Flight Crew Last 90 Days 28; Flight Crew Total 283; Flight Crew Type 283

Time Pressure; Situational Awareness; Distraction

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

Pilot reported the aircraft had an abnormally low RPM indication and a lower-than-normal rate of climb during initial climb-out; followed by smoke emanating from the cowling after landing.Upon rotation and takeoff from Runway XX at ZZZ; I realized that the aircraft performance was sluggish; and I was not attaining my normal rate of climb for the aircraft. At approximately 600 feet. MSL I was reading 2600 RPM (1000 lower than normal) and 63-65 kts for best rate of climb; but became concerned. At that point I retracted flaps and lowered the nose to gain airspeed; increasing it to approximately 73-75 kts; but without appreciable improvement in rate of climb.At that point I decided to return to the airport and called ATC; first reporting; as I recall; insufficient power and immediately thereafter returning to land.The engine continued at about the same RPM and the aircraft continued to climb to approx. 900 feet MSL when I was ready to turn base. I made a normal; stable approach; increasing from takeoff to full flaps and approximately 70 kts. I landed without incident and made the first taxi turn off to ZZZ south ramp; with instructions from ATC to proceed to tie down. ATC inquired whether I needed assistance; and I responded; 'Negative.'I taxied normally to [gate] and turned for line up to the tie down. At that point smoke started emanating from the cowling with an acrid smell; and my G1000 gave warnings of engine overheat and low oil pressure. I immediately shut off the engine (mixture idle cutoff; throttle idle) and turned the fuel selector to off. I then turned off the ignition and the master switch and lights. My passenger and I then disembarked the aircraft. Smoke continued coming from the cowling; but there was no evidence of fire.Thinking that I had failed to tighten the oil dipstick before departing and that oil had leaked on the engine; I walked around the nose and checked; but the dipstick was tight. At that point I walked back around the nose of the aircraft and realized that the cowl flaps were still installed. I removed them immediately to allow the engine to cool.Analysis of Cause:Root cause of this engine failure was obviously pilot failure to perform all elements of the pre-flight checklist. The background and reason for this pilot failure was an attempt to expedite the pre-flight check externally by working from memory; exacerbated by having a new; non-pilot passenger with whom I was conversing; and a suspense to return the airplane for the next rental. I had scheduled the aircraft for XA00; but the flight school office did not open until XB00; and I had not made prior arrangement to obtain the keys and flight book early. In addition; when reserving the aircraft; I realized that another pilot had reserved the aircraft for XC00; and I wanted to maximize the amount of time my passenger and I would have in the air.My passenger and I arrived at the airfield early; at approx. XA15; and knowing the aircraft rental office and keys were unavailable; we went immediately to the aircraft to do the external pre-flight check. I first checked the oil and ordered fuel. We then removed the canopy cover; stall horn plug; and pitot cover; but failed to complete the nose check of the aircraft or to notice and remove the cowl plugs. I untied the aircraft at all points; checked aircraft surfaces; and placed all equipment near the rear passenger canopy ready to stow.I returned to the office to pick up the flight book and keys; and subsequently for a pair of headphones.Upon returning to the aircraft; I was mindful of the time; but did not rush; anticipating that I would have a full 30 minutes of flight time; which was sufficient for the purpose of introducing my passenger to the airplane and his second flight in a small aircraft (first in the Diamond). I first used the Allen wrenches in the flight book to tighten all the nuts in the nose wheel fairing; and missing the opportunity to checkthe nose or notice the installed cowling plugs. Knowing I had not checked the fuel; I retrieved the fuel drainer and checked for contamination at all three points; finding none and returning the fuel to the tanks; but again failing to notice in crossing in front of the nose that the cowl flaps remained installed.Before entering the aircraft; I activated the master switch; adjusted the electrically-powered rudder pedals; turned on the lights and checked all the lights on the wings and the pitot heat; passing in front of the nose once again and failing to notice that the cowl plugs remained installed.After entering the aircraft; I went through the entire pre-start checklist; including the exterior; but only looked at the exterior portions cursorily; believing that I had covered them all. I would note at this point; that I also failed to do a final 360 degree walk around of the aircraft.Because overnight temperatures were at freezing; I used the cold start procedures; and the engine turned over normally. Pre-taxi checks were normal; and I departed the tie down for Runway XX and the run up.In hindsight; the aircraft did not seem as lively as it usually is during taxi; but power application running from 1000-1400 RPM all seemed normal.Run up appeared normal; except that in circulating the propeller three times; the recovery to 2000 RPM was more sluggish than normal. I attributed this; however; to the cold weather.Upon receipt of take-off clearance from ATC; I moved to runway centerline and again checked all engine instruments; all of which were reading mid-green. Engine oil pressure at 1000 RPM was - as is usual - just in the yellow; but responded immediately to mid-green when I advanced the throttle.When I began the take-off roll; the aircraft did not seem to accelerate as quickly as it normally does; and it seemed to take a split second longer to go from 55 kts to rotation at 60 kts. I do not recall if; during the take-off roll; I noticed that the RPM reached only 2600 rather than the full 2700.In hindsight - between the sluggish propeller response and the sluggish acceleration - I should have aborted the take-off. Lessons Learned:1. Use and follow every step of the checklist; ensuring that a written or electronic form is in hand when one begins the pre-flight.2. Do not attempt to expedite procedures due to artificial time constraints. Better to cancel the flight than rush the procedures.3. When introducing a passenger to the aircraft or to flying; ask him / her to assist by using and calling out checklist items. This will ensure full involvement and avoid distractions.4. Despite how well you believe you know the aircraft and its procedures; the occasional pilot should not trust that he / she has them committed to memory.5. Buy new cowling plugs with the little flags that stick up over the cowling so the pilot will notice them if not removed. (Closing the barn door after the horse has left.)6. Although not part of the official Diamond DA-40 pre-flight checklist; safety advocates and the aircraft rental and training facility leasing the aircraft; procedures call for a 360 final walk-around prior to engine start up. This should be used.7. My story now fits those of other pilots; whose emergency occurrences in some of my recent reading have prompted a similar observation - pay attention to those nagging little details (some would call it intuition) that don't seem right. Better to cancel or abort the flight and start all over again than to ascribe an unusual performance to benign causes.

DA-40 pilot reported a loss of power during climb; resulting in a precautionary landing and smoke emanating from the engine after landing.


Flight Crew Last 90 Days 45; Flight Crew Total 175; Flight Crew Type 90

Distraction; Situational Awareness; Training / Qualification

Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter VFR In IMC; Inflight Event / Encounter Weather / Turbulence

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

I was flying from ZZZ to ZZZ1. When I was in the TRACON area; I flew through a cloud at 4;500 feet. I kept my wings level and flew my course line keeping an eye on my GPS and six pack. I ended up going through another cloud at 4;000 feet and another at 3;500 feet. After informing TRACON every time I went through a cloud; TRACON asked if I would like to pick up an IFR flight plan. Not being instrumented rated; I informed him I was not personally Instrument Rated; but he kept offering for me to pick up a plan. I had only experienced clouds during the day during training. Experiencing night clouds were totally different and very freaky because of my lights in the cloud - without the lights though; it was only black (making the situation even scarier). I asked after going through a third cloud to divert to ZZZ2. The controller started reading off vectors and mentioned a cloud of precipitation off the west side of ZZZ2. Turns out I was going through clouds that had randomly popped up with the rain. These clouds were not reported on the ATIS/AWOS. Also; I was pointed towards a dark empty part of the terrain making it almost impossible to tell I was in a cloud until I was in one. I decided to continue on at 3;000 feet because in order to divert I would have to fly through more clouds (the pop up rain) to get to ZZZ2. I continued on and the flight was otherwise uneventful. It was super nerve wracking going through clouds at night. I had never experienced it before. I think it is important Private Pilots experience IFR conditions at night to remain calm like I had in these situations. I did everything to keep the plane level and descend down; but it was still scary since it was all new to me.

VFR Cessna private pilot reported encountering IMC conditions and requesting assistance from ATC.


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

Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy

Person Flight Crew; Person Air Traffic Control

Air Traffic Control Issued New Clearance; Flight Crew Returned To Clearance

While on arrival for Denver we received an arrival change and subsequent runway change due to the landing direction being changed from south to north. We set up on the ANCHR Arrival and loaded the ILS 35R as the expected approach and runway. During this time we were told to maintain speeds that differed from the published speeds on the arrival and were then instructed to fly the RNAVZ to 35R which we loaded and briefed. In our haste to get the procedure loaded and verify waypoints et al we forgot to sequence the FMC to leave the arrival after DOGGG and fly the approach. MSIMS appeared to be the active waypoint with FRONZ being the next waypoint as both were indicated magenta on the FMC. What we failed to notice was that after DOGGG the aircraft was programmed to continue straight ahead for 'vectors' off the arrival. We noticed our error right at MSIMS and immediately began to turn the rejoin the course. At the same time ATC noticed our error and gave us vectors for a visual approach to Runway 35R. We landed safely without further incident.

Pilot reported a navigation error when the aircraft was supposed to turn but did not.


