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ASRS Database Report Set
Multi-Engine Turbojet Aircraft Upsets Incidents
Report Set Description .........................................A sampling of reports concerning turbojet uncommanded control surface movement and unusual aircraft attitudes.
Update Number ....................................................31.0
Date of Update .....................................................March 31, 2017
Number of Records in Report Set ........................50
Number of New Records in Report Set ................18Type of Records in Report Set.............................For each update, new records received at ASRS will
displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.
National Aeronautics and Space Administration
Ames Research Center Moffett Field, CA 94035-1000
TH: 262-7
MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data
SUBJECT: Data Derived from ASRS Reports
The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.
ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.
Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.
After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.
The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.
Linda J. Connell, Director NASA Aviation Safety Reporting System
CAVEAT REGARDING USE OF ASRS DATA
Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.
Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.
One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.
Report Synopses
ACN: 1413522 (1 of 50)
Synopsis CL30 pilot reported the aircraft rolled suddenly left and right exceeding 30 degrees of bank
after encountering wake turbulence on approach to MEM.
ACN: 1411822 (2 of 50)
Synopsis EMB-135LR First Officer reported diverting to an alternate after experiencing difficulty
controlling the aircraft when the stabilizer pitch trim failed in the nose down position.
ACN: 1411370 (3 of 50)
Synopsis EMB-175 crew reported rejecting the takeoff at 90 knots after experiencing an
uncommanded left yaw. Control was regained and after returning to the gate for a
maintenance inspection, the crew departed normally in the same aircraft.
ACN: 1408667 (4 of 50)
Synopsis CRJ-900 Captain reported returning to departure airport after experiencing inflight
catastrophic failure of the left engine.
ACN: 1408242 (5 of 50)
Synopsis G550 First Officer reported a wake turbulence encounter at 17,000 feet while ten miles in
trail of an A380 that resulted in a 20 to 30 degree roll and a loss of 200 feet.
ACN: 1406591 (6 of 50)
Synopsis Embraer Lineage 1000 flight crew reported the Captain was having difficulty with pitch
control after takeoff. Control was reestablished using the F/O's pitch trim switch. After
returning to the departure airport it was discovered the Captain's pitch trim switch was
installed upside down.
ACN: 1403525 (7 of 50)
Synopsis B737-700 flight crew reported they descended below the glide slope on approach to MROC
airport, runway slope was cited as contributing to the optical illusion.
ACN: 1398994 (8 of 50)
Synopsis EMB145 flight crew experienced a SPOILER FAIL message with a SPLRS OPN inscription on
the EICAS on downwind. QRH procedures were followed and at some point during the
procedure the spoilers were noted to be down. The approach was accomplished using QRH
flap setting and approach speed for the anomaly to a successful landing.
ACN: 1396133 (9 of 50)
Synopsis B767-300ER flight crew reported the aircraft started to roll when the First Officer released
the brakes at the gate. The Captain, who had left the cockpit, thought the chocks were in
place and told the First Officer to release the brakes.
ACN: 1394863 (10 of 50)
Synopsis McDonnell Douglas Trijet Captain reported Number Three engine failure in cruise at FL350.
Flight diverted to a suitable field that was at an appropriate distance and directly ahead.
ACN: 1393496 (11 of 50)
Synopsis EMB145 flight crew reported they experienced multiple failures due to a faulty pressure
switch.
ACN: 1393474 (12 of 50)
Synopsis B747 pilots and flight attendants reported their perspective of an engine failure climbing
through FL230. Flight returned to the departure airport.
ACN: 1392802 (13 of 50)
Synopsis A319 Captain reported that during pushback, the tug driver called for brakes set rather
than breakaway when the tow bar became disconnected.
ACN: 1391224 (14 of 50)
Synopsis BE-400XP flight crew reported returning to the departure airport due to a roll trim
runaway.
ACN: 1391073 (15 of 50)
Synopsis
Falcon 2000 Captain reported an uncommanded 60 degree roll resulted from a wake
turbulence encounter descending through 14,000 feet on arrival into IAD despite being 16
miles in trail of a B777.
ACN: 1390685 (16 of 50)
Synopsis CRJ-900 flight crew reported the aircraft entered an uncommanded 45-degree bank after
encountering wake turbulence in trail of an A319 departing PHX.
ACN: 1390662 (17 of 50)
Synopsis EMB-145 Captain reported a possible pitch trim failure or runway trim during rotation with
the First Officer flying. Flight returns to the departure airport.
ACN: 1383903 (18 of 50)
Synopsis Lear 31A Captain reported a wingtip strike occurred on landing when roll authority was
compromised in the landing flare perhaps from ice accumulation on the wing.
ACN: 1370694 (19 of 50)
Synopsis An air taxi Captain reported receiving confusing taxi instructions to a different runway than
originally issued. Once airborne the aircraft was issued headings to an airway not
contained in their flight plan.
ACN: 1370332 (20 of 50)
Synopsis CRJ-900 Captain reported encountering windshear on takeoff from TYS with no windshear
warning provided.
ACN: 1365938 (21 of 50)
Synopsis EMB-145 First Officer reported a failure of the aircraft's pitch trim system during climbout.
All appropriate abnormal checklists were accomplished and the crew returned to the
departure airport, where an uneventful landing was accomplished.
ACN: 1365880 (22 of 50)
Synopsis
B757 First Officer reported encountering wake turbulence in 9-mile trail of a B787 on
descent.
ACN: 1362047 (23 of 50)
Synopsis B737-800 First Officer reported the aircraft yawed to the right at FL380 with Autopilot B
engaged. Substituting Autopilot A solved the problem.
ACN: 1359975 (24 of 50)
Synopsis B737 flight crew reported a split flap indication (25 and 30 degrees) with no rolling
tendency and no flap asymmetry indication. A go-around was initiated and the flap lever
was moved to 15 and the flaps both moved to 15. QRH procedures were accomplished and
a flaps 15 landing ensued.
ACN: 1359365 (25 of 50)
Synopsis A320 Captain experienced electrical anomalies during climb to FL350 which resulted in the
intermittent blanking of his PFD, ND and the upper ECAM display. With low ceilings at their
destination, the crew elects to return to their departure airport. The First Officer's displays
remain normal and he becomes the pilot flying for the approach and landing.
ACN: 1359125 (26 of 50)
Synopsis HS125 flight crew on a ferry flight reported experiencing flight anomalies created by an
unfastened panel on the engine pylon.
ACN: 1358171 (27 of 50)
Synopsis B737-800 flight crew reported rejecting the takeoff when the Captain's side window
opened.
ACN: 1357579 (28 of 50)
Synopsis A330 First Officer reported the flight crew chose to divert to an alternate airport after
noticing abnormal uncommanded aileron movement.
ACN: 1357484 (29 of 50)
Synopsis
B737 Captain reported encountering severe mountain wave in the vicinity of PUB that
resulted in speed and altitude excursions.
ACN: 1348361 (30 of 50)
Synopsis MD-80 Captain reported an overspeed in climb that he felt was related to a recent change
in procedure that calls for a high speed climbout.
ACN: 1348155 (31 of 50)
Synopsis A regional jet flight crew reported experiencing a minimum fuel condition due to ongoing
delays at the destination airport, which were attributed to multiple runway changes. They
also cited their company's fuel policy as a contributing factor to their fuel situation.
ACN: 1338459 (32 of 50)
Synopsis B737 Captain reported his aircraft rolled right and descended after encountering wake
turbulence in trail of a B777 at FL340.
ACN: 1336081 (33 of 50)
Synopsis Air carrier First Officer reported an uncommanded roll shortly after takeoff due to the
exhaust stream from a parked aircraft with engines running pointed toward the departure
runway.
ACN: 1328335 (34 of 50)
Synopsis EA50 pilot reported deviating from his cleared track departing FFZ when he experienced
FMS issues.
ACN: 1327278 (35 of 50)
Synopsis Air carrier flight crew reported being distracted during takeoff roll by a bird which emerged
from inside the cockpit. Aircraft control was maintained at all times and the bird
subsequently disappeared for the remainder of the flight.
ACN: 1324001 (36 of 50)
Synopsis
B757 Captain reported experiencing an uncommanded 45 degree bank angle at FL370 that
the reporter felt was related to jet stream activity.
ACN: 1321647 (37 of 50)
Synopsis EMB-145LR Captain reported the aircraft swerved suddenly during the takeoff roll possibly
due to wake turbulence from a landing aircraft on an adjacent runway.
ACN: 1317768 (38 of 50)
Synopsis A B757 flight crew experienced a dual generator failure during the takeoff roll and rejected
the takeoff.
ACN: 1317459 (39 of 50)
Synopsis B737-700 flight crew reported experiencing an uncommanded roll during flap extension on
approach. Flight landed with flaps set to position 5.
ACN: 1317203 (40 of 50)
Synopsis B757 First Officer reported a track excursion while on autoflight for unknown reasons.
ACN: 1316669 (41 of 50)
Synopsis The B737 crew experienced an autopilot and autothrottle disconnect at glideslope
intercept, which led to an unstable approach. The Captain elected to land.
ACN: 1313853 (42 of 50)
Synopsis B777 flight crew reported two flight attendants were injured when they encountered
probable wake turbulence at FL280 from a crossing aircraft at FL300.
ACN: 1312744 (43 of 50)
Synopsis Air Cargo Captain reported speed and track deviations related to fatigue issues.
ACN: 1311216 (44 of 50)
Synopsis
G-V Captain reported a wake turbulence encounter at FL320 that resulted in an
uncommanded 40 degree bank.
ACN: 1306332 (45 of 50)
Synopsis B757-200 flight crew reported diverting to a nearby alternate when they experienced
violent nearly uncontrollable rolls in climb at FL270 from a malfunctioning yaw damper.
ACN: 1305550 (46 of 50)
Synopsis A CRJ-700 crew experienced an uncommanded rudder input at cruise and diverted as per
the QRH. A Contract Mechanic and Company Maintenance Control diagnosed the system
and concluded an autopilot fault. However, this autopilot has no rudder input.
ACN: 1304387 (47 of 50)
Synopsis BAE125-850XP First Officer reported possible flight control icing, which led to an altitude
excursion at FL400.
ACN: 1302352 (48 of 50)
Synopsis CRJ-700 flight crew reported they deviated from cleared departure track out of LGA when
they were distracted at a critical time.
ACN: 1300945 (49 of 50)
Synopsis B767-300 flight crew experiences a sudden engine failure at 700 feet AGL after takeoff.
The engine is shut down and the flight returns to the departure airport for an overweight
landing. ARFF reports fluid leaking from the shut down engine and three of the four tires
on that truck deflate due to temperature.
ACN: 1299693 (50 of 50)
Synopsis A First Officer and Check Pilot reported a sudden, unexplained shutdown of the right
engine on a CRJ-700 aircraft during the landing rollout on a training flight. The Check Pilot
noted he never saw the FO pull the right engine shut-off trigger and only observed the
First Officer's hand on top of the power levers.
Report Narratives
ACN: 1413522 (1 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : MEM.Airport
State Reference : TN
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Turbulence
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : M03
Make Model Name : Challenger 300
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 18L
Flight Phase : Initial Approach
Airspace.Class B : MEM
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : M03
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Flight Phase : Final Approach
Airspace.Class B : MEM
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1413522
Human Factors : Situational Awareness
Analyst Callback : Attempted
Events
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Detector.Person : Flight Crew
Were Passengers Involved In Event : Y
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
We were on the Runway 18L localizer north of REISE intersection at 3000 ft and cleared
for the ILS RW 18L approach. We were configured with flaps 10, gear up, and flying
approximately 180 KIAS in IMC with rain and light to moderate turbulence. Wind was out
of the southwest at 50-60 knots at 3000 ft. Autopilot was engaged. The airplane suddenly
rolled right, then left exceeding 30 degrees of bank each way. The autopilot remained
engaged, and came back to wings level. About 3 seconds later, it happened again with
high roll rates and bank angles nearing 45 deg. I disconnected the autopilot and initiated a
climb out of wake turbulence. We were able to re-establish and fly the approach to landing
without further incident. We reported it to ATC and asked ATC what type of plane we were
following. They said we were #1 for 18L, but there was traffic for the parallel runways.
ATC was busy, so we didn't query any further. Our 2 passengers were pretty shaken up
about it, but we calmed them the best we could. I contacted MEM Approach Control by
telephone and reported it to him. He said they would review the tapes.
Synopsis
CL30 pilot reported the aircraft rolled suddenly left and right exceeding 30 degrees of bank
after encountering wake turbulence on approach to MEM.
ACN: 1411822 (2 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 135 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZZZ
Component
Aircraft Component : Horizontal Stabilizer Trim
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1411822
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
The Captain and I were cleared to "Descend Via" the Arrival and the plane suddenly rolled
to the right at a very rapid rate and pitched down as well. I immediately pressed the
"quick disconnect" button and held it. The Captain said, "That's just wake" and then I told
him it put us in a nose low trimmed attitude. The plane was in a Nose Down trim and
maintaining altitude was not possible and we continued to descend. The Captain alerted
ATC that we were still descending and wouldn't be able to make the altitude gates. The
Master Warning messages for both the main and backup trim were present. The Captain
ran the QRH while I continued to fly the plane. After the reset was unsuccessful we
[advised ATC] and asked to get direct to nearest airport and they gave us a vector [to the
alternate airport] for the ILS. We set up the approach and briefed it accordingly. My arms
and thumb were worn out and fatigued so the Captain relieved me and continued the
approach to landing via an ILS in IMC.
The training I received in initial was crucial for the happy outcome in this event. I would
encourage the training department in recurrent to give this problem without pre-briefing it
so that it gets ingrained how quick and dangerous it is.
Synopsis
EMB-135LR First Officer reported diverting to an alternate after experiencing difficulty
controlling the aircraft when the stabilizer pitch trim failed in the nose down position.
ACN: 1411370 (3 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 170/175 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1411370
Human Factors : Workload
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Troubleshooting
Analyst Callback : Completed
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1411375
Human Factors : Workload
Human Factors : Time Pressure
Human Factors : Situational Awareness
Human Factors : Troubleshooting
Analyst Callback : Attempted
Events
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : Taxi
Result.General : Maintenance Action
Result.General : Release Refused / Aircraft Not Accepted
Result.Flight Crew : Rejected Takeoff
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Returned To Gate
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
On the takeoff roll as we passed 90 knots we experienced a momentary loss of control, the
airplane pulled hard to the left. I had to apply a lot of right rudder in order to keep the
airplane on the runway.
As I was fighting to keep the airplane on the runway I called for the abort. The abort was
executed in accordance with Aircraft Operating Manual (AOM). We pulled off the runway
and asked City Operations to inspect our tires, my first thought was that we had blown a
tire. After getting our tires inspected and verifying brake temperature I called our
dispatcher and spoke with our Chief Pilot in accordance with FOM, we then coordinated a
gate return. I spoke with maintenance and did the required logbook entry.
Callback: 1
The reporter stated that station maintenance inspected the aircraft, but found no
anomalies. The reporter suspected that the aircraft may have hydroplaned on the wet
runway and been affected by a large aircraft landing on the parallel runway. They did
depart later with no problems.
Narrative: 2
Passing 90 KIAS on the takeoff roll, the aircraft experienced an uncommanded left yaw.
The PIC reacted with right rudder, but felt this constituted loss of aircraft control and
aborted the take off in accordance with Aircraft Operating Manual (AOM). We exited the
runway and asked City Operations for an external inspection of the aircraft. City
Operations reported that they did not observe any damage or abnormalities with the
aircraft. After coordinating with Operations, Dispatch, and the Chief Pilot, we returned to
the gate in accordance with FOM.
Synopsis
EMB-175 crew reported rejecting the takeoff at 90 knots after experiencing an
uncommanded left yaw. Control was regained and after returning to the gate for a
maintenance inspection, the crew departed normally in the same aircraft.
ACN: 1408667 (4 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 17000
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 900 (CRJ900)
Mission : Passenger
Flight Phase : Climb
Airspace.Class E : ZZZ
Component
Aircraft Component : Turbine Engine
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1408667
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Were Passengers Involved In Event : Y
When Detected : In-flight
Result.Flight Crew : Inflight Shutdown
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Landed As Precaution
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
At show time, the crew shows to a cold soaked, dark airplane. Neither electrical power, nor
cabin heated air were connected to the airframe. The temperature outside was minus two
degrees celsius, below freezing. The cabin and cockpit seemed in total chaos as switches
and items seemed out of place, order and positions. In short, the airplane was not ready
to be presented to the crew.
In the cockpit we found several switches out of position, but running through procedures
and checklists, it was all quickly found and put back to proper positions, places, and order.
Boarding started at an appropriate time and aside from a slightly chilly cabin, we would
have been out of the gate on time if it wasn't due to the jet-bridge breaking on us. After
departure from the gate, it was all normal.
