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

1813732

202106

1201-1800

ZZZ.Airport

US

0.0

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Parked

Coalescer Bag

X

Malfunctioning

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties; Boarding

Physiological - Other; Time Pressure; Other / Unknown

1813732

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

1813651.0

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

Person Flight Attendant

Pre-flight; Routine Inspection; Aircraft In Service At Gate

Flight Crew Overcame Equipment Problem; General Maintenance Action; General Flight Cancelled / Delayed

Aircraft

At approximately XA:30 hours; just moments prior to boarding; I smelled a very strong; musty; wet dog like odor inside the cabin. As I walked back towards the AFT galley (at approximately mid-cabin); the odor became much stronger. I immediately called out to the lead F/A and asked her to come back to observe what I was smelling. [Lead F/A] stated she could also smell the odor. Accordingly; I immediately made my way to the cockpit. The odor became so strong that my throat started to burn; and I began coughing. I told the Captain that we were being fumed and that I was going to notify the boarding agent to immediately stop boarding in order to prevent further issues (i.e. passenger exposure.) The Captain stated that he was notifying maintenance and agreed to hold boarding. I left the aircraft (no passengers were onboard). While making my way up the jet bridge to notify the agent; customers were beginning to walk down the jet bridge since boarding had commenced. I was able to stop the passengers and advised them to stop; turn around and go back into the terminal since we were having maintenance come to the aircraft. I did not advise them why. I entered into the terminal and advised the agent in a discreet manner to stop boarding as we were experiencing an aircraft fume event. I then returned to the aircraft briefly to advise the Captain that the agent was notified. The crew exited the aircraft and we remained in the jet bridge area for a few moments until maintenance arrived. We collected our belongings and exited the jet bridge into the terminal to gain better air quality. I continued to experience a burning throat and my cough continued. At that time; it was prudent to seek medical attention; therefore; I contacted Medical to seek advisement. I was given a clinic appointment at [medical name] and was seen by a doctor accordingly.Improper aircraft maintenance was the cause.Recommendations - Contacting numerous departments; is too much following an incident like this. One call should automatically provide the needed support; guidance and direction that we require during events like this. Because this is my 3rd fume event; I was able to more quickly identify the inherent risks; take appropriate action to limit passenger exposure; and limit extended exposure; however; it was still medically concerning and we should have less calls to make following these dangerous occurrences.

During the preflight the ground air was not sufficient to cool the aircraft. I had the ground crew turn off the ground air and the CA started the APU. After APU start; the CA started the APU BLEED. Almost immediately the CA and I smelled something strange. It did not smell terrible right away but it was cause for investigation. No passengers were on board yet. A FA came up to the flight deck saying he noticed a smell. At the point I radioed maintenance about the problem and we all exited the aircraft. A few minutes later the maintenance staff said they could smell the problem in the jetway. The whole crew then started the Fume Event process. We were all checked out at the on airport [company name] clinic. Reporter stated the cause was Aircraft XXX [which] is a known Fume Event multiple offender. I remember from my walk around that the belly of the aircraft had a high amount of oil streaks. When was this last belly washed? Airbus knows this is a problem and does not take it seriously. Reporter suggested company take known Fume Event aircraft out of service. Use them for parts; excluding the APU. Put filters like [other air carriers] has to protect crews and passengers. Implement bad air detection systems.

A321 Flight Attendant reported a fume event during pre-flight that was reported to Captain who stopped boarding and referred aircraft to Maintenance.

1856418

202111

0601-1200

SOP.Airport

NC

1.8

500.0

CAVU; 10

Daylight

Personal

Small Aircraft

1.0

Part 91

None

Personal

Final Approach

None

Class G SOP

Personal

Small Aircraft

1.0

Part 91

Personal

Final Approach

Class G SOP

Aircraft X

Flight Deck

Personal

Single Pilot

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

Flight Crew Last 90 Days 50; Flight Crew Total 4900; Flight Crew Type 2500

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Crew

1856418

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

Horizontal 1000; Vertical 0

Flight Crew Took Evasive Action

Airport; Human Factors; Procedure

Ambiguous

I was flying Aircraft X; had flown locally for slightly over an hour. Set up for the GPS 5 into SOP on the Garmin; with the ILS/DME 5 in the #2 and SOP in the #2 GPS. There was Aircraft Y; doing touch and go landings flying extremely; extremely tight traffic; landing about once every one and a half minutes. There was no other traffic in the pattern.I intercepted the GPS 5 about 11 miles from the airport; called a 'Moore County traffic; Aircraft X on a 10 mile final GPS 5; full stop landing; Moore County'. I repeated this call at 5 miles. Aircraft Y called turning downwind. Momentarily thereafter I repeated my position report at 2 miles. Aircraft Y immediately called turning base. I immediately transmitted 'Aircraft X on less than a 2 mile final'. Aircraft Y responded 'lots of room' and cut me off; maybe 1;500 feet in front of me. I was flying my approach profile at 120MPH; 105K; so I pulled the throttle to idle; applied full flaps. The distance decreased to about 1;000 feet. I was about to initiate a go-around but Aircraft Y landed and immediately took off again and I was so low and slow that I thought it safer to continue with the landing. I have no idea who was flying Aircraft Y or riding as a passenger.Dangerous non-towered operations are common at SOP and I have so previously reported and something needs to be done before someone gets killed. The airport manager could care less about this kind of behavior and the airport authority is clueless.

GA Pilot flying an approach at SOP non-towered airport reported being cut off in the traffic pattern by another aircraft and stated this type of operation is common at the airport and poses a safety hazard.

1178306

201406

1201-1800

ZKC.ARTCC

KS

31000.0

IMC

Thunderstorm; Turbulence; 0

Daylight

Center ZKC

Corporate

Eclipse 500

1.0

Part 91

IFR

Passenger

Cruise

Class A ZKC

GPS & Other Satellite Navigation

X

Design

Aircraft X

Flight Deck

Corporate

Single Pilot

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

Flight Crew Last 90 Days 110.6; Flight Crew Total 3324; Flight Crew Type 180.7

Human-Machine Interface; Training / Qualification

1178306

Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter Weather / Turbulence

Automation Air Traffic Control; Person Flight Crew

In-flight

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

Aircraft; Weather; Human Factors

Ambiguous

Initially I was at FL340 enroute to GCK. I was deviating to the NE (just W of DDC) for weather near GCK. There was a line of thunderstorms running from west to east that was just south of GCK. On the XM radar depiction; there appeared to be an opening to get north of that weather and allow me to approach the airfield from the north; clear of the thunderstorms. I requested to stay higher until I got through that weather. As I got into the small opening; the XM radar depiction updated and indicated that some weather had moved into that opening and it was not as clear as I believed it would be. Since I had requested to stay high; I was going to be a potential conflict with some other lower traffic if I were to try to descend into GCK. Therefore; as I was approaching that opening; ATC asked me to descend to FL310; which I did. As I approached FL310; I hit some severe turbulence which was enough to disconnect the autopilot. I immediately dropped about 600-700 FT. I began a climb back to FL310. As I approached FL310; I hit another pocket of severe turbulence; this time gaining approximately 800 FT; putting me in conflict with traffic at FL320 that ATC had originally descended me to avoid. ATC asked why I was climbing again; to which I replied that I had hit some severe turbulence and was descending back to FL310. One of the lessons re-learned is that there is a lag in the NEXRAD data provided by XM. Having used it in conjunction with the onboard weather radar in the past; it has proven very effective in picking through weather and precipitation. This most likely led to some complacency on my part that the hole I was seeing in the weather depiction would be enough for me to get through. However; the hole closed about the same time that I flew through it; causing severe turbulence and large altitude deviations. A better alternative would have been to turn around and divert to an alternate south of the thunderstorms or attempt to go around them to the west.

EA-500 pilot reports encountering severe turbulence at FL310 while attempting to avoid thunderstorms using XM Radar and altitude deviations occur. The next XM update showed the gap chosen as closing up.

1810194

202105

0601-1200

ZZZ.ARTCC

US

VMC

Daylight

Air Carrier

A300

2.0

Part 121

IFR

Passenger

Climb

Vectors

Class B ZZZ

Y

N

Y

N

Unscheduled Maintenance

Inspection; Testing

Indicating and Warning - Fuel System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Maintenance

1810194

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Maintenance

1810197.0

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural MEL / CDL; Deviation / Discrepancy - Procedural Maintenance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Fuel Issue; Inflight Event / Encounter Fuel Issue

N

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft; Human Factors; MEL; Procedure

Procedure

Aircraft was dispatched with the RT INNER fuel quantity indicating system inop. Per the MEL; the RT INNER fuel tank quantity would have to be verified by an alternate means. Arrived at the aircraft; fueling was complete and the fuel service form had been signed but the alternate verification had not been recorded in the system. Called Maintenance and they said it was in progress and would be signed off shortly. First Officer (FO) confirmed that they were dripping the tank while he was on his pre-flight walk around.Received an ACARS alert that the system had changed; verified the MEL signoff and it confirmed 6;600 pounds in the right inner verified by Magnetic Level Indicator 2.Fuel Service form showed block in fuel of 19.2 lbs. and that 11.0 lbs. of fuel had been added to bring us up to a total 30.2 lbs.Climbing out of ZZZ got RT INNER FUEL tank pump fault. As Pilot Monitoring (PM) complied with ECAM and turned the pump off and consulted the QRH. When I brought the FUEL page back onto the ECAM I noticed the RT OUTER tank was burning and we had a fuel split of 1000 lbs between the RT and LT outer tanks. The working pump in the right inner tank showed a green line which I took to mean fuel pressure from the RT inner tank but the RT outer was burning down.I put the crossfeed valve in line so that LT inner tank was feeding the #2 Engine. Fuel stopped burning from the RT outer tank at that time. After a minute or two closed the crossfeed valve to see if the RT inner tank would now burn. Fuel started burning out of the RT outer again. Put crossfeed back in line to manually manage the fuel burn and to minimize the imbalance between outer tanks.FO and I discussed what we thought was going on. At this point I believed there was no fuel in the RT inner tank. We both agreed that we could not continue on to ZZZ1 and talked of possible diverts. We discussed returning to ZZZ but I believed there was no fuel in the RT outer tank and if that was the case; we already had an almost 7000 lb split between left and right sides.At this point we were about 50 miles to the west ZZZ2 and decided that was our best divert option. FO continued flying and worked with ATC to change destination and begin descending. I tried to contact ZZZ2 Ramp on VHF 2 but got no response. Informed operations via ACARS of a fuel discrepancy and that we were diverting to ZZZ2. He acknowledged and sent us routing and new numbers. Coordinated arrival with ZZZ Center and ZZZ2 Approach and shot a visual approach and landing to RWY XXR ZZZ2. Left inner tank was empty by the time we started the approach and were burning tank to engine on both engines.Once in the chocks we discussed what had happened and ran numbers on how much fuel we should have and how much we actually had. We blocked out with 29.2 and as per the fuel burn indicators had burned just a little over 10;000 lbs. We should have had 19;200 lbs. RT inner tank; inop FQIS; showed 5;900 lbs; but was empty. LT outer showed 7.4 and RT outer showed 6.0 for a total for a total of 13.4.ZZZ2 Maintenance verified fuel on board with MIL sticks. LT outer 7.7; LT inner 0.0; RT inner 0.0; RT outer 6.0 for a total of 13.7.A failure in the system ensuring required fuel is on board when dealing with a Fuel System MEL.

Aircraft assigned had MEL for RT Inner fuel tank quantity indicator inoperative. When we got to aircraft and I began my walk around; I noticed maintenance moving a ladder over to the right wing inboard of the engine. As I got around to pre-flight the right main gear I asked the maintainer if they were checking the fuel quantity and he confirmed they were. This struck me as a bit odd since the system indicated Flight Ready when we were in ops. I finished my pre-flight and when I got to the cockpit I mentioned to the Captain they were checking the tank on pre-flight; but we both agreed there was no record of the check in the maintenance history. He called Maintenance and they said it was in work. We received an ACARS informing us the aircraft status changed to not flight ready. Shortly after we then received a Flight Ready ACARS notification. I then confirmed the fuel added from the previous flight block in and the fuel slip using the APS. The APS; fuel slip and fuel page all were within +/- 200-300 lbs of total quantity. We blocked out and departed on Runway XXR. After getting a turn east and a climb; ECAM indicated a RT Inner tank pump fault. The Captain began handling ECAM and QRH as Pilot Monitoring (PM). As Pilot Flying (PF); I was not head's down much but I did notice we had approximately a thousand pound split between the LT and RT outer tanks. The fuel page also showed the left pump in the RT inner tank still operational with a green line leading to the right engine. The RT inner showed approximately 5.7. The Captain informed me he was going to place the cross feed valve in-line to feed the right engine from left inner tank. When he did that the RT outer tank burn stopped. After a few minutes he closed the cross feed and again the RT outer tank quantity began decreasing after monitoring it for a minute or two. We then paced the valve back inline to manage imbalance. At this point we were leveling off and we began discussing what was taking place in the fuel system. Despite what the fuel system was indicating; we both came to the conclusion that there was no fuel remaining in RT Inner tank. Based on where we were; and the headwind we would have turning around to ZZZ; we elected to inform Center that we needed to land at ZZZ2. As PF; I took over ATC comms and FMS management to get a descent and set up for approach to ZZZ2 while the Captain attempted contacting operations via ACARS to tell them our situation and plan as well as call ZZZ2 Ramp. We descended and landed at ZZZ2 uneventfully. Once we were blocked in we discussed what we blocked out with-29.2 and had burned-10.0 per the fuel consumption gauges for each engine. The aircraft showed we had 19.2 onboard. We discussed this with Maintenance and they did the manual verification of the tanks confirming that the left and right inner tanks were empty and the actual fuel onboard was 13.7.Unsure other than a discrepancy between what amount of fuel was added and what reading was taken to manually verify RT inner tank quantity.I do not know what took place during the fueling / manual verification timeline to offer feedback on how to prevent future occurrences

A300 flight crew reported MEL procedures were not followed correctly and they had to divert due to insufficient fuel loaded for the flight.

1363048

201606

1201-1800

ZZZ.Airport

US

0.0

IMC

8

Daylight

1800

TRACON ZZZ

Personal

Cessna 180 Skywagon

1.0

Part 91

IFR

Training

Landing

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 20; Flight Crew Total 375; Flight Crew Type 240

1363048

Ground Event / Encounter Ground Strike - Aircraft; Ground Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Regained Aircraft Control; Flight Crew Took Evasive Action

Weather

Arriving runway 25 (the active runway); there was a crosswind from approximately 180; that was transitioning at times to a quartering tailwind. Landing started nominally with a 1 point landing on the front left wheel; transitioning to a 2 wheel landing. As the plane slowed; the wind began to push the tail to the right; causing the airplane to swing to the left. Correcting to the right; the plane came too far to the right and ground looped. The left wing touched the runway; as did the left elevator; causing damage to both; as well as the rim of the left wheel. No occupants were injured; and the plane was able to be taxied safely off of the runway.

C180 pilot reported losing directional control after landing resulting in a ground loop.

1604270

201812

0001-0600

ZZZZ.Airport

FO

0.0

Air Carrier

B747-800 Advanced

2.0

Part 121

IFR

Cargo / Freight / Delivery

Parked

Gate / Ramp / Line

Other Cargo compartment loading

Air Carrier

First Officer

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

Communication Breakdown

Party1 Flight Crew; Party2 Ground Personnel

1604270

Aircraft X

Other Cargo compartment loading

Air Carrier

First Officer; Relief Pilot

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

Communication Breakdown

Party1 Flight Crew; Party2 Ground Personnel

1604277.0

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

Person Flight Crew

Pre-flight; Routine Inspection

General Maintenance Action

Human Factors; Procedure

Ambiguous

I was responsible for the Main Deck Inspection for the flight. The airplane had come in late and there was some time pressure as the airport was due to close 45 minutes after our rescheduled departure time. The airplane had come in from ZZZ1 with a full load of cargo; some of which was staying on and some of which was pulled off and replaced with new cargo. We were given a very confusing NOTOC [Notice to Captain] (multiple sections were crossed out and pen and ink changed due to the cargo being moved around) and 3 tie down worksheets as we had two cars and an aircraft engine that were being loaded there. I came downstairs to do the Main Deck Inspection as the ground crew was loading the last pallets. The ground crew was just starting to put the straps on as the main deck door was closed; but I noticed that they were not referencing the tie down worksheets at all. When I thought they were done I looked at the special loads and noticed that the actual straps didn't match the tied down worksheet at all. I made a comment about this to the Loadmaster who told me that they hadn't actually finished and would get everything fixed before we left. So I continued checking the other cargo and noticed that there was a pallet with a Hazmat tag at position SL; but I didn't have anything listed on the NOTOC. The Loadmasters were busy so I made a mental note to have them figure out the issue when they were done. After checking the other cargo I went back to check the special loads because the Loadmaster indicated they were done. I noticed that the actual tie down still didn't match the strap plan on the tie down worksheet so I brought the issue up with the Loadmaster. For the cars; the worksheet indicated a total of 8 straps needed; but I counted 12 straps instead. There were extra straps in some locations and missing straps in one or two places. Additionally some straps were secured to the pallet; and some were secured to the aircraft itself. The Loadmaster told me that it was fine; that the tie down worksheets were just 'generic'; and that 'sometimes we just make things work.' This went against everything I was taught and had seen up to this point on the line. It also didn't make sense because why would we have tie down worksheets if we weren't going to follow them. In ground school when I was hired; the Loadmaster who came into our class made a point of telling us that if we had special loads the straps had to match the plan exactly (no more or less straps; and each strap secured as the diagram showed us). Also; on the line I had had Loadmasters tell me the same thing. I told the Loadmaster what I had been taught in ground school and that I had never seen a special load not match its tie down worksheet diagram. I also told him that the Captain had given me the tie down worksheets and told me to make sure everything was tied down correctly; so we believed the straps needed to be redone so they matched the diagram. The Loadmaster was noticeably upset with me and tried telling me that it was strapped according to the diagram; but I showed him the worksheet and pointed to several sections on the cars where the straps were different from the diagram. It took some time to get everything fixed because instead of taking the diagram and redoing the work; he would change one strap and ask if I was happy and so it was up to me to point out every place that things were different. I don't know if this occurred because he was upset with me or if it was because he was unfamiliar with the use of the tie down worksheet. As the Loadmaster progressed through fixing the straps the time pressure began to ratchet up. At first the Loadmaster made comments indicating he was going to put the delay on Flight Crew Special Request because of me; and then later in the process the Loadmaster and his supervisor started saying that the airport was going to close soon and we would get stuck and completely mess up the schedule of the airplane. It was clear there was more ofa focus on on-time performance than on safety and legality. Through all of the comments I remained polite but I definitely felt the pressure growing. Eventually the Captain came down to see what was going on; I explained the situation and he backed me up to the Loadmaster and supervisor and said we needed to get it right. During this whole conversation I also brought up the incorrect NOTOC that was missing information on the pallet at SL which had a tag but no information. After some investigation it turned out the information was on the NOTOC but had been crossed out accidentally as it was near some other pallets that had been offloaded. The Loadmaster told me not to worry about it because it was there even though it was crossed out. I told him that having it crossed out while onboard was not okay and so he finally agreed to correct the NOTOC. It took a while to get everything straightened out; but we got out of ZZZZ shortly before it closed. While in cruise I had some time to look through the manuals on my EFB (something I should've done before we left but didn't because of the time pressure). While reading the manuals in the car section; I noticed that the straps in the manuals were secured to the pallet and not the aircraft. The diagram we had made it look like the straps should be attached to the aircraft; and that's how the Loadmasters set it up. But once the pressure was gone and I thought back to previous times I've carried cars; if I remember correctly; they've been strapped to the pallet instead. It could be that either way is acceptable; I'm not sure. I also couldn't find a clear reference that said the tie down worksheet and diagram needed to be followed exactly. While at the time of departure I believed that everything was secured properly; upon reading the manuals afterwards I'm no longer 100% sure everything was correct. From reading the manuals I think it was okay for the straps to be attached to the aircraft here; but I could be misunderstanding the situation. There was so much back and forth that things got a little confused after a while. Later I also noticed that in the process to get out of ZZZZ before it closed; no one signed the tie down verification line on the tie down worksheets. In retrospect; as much as I tried to resist the pressure and make sure everything was done properly; it still got me a little bit. I don't know if we just caught [station personnel] on a bad night; but it seemed like the station personnel in general weren't familiar with the use of the tie down worksheets. They weren't used during the tie down process and the Loadmaster seemed a little confused by it at times while we were working through the issues. And from the Loadmaster's comments it seems like the general station policy is to just throw straps on where they feel like it and call it good. For my reference I talked to the Loadmaster that met the flight at our destination to make sure I wasn't completely off base. I asked if the tie down worksheet should be followed when securing special loads and he confirmed that yes it should and stated that they 'always use the tie down worksheet.' Logically; and from what I was taught in training the tie down worksheet should be followed; but unless I missed something I couldn't find a clear reference that I could point to in the future if this situation came up again. It would be helpful it one of our manuals was changed to include a clear directive about whether or not the straps need to match the worksheet and also whether or not extra straps are acceptable. Additionally; during Operating Experience I was taught to check the straps and tie down worksheet; and Captains I've flown with have routinely expected this. However; [Operations Manual] doesn't explicitly state this; so if this is something we shouldn't be doing; then additional clarification should be provided to the pilot group. The tie down worksheets we were provided were black and white photocopies of the original color document which made the entire process more difficult since the straps are shown in different colors for clarity. There was a legend but it was very difficult to match the different straps since they were in black and white. A color copy would have been very helpful. Finally; assuming I'm not incorrect about the proper tie down procedures; the ZZZZ station could use some additional training on securing special loads as there seems to be some different views among the stations about this issue. If ZZZZ was correct; then additional clarification for everyone should be provided too.

While loading the aircraft we had 2 cars and 2 engines loaded with tiedown worksheets. On inspection of the main deck we found the cars where not tied down per the tiedown worksheet. We brought this to the attention of the Loadmaster; and the cars where then tied down per the tiedown worksheet. We departed with a 54-minute delay. I was not intimately involved with the issues so I cannot speak directly to what exactly transpired; but to my understanding if a load is not properly secured we cannot leave the gate.

B747 flight crew reported numerous procedure and documentation errors regarding Hazmat shipment due to inconsistencies in company procedural manuals.

1808942

202105

0601-1200

GSO.TRACON

NC

20.0

3000.0

VMC

10

Daylight

Corporate

Medium Transport

2.0

Part 91

IFR

Personal

Initial Approach

Visual Approach

Class E BUY

Any Unknown or Unlisted Aircraft Manufacturer

Class E BUY

Aircraft X

Flight Deck

Corporate

Pilot Not Flying

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

Flight Crew Last 90 Days 185; Flight Crew Total 9100; Flight Crew Type 2600

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1808942

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

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

Flight Crew Last 90 Days 30; Flight Crew Total 7000; Flight Crew Type 3500

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1808945.0

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

Vertical 200

N

Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew Returned To Clearance

Human Factors; Procedure

Human Factors

While in route to Burlington Airport (BUY) descending from 11;000 feet to 4;000 feet and approximately 20 miles to the south of the field on a very clear VFR day; the Co-pilot and I both had the Burlington airport in sight and informed ATC (Greensboro Approach). We were then cleared for the visual approach for BUY and told to contact the advisory frequency 122.97; we then descended to 3;000; we were on an extended downwind for Runway 24 in BUY; I had spotted traffic off my left wing which was indicating 200 feet below our altitude. In an attempt to ensure there would not be a conflict with the traffic; I promptly climbed up to 4;000 momentarily until the conflicting traffic was no longer a factor. At that point descended back down to 3;000 feet and began our final approach into Burlington (BUY).

While in route to Burlington Airport (BUY) descending from 11;000 feet to 4;000 feet and approximately 20 miles to the south of the field on a very clear VFR day; the co-pilot and I both had the Burlington airport in sight an informed ATC (Greensboro Approach). We were then cleared for the visual approach for BUY and told to contact the advisory frequency 122.97; we then descended to 3;000; we were on an extended downwind for Runway 24 in BUY; I had spotted traffic off my left wing which was indicating 200 feet below our altitude in an attempt to ensure there would not be a conflict with the traffic; I promptly climbed up to 4;000 momentarily until the conflicting traffic was no longer a factor. At that point descended back down to 3;000 feet and began our final approach into Burlington (BUY).

Corporate flight crew reported NMAC on approach to land.

1851273

202110

1201-1800

ZZZ.Airport

US

250.0

Mixed

Cloudy; Rain

Daylight

Tower ZZZ

Caravan 208B

2.0

IFR

Takeoff / Launch

Autopilot

X

Malfunctioning

Aircraft X

Flight Deck

Captain

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

Confusion; Human-Machine Interface; Situational Awareness; Troubleshooting; Workload

1851273

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

Person Flight Crew

In-flight

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

Aircraft

On the evening of Date I was operating on C208B from ZZZ to ZZZ1. Weather was IFR in ZZZ1 so I was departing on an IFR flight plan. I spent around 5 minutes on the ground from startup to takeoff to ensure that all GPS's were fully booted up; avionics were all set; and autopilot had completed all of its self tests. My plan after takeoff was to hand fly the aircraft to 400 feet MSL; accelerating to 95 knots; then retract the first 10 degrees of flaps and make a climbing turn towards ZZZ1. The takeoff roll was normal; and I believe I rotated at roughly 60 knots. Around 200 - 300 feet MSL I had reached 95 knots and was preparing to retract the flaps and begin my turn when I heard 'Engaging Autopilot' spoken over my headset. I felt the autopilot servos engaging; the aircraft began to pitch down; and the 'LVL' autopilot mode was displayed on my PFD. I pressed the autopilot disconnect button; which seemed to disconnect the autopilot long enough for me to retract flaps and begin my turn. At this point I thought I had accidentally engaged the autopilot in some fashion and was quickly trying to determine what I had done. Within a few seconds of my pressing the disconnect button; I felt the autopilot engage again with no action from me. I pressed the autopilot disconnect a second time and felt the autopilot disengage; then reengage and continue to attempt to pitch the aircraft nose down. At this point I pressed and held down the autopilot disconnect button and continued to for the remainder of the flight; which did fully disconnect the autopilot.After these two engagements with no prompting from me I made the decision to return to ZZZ immediately. I radioed Tower and informed them of my need to return to the field; and that I could return VFR/ accept a special VFR clearance if possible. Flight visibility was fine and I had not yet entered the clouds. Tower cleared me to land and I flew a visual pattern back to the runway. On a base leg I did release the autopilot disconnect button momentarily and the autopilot did not reengage; however I elected to press and hold it down until I landed in case of another uncommanded engagement. The landing was uneventful and I taxied back to the ramp. Upon shutdown and postflight no circuit breakers were found to be popped.An unknown system issue with the GFC 600 autopilot which led to repeated uncommanded autopilot activation. If the issue was caused by a failure of the GFC 600 unit; that issue needs to be fixed. If it was due to a lack of knowledge of the GFC 600 system and its failure modes; perhaps more thorough training on the system is required. I did consider pulling the autopilot circuit breaker to reduce my workload during the flight; however due to the fact that my arm on that side was occupied flying the airplane and holding the autopilot disconnect; the phase of flight; and the weather I felt it would have taken too much of my time and attention to do so. Collars installed on important circuit breakers such as this one to make it possible to pull them by feel or with a quick glance might help situations such as these in the future.

