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Preventing Breaks in the Safety Chain

How breaking or weakening even one link can define the outcome of a flight.

The focus of my 34-year career with the airlines has always been passenger safety and comfort. But on this particular flight to London, the focus went to the dogs. My copilot, Steve, and I were the links in a safety chain that prevented the early demise of one beloved collie. Unbeknownst to its owner, the animal became very expensive to the airline, but not quite as expensive had it become a statistic.

All of us in the business of professional flying understand the safety chain. Breaking or weakening even one link can define the outcome of a flight. For an airline pilot, or any safety-conscious aviator, maintaining the strength of the links begins before the flight leaves the ground. In that regard, the FAA mandates air carriers develop a defined safety management program. None of this is news to the vast majority of Flying readers. This particular trip was an interesting example of how subtle threats could have affected links in the chain.

Steve returned from his walk-around inspection and tossed the notoc paperwork onto the center console of our 777. A notoc, or notice to the captain, is documentation that lists the location and type of restricted articles (RA) that have been loaded into the cargo compartments. Restricted articles can include many types of substances, from perfume to liquid chemicals. The materials have to be packed and inspected according to strict guidelines. Oftentimes, the quantity and/or weight allowable is limited per compartment.

On our particular flight, the restricted article was dry ice, a very typical substance that is used to preserve perishable items. Approximately 200 pounds were in the forward cargo compartment. No big deal. Dry ice discharges CO2, which decreases the amount of oxygen in confined spaces.

So, when the crew chief made a personal visit to the cockpit, he raised our eyebrows when he declared that a dog was being loaded. “Where?”

I asked. The response was, “Aft compartment,” which was a good answer considering the location of the dry ice. Steve stretched an arm to the overhead panel and turned the appropriate cargo heat switch to the “high” position, ensuring that air at a minimum of 65 degrees would be maintained for the collie.

Shortly thereafter, we completed our before-starting checklist and began a pushback from the gate. Routine stuff. During the regular process of reviewing takeoff data while taxiing to Runway 31L, Steve paused during his dissertation of comparing our final load close-out information to the planned information. He asked simply, “Where is the dog?”

I replied, “Aft compartment, last I remembered.”

“The load close-out is now showing an RA in the aft compartment,” Steve stated in a matter-of-fact tone.

“Live animal and dry ice? Don’t think that’s going to work.”

Steve said, “It’s possible that a certain amount can be loaded without issues.”

Although I was fairly certain that dry ice and animals don’t mix, I had Steve check out the company manual via his iPad. Yup, I was correct. Steve reached for the flight document folder lying in its usual spot on the jumpseat behind us and grabbed the notoc paperwork. My bad. I recalled the crew chief giving us a new copy at the last minute just before gate departure. I didn’t review the information, assuming it was a duplication of the original. It wasn’t a duplicate copy. An entry indicated dry ice had been loaded in the aft compartment. But was this a paperwork mistake?

As Steve attempted to analyze the hieroglyphics of the notoc, I asked JFK ground control for a turn off the main taxiway to park the airplane and rectify the situation with our company operations. I informed the flight attendants and our passengers of our “cargo loading” issue. We began a series of back-and-forth communications in an effort to establish the correct information. After a few minutes of silence on the company frequency, we heard, “Taxi back to the gate.”

We glanced at each other with shaking heads. Steve requested a taxi clearance and began the process of reversing the before-takeoff checklist by completing the items of the after-landing checklist. Flaps up, APU running and so on. Our return to the gate was met with a measured amount of frantic enthusiasm. Fuel was required since we had already burned the original dispatch amount and would require additional for the subsequent attempt at a normal departure. Fortunately, the fueler was hooked up to the airplane in short order.

I requested an updated notoc in addition to verification that our collie was alive and well. And yes, the crew chief confirmed that dry ice had been loaded in the aft compartment and that particular shipment was now completely removed from the airplane. He apologized for the error, indicating that someone above his pay grade had made the mistake. It didn’t matter. The links in the chain were intact — for the moment at least.

We breathed a small sigh of relief, taxiing back out toward Runway 31L. Our relief was short-lived, however. After being instructed by ground control to follow a Challenger, we watched as the corporate jet made a premature left turn, finding itself facing a series of cones blocking part of a parallel taxiway. I elected not to be a lemming. In all fairness, the rapid-fire clearance to the Challenger could have been easily misinterpreted due to the similar phonetics of the directed taxiways. We continued as per the correct instructions, listening as the corporate crew became the recipients of a mild New York-controller admonishment.

As Steve verbally reviewed the takeoff data for the second time, he discovered that the zero-fuel weight indicated on our load close-out information was different from that displayed on our FMS computers, which created a slight takeoff gross weight discrepancy. Apparently, the data hadn’t uploaded appropriately. With the nimbleness of a concert pianist, Steve manually corrected the FMS. Despite the adversity, we managed to traverse the North Atlantic with a routine landing at London Heathrow Airport.

For our flight home to New York the following day, we were presented with only one challenge involving the empty operating weight (EOW) of the airplane. The EOW includes the actual weight of the 777, the weight of all crewmembers plus their bags, catering equipment, cargo containers, cabin equipment, residual fuel, engine oil, potable water and chemical fluids. A discrepancy existed between the planned EOW and the final takeoff close-out EOW. After a check of our performance manual, also on the iPad, it was found that the load agent can adjust the weight for operating items that are heavier or lighter than standard. Discrepancy solved.

This particular trip was just a small example of threats to the links in the chain. The diligence of a professional crew is one of the best safety tools. It’s also an example of how much I appreciate the guy or gal sitting to my right. The prospect of a future with pilotless airplanes is just not comforting.

In any case, saving Lassie was gratifying, notwithstanding the fact we didn’t have to be surprised by a video clip of our flight on the 5 o’clock news.

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