Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude

Aircraft Equipment Problem Dissipated; Flight Crew Returned To Clearance

Captain and myself arrived in ZZZ in this aircraft and sat for six hours waiting for our passengers. Weather in the area included low ceilings; rain-showers and scattered thundershowers. It continued to rain all day. We departed and climbing on course through 35000; the Captain noticed a jump in the trim wheel. We were aware of previous auto pilot freezing scenarios on this model of aircraft and wanted to make sure that things would be ok. With this in mind; Captain disconnected the autopilot to make sure it was functioning normally. It was; so we reconnected the auto pilot and continued our climb to FL410. Upon level off; we completed the cruise check; and accelerated to our cruise speed while still in climb power. Approximately 2-3 minutes after level off; the autopilot pitched the aircraft significantly nose down and started down un-commanded below FL410. The autopilot at this point disconnected from the force being applied to the trim wheel. (Our best estimate of why). Both the Captain and I reached for the yoke to bring it back to nose level; at this point the Captain regained control and leveled off at an altitude of 40;300 feet. I immediately advised Center of our auto pilot issue and reason for our descent. The Captain smoothly returned to FL410; re-trimmed the aircraft and reengaged the autopilot system with my assistance. Because of our concern; we disconnected and reconnected the autopilot several times; in cruise to be sure all was operating properly. All autopilot operations seemed normal at this point; so we continued to the destination; advising ATC of its; now normal; operation.It is both the belief of the Captain and myself; that the cause of this incident was the freezing of either the autopilot servo; or the cables leading to the elevator trim of the aircraft. We believe this prevented the autopilot from properly trimming the aircraft because of the formation of ice somewhere in the trim system. Once the ice formation broke free; operation remained normal. For myself; this is the second such event in the same model aircraft; following the same scenario; (aircraft sitting in rain all day and then a high altitude trip). This is a reoccurring event in this fleet of aircraft. It happens any time the aircraft sits in all day rain and then climbs to altitude. I believe engineers need to figure out where this water is pooling and freezing in an effort to permanently find a fix using drain holes; or heat to resolve the problem.

The aircraft sat on the ground for 5+ hours in pouring rain at above freezing temps before the event. I have been assigned to the aircraft for three days without event. The aircraft is also fairly recently out of paint. We took off with 2 passengers. Climbing thru the mid-thirties; we experienced a 'jump' in the elevator trim wheel and a very slight 'feel' of the same. I momentarily disconnected the autopilot and actuated the elevator trim both electrically and manually. I re-engaged the autopilot and stated to my partner that there did not appear to be any binding or abnormality at all. We continued the climb to FL410 unrestricted and leveled off. As we accelerated in the climb detent to Maximum Operating Mach Number (MMO); the temp was -37 degrees Ram Air Turbine and we were VMC on top. As we approached MMO; the autopilot abruptly disconnected and the chime sounded as the yoke rapidly moved towards the panel. The First Officer and I both reached for the yoke as I retarded the throttles to avoid the over speed. We recovered from the pitch upset 700 feet later. We then ran the trim again electrically and mechanically and determined it was functioning normally. After satisfying our curiosities; we turned the autopilot back on as it was trimmed for hands off flight. It seemed that something had frozen and the autopilot to no longer 'muscle' the force necessary to hold our pitch attitude. After much discussion and troubleshooting; we determined if was safe for us to return to FL410 and continue to our destination. No other anomalies were noted for the rest of the trip. We did not get any warning (i.e. PITCH MSTRIM) or anything. The autopilot just disconnected and the yoke went forward.

CE560XL flight crew reported an elevator trim wheel malfunction while climbing through FL350. Crew believes the issue may have been frozen cables as aircraft sat in heavy rain before departure.


B787 Dreamliner Undifferentiated or Other Model

Deviation / Discrepancy - Procedural Published Material / Policy

I just want to make B787 pilots aware that the placement of the hand mic on the steering tiller is not appropriate. I was making a turn off the runway after landing and found the hand mic wedged into the tiller on the Captain's side. This is a convenient location for some pilots to place the mic while in cruise. As I used the boom mic upon taking my duty station for landing; I did not notice the placement of the hand mic until after landing. I have had this happen two times; the second time I noticed it prior to landing. Please advise pilots that this is not an appropriate location for storing the hand mic. The normal stowage for the hand mic is just below the tiller and creates no issues.

B787 Captain reported the use of the steering tiller by some pilots as a convenient place to store the hand mic in cruise. If not removed prior to landing it can jam the tiller.


Flight Crew Last 90 Days 121.6; Flight Crew Total 1475.7; Flight Crew Type 417.4

Communication Breakdown; Confusion; Situational Awareness; Workload

Party1 Flight Crew; Party2 Ground Personnel

Flight Crew Last 90 Days 159.6; Flight Crew Total 11551; Flight Crew Type 159.6

Communication Breakdown; Situational Awareness; Workload; Confusion

Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance; Ground Event / Encounter Object; Ground Event / Encounter Vehicle

Person Flight Crew; Person Ground Personnel

Aircraft Aircraft Damaged; Flight Crew Returned To Gate; General Flight Cancelled / Delayed; General Maintenance Action

We pushed back from [the] gate. Normal communication were established and push back proceeded normally; if very slowly. Tug operator spoke in heavily accented English but seemed to understand his role in the push back. We were cleared to start both engines which proceeded normally as we reached centerline of the taxiway E facing West [ramp] called to inform us there was a problem with the aircraft loading and we needed to return to the gate to have cargo containers moved from one pit to another. At that point I told the tug driver 'Do not disconnect' repeated 3 times. I informed him there was a weight problem and we may need to be towed back on the gate. Once it was determined we would need to return to the gate I told the tug driver I wanted to be towed on to the gate. He asked if I wanted to taxi back and I replied negative I wanted him to tow us back. I requested the First office to get us a clearance back on the gate. Once that was received a clearance I told the tug driver I was releasing the brakes and he was cleared to tow us back to the gate. Both engines were still run at this point and we started to roll forward. The Tug driver shouted to set the brakes; then informed me the tow bar was not connected. At no time was I informed the tow bar had been disconnected and the bypass pin removed. Ground hooked up the tow bar and towed us back to the gate; maintenance was call and an inspection was performed that found some metal gouged on the bracket hold the tow bar pin and paint scraped on the nose gear strut.There was break down in communications between ground and the cockpit. Standard phraseology was not used by the tug driver and he did not seem to entirely understand what was being required. The tug operator did not inform the cockpit they had removed the tow bar and I had assumed the tow bar was still connected and we were to be towed on to the gate. I also felt the was a language barrier that contributed to the incident. In retrospect I also feel using the phrase 'Do not disconnect' was not clear enough to convey what was needed. I think the tug operator may have interpreted the meaning to be 'Remain on the headset' Clear communications would have prevented this entire incident. If he had informed the flight the tow bar had been disconnected the incident would not have occurred. The relief pilot was monitoring the interphone communications with the ground; and no one on the flight deck heard a report the tow bar had been removed and/or the bypass pin had been removed.

During pushback we were told to contact [Operations] regarding a Center of Gravity issue. [Operations] informed us that we needed to return to the gate to move luggage bins. The Captain advised the push crew not to disconnect 3 times and that we needed to be towed back into the gate. We never received the 'tow bar disconnected and bypass pin removed announcement'. When the Captain Requested that we be towed back to the gate; the brakes were released and we rolled a very brief distance into the tow bar which had been disconnected. Brakes were set; the tow bar reattached and we were towed to the gate. A metal scrape was encountered on the nose strut and a write up was performed. Miscommunication and a lack of standard procedure by the ramp crew were contributing factors.

Flight crew reported a breakdown in communication with ground personal during the pushback/engine start maneuver. This miscommunication resulted in the aircraft rolling forward and contacting the disconnected tow bar; causing minor damage to the aircraft.


Flight Crew Air Transport Pilot (ATP); Flight Crew Instrument; Flight Crew Multiengine

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural MEL / CDL; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Overcame Equipment Problem; General Maintenance Action

Auto Speed Brake Inoperative. MEL says to reference 'Performance Handbook' for corrections. Upon reference Performance Handbook; all corrections have been deleted and no longer exist. Unable now to comply with MEL. A section of the Performance Handbook referencing takeoff with auto speed brake has been removed with no directions on what to do. The Company has failed to ensure that the required documents are made available for the safe operations of the aircraft. This is not the only place where information has been deleted from the Performance Handbook and the reference directing you to it still exists in the MEL.The company should immediately go through the MEL and look for all references of the Performance Handbook. They should then determine where the information that is being indicated and restore it to the Performance Handbook so that pilots can safely operate the aircraft.

B737 Captain reported performance correction for MEL no longer exist in Performance Handbook.


Flight Crew Last 90 Days 55; Flight Crew Total 55; Flight Crew Type 55

Workload; Time Pressure; Situational Awareness

Aircraft Equipment Problem Less Severe; Ground Event / Encounter Loss Of Aircraft Control; Ground Excursion Runway

Air Traffic Control Provided Assistance; Flight Crew Requested ATC Assistance / Clarification

As I finish my descent checklist and approached to ZZZ from the East 20 NM out I got my ATIS; called ZZZ tower and reported my position. I was instructed to enter the left downwind for runway XX. As I entered the left downwind and completed my before landing checklist I called the tower to let them know my position and I was clear to land. Abeam the numbers I began configuring my flaps after I slow down to my white arc. On base I selected my second notch of flaps and slow to 80 kts; on final I configured to flaps landing and I maintained my final approach speed. On final I stay on my center line; followed the PAPI and crossing the threshold I kept my airspeed about 70 kts began my flare and landed. It wasn't until my mains touched down and the nosewheel was on the ground and on the centerline that I felt a pulled to the left. I corrected to the right to no avail. The nosewheel did not steer to the right. As the airplane slowed down it continue to pull me to the left while I attempted to correct but there was no response on the airplane's nosewheel. The aircraft's left main gear and nosewheel went off the runway. I proceeded to do my shutdown checklist followed by a call to ZZZ Tower to informed them of the event. The tower sent a vehicle to pick us up. I called the tower on the telephone number as requested to provide my information.

