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|
Attributes | |
ACN | 506042 |
Time | |
Date | 200103 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 1000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Aircraft 1 | |
Controlling Facilities | tracon : a90.tracon tower : bos.tower |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : cfi pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 2400 flight time type : 500 |
ASRS Report | 506042 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : landed as precaution none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On takeoff from outstation in IMC, captain's eadi, ehsi and mfd went black for approximately 2 seconds when gear was selected up (gear functioned ok). Captain was initially PF, xferred controls to me. First officer's displays were unaffected. Captain realized problem was hydraulic pump operation (automatic in cause of gear operation) causes blacking of display. This exact problem had been written up the day before our flight. Maintenance reported something to the effect of 'operations checks ok on ground.' I flew remainder of flight in IMC. Bos was initially reporting good VMC. At arrival, conditions had deteriorated to approximately 1-2 mi in snow. This, in addition to continuing EFIS problem, caused definite narrowing of attention and/or distraction. After shooting ILS and landing, captain realized he had never contacted tower and/or received landing clearance. Later phone call (unsolicited) to tower revealed they had cleared us to land. Why this happened: combined distraction of mechanical problem and lower than expected WX. When captain's displays would blank, my side would lose flight director and flash comparator warning flags. This occurred every few mins throughout the flight -- very unnerving and distracting. My focus was totally narrowed on the task of flying the approach and I lost peripheral awareness of radio communications and if we had been cleared to land or not. All checklists were completed. Apparently, attention was only given to 'rote' items. Contributing factor: maintenance's failure to properly deal with an item. I have seen a tendency to 'operations check ok' items which are then written up a second time before they are really fixed.
Original NASA ASRS Text
Title: ON DEP THE CAPT OF AN SF34 EXPERIENCED FLT INST FAILURE. THIS DISTR LED TO THE CREW LWOC.
Narrative: ON TKOF FROM OUTSTATION IN IMC, CAPT'S EADI, EHSI AND MFD WENT BLACK FOR APPROX 2 SECONDS WHEN GEAR WAS SELECTED UP (GEAR FUNCTIONED OK). CAPT WAS INITIALLY PF, XFERRED CTLS TO ME. FO'S DISPLAYS WERE UNAFFECTED. CAPT REALIZED PROB WAS HYD PUMP OP (AUTOMATIC IN CAUSE OF GEAR OP) CAUSES BLACKING OF DISPLAY. THIS EXACT PROB HAD BEEN WRITTEN UP THE DAY BEFORE OUR FLT. MAINT RPTED SOMETHING TO THE EFFECT OF 'OPS CHKS OK ON GND.' I FLEW REMAINDER OF FLT IN IMC. BOS WAS INITIALLY RPTING GOOD VMC. AT ARR, CONDITIONS HAD DETERIORATED TO APPROX 1-2 MI IN SNOW. THIS, IN ADDITION TO CONTINUING EFIS PROB, CAUSED DEFINITE NARROWING OF ATTN AND/OR DISTR. AFTER SHOOTING ILS AND LNDG, CAPT REALIZED HE HAD NEVER CONTACTED TWR AND/OR RECEIVED LNDG CLRNC. LATER PHONE CALL (UNSOLICITED) TO TWR REVEALED THEY HAD CLRED US TO LAND. WHY THIS HAPPENED: COMBINED DISTR OF MECHANICAL PROB AND LOWER THAN EXPECTED WX. WHEN CAPT'S DISPLAYS WOULD BLANK, MY SIDE WOULD LOSE FLT DIRECTOR AND FLASH COMPARATOR WARNING FLAGS. THIS OCCURRED EVERY FEW MINS THROUGHOUT THE FLT -- VERY UNNERVING AND DISTRACTING. MY FOCUS WAS TOTALLY NARROWED ON THE TASK OF FLYING THE APCH AND I LOST PERIPHERAL AWARENESS OF RADIO COMS AND IF WE HAD BEEN CLRED TO LAND OR NOT. ALL CHKLISTS WERE COMPLETED. APPARENTLY, ATTN WAS ONLY GIVEN TO 'ROTE' ITEMS. CONTRIBUTING FACTOR: MAINT'S FAILURE TO PROPERLY DEAL WITH AN ITEM. I HAVE SEEN A TENDENCY TO 'OPS CHK OK' ITEMS WHICH ARE THEN WRITTEN UP A SECOND TIME BEFORE THEY ARE REALLY FIXED.
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.