All appropriate checklists completed, and passing 17,000ft, a loud bang was heard from
the rear of the airplane. It was both, felt and heard in the cockpit. A continuous vibration
followed and propagated through the entire airframe until the engine was secured. All
engine indications where normal prior to this event. As the event occurred, we could
confirm both by feel and engine indications that we had suffered a catastrophic engine
failure. The left engine gauges confirmed a sudden N1 and N2 drop to minimum
performance, further solidified by a left yaw motion. The ITT and Fan Vibration gauges
also confirmed engine failure as they quickly moved towards and beyond their respective
red lines.
After confirming the nature of the event as a Catastrophic Left Engine Failure, I decided to
bring the airplane immediately back to [departure airport] for landing. In what seemed like
a matter of 2 minutes, I passed the radios to First Officer (FO) with instructions to take us
back, I communicated [the issue] to ATC, yielded control of the airplane to FO, and talked
to [the] Flight Attendants (FA) about our situation and intentions. After communicating to
my immediate crew, I proceeded to address the passengers and alert the rest of our
ground crew about the situation commencing with Dispatch via ACARS.
Having freed myself from as many duties as possible, I followed procedure with the
Emergency Checklist Card, Severe Engine Damage (In Flight), followed as directed by the
QRH In-Flight Engine Shutdown, and later the Single Engine Approach and Landing
checklists. All emergency and non-normal checklists completed, I followed up with FO,
then with [the] FA's and the passengers.
After communicating with everyone for a second time, I proceeded with all normal
checklists and procedures. Upon conclusion, we were already on final approach at the
same runway we took off from. We landed normally with flaps at 20 Degrees, as per non-
normal procedures. Then we executed a gradual deceleration and stop, exiting near the far
end of the runway towards the terminal. After exiting the runway I communicated with the
FAs, then the passengers, then back to FO who I left communicating with ATC, and
Operations. From here we taxied uneventfully back to the same departure gate and
deplaned the passengers.
In conclusion, all pertinent checklists were completed in a timely fashion as per
procedures. All crew members, including ground crew members and personnel were
briefed, debriefed and communicated. We successfully and safely landed with no evident
crew induced damage to the airframe, or injury to passengers.
Captain decisions and crew action results:
One overweight landing at 76,100 pounds.
One overheated brake condition:
Left Main Outboard gauge white at 07
Left Main Inboard gauge white at 06
Right Main both gauges green
A safe return of all passengers uninjured to the gate.
A safe return of the airframe to an outstation without any evident damage induced by the
crew.
Synopsis
CRJ-900 Captain reported returning to departure airport after experiencing inflight
catastrophic failure of the left engine.
ACN: 1408242 (5 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : IAD.Airport
State Reference : DC
Altitude.MSL.Single Value : 17000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDC
Aircraft Operator : Government
Make Model Name : Gulfstream V / G500 / G550
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Route In Use.STAR : HYPER7
Airspace.Class E : ZDC
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Carrier
Make Model Name : A380
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 129
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Route In Use.STAR : HYPER7
Airspace.Class E : ZDC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Government
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 6200
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 300
ASRS Report Number.Accession Number : 1408242
Analyst Callback : Completed
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Regained Aircraft Control
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
[We were] level at 17,000 feet in cruise flight near LRP at 300 KIAS. ATC informed the
crew that they were ten miles in trail of an A380. A few minutes earlier, the G550 had
been cruising at 320 KIAS when ATC ordered a speed reduction to 300 KIAS to maintain
required separation with [the A380]. Crew complied with the speed reduction. [The A380]
was visible in the distance out of the cockpit windows. The G550 suddenly entered a 20 to
30 degree uncommanded right roll at 10-20 degrees per second. The left seat PF copilot
disengaged the autopilot and corrected roll using left roll input and turned on the seatbelt
sign. The G550 returned to level flight with about 200 feet of altitude loss. The Captain, as
right seat PM, then alerted ATC to the wake turbulence encounter and requested a turn
and descent. ATC then provided a vector to the right [to] take the G550 out of a trailing
position between [the A380]. No significant G forces were experienced during the upset or
recovery and there were no injuries or damage. Management was notified upon landing.
Synopsis
G550 First Officer reported a wake turbulence encounter at 17,000 feet while ten miles in
trail of an A380 that resulted in a 20 to 30 degree roll and a loss of 200 feet.
ACN: 1406591 (6 of 50)
Time / Day
Date : 201611
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 1200
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Corporate
Make Model Name : Embraer Lineage 1000 (EMB190BJ)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Climb
Route In Use : Vectors
Route In Use : Oceanic
Airspace.Class D : ZZZ
Component
Aircraft Component : Elevator Trim System
Aircraft Reference : X
Problem : Improperly Operated
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 6535
Experience.Flight Crew.Last 90 Days : 95
Experience.Flight Crew.Type : 4152
ASRS Report Number.Accession Number : 1406591
Human Factors : Workload
Human Factors : Troubleshooting
Human Factors : Confusion
Human Factors : Distraction
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 16200
Experience.Flight Crew.Last 90 Days : 59
Experience.Flight Crew.Type : 2840
ASRS Report Number.Accession Number : 1408179
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Maintenance
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Returned To Departure Airport
Assessments
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
Took off and after about 1200 feet noticed that it was difficult to lower the nose of the
aircraft. By 1600 feet started making a left turn to heading 300 and realized that
something was wrong with the trim of the aircraft. Asked the right seat pilot to help me
force the control wheel down to keep the airspeed. Looked at the pitch trim indicator and
saw it almost full nose up. Thought to myself we were having a pitch trim runaway. Called
pitch trim runaway memory item. First Officer went for the procedure but went back to the
control wheel to help push nose down to avoid stall. First chance I had I performed the
memory item for pitch trim runaway and followed with the remainder of the procedure.
Called out loud "pitch trim runaway", FO went for the QRH in the center console and went
back to help push the control wheel down. FO places the QRH on the top of glare shield.
[Advised ATC] and asked for time to troubleshoot. After pitch trim runaway procedure
realized that the problem remained, airplane is still trimmed full nose up and slow in
airspeed. By then I left my controls to try the procedure again. I let go of the control
wheels, reset the system, called briefly the FA to prepare for landing when FO realizes that
he can now control the airplane and the trim system is working. After that FO says that he
has control of the airplane and that the trim system was working at that time.
Got control of the aircraft at about 7500 feet. Headed back to the departure airport and
landed. Maintenance from Embraer and our company went to check the aircraft and
detected that the Captain pitch control switches were found installed wrong. Switches were
commanding nose up and down inverted. Luckily after we got control of the aircraft with
the autopilot, I took control of the airplane to land and never touched the pitch trim
switches again all the way to the runway. Had I touched those switches again problem
would come back in worst scenario and closer to the ground.
Narrative: 2
We were cleared to takeoff, fly runway heading to 9000 ft, and were given a left turn to
300 degrees. Due to the departure procedure we waited until 1600 ft to make our turn.
The pilot flying starting a left turn to 300 degrees during the climb and noticed the trim
was causing the aircraft to pitch up, and as he climbed higher it was climbing at a higher
pitch and it was getting uncontrollable and slow on airspeed. He requested help from me
to pitch the aircraft down. I assisted him and tried trimming down but my trim switch
must have been momentarily blocked from his trim switch, as it has priority over my
switch. After he ran the procedure, my switch still was not working, then suddenly my
switch freed up and I started trimming down and I got control of the aircraft and leveled
off. We [advised ATC] and returned back to the [departure airport] for the ILS approach.
The PF then requested the controls back and we landed safely.
The aircraft was just in for a maintenance inspection and the trim switch on the left side
was put in upside down, which caused reverse command from what the switch would
normally do. The factory mechanic found this out and also mentioned that some type of
block was being installed to prevent this, but it could still be forced in upside down.
Synopsis
Embraer Lineage 1000 flight crew reported the Captain was having difficulty with pitch
control after takeoff. Control was reestablished using the F/O's pitch trim switch. After
returning to the departure airport it was discovered the Captain's pitch trim switch was
installed upside down.
ACN: 1403525 (7 of 50)
Time / Day
Date : 201611
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : MROC.Airport
State Reference : FO
Altitude.MSL.Single Value : 4900
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : MROC
Aircraft Operator : Air Carrier
Make Model Name : B737-700
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 7
Flight Phase : Initial Approach
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 130
ASRS Report Number.Accession Number : 1403525
Human Factors : Situational Awareness
Human Factors : Confusion
Human Factors : Physiological - Other
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Experience.Flight Crew.Last 90 Days : 166
ASRS Report Number.Accession Number : 1403509
Human Factors : Situational Awareness
Human Factors : Confusion
Human Factors : Physiological - Other
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Aircraft
Primary Problem : Human Factors
Narrative: 1
After an uneventful flight we were on final approach on the ILS Runway 7 (I was the Pilot
Flying). While on glidepath and on localizer at approximately 4900 ft we encountered
moderate turbulence and at the same time the autopilot suddenly disconnected, the FMA
(Flight Mode Annunciator) indicated CWS (Control Wheel Steering) for both pitch and roll,
and both Flight Directors were lost. We were at this point in visual conditions with the
runway in sight so I elected to continue the approach visually.
A few seconds later we heard the "Glideslope" aural warning and realized we were indeed
below the glidepath. Looking out the window, we both commented that even though we
had the glideslope warning, we appeared to be high, so we continued the visual approach
using visual cues and landed normally on the touchdown zone.
After the flight and upon further review of all available information, I found a note on the
MROC route brief that warned of the potential for optical illusion due to upward slope on
Runway 7. At that point I realized that due to the compounding factors (moderate
turbulence, sudden loss of A/P, loss of Flight Director, etc.) we might have been below
glidepath for a portion of the approach.
I have been to [MROC] several times before (although never at night) and I can say that
the illusion is much more pronounced at night time.
In my opinion, the note should be added to the airport information page under the arrival
notes.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737-700 flight crew reported they descended below the glide slope on approach to MROC
airport, runway slope was cited as contributing to the optical illusion.
ACN: 1398994 (8 of 50)
Time / Day
Date : 201610
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 145 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Airspace.Class C : ZZZ
Component
Aircraft Component : Spoiler System
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1398994
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1399281
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Flight Crew : Landed in Emergency Condition
Result.Aircraft : Equipment Problem Dissipated
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
After being cleared for a visual approach I turned the base leg, called for flaps 9, and after
leveling at 3000, set the altitude for the first approach fix. Decelerating through 200 and
slightly above glideslope, I selected approach mode and pressed the Quick Disconnect
Button to hand-fly the approach.
At that time, the caution message SPOILER FAIL displayed and the Spoiler indication
showed open with the lever closed. I added power to somewhere in the area of 78% N1
and we were maintaining altitude and airspeed at 200 KIAS. I told the Captain (CA) that I
was going to maintain 3000 feet and then I kept the plane straight and level to gauge any
new handling characteristics. The CA took the controls and informed the tower then flew a
ground track over the runway with the intention of making a pattern to land.
After running the QRH procedure, we flew a pattern planning to land visually with gear
down and flaps 22 per the QRH. The Spoiler indication was open for some time. While
maneuvering, the CA pointed out that the spoilers showed closed, and I told him I would
be scanning them in the event they deployed again. Our pitch/power settings for landing
were normal for that configuration. The flight concluded uneventfully.
I believe that the spoilers did actually deploy without command on the initial indication. I
believe that they slowly "bled" back down during the second visual pattern as a result of
the QRH procedure. CA feels he wasn't certain how much they actually deployed because
at no point in his pattern did he feel an acceleration that would be typical of the spoilers
closing in normal operation. I agree there was not a surge like he mentioned, but I think
they clearly deployed at least partially due to the power settings I used to maintain
equilibrium after the initial indication.
The spoilers deployed independently of command during the approach phase of flight. This
worked well as a crew because I had recently reviewed this QRH procedure in training and
felt very proficient at it. I have always remembered this one because of the CB collars that
are already in place, and I had imagined this condition would be more dire than it was. I
assumed it was a bigger deal than it was and I think that was the best position for us to be
in.
In this situation we did not have a fuel issue in clear weather, next to the runway, with
other airports nearby. I can think of a couple flights this last summer while maneuvering
around thunderstorms that, if this same deployment had unexpectedly happened,
continuing to an unexpected alternate with only the planned 1701 LBS of reserve and
spoilers stuck open would have been a really undesirable situation to have flight planned
our way into. I will be much more aware of the potential for an unexpected higher fuel
burn to an alternate based on something like this.
Narrative: 2
On downwind, 3000 feet and 200 KIAS, received SPOILER FAIL message with a SPLRS
OPN inscription on the EICAS display. The CA, Pilot Monitoring (PM), took control of the
aircraft, becoming Pilot Flying (PF). The CA (PF) directed the First Officer (PM) to perform
the UNCOMMANDED SPOILER DEPLOYMENT IN FLIGHT checklist. Simultaneously the CA
informed Tower, and advised them we would join final at present altitude (3,000 feet) and
required a box pattern to perform the necessary checklists. At the beginning of the QRH
arrival checklist it directs the flight crew to apply 1.35x factor (spoiler open) to Flaps 45
landing data, and configure for a Flaps 22 landing. Runway (light winds) had sufficient
length for this emergency. The SPLRS inscription later changed to CLD, which only
requires to apply a 1.27x factor, but the CA elected to keep the original more conservative
factor of 1.35 in place. The PF landed the aircraft normally.
Airport is in a "valley" aligned with, with ridges on both sides and with rising terrain into
the approach for landing west. Weather was dusk. Flight control problems are by nature
unpredictable in their effect and thus their severity, as opposed to a generator which
either works or it doesn't.
Should teach our crews a rule of thumb of the possible QRH landing data penalty factors.
Most are under 2x, except Dual Hydraulic Failure (2.86). Both times I had to apply these
factors, my knowledge of these rules of thumb provided a significant time cushion and
allowed an initial determination that the destination runway was still sufficient in length
despite the emergency condition. Need to periodically emphasize that the QRH is applied
to FLAPS 45 settings in Aerodata, NOT Flaps 22. Some FOs will select Flaps 22 AND apply
the QRH penalty, i.e. a double penalty.
Synopsis
EMB145 flight crew experienced a SPOILER FAIL message with a SPLRS OPN inscription on
the EICAS on downwind. QRH procedures were followed and at some point during the
procedure the spoilers were noted to be down. The approach was accomplished using QRH
flap setting and approach speed for the anomaly to a successful landing.
ACN: 1396133 (9 of 50)
Time / Day
Date : 201610
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZZZZ.Airport
State Reference : FO
Altitude.AGL.Single Value : 0
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B767-300 and 300 ER
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Parked
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1396133
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1396132
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
Detector.Person : Flight Attendant
When Detected : Aircraft In Service At Gate
Result.General : Physical Injury / Incapacitation
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
After arriving and completing the shutdown checklist I stepped out on the airstair to see if
the chocks were in. I thought the chocks were installed and told the first officer to release
the brakes and the aircraft started to roll. The aircraft rolled about 6 feet, a flight
attendant and myself screamed to the first officer to set the brakes and he did. No one
was hurt and no damage was done to the aircraft.
Narrative: 2
Shortly after completing the shutdown checklist the Captain came back in the cockpit and
told me to release the brakes. I did so and went heads down to fill out the logbook. A
matter of seconds later I heard a commotion in the back and someone said "hit the
brakes". I looked up and saw that we were rolling backward. I immediately slid forward on
the seat and hit the brakes. It was rather abrupt and one of the flight attendants hurt his
back during the sudden stop. I checked with the purser afterward to ascertain if anyone
had been hurt. They said no one had. It wasn't until about an hour later that the Captain
and I learned about [the flight attendant] hurting his back. No damage to the aircraft.
I've seen many Captains verbally state "parking brake released (pause) we're not
moving". I think I will be adopting this down the road.
Synopsis
B767-300ER flight crew reported the aircraft started to roll when the First Officer released
the brakes at the gate. The Captain, who had left the cockpit, thought the chocks were in
place and told the First Officer to release the brakes.
ACN: 1394863 (10 of 50)
Time / Day
Date : 201610
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 35000
Environment
Flight Conditions : VMC
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Widebody, Low Wing, 3 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Cruise
Airspace.Class A : ZZZ
Component
Aircraft Component : Turbine Engine
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1394863
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
At FL350 we suddenly heard a muffled Boom, felt a momentary heavy vibration, and felt
the airplane yaw to the right. The number 3 engine began to immediately roll back. We
complied with the QRH procedures and landed at ZZZ airport which was directly in front of
our aircraft and on a perfect 3 to 1 aircraft descent ratio. The decision to go to ZZZ set us
up for an expeditious route/descent into a suitable airport while allowing us to manage our
airmanship and appropriate checklists.
Synopsis
McDonnell Douglas Trijet Captain reported Number Three engine failure in cruise at FL350.
Flight diverted to a suitable field that was at an appropriate distance and directly ahead.
