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|
Attributes | |
ACN | 152554 |
Time | |
Date | 199007 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mxp |
State Reference | FO |
Altitude | msl bound lower : 14000 msl bound upper : 15000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mxp |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | approach : visual departure other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : instrument pilot : military pilot : atp pilot : commercial |
Experience | flight time last 90 days : 80 flight time total : 1500 flight time type : 150 |
ASRS Report | 152554 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 5900 flight time type : 35 |
ASRS Report | 152798 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence other other anomaly other anomaly other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the first officer and we departed milan after a 4 hour delay. The delay was on the aircraft arrival and it was caused by a mechanical. We departed mxp and shortly after departure, requested a visibility departure and climb. The captain said he had ground contact, and the request was granted. We selected con on the engines and climbed out. We then requested a deviation to the right of ground track and the request was granted. The first officer had the area chart out and was calling out individual mountain tops and it was determined we would not make the mountain tops. The first officer requested a 360 degree turn. It was granted and we were told to maneuver as required. The captain entered the turn and, at this point. I felt sure we would make the ridge after a 360 degree turn. I then turned around and started my fuel calculations, times for ETA, off report, etc. I was then startled to hear the stick-shaker going off. (The captain had changed his mind about the 360 degree turn and was going for the lowest point in the ridge.) I spun around to see we were in the clouds. I made a mental recovery on the INS to see where we were and we were rolling to the horizon, still in a climb. I then responded to the captain's commands for continuous ignition and anti-ice. Within a few seconds we popped out of the clouds and I could see we would clear the lowest part of the ridge, as long as the aircraft didn't fully stall. We still had stick-shaker and, with the addition of some power, we were able to climb out of the stick-shaker. I believe this was a classic case of get homeitis. There were several contributing factors. First, the first officer was very new on the widebody transport. He told me that he was checked out in 1/90 and this was his first or second trip back on this aircraft since then. The captain had a very aggressive personality, he is a hard person to disagree with especially when it is a judgement call. Several of the cabin team had expressed to the captain their fears of missing commuter flts due to the delay. This seemed to motivate the captain to want to rush things to get home. The second officer on widebody transport does not carry charts so, I could not follow the progress of the flight close enough to see the situation for what it really was. I didn't really know where we should have been vs where we actually were, because I didn't have a chart to follow our progress. Also, the captain had his wife aboard and I think that may have had something to do with the reason we were on a visibility departure. I think he wanted her to get a good view of the alps. I feel I should have voiced my concerns sooner than I did and I should have waited before I stopped watching what was going on. With hindsight, I see I should have been able to recognize that you can't go direct from mxp across the alp at 700000 pounds. You have to circle to get enough altitude to clear everything out there. Personally, I think that visibility departures out of milan should be banned. Callback conversation with reporter revealed the following: the reporter is a first pilot on a military widebody transport in the reserves and has had operating experience in europe. He stated that VMC departure/climbs were authority/authorized in certain parts of the world so far as air carrier procedure but did not specify mxp as authority/authorized or unauthorized. He went on to state that he had had several problems with the captain as this PIC was difficult to deal with. The reporter had called several maintenance deficiencies to his attention, like all 4 gens out of proper frequency and had been told to 'stop trying to find something wrong with this aircraft.' he used non standard procedure and during engine start on this flight was in such a hurry to get on with the flight that he was still doing the pressurization check (or the before engine start checklist) while they were starting the engines. He had been known to depart with vital sub-systems not operating properly and pulling circuit breaker's to deactivate them during the required phase of flight. The second officer reported that the cabin attendants (F/a's) were pressing on the captain to get to destination as soon as possible for flight connections. At this time the air carrier is investigating all the parameters of the flight and the climb procedure used by the captain as he exceeded the egt limits of the engines and got into rangesexceeded 925 degrees C, which, if into for 15 seconds or longer, would have required engine shut down. Air carrier is recommending termination and the union is defending said captain. Early retirement may come about as a result of PIC's actions. No mention was made of sight-seeing of the alps. The second officer feels in the middle of this investigation and only wants the trust to be reported.
