37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 591006 |
Time | |
Date | 200308 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | msl single value : 8000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : den.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : takeoff cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 591006 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : ecam indication other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | other other |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
Aircraft had uncommanded symmetrical spoiler deployment/float of #4 spoilers after V1 at minimum unstick speed and aircraft going airborne, committed to takeoff. Spoiler deployment was due to failure of maintenance team to properly complete deferral procedure and lock down spoiler panels. Hydraulics had been shut off to actuators. Spoiler float reported by qualified observers from cabin (mechanic on pass travel, furloughed airbus pilot on pass travel). Maximum float increment reported to be approximately 6 inches, #4 panels only. Rotation was normal and aircraft required approximately 5500 ft of runway to reach V1/vr. Acceleration before and after rotation was normal, but the aircraft did not unstick with the usual deck angle of approximately 10 degrees. Additional stick pressure was required, and additional runway was used -- perhaps 3000 ft more -- to fly out to 2ND segment climb. Best estimate to 50 ft was approximately 8500 ft of runway. Gear retraction and flap retraction was normal, except that slat retraction caused vertical speed indication on the pfd to rapidly rise, and additional speed beyond green DOT was commanded and flown. 250 KTS was selected early, below 3000 ft afe. Aircraft maneuvered less characteristically of normal law, lateral control past 5 degrees caused considerable rumble buzz and vibration. Acceleration is clean confign was normal, straight ahead flight characteristics were normal, except for rumble from floating panels. Autoplt maintained good lateral control, but pitch management was degraded, even using vertical speed, aircraft had tendency to pitch abruptly for first hour of flight on autoplt. Hand-flying pitch characteristics were acceptable. Center of gravity on departure was 34% mac according to load planning. After 2 hours, fpred page showed mac had moved to 36%. Rumble had diminished considerably. Autoplt pitch characteristics were more representative of normal law. The fctl ECAM page is not presented on takeoff roll. It did not pop up either during rotation or climb out. When examined after initial climb out through approximately 12000-15000 ft, an amber deflected indication was noted above spoilers #4. ECAM did not give any level warning of the panel deployment. Initially, there was no way to determine if the handling quality was due to poor air stability as characteristic of denver in the midday of summertime, or if a mechanical failure had occurred. Crew decision was to continue through the initial climb out through 18000 ft. Speed was kept reduced to 250 KTS below 20000 ft and below 280 KTS below cruise altitude. It was not until acceleration to 280 KTS that the information concerning the visual confirmation of spoiler floatation was brought forward by the flight attendant. We elected to continue to a lower cruise altitude, with an intermediate stop at FL250. It was also decided that we would cruise slower, consider our options including a return to denver if necessary, or a diversion to any of several airports within the air carrier system and also without. Primary consideration was runway length, secondary consideration was WX or rather lack of it. We worked in concert with dispatcher and maintenance to determine how best to manage this problem. Maintenance found no reason to discontinue flight due to safety. Since the airframe vibration became more stable and less noticeable as the center of gravity shifted, continuation to destination became more probably. At 150 mi downrange from denver an intermediate of lincoln, northeast, or omaha were considered, should mechanical failure occur (panel separation or asymmetry). Fuel burn and considerations were discussed with dispatch and it was determined that if upon reaching pwe burn rates were excessive, we would divert to ord. At each of several waypoints along our route of flight, we were ready to divert to ord as an emergency aircraft. East of indianapolis, we again gave our fuel and burn rates to dispatch and we concurred that a successful continuation to phl was realistic. The flight terminated in a normal arrival, approach and landing on runway 9R in phl, with approximately 7500 pounds of fuel remaining. There was high activity and good coordination between the cockpit crew members. At each waypoint, there was inquiry as to whether continuation or diversion should be the course of action. Objective information: fuel remaining, aircraft handling qualities, cabin attendant comfort levels, passenger comfort levels -- were all given consideration. Additionally, any safety 'red flags' were considered, with an awareness that other courses of action might be offered by dispatch or maintenance. Continuation was only possible because all elements -- dispatch, lint maintenance, all flight crew, and of course, the airplane -- were in agreement that a safe outcome was certain. The possibility of an aircraft accident was created by incomplete maintenance procedures, lack of proper supervision and lack of adequate maintenance personnel to complete either the deferral of a repair. This is supposed to be a fairly routine procedure. This incident highlights the need for properly trained aviation maintenance technicians at air carrier stations. It highlights the need for readdressing how this company perceives its maintenance function. It also highlights the need for the company to further invest in the human element of maintenance, the amt. While maintenance may have failed to accomplish a maintenance procedure, other links in the chain of events held fast. A properly trained crew was able to safely fly a compromised airframe, without further damage. Crew communication with all resources made alternatives and options possible, increasing confidence that a safe outcome was assured. It is my hope that I have been able to convey the importance of this incident to the reader without painting too many emotionally-charged brushstrokes. This event points out how dangerously thin this company's resources are being pulled. Other airlines can suffer seemingly any number of calamities and skate on through. Our enterprise does not enjoy the luxury of any mistake! We need to become very introspective at every level within this organization.
