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ASRS Database Report Set
Altitude Deviations
Report Set Description .........................................A sampling of reports referencing altitude deviations for all types of operations
Update Number ....................................................28.0
Date of Update .....................................................April 28, 2017
Number of Records in Report Set ........................50
Number of New Records in Report Set ...............50
Type 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.
ACN: 1427065 (1 of 50)
Synopsis Airbus A320 series flight crew experienced a terrain warning descending to 10,000 feet
approximately 9 NM east of KICDO during the ILS 12 at BZN. The aircraft was climbed to
11,000 feet and ATC confirmed that 10,000 feet was the correct altitude.
ACN: 1426758 (2 of 50)
Synopsis Light twin pilot reported encountering severe turbulence and windshear on downwind for
the SLC ILS Runway 34L at 10000 feet in IMC. 2000 feet were lost and a terrain warning
was received along with a master warning for fuel pressure before control was regained.
ACN: 1422154 (3 of 50)
Synopsis Air carrier Relief Pilot reported descending to 2200 feet after being cleared for the CYHM
ILS Runway 12 direct APGOM. Pilot cited confusion as to the allowable minimum no
procedure turn (NoPT) altitude and noted a disparity between the ILS Runway 12 NoPT
(2200 feet) and ILS CAT II Runway 12 NoPT (2700 feet) altitudes.
ACN: 1419082 (4 of 50)
Synopsis B737-NG First Officer reported receiving a low altitude alert from ATC on approach when
the stab trim failed leaving them with manual trim only.
ACN: 1419020 (5 of 50)
Synopsis B737 Captain reported receiving a low altitude alert from ATC on approach to RNO even
though the aircraft appeared to be on course and altitude.
ACN: 1419010 (6 of 50)
Synopsis ZMA Controllers reported that an aircraft took a heading as a climb instruction and became
a conflict for another aircraft. Controllers reported the sector was combined and busy.
ACN: 1418920 (7 of 50)
Synopsis A general aviation pilot reported altimeter accuracy issues during a practice instrument
approach. Pilot elected to break off approach in VMC conditions and return to base airport.
ACN: 1418741 (8 of 50)
Synopsis CRJ-700 Captain reported being issued incomplete, confusing go-around instructions from
a TRACON Controller.
ACN: 1418434 (9 of 50)
Synopsis Military trainer pilot reported overshooting a 5,000 foot altitude constraint with traffic at
6,000 feet.
ACN: 1418407 (10 of 50)
Synopsis Pilot and ATC reported a miscommunication in issuing and receiving an altitude crossing.
The crew overshot the intended altitude, but corrected back once ATC clarified the
clearance.
ACN: 1418216 (11 of 50)
Synopsis A BTV TRACON Controller reported observing an aircraft descend below its assigned
altitude and below the Minimum Vectoring Altitude.
ACN: 1418186 (12 of 50)
Synopsis C550 pilots reported incorrectly setting their altitude during a descent to RNO resulting in
overshooting their assigned altitude.
ACN: 1417975 (13 of 50)
Synopsis B737-700 flight crew reported a sudden increase in tailwind resulted in climbing through
the assigned cruise altitude.
ACN: 1417942 (14 of 50)
Synopsis ZOA Controller reported observing another Controller work an aircraft in downdrafts over
mountains, but did not handle the situation according to standards.
ACN: 1417678 (15 of 50)
Synopsis
PA28 pilots reported experiencing carburetor icing at 10,000 feet. Their engine began to
lose power, so they applied carb heat and descended to 6,000 feet. During the descent
they regained full power and continued.
ACN: 1417397 (16 of 50)
Synopsis Air carrier First Officer reported missing a crossing restriction due to premature selection
of the next hard altitiude.
ACN: 1417282 (17 of 50)
Synopsis B757 flight crew reported an autopilot malfunction which resulted in a missed crossing
restriction and a track deviation. Reengaging the left autopilot caused more problems, but
the right autopilot functioned normally.
ACN: 1417158 (18 of 50)
Synopsis A321 Captain reported discovering that the older A321s have very poor performance when
compared with the newer ones that he is used to flying. The crossing restriction at KEGGS
on the LAX LOOP9 was missed by 500 feet.
ACN: 1416914 (19 of 50)
Synopsis B787 flight crew reported entering a small thunderstorm at night that they did not notice
on Radar due to the large scale selected.
ACN: 1416887 (20 of 50)
Synopsis Air carrier flight crew, while deviating around weather, was questioned by ATC if they were
proceeding to the cleared waypoint. The crew was convinced they were but ATC still
questioned their track.
ACN: 1416882 (21 of 50)
Synopsis Air carrier flight crew reported they exceeded an altitude restriction while on the KATMN5
SID.
ACN: 1416806 (22 of 50)
Synopsis
ZDV Controller and the flight crew involved reported they did not comply with a clearance
to be level at an altitude in two minutes or less. A loss of separation with opposite
direction traffic resulted.
ACN: 1416696 (23 of 50)
Synopsis CRJ-900 Captain reported descending below assigned altitude on approach to PIT and
receiving an obstacle warning from the EGPWS.
ACN: 1416372 (24 of 50)
Synopsis Air Carrier First Officer reported two unstable visual approaches by the Captain flying into
MMZH. The first ended in a go-around and the second was almost another go-around
when the Captain settled the aircraft down to near stabilized parameters.
ACN: 1416123 (25 of 50)
Synopsis MD80 Captain reported a right hydraulic system failure which necessitated a manual gear
extension with a normal landing and a tow off the runway.
ACN: 1415813 (26 of 50)
Synopsis EMB145 First Officer reported a terrain warning after being cleared by Approach to
descend to 3000 feet. Evasive action was taken, but no reason for the warning could be
found.
ACN: 1415788 (27 of 50)
Synopsis B757 flight crew reported a go-around from the flare due to a strong crosswind gust. The
airspeed was allowed to get low and the missed approach altitude was overshot.
ACN: 1415751 (28 of 50)
Synopsis B737 Captain reported descending on the IAH DRLLR5 Arrival for Runway 26R then
assigned Runway 27 and multiple speed adjustments. This resulted in crossing BYSUN 500
feet high.
ACN: 1414698 (29 of 50)
Synopsis
CE-750 Captain reported they were unable to make assigned altitude at their coast-out
point when the temperature rose above forecast.
ACN: 1414639 (30 of 50)
Synopsis CRJ-700 First Officer reported speed dropped off enough in severe turbulence to trigger a
momentary stick shaker at FL360.
ACN: 1414621 (31 of 50)
Synopsis CRJ-900 First Officer reported descending below a transition crossing altitude on the BOS
ROBUC2 Arrival. They attributed the error to missetting the Multifunction Display range
and confusing chart presentation.
ACN: 1414603 (32 of 50)
Synopsis CRJ-700 Captain reported executing a go-around after receiving a windshear aural alert on
approach to LGA.
ACN: 1414574 (33 of 50)
Synopsis A pilot reported not receiving the latest ATIS information for an airport and did not have
the fix they were cleared to programmed in their FMS.
ACN: 1414567 (34 of 50)
Synopsis CRJ-700 Captain reported an altitude overshoot on go-around due to a spoileron/outboard
spoiler malfunction.
ACN: 1414402 (35 of 50)
Synopsis Air carrier Captain reported confusion with expected altitude on descent clearance from
Houston Approach.
ACN: 1413426 (36 of 50)
Synopsis B787 First Officer reported a severe wave encounter at FL380 which resulted in an
overspeed and uncommanded 500 foot climb.
ACN: 1413229 (37 of 50)
Synopsis ZNY Controller reported of an unsafe situation when a fellow Controller climbed an aircraft
to avoid a loss of separation. The other Controller climbed the aircraft in what the reporter
thought was too short of a time period.
ACN: 1413202 (38 of 50)
Synopsis PA31 pilot reported while flying during extreme cold conditions, an inoperative cabin
heater caused the cabin of a twin piston aircraft to become abnormally cold. Pilot stated
this resulted in difficulty reading the GPS screens, failure of the autopilot, and the need for
ATC assistance with a diversion.
ACN: 1413139 (39 of 50)
Synopsis Airbus Captain reported an NMAC after departure from SJU. He received a RA to climb
which could not be complied with due to aircraft performance limitations.
ACN: 1412991 (40 of 50)
Synopsis B777 Captain reported encountering severe turbulence in departure climb.
ACN: 1412876 (41 of 50)
Synopsis CL-30 flight crew reported encountering severe turbulence in descent over the front range
of the Rockies.