C208 pilot reported the autopilot engaged uncommanded several times. Pilot kept the disconnect button depressed for the remainder of the flight until landing to prevent the autopilot from engaging.

989815

201201

1801-2400

BWI.Airport

MD

0.0

VMC

Night

Tower BWI

Air Taxi

Caravan 208B

1.0

Part 135

IFR

Taxi

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

Flight Crew Commercial

989815

Conflict Ground Conflict; Critical

Person Flight Crew

Taxi

Flight Crew Took Evasive Action

Airport

After I had taxied out of the ramp; I joined the taxi line and contacted Ground Control for taxi instructions. The Controller advised me to standby; so I continued taxiing through the uncontrolled area of the ramp. After I had made a 90 degree left turn; the Ground Controller gave me my taxi instructions. As this was happening; I noticed a tug pulling up to the gate to the right of the taxi centerline. I continued my taxi while I was reading back the instructions from the Controller. While I was doing this; the tug pulled past the security gate; and I noticed the brake lights illuminated by reflection from the luggage cart it was towing. I was moving rather slowly at this point; since most of my forward momentum had been used in the 90 degree turn. Still; I slowed down and rode the brakes until I saw the brake light reflection; and released the brakes. While I was near the end of my readback of taxi instructions; the tug accelerated right in front of me; necessitating my emergency application of the brakes. I interrupted my readback; and attempted to turn my landing lights and strobes on; but was only able to get one landing light on before the tug crossed my path. When the aircraft stopped; the propeller was approximately on the vehicle roadway edge line. When I stopped the aircraft; the tug was approximately 3 feet away from the propeller of the aircraft. The driver looked directly at me/the aircraft and kept traveling from my right to left. I then re-verified my taxi instructions and completed the rest of the flight uneventfully.The uncontrolled area of Baltimore airport is dangerous due to vehicle drivers not yielding to aircraft. This type of incident occurs on a regular basis and apparently with different types of aircraft and different pilots. It is truly unknown to me why someone would intentionally come within a few feet of the propeller of an aircraft just so they do not have to wait two seconds for an aircraft to pass by.

A C-208 pilot reported a near collision with a ground vehicle as he was transiting the ramp obtaining a taxi clearance from Ground Control.

1092911

201306

Air Carrier

Commercial Fixed Wing

Part 121

Electronic Flt Bag (EFB)

Apple

X

Design

Aircraft X

Flight Deck

Air Carrier

Relief Pilot

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Confusion; Distraction; Training / Qualification; Human-Machine Interface

Party1 Flight Crew; Party2 Ground Personnel

1092911

Aircraft Equipment Problem Critical; Flight Deck / Cabin / Aircraft Event Other / Unknown

N

Person Flight Crew

Aircraft In Service At Gate; In-flight; Pre-flight; Taxi

General None Reported / Taken

Manuals; Aircraft; Equipment / Tooling

Equipment / Tooling

Our EFB program due to poor implementation; training; and approval process has become a hazard to this operation. The mounting procedure currently being addressed is only one facet of an ill conceived and executed plan. I am an Apple product user for some years and consider my knowledge and experience of the hardware and operating system as above average. My company issued iPad will only charge from a domestic outlet with an Apple brand charger and/or cord or the hyperjuice battery. Not so with any other Apple product I own. My hyperjuice battery charging cord does not work and I use a Toshiba laptop cord to charge it. When I originally called the help desk; I was told my entire cord and hyperjuice would need to be turned into my flight office and wait for a new one or borrow a spare...if there was one available. I asked if I would be legal to fly without one; he asked what my seniority; aircraft; and seat and said as a Relief Pilot I probably would be OK; or something to that effect. Knowing there are limited spares; I opted to charge the hyperjuice with my laptop cord and avoid trying to chase down a spare every time I fly which is normally early turns or late Europe on weekends when the flight office is not manned. There are many issues with these units (iPads and batteries) of which I would estimate 25% of users share faster than normal battery drain and other issues. Today the TCPro App locked up again and after help from the help desk; the unit was reset for a third time and the App was deleted and reloaded. The response was within one hour and he was helpful.Training; training; training....remarkable that the FAA; our pilot union; and our Company signed off on implementation of a mission critical component by flight crew after watching some rather mediocre videos. -Stable platform. Tested prior to distribution. -Stable mount. [This should have been] properly evaluated prior to implementation. I find it hard to believe the manufacturer recommend wiping pliable rubber with an alcohol type solution. -24/7 Help desk....as we fly 24/7?! -Ample spares; back-ups; trained experts at each base. -Bandwidth to perform all necessary operations at any Company base/destination. I do not understand why a union has to negotiate this?

An international relief pilot for an air carrier expressed misgivings about the implementation of a tablet type EFB by his airline; citing training; spares; battery issues and lack of 24/7 support.

1580795

201809

1201-1800

ZZZ.Airport

US

0.0

VMC

10

Daylight

Personal

Amateur/Home Built/Experimental

1.0

Part 91

VFR

Personal

Takeoff / Launch

Direct

Gear Down Lock

X

Failed

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 7; Flight Crew Total 616; Flight Crew Type 28

Situational Awareness

1580795

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

Person Flight Crew

Taxi

Flight Crew Rejected Takeoff; General Maintenance Action

Human Factors; Aircraft

Human Factors

Gear collapsed during takeoff; due to gear lock disengaging while bouncing on the runway. Found out later that retaining spring to keep lock engaged was missing. This spring is not on annual nor on preflight check list. Strongly recommend to add on both list and check function on regular basis.

Experimental aircraft pilot reported a gear collapse on takeoff due to a faulty gear lock spring.

1470471

201708

1201-1800

ZNY.ARTCC

NY

41000.0

Center ZNY

Fractional

Medium Large Transport

2.0

Part 91

IFR

FMS Or FMC

Cruise

Class A ZNY

Facility ZNY.ARTCC

Government

Handoff / Assist; Enroute

Air Traffic Control Fully Certified

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

Situational Awareness; Human-Machine Interface

1470471

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

Person Air Traffic Control

In-flight

Flight Crew FLC Overrode Automation

Procedure; Human Factors; ATC Equipment / Nav Facility / Buildings; Equipment / Tooling

ATC Equipment / Nav Facility / Buildings

I was working the handoff position at the sector. There was a lot of weather deviations and route closures. Aircraft X had a flight plan which took them backwards. The pilot did not question the route and I did not catch the fact that the routing took them backwards. Aircraft X was coordinated with the adjacent sector who also did not catch that the routing would take this flight backwards. ATOP probed the flight as if he was going reverse course at a fix. The flight did not reverse course and came together with another flight at 41000 feet.ATOP should have a logic check when a flight reverses course like this. Also the pilot didn't fly flight plan.

ZNY Center Controller reported the flight plan processing software did not detect that an aircraft filed a route which reversed course at a fix.

1090611

201305

0001-0600

SKED.ARTCC

FO

34000.0

VMC

Center SKED

Air Carrier

B767 Undifferentiated or Other Model

2.0

Part 121

Passenger

Cruise

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Situational Awareness

1090611

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 200; Flight Crew Total 15000; Flight Crew Type 6000

Situational Awareness

1090612.0

No Specific Anomaly Occurred All Types

Person Flight Crew

In-flight

General None Reported / Taken

Company Policy

A portion of our route included VVC UB689 BOG UG447 SPP. This route overflies high terrain with mountain peaks exceeding 13;300 feet. The Planning guide; South America Region section; does not include a Terrain Critical Depressurization Procedure for this route. Approaching VVC; we contacted Dispatch and asked if the procedure may be located in another section of the guide. While waiting on the answer from Dispatch; we considered a course change including a course reversal. Dispatch [could not suggest any specific publications that covered this route.] We proceeded on our dispatched and cleared route with great caution. We discussed contingency plans for possible mechanical failures requiring a descent.

No additional information provided.

B767 flight crew discovers enroute that there is no pre planned escape route in their manuals for loss of pressurization over high terrain along their route in South America.

1188320

201407

1201-1800

ZZZ.Airport

US

500.0

Daylight

Tower ZZZ

Fractional

Gulfstream IV / G350 / G450

2.0

Part 91

IFR

Passenger

Takeoff / Launch

Class C ZZZ

Reverser Cascade

X

Malfunctioning

Aircraft X

Flight Deck

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Workload

1188320

Aircraft Equipment Problem Less Severe

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; General Flight Cancelled / Delayed; General Declared Emergency

Aircraft

All checks completed all normal. Took off and at approximately 500 FT AGL had the red THRUST REVERSER UNLOCK light come on and the auto checklist came up for the right engine. We declared an emergency followed the checklist and returned to the departure airport with the unlock light still illuminated. We returned without incident and landed as instructed by the checklist.

A GIV aircraft's right engine red THRUST REVERSER UNLOCK light illuminated after takeoff; so the auto checklist was completed; an emergency declared and the flight returned to the departure airport.

1498746

201711

ZZZ.Airport

US

0.0

Ground ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Taxi

Gate / Ramp / Line

Air Carrier

Ramp

1498746

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

Person Ground Personnel

Taxi

General None Reported / Taken

Procedure

[B737-800] was instructed to push to spot X. Prior to that another 737-800 was instructed to push to spot YY which is just in front of spot X on the north side of ZZZ Airport. There was no aircraft coming in which would give a reason to leave spot Z and spot YZ open. The push crew for [the first aircraft] had to stand in the jet blast of [the second flight] as they disconnected the tow bar. Even if there was an operational need this is still not safe. I believe that spots YZ and YY were put there for wide body aircraft and not for Control to use randomly. This is not the first time this has happened.

Air carrier ramp employee reported the push back crew for a B737-800 was subjected to jet blast from another B737-800 when the two aircraft were directed to adjacent ramp spots. Reporter suggested Ramp Control should give more consideration to ramp safety when they assign ramp spots for push back and tow bar disconnect operations.

1332634

201602

1201-1800

PWK.Airport

IL

146.0

17.0

2500.0

VMC

Haze / Smoke; 10

Dusk

6000

10

Tower PWK

FBO

Small Aircraft; High Wing; 1 Eng; Fixed Gear

2.0

Part 91

None

Training

Cruise

Direct

Class E C90

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

Cruise

Class E C90

Aircraft X

Flight Deck

FBO

Pilot Flying

Flight Crew Private

Flight Crew Last 90 Days 25; Flight Crew Total 175; Flight Crew Type 175

1332634

Aircraft X

Flight Deck

Government

Pilot Not Flying; Check Pilot

Flight Crew Flight Instructor

1330578.0

Conflict NMAC

Horizontal 400; Vertical 300

Y

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors

Reporting aircraft was returning to PWK. Traffic at 12 and several miles was seen on the TCAS. We were monitoring PWK Tower at the time of the incident. External lights were on. Right front seat passenger acknowledged traffic; PIC was not able to see it until it was within 5 miles. Conflicting aircraft was against darkening overcast. PIC saw the conflicting and a few seconds later; rear seat passenger said to pull up and turn to the right. Conflicting traffic passed below and to the right of the reporting aircraft. Listening to Chicago TRACON would have been helpful in avoiding the incident.

[Report narrative contained no additional information.]

GA pilot near PWK performed evasive climb to avoid traffic. Traffic was shown on TCAS display.

1789892

202102

0601-1200

ZZZ.TRACON

US

TRACON ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC

Climb; Initial Climb

Class B ZZZ

Aircraft X

Air Carrier

Captain; Pilot Flying

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

Distraction; Confusion; Situational Awareness

1789892

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

Person Air Traffic Control

In-flight

Air Traffic Control Provided Assistance; Flight Crew Returned To Clearance

Environment - Non Weather Related; Human Factors

Environment - Non Weather Related

Climbing out of ZZZ on the ZZZZZ TWO on our flight plan. After a short delay ATC cleared us direct to the ZZZZZ1 Intersection followed by the ZZZZZ2 and ZZZZZ3 intersections which are on the ZZZZZ2 THREE departure.During the departure briefing both the FO identified our lack of recency experience as a threat. When the clearance was sent to the FMC with the new routing the FO was not aware of the LOAD FMC prompt so the new routing was never loaded. When I reviewed the print out of the PDC clearance I remember being confused by the clearance.I should of voiced my concern to the FO when I did not understand the clearance. Unfortunately; I got distracted and never resolved the discrepancy. There's no substitute for diligence when it comes to the route check.

Air carrier Captain reported a track heading deviation. Captain stated when the clearance was sent to the FMC with the new routing the FO was not aware of the LOAD FMC prompt so the new routing was never loaded.

1494838

201711

1801-2400

CPR.TRACON

WY

10000.0

Night

TRACON CPR

Air Taxi

Caravan Undifferentiated

1.0

Part 135

IFR

Cargo / Freight / Delivery

Cruise

Vectors

Class E CPR

Facility CPR.TRACON

Government

Approach; Instructor; Supervisor / CIC

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 2

Training / Qualification; Situational Awareness

1494838

Facility CPR.TRACON

Government

Approach; Trainee

Air Traffic Control Developmental

1493512.0

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

Person Air Traffic Control

Other Post Flight

Air Traffic Control Issued New Clearance

Airspace Structure; Procedure; Human Factors; Chart Or Publication

Airspace Structure

Aircraft entered an MVA (Minimum Vectoring Altitude) of 10500 ft while at 10000 ft. I as Supervisor; was conducting training on approach control and a standalone CIC (Controller in Charge) was present. We had recently implemented STARS (New radar software) and I was sitting on the 'B' scope adjacent to the 'A' scope where training was being conducted. I was making new preference settings and watching from the 'B' scope. Additionally; I was familiarizing myself with some of the STARs features and suggesting alternate courses of action to the trainee regarding the expected arrival traffic.The trainee issued a 30 degree left turn which is a routine clearance for this aircraft and has always been safe because the 10500 ft MVA had not come into play for this aircraft prior to this event. Unfortunately; the aircraft was south of its normal route hence; closer to the 10500 ft MVA. I heard the trainee issued the climb but thought it was so he could tunnel a medevac aircraft underneath him. The MSAW (Minimum Safe Altitude Warning) did not activate and I was unaware that the aircraft entered the MVA too low. The trainee controller's shift ended and after he left work he called me back and advised me of the situation. That's when I became aware of it and filed a MOR (Mandatory Occurrence Report). I asked the controller in Charge what she remembered and she stated that she thought the aircraft had been climbed. I reviewed the radar replay and the aircraft was issued a climb prior to the MVA but the time was insufficient to clear the MVA.The trainee was getting close to certification and my attention to detail waned. The aircraft's route was further south than it typically is. The higher MVA had never been a factor prior to tonight for a 30 degree turn on this aircraft. At various times; the three controllers were discussing ATC questions and may have been distracted. I had been on Sick Leave earlier in the shift visiting a clinic. My shoulder was sore and my stomach was slightly upset. In fact; during this session I asked the CIC upstairs to send some Tylenol down the drop tube. It's possible that my ailments affected the performance of my duties. I'd also been on Flight Surgeon approved meds. One side effect of which is stomach issues.The trainee noticed the event at the time but did not advise myself or the CIC of the issue. I don't know why he didn't speak up. Fear of not getting certified? Lack of trust? It's possible that the situation could've been fixed. I asked him later why he didn't say anything at the time and he said he didn't know why. I encourage him to always say something in the future. The CIC is a new CIC; rated less than 2 weeks. Does a Supervisor in the room mean that others believe everything is under control when it may not be? Reiterate our Safety Culture to say something when you see it. Once again light traffic and distractions created a trap for three of us to step in.

[Report narrative contained no additional information.]

CPR TRACON Controller conducting training reported that undetected to him; a trainee vectored an aircraft below the Minimum Vectoring Altitude.

1224155

201412

0601-1200

PHL.Airport

PA

0.0

No Aircraft

Other Preflight planning

Aero Charts

X

Design

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 250; Flight Crew Total 12000; Flight Crew Type 6000

Situational Awareness; Human-Machine Interface; Confusion; Workload

1224155

Deviation / Discrepancy - Procedural Published Material / Policy

Person Flight Crew

Pre-flight

General None Reported / Taken

Chart Or Publication; Procedure

Chart Or Publication

PHILADELPHIA NINE departure. PDC states 'Cleared PHL9 departure climb via SID' (no altitude given). Nowhere on the PHL9 10-3 page is there any indication of the altitude limit. To find it one has to go to the 10-3-1 procedure text page. Also; nowhere on the Graphics page does it say to reference Text page for altitude information. This runs contrary to almost every other SID and as such makes it an easy thing to miss or forget.How hard is it to put the 'Maintain ____ or assigned altitude' on the same page as the graphic? If this departure had been assigned at the last minute prior to take-off the required altitude would have been difficult to find as it is on a separate page that has to be called up on an iPad that is slow to render the Jeppesen graphics. I feel this has potential for loss of situational awareness given the right circumstances.

Pilot reported the PHL 9 Departure altitude limit was not printed on departure page; requiring bringing up another IPad page to find the altitude. Reporter feels there is potential for loss of situational awareness.

1750056

202007

0601-1200

ZZZ.Airport

US

0.0

Tower ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying; Check Pilot

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

1750056

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

Person Flight Crew

In-flight

General Maintenance Action

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

Aircraft

We planned 26K Bleeds Off Takeoff due to Right Pack Inop and per MEL we applied Engine Bleed Off Takeoff or Landing with the APU Operating procedure. Cleared for takeoff on XXR. At 40% N1 CA TOGA. Both Engines advanced. Engine #2 achieved takeoff thrust of 100.8 N1. Engine #1 stagnated at 85.0 N1. Auto-throttles were on. I pushed on the #1 throttle lever to get a response; but engine stayed stagnated. I was not sure if it was an engine failure or bird strike; so I commanded PF to Reject. We Rejected below 80 knots. Announced Reject with Tower and they directed us to exit first available taxiway. We decided since we were not sure of the nature of the problem; it would be prudent to taxi back to gate and let maintenance troubleshoot the problem.A cascading effect of maintenance issues: During pre-flight the ground crew pulled the external power without our concurrence which caused a power interruption. Had to rebuild/recover several pre-flight items. Five minutes prior to pushback right PACK light illuminated. Could not reset. Maintenance MELed right pack. During pushback/engine start we could not get N2 rotation on #2 engine with Engine Start switch in GND and Start Valve Open light illuminated. Isolation Valve switch was in the Open position. We made several attempts; but each time we moved the Engine Start switch to GND the Isolation Valve would close; and we would lose right duct pressure. We decided to return to the gate via tug and made a logbook write-up. Maintenance fixed the problem and we pushed off the gate for a second time. The low speed reject was the subsequent event.First; more vigilance/coordination from ground crew prior to pulling external power. Second; local ZZZ maintenance mentioned the plane had been sitting idle for more than 60 days. I cannot verify this information. Maybe more Maintenance pre-flight or systems tests if aircraft has been sitting idle for an extended period?

Air Carrier Captain reported a rejected takeoff due to mechanical issues with an aircraft that had been sitting for a couple of months.

1801125

202104

0001-0600

ZZZ.Airport

US

VMC

Night

CTAF ZZZ; Center ZZZ

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Landing

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

1801125

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

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors

We were landing at ZZZ at XA40 local time after the tower has closed. We requested ILS [Runway] XX and were cleared for the approach from ZZZ Center. Outside the FAF we were switched to advisory freq; the FO made an initial call of an 8 mile final for the runway and adjusted the PCL (Pilot Controlled Lighting). Inside the FAF the FO made another radio call of short final to the runway. We landed normal and about 90 KTS I saw head lights on Taxiway 1 where I planned to exit; so I decided to roll to the next one. When the FO called 60 that['s when] we saw the truck was crossing the hold short line. I immediately applied full brakes and redeployed and used max reverse as we were only within a few hundred feet. The truck stopped on the runway when the driver heard our reversers; they were almost to the centerline when they stopped. We stopped about one and a half runway stripes from the truck which then reversed off the runway and we continued to our gate.Only thing that might better safety is sharing this experience with other crews for landing at untowered fields.

Air carrier Captain reported a ground conflict with a vehicle that had crossed the runway hold short lines during their landing roll requiring the Captain to immediately apply full brakes and thrust reversers.

1643338

201905

0001-0600

ZLC.ARTCC

UT

9000.0

Center ZLC

Air Taxi

Super King Air 200

Part 135

IFR

Ambulance

Descent

Vectors

Class E ZLC

Facility ZLC.ARTCC

Government

Instructor; Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 7.0

Training / Qualification; Situational Awareness; Confusion; Communication Breakdown

Party1 ATC; Party2 ATC

1643338

ATC Issue All Types; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Airspace Structure; Company Policy; Human Factors

Human Factors

The aircraft was planning the RNAV Approach. We had just split the sector and there was confusion as to which frequency the aircraft was on. The aircraft was close to the Initial Approach Fix and asked for lower. We assigned 9;000 feet and turned them 30 degrees right to give an appropriate intercept angle. We left the aircraft on the heading just a minute too long. We climbed the aircraft to 10;000 feet for terrain and turned them back to the fix; but while the aircraft was turning they got into a 10;000 feet terrain box while at 9;500 feet. A low altitude alert was then issued. On the job training was in progress.

ZLC ARTCC Controller reported due to a communications error after de-combining sectors an aircraft was left on a heading too long and flew below the Minimum Vectoring Altitude.

1561056

201807

0.0

Air Carrier

B737 Undifferentiated or Other Model

Part 121

Passenger

Parked

Flap Control (Trailing & Leading Edge)

X

Improperly Operated

Company

Air Carrier

Captain

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

Situational Awareness

1561056

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

Person Flight Crew

General None Reported / Taken

Procedure

The 737 fleet newsletter has; in the past; advised pilots experiencing an inadvertent flap torque brake activation to execute a go around and run the appropriate QRH procedure (Flaps--Trailing Edge Flap Disagree). The newsletter chided pilots for not automatically making the go around decision. I think this blanket one-size-fits-all guidance needs rethinking for at least three good reasons.First; it is not unusual to be dispatched to an airport wherein the Dispatch remarks require a bleeds off approach; flaps 5 go around. A torque brake lockout with flaps stuck at 5 degrees makes the go around performance questionable. I envision an approach at night in icing conditions into an airport surrounded by high terrain; and the pilot trying to execute a successful go around with flaps stuck around 30 degrees. Throw in an engine failure during this sluggish go around; and the consequences are dire.Second; the normal call outs for a routine go around begin with calling for flaps 15. I can see the flaps being oversped as the pilots muddle through a procedure never practiced; with flaps stuck nearer 25-30.Finally; the flight manual allows a pilot to land flaps 15 without exercising due diligence on stopping capability should an engine fail on final approach. With an engine failure on final; the pilot may continue the approach by increasing thrust; re-bugging to a higher speed; and selecting flaps 15. There is no prohibition against continuing the approach--even to a high altitude airport; a short runway; or a terrain critical airport; or all three combined. For those who would argue landing with a flap disagree due to torque brake lockout represents an unstable approach (not configured as briefed); I submit the engine failure on final scenario trumps that hands down: one must raise flaps; deal with resulting sink rate; achieve a higher target speed (lower the nose more); add full power on the working engine; and counter the asymmetric thrust. Totally unstable.I recommend company revisits the guidance that a go around is appropriate in all circumstances with a flap torque brake lockout. Perhaps the flight manual could advise that a go around for a flap torque brake lockout during a mandated bleeds off; flap 5 go around approach is inadvisable if flaps are stuck much beyond flaps 5. I'm not even sure if a normal approach predicated on a flaps 15 go around is capable of adequate terrain clearance should the go around be executed with flaps much greater than 15 degrees in certain circumstances. At any rate; landing with flaps stuck between 15-30 seems no worse than landing flaps 15 following an engine failure on final approach; particularly when landing performance issues exist.

A B737 Captain reported that procedures for flap torque brake activation should be reviewed.

1866809

202201

0601-1200

MIA.TRACON

FL

7000.0

IMC

TRACON MIA

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Initial Climb

Class B MIA

TRACON MIA

Any Unknown or Unlisted Aircraft Manufacturer

Class B MIA

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Time Pressure; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1866809

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Instrument; Flight Crew Multiengine

Communication Breakdown

Party1 Flight Crew; Party2 ATC

1866810.0

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

Automation Aircraft RA; Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory

Airspace Structure; Procedure

Procedure

Flight took off at XA32Z and was on departure from Miami International airport; with the First Officer (FO) flying and the Captain (CA) operating as Pilot Monitoring (PM). The flight was given a 090 heading on departure until 2000 ft. when Departure Control (Frequency 119.45) directed a vector to the North and cleared the flight to climb to 7;000 ft. At XA35Z; the flight was level at 7;000 ft. in Instrument Meteorological Conditions (IMC) and Departure Control ordered 'Turn right to 090'. Read back the radio call and began an immediate right turn. While turning; Departure advised there was another aircraft somewhere at 11 o'clock and 1000 ft. below Aircraft X (which was unseen because of IMC). Immediately after making the traffic call; at XA36Z; Departure Control ordered an 'Immediate Left turn to 070'. Aircraft X rolled from a right hand turn into a left hand turn and attempted to comply; while the CA read back the instructions. While attempting to comply; just as the turn was reversing; Aircraft X was approximately over the KR66U fix and received a RESOLUTION ADVISORY (RA) that stated 'DESCEND!; DESCEND!'. The FO expeditiously put the aircraft in the RA window on the display; and correctly executed the RA maneuvers. The CA broadcast our RA compliance on frequency 119.45 and the TCAS indicated a contact immediately off our nose at our exact altitude. As Aircraft X descended through 6;850 ft. (shortly after the RA maneuver began); the TCAS aural alert 'Clear of contact' announced. The CA then transmitted to Miami's Departure in Frequency 119.45 that we were clear of contact and able to return to the 7;000 ft. and 070 heading as ordered. At this time; Departure cleared Aircraft X to climb and gave another course correction to a 090 heading. The flight continued without further incident. ATC vectored us into a near miss with another aircraft. Review routing/congestion issues in Miami Departure Control.

