37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 848387 |
Time | |
Date | 200908 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.ARTCC |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb Initial Climb Takeoff |
Flight Plan | IFR |
Component | |
Aircraft Component | Rudder Trim System |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 300 Flight Crew Total 7000 Flight Crew Type 5000 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
I was pilot in command of this flight. I discovered we had a mechanical problem when I turned on the battery master switch and heard the ELT operating. I called maintenance control and informed them of the problem. We waited about 30 minutes for maintenance to show up. Maintenance never showed up; so I called again. This time when I turned on the battery master switch; the ELT did not go activate; so I told maintenance never mind. The aircraft came from remote parking; so it needed a security check; which was accomplished. The passengers were then boarded. Due to the fact that the aircraft came from remote parking; and needing a security check; the first officer was confused as to whether or not it was the first flight of the day. This became evident when I called for engine start; and he started the number one engine instead of number two. I inquired why he did that; and informed him that it was not the first flight of the day; because the aircraft had been ferried in that day from somewhere. I then told the first officer to stop and finished the starting engines checklist with only the number one engine started. We had anticipated a longer than normal taxi going to runway 27 and my air carrier really enforces the practice of single engine taxi; I made an error in judgment. I remembered in the past that I have taxied aircraft on the left engine only for various mechanical reasons to re-position the aircraft and knew the only problem with that was that the number 2 hydraulic system was not powered which means the outboard brakes do not have power. I also knew that the remedy for that was to turn on the 2B hydraulic pump. I then stated to the first officer that the reason our air carrier does not normally taxi on the left engine is due to this problem and turned on the 2B pump. I then pulled up the hydraulic page and showed him exactly what I was doing and why. I also asked if he had any questions or concerns with taxiing on the left engine; I also asked if he was uncomfortable with me doing this. He stated no; and we decided to taxi in that configuration. We then did the before taxi and taxi checks and called ramp control for taxi instructions. We called ground for taxi. We taxied to the runway via taxiway K. I asked for the engine start and the before takeoff checklist. That was completed and we held short of the runway. We were cleared into position and hold. The line up checklist was started. We were then cleared for takeoff from the runway with a 290-degree initial heading after takeoff. The line up checklist was completed with a 'takeoff config ok' green advisory message as normal. It was a reduced thrust; flaps 8 takeoff. Power advancement and aircraft performance was normal during the takeoff role and initial climbout to sometime shortly after gear retraction. At some point I think around 500 ft AGL the aircraft started to feel very mushy on the controls. It reminded me of slow flight from my private pilot days. I looked at the airspeed and it was about V2+10; which did not make sense to me. Shortly after that I noticed a rolling moment to the right and counteracted that with ailerons; which seemed to make things get worse. I then noticed the now extreme yaw to the right and the far left 'ball' on the skid indicator. I started to use rudder and figured out what was going on. I was calling for rudder and the first officer did not seem to know what I was asking for. I then noticed the trim was all the way to the right. I also looked at the airspeed; which was 180 KIAS; and the altitude was about 2;200 ft; and climbing at a good rate; however the aircraft was a 'handful' to fly. I considered the rudder jam immediate action items however the rudder was working perfectly. I also considered using max thrust and retracting the flaps; but at the time the aircraft was performing well; as far as rate of climb and airspeed were concerned; and I did not want to aggravate it. I also did not want to raise the flaps and increase stall speed; I just wanted all the altitude I could get. I then; with stress in my voice; exclaimed; 'trim the rudder'. After what seemed like an eternity; (probably less than a minute); the first officer was able to get control of the rudder trim and center it. We climbed to 3;000 ft before I was comfortable enough to turn on the autopilot and continued on with ATC like nothing happened; while we tried to sort out what happened. At about 13;000 ft we were switched to center. They gave us a climb to FL230. I then told the first officer where the circuit breaker was located for the rudder trim; and told him at the first sign of rudder trim movement; to pull it. I then gave the aircraft and radios to the first officer and called maintenance control; since we were still in the departure area. I informed maintenance control that after takeoff at about 500 ft; we had a rudder trim runaway; however at the moment we had the aircraft under control and the rudder trim was centered. I asked maintenance control if they had any info or guidance for me. They stated; 'well; if it is working now; continue up to our scheduled destination and write it up there.' I then stated that; 'well this was a flight control issue and I will need a little more info than that.' they did a lot of nothing and stated it was up to me if I wanted to bring it back. After that