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

1761146

202009

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Cruise

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Other; Party2 Flight Crew

1761146

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties

Communication Breakdown; Situational Awareness

Party1 Flight Attendant; Party2 Other; Party2 Flight Crew

1761148.0

Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Passenger Misconduct

Person Flight Attendant

In-flight

General None Reported / Taken

Company Policy; Environment - Non Weather Related; Human Factors

Human Factors

Captain was in cabin with Flight Attendant (FA) on board; he did not wear his mask. Flight Attendant reminded/requested the Captain to please wear your face mask. He did not put one on. He continued to hang around door and the cabin; and throughout without a mask on talking to FAs less than 6 feet away from them. I left the area were the Captain hung out to chat. When our standby reserve FA replaced our missing FA; we were ready to close the door. Captain did not brief the Flight Attendant; Captain continued to talk to catering [about] additional pilot cups; customer agents; FA without a mask. We closed the door; Captain; and passengers did not wear a mask when the aircraft door closed. I walked to cabin and saw the cockpit door open and Lead Flight Attendant made the announcement to wear your mask over your nose and mouth throughout the ferry flight.Sometime midflight; when I walked to door were all the crew meals are boarded; passenger X zone; I saw the Captain asleep without his mask; passenger did not wear his mask. Three vans were available to take the whole crew from ZZZ airport to Hotel. I believe three flight attendants and I were in the third van; we all discussed we would refused to share the van with the two company people [mentioned]; if they did not wear their mask. So I asked 'Would you gentlemen please wear your mask over your nose and mouth in such close space with us?' They put on their mask; I recall person replied 'I don't want 3 nagging mothers directing...to me...' I said; 'Sir our goal is to communicate safety requirements that are put out by CDC; we [are] in a close space; and since we don't know about each other's health and family situation; we just want to be safe.'Boarding; 2 company members did not wear their mask as they worked diligently; even after we boarded the personnel. I repeatedly reminded crew members 'mask mask mask please.' Even when company member was in GA with the military officer and his assistant; whom wore a face mask throughout their time on the aircraft. Crew member did not wear his mask. Crew member was resting in seat X and had a blanket over his face. I said; 'Sir the blanket is not a proper covering; you must wear your face mask.' I hear person shout '#@*$'. I walked away and did not speak to him again for the rest of the flight.

Captain and the pass riders on our ferry flight refused to wear [a] mask or wear them properly. Through the entire pairing; different flight attendants had to repeatedly ask the Captain to put on mask while walking around and taking crew rest break in the cabin. Captain indicated that they do not need the mask if no revenue passengers on board. FA Y asked to see in print and the Captain couldn't provide it. We also had to repeatedly ask the mechanics to put on mask properly even riding the shuttle to the hotel in ZZZ. I feel very unsafe having to deal with our fellow employees throughout this trip. They would put on the mask. After an hour or 2; the mask is either below nose or off.

Flight attendants reported issues with crew members not complying with face mask policy.

1695846

201910

1201-1800

ZZZ.Airport

US

IMC

Daylight

TRACON ZZZ

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

FMS Or FMC

Initial Approach

Class B ZZZ

N

Y

Unscheduled Maintenance

Testing; Inspection

Hydraulic Syst Reservoir Tank

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1695846

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Communication Breakdown

Party1 Maintenance; Party2 Flight Crew

1696274.0

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

Y

Person Flight Crew

In-flight

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

Logbook Entry; Human Factors; Aircraft; Procedure

Procedure

Prior to the flight in ZZZ1 while exchanging command with the inbound crew they apologized for their delay due to two maintenance items found in ZZZ2 prior to their flight. One of these items was hydraulic fluid found around the landing gear; the inbound Captain informed me that Maintenance in ZZZ2 had informed him not to submit the items to the [logbook]; but he indicated that after Maintenance fixed and serviced both items (including the hydraulic fluid) the aircraft operated normally for the flight from ZZZ2-ZZZ1. The flight from ZZZ1-ZZZ was uneventful aside from moderate turbulence enroute due to weather. On approach to ZZZ we were initially given an ATC initiated Missed Approach due to decreased separation from the deteriorating weather and the inability to continue PRM (Precision Runway Monitor) approaches. During this approach the gear was not extended. We were now noting our fuel was worth monitoring; but not in a critical state. On the 2nd approach we extended the landing gear; immediately I noted the extension both sounded and felt different from a normal extension. My attention immediately went to monitoring the landing gear indications which still showed in transit but felt was taking longer than normal. We received a HYD PUMP 3A Caution message approximately 10 seconds after extension and I immediately checked the Circuit Breaker Panel above the First Officer's head to determine if the pump had been overexerted and popped; but found it was still in. At this point I brought up the Hydraulic Synoptic Page which indicated 0% fluid in Hydraulic System 3; it was about this point we also received the GEAR DISAGREE warning message accompanied by a HYD 3 LO PRESS Caution message. We informed ATC that we needed to cancel our approach and be vectored to an area to work on a problem. I communicated to the First Officer we had a time threat limited by our fuel state; delegated him to declare an emergency and handed him the Block Start Report which had Souls on Board for to relay to ATC. I also transferred controls and radios to him and asked him to find us a 'spot' southwest of ZZZ3 where we could run our checklist and manage the problem. I also asked him to ACARS Maintenance our issue and to ask Dispatch for our nearest suitable VFR airport in case we had to face a potential gear up landing. At this point I began running the QRH and eventually was able to lower the landing gear via Manual Extension. I then called the Flight Attendant (who was on her first trip after IOE) and gave her a full briefing. I informed her that with the gear down and locked I anticipated a normal landing; with no need to brace; and no expectation for an evacuation or expedited deplaning. I then made a PA for the passengers and informed them of the situation and that our landing gear was safely locked. I told them to that we would be landing and sitting on the runway for some time; we would have fire personnel in and around the aircraft. I told them to not feel alarmed and that this is a normal process and to remain seated; calm; and to listen to both the direction of our Flight Attendant and myself. I came back from the PA and informed the First Officer to set us up on a long final for Runway XXC; ATC recommended Runway XXL for their operations; after discussing; we agreed 10L would be better as it was longer. I then proceeded to accomplish the HYD 3 LO PRESS Caution message and NOSE GEAR DOOR Open Warning Message QRH procedures. We then briefed the approach; discussed that if we went missed we would immediately be going to MSN as they were VFR; and with the gear being stuck in the down position; fuel would be critical because of the added drag and burn. We also discussed lack of nosewheel steering; possible asymmetric thrust during thrust reverser deployment; and loss of inboard braking resulting in the possibility of both pilots needing to brake together. At this point I asked my First Officer if he had anything he felt I had missed or would be doing anything differently as well as if we are happy standing by our decision making at this point. We both agreed we were in the best position we could be at this point; stood by our decisions and were safe to go into ZZZ3 for landing. I then briefly checked in with the Flight Attendant and she said she was seated and ready for landing and the cabin was secure. During the approach at 5;000 ft; our ILS Glideslope was acting erratically and captured prematurely; causing the aircraft to climb approximately 500 ft. I disconnected the autopilot and leveled the aircraft; then chose to recapture at 5;500 ft and monitor the glideslope behavior before reengaging the autopilot. We landed without issue and were able to stop fairly quickly with maximum reverse thrust. I immediately made an announcement over the PA for passengers to remain seated; to listen to mine and the Flight Attendant's direction; and to not be alarmed by fire personnel around the aircraft. Crash Fire Rescue met us at the aircraft and inspected both brakes and landing gear and noted no irregularities. During this time they requested an engine shutdown; which I secured #1 normally; allowing for us to still have outboard brake pressure. I did not shutdown the #2 engine until aircraft tow arrived and connected to the aircraft. Aircraft was towed with no other issues; proceeded to stand and greet all passengers as they deplaned; all seemed in mostly positive spirit. No injuries.Follow up would be required from Maintenance personnel in ZZZ2 on whether proper procedures were followed with regards to [logbook] Discrepancies and whether a proper corrective action for a possible hydraulic leak were followed. Judging by the lack of fluid in our system after we extended the landing gear; the exertion on the system exacerbated a leak causing the entire system to drain and fail.Retraining for maintenance personnel in regards to proper documentation of all discrepancies. I know as a pilot it would have been proper to stop the operation in ZZZ until proper documentation was made; but I was a third party to a conversation I was not present for and the inbound Captain informed me the aircraft was operating normally. At that point there were no known discrepancies which makes it hard for me to create a write up for something I was not present for.

During approach into ZZZ; the Captain called for gear down. Immediately after I selected gear down; the associated sounds and feelings were abnormal. The Captain leveled off; pointed out the landing gear had not extended properly (left gear - red dashes; nose - green; right gear - red dashes) and the associated warning message (gear disagree). Additionally; the hydraulic pump 3a caution message appeared. The Captain instructed me to [advise ATC]. We leveled off at 4;000 ft; the Captain transferred controls to me; and we were vectored around as he ran the QRH. We had plenty of fuel; but as the weather was IMC with 600 ft ceilings we asked Dispatch if there were any other VFR airports nearby. Once the checklists was completed; and the gear extended; we were vectored back around for the ILS Runway XXL. As the nose wheel steering was inoperative; we stopped on the runway where the emergency services met us. We were then towed to the gate.

CRJ-200 Captain reported a loss of hydraulic fluid that resulted in a diversion.

1070331

201302

1801-2400

ZLA.ARTCC

CA

254.0

7.0

2000.0

VMC

Night

Air Taxi

Helicopter

1.0

Part 135

None

Ambulance

Cruise

Direct

Class E ZLA

GPS & Other Satellite Navigation

X

Malfunctioning

Aircraft X

Flight Deck

Air Taxi

Pilot Flying; Single Pilot

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 40; Flight Crew Total 3700; Flight Crew Type 450

Distraction; Human-Machine Interface; Situational Awareness

1070331

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

General None Reported / Taken

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

Ambiguous

Loss of reception to both GPS receivers; Garmin 530 and 430 at the same time. Occurred at 2;000 FT MSL; 7 miles west (254 radial) from the POMONA VORTAC. Helicopter was flying eastbound straight and level; autopilot engaged and coupled to 530.

The reporter stated the there was no weather interference and known environmental influence which he was aware of at the time to cause the signal loss. He has researched this and previous GPS signal loses and does not believe they were the result of aircraft system's problems because they occur simultaneously and both GPS systems indicate no satellites available. The reporter stated that he checks the scheduled satellite outage reports as part of his preflight and several outages he has experienced occur during a time period list but for a different geographical area. He is wondering if there is an outage spillover of some type.

An Air Ambulance pilot reported that at 2;000 FT; seven miles southwest of POM; his helicopter's Garmin 530 and 430 simultaneously lost the GPS signal with both displays indicating no satellite signal for several minutes.

1733432

202002

0001-0600

JAC.Airport

WY

10200.0

Center ZLC

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC

Initial Climb

Class E ZLC

Facility ZLC.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 7.5

Confusion

1733432

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control

In-flight

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

Human Factors; Procedure

Human Factors

Aircraft X was released for departure off of JAC airport via the GEYSER Departure Procedure. The aircraft departed Runway 01 at JAC and reported on frequency. I radar identified Aircraft X 2 miles north of JAC and asked the pilot to confirm his altitude. I gave a control instruction to the pilot; leaving 14;000 feet MSL cleared right turn direct a fix south of Aircraft X's position. The pilot read back the clearance correctly. Continuing my scan I began to ship another Aircraft to ZDV and while doing so noticed a radar hit showing a right turn of Aircraft X at about 10;200 feet MSL. The minimum IFR altitude in that area was just over 11;000 feet MSL. The departure procedure requires a right turn to intercept the outbound course from the JAC VOR. At times a quick turn by an aircraft is translated as a bigger turn by the radar system; therefore I couldn't tell initially if that turn was due to the aircraft or the radar. I finished shipping the aircraft to ZDV and watched Aircraft X for the second radar return. The second radar return showed a continuation of the right turn southbound. I immediately restated the clearance to not turn on course until leaving 14;000 feet MSL. The pilot again responded with the correct clearance given. I informed my manager of what was happening while I continued to monitor the aircraft's climb rate. Aircraft X had a climb rate that was fast enough to stay out of high terrain so no low altitude alert was issued. The manager left and I then shipped Aircraft X to the next sector in ZLC after a handoff was accepted. Sector 08 received Aircraft X and continued their climb. The data block was dropped leaving R16's airspace. The response by the pilot was that the fix NALSI is a fly by point instead of a fly over fix. The FMS of the Aircraft X is being stated as the reason for the early turn. I have never witnessed an FMS system make a 'smart turn' 10 miles from a fix to stay on course. Not all aircraft make that early of a turn including Aircraft X flown by company to many destinations from JAC. I believe that fix needs to be made a fly over fix to mitigate the ability of an FMS system making that error.

ZLC Center Controller reported an aircraft turned early leading to a climb below the minimum IFR altitude.

999466

201203

1201-1800

ZZZ.Airport

US

VMC

Daylight

Tower ZZZ

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Class D ZZZ

Gear Extend/Retract Mechanism

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Commercial

999466

Aircraft Equipment Problem Critical; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

Flight Crew Diverted

Aircraft

We took off and the Captain called for gear up and I complied. The gear never retracted. The caution message appeared followed by the landing gear/lever disagree message following. We continued the normal call outs and cleaned up the airplane until we reached a safe altitude. Tower switched us over to Departure and he cleared us to 15;000. We asked to stay at 3;000 so we could take care of the issue at hand. We never declared an emergency. We then ran the appropriate QRH checklist; the Captain flew as I tried to fix. The QRH did not fix it so the Captain and I decided to transfer controls to me since he had more experience notifying who was needed to be notified. He then performed the crew brief and got a hold of the appropriate people. After we reached Dispatch; they told us to make our way to destination and we could divert to an en route alternate if need be in case fuel was an issue. We then climbed to 10;000 and made our way there. The Dispatcher's computer was down so he had to run the fuel numbers by hand which took longer than normal. The Captain and I both decided we would not be able to make it to destination and by about that time the Dispatcher gave us the new numbers and amendments to land in ZZZ for the diversion. We then made a safe landing in ZZZ and at no time were we in danger. The CRM was great. We could have climbed to a higher altitude to conserve fuel and also it would have been easier to contact everyone via radio at a higher altitude. It's easier to burn fuel than outright not having it.

EMB145 First Officer experiences the failure of the landing gear to retract after takeoff. The QRH is consulted to no avail and the Dispatcher requests that the crew attempt to make it to destination and divert if it becomes necessary. It becomes necessary.

1684782

201909

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Cruise

Cooling Fan; any cooling fan

X

Malfunctioning

Hangar / Base

Air Carrier

Dispatcher

Dispatch Dispatcher

Communication Breakdown

Party1 Dispatch; Party2 Flight Crew

1684782

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

Person Dispatch; Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem; General Maintenance Action

Equipment / Tooling; Aircraft

Aircraft

Approximately 75 minutes into the flight; the flight attempted a call to Dispatch via SATCOM to advise of an equipment cooling overheat EICAS message and fumes in the cockpit and cabin. No smoke was reported. The crew's SATCOM call was unreadable and dropped when conferencing with [Maintenance Control]. Subsequently; I attempted 3 calls to raise them on SATCOM and my coworker on Sector XX attempted a SATCOM call [as well]. All 4 calls failed to connect. Aircraft is equipped with Iridium and this happens too frequently. It compromised the safety of flight as we were unable to provide Dispatch and Maintenance Control support in a timely manner. All information relayed was delayed because we needed to use ACARS communication in this situation.

Dispatcher reported a communication breakdown with a flight crew regarding a cooling fan malfunction and associated fumes.

1705017

201911

1201-1800

ZZZ.Airport

US

4500.0

IMC

Turbulence; Windshear; 1

Daylight

800

TRACON ZZZ

Corporate

Embraer Legacy 450/500

2.0

Part 91

IFR

Passenger

Initial Climb

Class D ZZZ

Aircraft X

Flight Deck

Corporate

Pilot Not Flying; Captain

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

Flight Crew Last 90 Days 100; Flight Crew Total 8250

Human-Machine Interface; Time Pressure

1705017

Aircraft X

Flight Deck

Corporate

Pilot Flying; First Officer

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

Time Pressure; Human-Machine Interface

1705030.0

Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Regained Aircraft Control; Flight Crew Returned To Clearance

Weather

While departing on a SID we were advised on the ground to level at 5;000 feet MSL. At approximately 4;500 feet; our aural warning on our autopilot went off and a violent pitch up moment occurred with I believe was due to turbulence or possible wake turbulence. I was able to get aircraft back under control at approximately 5;500 - 5;700 feet MSL before I could advise ATC. They informed me I should be level at 5;000 feet and cleared to 6;000 feet. I realize this is a pilot deviation of 700 feet; but [I was] unable to control the aircraft climb for 600 feet - 700 feet due to pitching moment. I informed Center of the severe turbulence in the area and heard other pilots on frequency reporting turbulence. Crew was not tired and properly rested. This event caught us by surprise.

[Report narrative contained no additional information.]

EMB-550 flight crew reported severe turbulence during initial climb resulting in a momentary loss of aircraft control while attempting to level off.

1025589

201207

1201-1800

DBQ.Airport

IA

0.0

VMC

10

Daylight

20000

10000

Tower DBQ

Corporate

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

VFR

Personal

Taxi

None

Aircraft X

Flight Deck

Corporate

Single Pilot; Pilot Flying

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 54.9; Flight Crew Total 3279.1; Flight Crew Type 210.1

Communication Breakdown; Time Pressure; Situational Awareness; Distraction

Party1 Flight Crew; Party2 ATC

1025589

Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway

Horizontal 10000; Vertical 1000

Person Air Traffic Control; Person Flight Crew

Taxi

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

Airport; Human Factors

Ambiguous

Was taxiing out to Runway 18 and crossed over hold short. When I realized; I made an immediate 180 turn back behind hold short line. I was not familiar with airport and became distracted. Tower instructed plane on approach to go around. This was first time in my 30 years of flying where I have not been aware of hold short line. I was pre-occupied in preparing for departure in gusty wind conditions rather than task at hand of taxiing the aircraft.

A pilot crossed the DBQ Runway 18 hold short line; which is a long distance from the runway; and upon realizing his error returned behind the line as Tower issued a go around to an aircraft on short final.

1441221

201704

1201-1800

ZZZ.ARTCC

US

35000.0

Mixed

Daylight

Center ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Y

N

High

Cabin Lighting

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 127; Flight Crew Type 17000

Communication Breakdown

Party1 Flight Crew; Party2 Other

1441221

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown

Party1 Flight Crew; Party2 Other

1441264.0

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

Person Observer

In-flight

General Release Refused / Aircraft Not Accepted

MEL; Aircraft

MEL

FAA on jumpseat to ZZZ. Halfway through the flight FAA Inspector asked to look at logbook. He found MEL 33-2-XX Cabin Interior Lighting was; in his opinion; misapplied. We were getting close to TOD so we decided we would discuss on ground. I sent ACARS for Maintenance to meet us at gate. On the ground I was asked if I thought that MEL applied. FAA Inspector thought it did not because it was not the lights; they were on full bright. FAA Inspector pointed out it was the switch; not the lights. I countered; to no avail; that the switch is part of the lighting system covered by the MEL and all MEL items A through E are being complied with. He said it was the switch and that is was not covered. Then he asked me to make the decision on the spot if I thought the MEL was right or wrong. Hello rock; meet hard place. I have the perfect textbook answer. I don't make those calls on my own. I am tasked with calling Dispatch and getting Maintenance Control in the loop as well. And that's what I did.ZZZ Maintenance showed up. FAA Inspector; Maintenance; and I walk to the back of the aircraft; as FAA Inspector wanted to see the switch and the lights. Maintenance was unable to dim the lights with the switch. FAA Inspector took pictures of switch and lights illuminated. We called Dispatch and Maintenance Control. Maintenance Control said it was the correct MEL; but would try to get it fixed. FAA Inspector let me know he was staying right there with me so he could document whether I took off with the aircraft with a no-go item. Maintenance said they couldn't fix it but that it was good to go as is.I headed up to the top of the jetway to tell the Agent we were holding off boarding only to find the Agent had everyone lined up and was about to start boarding! The Agent asked me to stand in her place and tell the Passengers we were not boarding because she thought they would be less likely to take their frustration out on the Captain. It worked. Passengers were satisfied. If I was not willing to fly the aircraft; they didn't want to get on it either.I then got a call from ZZZ Operations on the jetway phone asking me to explain why I'm wasn't boarding. I gave them a general thumbnail. I made a call to Dispatch and asked for Chief Pilot on Call patch. I gave him the thumbnail of the situation and let him know at this point I was not taking this aircraft. He agreed 100 percent! THANK YOU; THANK YOU; THANK YOU; for backing me. Chief also knew FAA Inspector was sitting right there on the aircraft with me. Thanks to whoever gave him the heads up and not putting me on the spot. At this point we were given a swap. Just to make sure; FAA Inspector stayed with us until we left the aircraft with Maintenance. We got a new aircraft and uneventful flight.Change the MEL to include the switch in the description. Maintenance Control was very sure this was the proper MEL. At this point; I just don't know.

[Report narrative contained no additional information.]

B737 flight crew reported that the MEL for the cabin lights was misapplied.

1193882

201408

0001-0600

PDX.Airport

OR

TRACON P80

Air Carrier

B737-800

2.0

Part 121

IFR

Initial Approach

Visual Approach

Class C PDX

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Training / Qualification; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1193882

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

N

Person Flight Crew

In-flight

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

Human Factors; Procedure

Procedure

The Approach Controller issued clearance for a visual approach [to Runway 28R] with a [restriction] to cross 6 DME [of the I-IAP ILS DME] at 2;000 FT. I refused the clearance and stated that I could cross an intersection [TOLOC; on the ILS 28R ILS] at 7.7 ILS DME. I was advised that [TOLOC] was 6 DME from the runway. Discussion: The intersection I was referring to is 7.7 DME from the [far] END of the runway. DME is measured from [a ground based transmitter to the aircraft DME receiver]; not from a physical point [TOLOC in this case] to the [approach end of the] runway. In this case the raw data DME being displayed to the pilot is [derived from the ILS Localizer transmitter at the far end of Runway 28R]. When the aircraft is over the [approach] end of this runway the DME measures 1.7 DME. By accepting this Controller's clearance as issued I would have placed the aircraft 4.3 miles from the end of the runway at 2;000 FT which would have caused an unstable approach.Actually; because I rejected his clearance as stated and corrected it there was NO event but if this Controller continues issuing this type of clearance there most certainly will be in the future.

