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

1220995

201411

0601-1200

TRM.Airport

CA

1300.0

VMC

Daylight

CTAF TRM

Fractional

Embraer Legacy 450/500

2.0

Part 91

Passenger

Landing

Class E TRM

CTAF TRM

Cessna Aircraft Undifferentiated or Other Model

1.0

Initial Climb; Takeoff / Launch

Class E TRM

Aircraft X

Flight Deck

Fractional

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Crew

1220995

Aircraft X

Flight Deck

Fractional

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1220996.0

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

Automation Aircraft RA; Person Flight Crew

In-flight

Flight Crew Executed Go Around / Missed Approach; Flight Crew FLC complied w / Automation / Advisory

Human Factors; Airport

Human Factors

I was SIC (Second in Command) Pilot Flying in the left seat during a passenger flight to TRM; the weather was severe clear (day) with ASOS reporting calm winds. We planned/briefed a visual approach to runway 35 because our direction of arrival from the north set us up nicely for a 45 degree left downwind entry and that runway had an instrument approach with vertical guidance (LNAV+V). We cancelled IFR at about 12 miles and entered the downwind as briefed. My partner made our first radio call on CTAF at about 10 miles announcing our intentions. One aircraft replied stating that he had just departed runway 17 and was clearing the pattern to the east. No other aircraft replied. My partner made three subsequent calls on CTAF announcing our position and intended landing on 35: entering downwind; mid-field downwind and turning base. There were no replies and no other aircraft transmitted on CTAF. About halfway through our base leg; we heard an aircraft announce that he was taking runway 17 for takeoff. My partner immediately replied that we were about to turn final on runway 35. There was no reply. My partner again asked the other aircraft where they were and again there was no answer. Not knowing what this other aircraft was doing; we executed a missed approach at about 700 feet as we should have been turning final. We started a climb to pattern altitude (1500 feet) and I offset to the right side of the runway to clear the departure path and set up for a left downwind to runway 17. Climbing through approximately 1300 feet; we got a TCAS RA (climb). As I was executing the RA; I saw a single engine Cessna pass about 500 feet below us. After avoiding the traffic; we entered a left downwind for 17 and made an uneventful landing. I did not hear this aircraft make any CTAF calls other than the one announcing that they were taking 17. After disembarking the passengers; the FBO line crew told us that they saw the entire thing happen. They went on to say that the offending aircraft was based at TRM. This event would not have occurred had the pilot used proper communication procedures.

We were inbound to TRM after having just cancelled IFR with SOCAL approach. We were about 10 miles north and we were setting up for a 45 degree entry to a left downwind to runway 35. On my initial call on the CTAF I requested an advisory and one aircraft had reported departing runway 17 shortly before my call. We then considered using 17 however decided to continue inbound to RWY 35 as the winds were calm and 35 had an approach with vertical guidance we could use to back up our visual approach. There was no other traffic inbound or outbound as well so we could go with either runway but 35 seemed to make the most sense.I then announced an 8 mile 45 degree entry. I also announced a 4 mile call as well as a call turning downwind; midfield downwind; and a base call. Just before turning final; a single engine Cessna announced lining up on RWY 17. Out of concern; I again announced our position and queried the aircraft about which runway they were departing and got no reply. My partner verbalized his desire to go around if we didn't hear from them. I agreed and queried once again. At that point the aircraft announced they were rolling on 17 and before turning final we went around and joined a modified crosswind for 17.I announced turning downwind and could see the aircraft flying toward us climbing out. We then got a TCAS RA and complied climbing slightly above pattern altitude when the RA ended. We then flew a normal traffic pattern to 17 and landed uneventfully. I think if the departing aircraft would have communicated the event wouldn't have happened.

EMB505 Flight crew experiences an airborne conflict during a visual approach to Runway 35 at TRM. The crew made position reports during pattern entry; downwind and base. As they are about to turn final a Cessna announces entering Runway 17 for departure and does not respond to requests from the EMB505 crew to allow them to land first. A go-around is initiated and a TCAS RA is complied with.

1113985

201309

0601-1200

DEN.Airport

CO

0.0

VMC

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Time Pressure

1113985

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Workload; Time Pressure

1114371.0

Deviation / Discrepancy - Procedural Published Material / Policy

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

We departed off the North Ramp east taxi to 4E. Construction is causing delays at that intersection. We were headed to Runway 8; when we were offered 17L. We taxied ahead on EC to 17L. We have been using P7 intersection most of last month and this month. First Officer quickly started Number 2 and was working on performance data. We had been used to using P7 and accepted the data without a complete check of limits. We took the runway with a Flex setting and seemed to use more runway than usual; rotated about 1;000 FT later than normal. Out of 10;000 I had the First Officer check the data and we took off overweight from the intersection. I feel I hurried him and that caused this.

[Narrative 2 provided no additional information].

A319 flight crew reported taking off overweight because the First Officer was rushed in his calculations.

1103644

201305

0001-0600

ZZZ.Airport

US

800.0

VMC

Turbulence; 10

Dusk

CTAF ZZZ

Air Taxi

Stratolifter (C-135 / 717)

1.0

Part 91

None

Ferry / Re-Positioning

Cruise

Direct

Class G ZZZ

Aircraft X

Flight Deck

Air Taxi

Single Pilot; Pilot Flying

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

Flight Crew Last 90 Days 40; Flight Crew Total 3200; Flight Crew Type 326

Fatigue

1103644

Other Fatigue

Y

Person Flight Crew

In-flight

General None Reported / Taken

Procedure; Staffing; Human Factors

Procedure

While on the Part 91 leg (repositioning flight); I was the PIC of [Company] EC135. This was the second 'mission' of the evening in which I had flown 6+ hours and did not have a rest period between. At this time [Company] had no line pilots and I was the Chief Pilot. The Director of Operations had advised me that we were on a 24/7 on-call basis approved with our POI. I was instructed that if a call would be taken I had to have 10 hours rest before the next flight or I had to accomplish multiples of flights within 14 hours and then take a 10 hour required rest period under FAR part 135 rules; however a refueling or repositioning leg was to fall under FAR part 91 rules. While on my 'off' time I was required to train new-hire pilots from the hours of XA:00 am to XH:00 pm. On the day prior to the occurrence I was prepping new pilot records in preparation for their arrival. I was asked to do this on my time 'off' and not 'sign in' until a flight was activated. That evening we were activated for one flight that was accomplished and unremarkable; followed by a second flight that was accomplished under FAR part 135 with no issue. We were on the Part 91 leg repositioning the aircraft back to base. This flight had clear VMC weather and no ceiling. The flight originated during the hours of the night and during the Part 91 leg had become daylight. It was during this leg while the autopilot was engaged for a direct GPS route at approximately 800 FT AGL that I found myself fatigued during flight. I typically carry an energy drink in my flight suit; however I had taken it earlier during the first flight of that night. I noticed that I was fatigued and would open the pilot's side window and would vent air onto my face to remain alert.I realize that flying while fatigued is a safety risk. I should have landed the aircraft at the closest airport and taken a rest period before continuing to fly home. I believe that helicopter EMS should only be flown under part 135 rules every leg. I also feel that in order to prevent fatigue in the future no MedEvac operation should be allowed to operate with a single pilot on a 24/7 on-call basis. I also feel Medical crewmembers should be essential in ensuring that a pilot is not fatigued. Asking questions; interacting; becoming a part of the crew versus sleeping themselves in the cockpit.

EMS Helicopter pilot contends that his company's policy of operating under both FAR Part 91 and Part 135 subverts crew rest requirements and leads to crew fatigue.

1298330

201509

0.0

Air Carrier

B757 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Type 2418

Distraction; Situational Awareness

1298330

No Specific Anomaly Occurred All Types

Person Flight Crew

Taxi

General None Reported / Taken

Chart Or Publication

The new after start and before takeoff checklists are faulty. The new procedure requires flap configuration via flow; with no reference to take off data. It then requires an insanely detailed before takeoff checklist to be conducted during taxi out; with the result being the First Officer being heads down for an extended period and the taxiing Captain unable to properly and safely taxi and monitor what the First Officer is doing. The flap position is only checked during this long before takeoff checklist while the Captain is taxiing.The new checklist is a human factors disaster. The taxi should be treated as a sterile environment; with both pilots paying attention to the aircraft movement. Any required call outs; such as a before takeoff checklist; should be brief and to the point. It is this reason that many pilots are treating the new checklist as a threat to safety and only doing that before takeoff portion 'above the line' while parked with the brakes set.

B757 Captain stated he is unhappy with the new before takeoff checklist; asserting it is a 'human factors disaster.'

1444638

201705

0001-0600

ZZZ.Airport

US

0.0

VMC

Night

Ground ZZZ

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Taxi

Air Carrier

Commercial Fixed Wing

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 199; Flight Crew Type 11975

Situational Awareness

1444638

Conflict Ground Conflict; Critical

Person Flight Crew

Taxi

Flight Crew Took Evasive Action

Airport; Human Factors; Procedure

Human Factors

While taxiing out on C line; a tow on B line cut over close to my line; forcing me to stop. Had I not stopped; there would have been a collision on ground with aircraft damage between the two aircraft.

A320 Captain reported stopping the taxi because an aircraft under tow began to drifted towards the taxiway.

1474444

201708

1801-2400

62S.Airport

OR

20.0

8500.0

IMC

Turbulence; Haze / Smoke

Night

Center ZSE

FBO

Small Aircraft; High Wing; 1 Eng; Fixed Gear

2.0

Part 91

VFR

Training

Cruise

Direct

Class E ZSE

Aircraft X

Flight Deck

FBO

Instructor; Pilot Flying

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

Flight Crew Last 90 Days 57; Flight Crew Total 325; Flight Crew Type 54

1474444

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter VFR In IMC

Person Flight Crew

In-flight

Flight Crew Requested ATC Assistance / Clarification

Environment - Non Weather Related

My student and I were on a night cross country training flight. We were on our way back from Christmas Valley (62S) going to our home base. We had good visibility going to Christmas Valley but on the way home we hit a pocket of thick smoke and some turbulence. I looked around and couldn't find any outside visual reference. I took control of the aircraft from the student and called Seattle Center and requested flight following and advised them that we were in an inadvertent IMC situation. The controller called back and asked if we were going IMC or if we were already IMC. I told him that we were already IMC. He gave me my squawk code and told me to ident. I followed his instructions. We got radar contact and he asked if I had the ability to fly on instruments. I told him I have an instrument rating. I'm passed my first 6 months for currency but in the moment I was scared and wasn't thinking about that. Then he asked if I had the ability to maintain separation from the terrain on my own at 9;000 ft. I responded 'affirmative.' He gave me an IFR plan in flight to Christmas Valley and instructed me to climb and maintain 9;000 ft and to report when we were at 9;000 ft. We got to 9;000 ft and I reported it back to Seattle. At this time the controllers had switched. The new controller was displeased with me and said that I needed to file an IFR flight plan differently. I was so focused on flying that I can't recall quite what he said. It was something along the lines of that I needed to file on the ground in Christmas Valley before I took off. I tried to explain that the IFR plan was unexpected and the last controller had given it to me. I don't remember what he said after that but it didn't seem appropriate to be scolding me while I was in the middle of a stressful situation. I decided to file this report on the off chance I broke a regulation in how I came to be on an IFR flight plan. Once we were over Millican; we came out of the smoke and visibility increased to almost unlimited. I reported to Seattle that we had visual contact with the ground. Following their instructions; I closed my flight plan with FSS and then cancelled IFR. From there my student and I landed [at our home airport.]

GA flight instructor reported inadvertently entering IMC on a VFR night cross country flight due to smoke.

1114401

201309

0001-0600

ZZZ.Airport

US

0.0

Daylight

Gate / Ramp / Line

Air Carrier

Lead Technician

Maintenance Airframe; Maintenance Powerplant

Communication Breakdown; Situational Awareness; Workload

Party1 Maintenance; Party2 Maintenance

1114401

Deviation / Discrepancy - Procedural Published Material / Policy

N

Person Maintenance

Other During Maintenance

General Maintenance Action

Company Policy; Human Factors; Procedure

Company Policy

After completing the [Human Factors] Behavior training; I; as a Lead Mechanic; have a safety concern over the elimination of the second Taxi-Tow Lead Mechanic's slot on afternoon shift; as well as; not adding a Lead Mechanic to the second (new) Taxi-Tow crew on dayshift here in ZZZ. The new way of doing things in ZZZ will be to have one Lead Mechanic running two tow crews from a remote location or desk; on both dayshift and afternoon shift. I had addressed this concern to my local Management team here in ZZZ; back in August 2013; via company mail; but have never received a response from a single member. The [Human Factors] Behavior training placed an emphasis on safe aircraft movement by Maintenance.Currently; the Tow Crew Lead Mechanics on afternoon shift and on midnight shift are out on the moves; [onsite with the tow crews] overseeing them as required by our General Procedures Manual (GPM). A tow crew normally consists of six people: One Lead Mechanic and five Aircraft Maintenance Technicians (AMTs). The AMT's job assignments are as follows: towbarless tow vehicle (tractor) driver; radio operator; brake operator; and two wing walkers. The driver and radio operator are inside the tow vehicle; brake rider in the cockpit; and wing walkers are on the ground; clearing the area and walking wings. The Lead Mechanic acts as a sort of a quarterback for the crew. The Lead Mechanic oversees the [aircraft] moves; ensuring that safe practices and procedures are adhered to; equipment and personnel are being cleared; vehicles don't operate in the vicinity of the aircraft under tow; on and off the gate and [at] remote parking spots wing walkers are in place. [He also] acts as a tail walker; guiding the aircraft safely on push backs in congested areas; and as a guide man when parking an aircraft; marshalling in the aircraft while the wing walkers are in their positions at the wing tips; as well as dealing with the administrative portion of the moves and job assignments. The driving force to eliminate these jobs is to save money. It will cost more money than being saved with just one accident or incident between repair costs; lost time due to injury and lost revenue. The elimination; or not covering of those slots/crews [with Lead Mechanics]; will increase the likelihood of aircraft damages; goes against compliance with the GPM; and the new behavior mindset that frontline [Management] Leaders are supposed to endorse and practice. The only way to oversee any aircraft movement as required by the GPM; is to physically be in the immediate area of the aircraft being moved. There is no way a Lead Mechanic can oversee a move from a remote location; such as a desk or office as is being requested by ZZZ's Management. Recommend supplying each taxi-tow crew with its own Lead Mechanic; as has been historically done in the past. The respective Lead Mechanic's would then be able to oversee the moves; ensuring that equipment is cleared and safe practices and procedures are adhered to. This should help reduce the number of incidents/accidents that occur with aircraft movement; which appears to be a high priority; according to the [Human Factors] Behavior's course. Hangar and Line/Gate locations [involved].

A Lead Mechanic describes his safety concerns after elimination of Lead Mechanic positions on the second taxi-tow crew slots for days and afternoon shifts. He also adds historical relevance to the benefits of having Lead Mechanics directly involved with the taxi-tow crews and not be assigned to a remote desk away from the actual aircraft movement.

1432779

201703

0001-0600

LAN.Airport

MI

2400.0

VMC

5

Night

5000

TRACON LAN

Air Carrier

Widebody Transport

2.0

Part 121

IFR

FMS Or FMC; Localizer/Glideslope/ILS Runway 28L

Final Approach

Visual Approach

Class C LAN

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 75; Flight Crew Total 7500; Flight Crew Type 2500

Situational Awareness

1432779

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 85; Flight Crew Total 18250; Flight Crew Type 9500

Situational Awareness

1432783.0

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

Automation Aircraft Terrain Warning

In-flight

Flight Crew Became Reoriented

Human Factors

I was the Pilot Monitoring (PM) on this flight to LAN. We were flying a visual approach to 28L. There are a couple of towers south of the final approach course that must be avoided--we had discussed these towers earlier in the evening as well as previously in the week. The Captain (Pilot Flying) was descending to 2;400 feet on a base leg that would intercept the final approach course a mile or two outside of BURYE. We could see all the towers; and we were just above and just to the west of the 1878 feet tower. We were either in a very shallow VS descent or had gotten ALT CAP when the EGPWS caution sounded. This was followed almost immediately by the EGPWS warning (Obstacle; Obstacle; Pull Up). The PF disconnected the automation and began a climb. We were clear of the obstacle right away and we were able to fly a normal; stable approach and land without further incident. I suspect that the cold temperature may have been a factor in this incident. Had we calculated the temperature induced altimeter error we probably would have found that we did not have as much vertical clearance as we thought we did.

We were cleared for the visual approach to 28L at Lansing. I was on a base leg to the runway descending out of 3000 feet to 2400 feet. To our right (EAST) are two radio towers that are noted on the approach plate (ILS28L) south of the final 28L approach course. The one tower is at 1878 feet and the other tower is at 1923 feet. I was in terrain mode on my radar screen. As I descended from 3000 feet to 2400 feet on the base leg I saw the tower (1878 feet) to our right. I was well clear of it in the descent and went from flight level change to vertical speed and selected 800 FPM. As I approached 2500 feet I received a Caution Obstacle warning; I stopped the descent; I then received a EGPWS Pull Up warning; at that time we executed the CFIT maneuver; climbed to 2700 feet. The warning stopped and we then continued on the base leg to final and finished configuring the aircraft and landed uneventfully on runway 28L. We had the tower in sight the whole time on the base leg and thought we had adequate clearance from it. I would suggest to stay at 3000 feet on the base leg until well clear of the towers so as not to activate an obstacle warning on the EGPWS. Like I noted in the report I saw the towers and thought I had adequate clearance.

Air carrier flight crew on a visual approach to LAN reported receiving an EGPWS aural Pull-Up warning.

1594775

201811

1201-1800

ZZZ.Airport

US

28000.0

Turbulence

Center ZZZ

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Cruise

Class A ZZZ

Cooling Fan; any cooling fan

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

1594775

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

Person Flight Crew

In-flight

General Maintenance Action

Aircraft

We were cruising at FL280 when I heard a buzzing noise coming from the floor on the Captain's side that lasted a couple of seconds. Then my First Officer and I smelled smoked in the flight deck. I told the First Officer to put on [the] oxygen mask and smoke goggles. We accomplished the QRH checklist and [diverted to an alternate airport].After landing; maintenance told us the #2 avionics fan shorted out and that was what probably caused the smell of smoke and buzzing noise.

EMB-145 Captain reported a buzzing noise and smoke in the cockpit that was later traced to a short in the #2 avionics fan.

1357469

201605

1201-1800

EWR.Airport

NJ

7000.0

VMC

Daylight

TRACON N90

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

Class E N90

Sail Plane

Part 91

Class E N90

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 162

Situational Awareness

1357469

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 175; Flight Crew Type 8000

Situational Awareness

1357496.0

Conflict NMAC

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

We had just leveled at 7000 feet over SWEET intersection on the arrival into EWR when the First Officer spotted a glider and called the traffic. We then saw the glider pass approximately 200-300 feet below the nose of our aircraft. It appeared that the glider was maneuvering to avoid us. We were headed northeast and the glider was headed west. We did not have a chance to maneuver our aircraft to avoid the glider. We did not receive a TCAS Alert because the glider did not have a transponder. ATC did not report the traffic but did say gliders had been a problem in that area when we reported the near miss. The rest of the flight was uneventful. We reported the near miss to ATC and Dispatch.

[Report narrative contained no additional information.]

B737 flight crew reported an NMAC with a glider that was not equipped with a transponder while on approach to EWR.

1802127

202104

1201-1800

ZZZ.Airport

US

Daylight

TRACON ZZZ

Corporate

Citation Excel (C560XL)

2.0

Part 135

Passenger

Initial Climb

Class D ZZZ

Air Conditioning and Pressurizaton Probes & Sensors

X

Malfunctioning

Aircraft X

Flight Deck

Contracted Service

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Troubleshooting

1802127

Aircraft X

Flight Deck

Contracted Service

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Troubleshooting

1802128.0

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

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

Aircraft

Climbing out; EMERG PRESS ON came on; ran checklist; unable to fix; [advised ATC]; landed.

Climbing out of ZZZ; EMERG PRESS ON light came on; ran checklist; wouldnt turn off; [advised] ATC; landed back at ZZZ.

Citation flight crew reported experiencing pressurization malfunction after takeoff.

1264056

201505

0601-1200

ZNY.ARTCC

NY

VMC

Center ZNY

Air Carrier

A319

2.0

Part 121

IFR

Passenger

Cruise

Class A ZNY

Company

Air Carrier

Dispatcher

Dispatch Dispatcher

Time Pressure; Workload; Situational Awareness

1264056

Aircraft X

Galley

Air Carrier

Other / Unknown

Flight Crew Air Transport Pilot (ATP)

1264821.0

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

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented

Human Factors; Procedure

Human Factors

Flight to MDPC received a reroute from ATC and accepted it 15 min after departure.Pilot ACARS and asked if they need a new release due to the flight was now under 100 NM than previous and class 2 question I replied 'no need I believe that's all pre-departure on class 2...I'll ask just don't go into the WATRS (Western Atlantic Route System) NY area but give me route and I can verify winds are not an issue and you can uplift DM.'I was extremely busy at time and saw that a route was sent back but did not take time to rebuild release not thinking it was in WATRS; just knowing it was less than previous flight plan mileage did not make it a priority; due to sick call I had over 20 flights in the air and several over 12 within the hour to build up. Task saturation was in play. Co-dispatcher received a call from ATC asking if we had HF frequency on our MDPC flight and why we would let our flight into the ZNY oceanic WATRS without it and was contacting flight by bouncing off other aircraft to give our flight routing guidance. I immediately told supervisor and tried to contact crew but could not and they responded by saying HF radio was required. I contacted ATC procedures and they said they were successful in rerouting aircraft back towards the coast and the would be back into radar coverage in about 30 more min via SUMRS (ATC WATRS boundary) direct NUCAR then as previously filed. Once aircraft was closer to boundary they told me the same routing.1) I think better training is needed on both the Dispatch side and the pilot side on accepted and not accepting routes over WATRS. 2) See if we can give ATC a notice that we cannot accept these routes that require a HF radio and or put remarks in the ATC filing strip that we are not HF radio capable (these type of situations have come up before where pilot wondering why they cannot accept these routes especially over AZEZU the key fix dispatchers are self-trained to look for.3) Put a crew mail on all flights on Midwest and Northeast to flight and or MDPC that we cannot accept these routes.4) Change the confusing FOM language; it says that we are authorized to conduct RNP-10 operations over the Gulf of Mexico; WATRS; WATRS plus; Miami Oceanic and the San Juan CTA/FIR.

I was on a scheduled deadhead to MDPC for the purpose of acting as a crewmember on the returning flight. While enroute; I was requested to speak with the Captain of the flight from the rear galley interphone. Upon speaking with the Captain; whom I am familiar with and have flown with on prior trips; I learned that we were on routing that would take us farther east of our normal flight path that I am familiar with. I then advised that the crew contact the previous controller and ask for a new clearance on a route that would take us closer to shore. The Captain and I agreed and then we hung up the interphone. Approximately 20-30 minutes later; I called back to see if anything had been resolved. I was told that they were unable to reach the previous controller and they were relaying communications through another flight. I hung up the interphone once again and a few minutes later; the Captain requested that I enter the flight deck to provide a second opinion as well as to provide situational awareness. Upon entering the flight deck; we worked as a crew to establish a clearance back to an airway that we normally fly for use on the route. Once we received our clearance and reestablished communications with a Center Controller; I returned to the aircraft cabin without further incident. A company memo or training module that outlines operations along the East Coast and differences in airspace and equipment requirements of overwater operations and routes that require HF radios.

Air carrier flight crew and a dispatcher describe a flight to MDPC that is rerouted over the WATRS area by ATC. The crew accepts the clearance before realizing a HF radio is required to fly this route. Significant time is required to get the flight routed back into VHF range.

1494912

201711

1801-2400

ZZZ.Airport

US

4000.0

IMC

TRACON ZZZ

Air Carrier

B787 Dreamliner Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Initial Approach

Class B ZZZ

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 17085

Human-Machine Interface

1494912

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Total 7073; Flight Crew Type 878

Situational Awareness

1494922.0

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

Person Flight Crew

In-flight

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

Airspace Structure; Human Factors

Human Factors

We were on downwind on vectors. We were expecting vectors to base. ATC issued heading of left turn 010 degrees. I slewed the bug over to the heading. First thought it was quite a big turn. Low ceilings made me think it might be a delay vector. The turn ended up being more than 180 degrees which results in the plane turn opposite the direction I moved the heading bug. Upon noticing the plane turn direction opposite what was commanded; I switched off the autopilot and corrected to a left turn. The controller corrected the heading to 110 degrees. Flight was maintained in level flight.

[Report narrative contained no additional information.]

B787 flight crew reported that ATC issued an incorrect heading resulting in the aircraft turning the wrong direction.

1091195

201305

1201-1800

ZZZ.Airport

US

400.0

VMC

Daylight

Tower ZZZ

Air Carrier

Dash 8-200

2.0

Part 91

Ferry / Re-Positioning

Climb

Class C ZZZ

Turbine Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 85; Flight Crew Total 2925

1091195

Aircraft Equipment Problem Critical

Person Flight Crew

In-flight

Flight Crew Returned To Departure Airport; Flight Crew Inflight Shutdown; Flight Crew Landed in Emergency Condition; General Declared Emergency

Aircraft

I was operating a ferry flight and just after departure around 400 FT; the #1 Engine torque immediately shot up to 116% with a noticeable change in yaw (and sound). My First Officer called out 'engine failure;' and while correcting for the yaw; I asked him to identify that the #1 Engine had failed and feathered. He said the engine had failed but did not feather; and I elected to immediately shut down the #1 Engine and feather it. We notified ATC of our engine failure and emergency condition. We ran the Engine Failure Checklist and circled back to land for a visual. With the Emergency Checklist not fully completed and clouds beginning to hide the airport; I requested additional vectors for the ILS in order to assure proper landing and to complete the Emergency Checklist in full. We then landed single-engine without incident.

