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|
Attributes | |
ACN | 310943 |
Time | |
Date | 199507 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : dsm |
State Reference | IA |
Altitude | msl bound lower : 25000 msl bound upper : 25000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zmp |
Operator | common carrier : air taxi |
Make Model Name | MU-2G/K |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : takeoff cruise other descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : cfi pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 175 flight time total : 10710 flight time type : 3000 |
ASRS Report | 310943 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
On jul/tue/95, I was in command of an mu-2-B-30-G-715. My copilot and I were conducting a routine flight in VFR conditions on an IFR flight plan. Our air taxi is under contract with the federal reserve bank to move all forms of bank material, my route originates in oma and moves to mdw with 1 intermediate stop in dsm and the returns in reverse order to oma later. The only departure from our normal operations was that on the first leg from oma to dsm we had on board an FAA inspector conducting a route check. He would be getting off at dsm and riding another company flight back to oma. At XA00 UTC, jul/tue/95, we departed oma on schedule. The departure was normal with the exception of a large fluctuation in fuel flow during takeoff. With no indication of unstable egt or torque, I felt that this was an indicator problem and monitored the flow until it stabilized, there was no indication of adverse yaw so the takeoff was continued. Just prior to let-down into dsm, the right engine fuel flow, egt and torque began to fluctuate slightly. I was able to dampen out these fluctuations with the power lever. During the descent these fluctuations were intermittent. Also, I received a master caution. Looking at the annunciator panel I had no corresponding indication of any item. I continued to monitor, and attempted to cancel the master caution, it would not cancel. I have encountered problems with this aircraft before in canceling master caution indications, but never have I received a master caution without a corresponding annunciator indication. We continued on and landed safely at dsm. After checking the MEL on this aircraft, I found nothing listed under either srl computer or master caution. As we were getting out of the aircraft I asked my copilot if he would like to spend the rest of the night at a motel. The FAA inspector inquired about the master caution and the fuel flow indications. I expressed my concerns about the right engine, but told him that the master caution problem was one I had seen before and that it would be easy to fix. However, the aircraft was going to be grounded at dsm. I called my dispatcher at tulsa, ok (company headquarters). I explained the situation to him and told him to inform the director of maintenance, and let him know that I needed to talk to him, and to inform the zone manager (also the mkc based pilot) of the problem, and find out what he wanted me to do. As I waited I felt that we would be told to send the other aircraft (already en route to dsm and oma) back to mdw and to take the FAA inspector with him and that we would be told to get a motel and wait until the aircraft had been looked at and the write-ups were cleared. When dispatch returned on the phone the dispatcher relayed a message from the zone manager to me, that message is as follows: send the FAA inspector back to oma with the other aircraft and when they have gone a safe distance, load our aircraft and proceed to mdw. I could not believe what the zone manager was asking us to do. I asked the dispatcher to repeat the message. I told him that the zone manager was asking us to violate the regulations. The dispatcher said he could not believe it either. Later I talked to the department manager and we discussed the aircraft problem and attempted