Departed at XA32Z and was on departure from Miami International airport; with the First Officer (FO) operating as pilot flying (PF) and the Captain (CA) operating as Pilot Monitoring (PM). The flight was given a 090 heading on departure until 2000 ft. when Departure Control (Frequency 119.45) directed a vector to the north and cleared the flight to climb to 7;000 ft. At XA35z; the flight was level at 7;000 ft. in Instrument Meteorological Conditions (IMC) and Departure Control ordered 'Turn right;' to a specified heading. Aircraft X read back the radio call and began an immediate right turn. While turning; Departure advised there was another aircraft somewhere at 11 o'clock level at 6000 ft. Immediately after making the traffic call; at XA36Z; Departure Control ordered an 'Immediate Left turn to another specified heading. Aircraft X rolled from a right hand turn into a left hand turn. While in the left turn; there was a RESOLUTION ADVISORY (RA) that stated 'DESCEND!; DESCEND!'. The FO expeditiously put the aircraft in the RA window on the display; and correctly executed the RA maneuvers. The CA broadcast our RA compliance on frequency 119.45 and the TCAS indicated a contact immediately off our nose at our exact altitude. As Aircraft X descended through 6;850 ft. (shortly after the RA maneuver began); the TCAS aural alert 'CLEAR OF CONTACT' announced. The CA then transmitted to Miami's Departure in Frequency 119.45 that we were clear of contact and able to return to the 7;000 ft. The flight continued without further incident. ATC Error. Lots of traffic in the area at the time of the occurrence. De-congesting the airspace by spacing the arrivals and departures.

Flight crew reported taking evasive action after receiving a TCAS RA while on departure.

1272184

201506

0601-1200

ZZZ.Airport

US

0.0

Daylight

Air Carrier

Commercial Fixed Wing

Part 121

IFR

Passenger

Parked

Cabin Furnishing

X

Aircraft X

Galley

Air Carrier

Flight Attendant (On Duty); Flight Attendant In Charge

Flight Attendant Current

Boarding

Physiological - Other; Time Pressure; Troubleshooting

1272184

Aircraft X

Galley

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Boarding

Physiological - Other; Troubleshooting; Workload

1272181.0

Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Person Flight Attendant

Pre-flight

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

Company Policy; Human Factors; Procedure; Aircraft

Human Factors

Upon boarding aircraft; crew was overcome by strong smell of vomit in cabin. Cleaners were cleaning aircraft- once they got to back galley; they indicated a passenger on the inbound flight had vomited on the carpeting between the two aft lavs; on the walls and into the aft galley.Cleaners tried in vain to clean the aircraft; altogether taking over 2 hours (and delaying the aircraft) to get the carpet cleaned and the smell reduced. Cleaners DID NOT use proper safety tools to clean the biohazard; no gloves for most of the employees; (some did have gloves on) and even used a regular vacuum to vacuum up the absorbent material.End result; the aft carpets had to be steam cleaned which in the end reduced the smell of vomit; but greatly increased the smell of chemicals in the aft cabin.Onboard Supervisor was on hand; as well as the Chief Pilot on duty and the Ops Manager. Everyone worked hard to find a solution but in the end we were given the impression from management that if we did not take the plane and deal with the chemical odor we would be given a direct order to do so.While I understand the operational needs of the company; the impact of having to breath a unknown cleaning chemicals as well as having to breath the odor of human vomit for the duration of a 3 hour flight out and then another 3 hour flight to return is unhealthy and presents a safety concern for our passengers and crew.

The floor was steam cleaned yet the smell was still strong while standing in the aft galley. FAs were informed that even though the smell remainded there was no other action to be taken and the aircraft must be taken by the scheduled FAs.

Passenger vomit removal from the previous flight was completed but the offensive odor remained after extensive cleaning. Management strongly suggested the crew complete the scheduled round trip or be ordered to do so with the aircraft in the current condition.

1572979

201808

ZZZ.Airport

US

0.0

VMC

Ground ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

Passenger

Taxi

Main Gear Tire

X

Failed

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 186; Flight Crew Total 13534; Flight Crew Type 3750

Situational Awareness

1572979

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

Person Flight Crew

Taxi

Aircraft Aircraft Damaged; General Maintenance Action

Aircraft

Normal; landing with nice touchdown and no side loads. Departed the runway at the high speed at approximately 40-45 kts. Let the aircraft slow on its own while going up the hill toward XX. Made the turn onto XX at approximately 10 kts; then held short [taxiway] for another aircraft. Made the left onto [taxiway] and continued the taxi holding short of [taxiway] for another aircraft. Taxied approximately another 20 ft. when we felt the right side suddenly drop slightly then a very rough ride then stopped immediately suspecting a flat tire (felt like hitting a large pot hole followed by a blow out in a car). Told Ground Control that we suspected a flat tire and asked if they could see anything. They said they could not. The FO (First Officer) opened his window and looked back confirming a flat. Ground Control called emergency vehicles and we set up maintenance and operations services to offload passengers and get the aircraft fixed. The landing and taxi evolution were absolutely uneventful until the second tire went flat. The landing was great; side-loads were not excessive; taxi speed was well within limits; and there was nothing to indicate a problem. Looking at the pictures that we took; I suspect some kind of internal damage from a manufacturers defect of one of the tires that finally gave way either on landing or taxi (possibly rounding a turn); which lead to the second tire taking the entire load of the truck and the brakes on that side leading to excessive heat and fuse plugs melting. The tire appears to have failed in the direction of internal tire plys. Just a guess; but I'm no tire engineer.

B737 Captain reported two tires failed during taxi.

1009394

201205

1801-2400

ZZZ.Airport

US

4000.0

VMC

Night

TRACON ZZZ

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

Initial Approach

Vectors

Class C ZZZ

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Last 90 Days 392; Flight Crew Type 4000

Communication Breakdown

Party1 ATC; Party2 Flight Crew

1009394

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 525; Flight Crew Type 25000

1009673.0

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Procedure

Procedure

On descent we were speaking to TRACON. We were on vectors for the visual for 26R. TRACON called out traffic for 26L; another carrier's heavy; we advised in sight and would maintain visual. TRACON then stated; 'Roger; follow the other carrier...he's for the left; you are cleared the visual 26R'. As we proceeded inbound; at about the time we pulled abeam the other carrier; ATC blasted us and said; 'Company; what are you doing? I told you to follow the other carrier!' The Captain responded with; 'We understood he was for the left; we are for the right...how do we 'follow' to separate runways'' TRACON did not like our query...we were never told that the other carrier 'should not be passed; etc.' At that time; we received a Climb RA. We responded to RA for a short climb; followed by an uneventful landing on 26R. The other carrier also received an RA and chose to go-around. 'Company is cleared the visual 26R; the other carrier is for the left do not pass or overtake.' This is a phrase we have all heard; and complied with. The Controller upon initial check-in was clearly agitated with all four aircraft he was handling. He was very 'testy' in ALL his transmissions.

[Narrative #2 contained no additional information.]

Air Carrier was instructed to 'follow' traffic that was landing on a parallel runway confusing the flight crew; the reporter noting the clearance was unclear and a 'do not pass' instructions should have been issued if required by ATC.

1741777

202005

1201-1800

BKL.Airport

OH

0.0

VMC

Daylight

Ground BKL

Any Unknown or Unlisted Aircraft Manufacturer

2.0

Taxi

Aircraft X

Flight Deck

First Officer

Flight Crew Commercial; Flight Crew Multiengine

Confusion; Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1741777

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

Person Flight Crew

Taxi

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

Chart Or Publication; Airport

Chart Or Publication

Our taxi instructions from BKL Ground Control were to taxi via Golf; Alpha; cross 6R and hold short of 6L. When planning my route using the Jeppesen taxi diagram; I saw that Golf went all the way to the end of 6R; at which there was a slight dogleg across the runway to get to Alpha. On our taxi; reaching the end of Golf; we were informed that Alpha was slightly behind us; but that we could taxi onto 6R and across to Alpha. After completing the flight; I compared an older taxi chart with my newly updated chart; and there is a discrepancy. The older chart does in fact have the Alpha taxiway crossing 6R; but the newly updated chart does not depict it at all. The current NACO chart also agrees with the most current Jeppesen diagram. The airport was not busy and there were no further issues.

A First Officer reported a taxiway incursion at BKL airport. Reporter stated Taxiway A is not properly charted in the current NACO and Jeppessen diagrams.

1749438

202007

1201-1800

ZZZ.ARTCC

US

20000.0

Center ZZZ

Air Carrier

A319

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

Vectors

FCU (Flight Control Unit)

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Troubleshooting

1749438

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Troubleshooting

1749444.0

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Landed As Precaution

Aircraft

On vectors north of airport to join ZZZZZ arrival at ZZZZZ intersection; due to weather. During descent out of approx. 20;000 ft.; ECAM F/CTRL ELAC 1 fault appeared. I remained flying pilot; First Officer ran ECAM per SOP; and [our] follow up. ELAC 1 would not reset; and the resulting loss was also one of two available servo jacks in each aileron. After discussion with First Officer regarding the resultant flight control malfunction; we decided to [request priority handling] as it was the conservative thing to do. ZZZ was the closest airport so continued there. First Officer notified ATC and company of malfunction; and I briefed the flight attendants of the situation and to treat as precautionary landing. Briefed the passengers of the situation and assured them that all systems were operating normally. Also told them there would be safety vehicles near the aircraft after landing and nothing to be alarmed about. After vectoring around the weather in the area; we accepted visual approach to Runway XX. Landed without incident and taxied to gate.Weather was about the only factor having any effect on the whole situation. Was handled calmly and per SOP. There was a previous write up in logbook for same ECAM.

At 20;000 ft. descending on the ZZZZZ into ZZZ we had an ELAC1 fault. The Captain was flying. I ran the ECAM per SOP; and did the follow up. The system did not come back on line. We thought because it is a flight control malfunction that we [request priority handling] and proceed to land at the destination airport at ZZZ. I notified ATC; and company while the Captain handled the FA; and customers. We were vectored around weather and proceeded to fly the visual to Runway XX. Once on the ground we proceeded to the gate and the Captain made an AML entry.

Flight crew reported an ELAC 1 fault on arrival resulting in a precautionary landing.

1485869

201710

1201-1800

ZZZ.Airport

US

VMC

Center ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

EICAS/EAD/ECAM

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 2656

1485869

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

1485854.0

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

N

Person Flight Crew

In-flight

General None Reported / Taken

Aircraft; MEL

Aircraft

Dispatched with a placard; MEL XXXX; for the lower Multi Function Display Unit inoperative. Placard was authorized on the previous day. Checked and complied with the MEL before departure. Specifically; we verified that the engine indications could be manually selected to either the Captains or FOs inboard display unit and that all other display units were operative. Even though we complied with the MEL before departure; during cruise the FO and I had further discussion about the MEL verbiage and the indications that we were able to see. Specifically; we were able to see all engine indications compacted on the upper MFD but were not able to view hydraulic quantity and pressure. Earlier; we initially dismissed not seeing this as a condition of the MEL placard but we increasingly thought that this didn't make sense. Decided to send a message for Maintenance to meet the aircraft upon arrival and followed up with a radio request to Maintenance to discuss the MEL placard. Made the following Aircraft Maintenance Log entry: With current placard for lower display unit inoperative unable to view hydraulic quantity and pressure. Discussed entry with Maintenance and briefed oncoming crew.Possibly an additional unaddressed system display indication failure. If this is true; it would have been better if it was caught sooner by the Flight Crew or maintenance. MEL addresses being able to see engine indications but doesn't address system indications.

During the flight we noticed that the hydraulic information (pressures and quantities) was missing and could not be pulled up by pushing the SYS switch which is normally the case. That information was missing and could not be found during or after flight. Possible software issue that does not allow for hydraulic information to be displayed.

B737 flight crew reported that with the Lower Multi-Function Display Unit deferred; all engine instruments were displayed except for hydraulic quantity and pressure on the Upper Display Unit.

1347336

201604

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Air Taxi

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

Part 135

IFR

Ferry / Re-Positioning

Landing

Nose Gear

X

Failed

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Troubleshooting; Confusion

1347336

Aircraft X

Flight Deck

Air Taxi

Pilot Not Flying; First Officer

Confusion; Troubleshooting

1347337.0

Aircraft Equipment Problem Critical; Ground Event / Encounter Ground Strike - Aircraft

Person Flight Crew

Other Landing roll out

Aircraft Aircraft Damaged

Aircraft

Aircraft was departing on an empty reposition leg to a nearby field. Engine start and taxi were normal with the possible exceptions of the Power Transfer Unit (PTU); which seemed to take several flight control/speed brake cycles to reach 2800 PSI; and the PIC elected to shut the right engine down for the long taxi from [the FBO] to the runway. Holding short; right engine was started and Thrust Reverser (TR) tested with 2 minute warmup observed. Aircraft was cleared to line up and wait on the runway; where the tower then instructed the aircraft to taxi forward to the power up line so he could get [another] jet behind us. During the brief taxi forward; the Pilot in Command (PIC) did another quick flow; noting Parking brake (Off);Trim position (rudder and aileron); Flap position; Speed Brake position and CAS window clear.Aircraft sat on runway 1R for approximately 5 minutes before being cleared for takeoff. A few seconds after thrust levers were advanced to Takeoff (TO); the red no takeoff warning annunciated and then cleared after a few seconds. PIC elected to continue the takeoff. TO was continued; Second in Command (SIC) noted the late 80 knot call while searching for the red annunciation. Rotation was normal and gear retraction appeared normal. Aircraft was vectored for the RNAV (GPS) approach. The aircraft was cleared for the approach. Several conversations were made between the PIC and the SIC regarding why the VNAV was not working. This (most likely) is because while the PIC may have done about a hundred of these things he is only successful 50% of the time. PIC decided to dive and drive the approach. After manually descending to 2800' the airport was acquired visually and PIC descended on the PAPI's. Flaps 15 and gear down were selected. Gear extension appeared normal. Final flaps and Landing Check were completed prior to the FAF.Tower cleared aircraft to land. Gear down; three green; no red annunciated by BOTH PIC and SIC. The Approach and Landing phase seemed normal with the PIC holding VREF + 15 decelerating to VREF over the fence. Touchdown was normal; PIC deployed speed brakes and began lowering the nose. Nose gear touched down briefly (then the gear handle snapped up and the gear unsafe horn began to blare) and then the aircraft nose continued to descend below the horizon until the aircraft was resting on the nose gear doors. From that point onward; there was only the sound of metal grinding; gear unsafe horn blaring and the PIC screaming obscenities. The aircraft stayed mostly on centerline after PIC stopped using nose wheel steering and used some differential braking. The Tower noticed the aircraft predicament and began to call CFR folks. PIC informed Tower and completed the checklist. After aircraft shutdown; PIC and SIC deplaned a safe distance from aircraft and looked for evidence of fire or fuel leakage. Noting no evidence of fire or fuel leakage; PIC deemed it safe to re-enter aircraft and retrieve his cell phone and begin the painful process of notifying company Personnel. No injuries to either PIC or SIC were experienced.

[Report narrative contained no additional information.]

An Air Taxi flight crew reported a nose gear collapsed upon landing roll out. No abnormal indications were present prior to landing.

1737991

202003

0.0

No Aircraft

Gate / Ramp / Line

Air Carrier

Ramp

Situational Awareness

1737991

Deviation / Discrepancy - Procedural Published Material / Policy

Person Ground Personnel

General None Reported / Taken

Company Policy; Environment - Non Weather Related

Company Policy

Working to close; we are given 2 antiseptic wipes for equipment; no wipes for work areas; ready rooms. In product sort instead of spreading people out; they are putting everybody together in a section. If anyone contracts virus it's very possible to spread.

Ramp agent reported working too close to others and not having sufficient antiseptic wipes.

1797031

202103

Air Carrier

Commercial Fixed Wing

Part 121

IFR

Passenger

Hangar / Base

Air Carrier

Dispatcher

Dispatch Dispatcher

Workload; Time Pressure; Communication Breakdown

Party1 Dispatch; Party2 Dispatch

1797031

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

N

Person Dispatch

General None Reported / Taken

Staffing; Company Policy; Procedure

Company Policy

This report is to provide information into the ongoing workload issues we are seeing. I was working day shift Desk XX this day and the amount of flights on this desk if they were not following each other AND I did not have good support around me would of been un-manageable. I am on the workload committee I/WE followed all procedures but this day the Duty Officer and Chief did not want to move any flights off my desk. Thank goodness for my fellow dispatchers they convinced the Duty Officer to move the ZZZ to ZZZ1 flight from this desk there would of been no way I could of released it at sometime around XA:30 LCL time. The flights worksheets were not balanced on MIDs for the dayshift so that is why we requested the ZZZ to ZZZ1 flight be moved right away at XB:10. I just looked at my worksheet and knew I would have issues with that flight given the fact I had 4 other long hauls to release; one of them being the ZZZ2-ZZZ3 flight and due to the amount of flights I had airborne all shift.Please see the attached screen shot from DV (Dispatch View). I am also attaching the afternoon's worksheet. My fellow co-workers and myself requested to have a couple flights moved from afternoon worksheet with no luck. I have no idea what happened after I left. If you look at Desk XY that day you will notice the workload very different. They had some flight yes; but I knew if anything happened I had backup. There was lots of turbulence all the way across the North-Pacific this morning. One of my ETOPS ALT was marginal; ZZZ4; with I was updating my flights about. One thing that was good and I want to point out is that ZZZ5-ZZZ6 flight were all following each other. That provided help and was the only way this desk could be manageable. We recommend that on the committee. Same city pairs on a desks. What would of helped if the ZZZ7-ZZZ6 flight was released on another desk and or the ZZZ3-ZZZ8 flight also moved. That would of made this desk way more manageable

Dispatcher reported frustration at the workload on various Desks during normal shift.

1037909

201209

1201-1800

ZMA.ARTCC

FL

36000.0

Thunderstorm

Center ZMA

Any Unknown or Unlisted Aircraft Manufacturer

IFR

Cruise

Class A ZMA

Facility ZMA.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Situational Awareness; Communication Breakdown

Party1 ATC; Party2 ATC

1037909

ATC Issue All Types

Person Air Traffic Control

General None Reported / Taken

Human Factors; Procedure

Procedure

Severe weather (thunderstorms) over Key West caused numerous aircraft many miles of deviations for weather. W174C was active so all aircraft were deviating north of CANOA and MAXIM. The Supervisor advised us that all of W174 was going to be active surface to FL500. I advised the Supervisor that all my traffic was deviating north and would be in the Warning Area W174B and E. He advised he did not have a choice. The B646 corridor was blocked by severe weather tops to FL420 and all the traffic was deviating into W174B and E. I advised the Supervisor that there was a 'CAR' that required TMU to have Telcons and reroute traffic away from the weather and Active Warning Areas. I suggested to the Supervisor that traffic could be rerouted thru ZHU airspace over MINOW and be clear of weather and away from the Warning Areas. The Supervisor advised me he would tell TMU. Later I still had not been advised of any action by the Supervisor or TMU. At that time; I called Havana Center and advised them that due to weather deviations and upcoming Active Warning Areas I could no longer accept traffic over MAXIM/CANOA and the B646 corridor. I then asked Havana Center to reroute all traffic over TADPO and the G448 corridor with east deviations since W465A and B were cold. This worked for about 20 minutes until W465 also went Active. Numerous arrivals and departures were deviating for weather and spilling into the Active Warning Areas. The Supervisor then left and assigned the Area to a CIC. This operation upset many people and was unsafe. The TMU should have been proactive and reroute inbound traffic over ZHU via MINOW and away from the weather and Active Warning Areas. The TMU should have ground stopped all departures filed over TADPO; MAXIM; CANOA until the weather moved out or the Warning Areas went cold.

ZMA Controller described possible airspace incursions due to weather deviations and the Supervisor/TMU failures to coordinate and provide re-routes prior to the incidents.

1664952

201907

0601-1200

ZZZ.Airport

US

Daylight

TRACON ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

FMS Or FMC

Climb

Class E ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Situational Awareness

1664952

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

Person Dispatch; Person Gate Agent / CSR

In-flight

General None Reported / Taken

Procedure; Human Factors

Procedure

During climb-out; received a message from Dispatch saying; '[Origin airport station] advised Dispatch at that a passenger had in their checked luggage a small lithium battery for a scooter. We have consulted with cargo load [planner] and [Customer Service Manager] and are in agreement it is OK to continue to [the destination].' FO and I discussed it and agreed to go on to [the destination]. No problems with the flight.

B737-800 Captain reported Dispatch ACARS notification regarding Lithium Ion battery in a passenger checked bag.

1004442

201204

1201-1800

ZZZ.Airport

US

3000.0

VMC

Daylight

TRACON ZZZ

Air Carrier

A300

2.0

Part 121

Initial Approach

Class C ZZZ

Flap Control (Trailing & Leading Edge)

X

Failed

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1004442

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1004444.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

On approach; flaps system 1 and 2 faulted; causing flaps stuck at less than 15 degrees. Captain was pilot flying. First Officer recycled slats/flap handle to 15/0; then back to 15/15; flaps still stuck. leveled at 3;000 MSL and got delay vectors. Declared emergency completed QRH procedure and made uneventful landing. Safety was enhanced by extra fuel added by Captain to original flap panel/right fuel.

On approach flaps stuck less than 15 degrees with system 1 and 2 flap fault lights illuminated. Cycled slat/flap handle per phase one. Flaps remained stuck less than 15 degrees. Accomplished QRH procedure for flaps stuck less than 20 degrees at or below maximum landing weight. [We] declared emergency [with an] uneventful landing.

A300 flight crew experiences stuck flaps during approach at less than 15 degrees with system 1 and 2 flap fault lights illuminated. An emergency is declared; QRH procedures complied with; and an uneventful landing ensues.

1281490

201507

1801-2400

ZZZ1.Airport

US

11000.0

VMC

Night

TRACON ZZZ1

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Climb

Class E ZZZ1

Pressurization System

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 223

Situational Awareness; Training / Qualification; Fatigue

1281490

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural FAR; Flight Deck / Cabin / Aircraft Event Illness / Injury; Inflight Event / Encounter Weather / Turbulence

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Returned To Departure Airport

Human Factors

We had flown in on the all-nighter ZZZ-ZZZ1 and arrived at XA:00L; about 30 minutes late. By the time we finally got to the hotel it was around XB:00L. Pickup was at XL:30L and once we arrived at the airport it was discovered that the aircraft was late inbound and on top of that; the gate was occupied by a delayed flight. The end result was that we could not get onto our aircraft until it was almost scheduled departure time. We were then further delayed due to the ramp shutting down because of thunderstorms which had rolled through. It looked like we were finally ready to go so; as the PF; I gave the Captain's Departure brief and the Pilot Flying brief. This was immediately followed by the Preflight checklist. Unfortunately we were then further delayed another 20 minutes for connecting bags. By the time we blocked out we were 1:17 behind schedule. We conducted a single engine taxi; starting the second engine approaching runway. All appropriate checklists were run and flight was given clearance to 'line up and wait'. Upon receipt of takeoff clearance I pushed the throttles up and the pushed the TOGA button. The auto-throttles set takeoff thrust and I made the 'check thrust' callout. The PM announced that thrust was set at 95.7% which was the expected number per the takeoff data message. However; thrust continued to advance and finally settled at 98.2% which was the value displayed in the FMC. PM subsequently announced 'thrust set; 98.2%'. I remember thinking to myself that the power setting felt pretty high; but it matched the displayed N1 setting in the FMC so I suppressed my concerns. Obviously in hindsight I realize that one possible explanation for the higher than expected thrust was that the engine bleed air switch was positioned to off. We took off and cleaned up the aircraft then ran the After Takeoff checklist. Climbing via the SID our initial altitude was 10;000; but we were subsequently given a climb to 17;000 FT. Passing through approximately 11;000 FT the Cabin Altitude warning horn began to blare and the Cabin Altitude warning light illuminated. We conducted the immediate action items for Cabin Altitude Warning Horn/Light in Flight. I selected ALT HLD to level the aircraft and attempted to select A/P A; which would not select. I continued to hand fly the aircraft and established communication with ATC; and requesting an immediate descent to 9000 FT. I directed the FO to run the QRH FOR Cabin Altitude Warning Horn/Light in Flight. In the heat of the battle; with everything happening; the FAs repeatedly chimed the cockpit out of concern for our safety. From their jump seat they clearly heard the warning horn and did not know what was going on. Not having time at that moment to talk with them I made a PA announcement for the FAs to be seated; which allayed their fears of our demise and got them to cease chiming us. While running the QRH the FO realized that the engine bleed air switches were in the 'off' position. The FO turned the switches to the 'on' position and cabin pressurization was then re-established in the manual mode. This; combined with the descent; resulted in the silencing of the warning horn and the extinguishing of the warning light. We removed our oxygen masks and then got about the task of coordinating a return to ZZZ1. Switching roles; I handed the aircraft to the FO who was subsequently able to engage the B autopilot. ATC gave us vectors direct to ZZZ1; but since we were not ready for the approach we requested delaying vectors/holding while we went about the task of coordination with company. I sent a message to dispatch to 'call me' and seconds later communication was established. Maintenance Control and Dispatch were conferenced in and we discussed what had happened; including the fact that we were in manual pressurization having been unable to establish pressurization using the Auto mode. All things having been considered I chose to return to ZZZ1. As we were 10;000 pounds overweight for landing; the next decision to be made was whether to burn down our fuel or land overweight. Discussion with Maintenance Control gave me the sense that an overweight landing was really a nonissue as long as it was not a hard landing. So given the choice between burning down to landing weight - about two hours - or landing overweight I chose the latter. This decision was influenced by the fact that the FAs had reported that several passengers were feeling ill.Given the higher approach speeds associated with the heavy weight; we decided to request vectors to the longest runway - 27R. ATC gave us vectors for the ILS approach to 27R and as we proceeded inbound we completed the Approach Descent followed by the Approach checklist. The approach and landing were normal with a smooth touchdown. After clearing the runway we informed tower that no further assistance was required. When we taxied to the gate we noticed that the aircraft was still pressurized so I instructed the FO to open the outflow valve using the manual control switch. The aircraft was depressurized; the jetway pulled up and the passengers disembarked. Even though we could legally have continued on with the flight; with all that had happened we elected not to consider this but rather to terminate. Notes: The Cabin Altitude Warning Horn/Light In Flight QRH has a serious shortcoming. The checklist ends with the establishment of cabin pressurization in the manual mode. No mention is made of system degradation or future required actions; such as depressurizing the aircraft prior to landing. Other checklist; such as the Auto Fail QRH; all end with 'Checklist complete except deferred items'; one of which is how and when to depressurize the aircraft for landing when in manual mode. With no guidance; reminders or mention of this in the Cabin Altitude Warning Horn/Light in Flight QRH; the thought of depressurizing the aircraft never crossed my mind as this is always taken care automatically by the pressurization system. Unfortunately we were in the manual mode and ended up landing with the cabin pressurized. After the fact I realize there is a Supplementary 'Manual Mode Operation' QRH which would have been a good reference item for the Cabin Altitude Warning Horn/Light in Flight QRH. The FO states that she never touched the engine bleed air switches during preflight; taxi and takeoff; so they must have been off when we got to the aircraft. There is no checklist or parking/termination procedure that puts these switches in this position. Consequently; I believe habit lead her to assume that these switches were in the correct position -ON - when in fact were actually OFF. When I responded to the challenge on the Preflight Checklist challenge 'Pressurization'; saw that the pressurization control panel had the correct altitudes set; auto was selected and bleed/pack switches were married up; leading me to assume they were set to the correct position. Again; this is because Bleeds - OFF is such an unusual position my brain registered that they were both ON.