When approach cleared a B737NG to cross 6 DME from the runway at 2;000 FT; cleared to land Runway 28R at PDX the Captain refused the clearance reminding the Controller that the ILS DME is transmitted from the far end of the runway by the localizer transmitter and; as a result; 6 DME was just 4.3 NM from the approach end of the runway and an approach from that altitude at that distance would; by definition; exceed stabilized approach criteria.

1731285

202002

0601-1200

GRK.Airport

TX

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

General Seating Area

Air Carrier

Off Duty; Other / Unknown

Other / Unknown

1731285

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

Person Gate Agent / CSR

Pre-flight; Routine Inspection

General Maintenance Action

Human Factors

While deadheading out of ZZZ; I checked in. I had placed a can of Lysol in my check bag because they do not have KCM (Known Crew Member) at the airport and I was out of uniform. [Later] I heard a P.A. asking that I return to the check in counter. I left the secured area and went to the counter where the ticket agent asked for my ID. I gave her my driver's license and she made a copy of it. She stated the Lysol can was considered HAZMAT and that a file will be opened and reported to the DOT (Department of Transport). The can was taken and I proceeded to return to the gate.

Flight Attendant reported checking a personal bag with a can of Lysol inside; which was considered HAZMAT.

1416283

201701

0.0

Air Carrier

B777 Undifferentiated or Other Model

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 240; Flight Crew Total 15000; Flight Crew Type 3000

1416283

Flight Deck / Cabin / Aircraft Event Other / Unknown

Person Flight Crew

Taxi

Company Policy

The current SOP regarding use of flight deck speakers to INCLUDE ANY PHASE OF FLIGHT INCLUDING AND ESPECIALLY PUSH BACK FROM GATE OPERATIONS is completely unsafe and distracting. The response suggesting that as many people who find the new SOP distracting is equaled by those who find it 'SAFE' is ludicrous. The current SOP allows blaring flight deck speakers to be used during pushback operations when in reality the cap should be SOLO in communication with the push crew and the First Officer should ONLY be on ATC. Do we really need to look at the history of killed and maimed ground personnel due to distractions that lead to forming the excellent SOP that preceded the change? We can review all of those accidents if need be...and the explanation by the responder who says that we wrote the new SOP to 'align with the MEL'??? Since when do we do that? The MEL is written for when we are forced to use speakers. In those few and far between cases we use the MEL; BUT FOR EVERYDAY OPERATIONS WE NEED A SAFE ENVIRONMENT. One in which we 'don't have to ask someone to turn off the loud distracting speaker on an everyday; every flight basis.' THAT is how it is currently written. In addition; the argument that the speakers on the ground allow the 'jumpseaters' the opportunity to listen in is bogus. The jumpseater CHOOSES whether to participate or not. If they want to listen in they are provided a headset.

B777 First Officer reported that he feels the current SOP allowing use of flight deck speakers to include any phase of flight including pushback is unsafe and distracting. He stated that the Captain should be solo in communicating with the push crew and the First Officer should be only on ATC frequency.

1120315

201310

0001-0600

MEM.Airport

TN

0.0

VMC

Tower MEM

Air Carrier

B757-200

2.0

Part 121

Landing

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Confusion

1120315

ATC Issue All Types; Conflict Ground Conflict; Less Severe

Person Air Traffic Control

Air Traffic Control Issued New Clearance

Airport; Procedure

Procedure

Upon landing; Tower briefly told us to stop on runway; then immediately told us disregard. Another aircraft flew by in front of us. I assumed he was landing Runway 18L MEM; but the Captain said he was on a go-around. I can't be sure because we were on different Tower frequencies. Upon landing on MEM Runway 27; the aircraft landing on Runway 18L was told to go-around. The Tower told us upon touchdown to stop on the runway then disregard. I saw the south landing aircraft flash by but because he was on a different Tower frequency I was not truly aware of what he was actually doing until Captain and I discussed this later. Because I was the Pilot Flying my focus was on aircraft control more than communications; but the instruction from the Tower came right as the Captain was taking the airplane; and I was assuming the radios. It is not normal to receive a communication from Tower at this point in the landing; so it caught me by surprise. We asked the Tower if there was a problem; and he said no; not with us; but with him. He indicated to us that he had no problem with what we did. I believe the Tower's sequencing got a little out of sync. They initially wanted us to widen out our turn to final on Runway 27 and go behind someone else then he changed his mind and told us to turn to final and keep speed up; after we began a slow down. We sped up a bit then had to reduce to configure. It never became clear to me where exactly the mix up originated.

B757 First Officer rolling out on Runway 27 at MEM reports another aircraft fly by in front of her; approaching Runway 18L.

1199439

201408

0601-1200

CZQX.ARTCC

NF

26000.0

VMC

Turbulence

Center CZQX

Air Carrier

B767-300 and 300 ER

3.0

Part 121

IFR

Passenger

Cruise

Oceanic

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Attendant

1199439

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

N

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Took Evasive Action; Flight Crew Exited Penetrated Airspace; Flight Crew FLC Overrode Automation

Human Factors; Weather

Weather

Large area of reported severe turbulence was over Greenland. We were on track Alpha west bound when SIGMET was issued. I had just returned to the cockpit after crew rest break and was briefed by other pilots of what was forecast. [We had descended to] FL260 that put us below the altitudes included in the SIGMET. Just prior to entering the SIGMET area I requested a speed reduction to .78 Mach. Just prior to the SIGMET area the Captain had briefed the flight attendants and also made a PA to the passengers about possible turbulence. The flight was smooth till about halfway into the SIGMET area. We [then] had a smooth vertical up and down like a mountain wave but no turbulence. Shortly there after we entered an area of severe turbulence at 6243N Lat. Engine igniters and anti-ice were turned on and we also disconnected the autothrottles. The Captain made another PA while I monitored the flight controls and throttles. First turbulence was short lived followed quickly by a second hit of longer duration and harder turbulence. We were below the Tracks. The Captain elected to descend to get out of turbulence and set FL240 in the window. We slowed to 290 knots and descended to FL 240. Capt made radio calls on all frequencies to advise and entered a CPDLC free text about turbulence and altitude change. Gander returned a CPDLC message approving FL 240. Capt also alerted Dispatch. Severe turbulence lasted about 30-40 seconds which ended passing FL250. Even though the Captain had advised the cabin crew of the turbulence area and to remain seated until clear [of the forecast area]; the carts were out and set up for second service in the aft galley. All carts were thrown and contents emptied throughout the aft galley. No crew member or passenger was injured during this event.

A B767-300ER encountered a SIGMET forecast area of severe turbulence enroute over the Atlantic Ocean and descended without clearance to FL240 where the turbulence abated. Despite advance notice from the flight crew passenger service carts; left unsecured; were upset and emptied of their contents. No injuries or damage to the aircraft itself were sustained.

1439930

201704

1801-2400

UMP.Airport

IN

20.0

VMC

Haze / Smoke; 10

Dusk

24000

CTAF UMP

FBO

Cessna Single Piston Undifferentiated or Other Model

2.0

Part 91

None

Training

Initial Climb

None

Class G UMP

Personal

Cessna Single Piston Undifferentiated or Other Model

1.0

Part 91

Personal

Initial Climb

Class G UMP

Aircraft X

Flight Deck

FBO

Pilot Not Flying; Instructor

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

Flight Crew Last 90 Days 70; Flight Crew Total 2200; Flight Crew Type 50

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1439930

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

Horizontal 200; Vertical 400

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors

Flight was a short and soft field takeoff and landing practice with a student that is nearly finished with his private pilot certification. We were holding short for 2 announced planes in the pattern and were maintaining visual contact with them. After the second plane cleared the runway; we taxied onto the active runway. Both the student and I remember looking down final to check for other aircraft. I definitely try to instill this into my students to avoid situations like this one and was shocked that it happened to us. The student started our takeoff roll and just as we left the ground we noticed another Cessna that was unannounced on the CTAF fly over us just upwind of the runway with approximately 400 ft vertical separation. He had obviously initiated an immediate go-around due to our takeoff roll. We were able to continue our climb out almost as normal with a slight offset to the downwind side; although we were both concerned about wake turbulence since there was a crosswind. However; we did not encounter any.Both the student and I were surprised we did not see him on final. The Cessna that we made go-around continued a fairly tight pattern and landed without any radio communications on the CTAF and taxied to the FBO ramp. We had continued in the pattern and were on short final as the Cessna requested a radio check from the ramp. I replied 'now we hear you' and he then apologized for being on the wrong frequency; I apologized for not seeing him. He claimed to have been high but that his landing light was on. The previous two aircraft that landed before him were much more noticeable due to their landing lights being on against the high overcast layer and near sunset time. Both the student and I believe we would have seen his landing light if it he was on a normal final when we had pulled onto the runway.I feel the factors the contributed to us not seeing the other Cessna are as follows:1. Lack of radio cues to look for aircraft. However; it is an uncontrolled field so it is still solely our responsibility in this case to see and avoid. I do not fault the pilot of the other aircraft. Given enough time every one will encounter a no radio aircraft; especially at a non-tower field.2. High overcast layer with near sunset lighting while looking southeasterly down final did not provide a much contrast to spot the aircraft.3. A high base/final leg by the other aircraft resulting an angle hard to see from our aircraft.

Cessna flight instructor reported a NMAC on takeoff from UMP with another aircraft that was on a high approach which had to perform a go-around. The other aircraft was on the wrong frequency.

1170688

201403

1201-1800

ZZZ.Airport

US

5.0

VMC

Tower ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Initial Approach

Class C ZZZ

UAV - Unpiloted Aerial Vehicle

1.0

Class C ZZZ

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Other / Unknown

1170688

Conflict Airborne Conflict

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

We were on a visual approach; on about a 5 NM right base. I was flying; Captain was pilot not flying. As we were flying on the approach; the Captain suddenly noticed a small flying object which he later described as a camouflage painted UAV; due to his experience in the military with them; it was easily identifiable for him. I never saw the UAV; nor got any TCAS TA or RA; as they do not show up. He notified ATC as soon as practicable and safely within our FOM guidelines. I continued on with the approach and landed as normal. We did not encounter any damage because of the UAV as it wasn't in our flight path I believe. I'm not sure why the event occurred. I can only guess it was poor planning and communication between the Control Tower at ZZZ airport and the military entity operating the UAV.

Air Carrier flight crew reports sighting a UAV in close proximity during a visual approach.

1800835

202104

0601-1200

SCT.TRACON

CA

VMC

Daylight

TRACON SCT

Personal

Small Aircraft

Part 91

IFR

Personal

Cruise

Vectors

Class E SCT

Aircraft X; Facility SCT.TRACON

Government

Approach; Departure

Air Traffic Control Fully Certified

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

Time Pressure; Situational Awareness; Distraction; Workload

1800835

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Airspace Structure; Human Factors; Staffing

Human Factors

Aircraft originally put on a vector. Needed to widen out his downwind for a turn onto final. I planned to only have him on a vector for 1-2 miles. I got busy; requested a Radar Assist or to split the sector. Didn't realize he was in a 6;000 foot Minimum Vectoring Altitude but noticed him very close to my 9;900 foot Minimum Vectoring Altitude. As the pilot was reading back his clearance I turned the aircraft towards the final approach course and lower terrain immediately after noticing.

SCT TRACON Controller reported they left an aircraft on a heading longer than they planned and the aircraft flew below the Minimum Vectoring Altitude.

1576882

201809

1801-2400

ZZZ.Airport

US

1500.0

VMC

Tower ZZZ

Air Carrier

B757 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Climb

Class B ZZZ

Air Data Computer

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Flight Crew Total 8911

1576882

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 339; Flight Crew Total 5101

1576892.0

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Flight Crew FLC Overrode Automation; Flight Crew Returned To Departure Airport; Flight Crew Overcame Equipment Problem; Flight Crew Landed As Precaution

Aircraft

Aircraft was worked on for a multitude of maintenance issues. Systems were tested and deemed repaired. All previous issues that were worked on returned during climbout at approximately 1;500 feet. The following EICAS cautions appeared. L ENG EEC; R ENG EEC; ALT DISAGREE; IAS DISAGREE; RUDDER RATIO; MACH/SPD TRIM along with erroneous airspeed and altitude indications on the First Officer's panel. Control was transferred to the Captain as it was determined that his indications were correct. [ATC was advised]; all appropriate checklists completed; Dispatch contacted; cabin crew and passengers briefed landing data obtained and FMC set up for a return to [departure airport]. The subsequent approach and landing to Runway XXR was uneventful.

Immediately after takeoff; the FO (First Officer) noticed an airspeed fluctuation followed immediately by ALT DISAGREE; IAS DISAGREE; L/R ENG EEC'S; MACH/SPEED TRIM; RUDDER RATIO and AUTOTHROT DISC. These were the exact same issues the aircraft had experienced on the inbound flight. Maintenance had narrowed it down to the FO'S ADC. Since we knew my (Captain's) instruments were accurate; I assumed control. We ran through applicable checklists; briefed the FAs (Flight Attendants) and passengers; notified company through radio calls and ACARS and returned to the airport without incident.

B757 flight crew reported that the First Officer's flight instruments started to malfunction and disagreed with the Captain's side causing a return to their departure airport.

1558787

201807

0601-1200

YSSY.Airport

FO

5000.0

VMC

Tower YSSY

Air Carrier

B787 Dreamliner Undifferentiated or Other Model

3.0

Part 121

IFR

Passenger

FMS Or FMC

Takeoff / Launch

Tower YSSY

B777-300

2.0

IFR

FMS Or FMC

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Flight Crew Total 19729; Flight Crew Type 1265

1558787

Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

Person Flight Crew

In-flight

Flight Crew Returned To Clearance

Environment - Non Weather Related; Procedure

Procedure

Cleared for takeoff 1 minute behind B777-300. Mentioned I was concerned about wake; which we did encounter. Deviated off flight director commands slightly right of track and delayed clean up. Received turn as I was cleaning up aircraft. Became slightly overloaded and overshot 5000 ft. by 300ft. Received automated altitude warning and verbal warning from IRO just as we were cleared to higher altitude.

B787 First Officer reported overshooting charted altitude departing YSSY after encountering wake turbulence from preceding B777-300.

1765043

202010

1201-1800

P50.TRACON

AZ

3400.0

VMC

Daylight

TRACON P50

Fractional

Light Transport

2.0

Part 91

IFR

Ferry / Re-Positioning

Initial Approach

Other DESERT2 RNAV

Class B PHX

Aircraft X

Flight Deck

Fractional

Captain; Pilot Not Flying

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

Distraction; Human-Machine Interface; Situational Awareness

1765043

Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Undershoot; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Unstabilized Approach

Automation Aircraft Terrain Warning; Person Flight Crew

In-flight

Flight Crew Executed Go Around / Missed Approach

Human Factors; Procedure

Procedure

Coming into Scottsdale from ZZZ; we were cleared direct to DSERT for the DSERT2 RNAV (Area Navigation) arrival; then given instructions to cross YOLOW at 7;600 ft. and 250 kts. I put the altitude and speed in the FMS (Flight Management System) and the PF (Pilot Flying) set the AAD to 7;600 ft. and initiated the descent. Prior to reaching YOLOW; we acquired the runway at SDL and informed Approach; who simply acknowledged our transmission. We crossed YOLOW at 7;600 ft. and 250 kts; and shortly after were cleared for the visual approach to Runway 21 and instructed to contact Tower. The PF (Pilot Flying) began slowing the aircraft by reducing throttle and extending speed brakes while I activated the secondary flight plan containing the DSERT visual Runway 21 approach and activated the leg from YOLOW to EEDGR. The PF put 3;400 ft. into the AAD and activated VS (Vertical Speed) and dialed in a descent rate to reach 3;400 ft. at EEDGR. The PF directed me to extend the gear to assist with the descent and speed. Just prior to EEDGR we received a SINK RATE alert; and the PF shallowed the descent slightly; so we crossed EEDGR at approximately 200 kts and 3;600 ft. At the appropriate speeds; I extended the flaps; and shortly above 1;000 ft. AGL (Above Ground Level) we received a TERRAIN PULL UP alert; at which point I called for a go-around; which the PF executed. We climbed to 3;000 ft; ran the appropriate checklists; and then made a normal visual approach and landing.As we crossed EEDGR; the PF dialed the AAD to TDZE (Touch Down Zone); allowing the aircraft to continue descending while we attempted to get on profile.The PF and I were both distracted attempting to configure the aircraft and meet the profile of the approach. We both felt that the altitude and airspeed assignment at YOLOW made the switch to the REQUIRED visual approach with RNAV waypoints very difficult; and if we had simply flown a normal visual approach (which we've been doing for 15 years); we would have been fine. We were unable to configure early due to the ATC (Air Traffic Control) clearance; and the extra altitude carried past YOLOW forced a potentially unsafe descent rate. In the future; I will refuse a clearance to cross YOLOW at 7;600 ft and 250 kts if I expect to fly the visual to Runway 21. I feel the [Company] procedure as published actually reduces safety by drawing one or both pilots' attention into the cockpit during a critical phase of flight.

Flight Crew reported terrain alert on approach.

1600909

201812

PBI.Airport

FL

0.0

Haze / Smoke; 10

8000

Corporate

Any Unknown or Unlisted Aircraft Manufacturer

2.0

Part 91

IFR

Taxi

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

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

Flight Crew Last 90 Days 50; Flight Crew Total 3100; Flight Crew Type 1000

Physiological - Other; Situational Awareness

1600909

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

Person Flight Crew

Taxi

Flight Crew Became Reoriented

Human Factors; Environment - Non Weather Related

Human Factors

Night landing had trouble seeing the crossing runway; was given a turn for an immediate exit onto the crossing runway in ZZZ. Due to loss of night vision mistook the runway edge lines to be the center of the crossing taxiway. Ended off the runway. Was able to turn back onto an active runway. Was communicating with tower control the entire time.

Pilot reported misidentifying the runway edge as the centerline during taxi which resulted in a runway excursion.

1609748

201901

1201-1800

LFPG.Airport

FO

0.0

Air Carrier

B777-200

2.0

Part 121

IFR

Passenger

Cruise

Hangar / Base

Air Carrier

Dispatcher

Dispatch Dispatcher

Communication Breakdown

Party1 Dispatch; Party2 Ground Personnel

1609748

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

Person Dispatch

In-flight

General None Reported / Taken

Human Factors; Procedure

Procedure

Ramp agent did not advise of dry ice in the forward belly. [I suggest] some type of trigger in the FPS [Flight Progress Strips ] or workbench to tell Dispatcher they are loading dry ice in the lowers of the B777.

Dispatcher reported ramp load personnel neglected to notify Dispatcher of Hazmat [dry ice] loaded in cargo compartment.

990669

201201

0001-0600

ZZZ.Airport

US

0.0

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

Parked

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown

Party1 Dispatch; Party1 Maintenance; Party2 Flight Crew

990669

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Commercial

990670.0

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

Person Maintenance

Routine Inspection

General None Reported / Taken

Aircraft; Human Factors

Aircraft

After performing successfully all first flight of the day checks (which included O2 pressure level and O2 Mask); I proceeded with the logbook review. Upon review of it; I noticed that MEL 25-10 (observer seat and equipment) was still open despite the oxygen pressure level being at optimum range. The entry referring to Low Level O2 had been previously balanced and didn't mention anything related to a leak; it actually only mentioned the cockpit O2 to be below the required level; and the balancing entry was 'O2 serviced to 1;800 PSI'. After calling Maintenance to ask about the reason for MEL 25-10 being still open despite the O2 Level found to be within required range; he replied they were not required to clear that MEL until the next PS2. Upon arrival we were informed by our Chief Pilot of a Maintenance discrepancy found relating a possible O2 leak on our aircraft. During preflight; in cruise and after landing 02 pressure level was always found to be above 1;750 PSI.

On the previous day's logbook page; there was an entry showing that the cockpit O2 system was serviced; but with no indication that the MEL had been restored. Maintenance was called to verify whether the MEL should be open or closed. When the mechanic arrived at our aircraft; we questioned him on the matter. His response was that even though the O2 system was fully serviced; the MEL was to remain open; and that the next PS2 inspection would resolve the observer seat MEL issue. Several minutes prior to gate departure; an ACARS request was sent to our Dispatcher to keep the aircraft for our subsequent RIC turn. His response came a few moments before takeoff; which was approximately 20 minutes after gate departure. To the best of my recollection; the message suggested that the aircraft could not fly with a suspected O2 leak; and that we should expect to deplane. I assumed he was referring to our planned aircraft swap as a response to my original inquiry. The flight took off moments thereafter. O2 level was 1;700 plus PSI at departure; and 1;800 PSI upon arrival.Since there were no logbook entries suggesting anything about O2 leakage; we had no reason to suspect that prior to gate departure. Our Dispatcher mentioned O2 leakage in his ACARS message. Perhaps that should have served as a warning; but it did not trigger the proper response from us as a crew.I believe it is fair to argue that inadequate logbook procedures greatly contributed to the event. Our preflight AML review was thorough and complete. The detail in our review even prompted us to question a mechanic in person for clarification. That individual asserted that the aircraft was airworthy; when the Dispatcher mentioned the words 'O2 leakage' perhaps that should have prompted more scrutiny of the matter. We did not regard his message as notification of an unairworthy condition. If the Dispatcher was trying to warn us of a situation; then more specific verbiage or instructions might have prompted a better response from us as flight crew.

EMB145 flight crew is dispatched with the observer seat MEL'ed apparently due to low oxygen level; yet the oxygen had been serviced to full. After landing the crew is informed that an oxygen leak was suspected and the aircraft should not have been flown.

1855376

202111

0601-1200

ZZZ.Airport

US

0.0

Ground ZZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Descent; Landing; Taxi; Parked

Coalescer Bag

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Physiological - Other

1855376

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

Person Flight Crew

In-flight; Taxi

Flight Crew Overcame Equipment Problem; General Maintenance Action

Aircraft

On the descent into ZZZ1 on Aircraft X from ZZZZ - ZZZ1 we experienced a strong dirty socks odor that persisted all the way to the gate. The First Officer complained of an irritated throat. I was the Captain for flight XXX and did not experience any side effects. A log book write up was made as well as a fumes event report included in logbook. Previous flight into ZZZZ also experienced an odor event with a deferral of the APU bleed by maintenance in ZZZZ for our flight.

