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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 158653 |
Time | |
Date | 199009 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mem |
State Reference | TN |
Altitude | msl bound lower : 800 msl bound upper : 800 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mem |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 16000 flight time type : 9000 |
ASRS Report | 158653 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude conflict : airborne less severe |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : unable other |
Consequence | Other |
Miss Distance | horizontal : 3000 |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
After takeoff on runway 18R we received a 'tail compartment temperature high' light on. While climbing to 4000' we ran the cockpit operating manual procedure (communication) for the problem. We informed departure control we would need to return to the airport. ATC then gave us a downwind turn (to the north) and descent to 3500' and called small aircraft traffic to us. We saw the small aircraft shortly after in our 10:30 to 11:30 position traveling southeast. After a 2 min wait (communication procedure) the red warning light was not extinguished. Rather than complete the lengthy communication procedure for isolation of the eighth stage air I elected to declare an emergency and land as soon as possible. I directed the first officer to declare the emergency and I left 3500' to set up for the landing. At 3100' ATC asked what my altitude was. I then realized the emergency had not been declared as I directed. When I looked over at the first officer he was talking to the company, finishing the climb checklist and had not heard my command. I then declared the emergency with ATC. The small aircraft passed 1/2 mi behind us. No evasive action was required by either aircraft since we had each other in sight for some time. The landing was west/O incident. I believe the company cumbersome checklist combined with a two man crew contributed to the breakdown of communication in the cockpit. NASA has previously issued a study of checklist design. It was not complimentary of the company procedures. Rethinking the company philosophy concerning checklist construction is in order.
Original NASA ASRS Text
Title: MLG TROUBLE SHOOTING EQUIPMENT PROBLEM HAS CONFLICT WITH SMA.
Narrative: AFTER TKOF ON RWY 18R WE RECEIVED A 'TAIL COMPARTMENT TEMP HIGH' LIGHT ON. WHILE CLBING TO 4000' WE RAN THE COCKPIT OPERATING MANUAL PROC (COM) FOR THE PROB. WE INFORMED DEP CTL WE WOULD NEED TO RETURN TO THE ARPT. ATC THEN GAVE US A DOWNWIND TURN (TO THE N) AND DSNT TO 3500' AND CALLED SMA TFC TO US. WE SAW THE SMA SHORTLY AFTER IN OUR 10:30 TO 11:30 POS TRAVELING SE. AFTER A 2 MIN WAIT (COM PROC) THE RED WARNING LIGHT WAS NOT EXTINGUISHED. RATHER THAN COMPLETE THE LENGTHY COM PROC FOR ISOLATION OF THE EIGHTH STAGE AIR I ELECTED TO DECLARE AN EMER AND LAND ASAP. I DIRECTED THE F/O TO DECLARE THE EMER AND I LEFT 3500' TO SET UP FOR THE LNDG. AT 3100' ATC ASKED WHAT MY ALT WAS. I THEN REALIZED THE EMER HAD NOT BEEN DECLARED AS I DIRECTED. WHEN I LOOKED OVER AT THE F/O HE WAS TALKING TO THE COMPANY, FINISHING THE CLB CHKLIST AND HAD NOT HEARD MY COMMAND. I THEN DECLARED THE EMER WITH ATC. THE SMA PASSED 1/2 MI BEHIND US. NO EVASIVE ACTION WAS REQUIRED BY EITHER ACFT SINCE WE HAD EACH OTHER IN SIGHT FOR SOME TIME. THE LNDG WAS W/O INCIDENT. I BELIEVE THE COMPANY CUMBERSOME CHKLIST COMBINED WITH A TWO MAN CREW CONTRIBUTED TO THE BREAKDOWN OF COM IN THE COCKPIT. NASA HAS PREVIOUSLY ISSUED A STUDY OF CHKLIST DESIGN. IT WAS NOT COMPLIMENTARY OF THE COMPANY PROCS. RETHINKING THE COMPANY PHILOSOPHY CONCERNING CHKLIST CONSTRUCTION IS IN ORDER.
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.