37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1109169 |
Time | |
Date | 201308 |
Local Time Of Day | 0001-0600 |
Aircraft 1 | |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | Cruise |
Flight Plan | IFR |
Component | |
Aircraft Component | Hydraulic Fluid |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 215 Flight Crew Total 22000 Flight Crew Type 8500 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy |
Narrative:
At FL310; about one hour after takeoff the hydraulic qty low 1 EICAS light illuminated. I requested the pilot not flying get out the checklist. She did; and started reading the checklist. After about 2 items on the checklist; I glanced at the flight instruments to see the aircraft had descended about 40 ft and was starting a slight left hand turn. I immediately started hand flying; returning the aircraft to altitude and heading. I was also handling ATC. I heard the pilot not flying say; 'it says to land at the nearest suitable airport.' I thought that was strange; land for a hydraulic failure? I asked her to pause for a minute; while I dealt with getting an autopilot back on and confirming altitude and course. While I was doing that she awakened the 2 relief pilots. I took the checklist; and within 30 seconds was totally confused. The checklist is poorly written; confusing; and extremely difficult to work with. I asked her to contact dispatch and maintenance control; and I continued to study the checklist. There is a line that says; 'land at the nearest suitable airport.' by now the relief pilots were at their stations; I handed them the checklist and asked them to read it and give me their interpretations. There are now 4 pilots; a dispatcher; and a maintenance person all looking at the situation. With 6 of us reading the same checklist; there was confusion galore! Finally the maintenance person said to reread the checklist; (keep in mind we had already read it about 10 times); eliminate the references to hydraulic system 4; and then we would not need to divert. We did that and all agreed with him. We re-ran the entire checklist to make sure everything had been accomplished; and continued on to destination. The pilot not flying spent a good 40 minutes going step-by-step through the checklists; putting post it notes numbered from 1-5; on the checklists we would need for landing. This involved several pages in the QRH. This is unacceptable! The checklist is unclear; confusing; flips back and forth; and makes references to totally irrelevant material. There are arrows; boxes; lines of boxes that make no sense. For instance; if we are dealing with a hydraulic system 1 failure; why is hydraulic system 4 even mentioned? In our case; hydraulic system 4 was working normally. It lead us to the false assumption that we would need to land; and only after considerable time was wasted were 6 people able to determine that was not the case. This particular checklist is dangerous! The next issue deals with communications. We were approx 9 hours out when this failure occurred. In our particular case; we could land the aircraft normally with the alternate extension of gear and flaps; but we could not taxi. Therefore when we landed we would be effectively shutting down landing operations. In all of that time we sent numerous ACARS messages to dispatch and station ops; requesting that a tug be in place to tow us as soon as possible. We were constantly reassured that all had been handled. After landing we were several minutes on the runway without a tug in sight. The tower asked us how long it would be before a tug got there. We responded that we would call our operations immediately. Our operations told us; 'we just heard about it and are trying to set something up.' we repeated that to the tower; and he said there was a ground stop due to us sitting on the runway. A few minutes later the tug appeared and towed us off the runway. As we deplaned the aircraft; we saw the chief pilot. He informed us that he heard of our situation when we were on short final. This type of communication in a 9 hour span is unacceptable. ATC had been informed; they were very helpful and professional. Apparently the communication with ATC was the only communication that occurred in the 9 hour span. Even the mechanic that met the aircraft said he had heard about our situation 'only a short time ago.'
Original NASA ASRS Text
Title: B747 Captain experiences the failure of the number one hydraulic system in cruise due to loss of hydraulic fluid and the confusion that reigns while trying to interpret the QRH procedure for this failure. Eventually it is determined that the aircraft can continue to destination.
Narrative: At FL310; about one hour after takeoff the HYD QTY LOW 1 EICAS light illuminated. I requested the pilot not flying get out the checklist. She did; and started reading the checklist. After about 2 items on the checklist; I glanced at the flight instruments to see the aircraft had descended about 40 FT and was starting a slight left hand turn. I immediately started hand flying; returning the aircraft to altitude and heading. I was also handling ATC. I heard the pilot not flying say; 'It says to land at the nearest suitable airport.' I thought that was strange; land for a hydraulic failure? I asked her to pause for a minute; while I dealt with getting an autopilot back on and confirming altitude and course. While I was doing that she awakened the 2 relief pilots. I took the checklist; and within 30 seconds was totally confused. The checklist is poorly written; confusing; and extremely difficult to work with. I asked her to contact Dispatch and Maintenance Control; and I continued to study the checklist. There is a line that says; 'Land at the nearest suitable airport.' By now the relief pilots were at their stations; I handed them the checklist and asked them to read it and give me their interpretations. There are now 4 pilots; a Dispatcher; and a Maintenance person all looking at the situation. With 6 of us reading the same checklist; there was confusion galore! Finally the Maintenance person said to reread the checklist; (keep in mind we had already read it about 10 times); eliminate the references to HYD SYS 4; and then we would not need to divert. We did that and all agreed with him. We re-ran the entire checklist to make sure everything had been accomplished; and continued on to destination. The pilot not flying spent a good 40 minutes going step-by-step through the checklists; putting post it notes numbered from 1-5; on the checklists we would need for landing. This involved several pages in the QRH. This is UNACCEPTABLE! The checklist is unclear; confusing; flips back and forth; and makes references to totally irrelevant material. There are arrows; boxes; lines of boxes that make no sense. For instance; if we are dealing with a HYD SYS 1 failure; why is HYD SYS 4 even mentioned? In our case; HYD SYS 4 was working normally. It lead us to the false assumption that we would need to land; and only after considerable time was wasted were 6 people able to determine that was not the case. This particular checklist is dangerous! The next issue deals with communications. We were approx 9 hours out when this failure occurred. In our particular case; we could land the aircraft normally with the alternate extension of gear and flaps; but we could not taxi. Therefore when we landed we would be effectively shutting down landing operations. In all of that time we sent NUMEROUS ACARS messages to Dispatch and Station Ops; requesting that a tug be in place to tow us as soon as possible. We were constantly reassured that all had been handled. After landing we were several minutes on the runway without a tug in sight. The Tower asked us how long it would be before a tug got there. We responded that we would call our Operations immediately. Our operations told us; 'We just heard about it and are trying to set something up.' We repeated that to the Tower; and he said there was a ground stop due to us sitting on the runway. A few minutes later the tug appeared and towed us off the runway. As we deplaned the aircraft; we saw the Chief Pilot. He informed us that he heard of our situation when we were on short final. This type of communication in a 9 hour span is unacceptable. ATC had been informed; they were very helpful and professional. Apparently the communication with ATC was the only communication that occurred in the 9 hour span. Even the Mechanic that met the aircraft said he had heard about our situation 'only a short time ago.'
Data retrieved from NASA's ASRS site as of July 2013 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.