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

Flight Crew Last 90 Days 100; Flight Crew Total 600; Flight Crew Type 550

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter Fuel Issue

Flight Crew Landed in Emergency Condition; Flight Crew Took Evasive Action

It was a normal training flight. We had planned to practice Simulated Emergencies and basic maneuvers. Like always; since we have reduced fuel we estimated how much fuel we would need. We calculated roughly 7 gallons were all we were going to need for our 1.5 hr flight today. The weather was clear. Winds were 200 at 10 knots. Fairly calm.Upon arrival to the airplane; we began the preflight. Everything checked out to be ok; except for the right tank. The right tank had some water contaminate in the fuel. We had to sump the tank 3 times to get the water out and to be able to verify that the fuel was clean. Once we verified that the fuel was clean; we manually dipped the tanks to find that we had a total of 17 gallons. 9 gallons in the left tank and 8 gallons in the right tank. Seeing that we had 7 gallons we knew that that should give us roughly 2.5 hrs of flight allowing us to meet VFR fuel requirements of a reserve and then some. From there we started the plane up; with no issues. The run up was text book perfect. We had no issues with flying the plane.We departed from ZZZ and made a slow climb; avoiding Bravo airspace; up to 6;000 feet MSL. We started our maneuvers like Steep Turns and Slow flight. We were in slow flight with reduced power for roughly 30 minutes. We then practiced a Simulated Emergency Engine Failure; which allowed us to get to an altitude appropriate for Ground Reference maneuvers. From there flew over to ZZZ1 for 1 touch'n'go and 1 go-around. We then departed the area to the north back to ZZZ.Once we were above the VFR Waypoint at 4;000 feet; we called to Tower and received clearance to enter Right Traffic 17R and to Report Mid-Field Downwind. Shortly after reporting back the call we felt the engine start to sputter. In attempt to give the airplane as much possible power; we gave the airplane a full rich mixture; fuel pump on; and full throttle. We noticed no change in power; so we started to prepare ourselves for a forced landing. I considered turning and trying to glide towards ZZZ since we were so close; but being only 1;500 feet off of the ground the math didn't add up. We wouldn't have made it to ZZZ. Fortunately; my student has a couple of thousands of hours in helicopters; so he took the radios; and I flew the plane. We executed good Crew Resource Management. He helped me by pointing out obstacles to avoid on our way down. I had made my 180 degrees turn to face into the southerly wind and when landing on the [highway] was assured I nosed down to allow myself to have some extra speed to bleed off during the landing flare. I tried to stay 15-20 feet off the ground while bleeding the speed to allow car traffic to see me. As we slowed down; I slowly bumped in flaps helping keep us aloft. Traffic cleared and we had plenty of space to touch down. We did not hit anything. The touch-down was very soft. There were no injuries to [the student] nor I. There was no damage to the airplane itself.

C150 instructor pilot reported a loss of engine power and off field landing due to fuel starvation.


Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Flight Crew Diverted; Flight Crew Landed As Precaution; Flight Crew Took Evasive Action; Flight Crew Regained Aircraft Control; General Maintenance Action

Enroute on an empty reposition leg; we encountered severe turbulence and mountain wave near ALS. Aircraft began to climb in excess of 1000 fpm and accelerate near red line despite us slowing in anticipation to M .76. Upon acceleration I quickly went to idle thrust; and then deployed the boards to 1/4. At that time the plane began to encounter the turbulence. The plane banked to what looked like near or slightly over 30 degrees left and was rattled by heavy jolts of turbulence at the same time. The other pilot helped by grabbing the ailerons at which time we worked as a team. He tried to keep the wings level and descend as I adjusted power and boards to keep plane at a safe speed. We advised ATC of turbulence and need to descend to which they cleared us to FL370. We were unable to adequately see the altitude and told them we would be descending until we could get good control of the aircraft. ATC turned a couple of planes out of our way; and we recovered and smoothed out at FL350. After a bit and a visual check of the wings and control checks; we decided it was best to make a precautionary landing to get a better exterior inspection and contact our mechanic. Enroute weather also made us decide to get a better idea if any damage occurred before entering more possible turbulence. Upon landing; we contacted our mechanic; looked at the areas that he recommended for damage; and found none. We also looked at the chart he emailed to us from the maintenance book about weight to G force ratio; and we decided we were in the clear; and no further inspections were needed. The flight continued with no further issues.

CL604 Captain experiences severe turbulence over ALS at FL390 resulting in a 1;000 FPM climb at idle thrust and partial spoilers. Flight eventually descends to FL350 with ATC's approval; but the Captain cannot read the altimeter during the initial descent due to the turbulence. The crew elects to divert to inspect the aircraft for damage before continuing to destination.


Flight Crew Last 90 Days 37; Flight Crew Total 1160; Flight Crew Type 700

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

Flight Crew Last 90 Days 132; Flight Crew Total 14693; Flight Crew Type 150

Deviation - Speed All Types; Ground Event / Encounter Ground Strike - Aircraft; Ground Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Aircraft Aircraft Damaged; Flight Crew Regained Aircraft Control; Flight Crew Executed Go Around / Missed Approach

I was flying with my instructor and we had just taken off. We were going to practice power off spot landings. It was a windy day. As I was in the landing phase; I started to sink abruptly; possible due to airspeed or a gust. I went to full throttle but the airplane hit the ground hard and the left wing contacted the ground. We did a go around and came around to land normally. On inspection of the airplane; we found damage to the left wing [and] damage to the tip tank. After an inspection by the mechanic on the field; we determined the airplane was not flyable. The airplane will be inspected and repaired.

At about five feet above the runway; while practicing a power off 180 accuracy landing; the pilot got too slow and the airplane stalled; dropping a wing as it stalled. Prior to flying; the pilot and I had discussed the possibility of the need for increasing glide speed to reach the target if the head wind might prevent us from reaching the target. We also discussed how increasing the propeller control from flat pitch to coarse could accelerate the airplane towards the target while at the same time adding flaps to balloon the airplane up. We chose the 1000 foot marker as the target; so that we had runway to land on prior to the target if we found ourselves coming up short. As we approached the runway it was evident that we were going to come up short. The pilot; instead of using any of the techniques we discussed; started increasing the pitch in an attempt to 'stretch' the glide. I told him he was starting to get slow and to lower the nose. When I realized the pilot was not taking preventive action I started to reach to the throttle to add power just as the pilot 'slammed' the throttle in. The engine; being turbonormalized; did not immediately respond; and the airplane stalled; dropping the left wing as it did. We hit the runway hard; dragging the left wing tip tank in a wing low yawed state. At that point the pilot had pulled the throttle back and then reapplied power more smoothly; while at the same time I had taken the controls; adding right rudder to straighten the airplane out in relationship to the runway and leveling the wings as we bounced back in to the air and initiated a go-around. Had I not taken over the controls there was a fairly good chance the airplane would have exited the runway and cartwheeled as it encountered the soft grass on the edge of the runway.My lesson learned: even when working with a client with whom you have flown hundreds of hours with and whom you trust; DO NOT let down your guard!

BE36 instructor and student pilot reported striking the wingtip following a stall during the flare.


Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 18; Flight Crew Total 358; Flight Crew Type 79

Confusion; Distraction; Situational Awareness

Conflict NMAC; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Bird / Animal

Chart Or Publication; Human Factors; Software and Automation

I departed my home base airport on a VFR flight for the purpose of gaining experience using the VNAV (Vertical Navigation) function of recently installed GPS Navigators and an autopilot in the aircraft.  As I was intending on changing altitudes throughout the flight to test out the VNAV I decided to not request flight following and instead on my Comm 2 radio I monitored 121.5. The conditions were VFR with about 10 miles visibility; but there was significant haze. To best test out the VNAV functions I created a flight plan with a final fix (another airport) located approximately 79 miles from the departure airport.  My initial intent was to test out the VNAV functionality throughout that path on a few different occasions and with different step downs; then turn around at the final fix; without landing; and return to my home base airport.  While descending to 3;500 feet about 45 miles from the final fix; I flew about 2 miles north of a non-towered airport and about 5 miles north of a city.  When flying in that area; I looked at my IPad which has Foreflight and I did not notice any Parachute Jump Area (PJA) rings over that airport and expecting to see those rings in the relevant areas I did not notice the parachute symbol by the airport that appears on the VFR Sectional on the IPad.  Having successfully completed one test of the VNAV about 45 miles before arriving at the final fix; and predominately due to the haze; I decided to discontinue flying towards the final fix and to begin heading back to my home base earlier than originally anticipated.  Looking again at the IPad I did not notice any PJA rings or the parachute symbol by the airport near the city and I decided to use that airport as part of my route towards my home base airport and turned toward that airport.  Within a couple of minutes I overflew that airport eastbound at 3;500 feet MSL (approximately 2;300 AGL) while using the autopilot and noticed a small aircraft landing southbound on the airport's runway.  I then looked up about 45 degrees from the horizon and saw one open canopy parachutist about 300 feet above the airplane and another at about the 2 o'clock position 500 feet laterally and 300 feet above the plane.  It was immediately clear from their rate of descent that I would be past both of them before they would reach my altitude.  I quickly scanned for other parachutist and put my thumb over the autopilot disconnect switch; but not having any idea how many parachutists were out there and not seeing others except for the two with which I recognized I was not in a collision course; I thought that maintaining heading and altitude would make me as predictable as possible and it would give any other parachutist that could see or hear me the best opportunity to avoid me.  Thus; I covered the controls to use them to override the autopilot if needed but did not disengage the autopilot or perform any evasive maneuvers.    Upon landing; I immediately checked my iPad again to see if there were any PJAs over the airport; and none were present over that airport; and I then noticed there were no PJAs depicted anywhere over any airports.  When looking at the IPad on the ground I did identify the Sectional's parachute symbol near the airport.  I then compared my IPad's Foreflight map display with that on my IPhone and saw that the IPhone displayed the PJA rings.  The next day I contacted Foreflight as I could not identify the difference in the settings that was causing the IPhone to display PJA rings and not on the IPad.  They very quickly pointed me to a setting for Airspace that I had not enabled on the IPad and as soon as I enabled it; the PJAs showed up on the IPad. I believe my over reliance on Foreflight's PJA rings caused me to not inspect the map closely enough to identify the parachute symbol by the airfield near the area that I was not originally intending to use as a turn around point.  Verifying that this setting is enabled is now a checklist item for me;and when there are changes to a plan that will cause me to fly near an airport; regardless of the altitude over the pattern; I will more closely inspect for the parachute symbols even if there is no ring depicted on Foreflight.  Also; even when engaged in local flights that require maneuvering and changes in altitude and that may place me near multiple airports; I intend to request flight following.

