37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 790058 |
Time | |
Date | 200806 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : zzz.vortac |
State Reference | US |
Altitude | msl single value : 37000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Turbulence Ice |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 790058 |
Events | |
Anomaly | inflight encounter : turbulence maintenance problem : improper documentation non adherence : far non adherence : company policies non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : regained aircraft control flight crew : exited adverse environment |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Environmental Factor |
Primary Problem | Environmental Factor |
Narrative:
Encountered undetected severe turbulence in daylight IMC at FL370 in the vicinity of abc VOR. No hazardous indication was present either on the aircraft radar or given by ATC. A small cell appeared on radar just as the airplane entered severe turbulence. The autoplt disengaged and the first officer (PF) corrected the upset attitude. The upset aircraft condition was mainly in bank. Both crew members reverted back to basic instrument flying by pointing out attitude and acknowledging corrections. Instrument indication was difficult to read due to turbulence. Turbulence did not seem to produce high G forces. The first officer stated that he saw ice build-up on his dv window which was not present on the captain's side. No ice build-up was noticed on the windshield. No ice was detected by the ice detectors and manual override was selected. Communication with ATC was very difficult due to heavy static and volume. While advising ATC of turbulence and deviating heading; an amber indicated airspeed appeared on the pfd. Captain's airspeed was observed to be at 120 KTS and decreasing while the isis and first officer's airspeed still showed around 220 KTS. Captain's airspeed finally dropped below 40 KTS and disappeared. Situation was related to ATC but no confirmation could be heard due to heavy static. Main focus by both crew members was on basic attitude flying; with isis airspeed check. As the static decreased a little; ATC again was notified of the situation followed by a request of a lower altitude. The request was granted and ATC then declared an emergency on our behalf. When the airplane exited the turbulence and IMC; captain's airspeed was regained and doublechked with the first officer's and isis. Residual icing on first officer's dv window disappeared as quickly as it had formed; as well as the few EICAS messages that were generated during the turbulence. Only EICAS message that I remember was 'autoplt fail.' after double- and even triplechking airplane system and control forces; no discrepancy or faults were noticed and no uncontrollable or potential dangerous situation existed. Icing manual override was deselected. Flight attendant reported no injuries or other abnormalities in cabin. It was agreed that no emergency situation was presented; and ATC was asked to cancel the emergency. Flight proceeded normally and dispatch and maintenance were both notified of the incident over company radio. Landing was uneventful; and aircraft was met by 3 maintenance vehicles. 3 days later; I received a phone call from the chief pilot inquiring about the incident. Apparently; the airplane flew without the completion of maintenance checks required after encountering severe turbulence; due to the fact that the word 'remark' was highlighted instead of 'discrepancy.' after checking with the operations manual; I determined to submit this safety report. It states to report severe turbulence as a discrepancy in the aircraft maintenance flight log and to notify maintenance control; but it also states; 'note any discrepancies to be repaired by maintenance.' since we didn't see anything on the airplane that needed to be repaired; I decided to highlight the work 'remark' with the intention of maintenance to figure out what procedure to follow. I regard anything that I enter into the airplane logbook pertinent to safety; regardless whether the words 'discrepancy' or 'remarks' are underlined; circled or left blank. In addition; at least 3 mechanics were informed when they met the aircraft; as well as maintenance control and dispatch over the radio. Entry was made in aircraft maintenance logbook; regarding severe turbulent and temporary loss of airspeed. Both crew members were uncertain about the severity of turbulence and the description of 'extreme turbulence' was used. Since no mechanical discrepancy was discovered after postflt walkaround; 'remarks' was highlighted with the intention of proper action by maintenance personnel. A mechanic was waiting for me to clear the seat in order to connect a laptop to the airplane. No time existed to consult the operations manual for exact and thorough reference. After the download was complete; I asked whether the aircraft had exceeded its G force limitation and was told that I could not be immediately determined since the download contained raw data. At least 3 mechanics were told about the turbulence and the next crew meeting the airplane. Dispatch was contacted regarding paperwork and was told that the cell causing the turbulence was only visible on radar for 3 mins as a small cell. Paperwork was faxed the same day. Maintenance should never turn a blind eye on any items entered into the aircraft logbook. Since we operate in an environment that requires safety from everyone; and human errors in various forms are always possible; I do not understand why highlighting the wrong word can lead to the fact that an entry in the aircraft logbook is deliberately ignored and not further inquired upon. Simply omitting to circle or underline the correct word would have lead to the corrective action. If doubts would have existed about the write-up; the previous crew (ie; me) should have been contacted by maintenance immediately. In addition; maintenance was called over the company radio with the log page and write-up number. There seems to have been no communication between line mechanics and maintenance control regarding this write-up. The operations manual does not state that items written-up as 'remarks' are to be ignored by maintenance personnel. The note only refers to flight crews and not maintenance personnel.