a run-up and test of the aircraft system. I attempted to duplicate any condition in which the master caution would come on by pulling circuit breakers and opening switches, but I could not duplicate the problem. The department manager also could not believe that the zone manager had asked me to go on to mdw. The more we discussed the problem, the more we felt that we really did not have a problem. The master caution system appeared to be functioning normally and there were no fluctuations on the run-up. The department manager asked if I had written up anything on the manifest. I said no. He said it is up to you. I reaffirmed my orders from the zone manager and felt that the problem was not a safety of flight item and it had tested out alright. Unfortunately, I misinterpreted these facts as being a release to proceed on to mdw. We departed for mdw at XB44 UTC and arrived in mdw at XC46 UTC. All the way to mdw I was having doubts more and more about my decision to fly, and was becoming more and more angry at myself and at the zone manager for even suggesting that we should move on. I and my copilot did not believe that I had made the right decision. On the flight to mdw the aircraft performed normally, with all system nominal. We flew at FL250 with a -15 degrees C tat. After landing at mdw I wrote up the problem with the master caution and called the department manager while the a&P at mdw worked on the aircraft. Later the department manager had the a&P run the aircraft through some diagnostic tests to see if any system were functioning abnormally. The aircraft was fixed and tested fine, and the write-up was cleared off. I told the department manager about the right engine when I was in dsm. While at mdw, he asked about it and I told him it was fine. The next night we swapped out of that aircraft and it was sent to tul so the department manager and our maintenance staff could have a look at this problem. These intermittent fluctuations were becoming very troubling and the department manager wanted to get the aircraft down to tul as soon as possible. The swap occurred at mdw on jul/wed/95. The zone manager was informed of my displeasure of being told to continue to mdw. He then got into a shouting match with me, telling me that he had never told me directly to continue to mdw. I told him that while we had not spoken directly he had given dispatch the aforementioned message. The chief pilot and the director of operations were furious with the zone manager for telling me to go on, especially after he lied to them directly about the matter. The dispatcher confirmed that he had indeed given the order. It should be noted that the zone manager in our company manual does have some authority/authorized delegated to him by the chief pilot for flight operations, but that authority/authorized is limited in scope. It should also be noted that the zone manager and I have not been getting along for some time. His management style is one of oppressive pressure with real or imagined threats. I commute to my base in omaha from phoenix and in over 5 yrs of jumpseat riding (1 1/2 yrs while at this company) I have never missed a flight for not being able to get to my base. This, however, happened in june and ever since then, the zone manager has been riding me about almost everything I do. Also our company is under new management and he is making power plays to position himself in company management. I have asked myself why I have allowed myself to be coerced into doing something that is against my better judgement and that I was uncomfortable with, and I fear some action from the FAA is possible. The contributing factors to this incident are as follows: 1) I did not have any intention of violating any FARS. 2) a misunderstanding with maintenance control was instituted on my part. 3) I later found that no legal release was given and I therefore was illegal to proceed. 4) undue pressure from the zone manager to continue the flight. I have had a reputation with my company of running a very tight ship, and have prided myself on making the right decisions, sticking to procedures and exercising good cockpit resource management. I have a clean record with the FAA and I feel I have a good relationship with the FSDO. I personally feel very badly about this incident, and I can assure you a real lesson has been handed me on this flight, and I can assure you that a repeat of this incident will not happen on my watch again.
