Flight Crew Last 90 Days 78; Flight Crew Total 931; Flight Crew Type 538

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

Air Traffic Control Provided Assistance; Aircraft Aircraft Damaged; Flight Crew Landed in Emergency Condition; Flight Crew Requested ATC Assistance / Clarification; General Maintenance Action

I am the owner of a Mooney M20E and have >300 hours in this plane. The flight in the late afternoon was a demonstration flight for a friend of mine who is considering beginning pilot training. He has done informal training many times over several years including with me; and has excellent instincts and innate skills that indicate he will be an excellent pilot. In addition; he has significant knowledge about airplanes; airplane systems and general aeronautical/ aviation information. Weather conditions were VFR and not challenging in any way. There were some mild clouds and precipitation in the area but we had no difficulty avoiding them throughout the flight.I flew left seat and handled all engine controls and critical phases of flight; takeoffs; landings; radio calls; etc. He had controls for much of the enroute time and legs of traffic patterns. We did standard maneuvers; mostly practice traffic patterns and landings at ZZZ1; which is close to ZZZ and is the most commonly used training field for many pilots out of ZZZ; including myself. We did three touch and goes and one full stop/ taxi back at ZZZ1. There was no indication of a gear problem for any of these several extensions or retractions. I have very recently done solo training flights with similar or greater numbers of gear extensions and retractions in a similar span of time with no indication of problem. After close to an hour of flying; we returned toward ZZZ for our final stop. We entered a long right base for Runway XXR; and at the appropriate time put the gear switch down. For the first time ever in this plane that I know of; there was a gear extension problem. The gear motor activated and could be felt extending the gear. It seemed mostly normal; but perhaps a little louder/ more forceful than usual. It stopped abruptly; it seemed to have taken a usual amount of time; but the gear on this plane do normally extend quickly and I could not be certain the motor had run as long as usual. The two gear down lights (one on the panel and one on the floor) did not illuminate. The gear actuator circuit breaker had popped out. I tried resetting the circuit breaker twice; but it did not stay in. The gear switch had no effect at this point; as expected with the circuit breaker tripped. The feel of the plane in flight felt as though the gear were down with the expected amount of drag.I advised ZZZ tower that we were breaking off the approach for troubleshooting of a gear problem; and headed generally north of the field in coordination with the controller. I pulled out the Owner's Manual; and my passenger assisted in reviewing the manual gear extension procedure; with which I am very familiar. I have practiced this on the ground a few times over the years at the time of annual inspection with the plane on jacks. I have also practiced it in the air at least once in this plane.With my passenger reviewing the steps out loud for me; I extended the gear manually. The hand crank did not reach a stopping point and the gear down lights did not illuminate. I checked the visual floor indicator; which is there as a backup in case of electrical failure; and the 'GEAR DOWN' sign was visible as normal when the gear extend; with the alignment bars lined up normally as per my memory of how they typically line up. Many additional cranks on the manual extension handle on several more tries had no further effect on anything that I could tell. We were concerned we might have a broader electrical problem of some type leading to failure of the indicator lights; even though the gear appeared to be fully extended. I checked another indicator light on the panel in the same cluster as the 'Gear Down' light (the 'Ram Air' light); which was working properly. I could find no other signs of electrical failure on board. There was no smell or sign of smoke.At this point; I contacted ZZZ tower and coordinated a low pass down Runway XXR to get a visual check of the gear. The tower controller was ableto see the gear well and reported all three appeared to be fully extended. The plane was performing well and maintaining control was not an issue. I was able to aviate; navigate and communicate easily and without difficulty; and to go through the appropriate manual gear extension procedure with plenty of time and focus. My passenger remained very calm; focused and helpful throughout. Neither of us became anxious or nervous; and we were able to communicate well and work together well. He was an asset to me functioning as part of the crew; even without formal pilot training. The ZZZ controller(s) likewise were extremely responsive; helpful and professional.I did not seem to have any additional options to try to get the 'Gear Down' lights to illuminate. I was fairly confident that the gear were fully extended. We were in no immediate danger; and there seemed to be no other emergency reason to land prematurely; although the possibility of some larger electrical system problem remained in my mind. As such; I decided that spending extra time in the air for additional attempts at troubleshooting was no longer wise and that we should land safely while conditions were good.The landing on Runway XXR was smooth; well controlled and uneventful. The wind was nearly straight down the runway and was light. I most often land with no flaps; and chose to do so in this case as well. I made sure to land with excellent technique; touching down gently just above stall speed; well aligned with the center line and with minimal control inputs. I made sure not to use the brakes; and I elected not to use the elevator for aerodynamic braking; as I wanted to avoid any unnecessary forces on the gear. I allowed the plane to roll out long on the runway; and all appeared to be going well. I let the tower know that I intended to roll out long due to the unknown status of the gear. Runway XXR is 7;500 feet long; I touched down not far past the numbers; and rolled out nearly to taxiway 1 for a total rollout distance of about 3;500-4;000 feet.After we had dissipated most of our forward speed without incident or sign of additional problem; I began a very gentle right turn toward the 'high speed' exit for taxiway 1. At that point; the plane began to settle toward the ground toward the left; with the front and right settling down very quickly after. The prop struck the runway and the engine quit; the plane skidded about 30 feet and came to a stop at a mild angle off center line. The impact with the runway was surprisingly soft from our standpoint. I quickly shut off the master switch; magneto switches; and fuel selector; and we exited the plane quickly and easily. There was no fuel spillage; smoke or fire. Neither of us sustained any injury of any kind.Using a heavy boom truck; we were able to gently lift the plane off the runway via the engine mount. I was able to easily manually extend the gear fully; and again was unable to get the 'Gear Down' lights to illuminate despite the gear being verified fully down; and the manual floor indicator properly aligned. While being towed away; the plane again settled to the ground toward the left when initiating a fairly gentle slow turn to the right. This time; only the left gear folded.At the time; shortly after; and for the next day or two I believed that I had properly pushed the crank forward to engage the manual gear extension mechanism and allow the handle to work properly. This is one of the basic few steps needed in the manual gear extension procedure; and I had done it many times. It is a small handle and lever located at approximately the left side of the left pilot's knee; and is easily reachable with your left hand. After reflecting on the events and going back to visit the plane; in fact I had not properly pushed that lever all the way forward. It appears that the manual gear extension mechanism will apply enough lowering force even when not properly engaged to allow the gear to fully or nearly fullyextend; but without the crank properly engaged it appears that you cannot get enough force to fully lock the gear in place.At the time of the [event]; although I and my passenger were under good control and responding well to the situation; I was approaching or beyond 14 hours since I had woken up and gone to work early that morning. I believe that pushing the end of my duty day; as well as familiarity with the procedure and not double checking myself that I had followed every step properly were contributing factors in my failure to fully lock the gear. I believe I could have prevented the gear collapse had I followed the checklist and double checked every step.We have not yet jacked the plane and examined all of the relevant components. Whether or not there is some other structural damage to the gear extension mechanism or any of the components involved; and whether or not we are able to ultimately demonstrate that the gear down lights were or were not in fact working; it does not change the fact that I did not properly complete one of the necessary steps on the checklist for manual gear extension. I also failed to catch this omission with a thorough review of the procedure and circumstances after the gear lights failed to come on. I allowed myself to give too much weight to the possibility of an indicator failure and did not continue to troubleshoot more when I have the ability to do so. I also believed that my familiarity with the procedure was sufficient that I did not consider that I might have omitted or failed to properly complete a step.As I reflect on this; it gives me a sense of humility and a reminder of my own fallibility; and reinforces that I need to double check checklists and critical steps at all times. My belief that my left hand had done what it was supposed to with respect to the one missing step was simply inaccurate. I could have and should have caught the error with a careful review of the circumstances; and there was not an emergency pressing need to get the plane on the ground immediately. I will carry this lesson for the rest of my life. Fortunately; no one was injured; and the mechanical and financial damage to the plane are the only costs. But it is still a humbling fact that I did a basic part of managing my aircraft incorrectly and caused damage as a result. In another circumstance; I or someone else could have been hurt with such an error. I will redouble my efforts to be meticulous for procedures; checklists; and review of critical items at all times. In addition; I will be more careful with respect to aircraft operations beyond 12 or 13 hours since waking up in the morning on any particular occasion.

Pilot reported landing gear failed to indicate extended and during alternate extension procedures; communications problems and failure to follow check lists resulted in the landing gear collapsing on landing roll out.


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

Confusion; Situational Awareness; Communication Breakdown

Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

We were cleared direct to YOSST at 7700' for the RNAV Visual to 8R. Prior to hitting YOSST we were given a traffic call to follow; when I looked back inside the flight deck the Captain; PF; was distracted with his shoulder harness and we were at 7000' outside of YOSST; we were 700' low. When I looked away the first time we were on path and had 7700' set in the MCP. Now he had 'V/S' selected and 5500' in the altitude window (I have no idea where that altitude came from or why or when he chose it). I pointed out we were low and needed to climb to 7700'; he started punching various buttons and then aircraft went into CWSP (Control Wheel Steering Pitch). I pulled up on the yoke to start a climb; set 7700' in the altitude window; reengaged VNAV and the Captain finally re-engaged and took back over flying duties. Once we are on path; I 'coached' him to set zeros. I'm not sure he ever fully understood what happened. He's very difficult to communicate with and this is the second ASAP this trip; both times; he was Pilot Flying. My monitoring skills weren't effectively keeping up. I've been actively engaged with this Captain all trip. He's very aloof and says 'yeah; yeah; yeah' constantly; but not sure he actually means yes. I pointed out the Arrival page that addressed the RNAV visual. He never once looked at it; but said 'yeah; yeah; yeah' the two times I mentioned it. So I just read it out loud. However; when ATC made traffic calls before giving clearance; he seemed confused at what they were needing; even though we spoke about it and it's clearly written in the page he never read.

