2006, this month
marks an interim milestone, the 25th Anniversary of the Monthly Safety Bulletin, CALLBACK.
Since its inception, the Aviation Safety Reporting System has received and analyzed more than 600,000
reports from pilots, air traffic controllers, flight attendants, maintenance personnel, and others. ASRS data
is used to:
1. Identify aviation system deficiencies for correction by appropriate authorities.
2. Support aviation system policy, planning, and improvements.
3. Contribute to aviation human factors safety research.
An additional use for ASRS data was envisioned in 1979 when the ASRS Advisory Subcommittee—an
industry/government group established to function in an advisory role—recommended that NASA develop a
means of increasing the visibility of the program and sharing information obtained through the ASRS with
the aviation community. In response, the late Captain Rex Hardy, a decorated Naval Aviator and corporate
　
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