A Cirrus pilot reported a conflict with skydivers while flying through a designated parachute jump area. The reporter stated incorrectly configured settings in their Foreflight app to hide parachute jump areas contributed to the incident.


Small Aircraft; Low Wing; 2 Eng; Retractable Gear

Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 28.5; Flight Crew Total 984; Flight Crew Type 645

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

I was enroute to the IAF for the RNAV 18 approach into DMO. Runway 18/36 had been closed for the day per the NOTAM issued by Mr. X; for grass seeding operation and runway lighting repair. Prior to the flight I contacted Mr. X via phone and stated I would be enroute to the airport and due to low ceilings I would not be able to complete the circle to land approach to 5/23. I asked him if it would be possible for him to open the runway temporarily so I could land on 18/36. Mr. X stated that would not be a problem at all; he would ensure all personnel and equipment would be removed from the runway prior to my arrival. He requested that I contact him prior to departing so he would know when to expect me. I contacted Mr. X 15 minutes prior to my departure and informed him I would be landing around XA:00 and would contact him on CTAF to insure personnel and equipment were clear. Mr. X stated that would be fine; and the work crews were expecting my arrival.While enroute to the IAF I requested the RNAV 18 approach into DMO with Whiteman Approach. Approach stated the runway was closed at Sedalia and they could not clear me for the approach. I stated that I was aware of the NOTAM and explained that I had spoken with Mr. X and he had opened the runway temporarily for me to land; and if they would like I had the phone number for Mr. X to contact him with any questions. They stated they still could not clear me for the approach. I then requested the RNAV 18 circle to land 23 and approach stated they could not clear me for that approach either. I asked approach how they would like to proceed and they requested the number for Mr. X. I gave approach the phone number and they informed me to standby. While I was standing by I was nearing LAKLE and requested to proceed to LAKLE and hold as published until we could get things sorted out. My request was approved. As I crossed over LAKLE for the hold entry Whiteman Approach gave me this clearance 'Cross LAKLE at or above 3000; cleared RNAV 18 into Sedalia; land at your own discretion.' I copied back the clearance and began the approach. Nearing the final approach fix Whiteman Approach told me I was cleared to advisory frequency and to report cancellation on their frequency or with Flight Service on the ground. I copied the instructions and changed to DMO CTAF. Once on CTAF I confirmed with Mr. X via radio that the runway was clear and open; and I had permission to land on 18. He confirmed that the runway was clear and open for me. I continued the approach and broke out of the clouds 100 feet above minimums. I landed on runway 18 and made the first turn off. Personnel and equipment were clear of the runway and staging on the ramp waiting for me to clear so they could return to work. I contacted Columbia radio and cancelled my IFR flight plan. To avoid the confusion with ATC and increasing their workload I could have waited until the NOTAM for runway closure had been cleared out to make the return flight to DMO. I could have also spoken with Whiteman Approach over the phone prior to my flight to advise them of the situation and get things worked out before departing.

Light twin pilot reports obtaining permission from airport management to arrive during a NOTAM'd runway closure; but ATC will not clear the reporter for the approach necessary to get in. After ATC contacts the airport the approach is approved.


Situational Awareness; Time Pressure; Troubleshooting

[The aft lavatory dump] valve was found damaged. A large chunk of ice was found around the service panel. [I] determined the valve was damaged and needed replacement. The hangar was informed to replace the valve. A Supervisor signed off the leak check as ok. The aircraft was sent to the gate leaking causing an unsafe condition and a delay. The aircraft was sent back to the hangar where the valve was replaced. This substandard maintenance needs to be stopped; pressure from management to produce aircraft. Schedule outweighs safety in the eyes of some management employees. Suggest not allowing management to disregard procedures and leave assignment of all out of service aircraft to the crew chief and maintenance technicians.

Following the discovery of 'Blue Ice' in the aft lavatory service panel; the aircraft was relocated to the hangar for a dump valve replacement. It was reported that a supervisor cleared the leak check as okay; and the aircraft was sent back to the gate for a scheduled flight. Prior to departure; it was determined that the valve was still leaking; so the aircraft was again sent to the hangar and the valve was replaced.


Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Maintenance

Automation Aircraft Other Automation; Person Flight Crew

Flight Crew Rejected Takeoff; General Release Refused / Aircraft Not Accepted; General Maintenance Action

Had a rejected takeoff because of the ISI. On the takeoff roll we had a RED IAS message and a yellow message; but couldn't catch what it was. Went back to the gate and Maintenance said there wouldn't be any codes since it is a direct instrument and that they would have to do a taxi test. Well we never received the message on the taxi so the First Officer and I felt that it would need a high speed taxi. I called Dispatch and got the okay from them and went and did the test. We were to do the test on 1R. On the taxi to 1R we never got too fast but never received the message. Once on the runway I pushed up the power levers and we had the RED IAS message and a yellow SSEC message. The speed on the ISI hung and didn't match the PFD 1 and 2. Maintenance saw all what they needed and we went back to the gate. Once back at the gate the Maintenance went to look at what SSEC meant. It meant that there was an internal fault. After the high speed test I asked is this going to take a while and was told yes. So the First Officer and I went to go eat. After finishing eating I received a phone call from scheduling saying it was fixed. I found this odd that it was fixed so fast. I went to the airplane to talk to Maintenance and they had already left. I called Maintenance Control and asked if we could do another high speed taxi and was told no. I went to look in the can to see what had been fixed and all was done was water drained. I am not a mechanic but water in the line doesn't make an internal fault within the instrument. So we went back out to runway with passengers again and this time; as we were putting power in; we got the SSEC message first then the RED IAS message. We went straight to the gate and waited a while for Maintenance to show up and ask why we didn't do another high speed taxi. I was shocked by their answer. They told me that they wanted to; but were turned down by Maintenance Control. I was beyond upset because the First Officer and I wanted to do another one as well as Maintenance. It was so embarrassing to have the same issue happen twice.

A DHC-8-400 flight crew rejected their takeoff due to IAS warning messages.  A high speed taxi test confirmed the fault.  Maintenance was performed.  Flight crew wanted another high speed test to confirm the repair.  Their request was denied.  Boarded passengers and attempted another takeoff.  Same warnings returned.  Rejected takeoff.  Returned to gate and Maintenance advised they wanted another high speed test as well; but Maintenance Control turned down their request.  Reporter was 'beyond upset.'


Flight Attendant Airline Total 3; Flight Attendant Number Of Acft Qualified On 3; Flight Attendant Total 7; Flight Attendant Type 75

I have been a Flight Attendant for 3 years. [My] company has created a culture; specifically among flight attendants; that fatigue calls are not allowed. We only know this is an option due to word of mouth; and after a fatigue call the company holds a meeting among supervisors to determine if you were truly fatigued or if the fatigue is placed on your record as a 'trip failure' or 'occurrence' -- which you are punished and/or fired over. We have such a staffing shortage currently with flight attendants that those of us who have spent years on reserve are working 6 day trips at least twice a month with usually 2 days off between to recover (possibly 3 at most). Fatigue report: 12/XX (third consecutive day flying) - I woke up early [and] hungry as there was no food available in the hotel/area; and no transportation available. After arriving at the airport; it was discovered they did not have the correct anti-ice fluid for snowy conditions. After a 2 hour delay the snow tapered 'enough' to de-ice the wings and tail with the type A fluid (not the fuselage). The block time back was +3 hours. My second flight took off and then had mechanical issues in flight and had to air return.  We swapped aircraft and continued; dutying out at 2:11 a.m. After getting a taxi and arriving at the hotel; I got in bed at 3:15 a.m. I slept almost 5 1/2 hours (airport van at 9:50 a.m.). (8 hours reduced rest) [On the next day]; fourth consecutive day flying; I woke up tired from such little rest and had an almost 2 hour Maintenance delay. I worked a turn and was then assigned another turn that put my duty day at 11:53. We boarded and taxied out to the runway; but had to gate return with yet another maintenance issue. The Mechanic was not able to quickly diagnose the issue so we deplaned. With the new departure estimate; my duty exceeded 13 hours and I called in fatigued. I got to the hotel at 3 a.m.; was back at the airport at 10 a.m.; flew 4 flights; and just couldn't make it 2 more legs that would get me back around midnight. My body was physically shaking and weak and I felt like I was on the verge of vomiting. Even though my company feels like I should have 'sucked it up and continued;' I knew there was no way I could have prepared for any type of emergency; let alone even serve the almost 100 passengers on those 2 flights. I went home and slept until 9 a.m. the following day when I was called back in to work another 12 hour duty day; followed by yet another day of flying (day 6).

Regional air carrier Flight Attendant reported fatigue is a pervasive issue at his airline; which actively discourages calling in fatigued.


Flight Crew Total 19900; Flight Crew Type 5000

Flight Crew Returned To Departure Airport; Flight Crew Returned To Gate; General Declared Emergency

I was the secondary relief pilot on the flight. During [initial] climb; passing 100 AGL; a high vibration was felt in the aircraft and it was evident that it was caused by the Number 4 engine. The vibration monitor showed 5.0. Power was reduced on Number 4 until the vibration lessened at about 70% N1. We continued the climb as the analysis was made and upon level off after the after T/O check at 3;000 FT the Engine Limit/surge/stall checklist was accomplished. We declared an emergency aircraft without the need for additional assistance. After conferring with Dispatch and Maintenance Control we agreed the best course of action was to return to our departure airport. We notified the flight attendants and made a PA announcement to inform the passengers of the reason for the return to the field but the landing would be delayed due to the fact that we would need to dump fuel. ATC was notified of the need to dump and we were given holding over RAINS intersection to do so. Again Dispatch was notified with the intended amount of time in the hold. We also requested performance data for the landing. The approach; landing and taxi in to the gate were normal.