Pilot reported the nose gear steering became inoperative on landing; resulting in a runway excursion.


Flight Crew Multiengine; Flight Crew Flight Instructor; Flight Crew Air Transport Pilot (ATP); Flight Crew Instrument

Flight Crew Last 90 Days 60; Flight Crew Total 8500; Flight Crew Type 50

Flight Crew Inflight Shutdown; Flight Crew Landed in Emergency Condition

Loss of right engine oil pressure and inflight shutdown. Priority handling was requested and uneventful landing.

BE-200 pilot reported a loss of engine oil pressure inflight.


Time Pressure; Physiological - Other; Workload

Workload; Time Pressure; Physiological - Other

Aircraft Equipment Problem Critical; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Flight Crew Landed in Emergency Condition; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Diverted; General Declared Emergency; General Flight Cancelled / Delayed

Approximately 100 NM SE of a major airport at FL360 smoke and fumes began rapidly filling the cockpit. First Officer called out smoke and we put on O2 mask and goggles. First Officer grabbed the QRH and began the Smoke Fire and Fumes checklist. I declared an emergency and requested an emergency descent from ATC. ATC and First Officer pointed out a major airport was 80 miles in front of the aircraft. I requested diversion to that airport. There were no fire indications and all engine parameters were normal at this point. Number 1 Flight Attendant called to notify us of smoke and fumes in the cabin. First Officer completed Smoke Fire and Fumes checklist and began the Smoke Removal checklist. Number 1 Flight Attendant called to tells us that they were seeing smoke from the left engine but no sign of fire. I made a PA to passengers and flight attendants that we were making and emergency diversion; we would make a normal landing and follow the directions of the Flight Attendants. Passing through 10;000 FT the First Officer had completed the Smoke Removal checklist. The smoke had dissipated enough to remove the O2 mask and goggles. I advised the Number 1 Flight Attendant to prepare the cabin for landing and I did not plan on evacuating the aircraft after landing. As we were descending the left engine oil temp began to rise to a max of 177 degrees and oil pressure began to fluctuate with throttle movement. With the throttles at idle the left engine oil pressure dipped as low as 16 psi but when the throttles were advanced it would return to the normal band. We coordinated with Provo Approach for a visual approach to Runway 10. We landed with 30 flaps; autobrakes 3 to a full stop. After stopping we shutdown the left engine and waited for the AARF to check out the aircraft. I made a PA to the passengers to remain seated and that emergency vehicles would be approaching the aircraft for safety checks. The right engine was shutdown. AARF reported that fluid was leaking from the left engine. Aircraft was then towed to the gate and secured. I want to emphasize that that the First Officer and flight attendants performed professionally and the outstanding job they did insured the successful conclusion of this emergency.

I noticed that we were 100 miles from a major airport. I have been to that airport many times and suggested we head that way. The Captain declared an emergency; and ATC gave us vectors and a descent to the airport. The Captain loaded the FMC and proceeded direct to the airport. I started the checklist for SMOKE; FIRE or FUMES. The smoke was in the air conditioning system because it was coming out of the eyelets in the cockpit. After completing the checklist; I then proceeded with the smoke removal checklist. The Number 1 Flight Attendant saw smoke from the left engine which brought to our attention the left engine instruments. The Captain and I noticed that the oil temp on the left engine had crept into the red band and with the power at idle the oil pressure was low. By cracking the throttle on the left engine; the engine remained out of the red band. The Captain wanted to leave the left engine running because we were on short approach. I thought it was a very good choice. After completing the checklist; the smoke was greatly reduced. At 10;000 FT the smoke cleared for a fairly normal approach and visual landing. The approach control; Airfield Rescue and Fire Fighters and passengers were ready for our arrival. Landing was uneventful. I think the entire crew was prepared to do their job. After the Fire Chief checked our aircraft for fire or damage; the plane was towed to the gate and all passengers were very thankful and were placed on the next plane to our planned destination.

A B757 cockpit and cabin began filling with smoke; so an emergency was declared; the QRH procedure begun and after the diversion was announced a Flight Attendant notified the crew about left engine smoke. The crew then identified left engine high oil temperature and fluctuating oil pressure.


Training / Qualification; Distraction; Confusion

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy

I would like to discuss a significant safety issue that is incorrectly described to the pilots. It is 'Alt Hold' engagement during the takeoff roll. Before I go into this discussion; please allow me to state my background. I hold a B.S. in Aerospace Engineering; I am a Senior Officer in the military and I held jobs as Safety Department Head; Senior IUT Evaluator and an equivalent of Assistant Model Manager. Over last few years I observed 4 instances where 'Alt Hold' was engaged during the takeoff run; 3 in foreign airports and 1 domestically. The domestic event; I actually saw it change at about 80 KTS from VNAV to ALT. Before each flight; I brief the crew [on] what [I've] seen and the events that occur during this event. This is my brief: During the pre-departure brief; we as crew verify that we have everything setup properly. This is done prior to push from the gate and includes: vertical and lateral modes; usually in LNAV and VNAV; altitude is set to our clearance altitude; Flight Director's (FD's) are indicating properly; takeoff/go-around with LNAV/VNAV below and verify all other items indicate properly. During the takeoff roll; about 60-80 KTS; the VNAV changes to ALT; ALT HOLD button lights up on Mode Control Panel (MCP) and FD's are providing incorrect guidance. As the aircraft takes off; the FD's still provide incorrect guidance (fly down to takeoff altitude) until passing 300-400 FT. At that time the indication and FD guidance changes to VNAV SPEED giving proper indication. One can fly through the improper indication or turn OFF then ON both flight directors for proper guidance. If autopilot is turned on at 200 FT the aircraft will descend to the takeoff altitude and impact the ground. Worst-case scenario is Mumbai; maximum gross weight; at night; in Monsoon and engine failure at V1. We are instructed to turn autopilot 'ON' at 200 FT. A lot of things are happening at that time and my recommendation is to verify everything and not turning autopilot on until passing 500 FT. Many pilots that I brief stated that they been told that the initial altitude was set to zero in MCP. I can attest that is not the case. In Mumbai; the aircraft is warm and when entering the cockpit the MCP altitude is usually set at missed approach altitude and not zero. Discussing this issue with the FOQA personnel; I had been told that the FOQA was registering zero during the engine starts. I can attest that it is not the case. In my 25-year flying career I have yet to see initial altitude set to zero. It might be set zero at the gate; but after the briefs it is always set to initial clearance altitude. That is not what FOQA data is indicating and not what is passed to the pilot group. What I see are two separate problems. One: During the takeoff run; VNAV on its own; transitions to ALT (Hold) and gives improper guidance. Two: FOQA is recording improper indication from MCP. My recommendation is to brief the pilots that this is happening during the takeoff run with proper settings prior to taking the runway and not to engage the autopilot until 500 FT after verifying that all indications are correct. In addition to the 'Alt' (hold) problem; FOQA data recorder should be investigated why it is recording incorrect data. I see them as two completely separate issues.

The reporter stated that the exact chain of MCP takeoff state transitions is first TOGA/VNAV; at about 60-70 KTS an auto-transition to TOGA/ALT; then at 400 FT an auto-transition to TOGA/VNAV SPD. He believes that somewhere in the intervening software an error occurs because FOQA data indicates the MCP Altitude is set at zero while flight crews are confirming it set at the first departure procedure level off altitude. Most pilots do not monitor the FMA during VMC conditions and so at night in mountainous conditions this could lead to a dangerous descent if the autopilot is engaged at 200 FT; as per his company's training; and the aircraft attempts a descent possibly below field elevation. The Reporter stated that he was told 55 similar events have been reported.

A B777 pilot reported the Mode Control Panel (MCP) made an uncommanded mode change from VNAV to ALT HOLD during the takeoff roll at about 80 KTS.


Flight Crew Last 90 Days 34; Flight Crew Total 96; Flight Crew Type 12

Communication Breakdown; Situational Awareness

I was performing air work (steep turns; practice emergency descents; stalls; etc.) along a north-south route east of TVY. During each pass (south to north and north to south) I made radio calls and shallow banked 180 degree turns in order to watch for traffic. I also had an EFB with ADSB-In traffic information. At the south end of the valley; with a southerly heading; at 7500 feet; I performed a practice emergency descent; turning to the left at 45 degrees of bank.  Just before starting this maneuver; I heard a radio call from another aircraft stating that they were at the 'North end of the valley and would proceed south at 5800 feet in order to join traffic for Runway 17'. I noted this call but did not believe it would be a conflict since I thought they were in a different area of the valley. I had also just prior made a call stating that; 'Skyhawk XXXXX is performing maneuvers at 7500 ft. and below; 5nm east of the airport.' I descended from 7500 ft. to about ~6100 ft. during my emergency descent and rolled out on a northerly heading to practice preparation for an emergency landing. At this time I did not see any oncoming conflicting traffic; however my attention was divided between the outside; a checklist; and maintaining airspeed since I had the engine at idle and wanted to practice setting up an appropriate best glide speed. After working through the emergency checklist I noticed the aircraft passing underneath me with a relatively small clearance between the two aircraft; maybe 50 ft. horizontally and 80 ft.-100 ft. vertically. The rate of closure was such that by the time I had reacted by adding power the aircraft had already passed. I believe myself and the other pilot did not take sufficient steps to confirm each other's position. I did not confirm which part of the valley the aircraft was going to fly down and the aircrafts pilot did not confirm my location or intentions. The aircraft never appeared on my EFB's traffic display (although other aircraft in the area did). Additionally; a contributing factor to me not seeing the other aircraft was that I was distracted by maintaining airspeed and bank angle while performing an emergency descent. In addition to scanning for traffic prior to maneuvers I also looked at my EFB. Had the aircraft had ADSB out I believe this near miss could have been avoided since I would note that aircraft positioned at the north end of the valley and specifically scanned for it. Another possible prevention technique is that if I had been clearer about my intention 'Skyhawk XXXX performing emergency descent 7500 ft. to 6000 ft. ...' then the aircraft might have decided to delay flying underneath me. Alternatively; if the aircraft had stated 'Traveling down the east bench at 5800 feet I might have delayed my practice maneuver.