First officer reported communications problems with the captain.


Medium Transport; Low Wing; 2 Turbojet Eng

Human-Machine Interface; Situational Awareness

Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

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

Prior to departure I loaded the FMS with the first fix on the PDC that was 'PUMKN.' I inadvertently entered the fix as 'PMPKN.' When told to go direct to 'PUMKN' we started to turn towards the wrong Pumpkin (hundreds of miles away in the wrong direction.) ATC noticed the deviation and gave us a vector towards the right Pumpkin. I entered the correct identifier and started tracking. ATC had no further comment. I think 'my' pumpkin spelling seemed more logical to me. I somehow changed the spelling from the PDC because I was not attentive to the PDC spelling. Be more attentive to similar sounding fixes.

After being cleared direct to 'PUMKN' crew incorrectly typed 'PMPKN' resulting in aircraft track error.


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

Situational Awareness; Human-Machine Interface; Confusion; Communication Breakdown

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

Communication Breakdown; Confusion; Situational Awareness; Human-Machine Interface

ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control; Person Flight Crew

ZZZZZ 1B arrival into ZZZZZ. Received clearance 'descent to FL250 at ZZZZZ.' Complied. After ZZZZZ; received clearance 'descend via ZZZZZ 1B; maintain 14 thousand;' We started our VNAV path descend. Passing ZZZZ1; we were given vectors; heading 070 while still descending to 14K. To the northwest of ZZZZ2; we were given clearance 'direct to ZZZZ3 and descent to 10 thousand (or descend and maintain 10 thousand; definitely not DESCEND VIA'). LNAV and VNAVing to ZZZZ3; noticed we are not descending below 14K due to the altitude restrictions in the FMS; and knowing we weren't given descend via for the 10K; I either V/S or LVL CHGed to start descending to 10K. Passing 11.5K; VFR; it seemed odd that they would want us that much lower than published. We asked approach to confirm descend to 10K. ATC responded with we're below the altitude on the arrival; I immediately dialed in something higher in the altitude window and started a climb. At the same time we received CAUTION TERRAIN; ATC came back and said we're given a descend via to 10K and now to climb and maintain 12 thousand. We climbed back up to 12K and completed the arrival and approach. Being a domestic pilot my entire time at [Company]; pretty much all of it in ZZZ. This might be the second time I've been to ZZZZ with the previous occasion probably over 6 years ago. Only ever flew into [Country] a handful of times and no [Continent]. I made sure I read all the airport familiarization pages; all the Jepp pages; all the [Country] info in the FOM. And was extremely vigilant regarding 'direct to vs direct' and 'descend via and descend to' clearances. Those were the key words I was listening for. Me and the Captain both agree and the second clearance did not include descend via. I do believe my lack of outside of US experience played a role. I trusted foreign ATC and thought the that low descent was common local procedure. In training and all the distance learning modules; we get hammered on the difference between DIRECT TO and DIRECT. I don't recall as much of an emphasis on DESCEND VIA vs DESCEND UNRESTRICTED (which is official ICAO phraseology on an arrival) and DESCEND TO/DESCEND AND MAINTAIN; which is a FAA phraseology for US arrivals meaning to descend unrestricted. I believe these points should be emphasized in future training modules. In regards to ZZZZ ATC; in my opinion they should only use 2 descent terminologies on arrivals with altitude restrictions. Either DESCEND VIA or DESCEND UNRESTRICTED. Using a DESCEND AND MAINTAIN or DESCEND TO clearance on an arrival with altitude restrictions; from what I can tell is non-standard per our FOM and should not be used.

CLEARANCE......Descending Via ZZZZZ 1B except maintain 14;000. Just after ZZZZZ vectored off the STAR to the east for spacing and given a descent to 10;000 ft. with multiple speed changes. Approaching 10;000 ft. in VMC conditions I queried the Controller about our altitude he said we should be at 14;000 ft. descending via. We were on vectors. We immediately initiated a climb to 14;000 ft. and as per his request leveled at 12;000 ft. We were cleared direct to ZZZZ3 and were told to rejoin the STAR. We landed XXL I believe there was a freq change to a new controller who forgot about us. He made no mention of our altitude until I asked him to confirm. There was also no mention of rejoining the STAR.Remain on the STAR/SID to the max extent possible.

B737-800 flight crew reported communications issues resulted in a descent below assigned altitude during the approach. Flight crew climbed up to correct altitude and continued the approach to landing.


Communication Breakdown; Workload; Training / Qualification; Time Pressure; Physiological - Other; Confusion

Party1 Flight Crew; Party2 Ground Personnel

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Vehicle

General Flight Cancelled / Delayed; General Work Refused

We arrived at ten minutes past the hour (21 minutes early). Rampers met the aircraft at the gate and marshalled us in. Rampers then opened the bag door (I assume; so they'd trigger an on time arrival) and then left to go service other aircraft; but didn't actually offload any bags. I called operations on the radio to ask if they had a jetway driver coming and they advised that four aircraft had all arrived at the same time and they were doing the best they could. We were sitting at the gate with no jetbridge; engines shut down; APU running; and main cabin door closed. About five minutes later we noticed the fuel panel opened. The Captain called ops to remind them that we are not allowed to fuel with the cabin door closed. Several minutes went by and the fueler began fueling. The Captain asked a flight attendant to open the main cabin door and block the aisle (since the jetbridge was still not attached.) The Captain called ops again and told them to immediately stop the fueling; the person on ops said that no one was around so she went on the ramp herself to tell the fueler to stop. Fueling stopped after about 500 pounds had been pumped. About twenty minutes after we blocked a jetway driver finally arrived and we deplaned at deplaned the passengers.We were unable to communicate with the fueler. The station seemed understaffed.We need to ensure ground crews/fuelers know proper fueling procedures.

When the EMB-145 flight blocked in early there were insufficient ground personal do deplane the passenger and they remained on board. The flight crew had to remind operations personal that their attempt to fuel the airplane was inappropriate with the doors closed and no egress available in the event of an emergency.


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

Person Flight Attendant; Person Passenger

Air Traffic Control Provided Assistance; Flight Crew Returned To Gate; General Flight Cancelled / Delayed; General Maintenance Action

I walked to Row 21 to begin the safety demo and as I walked forward I immediately smelled a strong sour/rancid odor. I placed my demo kit on the floor and then walked forward to B Flight Attendant to inquire if she smelled the same thing. The B Flight Attendant said that she did so we walked to the A Flight Attendant to ask that she call the pilots. She did and they said that it was a deicing smell. We agreed to observe the smell and proceeded with the safety demo. Around the aft of the plane; after we completed the safety demo; the smell was still present and did not dissipate. I walked forward to ask the A Flight Attendant if I could call the pilots to inquire how long the smell would last. When I spoke to them they said it could dissipate after takeoff or linger; but it was hard to say. They said if we didn't feel safe going; we could let them know. The A Flight Attendant walked to the aft cabin to observe the smell and returned saying she smelt a faint smell. Then we were told to be seated for takeoff. We took our seats when the A Flight Attendant called the B Flight Attendant to see if we still smelled the odor. Both myself and the B Flight Attendant noted that we started to feel burning in our nostrils and I also told the B Flight Attendant that my nose/sinuses felt stuffy. Then the A Flight Attendant called the pilots who also said they smelled the odors and that we were returning to the gate. After we returned to the gate; we had a guest come to the galley to ask for water for his wife who felt dizzy. We checked with the guests in last rows 29 and 30 who also said they smelled the unusual odor. After we began deplaning; we checked in with our unaccompanied minor; in 29X to make sure she was OK and as we were standing by 29Y we could smell a faint sour odor again. Checking with the B Flight Attendant; I told her that I had a headache and felt light headed.

We were finishing up boarding on Flight ABCD when I myself called the flight deck from the back of the aircraft to tell them the aircraft was very warm and to please cool it down. They told me it was going take a few minutes for them to connect the APU. We then finished up boarding and I could tell that the APU had started. We closed the door and began our safety demo. We were almost done with the safety demo when the C Flight Attendant motioned to me she could smell something in the cabin. At the end of the safety demo she walked up to the front and we both informed the A Flight Attendant that we were smelling something sour in the cabin. The A Flight Attendant then called the flight deck to inform them of the odd smell. The flight deck informed the flight attendant that it was probably the leftover deicing fluid from the previous flight. We then finished compliance still smelling the small sour smell and took our jumpseat. As we taxied out the smell became stronger to the point that it was burning our nostrils. And we were starting to smell another scent. At this time guests [passengers] were also beginning to complain of the smell; the A [Flight Attendant] again called the flight deck and inform them of the smell becoming worse. At this time; myself and the C Flight Attendant were beginning to become lightheaded and headaches were beginning for both of us. The Captain at this point go on the PA and announced we were going back to the gate. Once we got to the gate I had a passenger come back and tell me his wife was not feeling well. I approach the guest and she was feeling lightheaded and nauseous I gave her some water but she mentioned she was OK. And did not need any further medical attention. Other guests stop me in the aisle and informed me they had smelt the smell. We then proceeded to quickly deplane all the guests off the aircraft.

A319 Flight Attendant crew reported strong fumes during taxi resulting in ground gate return. Health issues were experienced by Flight Attendant crew as well passengers.