A trans-pacific B747 flight crew experienced excessive engine four vibrations shortly after takeoff; declared an emergency; dumped fuel and returned to their departure airport.


Small Aircraft; High Wing; 1 Eng; Fixed Gear

Air Traffic Control Time Certified In Pos 1 (yrs) 5

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 28.3; Flight Crew Total 411.9; Flight Crew Type 221.3

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

Human Factors; Environment - Non Weather Related

As a Preface; the day was busy.  I got my butt kicked just about every session with the exception of one where I worked Data.  All the others were either North radar combined or south radar with ZZZ1 final and ZZZ2 final.  ZZZ1 arrivals were outrageous with fighters; C17s; T38s; and TEX2s all day.I was working south Radar dealing with a handful of T38s with poor radios for TACAN; ILS; LOC; and high TACAN approaches at ZZZ1.  We combined north radar to south radar in the middle of it since north radar didn't have very much traffic and we could get someone fresh to keep the rotation of positions going.  Aircraft X was direct ZZZ2 for the GPS XXL at 060 southbound.  Aircraft Y was westbound towards ZZZ3 at 060.  Honestly; I simply forgot that I was working north radar during my battle with getting the T38s on the ground and sequencing them behind a C206 on the GPS runway X at ZZZ1 while juggling the High TACAN T38s in with the regular approach T38s.  Before the conflict alert went off I heard 'Approach; what about this traffic at my 10 o'clock?'  I looked up searching for who could have said that and saw the Aircraft X and Aircraft Y on converging courses at the same altitude.  It wasn't good.  I turned Aircraft Y to a 240 heading then gave the traffic alert.  Then I turned Aircraft X to a 270 heading and gave a traffic alert.  During the exchange; someone was 'hotmic'd' so I was worried the instructions didn't go out; but both planes turned to divert.  The closest was 1.23 miles and 100ft.  I believe Aircraft X called us later on the phone saying he was going to final NMAC paperwork and that he was shook up.It would be very convenient for me to point the finger at someone else to say 'Someone could have been watching the scope with me'; but honestly; the buck stops with me.  I was burnt out on the session with the error and I could have spoke up and asked for an easier sector.  I could have been more vigilant in scanning my airspace to notice an extremely easy to see; textbook conflict and fixed it before it became a problem.

While en route from ZZZ4 to ZZZ2 on an IFR flight plan; I was given direct ZZZ2 while just off ZZZ4. En route; while approaching the X area; I noticed an ADS-B target on my iPad; traveling northwest bound at 230 knots ground speed; at my altitude. Based on my iPad; it appeared that we were likely to conflict. I estimate my distance from this target initially was 6-8 miles when I first noticed. Suspecting a conflict; I eagerly awaited ATC's turn instructions to either aircraft. I searched visually for the aircraft for the purposes of anticipating a traffic call from ATC; hoping to say 'Traffic in sight.' When I heard no instruction for either aircraft; and could not acquire the target visually; I queried ATC (ZZZ Approach) with the following phrase: 'ZZZ Approach; Aircraft X; do you have the traffic off my left wing?' This resulted in immediate instructions for me to make a turn to a heading of 270; and for the other aircraft to make a turn to the south; heading of 180 or 190. I initiated the turn prior to acknowledging ATC's instruction; and read back this instruction while in the turn. While turning; I received a traffic alert from Foreflight running on my iPad; which called traffic at '10 o'clock; same altitude.' I am convinced that had I not queried ATC regarding this conflict; the controller would not have taken action. After both aircraft were established on new; non-conflicting courses; the controller handed off the other aircraft to another facility. During the hand-off; the controller apologized to the other aircraft for the incident. I was then given vectors for the RNAV RWY XYL approach; was handed to the tower; and landed without issue. I believe ADS-B traffic information in the cockpit and the use of traffic information on my iPad while in busier airspace; combined with a proactive approach with ATC (my query about potential conflict) helped resolve this situation. I am surprised this occurred in such well-traveled airspace; very near a Class B airport and right at the Class B boundary. I would be curious to know if ATC received a CA-collision alert on their radar display.

TRACON Controller and an involved pilot reported an NMAC requiring evasive action.


Flight Crew Landed in Emergency Condition; General Declared Emergency

After lowering the gear we received a hydraulic #1 system fail warning. We prepared the cabin for an emergency landing; declared an emergency with the Tower and fire trucks met the aircraft. We stopped on the runway and notified operations for a tow to the gate.

[No substantive additional information was included in the secondary narrative.]

After suffering the loss of their number one hydraulic system the flight crew of an EMB-145 declared an emergency; landed safely and was towed to the gate.


Maintenance Powerplant; Maintenance Airframe

Maintenance Airframe; Maintenance Powerplant

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

Working Aircraft X for tire change write up on number one tire for wear found brake not centered on axle. Removed brake assembly for further inspection and noted brake sleeve missing. Inspection came out to identify damage to axle.

I helped change the number 1 brake on Aircraft X. As I recollect there was nothing strange while removing the brake. Also installing the new brake nothing seemed strange; no looseness or wobbliness was felt; also while installing the tire and spinning it for torquing no looseness was felt. This is the first and only time I have helped change a B787 brake assembly! I have changed many brakes on other fleet types. I can only speculate that maybe the sleeve was not there when I helped change the brake. I would think that if it would have come off with the brake I helped change; that it would be attached to the old brake assembly and that the overhaul shop would have notified someone about it! I do not remember who I was working with this night; but there was at least 1 other set of eyes on this job that did not notice a problem with this brake change. It was being changed for normal routine wear!

During tire change on B787 aircraft Maintenance Technician observed brake sleeve missing.


Flight Crew Rotorcraft; Flight Crew Flight Instructor; Flight Crew Commercial; Flight Crew Instrument

Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Requested ATC Assistance / Clarification

Received a flight request at about XA:30. I built the risk assessment on the iPad and didn't push send because I was waiting for our com center to send the flight to ZZZ. I went and talked with the flight crew to make sure that they would be comfortable with the thunderstorms out west and go over the risk assessment with them. They ended up being fine with the flight and I accepted it at XA:35. As I was walking through the com center I was told that there was a drone operating in one of the parking lots next to helipad and that the com center was going to call to have them stop operations. This was the biggest distraction for me. I knew nothing about any scheduled drone activity. When I lifted off I called the control tower and asked if they had been informed that there was a drone operating in their airspace. They also were unaware of the drone. The control tower said they would call the state police. Once I was clear of the hospital and no longer worried about the drone I realized I forgot to push send on the iPad for my risk assessment and wait for approval. I had my com center call and let them know. [Control] told them I would need to call in. Once I landed at the scene I shut down and called. [Control] got the flight approved and we finished the fight. The only thing I would say is maybe have my com center ask if I have sent in my risk assessment when I'm walking out the door. But this is not their responsibility and the fault is mine 100%. I got distracted and forgot to push send and wait for the approval from [Control].

Medevac helicopter pilot reported being advised of a UAV which was operating in the vicinity of his proposed flight path. This information caused him to be distracted which resulted in his non-compliance with company risk assessment procedures.


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

Ground controller cleared us to taxi full length Runway 25R. Just prior to reaching intersection F we switched to tower frequency 120.95. After passing F we were cleared for takeoff at F intersection so the Tower controller asked why we didn't stop. Our clearance limit was the end of 25R not a random intersection. The ground controller should have specified taxi to 25R and hold short at intersection F for possible intersection departure. The fact that there is a note on the chart to monitor tower for possible takeoff at that intersection does not require you to hold short.

While taxiing to LAX 25R; the First Officer reported that they were cleared for takeoff on a taxiway behind them after missing the hold short of taxiway note. Ground had cleared them to taxi full length.


Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter Wake Vortex Encounter

Environment - Non Weather Related; Procedure

While in cruise at FL300; The aircraft encountered the wake of a B747 ahead. The aircraft abruptly banked 45-60 degrees left uncontrollably. We also lost 200-300 feet in altitude. The FO (pilot flying) regained control of the plane and stabilized the flight path by overriding the autopilot. I advised ATC and was told the 747 was 10 miles ahead. We were talking to ABQ Center at the time in the vicinity of the beginning of the Eagul arrival into PHX.If we were really 10 miles behind the waking aircraft; as ATC claimed at the time; then that is woefully inadequate spacing. The aircraft banked in excess of our capability to correct initially. We had passengers thrown to the ground and scared. Wake turbulence dissipates over time not distance and that should be the criteria for adequate spacing to prevent these occurrences.

B737-800 Captain reported encountering wake turbulence at FL300 in trail of a B747 resulting in a 45-60 degree bank and loss of 200-300 feet of altitude.


Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Got a terrain warning coming into LSE. We briefed the company page on it before descent. Cleared for visual approach and entered downwind leg. Descended too low on downwind and got the terrain warning. Climbed higher and dropped the gear to get out of the terrain caution area.[Suggest] Make a higher and wider pattern; brief the company page closer to landing so it's fresh in our minds.

Captain reported receiving a terrain caution on approach into LSE airport.


Flight Crew Last 90 Days 210; Flight Crew Total 15000; Flight Crew Type 11000

Flight Crew Last 90 Days 10; Flight Crew Total 21000; Flight Crew Type 14300

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

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

I was the working relief pilot. Shortly after gear was retracted; I saw and smelled an acrid smoke. Seconds later; EICAS message; 'Smoke detected crew rest F/D.' Donned O2. Called Flight Attendant at 1L with no answer. Later found out they couldn't hear the chime over smoke alarm. Smoke seemed to dissipate a bit. Captain directed me to go to bunk area to confirm issue. Smoke was in bunk room; smoke alarm at 1L; and smoke detected alert on cabin alert panel. No fire witnessed just smoke seen and smelled. Returned to cockpit donned mask as precaution once again. I coordinated the satcom call with dispatch. Dispatcher was very difficult to understand. Very thick accent. Relayed message that returning to [departure airport]... Asked for phone patch to [maintenance control]. Relayed info to him and told him of the choice to land overweight. By this time we are being vectored onto final. Landing uneventful; mindful of brake temps after landing.