Original NASA ASRS Text
Title: ACFT EQUIP PROB. MEL REQUIREMENT. ATX CAPT FLIES AN ACFT WITH A MALFUNCTIONING FUEL CTL COMPUTER AFTER A MGR'S COERCION.
Narrative: ON JUL/TUE/95, I WAS IN COMMAND OF AN MU-2-B-30-G-715. MY COPLT AND I WERE CONDUCTING A ROUTINE FLT IN VFR CONDITIONS ON AN IFR FLT PLAN. OUR AIR TAXI IS UNDER CONTRACT WITH THE FEDERAL RESERVE BANK TO MOVE ALL FORMS OF BANK MATERIAL, MY RTE ORIGINATES IN OMA AND MOVES TO MDW WITH 1 INTERMEDIATE STOP IN DSM AND THE RETURNS IN REVERSE ORDER TO OMA LATER. THE ONLY DEP FROM OUR NORMAL OPS WAS THAT ON THE FIRST LEG FROM OMA TO DSM WE HAD ON BOARD AN FAA INSPECTOR CONDUCTING A RTE CHK. HE WOULD BE GETTING OFF AT DSM AND RIDING ANOTHER COMPANY FLT BACK TO OMA. AT XA00 UTC, JUL/TUE/95, WE DEPARTED OMA ON SCHEDULE. THE DEP WAS NORMAL WITH THE EXCEPTION OF A LARGE FLUCTUATION IN FUEL FLOW DURING TKOF. WITH NO INDICATION OF UNSTABLE EGT OR TORQUE, I FELT THAT THIS WAS AN INDICATOR PROB AND MONITORED THE FLOW UNTIL IT STABILIZED, THERE WAS NO INDICATION OF ADVERSE YAW SO THE TKOF WAS CONTINUED. JUST PRIOR TO LET-DOWN INTO DSM, THE R ENG FUEL FLOW, EGT AND TORQUE BEGAN TO FLUCTUATE SLIGHTLY. I WAS ABLE TO DAMPEN OUT THESE FLUCTUATIONS WITH THE PWR LEVER. DURING THE DSCNT THESE FLUCTUATIONS WERE INTERMITTENT. ALSO, I RECEIVED A MASTER CAUTION. LOOKING AT THE ANNUNCIATOR PANEL I HAD NO CORRESPONDING INDICATION OF ANY ITEM. I CONTINUED TO MONITOR, AND ATTEMPTED TO CANCEL THE MASTER CAUTION, IT WOULD NOT CANCEL. I HAVE ENCOUNTERED PROBS WITH THIS ACFT BEFORE IN CANCELING MASTER CAUTION INDICATIONS, BUT NEVER HAVE I RECEIVED A MASTER CAUTION WITHOUT A CORRESPONDING ANNUNCIATOR INDICATION. WE CONTINUED ON AND LANDED SAFELY AT DSM. AFTER CHKING THE MEL ON THIS ACFT, I FOUND NOTHING LISTED UNDER EITHER SRL COMPUTER OR MASTER CAUTION. AS WE WERE GETTING OUT OF THE ACFT I ASKED MY COPLT IF HE WOULD LIKE TO SPEND THE REST OF THE NIGHT AT A MOTEL. THE FAA INSPECTOR INQUIRED ABOUT THE MASTER CAUTION AND THE FUEL FLOW INDICATIONS. I EXPRESSED MY CONCERNS ABOUT THE R ENG, BUT TOLD HIM THAT THE MASTER CAUTION PROB WAS ONE I HAD SEEN BEFORE AND THAT IT WOULD BE EASY TO FIX. HOWEVER, THE ACFT WAS GOING TO BE GNDED AT DSM. I CALLED MY DISPATCHER AT TULSA, OK (COMPANY HEADQUARTERS). I EXPLAINED THE SIT TO HIM AND TOLD HIM TO INFORM THE DIRECTOR OF MAINT, AND LET HIM KNOW THAT I NEEDED TO TALK TO HIM, AND TO INFORM THE ZONE MGR (ALSO THE MKC BASED PLT) OF THE PROB, AND FIND OUT WHAT HE WANTED ME TO DO. AS I WAITED I FELT THAT WE WOULD BE TOLD TO SEND THE OTHER ACFT (ALREADY ENRTE TO DSM AND OMA) BACK TO MDW AND TO TAKE THE FAA INSPECTOR WITH HIM AND THAT WE WOULD BE TOLD TO GET A MOTEL AND WAIT UNTIL THE ACFT HAD BEEN LOOKED AT AND THE WRITE-UPS WERE CLRED. WHEN DISPATCH RETURNED ON THE PHONE THE DISPATCHER RELAYED A MESSAGE FROM THE ZONE MGR TO ME, THAT MESSAGE IS AS FOLLOWS: SEND THE FAA INSPECTOR BACK TO OMA WITH THE OTHER ACFT AND WHEN THEY HAVE GONE A SAFE DISTANCE, LOAD OUR ACFT AND PROCEED TO MDW. I COULD NOT BELIEVE WHAT THE ZONE MGR WAS ASKING US TO DO. I ASKED THE DISPATCHER TO REPEAT THE MESSAGE. I TOLD HIM THAT THE ZONE MGR WAS ASKING US TO VIOLATE THE REGS. THE DISPATCHER SAID HE COULD NOT BELIEVE IT EITHER. LATER I TALKED TO THE DEPT MGR AND WE DISCUSSED THE ACFT PROB AND ATTEMPTED A RUN-UP AND TEST OF THE ACFT SYS. I ATTEMPTED TO DUPLICATE ANY CONDITION IN WHICH THE MASTER CAUTION WOULD COME ON BY PULLING CIRCUIT BREAKERS AND OPENING SWITCHES, BUT I COULD NOT DUPLICATE THE PROB. THE DEPT MGR ALSO COULD