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paper that is a frequent source of confusion to pilots—the
aircraft MEL (Minimum Equipment List):
n I incorrectly interpreted the leading edge flap/slat
position indicator light procedure in the MEL. I deferred
an item that evidently was not deferrable. I had conferred
with Dispatch and the other pilot, and we were all in
agreement as to our ability to defer the item. I think the
problem was caused primarily by the wording of the MEL
title and the unclear verbiage in that section. I should
have read it more
carefully and called
Maintenance on the
radio for their interpretation.
Since MELs are generally not written in “plain English,”
repeated readings may be required for complete
understanding of their limitations and allowances. In
addition, direct contact with the Maintenance Control
Department may provide clarification that a dispatcher or
other pilot cannot offer.
The Color of Caution
Perhaps the most commonly misread piece of paper is the
aircraft checklist. This report of a checklist incident was
submitted by an air carrier Captain.
n We were taxiing out for takeoff. The Second Officer
read the taxi checklist and the First Officer responded.
One item is flaps [looking for a green light]. This was
responded to correctly. Prior to takeoff, the same challenge
was answered again. An FAA inspector on our jumpseat
stopped the checklist at this time and told us the light was
not green, but amber. We returned to the gate. The flight
was delayed for 24 hours for a flap problem.
All three crew members missed this call. The amber light
is associated with landing, not takeoff. This problem
could have caused a very interesting takeoff.
This incident could have been avoided by more careful
consideration of each individual checklist item, rather
than rote responses to the familiar pre-takeoff agenda.
Stray Blue Sheet
A corporate pilot reports that one more bit of stray
paper, a recent issue of CALLBACK, made an
impression. Apparently not quite a big enough
impression…
n I was just reading in the last CALLBACK about low
altimeter settings. I thought that could never happen
to me. Well, guess what? [As we were climbing out]
Center had cleared us to FL270. They asked our
altitude, as they showed us high. Sure enough, our
altimeter was set on 28.92. The previous crew had had
a setting of 28.96. I had not even looked at the first
two numbers. We had some other distractions, but
that is no excuse. Never say never.
The last two numbers of the altimeter setting were so
close that it didn’t register with the reporter that the
first two numbers were a problem—the 28 should
have been a 29.
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
December 1998 Report Intake
Air Carrier/Air Taxi Pilots 1895
General Aviation Pilots 604
Controllers 75
Cabin/Mechanics/Military/Other 165
TOTAL 2739
ASRS Recently Issued Alerts On...
http://olias.arc.nasa.gov/asrs
Number 236 February 1999
FK-10 stabilizer trim failure attributed to tail icing
Cessna 210 engine seizure attributed to a broken crankshaft
L-1011 system failure warnings caused by cockpit electrical fire
B-727 jammed aileron due to autopilot aileron servo malfunction
Autoflight disconnects attributed to a passenger's hearing aid
Where There’s Smoke…
A special report issued by the Flight Safety Foundation in
1994 noted that “aircraft fires are rare, but their prospect
is terrifying.” When such events do occur, crew and
passengers often have only moments to escape toxic fumes
and acrid smoke. (FSF Cabin Crew Safety, Vol. 28, No. 6
and Vol. 29, No. 1).
Some of the more common causes of inflight smoke and
fumes reported to ASRS are hydraulic fluid leaks in air
conditioning packs, and electrical shorts in cockpit
instrumentation. But several ASRS reports describe
highly unusual incidents involving inflight smoke and
suspected fire. We begin with a First Officer whose thirst
had nearly unquenchable consequences.
n While in level cruise at 11,000 feet, I was enjoying a
drink of water from a clear, plastic water bottle that I
normally carry with me on flights. Suddenly, the Captain
and I smelled smoke in the cockpit. About a second later, I
felt an intense burning pain on my left leg. When I looked
down, I found the smoke to be coming from my pants leg.
The cause of this unusual occurrence also became
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