elihoole/asrs-aviation-reports · Datasets at Hugging Face

1574675

201808

0601-1200

SNA.Airport

CA

5000.0

Daylight

TRACON SCT

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

FMS Or FMC; GPS

Initial Approach

Class C SNA

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Flight Crew Last 90 Days 175; Flight Crew Type 1900

Situational Awareness

1574675

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 357

Situational Awareness

1574727.0

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

Person Air Traffic Control; Person Flight Crew

In-flight

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

Human Factors

SNA RNP-Z to Runway 20R. The FMC was properly programmed and MCP panel [was] in LNAV/VNAV PATH. Upon crossing KLEVR at 5000 FT IAF; we set zeros in the altitude alerter. The aircraft did not descend to cross MNNIE at 4400 FT; next mandatory altitude. I noticed level flight and immediately selected Vertical Speed to try and meet MNNIE at 4400 feet. About the same time; SoCal Approach asked us if we were descending and flying the RNP-Z. The Pilot Monitoring (PM) said 'yes' but asked if we could be cleared the Visual Approach to try and mitigate any problems. SoCal said 'no problem' and gave us a 'heading of 030 and descend to 3000 FT; call the field in sight.' As Pilot Flying (PF); the field was on my side and we had it in sight and called - in sight. At that point we were cleared for the visual and told to contact SNA Tower. The rest of the approach and landing were uneventful and we landed safely on 20R. With short distances between waypoints and mandatory descending altitude restrictions; pilots should be quicker to notice any anomaly and react quickly to stay in/on VNAV PATH even if aircraft does not do it automatically.

We were cleared for the RNP RNAV Z 20R Approach and level at 5000 feet. We were in visual conditions; and just using the approach for ease of use. We had zeros set after the initial approach fix and in LNAV/VNAV PATH. After crossing KLEVR; the aircraft did not descend. We noticed it quickly; and the Pilot Flying intervened by using Vertical Speed to catch the profile. Very shortly after we began to intervene; ATC asked us if we were doing the RNP Z Approach. I told him we were; but the aircraft wasn't doing what we were wanting or expecting it to do; and I asked if he could vector us for the visual approach. He gave us a heading and altitude to fly. He asked if we had the airport; which we did; and he cleared us for the visual. We landed without incident. In the future; I need to monitor more closely; and not let the good weather lull me into complacency. If we're cleared for an approach; I will monitor it better.

B737-700 flight crew reported failing to make a crossing restriction on the RNP-Z Runway 20R approach to SNA.

1224894

201412

0601-1200

MSY.Airport

LA

1000.0

VMC

Daylight

Tower MSY

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Final Approach

Class B MSY

UAV - Unpiloted Aerial Vehicle

Class B MSY

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

1224894

Conflict NMAC

Horizontal 300; Vertical 0

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

On base to final turn to runway 1 in MSY at approximately 1;000 feet AGL; we passed within 100 yards (estimated) of an unmanned aerial drone. The drone was headed west at our altitude and made a quick turn to the south to avoid us. The drone was a fixed wing; single propeller type commercial unit. It passed off our right wing. I was the non pilot flying in the left seat. My First Officer was focused on avoiding a helicopter that had been pointed out to us; so she didn't get as good of a look at the drone as I did. She did; however; get a good enough look at it to determine that it was in fact an aircraft. We did not take evasive action because the encounter happened so fast I initially wasn't sure what we had seen. However; after taking a closer look out the right window; I was able to determine the drone was headed away from us and would be no factor. I reported this drone encounter to MSY tower; and subsequently followed up with a phone call to the TRACON after landing to relay the specifics. Increase awareness of those who operate drone aircraft in the vicinity of commercial airports as to airspace regulations and possible collision hazards with commercial aircraft. FAA needs to take action to regulate drone operations; especially within controlled airspace.

Captain reports sighting of a drone at 1;000 feet during approach to Runway 1 at MSY. No evasive action is taken by the reporter; but the drone appears to turn away.

1134202

201312

1201-1800

ZZZ.ARTCC

US

2600.0

IMC

Fog; Rain; 0.5

Daylight

300

Center ZZZ

Personal

SR22

1.0

Part 91

IFR

Personal

Final Approach

Direct

Class B ZZZ; Class C ZZZ; Class D ZZZ

PFD

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 50; Flight Crew Total 600; Flight Crew Type 100

Human-Machine Interface; Confusion; Situational Awareness

1134202

Aircraft Equipment Problem Critical; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence

N

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Air Traffic Control Issued New Clearance; Flight Crew Overcame Equipment Problem; Flight Crew Became Reoriented; Flight Crew Regained Aircraft Control; Flight Crew Requested ATC Assistance / Clarification

Human Factors; Aircraft; Procedure; Weather

Aircraft

I climbed to my filed altitude of 5;000 FT; and was right at the top of the clouds. It was kind of bumpy and the temperature was 50+/-. Departure asked me if I wanted 6;000 FT and I accepted. At that point I was in the clear the temperature was 46 +/-. I was expecting the ILS 2L into ZZZ1 and received weather and briefed the approach as necessary. The FPD flashed and I wasn't sure if I had blinked or if it really did. At this point I was VFR on top and all flight instruments were reading correctly. [Center] told me to expect the ILS 10...and I went ahead and made the following change in the aircraft and once again briefed the approach. I was cleared to descend to 4;000 FT and did so without incident. I once again noticed the PFD flickered.... I felt the PFD and it seemed really hot so I figured due to the heat it was messing with the screen. I turned on the fresh air vents and made sure the heat was also turned off in the plane. I was then cleared for the ILS 10 and asked to descend to 2;500 FT which they then corrected to 2;600 FT. The aircraft captured the ILS as it should and I slowed the aircraft to 130 KTS about 10 miles out; and continued to slow the aircraft to the flap range. I was switched to the Tower frequency and I was cleared to land. I went ahead and switched my MFD to the checklist page and did my pre-landing checklist. When I brought up the map screen again I noticed the aircraft was to the right of the ILS localizer. At this time I also noticed the aircraft was in a left turn shown by the PFD attitude indicator; however; the standby indicator showed a right turn. At this point I knew I had a problem. Almost at this exact time the Tower asked me to check my altimeter setting because they had a low altitude report. I then received a check attitude warning annunciator on the PFD. I was not sure what attitude indicator was giving me correct information at that time. At this point the PFD attitude indicator was almost 90 to the left and I quickly decided that it was the wrong one. I felt the aircraft buffet and I knew I was in an autopilot stall. I disconnected the autopilot; I got the nose down and the power in. I struggled not to try to follow it [attitude indicator] because it is so big and right in front of me. I let Tower know I was going missed; but at that time I realized my heading indicator was incorrect as well. Tower wanted me to make a right turn to 180 and maintain 3;000 FT. I knew where VFR conditions were and that was where I needed to get. After regaining control of the aircraft using my three standby instruments; I asked to climb to 5;000 FT. I struggled with my heading because of the compass location in the aircraft. As I was climbing to VFR conditions I was going through my checklist for failures. When I broke out I went ahead and reset everything hoping that it would right itself but it did not. I went ahead and reduced power to conserve fuel and climbed so I could keep leaning out my aircraft. The entire Midwest was low IMC. After running through my entire checklist and determining that I could safely make a GPS approach I asked Center for anyone with minimums good enough for a GPS approach. I chose ZZZ2 and using GPS and my standby instruments; I safely landed with my PFD red X'd out.

SR22 pilot became disoriented on approach in IMC when PFD began displaying erroneous attitude information. After entering stall buffet and receiving ATC and aircraft low altitude alerts; pilot regained control by using standby attitude instruments; returned to VFR and; with ATC assistance; preceded to an uneventful landing at an alternate field.

1222074

201411

1201-1800

CWA.Airport

WI

20.0

4000.0

Icing; Snow; 0.5

Daylight

300

Center ZMP

Personal

Baron 58/58TC

1.0

Part 91

IFR

Personal

Descent

Vectors

Class E ZMP

Pitot/Static Ice System

X

Failed

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Multiengine; Flight Crew Private; Flight Crew Instrument

Flight Crew Last 90 Days 100; Flight Crew Total 1800; Flight Crew Type 700

Situational Awareness

1222074

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Became Reoriented; General Maintenance Action

Aircraft

I had my pitot heat checked prior to winter and on prior flights. I was above icing at 10;000 ft. As I descended into minimal icing below 8000 ft. the pitot heat failed and the pitot tube iced up. I lost airspeed indication. This is a minor event with GPS ground speed on 2 GPS units to compensate. However within moments the AHRS started to malfunction and started intermittently cutting off heading information. Then at times it gave other error messages; flagged erroneous attitude indications and started falsely indicating 'dangerous' attitudes even during normal standard rate turns in the holding pattern. At one or two points the entire glass panel instrument display gave a fault and sit off all instruments (attitude; heading; HSI; glide slope; altimeter; etc.) requiring use of backup instruments. I was able to fly and complete the ILS approach using the intermittent indications; the GPS's (2) and backup indicators to minimums (300 ft.; 1/2) uneventfully. I contacted the avionics shop who advised me that loss of PITOT input ALONE can cause complete loss of AHRS FUNCTION; all modalities. The pitot tube was replaced and on the next flight I have had no problem. If this is true and loss of a pitot tube input can cause complete loss of the AHRS - loss of heading; attitude; HSI; altimeter; other vital indicators - especially in low IFR - this can become a very dangerous situation!! This is very bad engineering design without proper failsafe design. Loss of airspeed should allow a default mode that preserves indications of attitude; airspeed; the HSI; etc.!!!! This fault of the DESIGN could become life threatening to the pilot from what used to be a TRIVIAL problem in the past. The engineers can redesign this to have bester failsafe performance!

BE58 pilot experiences pitot heat failure descending through icing conditions at 8000 feet. Within moments the AHRS begins to malfunction along with other components of the glass panel display. Backup instruments and GPS ground speed are used perform an ILS approach to landing. The reporter is informed by his avionics shop that loss of pitot input can cause loss of AHRS function. He believes that the system should be designed to operate normally with loss of pitot input.

1733019

202003

1801-2400

ZDV.ARTCC

CO

32000.0

Turbulence

Center ZDV

Air Carrier

B737-800

Part 121

IFR

Passenger

Cruise

Class A ZDV

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Situational Awareness

1733019

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

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

Airspace Structure; Weather

Weather

At 32000 ft. just north of PUB the aircraft experienced Moderate to Severe turbulence. About 10 minutes before the incident the aircraft was in continuous light chop due to cloud tops. Seatbelt sign was on and PA was made by Pilot Monitoring and Pilot Flying reduced thrust to Mach .76. Pilot Monitoring contacted ATC for rides above; at about that time the airspeed began to show a decreasing trend and the Pilot Flying added power to adjust; airspeed continued to decrease and the Pilot Flying added even more power. At about that time the turbulence started and the right wing dropped and aircraft bank angles showed in excess of 50 degrees kicking off autopilot. Airspeed loss was an excess of 30-40 kts. whereby Pilot Flying applied max power. Barber poles came together however no overspeed or stall warning occurred. The aircraft lost at least 500 ft. during upset recovery with no excessive force to the aircraft. After recovery Pilot Monitoring requested an immediate climb due to Moderate to Severe turbulence up to 36000 ft. and was given 33000 ft. ATC gave us a frequency change and got an immediate climb to 36000 ft.; with no further incident. During upset recovery aircraft lost at least 500 ft. This is an approximate guess by the pilots since the loss of airspeed and power at firewall along with excessive bank angles were in the primary scan. ATC gave an immediate climb clearance and crew complied. No further action was taken. Keep seat belt sign on when crossing know turbulent areas like over the Rockies; even when weather radar; and ATC aren't reporting anything. Keep the Flight Attendant's informed and always give those important PA's to passengers 'when seated to keep those seatbelts securely fastened in case we hit any unexpected turbulence'. Because it really does happen!

B737 First Officer reported unexpected moderate to severe turbulence caused a temporary loss of control.

1000676

201203

0601-1200

ZZZ.ARTCC

US

24000.0

VMC

Dawn

Center ZZZ

Air Carrier

Dash 8-200

2.0

Part 121

Cruise

Class A ZZZ

Pressurization System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

1000676

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Aircraft

The First Officer performed the cruise checklist when directed to. He noticed the differential pressure to be about 5.5 PSI and the cabin altitude climbing past 10;000 FT at FL240. With no master warning or warning light we descended to FL200. The differential pressure lowered and the cabin altitude read below 8;000 FT.

DHC8-100 Captain experiences a high cabin altitude at FL240 with no associated cabin altitude warning. Flight descends to FL200 and cabin altitude descends below 8;000 FT.

990198

201201

0001-0600

ZZZ.Airport

US

0.0

Tower ZZZ

Air Carrier

MD-80 Series (DC-9-80) Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Landing

Visual Approach

Class B ZZZ

Tower ZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Landing

None

Class B ZZZ

Facility ZZZ.Tower

Government

Handoff / Assist; Local

Air Traffic Control Fully Certified

990198

ATC Issue All Types; Conflict Ground Conflict; Critical

Person Air Traffic Control

Flight Crew Executed Go Around / Missed Approach

Human Factors; Procedure; Airport

Human Factors

While working the Handoff position; I observed an A320; on landing roll Runway XXL; roll past the G3 exit. Exits G2 and G1 were occupied; leaving no 'normal' exits available. The A320 could have been instructed to turn left onto Taxiway Hotel; away from the terminal area. I advised the Local Controller that I thought he should send an MD80 around. The MD80 executed a go-around on his own. The FLM was notified. In the process of reviewing the QAR; the Quality Assurance office determined that the MD80 had passed the landing threshold; without being sent around; while the A320 was still on the runway; resulting in an Operator Error. Recommendation: turn the A320 left onto the open taxi; MAKE SURE the Local Controller heard my recommendation to send the MD80 around; cross the previous 'arrived' aircraft sooner; allowing the exits to be available.

Tower Controller described a go around event when two taxiway exits were blocked and the Local Controller elected not to use a turn off opposite the terminal.

1330846

201601

1801-2400

ZZZ.ARTCC

US

33000.0

VMC

Night

Air Carrier

MD-80 Series (DC-9-80) Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Engine

X

Failed

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1330846

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Diverted; Flight Crew Landed in Emergency Condition

Aircraft

We were at cruise flight at FL330. Approx. 30 minutes into cruise flight; in smooth air; we experienced a relatively intense shudder in the aircraft. During this shudder; an audible bang could be heard; although it wasn't very loud in the cockpit. The captain and I both immediately noticed that the N1 and N2 indications for the #2 engine were both rolling back; and the EGT was immediately maxed out. We both agreed that we had lost the right engine; and with the shudder; bang; and high EGT; we suspected engine damage. We [notified ATC] and started a descent. The flight attendants immediately started chiming; and I asked them to standby; as we were trying to deal with the situation.After we started the descent; I began going through the QRH. Upon completion of the checklist; I contacted dispatch and informed them that we were diverting which had already been coordinated with ATC. Our dispatcher was very helpful. He did a great job coordinating with and our station operations. He also gave us the weather.After returning from speaking with dispatch I called back to the flight attendants. It had probably been ten minutes at this point since I had asked them to standby and I commended them for their professionalism. They had obviously been calling up to tell us about the odd engine noise and vibration they heard and after they were asked to standby; they immediately went into action preparing the cabin for landing. By the time I called back to them they were already seated and ready to land.I informed them that we had an engine failure; were diverting and would be on the ground in 15 minutes; and that we didn't anticipate needing to evacuate. Next I briefed the passengers; and informed them that we had an issue with one of our engines; and gave them the same info regarding the landing airport and time remaining. We completed the single engine approach to landing checklist; and the single engine landing checklist.The Captain made a beautiful landing; and the rollout and taxi to the gate were uneventful. Emergency services were standing by on the ramp when we landed and they followed us to our parking spot. I want to compliment Captain on the job he did handling this emergency. He was calm and composed throughout; and did a great job getting the plane safely on the ground.As a line pilot; I don't want to assume that I know our maintenance practices; however; it seems that we push the engines on our fleet past the point that they should be run. Our operations program allows us to operate engines at a higher temperature simply because they can't operate under normal takeoff power settings without exceeding temperature limitations. This seems to be causing our engines to fail more often.

Flight crew experienced an engine failure during cruise. They diverted to a nearby suitable field followed by a normal landing.

1420737

201701

1201-1800

PRC.Tower

AZ

6000.0

VMC

Daylight

Tower PRC

Small Transport

1.0

Part 91

None

Training

Initial Approach

Visual Approach

Class D PRC

Tower PRC

FBO

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Training

Initial Approach

Visual Approach

Class D PRC

Facility PRC.Tower

Government

Local

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 6

Training / Qualification; Distraction; Situational Awareness; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1420737

ATC Issue All Types; Conflict NMAC

Vertical 200

Person Air Traffic Control; Person Flight Crew

In-flight

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

Human Factors; Procedure; Aircraft; Airport

Human Factors

I was working the Local 1 position; training in progress. The traffic pattern was getting unwieldy; so I took over and started to clean up the sequence. Aircraft X was number 1 on 3 mile final Runway 3R. Three aircraft were on the downwind; extended to follow Aircraft X. I saw what I thought was Aircraft Y cut out Aircraft X; but realized it was Aircraft X appearing to be on right base Runway 3R; inside the downwind. I re-cleared Aircraft X; and that was when Aircraft Z advised NMAC with Aircraft X.The pilot of Aircraft X should have advised me what he was doing; especially if it was safety related (birds; for instance). I could have at the very least called traffic.

PRC Local Controller observed an aircraft that had been established on final maneuvered on its own to a base leg position on a conflicting course with downwind traffic.

1415992

201701

1201-1800

ELP.Airport

TX

5500.0

VMC

Daylight

TRACON ELP

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

Final Approach

Visual Approach

Class C ELP

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 144; Flight Crew Type 1420

Communication Breakdown; Confusion

Party1 ATC; Party2 Flight Crew

1415992

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

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Executed Go Around / Missed Approach; Flight Crew Requested ATC Assistance / Clarification

Human Factors; Procedure

Procedure

We were cleared for Visual Approach to Runway 22 at ELP. The ILS to Runway 22 was NOTAM'd out of service. High on final; PF began a left S-turn. BIF (Biggs AAF) prevented turns to the right. ELP Tower indicated that left S-turn was approved; and MAY have used the word 'east' during the garbled transmission. Tower transmitted; at least once; possibly twice; to other company call sign (not our callsign) to climb to 7000 with no response. To clarify the previous call; the PM transmitted 'call sign'. Tower transmitted to (Other Company call sign) to climb 7000 followed by something garbled. Unsure that our landing permission was still valid; the PM asked to 'Verify (call sign) is still cleared to land on 22'. Tower responded: '(call sign) climb to 7000.' No standard phraseology was used to indicate that our landing clearance was cancelled; to go around or to perform a missed approach.PF initiated go-around at approximately 5000 MSL/1500 AGL. Runway heading pointed directly towards the Mexican border and Ciudad Juarez. A turn to the left was not prudent due to traffic on approach to other runway at ELP. A turn to the right was not prudent due to the 7900 terrain west of ELP and BIF. During the entire event; no TA or RA warning was received. PM repeatedly requested a turn and was again cleared to climb to 7000 and to contact Departure; with no frequency given. PM requested frequency and never received a Tower response. Now; heads down in the cockpit during the Missed Approach procedure; the PM located the Approach frequency on the ILS 22 page; which happened to be the standby frequency on the COMM 1 Radio. (Usually this frequency would have already been replaced with the Ground frequency; but due to task saturation; this had not yet occurred.) El Paso Departure directed a climb to 9000; then a right turn to heading 350. An uneventful downwind; vectors to the Visual Approach and landing on Runway 22 followed.Clear communications are paramount. When in doubt; verify any ambiguous directions. My initial concern was the border that we were approaching. Many with military backgrounds are extra cautious when it comes to international borders; especially as some are more critical than others. Neither the Captain nor ATC seemed to share my concerns; as border crossings are common in this area; where El Paso Approach handles traffic into airports on both sides of the border.

B737 First Officer reported very confusing ATC communications while on a visual approach to ELP Runway 22.

1351148

201604

1201-1800

CLT.Airport

NC

30.0

VMC

Daylight

Tower CLT

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Landing

Visual Approach

Class B CLT

Ground CLT

Military

Hercules (C-130)/L100/382

2.0

Part 91

IFR

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1351148

Inflight Event / Encounter Fuel Issue; Inflight Event / Encounter Wake Vortex Encounter; Inflight Event / Encounter Unstabilized Approach

Person Flight Crew

In-flight

Flight Crew Executed Go Around / Missed Approach

Environment - Non Weather Related

While on a visual approach to RWY 23 backed up with the ILS in VMC conditions; we were advised we were following a C130 by approximately 5 NM. The approach was stable through minimums. Below 1100 MSL; which is DH for the ILS; we received GPWS warnings about the GS. This is normal as one of the notes on the ILS chart indicate the GS is unusable below 1100 MSL. We entered the low energy regime with intentions to land. As the flare was initiated; we caught either a gust of wind or the wake from the preceding C130; causing us to balloon up approximately 50 ft above the runway with rapidly decreasing airspeed. The FO/PF called for and executed a go around. He set max thrust and I ensured max thrust was set because of our height above the runway; decreasing airspeed; and low kinetic energy. As the airplane started to accelerate; we momentarily had an engine overspeed message. I responded by reducing the thrust setting. Following ATC instructions; we climbed to 4000 on a heading. We were offered our choice of runway. I chose 18R due to our close proximity to that runway and that we would be facing a fuel situation if we did not land soon. We briefed; set up for; and ran the required checklists. As we aligned with the runway; I saw the FO was deviating from the GS. I decided to take the controls at this point. The second approach was stabilized with a normal landing.When we arrived at the gate; I called maintenance to advise them of the engine overspeed and an ITT exceedance during what I said was a go around. Shortly after getting off the phone; I started this ASAP and in describing the event; came to realize it was a balked landing; not a go around.

CRJ-200 Captain reported executing a low altitude go-around at CLT when the flight ballooned as a result of either a gust of wind or a wake turbulence encounter.

1188308

201407

0001-0600

LLBG.Airport

FO

0.0

VMC

Daylight

Tower LLBG

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Taxi

Aircraft X

Flight Deck

Air Carrier

Check Pilot; Captain

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Training / Qualification; Situational Awareness; Confusion

Party1 Flight Crew; Party2 ATC

1188308

Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway

Person Air Traffic Control

Taxi

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

Chart Or Publication; Human Factors

Human Factors

While taxiing in LLBG we were issued the following taxi clearance; taxi to Runway 08 via Kilo hold short of Foxtrot. The taxi chart did not appear to accurately reflect the physical layout of the post runway construction near the takeoff end of Runway 30; so we asked for verification that Taxiway F had a sign to identify it after we proceeded west bound on Taxiway K. Ground confirmed that a sign marked F. We saw the sign and stopped to hold short of Taxiway F on K. After stopping Ground Control directed us to hold our position; followed almost immediately with directions to move up to the hold short line. LLBG was landing Runway 21 and we could see an aircraft on final and the Runway 21 hold short line. Both I and the other crewmember interpreted the new clearance as to move forward to the runway hold short line short of Runway 21. After moving forward approximately 60-100 FT; Ground again told us to hold position; followed by a statement that we had passed the Taxiway F hold short line by 60 meters. The next taxi clearance was to continue on Taxiway K hold short of K4. K4 is not depicted on the chart; but did have a sign at the airport clearly marking its position. We were conducting single engine taxi and the beginning of the taxi instruction with respect to holding short Taxiway F coincided with the beginning of starting the right engine and moving toward the runway hold short line. At no time was there conflict with landing or taxiing aircraft. There was absolutely a difference in expectation between what the Controller expected base and his instructions and what we interpreted as being directed with respect to where to stop the aircraft in the vicinity of Taxiway F while taxiing of K. Ground charts that completely and accurately label and depict taxiway and runway layout. Better clarity/standardization in controller to pilot communications and vice versa. I will be back in LLBG soon and hope to see the exact area where the difference in expectation occurred and possibly even get the same taxi clearance. I did not have the benefit of being able to look behind the aircraft after the conflict was verbalized by Ground Control. If that occurs I will be in a better position to answer this question.