NOT BELIEVE THAT THE ZONE MGR HAD ASKED ME TO GO ON TO MDW. THE MORE WE DISCUSSED THE PROB, THE MORE WE FELT THAT WE REALLY DID NOT HAVE A PROB. THE MASTER CAUTION SYS APPEARED TO BE FUNCTIONING NORMALLY AND THERE WERE NO FLUCTUATIONS ON THE RUN-UP. THE DEPT MGR ASKED IF I HAD WRITTEN UP ANYTHING ON THE MANIFEST. I SAID NO. HE SAID IT IS UP TO YOU. I REAFFIRMED MY ORDERS FROM THE ZONE MGR AND FELT THAT THE PROB WAS NOT A SAFETY OF FLT ITEM AND IT HAD TESTED OUT ALRIGHT. UNFORTUNATELY, I MISINTERPRETED THESE FACTS AS BEING A RELEASE TO PROCEED ON TO MDW. WE DEPARTED FOR MDW AT XB44 UTC AND ARRIVED IN MDW AT XC46 UTC. ALL THE WAY TO MDW I WAS HAVING DOUBTS MORE AND MORE ABOUT MY DECISION TO FLY, AND WAS BECOMING MORE AND MORE ANGRY AT MYSELF AND AT THE ZONE MGR FOR EVEN SUGGESTING THAT WE SHOULD MOVE ON. I AND MY COPLT DID NOT BELIEVE THAT I HAD MADE THE RIGHT DECISION. ON THE FLT TO MDW THE ACFT PERFORMED NORMALLY, WITH ALL SYS NOMINAL. WE FLEW AT FL250 WITH A -15 DEGS C TAT. AFTER LNDG AT MDW I WROTE UP THE PROB WITH THE MASTER CAUTION AND CALLED THE DEPT MGR WHILE THE A&P AT MDW WORKED ON THE ACFT. LATER THE DEPT MGR HAD THE A&P RUN THE ACFT THROUGH SOME DIAGNOSTIC TESTS TO SEE IF ANY SYS WERE FUNCTIONING ABNORMALLY. THE ACFT WAS FIXED AND TESTED FINE, AND THE WRITE-UP WAS CLRED OFF. I TOLD THE DEPT MGR ABOUT THE R ENG WHEN I WAS IN DSM. WHILE AT MDW, HE ASKED ABOUT IT AND I TOLD HIM IT WAS FINE. THE NEXT NIGHT WE SWAPPED OUT OF THAT ACFT AND IT WAS SENT TO TUL SO THE DEPT MGR AND OUR MAINT STAFF COULD HAVE A LOOK AT THIS PROB. THESE INTERMITTENT FLUCTUATIONS WERE BECOMING VERY TROUBLING AND THE DEPT MGR WANTED TO GET THE ACFT DOWN TO TUL ASAP. THE SWAP OCCURRED AT MDW ON JUL/WED/95. THE ZONE MGR WAS INFORMED OF MY DISPLEASURE OF BEING TOLD TO CONTINUE TO MDW. HE THEN GOT INTO A SHOUTING MATCH WITH ME, TELLING ME THAT HE HAD NEVER TOLD ME DIRECTLY TO CONTINUE TO MDW. I TOLD HIM THAT WHILE WE HAD NOT SPOKEN DIRECTLY HE HAD GIVEN DISPATCH THE AFOREMENTIONED MESSAGE. THE CHIEF PLT AND THE DIRECTOR OF OPS WERE FURIOUS WITH THE ZONE MGR FOR TELLING ME TO GO ON, ESPECIALLY AFTER HE LIED TO THEM DIRECTLY ABOUT THE MATTER. THE DISPATCHER CONFIRMED THAT HE HAD INDEED GIVEN THE ORDER. IT SHOULD BE NOTED THAT THE ZONE MGR IN OUR COMPANY MANUAL DOES HAVE SOME AUTH DELEGATED TO HIM BY THE CHIEF PLT FOR FLT OPS, BUT THAT AUTH IS LIMITED IN SCOPE. IT SHOULD ALSO BE NOTED THAT THE ZONE MGR AND I HAVE NOT BEEN GETTING ALONG FOR SOME TIME. HIS MGMNT STYLE IS ONE OF OPPRESSIVE PRESSURE WITH REAL OR IMAGINED THREATS. I COMMUTE TO MY BASE IN OMAHA FROM PHOENIX AND IN OVER 5 YRS OF JUMPSEAT RIDING (1 1/2 YRS WHILE AT THIS COMPANY) I HAVE NEVER MISSED A FLT FOR NOT BEING ABLE TO GET TO MY BASE. THIS, HOWEVER, HAPPENED IN JUNE AND EVER SINCE THEN, THE ZONE MGR HAS BEEN RIDING ME ABOUT ALMOST EVERYTHING I DO. ALSO OUR COMPANY IS UNDER NEW MGMNT AND HE IS MAKING PWR PLAYS TO POS HIMSELF IN COMPANY MGMNT. I HAVE ASKED MYSELF WHY I HAVE ALLOWED MYSELF TO BE COERCED INTO DOING SOMETHING THAT IS AGAINST MY BETTER JUDGEMENT AND THAT I WAS UNCOMFORTABLE WITH, AND I FEAR SOME ACTION FROM THE FAA IS POSSIBLE. THE CONTRIBUTING FACTORS TO THIS INCIDENT ARE AS FOLLOWS: 1) I DID NOT HAVE ANY INTENTION OF VIOLATING ANY FARS. 2) A MISUNDERSTANDING WITH MAINT CTL WAS INSTITUTED ON MY PART. 3) I LATER FOUND THAT NO LEGAL RELEASE WAS GIVEN AND I THEREFORE WAS ILLEGAL TO PROCEED. 4) UNDUE PRESSURE FROM THE ZONE MGR TO CONTINUE THE FLT. I HAVE HAD A REPUTATION WITH MY COMPANY OF RUNNING A VERY TIGHT SHIP, AND HAVE PRIDED MYSELF ON MAKING THE RIGHT DECISIONS, STICKING TO PROCS AND EXERCISING GOOD COCKPIT RESOURCE MGMNT. I HAVE A CLEAN RECORD WITH THE FAA AND I FEEL I HAVE A GOOD RELATIONSHIP WITH THE FSDO. I PERSONALLY FEEL VERY BADLY ABOUT THIS INCIDENT, AND I CAN ASSURE YOU A REAL LESSON HAS BEEN HANDED ME ON THIS FLT, AND I CAN ASSURE YOU THAT A REPEAT OF THIS INCIDENT WILL NOT HAPPEN ON MY WATCH AGAIN.
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.