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

1022782

201207

0001-0600

CYYZ.Airport

ON

0.0

VMC

Daylight

Tower CYYZ

Air Carrier

Medium Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Confusion; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1022782

Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Clearance; Ground Event / Encounter Other / Unknown; Ground Incursion Runway

Person Air Traffic Control

Taxi

General None Reported / Taken

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

Ambiguous

Taxi out for takeoff on Runway 24L. On Tower frequency received clearance to cross 24R to hold short of approach of 24L. After crossing 24R and approximately 100 yards short of hold line for 24L we were told to stop. Tower Controller then asked landing traffic on 24L if he was comfortable landing as an aircraft was inside the approach zone for 24L. The aircraft on a visual approach indicated that it was not a problem and landed. We then heard other aircraft on the frequency receiving a similar clearance to cross 24R and the Controller then emphasized and added hold short of the '24L approach sign.' We did not recall hearing this clearance referring to the sign nor do we recall seeing a sign of this nature. No other comment was made and we were next for takeoff and departed without further incident. We reviewed all taxi charts prior to taxi out and after incident and could not find any reference to the 'Approach Sign.'

An Air Carrier crew failed to detect the CYYZ Runway '24L Approach' sign and were advised by ATC after they crossed the hold line that they had a runway incursion.

1197205

201408

1201-1800

ZZZ.ARTCC

US

29000.0

VMC

Center ZZZ

Air Carrier

MD-83

2.0

Part 121

IFR

Passenger

Descent

Class A ZZZ

MCP

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Training / Qualification

1197205

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

1198665.0

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

Person Flight Crew

In-flight

Flight Crew FLC Overrode Automation; General Maintenance Action

Company Policy; Human Factors

Company Policy

On a descent from FL290; I engaged the VNAV function for descent. This was the first time I'd tried using this outside of the simulator. Immediately upon selecting this mode; the aircraft pitched up and began climbing. I abandoned the VNAV function and selected indicated Mach for descent. I began a discussion with the Captain about various descent modes and did not press the mach changeover button to get the aircraft to descend in IAS instead of mach. Soon; we noticed the speed was increasing towards Vmo. I disconnected the autopilot and readjusted pitch to slow the aircraft. For my part; more vigilance in monitoring the aircraft's performance while under automation was called for. There were several traps that I could have been more aware of. Beginning a descent at IAS/Mach changeover altitude should probably have been initiated in IAS instead of in Mach. Also; more training in VNAV in the initial [training center] would also have helped. VNAV descents and climbs were not trained to any degree of proficiency and were left for us to learn on the line if we desired.

FO was pilot flying; and he had only been 2 weeks out of training. Captain was pilot monitoring. This was our second leg together; and his first actually flying the aircraft. FO appeared to have little or no concept of how to fly the aircraft. I had to intervene by taking control of the aircraft twice during climb to prevent altitude deviations. On descent; the FO became completely confused about how to control the aircraft speed. I saw the speed reach 340 KIAS with associated clacker for some time as I was attempting to first verbally; and later physically intervene to slow the aircraft below Vmo. I was not aware we had exceeded the Vmo by 19 KIAS until I was told by the Company. Had I known we actually passed Vmo by that much I would have written up the plane.I have flown with several new-hires in recent months. The FO's performance in this situation is pretty typical of what I have seen. This leads me to believe the problem is inadequate training from the [training center]; as there is no way that a dozen pilots are all deficient without some core cause out of their control. Other training problems I have seen include: suction feeding the engines on the ground with no boost pumps. When I asked what they were doing they reply that they were told to do that to shed electrical load on the generators. FMS programming is non-existent. Most FOs ask me to load everything. I later lean that they ask because they received insufficient training on the 'box.' No altitude planning. Inadequate autopilot knowledge.I tried my best on this flight; but I have not been trained to teach new hires; and my workload on the line is already sufficiently high to keep me busy. The [training center] needs to send them to the line with at least basic aircraft systems and autopilot knowledge. On this flight the First Officer's attitude was great; and he is a very sociable individual. I do not blame him; as I got the impression he was absolutely trying his best and attempting to listen to instruction. Do not send new-hires to the line until they are truly proficient.

MD83 flight crew is informed after the flight that Vmo was exceeded by 19 KIAS during descent. The event is described by the Captain as a new hire First Officer attempting to learn the auto flight system on the line; since the company will not do this training in the simulator.

1195507

201408

0601-1200

ZZZ.ARTCC

US

32000.0

VMC

Turbulence

Daylight

Center ZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

APU Electrical

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Workload; Troubleshooting

1195507

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Maintenance

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft; Procedure

Aircraft

ECAM Gen Fault Number 2 after start. [We] followed ECAM procedure for fault. Problem was not solved; contacted Maintenance Control. [We] returned to the gate per Maintenance Control for MEL; since not deferrable by crew. MEL 24-20-01B required running the APU for duration of the flight. Departure was normal. During cruise FL320; ECAM APU Fault appeared. [We] ran the ECAM per company procedures. Tried to restart the APU; started fine; APU generator would not accept generator load; then ECAM APU Fault illuminated. [We] started a descent for turbulence; cool starter motor and possible diversion. Level at FL300 repeat the previous steps with no success. Per APU starter limitation; tired one last start of the APU at FL280; no success. Communicated a plan with ATC; First Officer; A Flight Attendant and Dispatch for a diversion since aircraft was down to one generator. [We] advised the passengers of diversion and precautionary landing at a diversion airport. Performed the Overweight Landing QRH procedures; configured the aircraft early to burn fuel. [We] landed at 151;800 LBS at less than 300 FPM; with no issues. [We] made a logbook entry for overweight landing.MEL issued to aircraft; APU failure in flight; aircraft had overnight check before this event.

An A320 engine generator faulted after start and was MEL'ed. At cruise the APU faulted and would not restart so crew diverted to a nearby airport.

1657062

201906

0601-1200

ZZZ.Airport

US

0.0

Daylight

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

FMS Or FMC

Parked

Class B DEN

Aircraft X

Flight Deck

Air Carrier

Captain

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

Situational Awareness

1657062

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Situational Awareness

1657066.0

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

Person Flight Crew

Aircraft In Service At Gate

General None Reported / Taken

Human Factors; Procedure

Human Factors

Normal flight. After my F/O (First Officer) came back up from his post flight [walk around] he said he observed bags loaded above the line in the forward cargo compartment and touching the smoke detector. Also additional bags were loaded in the aft cargo without our knowledge or listed on [paperwork]. 13 bags total in aft not listed.

After we landed I did my walk around. As I passed the forward cargo I looked into it and noticed that the baggage compartment was completely full with bags up against the ceiling and against the fire detectors. I also saw the rampers unloading bags from the aft baggage compartment; which the [departure airport] rampers neglected to tell us that there were even bags back there. I stood there and counted 14 bags in the aft compartment when our [paperwork] said there were 0 bags back there. We could have asked ramp if any bags were in the back when we noticed there was a large amount of bags in the front.

E170 flight crew reported noticing post-flight that the baggage load and distribution was not properly completed or accurately reported before departure.

1608997

201901

1201-1800

SJC.Airport

CA

2.0

Mixed

Daylight

TRACON NCT

Air Carrier

B737-700

2.0

Part 121

Descent

Class C SJC

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Flight Crew Last 90 Days 376

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Crew

1608997

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

Person Flight Crew; Person Air Traffic Control

In-flight

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

Human Factors

We were flying the RAZRR 4 Arrival into SJC. While approaching the SHIKK intersection; NorCal [Approach] told us to expect the RNAV 12R. The First Officer went to the Departure/Arrival pages on the FMC and selected the correct approach. I was on the LEGS page to make sure it was loaded properly. The First Officer asked me if what he loaded looked ok. I responded 'No; it is not correct'; as there was a discontinuity after SHIKK. The First Officer looked at the moving map display and saw magenta lines showing what looked like the correct routing. He executed the route even though I said it was incorrect. The autopilot reached SHIKK almost instantaneously and proceeded to fly straight ahead. I told the First Officer to engage Heading Select and start a turn while I put in the intersection TRCOT. The First Officer still did not realize that we had flown through SHIKK; so I started the aircraft in the correct direction and reloaded TRCOT. About that time; ATC asked if we were still on the STAR. I told ATC that we had flown through SHIKK and [we were] correcting. ATC told us to proceed direct GGUGL. The First Officer was too quick to execute the changes even though he was made aware that they were incorrect.

B737-700 Captain reported a track deviation occurred on arrival into SJC when the FO executed an FMS change even after the Captain advised it was not correct.

1481878

201708

1201-1800

ZZZ.Airport

US

0.0

Daylight

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Parked

N

Y

Unscheduled Maintenance

Installation; Repair

Pneumatic Valve/Bleed Valve

X

Malfunctioning

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Maintenance Technician 14

Troubleshooting

1481878

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Maintenance

Person Maintenance

In-flight

General Maintenance Action

Aircraft; Human Factors

Ambiguous

Crew reported at XA:45 that they had a slow to accelerate spool up on #2 engine. Also on descent they noticed an unusual vibration. Within minutes thereafter I inspected the #2 Engine for damaged blades N1 and Exhaust. I noticed looking through the slim gap between the thrust reverser halves and the core of the engine bottom 6 o'clock position; there was a plug with a long shaft laying at the rear. I alerted the crew to hold boarding at about XA:52 because I would need to open the thrust reverser halves to inspect further. Originally I began looking at the borescope plugs but all plugs were installed and safetied. I noticed looking at the 5th stage check valve; that it was missing a plug as pictured. I inserted the plug and it was a match for the missing through bolt. I had another mechanic assisting me at the time; he took pictures and sent to Maintenance Control to alert of the finding and request support for operational checks once bolt was reinstalled. Maintenance Control notified me that a FADEC Motoring check done through the MCDU would be satisfactory. There was no difficulty reinstalling the through bolt and from the picture I have seen; it appears the bolt did not align with the flapper due to its failure and misalignment. I did not remove the valve for reinstallation of this through bolt; and in hindsight I should have done this as a precaution to inspect the valve for damage. I also would have been able to confirm that the butterfly indeed was aligned with the through bolt. Lesson learned! Bolt was installed; engines closed and secured and motoring check was satisfactory. Notified Maintenance Control approximately XC:00 work was complete and aircraft returned to service at XC:15 approximately.

A319 Maintenance Technician reported finding a check valve was missing a through bolt on an engine that was slow to spool.

1328016

201512

ZZZ.Airport

US

0.0

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Distraction; Other / Unknown

1328016

Conflict Ground Conflict; Less Severe; Ground Event / Encounter Other / Unknown

Person Flight Crew

Taxi

General None Reported / Taken

Airport; Human Factors

Airport

While parking the aircraft under the guidance of the parking system; not one but two vehicles transgressed the operational safety zone. The parking system was fully operational and indicating the aircraft position properly. The proper aircraft type and flight number were displayed. The distance thermometer was green and no obstacles were observed as I proceeded into the safety zone. After crossing the beginning of the lead-in line; a truck drove through the safety zone in front of the aircraft between the aircraft and the parking display. It was not until the vehicle had passed clear of the safety zone that the parking system displayed 'STOP'. After the vehicle had cleared safety zone; the 'STOP' signal was removed from view and the normal displays were once again visible. I proceeded with parking the aircraft. Immediately upon aircraft movement; another vehicle; a small baggage cart tug; crossed the safety zone between aircraft and the display unit. Once again; the display unit did not show a 'STOP' signal until after the vehicle had cleared the safety zone. The parking system's slow response makes this system impractical and unsafe. The response to a moving obstacle in the safe zone; should be immediate as to avoid and extremely unsafe situation. The slow response of the parking system could easily lead to an accident with possible injury to personnel and certain aircraft damage.

The A319 Captain reported that the parking system is slow to respond conflicting ground traffic in the Safety Zone.

1493257

201711

1201-1800

SBA.TRACON

CA

2500.0

VMC

Daylight

TRACON SBA

Personal

SR22

1.0

Part 91

IFR

Personal

GPS

Descent; Final Approach

Class C SBA

TRACON SBA

Corporate

Learjet 60

2.0

Part 91

IFR

Utility / Infrastructure

Descent

Visual Approach

Class C SBA

Facility SBA.TRACON

Government

Approach; Instructor

Air Traffic Control Fully Certified

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

1493257

Facility SBA.TRACON

Government

Trainee; Approach

Air Traffic Control Developmental

Communication Breakdown; Training / Qualification; Situational Awareness

Party1 ATC; Party2 Flight Crew

1492994.0

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

Person Air Traffic Control

In-flight

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

Procedure; Airspace Structure; Human Factors

Procedure

Aircraft X was being vectored for the RNAV Approach when Aircraft Y checked in for the Visual Approach. The trainee decided to make Aircraft Y number one and take Aircraft X off their approach. When he did this he gave Aircraft X a right turn; northbound toward higher terrain and the aircraft was at 2500 ft. The aircraft had to ask him if he wanted her to maintain 2500 ft; in which he agreed. I immediately advised him not to turn the aircraft northbound and to continue her turn back southbound. When he gave the aircraft a turn it was to a 100 heading and the aircraft replied with; 'Was that for me'? He did not hear her say that and at this point was entering a 3400 ft MVA (Minimum vectoring Altitude).I took over and proceeded to turn her immediately to a heading of 180 for higher terrain and attained from the pilot that they could maintain their own terrain clearance; to which they answered in the affirmative. This turn to the north has many consequences. One of which the trainee witnessed today. The aircraft can lose radio contact; not hear you; take a late or slow turn or fly into clouds or into terrain. I advised the trainee of several of the issues that can arise from turning aircraft northbound into a higher MVA. More education and experience in radar will help him learn.

[Report narrative contained no additional information.]

SBA TRACON Controller reported ATC trainee vectored an aircraft off the approach into an area with a higher Minimum Vectoring Altitude.

1758890

202008

0601-1200

ZZZ.Airport

US

10.0

VMC

Windshear; 10

Daylight

10000

Tower ZZZ

Personal

RV-3

1.0

Part 91

VFR

Personal

Landing

Visual Approach

Class D ZZZ

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 6; Flight Crew Total 900; Flight Crew Type 300

Other / Unknown

1758890

Ground Excursion Runway; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Unstabilized Approach

Flight Crew Regained Aircraft Control; General Maintenance Action

Human Factors; Weather

Weather

On final; passing over the numbers on XXR [and] preparing to touch down probably no more than 10 ft. above the runway; I experienced a wind shear which I think was a dust devil as I noticed swirling dust off my left wing. I lost all lift and hit the runway and subsequently veered off to the left-hand side. I was unable to control the direction of my aircraft.

Vans RV-3 Pilot reported encountering a dust devil on landing resulting in runway excursion.

1854743

202111

1801-2400

ZZZ.Airport

US

0.0

VMC

10

Night

12000

CTAF ZZZ

Personal

Beechjet 400

2.0

Part 91

IFR

Passenger

Takeoff / Launch

Other IFR Release

Class D ZZZ

Other Not Stated

Any Unknown or Unlisted Aircraft Manufacturer

1.0

Part 91

VFR

Other Not Stated

Landing

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 60; Flight Crew Total 9500; Flight Crew Type 825

Communication Breakdown; Distraction; Other / Unknown; Situational Awareness; Workload

Party1 Flight Crew; Party2 Flight Crew

1854743

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

Vertical 500

Person Flight Crew

Taxi

Flight Crew Overcame Equipment Problem; Flight Crew Took Evasive Action

Human Factors

It was just after Tower closed for the night; we had previously received a clearance from Tower. By the time our passengers were boarded it was after the Tower closed; so we proceeded to taxi to Runway X for departure since that is what the Tower had been using. On the taxi out we contacted Approach to get our IFR release. When we got our release the Second in Command didn't read back our void time to approach so I instructed him that was the correct to procedure to do so. I had started taxing on to runway looking for traffic looking both directions for traffic as doing so. Once on the runway I realized another aircraft was landing on the other runway. In the short time of us monitoring CTAF we had not heard a traffic call from the other aircraft and we had not made a reporting call yet. The lights of the airplane must of had blended into the background of the city lights. I was unable to vacate the runway before the other aircraft did a go around from the opposite end of the runway.

BE-40 Captain reported a Critical ground conflict after an inadvertent runway incursion resulting in a opposite direction landing aircraft to executed a go-around. Airport Tower had recently closed and flight crew had only monitored CTAF for a short time and had not heard any position radio reports or made any position reports.

1782629

202101

1801-2400

ZZZ.Airport

US

4000.0

VMC

TRACON ZZZ

Air Carrier

Regional Jet 900 (CRJ900)

2.0

Part 121

IFR

Passenger

Initial Approach

Vectors

Class C ZZZ

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Flight Crew Last 90 Days 175

Human-Machine Interface; Situational Awareness

1782629

Deviation - Altitude Undershoot; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

N

Automation Aircraft Terrain Warning; Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Took Evasive Action; Flight Crew Requested ATC Assistance / Clarification

Human Factors

On arrival into ZZZ; we were instructed to turn to a heading and descend from 11;000 ft. to 3;000 ft. We began a descent using speed mode set at 250 kts. Just below 4;000 ft.; we received an Obstacle Caution message. During the process of turning the descent into a climb; which removed the caution message; we were instructed to climb to 4;000 ft. I was able to identify the obstacle; an antenna; below and to the right of the aircraft. We passed the antenna above and to the left. We leveled off at 4;000 ft. From there; we were vectored to a visual approach to [Runway] XX and proceeded with a normal visual approach and landing.Descending in speed mode likely caused the aircraft to approach the level off altitude earlier than ATC anticipated thus causing the higher closure rate to the obstacle; generating the caution message. Better terrain awareness could have prompted a shallower descent rate; perhaps using vertical speed mode. Querying ATC about the level off altitude; suggesting a higher bottom altitude; could also have reduced or eliminated the occurrence of the caution message.

Air carrier First Officer reported that a high rate of descent during arrival triggered an obstacle caution message nearby an antenna.

1335367

201602

0601-1200

ZZZ.Airport

US

500.0

VMC

Daylight

CTAF ZZZ

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

None

Personal

Initial Climb

Class E ZZZ

Engine

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 5; Flight Crew Total 3200; Flight Crew Type 1000

Distraction; Time Pressure

1335367

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition

Aircraft

After performing a touch and go; on upwind; engine stopped producing enough power to climb then stopped performing enough to maintain altitude with significant shuddering. Called Pan pan pan on the radio and begun an immediate turn to downwind from the upwind. 3 aircraft in the pattern at the time responded and went around. While on downwind; the inability of the engine to maintain altitude resulted in a midfield base and final. Ultimately the pattern was completely nonstandard. I don't believe I could have done anything differently since the failure of the engine to produce power was revealed to be mechanical. I never 'declared' an emergency but there wasn't a need considering I decided to return to the runway. That is the one thing I suppose I could do differently next time. Alas the field is non-towered and I don't believe in this case it would have helped.

C172 pilot reported a loss of engine power in the traffic pattern that resulted in a nonstandard pattern to a successful landing.

1481538

201709

0001-0600

ORD.Airport

IL

0.0

Tower ORD

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Landing

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Distraction

1481538

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Distraction; Confusion; Situational Awareness

1481380.0

Deviation / Discrepancy - Procedural Other / Unknown

Automation Aircraft Other Automation

In-flight

Flight Crew FLC complied w / Automation / Advisory

Aircraft

Set off ROPS warning system on landing. Turned off at normal exit after moderate braking.

I was the PM (Pilot Monitoring); the captain was flying and this was our second leg of two for the day; and a red-eye flight. Upon landing in Chicago; seconds from touchdown in the touchdown zone; we received a ROPS (Runway Overrun Prevention System) alert that the runway was too short. Although we had briefed the SELs (Special Equipment List) on the aircraft before leaving [the departure airport]; I had forgotten that the aircraft was equipped with ROPS; and for a brief moment I was shocked (maybe a little disbelieving) that I was hearing the alert IN CHICAGO where we operate all the time. (I am new to the aircraft and apart from training slides cannot recall ever hearing the alert in the sim or the aircraft.) In the brief seconds before touchdown; immediately following the alert; these thoughts occurred simultaneously to me: 1) 'What is that? Does it mean if the runway is wet; it's too short to land. NO; that's not true.' 3) The runway is dry 4) We are going to land in the touchdown zone; but are we supposed to go around? 5) [As the airplane touches down in the touch down zone] 'Oh crap; we were supposed to go around.' At that time we got 'Max Braking.' The captain did a great job getting the airplane slowed enough to exit at the 90 degree intersection prior to the end of the runway; and it didn't seem to me that he was overly aggressive in doing so.

An Airbus flight crew reported the activation of the Runway Overrun Prevention System (ROPS) while landing at KORD. They were in compliance with all landing parameters and safely exited the runway after using moderate braking.

1283862

201508

1201-1800

JFK.Airport

NY

3000.0

VMC

Tower JFK

Air Carrier

A321

2.0

Part 121

IFR

Passenger

FMS Or FMC; Localizer/Glideslope/ILS Runway 13L

Final Approach

Visual Approach

Class B JFK

Personal

UAV - Unpiloted Aerial Vehicle

None

Class B JFK

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Distraction; Situational Awareness; Workload

1283862

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

Horizontal 0; Vertical 300

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

Procedure; Human Factors

Procedure

3 miles south of ASALT intersection on the RNAV Visual 13L at 3000 FT both pilots observed a small drone the size of a street garbage can cover with four vertical engines passes approximately 300 FT directly below our aircraft. We were on a north heading and drone appeared to be traveling south. However with our speed of approximately 220 KTS it may have been traveling in our direction with us overtaking it. The color of the drone was metallic in apprehended with orange colors near its four engines. Possibly the propellers were orange? No evasive action required. ATC notified around 10 seconds after both pilots confirmed our sighting. Upon landing JFK tower gave me a phone number with Radar to follow up on the verbal report.

A321 flight crew reported a near miss with a UAV at 3;000 FT while on visual approach Runway 31L at JFK near the ASALT intersection.

1484038

201709

1201-1800

ZZZ.Airport

US

0.0

Daylight

Air Carrier

Commercial Fixed Wing

Part 121

Parked

Air Carrier

B777-300

Part 121

IFR

Taxi

Gate / Ramp / Line

Air Carrier

Ramp

Situational Awareness

1484038

Ground Event / Encounter Other / Unknown

Person Ground Personnel

General None Reported / Taken

Equipment / Tooling; Human Factors; Procedure

Human Factors

After marshaling in Aircraft X into [the] gate; I began to complete my post arrival duties. I hooked up the Ground Power Unit and received the all clear from the captain that he had power. After that I got the air hose from the jet bridge and started unrolling it to connect to the aircraft. Once I hooked the air hose up to the aircraft I began walking back towards the jet bridge to turn on the air. As I got to maybe about the midway point between the engine and jet bridge I felt a gust of wind that started blowing. I thought it was maybe just a big gust of wind that knocked me off balance. I then noticed that the air hose blowing toward me at a rapid pace. Before I could react or move; the air hose had become wrapped around my ankle. Once the air hose wrapped around my ankle it then snatched my leg and started pulling me violently underneath the aircraft. I tried to pull my leg from the air hose but as I pulled it became tighter. I did finally manage to get my leg from the grasp of the air hose. When I looked to see what happened; I noticed that a 777-300 aircraft had turned to the north towards the taxiway that runs parallel to Alpha taxiway and jet blasted [the] gate [area].

Ground personnel reported of an air hose that came loose from an aircraft due to jet exhaust from another aircraft. The air hose wrapped around his ankle and pulled him down.

1288562

201508

1801-2400

ZZZ.Airport

US

200.0

VMC

10

Dusk

10000

5000

Tower ZZZ

Personal

SR20

1.0

Part 91

VFR

Personal

Initial Climb

Class D ZZZ

Engine

X

Malfunctioning

Flight Deck

Personal

Pilot Flying

Flight Crew Private

Flight Crew Last 90 Days 37; Flight Crew Total 440; Flight Crew Type 92

1288562

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Landed As Precaution

Aircraft

Forced landing on Runway XY due to power failure; oil light came on and I lost power after requesting a 'go around' on Runway XX. It was approved. I then advised tower of the problem and requested immediate landing on XY.

The pilot of a Cirrus SR20 experienced an engine power loss during go-around for unknown reasons.

1271099

201506

0001-0600

SCT.TRACON

CA

3000.0

Dawn

TRACON SCT

Personal

Small Aircraft

1.0

Part 91

IFR

Initial Climb

Class C ONT

Tower ONT

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Facility SCT.TRACON

Government

Approach; Departure

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 14.5

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

Party1 ATC; Party2 ATC

1271099

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

Person Air Traffic Control

In-flight

Air Traffic Control Provided Assistance; Air Traffic Control Separated Traffic

Human Factors; Procedure; Airspace Structure

Procedure

Aircraft X had filed an IFR flight plan from CCB to HHR. ONT TWR was 'contra ops'; which meant that they were landing RWY26; but departing RWY08. They do this at night for noise abatement and they end contra ops @ 0700 am local. A CCB IFR departure conflicts with ONT IFR departures; so these flights must be coordinated with POMR to avoid conflictions. I was working POMR and had only one aircraft; Aircraft Y; steadied in the 'rundown list' from ONT. There were no other aircraft flashing in the rundown list waiting release from ONT. The normal procedure for a CCB departure is for the pilot to call ONT ground for their release; and ONT tower will call and coordinate that release with POMR. CCB airport lies immediately outside ONT Class D airspace; but the departure procedure from CCB takes the aircraft though ONT airspace. Sometimes; the pilots tell us that the tower can't hear them on the ground frequency; so they'll call us on the 800-line (flight data) and we'll back-coordinate with ONT Tower. Aircraft X called SCT flight data and said that he couldn't raise the tower on ONT ground and wanted us to get his release. The only traffic I had impeding the CCB release was Aircraft Y; so I called ONT TWR and asked where Aircraft Y was and they told me he was mid-field; rolling (take-off in progress). The tower then started flashing 2 more IFR departures in my rundown list. I told the tower that Aircraft X was already on the phone; that he couldn't get them on ground frequency and was looking for a release. I told the tower that I would release Aircraft X as soon as Aircraft Y was airborne; and that I would release their two new departures once Aircraft X was airborne and separated from the departure corridor. ONT tower told me that they had 3 waiting to go. I informed them that no; Aircraft X was already on the phone before they started flashing the next two departures; and that he was and would go next. Tower then told me they had 2 aircraft with flow times for PHX. I told them I didn't care about that and that they should get new flow time for those aircraft. I ended the call.Aircraft X was released. Aircraft X was at 030; which was my MVA; so I turned him away from the ONT departures and steadied the 2 aircraft in my rundown list. I was informed that the tower supervisor had filed an report because I didn't apreq the CCB departure with ONT tower and was creating reportable delays. Keep in mind that only 6 minutes had passed from my initial call to ONT to the time ONT resumed normal departure ops after Aircraft X was turned out of the way. 6 minutes is not a 'reportable delay'. While the normal procedure is for the tower to call us and coordinate the CCB departure; in this reverse case I called them but did not use the word 'apreq'[Approval Request]. The only possible confliction between CCB and ONT departures would be if there were departures released from these airports simultaneously. Because I told the tower the sequence of departures that I would release and I did not steady the rundown list; there was zero confusion on anyone's part about what was taking place or who was being released when. The tower supervisor apparently was upset because I 'told' them how I was going to run the sequence; rather than letting them decide the sequence.After this event; during the conversation between my supe and the ONT Supervisor; the ONT supervisor told my supervisor (on a recorded line) that normally; when a CCB departure calls for a release; they decide the sequence of departures and 'make him last' (him being the CCB departure). This is a violation of 7110.65 2-1-4. Operational Priority; 'Provide air traffic control service to aircraft on a 'first come; first served' basis as circumstances permit; except the following.' Under the exceptions listed in this paragraph; I see no exception for commercial aircraft having priority over small IFR Cessnas simply because the little guy is slow.The reason this is a problem is that Aircraft X flies this route every morning; and he 'knows the drill'. I strongly suspect that he never actually called ONT ground for his release. I also strongly suspect that the reason he didn't call is because he knew the tower would 'make him last'; and he knew that SCT would 'make him next' (as per the 71110.65) and he wanted his proper place in the departure sequence. If ONT didn't habitually operate under the 'make him last' method; perhaps this entire scenario might have been avoided. Why does ONT operate under 'make him last' procedure? I suspect it is because they are more concerned with avoiding a reportable delay than they are anything else. It seems that we often have issues like this with ONT tower over someone getting hurt feelings or throwing common-sense out the window just to enforce an LOA procedure. A power struggle does not enhance safety; it degrades safety. The times for this incident were derived from the audiotapes. I only listened to the tape once; so my description of the events as listed above is subject to change.We have discovered that the tower has a recorded phone line that accepts outside calls. We are in the process of using this number for times when the pilots cannot use the ONT ground frequency for their release. Having the pilots use a land-line to call the tower directly will alleviate this problem.