C172 Pilot reported a NMAC while training.


Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 173.97; Flight Crew Total 22500; Flight Crew Type 8100

Communication Breakdown; Confusion; Troubleshooting

Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP); Flight Crew Instrument

Flight Crew Last 90 Days 213.15; Flight Crew Total 4337.37; Flight Crew Type 3984.27

ATC Issue All Types; Aircraft Equipment Problem Less Severe; Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Ground Equipment Issue

Person Air Traffic Control; Person Flight Crew

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification

Aircraft; Environment - Non Weather Related; Airport

Aircraft X joined taxi line for runway 4L. During the 45 minute taxi the flight was operating on upper antenna and all radio communications broadcast and received were normal. Flight was cleared to line up and wait 4L; comms normal. While in position a garbled; indistinct transmission was heard. Flight was expecting a takeoff clearance and called tower to verify they were broadcasting to us. No reply. Tower then came on and cleared flight to vacate runway; comm was loud and clear. Tower received our reply as well. Tower was then heard giving directions to a go around aircraft. The initial go around call to that flight was not heard by either pilot of our flight. Flight taxied back to departure end. Flight was cleared to line up and wait again; comms normal. Takeoff clearance was received and acknowledged. During initial takeoff roll tower came on frequency asking us if we were taking off. We replied we were and had acknowledged our takeoff clearance. Airborne tower wanted us to have our radio checked. Subsequent radio checks and communications with ATC were loud and clear for remainder of flight. I believe the transmissions during first takeoff clearance were blocked by a radio shadow.

While in position for takeoff on 4L at EWR both the Captain and I did not here the takeoff clearance given by tower which resulted in a go-around for another aircraft on final.  We did hear a garbled 'takeoff;' but that was it.  We both questioned it and when the Captain tried to clarify with tower were told to hold position and then received clearance to taxi off the runway; via BB and P.   Neither the Captain or I heard the takeoff clearance or the tower directed go around of the landing aircraft; but obviously the other aircraft did.  We than taxied back into position and it took the tower at least two tries to get us the takeoff clearance.  We only heard it once.  Upon departure we verified the VHF one was working correctly with multiple ATC agencies.   Sterile cockpit  procedures were followed and there were no conversations while in position on the runway.  Neither the Captain or I heard the original T/O clearance or the wave off call to the landing aircraft. The 10-7B pages for EWR state; 'Radio shadows exist in the vicinity of the first 1800 feet of the runways.' This is true and is an obviously known issue.    Not sure what causes this; whether it is certain airplanes or position of other planes on the taxiways.  At the time of the incident there was a line of 20+ airplanes on taxiway B. This condition is unsafe and needs to be corrected.

Air Carrier Pilots reported a communication dead spot at EWR airport.


Flight Crew Rejected Takeoff; Flight Crew Returned To Gate; General Maintenance Action

Initially cleared for takeoff and while taxiing onto runway got the alert. Taxied clear and attempted to evaluate the alert but it had cleared. Communicated with Tower our intentions and said we may need to return to line. On Second attempt for takeoff after being unable to duplicate the issue; power was run up and takeoff roll begun. At 20 KTS alert returned and we rejected. [We] taxied clear and returned to line for Maintenance to address intermittent problem. Brakes did not exceed 100 degrees. CSD needed 4-5 quarts oil.

We were taxiing for takeoff and were cleared so entered the runway. As we were doing so; the Gen Drive 2 Fault alert came on. We told Tower we needed to taxi clear to work an issue. After we cleared the runway and got out the QRH; the fault extinguished. We both decided it was safe to continue so told Tower we were ready for another try. The same fault came on; but this time it was at about 20 KTS as First Officer was setting power. We rejected and taxied back to the gate for proper maintenance action.

DC10 flight crew experiences a Gen Drive 2 Fault upon taking the runway and taxiing clear the fault disappears. On the next attempt the fault returns and the takeoff is rejected at 20 KTS and the crew returns to the line for maintenance. CSD was low on oil.


Deviation - Speed All Types; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Unstabilized Approach

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

We were being vectored for the ILS 35R into SDF. We were on a right downwind and ATC was leaving us high and we had to keep asking for lower altitudes which they gave us when asked. About 8-10 miles out they cleared us for a visual. We were still high and fast; 250 knots. The Captain set 230 kts on the speed and used speed brakes to slow. The Captain also disconnected the autopilot and started a turning descent towards the localizer. At 240 kts he called gear down and I selected gear down. At 220 kts we set flaps 1 and at 200 kts set flaps 2. The Captain was overriding the auto throttles at this time and at 190 kts he called flaps 3. I quickly checked the speed and set flaps 3. I must have missed the speed bug was not set for slower. At this time we armed the approach. He was in a right turn to intercept the localizer and I looked down for a second to look up the tower frequency and set it in standby. When I look back up we were passing through the localizer and descending below glide slope. I pointed out we're were passing through final and low. He started correcting up and more to the right and the aircraft began to accelerate. At this point we accelerated through flap speed and got the overspeed aural warning. At the same time ATC called out 'altitude alert; check altitude; below min vectoring altitude.' The Captain was correcting speed and altitude and I responded to ATC 'we're correcting'. We were almost full scale deflection to the left and below of the loc and glide slope but still well above 1000 feet and about 6 miles out. The Captain corrected speed and back onto the loc and glide slope. I selected a slower speed with the speed bug; I can't remember exactly what speed I set; I think 160 kts. We were handed over to Tower and cleared to land. We then selected flap 5; VAPP and completed the landing checklist. At 1000 feet instruments were normal and we were stable. We landed normally. It all happened surprisingly fast. Basically we were too fast originally. When the Captain was; I thought; turning to intercept the loc I looked down for a second to put the Tower freq in standby. When I looked back up we were well past; to the left; of the loc and well below glide path. It took me a second to figure out what was going on and make the call outs. Because the speed was still set for a speed above 200 and the Captain was overriding the auto-throttles to slow; when he released the throttles the aircraft accelerated and exceed flap speed by about 8 knots.First I should have stayed heads up until we were more stabilized on the final approach course and dealt with the frequency later. That way I could have helped monitor speed and configuration. And also better monitor the approach. When we got the low altitude alert from ATC and were almost full scale deflection on the ILS; I probably should have called for a go around. Even though we were before and above the 1000 foot call it might have prevented an overspeed. I would suggest that if ATC ever calls a low altitude alert crews should automatically initiate a go-around. Even in VMC.

If I had asked for a slower speed on approach; took a wider turn; or commanded speeds to be set this would have never happened.

EMB-175 flight crew reported ATC issued a low altitude alert to them on approach into SDF.


Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP); Flight Crew Instrument

Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural MEL / CDL

Aircraft arrived with (4) MELs. Two critical MELs; SATCOM inoperative and Number 2 ENG BLEED inoperative. The Number 2 ENG bleed was put on MEL. With SATCOM inoperative and without medical personnel on board; the FA (Flight Attendant) would be unable to contact the ON CALL medical personnel to help with medical support for a passenger or other crew-member. This would require an immediate divert to the alternate airport.Dispatching an aircraft over the North Atlantic with an inoperative bleed is criminal and incredibly stupid. Failure of the other bleed would require an emergency descent and immediate diversion to the alternate airport. Besides the potential of injury to the passengers and crew; this would create a very stressful work environment for the flight deck which would degrade the level of safety.The company is putting band-aids on aircraft to circumvent labor issues with maintenance personnel. The company needs to STOP flying aircraft in these conditions. Speaking for myself; it's the last time I'll accept an aircraft with MELs that degrade the safety of my passengers and crew.

A330 Captain reported that the aircraft was dispatched with MELs that compromised the safety of the passengers and crew.


Flight Crew Flight Instructor; Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 40; Flight Crew Total 1315; Flight Crew Type 20

Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 100; Flight Crew Total 6900; Flight Crew Type 250

Air Traffic Control Issued New Clearance; Flight Crew Landed As Precaution; Flight Crew Diverted; General Maintenance Action

We had just leveled off at our cruising altitude of 33;000 FT. Our filed altitude was 41;000 but because the winds were better at 33;000 for improved fuel burn and shorter flight time we elected to make 33;000 our final cruising altitude. We requested the change of cruising altitude to ATC and it was approved. After leveling at cruise (33;000) and completing the cruise checklist both inverters failed and we lost all primary flight instruments. We notified ATC immediately we had a problem. They gave us a descent to 27;000. I was instructed to begin the abnormal checklist for an inverter failure while the Captain flew the aircraft and began communicating with ATC. After completing the abnormal procedure for inverter failure it was clear that we could not get either inverter back online. We notified ATC that we had a problem with our inverters and were unable to navigate accurately. After deliberating with the Captain and checking the weather we determined that ZZZ was the best suitable airport to divert to; as it had maintenance facilities. We were in complete VMC conditions and in positive control of the aircraft and the safety of flight were never in question. Due to both inverters failing and losing primary flight instruments and navigation capability we requested ATC for vectors direct to our diversion airport which was granted. We remained VMC for the duration of the diversion and landed without incident. ATC performed admirably and professionally during the entire procedure.