ACN: 1412795 (42 of 50)
Synopsis Air carrier flight crew reported a diversion to BTV after runway conditions deteriorated at
CYUL. Captain reported BTV was not a very good alternate, but due to their fuel state
elected to successfully land even though he received a wind shear alert on the second
approach.
ACN: 1412626 (43 of 50)
Synopsis A flight instructor reported misunderstooding the clearance altitude while on a San Diego
Bay tour. They descended to 500 feet until ATC corrected them and they climbed to
assigned crossing altitude.
ACN: 1412623 (44 of 50)
Synopsis C182 pilot reported smoke in the cabin while on an IFR flight plan, and electing to divert to
a nearby airport without notifying ATC.
ACN: 1412163 (45 of 50)
Synopsis Aero Commander 690 pilot reported an altitude deviation occurred when the autopilot was
inadvertently disconnected.
ACN: 1412041 (46 of 50)
Synopsis Aircraft reported while on final approach the Tower frantically called to "CHECK
ALTITUDE", which set the crew up for a chain of events that led to a go-around.
ACN: 1411417 (47 of 50)
Synopsis B737 Captain detailed problems associated with a DCA RNAV arrival relative to FMC
capabilities and increased workload imposed on flight crews.
ACN: 1411411 (48 of 50)
Synopsis B737NG Captain reported flying the DFW VKTRY 2 RNAV Arrival "DESCEND VIA" set 7,000
feet as the final procedural altitude verses 5,000 feet, because after enlarging the
procedure on the EFB, the Runway Transition was not visible in the upper left corner,
opposite direction from the lower right final procedures' termination.
ACN: 1411410 (49 of 50)
Synopsis Airbus Captain reported encountering a mountain wave during a climb from FL290 which
oversped the aircraft during an uncontrollable climb to FL330.
ACN: 1411389 (50 of 50)
Synopsis B737NG Captain reported flying a visual approach with LOC Back Course back up to SNA
Runway 2L, executed a missed approach at an EGPWS TERRAIN Warning in weather far
worse than reported on ATIS. The second RNAV 2L approach was flown to minimums for a
successful landing.
ACN: 1427065 (1 of 50)
Time / Day
Date : 201702
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : BZN.Airport
State Reference : MT
Altitude.MSL.Single Value : 10000
Environment
Flight Conditions : IMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : BOI
Aircraft Operator : Air Carrier
Make Model Name : Airbus 318/319/320/321 Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : GPS
Nav In Use.Localizer/Glideslope/ILS : Runway 12
Flight Phase : Initial Approach
Airspace.Class E : BOI
Component
Aircraft Component : GPWS
Aircraft Reference : X
Problem : Design
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)
Experience.Flight Crew.Type : 498
ASRS Report Number.Accession Number : 1427065
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)
Experience.Flight Crew.Type : 482
ASRS Report Number.Accession Number : 1427046
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft Terrain Warning
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Air Traffic Control : Issued Advisory / Alert
Result.Air Traffic Control : Issued New Clearance
Result.Aircraft : Equipment Problem Dissipated
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Procedure
Primary Problem : Aircraft
Narrative: 1
In the descent to BZN, we were given direct KICDO (IAF on ILS 12) and a descent to
10,000 MSL. Approximately 9-10 miles east of KICDO, we received a GPWS "TERRAIN,
TERRAIN" while IMC. I, as pilot flying, performed the GPWS escape maneuver and climbed
up to 11,000 while the captain notified ATC and we were given a stop climb at 11k. The
controller said he doesn't usually have anyone have any GPWS hits in that sector but also
mentioned the MSA had recently changed in the past few months. We continued to fly the
ILS to a full stop without any more incidents.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Airbus A320 series flight crew experienced a terrain warning descending to 10,000 feet
approximately 9 NM east of KICDO during the ILS 12 at BZN. The aircraft was climbed to
11,000 feet and ATC confirmed that 10,000 feet was the correct altitude.
ACN: 1426758 (2 of 50)
Time / Day
Date : 201702
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : SLC.Airport
State Reference : UT
Altitude.MSL.Single Value : 10000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Windshear
Weather Elements / Visibility : Snow
Weather Elements / Visibility : Icing
Light : Night
Aircraft
Reference : X
ATC / Advisory.TRACON : S56
Aircraft Operator : Personal
Make Model Name : Small Transport, Low Wing, 2 Turboprop Eng
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Nav In Use.Localizer/Glideslope/ILS : Runway 34L
Flight Phase : Initial Approach
Route In Use : Vectors
Airspace.Class B : SLC
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 : Commercial
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 3200
Experience.Flight Crew.Last 90 Days : 20
Experience.Flight Crew.Type : 600
ASRS Report Number.Accession Number : 1426758
Human Factors : Other / Unknown
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft Terrain Warning
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Air Traffic Control : Issued Advisory / Alert
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Had lined up for the ILS 3 at OGD, but at glideslope intercept weather had dropped to 1/4
miles and 400 ft ceilings. Broke off approach and was vectored to the west to see if
weather would move through. That didn't occur so we requested an approach to land SLC
and were vectored to SLC ILS 34L. Approximately 10 miles downwind in solid IMC,
autopilot and altitude hold on and about to turn base we hit a downdraft that dropped us
approximately 2000 feet. Horizon ball was all brown, autopilot and altitude were
ineffective, the loss of control set off the master warning system due to lack of fuel (at the
time we had 750 lbs per side), and the terrain warning went off. Recovery was
accomplished, but with a 2000 foot gain (assigned altitude 10000 at the floor of incident
approximately 8000 at the ceiling of incident approximately 12000). I was then routed
back to the west and north on vectors for sequencing back to the ILS 34L SLC that was
shot with a side step on final in VFR conditions to RWY 34R. During taxi in I was instructed
to contact SLC TRACON by phone, which I did and he asked what had occurred and I
relayed a shorter version with not as many facts. He was very polite, professional, and
understanding.
Synopsis
Light twin pilot reported encountering severe turbulence and windshear on downwind for
the SLC ILS Runway 34L at 10000 feet in IMC. 2000 feet were lost and a terrain warning
was received along with a master warning for fuel pressure before control was regained.
ACN: 1422154 (3 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : CYHM.Airport
State Reference : ON
Altitude.MSL.Single Value : 2200
Environment
Weather Elements / Visibility.Visibility : 2.5
Light : Night
Ceiling.Single Value : 300
Aircraft
Reference : X
ATC / Advisory.Center : CZYZ
Aircraft Operator : Air Carrier
Make Model Name : Widebody, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Nav In Use.Localizer/Glideslope/ILS : Runway 12
Flight Phase : Initial Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Relief Pilot
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1422154
Human Factors : Confusion
Human Factors : Training / Qualification
Analyst Callback : Attempted
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Procedure
Primary Problem : Chart Or Publication
Narrative: 1
The flight to CYHM was turbulent and we never made it to the planned cruising altitude
due to turbulence. The arrival weather was approximately a 300 ft ceiling and around
4000 meters visibility and winds gusting from 25-30 knots at approximately 80-90 degrees
off of runway heading. I was sitting in the Jumpseat as an additional crewmember for the
flight. The conditions in the cockpit were loud and I was unable to hear much of what was
being said between the pilot flying and the pilot monitoring. I knew the planned approach
was the ILS to runway 12. I did not hear much of the brief due to the noise in the aircraft.
As we proceeded into the terminal area, we were cleared to the APGOM fix and cleared for
the ILS. Again, I did not hear much of what was being said cross-cockpit between the PM
and the PF when given the approach clearance. I did catch that the PF wanted to make
sure that the aircraft was stable for the approach as early as possible. I wholly agreed with
this philosophy due to conditions at the field. The approach was flown to a successful
landing.
After the fact I was informed by the Line Check Airman that the aircraft descended to
2200 ft (the min altitude for the no-pt (No Procedure Turn) routing) when it should have
been at 2700 ft (the MSA for the sector we approached from and/or the minimum altitude
for the procedure turn routing).
The No-PT routing minimum altitude of 2200 ft is confusing when the MSA is 2700 ft.
Additionally, the APGOM fix is depicted on the plan view of the approach plate, but not the
profile view, making it difficult to determine what the minimum altitude is for that fix when
cleared direct versus given the No-PT routing. The CAT-II ILS plate shows a No-PT routing
from the same fix, but with a minimum altitude of 2700 ft. The approach plate is
ambiguous for what altitude should be maintained when cleared to the APGOM fix and the
approach.
Synopsis
Air carrier Relief Pilot reported descending to 2200 feet after being cleared for the CYHM
ILS Runway 12 direct APGOM. Pilot cited confusion as to the allowable minimum no
procedure turn (NoPT) altitude and noted a disparity between the ILS Runway 12 NoPT
(2200 feet) and ILS CAT II Runway 12 NoPT (2700 feet) altitudes.
