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my Air Force Reserve unit and the last time, two
crossings in October 2000, the several airline pilots
also on the mission told me that 131.8 MHz is no
longer used and that in general, airline pilots over the
Atlantic are using 123.45 MHz. In fact, I monitored
both and heard no chatter on 131.8 and a lot on
123.45. I do not fly the Atlantic much anymore but
was surprised at that information, since I used to fly
the Atlantic a lot and 131.8 had always been used.
ASRS has verified with ATC sources that 123.45
MHz is the aircraft-to-aircraft communications
frequency now in use on most North Atlantic routes
under RVSM procedures — except the West Atlantic
Route System (WATRS), which is still using 131.8
MHz. Thanks to our readers for bringing this
change to our attention.
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
ASRS Recently Issued Alerts On…
False warnings of smoke in a CL65 cargo hold
B737-200 uncommanded yaw during takeoff roll
Non-compliance with DC9 radome repair procedures
Multiple reports of false GPWS / EGPWS terrain warnings
Late arrival clearances and runway changes at an airport
December 2000 Report Intake
Air Carrier / Air Taxi Pilots 2051
General Aviation Pilots 566
Controllers 56
Cabin/Mechanics/Military/Other 166
TOTAL 2839
Procedures are a means of
communicating the wisdom of experience in a standardized
form to operators. But procedures may need to be revised
when incidents and accidents demonstrate their
weaknesses. This continuous reinforcement loop between
experience and procedures is one of the most important
safety tools in aviation.
A Captain’s report to ASRS describes the dangerous
situation that developed for a Lear-60 crew when a
procedural oversight by maintenance was amplified by a
flight crew oversight during pre-flight.
Upon arrival, I…checked our aircraft’s flight log to make
sure that the previous day’s maintenance work was done
properly and signed off correctly... After determining that
the…paperwork was correct, I went out to assist the co-pilot
[with pre-flight checks]… This was a position leg with no
passengers on board the aircraft.
The discrepancy was that our oxygen system needed to be
topped off to remain in the required limits. When the
mechanic fills the oxygen system [he] must turn off the oxygen
flow to the crew and the passenger masks. Then after the
oxygen is topped off, the mechanic opens the valve and once
again passenger oxygen [is] available to passengers and
crew…
I asked my co-pilot if the pre-flight had been accomplished.
He stated that it was and we prepared to leave. After takeoff
we were cleared to 18,000 feet. Upon reaching 18,000 feet,
The Experience-Procedures Feedback Loop
I…proceeded to accomplish the transition level checklist.
When doing this a visual check of the oxygen pressure gauge
as well as checking the crew oxygen mask is required. I did
this and did not receive a positive flow of oxygen to my mask.
The co-pilot checked his and again received no oxygen
pressure. Thus we requested a lower altitude which was given
to us. I asked the co-pilot if he had performed the pre-flight
check which required him to test both crew member oxygen
masks. He said he thought he had, but it was obvious he had
not… The reason for this was that he was distracted by
ground crew who were bringing beverages and ice to the
aircraft.
This Lear 60 has a nose compartment oxygen system… In
[this]…system the oxygen indicator will read the oxygen bottle
pressure, even if the valve is turned off and the crew masks
are tested. When I boarded the aircraft to prepare for takeoff,
I looked at the oxygen indicator and it showed a normal
oxygen level…I, however, did not test my mask on the ground.
I believe each crew flying…should know where their oxygen
system is located and its operational characteristics… It is
now company policy for both crew members to check the crew
oxygen masks [during pre-flight].
It appears the maintenance technician who serviced the
oxygen did not open the shutoff valve after servicing the
bottle. The flight crew did not check the oxygen masks for
flow until 18,000 feet MSL – a potentially lethal situation
had they not detected the problem in time.
The Tie That Binds
A First Officer reports an unusual event involving what air
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