ACSF ASAP Team
Following are redacted Aviation Safety Action Program (ASAP) reports from four participating member companies during Q4 2023 (October to December). Topics include:
- Air Return – Engine Overheat
- Fuel Event – Minimum Fuel
- Weight & Balance Calculation Error
- Meteorological Conditions – Clear Ice
- Aircraft Equipment – Safety Pins Not Removed
Please consider sharing these ASAP Case Studies – Q4 2023 with your safety team in an upcoming training meeting.
AIR RETURN – ENGINE OVERHEAT
Departed out of SDL with two passengers flying as an SIC under part 135. On the departure, the captain and I had radar on and briefed on the ground that we would need to potentially deviate around thunderstorms headed to RIL. Upon climbing out of FL230 for FL290, the captain and I were notified of a R PYLON OVERHEAT Master Warning (CAS) message. The captain instinctively reduced R Engine N1 and I began working on the checklist while he flew and handled radios. Upon completion of the R PYLON OVERHEAT checklist, the CAS message remained illuminated to which the checklist referred us to the Engine Shutdown In Flight Checklist.
I notified the captain that I was to begin the checklist, and he notified ATC that we were declaring an Emergency and needed to return to SDL. Immediately after the captain began his turn back to SDL, the CAS message went away. All other indicators were completely normal and we elected to continue the flight on two engines after discussing best options amongst ourselves.
An important instruction to note is the checklist stated that we remained out of Icing Conditions, which would be impossible if we continued our flight to RIL. Once on a stable decent, with decent checklists completed, I turned around to the cabin to notify our passengers of what occurred, and that they were to remain seated and would be returning back to SDL shortly.
Upon completing final decent checklists, I notified the captain that we were going to be landing 500lbs overweight in SDL. We again discussed with each other if we were to burn off fuel and land at max weight, or land as soon as we could 500lbs over. Because of the nature of the emergency, and the fact that we would need to circle at a significantly lower (hotter) altitude, we decided that the safest possible action would be to land sooner rather than later to avoid receiving this CAS message again and potentially lead to an engine fire or failure. We had notified SDL Tower that we were not in need of emergency services as the message had gone away, and there were no abnormal indications.
The captain landed the aircraft incredibly gently and we made a safe exit off to the hanger where the plane began its flight. Once the aircraft was parked with chalks set, the passengers were briefed in detail on what occurred and were safely sent home.
KEY TAKEAWAYS:
- Pilots used good judgement in an emergency situation to land immediately, although calculated weight was exceeding the limits by 500 lbs.
- Good use of checklists, CRM, and communications to handle an emergency safety and in a timely manner.
FUEL EVENT – MINIMUM FUEL
This flight was planned on 11/25/23, and I checked the weather, which was showing marginal VFR. This remained the case until shortly before scheduled departure. The chosen route was based upon recently cleared flight plans going from PBI to EWR. The route was a SID out of PBI and direct to EWR. In hindsight, a better choice was to select a route which included an arrival as well, and that choice would have given more accurate fuel calculations.
When uploading fuel, I added additional fuel because I heard other airplanes being given extended delays on the ramp and during taxi. I underestimated the amount of fuel that was used during the ramp delay and taxi fuel burn. Prior to takeoff, I was still estimating landing at EWR with approximately 4000 lbs. of fuel.
During the flight, we were assigned at least two reroutes, both of which increased the amount of fuel needed. We also had unforecasted headwinds when we were expecting tailwinds.
As we approached the New York area, I heard several aircraft of different arrivals begin receiving holds and diversions. We were approaching top of descent and I got a crew alerting system message informing me that I had lost the stabilator trim. With the loss of the stabilator trim, the autopilot would no longer function. Shortly after this time, we were given a descent and then a hold. Around this time, I noticed that I was having fuel quantity fluctuations of approximately 400 lbs. on the left fuel tank. I also observed a discrepancy between the pilot and copilot multifunction display progress window. The pilot progress window was showing what I believed were accurate calculations of time and fuel burn. The copilot progress window was indicating approximately 4 hours and 40 minutes to the destination and landing with over 4000 lbs. of fuel. At that time, we were approximately 250 NM to the destination with an estimate of less than 4000 lbs. of fuel on board (due to fuel quantity indications being unreliable).