The First International Relief Officer (IRO) tried to contact the cabin crew and was unable to reach anyone. The smell had almost completely dissipated but we could still hear the alarm coming from the back. The IRO looked through the door and could see the lead Fight Attendant standing in the hallway area. We decided to send her back into the cabin to assess the situation since we could not speak to the Flight Attendants. The second IRO was monitoring the communications in the cockpit and guarding the door. The first IRO checked the bunk area and could not find any evidence of the source of smell or faint hazy smoke.

B777 flight crew reported seeing and smelling acrid smoke accompanied by an EICAS message regarding smoke detected in crew rest area after takeoff.


When we landed; we were supposed to have one more leg then a 14 hour overnight. I have a voicemail from scheduling; now I'm flying to ZZZ for the overnight; a longer flight; but it wasn't a big deal to me. When I got the chance to look at my schedule I saw under Leg 4. 'ATREST ZZZ XI:15' The Report time on my pairing was XH:30. I had never seen 'ATREST' for a leg in my schedule before; so I asked the Captain about it and he called scheduling after arrival. He confirmed that our show time will be XH:30; so we agree on a XH:15 van. We go to our rooms; but all 3 of our rooms were already occupied (probably by our crews who's night's just got messed up by us barging in on them sleeping). We all went back to the lobby and got rooms on another floor and free breakfast coupons. I set my alarm for XG:30am. By the time I got to bed it was XA:00 am at least. At XE:30 am my cell phone goes off and I wake up right away assuming that it was my alarm and it was XG:30. It was scheduling calling; 3 hours before my show time; on a reduced rest overnight. I was pretty upset. By XF:30 I was probably half asleep and they call again. I was more upset. I had just missed out on 2 hours of sleep on an already short overnight. The threat was the lack of sleep; and I would say that was entirely caused by scheduling. My original trip had a 14 hour overnight; then I got reassigned to a short overnight; then THAT got even shorter by repeated calls from scheduling.

A pilot reported how scheduling changes; hotel issues and calls from crew scheduling disrupted his rest period.


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

Flight Crew Last 90 Days 28; Flight Crew Total 4952; Flight Crew Type 468

Flight Crew Last 90 Days 27; Flight Crew Total 1326; Flight Crew Type 219.6

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Ground Strike - Aircraft; Ground Excursion Runway; Inflight Event / Encounter Loss Of Aircraft Control

Air Traffic Control Provided Assistance; Flight Crew Requested ATC Assistance / Clarification; General Flight Cancelled / Delayed; General Maintenance Action

After an Instrument Proficiency Check and Biennial Flight Review with the aircraft owner the last landing of the day was proceeding normally with the owner/operator pilot-flying. There was a crosswind on final approach but nothing abnormal. As the aircraft was entering the flare and about 5 feet above the runway (with power at idle; on centerline; at 75 knots) the aircraft nose suddenly slewed about 45 degrees left immediately taking the aircraft off the runway and over the grass. The pilot initiated a go-around with full power. The aircraft touched down on the grass and rolled straight for several hundred feet before the right wing settled to the ground and the aircraft rotated 90 degrees right and stopped.As instructor I did call for a go-around as directional control seemed lost; but that call was simultaneous with the pilot initiating a go-around. I cannot explain the initial sudden yawing moment. I speculate that the plane was hit with a gust during the flare and there was inadequate energy; even with full power; to keep the plane from contacting the grass. The attempt to prevent the plane from settling onto the grass caused a nose high attitude; along with full flaps; probably created excessive drag preventing acceleration.The METAR at the time showed wind 30009KT The 3 METARS before the incident showed wind 24011G17KT to 28009G14KT. The landing METAR was well within the Demonstrated Cross Wind for a Cirrus SR-22; but perhaps unexpected gusts were starting as we landed.There were no injuries but the airport was closed for several hours.

Just prior to touch down on Runway 20 a wind gust pushed the airplane extremely hard to the left; I initiated a go around but was unable to climb and regain control. I pulled power back and landed in a grass area. The airplane slid and the right landing gear dug in to the ground and separated from the airplane. The airplane came to a stop in the grass. There were no injuries. I was flying with a CFI at the time and had just completed a Biennial Flight Review and an Instrument Proficiency Check and everything had gone fine; the day was done and were landing at my home airport. I feel the cause was a combination of a strong wind gust and wind shear.

SR-22 pilot and instructor reported a runway excursion during landing.


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

Flight Crew Last 90 Days 20; Flight Crew Total 2800; Flight Crew Type 500

Flight Crew Landed in Emergency Condition

On initial approach; I experienced engine/mechanical problems and decided to immediately switch airports and land.  My left engine was experiencing problems so I requested vectors direct.  Then I advised ATC and flew directly to the approach end of the runway.  I landed uneventfully; and we are troubleshooting the aircraft to determine the reason for the left engine failure.

Baron pilot reported experiencing engine failure during descent.


Aircraft Equipment Problem Critical; Inflight Event / Encounter Other / Unknown

Flight Crew Returned To Departure Airport; Flight Crew Landed in Emergency Condition; General Maintenance Action; General Flight Cancelled / Delayed; General Declared Emergency

On climb out; while climbing through about 2000 ft MSL; we got a master warning along with right engine thrust reverser 'Arm' and 'Unlock' light. I was pilot flying; and we verified that the right (Emergency) Emer-Stow button was illuminated and the captain pushed the right side emergency stow. The captain notified ATC of our issue and we were given a vector to a downwind to run our checklist while returning to land at ZZZ. We completed the checklist; declared an emergency; and following the last item on the checklist; to land at our nearest suitable airport; which for us was ZZZ. Captain notified the passengers that we were returning to land. We were vectored to ILS 10L for an uneventful landing.

Reporter stated the two engines on their Beech Jet 400 XP were Pratt-Whitney PW JT-15D5 turbofans with external clam shell type reversers. The reversers are hydraulically operated and will open fully in about two seconds. There are two emergency-stow buttons for the left and right engine reversers; located at the glare shield on the Captain's side next to the master warning light.Reporter stated the right emergency-stow light did not indicate a re-lock of the right engine reverser after being pushed. So they returned to their departure airport. They did not feel any noticeable vibration during the event. He has experienced additional training in unusual upset attitudes simulating a reverser deploying on Takeoff; the training was quite challenging. If the thrust reverser opens in flight; pilots have to be aware that electric servos will Auto-Retard the throttle on the affected engine when the pilot hits the Emergency Restow button. The affected engine throttle will move aft. Engines do not have FADEC systems. Only direct cable from the throttles to the fuel Hydro-Mechanical Unit (HMU) on the engines. Reporter stated their QRH Checklist procedures directs pilots to slow airspeed; hit the Emer-Stow button and find the closest suitable airport. Maintenance said the event was an indication problem; not an actual reverser unlocking and ready to deploy. A sensor between the light and the engine had faulted. A former marine pilot and one of their trainer's; who had experienced an inflight reverser deployment said he had to use spoilers and rudder to recover before auto-restow of the reverser occurred.

During the climb out on departure off of runway 10L; at approximately 2000 ft MSL; the master warning light illuminated along with the Right Engine Thrust Reverser 'Arm' and 'Unlock' light. I was the pilot monitoring at the time. When I noticed what happened; I immediately pushed the right engine TR (Thrust Reverser) emergency stow button. I notified departure control that we had a problem with the thrust reverser and asked for vectors to complete a checklist. We followed the checklist for TR unlock in flight and I then declared an emergency and asked to return to ZZZ. I then notified the passengers of our emergency condition. We continued the normal checklist and made a normal landing on runway 10L.

During climbout; a Captain and First Officer respond to a master warning light illumination and a right engine thrust reverser 'Arm' and 'Unlock' light on a Beech Jet BE-400XP. The right engine reverser did not indicate Re-lock after the Captain pushed the Right Emergency-Stow button on the glare shield. Crew declared an emergency and returned to departure airport.


Aircraft Equipment Problem Less Severe; Ground Event / Encounter Other / Unknown; Inflight Event / Encounter Weather / Turbulence

Aircraft Aircraft Damaged; General Maintenance Action

Upon initial landing rollout left main tires locked and antiskid left failed. Suspected frozen brakes. Aircraft had been sitting on snow covered ramp for extended period of time in up to 8' of snow. Aircraft was brought up to frontline parking from rear ramp area and was pulled through high standing snow. Other Captain; and myself were concerned already about possible frozen brakes at next landing due to snow and slush on ramp and taxiway when aircraft was put in service. We exercised and attempted to warm the normal brakes during taxi; and allowed the landing gear to remain extended well after takeoff to prevent main wheel lock at next landing. Flew in cruise at FL400 for a 4 hour period; and suspect carbon brakes had build-up of ice contamination upon landing touchdown. After touchdown; both left main tires began skidding; lost pressure; and the aircraft listed left and began to angle towards left side of runway. After thrust reversers deployed; aircraft began slowing quickly and Captain was then able to regain some directional control and return aircraft towards the right and back on runway centerline. We then relayed our problem to the Air Traffic Control Tower; and cleared the runway. Soon after we came to a stop; Airport Operations personnel arrived and loaded up our passengers and transported them. A couple of airline mechanics arrived with Airport Operations and inspected left and right main landing gear tires and surrounding area for signs of damage. Saw no significant damage to landing gear area. The left main inboard tire was flat. The left outboard tire had significant damage and was able to hold enough tire pressure to allow for towing to the hangar. Avoid snow or slush at all times if possible. Freezing or near freezing surface temperatures make this process happen much sooner. Very difficult to avoid completely when conditions are favorable for main wheel lockup occurrence. Perhaps get the aircraft in a warm hangar for a safe amount of time and if allowable blow some compressed air onto the brake stacks to remove moisture collected around main tires. Even with conscious effort applying all suggested Aircraft Flight Manual procedures; and knowing this is a past problem; wheel lock still occurred upon landing. Carbon fiber based brake pads are very vulnerable to this condition of wheel lock/freeze up. Maybe an approved mod to replace with different material brake pads less susceptible to failure is in order.