DHC8-200 Captain experiences an over torque just after takeoff and elects to shut the engine down and return to the departure airport.

1620309

201902

1201-1800

UAO.Airport

OR

1.0

1000.0

VMC

10

Daylight

3500

Tower UAO

Personal

Skyhawk 172/Cutlass 172

1.0

Part 91

None

Personal

Initial Climb

None

Class D UAO

Tower UAO

Any Unknown or Unlisted Aircraft Manufacturer

1.0

Initial Approach

Class D UAO

Aircraft X

Flight Deck

Personal

Pilot Flying; Single Pilot

Flight Crew Private

Flight Crew Last 90 Days 7; Flight Crew Total 128; Flight Crew Type 90

Situational Awareness

1620309

ATC Issue All Types; Conflict NMAC

Horizontal 300; Vertical 100

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors; Procedure

Ambiguous

I was cleared for takeoff by the Tower Controller on Runway 17 at UAO. When starting my takeoff roll I requested a 'right turnout and then departure to the NW;' which was approved. At 500 feet AGL I turned right to a NW heading of approximately 320. When I reached 1;000 feet AGL I saw an aircraft on a northerly heading that was descending and going to cross paths with me. The aircraft was approaching me from the left (from the south) and I believe they were on a right downwind for Runway 17 at UAO. I felt that this distance was way too close for comfort and so I immediately stopped my climb and turned left to close the distance between me and the other aircraft before it descended to my altitude. I passed under the aircraft at approximately 100 feet below their altitude. I felt that if I had turned right instead passing under them; the pilot could have descended onto the top of my airplane. I initially thought I had possibly done something wrong and waited for ATC to scold me (or the other plane) for the loss of separation. Nothing ever came over ATC and I continued out of the airspace. As I thought more about the incident; I realize that I was flying exactly as I was cleared to by ATC. I'm not sure if the other pilot was incorrect; or lack of situational awareness by ATC. I'm still unsure. In the future I would make sure to advise ATC of the situation immediately instead of staying quiet.

C172 pilot reported an NMAC with another light aircraft while departing UAO airport.

1785315

202101

1201-1800

ZZZ.Tower

US

VMC

10

Daylight

4400

Personal

PA-46 Malibu Meridian

1.0

Part 91

IFR

Personal

Landing

Direct

Class C ZZZ

N

Y

Unscheduled Maintenance

Installation; Inspection

Nose Gear

X

Failed

Aircraft X

Flight Deck

Personal

Single Pilot; Pilot Flying

Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Private; Other High Perf; Cmplex; Hi Alt

Flight Crew Last 90 Days 84; Flight Crew Total 1139; Flight Crew Type 42

1785315

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Maintenance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Loss Of Aircraft Control; Ground Event / Encounter Ground Strike - Aircraft; Ground Excursion Runway

Person Flight Crew

In-flight

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

Aircraft

On DATE; Aircraft X was scheduled to depart on a two leg cross county trip from ZZZ to ZZZ1. The trip was slated to depart at XA:30 but was delayed approximately 50 minutes due to unforeseen complications dealing with one of the aircraft preflight checklist items. While checking the tire pressure of the landing gear tires; it was discovered that the left main landing gear tire valve stem was inaccessible due to the hub cap being installed incorrectly. There is a small access door that allows access to the valve stem through the hub cap and the hub cap was clocked in the wrong position rendering the valve stem inaccessible. A local A&P Service Center was contacted and on-site service was requested to remove the hubcap and re-clock. An A&P responded to the location and removed the hub cap. He asked to confirm the POH air pressure requirements; and continued to top off the air pressure per the POH. The hub cap was replaced in the correct position. All tire air pressures were serviced per the POH. This was the last remaining check list item to be completed; and Aircraft X departed ZZZ2 at XB:20 en route to ZZZ3 for the first leg of the trip. The taxi; take off; landing; and post landing taxi phases were normal. On DATE; Aircraft X departed ZZZ2 on the second leg of this cross country trip to ZZZ1. Taxi and takeoff were normal. The trip was uneventful. IMC conditions existed over ZZZ1 during our arrival time; with unknown tops and 4;400 ft. ceilings. VMC conditions existed below the ceiling with winds reported variable at 3 kts. The RNAV GPS approach was requested and granted into ZZZ1. Following the approach; the main landing gear touched down with the aircraft near center line just beyond the extended threshold. The aircraft responded as expected upon main gear touchdown. When the nose landing gear touched down the plane veered hard to the right. Left rudder pedal was used to counter the uncommanded right turn and the plane veered left and immediately began skidding to the left. The plane did not respond to input and skidded off the runway just short of taxiway F; into the landscaped area immediately adjacent to the runway. The nose wheel collapsed while the engine was still running and dropped the spinning prop to the ground. It was immediately obliterated. The turbine engine abruptly quit running. When the plane swerved to the right following the nose wheel touch down; the plane immediately felt unstable. It felt as if the runway was icy and without good traction. However; it was later determined there was no ice on the runway. I advised the tower when the plane came to a complete stop that I had just hit ice. This event duration happened extremely quick. There were no injuries. There was no known airport property damage observed. There is no other property damage. Emergency crews showed up quickly. The aircraft did not catch on fire. Emergency crews did not deploy any foam. The ELT activated. The airbag seat belts did not deploy. Environmental observation: Prior to decent; and while in cruise at FL270; I had been observing the OAT slowly creep down from around -45c to a max low of -51c. The minimum in-flight temperature limitation of this aircraft is -54c. When the temperature dropped to around -49c; I became acutely aware and concerned of the temperature as I knew I was approaching the maximum lower limit. I advised ATC I needed lower due to temperature limitations and they advised expect lower in three minutes. I was then instructed to descend to FL250. The temperature increased to above -49c. Shortly thereafter; the decent into the terminal area required a rapid descent of roughly 2;000 FPM.

PA46 Meridian pilot reported nose gear collapse on landing; resulting in a runway excursion and damage to the aircraft.

1714881

201912

1801-2400

ZZZ.Airport

US

0.0

Night

Ramp ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Parked

Gate / Ramp / Line

Air Carrier

Pilot Flying; Captain

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

Flight Crew Last 90 Days 561

Other / Unknown

1714881

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

Human Factors; Company Policy

Human Factors

I have flown in and out of ZZZ on a regular basis for over a decade. I noticed that the amount of FOD (Foreign Object Debris) on the Company Ramp; in the Safety zones; and taxiways has not improved. How does this affect the Company operations? As we taxi; we sometimes need to maneuver to avoid the FOD; shut down an engine on the way into the Safety zone to prevent the engine from ingesting the FOD; etc. It presents a real hazard to the safe operation of our jets. I have brought the issue to the attention of ZZZ Ground Control; and ZZZ Ramp Supervisor. I called the ZZZ Station Manager yesterday; but there was no answer. So far; there has been no noticeable improvement on this issue. The problem in ZZZ is not so much the fact that there is FOD on the flight line. The problem is 'ATTITUDE!' Nobody wants to pick it up. The ZZZ attitude is that FOD is somebody else's problem. The ZZZ FOD Awareness Program in very weak. There is no leadership behind it. Specifically; while we were waiting for ZZZ Maintenance to service our nose strut at ZZZ Gate XX; I noticed an abundance of FOD between the jet and the Passenger terminal. I approached the Ramp Agents and the Ramp Supervisor politely asking if they could assist in picking up the FOD. I was shocked at the response. The Supervisor gave some good 'lip service' to the FOD program; but was signaling in her words and inaction to the Ramp Agents; that 'we will not be picking up any FOD today.' The Supervisor failed to organize the Ramp Agents; who were just standing there waiting for Maintenance to finish with the nose strut; to pick up the FOD. She gave many excuses why it would be difficult; impossible; inappropriate; etc. for her or her Ramp Agents to pick up the FOD. There were crushed cans; crushed plastic water bottles; paper; etc. Understanding that nobody was going to act; I picked up as much of the FOD as I could before we started engines. The Supervisor and Ramp Agents watched; but nobody pitched in to assist. I was very disappointed with the apathetic; dismissive; lackadaisical; patronizing; 'I don't want to make the extra effort' attitude on the part of a Company 'leader;' Ramp Supervisor. As the Maintenance Technicians were wrapping up the paperwork; I asked about the FOD Awareness Program in ZZZ. The Maintenance Technician told me that FOD is a real problem in ZZZ and that there is little effort to fix the problem. There is an 'elephant' in the room. The 'emperor has no clothes!' Leadership either does not see it or does not care.Fixing this issue will require a top down approach. If [our] CEO showed some leadership on this issue; I believe that stations will take action to improve/revamp our so-called Company FOD program (The US Navy and US Air Force have excellent models to copy). The problem is particularly bad at the larger stations. Not too long ago; my #1 engine ingested a large plastic bag as we were about to takeoff. We needed to shut down the engine; return to the gate; and have Maintenance remove the FOD and inspect the engine for damage. Many people believe that the FOD Awareness Program does not involve them. It is someone else who picks up FOD. It's not my job! In order for us to reduce the risk of FOD from being ingested in our engines; EVERYONE on the ramp (Station Managers; Ramp Supervisors; Ramp Agents; Mechanics; and Pilots) need to participate. It's real simple. If you see FOD; YOU pick it up and dispose of it. Don't leave it for the next guy. We need to be trained that way. CEO; we need your help please. Thank you!

B737 Captain reported FOD concerns and that ramp personnel are unwilling to help.

1809079

202105

0001-0600

LAS.Airport

NV

5500.0

Tower LAS

Air Carrier

Airbus Industrie Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

FMS Or FMC; GPS

Initial Approach

STAR RNDRZ 1

Class B LAS

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Troubleshooting; Confusion; Situational Awareness

1809079

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

Person Air Traffic Control

In-flight

General None Reported / Taken

Software and Automation; Chart Or Publication; Human Factors; Procedure

Ambiguous

While level at 5;500 ft. and at 170 kts. and on the RNDRZ 1 RNAV; ATC asked us to fly heading 090. ATC gave us a left turn toward Runway 25L. ATC asked us if we had Runway 25L in sight. We responded that we had Runway 25L in sight. We were cleared a visual approach for Runway 25L and made a normal landing. As ATC noted on my phone call to them regarded a possible navigational deviation error; ATC admitted that they are having trouble with their new arrival charts. The ATC person told me that there have been many errors by pilots and agreed the chart is confusing to pilots and this problem needs to be re-examined. After reviewing the arrival chart at the gate; my First Officer and I noted that what is depicted on the arrival chart is not what is depicted on our PFD. On the chart; a small box is depicted at intersection 'BERBN' to look for another box for the runway transitions and its very confusing and can be easily missedThis RNDRZ 1 RNAV arrival needs to be examined and rectified so as to not confuse pilots as was noted by our ATC Specialist during our phone conversation.

Airbus Captain reported the STAR chart for the LAS RNDRZ 1 RNAV arrival is confusing and does not match the aircraft PFD.

1868186

202201

ZZZ.Airport

US

0.0

Air Carrier

B737-700

Part 121

Passenger

Parked

Fuselage Bulkhead

X

Malfunctioning

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Troubleshooting; Communication Breakdown; Situational Awareness

Party1 Maintenance; Party2 Maintenance

1868186

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

N

Person Maintenance

Aircraft In Service At Gate

General Flight Cancelled / Delayed; General Maintenance Action

Human Factors; Procedure; Aircraft

Aircraft

The day-to-day operations at ZZZ Line Maintenance is that all Line / Zones X - B work the through flights and [the] Hangar works OOS (Out of Service) aircraft and other scheduled maintenance tasks requiring longer ground time. Normally; no one from the Line / Zone is sent to [the] Hangar to work OOS aircraft since it reduces manpower to work through flights. Aircraft go OOS daily and there have been many occasions when OOS aircraft are parked at the Hangar waiting for manpower to be available. But even at that time; no one from the Line / Zone are sent to [the] Hangar to work OOS aircraft. The aircraft remains parked until [the] Hangar has manpower available to work. But on Date; it all changed. As a licensed A&P technician it is my duty and obligation to report known discrepancies. While working the Line / Zone Y; I reported two discrepancies on Aircraft X for cracks in vertical pressure deck web. Both of these cracks were verified by QC Inspector on log pages X and Y. Everyone knows how catastrophic; deadly; dangerous; and damaging vertical pressure deck web cracks can be. Immediately after that; I was re-assigned and sent to [the] Hangar to follow the OOS aircraft and start [the] open up for required sheet metal repair; which was out of the norm.When I arrived at [the] Hangar; the Lead Tech had already assigned other technicians to work this aircraft. Sending me to the Hangar did not alleviate any manpower shortages there; but created a shortage of manpower to work through flights at Line / Zone Y. This added unnecessary additional burden to work through flights on remaining technicians in Line / Zone Y. This was done clearly to punish; retaliate; single out; harass; discriminate; intimidate; threaten and create fear to report known discrepancies.On that day the following policies were ignored by management team: [company core values]. Instead; the following were used by the management team on duty: Punishment; Retaliation; Intimidation; Discrimination; Harassment; Threatening; [and] Fear tactics. Since this has happened; it has created a lot of animosity and anxiety among other technicians to come forward and report discrepancies in fear of retaliation and harassment. This makes for a hostile work environment for all and puts safety at risk. Unfortunately; it is becoming common practice" and "normal" here at ZZZ to retaliate only against technicians who report known discrepancies under the Director and his management team.Knowing the potential hazard posed by vertical pressure deck web cracks; no one from the management team has come forward and said; "Good find; let's get this fixed." Instead; they opted to punish and retaliate against [the] Technician for reporting [the] discrepancy. A disgraceful and shameful behavior from entire ZZZ Management Team involved."

B737-700 Technician reported discovering cracks in the vertical pressure deck web and was surprised to be removed from duty and reassigned.

1153968

201403

0601-1200

ZZZ.ARTCC

US

IMC

Center ZZZ

Air Carrier

DC-10 Undifferentiated or Other Model

Part 121

IFR

Cargo / Freight / Delivery

Descent

Class A ZZZ

Throttle/Power Lever

X

Failed

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1153968

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

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition; Flight Crew Executed Go Around / Missed Approach; Flight Crew Inflight Shutdown; General Declared Emergency

Aircraft; Weather

Aircraft

At top of descent number 2 throttle stuck at 92%; unable to move the throttle. Descended with Engines 1 and 3 at idle. Number 2 throttle remained physically stuck in the same position throughout the descent. At 10;000 FT Captain took control of the aircraft and First Officer assumed pilot not flying duties. Completed the Engine Shutdown Checklist and made an approach in IMC conditions. At approximately 700-800 FT executed a missed approach due to a headwind windshear alert. Flew a 2 Engine Missed Approach and landed uneventfully on a different runway.

DC10 First Officer discovers the number two thrust lever is stuck at 92% N1 when starting descent. The descent is continued to 10;000 FT where the engine is shut down and the Captain takes the controls for landing. A windshear alert at 800 FT results in a go-around with a second approach to a different runway being successful.

1210854

201410

0001-0600

OAK.Airport

CA

3400.0

TRACON NCT

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Descent

Class C OAK

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1210854

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1211156.0

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

Person Air Traffic Control

In-flight

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

Human Factors

Handed off to final approach controller. We're assigned 3400 feet but both of us heard 3000 feet. We descended to 3000 feet on downwind for Runway 30. Upon leveling 3000 feet controller called us and said to climb to 3400 feet terrain alert. We immediately climbed to 3400 feet. Weather was VMC and the EGPWS showed we were above all terrain as well as we had everything in sight. The controllers radio was very weak and hard to hear. We both thought we heard 3000 feet and read that back to controller. He did not respond with a corrected altitude. After the event we reported to him his radio was very weak - we had to turn our volume up full. He changed transmitters and everything returned to normal levels. Also reported that we read back 3000 feet - he missed it.I should have reported the radio on initial contact - I assumed it was going to improve as we got closer. There were no separation issues and terrain and airport was in sight the whole time.The controller did a great job of trapping the altitude and overall I thought the situation was handled very professionally by all concerned.

[Report narrative contained no additional information.]

B737 flight crew report receiving a low altitude alert from ATC on approach to OAK after misunderstanding altitude clearance.

1157990

201402

0601-1200

ZZZ.Airport

US

0.0

Daylight

Personal

Cessna 337 Super Skymaster

Parked

N

Y

N

Scheduled Maintenance

Testing; Repair; Inspection; Installation

Other Documentation

Cessna

X

Repair Facility

Personal

Technician

Maintenance Airframe; Maintenance Powerplant

Maintenance Technician 3

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

Party1 Maintenance; Party2 Maintenance

1157990

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

N

Person Maintenance

Other Oversight Inspection

General Maintenance Action

Incorrect / Not Installed / Unavailable Part; Human Factors; Aircraft; Environment - Non Weather Related

Human Factors

At the beginning of the contract I reluctantly verbally agreed to a reduction of my rate for a specific number of tasks and a specific period of time as I really needed the work. As the work progressed the customer kept adding extra jobs to the list; but the time to complete remained the same; also the customer continually reminded me that money was very tight and I should always choose the least expensive option regardless of time indeed; further to that he insisted that he would handle all purchase decisions personally and approve each purchase; this considerably lengthened the completion time. Indeed; I knew within a month of commencement that the completion date was physically impossible for one Mechanic; however; I failed to confront him on this matter as I was intimidated with his manner. Indeed; some conversations consisted of him shouting at me over the phone and all discussions about the project consisted of him talking and me listening. I failed to retain control of the scope and nature of the repairs and quickly became extremely stressed and physically sick over the pressure placed upon me. Upon beginning work on the plane and engine; I discovered multiple problems and work signed-off as Airworthy which was obviously not. The customer explained to me that he has a relative who has an Inspection Authority (IA) rating who is happy to work for $20 an hour for him and who has been responsible for his plane in the past and that this person said the particular repair in question was Airworthy. I had to add these 'repairs' to my list of I had to 'fix' these repairs. The nature and scope of the project kept expanding with contrary instructions sometimes issued daily with the consequence of the project falling further and further behind. During the course of the project I had received over 300 instructions. Multiple times the project details were verbally changed or amended. I found myself spending inordinate amounts of time in the office on the phone and internet and unable to undertake physical work on the plane. Finally; when the required completion day was five days away; he arrived at my Shop completely unannounced and informed me that he was now taking control of the project and literally camped outside my hangar entrance in his car and used my Shop and office as his own. He has admitted to removing paperwork and items without my knowledge from my shop. With his arrival and scrutiny; I felt even more pressure to complete my obligation to him to the point that in those last four days; I worked almost 55-hours without any sleep; knowing now that because of the situation I would not be getting paid. Anyway; it was under these circumstances and conditions that I rushed to try to finish the project; I failed to inspect the engine cylinder assemblies for correct configuration and assembly before installing them onto the plane. I failed to personally supervise unlicensed personnel that worked on the plane in my Shop and I had to correct several issues which further slowed me down. I agreed to install some quickly obtainable; but experimental Push-Pull Control cables. I installed unapproved Stainless Steel (SS) fasteners on the front engine case join; as I could not wait for the AN bolts and nuts to arrive. I had previously researched the tensile strength of Grade 8; AN fasteners at 120;000 LBS tensile strength and installed SS-316 fasteners with a tensile strength of 170;000 LBS instead; as I was exceeding the tensile strength specification I reasoned it was acceptable. When the completion day arrived and the plane was still not ready; he made arrangements to borrow a plane from another Maintenance facility at the airport for his trip abroad and informed me on the same day that as part of that agreement he was removing his plane immediately from my Shop and handing the project over to them. The plane was towed from my Shop an hour later. I attempted to put together a listing of outstanding items for the other Maintenance Shop but again; as I was rushed; this list was incomplete. I attempted to correct it when I remembered other items. However; as Work Order reference paperwork had been removed from my Shop; I was not able to reference much documentation and had to create the entries and lists from memory as far as possible. I was then again pressured over the period of the next days into rushing the logbook entries; as the new Maintenance Shop would not proceed without them and I have unintentionally missed or incorrectly entered several items in those entries.

Reporter stated he has only three years of maintenance experience. He was informed by his co-worker; who was an IA rated Inspector; that he (reporter) had been taken advantage of by the owner of the Cessna-337B aircraft. The stealing of his Maintenance documents that had detailed his findings about previous improper maintenance work that had been accomplished on the Cessna 337B and signed-off by the owner's so-called 'relative'; made his trail of record keeping very difficult.

An Aircraft Maintenance Technician (AMT) describes how he failed to retain control of the scope and nature of repairs that he had agreed to perform on a Cessna 337B aircraft and IO-360D engine. Reporter felt intimidated by the aircraft's owner who kept expanding the repair list but not extending the time required to properly accomplish the work.

1193250

201408

0001-0600

ZZZ.ARTCC

US

41000.0

Night

Center ZZZ

Air Carrier

Widebody; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Facility ZZZ.ARTCC

Government

Enroute; Oceanic

Air Traffic Control Developmental

Communication Breakdown; Distraction

Party1 Flight Crew; Party2 ATC

1193250

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

Person Flight Crew

In-flight

Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance; Flight Crew Took Evasive Action; General Declared Emergency

Aircraft

Aircraft X was on route in level fight when I received an altitude out of conformance message generated in response to the aircraft's last ADS-C altitude report. The flight was cleared to and last reported at FL410; but the new altitude report showed the flight at FL400; and subsequent reports showed the flight continuing to descend. I sent a message for the pilot to confirm altitude via HF. When I saw the aircraft was continuing to descend I called Commercial Radio Operator for a phone patch with the aircraft; this occurred less than a minute after I sent the confirmation message via HF and before the pilot could respond to the confirmation.The pilot then declared an emergency via the CPDLC Emergency up-link and voiced; 'MAYDAY MAYDAY' on HF as heard by the Commercial Radio Operator. The HF frequency the pilot was using was unreadable and I had him switch to a different frequency; which was better. The pilot confirmed a number two engine shutdown due to a low oil pressure light; and the flight was descending to FL260 direct ZZZZ. I issued the appropriate clearance and there was no traffic. A colleague coordinated the emergency information with [a foreign] Center and [my Center] Supervisor; and I sent the new route and altitude to [the foreign Center] via AIDC; later completed by the Relieving Controller.No recommendations to stop the emergency; this type of emergency happens. I can only comment that it was an [Aircraft X type] and there have been previous issues with this equipment. I cannot comment on if this incident was related to the previous known issues. The HF frequency the pilot was using was unreadable and I could barely make out; after many attempts; the pilots intentions; and could not make out the nature of the emergency until the pilot changed to the new HF frequency. Even though the aircraft was CPDLC and ADS connected; I feel direct voice contact is the fastest and easiest way to communicate with the flight deck in emergency situations; and allows the flight crew to concentrate more on the aircraft and less on texting via CPDLC.The pilot having bad HF frequencies made this method unusable until new HF frequencies could be issued causing the pilot to add to his already high workload. HF frequencies for ADS/CPDLC connected aircraft could be better managed to ensure all aircraft have readable frequencies.

Oceanic Controller reports of an aircraft that is not at the correct altitude and continues its descent. Emergency is declared and aircraft is directed to airport.

1597283

201811

PHX.Airport

AZ

36000.0

Center ZAB

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC

Descent

Aircraft X

Flight Deck

Air Carrier

Captain

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

Flight Crew Last 90 Days 432

Situational Awareness

1597283

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

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Procedure

Human Factors

We were instructed to cross KIRKM at FL360. The FMC was properly programmed and FL360 set in the altitude window. I noticed that the FMC was only giving us nine miles to lose 4000 FT. I mentioned it to the First Officer and he started a Vertical Speed descent. I was distracted by reviewing the STAR and approach procedures. ATC asked if we were going to make the crossing. When I looked back we were over 1000 FT high with less than five miles to the crossing. I informed ATC we would not make the crossing. He said there was traffic at FL370 and to expedite the descent. This is an ongoing issue with VNAV descents of short duration at high altitude. It comes up with unrealistic profiles. I should have watched better when it was apparent the First Officer was unfamiliar with this oddity of the VNAV system. When asked he said that he had started down at 2200 FPM but then noticed that we were low on the path so he went back up to the VNAV path by slowing the descent rate. In doing so we went back to the original problem.

Air carrier Captain reported they failed to make an altitude crossing on descent into PHX when they failed to monitor FMC performance closely enough.

1156712

201403

1201-1800

B18.Airport

NH

0.0

VMC

CAVU; 20

Daylight

12000

UNICOM B18

Personal

SR22

1.0

Part 91

None

Personal

Taxi

Direct

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 25; Flight Crew Total 1600; Flight Crew Type 1200

Human-Machine Interface

1156712

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

N

Person Flight Crew

Other landing roll

Airport; Human Factors

Airport

I had checked NOTAMs and called our destination airport [and learned there were] good 'ice runway' and surface conditions due to a small snow accumulation earlier that day; winds were calm. I overflew the airport; called UNICOM but got no answer; reported my position and intentions. Flag was down; no wind; checked AWOS at a nearby airport where winds were 220 at 7K. I flew a wide approach for RWY 19 and landed on the first 1/3 of the plowed [ice] runway; retracted flaps and felt I had plenty of length to stop. A safe landing was never in doubt until late in the roll out when I lost all braking action in the last 300 feet or so. We hit a snow bank at the very end of RWY 19 at 5 to 10K as I was unable to turn into the parking space due to total lack of traction.