ACN: 1419082 (4 of 50)
Time / Day
Date : 201701
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 2500
Environment
Flight Conditions : IMC
Ceiling.Single Value : 700
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
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
Mission : Passenger
Flight Phase : Initial Approach
Airspace.Class C : 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 Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 121
Experience.Flight Crew.Type : 6000
ASRS Report Number.Accession Number : 1419082
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Air Traffic Control
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
I was Pilot Flying on a vectored heading to intercept localizer final, level at 2500. The
autopilot was on and holding altitude. Just prior to course intercept, we got a Stab out of
Trim warning. I looked back at my instruments and the aircraft was descending and about
100 feet low with the autopilot on. I immediately disconnected the autopilot to manually
climb back up to altitude while intercepting the Localizer. The trim was heavy nose down,
and electric trim was inop while the aircraft continued to descend until I could get enough
muscle on the controls, and manual trim, to climb back to altitude. We were about 400
feet low and Approach called us and notified us he had a Low Altitude Alert on us, and
gave the min vectoring altitude 2100 MSL for our location.
We maintained localizer, climbed back up to 2500 MSL, captured the glideslope, ran the
QRH and continued the approach using manual trim. We talked about a missed approach,
but decided it would be safer to continue and land. We broke out at about 700 ft to a
normal landing using manual trim. After clearing the runway, the Captain tried his electric
trim and it was operational, so I tried mine and now it worked. The Captain wrote up the
trim; Contract Maintenance came out, we ran the trim but it would just stop on its own.
Maintenance determined the trim motor was going bad and the trim was intermittent.
I don't know of anything that we could change to keep this from happening again. We
don't use manual trim very often, and there is learning curve on how much you have to
spin the wheel and how much force is required to move it.
Synopsis
B737-NG First Officer reported receiving a low altitude alert from ATC on approach when
the stab trim failed leaving them with manual trim only.
ACN: 1419020 (5 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : RNO.Airport
State Reference : NV
Environment
Flight Conditions : Mixed
Weather Elements / Visibility.Visibility : 6
Light : Dusk
Ceiling.Single Value : 6000
Aircraft
Reference : X
ATC / Advisory.Tower : RNO
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Mission : Passenger
Flight Phase : Initial Approach
Route In Use.Other
Airspace.Class C : RNO
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.Last 90 Days : 197
ASRS Report Number.Accession Number : 1419020
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
This flight was flown into RNO during a period of variable weather and visibilities with
intermittent snow and rain in the area. The arrival time was near dusk. I was the Pilot
Flying and we briefed and flew the RNAV RNP Y 16R. The approach was flown in
accordance with our Standard Procedures with .3 set on the RNP on the LEGS page and
the ANP showing a .01 accuracy. I believe the temperature was above freezing. The
approach was backed up with the RNO ILS to 16R with 110.9 set in both NAV radios.
While on the approach approximately one mile prior to MASTR, and in contact with RNO
Tower, the Tower issued a Low Altitude Alert to us. No EGPWS Cautions or Warnings
occurred. We checked both EGPWS indications and raw radio altimeter indications and all
were normal and green. We were monitoring aircraft status on the approach, the approach
mode was in LNAV and VNAV PATH and our path indicators were centered for vertical and
lateral deviations. The autopilot and autothrottles were engaged in CMD mode. Nothing on
the approached looked abnormal and the ghost glide path indications from the 16R ILS
were centered with the VNAV PATH indications.
As the aircraft rolled out on final near OKITE all Localizer indications were centered as
well. Basically everything worked fine with the aircraft and we landed uneventfully. Upon
our taxi back we queried the Tower concerning the low altitude alert while on the
approach. They said that if the aircraft is near one of the mountains while on the approach
that their equipment will signal the warning. I think that if this is part of the normal
procedure while flying the RNAV RNP approaches that there should be a note either on the
approach plate or within the Company 10-7 pages to prevent confusion.
This is a high threat airport when it comes to terrain. The RNAV RNP approaches reduce
the risks extensively. If our procedures are going to cause an ATC low altitude warning,
then we need to know that either on the approach plate or on the Company information
page. I really should get no warning from ATC when the approach is flown properly.
Synopsis
B737 Captain reported receiving a low altitude alert from ATC on approach to RNO even
though the aircraft appeared to be on course and altitude.
ACN: 1419010 (6 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZMA.ARTCC
State Reference : FL
Altitude.MSL.Single Value : 23000
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZMA
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class A : ZMA
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZMA
Make Model Name : Super King Air 200
Flight Plan : IFR
Flight Phase : Cruise
Airspace.Class A : ZMA
Person : 1
Reference : 1
Location Of Person.Facility : ZMA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 11
ASRS Report Number.Accession Number : 1419010
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Confusion
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Person : 2
Reference : 2
Location Of Person.Facility : ZMA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Function.Air Traffic Control : Instructor
Function.Air Traffic Control : Handoff / Assist
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 5
ASRS Report Number.Accession Number : 1419332
Human Factors : Situational Awareness
Human Factors : Distraction
Human Factors : Confusion
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Staffing
Primary Problem : Procedure
Narrative: 1
Working sector 26 had just combined back with sector 6. Aircraft Y was level at FL240 over
TADPO and about to land at MTH which is close to TADPO. Aircraft X was coming from
Havana over TADPO at FL200. My D-side told me I had control from Havana to turn and
climb Aircraft X. I climbed Aircraft X to FL230 which the pilot read back. I needed to start
Aircraft Y down and keep Aircraft X climbing. Around TADPO I told Aircraft X to fly heading
310. Apparently he read back climbing to FL310 which I missed. A little later I observed
Aircraft X hadn't turned and I told him again to turn. In the read back Aircraft X
acknowledged the turn but also told me he was responding to an RA. I thought the RA was
because he was under Aircraft Y now and maybe he had climbed to fast and the RA was
forcing him down. I was able to turn him away from Aircraft Y and started Aircraft Y down
to get my separation back.
The sector was really busy and probably should not have been recombined but we had no
staffing. Also there was a lot of frequency congestion adding to the problem. I missed the
read back when I told Aircraft X to turn and he took it as a climb clearance.
Narrative: 2
At the time of the event I was training a developmental on the D-side. Traffic volume was
very high and the sector was red after having Sector 6 had been combined on to it.
Aircraft Y was in level flight north bound with Aircraft X overtaking from MUHA airspace. To
the best of my knowledge the R-side issued a climb to flight level 220 and the data lock
reflected this. This altitude should've kept the aircraft vertically separated, the trainee and
I were constantly on and off line making manual handoffs with MUHA ARTCC. I honestly do
not remember hearing a read back from Aircraft X as I don't remember if we were on or
off line. Apparently the R-side issued a turn to Aircraft X to fly heading 310 but the aircraft
took it as a climb and not a heading. This resulted in Aircraft X climbing through the
altitude of Aircraft Y.
Sector 06/26 is a disastrous sector. The sector is frequently over whelmed with traffic,
warning areas, and foreign pilots. The sector was combined too soon making of the sector
unworkable safely. Volume and frequency congestion is a direct factor in this event
occurring. They have been trying to redesign this sector for years now but have never
implemented anything that works. Sector 06 and 26 should've remained split apart and it
could have helped this particular situation.
Synopsis
ZMA Controllers reported that an aircraft took a heading as a climb instruction and became
a conflict for another aircraft. Controllers reported the sector was combined and busy.
ACN: 1418920 (7 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : LVK.Airport
State Reference : CA
Altitude.MSL.Single Value : 2300
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Fog
Weather Elements / Visibility.Visibility : 7
Ceiling.Single Value : 2300
Aircraft
Reference : X
ATC / Advisory.Tower : LVK
Aircraft Operator : FBO
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Training
Flight Phase : Final Approach
Route In Use : Vectors
Airspace.Class D : LVK
Component
Aircraft Component : Pitot-Static System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 2000
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 1800
ASRS Report Number.Accession Number : 1418920
Human Factors : Distraction
Human Factors : Troubleshooting
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Procedure
Primary Problem : Aircraft
Narrative: 1
While on the GPS 25R approach ATC alerted us that we were below altitude for the leg of
the approach we were on and to stop descending. The analog altimeter was reading 300-
400 higher than what ATC radar was receiving from our mode C transponder. The
altimeter was set correctly, and we confirmed this setting with the controller. We stopped
descent and checked alternate air in the case of static port blockage, but it had no
effective change in the indicated altimeter. I alerted the tower we were having "altimeter
trouble" and requested that he standby as we were troubleshooting the situation.