Original NASA ASRS Text
Title: ACR WDB PIC REPORTEDLY DOES NOT FOLLOW ACR GUIDELINES AND CHECKLISTS DURING ENGINE START AND THEN DOES NOT FOLLOW CLIMB PROC ON A VMC DEP IN IMC CONDITIONS AND OVERTEMPS ENGINES IN TRYING TO CLEAR MOUNTAINS.
Narrative: I WAS THE F/O AND WE DEPARTED MILAN AFTER A 4 HR DELAY. THE DELAY WAS ON THE ACFT ARR AND IT WAS CAUSED BY A MECHANICAL. WE DEPARTED MXP AND SHORTLY AFTER DEP, REQUESTED A VIS DEP AND CLB. THE CAPT SAID HE HAD GND CONTACT, AND THE REQUEST WAS GRANTED. WE SELECTED CON ON THE ENGS AND CLBED OUT. WE THEN REQUESTED A DEVIATION TO THE RIGHT OF GND TRACK AND THE REQUEST WAS GRANTED. THE F/O HAD THE AREA CHART OUT AND WAS CALLING OUT INDIVIDUAL MOUNTAIN TOPS AND IT WAS DETERMINED WE WOULD NOT MAKE THE MOUNTAIN TOPS. THE F/O REQUESTED A 360 DEG TURN. IT WAS GRANTED AND WE WERE TOLD TO MANEUVER AS REQUIRED. THE CAPT ENTERED THE TURN AND, AT THIS POINT. I FELT SURE WE WOULD MAKE THE RIDGE AFTER A 360 DEG TURN. I THEN TURNED AROUND AND STARTED MY FUEL CALCULATIONS, TIMES FOR ETA, OFF RPT, ETC. I WAS THEN STARTLED TO HEAR THE STICK-SHAKER GOING OFF. (THE CAPT HAD CHANGED HIS MIND ABOUT THE 360 DEG TURN AND WAS GOING FOR THE LOWEST POINT IN THE RIDGE.) I SPUN AROUND TO SEE WE WERE IN THE CLOUDS. I MADE A MENTAL RECOVERY ON THE INS TO SEE WHERE WE WERE AND WE WERE ROLLING TO THE HORIZON, STILL IN A CLB. I THEN RESPONDED TO THE CAPT'S COMMANDS FOR CONTINUOUS IGNITION AND ANTI-ICE. WITHIN A FEW SECONDS WE POPPED OUT OF THE CLOUDS AND I COULD SEE WE WOULD CLR THE LOWEST PART OF THE RIDGE, AS LONG AS THE ACFT DIDN'T FULLY STALL. WE STILL HAD STICK-SHAKER AND, WITH THE ADDITION OF SOME PWR, WE WERE ABLE TO CLB OUT OF THE STICK-SHAKER. I BELIEVE THIS WAS A CLASSIC CASE OF GET HOMEITIS. THERE WERE SEVERAL CONTRIBUTING FACTORS. FIRST, THE F/O WAS VERY NEW ON THE WDB. HE TOLD ME THAT HE WAS CHKED OUT IN 1/90 AND THIS WAS HIS FIRST OR SECOND TRIP BACK ON THIS ACFT SINCE THEN. THE CAPT HAD A VERY AGGRESSIVE PERSONALITY, HE IS A HARD PERSON TO DISAGREE WITH ESPECIALLY WHEN IT IS A JUDGEMENT CALL. SEVERAL OF THE CABIN TEAM HAD EXPRESSED TO THE CAPT THEIR FEARS OF MISSING COMMUTER FLTS DUE TO THE DELAY. THIS SEEMED TO MOTIVATE THE CAPT TO WANT TO RUSH THINGS TO GET HOME. THE S/O ON WDB DOES NOT CARRY CHARTS SO, I COULD NOT FOLLOW THE PROGRESS OF THE FLT CLOSE ENOUGH TO SEE THE SITUATION FOR WHAT IT