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|
Attributes | |
ACN | 532693 |
Time | |
Date | 200112 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : gsp.airport |
State Reference | SC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : gsp.tower |
Operator | common carrier : air carrier |
Make Model Name | Do 328 TP (Turboprop) |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : takeoff ground : parked ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 18 flight time total : 3800 flight time type : 650 |
ASRS Report | 532693 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : gear indicator other flight crewa |
Resolutory Action | other |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
I am a first officer for the airline. I actually was in an upgrade class for captain, but due to my own weaknesses in the simulator, I had to request a 'return to seat' to avoid getting pink slipped. This was my first trip/first leg after a 3 1/2 months time-frame away from the aircraft. I had flown some GA stuff (I own a small southeast aircraft) but from sep/sat/01 to dec/fri/01, I had only flown 6 simulator sessions in the dornier level D simulator. I had just passed a fresh proficiency check and was returned immediately to the line. On the day of the incident, I was asked by scheduling if I could 'do them a favor' and report to dulles at XA00 pm to be deadheaded to gsp rather than flying to laguardia and then deadheading to cae the next day -- this would save the company from canceling 4 trips. When I arrived at gsp, I was met by my captain who immediately asked if I was 'experienced.' I told him my story and he said 'hoo boy, I just got off 2 months of air force reserve, this is my first trip back.' I suggested that he call scheduling and try to explain this (that we were practically green on green). He said 'you know what they will say to that!' this should have been a warning sign for me to run away but I continued to go along. We found out that the plane had an APU generator deferred. This extra item was a substantial link in this chain. We would have to use a ground power unit (gpu) and start engines at the gate. I performed the preflight as normal. As is the custom, the captain was inside doing cockpit checks, I was outside. I returned to the inside and started doing all the prep work for the turn check and getting us out of the gate. Everything was pretty normal through the turn check and before start check. The captain was concentrating on starting the engines at the gate. We started in normal sequence and the captain called for an 'after start' checklist. I ran down all the items. This is when our combined time away from the airplane began to show. First, I have an 'uncage standby instruments' checklist item. I did this and the peanut horizon began to immediately tumble -- completely out of the ordinary and I called it to the captain's attention. He saw a cas message for 'standby air data computer/ahrs not available.' we checked the QRH and it simply directed that we did not have standby instruments to back up our normal EFIS displays and standard double ahrs computer. This didn't seem right but it wasn't a complete disaster. By the way we did complete the after start checklist before the standby instruments got our attention. The captain started a call to maintenance but it didn't go through. He then directed the ground crew to disconnect the gpu which caused quite a power fluctuation in the airplane. All sorts of instruments and screens fell off line and then returned one-by-one as the generators picked up the load. The captain called for a pushback. As part of the after start check, we are directed to set nosewheel steering to 'on' and 'high.' it didn't dawn on me until we were halfway back and I pointed out to the captain that the tug can't steer us with nosewheel steering set