37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 95650 |
Time | |
Date | 198810 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : mei |
State Reference | MS |
Altitude | msl bound lower : 31000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zme |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : commercial pilot : instrument pilot : cfi |
Experience | flight time last 90 days : 250 flight time total : 10000 flight time type : 6000 |
ASRS Report | 95650 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : undershoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Ambiguous |
Air Traffic Incident | other |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
We had requested FL350 prior to mei and center said standby. He said to turn to 250 degrees and expect direct mei shortly. The first officer read this back. A few moments later I asked the first officer if we had also been given FL350 in the very quickly worded instructions by center. We asked if we were cleared to FL350 and he said yes. We weren't sure of this previously and had not read this back on the initial instructions. Center had not noticed that we did not read this back indicating we didn't hear him. With the high traffic and busy controllers I am finding it commonplace for controllers not to listen to readbacks. This is deleting an important safety check. Upon landing at london gatwick, the ground controller informed us that a large portion of the #4 engine outboard cowling was missing. No indication of any abnormal flight characteristics noted, other than more than normal cruise power required at FL370 cruise. At FL350 cruise seemed normal. OAT was quite warm at FL370 leading us to believe temperature was reason for above normal power. Unable to determine where or when cowling separated. Aircraft sustained damage to engine components and some skin damage. Also approximately 1:45 prior to arrival at london #3 hydraulic quantity dropped rapidly. Unable to determine any correlation between this and cowling damage. Callback conversation with reporter revealed the following: the cowl is about the size of a 'vw'. The aircraft was grounded for several days and an engine change had to be made before it could be released. Foreign inspectors could find no damage to the cowl latches suggesting they were never latched. The cowl was found the next day beside the runway. The right outboard aileron was damaged when the cowl came off, but this surface is locked up in cruise and damage was not seen nor detected by the flight crew. Company procedure has been changed and a logbook entry is now required whenever an engine cowl is opened and the person securing the cowl must sign it off in the aircraft logbook. The horse is gone, but the gate is closed.
Original NASA ASRS Text
Title: ACR MLG MISSED AMENDED CLRNC ALT ASSIGNMENT.
Narrative: WE HAD REQUESTED FL350 PRIOR TO MEI AND CENTER SAID STANDBY. HE SAID TO TURN TO 250 DEGS AND EXPECT DIRECT MEI SHORTLY. THE F/O READ THIS BACK. A FEW MOMENTS LATER I ASKED THE F/O IF WE HAD ALSO BEEN GIVEN FL350 IN THE VERY QUICKLY WORDED INSTRUCTIONS BY CENTER. WE ASKED IF WE WERE CLRED TO FL350 AND HE SAID YES. WE WEREN'T SURE OF THIS PREVIOUSLY AND HAD NOT READ THIS BACK ON THE INITIAL INSTRUCTIONS. CENTER HAD NOT NOTICED THAT WE DID NOT READ THIS BACK INDICATING WE DIDN'T HEAR HIM. WITH THE HIGH TFC AND BUSY CTLRS I AM FINDING IT COMMONPLACE FOR CTLRS NOT TO LISTEN TO READBACKS. THIS IS DELETING AN IMPORTANT SAFETY CHK. UPON LNDG AT LONDON GATWICK, THE GND CTLR INFORMED US THAT A LARGE PORTION OF THE #4 ENG OUTBOARD COWLING WAS MISSING. NO INDICATION OF ANY ABNORMAL FLT CHARACTERISTICS NOTED, OTHER THAN MORE THAN NORMAL CRUISE PWR REQUIRED AT FL370 CRUISE. AT FL350 CRUISE SEEMED NORMAL. OAT WAS QUITE WARM AT FL370 LEADING US TO BELIEVE TEMP WAS REASON FOR ABOVE NORMAL PWR. UNABLE TO DETERMINE WHERE OR WHEN COWLING SEPARATED. ACFT SUSTAINED DAMAGE TO ENG COMPONENTS AND SOME SKIN DAMAGE. ALSO APPROX 1:45 PRIOR TO ARR AT LONDON #3 HYD QUANTITY DROPPED RAPIDLY. UNABLE TO DETERMINE ANY CORRELATION BTWN THIS AND COWLING DAMAGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE COWL IS ABOUT THE SIZE OF A 'VW'. THE ACFT WAS GNDED FOR SEVERAL DAYS AND AN ENG CHANGE HAD TO BE MADE BEFORE IT COULD BE RELEASED. FOREIGN INSPECTORS COULD FIND NO DAMAGE TO THE COWL LATCHES SUGGESTING THEY WERE NEVER LATCHED. THE COWL WAS FOUND THE NEXT DAY BESIDE THE RWY. THE RIGHT OUTBOARD AILERON WAS DAMAGED WHEN THE COWL CAME OFF, BUT THIS SURFACE IS LOCKED UP IN CRUISE AND DAMAGE WAS NOT SEEN NOR DETECTED BY THE FLT CREW. COMPANY PROC HAS BEEN CHANGED AND A LOGBOOK ENTRY IS NOW REQUIRED WHENEVER AN ENG COWL IS OPENED AND THE PERSON SECURING THE COWL MUST SIGN IT OFF IN THE ACFT LOGBOOK. THE HORSE IS GONE, BUT THE GATE IS CLOSED.
Data retrieved from NASA's ASRS site as of August 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.