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

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Maintenance; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Person Flight Crew; Person Flight Attendant

Air Traffic Control Provided Assistance; Flight Crew Overcame Equipment Problem; Flight Crew Returned To Gate; Flight Crew Requested ATC Assistance / Clarification; General Flight Cancelled / Delayed; General Maintenance Action

Upon holding short of the runway in ZZZ; we experienced a burning odor in the cockpit during the pneumatic ice protection test. We contacted Maintenance and began troubleshooting. Both packs were individually giving us a burning odor. The flight attendant had called us to let us know that he smelled it too. We then returned to the gate. Once at the gate; we submitted 2 write-ups; one for the burning odor and one for a flickering Multi-Function Flight Displays screen that was progressively getting worse. I was informed later that this plane had the same issue the month prior. After our write up; maintenance could not reproduce the problem and signed the aircraft off. I later learned; from my flight attendant who was now with the new crew on the same plane; upon engine startup; they immediately began to smell burning fumes. This was following the sign-off from maintenance. Flight crew shut down packs and taxi back to the gate.Captain recommended replacing all duct work and packs as burning odor/fumes seems to be a common issue; or find out what is causing so many similar problems.

Air Carrier Captain reported a ground gate return due to a fume event during Pneumatic Ice Test while holding for departure.


Automation Aircraft Other Automation; Person Flight Crew

Air Traffic Control Provided Assistance; Flight Crew Overcame Equipment Problem; Flight Crew Executed Go Around / Missed Approach

Climbing out of approximately 15;000 FT at about 300-315 KTS had L HYD QTY and L HYD SYS PRESS EICAS messages. We went to Status page and left hydraulic quantity showed 0.00RF. Performed loss of hydraulics for left system and turned off both left pumps (Engine Driven and Electric). Left system pressure on status page showed between 3050 and 3450 PSI (PTU pressure?). [We] reviewed systems with First Officer including Rudder Ratio and Yaw Damper malfunctions. Continued onto [our destination] and climbed to FL370. On arrival swapped duties with First Officer and flew the STAR and LOC XXL. [We] started lowering flaps early. Got flaps to 20. Upon lowering gear got a GEAR DISAGREE and I think at this time the POWER XFER UNIT Status message occurred. Did alternate gear extension and then tried to lower flaps further. [We] received a TE DISAGREE message. At this time we were about 800 FT and performed a Go Around. Completed checklists; came around and landed on [Runway] XXC. [We] cleared to the left on the high speed. After clearing we stopped and were towed in.Not much we could do to prevent the breakdown. In hindsight though; I should have declared an emergency. After the go around with the gear stuck down and the flaps at 20 we were going the wrong way burning 11;000 LBS/hour. Once requesting a turn downwind ATC was very accommodating and helped out by offering the center runway. First Officer was tremendous help.

When we looked at system display; all 3 hydraulic systems were being pressurized; but the quantity in the left was 0.00RF. We discussed implications of current situation. And then we discussed implications of further system failures. Aircraft was flying normally; so we decided to proceed to destination. As part of the discussion we kept ourselves appraised of potential landing sites should our situation digress. Cruise flight was normal.Upon reflection; we might have considered declaring an emergency; but the plane was behaving normally and crew was working the problems wisely and safely; so was unnecessary.

A B757-200 flight crew elected to continue to their destination after the left hydraulic system failed as they climbed through 15;000 FT after takeoff. Problems extending both the flaps and landing gear at their destination forced a go around and completion of associated abnormal procedure checklists. After landing they were towed to the gate.


Flight Crew Last 90 Days 164; Flight Crew Total 13800; Flight Crew Type 6678

Flight Crew Last 90 Days 143; Flight Crew Total 20000; Flight Crew Type 5609

Flight Crew Executed Go Around / Missed Approach; General Maintenance Action

On approach a 'TE DISAGREE' EICAS illuminated. We executed a go-around and completed the appropriate TE DISAGREE checklist. We were vectored for another approach and landed uneventfully.

During approach the 'TE Flaps disagree' EICAS illuminated. We executed a missed approach (no flap overspeed) and flew a vectored pattern to return for another approach. We completed the appropriate checklist and flew a flaps 20 with ref for 20 approach to an uneventful landing. Aircraft traffic was light and delay was not an issue. An emergency was not declared and a cabin prep was not initiated. At the gate we debriefed with Maintenance and entered the fault in the logbook.

B757 flight crew reports a TE FLAPS DISAGREE EICAS during approach and goes around. QRH procedures are complied with resulting in a flaps 20 approach and landing.


Human-Machine Interface; Time Pressure; Workload

Chart Or Publication; Procedure; Human Factors; Aircraft

The IVANE TWO RNAV ARRIVAL is an accident waiting to happen. The A321 CANNOT MAKE THE RESTRICTIONS and results in excessive workload and task saturation.The Airbus 321; using the auto flight system in Managed Mode; CANNOT MAKE THE RESTRICTIONS ON THE IVANE TWO RNAV ARRIVAL! Example: AMOBE to PELOY is 5.3 mi. The A321 CANNOT descend 1000 FT and slow from 250 to 210 KTS in 5.3 mi!!! IT CAN'T BE DONE in Managed mode; especially if there is a tailwind. The only way to comply with this restriction is to come out of managed speed; select a slower speed approaching AMOBE and then use FULL SPEEDBRAKES and extend flaps to make the restiction at PELOY. This is a poorly designed STAR -- no wonder there are so many problems with it.Get rid of it.

An A321 Captain expressed his displeasure with the demands of the IVANE RNAV STAR to CLT; citing the inability of the autoflight system to comply with crossing restrictions in Managed Descent mode.


Deviation / Discrepancy - Procedural Published Material / Policy; No Specific Anomaly Occurred Unwanted Situation

Staffing; Environment - Non Weather Related; Human Factors; Company Policy

On Day 5; the crew desk called me to assign me to a trip on Day 6 with a XA:40 report time.  I called in fatigued on Day 6 at approximately [3 hours prior]. I had just finished a 4 day trip from Day 2 to Day 5; with each day requiring subsequently later report times and the last 2 days requiring late or all night flying.  Additionally; even though this trip spanned 4 calendar days; it only included 2 sleep cycles.The previous 4 day trip created a significant cumulative sleep debt; as tracked my my Apple Watch. Day 1-Day 2; 6:38 of sleep at home prior to reporting for my 4 day trip. Day 2-Day 3; 8:44 of sleep in the ZZZ hotel. Day 3-Day 4; 5:26 of sleep after landing in ZZZ1; but I woke up at XA:00 am local time and had a XR:59 departure that night.  I attempted to take a nap prior to reporting for duty but I couldn't fall asleep and was awake for about 18 hours prior to flying a redeye. Day 3-Day 4; No sleep due to redeye.  I flew a redeye.  Extremely tired during the flight and took a 25 minute nap during cruise.  When I returned home; I slept from approximately XA:45 until the crew desk woke me from deep sleep shortly after XG:00.  After the crew desk woke me; I packed my bags and prepared for the new trip.  I attempted to go back to bed at XK:00 but could not fall asleep.  I realized that it was not safe for me to attempt to fly my 3rd transcontinental trip in 2 days so I called in fatigued. Day 5-Day 6; No sleep due to crew desk interrupting my recovery sleep from the previous redeye.Of note; my previous trip involved a significant cumulative clockwise circadian rhythm disruption in which every day required a later report time and each day flew later into the night.  Clockwise disruptions such as this are generally easier to tolerate compared to counter-clockwise disruptions.  However; this 4 day trip also was engineered to accumulate sleep debt.  Day 1 was 11 hours of duty and 20.5 hours of rest; which equates to a 31.5 hour long duty/sleep cycle.  Day 2 of my 4 day was 7:15 of duty and nearly 25 hours of rest; which was a 32 hour duty/sleep cycle.  Combined with each day's later duty periods; it was generally easy to fall asleep at the beginning of the rest periods.  However; it was not realistic nor possible to achieve 2 circadian rests or resets during the layovers; which meant that each day I would be awake for a longer period of time prior to reporting for late night flights.  This culminated when I reported for my redeye after being awake for 18 hours.  Upon landing I was absolutely exhausted and needed to catch up on the previous 4 days of missed sleep.  Unfortunately the crew desk interrupted this much-needed sleep and assigned me the new trip on Day 6.  In other words; the crew desk expected me to shift from my previous XM:00 pm and XS:00 pm local report times to a XA:40 am report time after disrupting my rest and being awake for over 12 hours.  Furthermore; the crew desk did not consider the larger picture of the 4 day trip and subsequent 2 day trip as a single 6 day long physiological marathon.  Considering the operational design of my previous 4 day trip; combined with a back-to-back 2 day trip; I do not think it's physiological possible or safe for anyone to endure such a disruptive 6 day period especially after the crew desk wakes you up in the middle of a much needed restorative sleep period.

Air Carrier First Officer reported they called in fatigued due to not being able to get sufficient rest from the previous four days flying schedule.


Airbus Industrie Undifferentiated or Other Model

Situational Awareness; Confusion; Communication Breakdown

Deviation / Discrepancy - Procedural Published Material / Policy

Airport; Chart Or Publication; Human Factors

Our flight release included an operational message advising FLL is undergoing a long term construction project including the re-designation of Runway 27L to 28L. The message said 'Currently; the primary Runway is 9L/27R and Runway 13/31 is an alternate.' The FLL NOTAMS included only one RUNWAY NOTAM; indicating that Runway 10L/28R had ungrooved pavement between Taxiway E and Runway 13/31. We had received an EDCT and expected to need to wait a while before taking off. Ground told us to taxi down B for departure on the newly-renamed 28L and to expect to hold in the run up area until our time came up. I repeated the instructions; but asked for confirmation we were cleared to cross Runway 13/31. I was surprised to hear the Ground Controller then tell me that; no; 13/31 had been decommissioned and was closed. I acknowledged that and we taxied towards Runway 28L on B. Shortly; we discovered that; not only was the runway closed; but Taxiway B was also barricaded where it crossed the old 13/31. We asked ground about that; and he had us join C at D to continue taxiing toward the runway after some other traffic on D passed. While I am concerned that the Ground Controller apparently was unaware of the status of B Taxiway; I am much more concerned that crews are not being made aware that FLL is currently operating in a single runway configuration. A pilot may think that; although FLL is a fairly busy airport; at least it has multiple runways available in the event something closes his primary planned runway. That is not the case; however; and certainly was a great surprise to us. Apparently the Dispatcher was aware as he said 'they have been working for months now' when I asked via ACARS if he was aware they only had one runway. This was our first visit to FLL in a long time; however; and despite reviewing our paperwork; we were not aware 13/31 was closed. We were fully aware there was construction (closing 27R) and changes to the magnetic variation (renaming 27R to 28R); but not that 13/31 was also closed.