SCT Controller describes a release off of an airport in his airspace that needed to be coordinated with another Tower. Controller coordinates and gets the aircraft airborne. Other Tower Supervisor has an issue with the way the aircraft was released and why their other traffic waited on the ground for this aircraft.

1092915

201306

0601-1200

ZZZ.ARTCC

US

Center ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Cruise

Class A ZZZ

Hydraulic System

X

Failed

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Human-Machine Interface; Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1092915

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1093078.0

ATC Issue All Types; Aircraft Equipment Problem Critical

N

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Flight Crew Diverted; General Declared Emergency; General Maintenance Action

Aircraft; Procedure

Aircraft

While enroute the Master Caution and FLT CONT light illuminated. We discovered the FLT CONT SYS B low press light on the overhead panel. We followed the QRH. After completion of QRH procedure we were left with System B flight controls un-powered. A System A loss would have put us in manual reversion. After having done that in the simulator I didn't want to expose myself or my passengers to that risk. I made the decision to divert. Prior to the diversion I notified Dispatch and talked to Maintenance Control to confirm systems status. Diversion was coordinated with ATC and was uneventful until talking to Approach. We were assigned Runway 35R I told them I would require a longer runway due to the degradation in flight controls. I was then assigned Runway 31R than runway gave us a direct crosswind and I didn't want that with the loss of the yaw damper. I told them I needed Runway 35C for operational reasons. Controller said 'understand you are declaring an emergency?' I said if that is the only way to get [Runway] 35C then yes. We were then cleared for [Runway] 35C and landing was uneventful.Pilots in general don't ask for things they don't need. So when I asked for a long N-S runway a little more consideration from ATC could have been given.

A storm was over the area; lots of circuit breakers and moderate chop so we descended to improve the ride and better control. We asked for [Runway] 35C for operational reasons but were then assigned [Runway] 31R - that would have been a decent crosswind with no yaw damper; some inoperative spoilers and the R reverser powered by the standby system. We elected to declare an emergency to get the longer runway (this was the only way Approach was going to give it to us). Normal landing and taxi to gate.

A B737NG flight crew elected to divert to a nearby airport when the B Hydrualic System failed thus eliminating one of two sources for multiple flight controls. The crew declared an emergency in order to land on the longest available runway and into the prevailing wind.

1838424

202108

0601-1200

ZZZ.ARTCC

US

127.0

7.0

5600.0

Mixed

Rain; 3

Daylight

2000

Center ZZZ

Personal

Any Unknown or Unlisted Aircraft Manufacturer

2.0

Part 91

IFR

Training

Initial Approach

Direct

Class E ZZZ

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Student; Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 7.1; Flight Crew Total 336.8; Flight Crew Type 37.1

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

Party1 Flight Crew; Party2 ATC

1838424

Aircraft X

Flight Deck

Pilot Not Flying; Instructor

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

Flight Crew Last 90 Days 58.7; Flight Crew Total 328.7; Flight Crew Type 1.3

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1838454.0

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

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

In-flight

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance; Flight Crew Executed Go Around / Missed Approach; Flight Crew Became Reoriented; Flight Crew Requested ATC Assistance / Clarification

Human Factors; Environment - Non Weather Related; Chart Or Publication; Procedure; Software and Automation

Human Factors

This was the first flight to work on regaining my instrument proficiency after an over 30 year layoff. I have about 12 hours of simulator time in the past several months; but this was going to be my first flight under the hood; mixed with some actual IMC in three decades and my first instrument time in my aircraft. Additionally; my aircraft has recently had an all new Garmin GPS MFD; CDI and autopilot system installed. I've practiced with the Garmin software simulator and watched training videos; but only used my specific equipment on two brief VFR flights. My instructor seemed generally familiar with my Garmin equipment but may have been less familiar with the details of things like loading and activating approaches. By agreement with my instructor; I used the flight director but not the autopilot on this flight.Two days before this flight I spent two hours with my instructor reviewing ground training material (e.g.; lost comm. procedures and reading IFR charts). At the conclusion of that session we decided to plan a trip from ZZZ to ZZZ1; intending to fly an LPV approach to DA; execute the published missed approach and then return to ZZZ; completing an approach and landing. I spent a fair amount of time studying the planned flight; particularly the available RNAV approach and its published missed approach procedure. However; the morning of our flight I arrived at the FBO and spoke with my instructor. He was concerned that some convective activity may be morning our direction; so we agreed to change our plans and fly to ZZZ2 instead. He instructed me to file a round-robin flight to ZZZ2 via ZZZZZ (an IAF/IF for the approach we intended to make into ZZZ2) and ZZZZZ1 (an IF/IAF for the approach we wanted back into ZZZ). I filed via ForeFlight and received an email that advised us to expect to be cleared as filed. I programmed our GPS with the expected route.We called for our clearance from ZZZ Center by telephone and departed. At 500 feet; per my instructor's instructions; I turned direct ZZZZZ and contacted ZZZ Center and continued climbing to our assigned altitude; 7;000 feet. Soon after reaching 7;000 feet we were told to cross ZZZZZ at or above 6;000 feet (we may also have been cleared for the approach at this point; but I don't remember for sure). After confirming with my instructor; I set my altitude select to 6;000 feet and began a descent. As we descended my instructor cautioned me that we did not want to descend below 6;000 feet and then asked a question about our planned approach and I went to look at the plate in ForeFlight I managed to close the plate accidentally. As I bobbled with my tablet; I lost track of my altitude. At roughly the same time; I noticed I was too low; my instructor told me I needed to climb and Center called on the radio with an altitude alert. I immediately started a climb to 6;000 feet and then acknowledged Center's alert.Sometime around when we got back to 6;000 feet Center cleared us (possibly for the second time) for the RNAV Y Runway XX approach; again instructing us to cross ZZZZZ at or above 6;000 feet. I repeated the clearance; accidentally saying Runway XY. My instructor corrected me and I corrected myself to Center. I believe this is the point my instructor took over communications for the rest of the flight. As we approached ZZZZZ my instructor told me to turn right to intercept final. I did so and tracked lateral and vertical guidance; struggling with the vertical; in particular. At 1;700 feet; a little above the published DA; my instructor declared a missed approach and our intention to return to ZZZ. Tower acknowledged and told us to contact Center when we climbed past an altitude (I believe 5;000 feet); which we did. As we climbed towards 7;000 feet my instructor told me to fly direct ZZZZZ1 and then amended that to ZZZZZ2. During this he was programming something into the GPS and making it difficult to track the CDI so I just tried to maintain my heading and climb for themoment. I believe he had an exchange or two with Center in this time. Soon the GPS was programmed for ZZZ via ZZZZZ1 and I was flying that route.On the way back; we were asked to copy a number and contact Center on the ground. Subsequently; we were cleared for the RNAV RWY YY approach into ZZZ. We executed the approach and circled to land on RWY YY without further incident. When we contacted Center we were informed of three possible Pilot Deviations:The altitude excursion prior to ZZZZZ. Failure to do a Procedure Turn (PT) before turning on final at ZZZ2. Not mentioned by ATC; but we may have made the same error coming back to ZZZ. Failure to fly the published missed out of ZZZ2.Lessons learned. This flight was likely overly ambitious. We should have spent time getting me used to flying my airplane under the hood maintaining airspeed; course; altitude; making heading and altitude changes; etc. instead of jumping to a short cross country with two approaches in MVFR or to IMC conditions. It likely would have been wiser to scrub this flight rather than change the intended plan at the last minute. Given how long it has been since I flew in simulated or actual instrument conditions; a radical plan change at the last minute increased my workload and stress level beyond my current ability to compensate. I should not be so complacent. I flew under conditions that I would not have were I solo; even if I could have dodged around the IMC. I should not have divided my attention during the descent prior to ZZZZZ. Once there; I should probably have used the autopilot; or at least requested permission from my instructor; before messing around trying to get the approach plate back up. I could have requested delay vectors or; ironically; flown the published hold; if I needed more time. I should have questioned my instructor more about the PT/hold-in-lieu It showed up on the moving map. More generally; before we got into a position were we had to fly it; my instructor and I should have briefed the approaches into ZZZ1; ZZZ; and any other approaches we might have had to fly; making sure up front we knew what to expect; including missed approach procedures.

While conducting an IPC with my student who has not flow anything instrument related in 30 plus years were flying on a IFR flight plan from ZZZ to ZZZ via ZZZ2 for a practice approach on the RNAV. Although the weather conditions were not perfect; they were VFR with constant visibility to the ground. While en-route and approximately halfway between ZZZ and ZZZ2; ZZZ Center cleared us for the RNAV Y XX into ZZZ2 telling us to cross over ZZZZZ at or above 6;000 feet. My student read this back as 'Cleared RNAV XY' not XX. I corrected my student but Center did not. I have found this to be common as it could be heard as XY. While continuing to ZZZZZ; my student struggled to maintain altitude and was continually descending. I was advising him to watch his altitude and regain the 6;000 foot assigned clearance ATC gave us. He continued to descend lower and lower. I was struggling to get control of the airplane as he insisted; he had the situation control and guarded the throttle and stick preventing me from assisting. It should be noted that my student is a larger gentleman and I am a smaller person relatively speaking. His hand was guarding the single throttle tightly not letting go and I was struggling to move in the cockpit of the small aircraft to gain control of the airplane. By this time it was too late and ATC gave us the 'low altitude' alert over the radio. As ATC was contacting us I was forcing myself to add throttle and pull the stick back to regain the altitude lost abruptly and dramatically. This was deviation 1. The lesson here to myself; as somewhat new CFII with lots of experience showing people how to fly in VMC but not on an instrument flight plan; is to not let the students over power you. Seeing as this was a smaller airplane with dual controls although limited access; it is certainly a mistake I will not be making again. Further on in the flight; while approaching ZZZZZ and after getting the clearance to fly the RNAV Y XX into ZZZ2; my student and I discussed how to enter the approach at XXXXX seeing as it was an IAP. We both agreed that turning directly inbound to the final approach course of XXX was the correct choice and not flying the procedure turn. I personally settled on the choice for 3 reasons. Because in all of my experience flying; whenever ATC wants me to fly a procedure turn; they specifically ask or tell me to do so. Seeing as no notification was received on our end; the lead me to believe a straight in turn was desired. This includes flights with numerous other CFIIs; other pilots and even DPEs. I have actually asked this question to numerous CFIIs who taught me and all have agreed with the decision I made before this incident occurred. From our perspective; the turn was approximately 90 degrees and was by no means unsafe or reckless in any manner to make that turn. We were on the correct side to make a straight in approach and procedure turn would have been more unnecessary all things considering. The Garmin GNC 355 with an up to date database; said to make that turn. Not saying I am one of them; but I know several pilots who will do anything their GPS tells them to do. As I do not think this is wise; coupled with the previous two reasons; it cemented my choice to make that turn. Every approached; even GPS approaches like an RNAV should be backed up with the proper approach plates and proper procedure. However; if the GPS unit in the aircraft is the one displaying guidance and if it is giving information you truly do believe to be correct; it is hard to ignore it. That was deviation 2. While it is easy for me to say that this deviation was 100% not my fault; after going back and looking at resources like Flightaware and our ground track on Foreflight; it can be seen that the turn was more than 90 degrees and telling us that maybe something was not right. In hindsight and now be able to look at the regulations closer (AIM 5-4-9); we were supposed to fly the procedure turn. However; after watching over another CFII giving instruction from the back seat on the following day; this exact same thing happened on the RNAV [approach] into ZZZ3. They were cleared for the approach via ZZZZZ3 and no 'procedure straight in' instructions were given. Approach did not mention anything to them as if it never happened and is an acceptable procedure. Overall this error in flying the approach is on me. Plain and simple; I cannot blame anyone else for it. With that being said I know for a fact that I have been told by several other instructors and seen it done numerous other times with ATC intervention or no repercussions what so ever. A good solution to this problem would be to increase communication between pilots ATC to ensure that they are both on the same page when it comes to entering a approach at the angle we did. I should have contacted them and asked to clarify. That is on me. After crossing over ZZZZZ and continuing the approach everything went flawlessly. I told my student to relax; and to fly the approach as he has done in the past. Somewhere around the final approach fix; ZZZ approach handed us off to ZZZ. In this transmitting I specifically remember him saying 'talk to you soon' implying that we are going missed and he will pick us up on the missed approach. This would make sense as this is how we filed and we were cleared 'as filled' when we took off out of ZZZ. After being handed off to ZZZ2 tower and continuing the approach; we hit the minimums for our training exercise and flew out on published missed approach. It should be noted that we were never given any specific missed approach clearance implying that we fly the published missed. While going missed; we informed ZZZ2 tower and they said passing though 3;500 feet to contact ZZZ Center. When we came through 3;500 feet; we contacted center and they asked us if we intended to go back to ZZZ to which we said yes. In our reply I recall asking them if we are cleared direct ZZZZZ1 to which I heard a yes from center and responded by saying 'cleared direct ZZZZZ1'. As we started to fly direct to ZZZZZ1; Center came back and told us to fly the published missed. We re-scrambled our radios/nav at that time and did as instructed. This is when I realized that something had happened. This was deviation 3. The lesson here is that there was a breakdown in communication on what was expected from us on the missed approach. Seeing as we filed from ZZZ-ZZZZZ-ZZZ2-ZZZZZ1-ZZZ and we cleared for this; the idea of proceeding to ZZZZZ1 was fresh in our mind so when we heard that 'ready to go back to ZZZ' call; we asked for direct ZZZZZ1. What we heard; or thought we heard was obviously different than what we were cleared for. For this; I am equally in the wrong as everybody else involved. More clarification once again should have been made between our aircraft and the controller. To offer a little bit more context and a possible explanation for some of these events; I would like to back track and set the stage before the flight. Remember; this is not an excuse; only a possible explanation. After we got in the airplane and taxied out; did our run up; we were ready to get our IFR clearance. Note ZZZ is an uncontrolled airport. We tried for a few minutes on the ground to get a hold of ZZZ Center on XXX.XX. This almost always works and we can get the clearance and copy it down with easy and proceed as directed. This time; there was an issue where it appeared Center could hear us but we could not hear them. We tried several times then gave up and called the clearance delivery phone number. They informed us that they could hear us and to try again; so we hung up and tried again. We did this to no avail and could still not get them on the radio. We then called the number again and got our clearance that way. What this means to me is there was some sort of radio issues that were happening possibly before we even took off. Seeing as clearance delivery over the phone said Center could hear us; this was negated especially as the weather at this time was MVFR-VFR; and we proceeded with the flight. Looking back this could have been the root for some of the issues. What if some of our messages were not getting to center during the procedure turn issue or the missed approach instruction issues? The weather was hazy and the atmosphere was polluted immensely. Could this have been a part of the issue? If I am remembering events incorrectly; a different way or in a different order; that is totally possible. I am only human. But one thing I remember for sure from this entire flight was the lack of clear communication between our aircraft and Center. I make mistakes and I am more than happy to and willing to own up to those. But I can say with confidence that as a CFI; flying with a student who over powers the airplane and poor communication when ATC who thinks you are doing something and not confirming does not help. For me; the overall take away points from this flight is to really ensure both pilots have 100% clear and total access to the controls. This means as a CFI that you need to make sure your student knows when to listen and correct the mistakes you are pointing out OR give up flight controls to the CFI to correct them. Also; clarifying any and all procedures. Communication was poor and both parties were assuming something different 2 different times and neither clarified effectively. With that; I am glad nobody got hurt and it was all in VMC conditions executed safely. I really do appreciate the professionalism of ZZZ Center that day and at the very least pointing out or mistakes. Happy Flying.

Flight Instructor and student reported the student deviated from assigned altitude resulting in a low altitude alert from ATC; failed to perform the procedure turn on approaches; did not fly the published missed approach procedure and the student would not relinquish aircraft controls to the Instructor.

1018873

201206

1201-1800

DZJ.Airport

GA

0.0

VMC

10

Daylight

5500

CTAF DZJ

Corporate

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

1.0

Part 91

None

Passenger

Takeoff / Launch

Direct

CTAF DZJ

Personal

Small Aircraft

1.0

Part 91

Takeoff / Launch

Aircraft X

Flight Deck

Corporate

Pilot Flying; Single Pilot

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

Flight Crew Last 90 Days 300; Flight Crew Total 1100; Flight Crew Type 170

Training / Qualification; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1018873

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

Horizontal 40; Vertical 0

Person Flight Crew

In-flight

Flight Crew Rejected Takeoff

Airport; Human Factors

Human Factors

Back taxied Runway 8 and did a runup off the runway facing where I could see both approaches. Made every radio call including departure; entered runway and began takeoff roll. Approximately 1;000 FT down the runway cresting the hill I spotted a plane on the runway. He made no calls and I did not see him land. I retarded the throttle and braked hard. Asked UNICOM for a radio check and was told loud and clear. I was hard to make out the aircraft due to the heat rising off the runway. I back taxied again and after UNICOM assured me the plane was clear of the runway; I took off. The aircraft never made a call and did not circle the field to determine it was clear if he was not using a radio. The FBO wrote down their tail number but was unable to speak to the person. They did not shutdown and departed the airport shortly after I did.

PA32 pilot rejected the takeoff at DZJ when another aircraft was found to be rolling out from the opposite direction. A crest half way down the runway and heat shimmers make sighting the other aircraft difficult and communications were never established.

1490679

201710

1201-1800

ZZZ.Airport

US

0.0

Night

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

Passenger

Taxi

Commercial Fixed Wing

2.0

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1490679

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Ground Personnel

1490682.0

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

Horizontal 0; Vertical 0

Person Ground Personnel

Taxi

Aircraft Aircraft Damaged; Flight Crew Returned To Gate; General Flight Cancelled / Delayed

Airport; Procedure; Human Factors

Human Factors

Just prior to push; we received a runway change and First Officer (FO) was reprogramming Weight and Balance. I noticed the Ground Crew stopped our push a bit short. I looked around and saw that the aircraft that had pushed off Gate to our left was very close. I was not aware that they had pushed. I did not hear their Ramp call and the jetway blocked my view during their push. Our wingtips were possibly overlapping.A Ground Ops person was between the aircraft and was signaling the other Crew to hold their brakes by raising a closed fist. He did not cross his forearms in the standard signal. As the other aircraft made its left turn out; the Ground Ops person did not make any overt signals for them to stop. My assumption was that he was marshalling and that there was clearance between the two aircraft; so I made no attempt to contact the other aircraft via radio. The other aircraft taxied out and there was no indication of contact.The Ground Ops person that appeared to be marshaling the other aircraft then came to our aircraft got on the headset and told us that the other aircraft and ours touched winglets. We returned to the gate; shutdown; and made a visual inspection of our aircraft with Maintenance. There was no indication of damage to our aircraft.During the discussions after we returned to our gate; the Agent told the First Officer that he noticed the Push Crew pushed our aircraft approximately eight feet to the west of our J-line. This was not apparent to us from the flight deck.We contacted Dispatch and Maintenance. After deplaning; completing the logbook entry; and discussing the situation with the Operations Center; the Chief Pilot on Call released us to continue the flight on a new aircraft.The other aircraft proceeded to take off and was recalled. Union Safety contacted me the next day and told us that no damage was found on either aircraft. While it was close; the two aircraft did not actually touch.

[Report narrative contained no additional information.]

The flight crew of a Boeing 737 reported that during push-back an adjacent aircraft was also being pushed-back and the winglets may have touched.

1605335

201812

0.0

Air Carrier

No Aircraft

Company

Air Carrier

Dispatcher

Dispatch Dispatcher

Time Pressure; Workload

1605335

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

Person Dispatch

In-flight

General None Reported / Taken

Company Policy; Human Factors

Company Policy

I believe with the new workload system in place I temporarily lost operational control of the desk this morning. I do not remember the exact amount of flights I took over; but after I completed my 'self-brief' I immediately began sending updates to my airborne flights about weather / turbulence and PIREP information for ahead. There was a low pressure system over the southeastern U.S. and at least 3 SIGMETS for MOD-SEV Turbulence across the Great Lakes and Ohio River Valley (FL270/370) as well as out west across the Front Range (FL170/380). With a great amount of PIREP and altitude change information coming through [my display]; I made sure I passed along as much information to my crews as I could. The amount of work as well as the geographical location of the flights on the desk was an issue. Especially with the amount of turbulence and the fact desks were recently closed. With the new workload distribution system that took effect [recently]; dispatchers are planning flights all over the Continental U.S.; Mexico; and Canada without a regional focus. Now they are responsible for all of the WX and NOTAMS for every hub; more messages; alerts; and out-stations than what we had before. [Dispatch and Flight Planning systems] had latency issues right when I was busy releasing a bank of early morning departures. The Chief Dispatchers were aware of the issues and had also 'rebalanced workload across all the open Domestic desks.' Around the same time; I also had another flight return-to-blocks for a passenger with a medical issue. With approximately 4 flights to plan per hour [during the early hours of the morning]; all of the [flight planning system] issues; SIGMET changes; turbulence reports; and ACARS messaging to crews; I missed a few important SIGMET updates to crews (timing - as they were past a particular SIGMET area - or didn't pass along info in what I thought was ample time for crew to inform passengers). I also feel that I didn't have the time to completely read and ingest all of the ATC updates. I missed an ATC Advisory for a re-route and in turn released this flight without knowing that I had previously acknowledged the ATC Advisory.I was also pressed for time when my [morning] relief came in and I could only provide a 'Verbal Shift Briefing.'At the end of the shift I looked back and realized how busy I was over the past 8 hours. I felt like I had temporarily lost control of my operation on the desk at times due to the amount of workload and weather issues at hand. Other Dispatchers felt the same way; but with little time to even take screen shots and document these issues; I'm afraid no-one else with use the reporting system for this issue. Safety is the number one goal. We need to be able to safely do our job; not be set-up to fail.

Air Carrier Dispatcher reported that a new procedure resulted in increased workload causing temporary loss of operational control.

1356752

201605

0601-1200

LAS.Airport

NV

40.0

Windshear

Daylight

Tower LAS

Air Carrier

Airbus 318/319/320/321 Undifferentiated

2.0

Part 121

IFR

Passenger

Landing

Class B LAS

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

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

Party1 Flight Crew; Party2 Flight Crew

1356752

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Aircraft; Weather; Procedure; Human Factors

Ambiguous

FO's (First Officer) landing into LAS. [The First Officer] used config 3 and added 5 knots to Vapp because of a gusty crosswind on runway 25L. The wind was reported as 190/10 gust to 18 on ATIS but the tower's last report was 190/9. Everything looked great until about 40 feet when it appeared we had a 'sinker' setting in. The first officer mechanically retarded the autothrust at 30 feet anyway and exacerbated the sinker. [The First Officer] decided to arrest the descent by over-rotating the airplane. I had time to say 'Pitch' only once before the auto pitch call out occurred. We were in quite a crab with a high rate of descent so my primary attention was outside. The touchdown was normal but quite nose high. The ACARS report said the pitch attitude was 8.1 degrees.We pre-briefed the gusty crosswinds; landed with config 3 which produces the most tail clearance and added an extra five knots to Vapp. It was quite honestly too late for me to take action. I was a check airman for many years on a different airplane and know firsthand that at some point in a landing; the situation is not salvageable. This was that time. [The First Officer] obviously didn't detect the 'sinker' and certainly shouldn't have retarded the thrust. We discussed different strategies to prevent another occurrence like this. As mentioned above; we discussed some techniques to prevent this from happening again. I don't think [the First Officer] was looking far enough down the runway to detect the 'sinker.' I also asked if [the First Officer] had ever landed with the autothrust off and the reply was no. This is a huge gap in our Airbus pilot's skill set. I almost always land with the autothrust off in gusty conditions so that I am 'connected' to the airspeed and sink rate trends. With the autothrust on; it is impossible to add thrust in the flare to counteract that dreaded 'sinker.' I rarely fly with pilots comfortable enough in the jet to turn the automation off and be pilots. This is a frightening trend.

An Airbus A320 series First Officer over rotated during a LAS crosswind landing after the 'bottom fell out' in the flare with autothrottles off. ACARS reported an 8.1 degree pitch angle.