B737 Captain reported receiving a cabin altitude warning horn and light. They soon realized the engine bleed switches were in the off position. Reporter mentioned engine bleed switch position is not on their checklist.

1025383

201207

1201-1800

SFB.Airport

FL

800.0

Tower SFB

Personal

SR20

1.0

Part 91

VFR

Final Approach

Class C SFB

Tower SFB

Any Unknown or Unlisted Aircraft Manufacturer

Final Approach

Class C SFB

Facility SFB.Tower

Government

Local

Air Traffic Control Fully Certified

Situational Awareness

1025383

ATC Issue All Types; Conflict Airborne Conflict

Person Air Traffic Control

In-flight

Air Traffic Control Separated Traffic

Human Factors

An SR22 was inbound from the south on a modified right base entry; requesting pattern work. Aircraft was at 1;500 FT; was given the instruction to descend to pattern altitude at pilot's discretion; and to enter the right base to Runway 09R. Additional traffic was to this aircraft's left; making a base entry to Runway 09C for a full stop. Additional traffic was already established in the right traffic pattern of Runway 09R. I misjudged the timing of the inbound the SR22 with the other aircraft in the pattern. My plan was to have the SR22 be first to the runway; and the established aircraft follow the SR22. It ended up being a tie; and I tried to correct the situation by having the SR22 fly eastbound (opposite direction of the other aircraft) with the attempts of having the SR22 now follow the other aircraft. I issued traffic to the SR22 after I told him to make the eastbound turn. The pilot did so; and came close to the other aircraft. There are many things: keep the inbound aircraft at 1;500 FT altitude; could have had existing aircraft make a left 360 in the downwind to create more spacing; could have extended the existing aircraft's upwind; could have turned the SR22 westbound; could have had more urgency with the pilot to have him execute his eastbound turn immediately and give a traffic alert to advise him of the reason for the immediate turn.

SFB Controller described a pattern conflict resulting from ATC spacing misjudgments.

1841044

202109

1801-2400

0.0

VMC

Ground ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Ground ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 138.68; Flight Crew Total 10798.08; Flight Crew Type 7553.10

Other / Unknown; Confusion; Communication Breakdown; Time Pressure; Situational Awareness

Party1 Flight Crew; Party2 ATC

1841044

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

Flight Crew Last 90 Days 130.9; Flight Crew Total 3405.27; Flight Crew Type 3405.27

Other / Unknown; Time Pressure; Situational Awareness; Confusion; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1841045.0

ATC Issue All Types; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

Person Air Traffic Control; Person Flight Crew

Taxi

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

Human Factors

I went off of comm one briefly to call ramp. We were approaching taxiway 1 for the ramp and parking. I got cleared in from ramp. I turned my head up and left and saw Aircraft Y that seemed to fill the entire windshield. The Captain was already starting to brake and I added additional braking from my side because he was so close. I told ground we almost hit Aircraft Y. Ground said sorry. Aircraft Y said ground told him we would give way. I never heard that clearance or acknowledged it. Aircraft Y was taxiing fast down taxiway 1. Was not stopping for anything obviously.

Landed at ZZZ; taxi instructions taxiway 3; 2; 1 to enter ramp for gate.Making the left turn from 2 onto 1; had to slam on the breaks to avoid a collision with Aircraft Y traveling at a high rate of speed southbound on taxiway 1. Asked ground what happened and they said 'sorry' while Aircraft Y stated that we were supposed to give way to them.We did not hear or acknowledge any such instructions. Continued the taxi to gate.

Air Carrier Pilots reported a critical ground conflict during taxi to their ramp/gate. The pilots were forced to initiate an abrupt stop just prior to entering a taxiway. Another aircraft; was proceeding down the taxiway and was not going to yield. The pilots reported they did not hear any instructions or acknowledge to yield for the other aircraft.

1163198

201404

1801-2400

ZZZ.Airport

US

796.0

VMC

10

Daylight

Tower ZZZ

Personal

PA-32 Cherokee Six/Lance/Saratoga/6X

1.0

Part 91

None

Personal

Landing

Direct; Visual Approach

Class D ZZZ

Main Gear Tire

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Instrument

Flight Crew Last 90 Days 33; Flight Crew Total 1948; Flight Crew Type 1100

Confusion

1163198

Aircraft Equipment Problem Less Severe

Person Flight Crew

Taxi

General Maintenance Action

Aircraft

I landed and had a flat right main tire. I was unable to exit the runway. It took approximately 1 hour to clear the runway. The issue is that when speaking to the FAA inspector he asked for my registration. I explained that I have been waiting for the FAA to send it; but they are backed up. It has been a very frustrating experience. The pink form 8050-1 states; 'Pending receipt of the Certificate of Aircraft Registration; the aircraft may be operated for a period not in excess of 90 days; during which time the PINK copy of this application must be carried in the aircraft.' Upon advice of the inspector; I called FAA and they explained that I should not have been operating the aircraft. That section does not apply. I have not gotten an explanation why if the form says I can operate then why can I not? This is very confusing and it is exacerbated by the difficult process of getting my registration. If I operated the aircraft when I shouldn't have then the PINK form needs to be changed. I don't think there is any interpretation other than the one that the form states very clearly. I truly believed that I was operating legally. My mechanic is changing the tire tomorrow and he might have an explanation for the blown tube. I don't know if I ran over anything on takeoff or on the landing.

After landing with a flat tire; a PA-32 pilot is informed that his temporary registration may not be valid although the 8051-1 clearly states that the aircraft may be operated up to 90 days with the pink copy.

1131281

201311

0001-0600

ZZZ.ARTCC

US

27000.0

Center ZZZ

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

IFR

Climb

Class A ZZZ

Center ZZZ

Challenger CL600

IFR

Climb

Class A ZZZ

Facility ZZZ.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Situational Awareness

1131281

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

Automation Air Traffic Control

General None Reported / Taken

ATC Equipment / Nav Facility / Buildings; Procedure

ATC Equipment / Nav Facility / Buildings

Aircraft X was climbing to his requested altitude. Aircraft Y was underneath and in front of Aircraft X. Due to westbound traffic; and not wanting to delay Aircraft Y at FL270 for 60 miles; I decided to stop the climb of Aircraft X at FL270; and climb Aircraft Y through Aircraft X. Aircraft Y was out climbing Aircraft X 4:1 at one point. There was a 60-ish knot overtake the entire time; with Aircraft X behind Aircraft Y; however it was a controlled and calculated overtake and climb. I calculated the closure rate; the climb rate of Aircraft Y; put a 'J-Ring' on Aircraft Y; and decided there was no risk involved with this maneuver. Apparently; my calculation was 8 seconds off. The loss of separation occurred. This is the first operational error of my career. There was no traffic complexity or volume in the sector. I had nothing to watch except this situation; and that's what I was watching. Not once did I observe the target of Aircraft X go inside of the 'J-Ring' on Aircraft Y. Had I thought my calculations were incorrect and this was going to be a loss of separation; it was incredibly easy to fix; using turns; stopping an aircraft's climb; etc. It was well calculated and was not going to be an issue. The fact that I was apparently 8 seconds off (2/3 of a single RADAR sweep) in my calculation could be attributed to any number of factors; including a late report by the pilot; right down to the acceptable margin of error for the RADAR mosaic resolution; especially considering multiple RADAR Sort Boxes were in play. The lateral separation was reported to me as 4.96 NM...or less than 50 feet horizontally. If someone can actually prove to me that the aircraft were 49 feet off of those 5 miles; I'll eat my shoe. Like I said; I monitored the entire situation almost exclusively and not once did I observe the target inside the 'bubble'. A move to ADS-B/NEXGEN RADAR so we can actually get accurate position resolution.

Enroute Controller experienced a loss of separation detected by automation; the reported estimating the separation loss at less than fifty feet.

1070878

201302

0601-1200

MEM.Airport

TN

10000.0

VMC

Daylight

TRACON M03

Air Carrier

MD-11

2.0

Part 121

IFR

Cargo / Freight / Delivery

Descent

STAR TAMMY 4

Class E M03

Autoflight System

X

Design

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Flight Crew Last 90 Days 84; Flight Crew Total 8500; Flight Crew Type 1970

Situational Awareness; Human-Machine Interface; Distraction; Communication Breakdown; Workload

Party1 ATC; Party2 Flight Crew

1070878

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

N

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance

Human Factors; Procedure; Chart Or Publication

Procedure

We may have exceeded the required airspeed at ROCAB on the [MEM] TAMMY RNAV STAR; landing north transition. The Captain was flying and I was the pilot monitoring. Flight arrived from the west. But first; some aircraft autoflight system background. The MD-11's automation [is programmed to achieve exact compliance with airspeed and altitude crossing restraints at waypoints on such arrivals]. However; it ensures altitudes will take precedence. In other words; it will speed up to comply with altitudes if high on profile; thus exchanging altitude for airspeed. This usually happens when arriving from the west; especially in the winter due to the usual strong tailwinds.Memphis ATC tries to move traffic expeditiously. This is great if given enough notice to allow the airplane to meet the requests. Here is what happened. ATC cleared us direct TAMMY and to comply with the STAR thereafter; which we attempted to do. The Captain used speed brakes; to the best of my recollection; for the entire descent until very close to ROCAB where we were given a heading off of the arrival. The Captain had me ask ATC what speed they desired. They stated to comply with the arrival published speeds. We made the altitude restrictions; but I'm not sure of the speed restriction at ROCAB. In fact I don't believe the speed that ATC wanted us to fly was technically the speed we were required to fly; as I believe the clearance for the heading was immediately before ROCAB; which has a 230 KT speed restriction. The speed restriction on the arrival prior to ROCAB is 290 KTS. We were either at 230 KIAS or close to it; I'm sure we were definitely below 250 KIAS. Regardless; what we thought and what ATC thought were two different things. We assumed the Controller wanted 230 KTS; so that was our target speed. That is also why we asked what speed he; the Controller; desired. He never gave us an exact number.Here's what I recommend as the easiest solution to this confusion; clear us for the arrival; let us fly it; and no short cuts. I would not be writing this report if this were the case. Or else; since we are supposed to depart ROCAB on a 067 degree heading. Let us fly that heading. If something else is desired; then change the procedure or use this type of clearance; 'upon reaching ROCAB; depart ROCAB on heading (insert desired ATC heading). This is very clear to all pilots. When given headings at/around clearance limits; it gets confusing.Have the Approach Controller's jumpseat on our aircraft to see how difficult things get when given 'short cuts.' The airplanes I fly are programmed to fly the most efficient and exact flight profile to save the most amount of gas; and as a result; limit noise pollution.Limit the short cuts for east bound traffic--especially in the winter--to at most 10 track NM; as it is very difficult to comply with both altitude and speed constraints when given short cuts. Note that every short cut we get requires the usage of speed brakes to comply with the clearance.Have ATC provide us information; such as 'expect more direct routing;' as soon as possible; preferably when descending while on center frequency. Knowing what sequence we will be allows us to anticipate ATC's intentions of giving us a shortcut. If we know we are leading the pack; then we can quickly program the FMS to start an earlier descent; which isn't the most efficient; but will alleviate a lot of problems.Pilots need to stop accepting clearances blindly; as sometimes we just can't comply with what they're asking us to do. From a CRM point of view; we need to stop trying to 'make it happen.' Note that most pilots I fly with are mission oriented; which is good for the military; but may not be for civilian flying.

The flight crew of an MD11 experienced difficulty complying with the crossing airspeed restriction at ROCAB on the TAMMY RNAV STAR to MEM when they had previously been cleared direct to TAMMY thence descend via the STAR.

1621391

201902

1201-1800

ZAU.ARTCC

IL

26000.0

Daylight

Center ZAU

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

FMS Or FMC

Cruise

Class A ZAU

Center ZAU

Any Unknown or Unlisted Aircraft Manufacturer

IFR

Cruise

Class A ZAU

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 348; Flight Crew Type 14000

1621391

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 494

1621454.0

Inflight Event / Encounter Wake Vortex Encounter; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; General Physical Injury / Incapacitation

Environment - Non Weather Related; Procedure

Ambiguous

During cruise we encountered two to four seconds of wake turbulence/moderate turbulence. Prior to incident; during climb and cruise; conditions there were occasional light chop with ATC (MDW and IND ARTCC) reporting the same ahead of us. During climb; I had authorized F/As (Flight Attendants) to get up to conduct a water service and then clean/secure the cabin for anticipated turbulence projected for the last third of flight. When encountered; I made a PA immediately for the F/As to take their seats. Afterwards we contacted F/As to check on their status. We were informed that the C F/A had fallen to the floor; injuring her back. When queried; she informed me she was in a lot of pain and could not continue her duties. She then told me she was going to apply ice and take ibuprofen for the pain. I discussed with her about contacting Stat-MD and she felt it was not necessary. I discussed with the F/O (First Officer) that we would check on her status in ten minutes and if no improvement; then contacting Stat-MD. When I checked with her after ten minutes; she informed me that the ice and ibuprofen had helped but she still did not feel well enough to continue her duties. I instructed her to stay seated and we would have EMS meet the aircraft. During this process; Dispatch was notified of situation; to contact EMS to meet aircraft; and notify F/A scheduling. Arrival; landing; and taxi to gate were uneventful. Passengers were kept seated while EMS came on board and assisted her off the aircraft. We talked with her in terminal and suggested she go to local hospital to be completely evaluated (EMS did not have facilities to do so). She declined; choosing to go home and be evaluated there. After the initial turbulence encounter; we did not encounter any more moderate turbulence; along with the short duration; leads me to believe what we encountered was due to wake turbulence.

During cruise we asked ATC for a ride report. We were told to expect occasional light chop. Shortly thereafter the Captain asked me to relay to the cabin crew that he would like them to do a water only service. A couple minutes later we hit what felt like two distinct wake turbulence bumps followed by a third a couple moments later. I would characterize them as strong light to weak moderate. A few moments later; one of the crew called up to inform us that our C Flight Attendant had injured her back.

B737-700 flight crew reported encountering probably wake turbulence in cruise flight at FL260 that resulted in a minor injury to a Flight Attendant.

1346241

201604

1201-1800

ZAU.ARTCC

IL

15000.0

Daylight

Center ZAU

Air Carrier

B777 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Descent

Direct

Class E ZAU

Center ZAU

PC-12

1.0

IFR

Passenger

Climb

Vectors

Class E ZAU

Facility ZAU.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 22.0

Training / Qualification; Situational Awareness

1346241

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

Aircraft X was on the arrival and level at 15;000 feet. Aircraft Y was stopped short at 14;000 feet. The Aircraft Y passed 5-6 miles behind Aircraft X and reported severe turbulence; determined to be wake turbulence.[We need] better awareness of wake turbulence.

An aircraft reported severe wake turbulence.

1815173

202102

1201-1800

GMU.Airport

SC

500.0

VMC

Daylight

CLR

Tower GMU

FBO

Small Aircraft; High Wing; 1 Eng; Fixed Gear

2.0

Part 91

None

Training

Final Approach

Visual Approach

Class D GMU

Tower GMU

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

Initial Approach

Class D GMU

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Student

Flight Crew Last 90 Days 6; Flight Crew Total 32; Flight Crew Type 25

Communication Breakdown

Party1 Flight Crew; Party2 ATC

1815173

Conflict NMAC

Horizontal 100; Vertical 50

N

In-flight

Air Traffic Control Separated Traffic; Flight Crew Took Evasive Action

Human Factors; Procedure

Procedure

I was performing touch-and-go's during a supervised solo flight. On my final approach (GMU Runway 19); the other aircraft; who was told by ATC to continue flying through the final; took a northbound turn straight in front of me; flying directly towards me. I took evasive maneuvers by dropping down to the right. The other plane; only after being told by ATC that he had cut someone's final off; also took evasive maneuvers and started flying to his right and upwards. Following the evasive maneuver; landing on Runway 19 was uneventful.

Student pilot reported a Near Mid Air Collision on final approach with another aircraft that required reporter to take evasive action.

1020208

201206

1201-1800

ZZZ.Tower

US

200.0

35.0

1000.0

VMC

10

Daylight

Tower ZZZ

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

DVFR

Personal

Cruise

None

Engine

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 120; Flight Crew Total 13000; Flight Crew Type 6000

1020208

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition

Aircraft

Made an emergency landing at [a military field] due to engine misfiring.

C172 pilot reports landing at a military field due to a rough running engine.

1748965

202007

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Parked

Vectors

Class B ZZZ

N

Y

N

Unscheduled Maintenance

Installation; Inspection; Repair

Cargo Door

X

Improperly Operated

Aircraft X

Other Exterior

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Time Pressure; Workload; Troubleshooting

1748965

Aircraft X

Other Exterior

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Troubleshooting; Workload; Training / Qualification; Time Pressure

1749115.0

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

Person Maintenance

Aircraft In Service At Gate

General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; Incorrect / Not Installed / Unavailable Part; Procedure

Procedure

I failed to control the situation correctly. This is my error only. I should have stopped Aircraft X when I was told that there was a roller possibly missing from the cargo door support on the rail. The door was reinstalled to the rail and allowed to continue. We are not allowed to fly with missing parts. I hesitated at the time but erroneously called this a non event and allowed Aircraft X to continue to ZZZ1 flight. This was my error.

We took a call from Company Maintenance stating the cargo door stuck when the ramp. Agents tried to close it. I went to Aircraft X to find the door was off its track on both sides and the aft upper track roller was missing; just the wheel axle was present. I re-seated the door on its track and was able to close and lock the door for flight. I called Maintenance Control and informed [them] of the missing track wheel and if [they] wanted to place it on MEL or clear the item; Maintenance Control informed me that there is no MEL/CDL relief for this specific item and told me to sign the Corrective Action and [complete the appropriate paperwork]; putting the aircraft back into service as serviceable. Aircraft was then released for service and flew from ZZZ to ZZZ1 with 49 souls onboard.

Technician reported allowing aircraft to fly with parts missing on cargo door.

1292003

201508

1801-2400

ZZZ.Airport

US

0.0

Daylight

Ground ZZZ

Air Carrier

B757 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Taxi

Checklists

X

Design

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 117; Flight Crew Type 386

Communication Breakdown; Workload; Training / Qualification; Time Pressure; Distraction; Human-Machine Interface

Party1 Flight Crew; Party2 Other

1292003

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

Person Flight Crew

Taxi

Flight Crew Took Evasive Action; Flight Crew Became Reoriented

Environment - Non Weather Related; Procedure; Human Factors; Company Policy; Chart Or Publication

Company Policy

I had the opportunity to use for the first time the new 75 taxi without final weights procedure and the new Before Takeoff Checklist. This new checklist and procedures are completely unsafe and a step back in time. The taxi checklist was eliminated in order to have the FO more engaged in taxiing in order to reduce runway and taxiway incursions. Now we decided to put all the garbage back into a checklist and have it done right before we takeoff. I watched my very experienced FO flip through multiple pages in the FMC and multiple pieces of paper in order to locate all the information that need to be read on the Before Takeoff Checklist. This took a number of minutes where he was completely out of the loop and of absolute no use to me in the safe taxiing of the aircraft. Basically he was no use to me in taxiing; and I was of no use to him in confirming all the information he was reading. I found myself just saying 'SET' in order for us to get through all the words and numbers that were being thrown at me. I finally stopped on the taxiway in order to make sure the aircraft was safe and configured correctly. Once the checklist was complete; we continued our taxi. I feel that having to stop on a taxiway on a clear VFR day in order to run a checklist is a clear indicator that the procedure and checklist are not practical; have no basis in human factors; and is completely unsafe. This also shows a lack of professionalism on the part of our airline. What if it was night; a congested taxi; unfamiliar airport; new FO; single engine taxi; etc. Basically I would never utilize this procedure. I would push back; set the brake; run the 'After Start Checklist' followed by the 'Before Takeoff Checklist' up to the LINE; before I would call for taxi.I also cannot understand why there was mandatory CBT training for [other aircraft types in our] fleet; but it was optional for the 75?It is clear that this new procedure and checklist change have nothing to do with standardization and safety; but has everything to do with Load Plannings inability to get accurate weights to the aircraft in a timely manner.

A B757 Captain questioned his Company's new Before Takeoff Checklist procedure which takes the First Officer's full attention during taxi; leaving the Captain solo while taxiing for takeoff.

1764969

202010

0601-1200

F70.Airport

CA

VMC

No Aircraft

Company

FBO

Other / Unknown

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

1764969

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

Flight Crew Took Evasive Action

Airport; Human Factors

Airport

It is my responsibility to alert pilots of a growing concern at the F70 (French Valley) uncontrolled airfield. In the past 6 months there have been 8 traffic conflicts (evasive maneuvers taken); 3 Near Mid Air Collisions; and 6 unsafe (not in compliance with FAA rules and regulations) traffic pattern operations. As this airfield continues to grow in popularity and activity there is an increasing desire and need to have this airfield added to the Contract Tower list for controlled airspace.

Reporter stated there are multiple traffic conflicts and near mid air collisions reported at F70 uncontrolled airport.

1807000

202105

1201-1800

ZZZ.ARTCC

US

33000.0

IMC

Cloudy; Icing

Daylight

Center ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Descent

STAR ZZZZZ1

Class A ZZZ

Pitot/Static Ice System

X

Malfunctioning

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 166; Flight Crew Total 11027; Flight Crew Type 11027

1807000

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

N

Person Flight Crew

In-flight

Flight Crew Took Evasive Action; General Maintenance Action

Weather; Aircraft

Weather

Started descent for the ZZZZ 1 arrival into ZZZ from FL400. At approximately FL330 we received an IAS DISAGREE message. I checked all 3 airspeed indicators and mine matched the standby while the Captain's showed 10 KTS slow. Captain ran the appropriate checklists. Shortly after finishing the checklist we got an ENG master caution. I looked up and saw the Electronic Engine Control (EEC) had both reverted to ALTN. Captain ran the checklist. At approximately FL200 we got the ALT DISAGREE message; again ran the checklist. As we descended the Captain's airspeed indicator got as low as 40 KTS slower than my airspeed indicator and the standby airspeed indicator. We continued to descend via the arrival and shot the visual approach to Runway XXL with no other issues or incidents.

B737 First Officer reported an airspeed split and Electronic Engine Controls both switching to alternate while in icing conditions.