conversation; someone else was on the same frequency and started stating I would bring it back and to add speed to vref. This apparently made maintenance control angry because they stated that was not maintenance and started asking who that was. The first officer and I had a discussion about the situation; and what maintenance stated. At FL190 I finally had enough; and told maintenance that we were coming back. They stated ok; and I switched to dispatch. I first told ATC that we needed to return to the departure airport. At this point I still did not declare an emergency; I just told them we had to come back. They gave us some turns and eventually cleared us to the airport. I asked for a hold to burn fuel and run checklists; which ATC gave us. I called dispatch and asked for any numbers for a landing with the rudder trim fully deflected and an overweight landing; which they gave me; and switched back to maintenance control; which was in standby. Surprisingly; maintenance control was calling us. I answered and the only thing they wanted to know was whether or not we were declaring an emergency. I stated yes and asked them about the overweight landing. They stated as long as I landed with a rate of descent below 360 feet per minute; I would not even have to write it up. I said ok and got off the radio with them. After entering the hold I then informed the flight attendant exactly what was going on and that we were returning to the departure airport. It would be a normal landing but the fire trucks would be beside the runway. I then informed the passengers that it was just a computer glitch and we were going back to check it out; there would be fire trucks out but that was just normal procedure and I apologized about any delay getting then to our scheduled destination. I then informed ATC we were declaring an emergency due to rudder trim runaway and to roll the trucks at the airport. I gave them the info they asked for. We then finished our checklists and landed 18L uneventful. I cleared the runway and taxied to the gate; de-planed the passengers and called the chief pilot.after this incident I went back into the flight standards manual to inquire about the left engine taxi. I learned in a note that the only time you can taxi on the left engine is for a mechanical reason which was not the case. I also thought about the fact that taxiing on the left engine was not standard operating procedure. This was not the correct thing for me to do. I should have taxied on both engines or started both and then shut down the left engine. I will not do this in the future. I also learned that there is anabnormal procedure in the QRH that deals with rudder trim runaway. Apparently my air carrier has taught me enough systems knowledge that I performed the QRH procedure without knowing it; however I am taught to go into the QRH with a message. When there was no message; I did not understand that there might be a procedure for it anyway in the QRH. In any future events; I will go into the QRH with whatever problem exists; even if there is not a message on the screen. Most importantly; I'm not satisfied with the support I received from maintenance control. Under CRM; my air carrier always encourages a pilot to get as much information as possible; from all available resources. They encourage a pilot to talk to as many people as possible; before making a decision. The company specifically singles out maintenance control; dispatch; chief pilots; etc. However; my air carrier has also repeatedly undermined 'captain's authority.' they often attempt to discipline a pilot if a flight is delayed or canceled when this authority is invoked. There have been numerous occasions where captains have been disciplined for not complying with maintenance control's direction; especially in the area of MEL items. When faced with an event such as this; often a pilot (and I experienced this first hand during this event) cannot help but think about possible disciplinary action taken by our supervisors if we make a decision that negatively impacts my air carrier's operational integrity in this 'fee for departure' world we live in. Yes; under these circumstances; this concern should never interfere with a pilot's thought process when handling such events; but this is an everyday reality for far too many of my air carrier's pilots. Our director of operations has stated that MEL's override captain's authority. Having knowledge of this along with past disciplinary practices of my air carrier management resulted in me considering continuing to our original destination before writing up this malfunction. I knew; with all my previous training; that continuing on was not only poor guidance from maintenance control; but potentially unsafe as well. In addition to the workload; the consideration of possible disciplinary action for not continuing on to our destination delayed our return to the departure airport as we made it all the way to fl 190. While I'm disappointed with my hesitation; I cannot state enough that this mindset has nearly become the norm at my air carrier. Yes; my passenger's safety comes before flight completion numbers; but I momentarily lost sight of that. Not getting fired so I can put food on the table and the contemplation of disciplinary action was a distracting factor during this event. I will not allow this to occur in the future. I will do what I know is right; no matter what pressure is placed on me or my crew by my air carrier management for the sake of operational integrity.
Original NASA ASRS Text
Title: An air carrier pilot described a serious rudder control system malfunction. Concern about discipline because of an air turnback nearly affected his decision to declare an emergency and return to land with a serious flight control malfunction.