1763132

202009

1801-2400

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 In Charge

Flight Attendant Current

Deplaning; Boarding; Safety Related Duties; Service

Communication Breakdown; Distraction; Other / Unknown; Troubleshooting; Workload

Party1 Flight Attendant; Party2 Other

1763132

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

Y

Person Flight Attendant

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

General None Reported / Taken

Environment - Non Weather Related; Human Factors

Human Factors

When working I gently remind passengers that are not compliant with face masks/coverings of our policy as they're boarding the aircraft. It is also something that's included in our announcement before departure and our welcoming/safety announcement. When working AFT I actively check for mask; bag; and seat belt compliance prior to closure of the boarding door. I also ask the flight deck to make an announcement regarding face masks and to ensure coverage of both nose and mouth is included so that we are all unified. All gate agent pre-boarding announcements and Flight Attendant announcements should be updated to specify that passengers must cover their nose and mouths throughout the full duration of flight unless actively eating or drinking.Passenger X (X1) was the last passenger to board. The gate agent waited 10-15 minutes for this passenger. She mentioned that she reminded this passenger regarding mask compliance at the gate; however I was unaware until I saw her in passing between flights. I reminded this passenger to comply with his mask during boarding. Once the boarding door was closed the AFT FA asked the passenger to turn his phone on airplane mode and to disconnect his call. He complied until she walked passed and got directly back on the phone all through our safety demonstration. The non-revenue FA that sat in row X in front of the passenger rang the FA call button before I took my jumpseat to discreetly inform me that he was still on his cell phone. I glanced back and he was indeed holding a full conversation on his cell phone. I was unaware that the AFT FA had already asked him to end his call. He complied and I witnessed him turn his phone on airplane mode. I also asked this passenger to wear his mask properly and informed him that after I'd have to share our final warning. The non-revenue FA in row X rang me again to inform me that as soon as I took my jumpseat this passenger took another call and talked until his phone disconnected at 10;000 feet. During the duration of our flight this passenger manipulated the mask policy with food/beverages and was being completely rude towards me during the duration of our flight something the non-revenue FA witnessed also. Upon landing he positioned his mask to cover his mouth only intentionally. He became; loud; frustrated; combative; and used profanity when I kindly asked all passengers to take their seats during deplaning. He tried rushing to the aisle to exit the aircraft. He Immediately stormed off the aircraft. The non-revenue FA complimented me on how I handled everything. I also informed the flight deck.

Flight Attendant reported a passenger did not adhere to the cell phone or face mask policy. FA stated the passenger was rude; loud; combative and used profanity.

1105680

201307

1201-1800

FWA.Airport

IN

1520.0

Daylight

Tower FWA

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC; GPS

Initial Approach

Other RNAV Runway 23

Class C FWA

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Confusion; Distraction

1105680

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

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

Chart Or Publication; Procedure

Chart Or Publication

The flight was assigned the RNAV 23 approach to Runway 23 into FWA. The Commercial Plate has an ambiguous note. The black circle 2 note on the 12-3 plate states 1;520 FT applies to LNAV only approaches but it is not possible to ascertain exactly how it applies to the LNAV only approaches. The NOS charts show that there is a level off at 1;520 FT between AKEWS and BABAC and that level off is not depicted clearly on the Commercial Chart. One could assume from the Commercial Chart that 1;520 FT is required but is not clear which point to which point that altitude would apply. The Commercial Plate should be revised to clearly denote 1;520 FT is a level off altitude between AKEWS and BABAC for LNAV only approaches as well as the MDA of 1;300 FT after BABAC.

The reporter believes that the descent constraint at BABAC with Auburn's altimeter setting is 1;500 FT and then a descent to 1;360 FT is permitted as the VNAV minimum. There is a great deal of confusion about this approach and it should be clarified and republished.

An air carrier Captain on the FWA RNAV 23 was confused by the Commercial Chart Note 2 which constrains a descent at BABAC to 1;500 FT when using the Auburn altimeter setting but does not clearly indicate what the descent minimum is after BABAC.

1568796

201808

0001-0600

ZZZ.Airport

US

16000.0

VMC

TRACON ZZZ

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Climb

Class E ZZZ

MCP

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 1206

Workload; Troubleshooting; Distraction

1568796

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 1334

Workload; Distraction; Troubleshooting

1568801.0

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Overcame Equipment Problem; Flight Crew FLC Overrode Automation; Flight Crew Requested ATC Assistance / Clarification

Aircraft

During climb out of ZZZ at 16000 [and] cleared to FL360; altitude control knob on FCU broke off at FL270 as Pilot Monitoring was setting altitude to FL360. [We] notified ATC that we needed to level off initially at FL270 to investigate the problem; aircraft leveled off on autopilot with no issue. [We] could not reattach knob to change altitude on FCU so asked for a block altitude of 270-280 in order to use VS to climb. Aircraft started climb; so [we] requested FL360 and was granted climb. After 200 feet altitude alert warning horn came on and wouldn't silence so [we] requested descent back to FL270 and was approved. At approximately FL280; warning horn ceased so [we] requested FL280 as final and was approved. VS was only mode working to change altitude. Speed and NAV were both working on autopilot. [We] checked with Dispatch for fuel burn and checked weather along route and decided to continue on to destination. No issues enroute with autopilot and VS mode kept altitude at FL280 with no problems. Contacted Fleet Coordination and Maintenance about problem and asked if there was a circuit breaker we could pull to silence the altitude warning during descent. They said no. [We] reviewed [the] flight manual about warning horn and decided on slowing down and dropping gear early to silence the warning during the descent. [We] also asked ATC for direct routing to IAF to minimize level offs on descent and to save fuel. This was granted. [We] started descent and warning horn sounded as predicted. Pilot Monitoring then said 'let's try ECAM emergency cancel' which silenced the warning; so [we] continued descent at 240 knots with speed brakes deployed. [We] started to get high on descent because [we] planned on descending with landing gear deployed; so [we] put gear down early about 12000 feet to help descent. [We] had to avoid some weather on descent and used some S turns to get on profile. VS and autopilot [was] used during descent until on final for visual Runway XXR at ZZZ1.Work load was very high using VS. As not to over speed gear or flaps; [we] monitored glide path [and] clicked off autopilot and auto throttles at approximately 3000 feet when field was in sight. This actually reduced workload and allowed me to get on profile faster. Still; [we] were a little high but stabilized at 500 feet and landed with no further issues. No emergency was declared or limits exceeded; but profile was high on descent and workload was very high especially since we were delayed over 4:30 hours and ended up landing 52 minutes before 12 hour duty day. I did not think the emergency cancel would silence the landing gear warning horn and it is not listed in the landing gear warning section of the flight manual as a way to silence it; but [I] should have known that and it would have helped in descent planning. Also; we could not find any reference to this particular situation in the QRH or flight manual.

[Report narrative contained no additional information.]

A319 flight crew reported the altitude select knob on the Flight Control Unit (FCU) broke entirely off.

1011154

201205

1201-1800

SJC.Airport

CA

Tower SJC

Air Carrier

B737-300

2.0

Part 91

IFR

Passenger

Initial Climb

Class C SJC

TRACON NCT

Skyhawk 172/Cutlass 172

1.0

Part 91

VFR

Descent

Class C SJC

Facility SJC.Tower

Government

Local

Air Traffic Control Fully Certified

Confusion; Situational Awareness

1011154

ATC Issue All Types; Conflict Airborne Conflict

Person Air Traffic Control

In-flight

General None Reported / Taken

Procedure; Human Factors

Human Factors

Runways 30L/30R were in use at SJC. I took a point out from Lick Sector on a VFR Skyhawk 10-miles to the southeast of SJC; tracking northwest toward SJC with destination SQL or PAO airport. When the Skyhawk was 2-3 miles east of SJC at 2;000 FT MSL; the aircraft was tracking in a direction that would place it over mid-field SJC airport; so as to not be a factor for jet aircraft departing Runway 30R at SJC. The Skyhawk was on an 'N' tag as it approached SJC; indicating that Moffett (NUQ) would soon be in control of the aircraft. At this time; a B737 was told about the VFR Skyhawk at 2;000 FT; and that it would pass behind. The B737 was cleared for take off. After the B737 began its take off roll; the Skyhawk was observed making a right turn; tracking northbound instead of continuing its previous track toward NUQ as expected. I called NUQ and asked if they were talking to the C172; to which they replied negative. At the time the B737 was lifting off Runway 30R; the C172 was on the north side of the Runway 30R departure corridor; tracking north at 2;000 FT MSL. I then told the B737 that the traffic was passing off their right side; no factor; and to contact Norcal Departure. I told the B737 that traffic was no factor based upon the RADAR track of the C172. After the B737 was switched to Departure frequency; the RADAR track for the C172 immediately; and unexpectedly; began to turn toward my departure corridor; and toward the B737. I called Toga Sector; the sector who would be talking to the B737; to inquire about the C172 and advise them that I was not talking to the C172. Toga was not talking to the C172; nor was NUQ when I called Moffett back. Norcal later called SJC Tower to let us know that the C172 was instructed to cross SJC midfield westbound; as I had expected. Norcal said that the pilot of the C172 may be issued a pilot deviation. The RADAR targets of the two aircraft did not merge; however the proximity of the C172 to the B737 may have caused alarm for the two pilots. When I accepted the C172 point out from Norcal TRACON; I expected that the TRACON would keep the C172 clear of the departure corridor; because I had obtained releases for several jet aircraft which would fly through that protected corridor. I continued departures based on the fact that I had these releases and based on the track of the C172. The C172 made an immediate; unanticipated course change toward the B737; which was not evident on the RADAR when the B737 was changed to Departure frequency. I will exercise additional vigilance when aircraft are operating near my departure corridor; and I will remember to factor in the possibility of unexpected pilot actions; especially when I am not in direct communication with them. When communicating 'traffic no factor' I will remember to take into consideration that a RADAR track is slightly delayed information and that slower aircraft can change course much more rapidly than faster aircraft.

SJC Controller described a conflict between a VFR point out from NCT and an IFR Air Carrier departure from Runway 30R; the VFR traffic apparently not complying with airport crossing instructions.

1317374

201512

0001-0600

ZZZ.Airport

US

0.0

Night

Air Carrier

B737-700

Part 121

Parked

Fuel

X

Failed

Gate / Ramp / Line

Air Carrier

Airport Personnel; Ramp; Vehicle Driver; Technician

Maintenance Airframe; Maintenance Powerplant

Situational Awareness; Training / Qualification

1317374

Deviation / Discrepancy - Procedural Other / Unknown; Ground Event / Encounter Other / Unknown

N

Person Maintenance

Pre-flight

Aircraft Aircraft Damaged; General Maintenance Action

Equipment / Tooling; Human Factors; Procedure

Equipment / Tooling

I drove a tug out onto the ramp to pull and refuel carts. I saw a heat cart on fire next to the left side of the aircraft and drove towards it. I called on the radio for somebody to call the fire department that there is a heat cart on fire. When I got to the scene I saw a work truck with a fuel cart attached to the vehicle next to the burning heat cart. I saw [an employee] using a fire extinguisher to put out the fire. Our shift manager was on the radio saying get away from the fire. I was going to drive away with the work truck that had the fuel cart attached to it but the fuel nozzle was still attached to the heat cart that was on fire. I was afraid the fuel nozzle was still pumping fuel. I saw [someone] walk to us with a fire extinguisher and began to put out the fire. Then I saw [the first employee] hit the fuel nozzle with the fire extinguisher and the fuel nozzle detached from the aircraft and when I saw the fuel nozzle was not pumping fuel; I then got into the work truck and drove away with the fuel cart attached to a safe distance. I saw the fire department arrive and extinguish the fire.[We need] better maintenance of heat carts and better fueling procedures.

Mechanic witnessed a heat cart catch on fire while still next to an aircraft. Nearby ground personnel and firefighters were able to respond quickly to extinguish the fire.

1476072

201708

0601-1200

ZZZ.ARTCC

US

26000.0

VMC

Daylight

Center ZZZ

Air Carrier

Super King Air 350

2.0

Part 135

IFR

Passenger

FMS Or FMC

Cruise

Class A ZZZ

Pressurization Control System

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 150; Flight Crew Total 1800; Flight Crew Type 700

Situational Awareness

1476072

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

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Aircraft Equipment Problem Dissipated; Flight Crew Overcame Equipment Problem; Flight Crew Took Evasive Action

Aircraft; Human Factors

Human Factors

My First Officer (FO) and I experienced a sudden depressurization of the cabin while at FL260. We first experienced the pressures difference in our ears followed by seeing the cabin altitude VSI go to a sudden climb greater than 3;000 feet per minute and the cabin altimeter increasing. We then got both the red 'CABIN ALT HI' annunciation and white 'CABIN ALT' annunciation.FO was the pilot flying; I took controls and operated the radios and we proceeded by donning our oxygen masks; [advising ATC] and starting a descent down to 14;000 feet with vectors for the terrain. Air Traffic Control informed me of the altimeter setting for [our location] and I put it in my altimeter. In the descent FO got out the QRH to run the 'loss of pressurization' checklist. I asked him to check the dump switch. He noticed the switch was in the 'DUMP' position. He informed me and then cycled the switch through the 3 positions and back to the normal operation position. At the start of the flight we had 1700 pounds of oxygen; in the descent we noted we still had 1000 pounds of oxygen remaining which was a sufficient amount to make it to [destination]. Upon reaching 14;000 feet we leveled off and the cabin stabilized back to a normal cabin altitude. We notified the passengers of the situation and followed all or descent checklists. We [advised ATC] and requested to climb back to 16;000 feet in order to proceed back direct [destination]. From this point on the flight proceeded as normal with no further issues.Upon reaching [our destination] I spoke with the passengers about the situation. Everyone seemed a bit noticeably shaken but in good spirits everything was okay and we were on the ground. I informed dispatch of the situation and contacted maintenance.In debriefing after the flight neither FO nor I know how the 'Dump Switch' could have been moved to the 'DUMP' position. Noting; at the time of depressurization neither I nor FO's hands were [anywhere] near the switch. The cause for depressurization is not known to us; but considering we had no 'BLEED AIR FAIL' annunciation and the cabin re-pressurized when leveling at 14;000 feet the switch is the only possible determination.

A King Air 350 Captain reported that while in cruise they experienced a sudden loss of pressurization in the cabin.

1470548

201707

1201-1800

EWR.Airport

NJ

15000.0

VMC

Daylight

Center ZNY

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC; GPS

Climb

Class E ZNY

UAV - Unpiloted Aerial Vehicle

Other 107

Cruise

Class E ZNY

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 989

Distraction

1470548

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

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Environment - Non Weather Related

Environment - Non Weather Related

I was the flying pilot departing EWR momentarily level at 15;000 before resuming our ATC climb past Colts Neck (COL) VOR when I saw a bright flash at my 2 o'clock position that caught my attention. I looked over towards the bright and highly reflective object. I tracked the path/trajectory and it appeared to be relatively level traveling opposite direction and below our flight path. It passed below and outside of the right engine nacelle about midway out from the length of the right wing. It was highly reflective and shimmering so I could not get a clear image of it relative size and shape. However; it appeared to be the size of a football with a fairly stable trajectory. I looked back towards the Captain and the jumpseater and said 'did you see that?' The jumpseater said that he did and the Captain indicated that he did not. The jumpseater and I said it looked like or could be a drone. Our assumption. The best I could compare it to visually was a flare with its highly reflective appearance but a smooth (not random or wobbly) level flight path whizzing by us at a consistent speed. I could not see any identify features; such as rotors; paint color; or markings.

B737 First Officer reported a shiny object passed very close to the right engine while level at 15000 ft during an EWR departure.

1730759

202002

1201-1800

ZZZ.Airport

US

0.0

VMC

7

Daylight

14000

CTAF ZZZ

Personal

PA-18/19 Super Cub

2.0

Part 91

VFR

Training

Landing

Class G ZZZ

Aircraft X

Flight Deck

Personal

Instructor

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

Flight Crew Last 90 Days 97; Flight Crew Total 326; Flight Crew Type 23

Situational Awareness; Training / Qualification

1730759

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

Person Flight Crew

Other Landing

Aircraft Aircraft Damaged

Human Factors

Student was working on a tailwheel endorsement. The initial touchdown was smooth in the three point attitude. The student relaxed the elevator pressure; the instructor failed to catch it and the aircraft started side loading. The aircraft then went off the runway hit a berm and caused a prop strike.

An instructor pilot reported the student lost control of the aircraft during landing resulting in a prop strike and the aircraft running off the runway.

1496878

201711

1801-2400

GEG.TRACON

WA

5000.0

Marginal

TRACON GEG

Military

Stratotanker 135

IFR

Training

Final Approach

Vectors

Class C GEG

Facility GEG.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Workload; Situational Awareness; Time Pressure

1496878

Facility GEG.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Workload; Situational Awareness

1497137.0

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; Air Traffic Control Issued Advisory / Alert

Airspace Structure; Staffing; Procedure; Human Factors; Company Policy

Airspace Structure

I was called in to work handoff position because the Radar position had gotten busy. I ran into the TRACON to open the position. I did not receive a briefing because the Radar Controller was busy working traffic and hadn't had a moment. I opened the position and started helping by updating data blocks and answering coordination. I was looking at all the traffic when I noticed an [Aircraft] at 5000 feet about to enter a 5500 foot Minimum Vectoring Altitude (MVA) when I said climb him and pointed at him. The controller gave them an immediate climb to 6000 feet and eventually 7000 feet but the aircraft entered the MVA as they were initiating the climb.Contributing factors would be that Handoff position probably should have been open earlier in anticipation of the traffic. This would have allowed time for a briefing. The Tower Radar was out at a satellite airport requiring more coordination than normal. The weather had just gone from VFR to MVFR as the ceiling was lowering; increasing workload due to Instrument Approaches instead of Visual Approaches. I recommend our facility make a practice of keeping Handoff for Radar open; or at least having it open when equipment outages cause increased workload. Especially when weather deteriorates.

Looking back on the Falcon replay it didn't look like I was as busy as I felt at the time. When I originally started; I had a handoff position who closed the position to go home. As the traffic started to pick up again; I asked for a handoff but still felt like I was a little behind after the handoff started working. [An Aircraft] was in the radar pattern doing practice approaches. I put him on a 360 heading to gain some spacing and got distracted by a departure that was in conflict with 2 other aircraft. I went back to the tanker; turned him towards final; and then realized he was going into the 5500 foot Minimum Vectoring Altitude (MVA) at 5000 feet so I climbed him. I should have issued a low altitude alert and I don't know why I didn't. I usually respond quickly with that kind of thing but I'm wondering if the MSAW (Minimum Safe Altitude Warning) had alarmed maybe; I would have? I also wonder why the MSAW did not alarm? I will consider just climbing a tanker in the pattern if I am giving a vector in that direction from now on; if traffic permits. Although it was completely my mistake I think the MSAW should alarm in these situations. Also; I think as a facility we are getting busier and the traffic is somewhat unpredictable. I think we need to consider either having handoff positions open or the 2 radar sectors split more often; especially when the military is doing practice approaches.I have been guilty myself of thinking we wouldn't be busy; closing certain positions and then everything blows up. Also; I would like us to have a military flying schedule. When I first got here we had one every week and would staff the positions accordingly when we knew the tankers would be practicing. I've asked management about this and they said the military is not willing to give us a schedule anymore because of 'security' reasons. We all have security clearances here so this should not be an issue in my opinion.

GEG Radar Approach controllers reported their sector vectored an aircraft below the Minimum Vectoring Altitude.

1037675

201209

1801-2400

ZZZ.Airport

US

2800.0

TRACON ZZZ

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

1.0

Part 91

IFR

Final Approach

Direct

Class C ZZZ

Facility ZZZ.TRACON

Government

Approach; Departure

Air Traffic Control Fully Certified

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 ATC

1037675

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

Person Air Traffic Control

In-flight

General None Reported / Taken

Human Factors; Procedure

Procedure

Two aircraft requested IFR practice approaches to the airport. Both wanted the RNAV 4L approach with missed approach clearances. There was little sequencing that needed to be done. However according to the flips today the approach plates changed dramatically. I cleared both aircraft to the east side T fix ABCDE and issued an approach clearance. I even referenced the SAIDS approach plate to ensure accuracy. According to the new flips that T fix no longer exists. Later in the day I became aware of this and notified management who had no idea there was changes. In fact no one at the facility had any idea that there was a change. There was also nothing in any briefing items notifying any change. Notify controllers when there are significant changes to instrument approaches.

Approach Controller cleared two aircraft to a 'T' fix on an RNAV procedure only to later discover that the 'T' fix was removed from the approach on a recent procedural change.

1292898

201509

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Switch

X

Aircraft X

Flight Deck

Air Carrier

Captain

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

Flight Crew Last 90 Days 235; Flight Crew Total 26500; Flight Crew Type 18500

Situational Awareness

1292898

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

Person Flight Crew

Pre-flight

General None Reported / Taken

Human Factors; Procedure

Ambiguous

Cockpit switches and MX personnel procedures for work in cockpit.[I] have received numerous aircraft over the last year that the white tip on switches are covered in gunk and grime. While a little is not uncommon; now the switches are covered in oil; grease; and hydraulic fluid to the point they are falling apart and feel greasy. Once again with maintenance working multiple issues on the aircraft [there's the] occasional problem. What I have noticed now is that maintenance personnel are starting to wear gloves to prevent them from getting their hands too dirty. That being said we don't know when the last time they changed their gloves and if they had been working a lavatory or hygiene issue; it has now been brought into the cockpit and deposited on all the switches. I don't know how often all the controls in the cockpit are cleaned but based on the appearance of the switch controls I see it is very seldom.

An air carrier pilot reported a concern about the transfer of unhealthy fluids to the switches and other areas of the flight deck by Maintenance personnel.

1434404

201703

1201-1800

A80.TRACON

GA

13000.0

VMC

TRACON A80

Air Carrier

A319

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

STAR DRMMM1

Class E A80

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1434404

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1434409.0

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

Person Air Traffic Control

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented

Human Factors; Procedure

Human Factors

Descending via DRMMM1 arrival we contacted ATL approach with our ATC assigned speed of 310 kts and clearance to cross DRMMM at 13000'. Approach told us after what we perceived he had said as RAIIN slow to 250 kts. The first officer read back the restriction as RAIIN after a short confirmation discussion between ourselves. After passing DRMMM ATC asked to confirm we were slowing to 250 kts. We told them we thought he had said RAIIN and ATC said slow to 250 kts now.There is no phonetic correctness to pronunciation of intersections. Center in our descent I believe pronounced DRMMM as 'Drum' while the approach controllers were pronouncing the same intersection as 'Dream'. I believe Drum would be appropriate for literal translation of this intersection since no vowel exists between R and M. So when we were told to slow at 'Dream' we mistook it for the next closest pronunciation on the STAR as RAIIN. It doesn't help matters here when all the arrivals are NOTAMed to disregard all altitudes and air speeds on the chart they will be assigned by ATC. This takes all the predictability and fore planning out of the arrival briefing and with arbitrary interpretation of the pronunciation of the intersections leaves open a myriad of possible problems. Also with the intersection depicted on the STAR as 280kts there was also no thought given to the possibility of being that slow at that point. It's almost to the point where all intersections need in small print under the intersection of how all of us are to pronounce the intersection ATC and pilots alike.

[Report narrative contained no additional information.]

A319 flight crew reported missing a speed restriction on the DRMMM1 arrival into ATL when they misunderstood a Controller's pronunciation of DRMMM intersection.

1206147

201409

1801-2400

MSO.Airport

MT

IMC

Night

TRACON GEG

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Localizer/Glideslope/ILS Runway 11; VOR / VORTAC MSO

Initial Approach

Class E GEG

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1206147

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Situational Awareness; Training / Qualification

1206146.0

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Executed Go Around / Missed Approach

Procedure; Human Factors; Weather

Human Factors

I was the pilot monitoring while my First Officer (FO) performed the VOR DME B approach to Runway 29 in MSO. We had requested and were proceeding via JEPSN IAF. The controller left us high and then vectored us east of course after crossing JEPSN. He then had us rejoin the course but the FO had difficulty capturing the VOR due to distraction with altitude loss; crosswinds (45 knots direct crosswind); forgetting the spoilers were extended and going to green needles. He was unable to get centered and capture course on the final approach course prior to the FAF and I called missed approach. He did not call out the profile but seemed confused. I then called the profile calls out and helped him with the go around. I reported a missed approach with approach control and he vectored us around to try again. We discussed the course deviation and altitudes on the approach and he attempted the approach again. This time he was able to capture the course. Although the VOR was captured; the aircraft was 'swimming' on course to counteract the changing winds. In his early level-off at STEVI intersection; I was cross-checking the next step down at ERRIK (as he was getting behind the aircraft) when he got the stall stick shaker for a second as his trend vector decreased and he was slow to add power. He called MAX THRUST and after gaining speed; I called GO-AROUND/MISSED APPROACH. He was again slow to respond and had trouble leveling off and following ATC directions. I put the autopilot on; requested the ILS Z Runway 11 approach and took control of the aircraft. Fuel was estimated to be above minimum fuel per SOP at landing after the ILS approach. I briefed and set-up the ILS approach and landed safely in MSO. Factors: ATC vectoring and high altitude assignments. First officer lack of judgment due to unstable approach. First officer lack of profile knowledge and execution. Nighttime IMC in mountainous terrain. Crosswinds on complicated non-precision approach. Suggestions: Performing circling approach; namely this approach in simulator training. Stressing importance of missed approach/go-around profile in approach briefings.

On approach into Missoula we asked for direct JEPSN which is a IAF for the VOR DME-B approach into MSO. On the first attempt approach vectored us off course and gave us a descent and I thought he was bringing us down on vectors to the runway since we were under radar contact with Spokane. Instead he vectored us back on to the approach and in my confusion I didn't properly setup the approach since he put us right over the final approach fix and didn't give much time to do so. With strong winds and poor vectoring we were not able to complete the approach stabilized so we executed a missed. We were vectored out to the east to attempt again and were able to capture the course but in the descent it was swimming back and forth with the winds which was distracting. As I was leveling off the airspeed dropped off and the trend vector was increasing rapidly as I was bringing in power. The stall shaker went off and kicked off the autopilot and I put in max thrust as my CA called for a go around and we went back on with approach to try for the ILS Z RWY 11 which was successful and landed above minimum fuel.With the first approach was initially my misunderstanding of what the controller was going to do and then having them vector us right over the FAF without being able to properly get setup for the approach. On the second attempt the main problem was that I was distracted with the wavering of the autopilot trying to stay on course and I let the airspeed drop out to fast on level off as it was all happening at the same time.Always be prepared for missed approaches and possible odd ATC commands. Don't just assume they are going to do what you think they are; always ask if you aren't sure.

CRJ-200 flight crew reported an unstable approach with speed and altitude deviations to MSO. Weather; ATC procedures; and First Officer inexperience were factors in this report.