1426772

201702

1801-2400

ZZZ.ARTCC

US

15000.0

VMC

20

Night

CTAF ZZZ; Center ZZZ; TRACON ZZZ

Personal

SR22

2.0

Part 91

IFR

Personal

Cruise

Class E ZZZ

Magneto/Distributor

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 9; Flight Crew Total 652; Flight Crew Type 20

Situational Awareness; Troubleshooting

1426772

Aircraft Equipment Problem Critical; Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance; Flight Crew Diverted; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Landed in Emergency Condition; General Maintenance Action

Aircraft; Human Factors

Aircraft

I was pilot in command and my passenger was a private-certificated; instrument-rated co-owner of the incident aircraft. We were on an IFR flight plan; the first leg of a multi-day trip. We were established in cruise at 15;000 feet and ahead of us at our altitude was a line of clouds that presented an icing risk; corroborated with a NEXRAD SLD risk; so I requested and received a climb to 17;000 from center. Before commencing the climb; while still programming the new altitude into the flight director; the engine suddenly began noticeably shaking and running rougher. I immediately responded by reducing power and telling center to 'standby' in response to the altitude change. I disabled the autopilot and began a left turn to where I had a general conception of the Central Valley (and flatter terrain) to be. Center again asked to confirm the altitude change; and I told them we were troubleshooting an engine problem. Center offered two airports; ZZZ more or less below us and ZZZ1.I was concentrating on how to react to the engine roughness; and eventually with my passenger's prompting; checked all major fuel-injected piston memory items: mixture rich; fuel pump on; switch tanks. This had no effect. Airspeed was decreasing and I had commenced a controlled 500-fpm descent from our cruising altitude. The engine roughness was manageable below about 30% power.Center meanwhile continued to offer up information about ZZZ (runway length; lighting; etc.) while I tried to focus on what to do about the engine. After conversing with Center; and perceiving the risks of attempting a landing at the smaller and more isolated ZZZ to outweigh the risk of flying to ZZZ1; I informed Center of our intention to divert to ZZZ1. Center gave me a heading. They offered to hand us off to approach but I was too task-saturated to accept the handoff. Shortly thereafter reception with Center became weak so I requested and received the handoff.After being handed off; I informed approach of our intention to maintain our slow descent and circle overhead the runway to lose altitude within gliding distance. They advised me that radar reception would be limited directly overhead so I opted to circle southeast of the runway in a position to enter the pattern. I was given clearance for a left traffic pattern for ZZZ1At this time; I finally had the presence of mind to call for the checklist; which my passenger began reading off. When trying the left magneto; the engine shut down; so I quickly returned the magneto switch to BOTH. Remembering that not 3 months ago the right magneto had failed on the ground in a similar way; I was now fairly certain that the left magneto had failed.I performed a descent checklist and had my passenger help prepare for the landing by getting the ATIS and finding an FBO. The circling descent was wide and left us well out of gliding distance from the airport; which my passenger objected to; so I corrected. We flew a high base to final and landed without incident.A later inspection revealed that the left magneto's main gear had been destroyed; exactly the failure that plagued the right magneto 3 months prior (on the ground).Factors affecting the quality of human performanceFactor: I failed to consider moving the magneto to the RIGHT position so that we could potentially get more power from the engine without excess vibrations.Root cause: Failure to complete the Engine Partial Power Loss checklist due to the 'scare factor' of the engine quitting when in the LEFT position.Contributing issues: A lack of critical thinking about the checklist's purposeFactor: I was slow to commence the Engine Partial Power Loss checklist.Root cause: I was having trouble concentrating on; and organizing my approach to; the emergency tasks.Contributing issues: A lack of familiarity with engine power loss scenarios; and interruptions in my train of thought in the course of help provided by the controller and my passenger. The controller and my passenger provided an abundance of unprompted help but I was unable to properly prioritize the radios lower than running the checklist.Factor: I circled outside of gliding range during my descent.Root cause: I lost the 'emergency mindset' once I believed that the failure was identical to that of the right magneto 3 months prior; and the situation became familiar to me.Factor: Initial human response to the engine power loss was slow.Root cause: Startle factor

SR22 pilot reported a rough running engine at 15;000 feet and elected to divert to a suitable airport. During descent it was suspected that the left magneto had failed.

1119742

201310

0601-1200

ZZZ.ARTCC

US

36000.0

VMC

Daylight

Center ZZZ

Air Carrier

A320

2.0

Part 121

Passenger

Cruise

Class A ZZZ

Unscheduled Maintenance

Emergency Light

Airbus

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 250; Flight Crew Total 17000; Flight Crew Type 4000

Troubleshooting

1119742

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

N

Person Flight Attendant

In-flight

Flight Crew Overcame Equipment Problem; General Maintenance Action

Aircraft

At cruise over ZZZ; Flight Attendant called to say lights in both aft lavs were flickering; [and] then went out. Emergency Exit light in aft lav was only light on; and too hot to touch. I passed information to Maintenance Controller and he suggested pulling Circuit Breaker (C/B) H7 on Captain's overhead panel that controls the three Emergency lights in three lavatories. I pulled C/B and had Flight Attendant check; hot light went out. All other operations normal; continued to destination. Maintenance Control suspected light batting [insulation].

Reporter stated the aft Flight Attendant called him after she started noticing an odor that smelled like overheated; melting plastic coming from one of the aft lavatory light fixtures on an A320 aircraft. Concerns about potential cabin smoke or fire developing could have been a greater issue if pulling the Circuit Breakers (C/B) for the aft lavatories Emergency Lights had not shut the lights off and stopped the odor.

Captain on an A320 aircraft reports the aft Flight Attendant informed him of an odor that smelled like overheated; melting plastic coming from one of the Emergency light fixtures in the aft lavatory.

1420341

201701

0001-0600

KZAK.ARTCC

HI

32000.0

VMC

Night

Center KZAK

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

FMS Or FMC

Cruise

Oceanic

Class A KZAK

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 1733

1420341

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Procedure; Weather

Weather

Enroute [while over the Pacific Ocean] I was notified by ATC and Dispatch of a SIGMET that had a report of Observed Severe Turbulence on our route and altitude. I attempted for one hour to get a new route north of the area or lower altitude below the reported/forecast area of turbulence. Approaching fix GITLE after ATC was only willing to let me offset 50 NM south into the forecast area to get a lower altitude and Dispatch was unable to get ATC to change my route; I [exercised my Captain's authority]. We turned 45 degrees north and offset 15 NM then descended to FL270. Then we returned to our route. FL270 was below the SIGMET area. I prepped the cabin for turbulence while we passed the area just in case. The flight was normal and ATC and Dispatch were advised.

B737 Captain reported deviating around an area of reported severe turbulence on a trans-Pacific flight without ATC approval.

1467950

201707

0601-1200

S46.TRACON

WA

2700.0

VMC

Daylight

TRACON S46

Fractional

Light Transport; Low Wing; 2 Turbojet Eng

2.0

Part 135

IFR

Passenger

Descent

Visual Approach

Class E S46

Personal

Small Aircraft

1.0

Part 91

None

Personal

Cruise

None

Class E S46

Facility S46.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Distraction; Situational Awareness

1467950

Conflict Airborne Conflict

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

In-flight

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

Airspace Structure

Working Boeing sector stand-alone due to Flight Check aircraft maneuvering in the airspace. VFR; high volume and complexity. Aircraft X; landing BFI on the localizer for runway 13R at BFI. As I cleared Aircraft X for the visual approach; I called traffic on a VFR tag; Aircraft Y; at 2100 ft heading NE towards the final approach course for 13R. Aircraft X subsequently reported traffic in sight; but still encountered a TCAS-RA with respect to the VFR. The supervisor was immediately made aware of the TCAS-RA and Aircraft X continued on the visual approach without further incident.This is another report of a continued problem within our airspace. The VFR traffic crossed approximately 1 NM NW of ISOGE from the SW to the NE; directly through the final approach course 100 ft below; and then climbing through; our required crossing altitude at ISOGE on the ILS. A review of the FALCON replay indicated that before the VFR and Aircraft Y crossed paths; the separation was .71NM laterally and 600 ft vertically. Fortunately; Aircraft Y only climbed 100 ft in response to the TCAS-RA; because had the aircraft elected to execute a complete go-around it would have been much worse. The Seattle final was busy; there were aircraft on the downwind in the vicinity of Aircraft X; and a Flight Check aircraft doing arcs across the Seattle finals at 1900 ft in the Class Bravo airspace.Something needs to change. The VFR aircraft are transiting a very narrow; busy corridor of airspace and are doing so without any communication with ATC. It is simply unsafe. The VFR aircraft in this area at the very least need to be in communication with ATC so that we can assign; as necessary; altitude restrictions ensuring the safety of all the aircraft involved. The solution(s) are not hard and while they are potentially more restrictive to VFR aircraft the bottom line is that what happens day in and day out in that airspace as it exists and operates now will eventually result in a very bad accident.

S46 TRACON Controller reported a VFR aircraft caused an airborne conflict north of the BFI area. This is a recurring issue.

1075839

201303

1201-1800

ZZZ.ARTCC

US

37000.0

VMC

Daylight

Center ZZZ

Personal

Gulfstream IV / G350 / G450

2.0

Part 91

IFR

Personal

Climb

Direct

Class A ZZZ

Pressurization System

X

Failed

Aircraft X

Flight Deck

Personal

First Officer; Pilot Flying

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

Flight Crew Last 90 Days 115; Flight Crew Total 5800; Flight Crew Type 500

Human-Machine Interface; Training / Qualification

1075839

Aircraft Equipment Problem Critical; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

N

Person Flight Crew

In-flight

Flight Crew Returned To Clearance; General Declared Emergency; General Maintenance Action

Aircraft; Human Factors

Aircraft

As we were climbing through FL350; the cabin altitude started to climb. I put on my oxygen mask; contacted ATC and told them I needed to descend immediately. I was cleared to FL240. As the cabin altitude rapidly climbed through 14;000 FT I initiated an emergency descent; declared an emergency and requested a lower altitude. I was re-cleared to 11;000 FT. As a result of my rapid rate of descent; I descended 300 FT below my assigned altitude as I leveled off but immediately climbed back up to 11;000 where we were given a heading while we assessed the situation. None of the passengers or crew was injured. We cancelled the emergency and continued to our destination at a lower altitude. Closer to our destination we diverted to another airfield for maintenance. In the future I would try to start arresting my descent rate earlier in order not to descend below my assigned altitude. Today I realized the importance of the use of oxygen masks at high altitude and the training that we receive regarding emergency descents. I am very thankful for both. Without oxygen this situation could have ended up much worse.

While making an emergency descent due to a loss of pressurization at FL350 the flight crew of a G-IV descended 300 FT below their cleared altitude of 11;000 MSL before recovering.

1232742

201501

1801-2400

ZLC.ARTCC

UT

14000.0

Snow

Night

Center ZLC

Fractional

Light Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Final Approach; Landing

Other Instrument Approach

Class E ZLC

Facility ZLC.ARTCC

Government

Approach

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 4

Communication Breakdown; Confusion; Situational Awareness

Party1 ATC; Party2 ATC; Party2 Flight Crew

1232742

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

Person Air Traffic Control

In-flight

Human Factors; Procedure

Procedure

I was the radar controller working an average session on sector 16; the Jackson Hole sector. Aircraft X was arriving to JAC; everything was a standard flight. At XX00 I cleared him for an RNAV Z approach for runway 19 into Jackson Hole. At XX+03 I terminated his radar and told him to contact tower at 118.07. He read that back correct. At XX+13 he came onto my frequency and said he just broke out 300 feet from surface and can see the airport. I was surprised to be talking to him; so I asked if that was Aircraft X. He said it was; I again told him to contact tower. I called tower about a minute later to inquire. They said they had never talked to him until he came over at XX+13 basically on the ground. Come to find out there was a snowplow on the runway and Aircraft X apparently came to a stop within 15 feet of the snowplow. I finished the session; and told management what happened. They reviewed the tape; and I did indeed tell him to contact tower on the correct frequency; and the pilot had a correct read back. I don't know what happened; whether the pilot forgot to contact tower; or tower couldn't hear him; who knows. But it could have been bad.Pilot should switch frequencies when told. Tower could advise center when snow plows are out; and maybe be more concerned if they haven't heard from an aircraft they know is landing soon.

ZLC Controller reports of switching an aircraft over to Tower; then at 300 feet the aircraft reports to the Center Controller that he just broke out and can see the runway. Pilot did not switch to Tower frequency and landed on a runway with a snowplow on it.

1222820

201406

1801-2400

ZZZ.Airport

US

0.0

Clear

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness; Training / Qualification

Party1 Ground Personnel; Party2 Flight Crew

1222820

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

Y

Person Flight Crew

Other Post flight

Chart Or Publication; Company Policy; Procedure; Human Factors

Company Policy

This event occurred due to the lack of experience and training by station personnel that are contracted out to do our ground operations in ZZZ. If the more experienced mainline ground personnel had been working they would have advised us of the device that was being loaded. In addition; ground personnel disconnected ground power without warning. This has become commonplace now as it seems that unqualified workers are routinely employed on the ramp. It is a safety sensitive position and not a minimum wage job.Today we started passenger boarding with a passenger that required an aisle chair. The Flight Attendant advised us that we would need an aisle chair; ramp; and wheelchair upon arrival. After the completion of loading the agent handed us a Cargo Load Report which included 16 Standard Checked Bags; 1 Heavy Bag; 4 Gate Checked Bags; and 39 lbs of Counter-to-Counter Small Package Shipment. The passenger count consisted of 15 adults; 7 children; and 1 infant. The Zero Fuel Weight was 31;577 lbs and the takeoff weight was calculated at 35;377 lbs with a pitch trim of 8 degrees. The flight was uneventful. After all passengers deplaned at our destination; we were waiting for an extended period of time for the aisle chair to arrive. Since all of the shutdown checklist items had been completed I decided to ground safe the aircraft and go outside to see what the situation was with the aisle chair. At this point I noticed the ground crew unloading a very large; and heavy; mobility aid for the aisle chair passenger. We are supposed to either use the actual weight of this device (if known) or the weight specified by the operations manual when calculating the weight and balance for the flight. Therefore the weight and balance was not properly calculated; but due to the light load and forward loading of the aircraft no limits were exceeded.Ground Support is not a minimum wage job and definitely should not have a high turnover. Experience and competence is very important and let us try to avoid a recurrence of a previous invalid loading implicated disaster. Unfortunately; since then; the airlines (business people...i.e. non-team players) have contracted out more and more ground support operations.

An air carrier Captain expressed concern regarding the training and competence of contract ground service personnel.

1604971

201812

1201-1800

PHL.Airport

PA

0.0

Ramp PHL

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain

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

Communication Breakdown; Confusion

Party1 ATC; Party2 Ground Personnel

1604971

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

Person Flight Crew

Taxi

Air Traffic Control Issued New Clearance

Airport; Procedure; Human Factors

Ambiguous

We were taxiing in at PHL on taxiway E. We were told to enter the ramp at E5 we called ramp on 130.575 and asked for clearance in. The controller said to call the other ramp on 129.75 at spot 12. So we taxied to spot 12 and called the ramp. The controller on 129.75 said we were in the wrong spot and that we shouldn't have been in that spot. We were cleared into park and no issues arose from this. No traffic was near us on the ramp and the flight was completed successfully. The Ramp Controller informed us of our mistake and we accepted it. Confusing ATC instructions are what caused me to go to the spot without clearance. The PHL ramp controllers didn't make very clear instructions to us and I am new to PHL so I was unfamiliar. It does not seem like the ramp controllers talk to one another and it seemed like one controller cleared me into another ramp that they did not control. It was very confusing but again no issues arose from this and the flight was completed without any further issues.

Air carrier Captain reported receiving conflicting and confusing taxi clearances from Ground Control and Ramp Control after landing at PHL.

1420822

201701

1201-1800

ZZZ.Airport

US

200.0

IMC

0.75

Daylight

500

Tower ZZZ

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

Landing

Class C ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 160; Flight Crew Type 20000

Distraction; Troubleshooting; Human-Machine Interface

1420822

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

Person Flight Crew

In-flight

General None Reported / Taken

Aircraft; Weather

Weather

[The area] was experiencing a severe winter storm. We were flying a 737NG; flaps -40; in heavy rain; moderate turbulence; strong gusty crosswinds; wipers on high; 0.75 mi visibility to ZZZ's runway. At 'minimums' we saw the MALSR's 'going outside.' The HUD worked great and with the runway environment in sight at 200 ft I said; 'landing.' That's when the fun started. Perceiving the runway environment is one thing. Having sufficient depth perception to finesse a normal flare and landing is quite another. The issue is that you need to visually transition to something real outside the window to land the aircraft; which is impossible when you're looking through a 'sheet of water.' I believe the B737 windshield wipers just cannot create enough of an air gap in heavy rain for adequate forward visibility. You feel like you're looking through glycol. Everything is blurry and it frankly is not safe. After having experienced this complete lack of forward visibility at least twice now; I'm convinced that the B737 wipers are inadequate in heavy rain. Tower visibility might be a couple miles; because they can see familiar landmarks on the airfield; but that's without looking through a 'layer of water' on their windows.It wouldn't be difficult to test the real-world ability of the B737 wipers against various rain intensities; an eye chart outside a cockpit window in a wind tunnel and a way to dump various amounts of water on the windshield. Then some real-world flight testing. I've taken a straw poll and pilots with Regional Jet experience reported that the steeper angle of the RJ windows allows the RJ to shed water aerodynamically. RJ's hardly ever need wipers. The Lockheed C-141 didn't have wipers. It used bleed-air to create a boundary-layer over the windshield. The B737 classics have rain-repellant. Why? Initially the fix would be to disallow approaches in +RA. Something needs to be used as the Go/No-Go determinator. The (+) plus in +RA (heavy rain) would tell us to not even try the approach; regardless if the visibility is legal. Once the wipers have been tested in laboratory conditions to determine the actual forward visibility in various down-pour severities; technological improvements can be implemented. Initially the fix would be to disallow approaches in +RA. Then thorough testing of the actual visibility in various intensity rain conditions.

Reporter is concerned of a wider problem associated with the amount of water and the visibility out the window relating to window wipers. He suggested using rain repellent like product; but then mentioned problems with possible fumes and possible Boeing warranty issues. Reporter recommended testing in a wind tunnel to adjust the window angle. Reporter was asked if it is a problem associated only to the NG series aircraft. Reporter stated the early B737 model had a button inside the cockpit by the window wiper that squirted rain repellent fluid on the window. Reporter also stated that newer aircraft have a film on the window to work like rain repellent; but it wears out in a year or so.

B737NG Captain reported window visibility issues when flying in heavy rain.

1210503

201410

1801-2400

ZMP.ARTCC

MN

Center ZMP

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

Cruise

Class A ZMP

Company

Air Carrier

Dispatcher

Dispatch Dispatcher

Other / Unknown

1210503

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue

Person Dispatch

Procedure

ATC issued reroutes from ZDV to BDL. It was my third straight day on this desk and that reroute had been out for all 3 days. I missed it on (flight#) resulting in a 4.4 arrival fuel. I told the crew once they entered ZMP center to request direct YYB. After Consulting with the Chief Dispatcher and ATC coordinator I advised the crew then to ask DCT NIPPY which ATC granted. Mistakes were made on both ends. The communication with Dispatch and Crew is one of the most important safety features we have. It broke down. Once the Crew asked me for the winds at FAR YQT YYB that was when I noticed I had them filed on the standard route. At that point I got the Chief and atc coordinators involved and asked the crew to request a dct routing to NIPPY resulting in about a 5.2 landing fuel.

B737-700 Dispatcher reports not noting a NOTAMed airspace closure and files the standard route. This results in a reroute by ATC and landing with less than planned fuel.

1337452

201603

0601-1200

EGGX.ARTCC

FO

VMC

Center EGGX

Air Carrier

B767 Undifferentiated or Other Model

3.0

Part 121

IFR

Passenger

Cruise

Oceanic

FMS/FMC

Honeywell

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 20796; Flight Crew Type 9034

1337452

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 95; Flight Crew Total 10413; Flight Crew Type 3319

1337302.0

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

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Aircraft

Upon returning to the cockpit from first break; the Captain provided me with the standard relief pilot change briefing. After that; he told me about an anomaly that they experienced upon coasting out at RESNO. Evidently; after executing R1 the FMC dropped the active waypoint and the aircraft turned right to intercept the offset in LNAV. The aircraft did not intercept the outbound course and continued to turn to the north. Both pilots recognized the anomaly and quickly intervened with HDG SEL keeping the aircraft well within GNE limits. They noted that the active waypoint was N5430 and redirected the aircraft to N5520 which had dropped out of the FMC. After confirming that the aircraft was back on track and navigating properly; the clearance was reconfirmed with both EGGX and Shanwick. The three of us formally debriefed after the flight and later the Captain provided us with feedback on NAV anomalies.

Upon coast out at Resno; we entered an offset of R1; the FMC then dropped the next waypoint and never caught the offset (LNAV course) and continued to turn to the right. We put the aircraft to HDG SEL to stay on course and had to reinstall the next waypoint N5520. Needless to say all class II procedures were followed; and the routing prior to coast out was confirmed at least three times. The aircraft began heading to the North; and should have headed to the SW towards the now ACTIVE waypoint of N5430; it should have been navigating to N5520; (N5520 had dropped out). We were well within GNE limits; however we did need to confirm routing with EGGX as they called us not more than a minute later. We were very busy entering the proper course and navigating the aircraft in the correct direction. We advised Shanwick to standby while we BOTH re-entered the correct routing and course. Once we corrected course; we then called Shanwick back. We had just been switched over to the HF frequencies with Shanwick control and had just tuned in HF 8879. Shanwick simply wanted to confirm our routing after RESNO. We believe this to be an anomaly. The aircraft turned North off course and dropped out the next waypoint. Please research. Further inquiry revealed possible anomalies in the Pegasus FMC/honeywell data base.

B767 flight crew reported upon coast out at RESNO an offset of R1 is entered and the FMC dropped the next waypoint. The FMC never caught the offset (LNAV course) and continued to turn to the right. The next waypoint had dropped from the FMC.

1777837

202012

0001-0600

ZZZ.Airport

US

VMC

TRACON ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Initial Approach

Visual Approach

Class E ZZZ

GPWS

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

1777837

Aircraft Equipment Problem Less Severe; Inflight Event / Encounter CFTT / CFIT

Automation Aircraft RA; Automation Aircraft Terrain Warning

In-flight

Flight Crew Took Evasive Action

Aircraft

After being cleared for the visual approach and landing into ZZZ on Runway XX; we continued to configure the aircraft for landing. We proceeded to descend below 3;000 just inside the ZZZZZ fix. As we turned final around 2;600 feet MSL around 1;300 AGL we received a 'Obstacle' GWPS warning which we were given an RA to pull up. I immediately complied with the command until it confirmed and we visually confirmed that we were clear and continued the approach to land without incident. During the incident we did not observe nor did Tower observe any obstacles that we were in close proximity to. We maintained proper clearance of at least 1;000 feet AGL from all of the published towers that were on the approach plate.Cause - There were no noted obstacles that were within 1;000 feet AGL clearance and can only come to the conclusion that it was an anomaly with the GWPS system. At 2;800 feet we had turned inside the Tower that was 1;740 feet and turned well before the Tower at 1;809 maintain safe and legal separation from structures.Suggestions - Continue to follow protocol and respect a Resolution Advisory.

EMB-175 Captain reported receiving an Obstacle GWPS warning followed by a 'Pull up' RA command during a visual approach; which was followed by the crew. The Captain stated it was most likely a GPWS anomaly that triggered the warnings as no problem obstacles were noted.

1364942

201606

1801-2400

TVL.Airport

CA

160.0

12.0

14000.0

Mixed

Cloudy; Icing

Daylight

Center ZOA

Personal

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

IFR

Personal

Cruise

Vectors; Direct

Class E ZOA

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Commercial

Workload; Situational Awareness; Confusion; Time Pressure

1364942

ATC Issue All Types; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Air Traffic Control Issued Advisory / Alert; Flight Crew Landed As Precaution; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Diverted

Human Factors; Procedure; Weather

Weather

Planned to depart O57 VFR. Surface winds were 190@6 and sky clear. Expected route follow Hwy 395 then direct. Preflight planning indicated area gusty winds in the valleys east of the sierra. Called an instructor at destination airport and we discussed local wind conditions; sky; visual to the east of the airport; and ride expectations over the Sierra with gusty winds on the east side of the Sierra. Overall; we generally agreed the ride would light to moderate turbulence on the east slope but smooth out once on west slope.Departed and climbed in valley surrounding the town to altitude of 12;500 before following Hwy 395. Observed cloud conditions over sierra confirmed my suspicion that route would be less turbulent south of TVL. Sacramento Valley was visible on other side of layers clouds over west slope of Sierra with strong winds out of the south. At the time; I believed it was possible to 'go over the top' at 14;500. Ride was smooth. As cloud tops rose I was unable to climb to stay in VFR and filed IFR with CTR and was given direct LIN @140. I told the controller that I wanted lower as able to descend below the cloud layer. Shortly after entering IMC the aircraft began to pick up ice. Prior to entering IMC; I had introduced carburetor heat & turned the pitot heat on. Soon after I advised ATC I was unable to maintain altitude and asked for lower. Acknowledging my predicament; ATC began vectoring my path while (presumably) checking area topography towards TVL. After approximately 2 to 3 minutes (guessing); I was able to see terrain to the left and below the aircraft; although I was still IMC. Shortly after that TVL came into view as well as Lake Tahoe off to the right of the aircraft and I diverted. Once clear of clouds and once again VFR; ATC provided local winds at TVL and I cancelled IFR and landed. On short final; I checked back with CTR and advised that we were short final; 'things' were okay; and thanked them. I rechecked surface winds and we landed. Once safely on the ramp; as we were securing the aircraft; a helicopter pilot appeared at the plane in a pickup truck and handed me a piece of paper with the telephone number and said the controller wanted to check on me and make sure that I had arrived safely. I called; a little later after gathering myself and we talked for about 7-10 minutes. I thanked the controller and told him I was very appreciative of his efforts. I was certainly glad he was there and that I had elected to file a clearance before entering IMC and at least had plan in place before things turned bad. We began to discuss the weird meteorological conditions and the noticeable temperature differential between [the east and west sides of the mountains]. Afterward; it brought into focus a similar remark made by the pilot about his observations from the ground while driving from his home. I told the controller of my flight planning efforts and that I generally had expected scattered to broken clouds over the eastern Sierra; as well as; about my direct call and discussion with folks at [my destination]. No other discussion occurred; nor was there mention of that any incident report would be filed; or any potential accusation regarding deviation from any FAR. When the call ended my impression was that the matter was closed and I was very fortunate; however; to be able to call and we both could learn from the experience. I felt compelled to file this report; however; because I had not experienced such a weather phenomenon in my 40 years and more than 4000 hours of safe flying and that I felt others could learn from what ultimately turned out to be judgment error. Once IMC and icing began I almost immediately had trouble maintaining altitude; my mind operationally went to: (1) 'stay calm'; (2) 'fly the airplane'; (3) 'listen to instruction' (as best possible); (4) respond to questions asked; and (5) continue to report your challenges to ATC. Thankfully; I believe that good training allowed me to laterthank ATC for their help and debrief the incident proactively. Later my passenger with me remarked on the calmness and professionalism he observed. As I write this account; more than 24 hours later; I am not sure my adrenalin level is totally back to normal; but I am certainly glad to be able to recount my experience for others. Most of all I remain thankful that I was able to call and personally thank the ATC controller and tell him that I wanted to communicate my lessons learned with others.