[Narrative #2 contained no additional information.]

LJ31 flight crew experiences a dual inverter failure at FL330 rendering all primary flight instruments inoperative. With ATC assistance; the crew elects to divert to a suitable airport for maintenance.


Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural MEL / CDL

I made the decision to reject the takeoff at what I believe was around 115 knots because of a Left Thrust Rev Unsafe caution message. I took control of the aircraft; doing the aborted takeoff; and slowing back to a safe taxi speed. We exited the runway and safely taxied back to the terminal to call maintenance.The left thrust reverser had been written up and placed on an MEL the prior day. The flight that we did the rejected takeoff was our fifth flight of the day. On the previous four flights we had gotten the same message 'Left Thrust Rev Unsafe' caution message after the plane had left the ground and was weight off wheels per the MEL. This happened the exact same time on each and every flight except for the flight when we aborted the takeoff. The caution message happened at what I remember was 115 knots just below our V1 speed of 129 knots. Because the caution message happened at a different time or point in our takeoff and departure than the previous four flights I made the decision to discontinue the takeoff. Another factor that I feel may have been a factor in the rejected takeoff was we had a problem with the plane before this flight. We had written the plane up for a Prox System Fault that was cleared by maintenance. Knowing there was history of problems with the Prox System caused me to wonder if there was some problem that may have been bigger than our original message of a Left Thrust Rev Unsafe message. I chose to abort the takeoff for the safety of the flight.As a flight crew I felt I could have been a better leader in leading the briefing of the situation that we were in. We had brief the weather and terrain that was around us but briefing all the potential problems and messages we were going to receive because of this MEL. This was the fourth flight of the day in this airplane and my briefing was probably a little rushed through. Complacency was setting in from dealing with this issue all day. Next time I will tackle the briefing as if it was the first time we had briefed the problem and possible situations it can put us in no matter if it is the first flight of the day or the sized flight of the day.

I was Pilot Flying; and as we began the takeoff roll all indications were normal. After the airspeed check callout; I transitioned my eyes outside. As we approached V1; a gust of wind (straight down the runway at 23G33) hit and I could feel the nose gear become very light. [Shortly] after I heard the caution message chime and we received a L REV UNSAFE caution message. At this point the main landing gear were still on the ground. I believe we were close to V1; however my eyes were outside and I can't recall hearing any V speed callouts. The Captain called 'Abort; my controls' to which I responded 'Your controls'. We were able to stop by the end of the runway and taxi back to the gate area.Fixation on LLWS; led to complacency with other threats; including L REV MEL and associated L REV UNSAFE caution message. Previous delay of inbound leg led to rushing; compounded by the quick turn. Also; approaching weather contributed to sense of urgency to depart quickly. Wind gust on takeout may have possibly caused premature rotation of aircraft nose; leading to L REV UNSAFE caution message with main gear still on the ground; causing Captain to call for the abort.

CRJ-200 flight crew reported rejecting the takeoff at approximately 115 knots; about 14 knots below V1; after receiving a LEFT THRUST REV caution message.


Aircraft Equipment Problem Critical; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence

Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem

Altitude deviation; few miles south of LHS VOR on V459 at 10;000 feet. IMC with light icing condition. Airspeed indicator showed slow decrease from 135 KIAS. I checked that pitot heat switch was on position and wing boots clear the ice. I thought that ice was over and or under the wing. As the airspeed indicator approached 110; I requested 9;000 feet to ATC. ATC said 'stand by'. Airspeed indicator kept decreasing. Airspeed approached 100; I reported 'unable to maintain 10;000' and lowered the pitch [to] gain airspeed. But airspeed did not increase; then I tried to recycle pitot heat switch. Few second later airspeed showed normal; and I climbed back to 10;000. I deviated 800 feet.Cause:1. Pitot/Static heat switch did not work properly.  2. I did not check other side of instruments (lack of scan). 3. When I requested 9;000; I should say why (due to icing etc.) 4. When I started to descend; I should declare emergency.

C-208 pilot reported deviating from assigned altitude when he experienced abnormal airspeed indications while in icing conditions; pitot/static heat switch problem was suspected to be a factor.


Flight Crew Last 90 Days 43; Flight Crew Total 5255; Flight Crew Type 1304

The issue is what happens [in the late afternoon between flights at an international terminal]. Required to stay on the plane while passengers disembark. About an hour with constant PA announcements. Then we are placed on an inter-terminal bus. Neither clean nor comfortable. This lasted just over 2 hours. We had to change buses once because the AC didn't work on the first bus. (NO CHANCE FOR ANY REST AT ALL!) Allowed back on the plane to perform pre-flight duties. Already on the back side of the clock and put in deplorable conditions without even a facility to use for personal hygiene/bodily functions. (NO REST ROOMS!) Fighting bad weather on the return [flight] made this a very frustrating and possibly dangerous situation. We both felt very fatigued during the return flight. There has to be a better way. Both of us passed out on the ride back to the hotel. (I almost never sleep on a bus.)

Air carrier Captain reported experiencing extreme fatigue on a two-leg international assignment.


Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Security; Ground Event / Encounter Other / Unknown

Management was advised that Customer Service employees did not feel safe in their break room; offices; and locker room because of the employees of [company].  Employees of [company] all had unescorted access to these areas. To access these areas you have to have the code for the cipher locks. When Management was told that Customer Service employees did not feel safe in these areas due to the access of the vendor his response was why; they pass a background check to get badged. He was told of specific incidents between Customer Service and [company]. They still did not think there was an issue.  It is a revolving door of employees with [company] and we no longer know who they all are.  Some [company] employees have also resigned or have been fired.  The cipher lock code did get changed and the code was not to be given out and [company] was not to be in these areas. Months later everyone at [company] has the code and come and go as they please through the break room and offices. There is SSI (Security Sensitive Information) in these areas that is not locked in any cabinets.  One of the doors with a cipher lock is approximately 6 inches from the public water fountain. If anyone is at the water fountain they can see what the code is.  Cipher locks are not secure locks in public areas. With more workplace violence and active shooters; management needs to do more to ensure the safety of its employees. [Airport Management] was also advised of this issue during the summer and nothing has been done.

Ground personnel reported carelessness with door codes; allowing unauthorized personnel access to secure areas.


Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor; Ground Event / Encounter Other / Unknown

Flight Crew Took Evasive Action; General Declared Emergency; General Flight Cancelled / Delayed; General Maintenance Action

During first flight of the day preflight the aircraft was powered using a GPU. All required systems were then powered up including the air conditioner. During the preflight walk around the Captain noticed a strange odor coming from the rear baggage compartment area. The Captain notified the First Officer of the odor and asked for help in identifying where the odor was coming from. Upon inspection it was found that the AC compressor was sparking with smoke beginning to flow from the unit. The air conditioner was immediately turned off at which time it caught fire. The cockpit halon fire extinguisher was then used to put the fire out and the Fire Department was called. The Fire Department arrived and determined the fire was indeed extinguished and remained on site until the AC unit cooled.

During preflight; GPU and AC on; I observed sparks emanating from AC unit while inspecting aft equipment bay. The sparks were faint; so I asked my partner to have a look as well. While he was observing the AC unit; I began to see smoke developing from the lower vent area. I ran to turn the AC unit off. According to my partner; it was then that flames erupted from the AC. As I was returning to the rear of the plane; my partner yelled to me that we had a fire. I immediately returned to the cockpit to secure the fire extinguisher. He met me at the wingtip and took the extinguisher to the fire. He suppressed the fire and I instructed ground personnel to call fire rescue. GPU and Battery power were removed from aircraft. The firefighters arrived on scene and utilizing thermal imaging equipment determined that no fire threat remained. I notified the on duty Assistant Chief Pilot and advised him of the situation. I conferred with Maintenance personnel on the details of the subsequent write up and they agreed that the wording covered the episode and any necessary maintenance which might be required.

The Reporter had no additional information.

A Citation 560 air conditioning compressor caught fire during preflight on ground power at the gate; the flight crew extinguished the fire using the aircraft's walk around halon bottle.


Air Traffic Control Time Certified In Pos 1 (yrs) 2.6

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Glider; Flight Crew Commercial; Flight Crew Flight Instructor

Flight Crew Last 90 Days 130; Flight Crew Total 4400; Flight Crew Type 300

Human-Machine Interface; Situational Awareness

Aircraft Equipment Problem Less Severe; Airspace Violation All Types; Deviation - Altitude Crossing Restriction Not Met; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Separated Traffic; Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Became Reoriented

Procedure; Chart Or Publication; Manuals; Aircraft

Aircraft X checked on descending to and almost level at 24000 feet RNAV arrival. I told the pilot to descend via the arrival and the pilot read it back correctly. The aircraft leveled at 24000 feet. I then saw the aircraft descend below 24000 feet prior to the fix which has a published altitude of 24000 feet. I stopped their descent; but not before they violated the underlying sector's airspace. I told the pilot the published altitude at the fix and asked why they descended early. They said the computer did it. Once they were in my airspace I gave them a descent clearance.

[Report narrative contained no additional information.]

ZBW Center Controller and flight crew reported the aircraft descended below a published crossing restriction.