An SR-22 pilot lost braking action during rollout on an ice runway and exited the runway striking a snow bank.

1780412

202012

1801-2400

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Cruise

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties; Service

Communication Breakdown

Party1 Flight Attendant; Party2 Other

1780412

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

Y

Person Flight Attendant

In-flight

General None Reported / Taken

Environment - Non Weather Related; Human Factors

Human Factors

Passenger X was reminded to keep mask on several times. Mr. X continued to pull his mask down and have conversations with other passengers around him right after takeoff after being asked to keep his mask over his nose and mouth. Passenger Y rang call light to inform us Passenger X was not wearing mask. Passenger X was traveling with Passenger Z. Both passengers were served several rounds of wine and asked for more and was told that were out of wine. During pilot break the D FA was blocking and signaled for more line. D FA did not move and told her to wait a second. Passenger X rang call light while D FA was blocking. B FA responded to call light and informed them they were cut off because they would not comply with face mask policy. Passenger Z also came to front galley and asked for more wine after being told we were out. During the pilot break C FA also came up and spoke with Mr. X about mask policy. Passenger X became argumentative and used profanity with C FA. Passenger X was given several warnings and was also issued a [warning] by C FA.Passengers X and Z should be banned from flying on [airline] from this point forward until the mask policy is over. Other passengers should not have to feel unsafe and crew member should to jeopardize their health by having to confront these passengers with their mask off.

Flight Attendant reported that two passengers were non-compliant with face mask policy; despite multiple requests from other flight attendants. Flight Attendant reported one of those passengers became argumentative and used profanity.

1687063

201909

0601-1200

ZZZ.Airport

US

VMC

Tower ZZZ

Air Carrier

EMB ERJ 135 ER/LR

2.0

Part 121

IFR

Passenger

Climb

Class B ZZZ

N

Y

Unscheduled Maintenance

Inspection; Testing

Gear Extend/Retract Mechanism

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1687063

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

Person Flight Crew

In-flight

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

Aircraft; Procedure

Procedure

Based on the final cockpit scan as directed by AOM1 (Aircraft Operating Manual); me and the Captain checked the circuit breakers were in closed or out and collared; after takeoff we had a LG/LEVER DISAGREE we [requested priority handling] and followed the procedures back to ZZZ. I meet the maintenance guys at the bridge and I heard from them taking to the Flight Attendant that they were working on the same problem we had (landing gear not retracting).I understand that the reason behind the LG/LEVEL DISAGREE was a circuit breaker was pulled out and collared based of AOM1 when I checked the circuit breaker in the cockpit safety scan I ensures that all breakers are IN (closed) or OUT(collared). I will take my time to check each collared circuit breaker before flying the aircraft.

EMB-135 First Officer reported overlooking a circuit breaker that was pulled and collared by Maintenance and caused an Air Turnback when the landing gear would not retract.

1114665

201309

1801-2400

ZZZ.Airport

US

0.0

Night

Air Carrier

B737 Undifferentiated or Other Model

Part 121

Passenger

Parked

Scheduled Maintenance

Work Cards; Testing

Hydraulic Main System

Boeing

X

Hangar / Base

Air Carrier

Technician

Communication Breakdown; Workload; Situational Awareness

Party1 Maintenance; Party2 Maintenance

1114665

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

N

Person Maintenance

Other During Maintenance

General Maintenance Action

Company Policy; Procedure; Human Factors; Chart Or Publication

Human Factors

B737 aircraft was docked in ZZZ in Bay-X at approximately XA:30pm. At XB:15pm the mechanics started working on the aircraft. The normal procedure is to do all the Hydraulic Checks first; although I am not aware if this is policy anywhere. On this night; the Hydraulic Checks were started in accordance with the General Maintenance Manual (GMM) and there was no one or equipment around the aircraft. Within 45 minutes there were eight ladders and three scissor lifts under the aircraft and the Checks had to stop on four occasions: Once; as an individual climbed onto the jackscrew compartment as the Rudder Checks were being accomplished. Once; as a ladder was moved under a flap canoe. Once as a Mechanic rolled his toolbox under a flap and once as an individual tried working in the Leading edges as the Flap Checks were being accomplished. I am unclear if this is acceptable or unacceptable procedure or not. Even following the GMM procedure for clearing flight controls prior to moving them; there is just too much happening at once and too quickly for one or sometimes even two ground personnel to clear the area. There is just too much at risk with aircraft damage or personnel injury and puts too much responsibility on the one individual giving the clearance. Several of the Checks are done with a BITE Check (i.e. uncommanded Flap Check) and once the BITE Check has started there is not a way to exit it to stop the test if someone or something moves in the way. Recommend having Lead [Mechanics] coordinate jobs and job cards; according to a sequence. NO one is to start any work until all the Hydraulic Checks are complete and tagged out.

An Aircraft Maintenance Technician (AMT) describes his efforts to accomplish Hydraulic Checks in a chaotic work environment at a company maintenance hangar. Concerns also raised about the lack of Job Card coordination for sequencing maintenance work and the potential for personnel injury.

1134116

201312

0601-1200

ZZZ.Airport

US

0.0

Daylight

Ramp ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Parked

Oxygen System/Crew

X

Design; Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Other / Unknown

1134116

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Other / Unknown

1134124.0

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

Person Flight Crew

Pre-flight

General Maintenance Action

Equipment / Tooling; Procedure

Procedure

During our preflight check we discovered that when the Captain or First Officer mask was tested the crew oxygen pressure went to zero. The crew oxygen bottle had been replaced the night before. Maintenance was called and the crew oxygen valve was discovered to be not fully open. Maintenance opened the valve fully; safety wired it; and signed it off in the logbook.

[Report contains no additional information].

A B737-800 Captain and First Officer discovered their oxygen mask pressures at 0 PSI during the preflight mask test and maintenance discovered the oxygen bottle valve not fully open after the bottle had been replaced the previous night.

1764535

202010

1201-1800

BOS.Airport

MA

1200.0

VMC

Tower BOS

Small Transport

2.0

IFR

Passenger

Initial Approach

Class B BOS

UAV - Unpiloted Aerial Vehicle

Cruise

Class B BOS

Aircraft X

Flight Deck

Pilot Flying; Captain

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

1764535

Conflict Airborne Conflict

Person Flight Crew

In-flight

General None Reported / Taken

Airspace Structure; Procedure

Ambiguous

I observed a drone while on final for Runway 4R; about 3 NM out of BOS at 1;200 ft. The previous aircraft (company) also reported that an unknown object was flying in the area. I saw a silver drone flying at a decent speed around Runway 4R's final approach path. I continued the approach and did not have to maneuver to avoid the drone because it was visible and at a reasonable distance. The unauthorized drone was flying within the inner shelf of the Boston Class B airspace. Suggest creating more awareness of the restrictions on UAS operation around busy Class Bravo airspace.

Captain reported sighting a drone while on final approach to BOS airport.

1326932

201601

1801-2400

SDF.Airport

KY

0.0

VMC

Snow

Night

Ground SDF

Air Carrier

Medium Large Transport

2.0

Part 121

IFR

Passenger

FMS Or FMC

Taxi

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 167

Confusion

1326932

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 193; Flight Crew Type 12634

Confusion

1327622.0

Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Became Reoriented

Human Factors; Weather; Airport

Weather

We were instructed to exit Runway 35R at Taxiway D5 instead of Taxiway D4. We were instructed to taxi via D5 to P Taxiway. The Taxiway D5 was clear of snow at the runway turn off; but was obscured with 3-5 inches of snow at the intersection of D5 and D taxiway. Taxiway P was completely obscured with snow and Taxiway D had been plowed and was contaminated with a thin layer of ice and snow. Taxiway D5 makes a 30-45 left turn at the intersection of D5 and D taxiway; and then continues for approximately 60 feet until it intersects with Taxiway P. We mistakenly turned right onto Delta Taxiway off of Taxiway D5 because it had been plowed and the taxiway lines were visible and could be followed. Had we taxied as instructed; we would have had to taxi through 3-5 inches of unplowed snow with no visible cues as to where the taxi lines were or if we were on the concrete taxiway or not. We took the safest course of action and in doing so; failed to follow the Controller's taxi instructions. The entire airport was a sea of white with blue lights and poor airfield markings due the heavy snow that had fallen. The Ground Controllers were truly unaware of the field conditions around the airport and were instructing other aircraft to follow hazardous taxi routes. This was apparent as other Pilots were refusing the obscured taxi routings as well.

[Report narrative contained no additional information.]

Air crew was not able to see cleared taxiway exit point off of runway during landing rollout due to snow conditions.

1714787

201912

0001-0600

ZZZ.Airport

US

0.0

Air Carrier

B737-900

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Boarding; Safety Related Duties

Physiological - Other

1714787

Aircraft X

General Seating Area

Air Carrier

Flight Attendant (On Duty)

Safety Related Duties; Boarding

Physiological - Other

1714769.0

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

Person Flight Attendant

Routine Inspection; Pre-flight

General Flight Cancelled / Delayed; General Maintenance Action

Aircraft

We arrived for our overnight flight and when the Customer Service Agent opened the aircraft door; there was an odor and a slight haze in the plane. We walked off the plane and discussed with the pilots that it was not safe to be onboard. The Supervisor showed up and said this was a regular issue when it is so cold and there is nothing they can do about it. The pilots had them disconnect the ground feed and started the APU. We cracked the doors to get fresh air and waited for the smell to dissipate before boarding the plane. Determine what is causing this fume issue and either maintain or reposition the equipment do the fumes are not entering the plane.

Boarded the aircraft into a haze of carbon monoxide fumes from the external air unit so strong we all immediately got a headache and we exited the aircraft into the jetway! We had to delay boarding because we needed to get the fumes out of the cabin before we brought small children and all passengers on board. Every station that has that has a external air unit needs a safe exhaust system that is nowhere near the aircraft.

B737-900 Flight Attendant crew reported haze and odor upon arrival. The entire cabin crew experienced physiological issues.

1290735

201508

1201-1800

HEF.Airport

VA

2300.0

VMC

10

Daylight

10000

TRACON PCT

Corporate

Light Transport; Low Wing; 2 Turbojet Eng

2.0

Part 91

IFR

Passenger

FMS Or FMC

Initial Climb

SID ARSNL4

Class E PCT

FMS/FMC

X

Design; Malfunctioning

Aircraft X

Flight Deck

Corporate

Pilot Flying; First Officer

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

Flight Crew Last 90 Days 50; Flight Crew Total 8200; Flight Crew Type 30

Workload; Time Pressure; Situational Awareness; Distraction; Confusion

1290735

Aircraft X

Flight Deck

Corporate

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 60; Flight Crew Total 11000; Flight Crew Type 3500

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

1290737.0

Aircraft Equipment Problem Less Severe; Conflict Airborne Conflict; Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

Horizontal 1800; Vertical 700

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

In-flight

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

Aircraft; Procedure

Aircraft

We were cleared as filed to our destination with a clearance to fly the ARSNL4 departure out of KHEF and climb via the SID. The departure runway was 34R. The first fix on this route was SHRLI with a crossing altitude of 2000 ft MSL. Prior to departure; both crew members verified the Flight Management System (FMS) and Flight Director (FD) were programmed correctly to level the aircraft at 2000 prior to SHRLI and then to continue the climb to cross CSN at 3000. The departure was briefed thoroughly prior to takeoff. After a normal takeoff; the crew selected the appropriate vertical and lateral modes on the FD to track towards SHRLI and level at 2000. Despite this; the FD did not command a level-off as intended at 2000. The error was caught by the crew but by the time action was taken; the aircraft had climbed to approximately 2300 MSL. The aircraft was hand-flown back down to 2000 ft expeditiously. About the same time; ATC noticed the altitude deviation and commanded a left turn to 230 degrees and a return to 2000 ft. As ATC was speaking; the crew received a TA warning for 2-3 seconds for an aircraft above at 3000 ft. This quickly went away and never escalated to an RA. ATC advised the crew of a possible pilot deviation and gave a number to call. The remainder of the flight was conducted without further incident. ANALYSIS/MITIGATION STRATEGIES:The PF has over ten years and 4000 hours operating this aircraft's particular avionics system (Collins Pro Line 21) - both as a pilot and instructor. There is little doubt to him that the FMS and FD were set up properly to fly the SID correctly. It is not understood at this point why the airplane did not level as it should have. All systems in the aircraft are in good working order with no previous anomalies noted. With 'Climb Via' SIDS; guidance from the manufacturer suggests setting the 'Top Altitude' in the Altitude Pre-Select; arming VNAV and then allowing the FMS to set any intermediate level-off altitudes. In this particular case; 3000 ft was set with the altitude pre-select and 2000 ft was verified as the initial FMS-driven altitude.Although it shouldn't be necessary; a possible mitigation strategy going forward would be to set the altitude pre-select to the first target altitude and then manage the subsequent altitude restrictions manually. The PF could have chosen a reduced initial climb rate which would have allowed for a more rapid correction to the correct altitude and earlier detection of the impending error. ATC could have queried the crew prior to 2000 ft to ensure level off at the correct altitude. The IFR clearance given to crews could be amended to simply maintain 2000 ft instead of 'Climb Via' the SID. Altitudes above 2000 ft could be issued by Potomac departure once airborne.

[Report Narrative Contained No Additional Information.]

A corporate flight crew properly programmed their Collins Pro Line 21 for the HEF ARSNL4 Departure with a 2;000 ft level off. LNAV and VNAV were engaged but the aircraft did not level at 2;000 ft. At 2;300 ft the crew descended just as the TCAS alerted a TA.

1785459

202101

1201-1800

TEB.Tower

NJ

820.0

VMC

Tower TEB

Fractional

Medium Transport; Low Wing; 2 Turbojet Eng

2.0

IFR

Initial Approach

Aircraft X

Flight Deck

Fractional

Captain; Pilot Flying

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

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew

1785459

Aircraft X

Flight Deck

Fractional

Pilot Not Flying; First Officer

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

Situational Awareness

1785376.0

Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence

Automation Aircraft Terrain Warning

In-flight

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

Human Factors

ILS [Runway] 06 circle to land [Runway] 01 just after dark with gusty winds and windshear. Miscommunication in the cockpit dealing with 'programming' the airplane for the approach. Got distracted on the maneuver which got us close to the towers; then got a pull up prompt. Recovered and landed safely.[Cause was] Lack of cockpit communication.[Suggest] Training this approach with bad weather in simulator.

Clearance by Approach Control - Intercept the Runway 06 approach course and expect the Runway 06 ILS; circle Runway 01. Clearance by Tower - Cleared for visual approach Runway 06; at TORBY cleared to circle to land Runway 01. During the circle we received TAWS Aural Warning - ''Obstacle; Obstacle; Pull Up'. The pilot flying began a climb from 820 ft. MSL to approximately 1;300 ft. MSL. Message cleared and the approach was continued to a full stop landing. The aircraft was flown too close to obstructions during the circling to land approach. 2 contributing factors: Unfamiliarity with the procedure at TEB and reliance on autopilot.With the frequency that [our company] operates in and out of TEB; it may be advisable to add some type of briefing to the pilot [group]. This is a common procedure at TEB; but it doesn't occur frequently enough to build pilot confidence in the circle to land maneuver.

Fractional jet flight crew reported receiving a TAWS obstacle warning on a circling approach to TEB Runway 01.

1762536

202009

1801-2400

ZZZZ.Airport

FO

0.0

Air Carrier

Commercial Fixed Wing

3.0

Part 121

IFR

Aircraft X

Flight Deck

Air Carrier

First Officer

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

Communication Breakdown; Distraction; Time Pressure

Party1 Flight Crew; Party2 Other

1762536

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

Person Flight Crew

Pre-flight

General Flight Cancelled / Delayed

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

Environment - Non Weather Related

In flight between ZZZZ-ZZZZ1; we received an ACARS message from Duty Pilot stating that there was going to be an issue with my duty time compliance. I called scheduling and Duty Pilot. He explained that the X foreign government had moved our departure slot time out of ZZZZ1 later by 90 minutes; and this would not allow me to return to ZZZZ to start my scheduled duty time compliance in time to be legal. Duty Pilot; advised me that the Operations was involved and in contact with the FAA and all were working on a solution. After about an hour I received a call back. They looked at moving the airplane to ZZZZ2 or deplaning the crew to go into rest. Both of these requests were denied by the foreign country. I was advised by Duty Pilot; that we as a crew did nothing wrong and were legal to operate ZZZZ-ZZZZ1 at the time of departure. He said my only option was to continue the flight back to ZZZZ and file a report. The return leg was uneventful and I entered my rest period less than 1 hour later than what was legal.In doing a 7 day look back; crew scheduling had ample opportunity to better schedule my previous duty time compliance; so that a 90 minute delay would not have caused this issue. In our defense; we were not able to convince the foreign government to file a flight plan to ZZZZ2 and due to the COVID-19 pandemic; the crew was not allowed to get off the aircraft in ZZZZ1.

Air carrier First Officer reported an issue relating to duty time compliance.

1018615

201206

1201-1800

HWD.Airport

CA

0.0

VMC

Daylight

Ground HWD

Personal

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

None

Personal

Taxi

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 11; Flight Crew Total 770; Flight Crew Type 568

Confusion; Situational Awareness; Distraction

1018615

Ground Incursion Runway

Person Air Traffic Control

Taxi

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented

Airport; Human Factors; Environment - Non Weather Related

Ambiguous

After completing a VOR check at the VOR check point and configuring the aircraft for departure I contacted Ground and received instructions to taxi to Runway 28L. Having just landed for the purposes of the VOR check I was not planning to do a runup so I intended to taxi to the hold short line and contact the Tower. As I was taxiing my attention was briefly on something inside the cockpit. At this point Ground called and told me told me to hold position. I realized I had taxied several feet past the hold short line. However; I was still some distance away from the runway itself. Ground then told me to contact the Tower. I did and received my departure clearance and departed normally. The hold short line in this instance was somewhat unusual in that it was perpendicular to the runway with the taxiway continuing another 200 FT before making a U turn to the start of the runway. I was expecting the more standard hold short line which is parallel to the runway that you encounter when approaching at a right angle to the runway. While my attention was inside the cockpit I missed seeing the hold short line. Although I'd been to this airport many times before I did not remember anything unusual about the hold short line; possibly because I might have previously made intersection departures rather than taxiing to the end of the runway. Clearly I should have been paying more attention outside the cockpit while taxiing and left inside the cockpit tasks until the plane was stopped. Contributing factors were the unusual placement of the hold short line and my unfamiliarity with the airport.

A small aircraft pilot incurred HWD Runway 28L after he did not recognize the runway hold short line on Taxiway A because of its distance from the runway and because it was perpendicular to the runway orientation.

1759313

202008

No Aircraft

Aircraft X

Cabin Jumpseat

Air Carrier

Flight Attendant (On Duty)

Flight Attendant Current

Safety Related Duties

1759313

No Specific Anomaly Occurred All Types

Person Flight Attendant

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

Ambiguous

Exceptions for face coverings is active eating and drinking and clarified as safety related duties including making a PA per policy. However; I have sought clarification from in-flight and have failed to address critical phases of flight concerns and emergency procedures. Wearing a face covering reduces the ability to perform safety functions critical to the safety of everyone on board. Why are we sitting away from jumpseats while customers are able to sit in all usable seats. We need to sit in our assigned jumpseats and not use alternate seating especially on full flights. Safest place is a jumpseat. Takeoff and landing; we need to stay in brace position and a face covering can hinder evacuation commands; communications with flight deck and instant situational awareness that is distracting due to face coverings. Pilots are able to remove face coverings for safety of flight issues on the flight deck and why are flight attendants not being allowed to be subject to the same safety and security standards? We need exceptions that are not political; safety of flight is our top concern.

Flight Attendant reported that having to wear a face mask could affect the FA's ability to perform certain safety functions; especially in the case of an emergency situation.

1838281

202109

1801-2400

F11.TRACON

FL

8000.0

TRACON F11

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Descent

Class B MCO

Aircraft X

Air Carrier

Captain; Pilot Not Flying

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

Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1838281

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

Person Air Traffic Control

In-flight

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

Environment - Non Weather Related; Human Factors; Procedure

Procedure

On the GRNCH arrival. Landing south. At approx. BUGGZ int; airport changed to landing north. ATC tells us to expect 36L. We change the arrival to landing north. Shortly after; ATC clears us from 11;000 ft to 7;000 ft. We readback. Passing 8;000 ft; ATC asks us; says did he give us 9;000 ft? We say no; 7;000 ft. He tells us to maintain 8;000 ft; we climb from 7;800 back to 8;000 after advising him we were passing thru 8;000. ATC was busy to begin with and they got busier with the runway change landing south to landing north. At times; the controller sounded confused regarding our clearance; at one time asking us what fix we were flying to. I know that new arrivals have started in many cities; and do not know if this was a factor. It was the first day of the new database.We did nothing wrong. Proper read backs were given. We were busy from south flow changing to 36L then to 36R while working around some weather and managing the arrival. The controllers were very busy. I am concerned about the altitude assignment and the controller changing the altitude assignment. We have confidence that we received a clearance to 7;000 ft.We worked hard to communicate with the busy controller and use proper radio phraseology. We were very surprised when he asked about our altitude as we were sure we were where we were supposed to be.

Pilot reported possibly over shooting an assigned altitude after being questioned by the Air Traffic Controller.

1213018

201410

0601-1200

TTPP.Airport

FO

0.0

VMC

Tower TTPP

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 Last 90 Days 150; Flight Crew Total 5000; Flight Crew Type 697

Distraction

1213018

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

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors

Numerous little distractions kept us from noticing that the fuel was out of balance until after takeoff. Distractions included being a day late due to a mechanical; 35-minute late van; aircraft not being at the gate when we arrived; aircraft not cleaned or catered; aircraft repair not complete due to contract-maintenance error; late fuel slip; late final weights; communication with load planning about need to move passengers for balance; inop VNAV; NADP1 departure; ACARS2 and Sabre learning curve. Additional factors include the fact that because we dispatched with fuel on board (from our cancelled flight the night before) a fueler never had the chance to fix the imbalance. Finally; we suspect the yellow IMBAL annunciation did not catch our attention because we are so used to seeing the yellow CONFIG annunciation on takeoff. Also; we have gotten used to just looking at the total fuel indication; and we forget to check the individual tanks for balance. We assume the imbalance was created by extensive APU use by the tow crew the day prior. Enough fuel was burned to indicate that the APU was running for many hours. We should have caught this imbalance on the preflight but missed it. It's noteworthy that before push we discussed feeling like we had lots of little alligators at our heels; one got us.

B737 First Officer reported departing with fuel out of balance; citing a number of distractions as contributory.

1059705

201212

0601-1200

ZZZ.ARTCC

US

31000.0

VMC

Dawn

Center ZZZ

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

IFR

Passenger

FMS Or FMC

Cruise

Class A ZZZ

Engine Air Pneumatic Ducting

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Time Pressure; Training / Qualification; Situational Awareness

1059705

Aircraft Equipment Problem Critical

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft

At 31;000 FT in cruise a RED and AUDIO BLEED AIR DUCT message occurred. Ran the appropriate QRH. At that time the engine bleeds closed and the aircraft started a slow decompression. We declared an emergency with Center. At that point; started a very quick descent from 31;000 FT to 8;000 FT due to cabin pressurization rising. At 8;000 FT we finished the QRH; informed the flight attendants of the situation; and we diverted. We did not brace the cabin. Cabin altitude never went above 10;000 FT and the passenger oxygen mask never deployed. Landed with no further events.

A CRJ-700 CAS and AUDIO Warning alerted BLEED AIR DUCT so an emergency was declared; the QRH completed with a descent to 8;000 feet and the flight diverted to a nearby airport.