The weather was improving and the field was in sight and I was reasonably sure I could
return to [home airport] for final landing, so I requested low approach only with a return
to Approach frequency ASAP. The filed flight plan said training/multiple approaches in the
remarks section and I was hopeful for a seamless and constant communication with
Approach for the return leg. Tower ATC asked if we were canceling our IFR flight plan and
continuing VFR. I said "no" and that we could maintain VFR through the low approach and
climb out, but to transfer us back to Approach ASAP. ATC stated that he was in a
"quandary" as to whether we were canceling IFR and going VFR. I said no, so he then told
us to go missed approach, which we did, and we were transferred to Approach soon after.
Approach stated that our intention to return to [home airport] threw them off guard and
that they were there to help. I stated how our flight plan said training flight and multiple
approaches and apologized. He vectored us back without any more incident. While
researching the potential problems with the altimeter, I learned that since there had been
a significant rainstorm for the previous 2-3 days with heavy winds and downpours that
there was a chance water had somehow entered into the static port.
I am reporting this incident because after recollecting the series of transmissions and
events during the critical phase of approach flight and the controller's curt and pressing
demands for answers while we were in the midst of troubleshooting, that this event could
have led to this situation becoming more serious. If I wasn't being pressed for hard
decisions during this time and instead supported through the tower by more informational
data regarding our current received transponder altitude and comparing it to what our
analog altimeter was reading, I feel I could have made my transmission in a more concise
and effective format. For instance, when he asked if we were canceling IFR and returning
VFR and I said I could maintain VFR through the low approach, I should have said VMC
instead of VFR, but my focus at that point was maintaining safe flight with this student and
keeping the aircraft and cockpit managed. During the return leg to [home airport], I kept
an eye on both the transponder's indicated altitude as well as the analog altimeter. Minor
discrepancies continued, but with the weather becoming VMC, it wasn't as critical to
resuming a safe flight. The aircraft was squawked upon return.
Synopsis
A general aviation pilot reported altimeter accuracy issues during a practice instrument
approach. Pilot elected to break off approach in VMC conditions and return to base airport.
ACN: 1418741 (8 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : PHX.Airport
State Reference : AZ
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Light : Night
Aircraft
Reference : X
ATC / Advisory.TRACON : P50
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.Localizer/Glideslope/ILS : Runway 7R
Flight Phase : Initial Approach
Airspace.Class B : PHX
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 : 1418741
Human Factors : Communication Breakdown
Human Factors : Confusion
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Procedure
Narrative: 1
The weather was overcast and raining at PHX, so we were vectored onto the ILS for
Runway 7R. The First Officer had the autopilot join the localizer and descend to 3000 feet.
The autopilot was having a hard time tracking the localizer with a strong crosswind, and
we were about one dot left of course. Just as the autopilot captured the glideslope, the
approach controller pointed out traffic on the localizer for Runway 8 and asked if we had it
in sight. I replied that we were IMC.
The controller instructed us to climb and maintain 4000 feet. No other instructions.
Normally when a controller breaks you off the approach, he says something like "approach
clearance cancelled, track the localizer, climb and maintain 4000 feet". This guy only said
to climb to 4000 feet, and nothing else. Since we were unsure of what the controllers plan
was, we didn't know if we should reconfigure the airplane for a go-around or if we could
expect to resume the approach momentarily. The First Officer disengaged the autopilot
and slowly climbed to 4000 feet while still in an approach configuration. Spotting the
airport through the rain, I realized that there was no way to resume the approach. At that
point the controller added to our confusion by instructing us to contact tower. WHAT? I
told him that we were at 4000 feet and not in a position to land. He repeated his
instruction to contact the tower, with a snarky attitude. By now the First Officer and I were
both thoroughly confused and had no idea what the controller had in mind. While I
switched to tower, I noticed that the First Officer had climbed to about 4300 feet or 4400
feet briefly, and then descended back to our assigned altitude. I checked in with tower
stating that we were overhead the airport at 4000 feet. The tower finally gave us a
heading, altitude, and stated that we would get turned back out for another approach.
Fantastic, now we finally knew what the plan was. The remainder of the flight back around
for another approach and landing was uneventful.
The main cause of this event was the approach controller not clearly communicating his
plan for exactly what he wanted us to do. As a crew, we need to know a bit more than
"climb to 4000". I need to know what his plan is for us so we can react accordingly and
configure the airplane properly. His instruction to contact tower with no explanation as to
why added to our confusion. A contributing factor was the autopilot's poor performance in
tracking the localizer in the crosswind. I suspect that being 1 dot north of the localizer is
what caused the controller to be concerned about lack or separation with the traffic to
Runway 8.
The easiest way to avoid a situation like this is for the controller to use standard
phraseology when breaking an aircraft off an approach ("approach clearance cancelled,
track the localizer, climb and maintain..."). If the crew has a question about what the plan
is because of the controller's lack of communication skills, the controller should clarify the
plan without getting an attitude about being questioned.
Synopsis
CRJ-700 Captain reported being issued incomplete, confusing go-around instructions from
a TRACON Controller.
ACN: 1418434 (9 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : NQI.Airport
State Reference : TX
Relative Position.Angle.Radial : 110
Relative Position.Distance.Nautical Miles : 6
Altitude.MSL.Single Value : 5000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 4
Light : Daylight
Ceiling.Single Value : 600
Aircraft
Reference : X
ATC / Advisory.Tower : NQI
Aircraft Operator : Military
Make Model Name : Military Trainer
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Training
Flight Phase : Initial Climb
Route In Use : Vectors
Route In Use : Direct
Airspace.Class D : NQI
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Military
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Experience.Flight Crew.Total : 2900
Experience.Flight Crew.Last 90 Days : 77
Experience.Flight Crew.Type : 750
ASRS Report Number.Accession Number : 1418434
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Workload
Human Factors : Time Pressure
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
Upon departure from runway 13R at NQI, ATC issued Aircraft X an intermediate level off
altitude of 5,000 feet MSL at a climb altitude of 2,000 feet MSL and advised of south
bound Gulfstream traffic to the east of Aircraft X's position at 6,000 feet MSL. The
intermediate altitude was 2,000 feet less than initial clearance of 7,000 feet MSL. While in
the non-standard left hand turn to MOA entry point and scanning for the traffic Aircraft X
missed level off altitude of 5,000 feet MSL by 400 ft. Aircraft X pilot made an immediate
correction back to 5,000 feet MSL. Kingsville departure queried Aircraft X pilot to confirm
updated level off altitude of 5,000 feet MSL. Aircraft X was visual of Gulfstream traffic
during climb and left turn.
Synopsis
Military trainer pilot reported overshooting a 5,000 foot altitude constraint with traffic at
6,000 feet.
ACN: 1418407 (10 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZME.ARTCC
State Reference : TN
Altitude.MSL.Single Value : 13000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility.Visibility : 3
Light : Dawn
Ceiling.Single Value : 300
Aircraft
Reference : X
ATC / Advisory.Center : ZME
Aircraft Operator : Corporate
Make Model Name : Medium Transport, High Wing, 2 Turboprop Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Descent
Route In Use : Direct
Airspace.Class E : ZME
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 : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 8000
Experience.Flight Crew.Last 90 Days : 90
Experience.Flight Crew.Type : 3000
ASRS Report Number.Accession Number : 1418407
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
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 : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1418412
Human Factors : Communication Breakdown
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
Miss Distance.Vertical : 2000
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Control gave us a crossing restriction to cross ZZZZZ Intersection at 10000 feet. As we
passed through 12000 feet, controller told us to maintain 13000 feet, as we passed
11500, we climbed back up to 13000 and was handed off to approach control. I initiated a
call to Memphis Center to clarify our instructions after landing. After receiving a call from
Quality Control, The Controller had amended our altitude at the same time we were
transmitting our instructions to descend to 10000, the controller did not verify our altitude
to be anything different than 10,000 what we had initially heard. From my understanding,
the controller was transmitting to us at the same time we verified our initial instruction of
10,000 feet and we never received the amended altitude of 13000. There was no traffic
and no conflict.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Pilot and ATC reported a miscommunication in issuing and receiving an altitude crossing.
The crew overshot the intended altitude, but corrected back once ATC clarified the
clearance.