REALLY WAS. I DIDN'T REALLY KNOW WHERE WE SHOULD HAVE BEEN VS WHERE WE ACTUALLY WERE, BECAUSE I DIDN'T HAVE A CHART TO FOLLOW OUR PROGRESS. ALSO, THE CAPT HAD HIS WIFE ABOARD AND I THINK THAT MAY HAVE HAD SOMETHING TO DO WITH THE REASON WE WERE ON A VIS DEP. I THINK HE WANTED HER TO GET A GOOD VIEW OF THE ALPS. I FEEL I SHOULD HAVE VOICED MY CONCERNS SOONER THAN I DID AND I SHOULD HAVE WAITED BEFORE I STOPPED WATCHING WHAT WAS GOING ON. WITH HINDSIGHT, I SEE I SHOULD HAVE BEEN ABLE TO RECOGNIZE THAT YOU CAN'T GO DIRECT FROM MXP ACROSS THE ALP AT 700000 LBS. YOU HAVE TO CIRCLE TO GET ENOUGH ALT TO CLR EVERYTHING OUT THERE. PERSONALLY, I THINK THAT VIS DEPS OUT OF MILAN SHOULD BE BANNED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE RPTR IS A FIRST PLT ON A MIL WDB IN THE RESERVES AND HAS HAD OPERATING EXPERIENCE IN EUROPE. HE STATED THAT VMC DEP/CLBS WERE AUTH IN CERTAIN PARTS OF THE WORLD SO FAR AS ACR PROC BUT DID NOT SPECIFY MXP AS AUTH OR UNAUTH. HE WENT ON TO STATE THAT HE HAD HAD SEVERAL PROBS WITH THE CAPT AS THIS PIC WAS DIFFICULT TO DEAL WITH. THE RPTR HAD CALLED SEVERAL MAINT DEFICIENCIES TO HIS ATTN, LIKE ALL 4 GENS OUT OF PROPER FREQ AND HAD BEEN TOLD TO 'STOP TRYING TO FIND SOMETHING WRONG WITH THIS ACFT.' HE USED NON STANDARD PROC AND DURING ENG START ON THIS FLT WAS IN SUCH A HURRY TO GET ON WITH THE FLT THAT HE WAS STILL DOING THE PRESSURIZATION CHK (OR THE BEFORE ENG START CHKLIST) WHILE THEY WERE STARTING THE ENGS. HE HAD BEEN KNOWN TO DEPART WITH VITAL SUB-SYSTEMS NOT OPERATING PROPERLY AND PULLING CB'S TO DEACTIVATE THEM DURING THE REQUIRED PHASE OF FLT. THE S/O RPTED THAT THE CABIN ATTENDANTS (F/A'S) WERE PRESSING ON THE CAPT TO GET TO DEST ASAP FOR FLT CONNECTIONS. AT THIS TIME THE ACR IS INVESTIGATING ALL THE PARAMETERS OF THE FLT AND THE CLB PROC USED BY THE CAPT AS HE EXCEEDED THE EGT LIMITS OF THE ENGS AND GOT INTO RANGESEXCEEDED 925 DEGS C, WHICH, IF INTO FOR 15 SECONDS OR LONGER, WOULD HAVE REQUIRED ENG SHUT DOWN. ACR IS RECOMMENDING TERMINATION AND THE UNION IS DEFENDING SAID CAPT. EARLY RETIREMENT MAY COME ABOUT AS A RESULT OF PIC'S ACTIONS. NO MENTION WAS MADE OF SIGHT-SEEING OF THE ALPS. THE S/O FEELS IN THE MIDDLE OF THIS INVESTIGATION AND ONLY WANTS THE TRUST TO BE RPTED.
Data retrieved from NASA's ASRS site as of July 2007 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.