A320 Captain reported a fume event of 'dirty socks' during descent that lasted until gate arrival.

1774655

202011

1801-2400

ZZZ.Airport

US

0.0

Marginal

Windshear

Daylight

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Ferry / Re-Positioning

Landing

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Communication Breakdown

Party1 Flight Crew; Party2 ATC

1774655

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

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Weather

Weather

On approach to ZZZ; the ATIS was obtained with reported winds of 340 @ 15 G 28. The airport was configured to land east; utilizing Runways XL and XXC. The First Officer (FO) and I discussed how this was odd and not desirable as the tailwind component with gusts was at our 10 knot limitation. Additionally; the ATIS stated there were wind shear advisories in the area. On final approach inside the FAF; maintaining target airspeed within Vref +10 was extremely difficult due to the high wind gusts; shifting winds; and shear. As pilot flying; my airspeed was hovering at +10 with occasional jumps up to +20. The wind vector on the MFD was showing winds at 030 between 20-35 knots until 100 feet or so; where the winds sheared to 340 at an unknown speed. I touched down within the touchdown zone but off centerline by approximately 10 feet. Taxi to the hanger was uneventful and no damage was noted. During the debrief; the FO and I agreed a go-around with a request to land on a Westerly direction should have been made. The cause of this event were gusty winds; poor traffic flow decision by ATC; and undesirable speed control by the Pilot Flying due to windshear. ATC decision to land to the east with reported winds of 340 @ 15 G 28. This decision by ATC caused an unsafe tailwind condition when coupled with very strong and gusty crosswinds. Additionally; myself or the FO should have requested a landing to the west. However; the First Officer and I determined that any request would be denied as ZZZ has a reputation for not accommodating these types of request in order to maintain efficient traffic flows. There is pressure to land with the prevailing flow of traffic at a major airport like ZZZ when the crew sees other aircraft landing in the existing conditions; even if the crew would prefer an alternate runway. I strongly believe ATC created an unsafe situation that may have inadvertently pressured pilots into landing with a tailwind in gusty conditions. When I made the decision to conduct the approach; a go around would have been the correct action when the wind sheared at 100 feet.

Air Carrier Captain flying CRJ-200 aircraft reports unsafe tailwind condition during approach to landing.

1462074

201707

1201-1800

ZZZ.Airport

US

Daylight

Center ZZZ

Air Carrier

Q400

2.0

Part 121

IFR

Passenger

Climb

Class E ZZZ

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Service

Situational Awareness

1462074

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

Person Flight Crew; Person Flight Attendant

In-flight

Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; Flight Crew Landed As Precaution; General Evacuated

Aircraft

As we took off from ZZZ this morning we received the after takeoff chime and as we started setting up the cart to start the inflight service we heard a loud noise that sounded like a decompression; as if a tire had blown and all of the air was being released and the sound was coming from the cargo compartment. I immediately called our CA and he said that he was just about to call us and that the flight deck warning light indicated that a fire in the cargo compartment could be a possibility. The FO asked if we could see smoke and I replied no. I felt the back galley wall to see if I could feel heat; which I did not. The CA said that we would be going back to ZZZ and that he would make a PA. We quickly put away the cart and made the announcement to prepare the cabin for landing. The CA told us that we would be doing an expeditious deplaning of passengers and I repeated the instructions back to him. I did my silent review preparing that we could have a fire in the cargo compartment going over in my head; donning the oxygen equipment; fire extinguishers; evacuating the aircraft. When we landed I could see the fire truck but was still unsure if we had a fire or not. Our CA made a PA remain seated; we taxied to the gate and did an expeditious deplaning of the passenger. I made an announcement to leave all personal belongings behind; to exit out of the main cabin door only. The CA instructed the passengers to congregate by the stop sign. After we got all of the passengers off I made sure that there we did not have any passengers still on the aircraft. The crew exited the plane.The CA spoke with the fire department and what bothers me is that the fire department had stated to the CA that if we were on the taxiway we should not have deplaned the passengers immediately after opening the cabin door. I don't understand this thought process at all. Shouldn't our priority be to get the passengers off of the plane in the event that we did have a fire regardless of where we deplane the passengers? The fire department verified that there was not a fire and one of the firemen checked with a heat sensor. After being on the tarmac with the passengers we asked the ground crew if they would direct the passengers inside. The passengers did follow our instructions and they did leave all personal belongings on board. After discussing what to do to return the personal belongings to the passengers originally the ground crew thought that they would collect all belongings and put them on the cart; which I spoke up and said I didn't feel comfortable with that and I did not want to be responsible for collecting all personal belongings. After discussing it we decided that the best alternative would be to have 5 passengers at a time come back onto the plane and collect their own personal items which worked out well. As the passengers came back on board I asked each one if I could help in any way; if they needed anything. During this the duty officer had called. A fire is a very serious situation and in our training we know how quickly a fire can spread. I am thankful that we did not actually have a fire; I am thankful for flying with a crew that communicated well as a crew and that we talked about what happened. We debriefed and we took the time to debrief. I appreciate that the FO took the time to show us the checklist. I now know what it sounds like to have the pilots oxygen donned. I feel that in a situation like this that you should automatically be taken off of your trip to decompress. You shouldn't have to decide if you want to continue to fly or not. We each handle situations differently but to take myself off of the trip was the absolute best choice for myself. We deadheaded to ZZZ1 and when we landed our supervisor entered the back of the aircraft. I thought that he was there to discuss what had happened but did not.

Q400 Flight Attendant reported that as they started service they heard a loud noise that sounded like decompression that came from the cargo compartment.

1508035

201712

ZZZ.Airport

US

0.0

VMC

Air Carrier

B777 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Parked

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 13578; Flight Crew Type 1412

1508035

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

Person Flight Crew

Pre-flight; In-flight

General None Reported / Taken

Human Factors; Company Policy

Company Policy

Regular FO (First Officer) was able to get vacation drop and trip was assigned to a reserve pilot. During flight planning FO said it was good I was an LCA (Line Check Airman) since he had questions. He also told me I would need to watch him like a hawk. During set up the FO asked very basic questions and when I reviewed the FMC I found numerous errors. No position loaded alignment didn't complete; no tail number with data reset; unable to remember how to pull up intersection data and get it to load. When I asked him how long it had been since he sat in the right seat for takeoff replied around 8 months since he had attended 2 landings classes within the last a few months prior. This pilot was not prepared. He had lost confidence; when I asked if he really didn't know some of his questions his reply was I think they are right I just want to double check. I found myself falling into OE (Operating Experience) mode and spent the rest of the flight as if it were an OE. With a strongly worded debrief that if this had been a line check he would not have [passed]. By the second leg; which he flew; he was at end level proficiency. This pilot told me he bids reserve for more time off. This report is not to rat him out; but to point out the problem our current system of scheduling has on maintaining proficiency. He told me he had studied but admitted he was not prepared. Anytime a pilot tells you 'To keep an eye on him 'should raise warning flags. I would also like to point out if a pilot missed work for an 8 month period; he would require [recurrent training] for 2 legs.

B777 Captain reported that the reserve First Officer had not flown in 8 months and was not proficient in the aircraft.

1693388

201910

1801-2400

BTL.Tower

MI

500.0

VMC

Fractional

Medium Transport

2.0

Part 91

IFR

Passenger

FMS Or FMC

Landing

Aircraft X

Flight Deck

Fractional

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Confusion; Situational Awareness; Fatigue; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1693388

Aircraft X

Flight Deck

Fractional

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Confusion; Communication Breakdown; Fatigue

Party1 Flight Crew; Party2 Flight Crew

1693389.0

Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway

N

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

On a flight into BTL we had briefed a visual approach to Runway 23R back up with the ILS. Upon arrival to BTL the Tower cleared us to land Runway 23R; after landing and taxiing off the runway the Tower cleared us to parking with him. It was at this point I realized we had landed on Runway 23L. No indication of the error was given by the Tower. Taxied into the ramp uneventful and shut down.Both of us had a duty day over twelve hours with connecting airline flight and an hour long car ride to reach the airplane followed by a flight to BTL. Fatigue was without a doubt a factor.

Flying in to BTL we were cleared to land on Runway 23R. ATIS was telling us Runway 31 was in use and we briefed enroute we would ask for Runway 23R and we did. We approached the airport from the southeast. Tower cleared us to land and the Pilot Flying began to turn directly to the airport like he was setting up for final on Runway 31. I corrected him and told him he needs a base for Runway 23R. Pilot Flying then asked if the REILS that were flashing was the intended runway and I said yes (it matched my centerline direction) and he then turned for a base leg for Runway 23L. We landed on Runway 23L without the Tower correcting us at all. I was distracted from our approach which was short and lower than I like. We were turning on Final at 500 feet AGL and realized we were landing on Runway 23L just before touchdown. I knew it was long enough from the briefing but my centerline was for Runway 23R. I can only contribute not matching the two due to fatigue. We both had the ILS Runway 23R set in and did not catch it. I always have a centerline which has helped a handful of times over the years. After landing we asked the Tower if we should go to ground for taxi (we were clear of runway) and he said to stay with him. We did not get any taxi instructions and proceeded to [FBO]. The Tower never asked about the landing and we were not given a phone number to call anyone.I can only attribute to us both being fatigued a little bit the reason we landed on the wrong runway. We should have gone around when Pilot Flying was confused about the approach to Runway 31. If we had gone around we would've realized the error. The Tower didn't correct us but we should've landed on the right runway.

Medium Transport flight crew reported fatigue and distraction on final approach resulted in a landing on the wrong parallel runway.

1194293

201408

0001-0600

LAS.Airport

NV

3500.0

VMC

Daylight

TRACON L30

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Final Approach

Visual Approach

Class B LAS

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Last 90 Days 210; Flight Crew Total 19000; Flight Crew Type 14000

Communication Breakdown; Confusion; Situational Awareness

Party1 Flight Crew; Party2 ATC

1194293

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

Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew Became Reoriented

Procedure; Airspace Structure

Ambiguous

On arrival to LAS via the GRNPA ONE STAR we were told to expect the visual approach to Runway 19R. We had already selected the RNAV 19R from the FMC database; and briefed the approach from paper charts in the ship sets. As a side note; selecting the RNAV approach was done because the RNAV GPS approaches to 19R and 19L infringe on Nellis airspace per previous operations bulletin. Upon transfer to the second Approach Control frequency; we were cleared to fly from TRROP to LEMNZ; to cross LEMNZ at or above 3;500 FT and cleared for the visual approach to [Runway] 19R. I questioned the Controller asking for the RNAV 19R; an approach previous aircraft were being cleared for. He advised we; my air carrier; were not authorized for it. Subsequently we accepted the previously issued clearance and began our approach. LEMNZ is 2.6 NM from Runway 19R. By crossing it at 3;500 FT; you are 1;400 FT AGL. We immediately recognized this threat and through appropriate energy management were able to complete the approach. This clearance is dangerous; and will set up crews every time for an unstable approach.

An air carrier crew on approach to LAS Runway 19R was cleared to cross LEMNZ Intersection at or above 3;500 FT but consider 1;400 FT AGL at 2.6 NM from the airport an unstabilized approach setup.

1581106

201809

1801-2400

ZZZ.Airport

US

2300.0

TRACON ZZZ

Golden Eagle 421

1.0

Part 91

IFR

Initial Climb

Vectors

Class D ZZZ

Facility ZZZ.Tracon

Government

Approach

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 3.5

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 Flight Crew

1581106

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control

In-flight

Air Traffic Control Provided Assistance

Weather; Aircraft

Aircraft

On the day of the incident it was LIFR [Low Instrument Flight Rules] conditions. Aircraft X had just departed RWY XX from ZZZ; and had called me for his check on at about 023 ft. I told him 'Radar contact; climb and maintain 040'. I then went on with my scan of my sector; and when I came back to Aircraft X; I noticed his altitude was 015 [feet]; the pilot had descended on his own; I then asked if everything was ok and if he needed any assistance. The pilot informed me that he was having control issues and was having a hard time keeping his plane in level flight. I told him ZZZ was 4 or 5 miles south of him if he wanted to return; I then informed the Supervisor of what was going on and coordinated with ZZZ about the situation. The pilot asked me what highway he was flying over; I informed him and ZZZ was 3 miles S/SW of him. The pilot then informed me he lost all his instruments. I then continued to inform him of his position in relation to ZZZ. I also coordinated with ZZZ to issue the pilot a landing clearance if/when he got ZZZ in sight. Thankfully; the pilot was able to finally see ZZZ about 1.5 miles from the field; I issued a landing clearance and switched the pilot over to ZZZ Tower and the pilot did land safely. While I did not issue the 'low altitude alert'; which was the reason this incident was brought up again for [report] purposes; I was so engrossed in trying to get the plane and pilot back to the ground safely I should have issued the 'low altitude alert'.

D10 Controller reported a twin Cessna pilot descended below clearance in low IFR weather.

1242614

201502

PRC.Airport

AZ

500.0

20

Daylight

Tower PRC

FBO

Skyhawk 172/Cutlass 172

2.0

Part 91

None

Training

Final Approach

None

Class D PRC

Aircraft X

Flight Deck

FBO

Instructor

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

Flight Crew Last 90 Days 300; Flight Crew Total 4300; Flight Crew Type 3000

Situational Awareness

1242614

ATC Issue All Types; Conflict NMAC

Horizontal 150; Vertical 100

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors; ATC Equipment / Nav Facility / Buildings

Human Factors

During a routine pre-solo traffic pattern flight we had a near mid-air with a Bell Jet Ranger helicopter. The runway in use at Prescott was Runway 30 with the winds out of the north with gusts to 22kt; and visibility greater than 10SM. We had been cleared for a touch and go on 30 from the left downwind. Sometime before turning base tower gave right traffic entry instructions for a helicopter that was approaching the airport from the east (I do not recall the exact instructions that were giving to the helicopter). Soon after we turned on an approximately 2.5NM final I heard the helicopter report right base. The helicopter did not give a distance out; and tower told him to turn back to the right downwind. This caught my attention and I begin to scan for traffic off the right wing tip; and behind the wing. This was where I determined that helicopter would be according to their radio calls. I checked the MFD for any ADS-B traffic; but due to a radar outage any non-ADS-B equipped aircraft would not show on the MFD. The student continued to fly down final. When we were on an approximately 1.5NM final I turned my attention back to our final approach course; as I was unable to locate the helicopter off my right side. I located the helicopter shortly after looking back at final. We were still about 1.5NM out and approximately 500 feet AGL. The helicopter was at our one o'clock and headed straight for us (approximately 150 feet lateral and -100 feet vertical). I took evasive action by pulling hard on the elevator and banking to the left to avoid sudden impact with the helicopter. My best guess is we were 3 seconds from impact. I continued to climb to TPA on runway heading. My student never saw the helicopter.The helicopter pilot then reported to tower that he had a near mid air; I responded that he had just crossed the final approach course. Tower then had him turn back to the right downwind for 30.Other contributing factors were that Prescott tower's radar feed was also out of service; which left the tower without a valuable aid in sequencing aircraft arrivals. This coupled with the fact the helicopter was a transient aircraft that may have not been adequately familiar with the area.

C172 instructor pilot reported an NMAC with a helicopter at PRC during a time the Tower's radar was out of service.

1124089

201310

0001-0600

ZZZ.Airport

US

0.0

Night

Air Carrier

A320

Part 121

Parked

Y

N

Scheduled Maintenance

Installation

Compressor Bleed Valve

X

Malfunctioning

Hangar / Base

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Distraction; Training / Qualification; Situational Awareness; Confusion

1124089

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

N

Person Maintenance

Other During Maintenance

General Maintenance Action

Aircraft; Chart Or Publication; Human Factors; Incorrect / Not Installed / Unavailable Part; Manuals

Human Factors

I was assigned to work an MEL on an A320 aircraft and I was supposed to change the High Pressure (HP) 10th stage bleed valve closure solenoid (4029ks). Instead I changed the HP 10th stage solenoid (4023ks); not realizing I changed the wrong solenoid because the terminology confused me. See Aircraft Maintenance Manual (AMM) figures [drawings] in Chapters 75-23-53 and Troubleshooting Manual (TSM) 36-11-00. I was working at night; outside on Pad-5 on my third night. At the same time; I was assisting a Mechanic working a 2.5 bleed actuator on the opposite motor and may have been distracted. I had changed the wrong part and re-deferred the MEL. Two nights later; another Mechanic was assigned the same job to fix the MEL; but could not locate the part in stock that I had installed incorrectly. After researching; that Mechanic found the part installed in the incorrect position. Distraction and confusion between AMM figures in 75-32-53 and TSM 36-11-00; the MEL was cleared during the second visit.

An Aircraft Maintenance Technician (AMT) reports he mistakenly changed the High Pressure 10th stage solenoid (4013ks) instead of the High Pressure (HP) 10th stage bleed valve closure solenoid (4029ks) on an A320 aircraft engine. Distraction with helping another Mechanic and confusion with the drawings in the Aircraft Maintenance Manual (AMM) and Troubleshooting Manual (TSM) were noted as contributors.

1274088

201506

1201-1800

ZZZ.TRACON

US

4500.0

VMC

Haze / Smoke; 10

Daylight

TRACON ZZZ

Government

Light Transport; High Wing; 2 Turboprop Eng

1.0

Part 91

None

Tactical

GPS

Cruise

Direct

Special Use ZZZ

Military

UAV - Unpiloted Aerial Vehicle

Tactical

Cruise

Special Use ZZZ

Aircraft X

Flight Deck

Government

Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 150; Flight Crew Total 6000; Flight Crew Type 90

Situational Awareness; Time Pressure

1274088

Airspace Violation All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural FAR

Horizontal 500; Vertical 500

Automation Aircraft TA

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Exited Penetrated Airspace

Human Factors; Airspace Structure; Procedure

Human Factors

I was dispatched to a fire with two BLM (Bureau of Land Management) personnel onboard on an Air Attack mission for firefighting. We did not have coordinates for the fire until airborne and therefore did not have time to properly check the sectional for airspace before I left; which was my mistake. I got airborne and received the fire coordinates from State Forestry and input them into my GPS and started heading to it. I knew I was close to Class C airspace so I contacted approach and they gave me a squawk code. Shortly after they told me to climb from 4500 to 5500 for traffic; which I did immediately. We had also seen traffic ahead on our onboard TCAS display; which was not an immediate threat. We later saw the traffic (UAS) pass below us. We proceeded to the fire and when Approach gave me the clearance for frequency change out of their airspace they told me to call a number for a possible Restricted Area intrusion. I still had no idea what they were talking about until I later reviewed the sectional closer. I then called them from the Satellite phone and later from my cell phone to talk with TRACON and discuss my mistake. They said I just barely clipped the Restricted Area by the Air Force Base; which was active at the time and the traffic I climbed to avoid was a drone.I realize my mistake was not reviewing airspace properly before being dispatched for a fire; but also believe the nature of fire dispatches along with my unfamiliarity with the area caused this to happen. From now on I demand to know the fire coordinates before getting airborne so I can review the airspace.

Light twin pilot reports being dispatched on an air attack mission for the Forest Service without precise coordinates or a proper preflight of the route. The route passes through restricted airspace and results in a conflict with a military drone.

1483597

201709

0601-1200

ZLA.ARTCC

CA

13000.0

Daylight

Center ZLA

Light Transport; Low Wing; 2 Turbojet Eng

2.0

Part 91

IFR

Passenger

Cruise

Vectors

Class E ZLA

Center ZLA

Air Carrier

Widebody Transport

2.0

Part 129

IFR

Passenger

Descent

Class A ZLA; Class E ZLA

Facility ZLA.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 9.0

Workload; Situational Awareness; Confusion

1483597

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

Person Air Traffic Control

In-flight

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

Airspace Structure; Procedure; Human Factors

Human Factors

There were multiple aircraft situations that preceded this loss of separation. A light aircraft at 14000 feet west bound. Multiple Burbank arrivals and a BFL departure; destination LAX at 13000 feet. The arrival at 14000 feet was in the middle of the sector adding complexity. I meant to stop another landing aircraft above 15000 feet; but apparently issued 14000 feet instead. When that aircraft didn't stop descent I vectored it to the west to avoid the other aircraft at 14000 feet who I also turned to avoid that situation. Meanwhile; Aircraft X was under both aircraft at 13000 feet and not sequenced with Aircraft Y and another aircraft. Both were from high altitude descending via a STAR. I vectored the BFL departure to the east to follow Aircraft Y; then turned it back; too soon; and lost separation with Aircraft Y. In post incident review the best solution would have been to hand the BFL to LAX aircraft off to adjacent sector for routing via their LAX stream and eliminate that aircraft from the scenario. It also would have helped if I had called the sector to the east for control to descend the SBA arrival aircraft. I find that the descend via procedures that we implemented have added complexity to the sectors. There are numerous new fixes along the routes and more of them. One factor that slowed me down was in the above situation was having to look up a fix for the arrival to rejoin the STAR after I vectored it off route. The User Request Evaluation Tool (URET) didn't display it when I looked. Additionally; the aircraft are now descending into the sectors from high altitude versus before when they only entered after a clearance.

A Center controller reported the vector for sequencing was insufficient and resulted in less than required separation.

