1. Recent Aviation Safety Events:
Safety and Quality Assurance Number 4, March 2016
Mission:
Providing pilots with up to date information on incidents and safety issues.
If you SEE something, SAY something: or
Sr. Safety Manager
Edgardo Walters
Aviation Safety Manager
Hessel van der Maten
Investigators :
Xochy Cerrud
Alvaro Pereira
Analists :
Sergio Luna
Julian Schanda
TOGA or not TOGA.
Last year we had an early TOGA (Take-Off/Go Around switch) activation which lead to a runway excursion in MIA. We were lucky, because we ended up changing the nose wheel tires of the aircraft and the airport had to change some of the runway edge lights that the aircraft struck on its way out.
The flight crew, as many of our crews, was attempting a rolling takeoff, which is common practice and an approve procedure in our Flight Manual. However, the activation of the TOGA switch shall be done only once we are aligned with the runway center line.
Moving to nowadays, we continue to see FDA data that shows flight crews still activating the TOGA switch before been aligned with the runway center line, despite several communications on behalf of Flt Ops, which warns crews of the dangers of early TOGA activation.
Next time you are performing a rolling takeoff remember to TOGA once you are aligned with the runway centerline and if not align DO NOT hit the TOGA switch.
Edgardo Walters
Sr. Safety Manager
Recent Aviation Safety Events:
Event:
Cancun Air turn Back due to pressurization problem
Route:
CUN – PTY
Aircraft Type:
Boeing
What happened:
During the initial climb, the flight crew found the First Officers headset-cable stuck in the First Officers cockpit window, and noticed the aircraft was not pressurizing.
What were the threats:
The mechanics requested to sign the aircrafts logbook, shortly after the start of the pushback, leading the FO to open the right side cockpit window.

2. What were the safety findings:
Once the mechanic signed the logbook, the First Officers head-set cable got stuck inadvertently in the window frame, preventing the First Officers cockpit window from properly closing, and the aircraft from pressurizing. Once in the air the flight crew noticed that the aircraft was not pressurizing and the flight crew made the decision to attempt to open the cockpit window in flight to free the headset-cable, in order to solve the pressurization problem. Their attempts were unsuccessful. They ended up returning to CUN.
Event:
Aircraft unable to pressurize after take-off
Route:
PTY - SXM
Aircraft Type:
Boeing
What happened:
The flight crew returned to PTY shortly after take-off because the aircraft was unable to pressurize. Maintenance had secured the left bleed valve in the closed position due to a bleed trip-off event during the previous flight and the right bleed valve had been turned off by the pilots applying the applicable operational procedure.
What were the threats:
A left bleed trip off was reported in the aircraft maintenance logbook; the right bleed valve was erroneously placarded as inoperative; the Deferred Maintenance Item (DMI) was not presented on the flight plan; due to a late inbound flight, the aircraft turn-around time was reduced. This resulted in added operational pressure to the pilots and maintenance technicians to have the outbound flight depart on time
What were the safety findings:
The maintenance technician erroneously placarded the right bleed valve as inoperative; the pilots did not verify the maintenance action taken after the technician returned the aircraft maintenance logbook; the pilots did not verify that the aircraft was pressurizing appropriately after the verification of the air-conditioning and pressurization selections with the after take-off checklist; the Captain (CP) continued the climb, even though the aircraft was not pressurizing; the pilots did not donn their oxygen masks and establish communication when the cabin altitude warning light illuminated; the pilots did not perform the “intermittent Warning Horn or Cabin Altitude Warning” checklist.
Event:
Flight PTY to SFO diverted to LAX due to insufficient fuel
Route:
PTY - SFO
Aircraft Type:
Boeing
What happened:
The flight crew diverted to en-route alternate Los Angeles (LAX) due to insufficient fuel to reach its final destination.

3. What were the safety findings:
What were the threats:
High ambient temperature at PTY. Several arriving aircraft using the same runway at the time of departure. Re-dispatch point en route alternate selection. Headwinds along the route of flight.
What were the safety findings:
The extra-fuel that was required on the flight plan to complete the flight within company policies, it was not able to be loaded due to high temperatures and fuel density. SOCC did not consider the need to assure that a sufficient amount of fuel was putted on the flight plan to account for the pound “Boeing737 NG fuel Phenomenon.”
Flight Data Analysis, Trends:
Data shows that the flight crews are still using speed above 250 knots below feet.
Despite the fact that we have a restriction of not flying higher than 250knots below feet. The data showed that 12.8% of total flights flew above this restriction, especially at Panama airport with the high concentration of birds.
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