1275837

201507

1801-2400

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Corporate

BAe 125 Series 800

2.0

Part 91

IFR

Ferry / Re-Positioning

Takeoff / Launch

Engine Control

X

Failed

Aircraft X

Flight Deck

Corporate

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Time Pressure; Confusion; Workload

1275837

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Workload; Confusion; Time Pressure

1275836.0

Aircraft Equipment Problem Less Severe

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft

While on the takeoff roll on runway 16 at Airport ZZZ we experienced an engine rollback at approximately 95 KIAS. Upon discovering the engine rollback; I commanded the pilot flying to abort the takeoff. I then advised ATC that we were aborting on the runway. At this point I wasn't completely sure what had just happened because I didn't hear or see anything that would obviously indicate an engine failure (red annunciator lights; loud bangs etc.) and when tower inquired as to what had happened; I first said; I'd get back to them as to the nature of our abort. Tower then instructed us to exit the runway onto taxiway X and taxi to the FBO. After clear of the runway; I took a moment to scan the annunciator panel and discovered the number 2 engine computer indicated that it had failed. I advised tower that it was an engine computer issue and that we'd not need any further assistance. We contacted ground control and taxied to FBO uneventfully then contacted flight tracking and maintenance control to coordinate our flight cancellation and repairs.

During Takeoff Roll after the 80 knot call out (around 100kts) the Right engine rolled back and the rudder bias activated.

HS 125-800 experienced an engine rollback during takeoff resulting in a high speed rejected takeoff. This was caused by an engine computer failure.

1823198

202107

1201-1800

ZZZ.TRACON

US

12000.0

VMC

Temperature - Extreme

Daylight

TRACON ZZZ

Air Carrier

Regional Jet 900 (CRJ900)

2.0

Part 121

IFR

Passenger

Climb

Vectors

Class B ZZZ

Pneumatic Valve/Bleed Valve

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

1823198

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

N

Person Flight Crew

In-flight

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

Aircraft

During the climb out we experienced a L BLEED DUCT warning message. The First Officer was the Pilot Flying. He remained on the controls and radios while I ran the appropriate checklists and made the necessary communications to the crew; the passengers; and the company. [We advised ATC] and we were given priority handling back to land at ZZZ. The temperature in both the cabin and the cockpit reached 40 degrees Celsius because we were unable to maintain an open engine bleed valve. The warning occurred at approximately 12;000 feet MSL. We immediately got a clearance to descend below 10;000 feet MSL as pressurization could not be maintained. We then only had ram air to cool the cockpit and cabin. We landed safely on runway and taxied directly to gate where the passengers were deplaned through the normal method.

CRJ-900 Captain reported a loss of cabin pressure and inability to control cabin temperature; resulting in an air turn back.

1225065

201412

1201-1800

MIA.Airport

FL

2000.0

TRACON MIA; Tower MIA

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Localizer/Glideslope/ILS Runway 26R

Initial Approach

Class B MIA

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying

Confusion; Workload

1225065

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

Person Flight Crew; Person Air Traffic Control

In-flight

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Procedure; Human Factors

Procedure

MIA landing west. From Curso 2 RNAV ARR; on initial contact; Miami Approach control assigned vectors to LOC DME RWY 26R. We were vectored north of the field on a right downwind. Right base turn was outside HINKU; then we were cleared to intercept 26R localizer at 3000 FT. We intercepted the LOC; but when inbound noticed spacing with preceding aircraft was approximately 3 nm (on TCAS). Approach then assigned a left turn heading 240 while advising us we would be brought back on downwind for the approach; which we presumed was for separation. After being established on a 240 heading (south towards active RWYs 27 and 30) we received an unexpected/conflicting clearance to turn back right to intercept the 26R LOC. By this time we were inside HINKU; still at 3000 feet; without approach clearance; and judging whether or not to continue the approach or request additional vectors. We were then cleared to 2000 feet; at which time we acquired a visual with RWY 26R; below the cloud layer; and called the runway in sight. Approach control then cleared us for a visual approach to RWY 26R; contact MIA Tower. On initial contact with tower; inside JODAX; at approximately 1300 ft.; were cleared to change runways; and cleared to land on RWY 26L. Pilot flying (PF)/Pilot Monitoring (PM) agreed and we accepted the clearance; reverted to the lowest level of automation; confirmed landing checklist complete; and landed visually and uneventfully; on RWY 26L. Three days in a row; [operating Air Carrier X flight] ZZZZ-MIA; we initially received ILS RWY 30; then a change of RWY to LOC DME 26R. Two out of three days; we were issued a last minute change to RWY 26L below 1500 FT. On the occasion of this ASAP report; the approach controller communication was less than professional. The controller appeared task saturated and situationally disconnected with spacing of arrivals. Indeed; both PF and PM; when assigned the 240 heading off the 26 R LOC; began internal cockpit questioning whether the controller actually knew which flight he was communicating that clearance to. Speed assignments; sequencing; and spacing should be better managed by Approach Control so as to mitigate the risk of miscommunication; confusion; and last minute runway changes which increase potential for errors.

A319 pilot reported receiving multiple late runway changes from MIA ATC on several different days that led to confusion and increased workload.

1758920

202008

1801-2400

ZZZ.Airport

US

0.0

Night

Tower ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Flight Crew Last 90 Days 154; Flight Crew Type 3000

Communication Breakdown

Party1 Flight Crew; Party2 Flight Attendant

1758920

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Communication Breakdown; Distraction

Party1 Flight Crew; Party2 Flight Attendant

1758942.0

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

Y

Person Flight Attendant

In-flight

General None Reported / Taken

Environment - Non Weather Related; Company Policy; Human Factors

Human Factors

The A Flight Attendant immediately contacted us through the service interphone after hearing the single ring indicating our climb through 10;000 feet. He stated that he was not seated during takeoff; his galley was not secure; and that coffee had spilled on himself and his iPad. He then went on to state that the reason he was not able to complete his tasks prior to pushback and departure was because he was having to deal with passengers and their improper usage of masks. The B; C; and D Flight Attendants did not mention any passenger issues to us.As the First Officer; take a more proactive role in ensuring the flight attendants acknowledge the single ring prior to takeoff. Also; it is my understanding that the flight attendants are supposed to immediately inform the pilots of any disruption or disturbance in the cabin in which they are unable to perform or complete their required tasks.

After giving the chime and monitoring the bell across the PA I called for the Before Takeoff Checklist. After completing the checklist we switched the radio to Tower and they cleared us for takeoff with an aircraft on a 3 NM final. With this distraction; I failed to listen to the A FA make his Departure PA. Around 10;000 feet the A FA called to say he had been in the aisle during takeoff. He told the FO he had been talking to a couple of passengers about wearing their masks and hadn't received the attendant chime. He told the FO he had not fully secured the galley and had coffee spilled on his EFB and personal device. He said he had no physical injury or harm and that overall he was fine. I clearly heard the chime; but failed to monitor his PA.A FA should not be monitoring masks before takeoff at that time because non compliant passengers are less of a safety risk than delaying preparation for takeoff. I will be more cognizant of listening to the FA PA per the AOM in the future.

Air carrier flight crew reported a Flight Attendant was not seated for departure due to having to deal with passengers not properly wearing face masks.

1591245

201811

1801-2400

ATL.Tower

GA

1200.0

Cloudy

Air Carrier

Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Other Instrument Approach

Facility ATL.Tower

Government

Other / Unknown

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 9

Confusion

1591245

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

Person Air Traffic Control

General None Reported / Taken

Human Factors; Procedure

Procedure

The weather at the time of the event caused a lot of factors for controllers at ATCT tonight. The visibility was 1/4 SM; OVC 003 and wind fluctuating between 10008KTS - 110012KTS. The Command Center; [Company A] airlines and [Company B] operations decided we should turn the airport from an east configuration (in favor of the winds) to a west configuration to accommodate getting the aircraft back to ATL. This caused the pilots to land in low visibility weather with construction and a tailwind. Pilots also had to depart with an 8-12 knot tailwind on a shortened runway.Another situation; our SOP states if the weather is below 300 and/or visibility is less than 1 mile; you should not depart RWY 26L with aircraft on the VICTOR end around taxiway. There were numerous aircraft that departed with planes on the Victor taxiway.If the winds favor an operation; stay with the safest possible situation. Safety is a 10; or that's what the FAA likes to make us believe.Change the SOP weather requirements if it's deemed aircraft are safe to be on taxiway Victor when the visibility is low.

ATL Tower Controller questioned SOP requirements during weather operations at their facility.

1101072

201307

0001-0600

ZZZ.ARTCC

US

Center ZZZ

Air Carrier

Widebody; Low Wing; 3 Turbojet Eng

2.0

Part 121

IFR

Cruise

Cargo Compartment Fire/Overheat Warning

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

1101072

Aircraft Equipment Problem Critical

N

Person Flight Crew

In-flight

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

Aircraft

Approximately 30 minutes after takeoff we received a level 3 forward lower cargo fire warning. Per Phase one procedures 'FLASHING DISCHARGE SWITCH PUSH' was accomplished. We were 80 miles south of ZZZ. We declared an emergency with Center and turned direct to ZZZ. We ran the emergency checklist for lower cargo fire. An ILS was flown to Runway 36C. We cleared the runway; stopped the jet; and had Crash Fire Rescue inspect the jet's forward exterior cargo area. They found no indication of fire. We then taxied to the ramp where CFR opened and inspected the lower forward cargo compartment. No fire indications were found.

In response to what turned out to be a false cargo fire warning the flight crew performed the associated checklists and procedures and diverted to a nearby airport. Inspections by CFR immediately after landing and at the ramp discovered no evidence of fire.

1487122

201710

1201-1800

ZZZ.Airport

US

0.0

Daylight

Ground ZZZ

Air Carrier

Dash 8-300

Part 121

Ferry / Re-Positioning

FMS Or FMC

Taxi

Unscheduled Maintenance

Testing

Engine Air

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Other / Unknown; Situational Awareness; Troubleshooting

1487122

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

Person Flight Crew

Taxi

Aircraft Equipment Problem Dissipated; General Evacuated; General Maintenance Action

Procedure; Aircraft

Aircraft

I was assigned a trip to ferry the aircraft [that] was parked for a length of time as it had previously suffered an engine number 2 fire in flight. As a crew; we discussed the situation and although apprehensive; we decided we would take our time to ensure we were safe and legal before proceeding.I was surprised to find that there was no [Company] Maintenance personnel at the plane to meet us and to fly the aircraft back as the logbook indicated major repair work was performed on the aircraft. Further; due to the previous fire and structural damage to the aircraft we would be forced to respect the Va speed of 177 KTS during the flight. There was no prior contact by the company to explain the situation to me.After several discussions with dispatch and maintenance; the FO (First Officer) and I agreed we were satisfied to perform the flight. After appropriate checklists and briefing; I started the number 2 engine. The engine appeared to start normally. After a short amount of time; less than a minute after starter cutout the FO remarked; Smoke. I took my eyes off the engine gauges and did in fact notice the flight deck was filling with smoke rapidly. I looked at the fire detection panel and there was no indication of fire. I did notice at this time the number 2 bleed was on along with the recirculation fans. We both agreed to evacuate the aircraft; and I executed the smoke before V1 immediate action items and the FO and I evacuated the aircraft without further incident.The smoke was acrid and thick and caused me to cough due to irritation of my airway and also burning of my eyes. There was no evidence of smoke or fire outside of the aircraft. I immediately called dispatch and then a Chief Pilot. After several discussions with company; we were requested to trouble shoot the cause of the smoke as the company believed the cause of the smoke was due to operation of the bleed after engine start. Further; the Chief Pilot pointed out that 300 model has a 'limitation' of 60 seconds before putting the bleeds on. The text is confusing; as it is found in section 9.7 Engine Start Procedures and [it] states the following: 'The re-circulation fan and engine bleed air switches may be selected on after the required verifications have been completed to meet cabin environmental demands. Engine bleed air for the -311 Series aircraft should remain OFF for 60 seconds following the engine-start procedure to prevent fumes from entering the cabin.'My question on this procedure is when is 60 seconds following engine start procedure? Is it starter disengagement? As the aircraft are so hot; it is imperative that we get airflow as soon as possible in the aircraft. Both the FO and I were positive this was not fumes from the engine start as we are both familiar with engine fumes ingestion. After multiple discussions with the company; the crew agreed to run the engine up with a contract maintenance personnel on board. The run up was successful this time. The aircraft was signed off and we were dispatched to destination without further incident.A [Company] mechanic should have been with the aircraft for the ferry flight. After discussing with senior maintenance personnel at destination after we arrived; they believed it was residual oil somewhere in the bleed system and was atomized when the bleed was open. Maintenance did not know if the Bleeds were exercised during the previous maintenance work. Potentially the FO and I may have had an acute exposure to turbine engine oil. Turbine engine oil is known to be very toxic; especially when it is atomized and ingested though inhalation. Well established acute and chronic diseases have been manifested through such exposure.I am concerned that [our Company] does not have any air quality guidelines or occupational exposure risk assessments that I am aware of. Has there ever been an air quality monitoring program ever been conducted? Many crewmembers are unaware of the possible chemical exposurefrom the bleed air system and what the permitted daily exposure (PDE) of said potential contaminants in the aircraft are. Lastly; after any occupational exposure to smoke or mist there is no further health assessment required by the company. I have attached a published article 'The Toxicity of Commercial Jet Oils' from the Journal of Environmental Research; Volume 89; Issue 2; June 2002; Pages 146-164; on the potential toxicity of turbine oil.

The Captain of a Bombardier DHC-8 reported that after engine start the cockpit started filling up with smoke.

1740637

202004

1201-1800

ZZZZ.Airport

FO

0.0

VMC

Daylight

Air Carrier

B767-300 and 300 ER

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Y

N

Y

N

Unscheduled Maintenance

Air Conditioning and Pressurization Pack

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 Maintenance; Party2 Flight Crew

1740637

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

Person Flight Crew

In-flight

General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; MEL; Procedure

Procedure

We flew Aircraft X from ZZZZ to ZZZZ1 to ZZZ. We operated with deferral 36-11-8-1-1a and 21-51-1-1. Under these conditions; the left AC pack should have been operated off. It wasn't! The flight should have not departed ZZZZ. The crew that was scheduled to fly Aircraft X from ZZZ to ZZZ1 noticed the discrepancy. The flight from ZZZ thru ZZZ1 to ZZZ was uneventful. I accept full responsibility for this event. I failed to take the proper time to review the MEL prior to the flights. After maintenance was performed on the aircraft; I reviewed the MEL items with mechanic in ZZZZ. My review of the MEL was obviously not thorough enough. I don't understand how I could have overlooked several of the items in the MEL; but I did. I should have been more proactive in including the First Officer in the decision making process. First Officer is an excellent pilot and this should not reflect poorly on him. I was very tired that day. This may have been a distraction. Considering everybody involved with this event; several people dropped the ball. Ultimately I am responsible.

Captain reported misreading multiple MEL's and departed an airport with a non airworthy aircraft.

1850413

202110

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Gate / Ramp / Line

Air Carrier

Lead Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown

Party1 Maintenance; Party2 Ground Personnel

1850413

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

Person Ground Personnel; Person Maintenance

Aircraft In Service At Gate; Routine Inspection

General Maintenance Action

Human Factors

As we were offloading mail out of the fwd cargo I noticed some boxes that had Lithium-Ion battery UN3481 labels and also a white label that said 'LITHIUM ION BATTERIES- FORBIDDEN FOR TRANSPORT ABOARD PASSENGER AIRCRAFT' There were at least 20 boxes that I could see. Some were individual boxes and some were within the white mesh like bags that USPS uses. [I identified] while offloading the mail. I saw many boxes with the Dangerous Goods label on them.This event occurred because the crew Chief and crew loading Aircraft X on [date] did nothing to stop this mail. I can see that the crew Chief who scanned the bags on this flight was [name]. I do not know if he was also in the fwd cargo area or if he had another crew load the mail. I told a Customer Service Manager. He asked for no information. Mail went to the cargo facility to be given to the USPS. More training and knowledge of why this is so important for all of us to be aware of these hazards. With Lithium-Ion batteries becoming more and more popular I think this should be a reoccurring lesson in person class.

Air Carrier Maintenance Lead Technician reported identifying Hazmat cargo labeled 'forbidden for transport aboard passenger aircraft' at destination arrival. Reporter suggested more Ramp personnel training is required.

1828584

202108

1801-2400

JAN.Airport

MS

0.0

Night

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Flight Crew Last 90 Days 60; Flight Crew Type 60

Situational Awareness; Troubleshooting

1828584

Ground Event / Encounter Other / Unknown

N

Person Flight Crew

Taxi

Flight Crew Became Reoriented

Environment - Non Weather Related; Airport

Airport

We taxied into Gate XX after a rain shower passed over the field shortly before arrival. Both the First Officer and I were unable to see the lead-in line or J-line with all the exterior lighting illuminated. Those lines are either non existent; obliterated or no longer have reflective capabilities. Either way we were only able to get some semblance of alignment with aid of clear and directive marshalling. I was very uncomfortable taxing into the gate under these circumstances and believe it is a significant safety issue. The lead-in line along with the J-line associated with Gate XX needs to be repainted with paint containing some reflective properties. In addition more ramp lighting would certainly help the situation.

Air Carrier Captain reported lead-in lines need repainting. Captain followed ground marshals signals.

1793267

202103

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

FBO

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

Part 91

None

Training

Taxi

Sundowner 23

Part 91

Taxi

Aircraft X

Flight Deck

FBO

Pilot Flying; Instructor

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

Flight Crew Total 1300

Situational Awareness; Training / Qualification

1793267

Conflict Ground Conflict; Critical; Ground Event / Encounter Loss Of Aircraft Control; Ground Event / Encounter Object

Person Flight Crew

Taxi

Aircraft Aircraft Damaged; Flight Crew Took Evasive Action

Human Factors

Taxiing back to the hangar at ZZZ after a training flight with a student. As we turned onto Taxiway H; I saw Pilot Y attempting to start his recently purchased BE23. It was parked at the tie downs and facing the X Hangars. I taxied past him and commenced to make a U Turn back to our hangar. As I was taxiing slowly in front of hangar X-E; I saw and heard the BE23 start up and rev up to very high RPM. I thought that was out of the ordinary. I then saw the plane start to come directly at us while picking up speed. Seeing Pilot Y's face; I could tell that he was not in control of his aircraft. I quickly increased throttle and was able to get out of his way as he impacted hangar X-E. I re-positioned my plane and shut down. We were not impacted by the BE23. I exited the plane and walked over to check on Pilot Y. He was uninjured and walked out of the aircraft.

GA flight instructor reported a ground conflict during taxi in as a BE23 pilot lost control of the aircraft during rev up in the hangar area. The flight instructor took evasive action while the BE23 impacted a hangar.

1630072

201903

0601-1200

D01.TRACON

CO

Marginal

Daylight

TRACON D01

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Initial Approach

Class B DEN

FMS/FMC

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Situational Awareness

1630072

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

Person Air Traffic Control; Person Flight Crew

In-flight

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

Aircraft; Human Factors

Human Factors

During arrival on the LDORA STAR; we originally briefed Runway 34R; but were given 35L on check in with approach. Center had us go fast on the arrival and assigned 300 kts or better until advised so time was reduced for checklists and arrival changes. I; the PM (Pilot Monitoring); changed the runway in the FMS and linked it from the LDORA arrival; it looked correct and the PF (Pilot Flying) verbally verified the change before I executed it in FMS 1. After passing the LDORA fix; the airplane did not follow the FMS course and I reached up and hit Heading mode on the FCP (Flight Control Panel) and turned to an intercept heading and notified the PF that we were not on course. A few seconds later ATC must have seen us overshooting and gave us a heading back to intercept. We immediately dialed in the new heading and intercepted with no further errors. It was later discovered that in our dual FMS airplane that the FMS's were not synced properly and the change I made in FMS 1 did not duplicate in FMS 2; and we did not realize the error in time to correct before overshooting course.The root cause was a flight equipment deviation that was not properly discovered or verified by the flight crew. Contributing factors were the preconceived notion the flight equipment had been set up properly before the flight by maintenance and or another crew. This is not something we are required to check every flight (FMS sync) and some of our company airplanes have two FMS's and others only have a single FMS installed.To avoid this error in the future I will make sure to check that each FMS is synced properly in dual FMS aircraft.

CRJ-200 Captain reported a track deviation occurred on the LDORA STAR into DEN; citing lack of FMS synchronization as contributing.

996787

201202

1801-2400

ZZZ.ARTCC

US

36000.0

VMC

Night

Center ZZZ

Air Carrier

A319

2.0

Part 121

IFR

Passenger

FMS Or FMC

Cruise

Class A ZZZ

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Distraction; Confusion; Situational Awareness; Troubleshooting; Training / Qualification

996787

Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Person Flight Attendant; Person Flight Crew

In-flight

Flight Crew Took Evasive Action; Flight Crew Diverted; Flight Crew Landed in Emergency Condition; General Declared Emergency

Aircraft

During cruise the flight deck and cabin crew detected an unrecognizable odor of which its source could not be identified. The odor would dissipate but would never completely go away. The decision was made to conduct a precautionary diversion. The divert airport's weather and proximity made it the most suitable airport for a diversion. We made the decision to wear our oxygen masks in the cockpit as a precaution against an escalating event as well as crew incapacitation can be hard to detect. I deferred the flying to our First Officer because I had recently studied and reviewed both the Smoke/Fumes/Avionics Smoke Checklist and the Emergency Descent checklist for an upcoming check ride. We did declare an emergency to give us the highest priority with ATC if an emergency descent was needed. The emergency authority would also allow us to run the Smoke/Fumes/Avionics Smoke Checklist if needed as well. I notified Dispatch; the passengers and flight attendants of our situation while we made our descent. While the First Officer continued the descent I preformed the procedure outlined in Flight Operations Manual. The approach and landing on the runway was routine and uneventful. We had the Airport Rescue and Fire Fighter vehicles follow us to the gate as a precaution. Once at the gate we were briefed and cleared by a member of the Airport Rescue and Fire Fighters; who informed us that they could not find any hot spots visually or through thermal imaging. The Airport Rescue and Fire Fighter Officer; who was trained in smoke identification; could also not recognize the odor. Three non revenue pilots on board each described the odor differently. Maintenance Control was notified and the crew was released by Dispatch to continue.

The pilots and flight attendants of an A319 detected an unidentified odor while at cruise so an emergency was declared and as the SMOKE/FUMES/AVIONICS SMOKE checklist was completed the flight diverted to a nearby airport.

1204278

201409

1801-2400

PHX.Airport

AZ

10000.0

VMC

Night

TRACON P50

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

STAR EAGUL 6

Class B PHX

FMS/FMC

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Total 6

Training / Qualification; Troubleshooting; Workload; Confusion; Human-Machine Interface

1204278

Aircraft Equipment Problem Less Severe; Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Person Air Traffic Control

In-flight

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

Human Factors; Procedure

Procedure

Pre-flighted and departed. In accordance with Company directives issued concerning JeppTC Pro Mid-Cycle Chart Changes; NAV DATA Base on FMC was configured to correct dates AUGXXSEPXY/XZ was changed to SEPXAOCTXB/XZ. As a result of doing this the filled and cleared EAGUL5 PHX arrival issued now became the EAGUL6 with corresponding different crossing restrictions in the FMC data base. The flight was filed for the EAGUL5; yet the FMC was programmed to the EAGUL6; this was not noticed by aircrew as the only EAGUL arrival now in the data base was the 6 not the 5. On the EAGUL arrival point GEENO now had a crossing restriction 'Between 12000' & 11000'' instead of the former 10;000' which ATC was expecting. In flight upon noticing the altitude mis-understanding; ATC told us that the EAGUL6 started 'tomorrow'; yet; it was approximately XE15Z on the XAth. The difference in filed EAGUL5 and planned EAGUL6 should have been noticed prior to departure and Dispatch/ATC queried at that time. It was my understanding that these Jepp Mid-Cycle changes became effective XA01Z; XA September as was distributed via the Company web site and crew information messages. However; once again; failure to notice the difference between filed route and FMC programmed route was due to me.Approaching GEENO; ATC directed a lateral separation for our aircraft to de-conflict with departing PHX traffic. After execution of this; ATC provide vectors to final Runway 8. Perhaps both EAGUL arrivals were in the former NAV DATA Base and once selected to the other NAV DATA base to reflect XA01Z during pre-flight we only had the EAGUL6. Upon landing at PHX the NAV DATA Base was swapped again and the 'NAV DATA Base Out of Date' message appeared. FMC was left in configuration SEPXAOCTXB/XZ.Direction was given how to approach the JeppTC Pro Mid-Cycle Chart Changes from the Jepp side of the house. Perhaps further instruction concerning how this change should be handled via FMC procedures needs to be included. Perhaps instruction for both the planning and execution needs to be addressed for operations that may be 'non-standard'.

A flight crew changed the FMC NAV DATABASE on XA00Z SEP to the next month which changed the PHX arrival to EAGUL 6 but the Company had filed the PHX EAGUL 5 arrival with the previous calendar day's date. ATC caught the error over GEENO because of a crossing restricting difference.

1263215

201505

1801-2400

F11.TRACON

FL

1000.0

Night

TRACON F11

Small Transport

1.0

IFR

Final Approach

Visual Approach

Class C FLL

TRACON F11

Air Carrier

Medium Large Transport

2.0

Part 121

IFR

Passenger

Final Approach

Visual Approach

Class C FLL

Facility F11.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Communication Breakdown; Situational Awareness

Party1 ATC; Party2 ATC

1263215

ATC Issue All Types; Conflict Airborne Conflict; Inflight Event / Encounter Unstabilized Approach

Person Air Traffic Control

In-flight

Air Traffic Control Separated Traffic

Human Factors; Procedure

Procedure

Aircraft X was on a visual approach to Runway 18R direct and told to keep the speed up; Aircraft Y was on a 240 HDG then vectored west for spacing to sneak the Aircraft X. They were six miles apart and Aircraft Y was cleared for the ILS 18R and told to reduce to final approach speed to follow. Looking up at the airport ground traffic monitor; there was nobody departing for Runway 18L. As Aircraft Y got closer he called traffic in sight and I told him to follow; re-cleared Aircraft Y for the visual; and even told him S turns approved East of final if needed. He said in sight and follow.I switched Aircraft Y to the Tower. Then I monitored the Tower frequency to see what they were going to do. They did not say anything to the Aircraft X to keep your speed up or tell Aircraft Y to slow and then waited for the Aircraft Y to get to roughly 1;100 feet and less than two miles. The tower says to Aircraft Y 'final got you too close to Aircraft X ahead' and then asked Aircraft Y 'can you accept RWY18L?' Aircraft Y replied 'why sure'. My beef with the tower is that they intentionally and deliberately waited to create an unsafe situation for Aircraft Y; creating an unsafe unstable approach for Aircraft Y to change runways at a thousand feet less than 2 miles from the runway intended to land. Tower says they cannot do speed control on final unless they need it for a departure; or they will send an aircraft around to get an aircraft off the runway. The tower takes no responsibility or accountability for working safe and expediting traffic. The tower controller intentionally and deliberately waited to create an unsafe situation for the pilot instead of offering another runway that was available right next to the one they are landing on before it even became a factor. Poor judgment by the tower controller on a situation that could've been resolved so much sooner. The tower continues to create unsafe situations not only with arrivals but also with departures especially in IFR conditions knowing that departures need at 2 increasing to 3 with ceilings at 200 feet.