1594608

201811

0001-0600

MEM.Airport

TN

180.0

3.0

2000.0

IMC

Rain; 5

Night

900

Tower MEM

Corporate

Medium Large Transport; Low Wing; 2 Turbojet Eng

3.0

Part 91

IFR

Passenger

Final Approach

STAR BRBBQ3

Class B MEM

Aircraft X

Flight Deck

Corporate

Pilot Flying; First Officer

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

Flight Crew Last 90 Days 50; Flight Crew Total 5400; Flight Crew Type 950

Communication Breakdown; Situational Awareness; Training / Qualification

Party1 Flight Crew; Party2 Flight Crew

1594608

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

Person Flight Crew

In-flight

Flight Crew Executed Go Around / Missed Approach

Company Policy; Human Factors

Human Factors

After a long duty day; I was flying the ILS 36C into MEM in IMC conditions. My [Captain] was the Non-Flying Pilot (will be referred to as NFP here on out) in the right seat. Before we even got established on the final approach; he was making mistakes in the FMS: while on a vectored downwind; hearing everyone else being cleared for the approach via the INITIAL fix; the NFP activated vectors in the FMS; which would only give us guidance for the FINAL fix. Of course when cleared to the initial fix; he had to scramble to put the approach back in the FMS to include that way point. This is relevant to show that his actions and time management were poor consistently before; during; and after the approach(s). Finally established on a stabilized final approach; fully configured and in trail of [another] arrival; MEM tower issues a go around for spacing. The command was 'climb 2000 feet; turn heading 270...' The NFP returned the radio call improperly missing the heading instruction. As I initiate the coupled go around and proceed to ask for the first flap reduction and gear retraction around 1500 feet MSL; the tower calls to confirm the wrong read back; to which he responds with the heading; but has completely disregarded the critical timing in this moment. I needed him to do his duties in the go-around transition regarding the configuration change; and set the guidance panel appropriately. He never changed the Altitude Selector from a previously set 4000 feet; to the tower assigned 2000 feet; and was talking on the radio for several seconds while the aircraft was pitching up and accelerating rapidly in the go-around. When the second tower call came; he should have remained available to me for just 1 or 2 seconds to perform the configuration and guidance panel changes. However with him on the radio my words to call for flaps and gear were never heard. More importantly; the autopilot coupled go-around pitched up and began a climb for 4000 feet rather than 2000 feet. In those moments I did not notice the NFP never reset the altitude for 2000 feet. I saw the pitch combination with the short climb to 2000 feet as a mismatch and an issue; but by the time I disconnected the autopilot and nosed it down; the aircraft had reached 2000 feet; and did not stop climbing until 2300 feet. Tower then assigned 3000 feet and switched us to approach control. The second approach was successful without problems.There is a personality issue underlying here that is difficult to explain. However for research purposes I want to mention those details; not as slander but as relevant information for safety. The NFP has the hazardous attitudes of macho pilot; rogue pilot; and a general inflated sense of self. Between myself and a third [highly experienced Captain]; the NFP I am referring to does not play the right seat well; showing a lack of crew concept; lack of trust in the flying pilot; and distracts himself with unnecessary babysitting. For example; somewhere in the volley of tower/plane calls initiating the go around; rather than listen to my commands for flaps; or rather than pause on the radio to help with the go around; he chose to spend several seconds on the radio during the transition of a couple go-around; and only broke the call for a half-second to tell me 'watch your speed...' while my speed was absolutely appropriate for the phase of flight. He must have wanted a higher speed in his mind; but until the configuration is changed; the speed was not to change either. His pilot skills are good; but he has failed to get up to speed on the [aircraft] system; the automation; and adapt a crew concept in THIS airplane since the company's [other aircraft; of a different manufacturer] was replaced years ago. My best interpretation is that he expected me to disconnect the autopilot and manually fly the go-around; in which case I may have climbed at a lesser rate and stopped at the correct altitude. However; in this airplane; while flying an autopilot coupled approach in IMC; not only is a coupled go-around encouraged; but it is considered standard; at least in the [years of flight and sim training and flight reviews I've done]. Minus the altitude bust; this type of scenario has played out almost the same way every other time we've had to go missed or go-around. He has shown a blatant disregard for this aircraft's limitations; best practices; and safety protocols. He 'wings it' based on his previous knowledge; and it leads to messy operations such as this. I take responsibility for not seeing the issues quick enough to better manage the situation; but I feel this person constantly deals you a bad hand. Authoritative; rogue pilot; macho attitude; inflated ego; above the law - these attitudes have been the cause of multiple situations of similar significance as this. This is a perfect scenario where the 'holes in the Swiss cheese line up.' People like this are a danger to the operation; and I hope that there one day be a personality test requirement to help better navigate this issue in our industry. Thank you.

Corporate First Officer reported an altitude deviation during go-around were attributed to serious CRM and SOP issues within the cockpit environment.

1241073

201502

0601-1200

TVC.Airport

MI

0.0

IMC

Snow; Icing

Daylight

Ground TVC

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

Passenger

Taxi

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Training / Qualification

1241073

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Training / Qualification

1240753.0

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

Person Flight Crew

Aircraft In Service At Gate

General Work Refused

Equipment / Tooling; Human Factors

Human Factors

After being pushed back and starting our engines prior to de-icing I noticed that the de-ice truck had a significant amount of smoke coming from the back area where the heat exchanger is on the de-ice truck. I asked the de-ice crew over the radio what was going on and what their plans are. The response I received was that they were 'waiting for the hydraulic fluid that was spilt on the heat exchanger exhaust to burn off'. They also said; 'Our mechanic has already looked at it and said it will clear soon'.I observed the de-ice crew then opening the rear access doors to the truck and when they opened them it appear to give whatever was burning a lot more oxygen and the smoke intensity increased significantly. After that observation I pleaded with them over the radio to not use the truck and shut it off based on my prior experience operating that type of equipment. They again re-affirmed that everything is fine based on what there mechanic told them and that 'a manager' had cleared them to use the truck.We had the aircraft configured for de-ice prior to these conversations. Before I could get another word in the de-ice crew jumped in the burning truck and proceeded to de-ice our aircraft. The crew would not respond to my radio calls for them to stop until I told them that I could smell the fumes in the cabin.As the deiced truck passed the Captain's side of the aircraft I observed flames coming from inside the de-ice truck (the rear access doors were left open by the de-ice crew the whole time; which in itself is a safety risk and not a standard operating procedure for anyone). The crew eventually moved the truck away from the aircraft. After I observed the flames I radioed ground control to call the fire department; as the de-ice crew was still not addressing the situation. After the fire department showed up; the de-ice crew came back on the radio and said they would be getting a different truck.It is still snowing and the same crew showed up with the new de-ice truck and started to de-ice us from the point they stopped with the old truck; and at a speed that would not make it possible to properly de-ice the aircraft. Before I could ask them what they were doing and why they did not start the process over again they were telling us over the radio that they were done and our aircraft was clean. There was no possible way that they could have cleared the aircraft of the old failed fluid; and re-applied new type I and IV.I explained to them that they would have to start the process over. The crew was getting very aggressive over the radio. Another flight then radioed 'this is (XXX); we will take it any way you want to give it'. The truck then left us and de-iced them. We had to then wait for the de-ice crew to return and de-ice us properly. The threat was the complete lack of understanding of the situation by the ground crew. That signal threat made it impossible for myself to accept the de-icing job they were doing.During this event I was on the phone multiple times with my dispatcher and the hub coordinator. Other than to talk to the dispatcher to explain why we were delayed; and to adjust the release and account for the additional fuel burned on the ground during the delay; I as the captain should not have to request that the ground crew do their job properly. I should never have had to debate and plead with the ground crew not to take risks with their safety; as well as mine and the passengers. The risks they took were completely unacceptable.

[Report narrative contained no additional information].

EMB-145LR flight crew reported while they were getting de-iced they noticed smoke coming from the de-ice truck and became concerned about fire danger to their aircraft. They also reported seemingly substandard de-ice procedures by the same de-ice crew.

1069448

201302

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

Part 121

Parked

N

Scheduled Maintenance

Gate / Ramp / Line

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Maintenance Technician 15

Communication Breakdown; Situational Awareness; Training / Qualification

Party1 Maintenance; Party2 Maintenance

1069448

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

N

Person Maintenance

Other During Maintenance

General None Reported / Taken

Company Policy; Human Factors

Company Policy

After being out of aviation for nine plus years I recently returned to Air Carrier X at ZZZ Airport to work Line Maintenance. My fifteen years in aviation did not prepare me for Line Maintenance as I had mostly worked in Overhaul type work. Air Carrier X has recalled many mechanics [at ZZZ] that are new to Line Maintenance and are not being trained in the work they are expected to perform. All of the aircraft are ETOPS rated and everyone is given ETOPS awareness training. The problem is that we are not being taught the different fleet types and work is being performed unsupervised by those who possess only the awareness training. Many become ETOPS qualified after just a two week class for a fleet type; but have no experience on the plane. Computer Based Training (CBT) has become the 'norm' but lacks the quality of instructor lead training when a question arises. This lack of training; supervision; and practical experience is a problem waiting to happen. The effort is not made to have new mechanics work with someone who is experienced; or to try to keep the new person on the same fleet type so that that airplane can be learned. The experience level is high at ZZZ; but without proper protocols this asset has not been realized and could have many downfalls.

An Aircraft Maintenance Technician (AMT) returning to Line Maintenance after a lengthy furlough describes an environment where new and returning mechanics are not being trained in the work they are expected to perform. Aircraft are all ETOPS rated; but work is being performed unsupervised by those who possess only ETOPS awareness training; not actual experience.

1310859

201511

1201-1800

ZZZ.Airport

US

0.0

Marginal

Turbulence; Icing; Thunderstorm

Dusk

Tower ZZZ

Air Carrier

EMB ERJ 145 ER/LR

2.0

Part 121

IFR

Passenger

Parked

Class C ZZZ

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1310859

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

Person Flight Crew

In-flight; Pre-flight

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

Human Factors; Weather

Weather

A line of severe thunderstorms was affiliated with a system extending from Mexico up to the Great Lakes and wrapping around back to the Plain States. Upon arriving for XA04 show time; severe weather had halted all flights and we were delayed indefinitely. When our plane arrived at XE30; I spoke with our dispatcher about my concerns for dispatching into this system. She said we should be able to penetrate the storm line around Monroe; go east of the WX; and fly north and land slightly ahead of the storms with some moderate turbulence; now slicing through LA-AR-MO to the Great Lakes. Our gate fuel was 5600 lbs with no alternate; moderate to severe turbulence reported on www.adds.aviationweather.gov; and the weather scheduled to arrive at ZZZ1 at the same time as we were. I requested severe weather alternates (escape routes) be added and more fuel be uploaded. She agreed to bring our ramp fuel to 6600 lbs and added ZZZ2 and ZZZ as 'unofficial alternates'; however; I told her I wanted to stay west of the line and let it pass ZZZ1. I also delayed the flight until the flight crew was comfortable that the weather was going to be manageable. Our XB04 scheduled flight departed at XF47; and we elected to fly IAH-ZZZ2-TXK-ZZZ1 west of the line of storms; but encountered continuous light with occasional moderate chop reported at all altitudes. Upon completing the Cruise Checklist; I observed that we would land with 2500 lbs at ZZZ1. The dispatcher notified us twice on free text ACARS that we needed to turn east toward Monroe and navigate through the weather to the east of the line. We declined and stayed on the west side; and she felt the weather would be worse penetrating further north. I advised ATC that we would evaluate the storm situation over ZZZ2 and make a 'go-no go' decision into ZZZ1 there. Center advised us that the weather had diminished and that there was a gap we could get through. As we got closer to ZZZ1; our landing fuel had decreased to 2300 lbs; and I mentioned to the F/O (First Officer) that diverting could be a problem now. We were also reporting light rime icing and moderate turbulence on the final descent. Upon contacting Approach; I declared 'Min Fuel'; even though we would be landing with 2300 lbs just as a precaution. The ATIS was calling for winds 160@26g39; so we set up for a flaps 22 landing on Runway 18R. We broke out in the clear on final approach; but got a red (increasing) windshear warning from GPWS on short final. We executed a missed approach and climbed out of the shear; evaluated our fuel; and elected one more approach. Once again; on short final; we received a red windshear warning and went missed approach. After evaluating the situation; I elected to declare for low fuel (we were at 2100 lbs on the EICAS) and had to decide between ZZZ2 or ZZZ. ZZZ2 was 140 nm away but with severe storms and windshear while ZZZ was 160 nm away but smooth ride and clear. The fuel planning showed we would land at ZZZ with 1100 lbs; and we elected to also select Muscle Shoals and Decatur as emergency landing airports in case we experienced an engine flame out. I briefed the flight attendant of the [situation]; informed the passengers as well as dispatch of the [situation]; and diverted to ZZZ. We executed a descent; approach; and visual approach to ZZZ; landed with 1200 lbs of fuel; taxied to the gate followed by emergency vehicles; and parked uneventfully. Upon completing the parking checklist; the station personnel asked if we were ready to depart for ZZZ1 and fly from there to Houston; scheduled to land at our duty day maximum thirteen hours. I informed them my crew and I were a bit uptight and tired and to give us at least 30 minutes to decide what to do. The line of severe weather was on top of ZZZ1 at this time. Thirty minutes later; fatigued and still deeply concerned over the situation which has just occurred; we elected not to fly anymore. I advised scheduling and spoke with the Chief Pilot on Call about the situation. The CP (Chief Pilot) called again and asked where we were. I told her the crew was still on the plane; the passengers inside; and us still waiting for Crew Scheduling to get us a hotel. She expressed great concern over these events and prompted Ops to get us to a hotel. Right away; the Hub Coordinator called and apologized for scheduling us ZZZ-ZZZ1-IAH; as he did not realize we had had a low fuel [situation]. The combination of severe storms; no alternates originally; over four hour delays; turbulence/windshear; and a company cost saving program which puts our minimum fuel dangerously low in critical situation could prove to be catastrophic in the future; I erred greatly in not getting the fuel brought up even higher than 6600 lbs to 8000 lbs for example- and not delaying the flight ever further until the storms were assured of passing east of ZZZ1. I further misjudged the situation by attempting a second approach attempt into ZZZ1 as opposed to diverting. Finally; ZZZ2 was closer and although thunderstorms windshear and hail were a threat; may have been more suitable fuel wise. Perhaps we could have diverted upon reaching ZZZ2 VOR. Perhaps; since many flights were cancelled out of IAH; we should have never been dispatched and cancelled the flight; as well. I am very concerned that our fuel cost program is putting flight crews in difficult situations where landing on emergency fuel; or worse yet; landing with flamed out engines may become a reality. Ultimately; it is my responsibility; and I failed to fulfill those responsibilities tonight.

EMB145 Captain reported a difficult flight due to turbulence and thunderstorms. Two missed approaches occurred at the destination airport due to windshear warnings on short final. The crew then diverted to an alternate; landing with 1200 pounds of fuel; and elected not to continue their duty day.

1460014

201706

0601-1200

ZZZZ.Airport

FO

0.0

Daylight

Air Carrier

B767-300 and 300 ER

2.0

Part 121

IFR

Passenger

Parked

Company

Air Carrier

Other / Unknown

Situational Awareness

1460014

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

Person Other Person

Other Post-Flight

General Maintenance Action

Human Factors; Manuals; Procedure

Ambiguous

I was made aware by the Human Resources department of an ongoing investigation into a potential procedural misstep I may have made. Flight had a biohazard situation with a passenger haven given birth in the 1st class cabin. Vendor maintenance reported to the aircraft on arrival. I received the phone call in Maintenance Control and queried the mechanic about the situation. I referenced a manual's Biohazard Contamination section and followed the procedures for aircraft dispatch. The mechanic reported that there was minimal evidence of bodily fluid stating that the crew and attending medical help contained the contamination to blankets and coverings. The universal infection kit was used during the flight. I asked the vendor if there was a cleaning crew that was qualified to clean a biohazard spill. He responded yes. I requested that the crew clean the area per procedures which he confirmed was completed. I requested that the contaminated articles be disposed of per the manual procedures. He confirmed that would be complied with. He suggested that the seat be deferred and the area be cleaned precautionary on return to the U.S. The seat cushions were removed and secured and the seat was deferred per MEL. The current manual revision requires that the row of seats be removed from service; a fact I am not sure was required in this version. If so; I did not defer the seat next to it per procedure.This is a common occurrence and falls directly in Maintenance Control's responsibility. Due to many factors including the severity of the biohazard issue i.e. minor cut to birth and even death on an aircraft there needs to be some latitude to the level of response needed to return the aircraft to service. The manual requires research in 2 other manuals providing cleaning procedures but does not give any definitive solution to allowing the aircraft to depart stations. The manual needs clarity and provide Maintenance with a full understanding when the clean-up is complied with and the aircraft can return to service at all stations other than the class 1 stations it references.

Maintenance Controller reported being informed of possibly mishandling a biohazard cleanup and MEL entry into the aircraft logbook after a passenger had given birth on the flight.

1023264

201207

1201-1800

BWI.Airport

MD

Daylight

TRACON PCT

Air Carrier

Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Climb

Vectors

Class B DCA

FMS/FMC

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1023264

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

Procedure; Airspace Structure; Human Factors

Ambiguous

After takeoff; we thought we were cleared to PAUKI. I read back what I thought was PAUKI. We had been cleared to FLUKY and were eventually given vectors to FLUKY. Make a greater effort to understand the clearance when issued by ATC. Though; I'm still not sure if we made the mistake or ATC did.

After departing BWI; an air carrier crew was cleared to FLUKY Intersection on the TERPZ TWO RNAV departure; but understood and read back clearance to PAUKI Intersection; which is 41 miles further southwest.

1086624

201305

Air Carrier

Commercial Fixed Wing

Passenger

Company

Air Carrier

Dispatcher

Dispatch Dispatcher

1086624

Other Dispatcher data error

Person Dispatch

Routine Inspection

General None Reported / Taken

Equipment / Tooling

Several times a day the controlling WSI [commercial weather service] forecast gets knocked out of [my display] by the NWS forecast. UHMA [commercial weather service] forecast was knocked out twice by NWS forecast today. All weather in our current systems should match and should show the controlling forecast. I have to call WSI and ask them to re-send the TAF to get it back into [my display].

Dispatcher reports that several times a day the controlling WSI forecast gets knocked out of the Dispatch program by the NWS forecast.

1110702

201308

1201-1800

ZSE.ARTCC

WA

14000.0

VMC

Daylight

Center ZSE

Fractional

Citation Excel (C560XL)

2.0

Part 91

IFR

Descent

Class E JAWBN3

Aircraft X

Flight Deck

Fractional

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness; Confusion

1110702

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

N

Person Air Traffic Control

In-flight

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

Chart Or Publication; Human Factors

Human Factors

Enroute to BFI; we were instructed to descend via the JAWBN 3 Arrival. We misread the restriction at JAWBN. The chart is misleading. The restriction box calls out landing north or south in reference to SEA. Below that it calls out 'BOEING FIELD/KING COUNTY RWY 13.' We read that as Boeing Field (all runways) or King County Runway 13. The Controller pointed out the deviation and instructed us to cross ALKIA at 12;000 feet. We did so. When we reached BFI we checked the NOS chart and realized our mistake.Change the chart to match the NOS chart which would eliminate the confusion.

A CE-560XL flight crew inbound to BFI on the JAWBN RNAV STAR misread the intent of the crossing restriction at JAWBN. The reporter believes the format of the commercially produced chart restriction 'LANDING BOEING FLD/KING CO RWY 13...Cross at and MAINTAIN 11000' was a contributing factor.

1721802

202001

ZZZ.Airport

US

0.0

VMC

Air Carrier

A320

2.0

Part 121

IFR

Passenger

FMS Or FMC

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

1721802

Deviation / Discrepancy - Procedural Hazardous Material Violation

Person Dispatch; Person Ground Personnel

Taxi

Air Traffic Control Provided Assistance; Flight Crew Overcame Equipment Problem; Flight Crew Returned To Gate; General Maintenance Action

Human Factors

On taxiout we were informed to return to the gate as the ramp had improperly loaded dangerous goods. We returned to the gate and the goods were loaded into the correct bin.

A320 Captain reported ground return to gate due to loading errors of Hazmat cargo.

1492890

201710

0601-1200

ZZZ.TRACON

US

27000.0

Center ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Cruise

Class A ZZZ

Hydraulic Main System

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1492890

Aircraft Equipment Problem Less Severe

Automation Aircraft Other Automation; Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Diverted; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Overcame Equipment Problem; Flight Crew Landed in Emergency Condition

Aircraft

The plane we picked up had been in maintenance for Hydraulic system B failure. This was the first flight since the repair. I briefed the First Officer (FO) about the issue and with this being the first flight; we are going to be on the lookout for any hydraulic system anomalies. At about 1;000 FT. from our cruise altitude of FL280; the hydraulic engine 2 system B 'Low Pressure' light illuminated. We leveled at FL280 and completed the HYDRAULIC PUMP LOW PRESSURE checklist. At this time; we were approximately 80 miles north of ZZZ. I gave control of the plane to the FO and called dispatch on the Dispatch Direct VHF Network. Dispatch patched me in with Tech. We agreed that; at this time; all other indications were normal so we would continue pending all conditions remained normal.I took over the pilot flying duties. FO and I conferred and agreed it to be prudent to start reviewing the checklists for a possible hydraulic system B failure and that we were in range of ZZZ for a landing if our scenario played out as in the previous flight. About 5 minutes later; hydraulic system B quantity rose to 106% and system A dropped to 71%. Pressures remained at 3;000 psi in both systems. Shortly thereafter; hydraulic system B pressure dropped to 50% with pressure remaining around 3;000 psi. Quantity then oscillated up and down then both pressure and quantity in system B dropped to zero. The FO started the LOSS OF SYSTEM B checklist and declared the emergency with ATC and instructed them that we were going to divert to ZZZ. I called the Flight Attendant (FA) and gave them the TEST items. While reviewing the LOSS OF SYSTEM B checklist and while getting vectors for ZZZ; we received an 'Oil Filter Bypass' alert for engine 2. FO then started the ENGINE OIL FILTER BYPASS checklist. The 'Oil Filter Bypass' alert remained on while the #2 throttle was at idle.I got clearance to descend. The descent was eventually stopped at 15;000 FT.; being vectored to stay on the northeast side of the airport close to the approach when we were ready to land. We advised ATC that we also had to shut our #2 engine down and ensured that CFR was advised. I stopped the descent at 15;000 ft. due to a solid overcast that topped at around 13;000 FT. with icing reported in the clouds. I wanted to stay VMC and out of the ice until we accomplished all of the checklists and were ready to be vectored for approach. We advised approach that we will need a long approach in order to configure using alternate flaps. The FO accomplished the ENGINE FAILURE OR SHUTDOWN checklist and ONE ENGINE INOPERATIVE LANDING checklist except for the deferred item of the Ground Proximity Flap switch. I advised ZZZ approach we were ready to be vectored for approach to 30L. We were vectored on a right base for approach. The FO accomplished the deferred item of the Ground Proximity Flap switch; the DESCENT and BEFORE LANDING checklists.The landing was uneventful. The aircraft was stopped straight ahead on the runway. I advised the passengers to remain seated. We asked CFR to get a brake temperature reading just as a precaution. They advised the right engine was dripping something but all temps were normal. I advised the passengers we would be taxiing close to the gate then; as a precaution; get towed the rest of the way in. CFR followed us to the gate.Time of windmill was approximately 10 to 15 minutes. Oil pressure and temp were normal. Landing weight approximately 136;000 lbs. FO did an outstanding job of checklist management and keeping things coordinated during this multi-emergency event.I don't know exactly what maintenance procedures were performed on the hydraulic system prior to us getting the airplane; other than changing the standby pump due to the fact that it was running while dry and refilling the system. Details weren't given in the aircraft log. I don't want to second-guess maintenance since I don't have all of the information. Perhaps better troubleshooting the indications prior to failure as to why the failure occurred in the first place.Thinking about this event; there are a few items of note that may be good to debrief flight crews on. The first is that I did TEST the Flight Attendants after the hydraulic issue and told them we would be landing in around 10 minutes. We were setting up for that emergency when the engine emergency happened. I did briefly consider calling the FA's back but decided there was no real difference in our landing situation as far as they may be concerned; i.e.; evacuation; fire; etc. After the event in the crew room; one of the FA's stated they were wondering when we were going to land because the time I told them had come and gone and we were still above the clouds. I didn't realize that time for them is much different than time for us in the cockpit in that we were constantly busy; but they now were not doing anything but waiting to land wondering why we were not. Going forward; finding the time; either through me; the FO; or jumpseat rider (if there is one) to call back to give a 10 second brief of what's going on would greatly help the FA's.The second is that when on the extended final and it came time to extend the flaps electrically; the FO held the switch; but it seemed nothing happened to the point where we both were wondering if anything was going to happen. I started going through my mind the possibility of a go-around to set up for a flap up landing. Then finally things moved. After the flaps started to move; they seemed to move at a descent rate. This might be a sim briefing item.Lastly; with the integration of the 737 Max in the checklist; the FO had to be very diligent in making sure he was not only in the correctly named checklist; but the correct checklist for the specific plane. I held above the clouds in VMC while we were going through the checklists in so as not to add icing and IMC into the mix. It also served to slow things down a little to ensure we were doing everything correctly. While I didn't want to needlessly delay our landing; I wanted to ensure everything was complete. Doing this gave us both time to ensure we were in the right checklist and all bases were covered.

B737-800 pilot reported that hydraulic system 'B' had erratic indications prior to a complete loss of the 'B' hydraulics.

1203903

201409

1201-1800

OMA.Airport

NE

0.0

VMC

Fractional

Embraer Legacy 450/500

Part 135

Passenger

Parked

Exterior Pax/Crew Door

X

Aircraft X

Door Area

Fractional

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Other / Unknown

1203903

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

Person Flight Crew

Routine Inspection

General Release Refused / Aircraft Not Accepted

Procedure; Human Factors; Aircraft

Aircraft

On post flight; found damage to airstair door (main cabin door). Contacted maintenance to get disposition of squawk. Maintenance attempted to tell me that the airstair door was a 'panel' and that the EMB505 MEL/NEF provided relief to defer ANY 'panel' in the aircraft; [MEL] 25-00-00. After discussing with my other crew member; we did not agree that this item was a 'panel'; nor did the FAA intend our company to decide any item on the aircraft was panel and a relief was provided to defer maintenance. Picture was provided to maintenance documenting the damage noted by crew on post flight. Maintenance furthermore provided the following in our company maintenance activity log provided to crews: 'Main airstair door upper cowling around snubber area is damaged. 2 areas cracked and damaged (crew refused NEF relief).' We as a crew took this to be pilot pushing; giving the impression to others that our maintenance write-up was not valid. I have seen a pattern of maintenance pushback in the past 6-9 months; where nearly every write-up is disputed and pressure applied to fly the aircraft. Maintenance should not be pushing pilots to fly broken aircraft.

EMB505 Captain discovers damage to the main cabin door on post flight; and makes a logbook entry for maintenance. Maintenance attempts to defer the airstair door as a 'panel;' stating that the EMB505 MEL/NEF provided relief to defer ANY 'panel' in the aircraft. The crew does not agree.