on. At the same moment the tug came to a halt and the driver said that the pin connecting the towbar to the airplane had just broken. This sheer pin is probably there to protect the plane from being damaged in just such an event. There were now a number of conversations between the captain and the pushback crew through the hamburger door (document door of the dornier). The captain was trying to figure out if the gear was broken or whether the towbar had broken. A piece of metal was passed to the captain that looked like the linkage normally screwed on to the plane where the towbar connects. The captain asked the ramp if this was part of the gear and whether the plane was damaged. The final outcome was that the rampers said the gear was ok but this came off the plane. The captain was debating about returning to the gate. I was all for that. The rampers then had problems moving the tug and were seen arguing about the towbar. The captain then did a 180 degrees on me and said 'this must be part of their towbar, let's go.' here I must show my state of mind because I really wanted to say 'no, I'd rather go back to the gate' but mentally acquiesced and said 'ok.' the captain called the ramp and said we decided to continue. We got a wave off from the crew and taxied out for takeoff. After takeoff and on gear retraction, we got a nose gear unsafe and the gear would not retract. When placed in the 'down' position we did get 3 green. The captain was relieved that we could get the gear down but was chagrined that the 'broken piece' must have been from our aircraft. As it turns out in all the mayhem, the ramp crew left the gear pin in nose gear and our wave off was not genuine. I never saw a pin during wave off but the captain says the ramper showed him a pin and gave him a thumbs up. In retrospect, I feel completely embarrassed by my performance in light of the events. Although the captain bears a large part of the blame, my head was not 'in the game.' I was rusty, not thinking through problems and never challenged authority/authorized. This was a flight and an event that should have never happened. Blame can go in all directions. Scheduling at our company is the largest and first link in the chain. For the sake of making one more pairing work, they put together 2 crew members who were practically green on green. I know that there is no regulation on this but really -- the captain was just inside his legality of 3 takeoffs and lndgs in the last 90 days and I was woefully out of practice. We were thrown together and deadheaded at the last min -- rushing and very inconvenienced. The flight was at XO00 on a day that I didn't even think I was working. I had been up since XA00 to do chores around my house and getting ready to 'commute' to lga. I had no thoughts that I would be flying an airplane that night. Of course, I never had to agree to take this trip, but I was so embarrassed by failing in my upgrade attempt that my ego was shot. I wanted to try and help the company when they had been paying me and trying to help me upgrade and I let them down. Now, instead of a captain, I was returning as a lowly first officer and not feeling good about my talents as a pilot in general. The airplane always has MEL items -- the APU and APU generators are always breaking and it is one big headache on this plane. What I don't understand is why there isn't some kind of alternate checklist in the QRH for gpu/'puffer cart' starts. This is a high workload environment with numerous details that need to be accounted for. My captain's errors are noted including the fact that during the taxi check I noticed that the batteries were not selected on. In arriving at the airplane powered by the gpu, he had simply selected that power and then started engines from auxiliary power. The reason we didn't' have standby instruments is because they come off the battery bus. If I had half a brain working I could have figured that out before all this mess started. By not vocalizing my ill feelings about continuing with the flight I could have endangered a lot of people. Safety is job one. I preach it to all my students -- why am I exempt? My only excuse was my frame of mind -- I felt less of a pilot on this first night back.