F11 Approach Controller reports of the Tower waiting to change the runway of an arrival that was catching the preceding arrival. The second aircraft was changed to a parallel runway and landed safely.

1754697

202008

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties; Service; Deplaning

Workload; Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Other

1754697

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

Y

Person Flight Attendant

In-flight

General None Reported / Taken

Human Factors; Environment - Non Weather Related

Human Factors

When we began our inflight service; I walked through the cabin offering snacks. I noticed a passenger not wearing his mask properly. The mask was only covering his mouth. I reminded him to wear his mask so that it covered both his nose and mouth. He shook his head no and continued reading his book. I asked him again to adjust his mask and he said; 'I'm not going to wear my mask like that for the next two hours.' I reminded him that he had agreed to wear a mask when he checked in for his flight. He then adjusted the mask so that it covered both his nose and mouth.After finishing snack service; I went to the forward galley to share with the A and C Flight Attendants about my interaction with the passenger. The A FA said she also had to ask him to put his mask on during the final walk-through just before takeoff. We decided that if he had to be asked a third time to wear his mask properly; we would contact the pilots and request a Customer Service Supervisor to meet the aircraft in ZZZ1.As I returned to the aft galley and passed the passenger's row; I noticed his mask was once again only covering his mouth. I tried to get his attention; but he would not look up from his book. I stated that his mask needed to cover both his nose and mouth and asked if he was going to comply. Again; he would not look up from his book or verbally respond.I continued back to the aft galley and shared with the B FA about the interactions with the passenger and then called the pilots to inform them of the situation and to request a Customer Service Supervisor to meet the aircraft in ZZZ1.A few minutes later; another passenger who was seated in the row directly in front of him walked back to the aft galley. She had observed/heard my interactions with the passenger and was very unsettled by his noncompliance. I apologized for the situation and invited her to relocate to an empty row toward the back of the aircraft.During our final descent into ZZZ1; we secured the cabin and I again noticed the passenger wearing his mask improperly; but did not make any attempts to communicate with him about it. The C FA and I swapped positions so I would have an opportunity to speak with the Customer Service Supervisor in the jetbridge before the passenger deplaned. Once the passenger deplaned; the Customer Service Supervisor accompanied him up the jetbridge.

Flight Attendant reported a passenger was asked several times to comply with the face mask policy during the flight. The passenger did not comply and was met on arrival by a Customer Service Supervisor.

991139

201201

1201-1800

ZZZ.Airport

US

IMC

Daylight

200

Tower ZZZ

Air Carrier

Regional Jet 900 (CRJ900)

2.0

Part 121

IFR

Passenger

Climb

Class B ZZZ

Air Conditioning and Pressurization Pack

X

Failed

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Time Pressure; Workload; Distraction; Communication Breakdown

Party1 Flight Crew; Party2 Maintenance

991139

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Physiological - Other; Communication Breakdown

Party1 Flight Crew

991391.0

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

Person Flight Crew; Person Flight Attendant

In-flight

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

Procedure; Aircraft

Aircraft

We were to begin the first leg of a four day. Our original aircraft arrived and was subsequently taken off line to the hangar by maintenance for a failed AILC. Two hours later our replacement aircraft arrived reporting a burning smell on takeoff that almost caused the crew to return immediately to the departure airport. Maintenance ran up the aircraft at the remote and determined a malfunction with left pack. The left pack was deferred. Passengers were boarded and we pushed from gate about three hours late. As the pilot flying; I advanced the thrust levers for takeoff. Immediately upon rotation; we received the emergency bell notification from the lead Flight Attendant and I noticed white smoke in the cockpit accompanied by a burning smell. I donned my oxygen mask and established communications with the Captain who relayed from the Flight Attendant there was white smoke in the cabin as well. The Captain as the pilot not flying declared an emergency and asked for an immediate return for landing and ARFF activation. I leveled at 3;000 FT and engaged the autopilot. We flew a right traffic pattern in IMC and flew the ILS 18C to minimums. I noticed the cockpit become very hot and verified uncommanded unusually high temperature output on the right pack while on short final. Since the smoke dissipated on downwind we proceeded after landing with ARFF escort to the gate to park and deplane the passengers by jetbridge about thirty five minutes. Upon debrief with the Chief Pilot and Assistant Chief Pilot we learned Maintenance had determined the right pack had a similar overheat and internal failure to the left pack diagnosed prior to our flight. I was informed Maintenance would remove and replace the right pack and the aircraft would be ferried by a Ready Reserve crew to pick up passengers for the rest of the day of flying with the left pack still deferred. I asked for further research about why both packs would simultaneously fail catastrophically within hours of each other and if any CRJ90 had ever had both packs fail together before. I also expressed my discomfort flying the same aircraft out single pack again without first determining the possible root cause of such a statistically improbable simultaneous failure. I hope there is enough information gathered as a result of this incident to determine the root cause and eliminate the recurrence in other CRJ aircraft in the future.

[Narrative #2 had no additional information.]

A CRJ900 left pack failed in flight and was MEL'ed. On the next takeoff the right pack failed causing cabin smoke and an excessively high temperature so the crew declared an emergency and returned to the departure airport.

1765442

202010

0601-1200

LAX.Airport

CA

400.0

Daylight

TRACON SCT

Air Carrier

Airbus Industrie Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Climb

Class B LAX

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Troubleshooting; Situational Awareness; Distraction

1765442

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Distraction; Situational Awareness; Troubleshooting

1765443.0

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

Person Flight Crew

In-flight

Human Factors

Departure clearance was via ZILLI 4 RNAV Departure with LAUER transition from Runway 25R. Early in takeoff roll; after thrust was set; ECAM 'Hot Brake' annunciated. One of the brakes indicated 300 degrees. My decision was to continue the takeoff. At 'Positive Rate' callout I decided to leave the gear down to cool the brake. AP1 (Autopilot 1) was engaged somewhere before reaching DOCKR waypoint. LAX Tower had us contact SoCal on 124.3. Crossing DOCKR waypoint; the aircraft failed to turn left toward WEILR waypoint. I failed to notice that deviation. About 1- 1.5 miles past DOCKR the FO (First Officer) alerted me about the deviation. I selected HDG (heading) mode and turned left to intercept the course to WEILR waypoint. At Flaps 0 callout I also called for 'Gear Up'. SoCal gave us Direct TANDY at about that time. Flight was uneventful from then on. The course deviation was because I did not ensure NAV (navigation) mode after reaching 400 feet AGL. I allowed the hot brake and gear down situation to distract me from flying the aircraft.

We are departing from Runway 25R; ZILLI4 RNAV Departure. To LAUER transition. During the take off roll; as engine was spooling up and accelerating; we had ECAM annunciated one of the brake is 300 degrees. We continued to takeoff; and kept the gear down to cool the brake. Captain engaged AP1 (Autopilot 1). As we handed over [to] Departure; ATC advised us the Tower noticed we still had gear down; and we explained keeping it down for a little longer to cool brake. When we passed DOCKER; we supposed to make left turn to WEILER; however we kept going straight on heading 251. So; I pointed to Captain to make left turn. As we are turning left; ATC gave us direct to TANDY. The curse deviation was because we did not confirm NAV (navigation) selected. We were in HDG (heading) mode. Although; we kept gear down due to hot brake was distraction; we must check and confirm FMA.

Airbus flight crew reported course deviation during climb out.

1811286

202105

1201-1800

ZZZ.Airport

US

10.0

5000.0

Mixed

Turbulence; 10

Daylight

3000

TRACON ZZZ

Personal

Cessna Citation Mustang (C510)

2.0

Part 91

IFR

Personal

FMS Or FMC; GPS

Initial Approach

Vectors; Visual Approach

Class C ZZZ

Engine Control

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 48; Flight Crew Total 866; Flight Crew Type 168

1811286

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

N

Person Flight Crew

In-flight

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

Aircraft

While being vectored for the visual approach at ZZZ; approximately while descending through 5;000 feet; the Amber CAS message (ENG CTRL SYS (L-R)) appeared as well as the Master Caution System light; I referenced the Manufacturers Emergency/Abnormal Checklist which dictated the first step is to reset the FADEC to the affected side; which in this case was both sides; the checklist goes on to say if the CAS message clears then no further action is required; or if the CAS message remains; to land as soon as practical. The checklist also goes on to advise of the possible effects that may be encountered; they are:- Degraded or lack of response to throttle movements including possible surging or flameout.- Possible inability to restart.- Possible inability to achieve ground idle.- Loss of automatic Interstage Turbine Temperature (ITT) limiting during ground idle.- Loss of automatic ITT limiting during ground or windmill starts.- Loss of ITT indication.The message did not clear after the reset; and given the possibility of a flameout; I chose to land ASAP; I notified ATC and requested to proceed directly to the final approach course for landing. ATC complied with my request and gave me priority. The landing was uneventful; but on the landing roll out; the L Engine Fail Warning CAS message came up; it distinguished about 15 seconds later; then appeared once again about a minute later during taxi and stayed on for 10 seconds then went away.Once I arrived to the ramp at the FBO I shut the engines down and powered down the aircraft with no further incident.

C510 pilot reported the left engine control failed while on vectors for a visual approach.

1204991

201409

0601-1200

CLT.Airport

NC

14.0

800.0

VMC

10

Daylight

TRACON CLT

Air Taxi

Helicopter

2.0

Part 135

VFR

Passenger

Cruise

Direct

Class E CLT

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 50; Flight Crew Total 7000; Flight Crew Type 3000

Confusion; Situational Awareness

1204991

Airspace Violation All Types

Person Other Person

Airspace Structure; Human Factors; Procedure

Airspace Structure

Flying at 1600 feet MSL; 800 feet AGL on a direct course toward [our destination]. On departing JQF climbed to 1600 feet MSL in order to stay below the CLT class B airspace. Our course took us very close to the Mcquire nuclear power plant located on the south end of Lake Norman near Charlotte; NC. At approximately XX00 local time I received a call from a FAA inspector who is assigned to the Charlotte FSDO. The inspector informed me that the nuclear plant called JQF to determine the identity of the helicopter that overflew their plant and the tower identified us. The inspector told me that he/she could find no restrictions concerning operations over or near nuclear power plants; and there were no notations on navigation charts either. The inspector let me know that that was all he/she knew and inferred that there would be nothing more to come. I stated that I wanted to be a good neighbor and would do my best to avoid the plant in the future.

Pilot gets notification by a ground observer who reports the flight to the FAA that their flight went over a nuclear power point. No restrictions were to be found not allowing the pilot to do so.

1108561

201308

1801-2400

LIT.Airport

AR

Night

Tower LIT

Air Carrier

Medium Large Transport

2.0

Part 121

IFR

Passenger

Final Approach

Class C LIT

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Physiological - Other

1108561

No Specific Anomaly Occurred All Types

Person Flight Crew

In-flight

General None Reported / Taken

Environment - Non Weather Related

Landing on 4R at LIT at night; as pilot flying; the extremely bright sign on the airport parking garage just to the left of the runway on final approach was distracting and compromised the safety of our flight. This sign's bright intensity should be decreased by at least 50% at night to avoid landing distractions to pilots approaching 4R at LIT.

The reporter states the sign is essentially a stadium video screen with moving advertisements and is far too bright at night to be that close to the end of the runway. When an aircraft is on final approach to Runway 4R at 500 feet the sign is about 30 degrees to the left.

Air Carrier Captain reports being distracted during a night approach; by a very bright sign on the roof of a parking garage just to the left of Runway 4R at LIT.

1220898

201411

1201-1800

TPA.Airport

FL

15000.0

IMC

0.25

Daylight

1500

TRACON TPA

Air Carrier

Commercial Fixed Wing

2.0

Part 121

Descent

STAR FOOXX4

Class E ZJX

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Last 90 Days 155; Flight Crew Type 155

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1220898

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

Person Flight Crew

In-flight

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

Environment - Non Weather Related; Procedure; Weather

Weather

We were descending into TPA on the FOOXX4 STAR; approaching waypoint TABIR; through FL180 to 15;000 FT. WX radar was showing high-intensity (red) returns associated with a line of weather across our flight path a few miles past TABIR. We made repeated attempts to call ATC for a 30 degree left of course deviation starting about 35 miles from the severe precipitation. The frequency was overloaded with too many aircraft all attempting to request deviations and altitude changes. Aircraft and the Controller kept blocking each other's radio transmissions. At points; the Controller became completely unresponsive when someone would succeed in transmitting a request. We successfully transmitted our course deviation request multiple times with no response. When we came within 10 miles of the severe weather we initiated an eastbound turn off course (we turned about 80 degrees off course since we were so close to the severe weather at this point). We continued to advise ATC of our actions with no response. At this point multiple aircraft were self-vectoring around the severe weather; and the Controller had completely lost the picture and was minimally responsive. We self-initiated multiple heading changes to work around the weather and back toward our cleared course over the next several minutes with a close eye on the TCAS display and advising ATC the entire time. Finally; we ended up at a point approximately 20 miles NE of GUSNE intersection with an approximate track towards GUSNE through a hole in the weather. It is at this point that we finally got a response from the Controller: he told us to maintain our current heading and handed us off to the (next) Approach Controller. Decisive Pilot action to deviate from a cleared routing and avoid severe weather was driven in this case by acute ATC frequency congestion and the Controller's inability to take charge of the situation and adequately prioritize his traffic management tasks. As the Crew; I strongly feel that we took the best course of action in a challenging situation to preserve life and property. JAX Center/Tampa Approach needs to consider/execute a better airspace management plan when a line of severe weather cuts through a busy arrival corridor. In my many years of flying; that is the most severe case that I've encountered of a Controller 'losing the picture' and exhibiting a complete lack of ability in managing the air traffic situation during challenging weather conditions. I think some retraining would certainly be in order.

During arrival into TPA; a B737-800 First Officer reports requesting a weather deviation along with numerous pilots. The frequency becomes completely congested and the Controller becomes unresponsive. The crews involved deviate around the weather at will without any input from ATC. Eventually a frequency change is issued and the crew continues to a normal landing.

1489070

201710

0601-1200

ZZZ.Airport

US

0.0

Thunderstorm

Daylight

Tower ZZZ

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Ground Personnel

1489070

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

Person Flight Crew

In-flight

General None Reported / Taken

Procedure; Human Factors

Human Factors

We were loaded with an amount of bags that wasn't even close to what was on the CLR (Cargo Load Report). CLR stated we had 28 checked and 22 gate claim; we actually had 13 checked and 26 gate claim; a difference of 370 lbs. I noticed on takeoff that the plane didn't feel like it was trimmed correctly; and engaged the AP shortly after takeoff. When I disengaged the AP for landing I noticed that the plane still felt off; like it was out of CG was the only thing I could think of. When we landed I got out quickly and asked the ground crew to do a count and got the actual totals submitted in this report; they copied the CLR and their count totals for their records. As the plane was mostly full; I believe that we were probably out of the CG window for landing. I took the CLR to the Chief Pilots and told them what happened to help ensure this kind of thing stops happening.

CRJ-200 Captain reported incorrect baggage counts which led to issues with weight and balance.

1084684

201304

0601-1200

ZZZ.Airport

US

0.0

Daylight

Personal

Rangemaster (Navion)

Part 91

Personal

Cruise

N

Y

Unscheduled Maintenance

Inspection; Installation

External Power

Navion

X

Repair Facility

Personal

Technician; Inspector

Maintenance Inspection Authority; Maintenance Powerplant; Maintenance Airframe

Maintenance Inspector 11; Maintenance Lead Technician 15; Maintenance Technician 25

Communication Breakdown; Confusion; Situational Awareness; Troubleshooting

Party1 Maintenance; Party2 Maintenance

1084684

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Landing Without Clearance; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor; Inflight Event / Encounter Other / Unknown

N

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Landed in Emergency Condition; General Maintenance Action

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

Aircraft

Cabin Air Mixture Valve housing chafed above terminal boot against 'Positive' cable terminal of Aux Power plug. The path to 'Ground' was through actuator cable to instrument panel. Cable subsequently heated up; creating smoke in the cabin from internal lubricants in the cable and a very small area of an adjacent interior side panel. Aircraft in controlled airspace and had to shut-off electrical power; flight continued and landed without further incident at an uncontrolled field. Pilot contacted ATC via landline; no emergency or priority handling by ATC was given.

Reporter stated the Aux Power cable for External Power hook-up; is always 'Hot' electrically; when the Master switch is in the 'On' position. No Circuit Breaker (C/B) or electrical switching solenoid were designed or installed in the Navion 'G' model in 1962; the year his aircraft was built. The Master switch is the only electrical cut-off for the Aux Power cable. The air volume control for the Air Mix Valve is a Bowden 'Push-Pull' type cable with an outer sheath; both are metal. The 'Push-Pull cable is attached to the Air Mix Valve box and in very close proximity to the Aux Power cable receptacle. He had to shut off the Master electrical switch when smoke in the cabin occurred; because the metal Air Mix Valve housing had chafed through the protective boot on the 'Positive' terminal stud of the Aux Power receptacle and went to 'Ground' through the Air Mix box housing and the 'Push-Pull cable attach location on the instrument panel.Reporter stated that during his troubleshooting of the cause for the smoke in the Navion's cabin; he could not understand why the Cabin Air Mixture Valve housing; which is in a tight location above the aircraft's Auxiliary (Aux) Power cable; did not have better support. He could not find any provisions for a Stand-off; or factory pre-drilled holes; in the Engine compartment's structure that would indicate additional support should have been there. The current Illustrated Parts Catalog (IPC) for the Navion Rangemaster 'G' models does not show any additional support for the Air mixture housing. He could not find any information in the FAA's data base about a Navion Air Mix Valve housing. Reporter stated that over the years; Navion aircraft have had different Type Certificate (T/C) holders. The brace part was available and was installed. Part-91 Owner/ Operators may not always see Service Bulletins; maybe Airworthiness Directives (A/D); but not necessarily other information about their aircraft. So he filed this NASA ASRS report hoping to alert other owners and operators of the Rangemaster 'G' models about the potential for the Air Mix Valve housing to chafe on the Aux Power cable due to a missing support brace.

An Inspector/Technician reports a metal Cabin Air Mixture Valve housing had chafed through a terminal boot on the 'Positive' cable terminal stud at an Auxiliary Power receptacle creating smoke in the cabin of a Navion Rangemaster 'G' model aircraft. Pilot had to shut off electrical power with Master Switch while in controlled airspace.

1236339

201501

1201-1800

ZZZ.Airport

US

0.0

Dusk

Air Carrier

Bombardier/Canadair Undifferentiated or Other Model

Taxi

Navigation Light

X

Improperly Operated

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown

Party1 Ground Personnel; Party2 ATC

1236339

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Communication Breakdown

Party1 Ground Personnel; Party2 ATC

1236341.0

Aircraft Equipment Problem Critical; Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Other / Unknown

N

Person Maintenance

Taxi

Company Policy; Human Factors; Aircraft; Procedure

Procedure

Aircraft was being towed by high speed tractor on Runway. Aircraft had no nav or anti-collision lights illuminated. No mechanic in cockpit to ride brakes as required per our Airport's Dept. of Aviation rules and regulations. Weather VFR. [Recommend to] require aircraft mechanics to tow aircraft so that the aircraft will be powered and light and brakes will be monitored as per FAA and Airport rules and regulations.

[Report narrative contained no additional information.]

A Line Aircraft Maintenance Technician (AMT) reports observing three Regional jet aircraft that were towed with high speed Tugs on active taxiways at airport without Navigation or Anti-collision lights on and no Mechanic in the cockpit to ride brakes.

1325670

201601

1201-1800

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Corporate

Falcon 20FJF/20C/20D/20E/20F

2.0

Part 91

IFR

Passenger

Landing

Visual Approach

Main Gear

X

Malfunctioning

Aircraft X

Flight Deck

Corporate

Pilot Flying; Captain

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

Flight Crew Last 90 Days 80; Flight Crew Total 8785; Flight Crew Type 155

1325670

Aircraft X

Flight Deck

Corporate

Pilot Not Flying; First Officer

Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 60; Flight Crew Total 773; Flight Crew Type 105

1326901.0

Aircraft Equipment Problem Critical; Ground Excursion Runway

Person Flight Crew

In-flight

General None Reported / Taken

Aircraft

On takeoff we had a gear light problem on right main saying gear was not up. Recycled gear and light went out. On approach I decided to do a flyby the tower to make sure all gear were down. Tower confirmed gear down; lights confirmed gear down. On touchdown all gear was on the ground. After a few feet right wing started to drop and hit the ground. Applied all means to stop aircraft. Aircraft skidded length of runway and off the end before stopping. No injuries.

[Report narrative contained no additional information.]

Falcon 20 flight crew reported the landing gear collapsed after landing.

1261465

201505

ZME.ARTCC

TN

35000.0

Daylight

Center ZME

Air Carrier

Medium Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

FMS Or FMC

Cruise

Class A ZME

FMS/FMC

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 176

Human-Machine Interface; Confusion; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

1261465

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

Person Air Traffic Control

In-flight

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

Aircraft; Airspace Structure; Human Factors; Procedure

Human Factors

During preflight; non-standard flight plan; Captain retrieved and typed in fixes from PDC while I wasn't there. When I returned I looked at PDC and then briefed the routing as Captain QC'd [quality checked/controlled] the fixes in the box. Phonetically called out fix HRTUN (HURTIN). Captain had misspelled it as HURTN. Center cleared us direct HRTUN. I pulled up the fix to top of the page; we confirmed it; and selected it. A couple of minutes later; ATC queried our heading. We confirmed direct HRTUN; he spelled it out phonetically; and that's when we caught it. Put in the right fix and adjusted the heading about 20 degrees. The headings were fairly close at that distance; two fixes that phonetically sound the same; with a letter shift difference. Recommend changing HRTUN or HURTN to something different. Both in same geographic area and are less than 100 miles apart. Continue QC checks of points and hard look at points on both flight plan and FMC. This one was hard to catch with same letters and slightly different order.

Airline flight crew was advised of a track deviation in flight while navigation to HRTUN intersection and realized HURTN had been programmed during preflight. The waypoints are less than 100 NM apart.

1605232

201812

0601-1200

ZZZ.Airport

US

65.0

30.0

2500.0

IMC

Cloudy; Fog; 5

Daylight

Center ZZZ

Personal

Skylane 182/RG Turbo Skylane/RG

1.0

Part 91

VFR

Other Medical

Initial Approach

VFR Route

Class G ZZZ

Aircraft X

Flight Deck

Personal

Single Pilot; Pilot Flying

Flight Crew Private

Flight Crew Last 90 Days 18.00; Flight Crew Total 770.00; Flight Crew Type 280.00

Time Pressure; Situational Awareness

1605232

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Air Traffic Control Issued Advisory / Alert; Flight Crew Diverted; Flight Crew Requested ATC Assistance / Clarification; General Flight Cancelled / Delayed

Human Factors; Weather

Weather

This mission was to transport a [medical] client to ZZZ. Also on board was a non-pilot friend. I had been studying the WX the night before and realized fog was predicted using my Foreflight App including TAF; MOS and forecast discussion. Before departure; I reviewed the WX again. The forecast had improve slightly; with MVFR expected [later] at ZZZ. My hopes were that clouds would be at least broken by the time I reached the arrival area with ceilings at 2;500 [feet]. We departed expecting a 2hr 10 min flight; thus arriving in the Modesto area as conditions were improving. I contacted ATC and initiated flight following after hand off from [departure airport].Upon passing [an airport] I noted broken clouds ahead and mostly overcast to the East. I choose to fly slightly west to stay on the margin where clouds were broken. In the vicinity; I began a VFR descent to 2;500 MSL to get under the deck. Initially base of clouds were 2;500 MSL which I reported to ATC upon request. My logic; although questionable in retrospect; was: 1. WX forecast led me to believe that ceilings were 1;500 [feet] with 3-5 mile horizontal visibility en route.2. Terrain was generally flat with area elevations between 100 and 150 ft. MSL and minimal obstructions. My minimum safe altitude limit was 1;500 MSL. 3. Should WX be unsatisfactory; I could turn around and exit the area. I had identified ZZZ1 as my alternate airport prior to departure. It was reporting 10 SM and unrestricted which I checked at [departure airport].4. I was using my Garmin 650 primarily for traffic and my Foreflight I-Pad mini (wheel mounted) for navigation; including Sim vision.5. I had sufficient experience and familiarity with my aircraft/instruments.ATC was monitoring and communicating throughout this event. Initially they asked why I had gone off my direct course to ZZZ and I responded to get under the deck. After; they updated me on ZZZ WX and obtained a PIREP indicating that an airport (whose name I do not recall now) in the vicinity was indicating better WX that ZZZ. ZZZ was reporting 1;500 [feet] ceiling and I believe 5 (or 7?) miles visibility prior to my descent using FIS-B on my Garmin 650. I also had picked up ZZZ info 'Tech' confirming above conditions.After about 10 minutes proceeding directly toward ZZZ; the ceiling lowered to about 1;500 [feet]. In the vicinity of [a wildlife refuge]; it lowered further. At first I thought this was a brief 'sag' in the clouds and would return to 1;500 [feet]. After about 15-20 seconds in IMC and no longer able to see the ground; I executed a climbing std. rate left turn in order to return to VFR on top. I used my Garmin G5 to fly this segment in IMC. Just prior to this; ATC had warned of an obstruction at my 2 o'clock which I noted on my Foreflight display as well; hence the left turn. During the ascent; ATC asked if I was IFR rated and wanted an IFR clearance. I responded negative.Once VFR on top; I completed a 360 turn and headed west toward ZZZ1 which ATC suggested as a VFR airport. En route; I determined ZZZ3 was VFR and closed for my client to be picked up. I notified ATC and terminated flight following with airport in sight. If needed I have the Foreflight track log for your use. I appreciated ATC's attention and support. In retrospect the PIREP info from ATC slightly mislead me to believe my initial plan was viable and to continue inbound. I would not in the least way; consider this a criticism of ATC.

C182 pilot reported a VFR into IMC encounter.