1255136

201504

1801-2400

LAS.Airport

NV

200.0

VMC

Windshear

Dusk

TRACON L30; Tower LAS

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Landing

Visual Approach

Class B LAS

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 183

Workload; Physiological - Other; Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Dispatch

1255136

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

Flight Crew Landed As Precaution; Flight Crew Took Evasive Action; Flight Crew Executed Go Around / Missed Approach

Airport; Weather; Procedure

Weather

We dispatched to LAS to arrive with fuel 7.2. Gusty winds were forecast at LAS but fuel seemed to be sufficient. The forecast did not require an alternate. Enroute; Dispatch advised us that blowing dust was reducing visibility to two miles which was supposed to end at the time of our arrival. The sun was setting at our arrival and visibility was picking up as forecast. We briefed and flew ILS 1L but were able to see the field from approximately four miles. Gusty wind conditions were reported on the field but it was not until breaking out that we encountered the turbulence and fierce gusty winds. After breaking out; we heard the aircraft in front of us go-around for windshear. This was our first indication of a windshear threat. We commenced a go-around on this first approach due to a strong side gust around 200 feet AGL which caused directional nose shift and a pitch up. I started to do a normal go-around; retracting flaps to 15 as we climbed away but then the climb stalled and we went to emergency thrust and held pitch as necessary to climb to 6;000 feet MSL. We never received a verbal warning from the GPWS.At this point the fuel totalizer read 5.3. I sent a message to Dispatch for an alternate with our fuel state; expecting Nellis. Instead he gave me Ontario with a burn of 3.2. This would've put us in Ontario with emergency fuel at 2.1. I told him too far.While we waited for a response from Dispatch; ATC vectored us on a downwind and First Officer (FO) and I discussed our plans. FO pulled up Nellis on the [charts] and it listed no approaches available. We asked ATC if aircraft were landing at LAS and they said yes. ATC advised we were number nine for the approach. I declared minimum fuel and they began discussions with another Aircrew to work us ahead of them. Visibility was picking up and we could now see the field from 6;000 feet. Based on this information we decided attempting another approach was our best option; as opposed to landing well below emergency fuel in ONT. On base; Dispatch advised us that we could use St. George; with a burn of 2.3. The FO was familiar with its location; and we discussed it as last resort after this attempt which was upon us.Final was similar to the first approach and very difficult; with airspeed plus or minus 15 and strong side-gusts; but glideslope steady. Once again we received a side gust around 200 feet. Normally this would again have meant a go-around. I decided to work through it and accept a long landing; using emergency authority. Fortunately we did not receive any more difficult gusts of wind and were able to smoothly land the aircraft between 3;000 feet and 4;000 feet down the runway. We were able to brake normally and taxi clear at Taxiway N. We arrived at the gate with fuel 4.4. Afterwards I contacted Dispatch and we had a discussion about the event.LAS is an airport with few alternate options when it comes to gusty winds in the region and the possibility of turbulence and windshear inhibiting landing. If winds exceed a certain predetermined amount; it would seem best to have a written Company policy of a required non-regional alternate and the safety of the matching fuel. LAS arrivals from the east also require a descent to the mid to low 20's from as far out as 200 miles. We received a similar early descent; which caused a lower fuel state on final than planned. This should be reflected in the flight plan. The severity of the turbulence and windshear affecting finals did not just occur with our arrival. From my perspective; Dispatch did not appear to be proactive but rather reactive. I think they could have sent warnings of the windshear threat and possible ensuing fuel issues before we encountered it ourselves.My initial thoughts when I saw the winds regarded the challenge; not the threat of multiple approaches and windshear. In the future I will be more proactive when it comes to fuel anytime I see high winds; especially in areas like LAS and DEN.

A B737 was dispatched to LAS and arrived to find gusty winds and dust. The crew executed a go-around on the first approach but with fuel considerations landed on the second approach by flying beneath the gusts near the surface.

1852400

202111

1201-1800

ZZZ.Airport

US

7500.0

VMC

10

Daylight

Personal

Skylane 182/RG Turbo Skylane/RG

1.0

Part 91

None

Personal

Cruise

Direct

Class B ZZZ

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 200; Flight Crew Total 8250; Flight Crew Type 200

Situational Awareness; Physiological - Other; Fatigue

1852400

Airspace Violation All Types; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; No Specific Anomaly Occurred Unwanted Situation

Person Flight Crew

In-flight

Flight Crew Exited Penetrated Airspace; Flight Crew Landed As Precaution; Flight Crew Became Reoriented

Human Factors

I was enroute from ZZZ1 to ZZZ2 in a Cessna 182. About 40 minutes from my destination at a cruise altitude of 7;500 MSL on the autopilot I began to feel a small amount of fatigue. I felt that if I could rest my eyes for a moment that would be okay. I fell asleep almost immediately. I awoke 30 minutes later inside the outer ring of ZZZ Class Bravo airspace.I immediately performed a 180 turn and exited the airspace; descended outside the airspace and proceeded to ZZZ1 which is my destination. I did not have clearance to enter Class B airspace.As a professional pilot I take this event very seriously. After some introspection of my errors I have identified two areas that need to be improved upon.My process for determining fatigue levels needs to be modified so that I have a greater awareness of my fitness to fly. In the future I will land the plane at the nearest suitable airport when I feel the need to 'rest my eyes'.I was not using any TRACON services such as VFR flight following. This omission was an unnecessary risk especially as I approached a busy airspace. I will use some type of radar services whenever available.

C172 pilot reported feeling fatigued; closed eyes for a few moments to recover with autopilot on; but fell asleep and violated a Class Bravo airspace.

1764941

202009

0601-1200

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Boarding; Safety Related Duties; Deplaning

Communication Breakdown; Distraction; Situational Awareness

Party1 Flight Attendant; Party2 Other

1764941

Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Passenger Misconduct

Y

Person Flight Attendant

In-flight; Pre-flight

General None Reported / Taken

Environment - Non Weather Related; Company Policy; Human Factors

Human Factors

Our passenger boarded the flight at the very end of boarding. I noticed him walk on with the gate agent who was asking him to put his mask back on. The gate agent then told me that they had been trying to get him on a flight for 3 days. I asked more about this; feeling a little concerned as to what could have caused them to deny him boarding these previous days and if it could be an issue during the flight. They told me the previous days he had not wanted to board the plane. He had explained to them that he hadn't gotten sleep and also hadn't eaten. I'm not sure what happened those past few days but it was communicated that he had gotten enough sleep and was able to finally board the plane.I made sure to ask clearly if they thought there might be any issue during the flight or if there was anything I should know that could cause an issue in-flight. The agent I talked to said she thought he was harmless.During boarding a woman nearby asked if he was going to wear his mask. I looked over and he had it down at his chin. I asked him to put it on and he did. This was an ongoing issue during the flight - he kept taking it off and we had to keep asking/reminding him to put it on.While taxiing to takeoff he got up out of his seat and moved a few rows back. I alerted the Captain but by this time he was already seated back down. We took off. I had him move back to sit in his original seat and he seemed fine the rest of the flight. Right before takeoff while we were still taxiing; [he] got up out of his seat and moved back a few rows to the exit row. I called the Captain and let him know someone was out of his seat. By this time [he] was seated a few rows back. The pilot made an announcement that everyone needed to be in their seat and then we took off. We just continued with taking off when we were scheduled. The thing is; [he] was now seated in an exit row for takeoff and he had not been briefed to sit there. I also doubted his ability to perform the necessary exit row duties. Once we were up in the air I did go back and confirmed that [he] was now seated in an exit row. I had him move back to his original row where he stayed for the duration of the flight. The only other issues we had was that when I would walk by he wasn't always wearing his mask. I would remind him and he would put it on. He seemed not to be intentionally doing it but perhaps just not mentally 'all there.'More communication from CSA to CSA. When we arrived in ZZZ1 I alerted the gate agent that we had a meet and assist and the D FA pointed him out to the gate agent as he deplaned. I don't think the extent of the situation had been communicated. Then again it's not our job to babysit people. Maybe his family should have been contacted and asked to fly with him? He seemed unfit to fly on his own.

Flight Attendant reported a passenger kept switching seats and did not comply with face mask policy during flight.

996070

201202

1201-1800

0.0

No Aircraft

Company

Air Carrier

Dispatcher

Dispatch Dispatcher

Other / Unknown; Training / Qualification

996070

No Specific Anomaly Occurred All Types

N

Person Dispatch

Other After the fact

General None Reported / Taken

Company Policy; Procedure

Company Policy

[Dispatch manager stated that his] records show [that I] planned a large amount of additional taxi fuel and [that I should] remember the impact of the cost to carry this fuel over the period of a year. [He asked that I] immediately reconsider this practice as it is very apparent that for the majority of operations this fuel is not needed...when there are no anticipated delays. [I consider this] bullying; intimidation; offensive and insulting commentary directed at a specific individual a possible FAR Part 121.533 violation.

Dispatcher who was personally cited by his Mangager for purported excessive fuel loading; felt that such intimidation might be in violation of FAR 121.533.

1591526

201811

0601-1200

ZZZ.Airport

US

0.0

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Parked

Facility X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Boarding

Communication Breakdown

Party1 Flight Attendant; Party2 Other

1591526

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

Y

Person Flight Attendant

Aircraft In Service At Gate

General Work Refused

Human Factors; Procedure

Procedure

Flight began boarding when a passenger entering main cabin made an attempt to stow a carry-on in the overhead and apparently injured himself. The injury in turn caused a [large] amount of bleeding of which was spread out in the cabin; cabin seating (several) overhead bins; galley floor and passenger bag that he then removed from bin as it didn't fit. Passenger upon proceeding to bring Flight Attendant item what notified by numerous passenger that he was now bleeding all over the area and passengers. Unaware of the chaos and what all the screaming was directed at I extended my hand to take item just as passengers screamed to me not to touch the bag as he had bleed all over it. It was too late. I looked down and the item was covered with this individual's blood. I was made aware of visibly obvious tainted areas. I reported to crew that we had biohazard in the cabin/galley area and that I had been exposed to someone's blood. I need to be seen by a medic as I realized a little later in the incident that I had two small recent cuts on both hands. We took actions to contact who we thought to be a HAZMAT team. To which became an epic fail as the procedure to handle a HAZMAT such blood per ZZZ airport standards is a joke. Or the manner in which this was attempted to resolve was not safe/healthy and considerate of the passengers; crew or rescue/cleaning team. Initially two young men arrived. One wearing a latex like glove the other I did not see have any protective gear on. I bottle with the resemblance of a body splash was sprayed on the galley floor with passengers still on board. The team used standard paper towels and proceeded to clean the entire galley floor with this solution. The procedure and product was questioned as this did not seem to be a safe and sure manner to handle a blood HAZMAT issue. I request for a head supervisor was called at this point and I had made proper contact with my inflight supervisor to whom was enroute to the aircraft. A HAZMAT supervisor did arrive with another solution that to my understanding said it was to clean bodily fluids such as vomit...etc. This solution was sprayed and again wiped across the galley floor again with passengers on board. They wiped the floor with the same paper towels but the proceeded to wipe down the beverage cart and the galley counter with this same exact bunch of paper towels they had cleaned the floor with. I haven't been in health and safety ever and it's been a while since food and beverage was near my title; but I for self; know this was so wrong on so many levels. A better action; reaction and procedure has to be formulated for those exposed to a blood HAZMAT. Not only that but the procedure at the airport clinic raises a brow as the doctor basically told me that there was not much to do unless I had any open wounds no real protocol to access me. It is my understanding that this passenger again had another bleeding episode and passengers informed gate and crew after I left to be seen. I was given alcohol wipes to see if I had an open wound that would burn if exposed and advised to get a hepatitis shot. I will be contacting my personal General Practitioner to move forward with my care in ZZZ1. I will keep company/union abreast. This total ordeal is inexcusable and very concerning.

CRJ-200 Flight Attendant reported a breakdown of procedures by airport medical personnel attempting to handle BioHazard fluid from a passenger injury.

1277460

201507

1201-1800

EWR.Airport

NJ

0.0

VMC

Daylight

Ground EWR; Tower EWR

Air Carrier

B737-700

2.0

Part 121

IFR

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Last 90 Days 199

Confusion; Distraction

1277460

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Last 90 Days 183

Workload; Distraction; Situational Awareness

1277462.0

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

Person Air Traffic Control

Taxi

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

Airport; Human Factors; Procedure

Human Factors

ATIS was showing the departures on Runway 22R at W. I reviewed the ramp and taxi procedures at the unfamiliar airport. I had Ramp Control on radio number two. Ground Control on radio number one. After pushback and starting one engine for a single engine taxi; Ramp Control cleared us to [pushback];contact Ground Control.Ground Control cleared us to taxi via B; hold short of G; and to call clearance for a reroute. While holding short of taxiway G; Ground Control said they had to move us and asked how long it would be until we got our clearance. We were receiving it then. Ground Control asked us to move along B and join S where; if we needed; we could stop to reprogram our computers.The First Officer (FO) reported that he would be heads down. He reprogrammed the FMC and started the other engine. We didn't stop; but we taxied very slowly on Taxiway S and we told Ground Control we could continue. We were cleared Taxiway K then R to the runway. The FO reported heads down again to check the FMC. Approaching Runway 11-29; we turned our external lights on; cleared left and right and crossed the runway. Ground Control started to say something then said contact Tower. As we approached the hold line of Runway 22R; Tower asked if we were up and we asked him to standby. We completed our route review and checklists then told him we were ready to go. He explained about 'the hotspot' where we were and how our taxi route encroached upon the runway then cleared us for takeoff; full length Runway 22R. Confused at first; we realize we had missed Taxiway W; the ATIS reported departure point.Stop the aircraft; set the brakes; and wind the clock. Program; brief; checklist. Take a big deep breath then proceed. I do not remember a specific clearance to Runway 22R at Whiskey. We were task saturated.

Our inbound aircraft arrived late. We were rushing to catch up. Our initial taxi out instructions were taxi to Runway 22R via [Taxiway] B; hold short of G. We taxied out single engine. On B holding short of G; Ground advised us to call Clearance on a separate radio for a new route clearance. At this time; we divided duties. The Captain remained with Ground Control and I switched over to Clearance on the second radio. Shortly after receiving the new clearance; the Captain said that ATC had us number one for departure and was wondering if we'd be ready. I replied that I had the clearance but still had yet to input it into the box and that if we were going to be ready we'd have to start the other engine shortly. At that point I began rushing to input the new route into the box. Ground must have given us a revised taxi route to get us out of the way and then given us a second clearance to Runway 22R. I don't know what the taxi instructions were because I was heads down modifying the flight plan and the Captain was talking with Ground. As soon as the flight plan was in the box; I finished starting the second engine. When I had everything finished; I looked up and saw we were approaching a crossing runway and I asked the Captain if we had clearance to cross the runway. He said we had been cleared all the way to 22R. On the other side we held short of 22R and followed procedure by stopping the aircraft and reviewing all changes to the flight plan and clearances and running the Departure Checklists. Tower tried to talk to us but the Captain responded with a 'standby'. Once we had double-checked everything; and finished the checklists we talked to Tower. Tower mentioned something to us about hotspot area with the intersecting runway near W. It was then we realized that they normally depart 22R at W (something I overlooked on ATIS due to rushing) and that we'd crossed Runway 11-29 for a full length take off. I am embarrassed to say that we committed so many classic aviation errors that we all know (from experience) not to do. First of all; read the ATIS information in its entirety instead of skimming it to fill in the boxes on the ATIS card. Second; do not rush. There is no need to put added pressure by rushing and increasing the likelihood of mistakes. Also; never completely divide the flight deck into each Pilot separately performing different duties while not really aware of what the other person was doing. I wish I would have taken a break from inputting information into the box and reviewed the new taxi instructions and gone heads up; especially at a complex; busy; unfamiliar airport like Newark. I honestly wish I would have listened for; or that at least we would've reviewed each new taxi clearance given.

B737 flight crew departing EWR reports a runway incursion during taxi to Runway 22R. ATIS had stated that Runway 22R at W was the departure runway and the crew planned accordingly. However; during taxi out the crew is told to contact clearance for a revised route. The First Officer is fully occupied as the Captain continues to taxi to Runway 22R. The initial clearance was to Runway 22R at W; which was forgotten during the complicated taxi and reroute; and Runway 11/29 is crossed without clearance.

1365146

201606

0601-1200

HOU.Airport

TX

9000.0

Mixed

Daylight

TRACON I90

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

FMS Or FMC

Descent

Class B HOU

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 203; Flight Crew Type 5000

Communication Breakdown

Party1 Flight Crew; Party2 ATC

1365146

ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Human Factors; Procedure

Human Factors

We were cleared to descend via the BAYYY2 RNAV STAR; then they turned the airport around from landing on 12R to now landing 30L and we were given a different STAR to fly. Moments later; before we could even finish programming this change; they changed our STAR again; this time to the PUCKS 2RNAV STAR with the clearance of descend via (meaning 6000 feet MSL). Now we were way high and fast and trying to get down to comply. These multiple changes in our clearances and turning the airport around led to more reprogramming and more briefings. At approximately 9000 feet; the Controller asked us; 'What altitude are you descending to?' I replied; 'We are descending via the PUCKS2; down to 6000 feet as we were cleared.' She replied; 'No...I believe I cleared you to only descend to 11;000 feet.' So I told her; 'If you did; we never heard that and certainly did not reply to that radio call.' As you can imagine there was a lot going on with attempting to update the ATIS to determine what was happening at HOU; updating ATIS; reprogramming the FMC twice; and new briefings; but we (the two pilots) both looked at each other and said; we never heard that. Then the Controller said; 'Just descend to 6000''; so we did.In my general aviation flying; my military flying; and other airline flying; we were always taught whenever you hear a Controller speak; all briefings and talking stops and listen. That is not our policy and it should be. Also; a Controller knows when they tell a Crew something; if the Crew does not respond back acknowledging this clearance; they did not hear it (regardless why they didn't hear it) and therefore they will not be complying. We can't comply with what we didn't hear.

B737 First Officer reported overshooting an altitude clearance they never acknowledged in descent following multiple STAR clearance changes.

1700894

201911

0601-1200

TEB.Airport

NJ

1500.0

VMC

Daylight

TRACON N90; Tower TEB

Personal

Small Aircraft

Part 91

IFR

Personal

GPS

Final Approach

Class D TEB

TRACON N90

Medium Transport

IFR

Final Approach

Class D TEB

Facility N90.TRACON

Government

Approach

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 1.0

Confusion; Situational Awareness; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1700894

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Instrument

Flight Crew Last 90 Days 132; Flight Crew Total 2107; Flight Crew Type 1330

Situational Awareness; Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1701167.0

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

Person Air Traffic Control; Person Flight Crew

In-flight

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

Airspace Structure; Procedure; Human Factors

Human Factors

Aircraft X was cleared for ILS 6 approach to TEB. Shortly after; I noticed him go through the localizer and called the Tower to give instructions to rejoin approach. At the same time I received a low altitude alert and told the Tower. I called Tower to alert them because it appeared to me he might be heading toward their airport. Shortly after it appeared he was turning west bound towards Aircraft Y and at some point I heard the Tower say over the shout line that he wasn't following instructions. I turned Aircraft Y northwest to try to get away from Aircraft X. To me it looked like Aircraft X was headed right at Aircraft Y so I climbed Aircraft Y to 3;000 feet since I told Tower to have Aircraft X climb to 2;000 feet. This vector brought Aircraft Y into conflict with Aircraft Z. Once it appeared Aircraft Y and Aircraft X were no longer a factor I turned Aircraft Y back to a 340 heading away from Aircraft Z. Separation was re-established between all Aircraft and they were re-sequenced to the airport.If Aircraft X had flown the approach as cleared or been issued the 030 heading to rejoin that I initially issued to the Tower; this would have never happened. I was worried about Aircraft Y and Aircraft X hitting which caused me to turn Aircraft Y into Aircraft Z. In hindsight I could have probably used less of a turn for Aircraft Y so that I would have at least had divergence with Aircraft Z; but at the time was more concerned about Aircraft Y and Aircraft X actually hitting that the loss of separation with Aircraft Z seemed less critical so I can't say I wouldn't do the same thing in the future. As I discussed with my supervisor after the incident the one thing I would do differently is not ship Aircraft X to the Tower so soon. It may not have prevented the incident but may have helped make it easier to control if I didn't have to coordinate with the Tower and was directly talking to the aircraft.

I was cleared for the approach for Runway 06 in TEB. I had the incorrect localizer frequency in my GPS and thought I had the airport visually but saw the incorrect airport. I was given a heading to hold and a new altitude. I followed air traffic's new headings and altitudes and realized the wrong frequency was in. I put the correct frequency in and was re-cleared for the approach. During this there was a near miss and another aircraft had to circle to re-shoot his approach. When I landed; Tower asked me to call the TRACON which I did and a report was filed for this incident. It was VFR conditions and I should have double checked frequency before thinking I had the field since there are so many airports close by TEB.

N90 TRACON Controller and pilot reported the pilot flew through approach course and towards another aircraft before pilot was reoriented and communications restored.

1466533

201707

0601-1200

ZLC.ARTCC

UT

7500.0

VMC

Daylight

Center ZLC

Personal

Small Aircraft; High Wing; 1 Eng; Retractable Gear

1.0

Part 91

IFR

Personal

Climb

Direct

Class E ZLC

Any Unknown or Unlisted Aircraft Manufacturer

Class E ZLC

Facility ZLC.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 7.8

Distraction; Situational Awareness

1466533

Conflict NMAC

Person Flight Crew

In-flight

ATC Equipment / Nav Facility / Buildings; Airspace Structure

ATC Equipment / Nav Facility / Buildings

Aircraft X called on ground at RIW looking for an IFR clearance to ZZZ. Advised aircraft that there was no flight plan on file but would file it for him. Aircraft X gave the flight info; requested routing; requested altitude; etc. I then issued Aircraft X an IFR clearance. In the area of RIW there is poor to no radar coverage below 12000 ft MSL. Aircraft X checked on after departure climbing to 16000 ft. Because Aircraft X was ADSB equipped I was able to radar identify the aircraft out of 7000 and went on with other duties. A couple minutes later; the pilot of Aircraft X broadcast that he had just had a near miss with another aircraft about 500 ft from him. There were no other targets in the area due to the lack of radar coverage so there was no way to call any traffic to him. Aircraft X happened to be on my scope because he has ADSB onboard.

ZLC Center Controller reported that an aircraft reported a NMAC with another aircraft in an area of poor radar coverage.

