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|
Attributes | |
ACN | 499620 |
Time | |
Date | 200101 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : stl.airport |
State Reference | MO |
Altitude | agl single value : 500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Turbulence |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : t75.tracon tower : stl.tower tower : dtw.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 205 flight time total : 11000 flight time type : 6000 |
ASRS Report | 499620 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : turbulence inflight encounter : weather inflight encounter other maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Weather Maintenance Human Performance Aircraft Company Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
As we departed out of stl, the first officer's ADI failed. No flags -- it just didn't show any bank. I took control of the aircraft and we continued on to our destination (msp) about 1 hour 15 mins away. The question is, 'why didn't we return to stl?' that option was never mentioned. An instructor in the left seat, experienced first officer in the right and another company pilot in the jump seat, commuting home. Contributing factors: 1) 4TH leg of a long day. 2) running 2 hour late due to WX at stl. 3) full load of passenger had been waiting a long time for the crew to arrive. 4) blocked out and returned to gate because we were overweight for departure. 5) runway change as we started taxiing the second time caused more delay. 6) rain and gusty xwinds on takeoff, turbulence on departure. 7) destination WX not much better. 8) maintenance at destination to handle problem. 9) 14 hour duty by the time we got to destination. Arrived for XA00 departure the next morning, after 11 hour 15 min crew rest. Assigned the same aircraft with malfunction signed off. Changed gyro, and operations checked ok. Suspected we might encounter the same problem. No mention of returning if problem recurred. Briefed to look for problem early and anticipate problem. ADI failed again and we continued to hub. Contributing factors: 1) dark, early morning department. Had snowed night before. Limited airport operations. 2) WX was better at hub and daylight landing. 3) 2 more legs ahead of us to complete a 4 day trip and go home. 4) hub maintenance available to correct problem. 5) knew we flew aircraft out and would be able to fly it back. It should have been obvious that the prudent option would have been to return to base on the first leg and the second occurrence wouldn't have happened. Also, obvious that had this occurred in the simulator, we would have more than likely returned and landed overweight. Why didn't this carry over to flight operations and why is it so much easier to see the obvious sitting here drinking a cold root beer.
Original NASA ASRS Text
Title: DC9-30 CREW HAD ADI FAILURE IN STL CLASS B AIRSPACE.
Narrative: AS WE DEPARTED OUT OF STL, THE FO'S ADI FAILED. NO FLAGS -- IT JUST DIDN'T SHOW ANY BANK. I TOOK CTL OF THE ACFT AND WE CONTINUED ON TO OUR DEST (MSP) ABOUT 1 HR 15 MINS AWAY. THE QUESTION IS, 'WHY DIDN'T WE RETURN TO STL?' THAT OPTION WAS NEVER MENTIONED. AN INSTRUCTOR IN THE L SEAT, EXPERIENCED FO IN THE R AND ANOTHER COMPANY PLT IN THE JUMP SEAT, COMMUTING HOME. CONTRIBUTING FACTORS: 1) 4TH LEG OF A LONG DAY. 2) RUNNING 2 HR LATE DUE TO WX AT STL. 3) FULL LOAD OF PAX HAD BEEN WAITING A LONG TIME FOR THE CREW TO ARRIVE. 4) BLOCKED OUT AND RETURNED TO GATE BECAUSE WE WERE OVERWT FOR DEP. 5) RWY CHANGE AS WE STARTED TAXIING THE SECOND TIME CAUSED MORE DELAY. 6) RAIN AND GUSTY XWINDS ON TKOF, TURB ON DEP. 7) DEST WX NOT MUCH BETTER. 8) MAINT AT DEST TO HANDLE PROB. 9) 14 HR DUTY BY THE TIME WE GOT TO DEST. ARRIVED FOR XA00 DEP THE NEXT MORNING, AFTER 11 HR 15 MIN CREW REST. ASSIGNED THE SAME ACFT WITH MALFUNCTION SIGNED OFF. CHANGED GYRO, AND OPS CHKED OK. SUSPECTED WE MIGHT ENCOUNTER THE SAME PROB. NO MENTION OF RETURNING IF PROB RECURRED. BRIEFED TO LOOK FOR PROB EARLY AND ANTICIPATE PROB. ADI FAILED AGAIN AND WE CONTINUED TO HUB. CONTRIBUTING FACTORS: 1) DARK, EARLY MORNING DEPT. HAD SNOWED NIGHT BEFORE. LIMITED ARPT OPS. 2) WX WAS BETTER AT HUB AND DAYLIGHT LNDG. 3) 2 MORE LEGS AHEAD OF US TO COMPLETE A 4 DAY TRIP AND GO HOME. 4) HUB MAINT AVAILABLE TO CORRECT PROB. 5) KNEW WE FLEW ACFT OUT AND WOULD BE ABLE TO FLY IT BACK. IT SHOULD HAVE BEEN OBVIOUS THAT THE PRUDENT OPTION WOULD HAVE BEEN TO RETURN TO BASE ON THE FIRST LEG AND THE SECOND OCCURRENCE WOULDN'T HAVE HAPPENED. ALSO, OBVIOUS THAT HAD THIS OCCURRED IN THE SIMULATOR, WE WOULD HAVE MORE THAN LIKELY RETURNED AND LANDED OVERWT. WHY DIDN'T THIS CARRY OVER TO FLT OPS AND WHY IS IT SO MUCH EASIER TO SEE THE OBVIOUS SITTING HERE DRINKING A COLD ROOT BEER.
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.