1621157

201902

1201-1800

JFK.Tower

NY

660.0

VMC

Light Wind; 10

Night

6500

Tower JFK

Air Carrier

Regional Jet 200 ER/LR (CRJ200)

2.0

Part 121

IFR

Passenger

Localizer/Glideslope/ILS Runway 13L

Final Approach

Other VOR OR GPS RWY 13L/R

Class B JFK

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

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

Training / Qualification; Situational Awareness

1621157

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

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

Situational Awareness

1621159.0

Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control; Person Flight Crew

In-flight

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

Human Factors; Procedure; Environment - Non Weather Related

Human Factors

We received a low altitude alert from Kennedy Tower while flying the VOR or GPS 13L approach into JFK. We were in the process of correcting our altitude when Tower gave us the alert and when we rolled out onto final we were only slightly below glide path with one white and three red on the VASI. We were fully configured and ready to land on airspeed with a shallow descent rate or 200-300 foot per minute. I was flying and started the descent too early after crossing DMYHL (the missed approach point) at 800 feet. This was only the second time I have flown this particular approach and the first time doing it at night. Like I said it was a very shallow descent I started after DMYHL; I just started it too early; the Captain noticed I looked a little low and advised me to level out my descent. As I was correcting our altitude Tower gave us an altitude alert and a new altimeter setting of 30.33; we still had 30.37 set from the current ATIS that we called up with. The problem was resolved almost immediately and we performed a safe and stable approach to land when we rolled onto final.Suggestions: Find a way to provide advisory VNAV on this approach; or practice this approach in the simulators to better prepare pilots for it and prevent them from getting low.

On approach to Runway 13L into JFK conducting the visual descent after the final fix DMYHL; during the turn I informed the First Officer that he looked a little low. First Officer responded leveling off. We were still in the turn following the strobes. A moment later Tower gave us an alert and gave us correct altimeter setting of 30.33. We were using altimeter setting from information of 30.37. This put us an additional forty feet lower. We were approximately 660 feet AGL at the time. Unsure if this was before or after changing the altimeter setting. Almost instantaneously we picked up the PAPI showing 1 white 3 red. Our altitude; speed; and configuration was setup to continue for a normal landing. Suggestions: On other approaches we have the capabilities to set up a vertical reference; but unfortunately there is no runway fix to setup a descent point on this approach. If it is possible to set a runway point maybe a vertical guidance could be set up.

CRJ-200 flight crew reported a CFTT event while on the VOR OR GPS RWY 13L to JFK airport.

1039894

201209

1201-1800

SWF.Airport

NY

2000.0

VMC

15

Daylight

10000

Tower SWF

Personal

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Training

Final Approach

Class D SWF

Aero Charts

X

Design

Aircraft X

Flight Deck

Personal

Pilot Not Flying; Instructor

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

Flight Crew Last 90 Days 270; Flight Crew Total 13470; Flight Crew Type 78

Training / Qualification; Workload; Confusion; Distraction; Situational Awareness

1039894

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Executed Go Around / Missed Approach; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Exited Penetrated Airspace

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

Human Factors

This was an instructional flight and we were working on pilotage and dead reckoning navigation. Our destination was Orange County (MGJ) which is 7 NM to the west of Stewart (SWF). I had mentioned to my student that if he conducted the flight to my satisfaction I would sign him off for solo cross country privileges. He was doing well with navigation as well as overall operation of the flight. As a result; I relaxed my vigilance. My student started having difficulties approximately 15 miles south of MGJ. The current NY sectional chart shows a prominent lake approximately 9 NM southwest of MGJ that he had planned to use as a visual checkpoint. He was not able to locate the lake; and when I tried looking for it I couldn't see it either. Eventually I spotted a lake east of the expected location and concluded that was the lake we were looking for even though it didn't seem to be exactly the right shape and size. In any case I wasn't concerned because I could see hangars in front of us in the approximate direction and distance that I expected MGJ to be. In addition to the confusion about the visual landmark; my student was having a hard time in managing the radios to obtain the ASOS weather at MGJ as well as tune in the CTAF frequency. Since I had planned to sign him off after today's flights; I was monitoring his operation of the radios more closely than usual. Again; I was not overly concerned about the navigation as I could see airport buildings and other cues getting closer in the approximate location I expected. By the time my student had sorted out the radios; we were within a few NM of the airport I had seen. My student saw it as well and as we approached the airport; I took a quick look at MGJ's airport diagram. It has two runways 26-8 and 21-3. Since I had been extremely rushed during the last portion of the flight; I did not notice that the airport we were almost directly over did not have the proper runway layout. We crossed over Stewart (SWF) at 2;000 MSL; and my student entered what he thought was a right hand pattern for Runway 21 at MGJ when he was really on a right downwind for Runway 27 at SWF. I could see the indications on his DG were not consistent with Runway 21 but I let him continue since I wanted to see how far he would go before realizing his mistake. Unfortunately; I was making a mistake as well since I thought he was on downwind for Runway 26 at MGJ; and the DG indications supported that conclusion. On short final I asked him to go-around and we climbed back up to 2;000 FT for another pattern entry. He again set himself up on a right downwind for Runway 27 thinking it was Runway 21 at MGJ. This time I was much more aware of the inconsistent DG indications and other cues and realized we had been operating in SWF Class D airspace without communicating with the Tower. Shortly after realizing the error I radioed SWF Tower and explained the circumstances on the telephone after landing. Summary of factors contributing to the situation: 1. Lake on chart to be used as a visual landmark not visible on the ground. 2. Lack of vigilance on my part during the first two-thirds of the flight since student was doing very well. This allowed us to end up east of our intended track heading toward SWF. 3. Overly engrossed in student's operation and management of the radios during the last third of the flight. 4. Seeing an airport environment 10 - 15 miles out and assuming it's the airport of destination since up to that point the navigation exercise had gone well. 5. MGJ and SWF having similar runways (26 at MGJ and 27 at SWF). 6. Not having been to MGJ in the past. Note: I flew the same route with my student a few days later. The lake that shows on the NY sectional on a bearing of 225 degrees magnetic and 9.5 NM from MGJ was not visible from the air. After the flight I checked an older sectional (79th edition effective 7 May 2009) and the lake is not on it. I wonder if the lake is indicated on newer sectionals in error.

An instructor pilot discovered the New York Sectional map depicted a lake about nine miles bearing about 225 degrees from MGJ; but the lake cannot be seen from air and presents a false visual navigation landmark.

1330111

201602

0601-1200

ZZZ.Airport

US

VMC

Daylight

Center ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Descent

Class A ZZZ

Electrical Distribution

X

Failed

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 158; Flight Crew Type 7563

Situational Awareness

1330111

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 165; Flight Crew Type 6969

Confusion

1330119.0

Aircraft Equipment Problem Critical

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Landed in Emergency Condition

Aircraft

On descent/arrival we got a #2 Source OFF light. I called for the QRH. FO ran the checklist. After completing the checklist the Source OFF light went out but the #2 Bus OFF light came on. I called for the QRH. After running the checklist the #2 Bus OFF light stayed on. A short time later the autopilot disconnected. I tried to reengage it. It was inop. When I tried the electric trim I found it to be inop. So now I was hand flying and using the manual trim wheel to trim the aircraft. One by one we had additional failures on the arrival and approach. These additional failures were Battery Discharge Light; both Engine EEC (Electronic Engine Control) lights; FO FMC inop; FO inboard Display Unit inop; FO outboard Display Unit inop; Two out of four wing electric fuel pumps inop; Left Electric Hydraulic pump inop; PSEU (Proximity Switch Electronic Unit) Light on; Speed Brake Do Not Arm Light on; and lastly the Trailing Edge Flap Gauge. Upon selecting flaps for the approach we noticed that the flap gauge was not working. We believed the gauge to be inop because the right side of the forward instrument panel (where it resides) was basically dead AND it felt like the flaps extended normally. The Leading Edge Devices were verified to be extended via the overhead panel. Upon selecting flaps 10 on approach; the aircraft went into an unusual and unfamiliar shudder. Believing this to be a stall buffet I lowered the nose and increased power. I told the First Officer that we must assume that we have no trailing edge flaps (meaning the flap gauge could indeed be correct). I asked him to bug me to 200 knots and select Max auto brakes. We left the flap handle at 10; increased to 200 knots and landed. The landing was completely normal despite our non-normal configuration. We did not use excessive runway and made a normal turn off at high speed turn off.

Descending on the arrival we experienced a Gen 2 Source off. The captain called for the QRH for source off light illuminated QRH; which I did and went to put the APU generator on the effected side. After doing so; we had the Transfer Bus Off illuminated on the same side. After completing the Transfer Bus Off QRH; we started to experience other electrical failures. The auto-pilot failed followed by the electric trim. At this point the captain was hand flying the aircraft and using manual trim. Next; the FO's display units failed as well as the FO's FMC failed; the PSEU light was on; the system A Hydraulic Electric pumped failed; both EEC lights where on; the Battery Discharge Light on; two fuel pump lights on; speed brake do not arm on. At this point we were turning into the approach. As we configured the flaps for landing we noticed the flap gauge pointer did not move properly; however the Leading Edge Devices where verified to be functionally normal. At this point we discussed that the flap gauge could possibly be failed as well. I asked the captain how the aircraft was handling while we configuring the flaps to 10 degrees. The captain stated that he felt a possible buffet and then proceeded to lower the nose and increase power to achieve a higher airspeed. We then decided to treat this condition as a flap up landing. The captain told me to set 200 knots as an approach speed and select MAX auto brakes. Captain landed the aircraft successfully and turned off.

B737 flight crew experienced a Gen 2 Source Off light during descent. After switching to the APU generator; the Transfer Bus Off light illuminated. After completing the Transfer Bus Off QRH; they started to experience numerous other electrical failures; among them the flap gauge. When flaps 10 was selected and the aircraft slowed; a rumble is felt and a flaps up landing procedure was followed.

1037831

201209

1201-1800

ZZZ.Airport

US

0.0

Fog

Daylight

Air Carrier

MD-11

Part 121

Cargo / Freight / Delivery

Parked

Y

N

Y

N

Scheduled Maintenance

Work Cards

Escape Slide

McDonnell Douglas/Boeing

X

Gate / Ramp / Line

Door Area

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown; Confusion; Situational Awareness

Party1 Maintenance; Party2 Maintenance

1037831

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

N

Person Maintenance

Aircraft In Service At Gate

General None Reported / Taken

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

Human Factors

MD-11 aircraft arrived. As I was doing my cockpit checks [for] an aircraft turn; station personnel informed me that there was a blown [escape] slide lying on the [aircraft's] ballast pallet. I looked at the onboard deferred list and saw that the blown slide was on MEL [for] the Right Forward (R1) Entry Door. It was stated on the deferred list at the end of the placard that the slide was removed; but the placard did not state what to do with the slide. Not knowing that the Engineering Authorization (EA) had not been done; but knowing it could not go with the ballast pallet; I removed it and shipped it to Stores. Aircraft left on [next] flight. MEL was not properly followed when being [applied] to aircraft and MEL placard was not clear as to what was to be done with the slide since the MEL covers two possible scenarios; making it unclear to someone coming in after the fact on the flight line. Insure MEL is properly performed when originally attached to aircraft. It should be stated on the placard that slide should stay on; or be removed from aircraft. There should be two separate MELs; one for each scenario. I will make sure I will read entire MEL before taking any action.

A Line Mechanic reports about an MD-11 aircraft that arrived with a Right Forward (R-1) Entry door escape slide that was previously blown; deferred; and laying on the aircraft's ballast pallet. Mechanic noted there should be two separate deferrals indicating whether a blown slide should be removed from the aircraft or remain onboard.

1769959

202010

0601-1200

ZZZ.Airport

US

0.0

Rain; 13

3000

4000

Personal

Small Aircraft

1.0

Part 91

VFR

Personal

Landing

Direct

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 23; Flight Crew Total 900; Flight Crew Type 122

Other / Unknown; Time Pressure; Human-Machine Interface

1769959

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

Person Flight Crew

Other Landing Roll

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

Human Factors; Weather

Human Factors

I departed ZZZ VFR. I requested and received a discrete squawk code from ATC for flight following to ZZZ1. The flight was uneventful. I was in communication with ATC throughout the flight and while approaching ZZZZ I called in to ATC to advise I had 13+ mile visibility. Following that call ATC instructed me to squawk 1200 and advised frequency change was approved. I then switched to the CTAF frequency for ZZZ1. I monitored the CTAF for traffic and started my radio callouts approximately 10 miles north west of ZZZ1. I checked the weather displayed on the MFD which indicated a four kt. wind and altimeter reading of 29.93 and there was light rain. Since the wind was calm I decided to land on Runway XX; the preferred runway. Runway XX requires right traffic. I entered the right downwind for Runway XX at 1;000 ft. (pattern altitude). I then entered a right base and then turned final. I had deployed full flaps and focused on the dissent angle and airspeed. I descended over the runway threshold about 50 ft. over the sand dune at a speed of approximately 83 kts.; the plane was stable; however just prior to touchdown I felt as if the plane was pushed forward; at this point my main gear touched down and I was unable to maintain directional control. I tried to maneuver the plane to be directionally straight however due to lack of directional control I felt a 'go around' was not advisable.The plane continued to slide and the plane slid into the fence at the perimeter of the airport and came to rest on the west side of road. The fence seemed to absorb much of the impact. Once stopped; I shut down the plane; called the Airport Manager and explained what happened. She asked if I was OK and then called police and fire personnel.

Single pilot reported loss of directional control on landing resulting in a runway excursion and collision with perimeter fence.

993569

201202

1801-2400

ZZZ.Airport

US

0.0

Tower ZZZ

Air Carrier

MD-82

2.0

Part 121

IFR

Passenger

Landing

None

Class B ZZZ

Tower ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Landing

None

Class B ZZZ

Facility ZZZ.Tower

Government

Flight Data / Clearance Delivery; Supervisor / CIC

Air Traffic Control Fully Certified

Communication Breakdown; Other / Unknown

Party1 ATC; Party2 ATC

993569

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

Person Air Traffic Control

General None Reported / Taken

Human Factors; Procedure; Staffing

Procedure

I was working CD/CIC combined in the Tower. The Local Controller had traffic landing Runway 1 and Runway 10. A MD82 was landing roll on Runway 10; and an E170 was on final behind him. I told the Local Controller several times that I didn't think it was going to work; meaning that we would not have the runway separation we would need. He replied that if he had to send him around he would. I trusted that he would do this; I had no reason to doubt him. When the E170 was short final for Runway 10; I stood up to see where the MD82 was and he did not appear to be clear of the runway. I told the Local Controller that it looked like he (the E170) needed to go around. He said that he thought it was going work. I gave it a few more seconds; and then told him; 'you need send the E170 around.' he did not. The MD82 was not yet clear of the runway and therefore separation was not ensured. It is extremely rare that we have any supervisors in the Tower as they generally stay in TRACON or their office during their shift. I am not the only controller that has had these problems with other controllers not listening to the CIC in the Tower; and I feel as though it makes the operation unsafe. I do not believe the Local Controller would have refused to do what I told him to do if a supervisor would have been present. I also feel as though we should be able to refuse the duty of CIC if we do not feel comfortable. I feel as though putting 'co-workers' in charge of each other throughout the day sets us up for failure in many different ways.

Tower CIC voiced concern regarding the lack of response to his direction to a controller reference runway separation; noting shift supervisor rarely reside in the Tower but spend time in the TRACON and their offices during the shift.

1765154

202009

0601-1200

ZZZ.TRACON

US

340.0

16.0

5000.0

VMC

10

Daylight

TRACON ZZZ

Personal

Cessna 210 Centurion / Turbo Centurion 210C; 210D

Part 91

IFR

Training

Climb

Vectors

Class E ZZZ

Manifold Pressure Indication

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Pilot Not Flying; Instructor

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

Flight Crew Last 90 Days 83; Flight Crew Total 6089; Flight Crew Type 224

1765154

Flight Deck

Personal

Trainee; Pilot Flying

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 16; Flight Crew Total 234; Flight Crew Type 144

1765147.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

Departed ZZZ on a training flight to ZZZ1. At 5;000 ft MSL during the climb the Pilot Flying noted that at full throttle the MP (Manifold Pressure) read 25 in Hg. The plane was properly configured for cruise climb and all other instruments were reading normal. We suspected an issue with the turbo charger and notified ATC that we would like to return to ZZZ due to a loss of Manifold Pressure. ATC provided priority handling and vectored us for the RNAV approach. We landed at ZZZ without incident.The maintenance shop at ZZZ investigated the problem and found a pin-hole leak in the line between the pressure transducer and the Manifold Pressure Gauge. They replaced the line and the gauge now shows the proper Manifold Pressure.

[Report narrative contained no additional information.]

Flight Instructor flying C210T aircraft reported problem with engine instruments inflight that resulted in an air return.

1500182

201711

0601-1200

ZZZ.Airport

US

0.0

Daylight

Beechjet 400

2.0

Part 135

Passenger

Parked

Powerplant Fire Extinguishing

X

Improperly Operated

Aircraft X

Flight Deck

Fractional

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Workload; Troubleshooting; Time Pressure; Physiological - Other

Party1 Flight Crew; Party2 Flight Crew

1500182

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

Person Flight Crew

Pre-flight; Routine Inspection

General Maintenance Action

Aircraft; Human Factors; Procedure; Staffing

Aircraft

Assigned Pilot-in-Command for [a] revenue trip. Upon arrival at the departure airport; I noticed there was one lineman only who would be assisting with aircraft ground operations to include fueling; Ground Power Unit (GPU) usage; coffee/ice/papers; and other duties. As routine practice; I delegated my First Officer the duty of pre-flighting the aircraft exterior and interior. I calculated W&B and performance and took the coffee pot out of the jet to be filled. During this time; our passengers showed up 40 minutes early. While my First Officer was in the cockpit still preflighting; I greeted the customers and was in the process of putting the coffee; ice; and newspapers on the jet when my First Officer brought to my attention the R F/V and R H/V switch was not working properly to reopen the valves after the fuel system test. I confirmed the switch was not functioning properly by depressing the R F/V and R H/V OPEN/CLSD switch. No movement of the valves indicated. I asked my First Officer if he had pushed another other guarded/non-guarded switches. His reply was 'No.' To troubleshoot; I called maintenance. I followed the guidance from maintenance in attempt to clear the discrepancy. It was determined that the valves were not showing movement because of incorrect switch activation in the fire protection system. After visually inspecting the fire bottle pressures in the aft baggage compartment; I saw the fire bottles had been discharged. I then started communicating with company to recover the grounded flight mission.This incident could have been mitigated had my First Officer followed the Pre-Flight Checklist. If a mistake had been made; having the integrity to admit and communicate early perhaps would have prevented bottle discharge. Unfortunately since there was limited ground personnel available to help us 'ready' the jet; my attention was not directed on observing the cockpit pre-flight checks. This is the first time in years of flying this aircraft to have this occur.

A BE-400 Captain reported that during preflight checks they were unable to open the engine fuel valve because the engine was fire bottle discharged.

1032788

201208

ZZZ.ARTCC

US

VMC

Center ZZZ

Air Carrier

a320

2.0

Part 121

Passenger

Cruise

Class A ZZZ

Hydraulic Main System

X

Failed

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Last 90 Days 200; Flight Crew Total 9000; Flight Crew Type 4500

1032788

Aircraft Equipment Problem Critical

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Landed in Emergency Condition; General Maintenance Action; General Declared Emergency

Aircraft

[We received an] ECAM at cruise altitude; Green Hydraulic System low quantity. [We] followed ECAM procedures resulting in an inoperative Green Hydraulic System. Captain and I reviewed all Flight Manual notes; including required landing distance in an abnormal configuration (loss of left reverser; some spoilers; nose wheel steering; and inoperative anti-skid brakes). [We] discussed issues with Dispatch and Maintenance Control. [We] agreed plan of action to continue to destination. Dispatch would discuss with ATC Representative; plan on landing on longest runway winds permitting; have emergency equipment standing by. Captain briefed Lead Flight Attendant. Declared emergency with Center; priority handling with Center and Approach. Manual gear extension accomplished. Aircraft landed on longest runway and was able to taxi clear with differential braking. [We were] towed to gate.

A320 First Officer experiences loss of Green Hydraulic System quantity in cruise and continues to destination. An emergency is declared and flight lands on the longest runway using gravity to extend the landing gear.

1139260

201312

1201-1800

MMV.Airport

OR

4.0

1700.0

VMC

10

Dusk

2000

CTAF MMV; TRACON P80

Personal

Cessna 152

1.0

Part 91

IFR

Training

Final Approach

Other Instrument Approach

Class E MMV

CTAF MMV

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

Training

Final Approach

Class E MMV

Aircraft X

Flight Deck

Personal

Single Pilot

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

Flight Crew Last 90 Days 25; Flight Crew Total 1600; Flight Crew Type 25

1139260

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

Horizontal 0; Vertical 200

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

I was accomplishing a practice ILS approach to Runway 22 at McMinnville Airport (MMV); Oregon in a Cessna 152 aircraft. The weather included an overcast layer of clouds from about 2;200 to 3;000 FT MSL. It was clear above and clear below the layer. I was operating on an IFR flight plan and talking with Portland Approach. During the straight-in approach and about 11 NM prior the runway; I was advised by Approach to change advisory frequency (CTAF) and to contact Approach again during the planned missed approach. Following the frequency change; I monitored the CTAF for a few miles with the intent of making my initial traffic advisory call just prior to glideslope intercept; which is 5.2 miles prior to the runway. About 7 to 8 miles prior to the runway; I descended below bottom of the overcast layer; into visual weather conditions. About 6 miles prior to the runway; another aircraft made an advisory call indicating they too were on the same ILS approach to Runway 22 at McMinnville. Their call indicated they were about 8 miles prior to runway (about 2 miles behind me). I assume the other pilot was making a practice ILS approach in VFR conditions; hopefully operating below the overcast layer. Immediately following their call; I made a traffic advisory call to include my position on the ILS approach. The pilot of the other aircraft asked for my airspeed; to which I replied 99 knots. The pilot declared his intent to pass directly below my aircraft. I continued the approach; visually searching for the other aircraft. In hindsight; I should have executed a climb out along the localizer course. About 4 miles prior to the runway I observed a much faster single-engine low-wing aircraft directly below my nose. The other pilot completed their approach; accomplished a missed approach and departed the area. I never heard any other radio calls from the aircraft. This is the first time I've ever been intentionally passed on an ILS approach.

Cessna 152 pilot reported he had an NMAC with another aircraft on approach to MMV when he was passed by the other aircraft during the approach.

1246010

201503

0601-1200

ZZZ.Airport

US

0.0

VMC

Snow; 10

Daylight

Air Taxi

Brasilia EMB-120 All Series

2.0

Part 91

IFR

Ferry / Re-Positioning

Taxi

Direct

Aircraft X

Flight Deck

Air Taxi

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 90; Flight Crew Total 4600; Flight Crew Type 500

1246010

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

Person Flight Crew

Taxi

Flight Crew Regained Aircraft Control

Airport; Human Factors; Weather

Ambiguous

We were making a slow taxi out from the terminal to the favorable runway. We had the ASOS weather and had received our clearance to depart and pick up our IFR flight plan enroute. I had completed the TAXI and BEFORE TAKEOFF checklists when we were headed south on the taxiway paralleling the runway. This taxiway ended at [an adjacent] runway where we started to make a right hand turn towards [our] runway. As we started to turn; the Captain said out loud that we were sliding. We were turning towards the right but we were sliding more towards the edge of the runway. At this time I said to put the power levers into reverse and I realized that the Captain had already done so and the engines were spooling up to produce reverse thrust. It was not enough as we slid towards the edge of [the adjacent] runway and finally came to a stop at a 45 degree angle as the left main wheels had come in contact with the snow bank on the side of the runway. I did not hear any unusual sounds or feel any unusual feelings as we came to a stop.

EMB-120 First Officer experiences a runway excursion during taxi due to icy conditions. The slide is eventually stopped by the snow berm at the edge of the runway.

1127830

201311

1201-1800

ZDV.ARTCC

CO

Facility ZDV.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Situational Awareness

1127830

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

Person Air Traffic Control; Person Flight Crew

Air Traffic Control Issued New Clearance

Weather

I had an air carrier come over from low altitude; climb was stopped at FL260 for traffic. When they leveled at FL260 and informed me that the were getting continuous moderate turbulence I expedited their climb and climbed them to FL340. Approxametly 2-4 min later a 737 checked on climbing out of Denver and I turned them to enable a climb; they reported severe turbulence and couldn't maintain altitude so they descended. Shortly after the first air carrier to check in; now at approx FL320; they reported that they had severe turbulence in the climb from FL260-FL265. I asked if they had any injuries reported and they said they would check. After I received 2 consecutive reports I told the supervisor on duty to shut off that one departure route. I was told that I can't do that because of the liability the government would incur. I then asked if we could have Denver Approach or Sector 6 put those aircraft on that departure procedure on a heading to avoid the area of severe turbulence. I was told I couldn't do that either because of the liability. I was told that no turns are allowed for turbulence. The original air carrier reported they were having problems with their radios; and said that the turbulence was FL260-280. They did no notify me of any injuries. Recommendation; there is got to be a better way to allow us to turn planes around a known area of severe turbulence for at least a short time until the airlines and all sourrounding facilities have been notified.

ZDV Controller described an unsafe condition event when several air carriers were encountering severe turbulence but controller efforts to give exit clearances were not approved; reported due to government liability.

1811311

202105

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Personal

Skylane 182/RG Turbo Skylane/RG

1.0

Part 91

VFR

Skydiving

Final Approach

Engine

X

Malfunctioning

Aircraft X

Flight Deck

FBO

Pilot Flying; Single Pilot

Flight Crew Commercial; Flight Crew Instrument; Flight Crew Multiengine

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

Troubleshooting

1811311

Aircraft Equipment Problem Critical; Ground Event / Encounter Other / Unknown; Inflight Event / Encounter Fuel Issue

N

Person Flight Crew

In-flight

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

Aircraft; Human Factors

Aircraft

We began the day at XA:00; the plane had 13 gallons of fuel on the pilots side; and 11 on the other. Generally we plan for 5-6 gallons per load of jumpers. After releasing jumpers I descended down from 9;000 feet AGL a couple miles east of the airport. Under 3;000 feet AGL on a 2/3 mile straight in approach to Runway XX @ ZZZ; I continued losing altitude as plane with the throttle fully out to lose airspeed. (It was put in every couple thousand feet descending to 'clear' the engine.) When the desired speed and altitude was reached; I pushed the throttle in with no response. I enriched the mixture and pumped the throttle; and that also made no change. Checked fuel selectors; mags; etc; all with no luck. I realized the aircraft would not make the runway fairly shortly. Continuing straight in; I would have hit the side of an adobe hill.Right was rougher terrain; so left was the best option. I made an announcement on CTAF but may have been too low at that time. I navigated to the smoothest looking area i could find given the very short amount of time I had to deal with the situation. Dropped full flaps; and slowed down as best I could. The plane touched down; bounced over a few hills; and came to rest slightly upward on another hill. I exited the aircraft thru the pilots door; and looked over the plane; then called Person X to inform him of the situation and was able to text him GPS coordinates While waiting I checked the fuel level in the aircraft; and the passenger side was empty; while the pilots seemed to have about 7 gallons; however the plane was at a slight angle so could have been inaccurate.Burning 17 gallons of fuel for 3 flights is about normal. Especially considering the slightly lengthy times to climb today.