Time Pressure; Communication Breakdown; Situational Awareness

Party1 Flight Attendant; Party2 Flight Crew

Time Pressure; Situational Awareness; Communication Breakdown

Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy

At the exact time the doors were being armed; a deadheader was converted to work the flight. She was seated at a window seat and had to have the entire row get up to get out. Other people also got up to switch seats at this time. We had around 6 people standing in the aisle; the door arming announcement had not been made yet and the Captain began to push back from the gate. The cockpit door was still open. Myself and the purser began to run up to the cockpit to inform them the doors were not confirmed armed yet; the all call was not yet initiated and the cockpit door was still open and there were multiple people standing in the aisle falling over onto each other because of the illegal pushback.The Captain looked back at us [and] told us it was fine and we would only be taxiing for a few more minutes. A [rewards passenger] seated in 2B was very off put and said she had never seen a Captain do this before and that she was frightened by the event. The crew all agreed we had never seen anything like it. Still taxiing with the cockpit door open; the purser initiated the all call; had everyone seated; and then closed the cockpit door. We played the safety demo. As soon as it was complete the Captain said 'Flight attendants please be seated for departure.' Before he finished the announcement he was already on the runway full speed ahead taking off. This caused myself to fall into my jumpseat as the passengers in exit row at 2L reached out to help.I looked to the back galley to see two flight attendants holding onto the carts; not in their jumpseats because they could not get to them in time as we are now off the ground and heading up into the air. The third flight attendant (who was supposed to be seated at 2R) was halfway down the economy aisle when the Captain took off with the short warning. She had to run to the back of the airplane as the Captain pulled the plane up. 3 of 5 flight attendants were either not in their assigned jumpseats or not in a jumpseat at all because of this Captain. Final safety checks were not able to be performed throughout the entire cabin.

Boarding finished; boarding door closed. Flight attendants in process of arming doors. Captain/pilots start pushing back/reversing airplane with 4 doors disarmed and cockpit door open. Flight attendant/purser tells Captain we are not ready yet - not all doors are armed and cockpit door was not closed. Airplane was still being pushed back while doors are in the process of being armed and the cockpit door was not closed. After safety video presentation cabin safety walkthrough checks.After the safety video; I proceed to do my safety checks from standing at my position at row 7. As I walk by the exit row (row 21); I hear the flight attendant prepare for takeoff announcement. I then hear the engines revving and the pilots soon start moving the plane - fast. I had to run to my jumpseat and strap in as we were lifting off. The other flight attendant; who was supposed to sit at door 2 was also caught off guard (her demo standing position was at row 30). She ended up sitting back at door 4 with myself and the other flight attendant. The pilots gave us no time between the prepare for landing announcement and actual take off.

B757 flight attendants reported pushback; taxi and takeoff occurred with minimal contact and time provided by the flight crew; and contrary to SOP.


B787 Dreamliner Undifferentiated or Other Model

Flight Crew Total 12712; Flight Crew Type 660

ATC Issue All Types; Conflict Ground Conflict; Critical

Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

We were holding; number 2; on Taxiway H short of Runway 25R at taxiway U. Tower cleared the Commuter [aircraft] and us to cross Runway 25R; at taxiway U; and contact ground on the other side. We noticed a B787 stopped on Taxiway B; short of Taxiway U facing east. The Commuter crossed the runway and turned right onto taxiway B. We followed and as we crossed Runway 25R we switched to ground. In the middle of crossing 25R; the B787 began taxiing. We had to break hard not to cause a taxiway collision. We stopped about 20 feet from the wingtip line of travel and our nose. We never heard ATC tell [the B787] to taxi and we were never instructed to hold. We queried Ground Control and they said wait for [the B787].

B777 Captain experienced a ground conflict with a B787 after being cleared to cross Runway 25R at taxiway Uniform by LAX Tower. Ground Control had apparently issued instructions to the B787 crew that the reporter did not hear.


Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Training / Qualification

Flight Crew Instrument; Flight Crew Air Transport Pilot (ATP); Flight Crew Multiengine

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Speed All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Loss Of Aircraft Control

Flight Crew Took Evasive Action; Flight Crew Regained Aircraft Control; Flight Crew Became Reoriented

Weather; Procedure; Environment - Non Weather Related

This happened after we departed off of Runway XXL in ZZZ on the ZZZZZ5 Departure at the ZZZZZ1 fix. There was weather moving into the area. ATC held us on the ground for about 15+ min for a possible reroute that never happened. We got cleared to taxi to XXL via Taxiway D. I overheard a wind shear warning on tower frequency; so I had the FO (First Officer) enter wind shear numbers into the ACARS. We were cleared for takeoff RNAV ZZZZZ1 XXL. At ZZZZZ1 conditions worsened significantly; we switched to Departure and were issued a climb to 15000 ft and heading of 120. We complied and the altitude and heading bug were set. But I had a bad feeling about this heading. However before I could query ATC; the [airliner] flight that took off before us and flew the route that was intended for us called ATC and said 'Don't turn them to the right! We just encountered severe turbulence and it kicked our ass' ATC immediately turned us left to 270. It was a little too late as we got caught in severe turbulence. We were turned another 40 degrees to the left. The aircraft was very difficult to control; I told ATC we are unable 15000 ft and was issued 5000 ft; I further asked for 4000 ft as 5000 ft would have put us right in the cloud base and even more turbulence. The FO handled the situation exceptionally well keeping control the best way he could. It was a struggle to maintain altitude; heading; and airspeed. The altitude loss and gain was +/- 200 ft to 300 ft; airspeed loss and gain was +/- 30+ knots and heading deviations of 10-15 degrees right and left of course. I called out the deviations to the FO and advised ATC of our progress. The goal was to simply escape the severe turbulence. We exited the turbulence got back on airspeed; altitude and heading and maintained all further instructions. My first priority was to check on the Flight Attendant and asked if everyone was ok and not injured; she responded with 'everyone is ok'. We continued on to ZZZ1 without any more incidents.I'm not sure that there are any suggestions on this as it was weather related and happened very suddenly and unexpectedly without a way to predict the turbulence event. ATC did a great job of vectoring; we did a great job in getting out of the turbulence and maintaining control; and the flight crew of the southwest flight did a wonderful job of quickly telling ATC to not turn us to the right. I feel an [Report] is warranted because we couldn't hold altitude airspeed and heading due to the intensity of the turbulence.

We were departing from the ZZZ airport on the ZZZZZ5 departure. We were in the turn going towards ZZZZZ1 and there were thunderstorms just north of the airport. Once we were in the turn towards ZZZZZ1; that was when the severe turbulence started. ATC had issued a turn to the right about 100-120 heading; but [the airliner] suggested a left turn towards a roughly 210 heading. I'm not entirely sure when we were out of the turbulence but once we were clear from under the clouds; all severe turbulence stopped. I had decided to not climb up to the issued 15000 and stopped climbing to remain clear of IMC conditions. We maintained 4000 ft until clear from under the clouds as well. We experienced about plus or minus 30 kts up to 280 kts. We also experienced altitude deviations of plus or minus 500 ft. I would suggest to abandon any STAR in the face of severe turbulence. I had my reservations about turning head first into the storm. We should have turned to the south and not to the north to avoid anything to do with the storm.

CRJ-200 flight crew reported encountering severe turbulence after takeoff.


Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 9; Flight Crew Total 435; Flight Crew Type 36

Deviation - Altitude Excursion From Assigned Altitude

For a visual approach to KVCB; I had been cleared to descend to 3000 MSL. Passing above KSUU's Class D airspace at 3000 MSL; I was asked by Travis Approach to notify when I had KVCB in sight. Unfamiliar with the area; I had difficulty locating KVCB but was aware I was getting very close.I mistook Vanden Road and its adjacent train track for Interstate 80; in part because in the vicinity of KVCB these routes are on opposite sides of the San Francisco sectional chart and in part because recent suburban development in the Fairfield-Vacaville area doesn't match the yellow fill on the sectional chart.As a result; I thought I was about 4nm closer to KVCB than I really was; and I began a descent. Still without the airport in sight; I neglected to advise Travis.At 2500 MSL; Travis reminded me that I had been assigned 3000. I quickly climbed back to 3000. Shortly after leveling off at 3000; I spotted KVCB; advised Travis; canceled IFR; and completed the flight.

GA pilot reported descending below assigned altitude during IFR flight to VCB.


Flight Crew Last 90 Days 55; Flight Crew Total 30000; Flight Crew Type 1200

Aircraft Equipment Problem Critical; Deviation - Altitude Overshoot; Deviation - Altitude Crossing Restriction Not Met; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Flight Crew Overcame Equipment Problem; Flight Crew Returned To Clearance

Arriving from (a high altitude airport with a high altimeter setting) into PHX (a low altitude airport with a low altimeter setting) both pilots failed to reset our altimeters to the PHX local setting causing us to cross some of the arrival fixes at lower than published altitudes. ATC advised of the lower than normal altitudes and we realized what we had done and reset out altimeters. There was no conflict with any other aircraft and ATC stated that there was no problem on their end. In turbine aircraft we reset our altimeters descending below FL180 when arriving into an airport; but since this was a short flight we never climbed that high and this got us out of our normal sequence and we missed the altitude check. We will devise a system to recheck altimeters at lower level flights in the future.

The flight crew of a Citation 650 failed to set the local altimeter setting on descent to PHX and; consequently; crossed some fixes on their arrival below the charted altitude.


Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 20; Flight Crew Total 595; Flight Crew Type 95

Situational Awareness; Confusion; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence

The Controller declared an emergency on my behalf because I entered IMC under VFR and was not able to give me a clearance because I was below the MVA. I had just transitioned a Class C airport's airspace southbound over the bay to land at a nearby Class D airport. The Class C airport was VFR. My destination had just gone IFR with BKN008. I was flying traffic watch and the previous traffic watch pilot informed us that they had just landed at my destination under Special VFR. I told Class C's Tower that it was my intention to land at my destination under Special VFR. I was surprised that the Tower handed me off to Approach instead of the Class D Tower. I learned later on the ground that they also did not tell Approach of my intentions. When the Approach Controller gave me a vector across the Class C airport's final approach; I assumed that was the reason and they would then pass me to my destinations Tower. I learned on the ground that Approach thought I was going to continue traffic watch southbound down the interstate. Approach asked me to maintain VFR. I was watching the clouds carefully because on the assigned vector; I would be in the broken layer in a few minutes. I had my destination in sight about 5 miles away off to my left. Then the Controller asked me if I wanted to continue down the interstate; which surprised me; but I responded that I was going to my destination. The Controller pointed out that my destination had just gone below minimums; which I knew. At that point I should have reiterated that I wanted to request Special VFR at my destination. I am not sure whether I did point that out to the Controller; but since I was on a vector away from my destination and the conditions were deteriorating; I instead requested the localizer approach into my destination. The Controller asked me to standby and maintain VFR. I set up the instruments for the localizer approach. About a minute later I could see the approach course for my destination coming onto the GPS; my vector was perpendicular to the approach. Right as I crossed the approach course I told the Controller that I was crossing the approach course and asked if I he was going to turn me. I thought he might have forgotten about me due to the busy Class C airport's arrivals. The Controller again reiterated for me to remain VFR. I said unable to maintain VFR. This is where the Controller asked if I was going IMC and I responded yes. Being familiar with the rising terrain ahead; I said I needed to climb immediately and began a max rate climb. The Controller asked if I was declaring an emergency and I responded negative; I did not feel that I had an emergency because I was instrument current; the aircraft was IFR certified and I was in control of the aircraft. The Controller said he was declaring an emergency on my behalf and instructed me to climb to 4;000 FT. I got on top at 3;500 FT and notified the Controller. He vectored me around for a while for the Class C airport's traffic sequencing; and then cleared me for the approach [into my destination]. The rest of the flight proceeded without further incident. After the flight; I spoke with a supervisor at Approach who indicated that even when on a vector; if instructed to maintain VFR; the pilot must do whatever is necessary to maintain VFR; even if that means reversing course. I did not reverse course at the time because the Controller had just vectored me through the final approach course of the Class C airport and I felt that if I reversed course into the Class C airport's final that I would have created a serious separation problem. My error was going IMC without a clearance; especially below the MVA; because I learned that ATC cannot issue an IFR clearance below the MVA. My other error was not clarifying my intentions with the Controller early enough so that they had a chance to coordinate. The fact that Class C Tower did not relay my intentions on to the Approach Controller contributed to the confusion; but in marginal VFR and busy airspace I need to leave myself and the Controller more time to handle the situation. Not acting sooner put the Controller in a difficult situation. It also put me into a potential controlled flight into terrain situation. The instruction 'Maintain VFR' must be followed; even if on an assigned vector or if it means crossing a final approach path.

VFR traffic watch aircraft encountered IMC conditions after being instructed to maintain VFR; weather; higher terrain; MVA minimums and ATC failed coordination all playing a part in this event; resulting in an ATC declared emergency.


ATC Issue All Types; Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Landed in Emergency Condition

I was the Second Officer on this flight; but the First Officer was on his break in the cabin when the event occurred. I was the Pilot Monitoring in the right seat. Captain was the Pilot Flying. En route the left engine abruptly rolled back and failed. Captain told me to [notify ATC] and start the checklist. On Control; I announced '[my intentions to ATC] with an engine failure and requires immediate descent.' It took a few radio calls for the controller to understand that we needed lower immediately. He advised unable lower because we had traffic 1;000 ft below us opposite direction. At this point Captain began a left turn off the airway to avoid the traffic as we started down. We again told the controller we were an [priority] aircraft and advised him we were now descending and in the left turn off course. I believe we received two TA's in the initial descent. I did see one aircraft opposite direction below us but we were well clear. I ran the 'Engine Failure or Shutdown' checklist and we discussed which alternate airport would be the best. We agreed ZZZ would be the best choice because I had been there many times; it was in a radar environment; had a long runway; and we were headed in that direction. It was approximately 100 miles away. ZZZ airport was closer but it was behind us; in a non-radar environment with high terrain and neither of us had been there. We advised [ATC] that we requested diversion to ZZZ1. He cleared us direct and shortly thereafter handed us off to [the next] Control. We decided not to attempt restart. N3 was zero and also we received a few shudders in the airplane and flight controls immediately after the engine shutdown. Once we got the situation under control; I called the lead flight attendant; advised her of the situation; and asked her to call FO back to the cockpit. I advised the company using the Diversion prompt of ACARS that we were diverting to ZZZ1. I also followed up with two more ACARS Free Texts advising we had an engine failure and that that we were diverting to ZZZ1. Once FO was back in the cockpit; I stayed in the right seat and continued Pilot Monitoring duties. Crew gave the flight attendants more detail of the situation; made a PA; and advised operations; and backed us up on the checklist. We set up for the visual backed up by the ILS to 17. Weather was good there and made an uneventful single-engine landing. The fire truck and ambulance was standing by for our landing. Station operations personnel should be commended for how well they handled this situation. They were incredibly efficient with very little notice of our arrival.Engine failure - unknown cause at this point.

Engine failure at FL390 while en route; cause unknown. [Notified ATC] and diversion to ZZZ1. All checklists were completed and followed. The landing was uneventful.

B-757 crew experienced engine failure en route. Crew was unable to obtain descent clearance from ATC. Crew turned off track and began drift-down descent. Crew diverted and landed safely.


Air Traffic Control Time Certified In Pos 1 (yrs) 19

Confusion; Situational Awareness; Communication Breakdown

Airspace Violation All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Separated Traffic; Flight Crew Took Evasive Action

Procedure; Human Factors; Airspace Structure

While working South Radar sector (SR); Aircraft X had completed VFR maneuvers south of SAV/SVN and was on vectors to the ILS28 approach at SVN. While on base leg a second VFR target which had been maneuvering/flying ENE of SVN in North Radars airspace; began a south bound turn in the vicinity of the Tybee Island Lighthouse. Aircraft conducting VFR work in the vicinity of the lighthouse is not uncommon; but as I got closer to my turn to final; I noticed that the target continued to track southbound directly towards Aircraft X on base leg. I called traffic and started the turn; dog leg to final; when the collision alert sounded. The collision alert was issued and the pilot of Aircraft X announced that the Aircraft Y appeared to also be joining the final/localizer. I advised him to take evasive action as needed. I contacted SVN Tower and asked if they knew who Aircraft Y was. SVN Controller advised me that he was 'breaking my guy out' and that he'd follow me! SVN does not have any airspace beyond 5 miles from their airport but has been caught vectoring for the ILS before; usually at 1;500 FT which their GCA can do if they request the GCA pattern. That was not done; yet this aircraft appeared to be vectored on an opposing base leg to my aircraft at the same altitude in my airspace by the SVN Controller. I cannot stress enough how frustrating it is to have one of my instrument approach aircraft nearly whacked out of the sky by an Army controlled aircraft in FAA airspace. The arrogance and non-compliance with national and local procedures by that Army facility is of historic proportion; yet pretty much unchecked. It is only a matter of time before the successfully kill an aircrew or two. We hope the debris field doesn't injure any additional innocents. The flight crew of Aircraft X did an excellent job of taking evasive action and could easily be commended for avoiding such a debris field on Tybee Island. The FAA should prohibit the SVN Control Tower from working any aircraft in any kind of radar pattern. Make the Army sign off and comply. This Army facility has a competent GCA that is not in the Tower and they can function in compliance with the LOA; but the Tower should be banned from anything similar. This Controller should be retrained and better supervised!

SAV Controller reports of a airborne conflict caused by SVN Tower vectoring aircraft in his airspace.


Flight Crew Last 90 Days 6; Flight Crew Total 1700; Flight Crew Type 65

Confusion; Human-Machine Interface; Situational Awareness

Airspace Violation All Types; Deviation - Speed All Types; Deviation / Discrepancy - Procedural FAR

Flight Crew Exited Penetrated Airspace; Flight Crew Took Evasive Action; Flight Crew Became Reoriented

I departed 1H0 and climbed to 1600 ft MSL which is near the floor of St. Louis' Class B airspace. After passing a 'cake ring'; I climbed to about 2500-3000 ft. When I saw another cake ring appear on the Garmin 530W navigator; I was unable to quickly ascertain the floor of the segment I was in. I quickly descended to about 1100 ft; probably exceeding 250 kts indicated because I was carrying full power in anticipation of a climb; not a descent. I was in a hurry to get down and didn't think of the speed issue until later. I leveled off about 1100 ft MSL and tried to figure out the cake ring altitudes on my tablet; using the Avare app. The tablet lost its GPS signal and locked up. As I was working to figure out the altitude restrictions; I saw some buildings go under my left wing; which made me think I might be over a populated area. And at 1100 MSL; I was only about 640 ft AGL. By then; there were no more buildings in sight; so I continued trying to figure out the altitude restrictions; this time on my Garmin 696 portable GPS. By the time I was able to pan over to the cake rings and decode them; I was clear of Class B airspace. I climbed to 7500 ft and continued to my destination [north bound]. So in summary; I had 3 issues: 1) entering class B airspace without authorization; 2) too fast in Class B airspace; and 3) too low over a populated area. The latter two issues resulted from the first one.Contributing factors: It is difficult to find the altitudes for Class B airspace on a Garmin 530W while hand flying a plane. The backup tablet locked up when it lost its GPS signal. And I had to pan to the rings on the portable GPS to show the needed information.What I plan to do about it: Clearly; I need to do a better job with situational awareness prior to entering high workload conditions; and I will. I learned a valuable lesson about that through this experience. But I also plan to put a PFD and MFD in the plane as soon as possible so the information is displayed right in the panel.