Original NASA ASRS Text
Title: FLT CREW OF E145 FAILS TO ENTER PROPER DISCREPANCY INFO IN AML AFTER ENCOUNTERING SEVERE TURBULENCE AT FL370.
Narrative: ENCOUNTERED UNDETECTED SEVERE TURB IN DAYLIGHT IMC AT FL370 IN THE VICINITY OF ABC VOR. NO HAZARDOUS INDICATION WAS PRESENT EITHER ON THE ACFT RADAR OR GIVEN BY ATC. A SMALL CELL APPEARED ON RADAR JUST AS THE AIRPLANE ENTERED SEVERE TURB. THE AUTOPLT DISENGAGED AND THE FO (PF) CORRECTED THE UPSET ATTITUDE. THE UPSET ACFT CONDITION WAS MAINLY IN BANK. BOTH CREW MEMBERS REVERTED BACK TO BASIC INST FLYING BY POINTING OUT ATTITUDE AND ACKNOWLEDGING CORRECTIONS. INST INDICATION WAS DIFFICULT TO READ DUE TO TURB. TURB DID NOT SEEM TO PRODUCE HIGH G FORCES. THE FO STATED THAT HE SAW ICE BUILD-UP ON HIS DV WINDOW WHICH WAS NOT PRESENT ON THE CAPT'S SIDE. NO ICE BUILD-UP WAS NOTICED ON THE WINDSHIELD. NO ICE WAS DETECTED BY THE ICE DETECTORS AND MANUAL OVERRIDE WAS SELECTED. COM WITH ATC WAS VERY DIFFICULT DUE TO HVY STATIC AND VOLUME. WHILE ADVISING ATC OF TURB AND DEVIATING HDG; AN AMBER INDICATED AIRSPD APPEARED ON THE PFD. CAPT'S AIRSPD WAS OBSERVED TO BE AT 120 KTS AND DECREASING WHILE THE ISIS AND FO'S AIRSPD STILL SHOWED AROUND 220 KTS. CAPT'S AIRSPD FINALLY DROPPED BELOW 40 KTS AND DISAPPEARED. SITUATION WAS RELATED TO ATC BUT NO CONFIRMATION COULD BE HEARD DUE TO HVY STATIC. MAIN FOCUS BY BOTH CREW MEMBERS WAS ON BASIC ATTITUDE FLYING; WITH ISIS AIRSPD CHK. AS THE STATIC DECREASED A LITTLE; ATC AGAIN WAS NOTIFIED OF THE SITUATION FOLLOWED BY A REQUEST OF A LOWER ALT. THE REQUEST WAS GRANTED AND ATC THEN DECLARED AN EMER ON OUR BEHALF. WHEN THE AIRPLANE EXITED THE TURB AND IMC; CAPT'S AIRSPD WAS REGAINED AND DOUBLECHKED WITH THE FO'S AND ISIS. RESIDUAL ICING ON FO'S DV WINDOW DISAPPEARED AS QUICKLY AS IT HAD FORMED; AS WELL AS THE FEW EICAS MESSAGES THAT WERE GENERATED DURING THE TURB. ONLY EICAS MESSAGE THAT I REMEMBER WAS 'AUTOPLT FAIL.' AFTER DOUBLE- AND EVEN TRIPLECHKING AIRPLANE SYS AND CTL FORCES; NO DISCREPANCY OR FAULTS WERE NOTICED AND NO UNCTLABLE OR POTENTIAL DANGEROUS SITUATION EXISTED. ICING MANUAL OVERRIDE WAS DESELECTED. FLT ATTENDANT RPTED NO INJURIES OR OTHER ABNORMALITIES IN CABIN. IT WAS AGREED THAT NO EMER SITUATION WAS PRESENTED; AND ATC WAS ASKED TO CANCEL THE EMER. FLT PROCEEDED NORMALLY AND DISPATCH AND MAINT WERE BOTH NOTIFIED OF THE INCIDENT OVER COMPANY RADIO. LNDG WAS UNEVENTFUL; AND ACFT WAS MET BY 3 MAINT VEHICLES. 