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into it. The situation never gets better. It only gets worse.
25. ...The timely and accurate flow of information from the
cabin to the cockpit was vital in resolving the situation.
Lesson learned: CRM (Crew Resource Management)
works!
Many ASRS reports conclude with a statement of the
lesson (or lessons) learned by the reporter. Here are 25
important lessons culled from the collective wisdom of the
reports submitted to NASA’s Aviation Safety Reporting
System over the past 25 years.
Taking the time to share a lesson learned through a
report to the ASRS is a good thing and, as mentioned
earlier, we appreciate all of the submissions. By heeding
the advice offered below, however, you may avoid a
mishap and we may not have reason to hear from you.
That’s a good thing too.
1. ...I learned that it is better to divert early than to press
on in deteriorating conditions hoping for a positive
outcome. No one should attempt to “scud run” in marginal
VFR conditions as I did (with a near disastrous result).
2. ...Even though I have been flying for a number of years,
I learned a valuable lesson about how fast weather can
close in and how stupid it is to “assume” that the weather
will clear.
3. ...For every flight I make now, IFR or VFR, outside air
temperature and icing forecasts will receive very close
attention. I will never again fail to scrutinize approaching
IMC for icing. It is an insidious trap.
4. ...Not knowing if the other aircraft was being provided
advisories shouldn’t have been a factor. It’s always, “see
and avoid” out there.
5. ...They say a good approach leads to a good landing.
Early recognition of a bad setup will enable a go-around
and prevent getting “into the hole” where few options
remain.
6. ...No matter how familiar the other guy says he is with
the airport, monitor, monitor, monitor.
7. ...From now on I’ll visually check the fuel myself and I’ll
keep track of the fuel I’m using in flight.
8. ...Here is what I learned: 1) To the extent possible,
always get prepared on the ground, not while in the air. 2)
Don’t let external pressures like time make you do
something you haven’t thoroughly prepared for.
9. ...I was making a rushed approach to land. I have
learned that when I am rushed is when I really need to
take the time for the checklist.
10. ...I guess the lesson to be learned is not to let personnel
(station, refueling, etc.) or situations rush and distract you
in your normal duties. Sometimes inattention to the small
details will cause as many problems as the large ones.
11. ... In a real-life emergency, the work load and noise can
be more distracting than the simulator can emulate. Don’t
get distracted from the first priority - fly the airplane!
Concentration is key.
CCAALLLLBBAACCKK From NASA's Aviation Safety Reporting System
Number 299 August 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… July 2004 Report Intake
Air Carrier / Air Taxi Pilots 2461
General Aviation Pilots 752
Controllers 208
Cabin/Mechanics/Military/Other 166
TOTAL 3587
Lear 25D engine failure incidents
B737-800/900 headset aural alerts volume control
B757-200 overheated wire bundle emergency
Personal Breathing Equipment (PBE) explosion
Eastern U.S. airport taxiway lighting deficiency
In the 16 months since fuel related
incidents were last discussed in
Callback (#283 April, 2003), 47 reports
have been submitted to ASRS regarding
preventable, fuel related, forced
landings. The NTSB database contains
a similar number of forced landings
caused by fuel problems for the same
period. The NTSB events were classified as accidents
due to significant damage and/or injury and therefore
were separate from the ones reported to ASRS.
Failure to monitor actual fuel usage, a factor cited in
many fuel starvation incidents, was covered in
Callback #283. Two additional factors that recur in
both the ASRS and the NTSB reports are:
1. Failure to select the appropriate fuel tank
2. Failure to visually confirm the fuel on board during
preflight
The following ASRS reports present some lessons
learned regarding these two additional “fuel failures.”
Focus on Fuel Failures
Tip Tank Tip: Select the Full One
After selecting the wrong tank, this PA32 pilot found
　
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