A crew taxiing on LLBG Taxiway K from Apron J could not identify several holding points and crossing taxiways resulting in a runway incursion. The Captain stated the commercial airport chart and pilot to controller communications were contributing factors.

1666922

201907

1801-2400

ZZZ.Airport

US

VMC

Daylight

Tower ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Landing

Class B ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1666922

Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach

Person Flight Crew

In-flight

Flight Crew Landed As Precaution

Company Policy; Procedure

Company Policy

We were on the visual to Runway XX in VMC conditions in ZZZ and given a base turn with speed at our discretion. They asked us if we had the airport in sight; which we did; so they cleared us for the visual approach. At this point; we were high; and Tower asked us if we were going to 'make it' down. I said 'yes' and we began to descend; albeit very slowly. I advised my First Officer; the Flying Pilot; to click off the autopilot and hand-fly. We got configured for flaps full and ran the before landing checklist. When we turned final; perhaps around 500 feet AGL; we were still high and got pushed slightly off the centerline by the wind. Then we got a 'HIGH SPEED' aural warning (approximately four or five aural warnings before we were out of the red); reaching 171 knots; which is 6 knots faster than the limitation. While descending; we also got two 'SINK RATES'; one around 40-50' and the other around 30'. The runway was assured; and we touched down in the touchdown zone; clearing Runway XX at Taxiway A. In retrospect; I should have called for a go around after we turned final; realizing that we were still too high and not stable. As the Pilot Monitoring; it is my duty to alert the Pilot Flying of a situation where I think that a missed approach should be executed. As a Captain; I need to be more proactive in calling for a go around even if it is in an airport with such heavily prohibited areas.

EMB175 Captain reported failure to follow procedure for an unstabilized approach.

1853503

202111

0601-1200

CEW.Airport

FL

0.0

VMC

10

Daylight

CTAF CEW

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Utility / Infrastructure

Taxi

CTAF CEW

Small Aircraft; Low Wing; 1 Eng; Retractable Gear

1.0

Landing

Aircraft X

Flight Deck

Contracted Service

Single Pilot

Flight Crew Commercial; Flight Crew Multiengine; Flight Crew Instrument

Flight Crew Last 90 Days 115; Flight Crew Total 400; Flight Crew Type 205

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1853503

Conflict Ground Conflict; Less Severe

Person Ground Personnel

Taxi

Flight Crew Took Evasive Action

Human Factors

I had just finished my run-up at CEW (Bob Sikes Airport) and was holding short of Runway 35 for departure. Winds were reported out of the north at 5 kts. on the ASOS. Upon reaching the hold short; winds heavily favored Runway 35 (7-10 kts. on windsock out of the north). From my position; I had a clear view of both base and final for [Runway] 35; as well as the left downwind/base and final for [Runway] 17. I scanned the pattern and observed no traffic; I also had not heard any calls over the CTAF since engine start (roughly 6-7 minutes prior). I made my CTAF call announcing I would be taking Runway 35 for departure. Before I started moving; an FBO vehicle made a call announcing that there was an aircraft landing on Runway 17. Soon after; I had a visual on a [light aircraft] in his flare that was previously obscured from the glare of the sun. I never crossed the hold short line; and I thanked the vehicle over frequency; who stated that the traffic had not been making any radio calls. After the aircraft vacated the runway; I made an uneventful departure to the north. Although there was no immediate danger; it was a little too close for comfort. Personally; I have had no experience at an uncontrolled field with an aircraft not making any CTAF calls. I understand that it was within their right to do so; but I believe in this case it made an unsafe condition possible. The pilot must have not have picked up the ASOS; because he landed with a 7-10 kt. tailwind; I believe this added to the confusion. Luckily; the pilot didn't even use half of the 8;000 ft. runway; so if I had continued to line up on the runway; I would have easily been able to see him. To some degree; I fell victim to an expectancy bias. I will definitely take this as an important lesson moving forward.

Light aircraft pilot reported he was about to take the runway at CEW; a non-towered airport; when a ground observer alerted him to traffic landing opposite direction who was not communicating on CTAF frequency.

1825746

202107

0601-1200

SHD.Airport

VA

0.0

VMC

Daylight

CTAF SHD

Any Unknown or Unlisted Aircraft Manufacturer

2.0

Takeoff / Launch

Any Unknown or Unlisted Aircraft Manufacturer

Final Approach

Aircraft X

Flight Deck

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1825746

ATC Issue All Types; Conflict NMAC; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy

Person Flight Crew

General None Reported / Taken

Airport; Human Factors

Human Factors

On taxi-out to Runway 5 we made a radio call stating aircraft type and runway of intended departure. Upon reaching the hold short line we contacted Air Traffic Control for IFR clearance; and waited for release time for takeoff. Hold short line faces approach end of Runway 5; but does not allow pilot to view departure end of runway for on-coming traffic. After copying clearance we switched back to CTAF frequency and continued to monitor the frequency. Upon moving the aircraft we announced taking Runway 5 for takeoff and intended direction of departure. As we took the runway and started takeoff roll we encountered an aircraft on short final for Runway 23. This aircraft had not made any traffic calls and was difficult to see on the hazy background of the sky. Aircraft executed a missed approach and re-entered the pattern for Runway 5. I failed to make an abort decision at the appropriate time and continued with the takeoff and departure. Jeopardizing safety in the process.The cause was inadequate communication used by both aircraft; white aircraft on similar background and poor illumination of landing aircraft to be seen. Inadequate decision making by Captain of departing aircraft and failure to abort the departure. Ways to avoid this would be for all participating aircraft to be communicating effectively and for all aircraft to monitor the frequency and flow of traffic. Other avoidance measure would be to have an ATC facility present at the airport and better positioning of the hold short line for both sides of the runway to be seen.

Pilot reported NMAC during takeoff from a nontowered airport.

1050008

201211

1201-1800

BUR.Airport

CA

5000.0

Mixed

Daylight

5100

TRACON SCT

Air Carrier

B737-700

2.0

Part 121

IFR

Localizer/Glideslope/ILS Runway 8

Descent

Vectors; STAR LYNXX8

Aerobatic

1.0

VFR

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Last 90 Days 218

1050008

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Last 90 Days 116

1050016.0

Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude

Horizontal 500; Vertical 200

Automation Aircraft RA; Automation Aircraft TA; Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; Flight Crew Took Evasive Action

Airspace Structure; Human Factors; Weather

Ambiguous

While on approach to BUR; I was the Pilot Monitoring. We were issued a heading and a decent from 6;000 feet to 5;000 feet. ATC advised traffic at one o'clock and five miles. We advised traffic was not in sight due to being in and out of IMC. ATC issued another vector and advised traffic appeared to be descending and at one mile. As we broke out of the clouds; the traffic was in front of us (moving right to left) in a rapid descending left turn. Immediately the TCAS called Traffic and Descend. The Captain kicked off the autopilot and pitched down and turned hard right to avoid the traffic. We estimate that we came within 200 feet vertical and 500 feet horizontal from the other aircraft. We leveled off at 4;000 feet and 10-20 degrees from our assigned heading. I advised ATC that we maneuvered in response to an RA and remained at 4000 feet. We continued and landed in BUR with no further issues. Hard to say what could have prevented this incident. The other aircraft was not talking to ATC and made several rapid maneuvers; apparently to avoid clouds. The TCAS system worked. We responded in a timely manner to avoid a collision.

Our aircraft was on a 170 degree heading at 5;000 feet MSL. We were IMC and on a vector off of the LYNXX 8 STAR into BUR. We had previously received a TCAS TA from traffic that had leveled off at 6;000 feet MSL. Our heading had placed us over terrain that peaked at 3;800 feet MSL (Oat Mountain); which was about 13 NM NW of BUR. Simultaneously; SoCal issued a Traffic Alert for that same traffic; we entered VMC conditions and spotted the traffic (appeared to be a Stearman); a TCAS RA 'Descend; Descend;' which was followed immediately by an 'Increase Descent.' I disengaged the autopilot and autothrust and began a descent; but immediately increased descent rate with the 'Increase Descent' call from the TCAS. The non-communicating traffic appeared to be 'scud running' by starting a sharp descending turn in front of us and heading southeast. I descended to 4;000 feet MSL with an avoidance turn to a heading of 190. In the commotion; my First Officer and I never heard the 'Clear of Conflict' call; but the display was clear. We advised SoCal of the deviation and our heading/altitude. The Controller cleared us to maintain 4;000 feet MSL with a vector to intercept the ILS to Runway 8. The Controller advised us that the traffic was inbound to VNY and was going to get a talking to by the Tower. We continued the approach and landing without further incident.

B737 flight crew reports taking evasive action for a TCAS RA during descent into BUR. Clouds obscured visual contact with the other aircraft until the first TCAS resolution had been enunciated.

1457717

201706

Turbulence

Daylight

Air Carrier

A321

2.0

Part 121

IFR

Passenger

GPS; FMS Or FMC

Cruise

4.0

Cabin Crew Seat

X

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Flight Attendant Airline Total 36; Flight Attendant Number Of Acft Qualified On 4; Flight Attendant Total 36; Flight Attendant Type 1

Service

Confusion; Other / Unknown

1457717

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter Weather / Turbulence

Person Flight Attendant

In-flight

Company Policy; Environment - Non Weather Related; Aircraft; Weather

Company Policy

My first time working on the Airbus 321 at [Company]. There are typically 3 flight attendants working the main cabin. We hit turbulence and had to immediately strap in and guess what? There are only 2 single jumpseats with seatbelts and harnesses in the rear of the aircraft. The 3rd flight attendant is out of luck. They can't get to 3L because we are trying not to kiss the ceiling. This situation MUST BE IMMMEDIATELY addressed. There needs to be double jumpseats with 4 seatbelts and harnesses available for working crew to keep them safe. All [Company] Airbus aircraft need to be retrofitted with these.

Flight Attendant reported airline's A321s are inadequately configured with jumpseats; seatbelts; and shoulder harnesses to provide safety for three flight attendants working in the aft of the aircraft during turbulence.

1827956

202108

0001-0600

ZZZ.Airport

US

0.0

VMC

Poor Lighting

Night

Corporate

MBB-BK 117 All Series

Part 91

N

Main Rotor Blade

X

Improperly Operated

Hangar / Base

Corporate

Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown; Time Pressure; Workload

Party1 Maintenance; Party2 Other

1827956

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

N

Person Maintenance

Routine Inspection

General Maintenance Action

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

Human Factors

During the track and balance of A/C S/N XXXX; there were issues getting the blades to fly together; blade swapping took place as well as blade replacements. I was doing the paperwork portion and trusted that the information given to me was correct. When I was told which S/N's were swapped and which were replaced. Logbook entries were made and signed off reflecting those actions. Fast forward a few weeks I was sent an RO (Repair Order) to get unserviceable blades sent out for repair. I printed out the RO's placed them in the blade boxes and got the blades sent out. Nowhere in this process did I physically check the S/N's of the blades. I trusted the mechanics to give me the correct information which was a huge mistake and I should have physically verified the P/N's and S/N's as outlined in our procedures. This is the end of my statement.Do not rely on others to verify P/N's S/N's. Physically Verify P/N's and S/N's. Double-check other mechanic work to ensure completeness and that what was said was done was actually done. Follow published guidance; policies; and procedures.

Technician reported not verifying part numbers and serial numbers prior to shipping main rotor blades out for repair.

1345134

201604

0601-1200

CLT.Airport

NC

8000.0

VMC

20

Dawn

TRACON CLT

Corporate

Falcon 900

2.0

Part 91

IFR

Passenger

Climb

SID KRITR1

Class B CLT

Aircraft X

Flight Deck

Corporate

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 100; Flight Crew Total 9700; Flight Crew Type 1047

Situational Awareness

1345134

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

Person Flight Crew

In-flight

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

Chart Or Publication; Procedure

Procedure

The Jeppesen KRITR 1 RNAV SID at KCLT has a 'Speed Restriction' box. The speed restriction box states 'Upon reaching 10;000 feet accelerate to and MAINTAIN 280 KIAS; if unable advise ATC.' It then in the same box states next 'CHARLOTTE/DOUGLAS INTL only; Accelerate to 250 KIAS; if unable; advise ATC.' This is confusing. Prior to reaching 10;000 feet we asked Charlotte Departure what airspeed they were expecting us to maintain above 10;000 feet to clarify. The Air Traffic Controller stated '280 knots' we maintained the correct speed of 280 KIAS. Problem solved for us; but this ambiguous statement could cause someone else to make an error.

Falcon 900 Captain reported some confusion of airspeed requirements on the KRITR1 RNAV SID and the statement 'Upon reaching 10;000 ft.' and 'Prior to reaching 10;000 ft.'

1045727

201210

1201-1800

MRI.Airport

AK

500.0

VMC

100

Daylight

40000

Tower MRI

Government

Small Aircraft

1.0

Part 91

None

Training

Final Approach

Direct; Vectors; Visual Approach

Class D MRI

Tower MRI

Small Aircraft

1.0

Part 91

Class D MRI

Aircraft X

Flight Deck

Government

Captain; Instructor

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

Flight Crew Last 90 Days 20; Flight Crew Total 900; Flight Crew Type 800

1045727

Conflict NMAC

Horizontal 250; Vertical 0

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors

Approaching Merrill Field from the northeast from the highway; we were instructed to enter the left downwind for Runway 7 and report Clark Middle School. Upon reporting we were at traffic pattern altitude of 900 FT. Tower instructed us to extend left downwind because of landing traffic at 1;800 FT. We had traffic in sight and turned left base over the downtown shoreline. We took a wide base turn because my student was flying. We were then set up for a long final approach. Landing traffic was clear the runway and we were cleared to land on Runway 7. Upon flying over the Sheraton Hotel (a notable landmark for its location to the traffic patterns of Merrill Field) we were approximately 500 FT MSL when my student called out traffic abeam to our right at our altitude. I saw the pilot of the other plane and it was close; maybe 200 FT by my perception. We immediately dove to the left. The [other aircraft] immediately banked away and to the right.Upon landing; I called the Merrill Field Tower to complain. They indicated that we were not at fault at all. The other aircraft did not listen to three instructions to follow behind us. Apparently the [other aircraft] claimed they were mistakenly following a military aircraft at Elmendorf AFB; which I think is a complete bunch of BS. I told the Tower Controller I wanted to pursue this with the FAA because I was not pleased at the other pilot's lack of situational awareness; attention on the radio; and overall flying abilities that I have never had anything like this happen before.The Tower Manager called me back; after having pulled the radar and radio tapes. He told me that the other aircraft did not listen to instruction; and that it was 1/20th of a mile (250 FT) from us on a T-Bone 90 degree intercept. I cannot believe how close this was. Assuming that plane was flying 70 KTS; we had 2 seconds before impact. I can't believe that pilot's poor attention to let something like this happen.

Small aircraft instructor pilot reported an NMAC with another small aircraft in the pattern at MRI.

993763

201202

1201-1800

ZMA.ARTCC

FL

3000.0

Daylight

Center ZMA

Any Unknown or Unlisted Aircraft Manufacturer

IFR

Initial Approach

Class E ZMA

Facility ZMA.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Other / Unknown

993763

ATC Issue All Types; Deviation / Discrepancy - Procedural Other / Unknown

Person Air Traffic Control

General None Reported / Taken

Procedure; ATC Equipment / Nav Facility / Buildings

Procedure

Once again the VRB RADAR was taken down for preventative maintenance in the middle of the day when it is needed most. We were very busy at sector three with numerous aircraft wanting to do practice instrument approaches. We had an aircraft that came from F11 wanting to do a practice approach at VRB and then return northward to SGJ. At some point we lost this aircraft on RADAR due to the RADAR outage. I was too busy to look closely; but it is quite possible that we had numerous non-RADAR deals with this aircraft as we had numerous aircraft on vectors at his altitude. There is no reason; other than the agency being to cheap; that this maintenance cannot be done on midnight shifts when there is no demand. Every time they take the RADAR during daylight hours it causes a severe degradation in safety and efficiency. That they continue to perform these operations during times of peak demand just shows that all the agencies talk of concern for safety is just that; talk. The VRB and MLB RADAR should never be taken offline for preventive maintenance during daylight hours.

VRB RADAR was taken down for maintenance during a busy traffic period. A ZMA Controller suggests; as a safety issue; this type of elective maintenance should be completed during late night operations.

1783079

202101

ZZZ.Airport

US

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked; Taxi

Gate / Ramp / Line

Air Carrier

Ramp

1783079

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

Person Ground Personnel

Taxi

General None Reported / Taken

Human Factors

Flight departed the gate showing dangerous goods unsecured. The ramp lead tried to final multiple times without the required 15 bags and this is the alert that populated in my [Software] bar.[Error Message] The flight was already showing off the gate and had been off the gate for some time before the ramp attempted to final and they attempted to final the flight 4 times without the required bags. The lead realizing the issue then went into [Load Planning Software] and manually changed the bag count which of course allowed them to final the flight.

Air Carrier Ramp personnel reported Hazmat Dangerous Goods transported without required Hazmat cargo configuration.

1591985

201810

CLR

Air Carrier

A330

2.0

Part 121

Passenger

Climb

Low

10.0

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Flight Attendant Airline Total 35; Flight Attendant Number Of Acft Qualified On 7; Flight Attendant Total 35; Flight Attendant Type 100

1591985

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

Y

Person Flight Attendant

In-flight

General Physical Injury / Incapacitation

Aircraft; Environment - Non Weather Related

Ambiguous

Strong burning dust odor/fumes upon climb out; near level off. Unknown passenger injury; most cabin crew had reaction to fumes. Coughing; bloody sinus discharge; headaches; dizzy; burning eyes. This event did not seem to affect me physically.

A330 Flight Attendant reported most of the cabin crew and an unknown number of passengers experienced physical effects from fumes in the cabin during climb.

1241805

201502

1201-1800

ZZZ.Airport

US

0.0

Daylight

Air Carrier

B787 Dreamliner Undifferentiated or Other Model

Part 121

Parked

Scheduled Maintenance

Inspection

Oxygen System/Crew

X

Improperly Operated

Hangar / Base

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown

Party1 Maintenance; Party2 Ground Personnel; Party2 Maintenance

1241805

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

N

Person Maintenance

Routine Inspection

General Maintenance Action

Human Factors; Procedure

Human Factors

Upon receiving three B787 oxygen bottles. I; Aircraft Maintenance Technician (AMT) in ZZZ inspected these bottles before putting them in service. This is normal practice in ZZZ. It was at this time I noticed one bottle was low; one was empty and the other was at 2000 psi (normal). My investigation revealed that all three bottles had damaged (bent) Gauges. ALL three is alarming to me. I have attached photos of all three bottles along with the Non-Rotable Parts tags. There needs to be an investigation to determine where the damage is occurring. And we need to check all B787s to determine if they are flying around with damaged bottles. Flight Deck Crew. Component.

Reporter stated flight crews have two oxygen bottles located in the Main Equipment Center (MEC) under the cockpit floor. Bottles are made of composite materials with a valve head on the bottle that is different from earlier composite bottles. Mechanics must shut off both bottles when servicing either bottle to prevent loss of oxygen from bottle not being serviced. Bottles have to be removed for oxygen servicing; requiring a two-person effort. No scratches or dents are allowed on any bottle.Reporter stated his air carrier went to an all metal box for transporting their oxygen bottles because they are shipped pressurized on aircraft with 2;000 pounds of pressure. The containers are designed to handle heat and bottle pressures. They recently identified the cause of the damaged oxygen gauges on the bottles to be from the plastic shipping containers that had previously been used to ship oxygen bottles by ground; but are still used for storing them. The B787 composite bottles were not secured in the plastic containers and would slide around inside. Damage to the bottle valve head and gauge was more likely to occur when the plastic box was stood up on one end. His air carrier has already accomplished a Fleet Campaign and found one bottle installed with the bent pressure gauge. Almost all of the bent; damaged bottle gauges were found to be leaking oxygen.

An Aircraft Maintenance Technician (AMT) reports finding three Crew Oxygen bottles with damaged (bent) pressure gauges during a Receiving Inspection procedure prior to putting the bottles in service. Concerns also raised as to where the damage had been occurring and whether other aircraft may be flying around with damaged bottles.

1424776

201702

1201-1800

700.0

Daylight

Personal

Stagger Wing 17

1.0

Part 91

Personal

Carburetor

Z

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 3; Flight Crew Total 2593; Flight Crew Type 18

Troubleshooting

1424776

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter Weather / Turbulence

N

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Landed in Emergency Condition; General Evacuated

Weather; Aircraft

Aircraft

I was flying about 700 feet AGL; when the engine sputtered and quit (I believe it was caused by carburetor icing.) I pushed the throttle ahead full; pulled carb heat and pumped the hand pump with no results so I ended up landed in the only safe place to land that would also cause the least damage to the aircraft. I landed gear up on the snow in a swamp instead of the woods.

A Beechcraft Staggerwing pilot reported losing engine power around 700 feet and landing straight ahead with his gear up.

1507525

201712

1801-2400

ZLC.ARTCC

UT

11000.0

Center ZLC

Personal

Caravan 208B

1.0

Part 91

IFR

Personal

Cruise

Direct

Class E ZLC

Facility ZLC.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 6

Confusion; Situational Awareness

1507525

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Procedure; Manuals; Human Factors; Airspace Structure

Manuals

A Cessna Caravan; not in radar coverage; was [getting] handed off to me from a Center Sector 10 [at] 11;000 feet direct to the KSGU airport on a random route. I attempted to contact the Center sector about the aircraft as they were going through several areas of high terrain and many active military use airspaces. There wasn't an answer. Eventually they contacted me. I told them I could not take the aircraft because he was non-RADAR on a random direct route where no points on his path were displayable on my scope.The controller became agitated and asked me how he could fix it. I didn't have an answer; at that point; the rule had already been broken and I wasn't sure how he could fix it. He then got even angrier that he didn't know that he should have read the FAAH 7110.65 before he started controlling traffic; instead of asking me to explain it to him over a shout line while I was busy. I finally got the aircraft; not in radar contact; and I knew the transferring sector wasn't going to fix it; so the safest course of action was to give the aircraft to me. I made sure the aircraft was level above the highest terrain in the area and cleared him direct to a VOR within NAVAID use limitations.

ZLC ARTCC Controller reported they were handed off an aircraft below their radar coverage on a random direct route instead of an approved non radar route.

1256321

201504

1201-1800

ZAU.ARTCC

IL

Daylight

Center ZAU

Air Carrier

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Cruise

Class A ZAU

Facility ZAU.ARTCC

Government

Enroute; Supervisor / CIC

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 2.75

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

Party1 ATC; Party2 ATC

1256321

Facility ZAU.ARTCC

Government

Enroute; Supervisor / CIC

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 2.75

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

Party1 ATC; Party2 ATC

1256325.0

ATC Issue All Types; Airspace Violation All Types; Deviation / Discrepancy - Procedural Published Material / Policy

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Separated Traffic

Airspace Structure; Human Factors; Procedure

Procedure

The WIANG A/B/C military airspace went active on the radar scopes in the Northeast Area 15 minutes earlier than scheduled. I had the Squib radar controller ask me if the airspace was active because his GI (general information) said that it wasn't to go active until XX00Z. I quickly checked the SAMS website and it said that it began at XX00Z.I then attempted to contact the military position in the Traffic Management Unit (TMU) to find out what was going on. They did not answer the phone due to being overwhelmed with multiple positions combined in TMU due to lack of staffing in the TMU. As I was about to walk up to TMU to ask them about the status of the airspace; the airspace turned off the radar scopes. Then TMU called me (the Northeast Area FLM) and the North Area Front Line Manager (FLM) on the VSCS. They explained that the WIANGs were turned on by accident; that the WIANGs were not going to go active until XX00Z; and that the VOK airspace was active early at XX00 minus 15 minutes Z (which was already coordinated with the North Area and does not impact the Northeast Area).A few minutes later; TMU called and said that the WIANGs airspace actually did go active at XX00 minus 15 minutes Z and to protect for it.I believe that the coordination between Chicago ARTCC's TMU and Minneapolis ARTCC's TMU is breaking down. I also believe that the lack of staffing and fatigue in Chicago ARTCC's TMU is playing a major role in this and yesterday's situation. I do not know what training was transpiring in TMU over the past two days.This is the second day in a row where the WIANG airspace was not executed/coordinated correctly. Get more staffing in Chicago ARTCC's TMU (TMCs and STMCs)! Hire more FLM staffing in Chicago ARTCC!Have Chicago ARTCC's TMU; Minneapolis ARTCC's TMU; and the military re-evaluate the process for activating the WIANGs airspace. However it might not be a problem with the procedure; but proper staffing and training.

