FLT CREW OF E145 FAILS TO ENTER PROPER DISCREPANCY INFO IN AML AFTER ENCOUNTERING SEVERE TURBULENCE AT FL370.

2008-06 · NASA ASRS report 790058

Date: 2008-06 · Aircraft: EMB ERJ 145 ER/LR · Phase: cruise

Anomalies: deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-loss-of-aircraft-control|inflight-event-encounter-weather-turbulence

Synopsis

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.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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