ACN: 1393496 (11 of 50)
Time / Day
Date : 201610
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 23000
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 145 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Airspace.Class A : ZZZ
Component
Aircraft Component : Rudder
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1393496
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1393495
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
At approximately 23,000 feet, during the beginning of climb and in very light chop, we
received EICAS messages AUTOPILOT FAIL, YAW DAMPER FAIL and SPS/ICE SPEEDS (as
we had just entered very light icing conditions). We ran the AOM-1 abnormal procedure for
AUTOPILOT FAIL. As directed by the procedure, we informed ATC we were no longer RVSM
compliant and would need to be held below FL290.
After this, we received the EICAS message RUDDER SYS 1-2 INOP. We ran the RUDDER
SYS 1-2 INOP abnormal checklist, which led us to turn off RUDDER SYS 1 and 2. As we
continued the procedure it led us to turning off RUDDER SYS-1. When we turned off
RUDDER SYS-1 it caused an uncommanded yaw movement to the right. We then re-
selected RUDDER SYS-1 ON, and yaw movement went back to normal with RUDDER SYS-2
INOP message remaining. We diverted to and landed at the nearest suitable airport.
Normal landing was successfully completed, and all crew and passengers deplaned under
normal conditions. Per maintenance, a pressure switch failure occurred.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
EMB145 flight crew reported they experienced multiple failures due to a faulty pressure
switch.
ACN: 1393474 (12 of 50)
Time / Day
Date : 201610
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZZZZ.ARTCC
State Reference : FO
Altitude.MSL.Single Value : 23000
Environment
Flight Conditions : VMC
Aircraft
Reference : X
ATC / Advisory.Center : ZZZZ
Aircraft Operator : Air Carrier
Make Model Name : B747 Undifferentiated or Other Model
Crew Size.Number Of Crew : 3
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Climb
Component
Aircraft Component : Turbine Engine
Aircraft Reference : X
Problem : Failed
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 11228
Experience.Flight Crew.Last 90 Days : 125
Experience.Flight Crew.Type : 556
ASRS Report Number.Accession Number : 1393474
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Experience.Flight Crew.Total : 11594
Experience.Flight Crew.Last 90 Days : 200
Experience.Flight Crew.Type : 1015
ASRS Report Number.Accession Number : 1393879
Person : 3
Reference : 3
Location Of Person.Aircraft : X
Location In Aircraft : Galley
Cabin Activity : Service
Reporter Organization : Air Carrier
Function.Flight Attendant : Flight Attendant (On Duty)
Qualification.Flight Attendant : Current
Experience.Flight Attendant.Total : 27
ASRS Report Number.Accession Number : 1394549
Person : 4
Reference : 4
Location Of Person.Aircraft : X
Location In Aircraft : Galley
Cabin Activity : Service
Reporter Organization : Air Carrier
Experience.Flight Attendant.Total : 18
ASRS Report Number.Accession Number : 1394322
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Inflight Shutdown
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Climbing through FL230, the aircraft experienced moderate to severe vibrations followed
by an audible bang. The relief pilot announced "engine failure." I looked at the engine
instruments and noted the EGT in red indicating 700 degrees with minimal N1 and N2
rotation.
The captain compensated for the loss of thrust with coordinated rudder and aileron. The
captain then delegated crew duties and the relief pilot and I secured the engine via the
Engine Severe Damage Separation checklist in the QRH.
The captain handed the aircraft and ATC communications over to me, while he and the
relief pilot contacted dispatch, coordinated with flight attendants, and formulated a plan
for a return to a nearby airport.
After getting a briefing from dispatch, it was determined that ZZZZ was the nearest
suitable airport. We proceeded direct to ZZZZ. ATC allowed us to make a straight-in ILS
approach. A normal 3-engine approach and landing was made by the captain.
After exiting the runway, local ARFF crews checked for an engine and/or brake fire. There
were none.
Normal shutdown and securing procedures were preformed. Maintenance was notified of
the technical problem. The captain spoke with local authorities and the Chief Pilot.
Overall the engine problem was a non-event. I believe we handled the problem
professionally and in accordance with Company procedures. We debriefed and critiqued
our performance and decided we handled the engine failure like we practiced in the
simulator during training events.
Narrative: 2
[Report narrative contained no additional information.]
Narrative: 3
On our ferry flight we had the number 4 engine go out at 23,000 ft. I felt a jolt and right
after that the captain made an announcement for the mechanic to come to the cockpit.
After that he made another PA announcement for the purser to come to the cockpit. Our
purser got all the information from the captain that we had an engine failure and are
landing in 15 to 20 min and to be prepared. Purser called for a briefing and relayed the
message. I was at door 1R and made sure all carts were stowed, galley secured, and did
my silent review. We landed safe and disarmed our doors.
Narrative: 4
After our climb out, I do believe seatbelt sign was off, 10,000 was chimed by captain, our
purser and I, were in upper deck galley setting up trays for their meal service, when
suddenly we heard a loud noise, not a boom, but a thud type noise, and we almost lost
our footing, as aircraft lurched sideways to the left, we had to hold on to keep from falling,
we said that didn't feel like regular turbulence, but kept setting up trays, then captain
called for one of our mechanics, we had 2 mechanics and 2 ops guys on board, as is with
all charter flights, to come to the cockpit. They talked a bit, then FO came out to look at
number 4 engine, out many windows in upper deck, then back to cockpit. They said that
#4 seized up, called for the purser to come to cockpit, for all of us to get out our books
and plan for a possible evacuation. The purser went up and we were told that #4 was not
working, seized up and we were going back. One of our crew said that there was smoke
coming out of the engine, I did not see this, as I was nearest to cockpit. The captain was
flying aircraft at this time and being very busy, just said that we were not expecting an
evacuation at this time, but be prepared, we were given a direct line to land in ZZZZ.
When we landed we were sent to a remote area, following a follow me truck. We had a
beautiful landing, the captain had said we should be landing in about 15 minutes, and we
did. As to why this happened, I have no clue, mechanics inspect engines each time they
land and before departure, they maintain engines on all charter aircraft, they had no idea
as to what happened either. We were all very happy with the cockpit and how they
handled the situation.
Synopsis
B747 pilots and flight attendants reported their perspective of an engine failure climbing
through FL230. Flight returned to the departure airport.
ACN: 1392802 (13 of 50)
Time / Day
Date : 201610
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Ramp : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : A319
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 1148
Experience.Flight Crew.Last 90 Days : 300
Experience.Flight Crew.Type : 293
ASRS Report Number.Accession Number : 1392802
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Ground Personnel
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
When Detected : Pre-flight
Result.Flight Crew : Regained Aircraft Control
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
Airplane we were taking arrived at gate XA:25. Our flight was due out at XB:05. The
Pushback coordinator on the headset called ready for pushback around XB:03. I told him
standby. FO read the before push checklist and called ramp for clearance. Our clearance
was received and I released the brake and told coordinator "brakes released cleared to
push." He acknowledged. My head was down as I was watching the FO put in our final
weights. I looked up and we were slowly moving backward in what seemed like a nice
smooth push. All of a sudden I hear coordinator say "set the brake, set the brake." I found
it difficult to set the brake while we were being pushed back, so I hesitated for a second
until I saw the back part of the tug start to appear in my forward window and realized we
weren't being pushed at all. I stopped the airplane and set the parking brake. It was a
little bit of a jolt but luckily we weren't moving fast enough to injure anyone or tip the
airplane on its tail. There seemed to be some confusion among ramp personnel as to why
the tow bar came loose. I personally think when I released the brake that the tow bar
appeared to be connected but wasn't. Thus we just began to slowly roll back. If in fact it
did disconnect during the push, the tug probably only moved a foot or two forward. They
reconnected the tow bar properly, we started the pushback protocol over, and completed
it normally. I reminded the coordinator that it is imperative you use the term "breakaway"
and not "set the brakes" if that ever happens again. It was counterintuitive for me to "set
the brakes" while the airplane was in motion during what I thought was a normal
pushback.
Synopsis
A319 Captain reported that during pushback, the tug driver called for brakes set rather
than breakaway when the tow bar became disconnected.
ACN: 1391224 (14 of 50)
Time / Day
Date : 201609
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Make Model Name : Beechjet 400
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Flight Phase : Climb
Airspace.Class E : ZZZ
Component
Aircraft Component : Aileron Trim System
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1391224
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1391223
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
During climb out we had an uncommanded roll trim runaway. After completing all
necessary checklists we were unable to rectify the situation. We returned to our departure
airport and landed the aircraft uneventfully with a significant amount of roll control input
from the pilot.
Narrative: 2
During climb out the control yoke began to deflect to the side, I noticed the roll trim was
in a runaway condition. We executed memory items and checklist items and were unable
to fix the problem. We [advised ATC] and returned to the airport. During arrival the
Captain said he would execute the landing I transferred the controls & we landed
uneventfully.
Synopsis
BE-400XP flight crew reported returning to the departure airport due to a roll trim
runaway.
ACN: 1391073 (15 of 50)
Time / Day
Date : 201609
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 14000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 20
Light : Daylight
Ceiling.Single Value : 8000
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDC
ATC / Advisory.TRACON : PCT
Aircraft Operator : Corporate
Make Model Name : Falcon 2000
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Nav In Use : FMS Or FMC
Flight Phase : Descent
Route In Use.STAR : HYPER7
Airspace.Class E : ZDC
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : PCT
Aircraft Operator : Air Carrier
Make Model Name : B777 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Descent
Route In Use.STAR : HYPER7
Airspace.Class E : ZNY
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 9600
Experience.Flight Crew.Last 90 Days : 40
Experience.Flight Crew.Type : 510
ASRS Report Number.Accession Number : 1391073
Analyst Callback : Completed
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Regained Aircraft Control
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Procedure
Narrative: 1
Descending on HYPER7 arrival in VMC conditions, smooth air, and winds (at our altitude)
nearly nil. Just as [ZDC] called to assign hand-off to POTOMAC TRACON we were jolted by
wake turbulence. The airplane suddenly rolled 60 degrees to the right. SIC/PF
disconnected autopilot and stabilized the aircraft. As quickly as the encounter occurred, it
was over. ATC called to repeat the freq change. I replied, including report of wake
encounter. By the time I switched to POTOMAC they were calling us. I checked-in and
acknowledged the new descent clearance (to 10,000 ft). After investigating TCAS (in
BELOW mode to see aircraft at our altitude and below that might be on the arrival ahead
of us) I asked ATC to identify the type aircraft ahead of us (the only one I could see, now
over HYPER intersection). It was a B777, also flying the profile STAR. After communicating
our wake encounter, TRACON issued vectors to take us off the STAR and away from the
path of the proceeding aircraft. Minutes later the POTOMAC controller inquired about the
incident, flight conditions, aircraft damage, and whether anyone was hurt. That was good.
The heavy was nearly 16nm ahead of us. That seems to be plenty enough separation to
avoid a wake encounter. Even with winds aloft nearly zero, the standard rules regarding
descent and dissipation of wake did not keep us from getting violently tossed. I am not
aware of minimum separation requirements for enroute and arrival aircraft, but it was
insufficient for these conditions.
Callback: 1
Reporter had no additional comments.
Synopsis
Falcon 2000 Captain reported an uncommanded 60 degree roll resulted from a wake
turbulence encounter descending through 14,000 feet on arrival into IAD despite being 16
miles in trail of a B777.
ACN: 1390685 (16 of 50)
Time / Day
Date : 201609
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : PHX.Airport
State Reference : AZ
Altitude.AGL.Single Value : 800
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : PHX
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 900 (CRJ900)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Climb
Airspace.Class B : PHX
Aircraft : 2
Reference : Y
ATC / Advisory.Tower : PHX
Aircraft Operator : Air Carrier
Make Model Name : A319
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class B : PHX
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1390685
Analyst Callback : Completed
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1390689
Analyst Callback : Attempted
Events
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Regained Aircraft Control
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
Taking Runway 7L behind an A319 or similar size type, with traffic on a 5 mile final for
same runway. We were given a departure clearance as the Airbus was rotating on
departure. I discussed a 5-10 degree course heading to the right if needed. As we rotated
and started climbing, the FO kept the speed back (under 200 KIAS) as we were
approaching acceleration altitude still at 8 degrees flaps, we encountered an un-
commanded roll of approximately 45 degrees to the left. Disconnecting the autopilot, it
was a couple seconds before full control was regained. I advised PHX tower of our
deviation off course for wake turbulence. We resumed our departure course crossing near
(south) SPRKY intersection.
Towers use of visual separation does not always provide a good margin of safety on
departures.
Narrative: 2
Taking off on a normal flexing flaps 8 takeoff from 7L. I was pilot flying. Before we took off
an Airbus 319 was taking off 7L as we were given the command to line up and wait.
Shortly thereafter we were cleared for takeoff. On initial climbout I kept the speed under
200 kts to ensure a steeper angle of attack to out climb the Airbus' wake turbulence. We
had talked before about a right deviation if needed but both of us found the flight angle
acceptable. Around 800 feet we encountered a light jet wake turbulence and an
uncommanded left bank while the autopilot was engaged. Suddenly the aircraft banked
harder left. As we were passing through 30 degrees of left bank I clicked the autopilot off
to take manual control. I had full right deflection of the yoke as the plane passed through
45 degree bank. The plane was at 45 degrees plus angle for a few seconds until full control
was established. After this we made a right deviation to parallel the other jet's course and
continued the climb. We contacted ATC however received no response.
Not much you can do except lengthen the time between departures. However in this case
the separation was normal.
Synopsis
CRJ-900 flight crew reported the aircraft entered an uncommanded 45-degree bank after
encountering wake turbulence in trail of an A319 departing PHX.
ACN: 1390662 (17 of 50)
Time / Day
Date : 201609
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : IMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 145 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Component
Aircraft Component : Elevator Trim System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1390662
Human Factors : Confusion
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
Shortly after rotation on takeoff, the aural warning system sounded "trim, trim" with an
aural ding. No EICAS message was presented. The FO reported to me that he did not use
any trim, and I reported to him that I had not touched the controls. We continued to climb
out on the departure. I noticed the FO was struggling with the trim, pushing nose down
with a lot of effort. We received multiple heading changes and altitude changes. At the
same time I was trying to finish the takeoff checklist. My FO told me he had no trim
control, and that he had excessive nose up pressure. He asked me to try my trim, which I
did, and it had no effect. We then knew the main pitch trim system was malfunctioning.
We did not receive any messages on the EICAS, so I looked up the QRH section pertaining
to flight controls. My FO continued to struggle with the pressure. We both agreed that we
should get the aircraft back on the ground as soon as possible. I then tried to find the QRH
section that best pertained to our situation, but still unclear as to whether it was pitch trim
runaway, or pitch trim inoperation. I tried to follow that later, since my FO wasn't positive
it was runaway, but he thought that it might be. I tried to follow the pitch trim inop QRH,
but ran out of time to complete it. We were already being vectored onto approach, and I
had to get the NAV equipment set up, and get the landing information. I did TEST the
flight attendant, telling her of our situation, and that we were going back to land. We then
landed uneventfully, and taxied to the gate with no further situations. During the
approach, I assisted the FO with the backup trim at his request. This worked very well.
Synopsis
EMB-145 Captain reported a possible pitch trim failure or runway trim during rotation with
the First Officer flying. Flight returns to the departure airport.
ACN: 1383903 (18 of 50)
Time / Day
Date : 201608
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 5
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Icing
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 900
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Government
Make Model Name : Learjet 31
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Landing
Route In Use : Direct
Airspace.Class E : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Government
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 9600
Experience.Flight Crew.Last 90 Days : 72
Experience.Flight Crew.Type : 1700
ASRS Report Number.Accession Number : 1383903
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
The event occurred on a Part 91 flight to ZZZ. The event aircraft was a Learjet 31A.
Enroute altitude was FL400. Descent was initiated 90 NM from ZZZZZ intersection, the
initial approach fix for the RNAV (GPS) RWY XX approach to ZZZ. Descending through
FL180 I turned on the nacelle heaters, but did not turn on the wing and stab heat, as I
anticipated a short descent through a shallow cloud layer to above freezing temperatures.
The approach proceeded normally, with the aircraft in the landing configuration and the
before landing checklist completed prior to glide path intercept. The aircraft entered the
cloud tops at approximately 1500 MSL and exited the bases at approximately 900 MSL.
There were no indications of ice accumulation on the normal reference area during
descent. During the landing flare (less than 10 ft AGL), as the flying pilot applied right
aileron to counteract the right crosswind, the left wing abruptly dropped. I immediately
took the controls, applying full right aileron as the left main landing gear contacted the
runway, followed closely by deployment of spoilers, thrust reversers and brakes to return
the aircraft to the runway centerline.
Upon exiting the aircraft, I observed a small amount (less than 1/4 inch) of rough, rapidly
melting ice on the leading edges of the wings. Inspection revealed that the trailing edge of
the left wingtip had contacted the runway surface, causing abrasion to the contact area. I
believe the combination of the small amount of ice, aileron deflection and mechanical
turbulence from buildings on the upwind side of the runway caused the left wing to stall at
a higher than normal airspeed, resulting in the uncommanded left roll. Contributing factors
include my failure to turn on the wing and stab heat prior to entering the cloud layer.