ACN: 1418216 (11 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : BTV.TRACON
State Reference : VT
Altitude.MSL.Single Value : 5100
Aircraft
Reference : X
ATC / Advisory.TRACON : BTV
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 200 ER/LR (CRJ200)
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 : Vectors
Airspace.Class C : BTV
Person
Reference : 1
Location Of Person.Facility : BTV.TRACON
Reporter Organization : Government
Function.Air Traffic Control : Approach
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 4.0
ASRS Report Number.Accession Number : 1418216
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Equipment / Tooling
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Equipment / Tooling
Narrative: 1
The aircraft had been switched to TRACON from Center. The aircraft was issued a vector
towards final and descent to 7000 feet. As the aircraft was getting closer to the final it was
issued a further descent to 5500 feet, this is very normal on an ILS Approach. The pilot
read back 5500 feet. I turned my head to scan some strips that had printed out. I turned
back and noticed the aircraft was indicating 5100 feet. I immediately told the aircraft to
climb to 5500 feet which they did.
The STARS R4.0 build has the capability to have altitude filters set in addition to the
Minimum Safe Altitude Warning (MSAW) alarm. Unlike the MSAW alarm which only looks
at projected path and the actual terrain this additional feature can be totally customization
for specific areas in an airspace where a altitude "hotspot" may exist and will flash the
aircraft's datablock to help catch the controller's attention. This feature should be
considered for use at BTV in specific area over both mountain ranges in our airspace.
Synopsis
A BTV TRACON Controller reported observing an aircraft descend below its assigned
altitude and below the Minimum Vectoring Altitude.
ACN: 1418186 (12 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : RNO.Airport
State Reference : CA
Relative Position.Distance.Nautical Miles : 10
Altitude.MSL.Single Value : 9000
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility.Visibility : 6
Light : Night
Ceiling.Single Value : 1200
Aircraft
Reference : X
ATC / Advisory.TRACON : NCT
Aircraft Operator : Air Taxi
Make Model Name : Citation II S2/Bravo (C550)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Initial Approach
Route In Use : Vectors
Airspace.Class E : NCT
Person : 1
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 : Flight Instructor
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Engineer
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 23039
Experience.Flight Crew.Last 90 Days : 60
Experience.Flight Crew.Type : 254
ASRS Report Number.Accession Number : 1418186
Human Factors : Human-Machine Interface
Human Factors : Fatigue
Human Factors : Distraction
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Taxi
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 5400
Experience.Flight Crew.Last 90 Days : 30
Experience.Flight Crew.Type : 120
ASRS Report Number.Accession Number : 1418194
Human Factors : Distraction
Human Factors : Human-Machine Interface
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Result.Flight Crew : FLC Overrode Automation
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
I was the co-pilot and flying pilot with no passengers. This was the third mission in this
airplane and unlike the usual aircraft I fly this one has a glass cockpit with the Mode
Control Panel in front of the Captain. We had worked together very well as a crew with
excellent CRM. We were descending to land at RNO where the weather was about 1200
overcast with tops about 8000 ft and because of the temperature, icing was expected,
level unknown. The autopilot was engaged. I had briefed the approach and we completed
the appropriate checklists. We were getting step down descents and when we were cleared
from 10000 to 9000 ft. I saw the captain select 9000 in the altitude preselect window but
failed to notice the arm button was not pushed. I had just called for engine anti-ice to be
turned on and we were discussing when to turn on the wing anti-ice. Then I noticed the
airplane going through 8700 ft. I immediately disconnected the autopilot and started a
climb back to 9000. Just as the airplane started climbing ATC announced "stop your
descent." We received further vectors and descents and accomplished the approach,
landing in RNO.
Contributing factors were I had little time on this glass panel airplane, night flight, IFR
weather ahead with possible icing and busy time of flight. We lost situational awareness
and my inaction was not confirming autopilot status and reliance on automation.
Narrative: 2
Prior to descent, all appropriate checklists/briefs were complete in accordance with SOPs.
PF was descending to assigned altitude of 10,000 ft. Pilots entered brief conversation
about cloud deck, thickness and potential icing. Decision was made to turn anti-ice on
(anti-ice switches accessed from left seat) PNF moved to select AI switches "ON."
Concurrently, ATC directed a descent from 10,000 to 9,000 just prior to PF reaching
10,000 (SOP calls for PNF to select/reset alt preselect controller to new alt (9,000) and
select ALT ARM -- this is to be announced and subsequently acknowledge by PF). Upon
receipt of ATC instructions, PNF selected 9,000 in Alt pre-select window. Announced "Pilot,
cleared to 9,000." PNF failed to select ARM as attention went back to verifying proper anti-
ice controls were in place.
Acknowledgment of "preselects" did not occur. Passing through 8800, PF recognized AP
failed to capture preselected altitude of 9,000. PF interrupted AP and started a smooth
climb (night IMC conditions at this time) back to 9,000. In process of maneuvering, the
aircraft descended to 8700. During climb back to 9,000 ATC directed "Stop descent."
During climb back to altitude, ATC directed subsequent vector and descent to intercept the
LOC with clearance for approach. Subsequent approach was uneventful.
ROOT CAUSE: Failure to follow SOP.
CAUSAL FACTORS: Distraction due to environmental factors; Crew fatigue, early morning
hours, PF completed early morning sortie the day prior. Although it was the fourth leg of
mission the PNF had not flown in 17 days.
Synopsis
C550 pilots reported incorrectly setting their altitude during a descent to RNO resulting in
overshooting their assigned altitude.
ACN: 1417975 (13 of 50)
Time / Day
Date : 201701
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 : B737-700
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
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 : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 214
ASRS Report Number.Accession Number : 1417975
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 : 1417981
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Jet stream wind speed accelerated from 80 knots to 150 knots in a very short time. The
aircraft autopilot and auto throttles couldn't adjust quickly enough to changing tailwind.
Aircraft accelerated from .78 Mach to .82 Mach in a matter of seconds. At FL380, aircraft
vertical velocity increased from 1500 fpm to over 6500 fpm. I disconnected VNAV and
attempted to halt the climb but couldn't stop aircraft from climbing through FL410. Finally
stopped ascent at FL420 and descended back to FL410. That was our assigned altitude.
Reconnected autopilot and wind settled back to an 80 knot tailwind. Rest of flight was
uneventful.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737-700 flight crew reported a sudden increase in tailwind resulted in climbing through
the assigned cruise altitude.
ACN: 1417942 (14 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZOA.ARTCC
State Reference : CA
Altitude.MSL.Single Value : 16000
Environment
Weather Elements / Visibility : Turbulence
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZOA
Aircraft Operator : Personal
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Retractable Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Cruise
Airspace.Class E : ZOA
Person
Reference : 1
Location Of Person.Facility : ZOA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 3.3
ASRS Report Number.Accession Number : 1417942
Human Factors : Training / Qualification
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Regained Aircraft Control
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
This is a situation that I witnessed, and do not think a [report] was filed. I feel it pertinent
to bring up. Aircraft X was flying at the lowest assignable attitude (16000 feet) over the
Sierra Nevada. The Minimum IFR Altitude (MIA) in that area is 15200 feet. The aircraft
experienced serious downdrafts, and lost over 1200 feet of altitude in only 2-3 radar
returns. The aircraft asked for help, and the controller working the sector initially
responded with "you're below my MIA, I can't vector you below the MIA." The controller
asked if he was getting icing, but the pilot said negative. When he finally gave suggested
headings, the controller was saying things like maybe this heading or maybe that heading.
Nothing concrete that would invoke any sort of confidence in the pilot. I feel that the
controller did a terrible job helping the pilot. He did not issue a low altitude alert or even
find out if he was IMC until 10 minutes after the issue started. It took another controller to
make him ask the pilot if he was IMC, and issue a safety alert. The controller gave a much
better service to another aircraft that was not in an emergency situation than he gave this
aircraft. When the Operations Manager came in the area he asked if the pilot was getting
carb icing (a very good question), and the controllers response was "he is not getting
icing." The controller NEVER asked the pilot if he was getting carb icing. While this was
probably not a contributing factor, this was pertinent information that could have helped
the pilot get more power out of his engine.
This particular controller has many difficulties working normal traffic, and a situation like
this put him over the edge. This was a very unsafe situation, and I feel that if the pilot had
not kept his cool he may have crashed. I feel that situations like these, that do not show
up as a loss of separation, airspace violation, or incident are not looked at very seriously
at our facility. Management filed an incident report but it was very vague and did not
properly narrate the situation. I don't even think management listened to the tape. I do
not want someone to be penalized, but I think we need to engage this controller, and offer
him more training on these types of situations. In fact, every controller, including myself
should be "called out" if they do not provide enough service to an aircraft in need. We do
run simulations with scenarios like this during our "recovery" training, but I feel this exact
situation should be re-created. We need to focus on all safety issues, not just separation
loss or airspace violations.