Original NASA ASRS Text
Title: A LNDG GEAR PIN NOT REMOVED AND A RETURN TO LAND THAT ARE PRECEDED BY EVENTS THAT HIGHLIGHT DEFICIENCIES IN COMPANY POLICY, CREW RESOURCE MGMNT AND PLT PROFICIENCY.
Narrative: I AM A FO FOR THE AIRLINE. I ACTUALLY WAS IN AN UPGRADE CLASS FOR CAPT, BUT DUE TO MY OWN WEAKNESSES IN THE SIMULATOR, I HAD TO REQUEST A 'RETURN TO SEAT' TO AVOID GETTING PINK SLIPPED. THIS WAS MY FIRST TRIP/FIRST LEG AFTER A 3 1/2 MONTHS TIME-FRAME AWAY FROM THE ACFT. I HAD FLOWN SOME GA STUFF (I OWN A SMALL SE ACFT) BUT FROM SEP/SAT/01 TO DEC/FRI/01, I HAD ONLY FLOWN 6 SIMULATOR SESSIONS IN THE DORNIER LEVEL D SIMULATOR. I HAD JUST PASSED A FRESH PROFICIENCY CHK AND WAS RETURNED IMMEDIATELY TO THE LINE. ON THE DAY OF THE INCIDENT, I WAS ASKED BY SCHEDULING IF I COULD 'DO THEM A FAVOR' AND RPT TO DULLES AT XA00 PM TO BE DEADHEADED TO GSP RATHER THAN FLYING TO LAGUARDIA AND THEN DEADHEADING TO CAE THE NEXT DAY -- THIS WOULD SAVE THE COMPANY FROM CANCELING 4 TRIPS. WHEN I ARRIVED AT GSP, I WAS MET BY MY CAPT WHO IMMEDIATELY ASKED IF I WAS 'EXPERIENCED.' I TOLD HIM MY STORY AND HE SAID 'HOO BOY, I JUST GOT OFF 2 MONTHS OF AIR FORCE RESERVE, THIS IS MY FIRST TRIP BACK.' I SUGGESTED THAT HE CALL SCHEDULING AND TRY TO EXPLAIN THIS (THAT WE WERE PRACTICALLY GREEN ON GREEN). HE SAID 'YOU KNOW WHAT THEY WILL SAY TO THAT!' THIS SHOULD HAVE BEEN A WARNING SIGN FOR ME TO RUN AWAY BUT I CONTINUED TO GO ALONG. WE FOUND OUT THAT THE PLANE HAD AN APU GENERATOR DEFERRED. THIS EXTRA ITEM WAS A SUBSTANTIAL LINK IN THIS CHAIN. WE WOULD HAVE TO USE A GND PWR UNIT (GPU) AND START ENGS AT THE GATE. I PERFORMED THE PREFLT AS NORMAL. AS IS THE CUSTOM, THE CAPT WAS INSIDE DOING COCKPIT CHKS, I WAS OUTSIDE. I RETURNED TO THE INSIDE AND STARTED DOING ALL THE PREP WORK FOR THE TURN CHK AND GETTING US OUT OF THE GATE. EVERYTHING WAS PRETTY NORMAL THROUGH THE TURN CHK AND BEFORE START CHK. THE CAPT WAS CONCENTRATING ON STARTING THE ENGS AT THE GATE. WE STARTED IN NORMAL SEQUENCE AND THE CAPT CALLED FOR AN 'AFTER START' CHKLIST. I RAN DOWN ALL THE ITEMS. THIS IS WHEN OUR COMBINED TIME AWAY FROM THE AIRPLANE BEGAN TO SHOW. FIRST, I HAVE AN 'UNCAGE STANDBY INSTS' CHKLIST ITEM. I DID THIS AND THE PEANUT HORIZON BEGAN TO IMMEDIATELY TUMBLE -- COMPLETELY OUT OF THE ORDINARY AND I CALLED IT TO THE CAPT'S ATTN. HE SAW A CAS MESSAGE FOR 'STANDBY ADC/AHRS NOT AVAILABLE.' WE CHKED THE QRH AND IT SIMPLY DIRECTED THAT WE DID NOT HAVE STANDBY INSTS TO BACK UP OUR NORMAL EFIS DISPLAYS AND STANDARD DOUBLE AHRS COMPUTER. THIS DIDN'T SEEM RIGHT BUT IT WASN'T A COMPLETE DISASTER. BY THE WAY WE DID COMPLETE THE AFTER START CHKLIST BEFORE THE STANDBY INSTS GOT OUR ATTN. THE CAPT STARTED A CALL TO MAINT BUT IT DIDN'T GO THROUGH. HE THEN DIRECTED THE GND CREW TO DISCONNECT THE GPU WHICH CAUSED QUITE A PWR FLUCTUATION IN THE AIRPLANE. ALL SORTS OF INSTS AND SCREENS FELL OFF LINE AND THEN RETURNED ONE-BY-ONE AS THE GENERATORS PICKED UP THE LOAD. THE CAPT CALLED FOR A PUSHBACK. AS PART OF THE AFTER START CHK, WE ARE DIRECTED TO SET NOSEWHEEL STEERING TO 'ON' AND 'HIGH.' IT DIDN'T DAWN ON ME UNTIL WE WERE HALFWAY BACK AND I POINTED OUT TO THE CAPT THAT THE TUG CAN'T STEER US WITH NOSEWHEEL STEERING SET ON. AT THE SAME MOMENT THE TUG CAME TO A HALT AND THE DRIVER SAID THAT THE PIN CONNECTING THE TOWBAR TO THE AIRPLANE HAD JUST BROKEN. THIS SHEER PIN IS PROBABLY THERE TO PROTECT THE PLANE FROM BEING DAMAGED IN JUST SUCH AN EVENT. THERE WERE NOW A NUMBER OF CONVERSATIONS BTWN THE CAPT AND