1650820

201905

1201-1800

ZZZ.ARTCC

US

VMC

Center ZZZ

Air Carrier

A321

2.0

Part 121

IFR

Passenger

Cruise

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

Situational Awareness; Training / Qualification

1650820

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

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem

Aircraft; Company Policy

Company Policy

Better guidance for the cabin crews on handling odor/fume events. As a pilot; you are behind a door with an oxygen mask on once the fume event is reported. You can't go back and investigate the nature of the odor/fume. The cabin crews need to be trained to make sure they are giving accurate and reliable information to the pilots.

A321 Captain reported better training required for cabin crew regarding handling and reporting of fume events.

1120541

201310

1801-2400

ZZZ.Airport

US

0.0

VMC

Night

Air Carrier

B737-700

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 222; Flight Crew Type 28000

Situational Awareness

1120541

Inflight Event / Encounter Fuel Issue

Person Flight Crew

In-flight

General None Reported / Taken

Company Policy; Weather

Company Policy

The new Flight Operations Low Fuel policy is unsafe and unwise. October X; 2013 we flew from ZZZ to ZZZ1. We pulled in the gate with 4.0 on the fuel. After an aircraft change; back to ZZZ; and then back to ZZZ1. We pulled into the gate in ZZZ1 with 3.9 total fuel and two low fuel lights. Planning for 5.0 fuel on the deck for any city-pair in the Northeast Corridor or anywhere else is not wise. One go-around; one blown tire; one delay of any kind; and flight crews will be forced to declare emergency Fuel. Is it the policy of the Company to routinely put pilots in the position to declare emergency fuel? We have crews returning to the gate; due to 'slight delays' for takeoff; because they do not have the minimum fuel required. Ruining our on time performance and disrupting the system is the result. A lady asked in XXX; 'Are you taking enough fuel?' 'Why do you ask;' I queried. She said her previous flight to XXX had to go back to the gate (TWICE!) to get more fuel. Should the passengers be worried about having enough fuel? When I called the Duty Chief Pilot about my situation; he recommended calling Dispatch and LOWERING my fuel even more to get airborne in the future! We are already short on fuel and we are asked to depart with even less? This is not wise. We are hurting ourselves trying to save a penny. Trying to save money at the expense of safety is not good policy. After several enroute ACARS exchanges with the Dispatch Supervisor voicing my concern over my pending low fuel situation; his response was; 'Am I missing something?' It must have looked great on paper according to the new policy in XXX. On a beautiful night in the Northeast; with no delays; I will be happy to send you a picture of my fuel remaining after a 'new normal' flight. With all that our pilots have to worry about; lack of fuel should not be one of them. Three hundred pounds taxi fuel is unwise and counterproductive to Company goals; first being safety and second; our ontime performance. Even with everything in our favor; actual flight operations do not reflect what may be the historic norm for a given route leg. Planning for 5.0 fuel on deck can easily become low fuel lights. The captain should not be required to negotiate with Dispatch over a prudent fuel load. The captain's years of training and operational experience; tempered by common sense and good judgment should always be the final arbiter. I will be available anytime to speak to anyone concerning this misguided; ill-advised and potentially dangerous policy.

B737 Captain laments the low fuel reserves routinely mandated by his company.

1305477

201510

1801-2400

HOU.Airport

TX

500.0

IMC

4

600

Tower HOU

Air Carrier

Medium Large Transport; Low Wing; 2 Turbojet Eng

2.0

Part 121

IFR

Passenger

Final Approach; Initial Approach

Class B HOU

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Last 90 Days 228; Flight Crew Type 6000

Situational Awareness

1305477

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Last 90 Days 240; Flight Crew Type 7900

Confusion; Situational Awareness

1305725.0

Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence

Person Air Traffic Control; Person Flight Crew

In-flight

Flight Crew Became Reoriented

Aircraft; Human Factors; Weather

Human Factors

We had a runway change late no GS for Runway 30L and winds were out of limits for Runway 4. It was very windy about 62 knots at 3;000 feet. We added 17 knots to approach speed for wind. Descended at 900 fpm; (zero set). We made call for approaching minimums. Looked out as Pilot Monitoring and saw runway. I created some confusion with the non-standard call of 'do you see it' the Pilot Flying took a second. I told him he was low as opposed to initially saying 'Minimums' he corrected. Don't think we ever broke minimums; but we came down early with the low ground speed because of the headwind. Took over visually and Tower said 'Low Altitude Alert' I said taking over visually and landed uneventfully.

Inbound to HOU we originally planned and briefed the ILS to Runway 4; passing through approximately 12;000 feet; we were notified of a runway change to 30L ILS with the glide slope out of service. We changed the approach in the FMS and rebriefed. The planned Approach speed due gusty winds was 152 knots for a flaps 30 landing. I calculated a descent rate of 800 fpm and a Derived Decision Altitude (DDA) of 570 MSL (MDA 520). I failed to account for a high headwind on final which probably reduced our ground speed by 20 knots from the planned speed; i.e. the descent rate should have been around 700 fpm. As a result we reached minimums farther from the runway than I anticipated. As we approached minimums; I failed to hear the 'Approaching Minimums' call (a lot of radio chatter and the noise from the windshield wipers were very loud and made communication difficult). As a result I was late transitioning my focus outside the aircraft. When the 'Minimums' call was made; it took another second or two for me to be comfortable calling the runway in sight and making the 'Landing' call. Unfortunately I did not arrest the descent rate and dipped below minimums prior to the visual descent point; the Pilot Monitoring stated (PM) we were low and I corrected the flight path. Right around that time the Tower issued a low altitude alert and stated the published minimums. We acknowledged and stated we were proceeding visually. We estimate that we leveled off around 400 feet AGL (450 MSL) so about 70 feet below published minimums. We continued and landed without further incident. Better planning of the descent rate so that we don't arrive at minimums too early and require us to 'Drive' in.

A flight crew reports descending below minimums prior to the VDP on a localizer only approach with the First Officer the flying pilot. A nonstandard minimums call from the Captain and a low altitude call from the tower occurred at the same time. The descent is arrested then a normal landing ensues.

1023826

201207

1201-1800

TEB.Airport

NJ

1000.0

VMC

10

Daylight

20000

TRACON N90

Corporate

King Air C90 E90

2.0

Part 91

IFR

Passenger

Initial Climb

Class D TEB

ILS/VOR

X

Improperly Operated

Aircraft X

Flight Deck

Corporate

Captain; Pilot Flying

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

Flight Crew Last 90 Days 50; Flight Crew Total 7900; Flight Crew Type 200

Human-Machine Interface; Situational Awareness

1023826

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

Person Air Traffic Control

In-flight

Flight Crew Returned To Clearance

Human Factors

PIC (pilot flying) did not fly the proper radial out of TEB. Pilot not flying input the wrong radial for the departure. No conflict -- (guessing 1/2 miles off course) -- PIC corrected error.

King Air pilot reports a track deviation departing TEB due to the wrong radial being set by the pilot not flying.

1848199

202106

1201-1800

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Taxi

Class B ZZZ

Turbine Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

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

Communication Breakdown; Confusion; Situational Awareness; Troubleshooting

Party1 Flight Crew; Party2 Ground Personnel

1848199

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

Communication Breakdown; Distraction; Situational Awareness; Training / Qualification

Party1 Flight Crew; Party2 Ground Personnel

1848445.0

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter FOD; Ground Event / Encounter Object

N

Person Flight Crew

Taxi

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

Aircraft; Environment - Non Weather Related; Procedure; Human Factors

Procedure

Landed Runway XX at ZZZ; taxied to gate. Didn't have 2 minute cool down; there were no marshalers at Gate XX. I was trying to find the Ops frequency and contacted Ops to see if we were still at Gate XX; at which point we saw marshalers going to Gate XY and started marshaling us in. I was watching them and didn't trigger to turn on the APU. Marshalers parked us; said chocks were set and captain pointed at the screen; and I turned the APU on (both engines still running at this point). Both engines were at idle. Around 30% spin up; felt a shunt and heard a noise from the right side of the cabin. Captain asked what that was; I thought it was the APU conking out (plane had been written up for a recirculation fan issue when we got it; and the only change we'd made was the APU turning). Captain asked if it was a baggage cart that had hit us or something; so I started looking around. Looked out and saw ground crew looking around and looking at engine 2. After the APU reached 100% and the engines were shut down; I (First Officer) opened the window and asked what happened; to which the ground crew said a cone went into the engine. Captain immediately sent message to Dispatch and was on the phone with company as I waited for the jet bridge to connect so I could do my walk around.When doing my walk around; asked the ground crew person who was handling the cone what happened; he said he 'got close to the engine; then something didn't feel right - like the cone was pulling'. He said he then 'pulled back; and that's when the cone got sucked into the engine'. It was an orange cone connected by a pipe. The cone closest to the engine had been sucked in. I did notice the ramper in question had Bose headphones around his head but not over his ears when I was talking to him. Don't know if that was a factor.On walk around; found most of the cone behind the intake; pieces in the stator vanes; and debris strewn across the ramp. Pieces found behind Left Main Landing Gear; and about as far back as about 30 feet behind the tail of the plane. No damage noted to landing gears or tires. Captain came out and also assessed the damage; and we informed the next crew of the situation as well.APU could have been turned on sooner to allow engine to be shut down quicker. Ramp crew should wait to approach engines until they're shut down.

We landed in ZZZ on Runway XX. The taxi to our planned gate; Gate XX; was short. The engines had not passed the 2-minute cool-down prior to entering the ramp. As we entered the ramp area; no rampers were at Gate XX; but they were starting to walk out to Gate XY. First Officer then tried to reach Operations via radio at least twice but didn't get a response. Simultaneously; I was being marshalled to Gate XY so we proceeded to park at Gate XY. I parked at the gate without incident and set the parking brake. I looked down and noticed the APU had not yet started and pointed it out to the First Officer. Between the cool-down period; trying to verify the gate; and watching for obstacles on the ramp; the APU had not yet been started. The engines were idle while the APU was starting. At approximately 20-30% APU; we felt an impact on the right side of the aircraft; followed by a loud noise. I asked what happened. There were no EICAS or gauge indications of a problem. The First Officer thought maybe the APU malfunctioned during the start and I asked if a baggage cart impacted the aircraft. Around this time the marshaller started looking toward Engine 2. When the APU reached 100% I shut both engines down. The First Officer opened his window and asked what happened. The ground crew indicated that ENG 2 had ingested an orange traffic cone. I immediately sent an ACARS to dispatch and called Maintenance to report the incident. The First Officer conducted his walk-around and assessed the ENG 2 damage; taking pictures which he sent to Maintenance via e-mail. Upon his return; the First Officer provided the following explanation from the employee who placed the cone:The ramper allegedly explained that as he went to place the cones in front of ENG 2; two orange pyramid-shaped traffic cones connected by a white plastic pipe; he felt the engine start to ingest the cone furthest from him. He stepped back but the cone didn't stay connected to the pipe. The First Officer noted that the ramper responsible for cone placement was wearing a Bose headset. This is extremely uncommon. So uncommon that I've never seen a ramp worker with a Bose headset or similar headset capable of playing music. I do not know if anything was interfering with the ramp worker's ability to properly hear the aircraft engines. After the APU was off and the airplane was connected to the GPU; I conducted a visual inspection of ENG 2 and called maintenance with an update of the ground crew's explanation of how the cone was ingested. I made a video recording of the fan blades. During this time; the ramp worker was telling the First Officer that he wasn't sure whether or not he should have told us to shut-down the engine when the cone was ingested. Ground crew should be trained to recognize when an engine is on and when to notify the crew to immediately shut the engine down. The ramp worker could have been killed due to his lack of training in recognizing an operating engine. Engines can be running at the gate for any number of valid reasons and ground crew should be trained when to recognize an operating engine. Ground crew should be properly trained in hand signals for an abnormality. Pilots could wait to taxi into the gate until the 2-minute cool down passes and the APU is operational to further prevent these kind of incidents.

Flight Crew reported a safety cone was ingested by a running engine after a ground crewman approached too close to the engine.

1347103

201604

1801-2400

ZZZ.Airport

US

0.0

Night

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Taxi

Cargo Restraint/Tie Down

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Training / Qualification; Situational Awareness; Distraction; Communication Breakdown; Workload

Party1 Flight Crew; Party2 Ground Personnel

1347103

Aircraft X

Flight Deck

Air Carrier

Captain

Flight Crew Air Transport Pilot (ATP)

Communication Breakdown; Workload; Distraction; Troubleshooting

Party1 Flight Crew; Party2 Ground Personnel

1346525.0

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

Person Ground Personnel

Pre-flight

Aircraft Aircraft Damaged; Flight Crew Took Evasive Action; General Release Refused / Aircraft Not Accepted

Aircraft; Company Policy; Procedure

Company Policy

During preflight; Crew Chief alerted us to damage in rear cargo hold caused by awkward and heavy metal cargo. Weight was approximately 1;260 pounds in total; or approximately 210 pounds per item (6 items total). The aircraft was taken out of service due to damage.Cargo was six small pallets each containing one large metal cylinder. Unknown circumstances caused one of these pallets to damage the floor of the rear cargo hold. Upon investigation by the First Officer (FO); it was learned that this cargo was not able to be anchored into the cargo hold; and was placed far aft of the aircraft.My concern as the flying pilot (FO) would be this cargo shifting rearward during takeoff roll and discovered upon reaching Vr. TPS called for Flaps 1 configuration; which allows for the least amount of clearance between the underside of the tail and the runway. Should the cargo have shifted aftward during takeoff/rotate; it could have caused a tailstrike; damage to the pressure bulkhead; lavatory storage; or other cargo. While unlikely; it could have caused excessive aft CG; thus presenting potentially catastrophic flight control issues.Secondly; upon assignment to new aircraft; the captain specifically notified dispatch that he was refusing the cargo for. I was a witness to this. We were assigned another aircraft in a different concourse. I notified the crew chief at the new gate about the issue and to not load the cargo should it arrive. He was aware and assured me it would not be loaded; per captain's orders. Approximately 20 minutes later; the crew chief notified me that the cargo did show up at the gate for loading and that he had refused it. I went outside to take pictures of the cargo to document the matter. Offending cargo was taken away and its disposition is unknown to me. B737s do not have sufficient mechanisms for securing heavy; dense; or awkward cargo. There are no floor locks; containers; sufficient cargo nets; etc. The 737 is designed to carry passenger luggage; mail; standard air freight; some AOG parts; etc. Had we not been alerted to the cargo (had it been loaded without incident); and the cargo shifted rearward on a FLAPS 1 takeoff; I fear a tailstrike would have been likely. The spring-loaded narrative during the history of passenger air travel is to blame the pilot first; last; and at every point in between for any aircraft mishap. Unless there is a manifestly obvious cause to counter the pilot error narrative; the pilot is left to defend his career and reputation with little evidence to support himself. In this incidence; I fear the shifting rearward of such cargo would have been attributed to improper pilot takeoff technique; rather than the shifting of the cargo causing unforeseen control issues. The captain and I (with a combined 47 years of service to the Company) would be to blame; not the cargo loading. There is no procedural mechanism to capture such a loading error. The preflight walkaround does not include the FO opening the cargo compartments and inspecting the cargo; nor does it include weight and balance calculations. For issues such as this; the crews are at the mercy of the competence of the load planners and ground crews.Limit the types of cargo taken in smaller passenger aircraft. Heavy; awkward; or dense cargo can't be secured. If so; they should not be put in the aft cargo for obvious reasons. Control issues are the primary concern; but aircraft damage is also at issue.I would also like for a simulation of this to happen and see what happens to the 737-800 if the cargo shifted in the aft cargo hold at rotate. If the Company wishes for me to participate; I am willing to do so; but only if I am taken off an existing trip with pay.

These over 200 pound hubs were strapped (insecurely) on individual tiny pallets. There were six of them I believe. They had to be top heavy in my opinion. Packaging cargo is not my expertise but if they had been properly secured on a larger pallet and placed in a cargo compartment other than the aft compartment; this may have not been a problem.

A B737-800 aft cargo compartment floor was damaged after six 210 pound unsecured pallets were placed in it. The crew was additionally concerned about the unsecure cargo shifting at Vr. The pallets were removed and the aircraft taken out of service.

1607322

201901

0601-1200

ZZZ.Airport

US

0.0

VMC

Dawn

UNICOM ZZZ

Air Taxi

Citation X (C750)

2.0

Part 135

IFR

Ferry / Re-Positioning

Landing

Visual Approach

Aircraft X

Flight Deck

Air Taxi

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 108; Flight Crew Total 9100; Flight Crew Type 346

Situational Awareness

1607322

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

Person Flight Crew

In-flight

Flight Crew Regained Aircraft Control

Aircraft; Human Factors

Aircraft

VMC Visual approach into ZZZ. I was Non-flying Pilot. PIC was on stable approach; fully configured on VASI [Visual Approach Slope Indicator] to Runway XX. Landed at ref speed in touchdown zone. Runway bare and dry. OAT -20C. No wind. After touchdown on centerline; aircraft veered hard right. Captain corrected immediately and it veered hard left departing runway at approximately 60 knots. Nose gear contacted a runway sign after departure from paved surface. After stopping; taxied back onto runway and to ramp without further issue. No eye witnesses and no other traffic in the area.

Citation First Officer reported a loss of control on landing resulted in a runway excursion and contact with a runaway sign.

1564493

201807

0601-1200

ZZZ.Airport

US

0.0

VMC

10

Daylight

12000

Corporate

PA-25 Pawnee

1.0

Part 137

None

Agriculture

Landing

Visual Approach

Class G ZZZ

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

1.0

Takeoff / Launch

Class G ZZZ

Aircraft X

Flight Deck

Personal

Single Pilot

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

Flight Crew Last 90 Days 70; Flight Crew Total 1100; Flight Crew Type 60

1564493

Conflict Ground Conflict; Critical; Ground Incursion Runway

Horizontal 1000; Vertical 0

Person Flight Crew

In-flight

Flight Crew Took Evasive Action

Human Factors

At ZZZ I encountered a runway incursion with another aircraft; a PA-28. I am an agricultural pilot; had just completed a mission; and was returning to ZZZ. My aircraft has no radio; therefore I do most of my traffic spotting visually with no radio for aid. I entered the traffic pattern at a 45 to downwind entry for Runway 07; the active runway that was being used all morning. I had been flying since [early morning]; and had made multiple landings that morning. I saw no traffic except for the PA28 taxiing for departure on the opposing Runway 25. I completed a standard traffic pattern; and landed on Runway 07. As I began applying brakes on my rollout; I saw Aircraft Y begin a departure roll. I quickly began to depart the runway towards the grass to avoid the oncoming traffic. The grass was my first option; as there were no close taxiways to turn onto. I stopped my turn before departing the runway; as I noticed the PA28 aborted its takeoff roll. The PA28 departed the runway at the next taxiway; and I followed behind at a distance. When I touched down for landing; the aircraft was nowhere near Runway 25. The aircraft then taxied down to Runway 07 and departed the airport and traffic pattern. I had the right of way in this situation; and although I did not have any radios; I had a very clear understanding of the situation at hand. I believe the other aircraft could have been too reliant on radios to aid in traffic avoidance; and did not see me; or could have been distracted by some other means. The runway incursion did not result in any harm to either aircraft as far as I am aware.

Agricultural pilot reported a ground conflict while landing as opposite direction traffic rejected take off.

1068103

201302

1201-1800

ZZZ.Airport

US

15.0

5000.0

VMC

10

Daylight

6000

TRACON ZZZ

Corporate

Challenger Jet Undifferentiated or Other Model

2.0

Part 91

IFR

Passenger

Initial Climb

Direct

Class C ZZZ

DC Ram Air Turbine

X

Improperly Operated

Aircraft X

Flight Deck

Corporate

Captain

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

Flight Crew Last 90 Days 100; Flight Crew Total 10400; Flight Crew Type 200

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

Party1 Flight Crew; Party2 Flight Crew

1068103

Aircraft Equipment Problem Less Severe

Person Flight Crew

In-flight

Aircraft Equipment Problem Dissipated; Flight Crew Returned To Departure Airport

Aircraft; Human Factors; Procedure

Human Factors

Inadvertent deployment of the RAT/ADG was the 'result' of a simple; yet important checklist item and poor decision making on [my] part. Compounding the 'missed item' on the After Start/Taxi Checklist was; in my opinion; poor crew mix; inadequate use of checklists; lack of meaningful recency of experience; and numerous other CRM and human factors. On this date my assigned SIC and I had a flight...taking two passengers.... Normal cockpit checks were accomplished and ATC clearance for the flight was obtained in advance.... As the SIC was getting into the cockpit; strapping in and getting his headset on; I went through the Before Start Checklist and began normal engine starts. About the time my SIC came up on the headset; I was beginning my After Start Checklist flows. At some point in that flow I recall us getting a Comm check with one another. For reasons I cannot explain; as I went through my normal flow; I completely missed checking and turning ON the main generators; and turning OFF the APU generator (first error). So; at this moment; we were running solely on a single generator from the APU. At completion of the After Start flows; I called for the After Start Checklist. The SIC mumbled some things and looked towards each item to verify that I had completed the requisite items during the After Start flows (should have used a Challenge-Response method as a minimum). Later; he stated that he looked down and left to the electrical panel; but did not notice the generator switches out of proper position; i.e. Mains-ON; APU-OFF (second error and first real chance to trap and correct the error). He then stated 'After Start Checks Completed.' I think this was a case of 'seeing what you want or expect to see...not what actually exists.' This was compounded by the SIC's stated trust in me over the past 4 plus years and the fact he had never seen me miss anything like that. We then called for taxi clearance and started out of the chocks. I called; 'Flaps 20; Taxi Checks.' He began to run the checklist; most of which is silent; during taxi. Now; when he went flaps 20 degrees; we did not note that the galley power was loadsheding along with all Utility Bus items as it was daytime (second chance to identify and trap the original error). SIC stated at some point that he wasn't getting a good ADG test/green light. We were near the end of the taxi with a couple aircraft stacked behind us. I asked him to run it again and we had the same results. We had an issue and I should have at that time told him to advise ATC we needed to get to a safe area; stop the aircraft; and resolve the issue to ensure the aircraft was in a safe condition for Dispatch. I minimized the problem as an electrical glitch during the test and made an inappropriate decision to continue (third chance to trap and correct the original error.) Prior to contacting Tower; the final item on the Challenger checklist is to do a 'Recall' on the 8/10 Caution Panel to account for any unknown caution lights or unresolved issues. The SIC saw the ELEC Caution light; which is in essence considered a 'normal abnormal' and is routinely cleared by selecting the APU Generator switch to Test/Reset to clear the light; IF there are no other problems. Apparently; he reached down and identified the wrong switch and moved the Number 2 Main Generator switch to Test/Reset from its already OFF position. Had he actually used the correct switch; the APU Generator would have gone off line and it would have become obvious what the problem was as we would have gone to Battery Power ONLY (fourth chance to identify and trap the original error). Note: RAT/ADG deployment is inhibited with weight on wheels. At that point we accepted a takeoff clearance convinced that we had a nuisance issue. After takeoff and positive rate of climb was noted by SIC/pilot not flying; I called for the landing gear up. A short time later; I called for 'Flaps UP; APR OFF; After Takeoff checks.' The SIC began to review them to include securing the APU. However; just prior to securing APU; we had the ELEC Caution light at which time he reached down and DID identify the correct switch and shut off our only source of AC Power; the APU generator. It did not occur to him that the APU Generator switch was in fact in an abnormal position to begin with. The RAT/ADG immediately deployed in a rather loud manner at approximately 235 KIAS and almost immediately I recovered my EFIS and other key items run by the ADG Bus. The SIC kind of froze and was somewhat out of the loop due to the event. I glanced down at the electrical panel and turned both Main Generators ON. I knew immediately what had happened and why. I simply missed those Main Generator switches after the engine starts. At this point; I had an SIC/pilot not flying who was so startled; baffled; and a bit scared that I simply said; 'It's the ADG...relax. I have ATC...please step back and advise our passengers that we have a maintenance issue; we are going back to the airport; and everything is okay.' I advised ATC we had a maintenance issue and needed to return to the airport. He asked if we needed assistance and I advised that we did not nor did I see any need to declare an emergency as the aircraft was safe and sound. I was just severely embarrassed. I received radar vectors back approximately 15 NM for a visual approach...with an uneventful landing...other than the ADG being deployed.... [We] and the flight department learned a great deal and I believe this incident woke us up to some operational issues we have had; and have since corrected; including a full; honest; open discussion to other crews about the event. It will remain a very embarrassing incident for me and highlights' problems with poor operating procedures-- complacency; lack of proper checklist usage; crew mix (weak SIC with PIC just coming back into aircraft); poor CRM; poor aeronautical decision making on my part; SIC's reluctance to clearly state problems; concerns; or confusion.

CL60 flight crew inadvertently took off with the APU generator on and engine driven generators off. RAT deployed when the APU was secured during the After Takeoff checks. Generators were activated and aircraft returned for an uneventful landing.