1776907

202012

1201-1800

ZZZ.Airport

US

0.0

Air Carrier

Medium Large Transport

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

First Officer; Pilot Not Flying

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

Confusion; Training / Qualification

1776907

Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Overcame Equipment Problem

Chart Or Publication; Company Policy; Human Factors; Procedure

Chart Or Publication

The Captain and I met at the airplane in the morning and the first topic of discussion was the automated parking guidance procedure as neither of us had used the system yet and they appeared to be operating. We referenced the flight manual as well as the local notes concerning the system and still felt that we were not sure exactly what we were supposed to do approaching the gate. We asked rampers prior to departing and their explanation; which did not help much. We departed and further discussed our plan for approaching the gate in our briefing for the return leg. As we approached the gate 3 rampers were present and the guidance panel worked well and was intuitive. We found a Ramp Supervisor and he discussed the details with us and answered questions we had. The guidance in the flight manual is inadequate as it does not address definitively whether or not marshallers are required to be at the spot. It does not specify the procedure for requesting assistance from ramp personnel if required It does not address what to do in the event that equipment is in the safety zone. Finally; the guidance as to when the screen symbology is required references 'the nose of the aircraft passing the jet bridge' which does not apply to the Aircraft X in where the system is active. My interpretation and common sense answers to these questions are likely to create a safe operation but safe and compliant are not always the same thing. We entered the gate area in compliance with the flight manual to the best of my knowledge and interpretation; however I feel that the guidance in the manual was inadequate. Part of the information we used to determine a plan for parking came from talking with rampers. They obviously have good insight but their word does not meet acceptable standards for determining compliance with a procedure. I would recommend a simple update to the manual that goes beyond description of the guidance panel and sets definitive procedures for entering the gate.

Air carrier pilot recommends changes to flight manual guidance concerning operations using the automated parking guidance system.

1087073

201305

1201-1800

ZZZ.Airport

US

0.0

VMC

Daylight

Ramp ZZZ

Personal

PA-28 Cherokee/Archer/Dakota/Pillan/Warrior

1.0

Part 91

IFR

Personal

Parked

Parking Brake

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 15; Flight Crew Total 530; Flight Crew Type 340

Human-Machine Interface; Distraction

1087073

Aircraft Equipment Problem Less Severe; Conflict Ground Conflict; Critical; Inflight Event / Encounter Loss Of Aircraft Control

Horizontal 5

Person Flight Crew

Taxi

Flight Crew Regained Aircraft Control; Flight Crew Took Evasive Action

Aircraft; Human Factors

Aircraft

After starting the engine and setting the parking brake; I noticed that my seat was too low and attempted to raise the seat. This required trying to lift my weight off the seat and at the same time activating the seat adjustment knob. While I was doing this; I felt a forward motion and looked up to see the aircraft rolling at a quick walk to a slow jog toward another aircraft parked on the ramp. I quickly applied the brakes and noticed the right wing tip narrowly missed another parked aircraft on the ramp. I previously positioned my aircraft to clear this one; but to clear the second aircraft would require turning the plane while taxiing. Since I couldn't be sure of the clearance I had with the second aircraft (having rolled past where I would have started the turn); I elected to shut down and manually reposition the aircraft. Two lessons learned. First; what we are all taught during primary; to not trust the parking brakes in light GA aircraft is true. They are not reliable enough to let your guard down. Second; while I thought I was minimizing my risks by doing necessary head down work while stopped; in reality it had never occurred to me that the aircraft might roll forward on a crowded ramp without my knowing. Next time; I will do as much work as I can prior to engine start; and leave any remaining tasks to the run-up area. The risk is forgetting to do these tasks later; but a sticky note or equivalent would solve that issue.

PA28 pilot reports starting his engine and setting the parking brake to discover the seat height needs adjustment. While head down making the adjustment aircraft movement is detected and the brakes are quickly applied. The aircraft narrowly misses two aircraft parked on the ramp during the undetected movement.

1428052

201702

1201-1800

ZZZ.Airport

US

0.0

VMC

10

Daylight

Tower ZZZ

FBO

Trinidad TB-21

2.0

Part 91

None

Training

Landing

Visual Approach

Landing Gear

X

Improperly Operated

Aircraft X

Flight Deck

Personal

Pilot Flying

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

Flight Crew Last 90 Days 250; Flight Crew Total 1002; Flight Crew Type 20

Confusion; Training / Qualification

1428052

Aircraft X

Flight Deck

Personal

Pilot Not Flying; Trainee

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

Flight Crew Last 90 Days 33; Flight Crew Total 3440; Flight Crew Type 204

Training / Qualification; Distraction

1429352.0

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Gear Up Landing

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Aircraft Aircraft Damaged

Human Factors

Misinterpreted gear horn for a stuck stall horn. Had not heard the gear up horn before while being checked out in flight. I have experienced a stuck stall horn before due to turbulence in a similar aircraft and assumed it was the same thing. Contributing factors included exchange of controls on base and before landing check. What can be done to prevent a recurrence is further training in unfamiliar aircraft and learning all systems more thoroughly before flight. Also; exchanging controls earlier on before landing; downwind for example; and increased frequency and quantity of before landing checks.

I am in the Professional Pilot Program and this was my first flight in this aircraft. There was a commercially produced checklist for the aircraft; not the standard checklist and I was trying to utilize the checklist on preflight; engine start; and before takeoff but the CFI was rushing or complacent through those checklists and missing items that needed to be checked; I caught some of the missed items. I had been conducting all aircraft control from taxi until the base leg. On the base leg the instructor took control of the aircraft to demonstrate a landing in this particular aircraft. On the final leg of the traffic pattern there was a tone in our headsets and the instructor asked me what the tone was and I replied that I didn't know. The instructor said it sounded like the stall warning; which I had only heard on preflight and while doing slow flight. I told him that we were above stall speed. In this aircraft I had not heard the gear up audio tone. I was listening to the instructor demonstrate and verbalize the maneuver and I didn't realize that the before landing check hadn't been completed. The instructor continued to talk through the landing all the way to the ground with the landing gear up. As we were sliding on the runway I retarded the mixture to cut off; the prop to low RPM and the throttle to idle. I turned off the magnetos and removed the key and turned off the fuel boost pump. The instructor was extremely surprised as to what was happening and took little action. All of the training that I have been through; if you are on the flight controls that individual is responsible for the radios and the checklists. I was not on the flight controls.

TB 21 instructor with a licensed trainee reported a gear up landing with the instructor at the controls. This was the first flight in this type aircraft for the trainee and the instructor interpreted a gear warning horn as a faulty stall warning indication.

1835128

202108

0601-1200

ZZZ.Airport

US

500.0

VMC

Daylight

CTAF ZZZ

Personal

Small Aircraft; High Wing; 1 Eng; Fixed Gear

2.0

Part 91

None

Passenger

Final Approach

Visual Approach

Class G ZZZ1

CTAF ZZZ

Personal

Light Transport; Low Wing; 2 Turboprop Eng

1.0

Part 91

Takeoff / Launch

Other taking off

Class G ZZZ1

Aircraft X

Flight Deck

Personal

Pilot Not Flying

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

Flight Crew Last 90 Days 180; Flight Crew Total 14000; Flight Crew Type 1000

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1835128

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

Horizontal 500; Vertical 0

N

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors; Procedure

Procedure

I am a pilot who hasn't flown GA in XY+ years. I hired this pilot to re-familiarize me in the GA world. Instructor is very capable and in my opinion did nothing incorrectly. We had been doing touch and go's at ZZZ1 airport; and we were returning to ZZZ to land. The runway being used was XX. The instructor was flying back and made all the required calls on the Unicom frequency. I was in the left seat; watching instructor fly and listening to instructor speak on the radio. I saw a plane turn toward us as instructor started to make base turn and I told instructor to roll out and stay downwind. Instructor lifted wing and saw the traffic coming right at us. He had taken off on Runway YY. He never made any calls. He was turning upwind when we were turning base. He finally saw us and passed behind us. He made a comment on the radio; admitting to making 'a huge mistake' and apologized for it. The runway in use was definitely XX with a 10 kt head wind. I shudder to think what would have happened if I hadn't seen him.

Pilot reported taking evasive action to avoid a collision with another aircraft that failed to follow established departure procedures.

1855230

202111

1801-2400

ZZZ.TRACON

US

16000.0

VMC

Night

TRACON ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Climb

Vectors

Class B ZZZ

Fuel Quantity-Pressure Indication

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Flight Crew Last 90 Days 120; Flight Crew Total 4500; Flight Crew Type 330

Troubleshooting

1855230

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

N

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Landed in Emergency Condition; Flight Crew Overcame Equipment Problem; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Departure Airport; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; Human Factors

Aircraft

It was my leg to fly and everything was standard and uneventful through takeoff and departure; our fuel indicated 23.8k before departing. We had fuel in the center tank and both center pumps were on. On climbout; the Captain noticed a slight fuel imbalance; with the right tank lower; and shortly after that the 'fuel imbalance' annunciator light turned on. We were climbing through about 16000 ft. when we started troubleshooting the issue. It appeared by the totalizer and right tank quantity indicators that we were either burning fuel from the right tank or had a fuel leak from the right wing or engine.As we climbed the imbalance worsened as the totalizer also indicated higher fuel loss than expected. The imbalance worsened to about 1500 lbs; and we attempted to balance the tanks by transferring fuel from left to right. The increase in fuel imbalance was abated using this method; and it also started to reduce the imbalance.We ran the QRH checklist for a potential fuel leak; deciding not to shut down the right engine to expedite the divert and due to our heavy weight; suspecting that would be less safe than keeping it running. We requested priority handling and returned to ZZZ via vectors to a visual approach Runway XX; with the ILS used as a backup.It was night and the weather was VFR. Upon an uneventful landing I utilized the left engine thrust reverser and we stopped on the runway and shutdown the right engine as a precaution. Emergency vehicles met the airplane to inspect the right wing and engine; nothing noteworthy was discovered. We taxied to the gate and shutdown the left engine; non-normal complete.CRM between myself and the Captain was excellent throughout the flight. The Captain read all non-normal checklist aloud and asked if I had any inputs or questions when appropriate. The demeanor in the cockpit was professional; calm; and business-like at all times as we worked our way through solving the problem and executing a divert back to ZZZ. The decision not to shut down the right engine was discussed at length and we both concluded that due to cockpit indications and our heavyweight the best course of action was to land immediately and shut it down on the runway. In retrospect this proved to be the correct call after maintenance personnel discovered multiple faults with the fuel totalizer and both wing compensators causing major fuel system instrument irregularities; and in fact no fuel leak was present.

B737 Captain reported an air turn back after a fuel imbalance was detected during climbout.

1816033

202106

1201-1800

ZZZ.Airport

US

14000.0

Daylight

Center ZZZ1

Fractional

Challenger Jet Undifferentiated or Other Model

2.0

Part 135

IFR

Passenger

Descent

Other Instrument Approach

Class E ZZZ1

Aircraft X; Facility ZZZ1

Government

Enroute

Air Traffic Control Fully Certified

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

Situational Awareness; Time Pressure

1816033

Aircraft X; Facility ZZZ1

Government

Handoff / Assist; Enroute

Air Traffic Control Fully Certified

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

Time Pressure; Workload

1816035.0

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

Automation Air Traffic Control; Person Air Traffic Control

In-flight

General None Reported / Taken

Environment - Non Weather Related; Human Factors; Procedure; Airspace Structure

Airspace Structure

I was working a Radar Sector with a Radar Associate controller. I was informed prior to the event that I would be very busy and over numbers for the sector. I was working multiple; 8 plus IFR arrivals into ZZZ using the ILS approach. The volume and complexity of arrivals/departures/and overflights in the sector was high. After an initial descent; I had cleared Aircraft X to cross ZZZ1 at or above 14;000 ft. and cleared him for the ILS approach. I inadvertently issued this clearance in a 14;600 ft. MIA (Minimum IFR Altitude) area. Once my Associate Controller alerted me to the MSAW (Minimum Safe Altitude Warning) alert; the aircraft was already exiting the 14;600 ft. MIA; and as a result I did not issue a low altitude safety alert. The aircraft continued on the approach. ZZZ has shown a pattern of having very high peak demand in respect to arrivals. These spikes in demand are usually left up to the Radar Controller to take care of with little outside assistance from the Center TMU (Traffic Management Unit). This has resulted in numerous errors and other safety events as the Radar Controller is saturated. This high workload is also due in part to multiple transmitters for overflights and ZZZ arrivals and high terrain around ZZZ. I would suggest that preemptive procedures be developed for times that ZZZ is experiencing peak demand. Another possible long-term solution would be the stratification of Sectors into a high/low configuration so as to reduce the added complexity of overflight traffic. Frankly; with the volume ZZZ sees on a daily basis; especially in peak seasons; I am surprised it does not have an Approach Control.

I was working the Assistant Controller position dealing with communication with Tower and point outs with adjacent sectors. Aircraft X was level at 15;000 ft. above a 14;600 ft. MIA (Minimum IFR Altitude) area when the Radar Controller issued a crossing restriction and clearance to Aircraft X to cross the ZZZ VOR at or above 14;000 ft. and cleared the aircraft for the approach. The aircraft descended below the MIA to 14;000 ft. before the Radar Controller realized the low altitude. No low altitude alert was issued. Spacing from adjacent sectors for ZZZ arrivals. And rerouting aircraft not landing into the sector around the airspace assisting in lower work load on the Radar Controller. The job was doable.

Center Controllers reported the Radar Controller issued a descent clearance to an altitude below the Minimum IFR Altitude and did not notice it until the MSAW activated.

1683115

201909

0601-1200

ZZZ.Airport

US

0.0

VMC

Air Carrier

MD-11

2.0

Part 121

IFR

Cargo / Freight / Delivery

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Situational Awareness

1683115

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

Person Flight Crew

Pre-flight; Routine Inspection

General Work Refused

Equipment / Tooling; Incorrect / Not Installed / Unavailable Part

Equipment / Tooling

During inspection of DG Hazmat can; First Officer noticed fluid on floor of Hazmat can. Can was deemed not safe and removed from aircraft. [The cause was] human error or leaking package.

MD-11 flight crew reported Dangerous Goods container leaking fluid during preflight. Dangerous Goods removed from flight.

1641933

201905

0001-0600

BOS.Airport

MA

17000.0

Marginal

Turbulence

Daylight

TRACON A90

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Descent

Class B BOS

TRACON A90

Air Carrier

B767 Undifferentiated or Other Model

2.0

Part 121

IFR

Initial Approach

Class B BOS

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Flight Crew Total 2900; Flight Crew Type 670

Situational Awareness

1641933

Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Wake Vortex Encounter

Person Flight Crew

In-flight

Flight Crew Regained Aircraft Control; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Environment - Non Weather Related; Procedure

Environment - Non Weather Related

On the arrival between 21;000 feet and 17;000 feet and 280 knots encountered severe turbulence in smooth air with no warning. Auto pilot kicked off and sudden bank to the right followed by oscillation in bank angle.On the descent starting around 21;000 feet; the aircraft rolled suddenly and hard right 30 to 50 degrees of bank and then oscillated left and right 30 to 40 degrees of bank. Auto pilot kicked off and both Pilot Flying and Pilot Monitoring had to be on the controls to regain stability. No loss of altitude other than what was planned since we were on the descent at about 2300 fpm. Took manual control of aircraft after event started and auto pilot kicked off. Slowed aircraft to 250 and shallowed descent. Captain immediately checked on Flight Attendant and passengers after event occurred and everyone was okay and seated. Seat belt sign was on at the time the event started.After event; ATC informed us we were following a 767 which was around 10 miles in front of us with a 40 knot tail wind in the descent and no other turbulence in the area; I believe it was wake turbulence.

EMB-145 First Officer reported encountering severe wake turbulence on arrival into BOS in trail of a H/B767.

1717952

202001

0601-1200

ZZZ.Airport

US

100.0

VMC

Daylight

Tower ZZZ

Personal

Small Aircraft

2.0

Part 91

VFR

Training

Takeoff / Launch

Class D ZZZ

Cockpit Canopy Window

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Multiengine; Flight Crew Commercial; Flight Crew Instrument

Flight Crew Last 90 Days 100; Flight Crew Total 5500; Flight Crew Type 400

1717952

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport

Aircraft

Day VFR conditions. Approximately 45F; Winds 310@10. Start and taxi were normal. Crew closed and locked canopies in the chocks at start up due to cold wind. After an uneventful run-up crew performed a normal Verbal and Visual confirmation 'Two canopies down and locked; Lights Out.' Aircraft is equipped with canopy lights (Front and center on this aircraft panel on their own and extinguished at that time). Rear crewmember also did two elbow taps outward to confirm a good locked canopy as he always does per his habit. Performed a normal takeoff.After airborne and about midfield over the left Runway; PIC noted a loud bang; rush of wind; and a red light illuminate for rear canopy. Aircraft configuration was left in T/O configuration and PIC continued straight ahead to assess status of rear aircrew (whose headset came off). Requested a 'low closed pattern' for an early return; Tower approved that and asked if we needed assistance and I said 'standby.' During low closed pattern; visually checked the aircraft and observed missing rear canopy plexiglass section and no obvious damage. Advised Tower that there would be 'canopy plexiglass' in the vicinity of the left Runway. Requested and was cleared to land on the right Runway. Flew final at 85 to 90 kts until landing assured due to unknown airflow effects. After clearing runway; another visual check was performed and no damage was observed. Recommend owners of Romanian IR23 Aircraft consider installing additional pins to hold these custom built canopies shut.

IR23 pilot reported that a section of the aircraft's plexiglass canopy detached while departing the runway. An air return and uneventful landing were made.

1709348

201912

0601-1200

MCO.Airport

FL

185.0

1.0

1800.0

VMC

Daylight

Tower MCO

Air Carrier

Commercial Fixed Wing

2.0

Part 129

IFR

Passenger

Final Approach

Visual Approach

Class B MCO

Personal

UAV - Unpiloted Aerial Vehicle

Final Approach

Class B MCO

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 80; Flight Crew Total 15000; Flight Crew Type 12000

1709348

Conflict NMAC

Horizontal 165; Vertical 0

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

During final app on visual app to Runway 36L in MCO about 1;800 feet MSL and about 5 to 6 miles of landing runway; we encounter a drone on our same altitude and approximately as close as 50 meters; in our right side and apparently flying hover flight. At the same time we identify the drone suddenly it descended and disappeared from our sight.

Air carrier flight crew reported that while inbound on a visual approach; a small drone was hovering at the same altitude within about 65 feet.

1836220

202109

1201-1800

ASE.TRACON

CO

12200.0

VMC

TRACON ASE

Any Unknown or Unlisted Aircraft Manufacturer

1.0

Part 91

VFR

Personal

Climb

None

Class E ASE

TRACON ASE

Air Taxi

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

Part 135

IFR

Passenger

Climb

Class E ASE

Aircraft X; Facility ASE.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Communication Breakdown; Human-Machine Interface

Party1 ATC; Party2 Flight Crew

1836220

Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter CFTT / CFIT

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

In-flight

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

Airspace Structure; Procedure; Human Factors

Airspace Structure

Additional documentation for Aspen's need for Class C [Airspace]. Aircraft Y was departing; a VFR (Aircraft X); not talking to ATC; flew into the departure corridor; climbing. Aircraft Y wasn't able to turn because of the mountains; was flying through a 12;100 foot MVA (Minimum Vectoring Altitude); was given a traffic alert. The VFR (Aircraft X) was at 12;200 feet; climbing; Aircraft Y got an RA and descended from 12;100 feet back into high terrain to 11;700 feet to avoid. Had ATC been talking to the VFR (Aircraft X); they would have been able to turn Aircraft Y away from the conflict. Aspen needs Class C Airspace to require VFR aircraft flying through arrival and departure areas are talking to ATC.

ASE TRACON Controller reported a Traffic Conflict in Aspen airspace and recommends a change to Class C for the airport to avoid future similar conflicts.

1446386

201705

ZZZ.ARTCC

US

Turbulence

Center ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Service

Situational Awareness

1446386

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

Person Flight Attendant

In-flight

General Physical Injury / Incapacitation

Procedure; Weather

Weather

While working the galley; the seat belt sign came on; but we continued service. Turbulence was light. We were handing out water and ice cream; and also picking up from the A zone aft. Suddenly the aircraft severely dropped. I was lifted completely off my feet and hit the ceiling in the aft galley and then was just as quickly slammed back to my feet and the floor. I kind of crumpled down. Five flight attendants were on the floor plus one passenger. Two crew grabbed jumpsuits; but there are only two jumpsuits in the back. A flight attendant who was back helping also sat on the floor in front of the 4L lavatory. Eventually it smoothed out; but I was feeling back pain. I tried to file the claim while on layover; but the phone number and all 'links' to this page would not load overseas.

A Flight Attendant reported that during some light turbulence the aircraft suddenly dropped injuring a Flight Attendant.

1027289

201208

1201-1800

TEB.Airport

NJ

2000.0

VMC

8

Daylight

TRACON N90

Air Taxi

Eclipse 500

1.0

Part 135

IFR

Passenger

Initial Climb

SID RUUDY

Class B EWR; Class D TEB

FMS/FMC

X

Design; Improperly Operated

Aircraft X

Flight Deck

Air Taxi

Single Pilot

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

Flight Crew Last 90 Days 20; Flight Crew Total 3500; Flight Crew Type 1500

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

1027289

Conflict Airborne Conflict; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew FLC complied w / Automation / Advisory

Aircraft; Procedure; Human Factors

Human Factors

Apparently the waypoints for the departure procedure were not loaded into the flight plan by the FMS although the SID was selected and loaded. I did overlook the fact that the waypoints on the departure were missing from the FMS sequence even though I did compare the waypoints that were loaded into the FMS with the ones on my NAV Log. The obvious reason I missed it was because I had not filed the departure electronically but was assigned to it by Clearance Delivery so they were not on the NAV log and when I was comparing everything matched. When I loaded the departure procedure in the FMS now that I think about it; the waypoint list said 'discontinuity' after the departure airport in the sequence. This is not abnormal but usually means that the departure or arrival procedure is simply radar vectors to a fix. As I briefed myself on the departure procedure prior to leaving an hour later it did not occur to me that I was missing the waypoints. I just knew that I had the correct departure procedure loaded and I was just thinking that the FMS would sequence through the appropriate waypoints as usual. The main thing that I was focusing on was the two altitude restrictions on the SID; making sure that I had the altitudes memorized and ready to execute them correctly. The first was to cross WENTZ at 1;500 and then to cross TASCA at 2;000. I was also aware that these fixes were fairly close to the airport and close together. After executing the takeoff and climbing out safely I transitioned to navigating the departure procedure. I selected my command bars to navigate and started tracking the course depicted on the SID. I made sure that I got to 1;500 FT but when I did not see WENTZ on my map or flight plan sequence I assumed that I must have just passed it as I knew it was close to the airport and immediately after the climb and turn. Having thought I was behind and passed the waypoint I immediately began a climb to 2;000 as to not miss the next altitude restriction. As I was leveling out I realized that the next waypoint on the SID did not match the one that I was attempting to navigate too and I realized that I was situationally unaware and could be at the wrong altitude. Almost immediately the Controller was contacting me (after not answering my initial check in moments earlier) and issuing me a command to turn to a new heading in order to avoid traffic and informed me where I was in relation to the assigned course. The cause of this deviation was due to my improper brief of the departure procedure and most likely the acceptance of a departure procedure that my FMS may not be capable of. It is also my belief that the departure procedure should not be able to be selected and loaded into the FMS flight plan sequence if it does not include the appropriate waypoints for the procedure. This is not typical of my flying. I consider myself a very safe and thorough pilot. With 10 years of professional flying experience I have never had another deviation. I have reviewed the procedure and the chain of events leading up to this situation and I will certainly learn from it. I believe this will make me a better pilot and especially more aware of little things that any amount of complacency may bring about.