An air carrier flight crew flying out of FLL was surprised to learn that Runway 13/31 had been decommissioned and the new East West runway was not yet open; making it a one runway airport.


Boeing Company Undifferentiated or Other Model

Due to unauthorized drone activity at RJBB; RJBBG was closed. Flight held for 21 minutes; the diverted to ZZZZ.

A Dispatcher reported a flight was delayed when an airport was closed due to an unauthorized drone in the area.


Flight Crew Commercial; Flight Crew Instrument

Flight Crew Last 90 Days 24; Flight Crew Total 2800; Flight Crew Type 1500

Confusion; Communication Breakdown; Situational Awareness

Deviation / Discrepancy - Procedural Clearance; Ground Event / Encounter Other / Unknown; Ground Excursion Taxiway; Ground Incursion Taxiway

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

Airport; Chart Or Publication; Human Factors; Environment - Non Weather Related

I was on the ramp at the FBO which is located at the end of the taxiway. I had received my IFR clearance for departure on Runway 7 on the clearance frequency. I then switched to the ground frequency and requested taxi clearance. (It was now well after sunset) I was told to taxi to Runway 7 via Foxtrot. I left the ramp and made an immediate left. Upon reaching Foxtrot 2; I realized that I wasn't actually on Taxiway Foxtrot; but was on a parallel road which was intended for vehicle traffic; not aircraft. I stopped at Foxtrot 2 and notified Ground control what had happened. I informed them that I could make a right onto Foxtrot 2 to get on the Foxtrot Taxiway. The controller notified me to hold my position and that he would send an Ops (Airport Operations) vehicle out. About 5 minutes later the Ops vehicle arrived behind me. The ground controller notified the Ops vehicle that I had stated that I could make the turn onto Foxtrot 2. The Ops vehicle approved that which I did and I made the right onto Foxtrot 2 and then left onto Taxiway Foxtrot and proceeded to the hold line for Runway 7 without further incident.After making the wrong turn on what I thought was Taxiway Foxtrot I did see a sign with an F on it with a black background on my right which is why I thought I was on Taxiway F. As I proceeded towards Runway 7. I commented to my passenger that there were several dips in the pavement which was unusual. As I approached F2; I saw a red sign past F2 indicating no entry. That's what was literally the red flag. Fortunately; I was in a high wing aircraft which cleared all lights and signs. This may not have been the case in a low wing aircraft. This second road was not shown on my airport taxi diagram which might have helped. I don't know if anyone else had ever made this same mistake; but I think better signage would have helped. Perhaps a sign coming out of the ramp on F1 indicating 2nd left to Foxtrot or a red no enter sign like the one at F2 might have might have also helped. I had not flown into this airport in over 15 years. I did not request progressive taxi instructions because the route appeared to be very simple. I will be more vigilant during night operations at unfamiliar airports.

GA pilot reported unknowingly taxiing on a vehicle roadway at ROC airport; thinking it was the taxiway.


Small Aircraft; High Wing; 1 Eng; Fixed Gear

Small Transport; Low Wing; 2 Turboprop Eng

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

Flight Crew Last 90 Days 140; Flight Crew Total 2000; Flight Crew Type 400

Communication Breakdown; Confusion; Situational Awareness

Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Took Evasive Action; Flight Crew Became Reoriented

Environment - Non Weather Related; Procedure; Human Factors

Both aircraft came to a stop with approximately 200 feet separation at the intersection of the (different) Runways (05 & 13) they used for landing at VNC (busy; uncontrolled airport with extensive flight training).My assumption that the transport aircraft was also using Runway 5 since the last time I listened to AWOS the wind was 060 and other traffic was also using Runway 5 (filtering out that the crew did a call-out for final Runway 13)- I was too much focused on training my student for the landing/traffic pattern. The air carrier crew did only ONE call-out for 5 Mile final (not recommended); did not call-out his aircraft type (I wouldn't have turned final if I would have known his type/speed) and didn't use recommended traffic pattern/entry.Recommend to make published operations at uncontrolled airports in AIM and AC's mandatory. I have too many examples of pilots going straight into the downwind crossing traffic on the upwind or crosswind. Or people overflying the field at 1;000 for an immediate turn into the downwind. Straight in approaches should only be allowed if sufficient call-outs from at least 10 miles out are given. Most commercial operated airplanes do a good job by even calling out 30 miles out so that other traffic can anticipate.

An instructor pilot reported he stopped his aircraft on CTAF airport VNC Runway 5 about 200 feet from an air carrier twin which landed on Runway 13. The air carrier crew apparently made only one position call out on final which failed to mentally register with the task saturated instructor.


Situational Awareness; Workload; Distraction

Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

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

I was the pilot flying. We were given a descend via the arrival instruction except to maintain .78 Mach. This was then changed to cross a fix at or below 18000'; maintain speed with caution following a heavy. I changed the constraint at the fix to 17000' to ensure the crossing. The whole way [we were] getting into and out of the wake from the heavy in front of us. To ease out of the wake and to comply with altitude; I switched from managed to vertical speed and we crossed just below FL180 as requested.The next fix was 7.2 miles away with a hard altitude of 17000'; we encountered more wake with roll and I used the VSI to get out of it again. We were out of the wake. I missed not getting out of vertical speed mode and sending it to manage. I recognized this just before crossing the fix four hundred feet low and started to correct. ATC issued [descend to] 14;000' at the same time.I set 14;000' and continued to descend with no further issue.In dealing with the change in the arrival to go fast & cross at a different altitude; while dealing with the wake of the previous aircraft I was put into the yellow. Hindsight says I should have done the obvious by asking for some relief and to verbalize (I can't remember if I did or not but I definitely will next time) my exiting managed mode and going to vertical speed.

While descending via the HLYWD 1 arrival we were given a clearance to cross AVATR intersection at or below FL180; 1;000 feet lower than the lowest altitude constraint for that intersection. ATC cautioned us to possible wake turbulence from a [heavy] ahead. We encountered the wake turbulence multiple times with significant intensity. As we approached DAAAY intersection ATC gave us a friendly reminder that DAAAY has an altitude restriction of 17;000 feet and cleared us to descend to 14;000 feet. I noticed that we were about 400 feet low for the DAAAY constraint. No loss of separation occurred.While being distracted by the intense wake turbulence; I failed to notice that the First Officer took us out of managed descent by using vertical speed mode to control the descent. Using vertical speed was inappropriate on an RNAV arrival and a better course of action may have been a request for a heading away from the turbulence.

A321 flight crew reported overshooting a crossing restriction after being distracted by wake turbulence and changes to the ATC clearance.


Air Traffic Control Time Certified In Pos 1 (yrs) 11

Communication Breakdown; Situational Awareness

ATC Issue All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Issued New Clearance; Flight Crew Executed Go Around / Missed Approach

Airspace Structure; Procedure; Human Factors; Company Policy; Chart Or Publication

Aircraft X was a student pilot on a practice ILS approach at TISX. The pilot was requesting one ILS approach at with a missed approach. I had coordinated with tower the missed approach instructions heading 045 as per the letter of agreement for props and turboprops departing to the northwest and climbing to 6000 feet. The tower controller acknowledged this instruction. I cleared Aircraft X for the ILS approach; gave the tower the position report (12 miles west) and switched Aircraft X to tower. I was expecting the aircraft to continue on a low approach to the departure end before turning to a heading of 045 when all of the sudden the aircraft is on the approach end and calls me back that is climbing out of 1000 feet to 6000 feet on the missed approach heading 045. The MVA (Minimum Vectoring Altitude) in that area is 2400 feet due to mountainous terrain on the north side of the airport. I asked the pilot if he could maintain his own terrain and obstruction clearance up to 2400 feet and the pilot stated that on a heading 050 he could avoid terrain. I then stated to the pilot to maintain his own terrain and obstruction clearance and leaving 2400 feet fly heading 300. Aircraft X acknowledged and when he left 2400 feet; he joined his route without any problem.It was my understanding that the tower controller at TISX has to be aware that by turning Aircraft X on the approach end instead of the departure end is going to put the aircraft in the proximity of terrain; especially a slow climbing and slow moving aircraft. I do not know if there was expectation bias on my part regarding what I expected from the tower controller and missed approach instructions regarding practice approaches. In the future I would be more specific with the tower regarding missed approach instructions when working practice approaches. I also should have issued Aircraft X a safety alert (low altitude alert).

ZSU Controller reported an aircraft initiated their go-around instructions from the approach end of the runway at TISX instead of the departure end which placed the aircraft below the MVA.


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

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

Flight Crew Rejected Takeoff; General Maintenance Action

Environment - Non Weather Related; Human Factors

At approximately XA:48 while departing Runway XX at ZZZZ airport; both the Captain and I noticed we did not have any airspeed indications on takeoff. We aborted the takeoff roll at what we estimate was approximately 90 KTS and exited the runway at the end. After returning to the gate; the mechanic came to the cockpit and informed us that he had not removed the pitot tube covers before we left the gate and that was the problem. I had not noticed them on my pre-flight walk around as the ramp is very dark; and the covers are not the normal type we are used to seeing. They are dark red in color and hard to see. After maintenance did their inspection; we departed without further incident.