Pilot transiting the Sierra Nevada Mountain Range at 12;000 feet encountered an overcast layer and was cleared VFR on top at 14;500 ft when clouds and icing were encountered. The pilot descended and diverted to TVL in order to clear the clouds.

1459271

201706

0601-1200

ZZZ.Airport

US

0.0

VMC

Air Carrier

B777 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Parked

Fuel System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 11215; Flight Crew Type 1797

Situational Awareness; Troubleshooting

1459271

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

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

Human Factors; Procedure; Aircraft

Ambiguous

Shortly after arriving at the aircraft a mechanic came to the cockpit and stated they needed to do some work because the fueler couldn't get the correct amounts in the tanks due to fuel shutoff valves closing. This isn't unheard of so I was not concerned. After stepping back to say hi to the flight attendants I saw the mechanics had opened the equipment access hatch in first class. This I have never seen before to work a fuel transfer issue; but again I wasn't concerned.Shortly afterwards the fuel issue was resolved and the fuel sheet was brought to the cockpit. At this point I noticed the fuel load of Left 63.1 Center 118.0 Right 63.1. I took note of it because it was exact (left and right) this is unusual but good; I thought to myself the mechanics did a perfect job!About 45 minutes later when preparing for the before push checklist I noticed the fuel was now 2000 lbs lower in the left tank and 2000 lbs higher in the center tank. Also after my before push flow the center right fuel pump should have load shed but this time it didn't. Right away I thought something in the fuel system is still set to transfer fuel or was left 'connected' between the left main and the center tank.After having maintenance come back out to the aircraft they looked the plane over made some adjustments (I am not sure what exactly they did) the fuel was again balanced and the center right fuel pump now load shed like it should.At this point we believed the issue was corrected. We then taxied for takeoff. After takeoff when passing 10;000 an IRO (International Relief Officer) asked what was happening with the fuel. We brought the fuel synoptic up and shockingly the left tank was now 3000 lbs higher than it was at the gate.We decided the best course of action was to get up to altitude before an in-depth discussion. After getting close to cruise the Captain called Dispatch and [Maintenance] on the satellite phone and I was in charge of flying and talking to ATC. The Captain; with input from the IROs; Dispatch; and [Maintenance] attempted to understand and remedy the situation. After quite a while it became apparent that none of the crew was comfortable taking the aircraft over the Pacific Ocean like it was.We elected to return to [departure airport] for further maintenance work. The crew was also not comfortable jettisoning fuel which would open more valves and further complicate what we considered an 'unknown' fuel system. By now we had the system burning out of the center tank and decided to use delaying vectors altitude and landing gear to increase our burn to a weight we were comfortable with.After arriving at that weight we conducted the arrival and made an uneventful overweight landing.

B777 First Officer reported returning to departure airport after experiencing fuel system anomalies.

1769887

202011

0601-1200

ZZZ.Airport

US

1000.0

Tower ZZZ

Air Carrier

Commercial Fixed Wing

4.0

Part 121

IFR

Landing

Visual Approach

Class B ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Communication Breakdown; Distraction

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

1769887

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Training / Qualification; Distraction; Physiological - Other; Communication Breakdown

Party1 Flight Crew; Party2 ATC; Party2 Flight Crew

1769888.0

Deviation / Discrepancy - Procedural Landing Without Clearance

Person Flight Crew

In-flight; Taxi

General None Reported / Taken

Environment - Non Weather Related; Human Factors

Human Factors

After receiving clearance from approach for visual approach Runway XXC; I was advised to stay with approach until ZZZZZ (Final approach fix) and then call Tower frequency. Landing checklist was completed; and we were stable at 1;000 feet. I was the Captain and pilot monitoring. The weather was day VFR -clear visibility and a crosswind wind gusting to 22 knots. After landing I realized that I forgot to switch the frequency to receive landing clearance. After clearing the runway; I contact tower and apologized. I was told by Tower that they gave me the green light as landing clearance.I always try to verbalize my landing clearance as technique and check the landing lights/ turn off lights position as required. For some reason I didn't do it this time. I'm not sure if the frequency switch location in conjunction with landing check list procedures was the reason for forgetting to switch to Tower. I take full responsibility and will learn to pay better attention in the future.

I was pilot flying in VFR conditions. The Approach Controller vectored us to join the final approach for [Runway] XXC between the course fix and final fix. He also cleared us for the approach and instructed us to contact Tower at the final fix. Upon capturing the localizer and as we intercepted the glideslope outside the final fix; I called for final flaps and landing checklist. We set the missed approach altitude and started down the glide slope. I used the autopilot until below 1;000 feet then hand flew the aircraft to landing in a crosswind. After landing; as we approached our anticipated exit from the runway; the Captain (pilot monitoring) queried ATC for exit/taxi instructions when we realized we had not switched to Tower or received a landing clearance. We immediately contacted Tower [and were told we] were cleared to land. We continued to parking without further incident. Traffic was light and weather was clear. Our actions did not disrupt any other operations/aircraft.This was my first operational leg after having been off for a month. I was so focused on my flying duties and landing in a crosswind I forgot to confirm we had received landing clearance. Contacting Tower at the final fix is a very routine action; yet was overlooked/missed by all crew members in this situation. Not exactly sure why I failed to confirm landing clearance except perhaps I was too fixated on the aviating and failed to communicate.

Air Carrier flight crew reported they forgot to receive clearance to land. First Officer reported this was the first flight after an extended period of time off.

1053204

201212

0001-0600

ZZZ.ARTCC

US

35000.0

VMC

Night

Center ZZZ

Air Carrier

B727-200

2.0

Part 121

Cargo / Freight / Delivery

Climb

Class A ZZZ

Pneumatic Ducting

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1053204

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport; General Declared Emergency

Aircraft

On climbout during acceleration passing 4;000 FT; Engineer informed the rest of the crew that we had a Lower Aft Body Overheat light illuminated. I continued to fly while he and the Captain ran the QRH. We leveled at 13;000 FT and when it was determined that the light was not going to go out; we turned back for the [departure airport]. Captain declared emergency. Landing was uneventful; fire crew checked the airplane with IR sensors and we terminated to emergency and taxied in. The light finally extinguished when ALL engines were shut down.

B727 First Officer reported receiving a Lower Aft Body Overheat warning on initial climb. Flight crew ran the procedure; declared an emergency; and returned to departure airport.

1008478

201205

1201-1800

ZZZ.Airport

US

150.0

5.0

1800.0

VMC

10

1500

TRACON ZZZ

Corporate

B777 Undifferentiated or Other Model

2.0

Part 91

IFR

Ferry / Re-Positioning

Final Approach

Visual Approach; Vectors

Class D ZZZ

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

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

Flight Crew Last 90 Days 1; Flight Crew Total 6500; Flight Crew Type 300

Situational Awareness

1008478

Aircraft X

Flight Deck

Corporate

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 100; Flight Crew Total 5000; Flight Crew Type 200

Situational Awareness

1010380.0

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued Advisory / Alert

Procedure; Human Factors

Ambiguous

ATC vectors kept us high (4;200 MSL) until approximately 7 miles from the runway. We were cleared to 2;000 MSL; and then cleared for a visual approach. Upon descent from 2;000 MSL; ATC advised that he had a low altitude alert. We climbed slightly and continued the approach. Upon turning final at about a two mile final; we were on the visual glide path as shown by the P-VASIs. No EGPWS alerts were encountered; terrain was not a factor. In our opinion; we were intercepting a normal descent profile for landing after having been kept high until very close to the runway.

[We were] cleared visual approach. [We] descended to remain clear of clouds. Approach gave callout 'too low terrain' over radio. Acknowledged the call and clarified cleared for the visual approach. They confirmed clearance and a few moments later again the same callout. We again told them we are VMC and continued our approach. The call confused the aircrew at what ATC wanted the crew to do. Both myself and the pilot flying did not understand what ATC wanted us to do. The landing was accomplished uneventfully.

A B777 flight crew was advised of a low altitude alert by ATC on approach; causing some confusion in the cockpit.

1494500

201710

0001-0600

ZZZ.Airport

US

0.0

VMC

20

Daylight

18000

Tower ZZZ

Personal

Bonanza 36

2.0

Part 91

IFR

Personal

Landing; Taxi

None

Class C ZZZ

Tower ZZZ

Personal

Piper Twin Piston Undifferentiated or Other Model

Part 91

Takeoff / Launch

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 21; Flight Crew Total 2926; Flight Crew Type 2490

1494500

Aircraft X

Flight Deck

Personal

Pilot Not Flying

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

Flight Crew Last 90 Days 0; Flight Crew Total 7610; Flight Crew Type 220

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1494504.0

ATC Issue All Types; Conflict Ground Conflict; Critical; Ground Incursion Runway

Horizontal 15; Vertical 0

Person Flight Crew

Taxi

Flight Crew Took Evasive Action

Airport; Procedure

Airport

I was acting as pilot (PIC) of my bonanza BE36; with my neighbor as co-pilot; on an IFR. My co-pilot was handling radio transmissions and requested and cleared for the ILS approach by Approach. We were then instructed to contact tower. When the co-pilot contacted tower; we were on a 5 - 6 mile final on the ILS approach. Tower informed us that we were number 2 following a Skyhawk and cleared us to land runway 14. The co-pilot then read back our landing instructions which included our call sign. The landing roll took us past taxiway D and I was slowing the aircraft to decide which taxiway to exit for [FBO]. By now; I was approaching runway 4 and the co-pilot turned to the right in time to see a Twin Piper on take-off roll. Since there are no brakes on the right; the co-pilot told me to STOP!! STOP!! STOP!! When I stopped; the aircraft was inside of the runway 04 edge line. I immediately turned to my right; and saw the Twin Piper on take-off roll. Coinciding with the above; the tower instructed the Twin Piper to abort the take-off. The pilot of the Twin aircraft did not abort the take-off; did not acknowledge the towers instruction to abort the take-off and became airborne. The twin passed us with approximately three feet of altitude and within fifteen feet of the nose of our Bonanza. By the time the abort take-off was issued by the tower; a collision with the Twin Piper would have been inevitable had we not stopped. Both the speed of the Twin and his lack of altitude when passing in front of us; only reaffirms my opinion that a collision would have been unavoidable. We were then given runway exit instructions by the tower to initially turn right onto runway 04. This was then amended to continue to taxiway Bravo; right turn. Ground control then cleared us to taxi to [FBO] via Taxiway Alpha; hold short Runway 04 - 22. We were then given clearance to cross runway 4; and proceed to [FBO].The tower should never have issued a take-off clearance to an aircraft departing a crossing runway without issuing and receiving confirmation of a land and hold short instruction of that crossing runway to landing aircraft.

[Report narrative contained no additional information.]

Bonanza 36 pilots reported that after landing; they had to make a sudden stop due to an aircraft taking off on a crossing runway.

988672

201201

1201-1800

ROA.Airport

VA

VMC

Daylight

Tower ROA

Air Carrier

Regional Jet CL65; Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Initial Approach

Visual Approach

Class C ROA

Y

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Training / Qualification; Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

988672

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

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Chart Or Publication; Company Policy; Environment - Non Weather Related; Procedure

Ambiguous

We had been cleared PSK to ROA from south of the airport. At about 20 miles out we had the field insight and we were given a right downwind to Runway 24. I asked my First Officer to confirm with ROA Approach that we were cleared the right not left visual approach for Runway 24. ATC confirmed that he needed us to do the right approach. I told my First Officer that I had never done a right traffic pattern to that runway; so I wasn't familiar with a good procedure to get in due to the height of Tinker Mountain (2;407 FT) on downwind that I would try to turn inside of the mountain to turn final. When we got close enough to the terrain I realized that at 160 KTS our turn radius would not allow us to make a safe right turn to final and clear the terrain on the other side of the mountain along with making a stabilized approach. I told my First Officer to ask for a turn out to the left and try to make another turn around Tinker Mountain and then a right turn back in. Again due to the terrain we questioned if we could safely make the turn with the terrain to turn final. We then told Tower that we needed to go way out to the valley and try again. We finally made a safe stabilized approach around Tinker Mountain in the valley. I contacted ATC when I landed because I was frustrated that we were given an approach that a CRJ could never safely make from the south direction. The ATC Supervisor was surprised that we were given that approach and concurred that it was unusual. I wish that my Company would have better policies when coming into airports like this. They should just ban any CRJ from accepting a right downwind to Runway 24. I wish that the ATC had a policy about not clearing certain airplanes for that approach. With our turn radius we can't safely make a traffic pattern unless we stayed at 3;500 FT and over flew the mountain; went into the valley and did a tear drop to turn on final; while at the same time losing visual contact with the airfield. I understand that we have sample approach path charts to take when accepting visuals to Runway 24; however one of them assumes that you are coming in from the north. I also think that it needs to be brought to their attention that turning in from the left downwind for Runway 24 before the mountains is pushing it. Most pilots split the two mountains when doing a visual approach to ensure a better stabilized approach. I also think the Airline needs to ban anyone from doing a visual approach to Runway 16. I was cleared for a visual approach into Runway 16 a few years ago. Due to the rising terrain on base; tight turn to final; and being not stabilized we had to go missed (we circled for Runway 24). I learned a valuable lesson that I can't do a visual to Runway 16 and I can't do a right downwind for the visual to Runway 24. I just hope that some other pilot doesn't have to learn this lesson.

A CRJ200 Captain described the complexity of flying a right downwind visual approach to ROA Runway 24 because of Tinker Mountain terrain and suggests the CRJ aircraft turn radius makes the approach unsafe.

1821480

202107

1201-1800

ZZZ.Airport

US

0.0

Ground ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

None

Aircraft X; Facility LAX.TOWER

Government

Ground

Air Traffic Control Fully Certified

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

Communication Breakdown

Party1 ATC; Party2 Ground Personnel

1821480

ATC Issue All Types; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Vehicle

Aircraft Aircraft Damaged

Airport; Human Factors; Procedure

Airport

I was working Ground Control 1 when Aircraft X notified me that an airlines [ground vehicle] came into contact with their right scimitar winglet. The incident happened while Aircraft X was taxiing eastbound on taxiway 1 just east of taxiway 5. I reached out to city operations; who typically monitor the frequency. I was not able to reach city operations; and neither was the Controller in Charge. I noticed Aircraft Rescue and Fire Fighting (ARFF) vehicles in the area so I reached out on the emergency frequency and got hold of ARFF-2 and send them to investigate. A few minutes later; city operations came on frequency and I advised them what happened. While moving traffic around the incident; I noticed that planes were not departing. I asked Traffic Management Unit (TMU) about it; as they had not informed me of their intentions. He said that departures were stopped. I asked why had I not been informed and he stated 'you should have known.'It seems like there are more issues with [ground vehicle] than there should be. A more rigorous training program may be in order.Also; TMU needs to be more active in the communication of their positions and advise everybody of their intentions.

Ground Controller reported aircraft report of contact by vehicle; and lack of communication with city operations and the TMU.

1870686

202110

1201-1800

N90.TRACON

NY

IMC

Icing; Turbulence; Rain

Daylight

TRACON ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Climb

Class B ZZZ

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Instrument; Flight Crew Multiengine

1870686

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Confusion; Situational Awareness

1870828.0

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Requested ATC Assistance / Clarification

Weather; Human Factors

Weather

On flight ZZZ to ZZZ1 we encountered severe turbulence on the arrival into ZZZ1. Aircraft control was not sustained; extremely unpleasant ride; basically the classic definition of severe turbulence. As Pilot Monitoring (PM) I reported the turbulence; we called maintenance on the ground and they inspected the aircraft. The next flight; from ZZZ1 to ZZZ2; during the departure we hit turbulence; The bumps were intense and an all around bad ride. As PF I elected to hand fly as I did not want the AP to disengage and wanted to maintain positive aircraft control through the turbulence. Airspeed was uncontrollable (+/-) 30 knots but altitude was maintained (6;000) and heading was maintained as best as possible. The Captain as PM reported the turbulence as severe while we were still in the turbulence and as PF and hand flying I didn't question the call on the turbulence. We reached cruise without any injuries or aircraft damage and determined that the turbulence was in fact moderate and not severe because I was able to maintain aircraft control and altitude at level off. Don't rush a radio call on rides. Turbulence creates a high stress environment but as pilots we need to be able to slow down and control the world around us in order to formulate the best answer or decision.

On Aircraft X into ZZZ1 we experienced severe turbulence. We were on a descent around 12;000 ft. and had already crossed a front of weather. No convection was showing on the radar. But it was uncontrollable and we went from a descent to a climb and speed acceleration with throttles at idle; that was written up in the logbook. On the departure out of ZZZ1 we were still in front on the line of weather. We requested a left turn to avoid some additional build ups. ATC told us to expect that before the weather. The turn was given before the weather but the ride was horrible. It was a high stress environment because we had just cleaned up the flaps and were leveling off at an altitude. As all that was being accomplished we had a radio switch too. When getting the transfer I informed ATC we had severe turbulence. This was the quickest way to get my point across for the kind of ride we went through even though we remained clear of the cell. After further discussion later in the flight with the First Officer (FO) we decided that was the wrong call to ATC. It had not met the definition of severe turbulence and was not like; or as bad as; the serve turbulence on the previous flight. The FO was hand flying and able to maintain control of the aircraft. He was hand flying and able to level off at assigned altitude. Looking back on what I should have said to ATC; severe was the wrong call. It should have been a moderate turbulence and I could have said try not to send planes through where we went. Slow down with radio calls and think about the reports you're giving.

ERJ-175 flight crew encountered turbulence and reported it to ATC as severe; however; afterwards decided it did not meet the criteria for severe turbulence.

1665891

201906

1201-1800

ZJX.ARTCC

FL

Marginal

Thunderstorm

Center ZJX

Any Unknown or Unlisted Aircraft Manufacturer

Climb; Cruise; Descent

Class A ZJX

Facility ZJX.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 7.0

Workload; Situational Awareness; Time Pressure

1665891

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

Person Air Traffic Control

In-flight

Air Traffic Control Separated Traffic; Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance

Human Factors; Company Policy; Airspace Structure; Weather

Weather

I was working with weather coming in from the west moving east. Military airspace was active up to FL500. There were aircraft coming from the west deviating towards the active military airspace. The traffic load was heavy and made traffic complexity high because there was more than normal traffic coming from the west at even altitudes that were tied up with southbound traffic at even altitudes trying to go through the same 15 mile hole in between the weather and active military airspace. When weather is pushing toward the active military airspace we need to slow traffic down for deviations and have a plan to go-around the airspace and weather.

ZJX Center Controller reported a complex traffic workload due to weather deviations and insufficient traffic flow management through their airspace.

1622607

201902

1201-1800

ZZZ.Airport

US

0.0

VMC

Gusts; 10

12000

UNICOM ZZZ

Personal

Cessna 210 Centurion / Turbo Centurion 210C; 210D

1.0

Part 91

None

Passenger

Takeoff / Launch

Class G ZZZ

Aircraft X

Flight Deck

Personal

Pilot Not Flying; Single Pilot

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

Flight Crew Last 90 Days 60; Flight Crew Total 3300; Flight Crew Type 40

Situational Awareness

1622607

Ground Event / Encounter Ground Strike - Aircraft; Ground Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

Taxi

Flight Crew Regained Aircraft Control

Human Factors; Weather

Weather

I was in the co-pilot seat of this VFR flight. The pilot had successfully completed one touch and go; and was taking off from the second one. A strong gust of wind pushed the aircraft towards the right side of the runway; and eventually the right tire went off of the pavement; and into the softer soil. The pilot was utilizing crosswind technique; but it didn't help keep the aircraft on the runway. The soft; somewhat grassy soil caused the aircraft to slow and eventually the nose wheel dug in and brought the aircraft to a quick stop. With this quick stop; it tipped up on its nose; and then settled back on all three wheels.Both occupants had shoulder and seat belts on; and no one received any injuries at all. One blade of the prop appears to be bent from the aircraft tipping on its nose. A local person on the airport helped to move the aircraft out of the soft soil and onto the runway. It was then towed to a nearby hangar; where it will be inspected and repaired. No lights or anything on the airport received any kind of damage. I believe the gusty winds contributed heavily to the pilot's problem of keeping the aircraft on the runway. The PIC (Pilot in Command) has received many hours of instruction in this aircraft; and was current as per CFR 61.56 and CFR 61.57.Because this incident doesn't meet the requirements of 49 CFR 830; no report but this one will be filed.

Observer pilot reported a runway excursion due to a strong gust of wind.

1153442

201402

1801-2400

SCT.TRACON

CA

7000.0

Turbulence

Daylight

TRACON SCT

Personal

Small Transport; Low Wing; 2 Turboprop Eng

1.0

Part 91

IFR

Personal

Descent

Vectors

Class E ZLA

Facility SCT.TRACON

Government

Approach

Air Traffic Control Fully Certified

Air Traffic Control Radar 20; Air Traffic Control Time Certified In Pos 1 (yrs) 3

Training / Qualification; Time Pressure; Situational Awareness

1153442

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Human Factors; Weather

Human Factors

Aircraft inbound to UDD IFR. Developmental was busy working numerous IFR arrivals into PSP. Aircraft was cleared down to 7;000 [FT] and assigned vector 110 for descent. Pilot kept asking for lower due to moderate turbulence descending out of 10;000 [FT]. The developmental responded that due to the MVA he could expect lower in 3 miles. The pilot then responded that he would need lower as soon as we could give him a descent. The developmental then issued a vector of 180 heading to get the aircraft out 7;000 MVA. When the aircraft was south of the 7;000 MVA; the developmental gave a descent clearance to 6;000 [FT] anticipating the aircraft would miss the next lower MVA of 6;500 [FT] into the 6;000 MVA 2 miles south of the 6;500 MVA. Unfortunately the aircraft clipped the 6;500 MVA at 6;200 [FT] on the descent. I discussed with the developmental that in the future when aircraft are getting bumped around and having problems holding altitude; to keep in mind that as soon as that descent clearance is issued the pilot will be quick with the descent. Hold off on the descent as long as possible. As on OJTI; remain a little more aware of the developmental control instructions in adverse IFR conditions to ensure all MVA's are met.

SCT TRACON Controller reported a Developmental Controller issued descent to an aircraft too early; which caused aircraft to violate the MVA rule.

1043112

201210

1201-1800

1N1.Airport

NM

0.0

VMC

50

Daylight

CTAF 1N1

Personal

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Personal

Takeoff / Launch

None

CTAF 1N1

Personal

Helicopter

1.0

Part 91

Takeoff / Launch

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 25; Flight Crew Total 150; Flight Crew Type 15

Confusion; Communication Breakdown; Situational Awareness; Time Pressure

Party1 Flight Crew; Party2 Flight Crew

1043112

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

Horizontal 750; Vertical 0

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors; Environment - Non Weather Related; Procedure

Human Factors

I was taking off from an uncontrolled airport with a 30 foot wide runway; length 4;800 FT; density altitude about 8;000. The (unpublished) preferred calm wind runway is 27. There is a 1% upward slope on 27; and there was a slight wind from the east; so taking off on 9 would have been plausible. I had just flown with a resident of the airpark about a half hour earlier (under similar wind); and he said he recommended 27 with such a light wind. The RV-9A I was flying has enough performance to take off in about a third of the runway length in these circumstances; but other; lower performance aircraft might well elect Runway 9. I monitored CTAF while taxiing and don't recall hearing any calls. I announced before entering 27 that I was departing 27: 'XXX traffic; YYY departing Runway 27; northbound departure XXX.' I didn't hear any radio calls; and I didn't see anyone in the pattern or on the runway. On takeoff roll; with nose wheel off the runway; maybe 50 KTS; I thought I saw something in the distance in front of me - a silhouette; no lights. Two or three seconds later; I discerned the aircraft heading toward me on Runway 9; maybe 20 FT AGL. I couldn't tell if it was landing or taking off. I lifted off and made an immediate right turn to get away from the centerline - while I was in the turn; maybe two to three seconds after lifting off; the opposing aircraft passed me opposite direction and made a radio call: 'Copter XXXX [didn't catch the number] - traffic now in sight.' With such a narrow runway; not knowing whether the oncoming aircraft was landing or taking off; and not familiar with copters; I felt that aborting my takeoff was not a good option. I don't know if he made a call that I missed (either due to the geography; or I just didn't hear it); or if he just turned his radio on after my call. I'm not sure how to interpret the other aircraft's call; 'now in sight.' It is possible the other pilot interpreted my radio call to mean I had already taken off and was in the process of leaving the area to the north - if this is how my call was interpreted; the pilot could have concluded the runway was unoccupied. My radio call could have been clearer: 'XXX traffic; YYY departing 27; planning right turnout; north departure XXX.' The use of 'planning' in the call might have kept the other pilot; if he was on frequency; from assuming I was already clear to the north.

The pilot of a single engine aircraft departed 1N1 Runway 27 after making CTAF traffic calls and took evasive action from a small helicopter taking off on Runway 9 but not making traffic calls.

1328162

201601

1201-1800

ZZZ.ARTCC

US

40000.0

Air Taxi

Citation X (C750)

2.0

IFR

Passenger

Cruise

Class A ZZZ

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1328162

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

Person Flight Crew

In-flight

Flight Crew Diverted; Flight Crew Landed As Precaution

Aircraft

Over Gulf of Mexico at 40;000 ft flight crew noticed strong burning smell in cabin. Performed smoke in cabin checklist. Advised ATC diverted to nearest airport. Smell dissipated after approx 5 minutes. Landed safely.

CE-750 Captain reported detecting a strong burning smell at FL400 and diverts to the nearest suitable airport. The burning smell dissipated after about five minutes.