THE PUSHBACK CREW THROUGH THE HAMBURGER DOOR (DOCUMENT DOOR OF THE DORNIER). THE CAPT WAS TRYING TO FIGURE OUT IF THE GEAR WAS BROKEN OR WHETHER THE TOWBAR HAD BROKEN. A PIECE OF METAL WAS PASSED TO THE CAPT THAT LOOKED LIKE THE LINKAGE NORMALLY SCREWED ON TO THE PLANE WHERE THE TOWBAR CONNECTS. THE CAPT ASKED THE RAMP IF THIS WAS PART OF THE GEAR AND WHETHER THE PLANE WAS DAMAGED. THE FINAL OUTCOME WAS THAT THE RAMPERS SAID THE GEAR WAS OK BUT THIS CAME OFF THE PLANE. THE CAPT WAS DEBATING ABOUT RETURNING TO THE GATE. I WAS ALL FOR THAT. THE RAMPERS THEN HAD PROBS MOVING THE TUG AND WERE SEEN ARGUING ABOUT THE TOWBAR. THE CAPT THEN DID A 180 DEGS ON ME AND SAID 'THIS MUST BE PART OF THEIR TOWBAR, LET'S GO.' HERE I MUST SHOW MY STATE OF MIND BECAUSE I REALLY WANTED TO SAY 'NO, I'D RATHER GO BACK TO THE GATE' BUT MENTALLY ACQUIESCED AND SAID 'OK.' THE CAPT CALLED THE RAMP AND SAID WE DECIDED TO CONTINUE. WE GOT A WAVE OFF FROM THE CREW AND TAXIED OUT FOR TKOF. AFTER TKOF AND ON GEAR RETRACTION, WE GOT A NOSE GEAR UNSAFE AND THE GEAR WOULD NOT RETRACT. WHEN PLACED IN THE 'DOWN' POS WE DID GET 3 GREEN. THE CAPT WAS RELIEVED THAT WE COULD GET THE GEAR DOWN BUT WAS CHAGRINED THAT THE 'BROKEN PIECE' MUST HAVE BEEN FROM OUR ACFT. AS IT TURNS OUT IN ALL THE MAYHEM, THE RAMP CREW LEFT THE GEAR PIN IN NOSE GEAR AND OUR WAVE OFF WAS NOT GENUINE. I NEVER SAW A PIN DURING WAVE OFF BUT THE CAPT SAYS THE RAMPER SHOWED HIM A PIN AND GAVE HIM A THUMBS UP. IN RETROSPECT, I FEEL COMPLETELY EMBARRASSED BY MY PERFORMANCE IN LIGHT OF THE EVENTS. ALTHOUGH THE CAPT BEARS A LARGE PART OF THE BLAME, MY HEAD WAS NOT 'IN THE GAME.' I WAS RUSTY, NOT THINKING THROUGH PROBS AND NEVER CHALLENGED AUTH. THIS WAS A FLT AND AN EVENT THAT SHOULD HAVE NEVER HAPPENED. BLAME CAN GO IN ALL DIRECTIONS. SCHEDULING AT OUR COMPANY IS THE LARGEST AND FIRST LINK IN THE CHAIN. FOR THE SAKE OF MAKING ONE MORE PAIRING WORK, THEY PUT TOGETHER 2 CREW MEMBERS WHO WERE PRACTICALLY GREEN ON GREEN. I KNOW THAT THERE IS NO REG ON THIS BUT REALLY -- THE CAPT WAS JUST INSIDE HIS LEGALITY OF 3 TKOFS AND LNDGS IN THE LAST 90 DAYS AND I WAS WOEFULLY OUT OF PRACTICE. WE WERE THROWN TOGETHER AND DEADHEADED AT THE LAST MIN -- RUSHING AND VERY INCONVENIENCED. THE FLT WAS AT XO00 ON A DAY THAT I DIDN'T EVEN THINK I WAS WORKING. I HAD BEEN UP SINCE XA00 TO DO CHORES AROUND MY HOUSE AND GETTING READY TO 'COMMUTE' TO LGA. I HAD NO THOUGHTS THAT I WOULD BE FLYING AN AIRPLANE THAT NIGHT. OF COURSE, I NEVER HAD TO AGREE TO TAKE THIS TRIP, BUT I WAS SO EMBARRASSED BY FAILING IN MY UPGRADE ATTEMPT THAT MY EGO WAS SHOT. I WANTED TO TRY AND HELP THE COMPANY WHEN THEY HAD BEEN PAYING ME AND TRYING TO HELP ME UPGRADE AND I LET THEM DOWN. NOW, INSTEAD OF A CAPT, I WAS RETURNING AS A LOWLY FO AND NOT FEELING GOOD ABOUT MY TALENTS AS A PLT IN GENERAL. THE AIRPLANE ALWAYS HAS MEL ITEMS -- THE APU AND APU GENERATORS ARE ALWAYS BREAKING AND IT IS ONE BIG HEADACHE ON THIS PLANE. WHAT I DON'T UNDERSTAND IS WHY THERE ISN'T SOME KIND OF ALTERNATE CHKLIST IN THE QRH FOR GPU/'PUFFER CART' STARTS. THIS IS A HIGH WORKLOAD ENVIRONMENT WITH NUMEROUS DETAILS THAT NEED TO BE ACCOUNTED FOR. MY CAPT'S ERRORS ARE NOTED INCLUDING THE FACT THAT DURING THE TAXI CHK I NOTICED THAT THE BATTERIES WERE NOT SELECTED ON. IN ARRIVING AT THE AIRPLANE POWERED BY THE GPU, HE HAD SIMPLY SELECTED THAT PWR AND THEN STARTED ENGS FROM AUX PWR. THE REASON WE DIDN'T' HAVE STANDBY INSTS IS BECAUSE THEY COME OFF THE BATTERY BUS. IF I HAD HALF A BRAIN WORKING I COULD HAVE FIGURED THAT OUT BEFORE ALL THIS MESS STARTED. BY NOT VOCALIZING MY ILL FEELINGS ABOUT CONTINUING WITH THE FLT I COULD HAVE ENDANGERED A LOT OF PEOPLE. SAFETY IS JOB ONE. I PREACH IT TO ALL MY STUDENTS -- WHY AM I EXEMPT? MY ONLY EXCUSE WAS MY FRAME OF MIND -- I FELT LESS OF A PLT ON THIS FIRST NIGHT BACK.
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.