I (the Front Line Manager (FLM) of the Northeast Area) received a call about 3 or 4 minutes prior to the WIANG A/B/C military airspace going active from FL180 through FL240 (normal stratum) from ZAU's Traffic Management's military line. They were asking if we could extend the WIANGs airspace up to FL290. I told them that I would have to check with the controllers that it affected and to see if there was any aircraft in or about to overfly the WIANGs (240B290). TMU told me to notify the North Area once I had an answer and that they would follow through with the coordination. When I asked all the controllers; they were fine with it and there was no traffic (at that time).I walked down to the North Area (which is the next aisle down) and told the FLM that we were good with it. This FLM was not a FLM from another area; had little to no familiarity with the North Area; and was placed in the North Area to have FLM coverageMinutes later I had the trainer from the Pullman sector (#25) walk up to me at the Northeast Area desk asking about what was going on with the WIANGs. I asked him what he meant. He told me that there was two Aircraft X types about to fly through at FL250. I walked over to the Pullman (#25) and Fremont (#24) sectors and told them that the airspace was released FL180 through FL290. The trainee at the Fremont sector told me that they were just told from the North Area controller that the planes could go through at FL250. They said that a tanker only wanted FL270 through FL290 and that planes could go through at FL250 and FL260.However; we released 180B290 and that is what Minneapolis Center and the military coordinator believes was active. I ran down to the North Area and barked at them that they needed to turn the aircraft out and re-explained the situation. I then got into an argument with the controller (radar and radar associate position combined) and two other controllers. He kept saying that it was okay that the tanker was 270B290 and the remainder of the WIANGs were 180B240. I asked him how the fighters were going to get to the tanker (because VOLK Air Force Base and ZMP were the only ones controlling the airspace and talking to the fighters and tanker).The North Area FLM then re-instructed them to get those planes away from there and he said that he needed a D-side immediately. The training team at the adjacent sector ceased training on their D-Side and the trainer slid over and jumped on the D-side to help.The Aircraft X aircraft flew into the WIANG A/B/C airspace at FL250 before being issued turns to exit the airspace.Additionally; the SAMS website was not updated and the ERAM/EDST only displayed 180B240 which added to the confusion. First; the controllers need to understand that they can't arbitrarily alter airspace once it has been given away without going through proper channels. The North Area controllers by-passed management and the traffic management units of both ZMP and ZAU. I think that the North Area needs to receive a briefing; eLMS course; and/or given a presentation explaining the proper procedure for coordinating airspace. It should explain all of the parties involved and possibly a flow chart of how the request and activation process works.A mandate should be issued and followed that a FLM who has never certified on any positions in a specific area should not be put in charge of that area. I believe that the FLM-IC was not familiar with the process for activating the military airspace; the airspace of the area (in general); and the people of that area. The FLM had no respect and received much doubt and second guessing due to him not being from that area. A FLM from that area would have known all of that and would know how to speak to certain people due to their familiarity. The FLM staffing is way below guidelines and has been this way for over a year; which has led to many areas not having enough FLMs to cover their areas throughout the week(i.e. 3 FLMs in multiple areas can't cover all the shifts). Many FLMs are being moved around the facility as 'mystery guests' to different areas and areas that they have no knowledge of. I believe that the entire facility should receive a briefing; an eLMS; and/or a briefing tracker (BT) presentation about ways to recover when an aircraft is about or has already entered military airspace. Methods such as using UHF guard to call in the blind to the military fighters and tanker to warn them about the traffic; using VHF guard to issue headings to the plane to keep them away; having the scheduling office give back airspace temporarily; etc.

A Chicago Center (ZAU) Front line Manager (FLM) reports of confusion concerning a reference to a Special Use Airspace (SUA) and whether it is hot or not and tries to figure it out. Aircraft are in the area and then they are notified that it is hot and has been for about 15 minutes.

1427065

201702

0601-1200

BZN.Airport

MT

10000.0

IMC

Daylight

TRACON BOI

Air Carrier

Airbus 318/319/320/321 Undifferentiated

2.0

Part 121

IFR

Passenger

GPS; Localizer/Glideslope/ILS Runway 12

Initial Approach

Class E BOI

GPWS

X

Design

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 498

Situational Awareness

1427065

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 482

Situational Awareness

1427046.0

Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter CFTT / CFIT

Automation Aircraft Terrain Warning; Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Issued Advisory / Alert; Aircraft Equipment Problem Dissipated; Flight Crew Took Evasive Action

Aircraft; Airspace Structure; Procedure

Aircraft

In the descent to BZN; we were given direct KICDO (IAF on ILS 12) and a descent to 10;000 MSL. Approximately 9-10 miles east of KICDO; we received a GPWS 'TERRAIN; TERRAIN' while IMC. I; as pilot flying; performed the GPWS escape maneuver and climbed up to 11;000 while the captain notified ATC and we were given a stop climb at 11k. The controller said he doesn't usually have anyone have any GPWS hits in that sector but also mentioned the MSA had recently changed in the past few months. We continued to fly the ILS to a full stop without any more incidents.

[Report narrative contained no additional information.]

Airbus A320 series flight crew experienced a terrain warning descending to 10;000 feet approximately 9 NM east of KICDO during the ILS 12 at BZN. The aircraft was climbed to 11;000 feet and ATC confirmed that 10;000 feet was the correct altitude.

1852365

202106

0.0

UAV: Unpiloted Aerial Vehicle

None

Remote PIC (UAS)

Flight Crew Commercial; Flight Crew Flight Instructor; Flight Crew Remote Pilot (UAS); Flight Crew Instrument

Training / Qualification; Confusion

1852365

Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Unauthorized Flight Operations (UAS)

Person UAS Crew

Other Post Flight

General None Reported / Taken

Human Factors

I am an ASEL and rotorcraft rated pilot and I teach Part 107 classes. I obtained my Remote Pilot certificate through the FAA Safety website and have had it for approximately X years. After two years; I renewed my certificate under the Part 61 Pilots Recurrent course. Since that renewal; my flight currency in manned aircraft has expired. I believe this means that I cannot use my 'Part 61 Pilot with Currency' certificate and have to take the Non-Part 61 recurrent course. I didn't realize this until I had been flying for approximately X months past my expiration of Part 61 currency. To aid in my Part 107 teaching; I decided to watch the 'Non-Part 61 Pilot Recurrent' training and saw that the intended audience included 'Part 61 Certificate Holders who do not have a current flight review'. I am now taking the appropriate course.

UAS pilot reported not completing the correct recurrent Part 107 training at the time of their Part 61 currency expiration.

993416

201202

0001-0600

ZZZ.Airport

US

0.0

Night

Air Carrier

B737-800

2.0

Part 121

Passenger

Parked

N

Y

Unscheduled Maintenance

Work Cards; Inspection

Hydraulic Syst Reservoir Tank

Boeing

X

Improperly Operated

Gate / Ramp / Line

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Confusion; Situational Awareness; Communication Breakdown

Party1 Maintenance; Party2 Maintenance

993416

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

N

Person Flight Crew

Pre-flight

General Maintenance Action

Manuals; Human Factors; Aircraft; Procedure; Chart Or Publication

Human Factors

As I started my preflight duties in the cockpit; I noticed the 'A' hydraulic system quantity indicating 106%. A logbook entry was made and Maintenance notified. After Maintenance arrived at the jet; one of the Maintenance Technicians apologized that the previous Maintenance crew had not noticed the over-serviced hydraulic system and that they had not corrected the issue. He went on to explain that the over-serviced hydraulics should have been corrected prior to the Pre-Departure Checks being signed-off. After this comment was made; my First Officer began having second thoughts about an observation he made on the #1 engine and asked me if I would mind inspecting the #1 engine with him. After going outside and looking at the #1 engine; I noticed what appeared to be a nick and some white-gray streaking on the front of and behind the # 10 fan blade on engine # 1. Also; there was a white 'nick' on the #1 engine spinner dome so I instructed my First Officer to enter this information in the maintenance log and we called Maintenance back to the jet to address this issue. Maintenance came out and ultimately determined there was a piece of paper that had lodged in the #1 engine. The paper was removed; the fan blade cleaned; along with the engine spinner dome; and the maintenance log was signed-off. After observing both of these incidents on the same scheduled ETOPS flight; both of us began to have reservations as to whether our mechanics in this airport are doing the job that our Air Carrier pays them to do and properly inspecting our jets prior to ETOPS departures. This event was caused by Maintenance's failure to correct the above mentioned mechanical discrepancies prior to signing-off the ETOPS Pre-Departure Checks.

A B737-800 Captain describes his reservations as to whether company mechanics at one of their island airports are properly inspecting their aircraft prior to ETOPS departures. An overserviced 'A' system hydraulic reservoir quantity and 'nicks' on #1 engine fan blade and spinner dome had not been corrected or addressed.

1503275

201712

0601-1200

ZZZ.Airport

US

Daylight

CLR

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Initial Approach

High

128.0

100.0

5.0

APU

X

Malfunctioning

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Airline Total 30; Flight Attendant Number Of Acft Qualified On 3; Flight Attendant Total 30; Flight Attendant Type 90

1503275

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

N

Person Flight Attendant; Person Flight Crew

In-flight

Flight Crew Returned To Departure Airport

Aircraft

On gradual descent; a very strong 'smelly sock' odor occurred. The worst one in my 30 years. On arrival at the gate; I asked the FO (First Officer) about the odor and if they smelled it. He said yes and it was because the APU was turned on during descent. We were then to go on to do a turn. All 3 FA's (Flight Attendants) said they felt odd. I said I could not pinpoint it but my head and body felt off. Half a headache and trouble speaking. I told the next flight deck about the situation. We took off and after about 15 minutes the Captain called me and asked if we still smelled the odor. I said yes. A moment later he made a PA saying we were returning to due to [a mechanical problem] and possible oil leak. We landed and were met by supervisors asking how we felt and if we're going to continue to go on to do the turn. The Captain said he did not feel safe going back on the plane. He had a headache and felt bad. He went to the chief pilot and then was going to the clinic. All 3 FA's felt dizzy; half a headache; and just felt off. Supervisor told me my bottom lip was quivering when I was trying to speak. All 3 FA's declined to work the turn and all went to the clinic. After the clinic; I stopped at ER to tell them what happened. They had me call poison control. It took a full 2 days for me to return to somewhat normal.

A319 Flight Attendant reported a strong smelly sock odor followed by a headache and difficulty speaking.

1853967

202111

1201-1800

ZZZZ.ARTCC

FO

40000.0

VMC

Daylight

Center ZZZZ

Air Carrier

B767 Undifferentiated or Other Model

2.0

Part 121

IFR

Ferry / Re-Positioning

Cruise

Vectors

N

Y

APU Electrical

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 150.97; Flight Crew Total 788.07; Flight Crew Type 788.07

Distraction; Communication Breakdown; Situational Awareness; Troubleshooting

Party1 Flight Crew; Party2 Maintenance

1853967

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

N

Person Flight Crew

In-flight

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

Procedure; Aircraft; Human Factors

Aircraft

We started this maintenance ferry from ZZZ1 to ZZZ with an APU that was not verified for ETOPS flights so we had to run the APU for the entire flight. Upon parking in ZZZ we lost the APU generator after engine shutdown. The APU was still running but the generator could not pick up the electrical load and the airplane lost all electrical power. We made a maintenance write up and went to hotel.The next day before our scheduled flight from ZZZ to ZZZ2 we told Maintenance that we were going to shut the engines down after start to verify that the APU generator can handle the load in case of engine failure or failures in flight. The APU generator was able to pick up the load and we proceeded on our flight to ZZZ2. Upon parking in ZZZ2 and shutting down both engines we lost the APU generator once again and the airplane lost all electrical power. We made another maintenance write up.During the day I called ZZZ2 Maintenance to find out what the status of our APU was and to let them know that we wanted to do another engine run before our flight to ZZZ3 and test the capabilities of the APU generator. I was told that it would be no problem and was welcomed as ZZZ2 does not have qualified engine run mechanics. We went to the airport early and received authorization from Maintenance Control to perform the engine run. We started the engines and then with electrical and bleed air load on the APU we shut down the engines and the APU generator once again handled the load.We took off headed to ZZZ3. We were at our cruising altitude of 40;000 feet and about 250 nm from our CP we lost the right FMC. We accomplished the non-normal checklist and also performed a Navigation Accuracy test due to our concern of headed to [foreign country] airspace. During our accuracy test we discovered the primary IRS was displaying 6.72nm and our RNP for the airspace was 4.0nm. We tried to establish contact with Dispatch multiple times for assistance and coordination but were unsuccessful either via Satcom or HF radios. Due to our concerns about Country X airspace being controlled by the military; our concerns about our navigation capabilities and with no way to contact dispatch directly we felt as a crew that the safest course of action was to return to ZZZ2.Also; the fact that we had very little confidence in our APU and we were down to 1 autopilot since the center autopilot was deferred and with the loss of right FMC we lost the right autopilot plus our inability to communicate with dispatch headed to a non English speaking and military controlled airspace; all contributed to our decision to return to ZZZ2.We were able to speak to Aircraft Y that was also headed to ZZZ3 and they let Dispatch know our concerns and our intentions to return to ZZZ2. We were finally able to contact ZZZ radio and received a clearance to return direct to ZZZ2. We did not declare an emergency.Upon shutting down our engines in ZZZ2 the APU generator for the 3rd time could not pick up the load and the airplane lost all electrical power. We wrote it up again.

B767 Captain reported that the aircraft APU failed three times to assume the electrical load after engine shut down. During a repositioning flight; the aircraft lost navigation and communication systems after which the Captain elected to perform an air turn back to the departure airport.

1660759

201907

1801-2400

ORD.Airport

IL

0.0

VMC

Ground ORD; Tower ORD

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 114; Flight Crew Type 95

Confusion; Time Pressure; Situational Awareness

1660759

Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Other / Unknown; Ground Incursion Taxiway

Person Flight Crew

Taxi

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Airport

Last leg of a 3-day pairing. FO [First Officer] was flying pilot. We were assigned RWY 27L ILS in visual conditions. FO flew on speed and touched down more than 1;000 feet down the runway but well within the touchdown zone. Though MED brakes were selected along with maximum reverse thrust; we were unable to make Taxiway A-1. As control was transferred to me during the rollout; I eased off the brakes a bit; intending to exit left at RWY 4L; which is closed but able to be used for turnoff from RWY 27L. As I began looking for the left turnoff beyond Taxiway A-1; I realized that RWY 4L no longer has any illuminated markings. I recently upgraded to the left seat from the right seat of [another aircraft type] and had not made a night landing on RWY 27L in several years; not since the runway was closed and all illuminated markings were removed. There are no lead-off lines; no taxiway centerline lights; and no taxiway edge lights. At night; RWY 4L left exit from RWY 27L is a dark spot between normally spaced RWY edge lighting. This being the case; I realized that I knew generally where the turn off was; but not exactly. My FO did not immediately realize my confusion until I was carrying excessive speed approaching the turn off. As I began to leave the centerline to make the turn off; I braked firmly and steadily; slowing to an almost stop at the right edge of the RWY 4L 'taxiway' location. Our nose was just short of the taxiway edge markings and I could see the edge lights in front of me. Since ATC had vectored our trailing aircraft so closely to us; I opted to do a slow speed; sharp left turn (similar to lining up on the runway for takeoff) in order to regain the taxiway centerline and exit the active runway. Though this entire evolution took very little time; the poor markings and momentary loss of orientation on my part made me extremely uncomfortable.

Air carrier Captain reported poor runway turnoff markings at ORD airport contributed to a momentary loss of orientation.

1233662

201501

0601-1200

ZSPD.TRACON

FO

IMC

Daylight

TRACON ZSPD

Air Carrier

B747-400

4.0

Part 121

IFR

Cargo / Freight / Delivery

FMS Or FMC

Initial Approach

STAR SAS 12I

FMS/FMC

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Time Pressure; Human-Machine Interface; Fatigue; Confusion

1233662

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 80; Flight Crew Total 5600; Flight Crew Type 400

Confusion

1233963.0

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

Person Air Traffic Control; Person Flight Crew

In-flight

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

Human Factors; Procedure

Human Factors

About an hour from ZSPD the relief crew asked for expected arrival procedure in to ZSPD. The relief crew asked two different controllers. Both controllers told them to ask the next controller. About 50 min from ZSPD Capt. and First Officer (FO) resumed operation of the aircraft. We also inquired about approach in use and were passed on to the next controller. At this point the controller cleared us direct to the second fix on the arrival and handed us over to a new controller. We inquired what to expect after (second Fix) and were give the following clearance - Cleared for the SAS12i arrival. This starts at SASAN. The SAS12i was entered in to the FMC; It appeared normal on the legs page and the ND and was executed. LNAV was engaged. About 30 sec later I said why is the Aircraft turning. The Aircraft had turned 30 degrees to the left of desired heading. My immediate action was to select 'Heading Select' and turn the aircraft about 60 degrees in the opposite direction in order to get back on Course. It came to our realization the IAF SASAN never cycled thereby creating a classic problem of having the active waypoint behind us. The clearance to fly the approach was given either right before the IAF SASAN or on top of it. The IAF SASAN was literally at the back of the Aircraft Diamond on the Navigation Display. I estimate the error to be less than one mile left off course given the speed of about Kias 280. ATC asked why we were turning and we tried to convey this to ATC; I am however pretty sure the information was not understood. Contributing factors: 1. Chinese ATC not giving an approach clearance in a timely manner when requested.2. Operating crew did not catch that the aircraft was close enough that it might not Cycle properly; as there is a small delay in the FMC. 3. The FMC contains 19 pages of arrivals in to ZSPD each has several variations and multiple transitions. It is time consuming to figure out exactly which one is the correct approach. Even when selecting the Runway in use in this case RWY 16 there is still 7 FMC pages with variations and transitions. These are not readily identifiable when compared to Jeppesen approach plates. Several must be entered in to the FMC in order to be compared to a Jeppesen plate for verification. 4. Fatigue: This was at the end of an 18 hour duty day with a rolling 2 hour delay.

[Report narrative contained no additional information.]

B747-400 flight crew reports being cleared direct to the second fix on an SAS 12I arrival to ZSPD before being cleared for the arrival. When the arrival clearance is issued the crew does not clean up the legs page in the FMC to reflect direct to the second waypoint and a minor track deviation occurs.

1157964

201403

0001-0600

ZZZ.Airport

US

3.0

1100.0

VMC

10

Daylight

12000

Tower ZZZ

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

None

Training

Final Approach

Class D ZZZ

Tower ZZZ

Skyhawk 172/Cutlass 172

1.0

Part 91

VFR

Training

Initial Approach

Visual Approach

Class D ZZZ

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 21; Flight Crew Total 250; Flight Crew Type 17

Communication Breakdown; Confusion; Training / Qualification; Situational Awareness

Party1 Flight Crew; Party2 ATC

1157964

Conflict Airborne Conflict

Horizontal 500; Vertical 100

Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Took Evasive Action

Human Factors

I am an instrument student currently flying a rental C-172P (17 hours) while my C-182P (110 hours) is waiting for completion of an engine overhaul. I currently have 45 hours of simulated instrument flying. I was flying a training instrument approach ILS 25 in VMC under the hood with lfight instructor serving as safety pilot. We had been cleared for instrument approach without separation services by Approach. We had contacted Tower and reported at the outer marker. The approach was proceeding well and we were on the localizer and on the glideslope. Another aircraft had just departed a nearby Class D heading to our airport for touch and goes. The aircraft turned toward our flight path and Tower advised the other aircraft that they were flying into the path of an aircraft on approach and to 'turn North immediately'. The other aircraft turned further toward intercept with our flight path. My flight instructor took the controls for evasive maneuvers rolling to the right and climbing to avoid a mid-air collision with the other aircraft.

A C172 hooded student instrument pilot reported his instructor took evasive action from an aircraft inbound to the same runway after the other pilot failed to turn away as directed by the Tower.

1597445

201811

1201-1800

ZZZ.Airport

US

IMC

Icing

TRACON ZZZ

Air Carrier

Embraer Undifferentiated or Other Model

2.0

Part 121

Passenger

Climb

Class B ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

1597445

Pilot Not Flying; First Officer

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

1597446.0

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition

Aircraft

During climb while in icing conditions; the following messages posted: ICE COND - A/ICE INOP (Warning); WG A/ICE FAIL (Caution); STAB A/ICE FAIL (Caution). The QRH directed the crew to exit and avoid icing conditions. The crew determined that an immediate return to ZZZ was the safest course of action. We [advised ATC] and returned to ZZZ. Discrepancy was entered into the AML.Unknown what caused the A/ICE FAIL.There isn't much training in the sim surrounding non-engine related emergencies. I would suggest that more time in the simulator; or more scenarios with situations like this are added to the training curriculum.

Shortly after takeoff; we received an EICAS advisory message of icing conditions. We were in the presence of visible moisture and the temperature was conducive to such conditions. As we continue our climb through 1;500 ft and were instructed to contact ZZZ Departure; we received WING and STAB anti-ice fail caution EICAS messages; a few seconds later we received the anti-ice fail warning message. As the Pilot Monitoring; I referred to the QRH Checklist; while asking ATC information about the cloud tops - in an effort to exit and avoid icing conditions as instructed by the QRH. At that time; we determined to return back to the airport. The captain asked me to [advise ATC]. After landing safely; the Captain entered the discrepancy in the [logbook].

EMB-140 flight crew reported an A/ICE FAIL condition after departure led to a return to the departure airport.

1848677

202110

0601-1200

ZZZ.Airport

US

0.0

VMC

Ground ZZZ; Ramp ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Other Push-back

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

Flight Crew Last 90 Days 27; Flight Crew Total 4240; Flight Crew Type 129

Time Pressure; Workload

1848677

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

Person Flight Crew

Other Pushback

Flight Crew Overcame Equipment Problem

Human Factors; Procedure

Procedure

During preflight; the crew had received the planned dangerous goods message. The First Officer and I had discussed the fact that we needed our Final Dangerous Goods message before pushback in our preflight briefing. We had completed our preflight briefing 20 minutes prior to schedule pushback; and in our haste to get the flight out on time; we started the push and had not received our Final Dangerous Goods message. Part way through the pushback; I recognized that error and decided to finish the push and then contact operations about no Final Dangerous Goods message. Shortly after setting the parking brake; we received our Final Dangerous Goods message. Since I made the mistake of pushing without that message I had decided not to taxi until we received it and fortunately we received it shortly after commencing the push. The rest of the flight was completed normally.

Captain reported push back from departure gate without required Final Dangerous Goods document.

1758196

202008

1201-1800

AUS.TRACON

TX

2000.0

TRACON AUS

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC

Other Holding Pattern

Vectors

Class C AUS

Engine

X

Facility AUS.TRACON

Air Carrier

Approach

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 28

Distraction; Situational Awareness

1758196

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

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Departure Airport

Airspace Structure; Human Factors; Aircraft; Procedure

Human Factors

Aircraft X departed and told the tower they had some sort of engine malfunction. They handed him to me after the pilot requested to level off at 2;000 ft. and go somewhere to hold while the crew evaluated their options. After speaking to the pilot I took action to vector him around in our airspace until they had a decision to continue or return. I asked if he wanted to stay at 2;000 ft. and he answered in the affirmative. While box vectoring the aircraft it may have entered a small 2;500 ft. MVA (Minimum Vectoring Altitude) in the southeast portion of the airspace before before completing an assigned turn to a heading of 360 away from the 2;500 ft. MVA.

TRACON Controller vectoring an aircraft in a box pattern pattern vectored the aircraft below the Minimum Vectoring Altitude.