Original NASA ASRS Text
Title: A320 FLT CREW HAS SPOILER FLOAT DURING TKOF FROM DEN.
Narrative: ACFT HAD UNCOMMANDED SYMMETRICAL SPOILER DEPLOYMENT/FLOAT OF #4 SPOILERS AFTER V1 AT MINIMUM UNSTICK SPD AND ACFT GOING AIRBORNE, COMMITTED TO TKOF. SPOILER DEPLOYMENT WAS DUE TO FAILURE OF MAINT TEAM TO PROPERLY COMPLETE DEFERRAL PROC AND LOCK DOWN SPOILER PANELS. HYDS HAD BEEN SHUT OFF TO ACTUATORS. SPOILER FLOAT RPTED BY QUALIFIED OBSERVERS FROM CABIN (MECH ON PASS TRAVEL, FURLOUGHED AIRBUS PLT ON PASS TRAVEL). MAX FLOAT INCREMENT RPTED TO BE APPROX 6 INCHES, #4 PANELS ONLY. ROTATION WAS NORMAL AND ACFT REQUIRED APPROX 5500 FT OF RWY TO REACH V1/VR. ACCELERATION BEFORE AND AFTER ROTATION WAS NORMAL, BUT THE ACFT DID NOT UNSTICK WITH THE USUAL DECK ANGLE OF APPROX 10 DEGS. ADDITIONAL STICK PRESSURE WAS REQUIRED, AND ADDITIONAL RWY WAS USED -- PERHAPS 3000 FT MORE -- TO FLY OUT TO 2ND SEGMENT CLB. BEST ESTIMATE TO 50 FT WAS APPROX 8500 FT OF RWY. GEAR RETRACTION AND FLAP RETRACTION WAS NORMAL, EXCEPT THAT SLAT RETRACTION CAUSED VERT SPD INDICATION ON THE PFD TO RAPIDLY RISE, AND ADDITIONAL SPD BEYOND GREEN DOT WAS COMMANDED AND FLOWN. 250 KTS WAS SELECTED EARLY, BELOW 3000 FT AFE. ACFT MANEUVERED LESS CHARACTERISTICALLY OF NORMAL LAW, LATERAL CTL PAST 5 DEGS CAUSED CONSIDERABLE RUMBLE BUZZ AND VIBRATION. ACCELERATION IS CLEAN CONFIGN WAS NORMAL, STRAIGHT AHEAD FLT CHARACTERISTICS WERE NORMAL, EXCEPT FOR RUMBLE FROM FLOATING PANELS. AUTOPLT MAINTAINED GOOD LATERAL CTL, BUT PITCH MGMNT WAS DEGRADED, EVEN USING VERT SPD, ACFT HAD TENDENCY TO PITCH ABRUPTLY FOR FIRST HR OF FLT ON AUTOPLT. HAND-FLYING PITCH CHARACTERISTICS WERE ACCEPTABLE. CTR OF GRAVITY ON DEP WAS 34% MAC ACCORDING TO LOAD PLANNING. AFTER 2 HRS, FPRED PAGE SHOWED MAC HAD MOVED TO 36%. RUMBLE HAD DIMINISHED CONSIDERABLY. AUTOPLT PITCH CHARACTERISTICS WERE MORE REPRESENTATIVE OF NORMAL LAW. THE FCTL ECAM PAGE IS NOT PRESENTED ON TKOF ROLL. IT DID NOT POP UP EITHER DURING ROTATION OR CLBOUT. WHEN EXAMINED AFTER INITIAL CLBOUT THROUGH APPROX 12000-15000 FT, AN AMBER DEFLECTED INDICATION WAS NOTED ABOVE SPOILERS #4. ECAM DID NOT GIVE ANY LEVEL WARNING OF THE PANEL DEPLOYMENT. INITIALLY, THERE WAS NO WAY TO DETERMINE IF THE HANDLING QUALITY WAS DUE TO POOR AIR STABILITY AS CHARACTERISTIC OF DENVER IN THE MIDDAY OF SUMMERTIME, OR IF A MECHANICAL FAILURE HAD OCCURRED. CREW DECISION WAS TO CONTINUE THROUGH THE INITIAL CLBOUT THROUGH 18000 FT. SPD WAS KEPT REDUCED TO 250 KTS BELOW 20000 FT AND BELOW 280 KTS BELOW CRUISE ALT. IT WAS NOT UNTIL ACCELERATION TO 280 KTS THAT THE INFO CONCERNING THE VISUAL CONFIRMATION OF SPOILER FLOATATION WAS BROUGHT FORWARD BY THE FLT ATTENDANT. WE ELECTED TO CONTINUE TO A LOWER CRUISE ALT, WITH AN INTERMEDIATE STOP AT FL250. IT WAS ALSO DECIDED THAT WE WOULD CRUISE SLOWER, CONSIDER OUR OPTIONS INCLUDING A RETURN TO DENVER IF NECESSARY, OR A DIVERSION TO ANY OF SEVERAL ARPTS WITHIN THE ACR SYS AND ALSO WITHOUT. PRIMARY CONSIDERATION WAS RWY