Synopsis
ZOA Controller reported observing another Controller work an aircraft in downdrafts over
mountains, but did not handle the situation according to standards.
ACN: 1417678 (15 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 10000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 8800
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
Aircraft Operator : Personal
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Cruise
Route In Use.Airway : V143
Airspace.Class E : ZDC
Component
Aircraft Component : Engine
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Engineer
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 17000
Experience.Flight Crew.Last 90 Days : 5
Experience.Flight Crew.Type : 250
ASRS Report Number.Accession Number : 1417678
Human Factors : Workload
Human Factors : Troubleshooting
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Private
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 200
Experience.Flight Crew.Last 90 Days : 25
Experience.Flight Crew.Type : 10
ASRS Report Number.Accession Number : 1417679
Human Factors : Troubleshooting
Human Factors : Workload
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Overcame Equipment Problem
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Filed for 8,000 ft but was getting bounced around. Asked for 10,000 ft and was cleared for
climb to 10,000 ft. We were shimming through the tops with clear above. Reported level at
10,000 ft to Washington Center. Within a couple of minutes we began to lose power and
started to lose altitude. At about a 200 ft loss, immediately asked ATC for lower, ATC
responded by standby. Applied carb heat twice. At 9,600 ft Washington advised "he
showed us at 9,600 ft and gave an altimeter setting." Asked again for lower and ATC gave
us 9,000 ft. We complied and once again had a hard time staying at 9,000 ft. I asked for
6,000 ft and was cleared for 6,000 ft. During entire descent had carb heat on. We leveled
off at 6,000 ft and all power was restored. We continued to destination with no further
problems noted.
Mistakes made: should have had carb heat on longer and should have told ATC of
problem, but was distracted by trying to hold altitude and figure out what was wrong. At
first I thought it was a cable problem with throttle. Probably should have declared an
emergency.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
PA28 pilots reported experiencing carburetor icing at 10,000 feet. Their engine began to
lose power, so they applied carb heat and descended to 6,000 feet. During the descent
they regained full power and continued.
ACN: 1417397 (16 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 27000
Environment
Flight Conditions : VMC
Light : Dawn
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
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
Mission : Passenger
Flight Phase : Descent
Airspace.Class A : ZDC
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 : 1417397
Human Factors : Training / Qualification
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We just began descending on the PHIBO arrival into Newark. Washington ARTCC had given
us a crossing restriction of FL270 at FUBAR as per the charted procedures. About one
minute later we get a frequency change to a new Washington ARTCC. After the captain
checked in, we were instructed to descend via the PHIBO arrival into Newark. The first
officer reached up and selected the next hard altitude of 11,000 feet at SUMTO. The first
officer did this before crossing FUBAR. The captain verified 11000 feet selected. About 30
seconds before crossing FUBAR the captain then stated we still need to cross FUBAR at
FL270. The first officer reached up and manually TCS (Touch Control Steering) the aircraft
to level flight and reselected FL270 recapturing the altitude. We descended approximately
150 feet below altitude when crossing FUBAR.
Synopsis
Air carrier First Officer reported missing a crossing restriction due to premature selection
of the next hard altitiude.
ACN: 1417282 (17 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZZZ.TRACON
State Reference : US
Altitude.MSL.Single Value : 8650
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
ATC / Advisory.TRACON : 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 : Passenger
Nav In Use : GPS
Nav In Use : FMS Or FMC
Flight Phase : Descent
Airspace.Class B : ZZZ
Component
Aircraft Component : Autopilot
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 : 18800
ASRS Report Number.Accession Number : 1417282
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
ASRS Report Number.Accession Number : 1417454
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Aircraft TA
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Overcame Equipment Problem
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Procedure
Primary Problem : Aircraft
Narrative: 1
I was the pilot flying as we were descending on the RNAV Arrival, approaching ZZZZZ
Intersection which has a 210 KT at 9000' restriction. We were in night IMC conditions in
moderate turbulence and rain. We had been cleared to delete all speed restrictions and
maintain 250 knots. The left autopilot was engaged in LNAV and VNAV with speed
intervene 250 knots selected. As we came within a few miles of ZZZZZ Intersection our
speed started decelerating and I asked the first officer to ask Approach Control if he still
wanted us to maintain 250 knots. As he was asking, the aircraft started a rapid pitch down
going through 9100'. I disconnected the autopilot and found the aircraft was trimmed
significantly nose down as I tried to level off at 9000' nearing ZZZZZ Intersection. At the
same time we received a TCAS traffic advisory and I glanced down at the TCAS display on
the center console but found that the turbulence rendered the display unreadable.
Approach Control said he still wanted 250 knots, and still needed 9000' at ZZZZZ
Intersection. I was unable to reverse the descent until between 8700' and 8600'. The first
officer told the controller that we had an issue with the autopilot, and we were
immediately cleared to 7000' as we were climbing back to 9000' over ZZZZZ Intersection.
After I manually stabilized on course to ZZZZZ1 Intersection descending to 7000', I re-
engaged the left autopilot in LNAV and Flight Level Change. Shortly thereafter the aircraft
started turning right and diverging from track. The flight director was commanding a turn
left back towards the course while the aircraft was increasing its bank angle to the right. I
selected the HDG Select roll mode and selected a heading to turn left to re-intercept the
course. The aircraft continued its right turn without starting a roll reversal to the left, so I
disconnected the autopilot again. We then were issued a speed reduction to 170 knots,
descent to 3000', and a 90 degree left turn vector for a base leg. After stabilizing the
aircraft again manually, I engaged the right autopilot which worked normally for the
remainder of the approach including a coupled ILS in VMC down to 200'AGL.
I called the TRACON supervisor on the phone and asked if he was familiar with my flight
number and the problem over ZZZZZ Intersection earlier. He indicated that he was, and
that they had "no issues."
Maintenance technicians told me that they did not find any stored faults in the avionics,
but that the aircraft had a history of left autopilot write-ups with no faults found. I had
written up a similar incident a few weeks earlier with the same roll mode faults, but no
vertical mode issues. I believe, but could not confirm that it was the same aircraft.
Technicians determined that the left flight control computer should be replaced.
I was informed that this aircraft had a history of left autopilot write-ups where trouble-
shooting found no faults and the aircraft was returned to service. A high percentage of my
write-ups are repeats of earlier discrepancies noted by other crews or myself. From my
perspective, this issue is becoming more common as these aircraft age. I suggest that
Maintenance management initiate a tracking methodology that identifies repeat write-ups
and requires more extensive troubleshooting. For critical systems such as autopilot
malfunctions, the corrective action, "Checked per [SOP] Okay for continued service"
should not be allowed.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B757 flight crew reported an autopilot malfunction which resulted in a missed crossing
restriction and a track deviation. Reengaging the left autopilot caused more problems, but
the right autopilot functioned normally.
ACN: 1417158 (18 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : LAX.Airport
State Reference : CA
Altitude.MSL.Single Value : 12500
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZLA
Aircraft Operator : Air Carrier
Make Model Name : A321
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.SID : LOOP9
Airspace.Class E : ZLA
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 : 1417158
Human Factors : Distraction
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Altitude : Undershoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
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 : Became Reoriented
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
We were flying an A321 and our close-out weight was above our planned weight which
prevented us from flying our planned cruise altitude. Loop 9 departure: direct LAX and
cleared to climb via except climb and maintain FL230. The FO was flying with the autopilot
on and managed climb and speed. Passing through 10,000 feet and crossing LAX VOR, the
aircraft began to shallow the climb as it accelerated beyond 250 knots. Almost
simultaneously, we entered IMC and engine anti-ice was turned on as TAT was below 10
C. LA center then called with a reroute. The reroute was unusual as it was very direct and
eliminated nearly every waypoint across the country, so we verified this with ATC. While
we were inputting the new route, LA center called out traffic. I replied that we were IMC.
The FO was still adding the reroute into the FMGS when I noticed we were not going to
make the KEGGS crossing restrictions and simultaneously LA center queried as to whether
or not we would make the crossing restriction of 13,000 at KEGGS. I replied that I thought
we would make the restriction, but it would be close. We pulled speed and spun in 250
knots to get the aircraft to climb rapidly and make the restriction. I believe we were 400-
500ft below the 13,000 ft restriction at KEGGS. The [older] Airbus aircraft have quite an
array of differences that pilots are not familiar with. In this case, neither of us had ever
flown the Loop 9 departure in an older A321 before. The lack of climb performance,
especially heavy with the anti-ice on while accelerating beyond 250 kts, was dramatically
poor in comparison to the [newer model] A321 which both of us were used to. This, in
addition to ATC poorly timed reroute, were enough to distract us long enough that we
could not recover to make the crossing restriction altitude. I would suggest a memo to
[Company] Airbus pilots highlighting the incredibly poor climb performance of the older
A321s. Perhaps dictate that that if you are above 180,000 pounds, your climb
performance will be poor and you may not make climb restrictions or your planned cruise
altitude.