Narrative: I was Pilot in Command of this flight. I discovered we had a mechanical problem when I turned on the battery master switch and heard the ELT operating. I called Maintenance Control and informed them of the problem. We waited about 30 minutes for Maintenance to show up. Maintenance never showed up; so I called again. This time when I turned on the battery master switch; the ELT did not go activate; so I told Maintenance never mind. The aircraft came from remote parking; so it needed a security check; which was accomplished. The passengers were then boarded. Due to the fact that the aircraft came from remote parking; and needing a security check; the First Officer was confused as to whether or not it was the first flight of the day. This became evident when I called for engine start; and he started the number one engine instead of number two. I inquired why he did that; and informed him that it was not the first flight of the day; because the aircraft had been ferried in that day from somewhere. I then told the First Officer to stop and finished the Starting Engines checklist with only the number one engine started. We had anticipated a longer than normal taxi going to Runway 27 and my air carrier really enforces the practice of single engine taxi; I made an error in judgment. I remembered in the past that I have taxied aircraft on the left engine only for various mechanical reasons to re-position the aircraft and knew the only problem with that was that the number 2 hydraulic system was not powered which means the outboard brakes do not have power. I also knew that the remedy for that was to turn on the 2B hydraulic pump. I then stated to the First Officer that the reason our air carrier does not normally taxi on the left engine is due to this problem and turned on the 2B pump. I then pulled up the hydraulic page and showed him exactly what I was doing and why. I also asked if he had any questions or concerns with taxiing on the left engine; I also asked if he was uncomfortable with me doing this. He stated no; and we decided to taxi in that configuration. We then did the Before Taxi and Taxi checks and called Ramp Control for taxi instructions. We called Ground for taxi. We taxied to the runway via Taxiway K. I asked for the engine start and the Before Takeoff checklist. That was completed and we held short of the runway. We were cleared into position and hold. The Line Up checklist was started. We were then cleared for takeoff from the runway with a 290-degree initial heading after takeoff. The Line Up checklist was completed with a 'Takeoff Config OK' green advisory message as normal. It was a reduced thrust; Flaps 8 takeoff. Power advancement and aircraft performance was normal during the takeoff role and initial climbout to sometime shortly after gear retraction. At some point I think around 500 FT AGL the aircraft started to feel very mushy on the controls. It reminded me of slow flight from my private pilot days. I looked at the airspeed and it was about V2+10; which did not make sense to me. Shortly after that I noticed a rolling moment to the right and counteracted that with ailerons; which seemed to make things get worse. I then noticed the now extreme yaw to the right and the far left 'ball' on the skid indicator. I started to use rudder and figured out what was going on. I was calling for rudder and the First Officer did not seem to know what I was asking for. I then noticed the trim was all the way to the right. I also looked at the airspeed; which was 180 KIAS; and the altitude was about 2;200 FT; and climbing at a good rate; however the aircraft was a 'handful' to fly. I considered the rudder jam immediate action items however the rudder was working perfectly. I also considered using max thrust and retracting the flaps; but at the time the aircraft was performing well; as far as rate of climb and airspeed were concerned; and I did not want to aggravate it. I also did not want to raise the flaps and increase stall speed; I just wanted all the altitude I could get. I then; with stress in my voice; exclaimed; 'trim the rudder'. After what seemed like an eternity; (probably less than a minute); the First Officer was able to get control of the rudder trim and center it. We climbed to 3;000 FT before I was comfortable enough to turn on the autopilot and continued on with ATC like nothing happened; while we tried to sort out what happened. At about 13;000 FT we were switched to Center. They gave us a climb to FL230. I then told the First Officer where the circuit breaker was located for the rudder trim; and told him at the first sign of rudder trim movement; to pull it. I then gave the aircraft and radios to the First Officer and called Maintenance Control; since we were still in the departure area. I informed Maintenance Control that after takeoff at about 500 FT; we had a rudder trim runaway; however at the moment we had the aircraft under control and the rudder trim was centered. I asked Maintenance Control if they had any info or guidance for me. They stated; 'Well; if it is working now; continue up to our scheduled destination and write it up there.' I then stated that; 'Well this was a flight control issue and I will need a little more info than that.' They did a lot of nothing and stated it was up to me if I wanted to bring it back. After that conversation; someone else was on the same frequency and started stating I would bring it back and to add speed to VREF. This apparently made