Synopsis
Lear 31A Captain reported a wingtip strike occurred on landing when roll authority was
compromised in the landing flare perhaps from ice accumulation on the wing.
ACN: 1370694 (19 of 50)
Time / Day
Date : 201607
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : JFK.Airport
State Reference : NY
Altitude.MSL.Single Value : 1500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : JFK
Aircraft Operator : Corporate
Make Model Name : Learjet 35
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 135
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Climb
Route In Use.Airway : V16
Route In Use.SID : SKORR3
Airspace.Class B : JFK
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 12000
Experience.Flight Crew.Last 90 Days : 200
Experience.Flight Crew.Type : 200
ASRS Report Number.Accession Number : 1370694
Human Factors : Confusion
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Miss Distance.Horizontal : 4
Miss Distance.Vertical : 500
When Detected : In-flight
When Detected : Taxi
Result.Flight Crew : Became Reoriented
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
This was a very bizarre incident. In 12000 hours of professional flight time, I have never
experienced an occurrence like this one. After a very thorough and detailed departure
briefing with my copilot, we were given taxi instructions to taxi to runway 4L at JFK.
During the taxi, we were instructed by ATC ground control to taxi via KE and left on Q to
hold short of N. Then we were instructed to follow a B777 on Taxiway B and to monitor the
Tower frequency. We were then instructed by the Tower to turn right on MB and then turn
right onto Runway 31L and lineup and wait. The Tower controller was speaking so fast that
his words were all mixed together and hard to understand. I responded with, "It sounded
like you said to turn left on MB, but the runway is to our right." He then repeated his
instructions more coherently so that we were able to understand him.
Then suddenly within a few seconds of the lineup and wait instruction, we were given
cleared for immediate takeoff on Runway 31L. We were completely taken by surprise as
ATC never told us to expect Runway 31L, and never asked us if we could accept a Runway
31L intersection departure from intersection MB. Then, again within seconds, as we are
running our Lineup Checklist prior to adding power for takeoff, the tower asked us if we
are going to takeoff. I had to stop the Lineup Checklist to respond to him that we were
running our Lineup Checks and would then start the takeoff roll. We didn't even have a
chance to realize that we were departing on a runway other than the one we had briefed
for the RNAV SID. So without knowing what heading we were expected to fly, when
handed off to departure, I immediately informed him that we were flying Runway heading,
at which the departure ATC instructed us to make an immediate left turn to some heading.
Then within a very short time, we were told to fly heading 180 degrees to intercept V16. I
read the clearance back and quickly realized that V16 was not on our clearance until much
farther down the flight plan well beyond the RNAV SID. Not wanting to wander into the
path of other aircraft, I joined the departure course hoping that it was also part of V16
until I could get in contact with ATC as he was somewhat busy with other traffic. We were
then instructed by ATC to turn left as we were not flying the course they instructed us to
fly. ATC then asked us if we were flying V16 and I told him that we understood that we
were to join and fly the RNAV SID and that if he wanted us to join V16 he would need to
tell us what fixes delineated the section of airway he wanted us to join. ATC asked us if we
were familiar with V16 and I said that we were not. He then assigned us a heading to fly
before clearing us direct to a fix on our flight plan.
After being switched to another frequency, we were told that we had deviated and caused
a traffic conflict and that we should expect a phone call at our destination. It should be
noted that our flight plan did not include V16 until about another 30 miles further along
our flight plan clearance. All of this occurred immediately after takeoff, before we even had
a chance to run our after takeoff check list. As of this writing, we have not received
instructions to call any ATC facility.
Synopsis
An air taxi Captain reported receiving confusing taxi instructions to a different runway than
originally issued. Once airborne the aircraft was issued headings to an airway not
contained in their flight plan.
ACN: 1370332 (20 of 50)
Time / Day
Date : 201607
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : TYS.Airport
State Reference : TN
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Windshear
Light : Dawn
Aircraft
Reference : X
ATC / Advisory.Tower : TYS
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 900 (CRJ900)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Climb
Airspace.Class C : TYS
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1370332
Human Factors : Confusion
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Ambiguous
Narrative: 1
Pushed back and called ATC for taxi [who then] cleared us to runway 5R for departure.
Airbus just landing 5R. Taxied to 5R, [another] Airbus landed on 23L. [The second Airbus]
cleared the runway and we were given take off clearance 5R, turn right to 070, climb 6000
ft. We had a deferred left thrust reverser so taking the runway I again briefed an aborted
takeoff with one thrust reverser. As we got to V1 and then rotate I pitched up to the flight
director, called for the gear up, and heading 070. Suddenly my airspeed started to
degrade so I started to pitch down. We [then] received a windshear warning with the red
eyebrow arrows [so] I started to pitch up to the bars and it went away. I thought it was a
malfunction since we had no warning. The first officer called out airspeed and I did not call
out for max power. The first officer noticed 25 knots of tail wind, we got to about 700 feet
before we saw positive performance.
Suddenly having a windshear with no warning [early in the morning] can certainly bring
about confusion. I believe if the two other aircraft could have provided a clue to the tower
to pass on a degraded performance on landing we would have [taken a] delay and held off
the runway till we got more information. As it was we were taking off with calm wind and
no thunderstorms anywhere near the airport [so] we figured a normal takeoff but once
again we found that normal is just a setting on a washing machine. As far as preventing
this event we should have called max power and as it [happened] with no clues to what is
going happen next was the big problem. We tried to stay SOP but this got thrown in and
caused confusion.
Synopsis
CRJ-900 Captain reported encountering windshear on takeoff from TYS with no windshear
warning provided.
ACN: 1365938 (21 of 50)
Time / Day
Date : 201606
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 145 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Takeoff
Airspace.Class B : ZZZ
Component
Aircraft Component : Elevator Trim System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1365938
Human Factors : Troubleshooting
Human Factors : Workload
Human Factors : Distraction
Human Factors : Time Pressure
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Returned To Departure Airport
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I was pilot flying on leg 4 on day 2 of a 3 day trip. It was visual conditions departing on
time. Immediately after takeoff while re-trimming we hear "ding" "trim" then saw a red
warning of PTRIM MAIN INOP. I continued to maintain control of the aircraft on the RNAV
departure. I noticed trim wasn't working correctly. Captain (CA) maintained radios and got
out QRH to start procedure. We had to get ATC to let us level out. We ran the QRH. If it
failed but Auto Pilot (AP) would still engage then we could continue? AP did engage and did
appear to be working. CA then got dispatch and maintenance on [commercial radio] while
I monitored flight. After explaining all we had done then looking at whether or not a reset
may not be successful in destination we decided to turn back. Once we started to return
the aircraft began an uncommanded climb from 2900. I then disconnected AP and used
backup trim to get aircraft back in control. AP was used again in descent. Aircraft was out
of trim and additional messages, AUTO TRIM FAIL and AP ELEV MISTRIM were presented.
I told CA I wanted no delays and wanted to [advise ATC]. So we did and proceeded
directly to the airport for the visual to runway 26L. Landed uneventfully.
Threats, Long duty day after min rest, previous day had maintenance issue and gate
return.
Immediately land and deal with indications on the ground. Do not continue flight with a
master warning.
Synopsis
EMB-145 First Officer reported a failure of the aircraft's pitch trim system during climbout.
All appropriate abnormal checklists were accomplished and the crew returned to the
departure airport, where an uneventful landing was accomplished.
ACN: 1365880 (22 of 50)
Time / Day
Date : 201606
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 7000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B757 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B787 Dreamliner Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 129
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 13000
Experience.Flight Crew.Last 90 Days : 180
Experience.Flight Crew.Type : 873
ASRS Report Number.Accession Number : 1365880
Analyst Callback : Completed
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Detector.Person : Flight Crew
When Detected : In-flight
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
On arrival into ZZZ, we encountered the wake of a preceding B787 that was reported to be
9 miles ahead. We were descending VIA the arrival in VERY smooth air above the haze
layer right at ZZZZZ intersection. Our speed was 220 assigned. The aircraft made 3
uncommanded rolls of approximately 5-10 degrees. The rolls were less than 1 second each
and were consecutive (LRL or RLR--not sure). It also felt like yaw and pitch accelerations,
but not very much magnitude. After the encounter, the air was still smooth, but we
descended into the haze layer shortly afterwards (30 seconds or so) where it was
intermittent light turbulence. The autopilot and autothrottles remained on. We all
remarked that it was a wake encounter and I called ATC and asked what we were
following. He said it was a B787 9 miles in front of us. We had heard him get 210 knots
earlier and we were at 220 assigned. At about 4 miles a minute groundspeed, we were
about 2 minutes behind him and because of the STAR, should have been at the same
altitude/descent profiles at that crossing restriction (ZZZZZ intersection 7000 ft). I am not
sure what the winds were but it was very smooth just above the haze layer.
ATC offered to let us fly higher on the arrival, but by that time, we were in the haze layer
where it was intermittent light turbulence and that should have broken up the wake
quicker. We didn't feel that an offset would help, either, once we entered the haze layer.
The wind vector there showed a SW crossing headwind and it was bumpy. The encounter
was more than light turbulence in roll accelerations, but was smoother in vertical g load. I
am not sure if there was much, if any, pitch change due to the wake encounter, but it was
very characteristic of wake encounters. We continued the arrival to a visual behind the
heavy and kept track of the crosswind on final to mitigate the chance of another
encounter. We had a 10 knot crosswind on final (although a slight tailwind component)
and felt that the wake would be well east of us. We did monitor that we had almost 5nm
on final (TCAS estimate).
If I were "rating" this encounter, I would say it was a "minor" severity event. These things
happen, and the wake had decayed to a point where it was manageable for us, a B757. I
wouldn't have wanted to hit that in an RJ or even a short coupled B737 or A319. We were
about 172k pounds. That said, a cup of coffee would have spilled, and flight attendants
could have been injured (they were not). If a passenger had been up getting things
into/out of the overhead, it could have been an injury (it felt a bit like a very tight "dutch
roll").
Callback: 1
Reporter stated the incident would have been more severe for a smaller aircraft.
Synopsis
B757 First Officer reported encountering wake turbulence in 9-mile trail of a B787 on
descent.
ACN: 1362047 (23 of 50)
Time / Day
Date : 201606
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 38000
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZZZ
Component
Aircraft Component : Autopilot
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1362047
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
In cruise flight at FL380, .78 Mach, autopilot CMD B engaged, the jet suddenly began
"driving" or yawing to the right. I would describe the motion as more of a constant drive
and definitely not a "snap" movement. I immediately grasped the yoke and attempted to
return the nose of the jet back to its original position. Concurrently, I scanned the
instruments/lights for any signs of an engine rolling off or other indications pertaining to
this unexpected movement (hydraulics, yaw damper, etc.). The CA (pilot not flying) felt
the jet move and asked me what I was doing; my response was that I was not making any
inputs to the jet to cause this drive/yaw and that my feet were flat on the deck when this
motion ensued. As the drive deepened the jet started to roll to the right. I immediately
clicked off the autopilot while simultaneously announcing my action. I manually flew the
jet back into our original state (.78 at FL380). I believe we may have gained/lost +/- 60
feet but I don't recall how many degrees of heading changed; I'm also not certain how
much we rolled but I'm guessing it was around 5 degrees when I reacted. After some
discussion, the CA elected to engage autopilot CMD A. The flight proceeded normally with
no further anomalies.
It was night, no turbulence or chop, and no "heavies" nearby that might have generated a
wake turbulence event. The CA requested maintenance meet us at the jet for a debrief.
After we debriefed the maintainer and after the passengers had deplaned, two of our flight
attendants (the number 1 and one from the back) asked us "what the heck happened back
there." They went on to describe their experience similar to the sensation of being on a
boat. A yawing, mushy feeling of working through waves, etc. Both also declared being
somewhat disoriented by the motion, perhaps due to inner ear fluid movement. After the
flight attendants were debriefed by the CA and myself, we surrendered the jet to
maintenance, deplaned and concluded our sequence.
Synopsis
B737-800 First Officer reported the aircraft yawed to the right at FL380 with Autopilot B
engaged. Substituting Autopilot A solved the problem.
ACN: 1359975 (24 of 50)
Time / Day
Date : 201605
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZZZ.Tower
State Reference : US
Altitude.MSL.Single Value : 2000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Component
Aircraft Component : Trailing Edge Flap
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 112
ASRS Report Number.Accession Number : 1359975
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 254
ASRS Report Number.Accession Number : 1359990
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
While being vectored for the approach we began our final configuration for landing.
Approaching the outer marker in a shallow descent passing 2000 ft MSL I commanded for
the flaps to be set at 30 degrees and we began the Before Landing Checklist. The F/O
(First Officer), who was the PM (Pilot Monitoring), read flaps, and I responded "flaps," as I
looked over at the flap gauge. We both verified on the flap gauge that the left flap was
indicating 30 degree, while the right flap was still at the 25 degree indication. There was
no indication of uncommanded roll, or yaw of the aircraft.
We immediately decided to discontinue the approach and requested vectors or a holding
pattern so we could run a checklist. We were cleared initially to 1500 ft MSL, and then up
to 4000 ft. Climbing through approximately 1200 ft MSL, I reengaged the autopilot to get
an additional level of automation working for me, so I could concentrate on the situation at
hand. We pulled out the QRH, and ran the Trailing Edge Flap Asymmetry Checklist from
the QRH.
We completed the QRH Checklist and ran landing performance numbers for landing with
flaps set at 15 degree. At this point the aircraft was taken care of, so it was time to notify
the Company, the F/As (Flight Attendants) and the Passengers. The Pilot monitoring took
care of these duties while I, as the PF (Pilot Flying), maintained radio communications with
Air Traffic Control, and flew the aircraft. After all external notifications were done and
checklists were complete, we requested vectors back to the approach course for landing.
The approach and landing were uneventful, and we arrived with Maintenance waiting for
us at the gate. I contacted Dispatch, and the Chief Pilot on Duty, by telephone, and spoke
with Maintenance Personnel while my F/O briefed the Crew that was to take the aircraft.
The aircraft was subsequently taken out of service for Maintenance, and my F/O and I
proceeded to another gate and pressed on with our day.
By using automation to lighten our workload, dividing up tasks and working together as a
team to diagnose and address a mechanical situation, using the appropriate checklists,
and letting other members of the Company Team know what was going on, an abnormal
situation was handled in a methodical and professional manner by everyone involved.
Narrative: 2
During a visual approach, the PF (Pilot Flying) called "Flaps 30, Before Landing Checklist."
We performed the checklist per normal procedure, and as the PM (Pilot Monitoring) was
aurally stating "FLAPS", we both noticed that the Left flap was indicating 30, while the
Right flap was indicating 25. Both indicators aligned with the index marks at each of the
flap positions respectively.
As the flaps were set to the final setting, neither of us noticed any rolling tendencies and
the aircraft appeared quite stable. The PF took the safest course of action by electing to
discontinue the approach, and requested the PM to notify the Tower. Tower was notified
that we were going around, and we were instructed to fly runway heading. I cannot recall
the altitude we climbed to initially (either 3000 ft or 4000 ft). During the normal go-
around maneuver, flaps 15 was selected, and the flaps correctly retracted to the selected
detent.
We then were switched to Departure, where we were given box vectors within the terminal
area, in order to complete the appropriate QRH Checklist (Trailing Edge Flap Asymmetry),
and return for landing. VREF - 146 IAS & VTARGET-151 IAS based on an approximate
landing weight of 113 pounds. After the QRH Checklist was completed, the PM notified the
F/As as to the situation at hand, that we expected a normal approach and landing, and the
amount of time to landing.
Also, an announcement to the Passengers was made to notify them of the basic condition,
and that we would be performing a checklist to allow us to return for landing. Ops was also
notified. Finally, we advised Approach Control that we were ready to proceed inbound for
landing. A flaps 15 approach and landing was conducted at a nominal touchdown rate of
descent, with an approximate brakes speed of 140 IAS. The aircraft turned off and taxied
to the gate where a normal deplaning occurred, and Maintenance was waiting.
Synopsis
B737 flight crew reported a split flap indication (25 and 30 degrees) with no rolling
tendency and no flap asymmetry indication. A go-around was initiated and the flap lever
was moved to 15 and the flaps both moved to 15. QRH procedures were accomplished and
a flaps 15 landing ensued.
ACN: 1359365 (25 of 50)
Time / Day
Date : 201605
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 32000
Environment
Flight Conditions : Mixed
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : A320
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class A : ZZZ
Component
Aircraft Component : Electrical Wiring & Connectors
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1359365
Human Factors : Confusion
Analyst Callback : Completed
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
About 20 minutes into flight while climbing through 32,000 feet to get to 35,000 feet we
heard a clicking noise coming from behind the circuit breaker panel and I noticed the
Captain PFD and ND flicker a few times. I suspected we might have a generator issue as I
had noticed in the logbook that an IDG had recently been changed on one of the engines
but I was not sure which one. We were not issued any ECAM messages. The electrical
page did not show anything abnormal except a possible high voltage on the left side TR
(no amber indications). We were flying to ZZZ which had weather right at minimums so I
attempted to start the APU. Starting the APU resulted in an APU auto shutdown. The
electrical issues continued and became steadier so I told the First Officer I thought we
should divert back. As we began the diversion the problem continued to get worse. I gave
the controls to the First Officer because my PFD/ND were going blank so often that they
were unusable. We were unsure which checklist to use as I attempted to look through the
QRH. No checklist applied to our issue. I did run a diversion checklist.