CE680 Captain reports accepting an aircraft that had been sitting on a snow covered ramp for an extended period of time in up to 8 inches of snow. Fearing frozen brakes on landing the brakes are used heavily during taxi out and the gear is left down for an extended period after takeoff. Upon landing the left main wheels are frozen causing one tire to blow and damage to the other.


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

Deviation / Discrepancy - Procedural Hazardous Material Violation; Deviation / Discrepancy - Procedural Published Material / Policy

After landing; the Ramp Agent notified us that the wheel chair that was on board happened to be an electric one with the batteries still connected. Our GOM (General Operations Manual) mentions that they are not allowed because of size and weight; the one we had on board was 45 [pounds]; we are awaiting more information on the model of the wheel chair and the type and size of the batteries; as there are some restrictions to them as well.

Air Taxi Captain reported an electric wheelchair was transported with batteries connected in violation of GOM.


ATC Issue All Types; Aircraft Equipment Problem Less Severe; Airspace Violation All Types; Conflict NMAC

Person Air Traffic Control; Person Flight Crew

VFR conditions prevailed during arrival into EWR. [We were] taken off of the FMQ RNAV arrival and given vectors for spacing and sequencing to the west of EWR for a landing on Runway 4R. Flying at 5000 ft; autopilot on and approx. 190 kts assigned; we were turned from a downwind to base heading. Approx 15-20 nm southwest of the airport we were given a traffic warning message from ATC 'Traffic 1 o'clock; 5500 ft and closing; may be descending'. The Capt and I spotted a single engine low wing aircraft (Cherokee) approximately 300-500 feet above and trying to turn away from us. Almost no time was available to take action; no deviations or changes in automation occurred. ATC stated that aircraft had inadvertently flown into the Class B airspace. We never received a traffic proximity warning as the TCAS was [on] MEL. During pre-departure briefing and during all flight phases we discussed the TCAS outage and ensured we were actively looking for traffic during all phases of flight. No further actions or occurrences were encountered.

EMB-145 First Officer reported a NMAC with a light aircraft on arrival into EWR.


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

During our takeoff roll on Runway 19R in MCI; we had an EICAS r side window alert message displayed. I called for the reject at approximately 50 kts. We informed the tower we were rejecting; that we didn't need assistance and requested somewhere to park for a few minutes. I called for the after landing checklist and once completed called for the rejected takeoff checklist in the QRH. Because it was a low speed abort we didn't have a brake cooling time to contend with. Once that checklist was complete I directed my First Officer to run the r side window checklist in the QRH. Executing that checklist cleared our issue. After a short debrief and answering a few questions from my First Officer I then asked him if he saw any reason why we couldn't depart. He agreed that we could depart. I then called for the before takeoff checklist and also briefed what we may see during our takeoff roll. The tower cleared us for another takeoff and shortly after V1 we received another r side window EICAS alert message. Once we had completed the after takeoff checklist I stated to my First Officer that I have the aircraft; the radios and asked again for the r side window checklist in the QRH. This procedure rectified our issue once more and we pressed on to ZZZ for an uneventful flight. I entered the write ups in the AML and also sent an ACARS message to Maintenance en route about our issue so they would have a heads up upon our arrivalComponent failure of the R side window system.Unfortunately this type of event can't be prevented as mechanical things; sooner or later; break.

Captain reported a rejected takeoff due to a right side window warning message.


Large Transport; Low Wing; 2 Turbojet Eng

FMS Or FMC; Localizer/Glideslope/ILS Runway 21

Inflight Event / Encounter Unstabilized Approach

ATC Equipment / Nav Facility / Buildings; Airport

During the approach and landing phase at CKB both myself as the PM and the PF noticed the autopilot having a difficult time tracking the ILS on RWY 21. The winds were not a factor considering they were steady state with little to no crosswind the cloud layer was 1000 OVC. We allowed the autopilot to try to stabilize on the ILS while we were outside the FAF; allowing the autopilot to command several s-turns to either side of the inbound course while it tried [to] chase the LOC course dot; which was deflecting a dot either side of desired track. The PF decided to disconnect the autopilot and hand fly the approach using the raw data on the ND in Arch mode and the approach was continued in a stabilized manner using this mode. The FD; LOC and GS; on the PFD continued to show erratic tendencies as the LOC/GS deviation displays. As the PM I was keeping close attention to the terrain on my ND and watching visually outside with 75% visual of the terrain. I noticed the FD continued to command corrections trying to chase the erratic LOC/GS deviations; including a pitch down while over the high terrain bluff on about a mile final; a potential dangerous situation if flown with a coupled approach down to minimums. While talking to the agents in the airport they confirm they had heard other pilots talking about irregular behavior with the ILS 21. We departed CKB and flew a coupled ILS 9L there and noticed no irregular behavior with the aircraft; which furthers my thought that there may be something wrong with the CKB ILS 21 Navaid/Approach. Have the ILS flight checked to see potential sensitivity and interference problems. Possibly request other feedback from pilots flying the approach into CKB. Possible memo to pilots on the potential for irregular tracking of the ILS using automation.

Air carrier Captain reported receiving erratic signals from the CKB Runway 21 ILS while on approach in IMC. The crew disconnected the autopilot and the approach was completed uneventfully. Ground personnel mentioned to the Captain that several pilots referenced the irregular quality of the ILS signal at CKB.


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

I was asked to supervise and show two mechanics how to properly install a number 8 main landing gear tire on a Boeing 767-300 aircraft. I showed the [mechanics] how to properly look up in the aircraft maintenance manual (AMM) the procedures and tooling required and read through the AMM with them while a tire was being procured by our lead. I assisted the two [mechanics] in the process of removing and replacing the wheel assembly but failed to check the part number of the tire being installed. Having worked international line maintenance before; I am aware of the part number differences between the B767-300 and the B767-300ER tires. I feel that the distraction of training the two students; and assuming the lead AMT was providing me with the proper effective tire for the aircraft; distracted me from checking the part effectivity for myself. Then when entering the information into the log I again overlooked the fact that the wrong Part Number (PN) had been installed onto the aircraft. Though the incorrect tire was provided for me; ultimately I am responsible for the equipment that is being installed and signed for. I supervised and help[ed] perform the maintenance task; and signed off the aircraft maintenance log. I was unaware of my mistake until [about a month later] I was made aware of the discrepancy by the hangar shift manager and my lead; and was informed that the tracking system had logged the error in part effectivity and that I needed to sit and make a statement for the internal investigation into the matter. I brought my error to the attention of the two [mechanics] that I was training and emphasized the importance of checking PN effectivity with the aircraft that is being worked; regardless of who provides the part for them. I also explained that ultimately regardless of the situation; the mechanic performing and signing for the work is responsible for insuring the airworthiness and effectivity of the part being installed on the aircraft.

During a B767-300ER Service Check an incorrect wheel assembly was installed on the Main Landing Gear. A wheel assembly for a B767-300 non-ER was used.


Distraction; Situational Awareness; Confusion; Communication Breakdown

Deviation / Discrepancy - Procedural Other / Unknown

Company Policy; Procedure; Human Factors

I was in charge of briefing the passengers in seats the Exit Row. I approached passenger in the row and asked that he review his safety card and that after his review I would ask him a question. He could not understand what I said to him. I continued trying to explain using hand signals etc. After several minutes I got the Purser. I was going to move the passenger but Purser spoke limited Spanish and got him to understand a little what we were trying to convey. I understand we are not supposed to deny passengers who do not speak English the right to sit in the exit row and it is written in several languages on the safety card but I do not agree. He could not understand me. How will he understand me any better when I am shouting out commands? How can he understand me when I am stuck in my jumpseat and shouting at him to get me out of my seat open the door etc. How can he understand when other English speaking people are asking him to help them? I agree that people who speak other languages should be able to sit in the exit row but one of those languages must be English. We do not allow any other language in the cockpit why would we allow it anywhere else where safety is a concern. Passenger must be able to understand the flight attendant's instructions clearly and be able to say yes clearly.

A B757 Flight Attendant reported that a non English speaking passenger was allowed to sit in an emergency exit row when he did not understand the questions regarding emergency exit operations.


GPS; FMS Or FMC; Localizer/Glideslope/ILS XXR

Communication Breakdown; Workload; Training / Qualification; Situational Awareness; Physiological - Other; Fatigue

Deviation - Altitude Overshoot; Deviation - Altitude Crossing Restriction Not Met; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Environment - Non Weather Related; Human Factors

While on descent in to ZZZ; I the CA was PF.  We received a different runway assignment than anticipated.  We were cleared to 'cross ZZZZZ at 3;000 feet; cleared the ILS [Runway] XXR approach ZZZ.'  The runway change was made in the FMS from YYR to XXR.  While in VNAV path and cleared for the approach we set FAF Glideslope intercept altitude of 2;000 feet in the altitude window.  The last-minute change left us a bit high so we lowered the landing gear and selected LVL CHG in order to re-intercept the path.  ZZZZZ the IF was in the FMS twice and while trying to correct that and heads down and distracted (because we were no longer in VNAV) the aircraft descended through 3;000 feet towards the 2;000 feet set in the ALT window.  I caught the mistake at approximately 2;600 feet MSL and leveled off until intercepting the glide path.  There was no correction from ATC; no known traffic conflict etc.  Normal uneventful landing.  Upon further consideration I determined it was best to file a report.Cause - Short night; last minute runway change; lack of recency of experience...infrequent flying over the last year with the pandemic.PF [should] have better situational awareness and avoid both pilots being heads down even if the PNF is having difficulty correcting the FMS issue.