An EA50 pilot was assigned the TEB RUUDY 4 RNAV Departure which was different from his filed SID and subsequently he missed the waypoint constraints because the FMS did not load the SID.

1041713

201210

1801-2400

GFK.Airport

ND

2100.0

Tower GFK

Skyhawk 172/Cutlass 172

2.0

IFR

Initial Climb

Vectors

Class E GFK

Tower GFK

Skyhawk 172/Cutlass 172

2.0

IFR

Initial Climb

Vectors

Class E GFK

Facility GFK.Tower

Government

Departure; Approach

Air Traffic Control Fully Certified

Situational Awareness

1041713

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance

Person Air Traffic Control

General None Reported / Taken

Company Policy; Human Factors

Company Policy

Cessna 172 X was issued a 080 heading and he read it back right. I watched him turn. When Cessna 172 Y reached the same point as where Cessna 172 X turned; I turned Cessna 172 Y to a 060 heading. There should have been 20 degrees of divergence between them; and Cessna 172 Y should have been north of Cessna 172 X. However; Cessna 172 X apparently wasn't on a 080 heading as what it looked like and what he read back when I looked out the window again. I'm guessing he must have been on a 060 heading. He started turning further south and then I took action to turn Cessna 172 Y to a 120 degree heading and I provided visual separation as I told Approach Control to turn Cessna 172 X out to the northeast. The pilot did not have has directional gyro set right; can't read; can't listen; or all of the above. They did get separated; but I'm tired of these student pilots with new instructors constantly doing stuff like this. They are a danger to themselves and the flying public at large. [We] should stress harder to pilots to comply with ATC as it is in their own best interests!

GFK Controller described a potential conflict event when a aviation training aircraft failed to comply with issued instructions.

1221963

201412

0601-1200

ZZZ.Airport

US

700.0

VMC

Daylight

Tower ZZZ

Fractional

Citation Excel (C560XL)

2.0

Part 91

Initial Approach

Class D ZZZ

Aircraft X

Flight Deck

Fractional

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Confusion; Fatigue

1221963

Conflict NMAC

Horizontal 0; Vertical 200

Automation Aircraft RA; Person Flight Crew

In-flight

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

Human Factors

At approximately 700 feet MSL while on final approach to runway 36 and after being cleared to land by the local controller; we both recognized at about the same time that there was a target on our TCAS display. It seemed to appear suddenly. Initially; we did not receive a Traffic Advisory (TA) or a Resolution Advisory (RA) associated with the target aircraft. I slowly arrested the descent as we both were trying to determine if the target was above us or below us. Because the target on the TCAS display was close to our aircraft icon symbol on the TCAS display; we could not determine if there was a plus or minus sign next to the vertical distance of the target. I gradually began a shallow climb while adding power. At approximately 900 feet MSL; we received an aural 'monitor vertical speed' TCAS alert. The VSI showed red below and a green arc above 0 VSI. At about the same time that we recognized the target on TCAS display; the controller asked the target aircraft what his position was and the pilot said that he was on final. So much concentration was being made by us to avoid collision that neither of us remember the exact dialog that the local controller was having with the target aircraft pilot. I think that I heard the local controller instruct the target aircraft pilot to turn to the east immediately and that he was told earlier to make a position report 4 miles from the airport. We executed a normal and uneventful landing after the second visual approach. Fatigue may have been a factor in my alertness and not recognizing this aircraft earlier on the TCAS display. I felt rested; but cumulative days of waking up at 2 and 3am body clock time; may have contributed to my alertness level. I think that management should factor in the time zones of the crew members when scheduling early flights especially for West Coast crews. Scheduled later starts/trips should be assigned at least every other or second day to avoid cumulative fatigue. Additionally; avionics manufactures that provide TCAS equipment that incorporate TA's and RA's; should be required to program this equipment to provide aural warnings all the way to the ground. We operate a lot in high impact traffic areas at smaller and often non-towered airports where this feature would be useful and could save lives.

CE560 Captain experiences a NMAC on short final during a day visual approach. An aircraft symbol was detected on TCAS in close proximity with no aural alert and a shallow climb is initiated. At 900 feet a TCAS RA is generated with any descent depicted as red and a go-around is initiated. A VFR aircraft that was told to report four miles; did not and was forgotten by the Tower.

1006272

201204

1801-2400

ZZZ.Airport

US

1000.0

VMC

Tower ZZZ

Air Carrier

A319

2.0

Part 121

Passenger

Takeoff / Launch

Class B ZZZ

Turbine Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 270; Flight Crew Total 21500; Flight Crew Type 3500

1006272

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Last 90 Days 150; Flight Crew Total 8800; Flight Crew Type 3000

1006282.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

With First Officer flying; shortly after takeoff we lost power on the right engine and then gained power. Engine was surging with no compressor stalls. We brought right engine to idle and declared an Emergency. We returned to a landing visually.

[Narrative #2 contained no additional information]

A319 flight crew experiences engine surging shortly after takeoff and returns to the departure airport with the engine at idle.

1245096

201412

0601-1200

PCT.TRACON

VA

2500.0

Clear; 10

Daylight

250

6000

TRACON PCT

Air Carrier

PA-31 Navajo/Chieftan/Mojave/T1040

2.0

Part 135

IFR

Passenger

Initial Climb

Vectors

Class G PCT

Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Single Pilot; Captain; Pilot Flying

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

Flight Crew Last 90 Days 150; Flight Crew Total 2421; Flight Crew Type 150

1245096

Aircraft Equipment Problem Critical; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

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

Aircraft; Human Factors

Ambiguous

I did an airplane swap with another company Pilot. I was given estimated fuel numbers from the other Captain when we did the weight and balance document together for accuracy. As the inner tanks had been topped off prior to arriving; I made the decision to fly the next leg using only the inner tanks.After doing the run up; I took off. Passing through 1;000 feet; the after take-off flow was executed and verified using the 'after take-off' checklist.Passing through 2;000 feet flying RWY heading; I was handed over to Approach and advised them of my altitude. I was then given a heading change to 350 degrees.When approaching 2;500 feet; left boost pump light illuminated and I leveled off momentarily. The left engine started searching and losing power. I moved the mixture; prop and throttle lever full forward and turned on the electrical fuel pump. Shortly after the right engine boost pump light illuminated and the right engine started losing power.I requested to ATC for a heading change towards the airport. ATC instructed me first to do a climb to 3;000 which I intended to do. ATC suggested twice a heading change away from airport which I declined. I requested the turn to be a right turn. ATC suggested a right turn to a heading of 150 degrees.After executing the turn; the power loss was so significant that I was unable to maintain altitude. I adjusted airspeed to maintain 107 knots (single engine best rate of climb speed).After completing the turn I was advised by ATC of an airport at my 3 o'clock. I located it at my 12 o'clock and ATC advised me it was [a nearby] airport. While descending towards the airport; ATC asked me to advise the nature of the situation. I advised that I was expecting dual engine failure with the indication of dual boost pump lights illuminated and that I was unable to hold altitude. I was cleared for a visual approach at [a nearby airport]. I read back the clearance and that was the last of recorded communication.I descended on a path that is similar to a left base. After clearing obstacle I made a turn toward runway. I lowered the gear and upon touch down on soft grass; left main and nose gear collapsed. The airplane skidded and turned 90 degrees to the left until the airplane came to a full stop.Upon full stop I quickly shut down the airplane and evacuated the aircraft. I did not have any injuries and there were no passengers onboard.

PA-31 pilot reported making a forced landing when he began having engine trouble related to fuel starvation.

1093749

201306

1801-2400

FCM.Airport

MN

2000.0

VMC

Daylight

Tower FCM

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

IFR

Personal

Initial Approach

Visual Approach

Class D FCM

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private; Flight Crew Instrument

Flight Crew Last 90 Days 45; Flight Crew Total 300; Flight Crew Type 175

Confusion; Situational Awareness; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1093749

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

Human Factors

I confused Runways 10L and 10R with Runways 28R and 28L; probably because of their close alignment with the direction from which I was approaching (I was arriving from the west; so runways 10L and 10R somehow seemed more appropriate even when told to expect 28L). After having confused the direction of the runways; being told to make a right midfield downwind for 28R made me think I needed to fly southeast bound to essentially come from the opposite direction toward what was really 10R. At this point I should have proceeded to query the Controller but flew southeast bound instead. After just a bit of flight to the southeast; the Controller told me to fly southeast for the downwind to 28L (I'm giving her the benefit of the doubt; but I was still thinking 10R and that she'd said 28R); confusing me further. Eventually after flying a left downwind for 28L; I asked if she wanted me to extend my downwind; but she replied that she then wanted a left base to 28L and cleared me to land; which I did without incident.

C172 pilot reports confusing Runways 10L and 10R with Runways 28R and 28L; while arriving from the west. An inappropriate ground track is flown when instructed to make a right midfield downwind for 28R. With ATC assistance a successful landing ensues.

1021713

201207

1201-1800

ADH.Airport

OK

0.0

VMC

10

Daylight

CTAF ADH

Corporate

Premier 1

1.0

Part 91

IFR

Passenger

Takeoff / Launch

Direct

CTAF ADH

FBO

PA-28 Cherokee/Archer/Dakota/Pillan/Warrior

1.0

Part 91

VFR

Training

Landing

Class G ADH

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 70; Flight Crew Total 3000; Flight Crew Type 390

Situational Awareness; Other / Unknown

1021713

Conflict Ground Conflict; Critical

Horizontal 600; Vertical 300

Automation Aircraft TA; Person Flight Crew

Other Takeoff roll

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

Human Factors

Ramp weight was approximately 12;520 LBS (maximum ramp weight 12;591); with an estimated takeoff weight of 12;429 LBS. Preflight checks were completed; the cabin door was closed; and engine start commenced. Winds reported at the time were light and variable at 5 KTS. Both wind socks on the field were indicating Runway 17 as the favorable runway. Temperature was 32C and our V speeds were set to V1 119; Vr 119; V2 125. Flaps were set to position 10. Calculated RTOFL [Rejected Takeoff Field Length] was calculated at 5;300 FT with a runway length of 6;200 FT. While taxing several aircraft were departing and in the pattern: First a training airplane reported departing 17 and remaining in left closed traffic. Second a Cirrus reported #1 and was departing Runway 17. Third an early to mid 1980s Citation II reported taxing from the terminal to 17 for departure and fourth a Diamond aircraft reported 10-15 miles to the north for a 17 approach. Five minutes later the Cirrus called departing the pattern. The Citation II stated they were rolling on Runway 17 for a south departure. After the Citation departed the training aircraft (a Piper Cherokee 140) stated they were departing Runway 17. Our Premier was arriving at the approach end of Runway 17 for departure with no visual on the departing Cherokee. As we were stopping at the hold short lines the Cherokee departed to the north on Runway 35 passing over the top of us about 100 FT opposite of the direction stated. We announced we were departing Runway 17 for a west departure. The Diamond aircraft reported a 6 mile final for Runway 17. Power was applied and all engine indications were normal; takeoff roll began. Airspeed indications showed normal and a cross check at 80 KTS revealed no issues. Upon reaching the 1;000 FT marker the Cherokee reported turning left downwind for Runway 35. We stated we had them on TCAS and visual contact was made. We stated they should be no factor and to keep us advised of their position. The Diamond aircraft reported a 2 mile final for Runway 17. At approximately 3;500-4;000 FT down the runway V1/Vr was reached and it was noticed that the Cherokee turned a midfield base to final for Runway 35. There was probably a 5-10 second delay in decision making while it was being determined what the other aircraft was doing. It became evident that the Cherokee was going to remain on short final and showed no indication they were aware of our position or were going to make any changes. It was estimated that by the time the aircraft turned final it was at a height of approximately 200-300 FT AGL and 500-1;000 FT away from the Premier. Thrust levers were immediately brought to idle; brakes applied full; and lift dump was deployed. The aircraft came to a stop on numbers 35 at the opposite end of the runway with an estimated 15-20 FT of runway remaining. The Cherokee at some point departed final with a right turn out to the east and circled over the town and reported re-entering a final for Runway 35. The Premier exited the runway and the Diamond aircraft reported breaking off approach to Runway 17 and was on a left downwind for Runway 35. The Premier remained on solid side of the hold short lines for Runway 35 and conducted the appropriate checklists to see if a second attempt at a departure was possible. It was at this time it was noted that the aircraft exhibited signs of flat tires and smoke was noticed billowing from underneath the aircraft. The aircraft was taxied to a safe location and engines were shut down and passengers deplaned. It was noticed that the Cherokee landed and two occupants were inside. Upon initial inspection it was noticed that both main tires were no longer on the rims; the brakes were overheated; and one hydraulic line was severed. The occupants of the Diamond aircraft after witnessing the event came over to see if everyone was ok. Pictures were taken and sent to Hawker/Beechcraft. It was determined that the aircraft was in need of new tires;rims; wheel bearing; brake pads; brake rotors; brake calipers; hydraulic lines; hydraulic fluid and several miscellaneous items and labor. Damages estimated to exceed $204;000. All on board aircraft witnessed the event. After speaking to others around the airport it was discovered that several individuals have had instances with the same aircraft taking off against the flow of traffic or performing un-safe maneuvers over the town.

Premier 1 Captain reports rejecting a takeoff at maximum gross weight and above V1 when a conflict develops with traffic landing opposite direction. Significant damage to the tires; wheels; and brakes of the Premier 1 are reported.

1629729

201903

0601-1200

ZZZ.Airport

US

0.0

VMC

10

Daylight

Tower ZZZ

Personal

Amateur/Home Built/Experimental

1.0

Part 91

None

Test Flight / Demonstration

Landing

None

Class D ZZZ

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 41; Flight Crew Total 3450; Flight Crew Type 54

Distraction; Situational Awareness

1629729

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

Person Flight Crew

In-flight

Flight Crew Landed As Precaution; Flight Crew Overcame Equipment Problem

Aircraft; Human Factors

Aircraft

Aircraft is an experimental gyroplane undergoing its initial Phase I testing. The flight entailed testing cooling duct effectiveness while in pattern. Takeoff and climb were uneventful. Upon turning on downwind leg of pattern; pilot noticed engine coolant temperatures at redline; and asked Tower for full-stop landing; which was cleared.Approach and flare were uneventful; but upon initial roll-out; aircraft veered to right; and momentarily rolled off runway; before pilot was able to correct. Pilot then re-aligned on runway; and continued to decelerate; eventually leaving runway for taxiway. Tower asked if assistance was needed; but pilot declined; and taxied to hangar once rotor was stopped.Problem was caused by pilot's inattention to roll-out due to high engine temperature concerns; and improper directional control. Corrective action will entail: 1) aircraft will be grounded to allow additional cooling modifications; and 2) manufacturer's Chief Pilot will be contacted with request for additional instruction and possible flight training for pilot.

Experimental aircraft pilot reported a runway excursion upon landing.

1051416

201211

ZZZ.Airport

US

12000.0

VMC

Daylight

CLR

Center ZZZ

Other Skydiving

Twin Otter DHC-6

2.0

Part 91

None

Skydiving

Climb

None

Class E ZZZ

Aircraft X

Flight Deck

Contracted Service

Pilot Flying; Single Pilot

Flight Crew Commercial; Flight Crew Flight Instructor

Flight Crew Last 90 Days 500; Flight Crew Total 3300; Flight Crew Type 20

Situational Awareness; Training / Qualification

1051416

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

Person Flight Crew

In-flight

Flight Crew Inflight Shutdown; Flight Crew Landed in Emergency Condition

Human Factors

Pilot took off for an 18 minute flight for skydivers with 200 LBS of fuel per side indicated (400 LBS total). At 10;000 FT; the left engine fuel flow gauge began to fluctuate which could be confirmed audibly. Pilot flying switched fuel to right fuel tank which resulted in stable fuel flow indications. At 12;000 FT both engines flamed out. Climb attitude had been maintained. Engines were secured and feathered. All jumpers exited and landed safely. Aircraft proceeded to runway and conducted an emergency spiral descent over the runway before landing safely. Pilot flying had less than 20 hours in type. At the time of the failure; fuel gauges were both indicating 100 LBS.

DHC6 pilot with minimal experience in type on a skydiver mission; ran the aircraft out of fuel; got the jumpers out; feathered the engines; and made a successful dead stick landing.

1492899

201710

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Air Carrier

MD-11

2.0

Part 121

IFR

Takeoff / Launch

Intake Ice System

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1492899

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

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

Human Factors; Aircraft

Human Factors

Preflight and taxi out normal; FO takeoff. At 80 kts callout I thought I heard the FO confirm 80 kts but in debrief what I heard was not his confirmation but rather a hesitation as he was trying to evaluate why he was seeing a much higher airspeed than I. As we continued down runway I could tell something not quite right and started to make some comparisons of the airspeed indicators. By the time I could determine the airspeed was in error it was too late to reject and the FO rotated aircraft and climbed out normally but Captain's airspeed was 30-40 kts lower than the FO's and upon looking at the auxiliary airspeed it did not appear to match either airspeed indicator so the climb out was pretty much conducted by attitude and power setting (which was done perfectly by the FO). At about the gear up call we had numerous alerts and failures. Trying to evaluate all the information was time consuming and extensive. I elected to have FO continue flying and coordinated with ATC to fly aircraft out over water because we were at least sure we had an airspeed problem and not sure what our actual speed was; it also would put us in position for an immediate approach back to [departure airport] if needed. Level 2 alerts SEL ELEV FEEL MAN and SEL FLAP LIM OVRD; Auto pilot would not engage; Flight directors removed from view; PROF did not appear to function and Flap retract speeds went away also IAS comparator light came on. After being confident the aircraft was flying in a safe regime (airspeed and altitude) began working the checklist initially for SEL ELEV FEEL MAN as it was on top of list. A jumpseater who was in the RFO seat initially suggested we were not in the flight mode but when the flaps came back on at 3000 feet that was discounted later he suggested it might be a central air data computer problem; I elected to continue with the checklist (not John Wayne the situation by pushing switches) as we were in good control and fuel was not an issue. The checklist (SEL ELEV FEEL MAN and SEL FLAP LIM OVRD) directed us to UNRELIABLE AIRSPEED which did eventually take me to the central air data computer and that did clear the problem. The jumpseater was also very helpful in visually backing us up and checking all the circuit breakers and trying to contact the company for us. While maneuvering out over the ocean we were constantly trying to determine our correct airspeed by cross checking the 3 Airspeed indicators/ground speed indications (INS/GPS) and ground speed from ATC; I elected to leave the slats extended throughout as I thought it allowed us a large room for error. When Capt on central air data computer 2 was selected all indications and auto flight systems were restored; but not completely trusted. Speed was again cross checked with GPS and ATC ground speed readout. When all checklists were done and we were confident that what our instruments were displaying was correct we [advised ATC] and maneuvered for the ILS. I elected to fly the approach manually and assumed control from the FO and disconnected the autopilot early to make sure I had a good feel for the aircraft. I added a couple of extra knots to the approach speed for safety sake and we had a normal flaps 35 landing. When we returned to the gate and talked to Maintenance they quickly went to check the pitot tubes and brought back to the cockpit a few pieces of fabric which was pulled from the Captains pitot tube. The fabric was easily traced back to the interior of the worn pitot tube covers onboard the aircraft. I believe these pitot tube covers need to be replaced with some that can hold up to the constant use (being installed and removed) every day. If they are used fleet wide it is easy to see this happening again. Also looking at the 80 kts callout almost in the same vain as a GO/NO GO callout; there really is very little time to evaluate indications before you are at V1 and VR. When pilot monitoring has the bad or in this case slower indications the person flying needs to challenge when he reaches 80 kts and has not heard the reference from the pilot not flying. This call needs to be clear and assertive.

MD-11 Captain reported returning to the departure airport after noting multiple system faults later traced to worn pitot tube cover debris.

1084210

201304

1801-2400

ZZZ.Airport

US

0.0

Night

Air Carrier

B757-200

2.0

Part 121

IFR

Passenger

Parked

Y

N

Y

Unscheduled Maintenance

Repair; Testing

APU Pneumatic System & Ducting

X

Malfunctioning

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Situational Awareness; Communication Breakdown; Confusion

Party1 Maintenance; Party2 Maintenance

1084210

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

N

Person Maintenance

Aircraft In Service At Gate

General Maintenance Action

MEL; Logbook Entry; Human Factors; Company Policy; Aircraft

MEL

Maintenance Manager advised me that Company Engineering has approved a deferral for cracked APU [pneumatic] manifolds on B757s. Manager cited the recently issued B757 MEL 49-X 'APU Pneumatic Functions' as the authority for deferring a cracked APU duct. This is contrary to everything I've ever been told. It's my understanding that there is a strict interpretation of the MELs. It's unclear to me how a Chapter-36 component can be deferred in Chapter-49 of the MEL without being referenced. Supposedly Company Engineering has left a trail of [information] to support the use of this vague MEL to defer cracked APU ducts. We [were] warned at ZZZ approximately two years ago not to use a loose interpretation of the MEL and the scenario they used was deferring an APU [pneumatic] manifold with the APU Bleed MEL. I see no distinction in using the 'APU Pneu Functions' over the 'APU Bleed' in a cracked manifold situation. If [our] air carrier wants a deferral from the spat of recent cracked ducts then they need precise verbiage rather than parceling with words.