The problem continued to get worse. The lower ECAM displayed multiple messages and the
overhead panel displayed multiple lights flashing on and off in sequence with the clicking
noises heard from behind the circuit breaker panel. The Captain's PFD/ND and upper ECAM
were mostly unusable. Multiple systems were shutting off and turning back on again. The
autopilot and autothrust failed. The First Officer's PFD and ND stayed useable for most of
the flight but would flicker on occasion. The First Officer's MCDU was useable but the
captains MCDU was not. We were in visual conditions all the way back.
When we put down the landing gear it appeared the aircraft went into alternate law
however this was intermittent. "Use manual pitch trim" was displayed in amber on the
FMA. I observed the trim wheel moving. The flaps and slats worked and the aircraft was
controllable for the approach and landing. Communication with ATC was intermittent due
to the electrical issues. Some uncommanded movement of the rudder was felt by the First
Officer and I noticed some clicking on the rudder pedals during taxi but the aircraft
remained controllable at all times.
After parking and shutting down engine #1 all the electrical issues went away. We
considered shutting off the left generator in flight but there was not enough data available
to support that decision. Also the APU would not start.
Callback: 1
The reporter stated that he believes that Maintenance replaced the generator control panel
to return the aircraft to service. He also discovered after the flight that the QRH does have
a checklist to cover the situation but it is not located in the electrical section. It is in the
section concerning displays.
Synopsis
A320 Captain experienced electrical anomalies during climb to FL350 which resulted in the
intermittent blanking of his PFD, ND and the upper ECAM display. With low ceilings at their
destination, the crew elects to return to their departure airport. The First Officer's displays
remain normal and he becomes the pilot flying for the approach and landing.
ACN: 1359125 (26 of 50)
Time / Day
Date : 201605
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Make Model Name : HS 125 Series
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class E : ZZZ
Component
Aircraft Component : Cowling/Nacelle Fasteners, Latches
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1359125
Human Factors : Confusion
Human Factors : Troubleshooting
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1359129
Human Factors : Confusion
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Air Traffic Control : Provided Assistance
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
Aircraft experienced gradual, uncommanded left roll/yaw at 16,000 ft and 300 KIAS, level
flight, while vectored direct for the Arrival. Continuous light vibration felt throughout
airframe. Slip/skid (ball) indicator displaced completely to the left of center (unusual for a
left yaw situation). No unusual engine or flight control malfunctions or abnormalities
indicated on the MFD/PFD/MWS.
Slowed to 250 KIAS, disengaged Auto Pilot (AP)/ Yaw Damper (YD), and centered the ball
by displacing rudder trim 2 indications to the left. Coordinated diversion with ATC. Aircraft
remained stable with rudder trim 2 indications to the left, rudder pedals difficult to move
as if Yaw Damp still engaged, and vibrations still noticeable. Flew stable visual approach.
ATC arranged for emergency vehicles to be on standby. Landed with no complications.
On post flight, discovered a fastener on the leading edge of an accessory panel, on the
underside of the left engine pylon, became loose and allowed for the leading edge of the
panel to be forced aft. Although it was understandable that the panel could cause the
aircraft to yaw left, it was confusing as to why the slip/skid (ball) indication was indicating
to step on the left pedal and add left trim. Notified ACP, maintenance and steward on
duty.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
HS125 flight crew on a ferry flight reported experiencing flight anomalies created by an
unfastened panel on the engine pylon.
ACN: 1358171 (27 of 50)
Time / Day
Date : 201605
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Mission : Passenger
Flight Phase : Takeoff
Component : 1
Aircraft Component : Cockpit Window
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : Headset
Aircraft Reference : X
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 219
Experience.Flight Crew.Type : 15000
ASRS Report Number.Accession Number : 1358171
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Experience.Flight Crew.Last 90 Days : 194
ASRS Report Number.Accession Number : 1358165
Human Factors : Situational Awareness
Human Factors : Distraction
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected.Other
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was the Pilot Monitoring (PM) for takeoff. Shortly after initiating the takeoff roll, my
sliding window rolled back. When this happened, the window caught my headset wire and
twisted the headset on my head. I turned to check the wire was free, and was then
readjusting it, when suddenly my First Officer (FO) asked me something about my
window. I was not sure, (due to noise and headset position) but I believe it was something
to the effect of if I was closing the window. I responded no. He immediately announced
and conducted a rejected takeoff. I was quite surprised he didn't simply continue the
takeoff as the window could easily have been closed once safely airborne.
Nonetheless, I felt it was prudent, under the circumstances, to simply take control of the
aircraft and complete the rejected takeoff. The reject was uneventful, and we cleared the
runway as requested by Tower. After arriving at a designated stopping point, I reviewed
the rejected takeoff procedure in the QRH. We also looked at brake cooling requirements
in the [flight computer]. On this note, I asked my FO (since I did not see it myself) what
speed he initiated the reject at. He said 75 knots. I believed it was actually at a slightly
higher airspeed, and therefore checked the [flight computer] for speeds of 85 and 90
knots. 85 knots showed 0 brake cooling time required. 90 knots showed nine minutes
required, which by then, we had.
I then checked minimum takeoff fuel, which was not a problem. I informed Dispatch of
what had occurred, and of our intention to continue. The reply via ACARS was "Ok." We
re-accomplished both the Before Push and Before Takeoff Checklists and departed without
further incident.
Preventative Measures: Two big lessons learned here are as follows: First, I should have
announced loudly and clearly "Continue." Yes it was a bit noisy, and my headset was
twisted on my head as a result of the window knocking the wire; however, I could easily
have communicated in a loud enough voice to be heard. In all honesty, while I am aware
that for any anomaly (particularly above 80 knots) this communication is required, due to
the distraction with my headset, and the fact it didn't even cross my mind he would decide
to reject, I did not say "Continue."
Second, I must, in the future, be more "assertive" when checking my window during pre-
flight. As a matter of explanation, I do (and believe I did in this case check the window).
However, as I have observed by many, my technique has never been to bang on the
handle with the side of my fist. Generally, I have always, (unless it appeared the window
was not correctly closed for whatever reason) simply tapped on the handle while visually
determining it is closed. In this case, there seemed no visual indication the window was
not properly closed, yet it obviously was not completely locked in place. I will be much
more cognizant of this possibility in the future and intend to check it by physically grasping
the handle and checking to see it is secure in the locked position.
Narrative: 2
Takeoff [in a] fully loaded -800, flaps 15, First Officer (FO) Pilot Flying (PF). Thrust set at
102.2% N1. As the aircraft started to move, the Captain's side window opened abruptly.
The Captain's response was to shut the window, as FO continued takeoff roll. Captain
remained distracted by open window and now has his back toward the FO. Captain stated,
"I can't close the window!" No [risk management] input, no callouts, no situational
awareness on the part of the Captain. Just complete distracted obsession with closing the
side window.
As PF, I am now also very distracted at all of this, the engine noise at 102% made hearing
the Captain difficult, but still nothing heard except not being able to close the window. I
was expecting to hear "reject," since we were still in the low airspeed regime, but that call,
or the continue call, never happened. I opted to abort on my own. Mind you, it's [a short
runway], and we are accelerating at full power. A decision needed to be made in seconds.
I said, "I'm aborting the takeoff," thrust levers to idle, reverse thrust.
My honest "guess" was airspeed below 80, but in all honesty I couldn't tell, as this all
occurred very quickly, and the distraction was more than I expected. I notified ATC of the
aborted takeoff. The Captain now faced forward, and realized I performed an aborted
takeoff and asked me "why?"
He took the controls. ATC asked us to accelerate to exit at the high speed taxiway. We
complied. ATC asked why we aborted. I told them about the window. On the taxiway, the
Captain again attempted to close his window, while I notified the Flight Attendants (FA),
and made a PA announcement to the passengers. Finally, the Captain got his window shut.
We taxied to the pushback location abeam the gates. The Captain checked the QRH, while
I worked the OPC for brake cooling. I asked the Captain about fuel, and we had enough to
continue. We ran the checklist from "Before Taxi" to "Departure Checklist" again. No brake
cooling was required, so we departed. Take off and flight uneventful.
Preventative Measures: Perhaps a place on the checklist to check Windows; "Doors and
Windows." Response "closed" or "secure." Just a reminder to check them. I really expected
the Captain to abort immediately, after the window opened. We were below 45 knots, as
the airspeed tape didn't even move yet. What's the problem with stopping and fixing this
issue on the taxiway, and then departing? Are we really that pressured to be on time, or
avoid paperwork?
Synopsis
B737-800 flight crew reported rejecting the takeoff when the Captain's side window
opened.
ACN: 1357579 (28 of 50)
Time / Day
Date : 201605
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 31000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : A330
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZZZ
Component
Aircraft Component : Aileron Control System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1357579
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
During climb and cruise we had what we thought was continuous light chop. The chop did
not subside and it seemed to us that the aircraft's pulsating/bumping movement was too
rhythmic, too steady to be turbulence. We had flown the aircraft 3 legs already with no
anomalies.
My first concern was the rudder as the movement had a fishtail quality to it. ECAM F/CTL
(flight control) page indicated ops normal on the rudder. However, the Captain noticed
that the indicator (carrot) on the left outboard aileron was moving up and down
rhythmically over a short range. The other seven aileron actuator indicators were near
motionless. Flight control computers appeared normal, as did Yellow and Green hydraulics
that powered the aileron.
Convinced that we had a bad left outboard actuator we opted to [advise ATC] and land
before the unit degraded further. The pulsing stopped upon flap extension during approach
and landing and taxi was uneventful.
Synopsis
A330 First Officer reported the flight crew chose to divert to an alternate airport after
noticing abnormal uncommanded aileron movement.
ACN: 1357484 (29 of 50)
Time / Day
Date : 201605
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZDV.ARTCC
State Reference : CO
Altitude.MSL.Single Value : 41000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZDV
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZDV
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 182
Experience.Flight Crew.Type : 5500
ASRS Report Number.Accession Number : 1357484
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Speed : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Environment - Non Weather Related
Narrative: 1
At FL410 we were cruising with very light Mountain Wave (MTW) at 52 NM west of Pueblo
(PUB) VOR, we then heard (other carrier) request altitude block and deviation for severe
mountain wave encounter at FL390, altitude plus or minus 200 feet, airspeed plus or
minus 30 knots. The location of encounter was at 45 NM west of Pueblo crossing the
Rockies. I did notice very slight variations at FL410, when suddenly this wave hit us (45
NM west of PUB), full strength the airspeed went straight beyond the barber poll 10 knots
into VMO/MMO [maximum operating speed]; speed attained was 252 KIAS or Mach .83.
I did everything in my power to abate the acceleration, ATS-OFF, Power Idle, and SPEED
BRAKES FLIGHT DETENT. Our altitude variation was over 50-180 feet, Denver ARTCC gave
us a 30 degrees offsite vector to the right with a block altitude FL410-390, and we
reported the severe mountain wave. I used Control Wheel Steering Pitch to maintain level
attitude, thereafter over PUB the event receded. It lasted only four seconds, but was
definitely severe and unforecasted at that location. Both Maintenance and Dispatch were
advised and a write up was entered.
Preventative Measures: Better MTW forecast and predictions. Alternate routing. But the
MTW was unpredictable and very localized, seemed in the wake of Pike's Peak.
Synopsis
B737 Captain reported encountering severe mountain wave in the vicinity of PUB that
resulted in speed and altitude excursions.
ACN: 1348361 (30 of 50)
Time / Day
Date : 201604
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : LAS.Airport
State Reference : NV
Altitude.MSL.Single Value : 11500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : L30
Aircraft Operator : Air Carrier
Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use.SID : SHEAD 9
Airspace.Class E : L30
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1348361
Human Factors : Distraction
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Primary Problem : Company Policy
Narrative: 1
The FO was the PF and I was the PM. Flying out of LAS on the Shead 9 departure ATC
instructed us to level off at 11000 feet instead the usual FL 190 for this departure. Our
new standard operating procedure is to use Cost Index 70 in the FMS which will climb the
plane at 335 KIAS once above 10000 until transitioning to Mach speeds at around FL250
or so. The plane was on autopilot with the FMS in VNAV. After passing 10000 feet the
airplane pitched down to accelerate to 335 KIAS. Once leveling at 11000 the FMS retarded
the autothrottles from climb power to a power setting that would maintain 335 KIAS. Our
VMO is 340 KIAS. So the barberpole and the airspeed indicator needle are almost on top of
each other while in this now "normal" mode. Subsequently ATC cleared us to FL190. I set
the altitude in the altitude pre-selector and the PF engaged the FMS in VNAV climb. The
autothrottles advanced and the aircraft started to pitch up, however, the autothrottles
added the power quicker than the autopilot did the pitching up. I was not "glued" on the
airspeed indicator since the airplane was in the proper automation mode and I was busy
attending to other duties as well (climb-check at 10000, entering proposed times in the
flight-plan log, adjusting cabin temperatures, verifying correct modes on the FMA,
changing the frequencies on Com 2 etc.) I was alerted by the overspeed clacker that we
must have accelerated to our VMO. I looked at the airspeed indicator and saw both
needles on top of each other. The PF promptly adjusted the climb speed on the DFGS to
320 KIAS in order to maintain a more acceptable buffer to our VMO in deviation from our
SOP guidance. I made a logbook entry upon arrival [and] no discrepancies were found.
Our new procedure puts our climb speed with 335 KIAS awfully close to our VMO on every
flight from approx. 10000 MSL until the mid-20s flight levels. That is a long time and gives
the airplane ample opportunities to "accidentally" accelerate to our VMO be it due to
sluggish autopilots, binary autothrottles that know only full forward or aft, sudden
turbulence, windshear, wake turbulence, gusts, inversion layers, embedded convective
activity etc. etc. Ever since that procedure was implemented "every" single FO that I have
flown with since modifies the FMS to climb out at a slower speed than commanded. And
while I agree that this is a good idea it also violates our standard operating procedure.
Why are we implementing a procedure that virtually no pilot feels comfortable following
ever on any single flight? And if you do follow it then you better stay glued to the airspeed
indicator in order to avoid overspeeds while neglecting other duties and a proper scan of
all other flight instruments.
It is my recommendation to implement [the new procedure] for cruise only and use a
more conservative Index for our climb profile. I will from now on override the FMS on
every single climbout in order to maintain a safe buffer between our actual airspeed and
VMO and 335 KIAS is not the number I shall use as it is too close to our overspeed limit
considering the capabilities of our equipment and the fluid dynamics of the ever changing
atmospheric conditions. Given the choice of following a newly implemented procedure or
maintaining a safe airspeed I believe it is in the best interest of safety to do the latter.
Synopsis
MD-80 Captain reported an overspeed in climb that he felt was related to a recent change
in procedure that calls for a high speed climbout.
ACN: 1348155 (31 of 50)
Time / Day
Date : 201604
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : DCA.Airport
State Reference : DC
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.TRACON : PCT
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 170/175 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Descent
Route In Use.STAR : FRDMM3
Airspace.Class B : DCA
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1348155
Human Factors : Time Pressure
Human Factors : Workload
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1348157
Human Factors : Time Pressure
Human Factors : Workload
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Equipment / Tooling
Contributing Factors / Situations : Company Policy
Primary Problem : Company Policy
Narrative: 1
Upon pushback and normal startup at the departure airport, upon taxi out, ground advised
us of a ground hold into destination airport. We parked on a taxiway and elected to
shutdown both engines, due to the length of the projected ground stop and due to the fact
that the fuel margin between planned and required was so slim. Once finally released
departure was normal. Prior to reaching the initial point for the FRDMM3 arrival, we were
vectored off the arrival. We were then cleared to LETZZ a little further down the arrival
and told to descend via the arrival. This is where things started to become so busy and
confusing.
ATC notified everyone at least 3 to 4 times that runway directions had changed at National
even though National had not published a new ATIS. They were landing south one minute
and north the next, requiring multiple FMS changes and entries.
This is when things started stacking up for ATC. ATC gave us a hold as published 3 miles
prior to the fix they wanted to hold at, which does not allow a proper FMS entry nor even
the ability to scramble and determine the hold via green needles without passing over the
fix. After informing them that it was too close to the fix, they then vectored us off the
arrival and holding fix.
At this point we had sent a [message] to Dispatch and told them we were being held. We
received back that minimum fuel was approximately 3,000 LBS. At this point we had
roughly 3,200-3,300 pounds and that we could only take one turn in the hold if that. We
declared minimum fuel. At this point we were roughly over IAD with 3,100 LBS of fuel.