Aborted Takeoff on Runway XX at ZZZZ due to a lack of airspeed indications on both the Captain's and First Officer's airspeed indicators. Upon return to the gate; discovered pitot covers had been installed during the aircraft layover; but not removed prior to pushback for departure.The mechanic was apologetic regarding his failure to remove the probe covers prior to flight. He was professional and efficient in dealing with the incident and related inspections; including deferral of a faulty brake monitor indication. I was impressed by his response and am confident it will not happen again on his watch. I am also confident the First Officer; who is capable and professional; has a heightened awareness of the importance of carefully inspecting the pitot tubes prior to departure. As Captain; prior to boarding I am in the habit of scanning the aircraft for the condition of the tires; any fluids on or under the aircraft; and any frozen contamination which would require deicing. In the future I will add the pitot tubes to that scan. Around the time of pushback there are probably 5-7 ground personnel around the nose of the aircraft at the conclusion of loading and prior to pushback. Some basic aircraft awareness training of those ground personnel regarding gear pins; engine inlet and probe covers might prevent a recurrence of a RTO or similar event like this in the future.

B767 flight crew reported a rejected takeoff at 90 KTS due to airspeed indication issues.  Pitot tube covers had not been removed prior to takeoff roll.


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

Crew used standard procedures to review the DG paperwork and inspect the DG can in position 1.  All was correct in accordance with the Flight Operations Manual. Upon landing in ZZZ; the [Dispatcher] informed us the load crew had improperly loaded lithium batteries in position 4 LEFT when the paperwork we were provided showed position 1.

B757 First Officer reported Load Crew improperly loaded Lithium Ion batteries in Dangerous Goods container.


Cessna Citation Undifferentiated or Other Model

In the conduct of initial new hire training in the EC130B4 helicopter; at the conclusion of maneuver practice at another airport nearby the pilot being trained was given simulated IMC conditions whereby he flew company prescribed recovery procedures and utilized the ILS 01L at Jones Riverside (RVS) for his instrument approach. The Airport tower was closed for the evening at this time; Delta airspace reverts to G. Tulsa Approach Control had been contacted and was providing vectors to final for the requested approach. Now while flying; I heard another aircraft (a Cessna Citation) report on frequency with Tulsa and too was landing RVS. He was given direction; 'fly 200 degrees; descend and maintain 4;000 feet'.With my aircraft on an intercepting course for final approach course the Citation was given a new heading of 240 degrees to maintain. My now being shortly outside the FAF we are given instructions 'maintain 3000 feet 330 degrees till intercepting the final approach course; cleared for the approach; squawk 1200; and change to advisory freq.Flying the approach; continuing inbound the pilot flying maintained course and glide slope. At approximately 800 feet AGL (1400 feet MSL) I announced to the pilot (flying) that I had the runway in sight; to remove his view limiting device and resume VFR. Also I told him to return his NVG's (Night Vision Goggles) to the down (use) position and begin sidestepping left as we would continue into the normal landing area for the helicopter located on the west side of the airport.At this same time the Citation approaching from behind us called on the CTAF freq. inquiring of our location. I informed him we were on the ILS 01L approach; but was breaking off at this time; clearing the centerline and he could have the runway.During the time of his reply that became immediately following my transmission he stated that 'he was on final and landing 01L'. His aircraft then passed by my right side approximately 75 feet and slightly higher of that less than 15 feet.I inquired on the radio if he did in fact see us as he passed; his reply was 'that you said you are clear of the runway and I have 01L'After both aircraft safely landed and we had shut down; myself and the pilot being trained went over and had a conversation with the pilot of the Citation. Asking about the recent near [miss] event he never stated that he did in fact have an absolute positive I.D. on our aircraft while on final; only that I told him I was clear of the centerline.

EC-130 Instructor Pilot reported an NMAC with a Citation in the vicinity of RVS airport.


Indicating and Warning - Flight & Navigation Systems

Air Traffic Control Provided Assistance; Flight Crew Rejected Takeoff; General Flight Cancelled / Delayed

On [takeoff]; we received a Red TAKEOFF CONFIGURATION warning and associated Master Caution and audible aural warning horn. The Captain elected to reject the takeoff. He maintained positive aircraft control on centerline throughout. I notified ATC of the abort. We taxied off the active runway and brought the aircraft to a stop. The CAPT and I checked all items in the cockpit that could have triggered the warning and affirmed that the aircraft had been fully and correctly configured for our takeoff.I coordinated with ATC for an immediate inspection for possible damage to the aircraft; with special attention to the wheels; brakes; landing gear. I ran the TAKEOFF CONFIGURATION checklist and reviewed the Brake Cooling Charts in the Performance Inflight Section of the QRH; noting and communicating to the Captain the possibility of melted fuse plugs. In addition to the aircraft inspection; Airport Rescue and Fire Fighting personnel and equipment did a sweep of the RWY and indicated that there was no evidence of tire failure; separation; or debris on the RWY. Upon inspection of the aircraft; they communicated that there was no evidence of fire or smoke; but both LEFT MAIN LANDING GEAR tires were flat (possibly suggesting that the tire fuse plugs melted sometime after coming to a stop).

B737-800 flight crew rejected the takeoff due to a Takeoff Configuration Warning. A check of the items that could activate the warning confirmed that the aircraft was properly configured.


Any Unknown or Unlisted Aircraft Manufacturer

Air Traffic Control Time Certified In Pos 1 (yrs) 8

ATC Issue All Types; Conflict Airborne Conflict

I was working Aircraft X as a visual approach to PSP. They were cleared about 15-20 miles NE of the airport. I noticed a 'Z' tag (PSP Tower) on a downwind departure that was moving quickly; so it caught my attention. I clicked on it to see that it was the local [aircraft type]; Aircraft Y.  This aircraft is notorious in our area for getting in the way of IFR arrivals to PSP; so I kept my eye on the data tag.Aircraft Y dropped off the Z tag and turned southbound after passing an arrival to 31L. This put them on a converging course with Aircraft X. I still had some altitude separation to work with; so I called traffic to Aircraft X and told them to stop at 045 since Aircraft Y appeared to be momentarily level at 040. I thought maybe Aircraft Y saw the arrival. After I stopped Aircraft X; tower called and said Aircraft Y had Aircraft X in sight. I then saw Aircraft Y start climbing; and issued a traffic alert to Aircraft X. At the same time Aircraft X started descending.Aircraft Y was never pointed out to me; and no coordination was performed by the tower. Aircraft Y pilot is notorious in our area because they fly around at high speed; in highly congested areas; doing aerobatic maneuvers without talking to anyone. Then they fly back in the PSP; skipping approach every time; avoiding any sequencing from us. They force us to move around them; since we don't know what their intentions are; and then call the tower right before the Delta to get pattern entry instructions. This is all legal; but unsafe. The plane is from a local area; and they are very aware of the procedures and traffic in the area. However; they continue to avoid talking to approach control because it is not required in a TRSA.The few times the pilot has been on approach frequency; they are argumentative and obviously frustrated with our instructions.  The safety culture has obviously left this pilot and they feel they are above the rest of us and our mission of safe and efficient flow.The issue in this event is the conflict happened right outside the delta; with no coordination; and probably some pressure from the pilot to get on course and on their way. The Tower probably felt pressure to terminate the aircraft; as they were already outside of their delta airspace; and the TRSA has no requirements for participation.PSP airspace needs a Class Charlie or Bravo airspace around it. We provide no protection to a steady stream of arrivals by having a voluntary participation airspace surrounding it. The airspace is BUSY. The controllers have no safe airspace to assume separation. Aircraft fly through our arrival and departure corridors at leisure; stopping departures; corrupting sequences and causing unstable or aborted approaches.UDD is located about 10 miles east of PSP and has VFR jet departures launching all day long; right at aircraft in the downwind for PSP. What major airport allows for aircraft to fly into the radar downwind?  This creates an incredibly confusing situation for the controller; as we have no idea what the intentions are of any of the aircraft. When you look at the amount of traffic; the speed; and the lack of maneuvering room; the Springs/Desert sector is a time bomb waiting to explode. We as controllers do the best we can to alleviate these situations; but with mountains surrounding almost all quadrants of the valley; there are few routes to take in and out; which results in many head-on situations.I have a similar report that I filed a few years ago where a YAK converged with an arrival for PSP 13R and the pilot reported a NMAC with the aircraft.  Protected Class Charlie or Bravo airspace would have avoided both of these situations. The controllers and pilots deserve to be afforded some level of protection when close into the airport. RA's and and NMAC's 5-10 miles away from a major airport are unacceptable.

SCT TRACON Controller reported a conflict between an IFR arrival and a high speed highly maneuverable aircraft just clear of the PSP Class Delta/TRSA.


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

Flight Crew Last 90 Days 220; Flight Crew Total 9967; Flight Crew Type 86

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

After departing Runway 29R; Stearman executed a VFR box climb within Class D airspace. The aircraft was on a right downwind approaching 1;500 feet when ATC advised it to level off and issued a traffic alert. Conflicting traffic; a white and green Cessna 177; was at the aircraft's 1 o'clock high position; almost directly over the Stearman. Position was initially obscured by the Stearman's upper right wing. Less than 300 feet of separation was estimated. The Cessna 177 was also executing a box climb; however; its rate of climb was minimal.Stearman leveled off; and continued an easterly track at 1;500 feet to gain separation with the conflicting traffic. Once sufficient separation was gained; a climb was resumed while maintaining visual separation with the Cessna 177. An uneventful climb out of Class D followed.The ATC who assigned me to level off had a distinctly different voice from the Controller working local control and could have been a supervisor. The crew of debriefed this incident; and feel the conflict was mainly the result of the Cessna 177's very low rate of climb. Our crew is very grateful for the hard work and diligence of ATC.Replay of the incident on an ADS-B Out monitoring website confirmed visual indications of less than 300 feet of separation. At the closest point of approach; the two aircraft tracks indicated 219 feet apart. After their initial climb on downwind; Cessna turned over TOA airport at 1;286 feet MSL. Had that aircraft made this turn at a higher altitude; a traffic conflict might not have occurred on its second climbing downwind leg.