Reporter stated the B757 APU Pneumatic Bleed Air manifolds have a history of cracking at the weld bead on the pneumatic duct sections. There are five sections of pneumatic manifold ducts from the APU in the tail area; connected along the lower fuselage sidewall to the forward bulkhead of the aft cargo pit. Most of the cracked ducts are found in that area. The APU duct then crosses over to a center line position and runs forward along the fuselage keel beam between the Left and Right Main Landing Gear (MLG) wheel well and continues forward between the Left and Right Air Conditioning packs. Reporter stated that his air carrier has noted the B757 reliability was being hurt by the number of APU manifold pneumatic leaks due to cracks at the weld bead. The cracks and resulting pneumatic leaks are a No-Go item unless the duct is replaced or the APU pneumatic bleed air is basically deactivated per the MEL. The potential for an explosive blowout of a pressurized duct in flight is the concern. When the APU Bleed Valve is open and pressurizing the pneumatic manifold; one can hear a distinct muffled whistle noise below the Cabin floor deck if a manifold duct is cracked. Since the B757 is no longer in production; new replacement manifold ducts are not available; so cracked ducts have to be re-welded over and over again. Line Stations like his cannot perform a re-weld on the ducts due to a lack of facilities to satisfy an FAA Airworthiness Directive (AD) that requires APU pneumatic ducts to be pressure checked in water after repairs. Reporter stated they previously used MEL Chapter-36 Pneumatic System Bleed Valve for deferral of the APU Pneumatic System. But the FAA's strict enforcement of the MEL noted that the APU Bleed Valve was not the problem; the cracked pneumatic manifolds were the problem. So his Company Engineering wrote an addition to their MEL APU Chapter-49 to include pneumatic functions. But using the deferral under Chapter-49 makes no reference to a cracked duct; neither on the cockpit placard or in the Logbook. Also; the APU Bleed Valve still has to be verified in the 'Closed' position; not operated; similar to MEL Chapter-36; to prevent pneumatic pressurization by the APU; of a deferred cracked manifold duct. He does not know why his Engineering group did not specifically identify APU pneumatic duct in their add-on language to Chapter-49.

A Line Mechanic reports his concerns for maintaining precise language in their MEL Manual when deferring cracked APU pneumatic manifold ducts on their B757 aircraft. Wording added to their MEL for APU Chapter-49 still does not specifically reference an APU cracked pneumatic duct.

1356812

201605

0601-1200

ZZZ.Airport

US

20.0

Tower ZZZ

Personal

PA-28R Cherokee Arrow All Series

1.0

Training

Initial Climb

Class D ZZZ

Reciprocating Engine Assembly

X

Malfunctioning

Aircraft X

Flight Deck

FBO

Instructor

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

Flight Crew Last 90 Days 70; Flight Crew Total 1200; Flight Crew Type 80

1356812

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport

Aircraft

Immediately after rotation and while still in ground effect engine started running rough and lost what seemed like 30 percent of power. Pilot in Command chose to reduce power all the way and safely land on the remaining runway

PA28 instructor pilot experienced a loss of engine power just after rotation and elected to land in the runway remaining; which is accomplished without incident.

1696555

201910

IAH.Airport

TX

0.0

VMC

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

General Seating Area

Air Carrier

Captain

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

Flight Crew Last 90 Days 181; Flight Crew Total 9992; Flight Crew Type 9992

1696555

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

Y

Person Flight Crew

Aircraft In Service At Gate

General Police / Security Involved

Human Factors

Flight arrived in IAH and deplaning commenced. Cleaners were told not to board until passengers deplaned. Aircraft was early with wheelchair passengers. On cleaner came aboard to confront Captain and I put my hand out and said stop. He was told he couldn't board and I identified myself as the Captain. He paused and then withdrew using profanity and elevated body language making calls to others including telling the others that I told him that I was the Captain and then he said 'I don't care [racial slur]!'. Deplaning continued until the others arrived and forcibly came onboard the aircraft despite my direction to stop. As passengers were deplaning I stepped in between the path of the hostile persons and the passengers to avoid a collision and injury and took a defensive stance. The boarding person (female) kept coming and ran into me inside the doorway approaching the aisle and then took a step back. The threat was such that I told them if they didn't withdraw that I was going to call security at which time the female said that she was security and said don't touch me. The second person (male) also tried to overwhelm the situation and advanced into me and said don't touch me before withdrawing presumably when realized the presence of the queue of passengers. The passengers deplaned without further interference. I then told the male cleaner that he could board. At some point after boarding the aircraft and being told the stop; the female and male persons verbalized that they were supervisors of the cleaning crew. After deplaning was completed; the flight attendant had given me a maintenance item to write up. The elevation of negativity by the male and some crew was enough that I decided to take the cosmetic item to the podium to call it in. The male decided he was going to follow me and the flight attendants and did so until disengaging well into the concourse. I said goodbye to flight attendants and returned to aircraft when a new crewmember on duty (Flight Attendant) was onboard to monitor any event that might happen with the stalking cleaner. I wrote up the cosmetic item and briefed the Flight Attendant on what was written up and then departed. The same male cleaner decided to follow me again and this time did not disengage. I stopped at [gate] and called the ground security coordinator for intervention. Intervention occurred and no further interaction with cleaning crew.

Captain reported a physical confrontation with aircraft cleaners that required security intervention.

1642330

201905

0601-1200

ZZZZ.Tower

FO

1500.0

VMC

Tower ZZZZ

Air Carrier

B757-200

2.0

Part 135

IFR

Cargo / Freight / Delivery

Initial Approach

Hydraulic System

X

Failed

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Situational Awareness

1642330

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition; Flight Crew Overcame Equipment Problem

Aircraft

I was the Pilot Monitoring while conducting the final operational leg from ZZZZto ZZZZ1. We experienced an L HYD SYS emergency; which resulted in the rapid depletion of all hydraulic fluid and gladly; a safe full stop landing.Weather was CAVOK with favorable winds down the runway. We were visual and completing the final descent to landing well inside the final approach fix (with final landing clearance) on the ILS XXL ZZZZ1. Passing 1500' with gear down; flaps 20 and speed brakes armed; we began final configuration from flaps 20-25. At this time (not necessarily coincident with flap movement) we began to see intermittent EICAS cautionary messages appear. These included L HYD SYS PRESS; L HYD QTY; and Rudder Ratio; and the auto pilot disconnected. As the PF announced manual flight; I announced the messages and selected the status page to check HYD Pressure. The L QTY was indicating 0 and the magenta RF was also visible. The Trailing Edge Flap disagree light illuminated and we noted that we were passing 800'. We immediately declared an emergency with tower and given the indications; the fact that we were configured to land and not knowing the nature of the immediate failure; determined as a crew that landing on the 10;000' runway right in front of us was the safest option over executing a full go around low to the ground with possible degradation in flight control response and full drag. The PF called for the QRH checklist and then quickly; and I think correctly; determined that there was a not enough time; asking me to focus outside and back him up. In doing so; we quickly discussed aircraft systems from memory that would be impacted by a complete L hydraulic loss and tried to accomplish what we could in the short time remaining. Ultimately; we choose to place the flap lever back in the flap 20 detent to match the flap indicator position. Additionally; we selected the ground prox flap override switch to override and used APS to quickly reference and set the correct flap 20 airspeed. The landing was very smooth and placed inside touchdown zone ensuring adequate roll out and stopping distance was available. We quickly made verbal reminders regarding auto brakes and nose wheel steering. We completed the roll out without issue and elected to stop on runway XXL abeam Charlie taxi way. At this point we pulled out the QRH again and ran the procedure for L HYD SYS Press (to the extent that we could on deck) and also reviewed the considerations listed for RTO. The latter leading us to communicate further with tower and emergency services that we would need to shut down in position and would require a tow to our parking position. From here we started the APU and conducted the normal checklist for shutdown. Emergency services began placing oil absorbent material and maintained a fire watch on the left hand side due to the left side being covered with expended hydraulic fluid. Having received an approximation for the towing services; we used the next ten minutes to communicate with the DO and [Operations] dispatcher. We were then towed into parking and conducted normal post flight duties and met with the [foreign country] Transportation Safety representative. After discussing the correct procedures with DO; we completed a short summary of events and provided our credentials for their records. At this point we transferred the security of the aircraft over to ground personnel and departed. In conclusion; I think we were very fortunate to have been in a full landing configuration and flying in VMC conditions. More time would be the only thing we could have asked for; but that said; we took the most conservative option available to us and had the aircraft safely on deck in less than 2 minutes. I thought [the] Captain did an excellent job swiftly transitioning to manual flight and executing a flawless flaps 20 landing and manual roll out. His demeanor was such that we were able to quickly share ideas and work together as team all week; nodoubt setting us up for success during this emergency situation. He did a great job managing this event both; during the flight and after; while professionally representing [company] with multiple host nation agencies.The maintenance report indicated that the LH MLG down lock line had been found as the cause of the leak.

B757 Pilot reported a L HYD System failure and what it took to land safely.

1474368

201708

0601-1200

ZID.ARTCC

IN

35500.0

Daylight

Center ZID

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Climb

Class A ZID

Center ZID

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

Cruise

Class A ZID

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1474368

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

1474385.0

Inflight Event / Encounter Wake Vortex Encounter

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

Environment - Non Weather Related; Procedure

Ambiguous

This event was wake turbulence related. We were given a climb to FL360 by ATC (don't recall if ZDC or ZID Center) following in trail (approximately 9 miles) of another aircraft at FL360. Our optimum altitude was FL360; assigned speed of .75 Mach for spacing and autopilot engaged. At approximately FL355 we encountered wake turbulence which rolled our aircraft left; at which point the autopilot disengaged. The aircraft rolled to approximately 35-40 degrees angle of bank; at which point I was able to manually take control and returned to straight and level flight. We did get the aural 'bank angle' call out. I continued the climb to FL360 without any further incident. We reported the wake turbulence incident to ATC.Although the spacing looked good and winds negligible; perhaps we were too close to the aircraft ahead. I'll pay more attention to the aircraft in my vicinity.

I called ATC (Indianapolis Center I think) and told them of the incident. The Controller told us; 'a company plane; same type is in front of you.' We understood that to mean [another] B737. It was a very controlled/smooth recovery.

B737 flight crew reported encountering wake turbulence in trail of another B737 at FL355 while climbing to FL360.

1797712

202103

0601-1200

ZZZ.Airport

US

1.5

1100.0

VMC

10

Daylight

Tower ZZZ

Personal

Skyhawk 172/Cutlass 172

2.0

Part 91

VFR

Training

Descent

Visual Approach

Class D ZZZ

Tower ZZZ

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

VFR

Training

Climb

Other Traffic pattern

Class D ZZZ

Aircraft X

Flight Deck

FBO

Instructor; Pilot Not Flying

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

Flight Crew Last 90 Days 18; Flight Crew Total 642; Flight Crew Type 384

Distraction; Situational Awareness

1797712

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

Horizontal 2640; Vertical 100

Person Flight Crew; Person Air Traffic Control

In-flight

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

Human Factors

Student Pilot flying. On the 45 to enter downwind on [Runway] 16; at approximately 1;100 ft. MSL (TPA 1;000 ft.); a turn in the opposite direction caused potential collision with traffic on crosswind turning to downwind. Situation was realized simultaneously by Tower and myself (CFI) at which point I took [control of] the airplane; as I saw other planes in the base for [Runway] 16. 'Traffic to follow' was mis-identified. To avoid collision the turn was continued to the left; away from downwind; at which point Tower instructions to climb to 1;500 ft. MSL and proceed east to a known reporting point were followed. Situation was stabilized; instructions from the Tower to re-enter the pattern for 16 were followed and successfully completed.What contributed to this situation:1) Student and CFI not adequately briefing the approach based on ATIS. 2) Not correctly identifying 'traffic to follow'. 3) Student Pilot did not realize she could ask for clarification or question my thinking. 4) I did not have the correct runway (16) approach visualized; I was distracted with coaching the Student Pilot.How to avoid in the future: Slow down the process to adequately brief the approach and ask for questions to understand that my student and I are thinking the same procedure with the given information. Properly identifying the 'traffic to follow' and verifying with Tower.

C172 Instructor Pilot reported an airborne conflict occurred in the traffic pattern when a 'follow traffic' clearance resulted in mis-identifying the aircraft to follow.

1564206

201807

0601-1200

ZZZ.Airport

US

0.0

Daylight

Tower ZZZ

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 180

Communication Breakdown

Party1 Flight Crew; Party2 ATC

1564206

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 220; Flight Crew Type 7000

1564184.0

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

Person Flight Crew; Person Air Traffic Control

Taxi

Flight Crew Took Evasive Action

Human Factors; Procedure

Procedure

After landing on RWY XXR; we were instructed to hold short RWY XXL. The First Officer went off frequency to call Company. Approaching the RWY XXL hold short line; ZZZ Tower cleared us to cross RWY XXL. I acknowledged Tower and continued across RWY XXL. Several aircraft were holding short and one was in position for takeoff.Since our aircraft was still in motion; little time was required to comply with the taxi clearance. Tower rescinded the taxi clearance and instructed us to hold short moments later. It was too late as we were already entering the runway environment. I elected to continue the taxi to expedite the only alternative to properly clearing the runway. Tower issued an abort instruction to the departing RWY XXL aircraft.Airport operations at several airports conduct very rapid serial communications; instructions and aircraft movements. Understandably; it's required for an efficient NAS environment. However; potentially significant errors can be introduced with scant time for detection and mitigation. Upon shutdown; I called the Tower Supervisor to learn what occurred. He had yet to review the tapes but indicated it was an ATC error. ZZZ Tower did a very good job in correcting a dangerous situation. I don't know what systems Tower Controllers have and use to prevent such occurrences. Within the aircraft; I will ask the First Officer to remain on Tower or Ground frequency until all runway crossings have been accomplished.

[Report narrative contained no additional information.]

B737 flight crew reported that ATC cleared the aircraft to cross the runway while another aircraft was cleared to takeoff.

1764410

202010

1201-1800

ZDV.ARTCC

CO

10000.0

Daylight

Center ZDV

Personal

Small Aircraft; Low Wing; 1 Eng; Retractable Gear

Part 91

IFR

Personal

Cruise

Direct

Class E ZDV

Facility ZDV.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

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

Communication Breakdown; Situational Awareness; Time Pressure

Party1 ATC; Party2 Flight Crew

1764410

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance

Airspace Structure; Procedure; Equipment / Tooling; Human Factors

Equipment / Tooling

I took airspace from previous controller. Aircraft X wanted to stay low to limit oxygen and couldn't take longer routing to save on gas. Previous controller let Aircraft X stay at the MIA (Minimum IFR Altitude) per request. Previous controller told Aircraft X he was going to need to climb to avoid terrain; which he acknowledged. In the briefing I was told about an Aircraft X needing to climb prior to terrain. As soon as I took the airspace; I asked Aircraft X if he could take a reroute to avoid terrain. Aircraft X said Center transmissions were starting to breakup. I tried multiple times to relay to Aircraft X to get Aircraft X to either change to a frequency he could hear me on or climb to 11;000 feet. Aircraft X unfortunately was unreachable through relays or ground transmitters. The transmitters were unable to reach Aircraft X at 10;000 feet prior despite MIAs being 10;000 feet. Aircraft X eventually climbed on his own to 11;000 feet after flying through an 11;000 foot MIA for several miles. I was able to relay through another aircraft and get Aircraft X to change to a frequency I could talk to him on. Frequency coverage of one frequency at lower altitudes in this sector is poor when at MIAs. Unless more transmitter sights are put in; the coverage at low altitude will continue to be spotty. Changing aircraft's frequency at low altitudes over sooner would help due to another frequency having better coverage in some spots between sectors.

A ZDV Center Controller reported they lost communication and could not issue a climb clearance to an aircraft due to poor radio coverage in mountainous terrain and the aircraft flew below the Minimum IFR Altitude before climbing on its own.

1243274

201502

1201-1800

TEB.Airport

NY

1.0

2000.0

VMC

Daylight

Corporate

HS 125 Series

2.0

Part 135

IFR

Passenger

FMS Or FMC

Initial Climb

Vectors; SID RUUDY5

Class D TEB

FMS/FMC

X

Design; Improperly Operated

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

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

Flight Crew Last 90 Days 35; Flight Crew Total 10000; Flight Crew Type 6000

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

Party1 ATC; Party2 Flight Crew

1243274

Flight Deck

Corporate

1243276.0

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

N

Person Air Traffic Control

In-flight

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

Chart Or Publication; Human Factors

Human Factors

I was the captain flying and departing TEB. Our clearance was the RUUDY5 departure GAYEL transition; etc... I had to manually program our FMS-GNSXLS- for WENTZ @1500 feet; TASCA @2000 feet and RUUDY intersections; and then the GAYEL transition. When we departed RWY 24 @ TEB; I was in heading mode to intercept the 260 degree course to WENTZ. I switched to NAV to track to WENTZ and cross @ 1500 feet. Crossing WENTZ; I switched back to heading mode to track 280 degree to TASCA to cross @ 2000 feet. We were cleared to climb to 10;000 feet. The PNF then switched back to Navigation (NAV) mode after crossing TASCA. Because the FMS had been programmed for the GAYEL transition; the autopilot turned north to GAYEL before crossing RUUDY because it is a 90 degree turn. We should have been back in heading mode and departed RUUDY on a 280 degree heading until vectors to GAYEL. ATC stated; 'XXX; I don't know where you are going but you should be heading 280 degrees'. We turned to 280 degrees and climbed to 10;000 feet. There was no conflict with other aircraft.After talking to the Pilot Not Flying (PNF) and the other pilots in our flight department; we have decided to not accept this departure (RUUDY5) because of the age of our FMS; the switching of modes 3 times in 8 miles while climbing; cleaning up of the aircraft; running checklist; avoiding traffic; and abiding by the noise abatement procedure for RWY24 at TEB.

The flight crew of an HS125 attempted to fly the RUUDY SID from TEB using a rapid reprogramming of heading and navigation modes in order to comply with the charted heading and fix to fix routing involved. Unfortunately; due to the aged minimalism of their FMS capability; the programming after TASCA was incorrect and the jet turned direct to GAYEL via a heading of 280 degrees after RUUDY as charted. Departure control caught the error and corrected their track.

1835516

202108

1201-1800

ZZZ.Airport

US

10400.0

Marginal

Daylight

TRACON ZZZ

Air Carrier

B737-900

2.0

Part 121

IFR

Passenger

Descent

STAR ZZZZZ

Class E ZZZ

Cessna 180 Skywagon

VFR

Cruise

None

Class E ZZZ

Aircraft X; Facility ZZZ.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

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

Party1 ATC; Party2 Flight Crew

1835516

ATC Issue All Types; Conflict NMAC

Person Flight Crew

In-flight

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

Weather; Human Factors; Company Policy; ATC Equipment / Nav Facility / Buildings; Airspace Structure

Human Factors

Working combined feeder sectors; typical arrival traffic; not busy but not slow. Aircraft X was arriving ZZZ1 via the ZZZZZ arrival and had been issued a descent to 8;000 feet as is normal for an aircraft in their position. Suddenly; Aircraft X announced that they had to level off because they had almost hit what they were describing as a Aircraft Y that was skimming along the tops of the cloud layer at approximately 10;000 feet. I had not previously observed traffic in the vicinity of Aircraft X; but upon their comment I did observe a primary only target emerging just east and behind ASA's radar target. I informed the supervisor of the event and subsequently issued the information to Center; because the primary target appeared to be continuing into their airspace and there were other aircraft inbound from that direction.Had I observed the primary target converging with Aircraft X; I would like to think that I would have issued the traffic regardless of the fact that it was only a primary return. Issuing traffic would likely have not prevented the incident; because even with traffic issued I would not have altered the descent instructions. However; traffic being issued would undoubtedly have prepared the crew more appropriately. It is also worth mentioning that we observe false targets in our airspace on a relatively regular basis. I would be naïve to assert that it is possible to issue traffic on every primary target to every aircraft 100% of the time. Particularly given that I was working both the feeder sectors combined; which essentially means my scan is the entirety of our airspace. Had the feeder sectors been split; there is an additional possibility that my scan would have caught the primary target and I would have issued traffic.Additionally; while I believe the primary target was technically just outside of the Mode-C/ADS-B Out veil around ZZZ1 at the location that the incident occurred my guess is that the aircraft departed from a satellite airport underneath that veil (even if just barely). To my knowledge no aircraft contacted the facility today to inform us of their intentions to operate in the vicinity of this incident without Mode-C/ADS-B Out capabilities. So; the aircraft's compliance with applicable regulations pertaining to their equipment may have averted this incident as well.

A TRACON Controller reported an air carrier pilot reported an NMAC with an unidentified VFR aircraft that was not displaying a transponder or in communication with ATC.

1280276

201507

0001-0600

SVZM.ARTCC

FO

36000.0

Air Carrier

Heavy Transport

2.0

Part 121

IFR

Passenger

Cruise

Class A SVZM

Navigation Database

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Last 90 Days 195.5; Flight Crew Total 12189.40; Flight Crew Type 5522.68

Other / Unknown

1280276

ATC Issue All Types

Person Flight Crew

In-flight

General None Reported / Taken

Chart Or Publication

The new procedure for UM423 says 'Between GNA and BVI proceed south along route to BVI and descend to 10;000 feet. Continue south along UM402 to MAO.'Along that route near KAV the grid MORA's (Minimum Off-Route Altitudes) are 15;200 feet. One revision reflects that the other database should be updated.

The charted altitudes on UM423 between GNA and BVI differ between two sets of information. One shows the MORA (Minimum Off-Route Altitude) to be 15200 feet and the other says to descend to 10000 feet.