ATC then gave us a heading for the river and a descent. After being cleared for the river
visual, they turned us off the approach again! We had started to configure at the point, we
were approximately at Flaps 2 with the gear down and around 210 knots and slowing.
After the turn we encountered a turbulent patch of air that [over sped] the flaps by a few
knots for 1 second. We were then turned back and recleared the river visual. Landing
phase was uneventful, turned off the runway with the fuel indications just beginning to
turn amber.
A determination should be established as to why National decided to change runways so
many times during light and variable wind conditions which in turn stacked up arriving
traffic. As well as the margins for fuel have become so stringent that it almost forces an
emergency situation anytime undue and unplanned delays occur, even in a CAVU day.
Narrative: 2
We are not being given enough fuel. This fuel program looks fine on paper, but it doesn't
work. Yesterday we boarded on a perfectly clear day. I didn't save the release to give you
exact numbers, but we had the "planned fuel" that Dispatch gave us. We pushed back
from the gate and started both engines because the departing runway was right behind
us. When Ramp Control turned us over to ground, ground informed us we were in a
ground stop for DCA and long story short it would be about a 25 minute delay. We shut
down both engines, leaving the APU on as our air/electrical source. We contacted Dispatch
and [departure] operations to tell them what was happening. They informed us Center was
the culprit and it was a volume issue.
Finally Ground released us and we started the engines and headed to the runway. The
time from Ground releasing us until the takeoff roll was about four minutes so we didn't
have the engines running for an absurd amount of time. When we crossed the hold short
line we were above the Minimum fuel by about 600 LBS if memory serves me. It may have
been a little more. Either way it was legal and above minimum fuel.
As soon as we were turned over to Departure Control we were given a twenty degree turn
off course. At this point we would be landing with 3,500 LBS of fuel. Center got us on
course only to turn us off course again. Landing fuel would now be 3,400 LBS. [Next]
Center does the same thing. Constant turns and they inform us that Runway 19 is in use
at DCA despite the fact that the ATIS is showing Runway 1. More turns, fuel now 3,300 at
arrival in DCA. I recognize the 2660 rule for declaring minimum fuel (or the reserve plus
the alternate fuel if it is more). But we have no alternate today and the weather is fine. My
mind cannot comprehend why the vectoring.
We check on with Potomac and they tell us the runway is now 1. They are vectoring the
people around us and then they announce holding. He told us to hold at ALWYZ, but I told
him he was too late on the assignment as ALWYZ now sequenced beyond us. He gave us a
south heading and an Expect Further Clearance (EFC) about twenty minutes from now. I
immediately could tell that would not work and informed him we would be diverting.
Dispatch gave us a minimum fuel of 3,004 LBS from where we were to DCA and IAD as an
alternate. We are now scheduled to land at DCA with 3,000 LBS so I told him we would be
diverting to IAD unless he could get us right in to DCA. He says he can and began heading
us east bound. I declared minimum fuel and he told me we were number one for DCA and
we were getting right in. He then switched us to another frequency and this controller said
he was aware we were minimum fuel and we were getting right in. Then he tells us to turn
90 degrees off course. At that point I told him he had ten seconds to figure out what he
was doing. He told us they had switched runways again to Runway 19. This is the fourth
runway change! Then he turns us back toward the river and clears us for the river visual
Runway 19. At this point we are showing 2,900 LBS on landing. As we configure for the
river visual and cross over the American Legion Bridge, he suddenly tells us to turn left
heading 150. I yelled at him. I don't know what I said, but he became nervous and then
gave us a 240 heading. At this point we had a flap over speed with flaps at 2 and speed at
210. It jumped to like 218 for like one second. I don't know how it happened, because
there was so much going on.
Finally he re-clears us for the approach and we landed with around 2,800 LBS. By the time
we got to the gate we were in amber.
I am concerned about this fuel program we have adopted. I feel it has compromised
safety. I have no idea what Potomac Approach was doing, but things happen and if we
would have only had 1,000 more LBS this would have been a non-issue. Our dispatcher
told me, "I will give you more fuel anytime you ask." Again, we were legal per the release,
(which is honestly my only measurement) but we are not given much room for errors or
for unpredictable events.
We wrote up the flap over speed.
Giving us more fuel would have helped a lot.
Synopsis
A regional jet flight crew reported experiencing a minimum fuel condition due to ongoing
delays at the destination airport, which were attributed to multiple runway changes. They
also cited their company's fuel policy as a contributing factor to their fuel situation.
ACN: 1338459 (32 of 50)
Time / Day
Date : 201603
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 34000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZDC
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Carrier
Make Model Name : B777 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZDC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 6701
ASRS Report Number.Accession Number : 1338459
Analyst Callback : Completed
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Environment - Non Weather Related
Narrative: 1
Twenty miles in trail of a B777 [at FL340], we got an uncommanded aircraft roll to the
right and altitude loss from wake turbulence.
Callback: 1
Reporter stated wake encounter was in the vicinity of ORF at FL340.
Synopsis
B737 Captain reported his aircraft rolled right and descended after encountering wake
turbulence in trail of a B777 at FL340.
ACN: 1336081 (33 of 50)
Time / Day
Date : 201602
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : SMF.Airport
State Reference : CA
Altitude.AGL.Single Value : 50
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : SMF
Aircraft Operator : Air Carrier
Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Climb
Airspace.Class C : SMF
Aircraft : 2
Reference : Y
ATC / Advisory.Ground : SMF
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Taxi
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 187
ASRS Report Number.Accession Number : 1336081
Events
Anomaly.Inflight Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Requested ATC Assistance / Clarification
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Primary Problem : Environment - Non Weather Related
Narrative: 1
I was PM. On taxi out I noticed Aircraft Y parked just clear of 34L, on Taxiway A8. We
proceeded normally for takeoff, completed checklists, and received takeoff clearance for
34L. Aircraft Y was still parked on Taxiway A8 facing east. Our takeoff roll was normal and
we started rotation approximately around Taxiway A10. Passing Taxiway A8, our aircraft
experienced an abrupt left roll due to the jet blast of Aircraft Y. We were approximately
50-100 ft in altitude. Passing 1000 ft, we configured for climb and I mentioned to the
Captain that "I knew that was going to happen." Tower gave us the handoff to departure.
Before switching frequencies, I mention to Tower that even though I assumed Aircraft Y
was at idle power, we received a significant jet blast induced roll at rotation. I also
mentioned that A8 wasn't the smartest place to park Aircraft Y.
I noticed this hazard on taxi out and minimized its significance. I had experienced a similar
situation in a different aircraft over 10 years ago. I failed to mention the hazard to the
Captain and/or Ground Control. I write this ASAP to highlight the hazard for SMF Ground
Control and general Pilot awareness.
Synopsis
Air carrier First Officer reported an uncommanded roll shortly after takeoff due to the
exhaust stream from a parked aircraft with engines running pointed toward the departure
runway.
ACN: 1328335 (34 of 50)
Time / Day
Date : 201601
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : FFZ.Airport
State Reference : AZ
Altitude.AGL.Single Value : 1000
Environment
Flight Conditions : VMC
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.TRACON : P50
Aircraft Operator : Personal
Make Model Name : Eclipse 500
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Initial Climb
Route In Use.SID : SACAT 1
Airspace.Class D : FFZ
Component
Aircraft Component : FMS/FMC
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 6000
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 190
ASRS Report Number.Accession Number : 1328335
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
Was given the Sacat 1 Departure off of FFZ using runway 22L, approximately 1000 ft AGL
got several CAS warnings, uncommanded trim, landing gear aural warning, and air data
computer fail, the programmed route and navigation was unreliable also. I did not want to
inadvertently fly into Sky Harbor's approach paths and airspace and was assessing the
situation for a possible return to the airport of departure. I made a left turn back towards
the airport of departure and advised the controller that I was having some issues and
requested a heading. The controller gave me direct to Mrbil and to climb to 5000 ft which I
was able to program into the FMS and I was also able to resolve the uncommanded trim
problem. I was in VFR conditions at the time of the deviation and was aware of the terrain
and other traffic.
Synopsis
EA50 pilot reported deviating from his cleared track departing FFZ when he experienced
FMS issues.
ACN: 1327278 (35 of 50)
Time / Day
Date : 201601
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : MTPP.Airport
State Reference : FO
Altitude.AGL.Single Value : 0
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : MTPP
Aircraft Operator : Air Carrier
Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1327278
Human Factors : Confusion
Human Factors : Workload
Events
Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Person / Animal / Bird
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Environment - Non Weather Related
Narrative: 1
FO was PF. During takeoff roll at MTPP right at rotate speed, a bird in the cockpit suddenly
flew from the Capt.'s left side to cross in front of the Capt., across the window, bumping
off the window/glare shield in front of me, and then headed right toward my face, causing
me to lean out of the way as it brushed by my face while I was pulling the aircraft nose up
through rotation. Aircraft control was not compromised. The bird passed by me, and we
were unable to locate it for the duration of the flight. Presumably it escaped our view in a
small crevasse and perished.
Prior to departing ZZZ for the MTPP turn, the aircraft was on the ground for three days. It
was towed from the maintenance hangar to our gate. As I boarded the aircraft for preflight
duties at ZZZ, ground personnel was attempting to remove a pigeon from the cabin and
apparently succeeded. The electronic maintenance log indicates that a pigeon was
removed from the aircraft, but unclear to me whether that entry refers to the preflight
pigeon or our inflight bird of unknown species. We were aware of no other in-the-aircraft
bird activity.
On the ground in MTPP, ground personnel secured the jet bridge door in the open position
throughout the ground time. There is a remote possibility the bird joined us from there
too. Regardless of where our avian friend originated that day, it most likely entered the
aircraft through open doors, especially if the aircraft was left open for days prior to the
flight. As such, I recommend the review of the existing guidance for leaving aircraft doors
open for extended periods of time and determine if the guidance is inadequate, or simply
not followed in this event.
Synopsis
Air carrier flight crew reported being distracted during takeoff roll by a bird which emerged
from inside the cockpit. Aircraft control was maintained at all times and the bird
subsequently disappeared for the remainder of the flight.
ACN: 1324001 (36 of 50)
Time / Day
Date : 201601
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : KZAK.ARTCC
State Reference : HI
Altitude.MSL.Single Value : 37000
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : KZAK
Aircraft Operator : Air Carrier
Make Model Name : B757 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Route In Use : Oceanic
Airspace.Class A : KZAK
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1324001
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
160 nm east of waypoint DUSAC over the Eastern Pacific we experienced a quick moment
of severe turbulence which caused the aircraft to bank as much as 45 deg. Altitude FL370.
Mach .80. Wind 260 @ 110. VMC on top. Layer 4,000 feet or more below us. LNAV/VNAV
on. Autopilot on. Seat belt sign on due to continuous light chop.
Aircraft slowly began to roll (similar to a mountain wave event) which got our attention.
Seconds later aircraft began to bank right excessively and rapidly. Autopilot and
Autothrottle were disengaged and a recovery to straight and level flight was achieved.
Recovery was smooth and forceful but not abrupt. Bank angle may have reached as much
as 45 deg right. Airspeed remained within limits. Descent was arrested manually before -
300 feet. No significant sink rate. Engine instruments normal. No ECIAS or STATUS
messages.
After autopilot reengaged and flight seemed normal, FO called FAs to make sure both they
and pax were okay. No reported injuries. A few minutes later I made a passenger
announcement. No one seemed to care. It just felt like turbulence to them. There were
two aircraft below us at 360 and 350 about 10-20 miles ahead. There was another aircraft
(likely a 737-800) 2,000 feet above us but far enough ahead to be out of TCAS range. In
my professional opinion (25+ years) this was not a wake turbulence event. A blind
announcement was made on guard. As air was again relatively smooth, returned to Mach
.80 speed and continued flight with no further incidences. Normal landing in HNL. No
apparent damage on walk-around.
I think this was a case of wrong place at wrong time. According to WX charts, we were
likely in the vicinity of the crossing of a 120 kt. jet stream at both FL340 and FL410.
Synopsis
B757 Captain reported experiencing an uncommanded 45 degree bank angle at FL370 that
the reporter felt was related to jet stream activity.
ACN: 1321647 (37 of 50)
Time / Day
Date : 201512
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ORD.Airport
State Reference : IL
Altitude.AGL.Single Value : 0
Environment
Weather Elements / Visibility : Icing
Weather Elements / Visibility : Snow
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : ORD
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 145 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Aircraft : 2
Reference : Y
ATC / Advisory.Tower : ORD
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Landing
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1321647
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Ground Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Returned To Gate
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Ambiguous
Narrative: 1
[We] encountered uncommanded swerving during the high speed regime of takeoff.
Around 110kts, 24kts below V1, the plane experienced a higher than normal vibration
possibly in the nose wheel and a sudden swerve to the right. I was pilot flying and called
the abort. During the deceleration, control was regained and kept the plane returned to
centerline. The procedure was performed as briefed and as previously practiced in the sim
by complying with the immediate action items. Once stopped, we ran all appropriate
checklists, coordinated with the cabin crew, and established a plan of action. The decision
was made to not attempt to taxi with snow and ice covering taxiways. We requested to
remain on the runway until a tug could pull our aircraft back to a gate. O'Hare Tower,
Maintenance, Dispatch, Cabin crew and passengers were all kept in the loop and aware of
the plan of action. It took about 40 minutes for a tug to hook up to the plane. We gate
returned and had all luggage reloaded to a new aircraft that was available to use as a
swap. The flight continued with the new aircraft with no other abnormal occurrences.
There was winter weather affecting operations. O'Hare tower when clearing us for takeoff
requested [us to] expedite due to spacing with a landing aircraft on 28C. Other than the
uncommanded swerving, there were no other signs of any mechanical issues that were
obvious to the pilots. The swerving could have been caused by wake turbulence from the
aircraft landing 28C. Unsure of the cause, I opted to be tugged back to the gate rather
than taxi with snow and ice on taxiways.
Synopsis
EMB-145LR Captain reported the aircraft swerved suddenly during the takeoff roll possibly
due to wake turbulence from a landing aircraft on an adjacent runway.
ACN: 1317768 (38 of 50)
Time / Day
Date : 201512
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B757-200
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Flight Phase : Takeoff
Component
Aircraft Component : AC Generation
Aircraft Reference : X
Problem : Failed
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1317768
Human Factors : Situational Awareness
Human Factors : Confusion
Analyst Callback : Completed
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1316603
Human Factors : Confusion
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Returned To Gate
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
During the takeoff roll, after calling "Standard Power set" and before the "80 Knots call"
our aircraft experienced a sudden and simultaneous complete electrical failure except for
the emergency/standby battery bus. All we heard in the cockpit was a 'clunk' followed by
complete dark cockpit except for the standby ADI and left radio and one IRU. The Pilot
Flying immediately performed a Rejected Takeoff (RTO) as I called the problems. Using
the remaining radio I called tower and informed them we were aborting and asked if they
could see us. They informed us we were completely 'dark'. As we came to a stop on the
runway the Captain and I analyzed the situation and determined we should start the APU
to get some taxi lights and outside visibility for safety. We accomplished this, got the
utility bus back on line, and with the towers permission taxied back to the ramp area.
This event was caused by the simultaneous coming off line by both generators leaving
battery power only. I have heard that there was a catastrophic failure of one Integrated
Drive Generator (IDG) which caused a surge knocking the other generator off line.
Speaking to our fleet experts after the event I was informed that what we experienced
was 'impossible' but yet it happened. If it had happened 10 seconds later we would have
been airborne with no checklist procedures to follow. Prior to turning the APU on we
confirmed we had no indication of fire with the tower and could not smell any
smoke/fumes. However the maintenance personnel said there was indication of 'burning'
electrical parts. Again, our experts have told us the chances of having a simultaneous dual
gen failure with no warnings is 'impossible' but I would think exploring the art of the
possible is perhaps needed.
Callback: 1
The First Officer expressed his concerns about the lack of a checklist procedure for a dual
generator failure and the response that "it can't happen."
Narrative: 2
During the Takeoff roll on above 40 KIAS and below 80 KIAS we lost all electrical power
simultaneously except for battery power. We were able to exit the runway safely after the
Rejected Takeoff (RTO). We started the APU and performed the applicable QRH procedures
to include referencing the Brake Cooling Chart.
Synopsis
A B757 flight crew experienced a dual generator failure during the takeoff roll and rejected
the takeoff.
ACN: 1317459 (39 of 50)
Time / Day
Date : 201512
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 2000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility.Visibility : 5
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-700
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Component
Aircraft Component : Trailing Edge Flap
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 131
Experience.Flight Crew.Type : 12000
ASRS Report Number.Accession Number : 1317459
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 181
ASRS Report Number.Accession Number : 1317698
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
The flight was unremarkable until configuring the flaps [for] landing. We were cleared for
an ILS approach to 4R. The aircraft was stabilized on glideslope and on course at 170
knots approximately eight miles from the runway. I was the Captain and the First Officer
was the Pilot Flying. The aircraft was cleared to land and was configured with the flaps set
to five and the landing gear down. The Pilot Flying (PF) asked for flaps 15. As I moved the
flap lever from the five detent to 15, the aircraft experienced a sudden un-commanded roll
to the right. The First Officer (FO) disconnected the autopilot as the aircraft rolled through
30 degrees of bank. At the same time I moved the flaps back to the five detent. The FO
recovered to a wings level attitude and I informed Tower we needed a heading and
altitude as we had to break off the approach. Tower told us to climb to 3000 feet and
contact Approach Control.