3 DAYS LATER; I RECEIVED A PHONE CALL FROM THE CHIEF PLT INQUIRING ABOUT THE INCIDENT. APPARENTLY; THE AIRPLANE FLEW WITHOUT THE COMPLETION OF MAINT CHKS REQUIRED AFTER ENCOUNTERING SEVERE TURB; DUE TO THE FACT THAT THE WORD 'REMARK' WAS HIGHLIGHTED INSTEAD OF 'DISCREPANCY.' AFTER CHKING WITH THE OPS MANUAL; I DETERMINED TO SUBMIT THIS SAFETY RPT. IT STATES TO RPT SEVERE TURB AS A DISCREPANCY IN THE ACFT MAINT FLT LOG AND TO NOTIFY MAINT CTL; BUT IT ALSO STATES; 'NOTE ANY DISCREPANCIES TO BE REPAIRED BY MAINT.' SINCE WE DIDN'T SEE ANYTHING ON THE AIRPLANE THAT NEEDED TO BE REPAIRED; I DECIDED TO HIGHLIGHT THE WORK 'REMARK' WITH THE INTENTION OF MAINT TO FIGURE OUT WHAT PROC TO FOLLOW. I REGARD ANYTHING THAT I ENTER INTO THE AIRPLANE LOGBOOK PERTINENT TO SAFETY; REGARDLESS WHETHER THE WORDS 'DISCREPANCY' OR 'REMARKS' ARE UNDERLINED; CIRCLED OR LEFT BLANK. IN ADDITION; AT LEAST 3 MECHS WERE INFORMED WHEN THEY MET THE ACFT; AS WELL AS MAINT CTL AND DISPATCH OVER THE RADIO. ENTRY WAS MADE IN ACFT MAINT LOGBOOK; REGARDING SEVERE TURBULENT AND TEMPORARY LOSS OF AIRSPD. BOTH CREW MEMBERS WERE UNCERTAIN ABOUT THE SEVERITY OF TURB AND THE DESCRIPTION OF 'EXTREME TURB' WAS USED. SINCE NO MECHANICAL DISCREPANCY WAS DISCOVERED AFTER POSTFLT WALKAROUND; 'REMARKS' WAS HIGHLIGHTED WITH THE INTENTION OF PROPER ACTION BY MAINT PERSONNEL. A MECH WAS WAITING FOR ME TO CLEAR THE SEAT IN ORDER TO CONNECT A LAPTOP TO THE AIRPLANE. NO TIME EXISTED TO CONSULT THE OPS MANUAL FOR EXACT AND THOROUGH REF. AFTER THE DOWNLOAD WAS COMPLETE; I ASKED WHETHER THE ACFT HAD EXCEEDED ITS G FORCE LIMITATION AND WAS TOLD THAT I COULD NOT BE IMMEDIATELY DETERMINED SINCE THE DOWNLOAD CONTAINED RAW DATA. AT LEAST 3 MECHS WERE TOLD ABOUT THE TURB AND THE NEXT CREW MEETING THE AIRPLANE. DISPATCH WAS CONTACTED REGARDING PAPERWORK AND WAS TOLD THAT THE CELL CAUSING THE TURB WAS ONLY VISIBLE ON RADAR FOR 3 MINS AS A SMALL CELL. PAPERWORK WAS FAXED THE SAME DAY. MAINT SHOULD NEVER TURN A BLIND EYE ON ANY ITEMS ENTERED INTO THE ACFT LOGBOOK. SINCE WE OPERATE IN AN ENVIRONMENT THAT REQUIRES SAFETY FROM EVERYONE; AND HUMAN ERRORS IN VARIOUS FORMS ARE ALWAYS POSSIBLE; I DO NOT UNDERSTAND WHY HIGHLIGHTING THE WRONG WORD CAN LEAD TO THE FACT THAT AN ENTRY IN THE ACFT LOGBOOK IS DELIBERATELY IGNORED AND NOT FURTHER INQUIRED UPON. SIMPLY OMITTING TO CIRCLE OR UNDERLINE THE CORRECT WORD WOULD HAVE LEAD TO THE CORRECTIVE ACTION. IF DOUBTS WOULD HAVE EXISTED ABOUT THE WRITE-UP; THE PREVIOUS CREW (IE; ME) SHOULD HAVE BEEN CONTACTED BY MAINT IMMEDIATELY. IN ADDITION; MAINT WAS CALLED OVER THE COMPANY RADIO WITH THE LOG PAGE AND WRITE-UP NUMBER. THERE SEEMS TO HAVE BEEN NO COM BTWN LINE MECHS AND MAINT CTL REGARDING THIS WRITE-UP. THE OPS MANUAL DOES NOT STATE THAT ITEMS WRITTEN-UP AS 'REMARKS' ARE TO BE IGNORED BY MAINT PERSONNEL. THE NOTE ONLY REFERS TO FLT CREWS AND NOT MAINT PERSONNEL.
Data retrieved from NASA's ASRS site as of May 2009 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.