1221381

201411

1201-1800

JAC.Airport

WY

0.0

Marginal

Daylight

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

Passenger

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Situational Awareness

1221381

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

Pre-flight

Procedure; Human Factors

Ambiguous

Lack of accurate runway surface condition report by ATC resulted in; reduction of contingency fuel by dispatch in order to accommodate load planning. ATC reporting of a wet runway when in fact the runway was dry by FAA definition; resulted in reduction of load carrying capacity to include removal of fuel; passengers; and cargo. Local ATC runway condition reporting is not accurate. Tower distance from the runway makes it impossible for controllers to give an accurate report. Or; airport OPS is not giving the tower; timely or accurate reporting information. Relaying runway conditions in official reports such as in ATIS broadcast; alters Company dispatch load and performance planning for reported runway surface conditions. When official reporting is not accurate; the Company cannot operate efficiently which results in loss of revenue; inconvenience to the traveling public; and a reduction of safety in the form of reduced contingency fuel with marginal weather conditions and gusty winds.The ATIS was report a wet runway at XA45Z; XB45Z; and again at XC45Z; for which the latter two reports I personally observed to be inaccurate; based on FAA definition. ATC facilities are wholly owned and operated by the FAA which administrates regulations that impact flight planning; and which directly impacts flight load planning. The reporting of runway conditions cannot be based on a 'guess or assumption'. They must be reported accurately both for better and for worse by individuals trained to observe and report actual conditions based on standard definitions. Lack of accurate reporting causes a number of problems in that it can unnecessarily restrict operations into short runways such as JAC. However; such inaccuracies could also cause a lack of restriction to the opposite if for example; the runway was icy but being reported as dry. The lack of integrity of the reporting must be corrected; primarily for safety; but also for reduction of loss of revenue and loss of essential air service for the traveling public.

CRJ700 Captain laments inaccurate runway surface condition report by JAC Tower. Tower reports a wet runway when in fact dry; resulting in removal of passengers and cargo.

1183676

201405

1201-1800

LEE.Airport

FL

2500.0

VMC

Daylight

TRACON F11

FBO

Small Aircraft; Low Wing; 1 Eng; Fixed Gear

1.0

Part 91

Training

Cruise

Class E F11

TRACON F11

Light Transport; Low Wing; 2 Turbojet Eng

2.0

VFR

Training

Cruise

Vectors

Class E F11

Aircraft X

Flight Deck

FBO

Pilot Not Flying; Check Pilot

Flight Crew Air Transport Pilot (ATP)

Distraction; Situational Awareness; Communication Breakdown; Confusion

Party1 Flight Crew; Party2 ATC

1183676

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

Horizontal 20; Vertical 200

Person Flight Crew

In-flight

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

Procedure

While just outside the LEE airspace departing to the east; flight crew leveled off at 2;500 FT in VFR condition. Standardization applicant was undergoing some basic instrument procedures therefore wearing a limited viewing device. Suddenly a small jet that was later identified by IP having registration; overflew our airplane by only few hundred FT headed in the same direction. IP contacted Orlando ATC to report the near mid-air collision and ATC explained that aircraft was under radar vectors for practice approaches at the Sanford airport and when they realized the alert on radar they immediately instructed the jet to climb. No further explanations were given; flight crew continued with planned lesson.ATC could provide better separation or higher altitudes vectors considering jet aircraft was well outside Orlando Class B airspace in a known congested area of flight training.

An instructor administering a pilot's standardization check at 2;500 FT reported a near miss after a small jet passed overhead while it was under MCO TRACON radar vectors for SFB practice approaches.

1673877

201908

0001-0600

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Dispatch; Party2 Ground Personnel

1673877

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Ground Personnel; Party2 Dispatch

1673858.0

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

Person Flight Crew

Pre-flight; Routine Inspection

General None Reported / Taken

Human Factors

Station did not notify us of wheelchair batteries as required per FOM 2.100 At close out; we noted on the flight deck report that we had two electrical wheelchairs on board. Upon reviewing FOM 2.100 we asked operations and the ground crew as to the status of the wheelchair batteries. We received conflicting information from the station and ground crew about the location of the batteries. I then asked the ramp crew to verify if the batteries where on the wheelchair or removed. They confirmed the batteries where removed. We then asked the 'A' FA if she was notified by the CSA. She said no. We asked her to find the guests and ask them where the batteries where for clarification. Per FOM 2.100 the CSA is to notify 'A'FA where the batteries are located. This was not done. In the flight deck report include where the batteries are located; cabin or cargo hold. Then there will be less confusion among all parties involved.

Upon receiving the close out and checking the flight deck report; the Captain and I discovered that we had wheelchair batteries onboard. We checked FOM 2.100 to learn more about the procedures. We inquired the station; ground team; and the A Flight Attendant as to where the batteries where located. The ground team said the batteries were disconnected and in the cargo compartment. The station said both batteries were in the cabin. The A Flight Attendant said she believed the batteries were in the cargo compartment. We had the A Flight Attendant inquire with the wheelchair guests as to the location of the batteries. She said the lithium battery was in the cabin and the dry or gel cell battery was in the cargo compartment. I inquired if the A Flight Attendant knew the location of the lithium battery as well as the location of laptop fire bag; the A Flight Attendant replied in the affirmative. Ready; Safe; Go. In the future; the CSA should verbally inform the A Flight Attendant and the CA of the batteries and their location. Additionally; the flight deck report should state one of the following 'Dry or Gell Cell Battery in Cabin;' 'Dry or Gell Cell Battery in Cargo;' 'Lithium Wheelchair Battery in Cabin;' or 'Lithium Wheelchair Battery in Cargo.' I believe this would decrease confusion in the future as it would provide more fidelity to the flight crew.

Commercial airline flight crew reported a communication breakdown regarding the transport of Lithium Ion and Dry Cell batteries; a violation of company Hazmat procedures.

1425266

201702

0001-0600

PHX.Airport

AZ

0.0

Tower PHX

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Taxi

Tower PHX

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Taxi

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1425266

Conflict Ground Conflict; Critical

Person Flight Crew

Taxi

Human Factors

Taxiing for takeoff at PHX runway 7L on E taxiway. As we became number one for takeoff we were proceeding past E4 taxiway to turn left on E3 taxiway to hold short for takeoff instructions. As we were crossing over the E3 threshold tower told us to stop to let another aircraft go ahead of us. I figure it was an aircraft behind us because the nose of my aircraft was half way through the E3 taxiway. Then I saw an aircraft on D taxiway making the left turn from D to D1 to E3 right in front of us at a high rate of speed. I told my First Officer (FO) I think he may clip our nose with his wing tip. My FO said his right main wheels were so close to the taxi way lights that he thought he was going to take them out. The wing tip of the aircraft missed us by 5 feet. After they had passed the tower called thanked us for stopping and apologized for the late call for stopping.They should have stopped and said they could not get through because we were blocking the taxiway. Had they hit us it would have damaged the aircraft.

A320 Captain reported another aircraft passed very close to the front of the aircraft while holding at a taxiway intersection.

1673553

201908

0601-1200

DIJ.Airport

ID

290.0

6.0

8000.0

VMC

Daylight

Center ZLC

Corporate

Small Transport; Low Wing; 2 Turbojet Eng

1.0

Part 91

IFR

Passenger

Initial Approach

Visual Approach

Class E ZLC

Fuselage Nose Cone

X

Failed

Aircraft X

Flight Deck

Corporate

Captain; Single Pilot

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

Flight Crew Last 90 Days 30; Flight Crew Total 4900; Flight Crew Type 250

Distraction; Situational Awareness

1673553

Aircraft Equipment Problem Less Severe; Inflight Event / Encounter Bird / Animal

Person Flight Crew

In-flight

Aircraft Aircraft Damaged

Airport

I had canceled my IFR flight plan in the air and was entering the DIJ traffic pattern for runway 22. Upon setting up and while entering the 45 entry for right downwind 22 the aircraft was struck by a medium size bird which appeared 30-50' in front of the aircraft. Impact was obvious due to the sound and debris on the windshield. I continued to enter the pattern normally and landed without further incident. Upon landing; a visual inspection determined the bird had impacted the radome causing serious damage.

Corporate pilot reported a bird strike to the radome while landing at DIJ.

1809411

202105

1801-2400

ZZZ.Airport

US

VMC

clear; 10

Dusk

10000

Personal

Golden Eagle 421

1.0

Part 91

None

Personal

Landing

Visual Approach

Class D ZZZ

Normal Brake System

X

Malfunctioning

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 25; Flight Crew Total 1700; Flight Crew Type 150

1809411

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

Person Flight Crew

Other Landing

Aircraft Aircraft Damaged; General Flight Cancelled / Delayed

Aircraft

After a normal landing at ZZZ the right brake would not activate. Once rudder authority was lost the aircraft departed the left side of the runway. The nose gear collapsed in the soft dirt and the engines stopped. There were no injuries and we exited the aircraft.

Pilot reported right main brake malfunctioned; causing a runway excursion and aircraft damage.

1578519

201809

1201-1800

ZZZ.ARTCC

US

36000.0

VMC

Center ZZZ

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Cruise

Main Gear Tire

X

Failed

Flight Deck

Air Carrier

Pilot Flying; Captain

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

Flight Crew Total 20000

Troubleshooting

1578519

Flight Deck

Air Carrier

First Officer; Pilot Not Flying

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

Flight Crew Total 18000

Troubleshooting

1578507.0

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

Person Flight Crew

In-flight

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

Aircraft

Enroute [from] ZZZ; [we] received Master Caution light at 36;000 feet for System A Engine Driven Hydraulic Pump. [We] executed QRH procedure then noticed quantity in System A was zero without the expected additional caution lights.Executed phone patch to Dispatch and Maintenance on ARINC. Maintenance expressed concern about running electric pump with a zero quantity indication.[We requested priority and] diverted to nearby to ZZZ1. [We] checked overweight landing app and hydraulic loss landing chart. [We] tried lowering landing gear early resulting in total loss of System A including expected low pressure lights. [We] conducted second Hydraulic QRH procedure for total loss of System A and integrated 737 qualified jumpseater in Manual Gear Extension procedure. Landed Runway XX at ZZZ1. ARFF personnel inspected aircraft and revealed tire damage and leaking hydraulic fluid. [We] had gear chocked and pinned. Passengers deplaned by [read] door and escorted by AARF to terminal on foot. [We] turned aircraft over to local Maintenance and contacted ZZZ Chief Pilot.It seems the #3 tire shredded and caused System A hydraulics to leak. Tire shred was unknown until after landing.Loss of System A QRH procedure starts with three low pressure annunciator indications; but we only had one of these; initially causing speculation whether this was the correct procedure to apply or not.

[Report narrative contained no additional information.]

Boeing 737-800 flight crew reported the complete loss of System A hydraulic fluid after a supply line was damaged by a tire failure.

1307071

201510

0601-1200

ZZZZ.Airport

FO

VMC

Rain; 15

Daylight

Center ZZZZ

Corporate

Global Express (BD700)

2.0

Part 91

IFR

Ferry / Re-Positioning

Cruise

Direct; Oceanic

Hydraulic System

X

Malfunctioning

Aircraft X

Flight Deck

Corporate

Captain

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

Flight Crew Last 90 Days 76; Flight Crew Total 4350; Flight Crew Type 1008

Troubleshooting; Workload

1307071

Aircraft Equipment Problem Critical

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft; Human Factors; Procedure

Procedure

Just after passing ZZZ Intersection we received an amber 'HYD 1 LO QTY' CAS message. We then displayed the hydraulic synoptic on the #4 DU for review and initiated the appropriate checklist. On the synoptic; we noticed the hydraulic system 1 quantity at 16% fluid and depleting rapidly. Anticipating total fluid loss we reviewed the HYD 1 LO PRESS checklist as a precaution; discussed situation; and elected to divert the aircraft to ZZZZ. In the descent to ZZZZ and hydraulic system 1 quantity at 6%; we started the APU and elected to perform a precautionary shutdown of the #1 engine. This was done after discussion and systems review to prevent possible further safety issues and aircraft system damage. [ATC was advised] at this time to ensure flight safety and priority handling. Shortly after precautionary engine shutdown; the quantity and pressure on hydraulic system 1 fully depleted. We then completed all appropriate single engine approach and landing checklists and subsequent single engine landing at ZZZZ with no further flight issues.

A Bombardier Global Express HYD 1 LO QTY CAS alerted so the crew completed the HYD 1 LO PRESS Checklist. They then secured the #1 engine as a precaution and diverted to the nearby airport.

1780021

202012

ZZZ.Airport

US

0.0

10

Dusk

10000

CTAF ZZZ

Personal

Small Aircraft

1.0

Part 91

None

Personal

Landing

Direct

Aircraft X

Flight Deck

Personal

Single Pilot; Pilot Flying

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 57; Flight Crew Total 1700; Flight Crew Type 32

1780021

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

Person Flight Crew

In-flight

General None Reported / Taken

Human Factors; Airport

Airport

I'm making a landing at ZZZ; I executed a missed approach on the first attempt. On the second landing I failed to initiate a missed approach in time and had to continue to the landing due to obstacles that would possibly be in the flight path of a go-around. Upon landing I was unable to stop the aircraft before exiting the end of the runway and hitting mowing equipment.

Pilot reported on second go-around; having to land to miss obstacles in the flight path. Pilot was unable to stop aircraft and exited runway hitting equipment.

1242468

201502

1201-1800

ZZZ.Airport

US

0.0

Daylight

Air Carrier

A320

2.0

Part 121

IFR

Passenger

Parked

N

Y

N

Unscheduled Maintenance

Navigation Light

Airbus

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 150; Flight Crew Total 10000; Flight Crew Type 6000

Confusion; Troubleshooting

1242468

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

N

Person Flight Crew

Aircraft In Service At Gate

General Maintenance Action

Aircraft; Human Factors

Human Factors

I did the walk-around prior to our flight. The navigation light switch was in the # 2 position which I've always known to illuminate the aft (outboard) Nav lights on the wing tips. The right wing tip was illuminated correctly but the left wing tip light was illuminated in the # 1 position (forward and inboard). When we switched it to the # 1 position then it illuminated the aft and outboard bulb. This seemed backwards from normal so we wrote up the discrepancy and after an hour of research maintenance said it was normal. We both explained that we had never seen it before but they said that was how it was supposed to work according to their wiring diagram. So either we are being taught incorrectly and our FM is vague or the maintenance document is incorrect. But I have never seen two different bulbs illuminated on opposite wing tips with a given switch position.

Reporter stated he saw the same A320 a week later and the same NAV light discrepancy still existed. He still suspects that having two different bulbs illuminated on opposite wing tips with a given switch position is not correct. Because if that opposite light bulb configuration is actually correct; that means all the other A320 aircraft are incorrect; which doesn't seem likely.

During a pre-departure walk-around; a First Officer (FO) notices two different light bulbs would illuminate on opposite wing tips when the A320 Navigation light switch was moved to either the # 1 or # 2 position. When in position #2; the right wing tip outboard aft Nav light was illuminated correctly; but on the left wing the inboard forward bulb was illuminated.

1801507

202104

1201-1800

ZZZ.Airport

US

0.0

Windshear; 10

Daylight

Personal

Small Aircraft

1.0

Part 91

None

Personal

Landing

Visual Approach

Aircraft X

Flight Deck

Personal

Pilot Flying

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

Flight Crew Last 90 Days 4; Flight Crew Total 19200; Flight Crew Type 220

1801507

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

Other landing roll

Aircraft Aircraft Damaged

Human Factors; Weather

Human Factors

Returning to the airport after doing some air work the Tower advised winds were 19 [kts.] gusting to 24 from 190 degrees. Runway in use [would involve a crosswind landing] so I made the decision to ask for [a different runway] as it was slightly more favorable considering the tail wind component.[This] aircraft was manufactured with brakes only on the left side with a stick and rudder pedals only on the right side; where I sat during the flight.Because the passenger said he had never flown [this aircraft] before and after the airwork we agreed I should make the landing...aeronautical decision making failure on my part; should have gone somewhere else or waited for better winds.I briefed the left seater that if I had a problem keeping the aircraft pointed down the runway I would call for rudder and a tap on the brake.I landed; the crosswind overcame the rudder; I yelled for rudder and brake but off we went into the grass; taking out a runway distance marker; ground looped and wiped out both gears.Even though I had practiced a left seat landing four days earlier; it was outright dumb of me to attempt a landing in that kind of wind condition; and secondly; my skill level wasn't up to the situation. No one was hurt; thankfully; but the gear collapsed and the airplane was [damaged].

GA pilot reported loss of directional control on landing roll that resulted in a runway excursion and aircraft damage.

1349183

201604

0601-1200

ZMP.ARTCC

MN

6000.0

VMC

Cloudy; 10

Daylight

6200

Center ZMP

Personal

Small Transport; Low Wing; 2 Recip Eng

1.0

Part 91

IFR

Personal

Cruise

Direct

Class E ZMP

Center ZMP

Personal

Small Aircraft; High Wing; 1 Eng; Fixed Gear

1.0

Part 91

VFR

Personal

Cruise

Class E ZMP

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Commercial; Flight Crew Multiengine; Flight Crew Instrument

1349183

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

Horizontal 30; Vertical 120

Person Air Traffic Control; Person Flight Crew

In-flight

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

Procedure; Human Factors

Procedure

The following is written from memory. I'm assuming audio recordings and radar tracks are available for reference by others. A small transport piloted by me was on an IFR flight plan cruising at 6;000 feet assigned and on assigned westerly heading. A VFR Aircraft Y was heading east and reported to ZMP Center query as being at 6200 feet. Center gave both aircraft progressive traffic advisories of 12 o'clock and 9 miles; then 6 miles then 4 miles distance. My response to ATC was 'looking' and two of us in the cockpit kept scanning visually. At the Center 6 mile advisory I turned on landing light and taxi lights. The strobe and rotating beacon were already on. Sometime between the 6 mile and the 4 mile advisory I heard Aircraft Y reply to Center's query for his altitude that he was at 6000 feet. At that point since neither aircraft reported seeing the other and since I had not received an instruction from Center but while still closing at about 300 knots (estimated) and understanding that both aircraft were at the same altitude; I initiated a slight deviation to the right and a slight climb. A moment later Center told me to climb. A moment later Aircraft Y acknowledged having me in sight and I acknowledged having him in sight. The Aircraft Y passed 120 feet below and about 30 feet to my left.Contributing factors:One aircraft was on an IFR flight plan. The other was VFR. I filed IFR for 6000 feet to stay below the freezing level referenced in an AIRMET for icing otherwise I would have filed higher. There was a narrow band of clouds at about 6200 feet MSL (estimated) between the two aircraft running from southwest of course to northeast of course.Human Performance Considerations:Perceptions; judgments; decisions. After the incident ZMP Center asked me over the same radio frequency if I had TCAS. I responded; negative TCAS; no TCAS. Was the controller assuming I had TCAS and expecting me to provide my own separation? Is that normal for ATC to assume aircraft have TCAS and will use that to provide their own traffic separation while operating under an IFR flight plan under ATC control? The VFR aircraft descending through the flight path of an oncoming aircraft given that both aircraft were listening and communicating respective altitudes through the ATC communications is hard to understand. The decision of the ZMP Center controller to delay providing separation instructions to either aircraft until they were closer than 4 miles and at the same altitude and closing rapidly (300 knots estimated) is questionable.Actions of Inactions:ATC did not inquire and the VFR aircraft did not offer during query for altitude report to report whether level; climbing or descending. ATC delayed too long to issue direction or altitude changes to either of the aircraft.

An IFR light twin pilot in VMC was advised by ZMP Center about a single engine VFR aircraft at the same altitude. ATC assumed the light twin had TCAS; but it did not and the aircrafts had a near miss.

1215931

201411

1801-2400

ZLA.ARTCC

CA

9000.0

Night

Center ZLA

Corporate

Small Transport; Low Wing; 2 Turboprop Eng

2.0

Part 91

IFR

Passenger

Descent

Class E ZLA

Facility ZLA.ARTCC

Government

Enroute

Air Traffic Control Fully Certified

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

Confusion; Distraction; Situational Awareness; Communication Breakdown

Party1 ATC; Party2 ATC

1215931

ATC Issue All Types

Person Air Traffic Control

In-flight

Air Traffic Control Separated Traffic

Equipment / Tooling

Aircraft X started flashing for me to take the automated hand off over the HII airport which is in my airspace already. The aircraft was showing at 090 descending to 060. My MVA in the area is 061. I called sector 10 who had control of the data block. They were in the process of radar identifying the aircraft and stopped him at 080. The controller at 10 told me he had just taken over the sector and was told the aircraft was radar contact lost but IFR. I didn't have any other IFR traffic in the area. No loss of separation. There has been an ongoing problem with the radar coverage in that area. I could see aircraft below Aircraft X but not him. I believe the auto pop function activated when the aircraft got back into radar coverage and started the hand off. Non radar procedure shouldn't have been needed during normal operations. I believe that is why sector 10 didn't realize there was a problem with picking the aircraft back up before entering my airspace. There has been several issues with the radar in the area of HII; EED; IFP airports. This is one more example of an unsafe situation in my opinion because of the radar not functioning properly.

ZLA Controller describes a situation where an aircraft is auto handedoff to him but is already in his airspace. He doesn't observe the target and coordinates with another sector who is handing off the aircraft to him.

1625153

201903

0601-1200

ZZZ.Airport

US

0.0

Rain

Daylight

Ground ZZZ

Air Carrier

B737 Next Generation Undifferentiated

2.0

Part 121

IFR

Taxi

Turbine Engine

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 161; Flight Crew Type 1085

1625153

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 191; Flight Crew Type 420

1625149.0

Aircraft Equipment Problem Critical

Person Observer

Taxi

Flight Crew Requested ATC Assistance / Clarification; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft

On taxi out; the aircraft behind us reported fire and smoke in engine number two tailpipe. We determined no cockpit indication of fire. We accomplished the Severe Engine Damage QRC and subsequent QRH. We shut down the number two engine; pulled the number 2 fire handle; and disconnected the autothrottle. No other actions were required of the QRH. The First Officer requested fire trucks to inspect the engine. I communicated with the Flight Attendants and passengers regarding the situation at hand. I asked the Lead Flight Attendant to visually inspect the tailpipe of the number two engine. She reported back to me that there was some residual smoke but no fire. We established communication with Fire and Rescue. Fire and Rescue and Maintenance visually inspected the aircraft. They reported back that the smoke had subsided. After approximately 10 to 15 minutes; they gave us approval to connect the tug and safely proceed to gate. The APU was started; and engine number one was also shut down. The Flight Attendants advised on debrief that the overall atmosphere in the cabin was calm throughout the event. The taxi back to gate was uneventful.

[Report narrative contained no additional information.]

B737NG flight crew reported shutting down the Number 2 engine after smoke and flames were reported by another aircraft.

1504683

201712

1201-1800

ZZZZ.Airport

FO

320000.0

VMC

Daylight

Center ZZZZ

Air Carrier

B767-300 and 300 ER

3.0

Part 121

IFR

Passenger

Cruise

Oceanic

Fuel Tank Cap

X

Malfunctioning

Flight Deck

Air Carrier

Relief Pilot

Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 200; Flight Crew Total 20000; Flight Crew Type 7000

Workload; Troubleshooting; Distraction

1504683

Aircraft Equipment Problem Less Severe; Flight Deck / Cabin / Aircraft Event Other / Unknown; Inflight Event / Encounter Fuel Issue

Person Flight Attendant

In-flight

Flight Crew Returned To Departure Airport; General Maintenance Action

Aircraft

About 20 minutes after takeoff; Lead flight attendant called the flight deck to inform us that a passenger observed fluid coming from the right wing. I asked; what color of fluid the passenger had seen; she informed me clear fluid.As relief pilot; I exited the flight deck about 10 minutes later to observe the right wing. I observed what I would judge to be about 1 or 2 gallon per minute of fluid streaming from the trailing edge of the right wing; and could trace the origin to the mid-wing fuel cap. I called the flight deck to inform the Captain of the situation. About 15 minutes later; the Captain called back to the cabin to ask me to reassess the leak. I observed no change in the situation.I returned to the flight deck to find the duty crew had initiated fuel dumping and had coordinated a diversion. I assisted in calculating our landing fuel; ACARS communication with dispatch; informing the flight attendants and passengers; and reviewing the QRH; as well as making logbook entries.After an uneventful landing; we were able to get the fuel cap O-ring replaced. Flight attendant duty time was an issue but they voluntarily waved their limit and we were on our way within about 4 hours. Remainder of the flight was uneventful.

B767-300 Relief Pilot reported that they observation of fuel streaming from the trailing edge of the right wing. It was determined that the source of the leak was a wing-tank fuel cap; and an uneventful return to the departure airport was accomplished.

1247464

201503

0601-1200

DFW.Airport

TX

5000.0

TRACON D10

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Climb

SID HUDAD1

Class B DFW

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

Flight Crew Air Transport Pilot (ATP)

1247464

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

Person Air Traffic Control

In-flight

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Human Factors; Chart Or Publication

Chart Or Publication

Received the clearance to fly the HUDAD1 RNAV Departure in DFW via PDC. On the PDC clearance the Altitude clearance was 'climb via SID' with no altitude listed. I consulted the departure using my LIDO charts. On the depiction the chart said for initial altitude see inset. I looked at the inset and saw an altitude of 5000 feet listed for YAMEL. I thought this was the initial assigned altitude so I set it in the altitude preselect. I briefed the clearance with the captain before pushback and the error was not detected. We taxied out to runway 17R and were cleared for takeoff. As we climbed we were told to contact departure. The captain checked in with departure and we continued to climb to 5000 feet. We began to level off at 5000 and remained there for a few seconds when departure queried as to what our assigned altitude was. The captain told him 5000. He told us to check the departure and that it was in fact 10000. He told us to continue the climb to 10;000; which we did. The captain apologized and the controller said 'no problem'. It didn't seem to be an issue with the controller since there was no traffic in the immediate vicinity. The LIDO chart format has very important information scattered. While it may seem trivial; having a visual depiction and a textual description on 2 separate pages is not user friendly. We cannot compare the two side by side. The visual depiction of the departure and the assigned altitude was also misleading. It has been very difficult to transition to the information depiction on LIDO charts; especially when going into unfamiliar airports. The only two ways this can be solved is getting comfortable with the charts; which may or may not happen and may result in other transgressions before one is comfortable. The other way is to use charts with better depictions of the important information; such as Jeppesen.