Once the aircraft was climbing, we decided to raise the gear but keep the flaps down. I
asked the FO to take over the radios and continue flying while I worked the QRH. We
briefly discussed what we thought the problem was, and what could have caused the roll.
We briefly considered wake turbulence, but decided it was more likely a flap malfunction
or failure as we were not close to the preceding aircraft on final. It took me a few minutes
to decide which checklist to run from the QRH. (Most of the excellent information that was
in the old QRH is difficult to find as it is not tabbed by system.). I knew that the older
model 737s have an un-commanded roll QRC checklist, but the -700 QRH does not
address this. I did find a reference to un-commanded roll at the beginning of the Trailing
Edge Flap Asymmetry Checklist. It was only one bullet point, but I decided this checklist
was the best one to use for an un-commanded roll after flaps are moved. We ran all of the
items for the checklist through the "Before Landing" portion. I also notified the Flight
Attendants and Passengers, sent an ACARS message to Dispatch, [notified] ATC. The FO
gave me control of the aircraft on a ten mile left downwind. He then reviewed the QRH to
make sure everything was accomplished correctly. We finished configuring the aircraft and
left the flaps at five for the landing.
I have never landed less than 30 flaps, except for in the simulator, so I was not sure what
to expect. I used the HUD on final, and had to keep the thrust levers near idle to keep
from getting fast on glidepath. The flare and touchdown didn't seem very different from a
flaps 30 landing. We taxied clear and told Tower we did not need any further assistance.
We taxied to the gate and finished the shutdown and parking procedures like any other
flight, except we opted to keep the flaps at five in case they were damaged. I did call
Dispatch and Maintenance Control and entered the flap discrepancy in the logbook. One
thing I did not do was pull the cockpit voice recorder circuit breaker. (I did not look at the
event reporting chart until after I was at the hotel and did not realize I was supposed to.)
As far as prevention goes, I do not have a suggestion. However; training for the event and
QRH guidance could be improved. It was very stressful trying to find un-commanded roll
guidance in the -700 QRH. I did not feel it was appropriate to study the AOM while burning
what little gas we had left with the flaps stuck down. Perhaps a blurb could be entered in
the flight control tab directing the Pilot to various conditions that might cause the roll. Also
if it is important for me to pull the circuit breaker on the CRV maybe Company could
emphasize this during training, or have Maintenance Control and/or Dispatch help remind
the pilots.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737-700 flight crew reported experiencing an uncommanded roll during flap extension on
approach. Flight landed with flaps set to position 5.
ACN: 1317203 (40 of 50)
Time / Day
Date : 201512
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : LAX.Airport
State Reference : CA
Environment
Flight Conditions : Marginal
Light : Night
Aircraft
Reference : X
ATC / Advisory.TRACON : SCT
Aircraft Operator : Air Carrier
Make Model Name : B757 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use.Localizer/Glideslope/ILS : Runway 24R
Flight Phase : Initial Approach
Route In Use.STAR : RIIVR 2
Airspace.Class B : LAX
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Flight Instructor
ASRS Report Number.Accession Number : 1317203
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I was the pilot monitoring. We flew the RIIVR 2 STAR and were cleared for the ILS to 24R
into LAX. We were on a very long final having previously completed all our checklists and
briefings and after we reviewed the waypoints in the FMS crosschecked with the charts. All
of a sudden the aircraft rolled to the left with the autopilot on in a way that was deliberate.
We were in LNAV and VNAV performing "VNAV to the feather." Prior to the roll we were
centered on the lateral course and centered on the vertical path. I noticed that the aircraft
banked to the left and I saw the "noodle" or white lateral course indicator curve in a circle
to the left on the map display. I said something to the Captain and then almost
immediately ATC asked us if we were on course. I replied that our RNAV system banked to
the left on its own. Then the Captain went into heading mode and armed the localized to
capture. That put us back on course and we continued the approach and landed normally.
It all happened very quickly but I would guess that we were still "established" on the LOC
course the entire time especially considering how far away from the runway we were.
I don't know why this occurred. The roll was not associated with an automation mode
change and the FMS points had been verified using the appropriate charts. I was
impressed by how fast ATC noticed a slight course change and asked us about it. It may
have been wake but it was so smooth and deliberate of a roll that my impression is that
this was not wake turbulence.
Synopsis
B757 First Officer reported a track excursion while on autoflight for unknown reasons.
ACN: 1316669 (41 of 50)
Time / Day
Date : 201512
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 500
Environment
Flight Conditions : Marginal
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use.Localizer/Glideslope/ILS : Runway XXL
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Component : 1
Aircraft Component : Autopilot
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : Autothrottle/Speed Control
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1316669
Human Factors : Distraction
Human Factors : Fatigue
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Human Factors : Confusion
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1316678
Human Factors : Workload
Human Factors : Time Pressure
Human Factors : Fatigue
Human Factors : Distraction
Human Factors : Confusion
Human Factors : Situational Awareness
Events
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We were established on the localizer to the ILS approach. As we were approaching the FAF
with the glide slope indication of a half dot above the aircraft, I as the Pilot Flying, called
for gear down and flaps to 15. At the point that I thought the Pilot Monitoring lowered the
gear, the autopilot and auto throttles suddenly disconnected. At that point, I tried to figure
out why and didn't noticed that I went through the glide slope to being above the glide
slope. I then applied correction to recapture the glide slope. When I adjusted pitch and
power to capture glide slope, I then noticed that the flight director was not showing in the
PFD. Having directional information still showing in the HUD and having clear sight of the
runway, runway lights and approach light, I elected to continue with hand flying using the
HUD and PAPI lights. I then began to notice that I was getting below the glide slope and
began to correct too much and went above it again. By 1000 feet, I elected to continue
because I still had the runway environment in sight and was correcting back to the glide
slope. By 500 feet, I was still correcting to the glide slope that was below the aircraft, and
because airspeed was under control and still in visual conditions, continued to correct pitch
to catch glide slope and then got an aural "SINK RATE" announcement. Made necessary
pitch adjustment, landed under better control in touchdown zone. I know, in hindsight,
that I should have gone around on a couple of locations on the approach because I was
not stable. I fully admit that my false sense of desire to salvage the unstable approach
caused me to make the poor decision to not go around throughout the approach.
Narrative: 2
I was the Pilot-Monitoring in a B737. We were given a RNAV Arrival, and then we were
vectored to intercept the LOC for the approach. Our set up for the approach was good and
we were "in the green".
The Captain was the Pilot Flying at the time. Approaching the FAF we had the autopilot
and the auto throttles on. Airspeed was approximately 180 KIAS with the flaps at 5. The
LOC was captured and the Glideslope was alive. At 1/2 dot below the glideslope the CA
called for "Gear Down" and just as I reached up to extend the gear, the autopilot and auto
throttles disconnected, and the PFD flight director command bars went out of view. I
extended the gear and we set the flaps to 15. I experienced the "swimming in glue"
feeling of trying to understand what had happened to our well set up approach.
The CA continued flying raw data, hand flying the aircraft and throttles with no flight
directors. I began calling out deviations, LOC tracking and airspeed were good, but
glideslope tracking was problematic. I called "Glideslope" when initially we were slightly
low (approx. 1/2 dot) and then called "Glideslope" again as we became one and then 2
dots high.
Our before landing checklist was complete and we were fully configured before 1000 feet
AGL. We still did not have flight director guidance on the PFD's and the captain was hand
flying the airplane and the throttles. The CA called for me to reset the flight director
switches, but we still couldn't make the flight directors work for us. At this point we had
the runway in sight and we were still too high. The captain called correcting but in
hindsight I should have called for a go around. We were too high and we were descending
too rapidly, it was not a stabilized approach.
Synopsis
The B737 crew experienced an autopilot and autothrottle disconnect at glideslope
intercept, which led to an unstable approach. The Captain elected to land.
ACN: 1313853 (42 of 50)
Time / Day
Date : 201511
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 28000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B777 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZZZ
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Cruise
Airspace.Class A : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 27000
Experience.Flight Crew.Last 90 Days : 160
Experience.Flight Crew.Type : 323
ASRS Report Number.Accession Number : 1313853
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 13750
Experience.Flight Crew.Last 90 Days : 214
Experience.Flight Crew.Type : 1254
ASRS Report Number.Accession Number : 1313850
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Physical Injury / Incapacitation
Result.Flight Crew : Diverted
Result.Flight Crew : Landed As Precaution
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Environment - Non Weather Related
Narrative: 1
We were level at FL280 with a smooth ride. The seat belt sign was off with no complaints
from any other traffic. Quite suddenly, we experienced a very slight roll momentarily,
followed by a couple of sudden moderate jolts. I reached up as quickly as I could to turn
the seat belt sign on. We were then immediately back to smooth air again. We told ATC of
our encounter and if there were any complaints out there. He responded that there were
no complaints all afternoon. We did notice that there was TCAS traffic about 17 miles
ahead and 2,000 ft. above us in a crossing pattern. I can only surmise that we possibly
encountered wake turbulence from that aircraft in front of us, as I have no other plausible
explanation. I called the cabin to check on everybody and found that two flight attendants
had been injured. Our Chief Purser headed to the back of the cabin to find out what
happened. In a little while he called back to tell us that one flight attendant had bruised
his arm or elbow during the event, and another flight attendant had a more substantive
injury. During the turbulence encounter, one of the large serving carts fell over onto her
foot creating an extremely painful injury.
Chief Purser then followed protocol and solicited onboard medical personnel. He wound up
with a paramedic, a nurse, and of all things, a podiatrist. They began attending to the foot
injury, while the Purser initiated a call to Medlink from the back cabin. As they were
working the problem in the back, I was giving Dispatch a heads up on what was taking
place. I advised that we were still waiting to find out about the seriousness of the problem,
and to be prepared for a possible diversion.
We finally heard back from [Chief Purser] and was told that [the foot] injury could be
some sort of fracture but really unsure of that. We were also told that she would definitely
be out of commission for the rest of the flight, with having to keep her foot elevated with
ice application and ibuprofen for pain and swelling. The docs all had decided that it would
probably be safe for continuing on to [destination].
I was concerned that such a long flight at high altitude could cause swelling issues and
pain beyond necessary. [Chief Purser] questioned her a bit more about her uneasiness to
continue, and found that she had just successfully battled cancer with a routine of
chemotherapy. When the onboard docs heard that, they immediately changed their minds
about continuing on. They didn't want to take any chances with possible blood clotting or
other complications. That then made the decision to divert quite easy and prudent. After a
quick call with Dispatch, we decided to divert to [a nearby airport].
Clearance was given right away to proceed direct to [the divert airport]. We proceeded
with the diversion, and began following our own protocol with the FOM [QRH] Diversion
Guide. We also made an announcement to our passengers about what was taking place
and why. At this point, we were about 30 minutes or so from [landing], and began
dumping fuel as we needed to lose 100,000lbs of weight to get down to max landing
weight.
There was medical personnel standing by upon landing. We blocked at gate and medical
personnel came aboard right away and headed back to attend to our injured flight
attendants. Both flight attendants were taken off the aircraft for medical evaluation.
Many thanks to all involved for a successful outcome to this event.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B777 flight crew reported two flight attendants were injured when they encountered
probable wake turbulence at FL280 from a crossing aircraft at FL300.
ACN: 1312744 (43 of 50)
Time / Day
Date : 201511
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZGGG.Airport
State Reference : FO
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZGZU
Aircraft Operator : Air Carrier
Make Model Name : Light Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Flight Phase : Climb
Route In Use.SID : VIBOS1A
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1312744
Human Factors : Fatigue
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
This is two events that are rolled into one. It was the 9th day of an around the world trip.
My pairing had just been revised and I was flying the first leg with a new first officer.
Everything was going smoothly until all of the sudden we were behind when closing up the
jet and getting ready for pushback. Prior to receiving the clearance I had entered the
Vibos1g departure off of runway 01 at ZGGG and briefed it and made a mental note to
verify that it was correct when we received the departure clearance. When we got the
clearance we were given the Vibos1a and I guess I got confused and assumed that that
was the one I had entered and briefed. After takeoff, the departure controller started
asking us what departure procedure we were on and there were a couple of transmission
before we figured out what he was asking. He said we were west of course, which didn't
make any sense to us. By the time we figure out what he was saying to us it was too late
and he started vectoring us.
We switched the FMS to the Vibos1a departure right as he started vectoring us. It was
executed but never cleaned up so a disconnect was created after the first point on the
Vibos1g - gg418. After it was executed, the speed restriction was deleted for the turn so
the airplane started to accelerate. We cleaned it up as we passed gg418 and commenced
the turn to the assigned heading of 270. As we passed gg418 and hit the disconnect, the
aircraft reverted to v/s and was in a high enough nose attitude that as we raised the flaps
we entered stick shaker. I disconnected the autopilot and recovered the airplane. We
continued to climb the entire time but it took a few seconds before we got the flight
directors off/on to get a pitch bar back. We went back on the autopilot and the rest of the
flight was uneventful.
It was entirely my fault for entering and then not verifying the correct departure
procedure. That led directly to a chain of events that caused the stick shaker activation. I
made another mistake of going heads down to look at what was entered in the FMS and
left the autopilot unattended at exactly the wrong time and missed the events unfold as
we raised the flaps. I looked up just in time to see our airspeed deteriorate into the foot.
Cumulative fatigue was involved as I do not sleep well on east bound around the world
trips. I did not realize how tired I was until we got to the hotel and slept solidly for 4 hours
but then tossed and turned for several more. I didn't think I was going to sleep at all when
we first got there.
More attention to detail prior to closing up and taxiing. The sudden rush we experienced
just prior to departure could easily have been prevented by just saying "slow down."
Maybe then we would have caught the incorrect departure procedure. I will also not get
complacent and go heads down when I'm the pilot flying - "like we are told repeatedly in
training!" On the fatigue issue, I have been trying to just sleep whenever my body says
too, but I'm still not doing well on east bound long haul trips. West bound I seem to do
much better.
Synopsis
Air Cargo Captain reported speed and track deviations related to fatigue issues.
ACN: 1311216 (44 of 50)
Time / Day
Date : 201511
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZOA.ARTCC
State Reference : CA
Altitude.MSL.Single Value : 32000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZOA
Aircraft Operator : Corporate
Make Model Name : Gulfstream V / G500 / G550
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class A : ZOA
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZOA
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Flight Plan : IFR
Flight Phase : Cruise
Airspace.Class A : ZOA
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 14100
Experience.Flight Crew.Last 90 Days : 60
Experience.Flight Crew.Type : 4100
ASRS Report Number.Accession Number : 1311216
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Environment - Non Weather Related
Narrative: 1
Were you aware of the other aircraft before the event? NO X
If so, how? Visual 0 ATC Traffic Advisory 0 TCAS 0 Other 0
What was the position of the OTHER AIRCRAFT, when you encountered wake turbulence?
Level
Flight Level Unknown?
Climbing
Descending
Opposite direction
Unknown Feet above?Unk Miles past
Same direction
Unknown Feet above?Unk Miles in front
Converging
Unknown Feet above?Unk Miles away
Crossing
Unknown Feet above ?Unk Miles in front
Briefly characterize the magnitude of the wake turbulence:
Moderate
Did you experience VERTICAL ACCELERATION?
?YES NO X
What was the change in ALTITUDE? No
What was the change in aircraft ATTITUDE? Estimate angle of change in:
?PITCH 0 ROLL 40 degrees right YAW 0
Was there buffeting? NO X
Was there stick shake? NO X
Was the autopilot engaged? YES X
Was the auto throttle engaged? YES X
Synopsis
G-V Captain reported a wake turbulence encounter at FL320 that resulted in an
uncommanded 40 degree bank.