LENGTH, SECONDARY CONSIDERATION WAS WX OR RATHER LACK OF IT. WE WORKED IN CONCERT WITH DISPATCHER AND MAINT TO DETERMINE HOW BEST TO MANAGE THIS PROB. MAINT FOUND NO REASON TO DISCONTINUE FLT DUE TO SAFETY. SINCE THE AIRFRAME VIBRATION BECAME MORE STABLE AND LESS NOTICEABLE AS THE CTR OF GRAVITY SHIFTED, CONTINUATION TO DEST BECAME MORE PROBABLY. AT 150 MI DOWNRANGE FROM DENVER AN INTERMEDIATE OF LINCOLN, NE, OR OMAHA WERE CONSIDERED, SHOULD MECHANICAL FAILURE OCCUR (PANEL SEPARATION OR ASYMMETRY). FUEL BURN AND CONSIDERATIONS WERE DISCUSSED WITH DISPATCH AND IT WAS DETERMINED THAT IF UPON REACHING PWE BURN RATES WERE EXCESSIVE, WE WOULD DIVERT TO ORD. AT EACH OF SEVERAL WAYPOINTS ALONG OUR RTE OF FLT, WE WERE READY TO DIVERT TO ORD AS AN EMER ACFT. E OF INDIANAPOLIS, WE AGAIN GAVE OUR FUEL AND BURN RATES TO DISPATCH AND WE CONCURRED THAT A SUCCESSFUL CONTINUATION TO PHL WAS REALISTIC. THE FLT TERMINATED IN A NORMAL ARR, APCH AND LNDG ON RWY 9R IN PHL, WITH APPROX 7500 LBS OF FUEL REMAINING. THERE WAS HIGH ACTIVITY AND GOOD COORD BTWN THE COCKPIT CREW MEMBERS. AT EACH WAYPOINT, THERE WAS INQUIRY AS TO WHETHER CONTINUATION OR DIVERSION SHOULD BE THE COURSE OF ACTION. OBJECTIVE INFO: FUEL REMAINING, ACFT HANDLING QUALITIES, CABIN ATTENDANT COMFORT LEVELS, PAX COMFORT LEVELS -- WERE ALL GIVEN CONSIDERATION. ADDITIONALLY, ANY SAFETY 'RED FLAGS' WERE CONSIDERED, WITH AN AWARENESS THAT OTHER COURSES OF ACTION MIGHT BE OFFERED BY DISPATCH OR MAINT. CONTINUATION WAS ONLY POSSIBLE BECAUSE ALL ELEMENTS -- DISPATCH, LINT MAINT, ALL FLT CREW, AND OF COURSE, THE AIRPLANE -- WERE IN AGREEMENT THAT A SAFE OUTCOME WAS CERTAIN. THE POSSIBILITY OF AN ACFT ACCIDENT WAS CREATED BY INCOMPLETE MAINT PROCS, LACK OF PROPER SUPERVISION AND LACK OF ADEQUATE MAINT PERSONNEL TO COMPLETE EITHER THE DEFERRAL OF A REPAIR. THIS IS SUPPOSED TO BE A FAIRLY ROUTINE PROC. THIS INCIDENT HIGHLIGHTS THE NEED FOR PROPERLY TRAINED AVIATION MAINT TECHNICIANS AT ACR STATIONS. IT HIGHLIGHTS THE NEED FOR READDRESSING HOW THIS COMPANY PERCEIVES ITS MAINT FUNCTION. IT ALSO HIGHLIGHTS THE NEED FOR THE COMPANY TO FURTHER INVEST IN THE HUMAN ELEMENT OF MAINT, THE AMT. WHILE MAINT MAY HAVE FAILED TO ACCOMPLISH A MAINT PROC, OTHER LINKS IN THE CHAIN OF EVENTS HELD FAST. A PROPERLY TRAINED CREW WAS ABLE TO SAFELY FLY A COMPROMISED AIRFRAME, WITHOUT FURTHER DAMAGE. CREW COM WITH ALL RESOURCES MADE ALTERNATIVES AND OPTIONS POSSIBLE, INCREASING CONFIDENCE THAT A SAFE OUTCOME WAS ASSURED. IT IS MY HOPE THAT I HAVE BEEN ABLE TO CONVEY THE IMPORTANCE OF THIS INCIDENT TO THE READER WITHOUT PAINTING TOO MANY EMOTIONALLY-CHARGED BRUSHSTROKES. THIS EVENT POINTS OUT HOW DANGEROUSLY THIN THIS COMPANY'S RESOURCES ARE BEING PULLED. OTHER AIRLINES CAN SUFFER SEEMINGLY ANY NUMBER OF CALAMITIES AND SKATE ON THROUGH. OUR ENTERPRISE DOES NOT ENJOY THE LUXURY OF ANY MISTAKE! WE NEED TO BECOME VERY INTROSPECTIVE AT EVERY LEVEL WITHIN THIS ORGANIZATION.
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.