C182 pilot reported a force landing due to a fuel issue during landing approach.

1724957

202002

0601-1200

0.0

FBO

Skyhawk 172/Cutlass 172

1.0

Part 91

Training

Climb

Aileron Control System

X

Malfunctioning

Hangar / Base

FBO

FBO Personnel

1724957

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Aircraft

Student Solo Event: During climb out plane increasingly wanted to bank/turn right as airspeed increased. Extreme difficulty in getting plane to turn left. Due to being unable to turn left; student pilot was forced to make right turns only. Main problem seems to originate from ailerons being uncoordinated; or not being in alignment. Straight and level flight was nearly impossible; even with little to no relative wind present. Aileron usage got significantly worse with an increase in airspeed. It improved only at lower airspeeds.

FBO Manager of Flight Safety reported a student on a solo flight in a Cessna 172 experienced abnormal aileron response.

1339023

201603

1801-2400

ZDV.ARTCC

CO

26800.0

Center ZDV

Corporate

Embraer Phenom 300

2.0

Part 91

IFR

Passenger

Climb; Initial Climb

Direct

Class A ZDV

Center ZDV

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Cruise

Direct; None

Class A ZDV

Facility ZDV.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

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

Situational Awareness

1339023

Facility ZDV.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 4.5

1339027.0

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

Vertical 800

Person Air Traffic Control

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

Human Factors; Airspace Structure; Procedure

Procedure

I was conducting On the Job Training (OJT) instruction on the radar associate position at the time. Sector initiated a handoff on Aircraft X; departing and climbing to 26;000 feet to the northeast. The radar controller acknowledged Aircraft X and climbed the aircraft to 27;000 feet; then shortly after issued a climb to 33;000 feet. During this time; the adjacent sector had started a handoff on Aircraft Y; departing westbound. The data block on aircraft x showed temporary 26;000 feet. Once the radar controller decided these two aircraft were in potential conflict; he advised Aircraft X that he 'needed them through 27;000 feet in 30 seconds.' during this entire scenario; not once did the adjacent sector call us regarding either of the two aircraft. Aircraft X indicated 26;800 feet when the radar controller asked the aircraft to 'say altitude leaving.' Aircraft X responded '27;200 feet' just as separation appeared to have been lost.Unfortunately; this is a common occurrence when working this sector. The adjacent sector has a habit of climbing two aircraft to 26;000 feet and handing them off to this sector with no positive separation ensured. Many times they take it a step further and actually switch both aircraft to our frequency. I assume they are expecting that most 'ski country' departures are high enough performing to 'get above' the departure.This is not an uncommon scenario. I have personally tried to address this by bringing it to my front line manager's attention when it happens. This has been the subject of 'crew breakouts' more than once. I have not noticed a decrease in the frequency of this behavior. It is always a challenge to work with the adjacent sector when any kind of significant volume or complexity exists. It is very common to receive aircraft on headings and assigned speeds with nothing being coordinated. Perhaps it has to do with the fact that this sector deals with low volume and low complexity for much of the year. Then during ski season; they are behind the curve.

I was working the radar position while training was in progress on the Radar Assist position. We were working a busy session with many departures as well as overflights. It is common to have many aircraft on headings and to use altitude leaving due to many head on climbing and descending situations. This was no exception. In the middle of this I was handed Aircraft X departing climbing to 26;000 feet. I climbed Aircraft X to 27;000 feet due to overflight traffic and moved on to do other tasks.I was alerted to the situation when Conflict Alert went off and I saw the alert flashing on my scope. I saw Aircraft X out of 26;100 feet climbing slowly with Aircraft Y head on level at 26;000 feet. The aircraft were about 1 minute apart from losing separation. I told Aircraft X to be at 27;000 feet in 30 seconds and climbed Aircraft X to 31;000 feet to ensure a fast rate of climb. When the aircraft were 5 miles apart I observed Aircraft X at 26;800 feet and Aircraft Y at 26;000 feet. I attempted to get a report from Aircraft X but by the time they reported out of 27;200 feet the targets had just lost separation. I believe the final result was 4.5 miles and 800 feet. It was too close to call while on position but the sector team decided to turn it in any way since it was a very close and very dangerous situation. Going back and looking at the radar replay; the other sector did not use altitude leaving rules so we had no form of positive separation. Aircraft Y appeared to have been cleared to 26;000 feet while Aircraft X was still at 25;800 feet.This is a recurring issue with that Sector controllers. Little or no separation is used with aircraft departing these airports in conflict. It is common to have two aircraft head on climbing to the same altitude. This isn't always an issue but we don't consistently get timely communication with the aircraft to solve conflicts. I wasn't even aware that there was a head on situation until after conflict alert went off. That is never a situation that one controller should put another one into. There was absolutely no reason for this situation to have happened aside from missing traffic.This makes me believe that the complexity is too great for that airspace and for an area that doesn't consistently see busy traffic. I don't know if this is a training issue or if this is simply a matter of that Area only having a few weeks of intense traffic but aircraft in the ski country area are constantly being handled in an inefficient; if not dangerous manner. Aircraft are constantly in conflict but appropriate steps are not always taken to insure positive separation. It is also important to note that their sector was combined with another sector during this time. Their sector had a Radar Controller side; Radar Assist Controller; and Tracker Controller but nobody was aware of this event beyond our sector control team.I'm not sure if new procedures for these airports need to be implemented or additional training be required for controllers using approved positive separation like altitude leaving. This is a recurring issue that has caused a great deal issues for all parties involved but nothing has been done to fix it in an effective way. It has improved over the years but additional steps need to be taken to insure a safe environment for the flying public in this area.

ZDV ARTCC Sector controllers were handed off two aircraft on converging routes at the same altitude. The reporters state this is a common occurrence of aircraft received from a particular sector.

1282263

201507

0601-1200

DCA.Airport

DC

2000.0

IMC

Daylight

TRACON PCT

Air Carrier

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

FMS Or FMC; Localizer/Glideslope/ILS Runway 19

Final Approach

Class B DCA

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1282263

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

Automation Aircraft Terrain Warning; Person Flight Crew

In-flight

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

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

Procedure

We were in IMC conditions; cleared on the LDA Y RWY19 approach into DCA. There was no localizer signal. We let ATC know this and they realized that they had the wrong information and the airport was actually using the LDA Z RWY19 approach. So; they canceled the approach and vectored us left. We were at 170k and 2000 feet. In IMC we received a terrain warning; 'WOOP WOOP; PULL UP PULL UP'. So; I canceled the autopilot and pulled up. We contacted ATC and informed them of the action and warning and they assigned us altitude 3000 feet. We climbed to 3000 feet and that was the end of the event. They vectored us back around for the LDA Z RWY19 and we had a normal landing.

A flight crew was being vectored for an approach that was not in use. ATC realized their mistake when the crew reported no localizer signal. While being vectored for another approach; they received a terrain warning and climbed appropriately. They were then vectored around for a normal landing.

1605614

201812

1201-1800

ZZZ.Airport

US

1000.0

Daylight

Tower ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Climb

Class B ZZZ

Fire/Overheat Warning

X

Failed

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Flight Crew Last 90 Days 448

1605614

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Returned To Departure Airport; Flight Crew Overcame Equipment Problem; Flight Crew Landed in Emergency Condition

Aircraft

At gear retraction after takeoff Master Caution/Fire bell annunciated with a wheel well fire indication. Gear finished retracting; we finished cleanup and requested immediate turn back to ZZZ and a level off. Completed QRH procedure; Diversion Checklist; ran performance data for Runway XX. Under VFR we descended normally for a normal landing on Runway XX. ARFF (Airport Fire Fighting and Rescue) was standing by and reported no visible fire indications. Ops and Dispatch were contacted and briefed on our situation. We shut down both engines with APU running and ARFF conducted an inspection of wheel wells. With no evidence of fire or smoke; we started both engines and returned to gate. All crew and passengers were deplaned normally.

B737 First Officer reported returning to the departure airport due to a wheel well fire warning annunciation at gear retraction.

1085440

201305

0601-1200

RYN.Airport

AZ

3.0

2200.0

40

Daylight

10000

Tower RYN

Personal

Amateur/Home Built/Experimental

1.0

Part 91

None

Personal

Initial Approach

Direct

Class D RYN

Tower RYN

Cessna Single Piston Undifferentiated or Other Model

1.0

Class D RYN

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Commercial; Flight Crew Multiengine; Flight Crew Instrument

Flight Crew Last 90 Days 40; Flight Crew Total 5000; Flight Crew Type 1300

Communication Breakdown

Party1 ATC; Party2 Flight Crew

1085440

Conflict NMAC

Horizontal 0; Vertical 100

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Procedure

Human Factors

I was inbound to Ryan Airport at Tucson; AZ at 2;200 FT AGL and had been given landing instructions from the Tower to report on a 2 mile left base for Runway 6 left. Other traffic was inbound from the same direction as myself and various traffic was pointed out to other inbound traffic but none to me. The next thing I knew a Cessna went underneath me from right rear to left front. I am in a low wing airplane and did not see them coming up from my lower rear. I called the Tower and said the Cessna traffic had just passed under me and was now off to my left at my altitude. I don't remember their exact comment as I was shaken a little after having such a close call. They did not give me any instructions for avoiding the plane during the rest of the flight. I continued inbound towards the left base entry I had been instructed to do. The Cessna continues on in the direction they were going when they went under me and made a downwind entry to Runway 6 left from the position they were in when I reported the incident to the Tower. The Tower then cleared me to land on Runway 6R. I assumed that was to give better separation when landing.

Experimental aircraft pilot experiences a NMAC with a Cessna approaching RYN from the north. No evasive action was taken by either aircraft.

1031251

201208

1201-1800

ZAU.ARTCC

IL

23000.0

Center ZAU

Air Carrier

A320

2.0

Part 121

IFR

Climb

Class A ZAU

Center ZAU

Air Carrier

McDonnell Douglas Undifferentiated or Other Model

2.0

Part 121

IFR

Cruise

Vectors

Class A ZAU

Facility ZAU.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

Communication Breakdown; Confusion; Situational Awareness

Party1 ATC; Party2 ATC

1031251

Facility ZAU.ARTCC

Government

Supervisor / CIC

Air Traffic Control Fully Certified

1031257.0

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

Person Air Traffic Control

General None Reported / Taken

Human Factors; Procedure

Human Factors

I was working another position when my Supervisor instructed me to go to the Badger D-Side. Upon plugging in my headset and glancing at the RADAR scope; I noticed that the sector was fairly busy. I decided to forgo the briefing; and simply ask if anything needed immediate action. A few point outs and coordination items were completed by me. Eventually a few minutes passed; and we received an aircraft from Sector 27 that was climbing westbound; roughly out of FL240. At the same time; we had an A320 routed Petty and points eastbound; climbing to FL230. At the time the aircraft were approximately 20 miles apart and my RADAR Controller decided not to climb the A320. The A320 was still out of FL180; so I estimated that there would be no need to call the lower sectors to inform them that we were not climbing the A320. A few moments passed; and now the A320 was approaching FL230; roughly out of FL220. At that time; the Conflict Alert started going off with an aircraft at Badger which we had no knowledge about; a McDonnell Douglas also climbing to FL230; roughly 5 miles ahead of the A320. I then told the RADAR to climb the A320; the Controller did; to FL240. In my opinion; there was very little to no delay of the A320 being level at FL230. After my personal review of the Falcon replay; there was already a loss of separation with the A320 at FL229 and the McDonnell Douglas at FL223. Squib had 'flashed through' the A320 with an AIT function. This is a sign to me that they had accepted responsibility for separation for the two aircraft that they had both received from the Harly Sector. The Harly and Squib Sectors need to learn how to separate their own traffic. Harly needed to use speed control between the A320 and the McDonnell Douglas; their own traffic. Badger had no knowledge whatsoever in the DTW arrival; the McDonnell Douglas. Also; Squib should not have turned the McDonnell Douglas who was on a vector towards the SUDDS Intersection however drastically they did to make the A320 and the McDonnell Douglas traffic for each other. Since the loss of separation occurred before Badger could do anything to resolve the situation and separate traffic; I do not feel that calling the lower sectors (Harly and Squib) would have achieved anything.

I was working BAE R-Side and an A320 checked on from low Sector 62 climbing to FL230. This aircraft was a flash through procedure with low altitude Sectors 62 flashing to Sector 27 and then to high altitude Sector 60. Conflict Alert went off shortly after as the A320 aircraft was over taking a McDonnell Douglas also climbing to FL230. Separation was lost between Sectors 62 and 27 airspace in low altitude stratum below my sector. I expedited a climb to FL240 for the A320. FL240 was only available due to traffic opposite direction. Stop the flash through procedure. Separation was lost due to confusion as to whose responsibility it was to separate the aircraft involved. Was it 62 or 27? Sector 27 took action by giving a control instruction to the McDonnell Douglas while being aware of the A320 aircraft because he executed a flash through. However; said Controller believes it was 62 Sector's responsibility to separate the two aircraft by using altitude because in the flash through procedure Sector 27 has control for turns on aircraft therefore Sector 62 should ensure or protect for such turns. Take away the flash through procedure; Sector 27 takes RADAR on all aircraft climbing through their sector. Or perhaps take away the ability for Sector 27's control for turns.

ZAU Controller described a loss of separation event involving a number of sectors; the reporter claiming the 'flash through' procedure was a contributing factor.

1263863

201505

0601-1200

PHL.Airport

PA

265.0

7.0

2100.0

IMC

Haze / Smoke; 3

Daylight

600

Tower PHL

Corporate

Falcon 2000

2.0

Part 91

IFR

Passenger

FMS Or FMC; Localizer/Glideslope/ILS Runway 27R

Final Approach

Class B PHL

ILS/VOR

X

Improperly Operated

Aircraft X

Flight Deck

Corporate

Pilot Flying

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

Flight Crew Last 90 Days 90; Flight Crew Total 6000; Flight Crew Type 350

Situational Awareness

1263863

Aircraft X

Flight Deck

Corporate

Pilot Not Flying

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

Flight Crew Last 90 Days 95; Flight Crew Total 4300; Flight Crew Type 900

Other / Unknown; Human-Machine Interface

1263894.0

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

Aircraft; Human Factors

Human Factors

I was the pilot flying and we were initially expecting the ILS to runway 26 and we had briefed and set up for the ILS 26. After talking with the first approach controller it appeared we were going to be on the ILS 27R. We were given a number of headings and altitude changes while the Non Flying Pilot (NFP) input the ILS 27R into the FMS. On the EASy INAV the NFP also went to the airport and was trying to select the ILS 27R tail to send the frequency and inbound course to the Primary Flight Display (PFD) and the computer. He inadvertently selected the ILS 27L tail. We were outside of the final approach course on the localizer well before GS intercept when the tower told us to go around because of spacing. We were then vectored around for another approach to ILS 27R again. Since we thought we had the correct frequency and course in the computer I neglected to brief the approach again (which I did not brief the first time for 27R). We then intercepted the LOC for 27L thinking it was 27R and the tower controller told us to make sure we were on the ILS for 27R and told us we were south of course. The needles were right on so we continued. He then asked again to make sure were on the 27R LOC and that's when we double checked the frequency and found it to be for 27L. We promptly switched to 27R and I turned the autopilot off and hand flew the airplane to capture the LOC and GS and hand flew the remaining approach. From the FAF on; the approach was uneventful and we confirmed with Tower that he showed us established. This was a very clear reason why every approach should be briefed even when it gets busy or you think you had the correct information in the computer from the first approach after a go around. If I had re-briefed the approach after the switch to 27R we would have noticed that the frequency was wrong even though the FMS was set for 27R. I also had a second chance to brief the approach the second time and still neglected to brief it thinking we had the correct info. This was a simple case of not preparing enough for changes that were made and becoming too comfortable with the computerized system. A briefing should be part of every approach; if multiple are made; and not just the first one.

Initially the aircraft FMS was loaded with the runway 26 information. The approach was briefed by the flying pilot including the appropriate frequencies and radials. As we were handed off to approach control we were advised to expect runway 27R. We then entered the information for 27R into the FMS. Upon final approach to 27R and before glide slope intercept we were instructed to go around due to insufficient spacing with the preceding aircraft. We initiated the go around procedure and were given an altitude and heading to fly to re-intercept the localizer for 27R. When lining up for final approach the second time we were advised by tower that we were showing 'south of course'. We immediately began double checking frequencies and discovered that we had inadvertently loaded the frequency for 27L. We corrected the frequency and continued the approach to 27R and made a normal landing. The error occurred due to our anticipating the incorrect runway in advance. The correct runway was loaded into the FMS upon being directed by approach control to do so but the ILS frequency was not changed [not correctly entered] from the ILS 26 to ILS 27R. Also missing was another brief after being told to expect and subsequently issued a clearance for runway 27R.The flight crew have debriefed the incident and determined that a more standardized instrument approach briefing should be used in the future. The time at which the brief should be expected as well as the information conveyed as part of the briefing will both be standardized during all future flight operations.

A DA2000 flight crew reports inadvertently selecting the ILS for Runway 27L when cleared for the ILS 27R. The flight is issued a go-around for spacing issues before the error becomes apparent. On the next approach the error becomes apparent to ATC and the crew eventually corrects the ILS 27R.

1465598

201707

1201-1800

ZZZ.Airport

US

3500.0

VMC

VFR; 10

Daylight

Tower ZZZ

FBO

Skyhawk 172/Cutlass 172

2.0

Part 91

VFR

Training

Cruise

Reciprocating Engine Assembly

X

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying; Instructor

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

Flight Crew Last 90 Days 145; Flight Crew Total 800; Flight Crew Type 699

1465598

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

My passenger and I were doing flight training. We were practicing a power on stall when a loud bang was heard; oil covered the windshield and a piece of the engine flew up through the engine cowling. I immediately shut the engine off; and made a distress call to tower. I was able to safely land in a field. No injuries were observed or reported due to this incident. Besides from damage to the engine and damage to the engine cowling from the engine; no other damage to the aircraft was witnessed.

C172 instructor pilot experienced an engine failure at 3;000 feet AGL and was able to land safely in a field.

1300425

201510

0601-1200

ZZZ.Airport

US

0.0

VMC

Tower ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 159; Flight Crew Type 7380

Distraction; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1300425

ATC Issue All Types

N

Person Flight Crew

Other Takeoff roll

General None Reported / Taken

Procedure

We were cleared for takeoff on Runway XX and commenced a normal takeoff roll. Around 100 knots we heard clearly ATC clearing another aircraft to cross Runway XX. Needless to say this was a major distraction during this phase of flight. I suggested we should abort and asked the Captain if he saw the aircraft downfield; which was holding short of Runway XX; moving. The aircraft was not and the Captain announced on the radio; [Our callsign] is rolling on Runway XX. The takeoff continued without further incident. Upon being switched to departure; Tower advised us the aircraft being cleared to cross Runway XX was behind us.

B737 flight crew at 100 knots on the takeoff roll; heard ATC clear another aircraft to cross the same runway. Crew elected to continue the takeoff and Tower subsequently advised that the crossing traffic was behind the takeoff aircraft.

1368299

201606

1201-1800

ZZZ.Airport

US

0.0

VMC

Daylight

CTAF ZZZ

Personal

DA40 Diamond Star

1.0

Part 91

None

Training

Landing

Fuselage Tail Cone

X

Aircraft X

Flight Deck

Personal

Check Pilot

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

Flight Crew Last 90 Days 120; Flight Crew Total 9100; Flight Crew Type 100

Confusion; Training / Qualification; Situational Awareness; Time Pressure

1368299

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

Person Observer

In-flight

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

Human Factors; Procedure

Human Factors

I was serving as a Designated Pilot Examiner for a Private Pilot ASEL applicant. Near the end of the checkride; the applicant had just departed Runway 17. In the climb I asked the traffic in the pattern in front of us if they would extend their downwind leg to permit us to do a simulated power loss and simulated emergency approach and landing. They agreed. About midfield downwind to Runway17; and at pattern altitude; I retarded the throttle and announced 'simulated power loss'. The applicant started going through his 'engine failure in flight' checklist; but continued flying downwind. As there was no attempt to turn toward the runway; I was beginning to think perhaps he was planning to put it into a nearby field. He eventually turned base; maintaining best glide speed and no flaps. He flew very nearly a square base; and I was again wondering if he planned to land off runway. He then turned final to Runway 17. He was low; but the DA-40 glides well; and I felt he had a reasonable chance at making it to the pavement. He entered ground effect over the last of the approach lights; and I felt he probably would have landed about 100 feet into the pavement. However I was concerned he may drag the tail thru the threshold lights; so I urged 'Go Around! Go Around!' He froze for a moment; and my hands went for the controls and throttles. He beat me to the throttle and jammed it forward; and simultaneously pulled back on his stick. The resulting pitch up and over-rotation caused a tail strike; and the start of a point of impact. I was on the controls by now and took over; recovered from the porpoising; and landed the aircraft. Knowing we had hit the tail; I instructed him to taxi to the school's maintenance facility to have the aircraft inspected. Initial inspection shows scraped paint and fiberglass on the removable tail skid/faring; no cracked fiberglass in the faring; and no apparent damage (at this point) to any structure above the skid.The applicant was notified of an unsuccessful test result because of poor judgement in the simulated emergency approach regarding flight path and energy management; as well as improper timing and procedure for the go-around.I have discussed the event with the recommending CFI; and will also discuss it with the school's Chief Instructor. I am proposing several changes to both training and testing to prevent a re-occurrence. I suggest that the school train students to mentally aim for the middle of a landable area in an emergency situation. I feel the students are unconsciously programmed to always land in the first 1;000 feet of a runway; even when there is 9;000 feet of pavement available. In future pre-flight test briefs; I will specify that the 'usable runway' for a simulated power off landing begins and ends at the 1;000 feet fixed distance markers on either end of the runway. This should allow adequate space to prevent actual low and short landings; yet allow fair testing all the way to the surface. Lastly; I have urged the school to train students regarding aircraft energy management such that simulated power off landings will be done in the middle 1/3 of the runway.

A Designated Pilot Examiner reported that a private pilot applicant in a simulated engine failure in the landing pattern nearly landed short. The examiner commanded a go-around at a very low altitude; which resulted in an aircraft tail strike.

1748340

202006

1201-1800

ZZZ.ARTCC

US

22000.0

VMC

Center ZZZ

Air Carrier

Widebody; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Cruise

Class A ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Flight Crew Last 90 Days 40.07; Flight Crew Total 1284.98; Flight Crew Type 55.75

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Dispatch; Party2 Maintenance

1748340

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

Person Other Person

General None Reported / Taken

Company Policy; Human Factors; Procedure

Procedure

We apparently flew 3 flights with this aircraft where both the pilots and Dispatch were unaware that the aircraft's CAT 3 status had expired. Aircraft was taken out of storage for this trip. Releases for all three segments were signed before the first flight; and there was no indication in the log history or the first maintenance release that CAT 3 had expired. On touchdown at ZZZ; the maintenance system 'auto-generated' a fault record; and then automatically issued a deferral. We were unaware that this had been entered into the electronic logbook; and must have missed it in the review of the maintenance release for the next (ZZZ-ZZZ1) segment. Dispatch discovered this after we pushed on the last segment (ZZZ1-ZZZ2); but was not able to contact us via ACARS; until after we were airborne. I called dispatcher after landing ZZZ2 to try to figure out what happened; and he looped Maintenance Control in for additional information. Weather was severe clear at all stations; and I am high minimums anyway; so safety was not compromised by not having CAT 3. The phase of flight/occurrence information above was where we were first informed of the issue by Dispatch.

Air carrier Captain reported flying three flights in an aircraft with an expired CAT III status.