ACN: 1306332 (45 of 50)
Time / Day
Date : 201510
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 27000
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B757-200
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Flight Phase : Climb
Airspace.Class A : ZZZ
Component
Aircraft Component : Autoflight Yaw Damper
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Experience.Flight Crew.Total : 15000
Experience.Flight Crew.Last 90 Days : 90
Experience.Flight Crew.Type : 12000
ASRS Report Number.Accession Number : 1306332
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
ASRS Report Number.Accession Number : 1307191
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Landed As Precaution
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Climbing through FL270 the aircraft started violently rolling left and right, uncommanded,
and very near uncontrollably. There were no associated messages on the EICAS panel nor
were there any lights illuminated on the overhead panel. What needs to be emphasized
here is that it was very difficult to maintain control of the aircraft and there were no
associated messages notifying us of a problem. We leveled off at FL270, slowed to 250
knots, notified ATC of our deviations and basically just worked to keep the aircraft straight
and level. Quickly, the FO and I determined that the first thing we should do was to isolate
the yaw dampers. After turning the right one off the problem persisted so we switched it
back on and tried the left one. Once it was switched off the problem stopped. At that
point, we notified ATC that we would be remaining at FL270 and would be returning to
normal speed. I called maintenance control and Dispatch to bring them up to speed on our
issue. Maintenance just told us to follow our QRH procedure of which there was none due
to not having any associated EICAS message, and Dispatch asked us if we felt comfortable
continuing on to [a nearby alternate], [to] which I replied yes because we were already
halfway there and had 95 knots of wind on the tail. The rest of the flight was uneventful.
Once on the ground, the mechanic meticulously followed his maintenance procedures
inspecting the aircraft for stress and damage and informed us that maintenance
engineering had pulled the data which apparently did not show a problem with the yaw
damper nor were any exceedences recorded. He ended up deferring the left yaw damper
and we pressed on to [destination].
Narrative: 2
[Report narrative contained no additional information].
Synopsis
B757-200 flight crew reported diverting to a nearby alternate when they experienced
violent nearly uncontrollable rolls in climb at FL270 from a malfunctioning yaw damper.
ACN: 1305550 (46 of 50)
Time / Day
Date : 201510
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 26000
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZZZ
Component
Aircraft Component : Autoflight Yaw Damper
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1305550
Human Factors : Training / Qualification
Human Factors : Troubleshooting
Human Factors : Workload
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Maintenance
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Maintenance
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.General : Release Refused / Aircraft Not Accepted
Result.Flight Crew : Diverted
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : FLC complied w / Automation / Advisory
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Procedure
Primary Problem : Aircraft
Narrative: 1
Normal flight until we were level at FL260. We felt something that we weren't sure what it
was. It felt like a yaw to the right, but we were in a turn to the left. We called the flight
attendants and asked them if they felt anything weird in the back. They said "no" so we
continued. About 10-12 minutes later we are in level cruise 320kts. The aircraft yawed 3/4
of the brick on the slip indicator to the right. This time the flight attendants felt it and we
knew it was un-commanded yaw. We ran the immediate action item and complied with the
QRH. Land at Nearest Suitable Airport. We [advised ATC] and proceeded to a nearby
airport.
After getting safely on the ground talking to the CFR people and deplaning, we called
maintenance (Mx) control. They in turn called out a local mechanic. He showed up to the
plane with little or no idea of what he was there to do. He asked me if I would mind
swinging the rudder full deflection from left to right using only one hydraulic system at a
time. So, system 1 only on back and forth the same for 2 and then 3. I'm not sure if it's a
coincidence or if he caused this problem by not referencing a task sheet so, I couldn't be
sure if this was an approved procedure or not. But it caused several faults that weren't
there before. Since there was no task sheet that the mechanic had for this procedure it
was unclear if this was normal for this procedure or not, but now we have SSCU 1 and
SSCU 2 fault status messages. He returns to the cockpit with "hey guys great news the
rudder travel is free and clear. You're good to go." The mechanic performing the test of
the rudder with no use of a task sheet made me a little suspicious. Now he has to deal
with the SSCU faults. He is on the phone with MX control. They start performing SPOST
test. The system will not test. They have tried doing this test 4 times. MX control tells the
local mechanic to re-rack the SSCU boxes in the avionics bay. They shut the plane down,
re-rack and restart. The system resets and test correctly. They are all patting themselves
on their backs. Nothing has been done about the yaw damper at all. To be extra vigilant
after one emergency and to prevent another. I ask the local mechanic if he minds showing
me the task sheet that he was given by our company. There wasn't one. Nothing. In the
name of safety, I asked him to please call maintenance control back and have him fax
over the task sheet for testing the yaw damper. After a while he appears with it and
proceeds to run the test on the yaw damper. Finally.
After all of this, I am informed that they tested okay and that they were going to defer the
autopilot system. I asked why? This is a 2 axis autopilot system. That's not going to
correct the problem. We still have the FCC giving signals to the yaw damper servos. After
learning what they are planning to with this aircraft I called [an expert] from [a division of
a manufacturing company]. I called him to confer with him about the aircraft systems.
Just to confirm my thoughts. He offered to speak with MX control to tell him that the route
that he was taking was not the correct. MX control and [the expert] spoke. I then spoke
with [the expert] and he said that he helped point the MX controller in the right direction. I
thought that was the end of the issue. I then have the captain's phone given to me. It's
MX control. He is still going to defer the autopilot against the recommendations of [the
expert]. Then he explains how he had a conference call with someone in engineering,
operations, and Quality assurance. He feels that his work is the best resolution.
At this time I have a major concern I feel like the maintenance controller has a very large
educational gap of our aircraft systems and is trying to use his limited knowledge to try to
strong arm us into flying an unsafe plane. I called [the expert] back he and I are on the
same page he said that he would not take this plane if he were on it. I am of the same
mindset. He then calls [company] and we decided to refuse the plane. [Company] called
the Captain and told him he would back our decision not to operate the aircraft. We did
accept the 2 hour extension to operate the relief flight, but scheduling gave that flight to
the fresher inbound reserve pilots.
My question is why does maintenance think that deferring the autopilot (which does not
disable the FCC's or YD's) would make it safe to dispatch an airplane that had already
experienced a rudder hard over in flight? Shouldn't they have disabled the YD controller?
The threat that mainly exposed itself was the fact that the person in maintenance control
needs further education on the CRJ7/9 systems. I cannot say that this will or cannot
happen again to an aircraft in our fleet. I do hope that this event has shown the weakness
in some of our procedures. Maybe there can be something done about that.
Synopsis
A CRJ-700 crew experienced an uncommanded rudder input at cruise and diverted as per
the QRH. A Contract Mechanic and Company Maintenance Control diagnosed the system
and concluded an autopilot fault. However, this autopilot has no rudder input.
ACN: 1304387 (47 of 50)
Time / Day
Date : 201510
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 40500
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Taxi
Make Model Name : BAe 125 Series 800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 135
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZDC
Component
Aircraft Component : Aeroplane Flight Control
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Taxi
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1304387
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Environment - Non Weather Related
Primary Problem : Aircraft
Narrative: 1
At FL400, two hours after takeoff, the First Officer's control stick began several forward
and aft movements as it attempted to trim to maintain altitude. Suddenly, without the
autopilot disconnecting, the nose pitched up and [the aircraft] began an immediate 1500
foot per minute climb. The First Officer disconnected the autopilot but the aircraft reached
between FL404 and FL405 before the climb was stopped. We immediately notified ARTCC
of the altitude diversion and requested a lower altitude to FL280 (out of the RVSM
airspace). The autopilot was not reconnected.
We noticed the pitch trim to be extremely difficult to operate with "catches" in the control.
Extreme stiffness and then a "catch" then stiff movement again. The aileron trim was not
moveable, frozen in position. On landing we noticed the aileron trim seemed free, and the
pitch trim was easily operated.
Speculation may lead to an iced control system. Weather in departure airport was light
rain, overcast at 2100 feet, winds 180/15 with 10 miles visibility and 30.17 inches of
mercury. We did encounter rain on the climbout, but had been clear at FL400 for over an
hour. The temperature at FL400 was -40C.
Complete a maintenance inspection and determine the cause of the flight control/trim
malfunction.
Synopsis
BAE125-850XP First Officer reported possible flight control icing, which led to an altitude
excursion at FL400.
ACN: 1302352 (48 of 50)
Time / Day
Date : 201510
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : LGA.Airport
State Reference : NY
Environment
Flight Conditions : VMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : LGA
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Climb
Route In Use.Other
Airspace.Class B : LGA
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1302352
Human Factors : Distraction
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1302350
Human Factors : Situational Awareness
Human Factors : Distraction
Human Factors : Training / Qualification
Events
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We experienced a lateral deviation while departing LGA Runway 13 on the Whitestone
Climb. We had just started a four day trip and since I had flown the first leg into LGA, this
was the FO's leg as pilot flying. The FO was not familiar with LGA operations so there was
a lot to discuss during our quick turn at LGA. Although our time was compressed, we
discussed everything as thoroughly as possible at the gate.
We pushed back and I taxied slowly so we would have enough time to prepare for
everything else that needed to be addressed. Since we hadn't reviewed the complex single
engine-out procedure at the gate, it took quite a while to find and brief the procedure on
the new EFB but all duties were completed before we reached the runway.
On takeoff the FO over-rotated which was alarming and caused a steep nose up attitude
and possible tail strike situation. I called for a reduction in pitch and monitored the pitch
angle. While my attention was being diverted the FO called for "NAV mode" and I
mistakenly selected "heading" on the FMS control panel. While the FO was attempting to
correct the pitch he called for "autopilot on". The autopilot was selected on but the pitch
was still so high the trim runaway clacker sounded. I had never heard this warning before
with the auto pilot on and this caused further concern.
During this time the aircraft remained on the 180 degree heading while climbing 2,500
feet per minute. This was happening while we were trying to get the pitch, v/s, flaps, and
now increasing air speed under control. We should have been turning to a 40 degree
heading but were still flying 180 degrees. The tower informed us of our mistake and then
gave us a north bound vector.
There was no known conflict and the rest of the flight was uneventful.
Threats were:
- The unique operating environment that LGA presents.
- The fast pace of operations at LGA.
- Multiple complex procedures at LGA.
- The lack of the FO's experience and familiarity.
- My lack of recent experience flying with a new hire pilot.
Errors include:
- FMS entry mistake and lack of recognition by myself.
- Over rotation on takeoff and lack of experience by the FO.
Undesired state:
The aircraft remaining on a 180 degree heading instead of turning to 40 degrees.
LGA requires that both pilots bring their "A" game and operate at 100% all of the time. I
will have to up my game when operating into LGA. I need to always select the correct
modes on the FMS and I must be especially vigilant when flying with an inexperienced FO.
The company could possibly prevent this from happening by providing more training or
exposure to new hires.
Narrative: 2
[Report narrative contained no additional information].
Synopsis
CRJ-700 flight crew reported they deviated from cleared departure track out of LGA when
they were distracted at a critical time.
ACN: 1300945 (49 of 50)
Time / Day
Date : 201510
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Relative Position.Angle.Radial : 080
Relative Position.Distance.Nautical Miles : 1
Altitude.MSL.Single Value : 1600
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 5
Light : Night
Ceiling.Single Value : 5000
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B767-300 and 300 ER
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Flight Phase : Takeoff
Airspace.Class C : ZZZ
Component
Aircraft Component : Turbine Engine
Aircraft Reference : X
Problem : Failed
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Experience.Flight Crew.Total : 10500
Experience.Flight Crew.Last 90 Days : 130
Experience.Flight Crew.Type : 95
ASRS Report Number.Accession Number : 1300945
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Experience.Flight Crew.Total : 8000
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 4000
ASRS Report Number.Accession Number : 1300947
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Inflight Shutdown
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
The takeoff was done by the Captain. Due to the heavy weight of 365,000 lbs and obstacle
departure procedure we elected to use a maximum thrust takeoff setting. Takeoff roll and
rotation was normal. At 400 feet we selected LNAV and commenced the right turn for the
departure. At approximately 600-700 feet AGL, in the right turn, there was a slight jerk to
the left and the aircraft stopped turning. We both verified the left engine had quit. The
engine failure was sudden and without warning. There were no abnormal indications prior
to the engine failure. After verifying what happened we were over our turn point for the
special engine out procedure. Heading select was called for and we continued the right
turn. At this point we contacted ATC and advised them of our intention to fly the 206
heading. We continued the climb to level off height and began to speed up and clean up
the aircraft. At this time we also confirmed that the left engine had flamed out. We
coordinated with ATC for a higher altitude and began to run the "Engine failure/Shutown"
checklist.
We both agreed that attempting a restart would be time consuming and distracting, and
going to [destination] was obviously not an option anymore. We made the decision to land
single engine back in ZZZ. After finishing the "Engine failure/Shutdown" checklist we
consulted the Non-Normal Configuration Landing Distance Table. We were going to land at
approximately 360,000 lbs, about 32,000 lbs over weight. We had virtually no center tank
fuel to dump and we were still feeding the good engine with what was left in the center
tank which was about 3,000 lbs. We asked for and were given the longest runway for
landing which gave us about 2,000 feet more runway for the overweight landing. The
approach and landing were uneventful. Manual brake usage was used on rollout and were
what I would describe as minimal. Deceleration was normal with maximum reverse thrust
used on the right engine. After turning left we informed the tower we would let the fire
crew examine the left engine. At this time we were informed by fire crew that there was
fluid leaking out of the left engine. Also at this time fire crew notified us of smoking left
brakes. Not wanting a pool of fuel by the hot brakes we cleared the fire crew away and
continued the taxi, very slowly, East towards the ramp to cool the brakes. The hottest
brake temperature we saw on the left was one 9 and three 8's. The right side was mostly
5 and 6. While taxing we were informed that the leak was still there. With brakes as hot as
they were, the possibility of fuel leaking and the potential for thermal plug discharge, we
elected to stop the aircraft and chock the aircraft. While waiting for ground support the
brakes cooled to reasonable levels. That's when the thermal plugs started to blow. The
brake temperatures at this time were one 7 and three 6's. We lost 3 tires on the left side
while waiting for ground support.
Narrative: 2
[Report Narrative Contained No Additional Information.]
Synopsis
B767-300 flight crew experiences a sudden engine failure at 700 feet AGL after takeoff.
The engine is shut down and the flight returns to the departure airport for an overweight
landing. ARFF reports fluid leaking from the shut down engine and three of the four tires
on that truck deflate due to temperature.
ACN: 1299693 (50 of 50)
Time / Day
Date : 201510
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Training
Flight Phase : Landing
Maintenance Status.Maintenance Deferred : N
Maintenance Status.Released For Service : Y
Component : 1
Aircraft Component : Throttle/Power Level
Manufacturer :
Aircraft Reference : X
Component : 2
Aircraft Component : Thrust Reverser Control
Manufacturer :
Aircraft Reference : X
Component : 3
Aircraft Component : Powerplant Fuel Control
Manufacturer : GE CF-34
Aircraft Reference : X
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1299693
Human Factors : Confusion
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Check Pilot
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1299694
Human Factors : Confusion
Human Factors : Situational Awareness
Analyst Callback : Completed
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected.Other
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We were on approach to landing Runway 27. I was pilot flying. The approach was normal,
in the flare I brought the thrust levers to idle at the appropriate time. The left thrust lever
stopped at idle and the right continued slightly. When I went to deploy reverse thrust, the
left reverser deployed and the right thrust lever went back a little bit more. The Captain
took control of the airplane when only the left reverser deployed. After we were pulled off
the runway, I saw the right engine was in shutdown and the engine was spooling down.
We stopped on the parallel taxiway and restarted the engine before taxiing back to the
gate.
Narrative: 2
First Officer (FO) was the Pilot Flying and I was the PM giving instruction. Approaching
Runway 27 everything looked really good, FO was doing a good job keeping airspeed and
keeping the aircraft on glideslope. Touchdown was firm and on centerline and well within
our standards. I was guarding the flight controls with my feet on the rudder pedals and
hand on the yoke. My right hand was down low on the lower pedestal just in case I needed
to take over and add power. After main wheels touchdown FO brought the nose wheel
down nice and gentle. On the roll out, FO deployed thrust reversers with only the left
deploying. I looked down at the switches and both reversers where armed. Rolling down
the FO told me there was a split on the power levers and it was then that I realized the
right engine was shut down. I took over the controls and taxied off the runway. I never
saw the FO pull the [shut-off] trigger and I always saw his hand on top of the power
levers. I really do not know how the right engine shut down. I really cannot say what the
cause of this was, since Standard Operations Procedures (SOP) was followed. FO or I
never pulled the trigger to shut down the engine. FO and I retraced our steps and could
not come up with an explanation on what could have caused the right engine to shut down
while on the rollout.
Callback: 2
Reporter stated the First Officer was in training and transitioning from Turboprops to their
CRJ-700 aircraft. The aircraft and FO were performing just fine when the right engine
suddenly shutdown. He has thought over and over again about the sequence of steps they
had accomplished prior to the engine event and cannot find any reason for the shutdown
except for an inadvertent contact with the shut-off trigger handle (switch) on the lower aft
side of the engine throttle lever. All the more frustrating because the First Officer had
performed very well and neither he, nor the FO could remember ever touching the shut-off
trigger. Since the right engine restarted without any problems and no EICAS fault
messages appeared, the possible movement of the right engine shut-off trigger seems to
be the only plausible explanation.
Synopsis
A First Officer and Check Pilot reported a sudden, unexplained shutdown of the right
engine on a CRJ-700 aircraft during the landing rollout on a training flight. The Check Pilot
noted he never saw the FO pull the right engine shut-off trigger and only observed the
First Officer's hand on top of the power levers.
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