EMB 175 FO reported difficulty interpreting the LIDO charts used for a DFW departure.

1015984

201206

0001-0600

ZZZ.Airport

US

0.0

Daylight

Air Carrier

B737 Undifferentiated or Other Model

Part 121

Passenger

Parked

N

Y

Scheduled Maintenance

Work Cards; Installation

Pax Seat

X

Gate / Ramp / Line

General Seating Area

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

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

Party1 Maintenance; Party2 Maintenance

1015984

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

N

Person Maintenance

Other Paperwork Audit

General Maintenance Action

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

Human Factors

I was assigned that night with another Mechanic (Y) to perform Line Routine Overnight (RON) Maintenance on Aircraft X and Y. I took Aircraft X while (Mechanic Y) worked Aircraft Y. I had changed two nose tires on another aircraft before working my Maintenance Visit Check on Aircraft X. I changed a taxi turn-off light and the # 2 Main tire before completing all assigned work cards and the Maintenance Visit Check (M/V) on Aircraft X. I then assisted Mechanic Y with the M/V Check on Aircraft Y by changing the # 3 Main Landing Gear (MLG) tire and both nose tires. Once done with the tire changes; I inquired what was left to do. Mechanic Y had completed all other work on Aircraft Y and had just finished replacing Passenger Seat Row XDEF. It was getting very late in the night (Morning) and we still had to complete all the paperwork. I assisted him in placing the old seat row on a cart for transport and filled out the Serviceable Parts Tag for him. I tilted the seat assembly in such a manner that I could read the seat Data Plate underneath. I saw several part numbers along with the Serial Number (S/N). Being fatigued and under time constraints; I transcribed the Serviceable Manufacturer's Part Number and Item Number for logbook onto the Removal section of the Parts Tag. I then documented the seat Serial Number (S/N) onto the tag. We rushed inside to complete both aircraft work packages before departure time. I completed Aircraft X's paperwork and also signed for the three tire changes on Aircraft Y. Mechanic Y pulled the Parts Compatibility list for the Main Ship Battery; O2 Bottle and the seat row. All showed to have correct 'Effectivity' and he signed-off his work package. We handed the paperwork to our Supervisor for review. We were done! Since; I was told that after his review our Supervisor handed the packet to the paperwork clerk and the plane was released with only a few minutes before departure time. Shortly after the plane took off the clerk noticed that the seat S/N # for the Manufacturer's P/N did not match. This mismatch caused the investigation to reveal that we had installed an 'Effective' part; but not at the location Row YDEF. It was in fact for row ZDEF. It is my opinion that this situation was caused by several broken links; failures and outside factors. An MEL was written for the wrong seat row; which led to the wrong seat to be ordered. This seat was installed and I filled out the Serviceable Parts Tag incorrectly. The seat row location was overlooked on the Parts Compatibility list. Several people failed to catch this oversight primarily due to workload; fatigue and time constraints. I am glad the Clerk discovered the mistake. However; I am very sad that Aircraft Y left and flew before it could be corrected. I could have broken the chain of events had I noticed the Manufacturer's Part number mismatch.[Recommend] reducing fatigue; adjusting headcount; moving personnel according to workload requirements; and changing the Parts Compatibility computer screen to alert the Aircraft Maintenance Technician (AMT) of critical positioning of the part [on the aircraft].

A Line Mechanic performing multiple tasks on two aircraft with another Mechanic was informed they had installed a replacement Passenger Seat Row that was effective for the B737 aircraft; but not at the row they had installed it.

1658679

201906

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

Parked

Gate / Ramp / Line

Air Carrier

Other / Unknown

Situational Awareness

1658679

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

Person Ground Personnel

Taxi; Routine Inspection

General None Reported / Taken

Procedure; Human Factors

Procedure

Flight XXX loaded without bags to secure. [Load Planning] talked to Lead and the Supervisor to correct the issue but issue corrected only on [load report]; but not on aircraft. Asked audit for arrival and no action taking by ZZZ team. Hazmat wasn't secure with bags and showing 15 bags in Pit 4 was not loaded.

Air carrier Load Planner reported; after aircraft departure; loading documents were altered to suggest correct Hazmat load configuration.

1091297

201305

0601-1200

ZZZ.ARTCC

US

10000.0

VMC

Daylight

Center ZZZ

Air Carrier

Commercial Fixed Wing

2.0

Part 121

Passenger

Climb

Safety Instrumentation & Information

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

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

1091297

Aircraft Equipment Problem Critical

Automation Aircraft Other Automation; Person Flight Crew

In-flight

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

Aircraft; Chart Or Publication; Procedure

Aircraft

While climbing through approximately 10;000 feet; we were alerted to a VIA (Versatile Integrated Avionics) FAILURE. After checking the QRH; multiple alerts began appearing. I contacted Maintenance Control and Dispatch and relayed our situation. They suggested a return to the departure airport. The alerts continued; and I declared an emergency. We had no map displays; the DU's (Display Units) were flickering; the Captains' airspeed indicator was unreliable; the stall warning was going off; no autopilot or autothrottles; and we were in manual pressurization mode. The First Officer was the flying pilot and did an outstanding job while I tried to prioritize what we had and didn't have. We landed and after evaluating the condition of the aircraft; decided to taxi to the gate with CFR trucks following us.It appears the #1 VIA had a complete failure. The QRH was no help. The level 1 alert only states; 'Do Not Change EIS Source' and that the fuel quantity comparator will be inaccurate. I feel the QRH should give you a bit more info as to what to expect.

A B717 VIA (Versatile Integrated Avionics) #1 failed in flight with numerous failures including the Captain's airspeed; stall warning; autopilot and autothrottles. An emergency was declared while the flight returned to the departure airport.

1835580

202108

0601-1200

YSSY.Airport

FO

0.0

Air Carrier

Commercial Fixed Wing

3.0

Part 121

IFR

Passenger

Parked

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Flight Crew Last 90 Days 0; Flight Crew Total 3826; Flight Crew Type 1305

Troubleshooting; Physiological - Other

1835580

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

Y

Person Flight Crew

Aircraft In Service At Gate

General None Reported / Taken

Airport; Procedure; Human Factors; Company Policy

Ambiguous

Upon landing in YSSY we were told the aircraft needed to be disinfected with a spray. They had us turn off the air conditioning and proceeded to spray the cabin with an insecticide. They made the crew and passengers remain onboard and closed the doors; the spray was so heavy it set off smoke detectors. One of the flight attendants had a very bad reaction to it and had to wash out the eyes; the next day flight attendant complained of a sore throat.I read the can and it is to be used as an aircraft insecticide. It is not intended to be used on humans.One of the warnings is avoid breathing fumes; mists; vapors; or spray. First Aid: If swallowed; do not induce vomiting; contact a poison information center. If in eyes; flood with water; if on skin wash with soap and water.They are spraying this on everyone; including a one month old baby. I confronted the agent who was spraying it (she was in a full hazmat suit) and all she said was the health minister authorized it. I complained that the can clearly states its poisonous to humans. They should not be doing this with passengers and crew onboard.

Air Carrier First Officer reported YSSY ground personnel boarded the aircraft and began spraying with the cabin crew and passengers still on board.

1043331

201210

0001-0600

ZZZ.Airport

US

0.0

VMC

10

Daylight

12000

Personal

Balloon

1.0

Part 91

None

Personal

Landing

Visual Approach

Aircraft X

Flight Deck

Personal

Pilot Flying

Flight Crew Commercial

Flight Crew Last 90 Days 30; Flight Crew Total 544; Flight Crew Type 544

Physiological - Other

1043331

Inflight Event / Encounter Weather / Turbulence

Person Flight Crew

Other Landing

General Physical Injury / Incapacitation

Aircraft; Weather; Human Factors

Ambiguous

Hot air balloon was landing in winds approximately 8-10 KTS. Upon ground contact the balloon continued to slide and came to rest with basket on its' side. Occupants remained in the basket; however the pilot's knee was pushed up against the other occupant's leg just above the ankle. Occupant (also a pilot) experienced bruising and swelling of the ankle. No medical attention was accepted at time of incident.

Hot air balloon pilot reports landing in 8-10 KTS of wind resulting in the basket tipping over and injury to the other occupant of the basket.

1579745

201809

0601-1200

ZZZ.Airport

US

0.0

VMC

Daylight

Tower ZZZ

Air Carrier

Regional Jet 700 ER/LR (CRJ700)

2.0

Part 121

IFR

Passenger

Takeoff / Launch

Oil Distribution

X

Malfunctioning

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Crew

1579745

Aircraft X

Flight Deck

Air Carrier

First Officer; Pilot Flying

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

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Flight Crew

1580113.0

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

Person Flight Crew

In-flight

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

Aircraft; Procedure; Human Factors

Aircraft

Flight was delayed due to completion of service check; about 1 1/2 hours late. Upon nearing the end of the runway and ready for takeoff a low oil level status message came up. Having seen these messages for years and always having enough oil/flight time I believed we had enough. However; I still pulled out the QRH and read through the appropriate message in the status message section having only glanced at the oil level on the display. I don't recall the number that I read on the screen at the time but I had the impression from what I read that we had enough and told the First Officer that we were good and we'll just keep an eye on it and if we needed oil we could get some at our destination. I put the QRH away and shortly after was cleared for takeoff; without looking at the oil level again I changed the screen back to the status message page. At the start of the takeoff roll I glanced at the engine instruments as usual to ensure everything was in the green; and all numbers were approximately the same for both engines.Climbing through 10;000 feet we noticed the oil pressure was decreasing and going yellow. I then rechecked the oil quantity and noted it was at 15%. I pulled out the QRH and checked for possible caution messages. Shortly after; I instructed the flying pilot to increase speed and reduce power to see if that would have an effect on the oil pressure. It increased slightly but overall kept decreasing. At 20 PSI we received a L ENG Oil Pressure warning message. I turned to the appropriate page and followed the procedure which led to a precautionary engine shutdown; [advising ATC]; and return to field.After the flight mechanics inspecting the aircraft told me that there appeared to be an oil leak within the engine; later after they had taken it to the hangar I was told over the phone that there was definitely a leak somewhere in the engine. Then; while waiting around the flying pilot and I discussed the events and at that time they made the remark that they saw 15% oil quantity once we got onto the runway but because I said we were good said nothing.An oil leak in the engine; running late and trying to rush knowing we had a longer route then usual due to ATC reroute for weather along our normal route. Poor communication between me and the First Officer prior to takeoff; specifically using ambiguous terms; i.e. saying we were good with the oil quantity versus saying what I saw on the gauge when I looked at it and what I read in the QRH.Slow down; especially when I feel pushed to get going. Say what I'm seeing and reading to ensure both of us see the same thing or catch a discrepancy; and also to arm the First Officer with knowledge so that if I make a mistake; misinterpret; or simply miss something; they are in a better position knowledge-wise to speak up.

First flight of the day. We got to the airport being notified that the airplane was still in the maintenance shop and would be an hour and a half delayed. Once the airplane was towed to the gate; I did my walk around and didn't notice anything unusual. Captain was trying to catch up on some of the delay we already had; so we set up the aircraft rather quickly; without putting safety in jeopardy. MCD [main cabin door] closed; started taxiing to Runway XX. I was Pilot Flying and we were holding short of the runway waiting for our release at this point. Right before we started rolling to line ourselves up; I noticed a status message pointing out a low oil level in the left engine. I saw the Captain was already looking in the manual at this point; and told me we were good to go for 1 leg; and decided we'd ask for an oil fill up once [at destination].We departed on a right downwind and climbing. Going through 8;000 feet he notices our oil pressure starts dropping at a rather fast rate. He pulls up the manual while I'm still flying and says that as long as our oil temperature remains in the green; we are good to continue. A few minutes later; climbing through 14;000 feet; the 'L ENG OIL PRES' warning message came up along with the aural warning. I kept flying the airplane; leveled off at 14;500 feet as he was slightly reducing the power on the defective engine. He then ran the QRH and advised me we needed to shut down the left engine. We followed the procedure; stabilized the airplane; and advised ATC of our intention to return to field. We turned around direct ZZZ and descended to 10;000 feet. With an excess of fuel; we decided to hold for about 45 minutes in order to get below MTOW in order to land. Right before our final descent; Captain became Pilot Flying and we proceeded to a safe landing on Runway XX. We were able to taxi to the gate on our own; and then deplaned everybody.I believe with the rush caused by the initial delay; the Low Oil Level status message before takeoff should have been looked at closer. I did not second guess his answer; and after talking about it past the incident; I believe I remember seeing a 15% level on the L ENG; where he can't seem to remember what number he definitely looked at. On initial climb; he looked at the level again; and we definitely both remember seeing 15% at that point as well. I believe once in flight we did everything in compliance with the procedure and the purpose of bringing the airplane back on the ground safely. After the fact; Maintenance told us that there was indeed an oil leak in the left engine.Once again; I should've second guessed what he looked at; being that 15% is definitely on the lower side of it. The rush to catch up time is something I encounter quite often; and don't necessarily understand. Operations and Dispatch are always working on taking care of this side of the airline. So in this case; I definitely believe asking for a couple more minutes to look into the issue would have helped. After fact; Captain talked to Maintenance and [we] were told that indeed an oil leak was found in the engine. So even though it was an unfortunate event; it luckily happened soon after departing and we were then able to return to field with plenty of fuel and beautiful weather.

CRJ-700 flight crew reported the engine oil quantity was decreasing after takeoff the engine and oil pressure started dropping.

1838523

202109

0601-1200

ZZZ.Airport

US

40.0

30.0

9000.0

VMC

10

Daylight

TRACON ZZZ

Hercules (C-130)/L100/382

Part 135

IFR

Passenger

Initial Climb

Vectors

Class B ZZZ

Engine Air Pneumatic Ducting

X

Malfunctioning

Aircraft X

Flight Deck

First Officer

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

Flight Crew Last 90 Days 180; Flight Crew Total 1900; Flight Crew Type 700

Troubleshooting

1838523

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Clearance

N

Person Flight Crew

In-flight

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

Aircraft

After departing ZZZ on climb through 9;000 feet; crew received a Red master warning indicating a left engine bleed leak. The crew performed the immediate action items and appropriate checklist which isolated the left bleed leak malfunction. The crew returned to ZZZ for a normal landing. Maintenance was then notified.

C130 First Officer reported a red master warning light that indicated a left engine bleed leak. First Officer reported performing immediate action items and completed the checklists to isolate the bleed leak; completing an air turn back and precautionary landing.

1820450

202107

0001-0600

ZZZZ.Airport

FO

0.0

Air Carrier

B777-200

2.0

Part 121

IFR

Cargo / Freight / Delivery

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Communication Breakdown

Party1 Flight Crew; Party2 Ground Personnel

1820450

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

Person Flight Crew

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

General Work Refused; General Flight Cancelled / Delayed

Human Factors

My First Officer noticed while checking the hazardous cargo pallet; there was a '4.3 DANGEROUS WHEN WET' box loaded on the very bottom of the pallet; with several boxes of other DG (dangerous goods) on top. It had been raining steadily for several minutes during loading; so the pallet had about a half inch of water or more that had puddled on the floor of the metal pallet. The pallet had plastic wrapping around all the boxes and of course the plastic was also wet due to the rain. But since this box was loaded on the bottom we couldn't tell if it was totally wrapped in plastic or bare to the pallet flooring. Also if there was a rip in the plastic; it could get the box wet. So I told the ramp agent I needed to see bottom of the box. The Ramp and DG Agent did not understand due to language issues and initially they put styrofoam under the box. My First Officer used Google translate and they finally understood. When they took the box off the pallet and showed it to me; it was wet on half of the bottom of the box; the box had absorbed a good bit of water as it looked darker. We had them remove that small box from the plane. It would have been easy to over look this!! My First Officer deserves a recognition for his attention to detail!! The DG Specialist most importantly needs to understand this could have been a very serious issue! I believe the package contained Lithium Phosphorus. 'Dangerous When Wet' DG should never be on the bottom of the pallet for this very reason. The cause was a poorly built DG pallet and a misunderstanding of how this box could easily get wet in the conditions presented. Ensure DG specialist at ZZZZ understand this issue and re-train as necessary.

Air Carrier Captain reported Hazmat cargo refused due to being incorrectly configured for transport.

1627528

201903

1801-2400

ZZZ.Airport

US

0.0

Air Carrier

Commercial Fixed Wing

Part 121

Passenger

Parked

Company

Air Carrier

Technician

Maintenance Airframe; Maintenance Powerplant

Training / Qualification; Other / Unknown; Communication Breakdown; Confusion

Party1 Maintenance; Party2 Maintenance

1627528

Company

Air Carrier

Technician

Maintenance Powerplant; Maintenance Airframe

Training / Qualification

1627527.0

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

Person Maintenance

Aircraft In Service At Gate

General Flight Cancelled / Delayed

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

Human Factors

While taxiing Aircraft X on cabin walk through found missing access panels and overhead bins out of alignment. Bin access panels were unsecured and flight crew mentioned that they felt overhead bins should close by themselves. Found all screws for panels missing and all bins not operating the way flight crew claimed. My only reference at the time was Aircraft X so entered discrepancies in logbook and went to next assigned aircraft move. Aircraft was moved to hangar and taken OTS (Out of Service). [Updated] and Emergency Exit rows with Tray tables installed were in question.Vendor installed new interior poorly aligning overhead bins; not installing hardware and overhead bins were found to have BAM (Bin Assist Mechanisms) inoperative. When following up on Aircraft X's status was informed bin access panels were NEF (Non-Essential Furnishings); bin gaps were covered by AMM (Aircraft Maintenance Manual) reference. I expressed my concern of missing fasteners and flight crews mention of overhead bins inoperative. [Lead Mechanic] took time to look up IPC (Illustrated Parts Catalog) for access panels and informed aircraft required each panel to be secured with screws. We then looked at other [Updated] aircraft and found that BAM worked. [Lead Mechanic] called [Maintenance Engineering] and suggested Aircraft X be taken OTS upon return to ZZZ. I called [Maintenance Operations Manager] to let them know that screws were missing and BAM were probably inoperative. My only reference to missing screws and inoperative BAM was Aircraft X; I was moving aircraft. I spoke to [Aircraft Maintenance Manager]. Was contacted by (ZZZ [Maintenance Operations Manager]) 10 minutes after [Aircraft Maintenance Manager] conversation that [a second Maintenance Operations Manager] wanted an explanation of Aircraft X and if I wanted a steward present to find one. Called an agitated [second Maintenance Operations Manager] in presence of [ZZZ Maintenance Operations Manager] and steward. Started to explain to [second Maintenance Operations Manager] that I had provided [Aircraft Maintenance Manager] with; [second Maintenance Operations Manager] made it clear I would explain myself and my inaction. After explaining Aircraft X's condition was told by an angry [second Maintenance Operations Manager] I should call FAA and self disclose that I let an aircraft fly out of configuration and file a report on my behalf. [Second Maintenance Operations Manager] then explained that I would be meeting Aircraft X when it reached ZZZ and correct my inaction. In my opinion [second Maintenance Operations Manager] tried to intimidate; pressure me and put blame on me for Aircraft X's condition.Outsourcing of Aircraft maintenance is a big part of this occurrence. Turnover and face to face with shift change on aircraft condition.

I decided to review OTS (Out of Service) on [web based system] for status of [updated] Evaluation visits at various stations.I noted that ZZZ Maintenance mentioned in an [web based system] update that [Engineering Order JXXXXXX] does NOT apply to Aircraft X. The aircraft was returned to service. This aircraft is in fact currently configured in the [updated] configuration. While the applicability status of this particular [Engineering Order JXXXXXX] revision is true; I questioned what other [Engineering Order] revisions might apply to this aircraft. According to [Maintenance Computer System] was accomplished at ZZZ1 on [previous year]. By the basic criteria applied to other aircraft; Aircraft X may fit the criteria for evaluation of the [update]. Review of the OTS History reports indicated that this aircraft has not had said evaluation complied with at any [company] maintenance station. If this condition is true; this aircraft needs to be evaluated in the same manner as all 14 other aircraft that were modified at ZZZ1 are being inspected.Apparently selection of the aircraft requiring evaluation of the [update] may have been based upon status of later [Engineering Order] revisions. [Engineering Order JXXXXXX] is an active revision. [Engineering Order] revisions [JXXXXXX] and [JXXXXXY] are marked as 'retired' and not viewable in the Currently Active [Engineering Order] search online.

Aircraft technicians reported incorrect installation of interior modification by air carrier outside vendor as well as miscommunication and incorrect information in maintenance systems.

1777767

202010

0001-0600

ZZZZ.Airport

FO

Air Carrier

Commercial Fixed Wing

Part 121

IFR

Cargo / Freight / Delivery

Parked

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Flying

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

Time Pressure; Situational Awareness; Communication Breakdown; Confusion; Physiological - Other

Party1 Flight Crew; Party2 Ground Personnel

1777767

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

N

Person Flight Crew

Aircraft In Service At Gate

General Flight Cancelled / Delayed

Airport; Environment - Non Weather Related; Human Factors; Weather

Ambiguous

My duty day started in ZZZZ. I was part of a 2-man crew; scheduled to operate ZZZZ-ZZZZ1-ZZZZ. At the time I left ZZZZ; the TAF for ZZZZ had a small period of low visibility in the forecast; which was to occur while I was on the ground in ZZZZ1; and the weather was forecasted to improve to be above CAT I minimums prior to my arrival back into ZZZZ. While on the ground in ZZZZ1; I was checking the ZZZZ weather and found out that the ceilings were WELL below CAT I minimums. I called Flight Operations for a briefing and was told the same thing. I decided to delay the flight for an hour to watch the ZZZZ weather and to 'time' my arrival into ZZZZ to coincide with the forecasted lifting of the weather. Flight Operations then called me back and asked for me to delay another 30 minutes so we would arrive 30 minutes after the period of low weather in ZZZZ - I agreed; as it was a good idea. I also knew that I was currently at an outstation where I really have zero options for adequate rest if we got stuck there since we can't deplane the aircraft without mandatory COVID tests and quarantine until test results come back negative. So; in reality; flying to ZZZZ1 is really a gamble in the first place but; for sure; I knew that staying there wasn't even an option. I eventually departed ZZZZ1 at the newly determined departure time and flew towards ZZZZ.Through the use of ACARS ATIS updates as well as messages to/from the company - it was determined that the weather in ZZZZ had not cooperated with the forecast. Visibility was 125 meters to 225 meters - well below CAT I minimums. I talked with my First Officer and we decided to enter high altitude holding and set a 'bingo' fuel number for us to know when it was time to have to go to the alternate airport; ZZZZ2. We burned through our holding fuel and were forced to divert to our published alternate airport. That's where the real fun began. This is the point where we found out that an alternate that looks good on paper doesn't always work in actual practice. We landed; parked in spot XX; and sat; and waited; and sat; and waited some more. It took almost an hour just to get a set of stairs brought to the aircraft - and took an equally long amount of time to get a GPU and wheel choked so I could release the parking brake. At this point; I became doubtful that we would have the duty time to allow us to continue to ZZZZ1 - and that feeling was mirrored back to me by Flight Operations on my first phone call to them. A plan for crew hotels was then started; as well as the continued effort to contact our 'handler' there in ZZZZ2. Next came the biggest issue...Customs. The handler first started telling me that we can't stay there because we can't clear customs 'in their country'. I reminded him that we were scheduled to land in ZZZZ; which is the same country - but he didn't care. Clearly; the thought of a crew having to get rest at this published alternate airport hasn't been approached before? Finally; after 4 hours on the ground; the handler comes to the aircraft; asks me to shut it down so he can take us to a hotel close to the airport. I complied; and as soon as I carried my personal items downstairs; I was told by that same handler that it would be another hour before customs can clear us and to please wait on the aircraft - which was now shut down. I opened the aircraft again and that's where we waited for almost 2 more hours before the handler came back to tell us that there is 100% no way we were gonna clear customs there at that airport. At this point; we had absolutely no choice but to stay on the aircraft. After talking it over with my crew; we decided that the only option would be to depart ZZZZ2 as soon as we were legally able to do so - even though sitting on the aircraft isn't actually 'rest' - we had no other options. I talked with Flight Operations and they told me that we could depart at XA:00Z; which was another 3 hours from then. Out of lack of betterideas; we agreed; got the plane ready; and blocked out at XA:01Z for ZZZZ. The real point in this report is to illustrate that so many of our flight plans might look OK on paper; but when it comes time to actually put contingencies into practice; the plan immediately dissolves - leaving crews stranded without the ability to legally continue operating; and without the ability to obtain legal rest. Vetting of our 'approved alternates' certainly needs to take place.Not properly vetting filed; 'approved;' alternate airports to facilitate crew egress between aircraft and legal rest facilities.Worked tirelessly with the ZZZZ2 handler to try to secure rest facilities for my crew. When that failed; I worked with my crew and with Flight Operations to determine when we could 'legally' leave.Time and manpower needs to be put forth in this company to actually find out what processes would need to take place at alternate airports or at intermediate stops to allow crew members a place to get safe; legal rest when needed.

Air Carrier Captain reported a delay due to weather at an international location resulted in crew rest issues. The Captain also stated they decided to not deplane the aircraft during the delay due to the requirement of having to take a COVID-19 test if they left the aircraft.