1245780

201503

0001-0600

ATL.Airport

GA

Night

Tower ATL

Air Carrier

Widebody; Low Wing; 2 Turbojet Eng

3.0

Part 129

IFR

Passenger

FMS Or FMC

Initial Climb

Other RNAV to FUTBL

Class B ATL

Facility ATL.TOWER

Government

Local

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 7

Distraction; Situational Awareness; Workload; Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1245780

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

Person Air Traffic Control

In-flight

Air Traffic Control Separated Traffic

Procedure; Human Factors

Procedure

I was working Local Control-3 (LC); combined with LC-4 and LC-5. It was late in the evening and I had just relieved another controller a few minutes earlier. I was standing up at the time. When I cleared Aircraft X 'RNAV TO FUTBL; RWY 27R; CLEARED FOR TAKEOFF'. Aircraft X read back the cleared for takeoff part and then asked what I had said at the beginning. I asked him to clarify his request and then reissued the previous instruction. Aircraft X did not read back the 'RNAV TO FUTBL' part; but that was not abnormal for foreign carriers to omit parts of the clearance that do not require a read back. Most of the day; the south winds were pushing aircraft within the first mile or two off the end slightly north before they established on the heading to FUTBL or SLAWW; our two RNAV fixes. Since I was standing; I observed Aircraft X start to drift north and then lost sight of him behind the Ground Control-C (GC) ASDE-X display. When I expected him to reappear from behind the screen he did not and then I saw on the RACD that he was significantly off course. I issued an immediate left turn; and shouted across the tower to LC-2 that I had Aircraft X turning. They were just starting to shout at me about Aircraft X. Once that was settled; I issued a 230 heading Aircraft X right as DR-S called in. I did impromptu coordination with DR-S; assuming they heard the 230 heading; and then switched Aircraft X.STOP RNAV OTG [Off The Ground]! How many deviations do we need to have before it is determined to be an unsafe operation? There are only a handful of ATC facilities that are easy to modify procedures; but there are millions of pilots worldwide that have to be proficient on the procedures; every time they are changed!If the above isn't possible; then anytime foreign language pilots give a controller an uneasy feeling due to the language barrier; then use headings instead of RNAV. I should have issued the heading when Aircraft X asked me the question about what I first said in my takeoff clearance.

ATL Local Controller has a clearance problem with a foreign carrier and when the aircraft departs it drifts off the RNAV course into another Local's airspace.

1117521

201309

0601-1200

ZZZ.Airport

US

0.0

Daylight

Air Carrier

DC-10 Undifferentiated or Other Model

Part 121

Cargo / Freight / Delivery

Parked

Y

N

Y

Unscheduled Maintenance

Installation

Reverser Lockout

X

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Confusion; Troubleshooting; Situational Awareness; Communication Breakdown

Party1 Maintenance; Party2 Maintenance

1117521

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

N

Person Maintenance

Aircraft In Service At Gate

Aircraft Aircraft Damaged; General Maintenance Action

Aircraft; Human Factors; MEL

MEL

DC-10 aircraft had an inbound write-up for '#3 THRUST REVERSER WOULD NOT UNLOCK U/L TURNS AMBER; BUT NOT GREEN. REV 3 PRESS FAULT ILLUMINATES.' Was unable to determine cause of malfunction and deferred Number 3 Thrust Reverser using MEL 78-30-01. Step-6 of MEL 'Install Lockout Tool in both Right and Left Center Gearbox unused pads of Fan Reverser.' Was complied with (c/w) under the fan cowls. Step-7: 'Tag and mark each deactivation tool to indicate the tool must be removed prior to system activation.' Was interpreted as meaning to install the red 'DO NOT OPERATE' 'signal plates' on the outside of the Thrust Reverser as a visual indicator that the lockout tool has been installed; the reverser has been locked out and the thrust reverser can't be deployed. From reading the write up and Maintenance entries; the ZZZ1 AMT's reactivated the thrust reverser for troubleshooting; the external red 'DO NOT OPERATE' 'signal plates' were not removed and the thrust reverser was damaged during deployment. [Contributors are] Human error and inconsistencies in procedures. ALL of our CF6 Thrust Reverser MELs [for our other fleets] call out [for] the installation of the 'stow bolts' and red 'DO NOT OPERATE' 'signal/warning plates;' EXCEPT the DC-10. Conversely; none of our CF6 Thrust Reverser MELs use the verbiage 'Tag and mark each deactivation tool to indicate the tool must be removed prior to system activation;' EXCEPT the DC10. All of our CF6 Engine Thrust Reversers use a similar deactivation tool that is inverted on the Center Drive Actuator Unit (CDU) and remains with the aircraft. Since all other CF6 thrust reversers require 'stow bolts'; red 'DO NOT OPERATE'; 'signal/warning plates' and the exact same red 'DO NOT OPERATE' 'signal/warning plates' are installed on the DC-10 fleet; it made sense to install the red 'DO NOT OPERATE' 'signal/warning plates' to satisfy Step-7: 'Tag and mark each deactivation tool to indicate the tool must be removed prior to system activation.' [Recommend to] standardize the procedure within the CF6 Thrust Reversers. Installing the 'stow bolts' and the red 'DO NOT OPERATE' 'signal/warning plates' takes a couple of minutes to install. Our other fleets currently use the procedure and the DC-10 has the identical thrust reversers and could be used as the validation for the procedure. If standardization isn't the solution; a clarification or a rewrite would be another solution; like a note in the current MEL that the 'stow bolts' and red 'DO NOT OPERATE' 'signal/warning plates' are not to be used [on DC-10 CF6 Thrust Reversers].

A Line Aircraft Maintenance Technician (AMT) describes how human error and inconsistencies in MEL procedures contributed to a company DC-10 aircraft incurring damage to Number 3 Engine Thrust Reverser during Maintenance troubleshooting.

1125051

201310

1201-1800

ZZZ.ARTCC

US

10000.0

VMC

Center ZZZ

Air Carrier

A310

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Aircraft X

Flight Deck

Air Carrier

Check Pilot; Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1125051

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

1125059.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem; General Declared Emergency

Aircraft

In level flight cabin pressure regulator #2 faulted. #1 regulator did not control cabin altitude and it rapidly climbed through 10;000 feet. Oxygen masks were donned; jumpseater awakened and told to put oxygen mask on; and crew began ECAM procedures. Cabin pressure control regained using manual control. Descent begun to 10;000 feet and emergency finally declared with Center. Once below 10;000 feet cabin altitude normal operations resumed and continued to destination. Excellent performance by the First Officer.

[Narrative had no additional information].

A310 flight crew reported loss of cabin pressure. An emergency was declared and control of pressurization system was regained using manual backup.

1651382

201905

1201-1800

BOI.Airport

ID

1500.0

VMC

Tower BOI

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Landing

Class C BOI

Horizontal Stabilizer Trim

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Flight Crew Last 90 Days 202; Flight Crew Total 3600

1651382

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Flight Crew Last 90 Days 197; Flight Crew Type 2095

1651377.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem; General Maintenance Action

Aircraft

At approximately 1;500 feet AGL; while attaining final flap configuration; the nose up trim quit working. I asked the Capt to try his trim switch to see if it would trim nose up and it would not. I bumped it forward to see if that worked and it did. The aircraft was a little nose heavy; but still fully controllable; so I elected to continue and land instead of going around and asking the Capt to try and trim manually during another approach. The flare and landing required more back stick force than usual due the out of trim condition; but it was completely controllable and the landing was normal. We submitted a maintenance write up; and I believe the Capt followed it up with a verbal to [Maintenance Control and required company notifications.]

Below 1;000 ft; elevator trim became intermittent for FO (First Officer). Captain's elevator trim only worked one direction.

B737 flight crew reported an electrical trim malfunction on short final.

1138665

201312

0001-0600

ZLA.ARTCC

CA

9500.0

Center ZLA

RV-12

1.0

Part 91

VFR

Cruise

Any Unknown or Unlisted Aircraft Manufacturer

Descent

None

Facility ZLA.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Situational Awareness

1138665

ATC Issue All Types; Conflict NMAC

Person Air Traffic Control

Flight Crew Took Evasive Action

Procedure; Human Factors

Human Factors

I was providing RADAR advisory services for VFR Aircraft X; a RV12/G enroute eastbound at 9;500 FT. A fast-moving Mode-C Intruder target was level at 11;500 NW of Aircraft X. I noted that the Mode-C intruder had descended to 10;500 FT and appeared to have leveled there for quite some time. Due to the fast rate of speed of that target; I made a traffic call to Aircraft X; noting traffic was at 7 to 8 o'clock and 5 miles at 10;500 FT; altitude unverified and type unknown; overtaking; and passing north to south. Aircraft X reported the traffic in sight. At some point; I commenced giving a position relief briefing. During the briefing; the Mode-C Intruder started descending into Aircraft X. Around the same time; there was a large number of track jumps; and the Mode-C Intruder was in close proximity with Aircraft X. I immediately issued a traffic alert to Aircraft X giving an approximate position due to the track jumps; apparent Mode-C swaps; and Aircraft X's vector line spinning quickly clockwise; either due to RADAR anomaly; or pilot action. There was no response to the traffic alert. Roughly 15 seconds later; the pilot noted that he had taken evasive action; and that the traffic was really close. I asked if the pilot of Aircraft X had seen the aircraft type of the other aircraft; and he responded that it was a large 4 engine prop; possibly an [P3] Orion. Following the incident; the Mode-C intruder continued to descend and turn westbound toward the Big Bear (L35) Airport. I immediately reported the event to Management; the only aircraft that landed within that time period was a Cheyenne. The pilot of the Cheyenne was apparently questioned and noted that he did not see any traffic during the descent.

ZLA Controller described a conflict event involving an apparent military aircraft and a VFR transiting aircraft at 9;500 FT; the identity of the second aircraft was never determined.

1100656

201307

1201-1800

LGA.Airport

NY

3000.0

IMC

Turbulence; Thunderstorm; Windshear

TRACON N90

Air Carrier

A320

2.0

Part 121

IFR

Localizer/Glideslope/ILS Runway 22

Initial Approach

Vectors

Class B LGA

Autothrottle/Speed Control

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Human-Machine Interface; Situational Awareness; Training / Qualification

1100656

Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

In-flight

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

Aircraft; Human Factors; Weather

Ambiguous

While being vectored for the ILS 22 through moderate weather we turned base; then final; armed the approach and began the descent. We came through the bases of the clouds and it became obvious through multiple lightning strikes; the clouds we were in were very convective which we did not previously know. There were multiple lightning strikes around us and the airspeed began to stagnate. I announced the stagnation and decrease in airspeed to the Captain and he responded that he was seeing it to. This was still before the FAF between 3;000 and 2;000 FT. I was busy switching from Approach to Tower at this time and [making] commanded configuration changes and running the Landing Checklist but the stagnation continued. I was waiting for the autothrust to give him additional power and it never came. Researching it later; below 3;200 radio altitude the autothrust should be more sensitive and should never accept the speeds that the aircraft was slowing too; well below the magenta bug. This makes me think there is a problem with the autothrust on approach with this aircraft. I then noticed he was taking an action; not necessarily what I would have done. He took the thrust and placed it in MCT or slightly between CLB and MCT and moved it around a little seeming to be trying to get the thrust up. After seeing multiple mode changes and continued stagnation I called for a go-around. We never received a Windshear Warning but it seems as if it was windshear. I notified Tower of the go-around and called positive rate. Captain responded with gear up and the speed increased quickly as if on the backside of the windshear. I mentally calculated it to be about a 30 KT shift and let ATC know. At this time the flap speeds were exceeded. I made a callout to pitch up since we were well below the command bars; more pitch was needed to get into the command bars or less power due to the intermediate go-around; the speed was increasing so fast that I treated it like a windshear and reconfigured the flaps on speed just announcing it and not waiting for the command. ATC assigned runway heading and 2;000 after we had already passed that altitude on our way to 2;700; I set 2;000 and selected and then ATC assigned 3;000; I set that altitude and selected. First and foremost I think the ATC facility should not have been using this runway. They continued to use it after we went around and announced the windshear. After landing we sat on the parallel taxiway watching the other aircraft land on [Runway] 22 and seeing the lightning strikes that surrounded them and knowing they were just realizing it when the were coming through the base layer left me with a feeling of disappointment in ATC. I know they do not like changing runways around but when the other 3 directions did not have any Convective activity and the winds were actually favoring landing on [runways] 4 or 31 according to the windsock; the runway change should happen faster. As far a piloting the aircraft goes. I feel more time training intermediate go-arounds and proper ways to turn off; when to turn off; and what to do when autothrust is not doing what is desired is needed. Trying to get the thrust to come up due to slow speed by bumping it up above CLB is poor technique. The entire situation would have been prevented by simply turning off the autothrust and setting about 60% N1 for configuration full to fix the slow speed. This should be previously trained and frequently practiced on the line. Additional training should also be done on intermediate go-arounds and what to do with pitch and power and how long TOGA is needed. ATC increased the confusion of the situation by having a published altitude; followed by an altitude we were already passing (2;000 FT) followed by a new altitude (3;000 FT) in an already complex situation.

A320 First Officer describes an ILS approach to Runway 22 at LGA with lightning; turbulence and possible windshear. The autothrust system is not maintaining the desired reference speed and the Captain's 'technique' to override it is not successful. A go-around is announced by the First Officer; above 1;000 FT; resulting in flap speed and altitude exceedances.

1443321

201704

0601-1200

ZAB.ARTCC

NM

20800.0

Daylight

Center ZAB

Air Carrier

B737-700

2.0

Part 121

IFR

Descent

Class A ZAB

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 216; Flight Crew Type 12600

1443321

Conflict Airborne Conflict; Flight Deck / Cabin / Aircraft Event Illness / Injury

Automation Aircraft RA

Flight Crew Took Evasive Action; General Physical Injury / Incapacitation

Aircraft; Airspace Structure; Human Factors

Ambiguous

ATC advised maintain FL200 for crossing traffic at FL190. Descending at 800-1;000 FPM got TCAS climb RA at FL208 and performed QRH procedure with climb of less than 1;000 feet. Advised ATC of RA climb and heard flight attendants discussing injuries in aft galley to 'B' and 'C' flight attendants. No other injuries. Six hours in hospital with no broken bones; but strained muscles and possible bruising. 'B' was most sore and was unable to sit on jump-seat for landing as she landed in the corner of galley on top of liqueur kit bottles. First Officer did an outstanding job calling out need for continued climb until clear of conflict. Never got a TA and red climb requirement to fly was tall. Uneventful landing and EMS met aircraft at the gate.Possibly sitting the flight attendants down earlier; but they were unfortunately cleaning up when a non-normal maneuver was performed for the safety of flight TCAS RA. We can't prepare them for that situation; as it is always a possibility.

B737 Captain reported a TCAS RA descending to FL200 with an aircraft at FL190. The response to the RA caused injuries to two Flight Attendants.

1751102

202007

1801-2400

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

Parked

Scheduled Maintenance

Inspection

Gate / Ramp / Line

Air Carrier

Technician

1751102

Deviation / Discrepancy - Procedural Published Material / Policy

Person Maintenance

Routine Inspection

General Maintenance Action

Company Policy; Environment - Non Weather Related; Procedure

Procedure

Doing a scheduled check for Aircraft X in long term storage on the ramp; and closing everything up upon completion I noticed speed tape torn around Pack 1 and 2 inlets and exhaust. Confused; I checked both inlets with a light to see if any tape was sucked in. But because the duct bends I am not 100% sure if any of the speed tape ripped and entered the system. Checked all the planes on the ramp. There is one other plane out of XX with speed tape on the pack intakes. I am unsure if it is required; applied new speed tape to both Pack 1 and 2 intake and exhaust and hung streamers to help prevent this in the future.

Technician completing a routine check on stored aircraft reported finding torn speed tape in the Pack 1 and 2 inlets and exhaust. Reporter could not visually verify if the tape had entered the system due to the duct bends.

1113924

201309

1801-2400

ZDV.ARTCC

CO

38000.0

VMC

Center ZDV

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

FMS Or FMC

Cruise

Class A ZDV

FMS/FMC

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Last 90 Days 120; Flight Crew Total 15775; Flight Crew Type 3700

Human-Machine Interface; Situational Awareness; Training / Qualification

1113924

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

Person Air Traffic Control

In-flight

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

Human Factors

The flight plan consisted of many direct fixes including the 'new' fixes such as KD54S. I had just read a report the previous day about mis-entry into the FMC using similar fixes. I was conscious of the potential for error while programming the FMC but still managed to transpose the cleared fix - KD54S- into an incorrect fix KD45S. The first officer and I noticed the big dog-leg in the flight plan; but I had thought it was for avoidance of a very large dissipating weather cell around the Denver area. Approximately 5 minutes after passing CLEVE; Denver Center queried us regarding the fix we were navigating to. I responded to KD45S and immediately saw the correct fix should have been KD54S. I entered the fix into the FMC and told the Controller what had happened and that we were turning toward KD54S. The Controller said it was not a problem and issued a clearance further west and more direct toward our destination.

Air Carrier Captain reports entering transposed numbers for a NRS (National Reference System) waypoint into the FMC; resulting in a track deviation detected by ZDV.

1008893

201205

0001-0600

ZZZ.TRACON

US

13000.0

IMC

Night

Center ZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Descent

Class E ZZZ

Air Data Computer

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Lighter-Than-Air; Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 240; Flight Crew Total 24000; Flight Crew Type 9000

Distraction; Human-Machine Interface; Troubleshooting; Workload; Communication Breakdown; Confusion

Party1 Flight Crew; Party2 Flight Crew

1008893

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Last 90 Days 200

Workload; Troubleshooting; Distraction; Confusion; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1008895.0

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

Person Flight Crew

In-flight

Flight Crew FLC complied w / Automation / Advisory; Flight Crew Overcame Equipment Problem; Flight Crew Regained Aircraft Control; Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Aircraft; Manuals; Chart Or Publication

Aircraft

We were cleared to descend to cross an en route intersection at 10;000. During the descent and at 280 KTS I noticed my airspeed decreasing. I assumed the autothrottles were not working properly and switched off autothrottles. When speed continued Towers minimum selectable I selected autopilot off and pushed the nose over. The First Officer was busy as this was our third or fourth route change and two runway changes and he was busy. Then he noticed on the descent checklist that we had degraded to CAT 3 single and was investigating that anomaly. In the meantime I was struggling to control the aircraft because my airspeed was wrong and I was getting close to overspeeding the aircraft by pushing the nose over and advancing the throttles. The First Officer called airspeed. He was referring to the impending overspeed on his side - I thought he was referring to the impending stall that I was sensing on my side. In the heat of this struggle we crossed the intersection at 11;700 vice 10;000 assigned and told ATC that we could not make it as we had a problem. After we discovered whose instruments were correct via reference to the standby instruments I switched to Captain on Air Data 3 and switched to Autopilot 2 and autothrottles back on. It was very confusing and now we were behind. I was not confident that the speeds were correct and the First Officer was very busy; but doing a great job as pilot not flying. He was reading the EMERGENCY QRC MACH AIRSPEED UNRELIABLE; setting up the FMGC for the new runway and communication with ATC. After confirming the aircraft was under control we proceeded hurriedly; but uneventfully to touchdown on 27L.

The reporter stated that this event lasted about 60 seconds and what ran through his mind was the A330 accident. The short period of this event was very confusing because there were no other indications of an airspeed malfunction nor any clue as to what the crew should do other than begin the AIRSPEED UNRELIABLE procedure. He was so shaken by this event that he removed himself from the remainder of the trip.

We were given a descent to cross the intersection at 10;000. As we started our descent I began the approach/descent checklist as the Captain was the pilot flying. Shortly thereafter we received a runway change from 27R to 27L. I entered the new runway into the FMGC and continued the checklist. Upon reaching the 'Status check' part of the checklist I noticed that CAT three single was displayed on the ECAM status page. Neither I nor the Captain knew why. I had just entered the new runway and I was trying to figure out if there were any correlations to the new approach. While I was trying to figure out why the Captain disengaged the autopilot and soon after disconnected the autothrottles; we were passing through 13;000 FT. The Captain then advanced thrust and then went to climb thrust and engaged the autothrust stating the autothrust was not working. I didn't understand the statement because it was commanding idle thrust and we were in open descent mode. Again the autothrust began reducing trust toward idle. We were at around 280 KTS and 11;000 FT when the Captain disconnected autothrust and went to climb thrust. As the airspeed climbed I asked the Captain to watch the speed and he said 'I know.' We climbed to 11;300 FT and airspeed was still increasing. I told the Captain that we were going to overspeed. That is the time we figured out that his airspeed indicator was incorrect with cross checking all three indicators. Captain switched to Captain on AIRDATA 3; the airspeed overspeed by about 5 KTS. The throttles were brought to idle and speed brakes deployed. By this time we were too high to make the intersection crossing and we notified ATC. We were given a descent to 9;000 FT and we were given a heading. We were later slowed and given a heading to intercept 27L. With all the confusion we passed slightly through the LOC intercept and we were given a heading of 310 to join. Total 1 1/2 dot south of centerline; we then centered LOC and the remainder of approach was normal.

An A320 Captain's airspeed decreased toward V1s during descent; so he disconnected the autopilot and autothrottles to manually increase airspeed when the First Officer discovered the aircraft was overspeeding. They determined the Captain's airspeed was in error and the air data computer was at fault.

1043707

201210

38000.0

Center ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

Passenger

Class A ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 200; Flight Crew Total 23000; Flight Crew Type 13000

Other / Unknown

1043707

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

Person Flight Crew

Aircraft In Service At Gate; Pre-flight

General None Reported / Taken

Company Policy; Human Factors; Procedure; Weather

Ambiguous

Looking at paperwork shows a FOD [fuel on deck] value of 6.4 with ACF calculations etc. etc. Flight planned at FL360. Noticed turbulence over Rockies and it was obvious that at some point we would have to descend below planned FL. Flew ABOVE planned at FL380 to save gas and added 1.5 then had to descend to FL320 and then FL300 for ATC requirements 1 hour out. Given this we landed with only 6.2. Now; figuring the savings at 380 vs. 360 was about 800 LBS for several hours if we stayed at 360 would have landed with 5.4 then less the 1.5 I added would have been 3.9 thousand pounds; unacceptable.

Air Carrier Captain laments the low fuel loads that the company flight planning software routinely provides and offers an example.

1436319

201703

1201-1800

ZMA.ARTCC

FL

35000.0

VMC

Daylight

Center ZMA

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Cruise

Direct

Class A ZMA

Navigation Database

X

Design

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 250; Flight Crew Total 15000; Flight Crew Type 250

1436319

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

Person Flight Crew