As we began holding, I heard other aircraft continuing to divert to alternate airports due to low fuel. ATC was advising indefinite holds due to severe turbulence and that no one was getting into EWR until further advised. After several turns in holding, I watched my fuel on landing estimate reach approximately 1600 lbs. At this time, I advised ATC not to keep me in a hold any longer. I said we are now minimum fuel. I made this decision based on all the information available to me coupled with unreliable fuel quantity indications. They had me complete one more turn in the hold before asking me what my alternate was. I said FRG. They advised me FRG was unavailable for the same reason EWR was unavailable. I discussed possible alternatives with my first officer and we believed that all alternatives we could get to were affected by the same weather. Other options outside of the weather would have been too far away in our opinion. ATC asked me if I was declaring an emergency and I indicated I was not. ATC then declared an emergency for me and told me to plan to land at ISP.
As we began flying towards ISP, we were given more delay vectors. As I began turning away from ISP, as ATC had directed me, my estimated fuel on landing went to 1300 lbs. I advised ATC I would not accept any further delay.
The approach to landing included severe turbulence as well as a ceiling that was approximately 500 AGL. The landing itself was bumpy and firm but safe with 2000 lbs. or one hour’s worth of fuel.
KEY TAKEAWAYS:
- Pilots used good judgement to analyze the situation and make a safe decision.
- Good case study to suggest requesting additional fuel during busy holiday season due to factors such as weather and ramp/taxi delays.
WEIGHT & BALANCE CALCULATION ERROR
I was acting as PIC of [flight number] from PANC to PAKU on aircraft [tail number]. Prior to departure, ground personnel provided me with a proposed passenger/cargo load sheet. With the proposed loading schedule, the aircraft takeoff weight would have been 65,121 lbs. The takeoff CG would have been 27.3% MAC. Both the takeoff weight and CG would have been well within aircraft limitations. I authorized the aircraft to be loaded according to the proposed load sheet and departed Anchorage for Kuparuk. Four days later, I was made aware that 200 lbs. of ballast, which was supposed to be loaded on [flight number] did not, in fact, make it on the flight. I reconstructed the weight and balance to account for the missing 200 lbs. of ballast, and found that the actual takeoff weight and CG was 64,921 lbs. and 26.18% MAC. This change of 200 lbs. and 1.12% MAC was very small and well within aircraft limitations.
KEY TAKEAWAYS:
- Oversight of an aircraft loading distribution could have had much greater consequences.
- Highlights importance for ground personnel/loading supervisors to inspect cargo holds for an accurate weight and balance calculations.
- Company implemented a new procedure where all personnel involved with aircraft loading and servicing conduct a pre-departure briefing.
METEOROLOGICAL CONDITIONS – CLEAR ICE
I was flying at night in a Queen Air. I had been in IMC and it snowed most of the flight, and I started to see clear ice build on the wings. I had never experienced clear ice before. As it was night, I was watching this via the ice light. One thing I’m sure of after the event is that it was clear ice. The severity and the cause I’m not sure of. At the time, it was precipitating and it wasn’t snow, so I thought it might be freezing rain. My airspeed was not bleeding; I was pretty steady between 165 and 160 knots as indicated. As I was watching the clear ice and trying to shed it via the boots, I noticed that my altitude was decreasing. I noticed it at about 8,800 feet and contacted Denver Center as soon as I was able to ask for a lower altitude. I told the controller that I was getting moderate clear ice and was unable to hold my altitude. He cleared me to 6,000 feet and asked me to tell him when the icing ended. I broke out at 7,800 and it was below freezing at 6,000 feet. I had no more issues afterward.
KEY TAKEAWAYS:
- Observant pilot’s proactive actions potentially prevented serious consequences.
- Important reminder to stay vigilant during winter months, with additional external factors affecting safety.
AIRCRAFT EQUIPMENT – SAFETY PINS NOT REMOVED
Landing gear failed to retract after takeoff from KORL. This was the second leg of an initial operating experience (IOE) flight, returning home after a long day. Preflight was completed a couple hours before passengers arrived due to them being late. The gear pins were left in because ground handling may have needed to move the aircraft to make room for arrivals. I was inside the building taking care of the passengers when they arrived, and [name] was in the plane making sure our route hadn’t changed. My normal procedure when walking out with the passengers was interrupted by the primary passenger asking me questions about an upcoming Costa Rica trip. So I didn’t do my normal walk around to check doors and pins. Before closing the door, I should have asked [name] if he had checked them, or got a flashlight and done it myself. This caused the gear to fail to retract, and is to return for landing at KORL.
KEY TAKEAWAYS:
- A simple oversight with serious consequences.
- Highlights importance of proper pre-departure inspection/walk-around, as well as appropriate CRM to delegate tasks accordingly.