1491122

201710

1201-1800

ZZZ.Airport

US

Daylight

Center ZZZ

Air Carrier

B747-400

2.0

Part 121

IFR

Cargo / Freight / Delivery

Cruise

Class A ZZZ

Fuel Distribution System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Check Pilot

Flight Crew Air Transport Pilot (ATP)

1491122

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Weight And Balance; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

General None Reported / Taken

Aircraft

Fuel Imbalance Main Tanks 1-4. Abnormal condition occurrence shortly prior Top of Decent point. Result; close flight plan fuel monitoring and QRH action reveals a sudden substantial loss of fuel related to Main Tank Number 01 within a 30 minute period during the final phase of flight.Research and Inquiry of previous flights into Maintenance logbook with inquiry amongst other crews also reveal an irregular intermittent trending history of fuel Imbalance 1-4 events with moderate to heavy fuel over-burns for those flights also. I am unsure if these events of other crews have been reported. Suspect cause is a possible insidious fuel leak of Main Tank Number 01 that may have increased in severity causing the rapid loss of a large amount of fuel within a 30 minute period prior to arrival; recommend serious MX investigation.Planned flight time of 04:20 minutes; actual flight time of 04:50; additional 30 minutes of flight time due to ATC and some wind differences taken into account however is not a trigger for an imbalance event with an over-burn that does not match the additional time considered. Fuel monitoring from takeoff to prior the top of decent point over a distance of 2000 nautical miles constant at -0.1 KGS then within a 19 nautical mile distance block prior the top of decent point fuel trends to -0.3 KGS vs computer flight plan fuel. Shortly afterwards EICAS message 'FUEL IMBAL 1-4' reveals main tank Number 01 at 2;200 KGS vs main tank #04 at 4;100 KGS.Initial covering of the QRH procedure was covered leading to meeting all the parameters of a suspected fuel leak. Further ORH procedures directs an engine shutdown due to the suspected loss of fuel. Sensible judgment dictated that in this area due to the heavy pilot workload during decent and arrival phase within the heavy traffic terminal area and shortly before a landing with sufficient Main Tank 1 fuel; completion of a long complicated engine shutdown checklist would not be a viable option. An alternative attempt to troubleshoot within a short period was made leaving Cross-feed valves open during descent and a constant main tank 1 monitoring program put into effect. This revealed a more rapid decrease in fuel in Main Tank #01 prior to landing and after approximately 10-12 minutes the cross-feed valves were subsequently closed to end the event.A non-eventful landing completed at destination however arrival occurred at approximately 5.7 tons below the recommended flight plan arrival fuel with a block in fuel of company minimum occurring at 9.0 tons. In the event an actual diversion to alternate had been required the estimated arrival would likely be an approximate total remaining fuel of less approximately 5.0 tons; this would be a fuel emergency event.Additional factors 1. It was also noted during the preflight that the airplane DRAG/FF Factor was incorrect at -0.3 however this relates to calculated vs totalizer FMS calculations and has no effect on the actual physical rate at which fuel decreases in a main tank.2. ATC arrival had changed the published arrival 3 times during the actual descent resulting in the aircraft finally being routed south of the airport then back with some speed control for the southern runway a benefit gaining a very short taxi time after landing; however most of the arrival changes occurred during high altitude resulting in more direct routing during the descent with little to idle power settings.3. Previous Flight Analysis example data from other crew;Computer Flight Plan Fuel 74.0; Actual Ramp Fuel 77.1 (3.0 tons extra requested)Computer Flight Plan Recommended Arrival Fuel 14.6 Actual Arrival Fuel 12.7This crew also experienced a brief Fuel Imbalance 1 -4 event during the departure phase with no further action required. The focus here needs to be on the time and rate at which Main Tank Number 01 decreased in fuel prior to landing as the problem may be insidious in nature and difficult to fully detect and based on apparent past events and log book fuel history the focus and basis to trouble shoot should be on the EICAS message 'FUEL IMBAL 1-4' and not the fuel burn itself.Actual Fuel Analysis of the flight is as follows also with picture attachments;1. Computer Flight Plan total fuel (with 2.7 ton extra) 63.02. Captain decision fuel (1.0 ton extra) 64.03. Planned flight time/ Actual flight time 04:20/04:50 (Difference 30 minutes)4. Computer Flight Plan Planned Burn/Actual Burn 47.6/53.9 (Difference 6.3 tons)5. Computer Flight Plan estimated burn 48.3 (P/M Score -5.6 tons)6. Logbook Fuel Remain/ Logbook Burn 9.0/54.9

B747 Captain reported they had a rapid loss of a large amount of fuel within a 30 minute period.

1823717

202107

1201-1800

HLN.TRACON

MT

12000.0

Tower HLN

Personal

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

IFR

Cruise

Class E ZLC

Corporate

Commercial Fixed Wing

2.0

Part 91

VFR

Cruise

None

Class E ZLC

Government

Local

Air Traffic Control Time Certified In Pos 1 (yrs) 2

Distraction; Workload

1823717

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

Vertical 400

Person Air Traffic Control; Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Environment - Non Weather Related; Aircraft; ATC Equipment / Nav Facility / Buildings; Human Factors

Environment - Non Weather Related

Aircraft X was IFR; level 120; and eastbound.Aircraft X reported Aircraft Y; four hundred feet above; opposite direction; crossing directly above. It was not confirmed; but the pilot believes the Aircraft Y climbed to avoid Aircraft X at the last minute; thus passing above by 400 feet. Aircraft Y was VFR and not talking to any HLN controllers. Aircraft Y later checked on with LC after the conflict was over. There was no time for evasive action by Aircraft X or control instructions from Approach in-between the report of Aircraft Y and the two aircraft passing.HLN is entirely non-radar. Approach cannot and does not see any VFR aircraft; and can only pass traffic if VFR pilots identify themselves. In this case; Aircraft Y did not check on with approach so no traffic was given.Both pieces of traffic were at 120; so they would have been on ZLC's radar and both had ADS-B. HLN does not have access to either of these. If HLN did have access to either one; approach could have called traffic in a timely manner and could have climbed or descended Aircraft X accordingly.HLN needs some form of surveillance; whether it is an ADS-B feed; or a display of already existing radar coverage.

HLN Tower Controller reported a NMAC between two opposite direction aircraft.

1432823

201703

0601-1200

PCT.TRACON

VA

11000.0

TRACON PCT

Air Carrier

Dash 8-200

2.0

Part 121

IFR

Passenger

Climb

Class E PCT

Autopilot

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1432823

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

1432827.0

Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem; Flight Crew Returned To Clearance

Aircraft

All operations prior to climb were normal. ATC assigned an altitude of 11;000 feet. 11;000 feet was set in the altitude selector. The autopilot was engaged in the following modes: LNAV; ALT SEL and in pitch (pitch attitude was set at 5 degrees nose up). These parameters were verified and confirmed. As the aircraft approached 11;000 feet the aircraft pitched up to more than 10 degrees nose high and did not capture the 11;000 foot assigned altitude. Both the FO and myself noticed this happen at the same time and also noticed 8000 fpm where 'pitch' was indicated prior. I immediately disconnected the autopilot and began a descent back to 11;000 feet. The highest altitude we saw on the altimeter was 11;400 feet. I directed the FO to contact ATC and inform them what happened. ATC acknowledged and proceeded as normal. We continued that flight and reengaged the autopilot with no other abnormal operations.

[Report narrative contained no additional information].

Dash 8-200 flight crew reported an altitude overshoot resulted when the autopilot pitched up for unknown reasons.

1010799

201205

0601-1200

ZMA.ARTCC

FL

VMC

Center ZMA

Fractional

Citation Excel (C560XL)

2.0

Part 91

IFR

Cruise

Class E ZMA

FMS/FMC

X

Design

Aircraft X

Flight Deck

Fractional

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Workload; Time Pressure; Human-Machine Interface; Distraction; Communication Breakdown; Confusion

Party1 ATC; Party2 Flight Crew

1010799

ATC Issue All Types; Aircraft Equipment Problem Critical

N

Person Flight Crew

In-flight

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

Procedure; Human Factors; Chart Or Publication; Aircraft

Procedure

We were en route to X51 and checked in with Miami Center. Center gave us a re-route that included the SSCOT1 RNAV arrival into X51. The problem is that there are no arrivals into X51. There are no arrivals in the FMS or the EFB for this airport. To access the SSCOT1 arrival in the FMS we would have to change the destination airport to TMB. To view the SSCOT1 arrival on the EFB we would have to select TMB. When I told the Controller that we were unable to fly that arrival and that there were no arrivals into X51 he said that his computer showed that to be incorrect. The Controller then assigned us fixes to fly. The next two Center frequencies also tried to assign us arrivals into X51. The FMS and approach plates do not match what ATC sees in their computers.

A Citation 560XL flight crew was rerouted via the SSCOT1 RNAV STAR for their arrival into X51 (Homestead General Aviation) but discovered the arrival was in neither their FMS database or their EFB for use into their destination and so advised ATC. Miami Center believed that to be incorrect but provided fix by fix clearances allowing the flight to continue to X51.

1601635

201812

1201-1800

APA.Airport

CO

6800.0

VMC

10

12000

10000

Tower APA

Personal

Beechcraft Twin Piston Undifferentiated or Other Model

1.0

Part 91

VFR

Personal

Landing

Vectors; Visual Approach

Class D APA

Tower APA

Cessna Aircraft Undifferentiated or Other Model

1.0

Climb; Takeoff / Launch

Class D APA

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Multiengine; Flight Crew Commercial

Flight Crew Last 90 Days 78; Flight Crew Total 564; Flight Crew Type 33

1601635

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

Horizontal 50; Vertical 300

Person Flight Crew

In-flight

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

Procedure; Environment - Non Weather Related; Human Factors

Human Factors

ATIS information; wind 080 at 7 altimeter 30.15. [I] was given instruction to turn left from northwest heading to intercept final approach for 17 left. Next [given] change to 17 right; contact tower on 123.75. [I] was cleared to land 17 right. [I] was on short final when the next instruction from tower (Go around right side; aircraft on runway) (Extend up wind). The aircraft on runway began take off as [I] was a beam the threshold on right. As [I] was climbing on right side single engine Cessna gained altitude very quickly and began to drift into [my] flight path. [I] turned right and climbed above pattern altitude to avoid collision with Cessna while trying to keep Cessna in view on left side. The tower restated the (instruction that [I] was to extend up wind) [I] then resumed course 17 at tower's instruction. The Cessna could not see the [my aircraft] on the right and above the wing. [I] was then instructed by the tower to turn right for downwind 17 right get back down to pattern altitude 6800 feet and get back on the east traffic pattern restriction. [I] was again given a clearance to land 17 right. Again [I] was on short final when [I] was given instruction to go around right side aircraft on runway extend up wind. [I] was then instructed to turn right for downwind 17 right. Again given clearance to land 17 right. Again on short final [I] could see an aircraft stopped on runway. [I] contacted the tower and asked if this was going to work. [I]was instructed to continue approach for a landing. [I] had already initiated a go around; when the tower gave instruction to go around right side air craft on runway. [I] went around and given instruction right turn for downwind 17 right. [I] was instructed to contact tower on 118.9. [I] was given clearance to land 17 left. [I] landed on 17 left without incident. In my option the operation of dissimilar aircraft in such tight spacing could have been a contributing factor in the near miss. The setting sun may have restricted the view of the tower to the west; not able to see the aircraft on runway to the west. Trying to make a tight turn after side stepping right for a go around doesn't allow enough room for maneuvering. [The highway] converges with the south end of 17 right narrowing that airspace considerably. With a cross wind out of the east the steep bank required to make a right turn; when aircraft are in a climbing turning slow in a steep bank should not be expected to stay east of [the highway].

Twin engine Beechcraft pilot reported an NMAC in the pattern at APA.

1748347

202006

0601-1200

EWR.Airport

NJ

3000.0

VMC

Tower EWR

Air Carrier

A319

2.0

Part 121

IFR

Passenger

FMS Or FMC

Final Approach

Class B EWR

Tower EWR

Air Carrier

Commercial Fixed Wing

Final Approach

Class B EWR

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Last 90 Days 14.93; Flight Crew Type 331.12

1748347

Deviation - Speed All Types; Inflight Event / Encounter Wake Vortex Encounter; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

General Maintenance Action

Environment - Non Weather Related; Procedure; Weather

Ambiguous

The autopilot was on and Captain flying. Following a heavy on the same runway. The Captain called for flaps 3 and I put flaps to 3 position. Shortly after that the plane seemed to hit turbulence and quickly exceeded flap speed. The Captain turned off the autopilot and corrected the situation. We landed without further issues and notified Maintenance for inspection.

A319 First Officer reported a speed deviation occurred on approach to EWR when they encountered either wake turbulence or ordinary turbulence.

1279988

201507

1201-1800

ZAB.ARTCC

NM

25000.0

Center ZAB

Air Carrier

Airbus Industrie Undifferentiated or Other Model

2.0

Part 91

IFR

Test Flight / Demonstration

FMS Or FMC; VOR / VORTAC GBN

Climb

Airway J2

Class A ZAB

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1279988

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 Flight Crew

1279997.0

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

Person Air Traffic Control

In-flight

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

Aircraft; Human Factors

Human Factors

Flight was a test flight after maintenance on the rudder and elevator components. Profile was to fly min of an hour and climb between 290-310Kts where multiple events had occurred. On the climb out at 300Kts ABQ Center did query about this being a test flight. We were cleared [Route X for our] first clearance; we were on heading vectors and the controller asked to reroute us [Route Y]. I was concerned with the reroute and fuel because it was a much longer route. We asked for [Route Z] and the arrival. Controller asked if we could turn within 9 miles. We stated yes thinking she needed the turn to start before 9 miles. We were cleared Gila Bend which was 180 degrees behind us. Direct TUS. As we started the left turn I left it in heading for a steeper bank angle versus NAV. Half way through the turn controller asked us to increase the bank. I kicked off the autopilot and rolled to 35 degrees of bank. We were heading direct to Gila Bend VOR. AQB center told us to call a phone number when we land. We asked why? Response was we were told to turn within 9 miles and we turned in 14? We started the turn on a vector? We called the center and spoke with the manager. He stated we went into restricted area but the military 'called a cease fire' so it was ok. Clear direction from ATC with turn reference with DME from an actual nav aid. Not pilotage 9 miles?

During climb out on a Maintenance test flight; ATC gave us a reroute. We determined that the length of the reroute would leave us with too little fuel at landing; so we requested a more direct routing. The controller said they could offer vectors only; due to restricted airspace being active. We elected to take vectors for more direct routing; and then the controller asked if we could make a turn towards GBN VOR and stay withing 9nm of our present position. We said we 'thought' we could and were cleared for a 180 degree turn direct to GBN VOR. during the turn the controller asked us to tighten the turn; so we took the autopilot out of NAV mode; and put it in HDG mode to increase the bank angle. A few moments later the controller gave us a new heading and told us to tighten the turn as much as we could. At that point the autopilot was disconnected and we banked the aircraft up to about 30-35 degrees. We were then cleared direct to GBN VOR again; and told to contact ABQ center upon landing. When we inquired as to 'why'; we were told that we had entered restricted airspace.Initially we thought 9 nm would be enough for a 180 degree turn. Had we known that we were about to penetrate restricted airspace; automation could have been turned off sooner to enable a tighter turn.

Airbus flight crew reported entering restricted military airspace after ATC asks if they can make a turn within 9 NM. Crew thinks that means start turn within 9 NM.

1666946

201907

0601-1200

ZZZ.Airport

US

0.0

IMC

Thunderstorm

Tower ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

FMS Or FMC

Takeoff / Launch

Hydraulic System Pump

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Workload; Human-Machine Interface; Fatigue; Communication Breakdown; Time Pressure

Party1 Flight Crew; Party2 Flight Crew

1666946

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Troubleshooting; Workload; Time Pressure; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1667401.0

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

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Aircraft; Human Factors

Human Factors

Cleared to line up and hold for Runway XXL; the FO (First Officer) stated I have an amber light. I told him to get the QRH while I tell Tower. Tower cleared us off the active runway and to circle back around and hold short of the runway while we sort through our problem. FO stated we had an ELEC2 hydraulic low pressure light and the procedure is to turn the pump off; end of checklist. Tower told all departing flights that thunderstorms may shutdown south departure flows. Tower asked if we were going to be delayed long. I told the FO I was ready. He asked if I was willing to takeoff and I said yes without realizing I had not gone through the MEL flow chart. After takeoff and clear of the thunderstorms; I noticed the amber Low Pressure light on the overhead panel and realized in my haste to get airborne; I forgot the MEL flow chart process.Three-day trip and I was reassigned on day one. I arrived at hotel at XA:00 and didn't get a good nights sleep; but didn't think I was fatigued. Day two; ground stop to ZZZ; but we were able to land at ZZZ only 30 minutes late. The FAs (Flight Attendants) informed me we had international connections. As soon as gate was open; we taxied to the gate; but agent had difficulty with jet bridge. As the FO and I walked past the gate for [the connecting flight]; we saw our passengers at the gate unable to board as the door was shut 10 minutes before departure. We were both upset we were not able to get them to their connection. This lead to a less than restful night sleep for me thinking what I could have done better. Nevertheless; I was tired on day three but still did not think I was fatigued. Uneventful taxi out for takeoff to ZZZ1. [Weather service] displayed a line of thunderstorms approaching ZZZ. Seven aircraft ahead of us and Tower informed all aircraft they may ground stop south departures. Finally; we had clearance to line up and wait and I felt we were going to make it. Then the Low Pressure light came on. The FO ran the QRH and I thought we were ready. I was so focused on getting airborne before the thunderstorms shut down the departures; I simply forgot about the MEL. I believe being tired and frustrated coupled with my desire to get airborne before the thunderstorms shutdown the airport caused my focus to be misguided.As I write this report; I ask myself how could I have simply forgotten to run the MEL? It just doesn't make sense to me now. But at that exact moment; it seemed so clear. The QRH checklist was called complete and we were good to go. We going to be able to get airborne and get these passengers to ZZZ1 on-time. My lesson learned here is to maintain my focus on procedures.

[Report narrative contained no additional information.]

B737-800 flight crew reported rushed departure due to impending weather which resulted in a failure to complete MEL checklist.

1677772

201908

0601-1200

ZZZ.Airport

US

0.0

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

General Seating Area

Air Carrier

Off Duty

Flight Attendant Current

Boarding

Physiological - Other

1677772

Flight Deck / Cabin / Aircraft Event Illness / Injury; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Person Flight Attendant; Person Flight Crew

Pre-flight

General Evacuated; General Maintenance Action

Aircraft

I was a deadheading crew member and pre-boarded the flight with my fellow deadheading crew members. We had just placed our luggage in the overhead bins and we were getting settled into our seats; when all crew members on board (both deadheading and working) noticed a very strong smell of burnt plastic / dirty feet come on. The odor developed rapidly and grew stronger by the second. I developed a headache and became lightheaded. When we realized there appeared to be a fume event; the working crew called for maintenance and we all exited the aircraft and waited for further direction on the jet bridge. At this time my headache worsened; and I continued to feel lightheaded to the point I was having to physically hold my head up with my hand. The First Officer exited the aircraft to do a walk around in attempt to locate the source of the smell; and upon his return he stated that there was a bleed in the aircraft; and that we would not be able to take the plane to our planned destination. At this point; I developed a strong throat irritation and labored breathing. I walked back onto the aircraft to grab my luggage; at which point my mouth started to tingle and went numb. I walked halfway up the jet bridge to get outside to the gate; and fell backwards; briefly unconscious. My crew member was able to catch me and sit me down and again; I passed out. The crew was quick to retrieve oxygen from the aircraft and administered it to me as we waited for paramedics to arrive. I was then taken to the ER for treatment.

A319 deadheading Flight Attendant reported strong fumes during pre-boarding resulting in health issues and deplaning of aircraft.

1463947

201707

1201-1800

ZZZ.Airport

US

5500.0

VMC

Daylight

Tower ZZZ

Personal

Cessna 152

1.0

Part 91

VFR

Personal

Cruise

Direct

Class E ZZZ

Engine

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Total 122; Flight Crew Type 122

Situational Awareness

1463947

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Took Evasive Action; Flight Crew Returned To Departure Airport; Flight Crew Overcame Equipment Problem

Weather; Aircraft

Ambiguous

As the pilot in command of the aircraft; I had done all the necessary preflight actions. The route of flight was [along the coastline] at 5500 feet. As we were cruising down the coastline; I remember the engine ran a little rough; and I turned on the carburetor heat. We flew for approximately 5 minutes before we started losing engine power. It looked like we were going to lose the engine power completely to me. I turned inland and went through the checklist. The engine still seemed as though it was going to turn off completely. I was gliding towards ZZZ1 airport. With the engine still giving slight power pulses; I remember going through the checklist at least 3 times. It was at about 3500 feet that the engine started giving me the power I needed. I kept the aircraft climbing to 6500 feet. Moments later the engine seemed to run smooth again; and so I decided to take the airplane back to ZZZ; [the departure airport]. I landed the aircraft; and I remember the controller asking me if I needed any assistance of some sort. I did not see the need. I taxied the aircraft back to the flying club; and parked it. I then spoke to the dispatcher and the mechanics regarding what had happened and that I suspected it to be carburetor icing.

C152 pilot reported a loss of engine power that resulted in a return to the departure airport. The pilot suspected carburetor icing.

1333320

201602

1801-2400

ZZZ.Airport

US

0.0

Night

Air Carrier

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

2.0

Part 121

IFR

Passenger

Parked

Fuel Booster Pump

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Time Pressure; Distraction; Situational Awareness

1333320

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Distraction; Time Pressure; Situational Awareness

1333323.0

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural MEL / CDL; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Human Factors

Upon Arrival to aircraft it was noticed that the FWD RIGHT FUEL TANK BOOST PUMP circuit breaker tripped. After notifying maintenance of the write up; they MEL'd the FWD right tank boost pump. It wasn't realized at the time; but maintenance turned off the AFT right fuel tank boost pump in accordance with the maintenance procedures and placed the yellow inop sticker next to it. Enroute after the center tank fuel was exhausted; the right inlet fuel press low light illuminated. This was obviously because the good boost pump was turned off and the MEL sticker was placed directly next to it. We ran the associated QRH and proceeded in the descent to our destination and landed safely without incident. The fuel burn and quantity was also indicating normal. After landing; I wrote up the problem only to realize after what had transpired. The MEL was correctly applied but was incorrectly administered and double checked. I failed to catch the mistake. Double checking what exactly is being done and the actions being taken. Cross referencing myself to make sure what is being done.

During the preflight inspection it was noted that the FWD right fuel pump circuit breaker was tripped; and that the FWD right fuel pump did not test satisfactorily. Maintenance was notified; and they applied MEL 28-01. Maintenance control proceeded to set the associated fuel pump to off; open and collar the associated fuel pump circuit breaker; and place the 'inop' sticker next to the AFT right fuel pump. It was not noticed at this time that maintenance turned off the AFT right fuel pump; as well as placed the sticker next to the AFT pump instead of the FWD right fuel pump. They did however open and collar the FWD right circuit breaker. During cruise after the center fuel tanks have been exhausted; the 'R Inlet Fuel Pressure Low' light illuminated. The PM complied with QRH for the 'Inlet Fuel Pressure Low' annunciation. Normal fuel burn was observed from this point for the remainder of the flight; and the flight continued to FAR under the agreement of the CA; FO; dispatcher; and maintenance control. It wasn't until after the flight that the crew noticed that the MEL was administered incorrectly. The captain and first officer; once coming to realization of what happened; debriefed the event; contacted dispatch; maintenance and the duty pilot.It is very important for crews to display very thorough attention to detail. Although it is the job of maintenance to apply an MEL; it the responsibility of the flight crew to verify that the MEL is correct; the aircraft is configured properly; and that the MEL applied makes sense and is safe. This event occurred after already returning to the gate due to a different maintenance discrepancy on a different aircraft; and this was our second aircraft. It is probable that the sequence of events may have led the crew to feeling somewhat rushed to pushback and make up some of the lost time; however crews should always take their time to ensure that all MEL's and everything necessary for safety of flight was properly completed and that it makes sense. It is a good learning experience and wakeup call that everybody needs to cross-check all paperwork. It should be stressed to all crews that not only is it important that the MEL is correctly reflected on the paperwork; but also that the aircraft is properly configured for the appropriate MEL.

The reporter indicated that fuel feed continued from the right wing tank through the engine driven suction fuel pump.

MD-80 flight crew reported the misapplication of a fuel boost pump MEL resulting in both boost pumps inoperative in the right wing tank. Fuel continued to feed the engine from the right tank through the engine driven fuel suction pump.

1097978

201306

1201-1800

ZZZ.ARTCC

US

35000.0

Center ZZZ

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Climb

Class A ZZZ

Center ZZZ

Air Carrier

Medium Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Descent

Class A ZZZ

Facility ZZZ.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Situational Awareness

1097978

ATC Issue All Types; Conflict Airborne Conflict; Deviation - Altitude Overshoot; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

Air Traffic Control Issued New Clearance

Human Factors

An A319 was in level flight at FL350 and he requested a climb to FL370. I did not do an adequate traffic search and climbed him. Within one minute; the A319 and Air Carrier Y started flashing. Air Carrier Y was in level flight at FL360. I quickly turned the A319 thirty degrees left for traffic and he complied. I then turned Air Carrier Y thirty degrees left and descended him to FL340 for traffic. Air Carrier Y then asked if he could climb to FL380. I came back on the frequency and told him to turn thirty degrees left and descend immediately. He came back questioning the turn and I told him to just descend and turn now. Luckily the A319 understood the gravity of the situation and picked up his climb rate and when I asked for altitude reports from both aircraft I had five miles and 1;000 FT. Air Carrier Y actions were not good enough. When a control instruction is issued for traffic; it needs to be accomplished and not debated. I was extremely concerned for about 30 seconds that the two aircraft might collide mid-air. I need to do a better traffic scan that is basic ATC. The pilots need to act quicker and accordingly and not drag their feet on these clearances.

Enroute Controller described a conflict event at FL350/370; claiming one of the aircraft was slow to respond when given an instruction contributing to the occurrence.