Air Carrier First Officer reported an altitude deviation during approach caused by possible fatigue; a late runway change and lack of recent flying experience during the pandemic.


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

Aircraft; Company Policy; Procedure; Incorrect / Not Installed / Unavailable Part; Human Factors

Last week we tried to rig the inboard ailerons per Maintenance Manual (MM) 27-11-00 on a B767-300 aircraft for an excessive rudder trim deferral and found two rig bars Part Nunmber P/N A27024-55; one with broken adjustment post and one with the safety not installed on the adjustment post. Red tagged both bars. This week we came in to do the Inboard aileron rig; thinking the tooling had been repaired and calibrated. When setting up for the inboard aileron rig; we noticed that the rig bar was safe tied but was not in its normal position. The adjustment post on the bar was from our previous experience: way too long. We went to engineering and had the tooling drawing pulled up and went and checked the bar with a string as a straight edge. The bar was out of rig (post too long) by almost two inches. We assumed that the bars came from a vendor calibrated. When we questioned tooling supervisors on who adjusted the bar post and what documentation they used to adjust it; they didn't know. They told us the rig bars are not a calibrated tool and repairs are done in house; if they are safe tied they are correctly adjusted. (Apparently not). Had we not had experience doing this job several times before; we would have severely misrigged the inboard ailerons. There is no way for me to verify that the bars are in the proper adjustment before I rig an aircraft flight control. All other rig bars that I saw in the rack are the same way; with no calibration seal or sticker.

B767-300 aircraft had a rudder trim problem. The Maintenance Manual (M/M) calls out for a rig bar for adjustment of the ailerons. Company has two rig bars. Last week I tried to use the rig bars but they were in an unserviceable condition; due to the fact one had a broken end and the other one had broken safety wire on the lock nut. I removed the rig bars from service and installed a tooling repair tag. This week I got the same B767-300 aircraft back to rig the ailerons again. I found that the rig bar had been repaired and safety wired; but the adjustment was wrong per the drawing. I asked the Tooling Supervisor if the bars were sent to a vender for calibration and he said 'No'; they were repaired in house. I removed the bar from service again and tagged the bar with a tooling repair tag. I later found the tooling supervisors adjusting the bar with no point of reference. The supervisors were making the adjustment with a piece of string instead of a laser or ridged straight edge. There are no calibration tags on any Company Flight Control Rig bars. There is no tamper proof safety wire or seal on the rig bar.

Two line aircraft maintenance technicians (AMTs) report about their efforts to rig the inboard (I/B) ailerons on a B767-300 aircraft due to excessive rudder trim but realize both A27024-55 rigging bars were not serviceable. Tooling supervisors told both AMTs their rig bars are not considered a calibrated tool and none of their rig bars had any calibration seals or stickers.


Distraction; Time Pressure; Situational Awareness; Workload

Aircraft Equipment Problem Critical; Ground Event / Encounter Object; Inflight Event / Encounter Object

Human Factors; Environment - Non Weather Related; Company Policy

Upon landing at ZZZ; our right generator went offline.  We ran the QRH and were unable to get the generator working; so we taxied in on two engines.  There was one Marshaller and one Wing Walker at the gate.  When taxing in there was a cone inside the safety zone.  It was far enough away from the aircraft that I didn't think it was going to cause any trouble; so I continued to follow the Marshaller's directions.  When moving the condition lever from the ground idle position to the start position; the feathering of the prop caused the cone to be sucked backward into the propeller chopping off the top piece of the cone.  After calling in the generator failure and exiting the aircraft; I was told about the cone incident and notified Maintenance and Dispatch.  The ground supervisors where also aware of the situation.  No one was injured and there was no damage to the aircraft.  The event occurred because in the rush to get the flight in and get the generator fixed; I overlooked a hazard.  I would suggest all crews hold outside the gate until all items are moved outside the safety zone; no matter how benign they may look.  In the process of trying to stay on time; potential hazardous items may get overlooked.  We all need to ensure safety is our number one priority at all times.

A SF340 Pilot rushing into the gate for a generator repair feathered an engine as he entered the gate and it struck a pylon cone inside the safety zone.


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

Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance

Flight Crew Returned To Clearance; Flight Crew Overcame Equipment Problem; General Maintenance Action

Descending into ZZZ the aircraft locked onto a glideslope signal at around FL340 and started to climb. Took a couple of seconds to figure out what it was doing; but once I saw the G/S on the FMA was green (meaning it was locked on) it was clear the aircraft thought it should follow the glide slope so it started a climb. At that point the autopilot was disconnected and ATC was notified that we had a problem. All the automation was turned off and once the aircraft was stable in the descent the automation LNAV/VNAV etc.; was re-established. Aircraft landed safely in ZZZ and was turned over to Maintenance. They discovered that the FCC computer on the A side had tripped a fault code and placarded the autopilot A inoperative. Flew the Aircraft back to ZZZ on autopilot B with no issues.

B737-800 Captain reported that an FMS malfunction resulted in an uncommanded climb during approach.


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

Flight Crew Last 90 Days 250; Flight Crew Total 700; Flight Crew Type 325

During a routine banner tow along the shoreline the low oil pressure indicator light came on and the engine lost oil pressure. I was cruising southbound at 500 feet AGL when the light illuminated. I promptly checked the second oil pressure gauge that also indicated oil pressure was down in the red and the oil temperature was all the way up in the read. My initial thought was that I was going to need to land at the beach. The beach was packed with people so I turned northbound to find a place to land and called ATC. At this point my engine was already running rough due to oil starvation. ATC asked if I needed to land at the beach and I told them that I'm going to ditch my banner in the ocean and try to see if I can climb up to sufficient altitude to glide the plane to the airport if the engine should quit completely. I dropped the banner and climbed slowly up to around 1500 - 1700 feet before I decided to give it a try. At this time I was approximately 3 miles southeast of the field and figured that if the engine failed before half way there I would be able return and land at the beach. The engine luckily lasted all the way to the airport but was running very rough at the end. It sounded and felt like it was going to quit on me multiple times. Safely on the ground I saw that the planes belly was completely covered in engine oil. I got it inspected by mechanics that concluded that the engine only had 2 quarts of oil left in it and the oil pressure gauge sensor had a severe leak.

A banner tow pilot experiences a loss of engine oil pressure at 500 feet AGL while towing a banner along the beach. The banner is dropped in the ocean and the pilot is able to make it 3 miles to the airport without the engine quitting.


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

Flight Crew Last 90 Days 100; Flight Crew Total 17000; Flight Crew Type 250

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Ground Strike - Aircraft

In perfect weather; on a normal flight to ZZZZ; normal approach to airport selected gear down on downwind to reduce airspeed to get to flap extension speed. The expected reduction in speed happened; due to the increased drag of the landing gear having extended. On the turn from downwind to base; while banking; I looked at the gear lights during the before landing checklist; and 'saw' 3 green lights. A normal stabilized followed; ending in a perfectly smooth touchdown on the mains but an INSTANT lowering on to the nose gear; which seemed to hold for a half second; only to give out and have the propeller hit the pavement at idle speed The airplane was sliding on two propeller blades; which were ground down but this prevented ANY damage to the airframe itself. The automatic gear extension system was in the 'normal' position (not over-ride) but no auto extension happened. Approach speed on final was 90 knots in accordance with the POH and very forward C.G. There was no Gear Unsafe light and no Gear Waring Horn prior to touchdown.I had a very distracting friend flying with me; constantly talking. Entering downwind; I had to tell him to stop talking as his distractions were interfering with listening to ATC. If there is more to the situation than thus far explained; his distractions would have been a major contributing factor. I am going to inspect the landing gear system this coming week and will comment on it more pending my further discoveries. If there is a lesson to be learned or safety related important information it WILL be disclosed by me to contribute to improvements in the overall safety of general aviation.

PA32 pilot reported the nose landing gear collapsed during landing.


Any Unknown or Unlisted Aircraft Manufacturer

Flight Crew Commercial; Flight Crew Flight Instructor

Flight Crew Last 90 Days 100; Flight Crew Total 300; Flight Crew Type 240

Conflict NMAC; Deviation / Discrepancy - Procedural Published Material / Policy

Four aircraft were flying in the pattern for Runway 05 and one aircraft was shooting ILS (Instrument landing System) practice approaches on Runway 23. A sixth aircraft reported he was 7 miles out for Runway 23; but then did not make another radio call. As we were on Runway 05 the practice ILS traffic went missed for Runway 23; so we continued with our touch and go. When we reached around 500 feet; I looked out and noticed an aircraft at the same altitude on a collision course with us. I took the flight controls from my student and quickly banked hard into the left crosswind. We missed each other by roughly 500 feet horizontally. The other aircraft did not acknowledge there was any issue and continued to land 23 even with other aircraft already established in the pattern on short final for Runway 5.I realize that in this case we were on a head on collision hazard and I should have turned the aircraft to the right instead of left; but chose to go right to maintain in the traffic pattern.

Instructor reported that during initial climb; they took evasive action to avoid a mid-air collision with landing traffic.


