REG NASA-LLIS-1377--2002 Lessons Learned Learjet Landing Mishap.pdf

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1、Lessons Learned Entry: 1377Lesson Info:a71 Lesson Number: 1377a71 Lesson Date: 2002-08-16a71 Submitting Organization: DFRCa71 Submitted by: John Marcrum / Bart HenwoodSubject: Learjet Landing Mishap Abstract: Unavailable.Description of Driving Event: The Dryden Flight Research Centers Learjet Model

2、24, call sign NASA 805, sustained substantial damage during a planned “touch and go“ landing at the Southern California Air Logistics Base (formerly George Air Force Base), near Victorville, CA on June 7, 2001. There were no injuries to the pilot, co-pilot, or the observer in the course of this even

3、t.The Learjet was used on an infrequent basis as a research testbed. The aircraft had just returned to flight status from an extended period in flyable storage. This type of usage did not permit the assigned aircrew to maintain currency. The flight was a scheduled recurrency flight. There was inadeq

4、uate guidance in the areas of piloting duties, crew pairing, recurrency requirements, and restrictions to carrying passengers. The daily flight supervision process was inadequate to mitigate the lack of DOP-0-300 guidance.The supervisory process did not provide adequate policy, procedures, nor overs

5、ight and insight for aircrew conducting flights to ensure significant qualifications, training and currency were met. The direct causes of this mishap were identified as: 1. Over control of the aircraft by the copilot (pilot flying) leading to an aggravated roll oscillation, hard landing, loss of co

6、ntrol, and subsequent impact. A significant factor was the copilots limited total piloting experience, particularly in high performance jet aircraft and in the Learjet.2. Failure of the pilot in command (pilot not flying) to recognize the deteriorating situation in Provided by IHSNot for ResaleNo re

7、production or networking permitted without license from IHS-,-,-time to recover the aircraft. A significant factor was the pilot in commands lack of currency in the Learjet, and his low overall experience in the Learjet.3. The combination of an inexperienced copilot flying an aircraft with a pilot i

8、n command who was not current in the aircraft and who had relatively little time in type.Lesson(s) Learned: 1. Flight Operations supervision should continuously monitor qualifications, currency, and assignment of aircrew in order to ensure before release of each flight operation that it can be compl

9、eted safely.2. 3. All local Flight Operations guidance should be reviewed annually to ensure that it complies with and properly implements applicable law, regulation, and headquarters guidance. Best practices of similar industry and other government activities should also be evaluated periodically f

10、or adoption as appropriate.4. The Aviation Safety program should continuously review flight operations to ensure that hazardous conditions are identified as soon as they appear and are promptly corrected.5. Initial and periodic training should be provided to all personnel who may in the course of th

11、eir official duties be involved in mishap response or mishap investigation, including aircrew and public relations personnel.Recommendation(s): 1. Revise Center Aircrew Flight Operations Manual (DCP-O-300) guidance to ensure compliance with the following aviation safety documents: NPG 7900.3A, “Airc

12、raft Operations Management,“ 41 CFR Part 101-37, “Government Aviation Administration and Coordination,“ 41 CFR Part 301-2, “Transportation Allowable,“ OMB Circular A-126, “Improving the Management and Use of Government Aircraft,“ NPD 8700.1, “NASA Policy for Safety and Mission Success,“ NPD 8710.2B,

13、 “NASA Safety and Health Program Policy“, NPG 8715.3, “NASA Safety Manual.“ The revised DCP-O-300 shall encompass the supervisory process which will provide insight and oversight for aircrew conducting flights to ensure that they are current and properly experienced by accomplishing the following:2.

14、 a. Establish clear qualifications and requirements for all categories of pilots and other aircrew members. b Revise the supervisory approval authority for sorties to ensure Flight supervisory approval process has adequate insight into proposed flight activity. c. Establish requirements for aircrew

15、pairing to ensure the required experience level is met. d. Establish training syllabi for all aircraft to ensure that no aircraft idiosyncrasies are overlooked. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-e. Provide training requirements that are

16、 clear and complete for aircrew to meet currency requirements for aircraft specific initial flight and to requalify after the aircrew has had an extended stay away from the aircraft. f. Define requirements for scheduling non-essential aircrew for flights. g. Establish documentation and an annual rev

17、iew process that ensures the aircrews training and experience is sufficient for the category of aircraft to be flown. h. Establish policy that delineates instructor and pilot checkout requirements for each aircraft. i. Establish procedures that shall ensure management policies and DCP-O-300 requirem

18、ents are reviewed annually, realized and adhered to by all aircrew. 2. Review and revise the Aviation Safety Program to ensure the Center has aircrew conducting flights that are current and properly experienced.3. Provide mishap training in public relations area.Evidence of Recurrence Control Effect

19、iveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Aircrafta71 Flight Operationsa71 Human Factorsa71 Safety & Mission AssuranceAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2004-02-09a71 Approval Name: Bart Henwooda71 Approval Organization: DFRCa71 Approval Phone Number: 661-276-5746Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-