1481209

201709

1201-1800

ZZZ.ARTCC

US

37000.0

Mixed

Thunderstorm; Turbulence; 10

Daylight

37000

Center ZZZ

Personal

EMB-505 / Phenom 300

2.0

Part 91

IFR

Training

FMS Or FMC

Descent

STAR ZZZZZ

Class A ZZZ

Aircraft X

Flight Deck

Personal

Instructor; Pilot Flying

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

Flight Crew Last 90 Days 250; Flight Crew Total 13000; Flight Crew Type 850

Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party2 ATC

1481209

Aircraft X

Flight Deck

Personal

Trainee; Pilot Not Flying

Flight Crew Instrument; Flight Crew Private; Flight Crew Multiengine

Flight Crew Last 90 Days 100; Flight Crew Total 2500; Flight Crew Type 70

Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 ATC

1481177.0

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 Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Human Factors; Weather

Weather

Instructor/Mentor Pilot was acting [as] PF. During the descent briefing the PF/IP informed the PIT (Pilot in Training) that the weather over the arrival was deteriorating. XM Weather and Active Weather Radar was painting numerous cells starting to top at FL400. Literally the entire area was bubbling up with convective activity creating a dangerous situation. Descent/Approach briefing completed the THREATS were clearly outlined as Severe Weather both on the arrival and the wind conditions at the field.[While cruising] at FL450 the Controller issued a clearance to descend to FL400. PIT (Pilot in Training) doing the radios advised the Controller to stand by. After conferring with the IP/PF both pilots agreed it was much safer to stay at FL450. PIT reported to [ATC] that we wished to stay at FL450 until we passed the worst of the weather. The Controller DEMANDED a descent. Again the PIT with authorization from the PF/IP advised we were unable to descend. The Controller then assigned us a heading of 210 and demanded a descent. The PF/IP made the call to begin the descent and try to help the Controller out. We accepted the 210 heading and descend to FL350. We heard the Controller ask for an expeditious descent through FL370. Upon rolling out on the heading of 210 we were closing in on a large cell. We asked the Controller for a 230/240 heading for weather. When we turned to that heading; it was obvious we were going to go through the tops of another cell.Now unable to get on the radio due to numerous aircraft requesting VECTORS FOR WEATHER we turned to a SAFE heading of 260 and at first break in the radio; advised the Controller we now needed a 260 heading for weather. The Controller replied with 'You are not cleared for a 260 heading'. We again advised 'sir; we need the 260 heading for weather!' again the Controller said 'you are not cleared on to that heading'. This left the crew no option but to [override the Controller] for safety. We immediately took a picture of the weather radar and view out of the window showing the imminent threat. Pilots should keep in mind that an XM Weather image may be 20-30 [minutes] old and that what matters most is the image out of the window and on the weather radar. The atmosphere had clearly reached a boiling point making safe flight very much in doubt. If we had the time we would have squawked 7700 prior to making the turn to 260 but it is always Aviate; Navigate and then Communicate. Didn't have time in a dynamic situation. I stand behind the decisions we took as a crew to have a safe conclusion to our flight.

[Report narrative contained no additional information.]

EMB-505 flight crew reported using Captain's authority to circumnavigate an area of thunderstorms.

1426775

201702

1201-1800

ZZZ.Airport

US

3000.0

IMC

3

Daylight

1000

TRACON ZZZ

Air Taxi

Super King Air 200

2.0

Part 91

IFR

Training

Climb

Vectors

Class B ZZZ

Aircraft X

Flight Deck

Air Taxi

First Officer; Pilot Not Flying

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

Flight Crew Last 90 Days 100; Flight Crew Total 3200; Flight Crew Type 415

1426775

Aircraft X

Flight Deck

Air Taxi

Captain; Pilot Flying

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

Flight Crew Last 90 Days 49; Flight Crew Total 6400; Flight Crew Type 208

1427381.0

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

Person Flight Crew

In-flight

Flight Crew Overcame Equipment Problem; Flight Crew Returned To Clearance

Human Factors; Procedure

Human Factors

I was flying in the right seat of a King Air 250 for a pilot with whom I fly regularly. He was being evaluated by an FAA inspector in a passenger seat for a part 135.297 IPC. After takeoff and upon reaching 500 feet and heading of 140 degrees departing ZZZ in IMC and after engaging the autopilot; the inspector stated 'the right engine has failed.' He expected either the pilot or me to simulate an engine failure despite the fact that neither the pilot nor I had actually been trained to reconfigure the right power and propeller levers to zero thrust. We knew ahead of time there would be a simulated engine failure but had never experienced that scenario in the actual aircraft. The pilot pulled the right power lever back thinking that was adequate to simulate engine failure while we simulated the memory items to secure the 'failed' engine.At this point we realized the right engine was creating enough drag that full left rudder could not overcome the adverse yaw and the autopilot kicked off. I was communicating with departure and was queried twice about our heading as we continued in a right turn. As the airspeed decayed and the aircraft could not be brought around to our assigned heading; we were told we could have our engine back and upon setting normal power we were able to fly normally and were vectored for an ILS approach back into ZZZ. I; along with the pilot and charter operator; will be meeting with the FAA tomorrow to discuss this incident. I have been informed the FAA is critical of my cockpit resource management during the flight.

[Report narrative contained no additional information.]

BE20 flight crew reported being unable to maintain heading or airspeed during a simulated engine failure in IMC while under FAA evaluation.

1793096

202103

1201-1800

SLC.Airport

UT

7500.0

Daylight

11000

TRACON S56

Personal

Small Aircraft

Part 91

IFR

Personal

Descent

Class B S56

Autopilot

X

Malfunctioning

Aircraft X; Facility S56.TRACON

Government

Approach

Air Traffic Control Fully Certified

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

Confusion; Workload

1793096

Aircraft X

Flight Deck

Personal

Single Pilot; Pilot Flying

Flight Crew Instrument; Flight Crew Commercial

Flight Crew Last 90 Days 25.4; Flight Crew Total 1382; Flight Crew Type 167

Workload; Confusion; Situational Awareness; Troubleshooting; Distraction

1793243.0

ATC Issue All Types; Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; 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; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Became Reoriented; Flight Crew Regained Aircraft Control; Flight Crew Returned To Clearance

Aircraft; Airspace Structure; Chart Or Publication; Human Factors; Procedure; Software and Automation

Software and Automation

Aircraft X was on an LDA Approach. I had not cleared them for the approach because I was trying to descend the aircraft for the Visual Approach. Just leaving 9;000 feet; the aircraft took a hard left turn. I keyed up and turned them to a 010 heading to which they stated they were having autopilot problems. The aircraft started descending below 8000 feet. I issued a Low Altitude alert. Shortly after; the aircraft took another hard left turn. I did not reissue a low altitude alert but restated altitude and heading with immediately. Because of this; I broke the aircraft following him off the approach and re-sequenced him. Aircraft X landed without further incident.I'm not sure what else to do in this situation. Pilots need to learn to fly without their autopilot. Everyone is way too reliant on technology and need to get back to the basics.

While transitioning from the RNAV arrival to the LDA Approach; my autopilot malfunctioned and caused the airplane to deviate from the approach. I was below the cloud bases and in VMC. I attempted to fly the airplane without the autopilot and regain the appropriate heading and altitude; while troubleshooting the autopilot issue. I was given a vector and an altitude by the approach controller and I did not maintain that altitude during the trouble shooting efforts. I went below 8;000 feet which is below the minimum vectoring altitude in that area.My fixation on troubleshooting the autopilot and not devoting full attention to flying the airplane caused this issue. The fact that I was in VMC further added to my lack of focus; as I was clearly able to see and avoid any terrain in the area. Focusing solely on the task of flying the airplane would have prevented this issue from occurring.

GA pilot and TRACON Controller reported the pilot flying a LDA Approach to SLC airport deviated from their course and altitude and flew below the Minimum Vectoring Altitude.

1756786

202008

1201-1800

LGA.Tower

NY

4.0

1000.0

Daylight

Tower LGA

Air Carrier

Commercial Fixed Wing

2.0

Part 121

IFR

Passenger

FMS Or FMC

Final Approach

Class B LGA

Aircraft X

Flight Deck

Air Carrier

Pilot Flying; Captain

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

1756786

ATC Issue All Types

ATC Equipment / Nav Facility / Buildings; Procedure

ATC Equipment / Nav Facility / Buildings

On RNAV (Area Navigation) Visual 31 Approach at 1000'; LGA Tower reported a 'low altitude' alert on us even though we were on the correct VNAV (Vertical Navigation) and LNAV (Lateral Navigation) profile. I leveled off and both Pilots verified we had the correct altimeter setting and were at or above the VNAV profile. I was visual with the runway and showed we were high on the PAPI Precision Approach Path Indicator) as well. I corrected our vertical path back to the RNAVS and visual flight path and landed in the touchdown zone without further incident. After landing; LGA Tower confirmed they have been having erroneous 'low altitude alerts' with other flights in the same area. LGA should check their altitude alerting information to insure it is giving accurate data.

Air carrier flight crew reported receiving a low altitude warning from tower despite cockpit instruments showing that they were above the RNAV glidepath.

1646493

201905

0601-1200

ZLC.ARTCC

UT

35000.0

Daylight

Center ZLC

Air Carrier

B737 Undifferentiated or Other Model

2.0

Part 121

IFR

Passenger

Cruise

Class A ZLC

Aircraft X

Flight Deck

Air Carrier

Captain

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

Flight Crew Last 90 Days 209; Flight Crew Total 4984; Flight Crew Type 4984

1646493

Inflight Event / Encounter Other / Unknown

Person Flight Crew

In-flight

General None Reported / Taken

Procedure

When cruising near GAROT Intersection; we experienced a dual GPS failure and XPDR FAIL light. This appeared to be GPS jamming. Another aircraft behind us reported the same issue. Center stated that the GPS jamming was not due to commence for 90 more minutes. Unscheduled GPS jamming is a serious safety issue.

B737 Captain reported experiencing GPS jamming while in cruise flight.

1693264

201910

0601-1200

CMH.Tower

OH

1800.0

Tower CMH

Medium Transport

2.0

Part 91

IFR

Final Approach

Visual Approach

Class C CMH

Facility CMH.Tower

Government

Ground; Local

Air Traffic Control Fully Certified

Workload; Communication Breakdown

Party1 ATC; Party2 Flight Crew

1693264

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

Procedure; Staffing; ATC Equipment / Nav Facility / Buildings

Staffing

Aircraft X was on a visual approach to Runway 10R. After being cleared to land; the low altitude alert went off and the Local Controller issued a low altitude alert to the pilot; and the aircraft was observed at 1;800 feet MSL; about 5 miles southwest of the airport; and appeared to [be] flying eastbound; as if the aircraft mistook something else for the airport. In the vicinity where the aircraft was; the MVA is 2;700 feet; and there are antennas and building obstructions in the area. Being that far away from the airport; at such a low altitude (potentially only 100 feet above obstructions); the low altitude alert should have gone off in a much more timely manner. After the Local Controller issued the low altitude alert; the pilot climbed up several hundred feet; and corrected towards the airport and landed without incident. Due to our staffing shortage; we were forced to work with only two controllers in the tower; at the time. The Local Controller was also working Ground Control. If we would have had a Ground Controller; and if CIC wasn't forced to be combined with another position; this situation may have not occurred; due to controllers being able to dedicate more attention to specific aircraft. This low altitude may have been noticed before to low altitude alert went off. If the low altitude alert worked properly; the pilot may have gotten this alert sooner; thus avoiding such an extremely low; and unsafe altitude. The low altitude and conflict alerts do not seem to go off at proper times. I have filed a report previously on conflict alerts. The parameters of the MSAW alerts needs to be looked into; and possibly changed; to create a safer environment. Even more important; our staffing shortage could have contributed to something catastrophic; had this situation not resolved itself correctly. We continue to be overworked; and understaffed. This staffing crisis needs to be corrected.

Controller reported that workload and a system malfunction caused a delay in issuing a low altitude alert to an aircraft that had descended below the MVA.

1742275

202005

0.0

Air Carrier

B737-800

2.0

Part 121

N

Y

Unscheduled Maintenance

Inspection; Installation; Testing

Oil Cooler

X

Improperly Operated

Company

Air Carrier

Other / Unknown

1742275

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

Person Flight Crew

In-flight

Air Traffic Control Provided Assistance; Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; General Flight Cancelled / Delayed; General Maintenance Action

Aircraft; Procedure; Incorrect / Not Installed / Unavailable Part

Incorrect / Not Installed / Unavailable Part

Removing and replacing No. 2 engine fuel oil cooler; when reinstalling line that was not removed but loosened and moved out of way; did not inspect gasket or remove and replace gasket; sure I tightened all lines; leak checked at idle while running did not see any leaks.

B737-8 Technician reported not replacing a gasket on an oil line during an oil cooler replacement.

1195291

201408

0601-1200

ZZZ.Airport

US

4500.0

VMC

7

Daylight

25000

Center ZZZ

Personal

Cessna 210 Centurion / Turbo Centurion 210C; 210D

1.0

Part 91

None

Personal

Cruise

None

Class E ZZZ

Engine

Failed

Aircraft X

Flight Deck

Personal

Pilot Flying

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

Flight Crew Last 90 Days 100; Flight Crew Total 7000; Flight Crew Type 200

Workload; Situational Awareness; Time Pressure

1195291

Aircraft Equipment Problem Critical; Ground Event / Encounter Gear Up Landing; Ground Event / Encounter Ground Strike - Aircraft

Person Flight Crew

In-flight

Aircraft Aircraft Damaged; Flight Crew Diverted; Flight Crew Took Evasive Action; Flight Crew Landed in Emergency Condition; Flight Crew Inflight Shutdown; General Declared Emergency

Aircraft

Departed and set up cruise flight westbound. Planned profile was an aircraft familiarization flight for another pilot and then return to the departure airport. Approximately 30 minutes into the flight; I noticed a slight engine roughness. This lasted about 30 seconds. The roughness then grew to a noticeably rough-running engine and power decay. We had a divert airport in sight. I took the controls and began to prepare for landing but did not begin configuring. After a minute or so; the engine failed and the propeller did not windmill. I decided that we could not make the glide to the nearby airport and chose a paved road for landing. Flaps were extended normally but the landing gear failed to extend. My passenger operated the alternate extension hand pump for the gear. The main gear extended but the nose gear did not. I landed on the road and the airplane traveled approximately 400 FT on the main gear and nose. After egress; I contacted 911; the FSDO; and my insurance company. We pushed the airplane into an unused driveway so that the road was clear. The FAA did not visit the scene but accepted a report completed by the highway patrol.

A C-210 engine failed at 4;500 FT but the pilot was unable to glide to a divert airport as the passenger pumped only the main gear down. A safe off airport landing was completed with the nose gear retracted.

1224888

201412

0601-1200

ZDC.ARTCC

VA

VMC

Turbulence

Center ZDC

Air Carrier

EMB ERJ 170/175 ER/LR

2.0

Part 121

IFR

Passenger

Climb

SID NATL3

Class E ZDC

Autoflight System

X

Improperly Operated

Aircraft X

Flight Deck

Air Carrier

Captain; Pilot Not Flying

Flight Crew Air Transport Pilot (ATP)

1224888

Aircraft X

Flight Deck

Air Carrier

Pilot Not Flying; First Officer

Flight Crew Air Transport Pilot (ATP)

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

Party1 Flight Crew; Party2 Flight Crew

1224889.0

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

N

Person Air Traffic Control

In-flight

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

Human Factors

I was the PM. We departed Runway 1 out of DCA. Followed the 328 DCA radial. After about 10 minutes ATC gave us a 070 heading. After another 5 minutes they gave us direct SWANN. At some point we both remember getting a 90 heading from ATC. As we passed BROSS ATC told us to turn to a heading of 010 then asked if they left us on a heading. We said a couple of frequencies ago they gave us a 90 heading. Leading up to this event we received numerous heading; alt; and speed changes. Again we are not 100% sure of them giving us a 90 heading. Between getting the speed; alt; and heading changes; the only other thing I can think of is that when we received direct SWANN the PF never pressed the NAV button. A lot of times when given several instructions some pilots will spin the heading bug in the direction of the fix to get the turn started then maybe throw in the new altitude or speed. Bottom line we either missed pressing NAV or was given the 90 heading and ATC forgot that we were on it.

Departed KDCA via NATL3 departure; runway 1. Was issued a 010 heading and proceeded as instructed for about 25 nm. Next; was issued a right turn to heading 070 and proceeded for roughly 5nm. Afterwards; was issued 'Proceed direct SWANN'. I first turned the heading bug to a 090 heading to get us going towards SWANN. I properly selected the FMS to proceed direct SWANN; and confirmed with the Captain. I cannot recall at this point whether or not I pressed the 'NAV' button. At this point the aircraft was proceeding towards SWANN and along our flight plan route. Between SWANN and BROSS intersections; we were issued various commands to avoid traffic. I cannot recall exactly all the altitude; speed; and/or course changes that were issued. This is due to the fact that I was reviewing aircraft manuals on the iPad. Our position Was now due east of BROSS and off-course to OOD when Washington Center issued a 010 heading. At this point I spun the HDG knob to 010 and pressed the HDG button. It was then; the aircraft entered ROLL mode. I pressed the HDG button a second time and the aircraft entered HDG mode. At this point; both the captain and I were confused as to why the aircraft would first enter ROLL mode since we both thought we were engaged in LNAV mode. After a brief period of time; we we're cleared to 'Redirect OOD and proceed on course'. The entire flight thereafter proceeded without incident.Due to the fact that pressing HDG upon selecting 010 on the knob caused the aircraft to enter ROLL mode; it is logical to assume that the aircraft was in HDG to begin with. It is unsure if we were correctly in HDG mode from avoiding traffic; if we were supposed to be in NAV mode from the point of receiving direct SWANN.There are a few ways this episode could have been prevented. Firstly; upon confirming FMS inputs with the other flight crew member; not only should the flying pilot select the proper autopilot modes on the panel; but the pilot should verify on the PFD that the proper modes are being carried out. Secondly; due to the nature of the flight; the pilot flying should not be heads-down on the company iPad; despite reviewing company manuals for operation. This task isn't time-sensitive and thus could have been carried out in a low-stress environment such as while not performing flight duties or perhaps in cruise flight while proceeding on-course. Finally; having had a heightened situational awareness as to exactly where and how the aircraft was navigating could have eliminated all confusion on the matter.

A track deviation resulted when the flight crew of an ERJ-175 failed to monitor and insure intended auto-flight modes when departing DCA on the NATIONAL DEPARTURE.

1017829

201206

1201-1800

ZZZ.Airport

US

19.0

2000.0

10

Daylight

CLR

Personal

Beaver DHC-2

1.0

VFR

Personal

Cruise

None

Fuel Distribution System

X

Improperly Operated

Aircraft X

Flight Deck

Personal

Single Pilot

Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 20; Flight Crew Total 6000; Flight Crew Type 600

Human-Machine Interface; Situational Awareness

1017829

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

Person Flight Crew

In-flight

Flight Crew Landed in Emergency Condition

Aircraft; Human Factors

Ambiguous

When engine quit; I switched from empty tank to rear tank which was half full and it did not restart. I was over some wetlands and I made a landing there. There was no damage to the plane or anything else. I inadvertently allowed my Class 3 physical to expire and I am renewing it.

DHC2 pilot experiences engine failure at 2;000 FT when the tank suppling the engine is used up. After switching to the rear tank which is half full the engine does not restart and an engine out landing in wetlands ensues without damage.

1007581

201204

0601-1200

ZZZ.Airport

US

0.0

Fractional

Cessna Citation Undifferentiated or Other Model

2.0

Part 91

Parked

Aircraft X

Flight Deck

Fractional

Pilot Flying; Captain

Flight Crew Air Transport Pilot (ATP)

Fatigue; Time Pressure; Communication Breakdown

Party1 Flight Crew; Party2 Ground Personnel

1007581

Other Fatigue

Person Flight Crew

Other Over the period of a scheduled flight sequence

General Work Refused

Company Policy; Human Factors

Company Policy

On [Day 1]; we had a 1215 EDT show and eventually finished up our day with an owner flight. Our duty off time was 0056 EDT with a total duty day of 12 hours and 41 minutes. We had delayed transportation to the hotel and eventually entered rest at 0120 EDT on [Day 2]. I had been up since 0700 EDT on [Day 1] for a total awake time of 17 hours and 56 minutes at shutdown. While I felt fit to fly the night flight; I did consume a couple of cups of coffee during the evening to help with my attentiveness. Our brief for [Day 2] was for an 1138 EDT show; 3 legs and a planned duty day of 9 hours. Prior to our shut-down on [Day 1]; I notified the company that I felt the chances of accomplishing that brief were not good due to the fact that I was going to have a hard time getting to sleep immediately due to the caffeine I had in my system. I told them a ten hour turn after a late night arrival wasn't the safest plan they could come up with. They said they would notify Scheduling of my concerns and to 'do my best.' I eventually fell asleep around 0345-0400 EDT and woke up at 0845 EDT due to noise in the hotel hall. I tried to fall back asleep for another hour or so but was unable to do so. I knew I hadn't gotten adequate rest to safely accomplish my flight duties and I notified the company of that fact at 1138 EDT when I checked in for duty. I was placed back in rest at 1230 EDT with a show of 0700 EDT on [Day 3].10 hour turns are difficult enough to get adequate rest in the best of cases - i.e. when you know they are coming and you are on a normal wake/sleep schedule. We never know what our show times are going to be on Day 1 of a trip; so adequately preparing for a trip is almost impossible. Also; when flight operation requirements dictate deviating from normal wake/sleep cycles; increased rest and shorter duty times should be the norm. On [Day 1 and 2]; the company took the alternate path of planning long duty days with minimum turns from late night operations. The only safety mechanism left at that point was my crew calling in fatigued. Specific recommendations: 1) use available fatigue abatement software to force Scheduling into a safer operation. Build in constraints for duty time and rest periods based on normal wake/sleep cycles. 2) When crews advise that the planned rest/duty cycle doesn't look doable; require an immediate review of the situation by a flight operations supervisor to determine if this is the best available plan. Lip service of 'do your best' isn't adequate. 3) Give a greater heads up on planned duty times for Day 1. Getting a brief at 1800L the night prior doesn't allow any [necessary sleep/rest cycle] modifications to be made for early or late operations.

A C560XL Captain for a fractional operator addressed debilitating scheduling practices that force flight crew members to refuse flights due to fatigue or to accede to them and risk violation of regulations requiring they fly only when fit for duty.

1769519

202010

0601-1200

DAL.Airport

TX

0.0

Daylight

Tower DAL

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 Instrument; Flight Crew Multiengine

Confusion; Situational Awareness; Human-Machine Interface; Distraction

1769519

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

Person Air Traffic Control; Person Flight Crew

Taxi

Air Traffic Control Provided Assistance; Flight Crew Returned To Clearance

Airport; Environment - Non Weather Related

Airport

We landed 31R in DAL and exited runway at M5; Ground issued B to D to the gate. We made turn onto M. Ground caught the error and issued new clearance 'M B5 ramp'. There was an Operations vehicle on the frequency and Ground asked him to look at the signage at M/M5 intersection; Ground stated we were the fourth aircraft to make the same error and he didn't want to file a deviation if it was a signage issue. The Operations vehicle stated that there was a sign for M but it was on M5 as you leave the runway; if you didn't see it exiting the runway there is no indication of M versus B. I had my iPad on and it automatically changed to 10-9 on landing. We had originally briefed 31L; but it closed when we were in the descent.

Air carrier Captain reported taxiway incursion at DAL airport and cited signage issues as a contributing factor.

1724332

202002

1801-2400

ZZZ.Airport

US

0.0

VMC

Poor Lighting

Night

Air Carrier

B737-800

2.0

Part 121

IFR

Passenger

Parked

Class B ZZZ

Y

N

Scheduled Maintenance

Inspection

Drinkable/Waste Water Syst

X

Failed

Gate / Ramp / Line

Other Exterior

Contracted Service

Technician

Maintenance Airframe; Maintenance Powerplant

1724332

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

Person Maintenance

Aircraft In Service At Gate

General None Reported / Taken

Manuals; Company Policy; Aircraft; Procedure

Procedure

Aft drain mast was removed in ZZZ. Was reinspecting tape and realized no blanking plate had been installed. Tape was blown out from inside. Contacted engineering was told the blanking plate was not required because drain mast was going to reinstalled so that step from amm is not necessary. I do not believe that is the proper interpretation of the AMM.

Technician reported that proper procedure was not followed when a drain mast was repaired.

1246342

201503

0601-1200

RSW.Airport

FL

2000.0

Daylight

TRACON RSW

Small Transport; Low Wing; 2 Turbojet Eng

2.0

VFR

Descent

None

Class C RSW

Facility RSW.TRACON

Government

Approach

Air Traffic Control Fully Certified

Air Traffic Control Time Certified In Pos 1 (yrs) 1.8

1246342

ATC Issue All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Landing Without Clearance

Person Air Traffic Control

Human Factors; Procedure

Procedure

While working radar approach I pointed Aircraft X out to RSW tower so Aircraft X can descend into FMY airport. Aircraft X reported FMY airport insight. I cleared him for the visual approach into FMY. He cancelled his IFR and told him that the RSW tower is watching him fly through to his destination. I accomplished other approach duties such as strip management and Class C service. RSW tower called me and told me that the Aircraft X just landed on RSW runway 24 without clearance.Aside from asking the pilot if he's 'sure you have the correct airport insight' I'm not sure what else could be done.

A Fort Myers (RSW) Approach Controller reports of an aircraft going to land at one airport; but instead lands at another airport. This happens under the Approach Controller's jurisdiction.