Pilot reported departing 1H0 northbound using a Garmin 530W to show the Class B airspace above. During the climb; the reporter became confused as to the floor of the Class B ring in his immediate vicinity and quickly dived to 1100 feet; exceeded 250 knots; and descended below 1;000 feet AGL over a populated area.


Training / Qualification; Situational Awareness; Communication Breakdown; Confusion

Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Maintenance; Flight Deck / Cabin / Aircraft Event Other / Unknown; Ground Event / Encounter Other / Unknown

Flight Crew Took Evasive Action; Flight Crew Became Reoriented

Company Policy; Human Factors; Procedure

APU was deferred and we started all 3 engines in the blocks. I believed that the aircraft was connected to the tug. As we started the Number 1 Engine the Ground Maintenance personnel informed us that he thought the aircraft was beginning to roll. Captain applied brakes and informed ground brakes were now set and inquired as whether the chocks were removed (I believe he also asked if tug was connected but not sure). Maintenance said chocks were removed. Captain and ground calmly discussed why chocks were removed without our knowledge and why we weren't connected to tug. Continued start and departed uneventfully. I believe the miscommunication between ground and cockpit caused this event. I was absolutely certain we were connected to tug (we were not) and I am still certain we were never told the chocks were removed. The note in the external air-start saying parking brake should be set should be a warning and the ground and cockpit should absolutely know configuration of outside equipment and chocks. Any time your normal habit pattern is broken; i.e. APU deferred and external air start; you should be extra vigilant.

Without notice; a Cargo Maintenance crew removed the chocks before an external airstart. The aircraft then began rolling with the first engine start because the brakes were also not set.


Aircraft Equipment Problem Critical; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Air Traffic Control Provided Assistance; Flight Crew Rejected Takeoff; Flight Crew Returned To Gate; General Maintenance Action

Leg 1 of a three day pairing. Preflight; push; and taxi out were all normal. I was the FO (First Officer) and Pilot Monitoring. Captain was the Pilot Flying. We were in position on the active runway when our takeoff clearance was given. Thrust levers were brought to 40% and I was waiting for the engines to stabilize to give the 'stable' call out. Just prior to engine stabilization on COM1 which was tower frequency we heard '(airline) HIT THE BRAKES!!!' An aircraft behind us on the taxiway advised Tower on frequency that we had a '2 foot flame' coming out of the back of the Number 1 Engine. The Captain upon hearing this immediately shutdown the number 1 engine and called for the QRC. Tower wanted us to clear the runway and we advised them that we need to run a checklist and will get back to them. After running the Engine Tailpipe Fire QRC and QRH we asked Tower if the aircraft could see any indication of fire out of the engine. They said that they could not see anything. The Captain and I both felt comfortable at that point to taxi the aircraft off of the runway and onto the parallel taxiway. Airport Fire and Rescue contacted us on a discrete frequency and approached the aircraft to verify there was no active fire. After their surveillance indicating no fire the Captain and I felt it was safe to taxi the aircraft back to the gate. We advised operations and maintenance of our intentions. Taxi back and shutdown were normal.Excellent job by the Captain. Immediate decision making on his part and excellent communication. For myself personally; as always just like in the sim; slow down when accomplishing checklists. Slow is smooth and smooth is fast.I have attached a picture of the engine 'torching' as the maintenance crew were performing a run up at the gate after we returned. The engine is at idle power and the very tip of the tailpipe you can see a blue flame.

Aircraft flight crew experienced an engine tail pipe fire during engine spool up on takeoff roll.


Flight Crew Last 90 Days 12; Flight Crew Total 860; Flight Crew Type 269

Ground Event / Encounter Other / Unknown; Inflight Event / Encounter Weather / Turbulence

Flight Crew Landed in Emergency Condition; General Declared Emergency

Flight planning was done obtaining info from flight svc; as well as talking with another pilot prior to the   flight; collaborating on a strategy. -use of people at meeting site and launch site. Surface winds were north and beyond 3000 ft was a south direction-approx; 30 minutes prior to launch. Launched and initially climbed to 1000 ft.  Winds were in a north direction sharper than what was seen; at 3000 ft winds did shift to south but quite slow...very slow began a westerly direction about 25 minutes into the flight. Seems what ever favorable winds seen at flight time had broken up. Higher the winds were stalled. At this time was approaching the lagoon;  I  began a descent  but only got more unfavorable direction and I could see this might require emergency assistance and contacted my ground crew to place a call to beach lifeguard and or 911. I briefed the passengers; that the landing could be an unfavorable situation with onshore winds that are common in the evening. As we descended to less that 1000 ft over the beach; the west direction shifted to a north easterly -over a 20 minute period. Now  over the ocean surf at about 700 ft still drifting in a westerly direction. At approx 100 feet the direction turned to a north east direction we were easily 300 yards over the surf with a SLOW drift to the shore. Once about 25 yards approx we were surrounded with surfers and lifeguard personnel; the balloon basket is 10-15 ft  off the water and descended into the surf a few times -passengers are getting scared at this point as 15 ft   surf boards are around us...still slowly moving to the shore point and yelling for help as a drop line is dropped to the emergency team there. The lead response commander-surfer; insisted the passengers jump to their surf boards approx 30 yards from shore as I might have a greater chance of not getting towed under as the waves are just beginning to make contact with the basket; I insisted they stay - however fear of the situation had each  passenger jump into the surf and the attention of the emergency lifeguard team the balloon reacting without the   weight of the passengers drifted up about 25 yards approx..as the east northeast direction prevailed I put the basket into the surf and the waves assisted in pushing the basket to the shore with the assistance of those  surfers that had the drop line...using the burners and the assistance of the surfers moved the balloon to the cliff wall and tore down immediately; once spectators were out of the way.  Immediately made contact with the   passengers and the emergency staff. FAA was notified by the Sheriff; I gave my brief and FAA Pilot Certificate to the site commander and was returned my FAA pilot cert. I was informed by the sheriff this is considered a surf landing aided by lifeguard team - FAA was not sending a rep so I was instructed to direct the team on removing  the equipment off the beach and the passengers insisted they were fine but wet. I apologized this was not the plan but given the circumstances things could have been much worse. They thanked me and were driven back and   cleared by site staff/lifeguard commander. In reviewing the situation -the 'mild winds' were a contributing factor however the winds forecasted...and actual in the air were not anywhere near accurate. My perception of being able to descend to a favorable area before  the coastline was far from adequate; as the west winds only increased till actually 300 yards from the coast-surf. NOT TO FLY this evening would have been ideal. I have limited experience in west  winds-offshore  winds- and the ability to recover without increasing the risk of a tragedy...of running out of daylight-fuel exhaustion  and no onshore winds even on the surface.

Hot air balloon pilot reports encountering unforecasted winds after launching near the coast. Winds at altitude push the balloon over the water and the forecast onshore wind at the surface does not materialize. A line is dropped and the balloon is towed to shore by Lifeguard personnel.


Maintenance Airframe; Maintenance Powerplant

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Other / Unknown

Flight Crew Returned To Gate; Flight Crew Landed in Emergency Condition; General Flight Cancelled / Delayed

Had to perform deactivation of spoiler servo control per Minimum Equipment List. Suspect key may have been defective after lockout procedure; missing prong to return servo to O [position]. Bad tool. [We should ensure] all tools and equipment are in working condition before use.

During push back from ZZZ and on first engine start received a 'Flt control Fault Spoilers'. We called ZZZ Maintenance and were told to return to the gate. After some trouble shooting maintenance deferred the ground spoilers. We departed Runway XXR on the ZZZZZ [Departure] Captain's leg. After aircraft clean up and on climb out we noticed an aircraft vibration. We assumed maybe some panel or door was left open by Maintenance. Then thought about maybe one of the spoilers being out because of the MEL. Aircraft control was transferred to me; the First Officer; and Captain called Flight Attendant to go back and look out the windows to see if they saw anything. Told ATC that we would be leveling off at FL250 as climb continued and turns were done we noticed that now Alpha Prot(High Angle of Attack Protection) was increasing more than normal and now assumed that the vibration was associated with a spoiler problem. We [advised ATC] and elected to go to ZZZ1 because of long runways. ATC informed that ZZZ1 was backed up due to weather. We changed diversion location to ZZZ2. Captain briefed the flight attendants advising of the precautionary landing in ZZZ2. We ran the QRH for Over Weight Landing. On arrival into ZZZ2 we asked for long final to approach and for shallow vectors because of the increased Alpha Prot. We landed visually on Runway XX without incident. Upon arrival at the gate; I; the First Officer; went to inspect the aircraft and noticed both ground spoilers were not fully stowed. When maintenance in ZZZ2 arrived at the gate they confirmed that maintenance in ZZZ left the spoilers in what he called 'Maintenance Mode' after the deferral.

A321 Flight Crew and Mechanics reported maintenance had not properly completed the spoiler lockout procedure which resulted in a diversion.