Maintenance Control angry because they stated that was not Maintenance and started asking who that was. The First Officer and I had a discussion about the situation; and what maintenance stated. At FL190 I finally had enough; and told maintenance that we were coming back. They stated OK; and I switched to Dispatch. I first told ATC that we needed to return to the departure airport. At this point I still did not declare an emergency; I just told them we had to come back. They gave us some turns and eventually cleared us to the airport. I asked for a hold to burn fuel and run checklists; which ATC gave us. I called Dispatch and asked for any numbers for a landing with the rudder trim fully deflected and an overweight landing; which they gave me; and switched back to Maintenance Control; which was in standby. Surprisingly; Maintenance Control was calling us. I answered and the only thing they wanted to know was whether or not we were declaring an emergency. I stated yes and asked them about the overweight landing. They stated as long as I landed with a rate of descent below 360 feet per minute; I would not even have to write it up. I said OK and got off the radio with them. After entering the hold I then informed the Flight Attendant exactly what was going on and that we were returning to the departure airport. It would be a normal landing but the fire trucks would be beside the runway. I then informed the passengers that it was just a computer glitch and we were going back to check it out; there would be fire trucks out but that was just normal procedure and I apologized about any delay getting then to our scheduled destination. I then informed ATC we were declaring an emergency due to rudder trim runaway and to roll the trucks at the airport. I gave them the info they asked for. We then finished our checklists and landed 18L uneventful. I cleared the runway and taxied to the gate; de-planed the passengers and called the Chief Pilot.After this incident I went back into the Flight Standards Manual to inquire about the left engine taxi. I learned in a note that the only time you can taxi on the left engine is for a mechanical reason which was not the case. I also thought about the fact that taxiing on the left engine was not Standard Operating Procedure. This was not the correct thing for me to do. I should have taxied on both engines or started both and then shut down the left engine. I will not do this in the future. I also learned that there is anabnormal procedure in the QRH that deals with rudder trim runaway. Apparently my air carrier has taught me enough systems knowledge that I performed the QRH procedure without knowing it; however I am taught to go into the QRH with a message. When there was no message; I did not understand that there might be a procedure for it anyway in the QRH. In any future events; I will go into the QRH with whatever problem exists; even if there is not a message on the screen. Most importantly; I'm not satisfied with the support I received from Maintenance Control. Under CRM; my air carrier always encourages a pilot to get as much information as possible; from all available resources. They encourage a pilot to talk to as many people as possible; before making a decision. The company specifically singles out Maintenance Control; Dispatch; Chief Pilots; etc. However; my air carrier has also repeatedly undermined 'Captain's Authority.' They often attempt to discipline a pilot if a flight is delayed or canceled when this authority is invoked. There have been numerous occasions where Captains have been disciplined for not complying with Maintenance Control's direction; especially in the area of MEL items. When faced with an event such as this; often a pilot (and I experienced this first hand during this event) cannot help but think about possible disciplinary action taken by our supervisors if we make a decision that negatively impacts my air carrier's operational integrity in this 'fee for departure' world we live in. Yes; under these circumstances; this concern should never interfere with a pilot's thought process when handling such events; but this is an everyday reality for far too many of my air carrier's pilots. Our Director of Operations has stated that MEL's override Captain's Authority. Having knowledge of this along with past disciplinary practices of my air carrier management resulted in me considering continuing to our original destination before writing up this malfunction. I knew; with all my previous training; that continuing on was not only poor guidance from Maintenance Control; but potentially unsafe as well. In addition to the workload; the consideration of possible disciplinary action for not continuing on to our destination delayed our return to the departure airport as we made it all the way to FL 190. While I'm disappointed with my hesitation; I cannot state enough that this mindset has nearly become the norm at my air carrier. Yes; my passenger's safety comes before flight completion numbers; but I momentarily lost sight of that. Not getting fired so I can put food on the table and the contemplation of disciplinary action was a distracting factor during this event. I will not allow this to occur in the future. I will do what I know is right; no matter what pressure is placed on me or my crew by my air carrier management for the sake of operational integrity.
Data retrieved from NASA's ASRS site as of April 2012 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.