1092466

201306

0601-1200

HHR.Airport

CA

1700.0

IMC

Daylight

TRACON SCT

Personal

Small Aircraft; Low Wing; 1 Eng; Retractable Gear

1.0

Part 91

IFR

Personal

Localizer/Glideslope/ILS Runway 25

Initial Approach

Vectors

Class B LAX; Class D HHR

GPS & Other Satellite Navigation

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 15.4; Flight Crew Total 1396.3; Flight Crew Type 719.2

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

Party1 Flight Crew; Party2 ATC

1092466

Aircraft Equipment Problem Critical; Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew; Person Air Traffic Control

In-flight

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

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

Ambiguous

I filed IFR to HHR. Departure Tower handed me off to Approach. Approach gave me vectors for my climb to 5;000 MSL. Upon reaching altitude; Approach gave me direct an airway fix and handed me off to SCT Approach. I contacted SCT Approach after they acknowledged me; I then requested the GPS/WAAS approach for HHR. The Controller asked me to repeat the approach and then said OK. I made the same request with all subsequent controller handoffs. On contacting the last SCT Approach Controller prior to be handed off to Tower; he cleared me for the Localizer/GPS approach. I advised him I was direct WELLZ Intersection and had previously requested the GPS/WAAS approach and I was requesting the GPS/WAAS approach from him. While WELLZ is also on the localizer course; in GPS steering mode on autopilot; the GPS was warning of the upcoming steep turn ahead and was preparing for the turn. The vectors given by controllers for my course heading put me on a narrow downwind to the final approach course. The Controller stated that the approach was unable and to fly the Localizer/GPS approach. I had the localizer approach frequencies set up in my back up NAV 2. I use NAV 2 as a double check to NAV 1 which was in GPS steering mode coupled to the autopilot. I was in IMC at the time and did not want to argue with the Controller that the previous controllers had accepted my request for the GPS approach which is what my autopilot was flying. I began to transition from the GPS approach to the localizer approach. I had not briefed the localizer approach and was working to bring up the approach plate. The Controller called up and said I was 2 miles from HASHY and said to maintain 1;600 FT till established cleared for Localizer/GPS approach all while I was in IMC. I changed the autopilot from GPS steering mode to heading mode. I tuned in a left turn on the autopilot heading mode. The airplane autopilot turns at a standard rate turn. The Controller called and stated [that] I needed to make a much steeper turn to make the localizer. I disconnected the autopilot and I cranked the yoke over to the left and watched the localizer come in on NAV 2. Controller called in and stated he observed me established on the localizer. I didn't think I was established due to the extreme bank and I thought my momentum was going to take me past the localizer which is why I had not yet started my descent and I made no report of being established. I reached down to reset the GPS to HHR when I noticed the Multi Function Display which receives its information from the GPS screen was blank and the previous programmed procedure in the GPS flight plan was now gone. I tried to program the GPS for HHR and I got GPS integrity error. I had no way points; no airports; no intersections on my MFD; nor my electronic HSI moving map which are both driven by the GPS which had apparently had no signal. Further; the GPS is my DME and I had no reference to distance from airport or waypoints. I changed my EFIS from map mode to Localizer mode so I could have my full Localizer needle on the HSI in front of me over using the number two NAV needles. In this short period of time of resetting radios in IMC; and trying to figure out what happened to my GPS; MFD and EFIS along with the momentum of my tight turn caused me to drift 10% right. I got a call from the Controller warning me of the deviation in which case I turned 10% left as requested by the Controller. After the Controller saw my course correction; he asked me to contract Hawthorne Tower. After landing; I was instructed to call a number for which I was informed of a possible pilot deviation. As a result; I was informed that the Controller for LAX adjusted traffic for three arriving flights into LAX. When I heard this; I thought this was strange; since I had no traffic alerts displayed on my MFD from my Garmin Traffic Avoidance System; nor did I hear any audio alerts. It turns out based on a NOTAM that the DOD was conducting testing in the areawhich there was a low level chance it could create anomalies with flight deck systems and TCAS. I called the number on the NOTAM and spoke to a gentleman to report my loss of GPS Signal and my loss of targets on my Traffic Avoidance System. I asked if this would have been caused by their testing and he replied yes.In conclusion; I was mentally prepared for a GPS approach but given a different approach. The new approach required a steep turn to the localizer which created some drift. This was exacerbated when the avionics shut down which I rely upon for my situation awareness. In this short period of time of fixating on the avionics; I should have paid more attention to NAV 2 localizer and just fly the plane. I favor flying the WAAS/GPS approach; they are more accurate than the ILS. All the approaches I have flown in the last year have been GPS/WAAS approaches. My autopilot has GPS steering and it couples more accurately to the GPS approach then the localizer approach. Lessons learned; I do not routinely practice ILS approaches. I fly LPV approaches which look and feel the same as an ILS. As such; on approaches for a GPS approach; I need to not only tune in a back up approach; but I need to be prepared to fly the backup approach; including having the approach plate up and available. I need to add ILS/Localizer approaches into my practice currency. Most important of all; I should have considered going missed when my avionics went out and need to add that to my currency practice. Have my Ipad with backup GPS in case of panel GPS failure.

A pilot was prepared for the HHR Runway 25 GPS approach; but because of GPS signal disruption was cleared for the LOC then overshot final as he transitioned NAV equipment and mental mapping to the non precision approach.

1283563

201507

1801-2400

SFO.Airport

CA

13000.0

VMC

Daylight

TRACON NCT

Air Taxi

Embraer Phenom 300

2.0

Part 135

IFR

GPS; Localizer/Glideslope/ILS Runway 28L

Initial Approach

STAR BDEGA ONE

Class E NCT

Aircraft X

Flight Deck

Air Taxi

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Workload

1283563

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 Issued New Clearance; Flight Crew Became Reoriented

Human Factors; Procedure

Procedure

Initial clearance [into SFO] was for the Golden Gate 6 arrival; initial fix RBG. Before crossing RBG; we were issued a new arrival; the BDEGA 1; landing West. We were expecting the 28R transition and briefed as such. The intersection CORKK separates the arrival for the left and right runways. Just before CORKK; ATC issued us to the 28L transition. I; as the Pilot Monitoring (PM); was very task saturated and started setting us up for the 28L ILS; reviewing charts and loading the approach into the GPS. As we sequenced over CORKK the A/P turned for the 28R fix; not 28L as assigned. Not long after the sequence; approach gave us a vector of 140 to sequence us behind traffic from the south. After the navigation correction; and set up for 28L; in the (downwind) vector; we were told to expect 28R again. Once again; we had to change the flight plan in the GPS; look at approach plates and re-brief whilst looking for traffic to follow and receiving further vectors and descents. We eventually landed 28R and taxied in without further incidence. I would say close to 100% of our flight plan arrivals change whilst enroute to RNAV STARS when we are able to fly them (NAV database current). So; briefing the filed arrival on the ground before departure is almost counterproductive as we are almost always issued a new one. We always try to brief early before transition altitude and we did. In this case I failed to sequence the GPS to the arrival runway when they changed the runway on us last minute. I was heads down; task saturated; loading the different ILS approach and reviewing approach plates. It wasn't long after the sequence that the controller corrected our navigation deviation and gave us a heading. I don't think ATC ever intended us to land on 28L but just gave us that transition just for flow and get us south. It would have been nice just to get a vector so we could have kept our approaches loaded and pilot tasks less saturated; rather than changing the flight plan and approaches twice in congested airspace.

EMB-505 First Officer reported a track deviation on arrival into SFO when he became task saturated following multiple runway changes.

1682965

201909

1201-1800

PAO.Airport

CA

136.0

2.0

1200.0

VMC

10

Daylight

12000

Tower SQL

Personal

Bonanza 36

1.0

Part 91

VFR

Personal

GPS

Initial Approach

Visual Approach

Class D PAO

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 33; Flight Crew Total 702; Flight Crew Type 598

Fatigue; Situational Awareness

1682965

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

N

Person Air Traffic Control; Person Flight Crew

In-flight

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Human Factors

I was entering the San Francisco Bay Area airspace on VFR flight following to SQL and erroneously thought I had SQL in sight. In fact it was PAO. I told approach I had the airport in sight and was handed off to SQL Tower. Tower told me to report 3 mile final Runway 30. I erroneously turned toward PAO and began my approach. About 3 miles out I realized the airport did not look correct (the terminal was not on the east side of the field as I had remembered 3 years before). I realized my mistake and began to correct when Tower queried me and I began my correction. I breached PAO airspace during my correction. While there is no excuse; there were many factors which led to this mistake:This was the conclusion of my second cross country flight of the day. Fatigue had set in by the conclusion of the flight which factored into negating the knowledge of the airport and airspace that I had studied the night before and early the morning of the flight. It had also been 3 years since I had flown into San Carlos.When I saw PAO I just 'went visual' and ignored my instruments. It wasn't until I realized my mistake and began correcting that I recognized the full deflection of the visual approach that I loaded. I thought I was on an intercept course; however I was not.Another factor to the incursion was that when I loaded the visual approach the 'magenta line' disappears. I was on a direct course and would have recognized my deviation much faster if I hadn't loaded the approach until I was 100% sure I was approaching the correct airport. Actions that could have prevented the incursion:Study the destination airport just before departure; not a leg before.Stay on flight following until they hand you to Tower and I am sure I have the airport in sight. Use my secondary GPS magenta line guidance when I load the visual approach.Be more focused on identifying landmarks. Fly IFR into complex unfamiliar airspace. Recognize that fatigue will set in after so many hours of flying much of which was above 10;000 ft.

Bonanza pilot reported fatigue; resulting in a visual approach to the wrong airport and a Class D airspace incursion.

1283401

201507

1801-2400

L30.TRACON

NV

12000.0

Night

TRACON L30

Air Carrier

Large Transport

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

STAR GRNPA ONE

Class E ZLA

Facility L30.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Communication Breakdown; Distraction; Time Pressure

Party1 ATC; Party2 ATC

1283401

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

Person Air Traffic Control

In-flight

Human Factors; Procedure

Procedure

While working the Granite arrival sector; the Lake arrival sector was receiving aircraft from LA center over the LUXOR waypoint on the GRNPA arrival. The airport was on Configuration 3; landing runways 25; and 19. Departures off of runway 1; fly east and climb directly at the arrivals from LUXOR in this configuration. This event is an example of an ongoing problem with LA center delaying communications transfer of aircraft handed off to L30 TRACON on a routine basis until aircraft are at or inside L30 TRACON boundary. Due to this continuing routine late communication transfer the aircraft in question was not vectored and issued descent in a timely manner and turned on his last assigned route right into departure traffic; creating an unsafe condition. This unsafe condition continued as the aircraft was finally on the Lake sectors frequency at an altitude and speed and location that made it impossible for a descent and landing on runway 25; so was therefore vectored to the other runway 1 impacting the traffic already destined for that runway. A complex situation was made very difficult and unsafe due to routine delay of aircraft communication change by LA center.I have worked as an ATCS for [many] years. In all those years it has been reasonable and customary for aircraft to be changed to the receiver's frequency as soon as possible after completion of radar handoff. LA center sectors 6; 7; 8 and 16 routinely delay the communications change of completed handoffs until the aircraft are at or inside L30 TRACON boundary. This delay causes aircraft to be delayed and or rerouted and causes increased complexity and decreased safety as a result.If there is a valid reason for this delay in communications change and that reason is systemic; than a systemic change must be made to allow immediate communication change upon completion of handoff. If there is an individual valid reason for the delay in communications change then coordination of that reason must be given so planning can take place. In the absence of the above corrective fixes; there is no valid reason for the delay and it must be eliminated.

L30 TRACON Controller reports of an ongoing situation where the overlying Center sector is not transferring communications of aircraft until at the sector boundary or inside L30's airspace. Reporter states this happens often and leaves aircraft high or in conflict with other traffic.

1345038

201604

0601-1200

ZZZ.Airport

US

IMC

Daylight

Air Carrier

Medium Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Descent

Tablet

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Distraction; Human-Machine Interface; Time Pressure; Troubleshooting

1345038

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Company Policy

Arrival weather reports indicated gusty winds and low ceilings; making the single direction ILS unusable. We came up with a plan to shoot the localizer and circle opposite direction; as this gave us the lowest minimums and the lowest workload. I had previously looked at the approach options before departure and in an effort to conserve battery life; I had pressed the power button; as I have done all month. When it came time to begin our descent; I pressed the power button to turn on the Surface EFB; and nothing happened; just a black screen. After dividing my attention between flying and getting the Surface to run for 3-4 min; I finally got the device restarted. I was without my own side navigation charts for 3-4 min; referencing my FO's charts across the cockpit. Landing occurred without event.Root cause is the Microsoft Surface EFB. Contributing is management's insistence on using this device despite the multitude of times it has crashed and pilots have lost situational awareness during it's extremely short test phase. Many of the crashes have occurred on my flight deck; on my device as well as my FO's; while conducting normal operations. Also contributing is the rushed timeline to get the device online and the normalization of deviance with the number of times this device crashes and zero effort made to address the issues. Pilots are just accepting that the thing crashes at least once a day. Contributing to the failure of the device is the lack of reports the company receives from pilots because of the time consuming process of submitting problem reports via the ASAP program; also the lack of training/documentation provided to the pilot group about reporting problems with the Surface EFB.

Air carrier Captain reported a problem obtaining critical flight information from his Microsoft Surface EFB in a timely fashion. He stated that the problem is chronic and is directly related to the brand of electronic device chosen by his company.

1618904

201902

0601-1200

MYAM.Airport

FO

5000.0

VMC

Daylight

Tower MYAM

Air Carrier

Medium Large Transport

2.0

Part 121

Passenger

FMS Or FMC

Initial Approach

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1618904

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

Person Air Traffic Control; Person Flight Crew

In-flight

Air Traffic Control Provided Assistance

Chart Or Publication; Human Factors

Chart Or Publication

Company charts and NOTAM's did not reflect an operational Control Tower/Ground Control/ATIS. We canceled IFR with Miami Center around 5;000 feet when we had the field in sight. I was making position reports on CTAF (Common Traffic Advisory Frequency) and was contacted by Tower over CTAF with a frequency for Tower. We were approximately 15 miles out and performing a left 360 for separation at the time. Tower ask us to report established on final. When we were back on final they cleared us to land. On short final I noticed that the rotating beacon was on. After landing and taxiing in; I discovered that the Tower had been operational for the past two weeks. On flight after departing VFR and getting back into ACARS range we received the missing NOTAM for the first time; which reflected the information about the new Tower and that the ARFF (Aircraft Rescue and Firefighting) had been downgraded. At this time we realized that the fire department on the field may not have been able to handle the amount of passengers our aircraft is able to carry.Lack of communication between the company and ATC. Previous [company] pilots not reporting changes over the past few weeks of flying into the airport.

First Officer reported not knowing the airport had an operational Control Tower until Tower Controller called the crew on CTAF and advised them of the correct frequency to be on.

1316368

201512

1801-2400

ZZZ.Airport

US

VMC

Center ZZZ

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

IFR

Passenger

FMS Or FMC

Climb

Class A ZZZ

Turbine Engine

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Distraction; Situational Awareness

1316368

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 11396

Situational Awareness; Distraction

1316370.0

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

Person Flight Crew

In-flight

Flight Crew Became Reoriented

Human Factors

During takeoff and climb out on departure; Flight Level Change (FLX) thrust was left engaged for approximately 18 minutes; exceeding 5 minute limitation. On takeoff; I left FLX thrust in (as we briefed prior to departure) to ensure compliance with two altitude restrictions on the departure. We were heavy and the temperature was ISA +10. Just prior to the second altitude-restricted waypoint ATC cleared us direct to a later fix. After proceeding as directed; we forgot to reduce the thrust from FLX to Climb (CLB) mode. I detected the mistake when leveling off and reduced the thrust to Cruise (CRZ).Suggest better monitoring of the thrust mode and timing; and also better adherence to the After Takeoff Checklist would help reduce the chance of recurrence of this event.

During takeoff we used FLX takeoff thrust. We were cleared to fly a departure procedure [that] has an altitude restriction of at or above 5000 feet at one fix and another altitude restriction for at or above 7000 feet. We discussed these restrictions in the preflight briefing. The First Officer; who was the Flying Pilot; elected to leave the power in the FLX mode until we were assured of meeting these altitude restrictions. As the Captain and the Pilot Monitoring; I agreed with this decision. Once we leveled off at our cruise altitude of 29;000 feet; the First Officer realized he had never moved the thrust levers from the TOGA detent into the CLIMB detent; allowing both engines to remain in FLX mode for approximately 18 minutes; which exceeds the engine limitation of five minutes for FLX mode. Upon arrival; I made a logbook entry of the limitation exceedance and notified Maintenance Control of the event.At the normal time; accelerating through approximately 220KIAS; I completed the After Takeoff Checklist; with the notation that takeoff power was still in FLX mode and not in CLB mode. Subsequently; I became distracted due to frequency changes; a new altitude assignment; and a clearance for us to proceed to a waypoint further along in our flight plan. Due to these distractions; I completely forgot about the thrust mode in use until it was brought to my attention once we leveled off at our cruise altitude of 29;000 feet. At this point; the thrust levers were placed in CRZ mode.To prevent this event from happening again; there simply must be a more disciplined approach to checklist usage. If there is a deviation from the normal operating procedure; then there should be a memory trigger of some sort to ensure that all items on the checklist are completed appropriately.

After takeoff; CRJ crew elected to leave the power in the Flight Level Change mode due to departure-procedure altitude restrictions. Upon level off at cruise altitude; crew realized that they had never moved the thrust levers from the Take Off Go Around detent into the CLIMB detent. This allowed both engines to remain in Flight Level Change mode for approximately 18 minutes; exceeding the engine limitation of five minutes for Flight Level Change mode operation.

1747109

202003

1201-1800

ZZZ.TRACON

US

4000.0

TRACON ZZZ

Air Carrier

B767-200

2.0

Part 121

IFR

Initial Climb

Class B ZZZ

Main Gear Door

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Distraction; Time Pressure

1747109

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

Upon gear retraction EICAS message 'GEAR disagree' and 'gear doors' with advisory lights. Performed QRH procedures. Contacted Maintenance Control and confirmed return to base. Extended the gear early and had the same EICAS messages; and no green down and locked lights for the two main gears. Performed QRH procedure for Gear disagree with handle in down position and did an alternate gear extension. The time lapse before we got the left green light was approximately four minutes; and we did not get the right green light for approximately an additional 1 1/2 minutes. The timing seem off to us so out of an abundance of caution we did a low approach so the Tower could confirm that all the gear was down. ATC advised us that they had equipment standing by. We came around for another approach and landed with the gear doors open.

B767-200 Captain reported a gear door problem and landed with out incident.

1353150

201605

ZZZ.ARTCC

US

35000.0

VMC

Center ZZZ

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Hydraulic Main System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Type 7088

1353150

Aircraft Equipment Problem Less Severe; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor; Ground Event / Encounter Other / Unknown

Person Flight Crew

In-flight

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

Aircraft

We received a low pressure engine 1 hydraulic master caution in cruise at FL350 approximately 1 hour into a 2 hour flight. We immediately accomplished the hydraulic low pressure QRH. The hydraulic A quantity was noted at 22%. After shutting off engine 1 hydraulic pump; the quantity continued steady decline to 0%. Pressure remained 3;000 PSI on both systems. Expecting a full hydraulic A failure; the Captain gave pilot flying duties to me while he coordinated with company maintenance; Dispatch; ATC; cabin crew and passengers. We [advised ATC of the situation]. Due to heavy thunderstorms in [destination] area; flight crew made a decision to return to [departure airport] rather than continue. We continued to [departure airport] to burn fuel to get below landing weight. We reviewed the hydraulic A fail QRH in anticipation of that event and reviewed landing distance data for loss of hydraulic A. We decided on straight in [landing]; First Officer landed (flaps 40/max brake); so that the Captain could switch to alt steering on runway if necessary.On landing; fire equipment was dispatched to aircraft and we advised Tower we would be stopped on runway. We had expected to taxi to the gate momentarily. Emergency workers noted mist/smoke from #1 engine with no fire indications. Expecting it was residual engine smoke; we elected to shut down engine 1. The smoke/mist briefly stopped then restarted and we accomplished engine fire checklist; pulling fire handle but not discharging bottles. Puddles reported around left main gear and we discussed that it would probably be safer to use a super tug to bring us to gate because hydraulic fluid was likely on the hot brake rotors.Captain regularly was in contact with the flight attendants and passengers; and was very reassuring to them. Though my primary responsibility was pilot flying; I was completely in the loop on all communication; decision making and my input was sought and considered at every opportunity. I think the crew acted with superior judgement and utilized CRM strategies very well. After debriefing with Captain; I am very pleased with our decisions and actions to land the aircraft safely.

B737 First Officer reported returning to departure airport after experiencing loss of 'A' hydraulic system.

1740234

202004

0601-1200

ZZZ.Airport

US

10000.0

VMC

Daylight

Air Carrier

Q400

2.0

Part 121

IFR

Passenger

Climb

Vectors

Class B ZZZ

Landing Gear

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1740234

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

Person Flight Crew

In-flight

Aircraft Equipment Problem Dissipated; Flight Crew Overcame Equipment Problem

Aircraft; Procedure

Procedure

Captain and First Officer; who were serving as the flight crew between ZZZ and ZZZ1 experienced a gear malfunction when the landing gear failed to retract when the landing gear selector was selected 'up.' It was subsequently determined that the Landing Gear Alternate Release was not fully closed.Prior to flight it was determined that the Park Brake pressure was below 500 psi. Per the originating checklist; the crew referenced the flight manual; section 7; Supplementary Normal Procedures.After referencing the Low Park Brake Pressure section of section 7; the crew followed Procedure 2. While performing these steps; both crew members exited the crew compartment in order to actuate the Brake Auxiliary Pump. Once sufficient park brake pressure had been achieved; the crew returned to the flight compartment and continued their preparations for departure. During a subsequent crew debrief; it was determined that the crew had overlooked step 3; which instructed the closure of the Landing Gear Alt Release Door.After takeoff when the gear failed to retract; the crew immediately determined the cause of the failure was due to the Landing Gear Alternate Release not being fully closed. The crew continued the departure and completed the remainder of the after takeoff checklist. The crew continued the climb to their initial altitude of 10;000 feet where they leveled off and maintained airspeed below 200 knots. The crew then referenced the checklist and completed the 'Landing Gear Fails to Retract' checklist; which resulted in the successful retraction of the landing gear. The flight continued to ZZZ1.Modify 'Low Park Brake Pressure' procedure 2. It is very easy to overlook step 3 due to frequent use of capital letters in steps 1; 2; and 3. Consider using bold text for step 3. Also; add a step 8 to verify step 3. When the crew needs to exit the aircraft; it creates a sense of urgency upon returning to meet departure time. As a result; a returning crew can be eager to continue their flight preparations and seeing they have completed step 7; believe they have successfully completed the checklist.

Q400 First Officer reported landing gear failed to retract when selected up; caused by the landing gear alternate release panel cover which was not properly closed.

1743796

202005

1201-1800

WRI.TRACON

NJ

Marginal

Dusk

1200

CTAF MJX

Corporate

Falcon 2000

Part 91

IFR

Ferry / Re-Positioning

FMS Or FMC

Final Approach

Class E ZDC

CTAF MJX

Personal

Amateur/Home Built/Experimental

1.0

Part 91

Personal

Landing

Class E ZDC

Aircraft X

Flight Deck

Corporate

Pilot Flying; Captain

Communication Breakdown; Time Pressure; Confusion

Party1 Flight Crew; Party2 Flight Crew

1743796

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

Person Flight Crew

In-flight

Flight Crew Took Evasive Action; General Flight Cancelled / Delayed

Airport; Procedure; Airspace Structure; Human Factors

Human Factors

Last Sunday night while returning empty to our home airport we had to execute a go-around due to an opposite direction aircraft failing to acknowledge us or give way while we were on short final. I was the Pilot Flying on this leg; our last leg of three for the day. It was dusk; wind was light; better than 5 miles Visibility; 1;200 ft. Overcast. We were with Approach who had cleared us for the ILS Approach due to the low ceilings; but had been monitoring CTAF on Com 1 for the last 20 miles. The pilot monitoring had made 3 traffic calls by this point. We proceeded on the approach; and once below the ceiling; visually acquired the runway; and cancelled our IFR Flight Plan with Approach at approximately 2.5 miles from the runway. Just prior to this we picked up a cyan target on TCAS at the opposite end of the runway; roughly 2 miles from the airfield; 5 miles from us. It appeared to be a helicopter at 600 ft. on a northerly heading but they had not responded or acknowledged our traffic calls. We initially thought it might be a transient since they had not responded. Upon fully switching to CTAF and giving a 'short final' traffic call; the opposing traffic changed its heading and lined up for the opposite direction runway in a head on situation. The pilot of this aircraft then radioed the following; 'Experimental Jet landing ...' The Pilot Monitoring quickly responded that we were a Jet on short final and the active runway was our runway. No further response from the Experimental Jet traffic; so I opted to execute a Go-Around. The Pilot Monitoring called our Go-Around on CTAF. There was no other traffic in the area so I rolled right; cleaned up and executed a right 360 degree turn in order to stay in VMC conditions and position us to return to land. In the turn; we heard the landing traffic call that he had cleared the runway. The pilot monitoring made an additional traffic call; but there was no further response from the traffic; and we landed without incident. The pilot of that aircraft never responded or apologized; and appeared to quickly park the plane at the airport hangars. A later conversation with the FBO line serviceman; who knew the pilot of this jet aircraft and revealed this pilot's name and the aircraft type. Later on this ramper texted with the jet pilot; and the pilot revealed that he was; 'very low on fuel and scud running' so he opted to land with a tailwind on the opposite direction runway. We were upset that this dangerous situation even occurred; as it could have been prevented with some basic airmanship. We believe that this pilot's behavior was an absolute hazard to himself and others on the ground. Yesterday morning I opted to do some online research; and I discovered that this individual was a Private Pilot and only qualified to fly his experimental jet.This careless and dangerous behavior could not only hurt this pilot; and those on the ground should an incident occur; but also general aviation as a community and the local community near the airport. This pilot does not appear to respect the FARs having demonstrated that it's acceptable to operate his aircraft in IMC while he is not qualified to do so. Additionally; he did not demonstrate adequate Private Pilot knowledge; AIM knowledge; nor did he respect his aircraft's specific limitations by operating on low fuel and then landing on the wrong runway despite the weather reports or that there was an inbound aircraft on the same runway.

A pilot landing at a non towered airport reported initiating a go around due to opposite direction landing traffic not communicating on CTAF.

1090688

201305

ZKC.ARTCC

KS

Center ZKC

Air Carrier

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

2.0

Part 121

IFR

Passenger

Cruise

Class A ZKC

Fuel Distribution System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

1090688

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1090704.0

Aircraft Equipment Problem Less Severe; Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

Flight Crew Became Reoriented; General Maintenance Action

Aircraft

During cruise flight; we observed that the quantity of fuel in all three fuel tanks (both wings and center) was decreasing simultaneously. This was a fuel management burn which did not comply with the normal procedure of emptying the fuel from the center tank prior to using main tank fuel (DC-9 Op. Man. Vol. 1; LIMITATIONS.) There is not a procedure in the QRH which specifically addresses the issue of all three fuel tank quantities decreasing simultaneously. The center tank pumps checked normal on preflight;therefore; we assumed that the center pumps were operating but supplying a lower pressure than normal. We performed the QRH procedure 'Fuel Not Feeding from Center Tank or Center Tank Fuel Pump Inoperative'. We employed the procedure as though the center tank quantity was not decreasing -- otherwise; the procedure states 'Continue normal operations' and we would have accomplished nothing. Although fuel was feeding from the center tank; had we continued flight without performing this procedure we would have landed with a significant amount of fuel in the center tank and the wing tanks well below full. We were able to reduce the center tank quantity to 700 LBS. employing this procedure and we didn't use any fuel from the wing tanks during the time we were employing the procedure. The center tank quantity continued to decrease after we completed the procedure; and the center tank was empty prior to landing. The approach and landing were uneventful. During the entire flight all other systems operated normally. As I previously mentioned; there wasn't a procedure in the QRH pertaining to this condition. Although the center tank pumps were operative; I suspect that they weren't supplying the pressure sufficient to ensure that the engines would feed from the center tank alone. We therefore employed the procedure that we did to ensure that the center tank emptied prior to burning any more fuel from the main tanks to comply with the limitation previously listed. This was performed in the interest of safety. I believe it was the safest and the proper action to take.

At cruise altitude observed fuel not feeding from center tank. Wing tank fuel quantities were decreasing when center tank should have been only fuel quantity that was decreasing. Executed QRH for 'Fuel Not Feeding from Center Tank.' QRH procedure resolved problem; flight continued uneventfully to destination. It's my understanding that the Captain wrote up the issue at the destination.

MD80 flight crew reports fuel decreasing in both wing tanks and the center tank during cruise when only the center tank should be decreasing. The QRH procedure for fuel not feeding from the center tank is employed to ensure most center tank fuel is used before turning the wing tank pumps back on.