1095378

201306

0001-0600

ZZZ.Airport

US

0.0

Night

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

Part 121

Parked

Y

N

Y

Scheduled Maintenance

Hangar / Base

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Distraction; Communication Breakdown; Fatigue; Situational Awareness; Time Pressure; Workload; Training / Qualification

Party1 Maintenance; Party2 Maintenance

1095378

Hangar / Base

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

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

Party1 Maintenance; Party2 Maintenance

1095379.0

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Other / Unknown

N

Person Flight Crew

In-flight

Flight Crew Diverted; Flight Crew Landed in Emergency Condition; General Maintenance Action; General Flight Cancelled / Delayed

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

Human Factors

I Mechanic X was about to service an aircraft with [engine] oil when the Crew Lead asked me to help a co-worker in the Deferral Action of a hydraulic Shut-Off Valve (SOV). I approached my fellow Mechanic Y; asking what needed to be done. Mechanic Y told me to take off the hydraulic pump from the left engine while she took the parts necessary for the deferral out of the 'Fly Away' kit. Mechanic Y instructed me to install the Blank-Off Plate in the mount [on the Engine Accessory Case] where the hydraulic pump was installed and to secure it along with Cannon plug. After I installed this plate and capped the [hydraulic] quick disconnect outlets; I asked if she needed any further assistance. Mechanic Y replied that all she needed to do was to place the hydraulic pump in the 'Fly-Away' kit. I proceeded to put my tools and toolbox away. With four minutes left before clock-out time; she approached me asking to sign a Job Card for the task which I was unaware that existed. I signed the blocks required; but failed to see the part where it mentioned the Spline Plug being installed before the plate. It was determined that the error was made by an emergency landing that the aircraft had to make at ZZZ1 airport due to the [engine oil] leakage. This is to the best of my knowledge lack of communication between co-workers. I assisted my co-worker by following her instructions; she had the paperwork and failed to inform me about the Job Card; also failed to provide the parts needed to perform the task. I failed to pay the necessary attention at the end of the day to the Job Card when filling [out] the [sign-off] blocks. Lack of knowledge and experience was also a factor. I've been employed for several months in this company and have never worked on the engine section of these [CRJ-700] aircraft. Also Mechanic Y explained to me that she has never performed this procedure [either]. Some of these mistakes might have been caused by stress and fatigue because it was at the end of the night and my co-worker expressed to me that these plane had to be at the gate [in a half hour]. [Recommend] better communication between mechanics when working as a team; especially if one joins another in the middle of the task; pay more time and attention to Job Cards when completing them even under stress.

CRJ-700 aircraft en route to ZZZ1; crew declared an emergency landing in ZZZ1 due to loss of oil on the Number 1 Engine. Once aircraft landed ZZZ1 Maintenance Crew removed Blank-off Plate from the Number 1 Engine Accessory Gear Box (AGB) and noticed no Spline Plug assembly was installed. [Contributing factor was] Number 1 Engine Hydraulic Firewall Shut-Off Valve (SOV) would not close once Fire Switch was pressed. Notified Supervisor; Supervisor informed me there was no Hydraulic Shut-Off Valve [in stock] and the HYD SOV would have to be deferred. Number 1 Hydraulic Firewall SOV MEL 29-11-8 and Number 1 Hydraulic Engine Driven Pump (EDP) MEL 29-11-1 per Job Card 29-XX-YYYY Engine Driven Pump Deactivation. This was approximately before dawn; the airplane was to be at the gate within an hour. My Co- worker; Mechanic X; was asked to help me defer the Number 1 Hydraulic (Hyd) EDP. We printed Job Card 29-XX-YYYY for the Engine Driven Pump Deactivation. Opened Fly-Away kit. Got EDP deferral items listed from the Fly-Away kit. Removed Number 1 Hydraulic EDP Spline from Accessory Gear Box (AGB); flexible hoses. Capped all lines and placed Blank-off Plate on Accessory Gearbox. Placed Number 1 Hydraulic EDP; Spline from AGB and flexible hoses in Fly-Away Kit. Closed Number 1 Engine Cowls. Performed Engine Run for Leak Check. No leaks noted. Mechanic X and I were under stress; knowing the aircraft was late to the gate. Got to work [later] that night and was told that the Spline Plug Assembly was not installed on the Number 1 Engine Accessory Gearbox; thus causing a oil leak and an emergency landing. My Co-Worker; Mechanic X; and I didn't realize that we had skipped a Maintenance Step in Step Two of the Job Card. The following morning I didn't perform a High Power Engine Run when checked for leaks. Mechanic X did open cowlings and Inspector verified no leaks. Mechanic X closed cowlings. The following day; to clarify my previous statement; I did perform an Engine Run and Leak Check; not realizing a High Power Run was required. I was also involved in numerous tasks at the same time. [I was] trying to get aircraft to gate.[Recommend] the Job Card should be a RII Card due to the oil loss of the engine and the high risk involved with this task. Step Two needs to be broke down in more steps. Not so many Critical Items in one step; makes it more likely for someone to miss a critical step. I would also like to see Buy-Back [second set of eyes verification] steps for the critical items.

Two Line Aircraft Maintenance Technicians (AMTs) report about a company CRJ-700 aircraft that had to divert in flight due to oil quantity loss on Number 1 Engine. They had previously removed the Engine Driven Hydraulic Pump (EDP) on the Accessory Gear Box (AGB) and had been 'pushing' to meet a morning departure schedule.

1468009

201707

ZZZ.Airport

US

0.0

VMC

Tower ZZZ

Air Carrier

A320

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 Type 581

Training / Qualification

1468009

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 790

Training / Qualification

1468020.0

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented

Company Policy; Human Factors

Human Factors

After pushback and during taxi; ground control advised us that we had a 1:10 minute ground delay for our flight due to construction at [destination airport]. Ground control gave us a place to pull over and we shut down both engines and left the APU running. After finishing checklists and discussing the delay and our ample fuel status; the CA asked if I was okay with opening the cockpit door. I replied 'absolutely.' So; as I was communicating our status with dispatch via ACARS; several passengers wanted to look in the cockpit. The Captain and I agreed that this was a fine idea as we thought it would be great for passengers to have something of interest to enjoy while we were waiting on the ramp for an hour or so. Several adults and children came up to the cockpit to take a look around and ask questions with some folks taking pictures; etc. It was really enjoyable handing out wings to the kids and talking to parents about [our company] and aviation in general. About 30 minutes passed and ground control advised us that our delay had been shortened and asked us to get ready for departure. We had all passengers sit down; secured the cockpit door and performed our preflight checklists as per SOP.We took off and landed without incident. The flight itself was uneventful.The reason I am reporting this is; during the cruise phase of the flight the Captain and I talked about the recent [industry problems] and wondered if any changes had been made to SOP concerning photos; etc. I looked in the FOM for anything concerning cockpit access on the ground and found the last sentence of a paragraph; which states that you should not allow cockpit access after you have pushed back; even during a ground delay with engines shut down; which was our exact situation. It actually states that you should not conduct cockpit tours; etc. Which is pretty much exactly what we did. So we talked about that and decided we had made a mistake and should report it. We both talked about learning a new lesson in the FOM. I've had people up in the cockpit many times at the gate; so I just deferred to that way of thinking. It was quite enjoyable interacting with our passengers but I realize now that I should have referenced the FOM first.

On this flight; as we approached the runway ATC informed us we had a wheels up time of 1 hour 7 minutes later. We were directed where to stop and shut down the engines and we did so.During my years as a First Officer (FO); many times during similar circumstances; both on and off the gate; Captains have opened the door and invited customers to visit the flight deck while waiting for the wheels up time. It was my understanding that with both engines off; opening the door was authorized. This time I thought it a good gesture for the passengers so I asked the FO if he was ok with doing that and he agreed. At the appropriate time we closed the door; prepared for flight and proceeded without incident. During cruise the FO and I began to wonder if the FOM contained specific guidance about such activity; and upon inspection we found in FOM that it is not authorized. I don't know if the guidance changed in recent years or if it has always been there; but I acted based on prior experience without first verifying if it was permitted by the FOM.

A320 flight crew reported receiving a ground delay after taxi and elected to shut down and allow passengers to visit the cockpit. Once airborne the crew decided to check the FOM and found that the practice was no longer allowed.

1274217

201503

1201-1800

P31.TRACON

FL

500.0

VMC

10

Daylight

CLR

TRACON P31

Personal

Military Trainer

1.0

Part 91

None

Personal

Cruise

Class C NPA

FBO

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Banner Tow

Cruise

Class C NPA

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Commercial; Flight Crew Sea; Flight Crew Rotorcraft

Flight Crew Last 90 Days 50; Flight Crew Total 3300; Flight Crew Type 175

Situational Awareness; Distraction; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1274217

Conflict NMAC

Horizontal 90; Vertical 15

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Human Factors; Airspace Structure

Human Factors

I was transiting westbound along the beach line at 500 feet MSL; a ¼ mile south of the coastline and had a very near mid-air collision with a banner-tow aircraft flying opposite direction. Distance between aircraft estimated at less than 100 feet horizontal and approximately 10-20 feet vertical. Banner-tow AC was not spotted by me (rear cockpit/passenger in front of cockpit) until approximately 2 seconds before aircraft passed each other. I turned hard right 90° to verify other aircraft (after passing). I was talking to ATC; had a squawk code and was [on] frequency. Event occurred just south of Pensacola Beach; FL approximately 1 mile west of pier and approximately 2 miles east of NAS Pensacola Class C surface area. I did not receive a traffic advisory radio call and afterwards queried ATC Controller if he had other traffic on radar scope. No definitive answer was given. I believed banner-tow AC was not participating with ATC; i.e. did not have a squawk code; [was not communicating] with ATC; and most likely came through NAS Pensacola (NPA) Class C airspace without clearance. While forward visibility in the plane is problematic [due to the aircraft design and seating configuration;] I believe the banner-tow aircraft was not keeping a sufficient forward look-out (we're guilty too; despite our aircraft's impediments and a properly briefed passenger; etc.) as well. This incident is reported in good faith in hopes of preventing future such incidents.

The pilot reported a 'very' near miss with a banner-towing high-wing aircraft in or near NPA Class C airspace while flying the beach at 500 feet. He was receiving advisories but the other aircraft was not; nor did the other aircraft have a Class C clearance.

1189405

201407

1201-1800

ZZZ.Airport

US

0.0

VMC

10

Daylight

CTAF ZZZ

Air Taxi

Learjet 45

2.0

Part 91

IFR

Other Reposition

Landing

Visual Approach

Brake System

X

Malfunctioning

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

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

Flight Crew Last 90 Days 70; Flight Crew Total 3500; Flight Crew Type 730

Confusion; Training / Qualification; Workload

1189405

Aircraft Equipment Problem Critical; Inflight Event / Encounter Loss Of Aircraft Control

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Took Evasive Action; General Maintenance Action

Aircraft

I was Captain and pilot flying. I was flying a normal approach (Visual) to Runway 7. After fully configuring the aircraft we continued to land. Upon touching down the main gear I lowered the nose wheel onto the runway; deployed the thrust reverses and applied the main brakes. I felt that I had no pressure pushed on the brakes again and I announced that; 'I have no brakes going to emergency braking; I've lost my steering.' As I gently pulled on the emergency brake handle my co-pilot reengaged the steering and reached over and extended the spoilers manually to ensure they were extended. I stated that emergency braking wasn't working and pulled a little firmer and said that I've still got no steering. The steering was reengaged but I didn't have any directional control at this time. My co-pilot said don't skid and I felt the plane start to go sideways. I kept holding the brake handle until we did come to a complete stop facing the opposite direction. At this point I shut down the plane and contacted Clearance Delivery to let them know that we were on the runway and that Runway 7-25 was closed as we could not move and then I called the owner. After shutting down the engines I could still hear something running; I looked over the panel and deduced that it was the Aux Hyd Pump. I shut this down and secured the aircraft. At this point we exited the aircraft and walked around the aircraft to assess for any damage. I pushed down the spoilers manually at this time. I then discussed with my copilot the approach and landing trying to understand what had just happened. The only conclusion that I had was that I lost my main brakes; my emergency brake wasn't effective and that I didn't have directional control. I have since spoken with the Maintenance Department; management and my co-pilot to figure out what had happened; I have also looked at what I can do differently in this situation to have a better out come.

A LR45 normal brake; emergency brakes and steering failed on landing. The steering reengaged but caused a 180 on the runway but came to a complete stop after which ATC was called to close the runway.

1828651

202108

1201-1800

ZZZ.Airport

US

0.0

Tower ZZZ

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

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

Party1 Flight Crew; Party2 ATC

1828651

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance

Human Factors; Procedure

Procedure

During landing roll between 80 and 60 kts tower rattled off taxi instructions ([Taxiways] XX-XY-XZ hold short [Runway] XXC) and I read them back. During the taxi in; while doing my after landing flow; we turned from [Taxiway] XY to [Taxiway] XA; this being the standard taxi route in ZZZ off of [Runway] XXL I didn't think twice until ATC came on and advised us we turned onto [Taxiway] XA and the instructions were [Taxiways] XY-XZ. Tower then gave new instruction [Taxiways] XA-XB-XZ short [Runway] XXC. We complied with the new instructions and continued to the gate without further incident. Receiving a taxi clearance during the landing rollout is never ideal. I was able to read back the instructions; but didn't register they were different expecting the standard taxi in in ZZZ. Tower waiting till we exit the runway to give taxi clearances; instead of between 100-60 kts.

A321 First Officer reported Tower gave them taxi instructions during landing roll which were read back but were not the expected instructions resulting in a taxiway incursion.

1435500

201703

1801-2400

BKF.Airport

CO

10000.0

TRACON D01

Military

Fighter

IFR

Initial Climb

Vectors

Class E D01

Facility D01.TRACON

Government

Approach; Departure

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 12

Distraction; Human-Machine Interface; Situational Awareness; Time Pressure

1435500

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

Person Air Traffic Control

In-flight

Human Factors; Procedure

Procedure

Aircraft X came off runway 14 at Buckley underneath simultaneous ILS landings north at Denver. Aircraft X was filed out over ALS so I was gradually working them southbound and climbing them little by little as traffic and MVA's allowed. Southwest corner of the dump airspace I finally got trapped. COS arrival was there going southeast at 110; a BJC arrival WNW-bound at 120; an APA arrival descending on the ZOMBZ arrival. I couldn't climb to 110 to meet that MVA because the COS arrival was stuck above me at 110. Then the flight didn't auto-flash to ZDV as it should and I didn't notice it until I was already in ZDV's airspace.Should have made the aircraft depart runway 32. It was the runway most aligned with the wind. If not that then I should have gone eastbound until I got to a less congested place where I could climb.

D01 TRACON Controller reported an aircraft being stuck under three aircraft and not being able to climb. The Controller violated ZDV's airspace.

1827696

202107

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Class B ZZZ

Turbine Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Communication Breakdown; Confusion

Party1 Flight Crew; Party2 Other

1827696

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Communication Breakdown; Time Pressure; Confusion

Party1 Flight Crew; Party2 Ground Personnel

1827700.0

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

N

Person Flight Crew

Other Take Off

Flight Crew Became Reoriented; Flight Crew Rejected Takeoff; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; Human Factors; Procedure

Aircraft

TOGA APU bleed on config 2. Cleared for takeoff; at about power stable and 1.5 EPR Engine 2 FAIL message (no fire indication) and single chime. Notified ATC of reject and needed to clear runway. Started ECAM procedures; at the same time another airline notified us over air that we had a fire on our number 2 engine. We then proceeded to extinguish fire with push button and squib. After finishing up procedure and coordination with CFR to make sure no fire was present we set up to be towed back to gate with no further incident.Apparently; Airbus is having issues with this config for takeoff. TOGA APU bleed on.Coordination with Airbus on reliable and safe max effort takeoff configurations.

Day 3 of a 3-day; early departure; last leg home. Gate XXX; short taxi to runway XXR. Allowed the engines to warm up for three minutes while on the ramp to get the five minutes required before takeoff. Winds were reported 280 degrees to approx 300 degrees. From previous experiences from flying the Airbus in and out of ZZZ; the winds can switch to a tailwind component very quickly when they use runway XXL/R for departure; so I expected a potential tailwind.We were cleared to line up and wait on runway XXR. The aircraft was lined up with the center line and the parking break was set. Control was then given to the FO as we awaited takeoff clearance. Once it was received and we read it back; we immediately experienced a single chime; which normally would indicate that perhaps the airplane was not configured for takeoff. Upon looking at the ECAM; we had an ENG 2 FAIL ECAM alert. Normally when we encounter ENG FAILs in the simulator; we are presented with a master warning and three chimes. This was a singular chime. I immediately told the FO we needed to clear the runway as there was a 90 degree taxiway (1) on the right side of the runway just 50 yards or so from us. FO advised tower we needed to clear for a warning.At this point I initially thought this might be a false warning. There was definitely a surprise factor to all of this. As we were clearing the runway (right turn) at taxiway 1; I glanced at the EGT and it was red. At the same time; another airplane that was getting ready to take the active runway said he saw fire coming out of out right engine. I stopped the aircraft on taxiway 1. I had the FO call for the CFR vehicles. The FO wanted to run the ECAM procedure; but I had him check the Quick Reference Card first as I remembered there was either a quick action or ECAM exception procedure that needed to be run prior to executing the ECAM procedure. The FO started to look that up... I called back to the cabin and asked the flight attendants to check to see if there was any smoke in the cabin or any sign of fire coming from the engine. The answer was that there was no evidence of fire or smoke; from the #3 or #4 FA. When I returned to the FO; he said the QRC procedure he found was for an ENG FIRE on the ground. After considering a possible evacuation; my focus shifted to getting the engine shut down. Since we had no indication of a fire from the cockpit (other than high EGT) nor any evidence from the cabin; we ran the ECAM ENG FAIL procedure and elected to discharge a fire bottle into the #2 engine. I made a PA to the passengers telling them we exited the runway due to an alert we received in the cockpit and to expect some emergency vehicles come around the aircraft. The fire trucks were not present at this point; so we asked the other airplane if they could see any evidence of fire. They couldn't see from their vantage point; so I taxied the aircraft South on taxiway 2 to taxiway 3 (50 yards?) to see if they could see any evidence of continued fire. They still could not see; so I stopped the aircraft at taxiway 3 and waited for CFR to show up. No fire indications in the cockpit; such as aural fire warning or ENG FIRE ECAM; other than the excessive EGT with the ENG FAIL ECAM.Once CFR arrived; communications were hampered as they were not on a dedicated frequency yet. I queried the tower and they gave us the right frequency to be on; when they arrived. CFR scanned the aircraft and did not find any hot spots. At this point; we had finished the ECAM procedure and were looking for any follow-up procedures (which is the next step in Airbus; non-normal methodology). The FO couldn't find them. They used to be in the QRH and were on [specific] paper... easy to find. Since a previous; major QRH revision; they are no longer on [specific] pages but are found within the QRH itself. I told the FO not to worry about finding them... that much of the material was not going to be applicable. I redirected our focus back to the STATUS page so we could discuss the current situation of the airplane. The big thing was that we had no nose wheel steering; so we summoned ops to get us a tug and advised CFR to follow us under tow. It took an inordinate amount of time to get a tug out to us (maybe 30 minutes or more); but seemed like hours. Made several PA's explaining that we were still waiting on our tug.Eventually towed back to the gate. Maintenance met the aircraft and asked about EGTs; duration; and the fire bottle status. I told them I remembered seeing an EGT of 669 at some point... maybe for 30 to 60 seconds. AML entry was made indicating all of this.When all of this was occurring during a short amount of time; I originally thought that maybe this was a false alert (only a single chime). After exiting the runway and realizing the extent of the emergency; I thought that perhaps we had the presence of flames due to a compressor stall; exacerbated by a wind that may have shifted to a tailwind.After returning to the gate; I was in contact with the Fleet Captain... who asked if the APU was ON for takeoff. I replied that it was. In Airbus world; you can do a Max power takeoff and run the packs from the APU; freeing-up the engines; giving you a little more power for takeoff. That was the case this morning. The Fleet Captain indicated that the ENG FAIL ECAM was caused by having the APU bleed ON. Apparently; this causes back pressure on the engine bleed and is a known issue. Tech Ops is increasing ground idle to prevent thisAfter speaking to the Fleet Captain; he mentioned that the QRC procedure (requiring completion before doing the ECAM alert) entitled ENG FIRE on GROUND is a procedure used when there is no electrical power to the aircraft. It is a procedure that is to be used in that situation. Perhaps I misunderstood him as our conversation occurred after the adrenaline started settling down a bit; but maybe it needs to be explained to the flight crews (the correct use of that particular QRC procedure).Also; the FO had difficulty in finding the ECAM follow-up procedures; to the point where I said we need to move to the final step of assessing the STATUS (page) of the airplane.Finally; communication from the tower on how to communicate with CFR/ARFF when they arrived could; be improved upon. In retrospect though; we never said the word 'emergency' to them. My instructions to the FO were to get the trucks rolling now... not very clear perhaps and maybe was a factor in the initial comm problems with CFR.Advised the Duty Chief that we were done flying for the day. The adrenal rush was subsiding and he was very helpful in accomplishing that for us.

A321 flight crew reported after taking the runway for takeoff and setting power; they received an ECAM message ENG 2 FAIL and rejected the takeoff; securing the engine and discharging the engine fire bottle. They required a tow back to the gate due to loss of nose wheel steering.

1564561

201807

0001-0600

0.0

Dawn

Air Carrier

Any Unknown or Unlisted Aircraft Manufacturer

2.0

Part 121

IFR

Passenger

Parked

Navigation Database

X

Gate / Ramp / Line

Flight Deck

Air Carrier

Captain

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

Time Pressure

1564561

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

N

Person Flight Crew

Pre-flight

General Maintenance Action

Company Policy

Company failed to update the NAVIGATION DATABASE on Aircraft X; an originator in ZZZ; a Maintenance Base. I elected to call out Local Maintenance after the FO (First Officer) discovered the out of date database on the preflight. I then called Dispatch; who connected me with Maintenance Control. The Maintenance Controller exerted pressure on me to MEL the aircraft rather take a delay. I deemed it necessary to update the aircraft with a current data base in order to operate in the National Airspace System (NAS). I believe that I can correctly deduce that numerous aircraft in the Company fleet were not updated; as the next day a cover sheet was attached to the weather package that read the following: '…Please verify that your navigation database is current in the FMC… If the SID/STAR plate does not display waypoint latitude and longitude; Pilots are approved to verify waypoints in the JeppFD-Pro. If ATC changes your clearance after you've verified waypoints on a SID or STAR; consider asking for radar vectors to better manage cockpit workload.'Are you kidding me; ask for radar vectors 'to better manage cockpit workload?' How about managing 'cockpit workload' by updating the NAV databases to begin with? This is an unacceptable demand of the Company on our Pilots and the FAA's Controllers. We are operating the aircraft in the NAS; with extremely crowded skies and massive weather systems; but [the company] wants us to go heads down to verify each waypoint; and if rerouted place the burden of navigation on the Controllers. He has obviously not been in the system in a flight deck in the last two months. This is an unacceptable additive condition to place on the Crews before even leaving the gate. It can take a Crew from the Green to the Red instantaneously. Moreover; two legs later we were going to take the aircraft to ZZZ1 and pass within yards of a Prohibited Area. The same company that resisted updating the data base directs its Crews on the ZZZ1 pages and ZZZ1 Safety Alert to 'When ZZZ1 is in a south flow; the FAA has requested Company Flight Crews to request the RNAV (RNP) Runway XY. The RNP approach provides improved operational efficiency and predictable lateral/vertical path which will assist in remaining clear of the Prohibited Area.' I resolved the issue before departing by conferencing in the Chief Pilot who agreed with me that any resultant delay was worth the time to provide the Crews with the tools they need; and the Customers with the Safety that they deserve. We only took a 16 minute delay to assure flying safely.Hold the leadership accountable for updating the NAV data bases across the fleet. [Company's] operational control of MELs and scheduled maintenance is sophisticated enough thatthese NAV data updates should not be missed. This is such a common occurrence that I actually have the dates for the NAV data base revision cycles programmed into my phone. We are constantly told that as crews we need to learn to operate more complex aircraft in more complex (and in the case of international destinations; less familiar) environments. Company Leadership has an obligation to provide the crews with the most basic of navigation aids. In this case; we are talking about current maps on the aircraft. I actually witnessed a Check Airman de-certify a Captain because his EFB (Electronic Flight Bag) was not up to date. I agree with the Check Airman; because as pilots we have an obligation to make sure that our charts are current. As pilots the Company has the right to ask us to bring our best game to the flight deck. The Company has the same obligation with their aircraft. Also; this MEL is an Administrative Control Item. I have the greatest respect for the FAA and have had the privilege to work with the FAA on many safety initiatives. I would specifically like to address the FAA Representative: how is this even possible? Why would the FAA allow a Part 121 Carrier to operate its aircraft in the NAS with out of dateNAV data bases/out of date charts? Why would an aircraft be allowed in RVSM airspace with an out of date NAV database? MEL relief should be for aircraft system failures; not a 'planned out' for management. Finally; this willful act violates every tenant of our very successful and effective [risk management] program. Please consider the following. Assessing Risk: Proactive management anticipates problems. When a Crew Member assesses the state of the aircraft and asks that the NAV data base be updated (40 minutes before departure in a Maintenance Base!); the request should not be met with derision by the Maintenance Controller. Factors Increasing Risk: Task Loading; Additive Conditions; Crew Factors. Use Resources to Improve Performance and Reduce Risk. POLICIES; Procedures; Flows: Policies should not be in place that increase risks of navigational errors and Crew fatigue; channelize attention and increase risk in general. Automation: by definition the automation is compromised and unreliable when the NAV data base is out of date. Managing the automation becomes a full time job for both Crew Members to verify the course; detracting from other flight deck duties. This continued failure of the Company to update the NAV databases has to be addressed. At the very least Company should provide their Pilots with the tools to do their job. Pilots; along with the flight attendants and customers they carry; and the controllers operating the NAS; have every reason to expect that from a business that made many millions dollars in operating income last quarter. Whereas as the tone of this report may lead you to believe that I am anti-Company; the actual opposite is true. I love this Company. I love the Company enough to hold it accountable at the operational level. More importantly; I hold the trust that I have with my passengers and crew even higher.

Air Carrier pilot reported the company failed to update aircraft navigation database.

1754202

202007

1801-2400

ZZZ.Airport

US

0.0

Dawn

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Time Pressure; Confusion

1754202

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

Person Flight Crew