Synopsis
A321 Captain reported discovering that the older A321s have very poor performance when
compared with the newer ones that he is used to flying. The crossing restriction at KEGGS
on the LAX LOOP9 was missed by 500 feet.
ACN: 1416914 (19 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : KZAK.ARTCC
State Reference : AK
Altitude.MSL.Single Value : 36000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Thunderstorm
Aircraft
Reference : X
ATC / Advisory.Center : KZAK
Aircraft Operator : Air Carrier
Make Model Name : B787 Dreamliner Undifferentiated or Other Model
Crew Size.Number Of Crew : 3
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
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 : 20000
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 2125
ASRS Report Number.Accession Number : 1416914
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 : 7269
Experience.Flight Crew.Type : 1349
ASRS Report Number.Accession Number : 1416916
Person : 3
Reference : 3
Location Of Person.Aircraft : X
Location In Aircraft : Crew Rest Area
Reporter Organization : Air Carrier
Function.Flight Crew : Relief Pilot
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Experience.Flight Crew.Total : 13724
Experience.Flight Crew.Type : 377
ASRS Report Number.Accession Number : 1417072
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Track / Heading : 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 : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Ambiguous
Narrative: 1
At FL360, and approaching 08N150W we entered a cumulous top that we were not aware
of primarily due to our map scales being too large to see the radar return. We encountered
moderate turbulence and strong up and down drafts. We scaled down our map displays
and immediately requested a climb to FL370 and a course deviation, but only the altitude
was approved. We were denied the course deviation due to traffic. We saw an immediate
need to deviate to the right by only about 5 miles off course, which we did, and returned
to our SLOP of R2 after passing the threat. Also, due to the up and down drafts being as
strong as they were, our altitude deviated by about 200 feet and we got 4 overspeed
warnings, which we observed to be about 5 knots. The weather cell was small, but intense
and rising rapidly. The whole event lasted around 3 minutes after which we checked on the
cabin crew and found everyone to be okay. Afterwards the airplane displayed status
messages of 'Cruise Flap Fault' and 'Flaps Secondary Fault.' On arrival and on descent, we
got several EICAS messages regarding GPWS and Single Source ILS. The radar did not
display weather until we were in it, when it finally displayed a large green area of what
turned out to be moderate rain and turbulence. We were at 12,000 feet. The subsequent
vectoring, ILS approach, and landing were uneventful and routine. The airplane suffered a
lighting strike on departure on the previous leg and was inspected before we accepted it.
We took a 3 hour delay for the inspection, which we were made aware of the night before.
On takeoff and descent, my position was IRO on this leg in the right rear jumpseat. It has
a very limited view, and it is very hard to hear communications between the crewmembers
because of the location and the noise from the ventilation.
Narrative: 2
Near 08N 150W while cruising at FL360, we encountered an individual isolated
thunderstorm cell that did not show on my radar screen due to the scale selected. We
noticed the cell visually just prior to entry and requested both a climb and lateral deviation
from ATC via ACARS. We were given the climb to FL370, but denied lateral deviations due
to traffic. While penetrating the storm, we encountered both overspeed warnings
(approximately 4) as well as altitude deviations of approximately 200-300 feet. Despite
being denied the lateral deviations by ATC, we did perform minor lateral deviations of less
than 5 miles to avoid the core of the cell and returned to our slop offset immediately after
exiting the cell. The entire event lasted approximately 2-3 minutes. Following the event, I
checked with the flight attendant crew to ensure there were no injuries with the sudden
turbulence.
Narrative: 3
[Report narrative added no additional information.]
Synopsis
B787 flight crew reported entering a small thunderstorm at night that they did not notice
on Radar due to the large scale selected.
ACN: 1416887 (20 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : SJC.Airport
State Reference : CA
Relative Position.Distance.Nautical Miles : 5
Altitude.MSL.Single Value : 8000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility.Visibility : 2
Light : Night
Ceiling.Single Value : 800
Aircraft
Reference : X
ATC / Advisory.TRACON : NCT
Aircraft Operator : Air Carrier
Make Model Name : Large Transport
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
Flight Phase : Initial Approach
Route In Use.STAR : FRLON2
Airspace.Class B : SFO
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 : 55
ASRS Report Number.Accession Number : 1416887
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
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.Last 90 Days : 150
Experience.Flight Crew.Type : 8000
ASRS Report Number.Accession Number : 1417304
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Heavy weather and thunderstorms moving through the bay area. Winds were gusting on
the surface and all Bay area airports were using non-standard runways. OAK closed while
we were on arrival and aircraft were holding and diverting. The frequency was very
congested. We were a couple of miles north of MNTNA intersection descending via the
FRLON2 Arrival. A large cell was just past the MNTNA intersection and we asked Approach
if we could maintain present heading for one to two miles for weather and then go direct
MISSS. That request was approved. We finished the deviation and reported we were
turning direct MISSS.
The turn toward MISSS ended up being a fairly hard left turn. The Controller at one point
asked if we were turning direct MISSS and we answered affirmative. He then said we
weren't headed to MISSS and gave us a heading. The navigational display clearly showed
we were headed to MISSS. After established on the heading we realized we hadn't been
given an altitude after deviating off the arrival. We were at about 6500 feet with 5500 feet
set in the altitude window. We asked what altitude we were cleared to and the Controller
said 7000 feet. We said "roger climbing back to 7000 feet," and he said just maintain 6000
feet. He then gave us a frequency change and added that we were never headed toward
MISSS. With all the frequency congestion and the high workload, we just shrugged,
acknowledged the frequency and pressed. We never got an altitude clearance when
cleared to deviate off the arrival, but we should have thought to ask.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Air carrier flight crew, while deviating around weather, was questioned by ATC if they were
proceeding to the cleared waypoint. The crew was convinced they were but ATC still
questioned their track.
ACN: 1416882 (21 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : PHX.Airport
State Reference : AZ
Altitude.MSL.Single Value : 8000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : P50
Aircraft Operator : Air Carrier
Make Model Name : Large Transport
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.SID : KATMN5
Airspace.Class B : PHX
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : P50
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
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 : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 146
Experience.Flight Crew.Type : 146
ASRS Report Number.Accession Number : 1416882
Human Factors : Confusion
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
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)
Experience.Flight Crew.Last 90 Days : 150
ASRS Report Number.Accession Number : 1417313
Human Factors : Confusion
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Automation : Aircraft RA
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
Our Clearance out of PHX was to depart on the KATMN5 Departure, climb via the SID. The
KATMN5 has a top altitude of 8000 feet and a crossing restriction at VANZZ intersection of
at or below 8000 feet. Both were briefed and 8000 feet was set in the altitude window.
After takeoff we were handed off to PHX Departure. As we began to turn left towards
DAVZZ intersection, PHX Departure gave us the revised clearance to "climb via the SID,
except maintain FL 210." We read back the clearance, I asked for VNAV on the
automation, then we put FL210 in the altitude box, and I engaged the autopilot.
At this point we had a miscommunication about the clearance and I thought PHX
Departure wanted us to "climb and maintain" FL210. Both the Captain and I questioned
each other about the clearance, and then removed the restriction of at or below 8000 feet
at VANZZ because of a misunderstanding of the climb clearance. We were then given (by
PHX Departure) that we had traffic around 2 o'clock. Traffic was in site and we were
climbing around 3000-3500 FPM because we were light. We then received an RA with the
traffic, which we complied with, and maintained visual separation. Shortly afterwards, PHX
Departure told us that we needed to maintain 8000 feet at VANZZ. We explained that we
believed he had given us a clearance to "climb and maintain" FL210 which removes all
restrictions. At that point we realized that we had made a mistake and misinterpreted the
"climb via" clearance.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Air carrier flight crew reported they exceeded an altitude restriction while on the KATMN5
SID.