GA flight crew reported taking evasive action due to low climb rate of another aircraft.


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

Flight Crew Last 90 Days 4.5; Flight Crew Total 1500; Flight Crew Type 35

Situational Awareness; Confusion; Time Pressure; Workload; Distraction; Communication Breakdown

Aircraft Equipment Problem Less Severe; Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Flight Deck / Cabin / Aircraft Event Other / Unknown

Person Flight Crew; Person Air Traffic Control

Air Traffic Control Separated Traffic; Flight Crew Took Evasive Action; Flight Crew Returned To Departure Airport

I drove to pick up my Mooney; which had been in the shop for 5 weeks getting new avionics. I replaced the gyros with an Aspen Evolution and also added in a GTN 750. I've had the aircraft [for almost one year] and have flown it about 35 hours out of the 1500 I have. I had prepared for the installation by using Garmin's online course; reading the manuals; and I recently completed my BFR in a 172 with the G1000. I thought I was comfortable flying with the new gear and intended to practice with it VFR on the way back. The work had be delayed a week and my wife and I intended to fly to go camping for the weekend. When I arrived; the shop was still debugging an issue with the DME. Originally I had planned to be at the shop for no more than 2 hours to pick up the aircraft but it was delayed 4 hours and I felt rushed to get home to pick up my wife and go [on a trip]. Nothing good ever happens in aviation when you're rushed. I waived a test flight with the shop since I wanted to get going and they had already performed two prior test flights without me so I didn't think I really needed it. I started the engine and thought I'd get a quick clearance since I just wanted to head east VFR. I got a full clearance and wasn't ready for it and messed up the frequencies which threw me off; especially with the new equipment. Several times I talked on the wrong frequency as I misused the swap feature on the radio. I was already getting behind the airplane. During taxi I noticed my CHT was pegged at zero. I thought it just needed time to warm up but it never left the peg. On climb out I got nervous about the CHT and was checking my cowl flaps; didn't have the approach frequency; and was getting used to new avionics. It was too much and I got behind the airplane. Departure told me to maintain 1600 and I thought I was level but kept checking the CHT and drifted up to 1900 where ATC alerted me and told me to turn. I got within 800 of a [commercial] flight but on the phone ATC said it was a suspected deviation. That through me off further and I told ATC I needed to head back to the airport as I was having engine gauge issues. I landed uneventfully and they gave me a number. What happened? I got behind the airplane bad; but it was from multiple things. Flying new avionics proved to be more of a distraction than I anticipated. I never ate lunch and was hungry so I wasn't at 100%. I was in a rush; waived the test flight and was eager to get back. I suspected something was wrong with the CHT gauge; doubted myself; and went on anyways. After the issue; not being prepared for the clearance I should have immediately turned back and had the shop check it. What I really should have done was go on the test flight instead of my first flight being the test flight and even though I thought I was prepared; the issues I encountered pushed me behind the aircraft. I think if nothing else had gone wrong I would have been fine with the new avionics since I have so much glass experience; however; I didn't have room for error. It was all too much. Looking back I shouldn't have been in a rush; should have stayed relaxed; and should have gone on the test flight. Assuming I didn't go on the test flight; I should have turned back and regrouped after the issue with the clearance; and definitely after the CHT issue. This has really humbled me. I consider myself a safe pilot and watch out for the accident chain and here it unfolded right before my eyes and I didn't notice it. So what did I learn? New avionics can be a distraction; even if you have time with similar gear etc.; you can't be rushed. Second; don't ever doubt yourself; as soon as the CHT needle didn't rise I should have turned back. Finally; be more critical of your own situation; being rushed was affecting my judgement and ability and I didn't stop to examine the whole situation. Having issues with the clearance proved I wasn't ready for the flight since I was rushing and it caused me to get behind the airplane. As soon as something happens you need to regroup. Writing the description of the situation; I feel I completely understand why this event happened. I will not allow myself to get into this situation again.

The pilot of a M20 reported becoming distracted by time pressure; an engine indication problem and advanced avionics familiarization; which led to several human errors; culminating in a successful return to the departure airport.


Flight Crew Returned To Departure Airport

CA (Captain) advised FAs (Flight Attendants) of a critical situation due to 'flaps' failure. We could not continue to destination ZZZ because runway was too short so we turned back to ZZZ1. Landing went OK and we arrived safely at gate without incident.

Air Carrier Flight Attendant reported an air return due to a flaps failure.


Communication Breakdown; Situational Awareness; Distraction

Party1 Flight Attendant; Party2 Ground Personnel

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

I am the A Flight Attendant. Passenger X was making a connection. She also needed an aisle chair. My tablet was acting glitchy and I could not pull the station flight service phone numbers. There was not a jet bridge phone and no plane phone numbers. There were 2 passengers trapped at the 1 and 2 seats while the aisle passenger was in the 3 seat. Total of 3 people stuck. Passenger X was getting very restless and stressed. I was not aware; for the passenger's safety; I was not to leave and inform the Agent of the urgency for the aisle chair. I deeply apologize; this will never happen again. Working conditions with COVID; are very stressful.Make sure that every flight has availability to jet bridge phones numbers; to communicate with the Gate Agents.

Flight Attendant reported staff shortage and poor customer service due to the COVID-19 pandemic contributed to some passengers not being able to deplane in a timely manner.


Air Conditioning and Pressurization Pack

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Other / Unknown

Flight Crew Diverted; Flight Crew Landed As Precaution

Our aircraft started the day with the cockpit PACK deferred on MEL; so we were restricted to cruise at FL410 or below. [Captain] was flying in the left seat and I was monitoring in the right. During the climb out to FL400; I noticed the cabin pressurization was higher than normal for the given altitude but was stable. We were experiencing light to moderate turbulence at FL400; and climbed up to FL410 for a smoother ride for the passengers. During the climb; our cabin pressure showed about 500 fpm climb; passing through 8000ft of pressure. Less than 1 min after leveling at FL410; we then received an amber CABIN ALTITUDE CAS message as the cabin surged to 9000ft. [Captain] donned his oxygen mask at the same time I requested FL380 to see if the lower altitude can help our weak PACK with pressurization. We barely leveled off at FL380 when I noticed the cabin pressure not stabilizing. At that point; we made a quick decision as a crew to initiate a [rapid] descent and divert to [a suitable alternate]. I briefed our startled passengers from my pilot seat and donned my oxygen mask. We landed safely. [Captain] and I heard one of the children in the cabin crying during the descent; which was caused by the abrupt changes in cabin pressure. The passengers were startled but had no injuries. According to the Citation X MEL; the aircraft is supposed to have normal pressurization with one PACK up to FL410. This was clearly not the case on our oldest Citation X with 15;200 hours. Depending on the exact cause of the problem; maybe we need to reduce that upper altitude limit while flying with one operating PACK.

The crew acted in compliance with our training and a positive outcome was achieved. The event occurred fairly quickly and the crew was very busy throughout. Due to how quickly the event occurred; no ABNORMAL/EMERGENCY checklist was used. A rapid descent procedure was performed and the proximity of the diversion airport didn't allow any time for troubleshooting the problem. Once the descent was initiated it was obvious to the crew that the trip would not continue to its intended destination and the priority was to get the aircraft safely on the ground as quickly as practical. It is my opinion that the crew worked well as a team and used good CRM to ensure a positive outcome for all involved. The crew's decision to descend and divert was unanimous. It was also decided that since the descent was necessary due to the inadequate cabin pressurization; the expeditious landing at a suitable airport was also necessary because it was obvious that at the lower altitude the trip could not continue to the intended destination. In light of those decisions there was no need loiter or enter a holding pattern to troubleshoot the pressurization problem. It is the opinion of the crew that we acted in a safe and efficient manner.

CE-750 flight crew reported a loss of cabin pressure when operating with one PACK at FL410.


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

Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Flight Deck / Cabin / Aircraft Event Illness / Injury; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Provided Assistance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Clearance; General Maintenance Action

Cruise flight at FL 390. Smooth air while overlying thunderstorms and VFR conditions. ATC authorized deviations left and right. Captain (CA) made PA call to Flight Attendants (FA) and passengers to all be seated and fasten seat belts. As the aircraft approached the far end of storm; severe turbulence rocked the plane and stick shaker and high speed warning activated twice. CA corrected and re-established control each time; but lost approximately 600 feet in so doing. Pilot Monitoring (FO) called FA's and FA1 reported FA2 was injured. They found her on the floor. FA1 asked for help from medical personnel and they responded. Destination was only 25 minutes away so we continued heading there in case medical attention was needed. Reported injury to ATC. Below 10;000 feet personnel in back advised paramedics were needed. Called for them to meet us at gate and proceeded direct to airport with ATC approval. Emergency vehicles were at the gate; but no ramp personal. FA2 was conscious but confused. She was taken to hospital. Dispatch and Maintenance contacted. I (Captain) called hospital from hotel and spoke to FA2. She was coherent but had no memory of any events previous to people talking to her from the passenger seat.