Flight Crew Last 90 Days 60; Flight Crew Total 460; Flight Crew Type 280

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Taxiway

Came in to land in Taunton (TAN). There was a NOTAM out for beacon out of service; not runway lights. As I approached Taunton; there were no runway lights working; just taxiway lights. I triggered the pilot controlled lighting (PCL) to try to get the runway lights to work but just saw the taxiway lights go through the low; medium; high intensity cycle. I elected that it was best given the circumstances and time to land on the taxiway. The flight terminated uneventfully. They are installing security cameras at the airport and I know they have shut the beacon off and it took 3 weeks before a NOTAM [was] issued. Now the runway lights are out of service without letting people know. There is an Instrument Approach to that runway and in an emergency situation someone unfamiliar with the field could be injured.

Small aircraft pilot reported TAN airport runway lights are out of service but no NOTAM to alert pilots of the outage.


Flight Crew Flight Instructor; Flight Crew Commercial

Flight Crew Last 90 Days 109; Flight Crew Total 600; Flight Crew Type 86

Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Clearance

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Executed Go Around / Missed Approach; Flight Crew Became Reoriented

I am a flight instructor who was teaching a lesson on takeoffs and landings with crosswinds and gusting winds. The ATIS reported the winds as coming from 080 degrees at 15 knots; gusting to 25 knots. The ATIS also reported LAL was using Runways 5 and 9. The flight began with us taxing with Ground to Runway 5; contacting tower that we were ready for takeoff; and holding short of Runway 5 for traffic landing Runway 9. While we were waiting for the landing traffic; I was briefing my student on the Crosswind takeoff and what to pay attention to while flying with the current winds. This is where I made my first mistake. Because of my personal familiarity with flying in LAL's traffic pattern; I know that we normally will taxi to; and take off of Runway 5 with instructions to join the downwind for Runway 9. And since the winds were gusting at 25 knots and coming from 080; I assumed Tower would give us this clearance. So I briefed my student on maintaining the crosswind correction on the controls while holding centerline for 5 during the takeoff all the way until turning downwind for Runway 9. Because I was talking; I missed part of Tower's radio call; and did not hear his instructions for after takeoff. My student made the 'clear for takeoff' transmission; but did not read-back the after takeoff instructions. Here I made my second mistake by not having either myself or my student call Tower back with the after takeoff instructions. As we began our turn from the upwind of runway 5 to left downwind for runway 9; the radio became busy with 2 or 3 other aircraft coming into LAL. This is when I made my third mistake. I reported midfield downwind; but did not state; as I should have; what Runway I was in downwind for. We received our clearance for touch and go; and I called back with our N number and cleared touch-and-go; but did not use proper radio phraseology and left out what runway we were cleared for touch-and-go on. At the point where we would want to begin our base turn for Runway 9; my student was high; fast; and off course. I was busy instructing my student with what he needed to do to fix his pattern. Here Tower called to tell us we were farther out from our pattern then we were supposed to be. I apologized for incorrectly compensating for the wind and said 'wilco' to Towers instructions to fix our course by starting an immediate left turn. What I again failed to realize was that Tower wanted us making our crosswind to downwind turn for 5; not our downwind to base turn for 9. When we were on Final for Runway 9 another aircraft that joined the pattern on extended final for 9; told tower that the cherokee in front of him was landing 9 instead of 5. This was when I first realized that something wasn't right; and that someone was making a mistake. However; I was not sure who that was. I guess I assumed that the other aircraft had me mixed up with someone else who was landing on Runway 5. I now know that I am the one that was mistaken. Tower told us to do a go around; and we immediately complied. While executing the go-around Tower asked what we were doing on 9 instead of 5. Here I confessed my mistake of thinking we were cleared for 9 not 5. Tower told us that we were cleared for 5 not 9 and had committed a runway incursion. I apologized and made sure I carefully read back every single instruction and correctly complied with them. The flight was finished without further incident; and we taxied back to parking with Tower. After the flight; I was replaying it in my head trying to figure out were the confusion came from. I replayed the radio transmissions from the flight and realized that I made the mistake before our wheels had even left the ground. And I also realized that if I would have used proper radio phraseology; with full read backs of instructions; my mistake could have been avoided; and/or discovered significantly earlier in the pattern. The factors that lead to my mistake are: my own certainty that Tower would give us the clearance I wanted; Improper Radio read backs of instructions; and my own distraction of being too busy talking and teaching instead of using sterile cockpit procedures; or asking for read backs of transmissions I only heard part of. This can be prevented from ever happening again if pilots; and CFI's follow a few simple steps. First- if you want to use a specific runway because of wind conditions; request it. Do not automatically assume Tower will give it to you because they have in the past. Second- Read back ALL clearances COMPLETELY with Runway Number and proper phraseology instead of abbreviating them. Third- If you only hear part of a radio transmission ask for Tower to read back their instructions; DO NOT assume you can guess what the rest of the instructions were! Fourth- If you are instructing be extremely careful about choosing when you are going to be instructing; and when you will be listening to what is going on around you. As an Instructor you must ALWAYS be on guard against tunnel vision. It is too easy to get lost in what your student is doing at a specific moment; and miss the larger picture. Fifth- and most importantly if you spend all of your flight time at a specific airport and are used to receiving a certain set of instructions MAKE SURE those are the instructions you are supposed to be following! The second you let a specific set of ATC instructions become a habit; you let your guard down and will miss out on vital instructions that you need; and when the clearance deviates from what you are use too.

Flight Instructor reports not hearing the after takeoff instructions prior to taking off from Runway 5 at LAL and assumes that he is to join the downwind for Runway 9 as is common. This is not correct and a go around is issued by the Tower.


Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; Flight Crew Inflight Shutdown

Dispatcher had stepped away while OJT (On Job Training) dispatcher was on the desk. Flight notified the Dispatcher of a low oil pressure on the #1 engine. There was an attempt to patch twice and the call went to the Chief Dispatcher and the transfer failed; the second time the crew reports there was just hold music. Dispatch attempted to call and was unable to connect. Finally patch was established; when the Dispatcher returned. The engine had not been shut down and the Dispatcher and Captain agreed on return to field. The flight was near ETOPS entry. There was no oil pressure showing without the EICAS alert. Coordination of the Chief and OPS manager; MX was handled. Dispatch was waiting to hear when the engine was shut down and had the QRH out and was under the assumption that the engine would be secure shortly. The Return to field (US command) and release was completed. Sabre placed the aircraft on the ground and the dispatcher was unable to pull position reports and the ACARs were now coming into the system from the next leg from the unreleased portion of DV. It took time figure out why the system was not providing correct information.  The crew began dumping fuel from the center tank to reduce landing weight. Dispatch requested position reports to provide landing data. No position reports were sent or accepted by the ACARS requests. A time and burn calculation was done to estimate landing weights and a position report entered into Sabre to reflect the dumped fuel and new estimated gross weight. Landing data was sent and noted that this was estimated due to the lack of current fuel and position report.Once on the ground the crew reported the communication issues. They also reported that the engine was shutdown at 40NM from the field.

Air Carrier Dispatcher reported difficulty communicating with a flight that was experiencing an engine problem and was returning to departure airport.


Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 71; Flight Crew Total 531; Flight Crew Type 145

Troubleshooting; Situational Awareness; Human-Machine Interface

Aircraft Equipment Problem Critical; Deviation - Speed All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Provided Assistance; Flight Crew Regained Aircraft Control; Flight Crew Landed As Precaution; Flight Crew Diverted; General Maintenance Action

Four minutes after takeoff rate of climb decreased from 789 ft/min to 250 ft/min. Airspeed decreased from ground speed of 69 knots to ground speed of 54 knots. Then a loud bang. Plane slid back and rolled to right. Plane dropped 2150 feet in 2 minutes. Was able to level plane at 2200 MSL. Was not able to keep heading. Wings were not stable. Coordinated flight was not possible. Made a complete circle before being able to fly somewhat straight. HSI had tumbled as had the attitude indicator. Asked departure control (NorCal) what was my magnetic heading. Significantly differed from reading on HSI. HSI was not stable. Magnetic compass was not helpful due to roll; and not being able to fly straight and level. Tossed around violently.At some point; someone told the controller to ask if I had autopilot. I answered yes. The person helping the controller told him to have me turn on autopilot and set heading. That was a mistake. The autopilot; within 10 seconds; pitched up to maximum pitch. Pitch warning signal sounded. Red pitch light on; the annunciator turned on. The autopilot could not keep wings level. I managed to disconnect the autopilot; and turned to land towards SNS. I made the decision that I had to land. The controller determined that the closest VMC airport was ZZZ. I flew there with difficulty on maintaining level altitude. Was in IMC most of the flight. Winds were gusting and swirling until I reached 8300 MSL. At ZZZ on the descent; had to deploy 10 degrees of flaps 11 miles out to descend to pattern altitude. Landed safely with wife and dog aboard. Secured plane. Returned with mechanic who did inspection; and then we flew the plane VFR. HSI is being sent for inspection of gyro. Autopilot will be checked completely. Met with flight instructor for an hour to review the flight using flightaware.com and my notes and recollection. When the downdraft dropped and rolled the plane; I was not sure we would make it. She said only thing she would have done differently than I did was to declare an emergency. Weather was changing. Thunderstorms were forecast later in the day. No reports at the time of takeoff. My wife; after we landed; did tell me that off to our right was a dark large cloud. Yet; clouds in front of me had diffuse sun light. All that I know is that after shortly being over the ocean it was like hitting a brick wall. Had latest weather information; but; clearly was insufficient. Not sure how to improve surface and low level weather predictions on the coast.

C182 pilot experienced severe turbulence at 4400 feet during climb to 7000 feet. The airspeed decreased and the aircraft lost controlled flight along with 2000 feet before control was regained. Attitude indicator and HSI were not reliable and ATC provided vectors to a VFR airport.