Air Traffic Control Fully Certified; Flight Crew Private

Flight Crew Last 90 Days 65; Flight Crew Total 304; Flight Crew Type 129

Ground Event / Encounter Loss Of Aircraft Control; Ground Excursion Runway

This was my final landing after a week-long trip; I was coming home. As I was fifteen miles out; I received my first ATIS; winds were 080-110 @ 7kts. When I was ten miles out I listened to ATIS again; report was much of the same but winds were now at 10kts. I lined up on final; everything was normal. I landed with my main gear on the numbers; my nose gear shortly landed after that and I put my flaps up and carb heat off. As I was rolling out; my airspeed was slowing rapidly and I begin to lightly apply even brake pressure; as I have done thousands of times before. However; as soon as I [applied the brakes]; the airplane takes a severe turn (about 45 degrees according to tire marks) to the right. At this point I was traveling about 30kts and headed directly towards the marsh. I knew at this point; going into the marsh was inevitable. Instead of over-correcting and potentially flipping the airplane; I tried to keep the plane level; cut mixture and fuel pump; then I braced myself for impact. When I came to a stop; I immediately exited the aircraft and walked to FBO to call authorities.

PA-28 pilot reported losing directional control on the landing roll for unknown reasons.


Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Human Factors; Environment - Non Weather Related; Aircraft

Approaching SADDE intersection; descending from 12;000 feet to 10;000 feet and slowing to 210 knots; we encountered moderate plus wake turbulence from heavy 777 in calm air; causing autopilot to revert to CWS from LNAV/VNAV CMD mode. After arresting control from wake rolling tendency; we overshot SADDE intersection and had to manually turn towards BAYST intersection before re-engaging LNAV/VNAV CMD mode. We were advised at the same time by ATC to turn immediately towards BAYST. Just prior to autopilot disconnect; we had advised ATC of the wake turbulence upset. Remainder of flight was uneventful after we reported heavy aircraft in sight for visual approach and remained above its glidepath.

Prior to SADDE we encountered moderate wake turbulence. It seemed to last longer than usual; and the pilot flying was struggling to maintain aircraft control. I told ATC we were in wake turbulence and asked what we were following. The reply was 'a heavy'. We later learned it was a 777. During the event the autopilot reverted to CWS. I saw this happen but did not announce it; due to the high workload the Captain was under. As we approached SADDE the wake was subsiding but we were still in CWS; in zero wind so it appeared we were on course on the MFD. I still did not announce CWS due to other distractions and concerns about the wake. We then flew past SADDE and did not turn toward to BAYST.

B737 flight crew reported track deviation on approach to LAX when the autopilot reverted to control wheel steering in response to a wake turbulence encounter.


Flight Crew Commercial; Flight Crew Multiengine; Flight Crew Instrument

Flight Crew Last 90 Days 30; Flight Crew Total 5600; Flight Crew Type 5000

Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence

I have many hours and many approaches to minimums as a single pilot operator over 30 years of flying; mostly Part 91. Very few missed approaches in that time span. Based upon current weather at time of approach; I expected to breakout well above the 250 FT DA. [Decision Altitude] The aircraft did not have an autopilot and my hand-flown approach was rock solid right down to DA. I looked up fully expecting to see the runway in sight for continuation and landing. I was flying the ILS as it had lower minimum than the RNAV/GPS approach. Looking up; I saw nothing of the runway environment as I tried to discern the nature and meaning of glowing globes through the fog (which I later concluded were lights on the ground diffused by the fog at dusk). I had made no mental accommodation to do a missed approach as I just KNEW that my skills would allow me to land as they had several times in past years. The only conscious control input that I can recall is leveling at the MDA while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at nor interpreting the flight instruments as I began what in retrospect was an uncontrolled; unconscious 90 degree turn to the left - still looking for the runway environment. Through a break in the clouds and fog - (don't know how low I was) I saw a clear picture of the runway lights (which I had clicked on 5 times at approach top of descent) showing the intersection of the two runways. I just happened to be on a (very) low right base to the cross runway and reacted by chopping power; setting full flaps (which probably saved me) and executed a steep right-hand turn at low altitude to uneventfully land and consider it a blessing to be writing this to you. I was tired when I began my flight; having circumvented convective activity with Center help on a previous flight earlier that day. I did file an alternate based on the weather (TAF) but really just wanted to get home; and really never seriously considered that I would have to make a missed approach. I was flabbergasted when I looked up and could not see the runway; and my behavior was all downhill from there. My perceptions; judgments and decisions from that point were automatic; faulty and flawed. The discipline to call a missed approached had totally evaded me as I wandered in the fog trying to see the runway. I will never again launch on an approach to low minimums without respectfully considering the real necessity of having to call a go-around and be much more than casually aware of the implications of making that decision. The TAF forecast visibility and ceiling was for better conditions than I encountered. At time of approach the ASOS was reporting visibility and ceilings better than I experienced. I'm also working up a personal minimum for low approaches to the effect that even though I do and always have enjoyed making approaches to low minimums; I will bring a different mindset to the game in the future. I'm still refining my personal minimum rule but something along the line of: If the approach DA is 250 FT (as in the case of this ILS) then double this figure to 500 FT. If the TAF is lower than that number; then there must be a total expectation and commitment to either not take the flight if one is tired (as I was) or be totally and irrevocably committed to a missed approach and alternate airport landing. I was not; but lived to relate this story to you. I would also treat the TAF visibility in a similar fashion but haven't as yet reflected on that component as a personal minimum.

A commercial and instrument rated pilot flying a single engine aircraft describes his near fatal loss of situational awarness when intentionally descending below minimums on an instrument approach.


Inspection; Installation; Testing; Work Cards

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

During pushback I started the right engine. The engine generator did not take over from the APU generator after start valve closure. I reset the [engine] generator; but it was still not coming 'online.' We gate returned and Maintenance swapped out a Generator Control Unit (GCU) which did not fix the problem. We deferred the engine driven generator and conducted the flights with the APU operating and supplying power to the right side bus. After arrival back in ZZZ; the Ramp agents connected external power and I tried to swap power from the APU to ground power. The right side [electrical] bus would not go 'offline' on the APU generator. I wrote up the problem and contacted Dispatch and Maintenance. Recurrence of this event is impossible to predict or avoid. Aircraft electrical failures are hard to predict. Maintenance should be complimented on their handling of this event. The system was troubleshot; tested; and deferred in less than 45 minutes. An outstanding job.

An air carrier Captain reports about a recurring Right Bus Electrical System malfunction on their MD-82 aircraft. The right engine generator did not take over from the APU generator after start valve closure and later; the right bus  would not allow the APU generator to go 'off-line' and swap to ground power.


Air Traffic Control Time Certified In Pos 1 (yrs) 2.5

ATC Equipment / Nav Facility / Buildings

Low ceiling/night time conditions with aircraft reporting breaking out of the clouds at minimums. Landing runway 9L. Runway not visible from the tower. Aircraft X on rollout reported a scary incident that the lights; all the lights; on the runway turned off for 'a couple of seconds.' The aircraft had just broken out when they said they picked up the lights and then they went off and came back on before the decision to abort the approach was made. The aircraft landed and reported the incident at taxiing speed.After discussing with other controllers they have seen lights turn off and then come on almost like the generator has an overlap. Usually it happens and there is little to no overlap especially with aircraft on final in VFR weather. The pilots sounded shaken from the incident and all the aircraft after I'm sure had added workload in the actual fear of not having lights available when they broke out. In my  years [as a controller] this was one of the most serious incidents to safety of an aircraft that I have seen.When switching to and from the generator power (if that is what caused this) then a NOTAM or a request to ATC from tech ops [is recommended] as when to do this. If it was an automatic switch on then there needs to be a zero overlap system put in.

ORD Tower Controller reported a recurring problem with momentary loss of runway lights.


Troubleshooting; Situational Awareness; Confusion

Flight Crew Last 90 Days 120; Flight Crew Total 12613; Flight Crew Type 360

Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Returned To Clearance

We were cleared for the Stadium Visual Approach to Runway 29 at EWR; with the RNAV (RNP) Y 29 loaded in the FMC as an [overlay] and the autopilot engaged. Clearance was to maintain 3000 ft until TEB; cleared for the approach. At about 2 nm from TEB; we set touchdown zone elevation of 100 ft in the MCP altitude window. We had a short discussion whether setting the altitude was too early. At about 1 NM from TEB the aircraft started down. I disconnected the autopilot at 2800 ft and was correcting back to 3000 ft at 2700 ft. In an effort to be smooth; I was not aggressive enough in getting back to 3000 ft.  We then received TCAS RA while correcting back to 3000 ft. I attempted to confirm the approach and re-engage the autopilot. The aircraft started down again and was not on the approach track. I do not believe at this point I was in LNAV and because of the MCP altitude; we went low again; I disconnected the autopilot and flew the approach. It was around this time Newark Tower informed us of a Low Altitude Alert and I made a correction. When the PAPI for Runway 29 came into view; we were on profile.

[Report narrative contained no additional information.]

Air carrier flight crew reported the autopilot descended too early while on the EWR Runway 29 Stadium Visual resulting in an RA.


Flight Crew Last 90 Days 95; Flight Crew Total 611; Flight Crew Type 611

ATC Issue All Types; Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Runway

Air Traffic Control Provided Assistance; Flight Crew Executed Go Around / Missed Approach; General Flight Cancelled / Delayed

We were cleared for an ILS to Runway 16R. Spacing was 5 miles behind Aircraft Y. ATC assigned a speed reduction to 170 kts. A further speed reduction to 150 kts was assigned. Traffic separation was 3 miles. Our target speed was 152 kts. We were cleared to land. I saw Aircraft Y fail to make the 2nd high speed exit and informed the First Officer that 'it was not looking good'. I started the go around at approximately 150 ft. The First Officer radioed the go around to Tower. There was a significant pause before ATC responded and they seemed surprised we were going around. We over flew Aircraft Y on Runway 16R. We were vectored around for a visual approach to Runway 16L. A normal landing ensued. After exiting the runway; ATC informed us there would be an investigation launched regarding the go around. My assumption is that the controller forgot about Aircraft Y on the runway which is why there was confusion as to what we were going around. Aircraft Y rolled long for unknown reasons and likely caught the Controller off guard due to an unexpected maneuver.

B737 Captain reported that an aircraft failed to vacate the runway; resulting in a go around.