1825187

202107

1201-1800

ORD.Airport

IL

0.0

VMC

Daylight

Tower ORD

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Landing

Class B ORD

Ground ORD

Air Carrier

Commercial Fixed Wing

Part 121

IFR

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Situational Awareness

1825187

ATC Issue All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Jet Blast; Inflight Event / Encounter Other / Unknown; No Specific Anomaly Occurred Unwanted Situation

N

Person Flight Crew

In-flight

Flight Crew Regained Aircraft Control

Environment - Non Weather Related; Procedure; Aircraft; Airport

Procedure

ATC advised we would be following a heavy aircraft on approach into ORD. While on short final; I observed the aircraft we were following on Taxiway P; headed eastbound. We continued on the approach and did not experience any effects of wake turbulence. I heard ATC instruct the aircraft to turn left onto Taxiway EE and taxi onto Runway 28R; which requires a turn of more than 90 degrees to complete. As the heavy aircraft negotiated the turn; I was just beginning to flare for the landing. I suddenly experienced what seemed to be a heavy crosswind from the right (much heavier that what was being reported); associated with a higher than normal pitch attitude to arrest the descent rate just before touchdown. Approximately 1-2 seconds before touchdown; the stick-shaker activated until the main landing gear made contact with the runway. A normal touchdown and roll-out was performed and we taxied to the gate without incident. The First Officer and I both agreed during the debrief that the approach and landing was stable and on proper speed throughout.I believe the cause of this event was a result of ATC giving the instruction to the heavy aircraft to make the left turn; causing its jet blast to cross directly over the approach end of Runway 28C. It appeared to create a crosswind/tailwind from the 5 o'clock position of our aircraft. I believe this is what contributed to the higher than expected crosswind from the right and the stick-shaker to activate just before touchdown. If ATC would have had the heavy aircraft hold short until the turn could be made in between arrivals; I believe this situation could have been avoided.

Air Carrier Captain reported encountering jet blast while landing as a result of ATC clearance to heavy aircraft while in close proximity to active runway.

1265940

201505

1201-1800

DEN.Airport

CO

10.0

10000.0

VMC

Daylight

TRACON D01

Air Carrier

Large Transport

2.0

Part 121

IFR

Passenger

Climb

SID SPAZZ

Class B DEN

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 243; Flight Crew Type 10000

Distraction; Confusion; Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1265940

ATC Issue All Types; Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

In-flight

Air Traffic Control Provided Assistance; Flight Crew Returned To Clearance

Human Factors; Procedure

Procedure

Climbing out of DEN on the SPAZZ Departure off Runway 17R; climb via except maintain 10;000 ft. Hand flying. Approaching 10;000 ft; Controller gave us direct SPAZZ. Turned the aircraft and then Controller called traffic one o'clock; ten miles; I thought I heard him say 'out of 11'. I thought it odd that he'd turn us towards a descending aircraft and proceeded to slow the climb. As we looked for traffic I made a remark to the FO that I 'didn't like this'. As we were looking for traffic I may have climbed slightly above 10;000 ft. Controller then said '(call sign) verify you're climbing to 11;000 ft.' Thinking I'd screwed up; I immediately raised the nose and started the aircraft towards 11 when the Controller corrected himself and said '10;000 ft'. At that time we were about 10;350 ft. FO and I looked at each other and there was an immediate discussion about what we were cleared to since the next waypoint we would've had was RAYDR; which is at or below 10;000 ft but once turned off the SID that shouldn't have applied. The aircraft was headed back down to 10;000 ft when we acquired and called the traffic. Controller then gave us a turn to 120 degrees. Started the turn and Controller then gave the 'possible pilot deviation call this number'. When we got to [our destination] we called. ATC said the Controller's instruction was 'direct SPAZZ; maintain 10;000 ft.' Neither of us recalled hearing the 'maintain 10;000 ft' and PM responded with 'direct SPAZZ' with no altitude mentioned. They also claimed we'd not leveled off at 10;000 ft and got as high as 10;500 ft; and that we were at 10;300 ft when the Controller queried us. They did acknowledge that the Controller did say 11;000 ft at first and then corrected himself. They said that since we had the aircraft in sight; there wasn't a conflict but they would have to pass it up for review and would get back with us. I believe this was more of a Controller error because when he asked us to verify we were climbing to 11;000 ft set the stage for the confusion that followed.

Pilot reports of a confusing transmission and instruction to climb to a different altitude then assigned and then descend back to the previously assigned altitude.

1211033

201410

1801-2400

ZZZ.Airport

US

6000.0

Tower ZZZ

Personal

Amateur/Home Built/Experimental

Part 91

Final Approach

Class D ZZZ

Tower BJC

Personal

Amateur/Home Built/Experimental

Part 91

Other Missed

Class D BJC

Facility ZZZ.Tower

Government

Local

Air Traffic Control Fully Certified

Communication Breakdown; Situational Awareness; Confusion

Party1 ATC; Party2 Flight Crew

1211033

ATC Issue All Types; Conflict Airborne Conflict; Deviation - Track / Heading All Types

Person Flight Crew; Person Air Traffic Control

Flight Crew Executed Go Around / Missed Approach

Human Factors

[Two yellow experimentals] were inbound from the north or northeast. Aircraft X was instructed to fly to right base and I can't recall if I instructed Aircraft Y for a right base or right traffic. I observed who I thought was Aircraft X turning base to final in front of a Cessna on a practice approach; and instructed Aircraft X to turn in towards the numbers. Being surprised that the base traffic was not flying a tight base as instructed; I immediately had the Cessna abandon the approach to the southeast. There was some haze in the area that made it more difficult than usually to spot aircraft as well. I was under the impression that Aircraft X was on final; but I believe he was actually still a few miles to the north; while Aircraft Y was on final. As this situation evolved; each time Aircraft X transmitted; I do not remember being able to understand anything other than the pilot's callsign. In hindsight; I think he was trying to bring to my attention that I had the two aircraft confused; and that he was actually NOT on final or the first aircraft in the sequence. I was attempting to get Aircraft X to fly a tight pattern to sequence him in front of the Cessna - but since I had the two aircraft confused; he actually turned base to final in front of Aircraft Y instead. I attempted to mitigate the situation by telling Aircraft Y to fly east (no pilot response); and finally Aircraft X said he was in front of Aircraft Y flying over the runway - and asked if I still wanted him to go around? (At this point I knew I needed one or both experimentals to go-around to protect runway separation). I observed Aircraft X was on the go and I instructed him to fly runway heading; while Aircraft Y crossed the threshold behind him and safely landed. From the go-around; I sequenced Aircraft X back into right closed traffic for an uneventful landing.As the aircraft proceeded inbound; I may have mixed up the targets with other aircraft operating outside the airspace to the north. Adding some confusion was that there was also an unidentified airspace violator southbound between 070-075 at the time. Some additional factors that added complexity were that I just changed runway configuration to accommodate practice approaches; and I was working from a different position in the cab than I usually would. Finally; the runway designators recently changed; making transmissions more challenging as we grow accustomed to using the new numbers. I feel a number of different factors came into play to cause the event. For whatever reason; I was convinced that I initially identified which aircraft was which; and then issued control instructions on that basis. I think some of the complexity factors identified above; along with a rush of inbound traffic; came together with the pilot/controller communications problem I encountered to make it difficult to detect that I confused the aircraft. I believe I overlooked the clues that I had misidentified the aircraft while I was focused on resolving a potentially hazardous conflict between base traffic and a practice approach. And finally; both aircraft have a similar appearance and perform similarly; which made it hard to tell them apart. Bottom line: be ready for the unexpected and constantly be on the lookout for clues that aircraft mis-identification may have occurred. In hindsight; it may have been more worthwhile to confirm the position of one of the other aircraft that was not experiencing radio problems - and this is another 'tool' I will take away and keep in mind for similar scenarios in the future.

Local Controller described a go-around event caused by his/her misidentification of two like aircraft in the pattern; radio communications adding to the confusion.

1307208

201511

0001-0600

RNO.Airport

NV

0.0

Ground RNO

Air Carrier

Medium Large Transport

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1307208

Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance; Ground Event / Encounter Other / Unknown

Person Flight Crew

Taxi

Flight Crew Returned To Gate; General Flight Cancelled / Delayed

Weather; Human Factors

Human Factors

After pushback during the after takeoff flow and checklist the Captain questioned the flap setting I had selected. We reviewed the takeoff and landing report and determined that; due to in flight icing conditions below acceleration height we needed to use icing performance data. The performance data we had in our Thrust Lever Resolver (TLR) did not provide a configuration that allowed takeoff at our weight. The Captain called Dispatch and the Dispatcher confirmed that the maximum takeoff weight for current conditions was well below our current takeoff weight. We notified the station that we needed to return to the gate. The station called back and said '[load planning] says you're not overweight and you need to call them right away.' We continued into the gate. Five passengers volunteered to take a later flight and the flight was re-released and operated uneventfully.The reason the airplane was pushed back and started without the correct performance numbers is because it was the first time I have encountered the situation of having icing conditions prior to acceleration height. If I had remembered this I would have told the Captain we needed new numbers and we would have caught the problem sooner.The real problem was the fact that it had been low ceilings; precipitation and cold temperatures in Reno and no one saw these conditions and the problem it was going to cause at our planned takeoff weight.The most serious issue was the attempt from [load planning] to override the Captain and Dispatcher's decision to return to the gate by telling the station to tell us that we weren't in fact overweight. We weren't over our structural max weight; but we were limited by climb performance in the current conditions. This is an operational control issue. [Load planning] as far as I know are not licensed Dispatchers or Airline Transport Pilots and should not be interfering with pilot or dispatcher decisions.

Q400 FO reported departing the gate overweight for the weather conditions. Flight returned to gate to offload some passengers.

1473948

201708

1801-2400

ZZZ.Airport

US

0.0

Night

Ramp ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 224

Situational Awareness

1473948

Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Illness / Injury; Ground Event / Encounter Other / Unknown

Person Flight Crew

Taxi

Flight Crew Returned To Gate; General Flight Cancelled / Delayed

Airport; Human Factors

Human Factors

Upon pushing back we started both engines and prepared to taxi. I cleared the left side and saw a passenger transport bus far out in the distance and looked like they had stopped to yield to us as we had our taxi light on in anticipation of taxiing. I asked the First Officer (FO) to clear the right side and he gave me the all clear as I verified it as well looking out the right side. I began moving forward to get some momentum to make the sharp left turn to taxi. As the aircraft moved forward and left I turned and saw that the passenger transport bus was starting to move slowly as well; yet far enough that he would yield to us. As we were moving further forward and now left with the tiller I was sure the driver saw our taxi light shining at them and would yield to us. It soon became apparent that the bus was not going to stop as it continued past us at a high rate of speed. My only course of action was to come to an abrupt stop. We may have been going 2-3 knots ground speed at that time. I reported the incident to ramp control informing them of the bus that had just crossed our path without yielding. The flight attendants at the time were doing the live demo in the aisle due to the MEL'd entertainment system. I called back to ask if everyone was ok and initially one of the Flight Attendants (FA) said they were ok but then paused and asked me to hold on as there might have been an injury to one of the flight attendants in the back. I was then informed that [another] FA had incurred an injury on her knee; could not continue and would need a wheelchair to get off. We called ramp and ops to pull back into [the gate] and the FA was removed from flight with a wheelchair. Replacement FA was called out and we went on our way.

B737 Captain reported coming to an abrupt stop when a passenger bus did not yield; which caused injury to a flight attendant.

1849290

202110

0601-1200

ZZZZ.ARTCC

FO

38000.0

VMC

Center ZZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Cruise

Hydraulic Syst Pressure/Temp Indication

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 191; Flight Crew Type 1965

Time Pressure

1849290

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

Automation Aircraft Other Automation; Person Flight Crew

Flight Crew Landed in Emergency Condition; Flight Crew Diverted; General Maintenance Action

Aircraft

Shortly after reaching cruise the # 1 engine hydraulic pump low pressure light illuminated; QRH (Quick Reference Guide) directs to turn off pump. It was a previous write up and pump was replaced a few days ago. A short time later the #1 engine Oil filter bypass light illuminated. After looking at QRH I decided to make the FO (First Officer) the flying pilot and take control of checklist which leads to an engine shutdown. We [requested priority handling] and descended to 260 in a drift down. ZZZZ looked to be the closest suitable airport and messaged dispatch with our condition and intentions and they agreed. Set course for ZZZZ and briefed the FA (Flight Attendant) with [acronym]. Discussed situation with passengers and then continued with preparing for arrival. I.E. Nonnormal landing config; one engine inop approach and landing; briefed the approach and discussed the threats. FO did a great job and parked at a hard stand. Very impressive how the Dispatch runs this place.

B737 Captain reported engine hydraulic and oil warning lights resulted in engine shutdown. Prior to this flight; maintenance had signed off repair of this previous write up.

1452132

201705

0001-0600

ZZZ.Airport

US

2800.0

IMC

Fog

Night

TRACON ZZZ

Air Taxi

EC130

1.0

Part 91

VFR

Ferry / Re-Positioning

GPS

Cruise

Visual Approach

Class E ZZZ

Aircraft X

Flight Deck

Air Taxi

Pilot Flying; Captain

Flight Crew Commercial

Workload; Situational Awareness; Distraction; Confusion

1452132

Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter VFR In IMC

Person Flight Crew

In-flight

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

Human Factors; Procedure; Weather

Weather

The crew and I just completed a scene flight and were at the hospital. I refueled the aircraft and double checked weather prior to making our return leg to base. All weather reporting stations along our route were all reporting VFR. The closest weather reporting station to our base; was reporting winds 240 at 8 knots; 10 SM visibility; ceilings 9;000 feet scattered; temperature 75 degrees; dew point 64 degrees; humidity 84%; and about 16% illumination. Winds at 1;000 feet AGL was 250 26-28 knots. We departed to the northeast enroute back to base at 2;000 feet MSL; which is a 20 minute flight.Approximately 15 minutes into the flight I noticed some small patches of fog below us at about 500 feet AGL. Our route takes us along the river; and we were approaching a power plant with several bright lights. Once we got to the power plant; the crew and I realized it was very hazy and I decided to deviate from our route and head northbound toward a local Airport. I could still see ground lights and cars driving on the roads. Weather wasn't looking much better to the north; so I made a slight left turn toward the northwest to attempt to get away from the river. I also elected to start a climb in the event we went in Inadvertent Instrument Meteorological Conditions (IIMC). I referenced the GPS and we were 11.3 NM south of the airport now at 2;500 feet. I already had the UNICOM frequency tuned in so I attempted to activate the airport lighting via radio clicks. I saw no signs of lights to the north; and ground lights were deteriorating directly below us. I told the crew we were IIMC and I was coming inside and committing to instruments.I followed the IIMC procedure and got established on a northwest heading. I knew we were in the clouds at this point because the strobe light on the belly of the aircraft was reflecting into the cockpit; so I turned it off. Once I was at my MSA of 4;000 feet MSL; I made a small left turn to 270 and planned on recovering to a county airport as we had just been there previously and I knew it was VMC there when we left about an hour prior. I then switched up Approach control; which was in the standby frequency; and established communication and let them know I was [requesting priority handling] for IIMC. I elected to maintain our company discrete squawk code. I stated my altitude and heading and requested radar vectors to the County Airport. Once they had me on radar he had me turn left to 220 and that would put me on a track toward the airport; which was 14 miles away. After flying this track approximately 5 minutes we broke out of IMC conditions. I told ATC that I was now VMC and had the Airport in sight; but was going to stay committed onto the instruments until I got closer. I told ATC I requested to get set up for the ILS into the county airport for planning purposes. I then descend down to glide slope intercept altitude of 2;500 feet as I was still currently VMC and wanted to make sure I could stay that way at a lower altitude. Approach then advised me that they knew I said I had the airport in sight; but wanted to confirm and the Airport was 12 o'clock and 5 miles. I stated that indeed I had the airport in sight and could cancel the clearance and descend down to the airport VFR. We landed at the airport with no other issues.Not much we can do to remedy this issue; except add more accurate weather reporting stations; especially in known troubled areas.

An EC130 helicopter pilot reported he unexpectedly entered IMC after doing a due diligence weather preflight which indicated VMC to his base airport. An IFR clearance was obtained enroute.

1565049

201807

1801-2400

DTW.Airport

MI

0.0

Marginal

Dusk

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Taxi

Generator Drive Indicators and Warning System

X

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Distraction; Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Other; Party2 ATC; Party2 Flight Crew

1565049

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Excursion Taxiway

Person Air Traffic Control; Person Flight Crew

Taxi

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

Human Factors

It was a normal flight with delays and thunderstorms going into DTW. During descent; vectors onto final we received an intermittent caution of Integrated Drive Generator (IDG) 1. I started the APU in anticipation of single generator operations and checked the status of the generator via the electrical page and the overhead panel. The left IDG on the electrical page would flash yellow and green with a caution associated. We decided it would be best to resolve the issue on the ground. During the approach and landing the IDG 1 caution message continued to go off. On rollout we taxied the aircraft towards the first available high speed exit A4 which was NOTAMed closed at the time of arrival. ATC told us after we were heading towards A4 to turn off on A5. I said 'We are turning off A4.' ATC replied 'Do you see the barricades?' I replied 'Yes sir; we do. We can turn around and taxi to A5.' Tower at this time called the proceeding traffic to go around. ATC then said 'Aircraft X; re-enter RWY 4L and taxi via A5 Alpha; and await further instructions.' We taxied on the runway and off A5 and on Alpha. Tower then transferred us to ground and we continued our taxi to the gate with IDG 1 caution still periodically chiming. We shut down engine 1 and proceeded to gate with no further issues. There was no contact with any barriers nor was there any damage of any sort to the aircraft or airport property. The cause of the event was inadequate briefing on current NOTAMs to highlight runway taxiway closures. This was due to delays and thunderstorm avoidance which diverted attention from a more complete brief. During final descent we had an IDG 1 caution chime and we decided to resolve the issue after we had landed. During approach and landing the chime did cause a distraction. This distraction diverted our attention and caused us not to notice that A4 was barricaded closed during a high-speed exit. Pilot's complacency and inattention to detail caused the main issue which was missing the A4 closure via NOTAMs. When giving and receiving briefings; make sure to verify all available NOTAMs. We were both familiar with DTW layout and operations however both pilots had not been to DTW in some time.

CRJ-200 pilot reported an inadequate briefing resulted in a taxiway excursion.

1703991

201911

1801-2400

ZZZ.Airport

US

0.0

VMC

Daylight

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Parked

High

Pax Seat

X

Design; Improperly Operated

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties

1703991

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

Person Flight Attendant

Pre-flight; Aircraft In Service At Gate

General None Reported / Taken

Aircraft; Company Policy; Procedure

Aircraft

I was the D FA (Flight Attendant) working and this was my first time working on a retrofit A321. I have noticed that a difference with the retrofit is that XA and XF seats sit so far back they partially block the L2 and R2 emergency door. When I went to arm and disarm the doors I had to reach over the passenger's heads and shoulders to put the safety pin in the pouch because they were blocking the pouch. The emergency handle on the wall for is blocked by the passenger row and the EVAC/RESET buttons are blocked by [the] passenger's head in XF.The seats are also allowed to recline and they even further block the exit door which is a huge safety hazard. How is it that on the 737 the row before an exit window the seats cannot recline but on the A321 they can? I am curious how both the Company and the FAA thought that safety wise this was ok to do when retrofitting the aircraft? This is a HUGE SAFETY issue if there was an emergency and should be looked at to be fixed. My recommendation is to move row X a few inches closer so that it isn't blocking the L2/R2 emergency exit doors.

A321 Flight Attendant reported that specific seats recline and block the emergency exits at L2 and R2.

1074395

201303

0601-1200

ZZZ.Airport

US

600.0

VMC

Tower ZZZ

Air Carrier

B757 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Initial Climb

Class B ZZZ

Y

Engine Control

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Last 90 Days 150; Flight Crew Total 14000; Flight Crew Type 5000

1074395

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 255; Flight Crew Total 19000; Flight Crew Type 8000

1074397.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Aircraft Automation Overrode Flight Crew; Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Landed in Emergency Condition; General Declared Emergency

Aircraft

Aircraft dispatched with deferred LEFT ENGINE PRIMARY CONTROL status message displayed. Takeoff roll [was] normal. At approximately 600 AGL the left engine experienced a compressor stall and slight surging; followed by idle power setting as indicated on the left EPR and N1 indicators. Tower initiated hand-off to Departure. I declared an emergency with an engine failure and decided to return to the departure airport. As I began to discuss the engine failure procedure with the Captain; the left engine was beginning to develop thrust and EPR/N1 was increasing. Engine was idle power for approximately 10 seconds. Reported to Departure that engine was once again operating; and reaffirmed our emergency status and return to land. I took control as pilot flying while Captain did pilot not flying duties and executed the compressor stall/surge checklist and communicated with company.ATC provided priority and vectors for an ILS. We coordinated with [airport] operations on VHF for a return and had them notify Maintenance and Dispatch of our situation. Approach and landing were normal. Emergency trucks were standing by on arrival.

During climb from [the airport] leaving approximately 800 FT AGL we experience a compressor stall and subsequent loss of thrust on the left engine. After getting the aircraft stabilized I gave the aircraft to the copilot while I ran the engine surge/stall checklist. Although we had both engine primary and secondary control EICAS status messages the engine continued to run within parameters and was controllable. We therefore elected to leave it running for an overweight landing back into [the airport].

During initial climb; the B757's left engine lost power; an emergency was declared and flight returned to the airport.

1002631

201204

1201-1800

ZZZ.Airport

US

0.0

Mixed

Hail; Rain; Thunderstorm

Daylight

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

Passenger

Parked

N

Y

N

Unscheduled Maintenance

Inspection

Trailing Edge Flap

Bombardier / Canadair

X

Gate / Ramp / Line

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Time Pressure; Situational Awareness; Confusion; Communication Breakdown; Training / Qualification

Party1 Flight Crew; Party2 Maintenance

1002631

Gate / Ramp / Line

Air Carrier

Pilot Not Flying; First Officer

Communication Breakdown; Confusion; Situational Awareness; Time Pressure; Training / Qualification

Party1 Flight Crew; Party2 Maintenance; Party2 Flight Crew; Party2 Dispatch

1002852.0

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

N

Person Maintenance

Pre-flight

Aircraft Aircraft Damaged; General Flight Cancelled / Delayed; General Maintenance Action

Manuals; Weather; Procedure; Logbook Entry; Human Factors; Company Policy; Aircraft

Human Factors

While returning to the gate due to severe weather and ATC ground stop; the CRJ-700 aircraft was subjected to 2-3 minutes of one and a half inch size hail. The airplane was stopped and the engines were off during the hail; we were waiting for the jetbridge to be moved to the aircraft; and we were on APU power. After the passengers had dis-boarded [de-planed]; I called Dispatch and Maintenance Control to find out if an inspection by a Mechanic was required by company policy. The Maintenance Control person I talked to said I could perform a normal walk around and pay special attention to the top of the fuselage and the top surfaces of the wings; and if no damage was found the rest of the airplane could be deemed undamaged. I performed my inspection; in diffused daylight under a mid-level overcast; of a wet wing and fuselage. I did not see or feel any hail damage. I called Maintenance Control afterward to report my findings; and he said that was all that needed to be done. While passengers were re-boarding; the First Officer and I discussed the situation; and the First Officer suggested I call our regional Chief Pilot to verify there wasn't a company policy requiring a Mechanic's inspection in this situation and that my inspection would be sufficient. My call went straight to the answering machine; and as I needed an immediate answer; I called the Pilot Locator Desk and asked to be connected with any Chief Pilot. The Locator Desk tried to call one or two for me; and then realized all the Chief Pilots were involved in a conference call. He then asked Mr. X personally; if this was an appropriate way to handle the situation; and relayed Mr. X's answer to me that yes; it was. I then continued the flight. After landing and while explaining to the airplane's new crew why we were four hours late; a company Mechanic who had come onboard to check something else overheard me; and seemed surprised that a Preflight Inspection by a pilot would be acceptable after an airplane had been hailed on. He then borrowed a flashlight; looked the plane over and discovered hail dents on the tops of the flaps and spoilers. He showed me what he had seen; and the damage was quite obvious when on dry surfaces and illuminated at a low angle in the dark. After he conferred with Maintenance Control he asked if I would write up the damage; and I did. Two suggestions: 1. A policy requiring a Mechanic's inspection and sign-off after an encounter with hail. 2. Pilots (myself; anyway) should recognize that the preflight and post-flight inspections of the aircraft's general condition [that] we do and are trained to do; are not the same as the more detailed and specific inspections Maintenance people; who have the training and experience to see and recognize subtle damage and are knowledgeable of the conditions to make certain defects apparent; do. 3. Personally I will write-up such events in the future: 'Possible damage from XXXX. Aircraft needs inspection.