Captain was Pilot Flying. Cruise at FL390 with smooth air flying over a thunderstorm. Deviations left and right approved. PA call to FA's (Flight Attendants) and passengers to all be seated and buckled. Far edge of storm was in sight. Severe turbulence; as published; was encountered. Stick shaker activated twice and Hi Speed aural warning twice. Both times; stick shaker stopped quickly before throttles were advanced to maximum thrust. Loss of altitude approximately 600 feet. Control was re-established. Called FA's and heard FA2 was injured. They found her on the floor. FA1 asked for help from medical personnel; two nurses and one flight attendant responded. Destination was only 25 minutes away so we continued heading there in case medical attention was needed. Reported injury to ATC. Below 10;000 feet; personnel in back advised paramedics were needed. Called for them to meet us at gate and proceeded direct to airport with ATC approval. Emergency vehicles were at the gate. FA2 was conscious but confused and in pain from a hip. She was taken to hospital. Dispatch and Maintenance contacted. I (Captain) called hospital from hotel and spoke to FA2. She was coherent but had no memory of any events previous to people talking to her from the passenger seat.

Air Carrier Pilots reported severe turbulence encountered and a Flight Attendant injured.


Flight Crew Last 90 Days 4; Flight Crew Total 301; Flight Crew Type 42

Situational Awareness; Communication Breakdown

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

Automation Aircraft TA; Person Flight Crew

Busy day at the airport in the ZZZ traffic pattern. I heard a slightly garbled message about a Piper Cub entering a tear drop for the 45 to Runway XX as I was turning crosswind. I continued looking for the cub but did not see it and made my downwind turn and radio call. About halfway through downwind TCAS alerted me that there was something closer than a mile about 300 feet below me even though I was at TPA (Traffic Pattern Altitude). Worried I was over top of another aircraft I turned left and then right aggressively to check under the wings and nose for an aircraft and I did not see anything. Passed the numbers on downwind and started my descent to base. Called my base turn; heard something garbled. Then heard someone calling 'the Diamond' to which the pilot said I had gotten within 100 yards of him and that I should watch for traffic better. I did look; I had been in the pattern practicing all morning; I made clearing maneuvers to make sure there was nothing in a blind spot but at the end of the day I did not see him. While radios are not required; he obviously had one. Some of the hardest things to see while in the air are airports and other planes. It also would have been beneficial had the Piper Cub been at published TPA and even though not required; when within a very busy non towered airport; clearly announcing his position.

Pilot reported communication issues caused a Near Mid Air Collision at a non-towered airport.


I was working Sector X and received the hand off from Sector Y on the B737 which was tracking towards the [ABC VOR] however route had over [DEF VOR] for military active airspace. The aircraft had departed with a DTA change and an Full Route Clearance (FRC) reroute due to military airspace which was correct in the computer. When the B737 checked on the frequency; I verified his clearance and he said he was cleared to [his destination] via [ABC VOR]. It must have been at least 2 to 3 RADAR controllers who worked that aircraft before he was given to me and did not realize his wrong clearance. Also the whole time the aircraft was flashing to me it was tracking towards the [ABC VOR] and the Sector Y Controller never noticed he was given a different route that the one he should have had from the computer for weather and military activity. It is alarming and disgusting how procedures and rules implementation has been lacking in this facility. The fact that several people (including D-Sides) did not notice the aircraft tracking the wrong way is scary. Overall the FAA has turned into a relax training environment and therefore now we have many new controllers that do not know how to separate traffic and or just do a poor job when it comes to coordination since no one can get in trouble anymore; or so the belief is. I have found out instances of almost mid air collisions that nothing seems to be done to retrain the controller in order to improve and for the situation not to happen again. Also there are many distractions that go on in the control room everyday. Most people think we are here to talk about our personal business and weekend stories other than listening to readback errors. Furthermore; I believe management picks and chooses who they want to reprimand when it comes to an error. I have seen senior controllers make mistakes and brush it off as ' no harm no foul ' but supervisors are afraid on coming down on them since they are seniors. I believe the rules should apply to everyone and that they must perform at a certain level in order to maintain their job. The FAA needs to get back to basics and retrain the whole workforce to understand the important nature of our jobs since we are not only the workers but the users of the systems and those 'targets' in our RADAR scopes are airplanes full of people.

Extensive weather and weather routes impacting southern airports; and a reroute was in effect due to active military airspace north. B737 on this day was supposed to fly the amended routing that was in the machine. Before we took the handoff on the aircraft; I mentioned to my R-Side that it appeared the B737 was headed for the north and not [DEF VOR]. When the aircraft checked on; my R-Side immediately inquired about his route and sure enough; the B737 said he was direct [ABC VOR]. My R-Side immediately called the previous sector for control for turns and issued the correct clearance that was already in the computer. Several controllers both estimated that the aircraft had to transit at least 4 other controllers airspace before getting to us. How could this go unnoticed for so long? It is 2 totally different routes of flight; and with all the weather at that time; the B737 had to have been cleared on course sometime within 40 miles of departure; even if you performed a route display on the aircraft; you could clearly see that the flight was way off course; and possibly not on the proper route. Without listening to tapes; I will tell you there is an epidemic in this facility of a lack of attention to detail and there nothing done about it.

Enroute Controller described an incorrect routing event expressing concern regarding the current 'state of ATC' with regard to controller performance and management oversight.


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

Air Traffic Control Provided Assistance; Air Traffic Control Issued New Clearance; Flight Crew Landed in Emergency Condition; Flight Crew Overcame Equipment Problem

ATC Equipment / Nav Facility / Buildings; Aircraft; Weather

I was receiving On the Job Training (OJT) on combined sectors and had just recently taken position. I was displaying weather information from FL330 and above. The first few minutes on position I had been coordinating weather deviations with pilots and adjacent sectors. I was on the line getting a ride report at FL380 well out ahead of an aircraft on my frequency that was getting a lousy ride at FL380 when I received a call on override from another sector. The sector was requesting to hand off Aircraft X climbing to FL390 which was not per SOP which I approved. Aircraft X checked on climbing to FL390 on course which skirted along the northern edge of the weather and asked if I knew what rides were like ahead as he had been in moderate turbulence the last 10 minutes.I provided him with the information I had to his east at FL380 of intermittent light turbulence. Aircraft X advised that he was going to need to deviate left of course. I coordinated this deviation with adjacent sectors who quickly approved it. Aircraft X advised he was getting moderate to severe turbulence and his new course was completely clear of my depicted weather so I started filling out a paper PIREP form at which point Aircraft X began to descend. I questioned his descent and Aircraft X advised that he was an emergency and was in a descent and that he had also lost an engine.Aircraft X had conflicting traffic at FL350 so I asked Aircraft X to maintain FL360 if able while I coordinated with other sectors. I coordinated the emergency descent information to the next sector who approved my request. Aircraft X when asked intentions advised he would like to divert to [nearby airport] so I provided a clearance with FL350 as an altitude to maintain and shipped the aircraft to the next sector. I feel like I did all I could to assist Aircraft X as he checked on a course that he had requested. I coordinated his deviations and provided him with any relevant information I had on the weather at the time which was very limited due to time on position and no aircraft traveling along his route previously.Perhaps upgraded weather information would allow controllers to be more aware of weather in their sector. Lots of controllers here talk about how nice it would be to have Weather and Radar Processor (WARP) weather which I'm unfamiliar with.

A Center trainee Controller reported an aircraft deviating for weather lost an engine and had to divert.


Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance

Company Policy; Human Factors; Procedure

We received load schedule from Agent. He said that the takeoff weight exceeded the planned takeoff weight by 259 pounds. Flight Crew discussed with the Agent we would delay takeoff and burn 300 pounds at the end of taxiway holding area until below planned takeoff weight. The maximum ATOG was 145.2 and the planned takeoff weight from the load schedule was 145;259. So both MAX ATOG and takeoff weight were the same at 145.2.	The Crew took off below planned takeoff weight after burning 300 pounds on the ground. The Crew realized; once airborne; that we should have contacted Dispatch prior to push off the gate to adjust weights to ensure all paperwork was correct. Crew was under the impression that both [our operations software] and [the performance computer] would not give performance data if overweight; but they did.

[Report narrative contained no additional information.]

B737-700 flight crew reported departing the gate over their max takeoff weight and questioned why the air carrier systems and procedures would allow that.


Air Traffic Control Time Certified In Pos 1 (yrs) 14

ATC Issue All Types; Deviation / Discrepancy - Procedural Other / Unknown; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Separated Traffic; General Flight Cancelled / Delayed

Airspace Structure; Company Policy; Staffing; Human Factors

I really don't know where to start; this being the third time this week I've been put in an unsafe situation. Today we had weather since I came in at XA:00. All the ZZZ departures and ZZZ1 departures were flying the same route deviating for the weather we had nobody to help and my scope was clutter with airplanes. I can't believe there was no spacing requested when everyone knew about what the airplanes were doing; except apparently our TMU (Traffic Management Unit. I couldn't call weather; and everyone was stepping on each other on the frequency because every aircraft want to deviate. It has been a bad week and like I said at the beginning this was the third time this week we were put in an unsafe situation. Our staffing is bad and they don't want to talk about it. Yesterday on the same sector a bunch of aircraft with in trail spacing to ZZZ2 and about 30 of the ZZZ2. The problem is not so much the traffic; it was the in trail spacing having all that traffic on headings to get the spacing. I'm pretty frustrated with the situations we have been dealing specially this week; hopefully we can be better to keep the flying public safe. Plan ahead there is no reason for me working that amount of aircraft before XA:30. If that is the case then why we have TMU for.

Center Controller reported consistently working sectors with excessive workloads due to weather deviations and insufficient staffing.


Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Illness / Injury

Air quality incident following de-icing in ZZZ.  I was in my aft jump seat during de-icing service.  Several moments later; Dizziness and blurred vision; and inability to read came over me.  Symptoms gradually subsided.  I inquired with my crew mates if others experienced symptoms; but I was the only one.  I was able to perform my duties; but my balance was compromised; and mitigated dizziness persisted for the duration of the flight; and even as I write this report 35 [minutes] after landing.

B737-800 Flight Attendant reported an air quality event after de-icing that resulted in physiological issues.


Maintenance Airframe; Maintenance Powerplant

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

Chart Or Publication; Company Policy; Human Factors; Manuals; Procedure

Removed and replaced HYD pump on engine and noticed that this engine and all the others don't have safety wire on the HYD tubing where it should be.  Has bothered me ever since and ended up being one of the reasons that I am not employed there.  I was told that they don't safety the large intake and return lines on the engine driven pumps even though there is clearly a place for it.

Aircraft Technician reported hydraulic tubing not secured with safety wire on a B717 aircraft.


ATC Issue All Types; Inflight Event / Encounter Wake Vortex Encounter

Environment - Non Weather Related; Procedure

It was my leg; and all preflight events were normal. After being cleared for take off behind a B757; the takeoff run was normal. After rotating and breaking ground a positive speed trend was observed and positive climb rate and 'positive rate' was called. I called for 'Gear-up/Speed Mode'; and was hit by a slight wake turbulence. The aircraft rolled about 10 degrees left-wing down; and the stick-shaker activated for about 1/2 a second. I lowered the angle of attack; and the aircraft continued as normal. We completed the climb/configuration and completed the checklists as normal. There were no deviations of airspeed; altitude; or track. The upset was not great; and at no time did the aircraft feel out of control. We were cleared for takeoff by ATC using the prescribed procedures; but with the statement 'Caution for the wake turbulence from the preceding Boeing 757'. As always in ATL; we must be on guard for this; and the training department even trains us in simulators for this exact event. I felt I have been given the appropriate training; and felt it was handled accordingly.

CRJ-200 First Officer described wake vortex encounter on takeoff in ATL behind a B757.


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

We received a message from Dispatch [during cruise] at (time) that HAZMAT (Radioactive Material) had been loaded aboard our aircraft without my knowing it and obviously without my signing a NOTAC (Notice To Pilot In Command) Company Air Waybill XXX-XXXXXXXX. We proceeded to ZZZ1 notifying Operations en route. Upon arrival at the gate; the Operations Agent informed us that no further paperwork or procedures were required of me as Pilot-In-Command of the Aircrew. No HAZMAT was listed on the Dispatch Release.

Air Carrier Captain reported airborne Dispatch notification of undocumented Hazmat cargo on board. Flight crew coordinated with destination Operations who stated no further action required of flight crew.


Cessna 210 Centurion / Turbo Centurion 210C; 210D

Air Traffic Control Time Certified In Pos 1 (yrs) 5.0

Airspace Violation All Types; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance

Chart Or Publication; Aircraft; Procedure; Manuals

I was working the Radar position at the beginning of the session. Two aircraft were IFR inbound to an airport. Aircraft Y was slightly behind and at 5;000 feet and direct to the airport. Aircraft X was slightly closer and at 6;000 feet setup to execute the RNAV approach into the airport. When Aircraft X checked in I informed him that I would have to issue holding instructions as the approach would make him later to the airport but if he wanted to execute a Visual Approach we could get him inbound first. Aircraft X said he would take the visual so I cleared him inbound direct; cleared him to descend to 4;100 feet which is the Minimum IFR Altitude (MIA). I told them to report the field in sight for a Visual Approach.Aircraft Y was informed that he was number 2 and would have to climb to 5;100 feet to provide separation between him and his friend both inbound at the same time. Aircraft Y then turned 90 degrees to the north (right at Aircraft X) and asked if he should go direct to the initial approach fix for the RNAV approach. I told him no and that I saw his turn and that he needed to continue westbound for the moment until we had altitude separation before I could issue a turn to the north. While this is happening Aircraft X crosses my boundary and I issue 3;900 feet which is my MIA and I inform him if he is unable to get the field in sight we may have to go to plan B as there were no lower altitudes I could provide. Aircraft X then proceeds to descend below 3;900 feet all the way to 2;100 feet and I asked him 'Do you have the airport in sight?' Aircraft X responds 'I have the ground in sight.' I am then getting my supervisor's attention to let her know what is going on (now about both aircraft) and that I need to have the brasher warning so I could provide it to them.  While I am getting her attention Aircraft X says field in sight cancel IFR... I accept his cancellation and then clear Aircraft Y inbound on the RNAV as it was obvious to me that 3;900 feet was not able to provide visual conditions to the field. I then give a briefing to the relieving controller and came here to report what had happened.Both pilots need a refresher as to what IFR means and maybe take a break for a bit. One pilot almost had an IFR to IFR conflict by turning without instruction; the other could have had collision with terrain as he descended below his assigned altitude... ridiculous!

An aircraft was descended to 3;900 feet for a Visual Approach. The aircraft descended on its own to 2;100 feet which is below the Minimum IFR Altitude before cancelling IFR. Another aircraft was climbed to 5;100 feet for separation. Instead the aircraft turned 90 degrees to the right on its own.


Maintenance Airframe; Maintenance Powerplant

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

I was seated in my jumpseat at L2 door during takeoff when another flight attendant and I heard a loud bang noise. My first thought was that something shifted from under the cargo hold. We stayed in our brace position and airplane continued to climb and the wheels retracted. Soon a passenger call button dinged at row seven on the right side. The Lead Flight Attendant took the passenger call and returned to the forward galley the other flight attendant and I saw that she was on interphone with the Captain. We then heard another passenger call; again on the right side of the aircraft. I rushed over to see what was happening and the passenger pointed at the engine. I looked out and saw that the engine housing was missing and appeared to have been ripped off. I told the passenger the Captain had been made aware of situation; to remain calm and that we would have more information for them as soon as we could. I made sure the passengers in that area were seated with their seat belts on and then returned to the aft galley to inform the third flight attendant what I saw. Since the Lead Flight Attendant was still on interphone with the Captain explaining what she saw; I made a PA announcement to inform the passengers that the Captain was aware and will give us more information as soon as he can and to remain seated with seat belts fastened since people might get curious and try to stand up and look over to the right side of the aircraft. The Lead Flight Attendant then informed us; per the Captain that we are going to return to our departure airport as a precaution. The Captain then made an announcement and we prepared the cabin for landing. A few people were nervous and I comforted them and informed them that everything would be ok and we would land safely in a few minutes. When we landed the Captain announced that emergency vehicles would inspect the jet as a precaution and; after about 20 minutes of being on tarmac; made another announcement that we would be towed to the gate.

Upon arrival I met the airplane at the gate and began my weekly check on the airplane. I first did a walk around of the plane and didn't notice any abnormalities. I then began my exterior servicing procedures. I serviced the engine oils first and then wiped down the struts. I opened up the left engine fan cowls to check the IDG oil level; which did not need service. Another mechanic was working on the engine at the same time so I left the engine fan cowls open and returned later to close them. I proceeded to check the right engine and found the IDG did not need servicing. I then closed the fan cowls and latched them shut. I continued on with my weekly check and finished it routinely. After doing all of my paperwork and write-ups for the aircraft I had asked the other Mechanic verify the latching and closing of the latches for the fan cowls. He then proceeded to do his verification that the fan cowl latches were closed and secured then signed off the verification above my sign off for the closing and verification of both engine fan cowls. ...during the company maintenance meeting call there was a call from Operations telling us that the aircraft was being escorted and towed to the gate and because 'a panel on the right side of the aircraft came off during take off.' I believe that an AD should be issued requiring more frequent inspections of the latching hardware and surrounding hardware for wear on IAE V2500 Engines. Also an AD to check the mounting hardware and surrounding hardware for wear and safe functionality and; also; to check for warped fan cowl doors on IAE V2500 Engines. Photos should be taken to show/prove that the fan cowl doors are latched and secured properly any time they are opened. Also routine engine run ups should be done anytime maintenance requires the opening of fan cowls.

When a A319 shed the left engine cowling during takeoff the flight crew returned to the departure airport for maintenance.


Embraer Jet Undifferentiated or Other Model

Situational Awareness; Distraction; Workload

Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

Prior to our takeoff; a B757; an A321 and a Q400 departed. We took off and immediately experienced wake turbulence associated with the previous departures. The RNAV SID calls for a nearly immediate and large course change to the east at 520 feet. At 500 feet I called for autopilot on to comply with best practices for RNAV SIDs. At acceleration altitude the Pilot Monitoring (PM) called acceleration altitude. Because the autopilot was on; we both reached for the FGC SPD button. I said; since the autopilot is on; I command the FGC. I called for flaps up. The First Officer (FO) subsequently ran the After Takeoff checklist. As the Pilot Flying (PF); I was saturated with flying the airplane as the departure has several short tight turning legs. Once we got up and out of the terminal airspace; I lowered the nose to accelerate the aircraft. At that time the aircraft wasn't accelerating normally. I scanned the cockpit and observed the Flaps were still in the 9 position. I observed our speed at that time to be 261 KIAS. I immediately reduced thrust to below 250 KIAS and retracted the flaps. We continued the flight and landed without incident. Made an AML entry. Cause: high workload and task saturation. This was an error that was made during a high workload time period and the associated confusion of who manipulates the FGC during an autopilot on departure for RNAV SID compliance. As such; a thorough debrief and review of the after takeoff checklist and flow is my suggestion. Also; highlighting the PF/PM duties and how they change depending on whether the autopilot is turn on at 500 feet or just the YD is turned on.

Embraer jet flight crew reported a wake turbulence encounter combined with a complex departure resulted in failure to retract flaps on schedule.