Severe thunderstorms and lightning shut down departures; so we decided to return to gate to let passengers off aircraft due to lengthy delay and severe weather in the area. We parked at the gate and shut the engines down and while waiting for Gate Agent to bring jetbridge up to airplane; it began to hail. The hail was approx 1' inch; in diameter and light to medium intensity. This lasted approximately three minutes. After the hail stopped and Gate Agent brought up jetbridge; we deplaned the passengers. The Captain and I discussed the policy; or procedure for doing a Hail Event Inspection. The Captain called Dispatch and Maintenance Control to discuss the issue and see what the procedure was and who is able to do it. Maintenance Control told the Captain that an inspection for hail damage could be done by the Captain. The Captain did a walk around and did not find any damage. The outside conditions: light rain; low light due to overcast weather. The Captain called Maintenance Control and reported that he did not see any damage to the aircraft that he noticed. After a delay; we were boarding passengers to return to ZZZ1 and the Captain and I discussed the concern of ours that just doing a walk-around was a good enough inspection. I suggested calling a Chief Pilot to discuss it further.I think that there should be a better policy in place to do a post Hail Event Inspection of the aircraft. This Inspection should be completed and signed-off by a Mechanic who is able to inspect the whole airframe by using ladders/ lifts to see upper fuselage and tail sections.

A Captain report's he performed a preflight type walk-around for a hail damage inspection of their CRJ-700 aircraft after Maintenance Control informed him the procedure would be adequate for dispatch. The First Officer suggested calling Chief Pilot who agreed. Mechanic at next station showed Captain the hail dents on flaps and spoilers that were missed.

1568150

201808

0601-1200

ZZZ.Airport

US

0.0

Ramp ZZZ

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Communication Breakdown

Party1 Flight Attendant; Party2 Flight Attendant; Party2 Flight Crew

1568150

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

Person Flight Attendant

Taxi

General None Reported / Taken

Company Policy; Aircraft; Procedure; Environment - Non Weather Related

Aircraft

Sat on taxiway with no movement. [9 minutes after doors closed] fumes entered Aft Galley where myself (#6) and #2 were seated. Passengers in last row commented on fumes. Flight Attendant #1 made public address 'fumes are due to engine restart and will dissipate once we're moving.'Fortunately; I carry a mask for these occasions; however; #2 did not have a mask and was suffering. And even though I do have a mask; I was still exposed as this mask doesn't necessarily filter jet engine exhaust; nor does it cover the eyes. #6 left jump seat because he could no longer bear the fumes. Meanwhile; #1 called me to ask if I wanted to return to gate. Yes; I wanted to; however; I wanted it to be a joint decision with the #6 but he was standing in the aisle. I yelled for him to return to Galley. He indicated he didn't want to return to gate. In my opinion; he was toughing it out and didn't want to appear weak; etc. He later admitted this was the incorrect decision. I had no time to talk sense into him because at that point takeoff was imminent. He required oxygen in flight.Knowing that this is a known potential issue on Airbus; pilots should have informed us of the situation so we would have had time to protect ourselves; or some other action should have been taken by pilots to protect us. Instead; we sat with the fumes for 30 minutes. Pilots never said a word to us or asked how we were. This is an extremely serious issue with potential long-term health impact and was preventable; in my opinion.

A321 Flight Attendant reported after engine start; fumes entered the cabin aft galley area.

1692659

201910

1201-1800

TTN.Airport

NJ

0.0

VMC

Windshear; 10

Daylight

Tower TTN

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

VFR

Personal

Landing

None

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 20; Flight Crew Total 120; Flight Crew Type 20

Human-Machine Interface

1692659

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

N

Person Flight Crew

In-flight

Flight Crew Regained Aircraft Control

Aircraft; Human Factors; Weather

Human Factors

I was landing at TTN. I had a nice smooth touchdown on Runway 24. On the ground roll when I was trying to exit the runway; a sudden gust of wind hit me. I lost control for a second and went off the side of the runway and into the grass. I was able to get off the grass and back onto the runway and taxi back to the ramp as directed by ATC.

C172 pilot reported a loss of control on landing that resulted in a runway excursion.

1810836

202105

1201-1800

ZZZ.Airport

US

VMC

Tower ZZZ

Air Taxi

Cessna 402/402C/B379 Businessliner/Utiliner

1.0

Part 135

IFR

Passenger

GPS

Landing

Class B ZZZ

Landing Gear

Malfunctioning

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

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

Distraction; Troubleshooting; Workload

1810836

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Overcame Equipment Problem

Aircraft

Landed without a locked nose gear. Heading into ZZZ; I did the before landing flow and put the gear handle down. The gear lights only indicated 2 green mains and the red unlocked light with no nose gear indication. Seconds after the lights illuminated for both the Left and Right Hydraulic Flow. I informed Tower I needed to break off my approach for a gear indication issue and troubleshoot. They gave me a heading and altitude then sent me to approach. Approach gave me vectors while I troubleshot. I performed the landing gear will not extend hydraulically checklist. Part of the checklist is to pull the emergency gear extension handle; I did so briskly and without twisting the handle. The indications did not change and I did not hear or feel a thump. I then pulled even harder on the emergency gear handle and braced myself by putting my feet on the floor then tried again and still no response. I finished the checklist then read through the next checklist to land with defective gear. I called approach and said my checklist was unsuccessful. I asked to return to ZZZ and told them there was no indication for the nose gear; and [advised ATC]. They brought me around for [Runway] XX; I ran through the checklist multiple times to ensure I had the procedure down; then left the book open. I landed softly and held the nose off for as long as possible. Performed the ground evacuation checklist then shut everything off and got out.

Pilot reported landing with the nose landing gear not locked and hydraulic flow indicators illuminated.

1329528

201602

1201-1800

PCT.TRACON

VA

13000.0

Daylight

TRACON PCT

Air Carrier

Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Climb

Vectors; SID TERPZ 6

Class E ZDC

TRACON PCT

Air Carrier

Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Climb

SID TERPZ 6

Class E ZDC

Facility PCT.TRACON

Government

Departure; Instructor

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 13

Confusion; Situational Awareness; Training / Qualification; Communication Breakdown

Party1 ATC; Party2 ATC

1329528

ATC Issue All Types; Conflict Airborne Conflict; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

In-flight

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

Procedure; Human Factors

Procedure

The Wooly sector of the Chesapeake (CHP) area of PCT handed off a number of TERPZ departures to the Fluky sector. Aircraft X was leading/ahead of Aircraft Y on the TERPZ departure. Initial separation when Fluky accepted the hand off was about 8 miles with Aircraft Y about 10 kts faster. When Aircraft Y got to 170 MSL; still in WOOLY's airspace; the overtake of Aircraft Y on Aircraft X was around 80 kts with minimal separation longitudinally. I instructed my trainee to turn Aircraft X westbound and increase to maximum forward speed and to then turn Aircraft Y southbound on a 210 heading. I'm not sure if separation was lost. I am sure after confronting the WOOLY controller in the breakroom about the overtake situation; he said he was not at fault; that the aircraft were 'separated when I shipped them' and that he no longer had any responsibility for the above mentioned aircraft. He was adamant that he did nothing wrong; and was rather smug in response to my questioning his action or inaction.I'm close to retiring and I'll admit it's been a while since I've sat down and read the .65; but I'm pretty sure a transferring controller is required to resolve all and any conflicts before an aircraft leaves his or her airspace. If this requirement has changed and no longer in effect please disregard this report. However; in my opinion; this action by the controller borders on negligence. My recommendation is that the controller and others like him; understand that all conflicts between aircraft need to be resolved before they leave your sector. Coordinate; amend an altitude; give a speed or a vector; anything to make sure we have separation. To smugly say you did your job and that you; in effect; are not concerned about a potential conflict; is not the FAA I grew up in. He might as well told me to 'go eat s#@%; it's your problem'. That's pretty much what I deciphered from his comment.

PCT Controller reported of a loss of separation resulting from a speed overtake. Controller was also training at the time and attempted to have the Developmental fix the situation. Reporter then confronted the transferring Controller who said it was not his fault and that the aircraft were separated when he shipped them.

1109955

201307

0601-1200

ZZZ.Airport

US

0.0

Daylight

Air Carrier

Dash 8-400

2.0

Part 121

Parked

Installation; Testing

Weather Radar

X

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Avionics

Situational Awareness; Communication Breakdown

Party1 Maintenance; Party2 Maintenance

1109955

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

N

Person Maintenance

Other Paperwork Audit

General Maintenance Action

Aircraft; Human Factors; Procedure; Manuals

Manuals

Previous Station did not install the Weather Radar; only the Transeiver and we should [have] caught it on the install of the commercial radio avionics coupler; we were waiting on parts to arrive to fix the aircraft. The parts were scheduled to arrive 15 minutes before the flight was scheduled to depart. They were supposed to arrive earlier but the flight it was coming on kept getting delayed. [Mechanic Y]; the Mechanic who was going to replace the [avionics] coupler was a Swing-shift Mechanic and it was starting to encroach the end of his shift. I told Maintenance Control that the plane would not be ready for its flight and they should swap it with our Routine Overnight (RON) [aircraft] that we were scheduled to do a Line Check on. The [Maintenance] crew was already wrapping up the Line check and that plane would be ready sooner than this one. The part finally arrived along with some other robbed [cannibalized] parts that needed to be installed as well. I went out to the plane to help and see where the Mechanic was at. He had installed the Timer/Monitoring Unit (TMU) and was working on the avionics coupler. I closed up the wardrobe while he finished installing the coupler. We were hoping to solve two discrepancies with the coupler. A Weather Radar fail and an FMS 'Configuration Module Fail' [message]. After the installation we turned on the FMS and the 'Configuration Module Fail' message returned. We decided not to test the Weather Radar then because the FMS 'fail' returned. With the clock ticking we decided to return to the Shop to do more research into the problem; get a turnover and Mechanic Y could sign-off what he had done. He signed off the install and wrote up the Operational (Ops) Check of the Weather Radar. I told him I would take care of the Operational test of the Weather Radar System. This is where the error in communication and technical publication happens. When I go to do the Operations Test; I only take the Operational Test. This task says nothing about needing to remove the radome. When the Mechanic turned it over to me he left both tasks. I had informed him that I had just recently worked this Operations Check and was well aware of it so he probably took from that that I knew I needed to remove the Radome. In the end the Operational Test check was good; Weather Transceiver (WX) fail message did not return because the Operational Test can be passed with only the Transceiver installed and I signed it off. I have two other mechanics [that] were with me for the entire Operations Check. [Contributors were] the previous Mechanic at another Station not installing the whole part assembly. Us not catching it when we replaced the commercial radio [Avionics] coupler because we didn't remove the radome and the communication breakdown between where Swing shift left and Grave shift picked up. [Recommend] putting the removal of the radome in the Operational Test of the Weather Radar [Unit].

A Line Aircraft Maintenance Technician (AMT) describes the chain of events that led to a repetitive Weather Radar and FMS 'Configuration Module Fail' message on a DHC-8-400 aircraft.

1332780

201601

1201-1800

ZZZZ.ARTCC

FO

Daylight

CLR

Center ZZZZ

Air Carrier

B777 Undifferentiated or Other Model

Part 121

IFR

Passenger

Cruise

Medium

310.0

210.0

13.0

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Flight Attendant Airline Total 37; Flight Attendant Number Of Acft Qualified On 5; Flight Attendant Type 50

Service

1332780

Flight Deck / Cabin / Aircraft Event Illness / Injury

N

Person Flight Attendant

In-flight

Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport

Aircraft

I was Flight Attendant (FA) #11 in the business class cabin picking up the meal trays and preparing for the dessert service. There was sudden onset of feeling lightheaded; dizzy; disoriented and a headache. FA #7 and #4 asked if I was feeling the same sensations as [they were] in the business class galley. I responded yes. At that time the Purser came back and said she and the first class galley were also feeling the same way. The Purser called the Captain to report what was going on. The #6 business class FA was also feeling ill. I managed to complete the dessert service having great difficulty due to my disorientation and being lightheaded. The Purser came back to start the 1st round of crew breaks. The Captain was still working on the issue. I went on first break feeling worse; but thinking if I could just lay down I would be okay. Right after I went into the bunk area FA #6 passed out. A doctor was paged and responded. The Captain decided that we were turning around back to [departure airport]. He told the purser to get all of the FA's out of the bunks onto the main deck to be checked out by the Doctor.I could barely walk at this point and the Doctor put me on oxygen and I laid down in an empty row.We landed back at [our departure] 2 hours later. The Captain had diversion locations picked out along the way if things got worse. There were 4 passengers who were also feeling ill. The Doctor who had assisted during the flight was feeling ill. The flight was met by a bio-hazard team and all passengers and crew were kept on the aircraft. After completing their inspection the paramedics came on to access the passengers and crew that were feeling ill. There were 8 flight attendants out of 13 feeling ill. We were released to go to the layover hotel; but told by the paramedics if we started to feel worse to go to the hospital. My observation was this: How quickly I went from feeling fine to ill. There was a definitive difference and it was quick. There were no fumes nor odor. The Captain took the aircraft up the next day with company mechanics to check the aircraft. Everything checked out fine. My feeling is it is impossible to replicate the exact event because of cargo; cruise altitude; cabin crew being active; catering on board; etc.

B777 Flight Attendant reported the aircraft turned back to departure airport after several flight attendants and passengers experienced symptoms consistent with air contamination. No odor or fumes were noticed; and no cause found.

1725947

202002

0001-0600

5.0

4000.0

IMC

Fog; Rain; 1

Night

200

Personal

Learjet 60

2.0

Part 91

IFR

Personal

FMS Or FMC

Initial Climb

Vectors

Class B ZZZ

Turbine Engine

X

Failed

Aircraft X

Flight Deck

Personal

Captain; Pilot Flying

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

Flight Crew Last 90 Days 35; Flight Crew Total 5801; Flight Crew Type 2057

1725947

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Diverted; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft

Shortly after departing ZZZ the right engine shut down. We [requested priority handling] and were given radar vectors. We complied with appropriate factory checklists and restarted the engine. We requested a precautionary landing at ZZZ1 after burning off excess fuel.

Lear 60 Captain reported an engine failure shortly after takeoff that resulted in a diversion.

1053755

201212

1801-2400

ZZZ.Airport

US

7000.0

TRACON ZZZ

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Descent

Vectors

Class B ZZZ

TRACON ZZZ

Air Carrier

Dash 8 Series Undifferentiated or Other Model

2.0

Part 121

IFR

Descent

Vectors

Class B ZZZ

Facility ZZZ.TRACON

Government

Approach; Departure; Instructor

Air Traffic Control Fully Certified

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 ATC

1053755

ATC Issue All Types; Deviation / Discrepancy - Procedural Published Material / Policy

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Human Factors

I was training on the East Final. We pulled in the other finals and were coming out of outboard widely spaced self monitored ILS approaches north to 36L and 36R and were going into a stagger. The CRJ was eastbound and descending out of 070 for 050 expecting 36L. The Dash 8 was westbound at 060 issued a descent to 040 expecting 36R. I told my trainee to slow and turn the CRJ. He slowed him to 210 KTS and did not turn. I told him again that's too fast you have to go all the way back and he's still going to need turned out. He slowed to 170 KTS but did not turn. As the CRJ got closer to the final I told him to change his landing runway to 36C so we could use reduced separation and that he was going to need to go across the localizer for spacing since he didn't turn him like I told him to. As the spacing became greater between the CRJ and the aircraft already on the final for 36R the CRJ needed turned in to the localizer. The Dash 8 was on opposing base a little further south than CRJ and still descending through 050. Instead of tuning the CRJ; the trainee turned the Dash 8 in toward the CRJ. I thought for a second that I missed Dash 8's altitude and that he must be a 040 if he was turning in but the data block of Dash 8 was overlapped by a VFR aircraft northbound at 035. I moved the data blocks to see the information and saw that Dash 8 was still not out of 050. I turned CRJ to heading 030 and then turned Dash 8 to a heading of 250 try to keep 3 miles. Shortly after; the CA went off. The *T function showed 3.8 miles and closing. I don't know how close they actually got before they passed. This trainee does not listen to what I tell him. I have told him countless times that you can not be anywhere near that 36R localizer unless you're a 040. I don't care if you have to turn back into the downwind to get down then you do it but don't be at anything other than 040 near the east localizer period. Ten minutes prior to this situation; he had the same thing going on with a different Dash 8. Descending westbound slowly and he told him to reduce speed to 170 as he was descending out of 052. I asked him what's more important his speed or his altitude? He said his altitude. So he then told the Dash 8 to expedite down to 040. That Dash 8 got down but only because I said something and the trainee didn't even bother to coordinate with the West Final to let him know he was still high. He seems to not believe what I tell him until the bad thing I was warning him about happens to him. Then he gets it. There has to be a certain level of trust between a trainer and trainee especially on the final where you're expected to put planes very close together and I no longer trust that he will do the right thing. He has a lot of hours on that position and should know better than to do what he did. Dash 8 had no business being turned in anyway since there wasn't even enough room for the CRJ to fit. Which is why he was going across the localizer in the first place and that would not have been needed if he would have listened to me and turned the CRJ out a little when he took the position.

TRACON Controller providing OJT described a loss of separation event during simultaneous approach procedures claiming the student failed to take steps as directed resulting in the conflict.

1090626

201305

ZDV.ARTCC

CO

25000.0

IMC

Center ZDV

Air Carrier

B737 Undifferentiated or Other Model

2.0

Passenger

FMS Or FMC

Descent

STAR BOSSS1

Class A ZDV

Air Carrier

Pilot Flying; Captain

Human-Machine Interface; Confusion; Workload

1090626

ATC Issue All Types; Deviation - Altitude Crossing Restriction Not Met; Deviation - Speed All Types

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance

Chart Or Publication; Human Factors; Procedure

Human Factors

On ZPLYN RNAV STAR cleared direct to QUAIL and already in the descent to cross QUAIL at ZPLYN altitudes (FL220-FL200). We were then cleared the BOSSS arrival and to descend via the BOSSS (QUAIL between FL190-17000). The FMC will not change the old altitudes to the new BOSSS altitudes while proceeding direct to QUAIL. We spent too much time heads down trying to get the new ones into the box. It will not happen! The only way to get the new altitudes in is to go into heading select mode; go direct to a waypoint behind you and activate it; then move QUAIL back to the active waypoint and activate it; then back into LNAV. HUGE THREAT! Since we were [now] higher than we needed to be ATC also wanted us to slow down. WE CANNOT SLOW DOWN AND STILL DESCEND; ATC NEEDS TO KNOW THIS. We did not violate any crossing restrictions but were too high and fast to fit in so we were vectored for a downwind leg and resequenced into the approach flow. All could have been avoided if there were no conflicting altitudes on the arrival procedures; if the FMC would program itself correctly; if ATC would give a more [reasonable] clearance change; if all of the [new] DEN arrivals and transitions were thrown out and the old were used again; if ATC would just let you fly the entire procedure without vectors off course. Another HUGE threat is having higher altitudes on the transitions than those on the STAR! Who came up with that one? With higher altitudes on the transition than the STAR the FMC will not let you go into an active mode. HUGE THREAT and too much time spent heads down reprogramming.

A B737 captain expressed general umbrage toward the recently initiated 'OPD' RNAV STARs to DEN. In the specific incident referenced they had been cleared direct to cross QUAIL as charted (Between FL220 and FL200) on the ZPLYN RNAV STAR; thence to descend via the STAR. Subsequently they were recleared via the BOSSS RNAV STAR via direct to QUAIL and to cross as charted; between FL190 & 17;000; but were unable.

1650169

201905

0601-1200

ZZZ.Airport

US

0.0

Air Carrier

EMB ERJ 145 ER/LR

Part 121

Passenger

Landing

Thrust Reverser Control

X

Technician

Maintenance Airframe; Maintenance Powerplant

Situational Awareness

1650169

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

Person Flight Crew

Other Landing

General Maintenance Action

Human Factors

I took a call from Aircraft X telling me that 'No.1 TR failed to open on landing '; which I had the Captain document in the log book. I then called ZZZ MX to alert them of this issue along with the fact that the No. TR was MEL'd and RIC was the ZZZ1 base it was at prior to this first flight of the day and to make certain the MEL deactivation was correctly performed. A call came in from ZZZ informing me that the wrong ICU was inhibited. They remedied the issue and the aircraft was returned to service. This was also an issue one day before; I was not working then; and the same discovery was made and remedied. I am guessing the closeness of the ICU 1 and ICU 2 is confusing to some. Follow Manual procedures and take close look at work after doing it while comparing it to manual pics.

Maintenance Technician found incorrect maintenance accomplished on aircraft thrust reverser.

1156535

201403

0601-1200

LAS.Airport

NV

4100.0

VMC

Daylight

CLR

Tower LAS

Air Carrier

A319

2.0

Part 121

Final Approach

Class B LAS

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Last 90 Days 120; Flight Crew Total 15000; Flight Crew Type 3000

Situational Awareness

1156535

Deviation / Discrepancy - Procedural Other / Unknown

Automation Aircraft Terrain Warning; Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Human Factors; Airport; Aircraft

Ambiguous

Cleared for a visual approach to Runway 1R in LAS. We installed the RNAV (GPS) RWY 1R approach into the FMGC as a backup. Weather was clear and visibility unlimited in day VMC conditions. While on a right base approximately .5 miles east of the FAF; GALNE; descending through approximately 4;100 feet at a rate of descent of about 800-1000 fpm; we received a GPWS 'Terrain; Terrain; Pull Up; Pull Up' warning. Although in day visual conditions with obstacles clearly in sight; I increased thrust and transitioned to a shallow climb. The GPWS warning immediately ceased. I was still in a position to make a stabilized approach so I returned to the profile and completed the approach without further incident.

A319 First Officer experiences a GPWS terrain warning during a day visual approach to Runway 1R at LAS. Although the aircraft appears to be clear of terrain; power is added and the warning immediately stops. A normal landing ensues.

1102732

201307

1201-1800

ZZZ.ARTCC

US

Center ZZZ

Air Carrier

B777-200

2.0

Part 121

IFR

Passenger

Cruise

Recirculation Fan

X

Failed

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

1102732

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

Person Flight Attendant

In-flight

Flight Crew Overcame Equipment Problem; General Declared Emergency

Aircraft

Number 1 Flight Attendant called and stated that there were smoke and fumes in the mid to forward cabin. She stated that the fumes smelled like burning plastic and the fumes/smoke were increasing. She turned off the Power Ports and IFE switches. We declared an emergency with Center and started a level left turn toward ZZZ. We accomplished the Smoke; Fumes; Fire Checklist. The fumes and smoke immediately dissipated with the accomplishment of this checklist. Reconfirmed with a Flight Attendant Instructor and two pilots aboard via intercom that the problem was solved. Per the checklist and having stopped the source of fumes and smoke; we cancelled the Emergency and continued to destination. After reading the maintenance follow-up; it appears to have been the Upper Recirc fan.

B777 Captain is informed of smoke and fumes in the cabin by the Lead Flight Attendant and declares an emergency with ATC. The Smoke and Fumes Checklist is accomplished eliminating the problem and the flight continues to destination. The upper recirculation fan is thought to have been the source of the smoke.

1843917

202110

1801-2400

ZZZ.ARTCC

US

250.0

2500.0

VMC

Night

FBO

Skyhawk 172/Cutlass 172

2.0

Part 91

None

Training

Cruise

Direct

Class E ZZZ

AC Generator/Alternator

Malfunctioning

Aircraft X

Flight Deck

Personal

Instructor

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

Flight Crew Last 90 Days 203; Flight Crew Total 875; Flight Crew Type 350

Situational Awareness; Troubleshooting

1843917

Aircraft Equipment Problem Critical; Airspace Violation All Types; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy

N

Person Flight Crew

In-flight

Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport; General Flight Cancelled / Delayed; General Maintenance Action

Human Factors; Aircraft; Procedure

Aircraft

During a training flight with a student we experienced an electrical failure/fault with our ammeter indicating a discharge. My student and I flew to another airport 50 NM away from our home airport for a night flight to satisfy PPL (Private Pilot) training requirements. We preflighted the aircraft and all systems were operational. Our runup was uneventful with normal indications and the ammeter showed an appropriate charge indication. We completed two full stop taxi-back landings at the other airport and departed back towards our home airport. About 25 minutes from our destination we heard an odd feedback in the headset and noticed the ammeter was ticking and indicating a discharge. We attempted to cycle the master switch/alternator switch but that did not remedy the situation. We heard the radio start to sound garbled as well. I elected to discontinue the training flight and head back to our home airport where the airplane could be serviced. However; due to the discharging battery; I turned off all electrical equipment in the aircraft including navigation lights and ADS-B out to conserve power so that we could put the landing light and navigation lights on during our approach and landing. This resulted in us not having ADS-B out or navigation lights on in airspace in which they are normally required. I felt it necessary to deviate from the regulations in order to safely get the aircraft back into our home airport where repairs could be made. I also avoided known busy airspace so as to deconflict from any other traffic in the area. We landed uneventfully and the plane was squawked so that it can be inspected.

Flight Instructor reported returning to home airport with NAV lights and ADS-B off after an alternator failure.

1153571

201402

1201-1800

ZZZ.ARTCC

US

VMC

Daylight

Air Taxi

Cessna Stationair/Turbo Stationair 7/8

1.0

Part 135

Cruise

Reciprocating Engine Assembly

X

Malfunctioning

Aircraft X

Flight Deck

Air Taxi

Pilot Flying; Captain

Flight Crew Commercial

1153571

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Diverted; Flight Crew Landed in Emergency Condition; General Declared Emergency

Aircraft

Enroute the aircraft engine began to run rough. I ran through the emergency procedures. Switched fuel tanks; mixture was already full forward due to my altitude below 3;000 FT. Prop full forward; throttle full forward; boost pump on. The engine seemed to run worse with the boost pump on so I secured it. At this point I was below 500 FT and had to focus on finding a landing spot. Only one suitable lake was within my gliding distance. I picked my landing spot and applied full flaps. I declared an emergency on company frequency; but did not hear a response. After touchdown the aircraft tires broke through the ice into about 12 inches of water and came to rest on a second layer of ice. The engine was still idling normally at this time. I was concerned that the aircraft might sink; or become frozen into the ice; so I attempted to taxi to the lake shore approximately 100 FT in front of the aircraft. It required full power to get the aircraft moving. After 3-4 seconds at full power the engine would become very sluggish; bog-out; no power. I returned the engine to idle; waited 5-10 seconds; and then reapplied full power. The plane would move forward then bog-out again. It would maintain full power for only a few seconds. I continued this procedure until I reached the shore. I did notice the engine was running very hot during this time; almost red line. After idling on the bank for a few minutes I managed to taxi through the snow to a firm looking piece of ground; slightly uphill from the bank. I shut down the aircraft engine; all lights and avionic except for 1 radio; to conserve battery power. I was then able to contact another company aircraft to begin the search and rescue operations. I was returning empty; with no passengers; or revenue on board.

Air taxi pilot experiences low engine power which results in landing on a frozen lake. After landing the wheels break through the surface ice and come to rest on a second layer of ice. With the engine still running the reporter is able to taxi to the shore and call for assistance.

1422940

201702

1801-2400

ATL.Airport

GA

0.0

Night

Ground ATL

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 142

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1422940

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 181

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1422939.0

Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

Person Flight Crew

Taxi

Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Human Factors

ATL taxi out instruction from Ramp 3 north taxi. Holding short of Foxtrot; Ground instructed to pass behind a Regional Jet (RJ) and continue to 26L on EC. As we started to taxi a ground truck pulled out in front of us causing us to stop to avoid contact. Having this in mind we then continued to taxi and I followed the RJ. My understanding was to taxi out and follow RJ but my First Officer said we were supposed to pass behind the RJ. Ground asked us to wait and once the RJ cleared he gave us instructions to continue to the runway for departure. There was a lot of ground communication and clutter during this time with multiple aircraft.

[Report narrative contained no additional information.]

B737 flight crew reported taking the wrong taxiway at ATL after a sudden stop to avoid a vehicle.

1652592

201906

0.0

Air Carrier

Commercial Fixed Wing

Part 121

Passenger

Parked

Hangar / Base

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Training / Qualification; Workload; Time Pressure; Situational Awareness

1652592

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

Person Maintenance

General None Reported / Taken

Staffing; Human Factors; Company Policy; Procedure

Company Policy

It has been identified that [a company] Maintenance Supervisor is accomplishing discrepancies and correcting actions in the Aircraft Maintenance Logbook while their qualifications are expired. Attached are images of maintenance qualifications plus log pages attached to the individual's name. This is a direct violation of [Company] Maintenance Policies.Note: Having an issue uploading training records image and log page image; if required please email for request.Individual is being pressured to release aircraft back into service by higher management and is willing to accomplish documentation regardless of their individual qualifications. Attached are log pages that individual has been linked to plus the qualification status as of [date].Individual needs to be approached about their Illegal activities and negligence for keeping training qualifications current; which violate [Procedures Manual] policies.

Air carrier mechanic reported maintenance supervisor signing off maintenance work without proper qualification.

1289481

201508

1201-1800

SFO

CA

4000.0

VMC

TRACON NCT

Air Carrier

Large Transport

2.0

Part 121

IFR

Passenger

Final Approach

Class B SFO

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 216; Flight Crew Total 7853; Flight Crew Type 5731

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

Party1 Flight Crew; Party2 ATC; Party2 Flight Crew

1289481

ATC Issue All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Automation Aircraft RA; Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; Flight Crew Took Evasive Action; Flight Crew Executed Go Around / Missed Approach; Flight Crew FLC complied w / Automation / Advisory

Airport; Human Factors; Procedure

Procedure

We were cleared for a visual approach with a left base entry to Runway 28L at SFO after reporting an air carrier jet in sight approaching the parallel Runway 28R from the east. We turned a 15 mile final and intercepted the localizer for 28L for which we had verified the proper ident. My First Officer indicated the air carrier jet looked like it had flown through 28R's centerline toward our course. I offset our track to the left to provide some additional spacing. We then received a climbing TCAS RA which I executed. We received a clear of conflict and the First Officer reported the TCAS climb to ATC; who asked if we were able to continue the approach. We responded that we could still continue the approach and I began to correct our vertical path to recapture a stabilized profile. I asked the First Officer if he could see the air carrier jet; which he responded he could not. As I asked this question I scanned my EFIS displays noticing traffic apparently on our same approach course below us. I received another TCAS RA and executed a missed approach.It's possible the air carrier jet erroneously intercepted the localizer/final approach course for 28L instead of 28R. In fact; I believe it was eventually cleared to land on 28L as we executed our missed approach.

An air carrier Captain reported executing a missed approach on a SFO Runway 28L visual after the second TCAS RA climb command from another aircraft which apparently erroneously lined up on 28L instead of the assigned 28R.

1440763

201704

1201-1800

ZZZ.Airport

US

0.0

VMC

10

Daylight

CLR

Tower ZZZ

Personal

Cheetah; Tiger; Traveler AA5 Series

1.0

Part 91

None

Personal

Landing

Visual Approach

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Student

Flight Crew Last 90 Days 14; Flight Crew Total 221; Flight Crew Type 101

Training / Qualification; Situational Awareness

1440763

Ground Event / Encounter Ground Strike - Aircraft

Person Flight Crew

Other Post Flight

Flight Crew Landed As Precaution

Airport; Human Factors

Human Factors

I was at ZZZ operating an sUAV taking photos of a newly constructed building at the airport. I was operating with the airport manager's permission and she was aware of the date and time I would be flying. No NOTAM was published for this flight. As a Part 107 and a Part 61 pilot based at ZZZ; I am familiar with airport operations; layout; and traffic patterns and was careful to avoid all safety conflicts and not violate 107.37 or 107.43. Runway XX was the runway currently in use and left traffic for that runway was well away from where I was flying; with the exception for one helicopter in the pattern flying right traffic; which overflies the building I was photographing.The helicopter traffic is at 500 feet AGL in that pattern; and I was doing my drone operation generally under 100 feet AGL; and at the absolute maximum I was at 180 feet AGL roughly. The company hangar is in front of the building I was photographing and while flying I heard their helicopter spooling up; and not knowing which way they may turn when they took off from their hangar; I landed the drone and waited until after they departed before flying again. Once I was back in the air; a company employee on the ground called the helicopter in the pattern to tell them 'some guy is flying a drone' over the building. I was operating with lights on my truck from inside the airport perimeter fence and at no point did the company employee approach me to ask who I was. After their exchange I got on the radio to clarify my operations and eliminate any concern to the helicopter pilots. Once I was done with my flight I made a radio call that I was on the ground and that drone operations were completed. I was later informed that company had been sending around a photo of me to airport tenants trying to figure out who I was.After the helicopter landed I called the pilot to apologize if it had caused any concern and he assured me that no safety concern was present to him at any time. I then called the airport manager (who was offsite) to mention what had happened so that she would be aware in case anything came up. She spoke to company and informed me that the miscommunication was all squared away; and that in retrospect; a NOTAM should be filed next time. Later in the day; two company employees drove over to where I was on the airport to express their concern and frustration. I assured them that given their proximity to where I was flying; I made sure to be on the ground when they were departing and that I was never in the air anywhere close to their aircraft. Regardless they informed me that despite the pilot of the helicopter in the pattern and a nearby FAA safety representative seeing no concern; they had filed a safety report to the FSDO. Given this knowledge; despite no FAR violations to my knowledge; I chose to file this report as a precaution; and in the hope that gaps in communication such as this can be avoided in the future.

UAS pilot reported that while operating a drone to photograph an airport building; a helicopter company at the airport had concerns about safety of operations.

1851147

202110

1201-1800

ZZZ.TRACON

US

VMC

Daylight

TRACON ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Initial Approach

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Other / Unknown; Confusion; Human-Machine Interface; Distraction

1851147

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Confusion; Human-Machine Interface; Distraction

1851148.0

Airspace Violation All Types; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Unstabilized Approach

Person Air Traffic Control; Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem

Human Factors

Cleared for visual approach to Runway XX at ZZZ. Had RNAV XX loaded for guidance and briefed the possibility of erroneous [airport] alignment on approach. Hand flying approach where final of [erroneous airport] crosses final of ZZZ.Cause of [the incorrect runway alignment with erroneous airport] was altitude low by 200 ft. nearing FAF area as we were turning final and lack of scan of instruments with complacency after briefing the possible wrong airport alignment. PF (Pilot Flying) saw we were lined up with a runway and commenced descent and approach. Shortly after I noticed a slight course deviation and low on the published RNAV approach glidepath. We had not been cleared to land yet and seemed like we were closer than normal to not have a landing clearance. Upon further review of the visual of the airport it appeared to be a [different] airport and at that point started becoming apparent that was the incorrect airport. We arrested descent to rejoin glidepath and made a right course correction to maintain course to proper runway. We were still above 1000 ft. and able to restabilize the approach safely to the correct runway. Shortly after we initiated correction ATC queried us for proper airport identification and we confirmed rejoining Runway XX alignment to ZZZ.Suggestion - Maintain strict course and glidepath guidance to ensure not mistaking the wrong runway. Also adding in an alert to the company page of the risk of aligning and landing at [erroneous airport] as the only mention of it is in a small parenthetical note in the plainview of the approach plate for IMC operations. Having an alert to potential wrong airport landing on ACARS and/or Company Chart would help in avoiding this as well.

We were given a visual approach clearance to Runway XX at ZZZ. The Captain and I thought it'd be a good idea to practice a full flap fully hand-flown visual approach since there was no other traffic. We had the RNAV Runway XX loaded and properly sequenced. When I turned base; I saw the runway for [different airport] and immediately assumed it was Runway XX to ZZZ. Because the Final Approach Course of the RNAV Runway XX into ZZZ crosses the final approach of [different airport] it 'confirmed' that I was in fact lined up for the correct runway. It wasn't until I saw a dot deviation on our lateral course that I became aware we were not lined up at ZZZ and realized it was [different airport]. I arrested my descent and made a slight turn to the right to line up with the RNAV course to Runway XX into ZZZ. ATC notified us of our error shortly after we began to maneuver back on course. [The incorrect course was caused by] Overconfidence. Since we briefed the threat; our guard went down. Expectation bias. I have never in my flying career been to this airport and never have I ever lined up for a wrong runway let alone an airport. I had set myself up for a typical right traffic visual approach and when I made my base turn and saw [different airport]; instinctively my brain told me that's where I was going to land and my instruments initially confirmed my assumption. [Reporter suggested to] add a note to company pages to alert crew of close proximity airport. Tighter tolerances on course and glide path deviation.

EMB-175 flight crew reported mistakenly aligned with a wrong airport during approach. Flight crew was correcting low altitude and course error when ATC notified flight crew of the error.

1668356

201907

1201-1800

ZZZ.Airport

US

0.0

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Parked

Unscheduled Maintenance

Repair

Cockpit Furnishing

X

Failed

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Time Pressure; Communication Breakdown

Party1 Flight Crew; Party2 Maintenance

1668356

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Troubleshooting; Time Pressure

1670989.0

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

Person Flight Crew

Pre-flight

General Flight Cancelled / Delayed

Aircraft; MEL; Procedure

Procedure

After arriving at aircraft the flight crew noticed write-ups; including the left hand emergency escape rope Velcro worn. I; (the Captain;) wrote in the logbook; 'Velcro on left side emergency rope worn. Requesting inspection.' Maintenance personnel came on board and spent approximately thirty minutes working with the Velcro to make it stick. I asked the Mechanic; 'Is it going to stick?' to which he responded; 'Well; they told me to 'Work my magic.' The only way I can get it to stay in is if I wedge it underneath the trim.' After this conversation; the Mechanic called Maintenance Control who told him they will get back with him after they figure out a game plan. After approximately 10 minutes; the Mechanic comes back on board and told me that they told him to 'Tape up' the emergency door. After hearing that the game plan of Maintenance is to tape the door; and my knowledge as I was reviewing the MELs; I realized that the only one applicable to the emergency escape rope is an MEL regarding damage to the door itself; not the Velcro holding the door up. Regardless; the Velcro in and of itself is an imperative item for this MEL. This MEL is as follows: (MEL 25-XX-XX-XX Lanyard; Emergency Exit Rope Cover. Exceptions: May be damaged provided Velcro is intact; secure; and does not impede use of emergency escape rope. Placarding: Escape rope cover.) I first made a call to Assistant Chief Pilot X to see what he thought of this. He did not answer. I recognized this to be a very questionable decision by Maintenance; and called my Dispatcher asking to be put on with Assistant Chief Pilot Y. Through Dispatch; he did not answer the phone; and Dispatch left a voicemail with his cellphone. However; he called moments later from his cellphone; which I answered. Assistant Chief Pilot X himself mentioned his hesitance towards that decision by Maintenance; as well; and handed the phone to Assistant Chief Pilot Y. I informed Assistant Chief Pilot Y of what was going on; and how uncomfortable I was about this situation. Assistant Chief Pilot Y then went on to say; 'You are not a mechanic; and when they sign it off it is their certificates on the line; not yours.' I responded to him; 'Yes; you are right; I am not a Mechanic; but I am an Airline Transport Pilot and Captain; and I think this is a shady situation.' He then made implications about what would happen if I didn't take the aircraft; and said; 'The Company is not going to lose thousands of dollars ferrying an aircraft because of Velcro.' At this point; feeling as though my authority as Captain was being undermined; as well as pressured into taking the aircraft; I ended the conversation and called my Union Representative. After talking with my Union Representative; I received a conference call from Maintenance Control regarding this situation. I requested my Union Representative to be present; and after he was patched in; we began the conference call. I expressed my concern with this decision by Maintenance; particularly regarding the MEL and the requirement that the Velcro needed to be intact and secure; and worried that the tape would impede the use of the emergency door; (be it in difficulty opening; or appearance by a passenger that it was not available for use.) During the conference call; the Company claimed that the Chief Inspector was in a position with the FAA and possessed authority to approve the sign off for this revenue flight. Throughout this conference call; I was made to feel under duress to take the aircraft; even though I felt that the write-up was questionable; as it directly contradicted that of which I read in the MEL.

I performed the preflight. When walking back into the aircraft; the Captain had the discrepancy log book out. The Captain informed me that the port side Velcro was no longer able to hold the wing egress rope cover plate on the wall and that according to the MEL; this was a grounding event. The Captain had already spoken with Maintenance and Dispatch. We held off boarding the aircraft until Maintenance could perform an inspection. It took local Maintenance about an hour to show up. Maintenance confirmed that the Velcro was unusable and that there was no replacement Velcro available on the airport. Local Maintenance was on the phone with (I assume) Company Maintenance for a while discussing. Local Maintenance then informed the crew that he was able to fix the cover plate in place using tape. The Captain made a series of phone calls since tape was not a solution per the MEL. At the conclusion of the Captain's phone calls we boarded the plane and continued the flight to the destination uneventfully.

CRJ200 flight crew reported feeling pressured to accept an aircraft for service that they felt was not in compliance with the applicable MEL.

1450187

201705

0601-1200

ZZZ.Airport

US

0.0

Daylight

Tower ZZZ

Personal

Skylane 182/RG Turbo Skylane/RG

1.0

Part 91

VFR

Personal

Landing

Visual Approach

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 45; Flight Crew Total 148; Flight Crew Type 30

Situational Awareness

1450187

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Regained Aircraft Control

Weather; Human Factors

Human Factors

I proceeded to ZZZ to perform a touch and go on Runway XX as directed by the Tower. The reported winds at that time were [10 degrees from runway heading] at 10 kts gusting to 18 kts. I reported to Tower when I was on downwind and continued in the pattern. Because of the direction and gusty winds; I prepared on Final with a slight crab to the right and only extended my flaps to 20 degrees crossing the threshold at about 75 kts. Up to this point the plane was in line with the center of the runway. At touchdown there was slight lift of the plane; but I was able to allow the plane to settle back to the runway where it began to skid sideways to the left of the runway centerline. Applying rudder and turning controls into the wind with back pressure; I attempted to bring the plane back to the center of the runway to then takeoff. I was unable to regain control of the plane and it continued to skid into the grass on the left side of the runway. I began braking and the plane rolled up an incline and platform area in the grass where it came to a stop when it rolled down the platform on the other side. Tower contacted me where I indicated we were not hurt but that the plane could not move on its own. The engine and all equipment were shut down and we waited for emergency assistance.In hindsight; I could have made different decisions than the ones I made. Once the skidding began; I could have added some power to regain a more forward motion or added full power for a go around. I also could have chosen to not attempt the landing with the winds gusty.I realize winds create great hazards to flying and deserve tremendous respect. Also; knowing my limitations and being able to make good judgment calls to keep myself; passengers; and property safe are necessary qualities I strive to emulate as a good pilot. I fully expect to learn from this misfortune and strive to continue training and educating myself to be the best pilot I can be.

C182 pilot reported a loss of control on landing that resulted in a runway excursion.

1280827

201507

1801-2400

ZAB.ARTCC

CA

25000.0

VMC

Night

Center ZAB

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Climb

Class A ZAB

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 241

Communication Breakdown; Confusion; Distraction; Troubleshooting

Party1 ATC; Party2 Flight Crew

1280827

ATC Issue All Types; Inflight Event / Encounter Other / Unknown

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

ATC Equipment / Nav Facility / Buildings; Equipment / Tooling

ATC Equipment / Nav Facility / Buildings

We were handed off from LA Center to Albuquerque Center Sector 45 frequency 124.500. After switching on to 124.500 it was nearly impossible to hear ZAB Controller instructions because 124.500 is also a frequency used by SoCal Approach Control for LAX Arrivals. Repeatedly; aircraft checking in to SoCal Approach on 124.500 blocked out the ZAB Controller. It was to the point that I was seriously concerned we could not hear what the ZAB Controller wanted us to do. ZAB Sector 45's location is at the western boundary of ZAB airspace. Aircraft climbing out of LAS have line of sight with aircraft descending into LAX thus it is very easy for the two to generate radio transmission conflict on the same frequency of 124.500.

A Captain reported having trouble hearing the Controller on a frequency he was assigned. This frequency is also an arrival frequency for LAX arrivals. The Captain reported of bleed over the frequency and wasn't sure if he was receiving all the transmissions from ZAB Center.

1679939

201909

1201-1800

ZZZ.Airport

US

0.0

VMC

Daylight

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Parked

Gate / Ramp / Line

Air Carrier

First Officer; Pilot Not Flying

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

Distraction; Situational Awareness

1679939

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

Person Flight Crew

Aircraft In Service At Gate

General Maintenance Action

Aircraft; Human Factors

Human Factors

We picked up a new plane in ZZZ on the XX hardstand for our seconded flight of the day. The plane had also flown and arrived from ZZZ1 that morning. It was hot; and clear around noon when I (FO) began the 'Walkaround Inspection' in place of the more detailed 'Exterior Inspection' as the plane had flown previously and had not undergone any known maintenance. While a more detailed inspection was made of the RVSM (Reduced Vertical Separation Minimum) Critical Area on the right side of the aircraft; the left side static ports were presumably covered with silver speed tape enclosed in the silver area around the ports. This went undetected on the walkaround and the flight operated to ZZZ2. Upon arrival in ZZZ2 the FO (First Officer) again inspected the plane in the post flight check; but did not detect the covered static ports. In ZZZ2; a new outbound crew took over the aircraft; and noticed the covered static ports on their inspection. As a result of the covered static ports not being discovered; the aircraft operated the flight as planned to ZZZ2 with covered static ports on the left side of the aircraft. No excessive cross altitude comparison deviations were observed between the three instrument systems. For certain; I the FO should have noticed the covered ports even on the walk around. Complacency of inspections should be held in check; and an increased thoroughness in preflights should be exercised. Additionally; I should recognize how ramp distractions (extended air tube; proximity to mobile boarding adapters at head height; and GPU (Ground Power Unit) cord trip/arc hazards; possible jetways blocking view of ports) may contribute to inadequate attention given to the actual preflight particularly around the door area. Perhaps a change in the order in which I inspect items in the preflight would have allowed me to see the ports at a more optimal angle to note abnormalities. While I (the FO) need to improve my preflight technique; there were a few other factors in this event I feel are worth mentioning. These factors are not intended to rationalize my short comings; but rather present additional information that may help other crews avoid this trap. I think a couple of us these ports on walkaround; perhaps these factors contributed: 1) The silver speed tape blends quite well with the dinner plate sized silver area surrounding the static ports; making it more difficult to detect. Perhaps an effort to utilize more visible tape or extend the silver tape out into the paint of the aircraft would make this procedure of blocking ports more visible. 2) As alluded to earlier; ramp safety has been a pretty big talking point in the company. As I prefer a clockwise inspection path; I would have arrived at these static ports in a pretty complex and busy ramp area. Before I would have seen these ports; I would have negotiated the ground air hose (trip hazard); had to duck under the MBA [Mobile Boarding Adapter] and around the door (head banging hazards); while making sure I didn't get caught up in the GPU cord (trip and shock hazard). All I'm saying there's a lot going on right there; apparently I let these issues distract me and didn't even realize it. I've probably been doing this for years and didn't even realize it. 3) These ports can be in a hard spot to see; possibly even covered by the bumper on the jet bridge. I suspect pilots overlook these ports more then they realize.

EMB-145LR First Officer reported failure to notice static ports covered with tape on walk around inspection.

1676618

201908

0.0

Air Carrier

B777-300

2.0

Part 121

IFR

Passenger

Parked

Gate / Ramp / Line

Air Carrier

Technician

Training / Qualification; Situational Awareness

1676618

Deviation / Discrepancy - Procedural Published Material / Policy

Person Maintenance

Aircraft In Service At Gate

General None Reported / Taken

Procedure

Unqualified techs assigned to work ETOPS ref GMM XX-XX-XX Section X Item X.

Technician reported that unqualified technicians are being assigned to do ETOPS work in violation of GMM.

1504303

201712

1201-1800

ZZZ.Airport

US

5000.0

Icing

Daylight

TRACON ZZZ

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Descent

Class B ZZZ

Aerofoil Ice System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Workload

1504303

Aircraft Equipment Problem Less Severe; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Aircraft; Weather; Human Factors

Aircraft

I checked in at 5000 ft in IMC with TRACON (the final approach control before tower) and told him we had light rime ice and immediately asked for lower as we simultaneously got the first indication of a problem which was an EICAS caution for our an anti-ice system; 'Wing Anti-Ice Fail' then 'No Ice Anti-Ice On'. A few seconds later this was followed by a 'Master Warning ICE COND-A/I INOP'. It's at this point I made a request to ATC to exit icing conditions which was a requirement of our QRH procedure.The controller told us to make a right to a 090 degree heading and descend to 4000 ft but I misheard and read back a 190 degree heading and descend to 4000 ft. In the cockpit my First Officer (FO) who was the PF corrected me and said we are to fly a 090 degree heading which we flew. Nonetheless; during the turn the controller asked us to fly a 050 heading and asked us if conditions improved. I indicated that they had improved but this was just for a moment as a few moments later I told him that it was worse than our previous heading as the same EICAS messages returned. I asked if we could get our previous east heading again which he gave us and said go due east at 4000 feet. On this heading we no longer received any further alerts on our EICAS regarding this problem. The controller then asked what kind of icing we got at 4000-5000 ft. It's at this point I explained to the controller why we needed to exit icing conditions and that we were getting light rime icing. As we flew east we got no further speed or altitude instructions from ATC until shortly before intercepting the localizer so I told my FO to keep his speed close to 250 kts out of an abundance of caution for icing on our wing. We were ultimately left high on the approach and task saturated while being given several adjustments to speeds in quick succession during the turn to intercept the approach final to Runway XXL. After instructions to slow to 200 kts and slow to 180 kts his next transmission was blocked and then when I asked to say again; we were told to turn to a 200 heading to intercept the localizer. The controller then asked us to expedite the right turn to 200 to intercept the localizer and to descend to 2500 feet. I told my First Officer to increase our turn radius. It's at this point that my FO told me he felt overwhelmed and relinquished aircraft control to me. As I took control and disengaged the autopilot to increase our rate of turn we were then cleared for the approach and told to maintain 2500 ft until established. As I took over the controls at this very task saturated point I overcorrected on the rate of turn and undershot the localizer but caught it just prior to a full scale right deflection and it's at this point the control told us to now fly a 190 heading to join the localizer. I continued to make appropriate corrections and made a stabilize approach and safe visual landing. The aircraft was written up for EICAS indications after arriving at the gate.I believe the stress of dealing with the anti-ice system failures in addition to the late vectors to intercept the localizer at the high speeds and at a higher than normal altitude increased our workload to a task saturation level that affected our performance. Regardless; we are grateful that this did not lead to a more serious outcome. If we were unable to exit icing conditions I would have declared an emergency and requested 3000 feet as I knew that while conditions were broken from 5000-6000 feet only few clouds were reported at 3000 feet. My FO was very new to 121 operations and this also affected his confidence with dealing with the flying of the aircraft at a critical stage of flight. I also believe that the MEL on our aircraft for an INOP Pack #2 may have likely led to the failure of the anti-ice system. Our MEL did not limit the aircraft from flying into icing conditions but after talking to maintenance they believe that this could have been a contributory factor to the system failure.

EMB-145 Captain reported track deviations resulted from high workload associated with wing anti-ice failure.

1561272

201807

1201-1800

BFI.Airport

WA

2800.0

VMC

Daylight

TRACON S46; Tower BFI

Personal

PA-24 Comanche

1.0

Part 91

VFR

Personal

Descent

Class B SEA

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 9; Flight Crew Total 918; Flight Crew Type 455

Situational Awareness; Communication Breakdown; Workload; Confusion

Party1 Flight Crew; Party2 ATC

1561272

ATC Issue All Types; Airspace Violation All Types; Deviation / Discrepancy - Procedural FAR

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

Airport; Airspace Structure; Chart Or Publication; Human Factors

Airspace Structure

I was enroute to Boeing Field with VFR flight following the entire way. I had descended to 10;500 ft. MSL and was flying over the mountains to the east of the city. I was handed off to the Seattle Approach and the controller asked if I wanted clearance into the Class B airspace or if I wished to remain outside of it.Initially I responded that I was unfamiliar with the airspace; having never flown there before and asked their advice. He responded that I should stay out of the Class B airspace. I then changed my mind and re-contacted the same controller and asked for a clearance into Class B airspace but instead he passed me to the next one without issuing me a clearance. The next controller said I was doing fine. I repeated to him that I was unfamiliar with the airspace and preferred a clearance. He did not issue me one and quickly passed me off to the Boeing Tower controller saying to avoid Renton Class D airspace.That controller was very busy and would not respond to multiple calls. During the whole time; I had descended to less than 3;000 feet MSL to stay below Class B airspace; but the Renton Class D tops out at 2;500 feet. Directly adjacent and west of Renton is a corridor with even lower attitude requirements. I was under the impression the Approach controller would vector me to sequence me into Boeing Field and allow me to descend safely while remaining under the Class B airspace. Trying to stay above the Renton Class D; but below the Seattle Class B airspace was very difficult and I believe I inadvertently penetrated Class B airspace as I flew north to get out of a potentially dangerous situation. Once I cleared the lower Class B airspace to the north I was able to contact Boeing Tower and was given instructions to enter the right downwind to 32R; which I did and landed uneventfully.My concern about the descent and approach into Boeing Field is that I communicated I was unfamiliar and did request Class B clearance; but was not given one and then was given no assistance to help avoid Renton Class D airspace and safely enter into the busy traffic pattern at Boeing. The Boeing Tower controller was very busy and in the time it took to establish 2 way communication I was given instructions by the previous controller to stay clear of the Class B airspace.

PA-24 pilot reported a lack of support from ATC led to a possible Class B airspace violation.

1442696

201704

1201-1800

RDD.Airport

CA

1300.0

VMC

10

Daylight

12000

Tower RDD

FBO

Skyhawk 172/Cutlass 172

2.0

Part 91

None

Training

Final Approach

Visual Approach

Class D RDD

Tower RDD

FBO

Duchess 76

1.0

Part 91

None

Training

Final Approach

Visual Approach

Class D RDD

Aircraft X

Flight Deck

FBO

Pilot Not Flying; Instructor

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

Flight Crew Last 90 Days 100; Flight Crew Total 530; Flight Crew Type 400

Situational Awareness

1442696

Conflict NMAC

Horizontal 150; Vertical 100

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Took Evasive Action

Human Factors

This was a training flight to a local training area that returned to RDD for pattern practice. After several circuits in the pattern at RDD; my aircraft was on left downwind for RWY 16. Tower instructed my flight; 'You are number 3 following a Duchess on right base; cleared touch and go; RWY 16.' I had mistaken a King Air that appeared to have just turned from a right base to final as the Duchess I was instructed to follow. For this approach; I asked the student to remain at Traffic Pattern Altitude (TPA) for the forward slip from TPA to on glideslope indication; to then a normal zero flap landing.When established on final approach; but right of centerline; I saw an aircraft on my left and immediately took control of the aircraft; applied full power for a climbing right turn to the east at 79 knots. While in the climbing right turn (west bound); I heard the Duchess pilot transmit that there was an aircraft near his aircraft on the right. The Tower transmitted that he wasn't aware of another aircraft on final for RWY 16. After several seconds; Tower asked the position of my aircraft and I transmitted that I was in a climbing right turn on a west heading. Tower instructed me turn immediately continue turn and climb on an east heading - I complied with the instructions. Tower asked my intentions; I replied that I would continue my eastbound climb out of class Delta airspace. Tower instructed me to turn north and report leaving class Delta airspace.After leaving class Delta airspace; I reported that I had left class Delta; and tower asked that I report when ready to re-enter class Delta for landing. After a few minutes; I asked [Tower] for a full-stop landing and was issued ATC instructions; which I followed for a successful landing and to parking. While taxiing; [Tower] asked that I call them. After securing the aircraft on the ramp; I called [Tower] and spoke with the Controller who I had been in contact with at the time of this incident.

C172 instructor pilot reported a NMAC in the pattern at RDD airport.

1103890

201307

0601-1200

ZZZ.TRACON

US

2000.0

Marginal

10

Daylight

1700

TRACON ZZZ

Personal

Baron 58/58TC

1.0

Part 91

IFR

Personal

Initial Approach

Class B ZZZ

GPS & Other Satellite Navigation

X

Improperly Operated

Aircraft X

Flight Deck

Personal

Captain; Pilot Flying; Single Pilot

Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Private

Flight Crew Last 90 Days 15; Flight Crew Total 2848; Flight Crew Type 1700

Confusion; Distraction; Human-Machine Interface; Situational Awareness; Time Pressure; Training / Qualification; Workload

1103890

Deviation / Discrepancy - Procedural Clearance

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Aircraft Aircraft Damaged

Procedure; Equipment / Tooling; Human Factors; Airport

Human Factors

IFR flight plan with new Garmin 750 and 500 panel. Got confused on set up for waypoint intersect. Controller was helpful and circled us around for a new setup. Broke out of clouds and got further confused with nearby airport.... Realized lined up for wrong airport and contacted Tower. Vectored to proper airport and with mental overload; landed safely on a short runway and blew left tire. No damage other than to my ego and the tire. Clearly I was overloaded for what should have been an easy approach and landing caused by the confusion of learning the new system and the need to be at a location on time. Silly pilot errors caused by overload and the domino effect of multiple tasks.

BE58 pilot; distracted by difficulties in programming a new GPS; lined up for landing at the wrong airport. After receiving a vector from ATC; pilot proceeded to the proper airport; but blew a tire on landing.

1751433

202007

0601-1200

ZZZ.Airport

US

0.0

Rain; 5

Daylight

1200

Air Taxi

Medium Transport

2.0

Part 135

IFR

Passenger

Landing

Aircraft X

Flight Deck

Air Taxi

Pilot Not Flying; Captain

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

Flight Crew Last 90 Days 10; Flight Crew Total 28000; Flight Crew Type 140

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

1751433

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 4; Flight Crew Total 1430; Flight Crew Type 85

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC; Party2 Flight Crew

1741439.0

Deviation / Discrepancy - Procedural Landing Without Clearance

Person Flight Crew

In-flight

General None Reported / Taken

Environment - Non Weather Related; Human Factors

Human Factors

FO hand flying ILS in clouds; we were cleared for the approach and told to contact Tower. I dialed the Tower frequency; but got distracted by correcting the flying of the FO and forgot to switch the frequency. We landed without a landing clearance and then realized we were not on the Tower frequency on vacating the runway. We contacted the Tower and apologized; and we were told to taxi to our gate. No further comments from the Tower Controller who was also handling Ground Control.

Because of COVID-19 I haven't flown at all. This was my second day on my rotation. On our second leg we were coming back to ZZZ from ZZZ1. I was the flying pilot; it was cloudy and there was a lot of turbulence. I was mainly focusing on staying at the glide slope and maintain safe airspeed. Captain was running the checklists and communicating with ATC. When we're almost 5 NM out ATC cleared us for ILS XX approach. I was so focused on flying the plane and I couldn't catch that Captain didn't switch to Tower frequency. He was doing suggestions and giving me instructions and he forgot to talk to the Tower frequency. When we passed the Final Approach Fix my main focus was on landing the airplane safely and smoothly. Which I did even though it was super windy and bumpy. After landing safely and slowed down the aircraft to a safe airspeed I gave the controls to Captain.We safely cleared the active runway and I tried to talked to the Tower since they didn't give us any taxi instructions or frequency change and that's when we realized Captain never switched to Tower frequency. As soon as I realized what happened I contacted Tower; I apologized and wrote down the taxi instructions. We went to the main gate and parked the plane. After that me and Captain talked about what happened and we talked about what we did wrong and we talked about how we will make sure that won't happen again. We were both agreed on that communication is really important and from this point on we will double check everything and always try to improve our communication skills. It's also proved [to] us that non-flying pilot's role is really important as well.

Air carrier flight crew reported landing without a clearance.

1320488

201512

0601-1200

ZZZ.ARTCC

US

34000.0

VMC

Daylight

Center ZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Hydraulic System Pump

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1320488

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Flight Crew FLC complied w / Automation / Advisory; Flight Crew Landed in Emergency Condition; General Maintenance Action

Aircraft

Received ECAM warning for a yellow system reservoir overheat. Performed ECAM actions which resulted in yellow system deactivation. Because of degradation of a major system I [requested priority handling with ATC]. Proceeded to destination without incident.Maintenance tech told me the one of the cargo door switches became stuck in the on position resulting in the yellow electric pump running continuously.

An Airbus pilot reported a hydraulic system malfunction which resulted in the deactivation of one of the hydraulic systems. Due to the degradation of some hydraulic system components priority handling was requested; however; the flight continued to destination and landed without incident.

992101

201201

1201-1800

ZZZZ.ARTCC

FO

37000.0

Mixed

Daylight

Center ZZZZ

Air Carrier

MD-11

3.0

Part 121

IFR

Cargo / Freight / Delivery

Cruise

Oceanic

Class A ZZZZ

Stall Warning System

X

Improperly Operated; Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Last 90 Days 222; Flight Crew Total 8600; Flight Crew Type 890

Workload; Troubleshooting; Distraction; Confusion

992101

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 88; Flight Crew Total 7691; Flight Crew Type 1100

Confusion; Troubleshooting; Training / Qualification; Distraction

992102.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew Overcame Equipment Problem; General Maintenance Action

Aircraft; Procedure

Aircraft

Event occurred at cruise; non-radar environment; HF position reports with ATC. Both I (right seat) and the Relief Pilot (left seat) were at the controls when both yokes started to vibrate to the degree of a light buzz. I was the pilot not flying and autopilot number 1 was engaged. I immediately checked altitude; airspeed and VSI. All parameter were normal. Aircraft was holding altitude; airspeed and had a zero VSI. Next we checked all circuit breakers to include autopilot and stall warning systems; and I did a quick test of the warning lights. All circuit breakers were in. The dull continuous vibration remained making it difficult to hold the yoke for any length of time. We tried swamping to autopilot number 2; this did not alleviate the situation. I consulted the QRH and Aircraft Operating Manual (AOM) for any reference to flight control malfunction or inappropriate stall warning or stall warning system malfunction. There was not applicable reference in the QRH or AOM for our situation. At this point the Captain relieved the Relief Pilot from the left seat and informed me that I should take my rest and that he and the Relief Pilot would work the situation. I let the Relief Pilot into the right seat and headed into crew rest. Before I retired I briefed the Captain that we checked all our lights and circuit breakers and found no anomalies. We consulted the AOM and QRH and found no reference for our situation. Upon returning to the cockpit after my two and a half hours of rest; the vibration has ceased in both yokes.

Vibration much less than normal stick shaker activation as experienced in the simulator. No other stall warning indications were illuminated. Our airspeed was around 300 KIAS and the V min foot was about 250 KIAS. The PLI was about 5 degrees above actual aircraft pitch attitude. We called Dispatch via satellite phone to inform them of this issue. Dispatch connected us to Maintenance Control. We described the situation to Maintenance Control and queried as to what the problem may be. We told Maintenance we alternated and disconnected the autopilot however the mild shaking continued. We did our best to work together as a team; however the information Maintenance provided did not help clear the discrepancy. In an effort to provide advance notice to the Company; we asked Maintenance Control to inform our destination Maintenance of the problem. After our discussion with Maintenance Control; we terminated the satellite phone call. After discussing this situation further with the crew; I decided to check the security of the stick shaker cannon plug on the Captain's yoke. Much to my surprise; the cannon plug was loosely secured and became disconnected from the yoke; as that happened; a Level 1 alert 'Stall Warn Fail' illuminated. The mild shaking remained. I re-secured the cannon plug and the alert extinguished. When we checked the security of the First Officer's stick shaker cannon plug; it too was loosely secured and disconnected. The mild yoke shaking ceased and no alert message illuminated. I did not re-secure the cannon plug and left it disconnected for Maintenance to re-secure. The remainder of the flight was uneventful. While airborne and in cruise flight; I did a complete and thorough logbook write-up. I also discussed and debriefed Maintenance after block in.

A MD11's control columns were mildly vibrating at cruise with no other indications. Both stall warning cannon plugs were found loose and when the left was connected; with the right disconnected; the vibration ceased.

1178351

201406

1801-2400

BHM.Tower

AL

1000.0

Tower BHM

Air Taxi

Small Aircraft

1.0

Part 135

IFR

Cargo / Freight / Delivery

Landing

Visual Approach

Class C BHM

VHF

X

Improperly Operated; Malfunctioning

Aircraft X

Flight Deck

Air Taxi

Single Pilot; Captain

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 130; Flight Crew Total 1350; Flight Crew Type 125

Communication Breakdown; Confusion; Distraction

Party1 ATC; Party2 Flight Crew

1178351

ATC Issue All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence

Person Air Traffic Control; Person Flight Crew

In-flight; Taxi

Flight Crew Became Reoriented

Environment - Non Weather Related; Human Factors

Human Factors

I was dodging thunderstorms enroute to BHM and approaching from an abnormal direction; I was planning on the localizer 24 approach; and had that briefed; tuned; and set on two different navs. I picked up the airport around 18 NM out; and was cleared for the visual approach; at that time went visual; mistook Runway 6 for 24 and no longer used my navs for course guidance. After being cleared for the approach I was switched to Tower; after checking in with Tower I was cleared to land 24; not seconds after getting cleared to land 24 there was a high frequency tone that I originally thought was being transmitted by an aircraft (I was later informed that this is a known issue from the TV towers on the hill southwest of the field) and at this stage of the flight needing to focus; there were storms just east of the field; I turned my radio down which unintentionally was all the way down. I immediately turned in to land on what I mistook for Runway 24. From what I understand Tower did try and call me to advise me of my lining up to the wrong runway but due to the interference from the antennas I had my radios all the way down. It wasn't until I was well off the runway after calling for taxi that I realized my radios were all the way down.

The reporter clarified the location of the antennas on a ridge line about 7 NM southwest of the field.

A General Aviation pilot reports being cleared for the visual approach to Runway 24 at BHM but becomes confused and lines up for Runway 6. A loud squeal from the radio caused by TV antennas 7 NM southwest of the field causes the radio volume to be turned way down and calls from the Tower go unheard.

1839467

202109

ZZZ.Airport

US

0.0

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 166

Communication Breakdown

Party1 Flight Crew; Party2 Dispatch

1839467

Deviation / Discrepancy - Procedural Hazardous Material Violation; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance; Ground Event / Encounter Other / Unknown

Person Dispatch; Person Ground Personnel

Pre-flight; Routine Inspection

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

Human Factors

During taxi in ZZZ for departure; while trying to determine the cause of late Weight [and Balance documentation]; operations requested us to return to gate in order to resolve a loading issue with dangerous goods loaded in the aft hold. First issue was the lack of documentation regarding the dangerous goods. We had not received any notification about dangerous goods prior to communicating with operations during taxi out. Second issue was the incorrect loading of the dangerous goods. This was obviously detected by ramp; and was the reason we were unable to get final weights during taxi out. Issue three; If ramp had not discovered; or trapped the loading error; we would have departed with an improperly secured load of unknown dangerous goods. After return to stand; the load was determined to be dry ice of a quantity not requiring prior notification to the flight deck. The ramp supervisor explained that only two bags had been used to surround the cargo; when four bags should have used. He described it as a calculation error.

A319 First Officer reported Dispatch notification of Hazmat cargo documentation errors and incorrect DG cargo loading configuration during taxi. Aircraft returned to gate to correct the errors prior to departure.

1157040

201403

1201-1800

LAF.Airport

IN

3000.0

Daylight

Tower LAF

Personal

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

IFR

Initial Climb

None

Class D LAF

Tower LAF

Personal

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

IFR

Descent

Visual Approach

Class D LAF

Facility LAF.Tower

Government

Other / Unknown

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (mon) 10

Communication Breakdown; Confusion

Party1 ATC; Party2 ATC

1157040

Facility LAF.Tower

Government

Local

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 17

Communication Breakdown; Confusion

Party1 ATC; Party2 ATC

1157070.0

ATC Issue All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Published Material / Policy

Person Air Traffic Control

Air Traffic Control Separated Traffic; Air Traffic Control Provided Assistance

Procedure

LAF is not a combined Tower and TRACON as this system displays. LAF is a non-approach Tower without a radar display. Additionally; the overlaying approach control Grissom Approach (GUS) is not managed by the FAA; it is managed by the DOD. GUS approach advised LAF flight data of an IFR inbound Aircraft Y to the airport; and coordinated the visual approach from the northwest. At (XX:XX) UTC GUS Approach advised LAF flight data the arrival was approximately 22 miles northwest of the airport. At (XX:+04) LAF flight data coordinated an IFR release of Aircraft X and GUS approach released the departure and coordinated runway heading and 3;000 FT in accordance with the LOA (the release is void after 5 minutes per the LOA). At approximately (XX:+06:30) LAF Local Control requested the LAF Flight Data Controller to contact GUS Approach and verify the departure aircraft was released reference the arriving IFR aircraft. At approximately (XX:+06:42) LAF flight data contacted GUS Approach as requested and GUS Approach responded with an affirmative; and advised: 'We're going to take that guy a little bit east to get that guy out'. At approximately (XX:+07:05) GUS Approach advised LAF Flight Data that Aircraft Y was 10 miles northwest and had the field in sight. At approximately (XX:+07:05) LAF Local Control cleared Aircraft X for takeoff and instructed the aircraft to fly runway heading and maintain 3;000 as directed by GUS Approach. At approximately (XX:+07:26) Aircraft Y contacted LAF Local Control and advised they were 7-8 miles northwest on a visual approach at 3;000 FT; LAF Local Control instructed the IFR inbound to report 3 miles northwest for right downwind Runway 28. At approximately (XX:+08:31) LAF Local Control instructed Aircraft X to contact GUS Approach. At (XX:+08:54); GUS Approach contacted LAF Flight Data and stated 'Just verify that Aircraft Y will be a right downwind'; and LAF Flight Data responded 'Roger'. At approximately (XX:+13:) Aircraft Y landed Runway 28 and LAF Flight Data advised GUS Approach of the arrival time. LAF is a non-radar; non-approach Control Tower; without a radar display. Without vertical; visual; on non-radar separation; LAF Tower has no way of ensuring separation of arrival and departure IFR aircraft. Normally; GUS Approach will retain control of an IFR arrival on a visual approach until the departure is radar identified and then transfer control of the arrival to the Tower. Sometimes; GUS Approach will request LAF Tower to find the arrival aircraft visually and then request the Tower to provide visual separation; and once coordinated; switch the arrival to the Tower. However; neither occurred in this situation. From the Tower's point of view; when the arrival was switched to the Tower; there was no type of separation being provided. Perhaps the Radar Approach Control was providing some sort of radar separation. However; at the time the arrival aircraft contacted the Tower; the departure was still on the runway; and it seems impossible that radar separation between the two aircraft could have been provided. Perhaps the Radar Controller believed they had 3 or more miles laterally from the runway; but by switching the aircraft to the Tower; had no way of ensuring the arrival would remain at least 3 miles north; especially since the arrival was on a visual approach; and no restrictions were coordinated with the Tower. GUS Approach was contacted about the incident and they simply replied they had radar 'All day long' between the aircraft. The LOA states the Tower is delegated the authority to provide initial separation between departing and arriving aircraft in the Delta Surface Area. It is unclear in this situation who was responsible for separation; and if separation was ensured. A MOR was filed for loss of non-radar separation.In the past; DOD GUS Approach will not share radar or voice data during an investigation (when requested by QC following up on the MOR). The incident gets closed without a determination. Perhaps the LOA could be re-written to require GUS to share radar and voice data with the FAA when requested. There is often confusion about which facility (Tower or Approach) is going to provide separation. For example; is the Approach going to hang on to the arrival until they get control of the departure? Or does the Approach think the Tower will separate somehow and immediately switch an arrival to the Tower right after giving a departure release? The LOA could be re-written to clarify. There is too much confusion as to what kind of separation (e.g. non-radar or radar) and also who is going to provide the separation after a departure release is coordinated. The LOA could be re-written to require GUS Approach to advise the Tower when they are providing radar separation; and therefore not expecting the Tower to use some non-radar initial separation rule. If GUS is going to use radar to separate; they should tell the Tower.

[Narrative #2 contained no additional information.]

Reporters questioned facility LOA about who is responsible for initial separation; the Control Tower or the overlying Approach Control.

1752939

202007

0601-1200

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

Flight Deck

Air Carrier

Captain

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

1752939

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

Person Flight Crew

Pre-flight

Aircraft Aircraft Damaged; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; Procedure; Human Factors; Company Policy

Aircraft

Operated Aircraft X. During the preflight exterior inspection of the aircraft I noticed some temporary repairs were made to some delamination in the area of the ADG door. I noticed aluminum 'speed tape' was applied to the area of the ADG door and the speed tape had been applied so that the door would not be unobstructed from opening. The door was taped over so that it may have been prevented from opening up successfully. I notified Maintenance Control. Contract maintenance was brought to the plane and reapplied the tape so that it wouldn't tape over the door. The Flight was then signed off and flown to ZZZ1 without issue.Improper maintenance procedures were performed on this aircraft day(s) earlier that allowed the ADG door to be taped over. Not only was the aircraft returned to service and operated an unknown amount of flights with improper maintenance performed; it also went undetected by at least one flight crew who flew this aircraft to ZZZ the night before. This situation was a safety issue that needed to be fixed before departure. Adding to the stress of managing this event in terms of coordination; making announcements; continuing to contact Dispatch and keep everyone informed; Duty Pilot and ZZZ2 Chief Pilot decided to try and intervene and force me to board the aircraft before Maintenance had arrived. I made the Pilot in Command decision to hold boarding the aircraft until Maintenance had arrived because I know it wouldn't take long to board; and COVID-19 concerns with keeping people confined to an aircraft longer than necessary. We knew we weren't departing immediately and there was no sense in boarding an aircraft in the middle of summer in the south with a pandemic going on until I knew when we would be able to depart. It was distracting to my duties as PIC to have management continuously interrupting my situation and duties with their concerns. That's not the time and place for those to be brought up. Pushing captains against their PIC decisions when they're making sound decisions in the interest of safety and health should be addressed as well as the maintenance repair issues.

Pilot reported questionable maintenance procedures regarding the temporary repair of delamination in the area of the ADG door.

1474198

201708

0601-1200

TWF.Airport

ID

210.0

65.0

17500.0

Mixed

Thunderstorm; Haze / Smoke; Rain; 10

Daylight

Center ZLC

Personal

Cessna 337 Super Skymaster

1.0

Part 91

VFR

Personal

GPS

Cruise

Direct

Class A ZLC; Class E ZLC; Special Use JARBRIDGE MOA

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private; Flight Crew Instrument

Flight Crew Last 90 Days 22; Flight Crew Total 2192; Flight Crew Type 594

Situational Awareness

1474198

Airspace Violation All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter VFR In IMC

Person Air Traffic Control

In-flight

Air Traffic Control Provided Assistance; Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Clearance; Flight Crew Exited Penetrated Airspace; Flight Crew Became Reoriented

Weather; Human Factors

Weather

Was VFR enroute to BZN at 15500 feet with flight following talking to SLC Center on 134.1. I contacted SLC Center and communicated I was going to climb to 17500 feet as I was approaching clouds ahead. As I was climbing up over the clouds my climb was accelerating upward due to convective activity and I was contacted by SLC who saw that I had climbed above 17500 and in fact had exceeded 18000 and was therefore in Class A airspace. I saw that it looked like I could descend back lower heading to the west but I decided I should request an IFR clearance to be able to fly in Class A airspace and climb higher. Before I could call I was contacted by SLC and told that I was to contact the military frequency for Jarbidge and was given a clearance direct to Mountain Home. I turned to the left toward Mountain home and contacted the military facility. I believe the frequency was 118.05. I contacted the military facility and was told that I needed to descend to a lower altitude. I told the controller that it looked like I would be able to descend up ahead. I failed to tell the controller about the convective activity I was experiencing and that I was above the clouds. However due to the aggressive convective activity of the storm building beneath me; I then asked the controller for an IFR clearance to BZN and was told that this was not possible within the military airspace that I was now in. I was called back by the military controller and told to contact SLC Center again and they were going to work something out for me. I contacted SLC Center again and I was given an IFR clearance to 21000 to BZN with vectors. I was given a heading of 070 which I could see was to fly me to the east out of the MOA. However I replied that I was unable to turn to the east due to a large buildup/ thunderstorm to the east on my right side. I continued to turn east as much I was able to and soon got on a heading of 070. In the process; the convective activity pushed me up beyond 21000 and I was contacted to get back down to my assigned altitude. In the middle of dealing with maneuvering around the thunderstorm to the east during the climb and the convective activity my engines were overheating due to the decreased cooling effect of the thinner air. At the same time all of this was going on I was managing changes to cowl flaps; mixture; power settings and airspeed to get the engine CHT temperatures under control. In the middle of this the convective activity was now pushing me down lower and I requested to descend to 19000. The convective activity carried me down below 19000 and I was again contacted and had to climb back up to the assigned altitude of 19000. I could see that I was staying south of restricted area R3204A and B as I exited the MOA.I realized that I should have executed a 180 degree turn when I was pushed above 17500 feet to get out of the convective area that I had flown into. Then I could have requested an IFR clearance up to a higher altitude prior to beginning my flight. I had in fact filed an IFR flight along the route I was flying and should have activated that flight plan when I took off so that I could have easily requested a change in altitude when I encountered the bad weather south of TWF. I am very thankful for the assistance of the controllers that helped me manage this difficult weather situation that I flew into. I plan to get more training to learn how to handle higher altitude VFR to IFR transitions. My experience with IFR flight at high altitudes has been new learning to fly the pressurized Skymaster. I also realize now that military controllers are not trained to handle IFR traffic for separation since their job is to manage military aircraft that are trying to intercept one another.

Cessna Skymaster pilot reported inadvertently climbing VFR into Class A airspace due to convective activity. He negotiated with the Center Controller and a Military Controller for a new IFR clearance away from the convective activity; restricted airspace; and out of the MOA to his destination.

1559714

201807

1201-1800

EWR.Airport

NJ

6000.0

VMC

TRACON N90

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

Descent

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 200; Flight Crew Total 24000; Flight Crew Type 14000

Situational Awareness; Time Pressure

1559714

ATC Issue All Types; Conflict NMAC; Deviation / Discrepancy - Procedural Published Material / Policy

Vertical 400

Automation Aircraft RA; Person Air Traffic Control; Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Took Evasive Action

Airspace Structure; Human Factors; Procedure

Ambiguous

We were inside DYLIN on the PHLBO Arrival at 6;000 feet. Approach was vectoring is on downwind for 22L at EWR. Were given traffic at 10 o'clock; not sure of the distance but it was at least several miles. Traffic was a VFR Cherokee at 5;500 feet heading from our left to right. [We] had traffic on TCAS first; altitude showed 400 feet below us. Picked up traffic visually then received a 'monitor vertical speed' RA (Resolution Advisory). We were above the TCAS pitch area and in level flight so we maintained pitch and altitude. Traffic passed beneath us. ATC said traffic was 500 feet beneath us; TCAS said 400 feet. Received 'clear of conflict.' Continued to EWR. I did not notify ATC of the RA as we did not have to deviate from our clearance.

B737 Captain reported receiving a Resolution Advisory caused by VFR traffic during approach.

1732405

202003

1801-2400

TTN.Airport

NJ

180.0

4.0

1000.0

VMC

Night

Tower TTN

Corporate

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

Part 91

IFR

Passenger

Final Approach

Visual Approach

Class D TTN

Aircraft X

Flight Deck

Corporate

Captain

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

Flight Crew Last 90 Days 85; Flight Crew Total 6600; Flight Crew Type 430

Situational Awareness

1732405

Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control

In-flight

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

Human Factors; Procedure

Human Factors

Assigned a heading; we were told to expect the Visual Approach to RWY 24 into TTN. Tonight we were being vectored and I noticed we were on a downwind; but we were further south of what would be a standard left traffic pattern. About midfield left downwind; we advised ATC we had the field in sight. After a short period of time we were issue a vector of 010 and cleared the Visual 24. I noticed that a vector of 010 would have us turning base to final at what I estimated to be a 2.5 mile final with the aircraft setup for a 129 degree intercept. We continued to descend and level off at a 1000' in order to fully configure and complete checks. After level off; we received a low altitude alert from TTN Tower. We were approximately 3 NM from the extended centerline of RWY 24. We turned base to final at 1000' white over white on the PAPI. We were stabilized; acquired normal glide path at about 2.0 NM. What occurred was not unsafe. However; a normal traffic pattern which I have flown many times into this same airport would have eliminated any guess work and we wouldn't have received the low altitude alert from Tower. During a normal visual pattern approach; I can discern distance from the runway off the wing and appropriate altitude in relation to the runway visually. An overlay extended centerline is used only to confirm the correct RWY. With a vector to a visual at that kind of intercept angle; while I can see the airport; you're forcing crews to estimate where altitude should be in space by referencing the overlay extended centerline relative to a 3 degree glide path; requiring our heads to be down. The vector we were given tonight required us to turn final less than 3 miles from the runway; requiring us to be fully configured and at approach speed (135KIAS) prior to making the base to final turn. During vector to visual approaches; I recommend that ATC communicate what distance the vector to final will achieve from the runway. Additionally; altitude guidance should be given with vector angles less than 90 degrees from the intended runway. I interpret 'cleared the visual approach' to mean I am free to maneuver so as to conduct a normal stabilized approach by visual reference to the runway while honoring published approach profiles. That's precisely what we did tonight and we got an altitude alert from TTN Tower. What I can do differently in the future to prevent future occurrence is to use the CAT D published circling altitude if there is an IAP to serve as a better way to plan our descent near the airport. In this instance; I was thinking visual approach during the approach; but I could have very easily drawn a 3.6 NM circle around Runway 24 and used that as a reference as well. ATC does a terrific job here; this is the first time I have ever had a nonstandard event here and I have been in into TTN dozens of times in [recent] years.

Medium Transport Captain reported receiving a low altitude ATC alert on a visual approach to TTN airport.

1284007

201507

1201-1800

PAO.Airport

CA

220.0

0.5

1000.0

VMC

15

Daylight

Tower PAO

FBO

Small Aircraft

2.0

Part 91

None

Training

Initial Approach

Visual Approach

Class D PAO

Personal

UAV - Unpiloted Aerial Vehicle

None

Class D PAO

Aircraft X

Flight Deck

FBO

Instructor; Pilot Flying

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

Flight Crew Last 90 Days 25; Flight Crew Total 1000; Flight Crew Type 250

Situational Awareness; Workload; Distraction

1284007

Airspace Violation All Types; Conflict NMAC; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural FAR

Horizontal 100; Vertical 5

Person Flight Crew

In-flight

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

Human Factors; Procedure; Environment - Non Weather Related

Human Factors

I was acting as a CFI on a training flight with a student returning to our home base PAO when we flew past a drone in the traffic pattern. My student was flying. We were entering the left downwind for runway 31 at PAO from a standard 45 degree entry when I spotted an unmanned drone 2-3 feet in size at our altitude; which was the standard left pattern altitude for 31 at PAO. We passed within approximately 100 feet of the drone and took no evasive action. It appeared to be hovering with no discernible motion. My student indicated that he did not see it. There were no prior traffic advisories from PAO tower or PAO ATIS regarding the drone or drone activity in the area. I reported the drone to PAO tower and tower made a broadcast to all aircraft of our drone report.By the time I saw the drone and recognized it as such; we had nearly flown past it. Such a small vehicle is difficult to spot until very close in. I usually focus on traffic scanning at distances that are further away. I had recently attended a meeting at PAO for CFIs where reports of nearby drone activity was mentioned and I think this helped me recognize it as a drone more quickly. Some pilot awareness of local drone activity may help facilitate close-in visual scanning and faster recognition of these small vehicles. Legislation requiring firmware in these commercially manufactured drones that prevents operation outside of the FAA limits would improve safety. The distribution of information to drone purchasers regarding local flight restrictions; airport locations; etc. may also help prevent this incident from occurring. To put this event into some context; bird activity also creates hazards at PAO and I have had several near collisions with birds there and elsewhere flying over many years. However; birds usually dive out of the way while the drone did not. This drone also likely weighed significantly more than a bird.

An instructor with his flying student was entering a 45 degree left downwind for PAO Runway 31 at 1;000 FT when he detected a UAV about 2-3 FT wide; approximately 100 FT beneath his aircraft.

1068497

201302

0601-1200

TEB.Airport

NJ

2000.0

VMC

Daylight

TRACON N90

Fractional

Citation Excel (C560XL)

2.0

Part 91

IFR

Ferry / Re-Positioning

Climb

SID RUUDY4

Class B EWR; Class D TEB

Aircraft X

Flight Deck

Fractional

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Confusion; Distraction

1068497

Aircraft X

Flight Deck

Fractional

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Workload; Fatigue

1068755.0

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

Person Flight Crew; Person Air Traffic Control

In-flight

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

Airspace Structure; Human Factors

Human Factors

While executing the RUUDY 4 departure out of TEB off runway 24; I leveled at 1;500 feet as required; with 1;500 feet set in the altitude alerter at the time. About the same time I was leveling off and adjusting power to keep the speed in check; my FO reached over and set 2;000 FT on the altitude alerter; while saying something I did not hear clearly; which distracted me somewhat. At about that same time; I heard an altitude alert and saw 2;000 FT in amber in the alerter window and thought I was late in beginning the climb to cross RUUDY at 2;000 FT. In so thinking; I started the climb without verifying that we had in fact passed WENTZ first. Just as we were reaching 2;000 FT; I realized my mistake and ATC called and mentioned our mistake. We acknowledged our error; apologized sincerely; after which he cleared us on. The controller was very professional and told us there was no traffic conflict this time but did emphasize the importance of adhering to the procedure for obvious reasons and to be more careful in the future. Set the highest altitude for the procedure in the altitude alerter during initial set up; rather than the initial limit; to limit the amount of knob turning necessary at a busy time during climb out; or if not; the pilot setting the new altitude 'stating' that he/she is setting the altitude for the next restriction but that 'we haven't passed the previous restriction fix yet'; if such is the case. Me; the pilot flying doing the professional thing and actually verifying having passed the previous altitude restricted fix. Something I did not do this particular time. Use the autopilot sooner in the departure to reduce the work load at a busy time. One of my tendencies is to like to hand fly on climb out up to 10;000 FT and below 10;000 FT on decent in order to stay proficient.

We were on the RUUDY 4 after we leveled of at 1;500 FT we started to climb to 2;000 FT before we got to TASKA [WENTZ]. New York Approach questioned us and said it was not a problem just don't do it again. Do not airline me all day and give me a short show and a 3:30 wake up my local time. This leads to task saturation.

CE560 flight crew reports climbing early on the RUUDY 4 departure from TEB when distracted by the altitude alerter being reset to 2;000 feet by the First Officer.

1504726

201712

1201-1800

ZZZ.Airport

US

0.0

VMC

Turbulence; 10

Daylight

25000

Tower ZZZ

Personal

Skylane 182/RG Turbo Skylane/RG

1.0

Part 91

VFR

Personal

Landing

None

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 49; Flight Crew Total 250; Flight Crew Type 30

Situational Awareness

1504726

Deviation / Discrepancy - Procedural Clearance; Ground Event / Encounter Loss Of Aircraft Control; Ground Excursion Runway; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Regained Aircraft Control

Human Factors; Weather

Weather

During landing the wind drifted my aircraft off the runway into the grass. I applied full opposite rudder. I could have applied more aileron into the wind in my ground roll. There was no damage to the airplane. I pulled back onto the runway and taxied aircraft to parking.

C182RG pilot reported a runway excursion following a crosswind landing.

1852195

202111

1201-1800

ZZZ.ARTCC

US

19000.0

Small Transport

1.0

IFR

Climb

Class A ZZZ

Large UAS; Fixed Wing

IFR

Cruise

Class A ZZZ

Large

Fixed Wing

BVLOS

Aircraft / UAS

Facility ZZZ.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Radar 27; Air Traffic Control Time Certified In Pos 1 (yrs) 27

Communication Breakdown; Situational Awareness; Workload

Party1 Other; Party2 Remote PIC

1852195

ATC Issue All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Published Material / Policy

Automation Air Traffic Control; Person Air Traffic Control

In-flight

Air Traffic Control Issued Advisory / Alert

Environment - Non Weather Related; Equipment / Tooling; Human Factors

Ambiguous

Aircraft X departed ZZZ en route to ZZZZ Center. Aircraft Y was orbiting in the special use airspace area. Sector X was having equipment issues and was having trouble communicating with the aircraft on frequency. I was trying to get the supervisors attention to see if he needed me to take the sector. I looked back and realized that Aircraft Y was still eastbound heading towards Aircraft X. It was too late to stop Aircraft X from climbing through. I tried to turn Aircraft Y to a 340 heading; given how slow Aircraft Y is he should have been able to stay clear if he had turned at that time. Unknown to me; Aircraft Y was monitoring VHF guard. Sector Y only has the capability to monitor UHF Guard. His voice indicator was still on; leading me to believe that I could communicate with him. I was unable to turn the aircraft to the east away from Aircraft Y because of the restricted airspace. The aircraft were 4.66 miles apart laterally and 700 ft. vertically at the time of loss.I believe when UAVs (Unmanned Aerial Vehicles) are operating in the [named] portion or any other area of the special use airspace area that could be problematic; they should be monitoring a frequency that is available on the controlling sector. If they are not; the voice indicator should be off.

Air traffic controller had trouble communicating with aircraft on frequency and experienced difficulty maintaining separation between a UAS and fixed wing aircraft.

1287597

201508

0601-1200

CLE.Airport

OH

TRACON CLE

Air Carrier

A319

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

STAR CHARDON3

Class B CLE

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1287597

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Situational Awareness

1287596.0

Aircraft Equipment Problem Less Severe; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

In-flight

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

Aircraft; Human Factors

Aircraft

On descent into CLE on CXR (CHARDON) arrival aircraft deviated from cleared route due to FMS error. Flight crew and ATC simultaneously detected the deviation and ATC reassigned original clearance. Flight crew programmed the intended fix which was published on [charts] page but not in FMS; and proceeded to fix without further incident. Subsequent reloading of arrival regardless of which runway was selected revealed that the LEBRN fix never showed in FMS despite being on published chart. Program FMS to include LEBRN fix on CXR arrival. Also reiterate to flight crews the importance of verifying AND CORRECTING FMS fixes and restrictions on arrival and departure procedures.

I think the FMS database needs to be looked at; and corrected; if necessary. With so much focus on altitudes and waypoints on complicated STARs; I think it is easy for us (or at least me) to get complacent when it is a simple STAR with one crossing restriction. An equal amount of focus needs to be placed on all STARS (and SIDs; for that matter); when verifying altitudes and waypoints.

An A319 flight crew reported deviating from cleared arrival into CLE when the FMS failed to load all the required waypoints.

1241879

201502

1801-2400

ZNY.ARTCC

NY

37000.0

Night

Center ZNY

Light Transport; Low Wing; 2 Turbojet Eng

2.0

IFR

Cruise

Class A ZNY

Center ZNY

Widebody; Low Wing; 2 Turbojet Eng

2.0

IFR

Climb

Class A ZNY

Facility ZNY.ARTCC

Government

Enroute; Oceanic

Air Traffic Control Fully Certified

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

Communication Breakdown; Confusion; Situational Awareness

Party1 ATC; Party2 ATC; Party2 Flight Crew

1241879

ATC Issue All Types; Conflict NMAC; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance

Person Flight Crew

In-flight

Human Factors; Procedure

Procedure

Aircraft X was coordinated inbound with SJU Center at FL340 his altitude options were FL340 or FL390 and they chose FL340 initially; then called and re-coordinated him at FL390; then called back and asked to coordinate him at FL370 climbing to FL390 which I approved reference the Aircraft Y at FL370 which was already coordinated from myself to SJU Center.A minute or two later I received a message from ARINC that the Aircraft X that he was responding to a TCAS alert which he said was 150 feet; not sure if it was above or below him. Not sure what to recommend.

ZNY Controller reports of an NMAC due to poor coordination of altitudes between two aircraft and possibly a slow climbing aircraft.

1045302

201210

1201-1800

ZZZ.Airport

US

0.0

Ground ZZZ

Beechjet 400

2.0

Part 91

Taxi

None

Facility ZZZ.Tower

Government

Ground

Air Traffic Control Fully Certified

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 ATC

1045302

Aircraft Equipment Problem Critical

Person Air Traffic Control

General None Reported / Taken

Airport; Procedure; Human Factors

Human Factors

I was training a developmental on Ground Control when we were advised by the CIC of an Alert II emergency for an air carrier on about a 6 mile final for Runway 24R with a burning smell. Single emergency vehicle and fire trucks then called for driving permission to their predetermined Runway 24R positions. Both vehicles were given instructions to hold short of Runway 24L by my trainee. As the vehicles were approaching Runway 24L I coordinated with the Local Controller to cross Runway 24L with the emergency vehicles. I was surprised when Local told me he had an aircraft rolling on Runway 24L when we needed to get the emergency vehicles to Runway 24R and I could cross behind the departing aircraft. We then crossed single emergency vehicle at Taxiway S first and a little later fire trucks at Taxiway K; by now our emergency aircraft was landing on Runway 24R. The emergency vehicles proceeded to hold short of Runway 24R not realizing the emergency aircraft had just landed and was holding short of Runway 24L at Taxiway N. Single emergency vehicle then asked if the emergency aircraft was next to land and I told them the aircraft had landed and was holding short of Runway 24L at N. I then told the vehicles they could drive either via Taxiway G or C; which kept them between the runways; to the aircraft. Local then told us the pilot wanted the vehicles to check his right engine before proceeding any farther. The aircraft was still holding short of Runway 24L at N. All vehicles were near the aircraft between the runways on Taxiway N. Fire trucks was told about the right engine check the pilot wanted. We then talked to some other ground aircraft when we heard the CIC yell out about an ARFF vehicle near Runway 24L and Taxiway N as Local had just given a take off clearance on Runway 24L. When I looked towards that intersection I saw an ARFF vehicle at the edge of Taxiway N headed Westbound away from the runway. The AMASS alert system never went off because the departing aircraft had barely started his take off roll. We had then known either a pilot deviation; runway deviation or something had possibly happened. We later learned through all the confusion that neither single emergency vehicle nor fire trucks ever reported verbally clear of Runway 24L after the initial Runway 24L crossing as they should by the LOA. We are now waiting to hear the outcome from all of this. Although the vehicles never reported clear everyone in the tower saw them clear of Runway 24L; then holding short of Runway 24R; then drive via Taxiway G and/or C to the aircraft holding between the runways. We think the ARFF vehicle never should have gone back onto Runway 24L without permission; approximately 3 minutes after the initial crossing and just because they never reported clear of Runway 24L; but everyone saw them clear; doesn't mean Runway 24L is still theirs. And the last clearance given to them was drive via Taxiway G or C to the aircraft holding short of Runway 24L at N. Anytime an emergency is in progress possibly stopping all other traffic from departing or arriving other runways ASAP to allow emergency equipment to get to their positions and continue until all emergency equipment are all clear again. This incident happened more because of aircraft continuing to depart when emergency vehicles were around the runway environment before and after the emergency aircraft landing.

Tower Ground Controller described an emergency event when Local Control cleared an aircraft off a parallel runway with emergency equipment trying to get to the emergency aircraft followed by complete confusion regarding vehicle runway clearance reports.