ACN: 1416806 (22 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZDV.ARTCC
State Reference : CO
Altitude.MSL.Single Value : 36600
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDV
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
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class A : ZDV
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZDV
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
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZDV
Person : 1
Reference : 1
Location Of Person.Facility : ZDV.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Trainee
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Developmental
ASRS Report Number.Accession Number : 1416806
Human Factors : Situational Awareness
Human Factors : Distraction
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)
Experience.Flight Crew.Type : 886
ASRS Report Number.Accession Number : 1418787
Human Factors : Situational Awareness
Person : 3
Reference : 3
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.Total : 11886
Experience.Flight Crew.Last 90 Days : 240
Experience.Flight Crew.Type : 3881
ASRS Report Number.Accession Number : 1417216
Human Factors : Situational Awareness
Human Factors : Human-Machine Interface
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Altitude : Undershoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Separated Traffic
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Ambiguous
Narrative: 1
I was the controller training on the sector. The traffic volume and complexity began to pick
up due to turbulent ride conditions and an aircraft that I was in communication with
making accidental transmissions over guard which indicated a medical problem on board.
Aircraft X came onto the frequency after taking the handoff from Sector 07. Upon check-
on Aircraft X asked about ride conditions at 37000 feet. I responded that 37000 feet was
reporting occasional light chop and Aircraft X then requested a climb to that altitude.
I observed traffic in front of Aircraft X opposite direction at 36000 feet and gave Aircraft X
a clearance to climb to reach 37000 feet in 2 minutes or less. The pilot read back the
clearance correctly and at this point had 40 miles of separation with 3 minutes before 5
miles of separation would be lost. At this time I began trying to gather information on
what was potentially a medical emergency being broadcast over guard by another aircraft
whom I also had on my frequency. Scanning back to Aircraft X the climb rate indicated he
would easily make his restriction but after a few more transmissions I observed that
Aircraft X had leveled out at 36600 feet. After observing this, I issued Aircraft Y a descent
to 35000 feet to achieve separation but the pilot than hesitated saying, "Descending in
response to a TCAS." Aircraft Y at this time had still not actually began a descent
according to our RADAR display and my trainer than keyed up to issue a descent clearance
once more. The aircraft broke required separation with 4.7 miles and 800 feet. Aircraft X
reached 37000 feet 3:20 minutes after reading back the restriction.
In this event, I would like that the pilot be instructed that if he cannot meet a climb
restriction to advise as soon as possible so an alternative action can be taken immediately.
Narrative: 2
In cruise at 35000 feet with Center we requested a climb to 37000 feet. Center issued the
following clearance. "Climb and maintain flight level 370, be level in 2 minutes or less".
Initiated climb and started timer. At 2 minutes we had attained 36,500 feet. I informed
ATC that we would not be able to make it to 37000 feet within the 2 minutes. ATC issued a
clearance to a converging aircraft to descend to 35000 feet. At 36600 feet we received a
TCAS RA "monitor vertical speed". A repeat clearance to Aircraft Y was made by ATC to
descend to 35000 feet. I had Aircraft Y in sight for the entire event and verbalized this to
ATC. We were able to maintain visual separation and vertical separation was never less
than 500 feet.
ATC issued timed climb without asking if we could accomplish it. We didn't realize that we
wouldn't be able to comply until 36600 feet.
Narrative: 3
[Report narrative contained no additional information.]
Synopsis
ZDV Controller and the flight crew involved reported they did not comply with a clearance
to be level at an altitude in two minutes or less. A loss of separation with opposite
direction traffic resulted.
ACN: 1416696 (23 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : PIT.Airport
State Reference : PA
Altitude.MSL.Single Value : 2500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : PIT
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 Approach
Route In Use : Visual Approach
Airspace.Class B : PIT
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 : 1416696
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft Terrain Warning
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While searching for our runway in visual conditions. Our assigned altitude was 3000
autopilot engaged, 3000 set in preselect, verified and then initiated descent to 3000. The
autopilot was engaged and preselect altitude had changed to 1900. We both were certain
we confirmed 3000 prior to commencing descent. While we were looking for airport, we
received an "obstacle" call from EGPWS. I immediately added thrust and began climbing.
Just as I added thrust, approach replied assigned altitude 3000. We returned to it, saw the
field, conducted a stable visual approach, and landed normally.
Cause: Fixation of both pilots outside the aircraft trying to visually find the airport. Instead
of one of us playing close attention to aircraft instruments.
Always prioritize aircraft state and constantly cross check instruments when in any phase
of flight, but especially during the critical phases.
Synopsis
CRJ-900 Captain reported descending below assigned altitude on approach to PIT and
receiving an obstacle warning from the EGPWS.
ACN: 1416372 (24 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : MMFR.ARTCC
State Reference : FO
Altitude.AGL.Single Value : 2000
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : MMFR
Aircraft Operator : Air Carrier
Make Model Name : Medium Large Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Final Approach
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 : 1416372
Events
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
During our arrival into MMZH we discussed how they keep you high and I asked if he
wanted me to request an early lower altitude he asked me to wait which I did. He finally
had me request it and we ended up being high. Instead of using VNAV to maintain the
descent profile he elected green vertical speed. I pointed out several times we were above
the vertical path. He stated he had it and would extend out if needed (26 does not have
any type of approach for backup). We were extremely high when he began making the
turn diving the aircraft. I had suggested prior possibly adding flaps and slowing up which
was ignored we were around 5,000 feet when he nosed the aircraft over. At 2000' off the
ground we were in an 1800 FPM dive. I said "we should probably go around". Approaching
1400', The thrust levers were advancing as he still had the flight director on and the
aircraft though we were still trying to climb he was ignoring the flight director. We were
way high 4 white I called Go Around.
AROUND he stuttered flaps 2 never making the appropriate call. Almost immediately he
began a hard left turn towards the mountain in the water I'm telling him "Level the wings
what are you doing" at this point the flight director and Flight path vector are full right and
were divining, Airspeed is approaching the upper limit. I was not making any further
configuration changes while we were headed into an unusual attitude.
I'm telling him "your about to over speed the aircraft as the turn continues. I decided if
the high speed alert went off I was going to take the controls. He managed to regain
control of the aircraft but still seemed bewildered. He rushed into the second approach and
once again had an excessive rate of descent. I started to call for the second Go Around
when he placed his hand in my face. The aircraft was settling down and near the stabilized
parameters. I placed myself in a position to take the controls if need be and we landed. It
was rough with swerving (though this was typical for every landing he made on our trip).
He also routinely taxied at high speeds and seemed very rushed.
The captain also stated several times on the trip that "I've probably used up all of my
goodwill" he also made statements about not knowing the aircraft well. He seemed to be
struggling with the automation.
After we landed he stated he was looking at the altitude I asked why he wasn't following
the flight director and why he was turning. The Captain also asked me at the end of the
trip "Would I still fly with him" He seemed to lack all confidence in his abilities as a
Captain.
Captain lacks understanding of aircraft automation and procedures and company policy.
Synopsis
Air Carrier First Officer reported two unstable visual approaches by the Captain flying into
MMZH. The first ended in a go-around and the second was almost another go-around
when the Captain settled the aircraft down to near stabilized parameters.
ACN: 1416123 (25 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 18000
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
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
Nav In Use : FMS Or FMC
Flight Phase : Descent
Airspace.Class E : ZZZ
Component
Aircraft Component : Hydraulic Main System
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 : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1416123
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Altitude : Undershoot
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Flight Crew : Landed in Emergency Condition
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I was descending out of 18,000 ft as pilot flying. When hydraulic pumps were selected to
high we received a right system hydraulic pressure low light. Checking gauges, right
hydraulic pressure was zero with an abnormally high quantity indication. I told the FO to
get out the QRH. I notified ATC that we had a hydraulic problem and might have a
problem making the assigned crossing. I was given relief from the crossing restriction. I
said we were working the problem and would advise them. I then notified the FAs of the
situation and would keep them advised. As we worked the QRH it was noted that we would
have to do a manual gear extension which would mean stopping straight ahead on the
runway. I then advised ATC and would be stopping on the runway and would have to be
towed off. I asked that the safety equipment be rolled as well. I then called the FAs. I then
made a PA to the passengers and let them know what was going on. The approach was
normal and the emergency gear extension accomplished. I landed at bug +5 with a soft
touchdown. Rollout was normal and I could feel the gear door bumpers dragging on the
rwy. I stopped on centerline approximately 10000 ft down Runway XXR. I made a PA
stating for everybody to remain seated. The safety trucks rolled up and we were contacted
by them. I asked them to check around the outside of the aircraft looking especially on the
right side by the gear. They said they noticed a fluid on the ground but everything else
was good. I then talked to the FAs and let them know what was going on. I then made a
PA to the passengers to advise them that we were going to be waiting for a tug to come
and tow us back to the gate and apologized for the inconvenience. It took approximately
40 minutes for the tug to show up and tow us back to the gate.
Right hydraulic fluid loss when pump selected to high resulted in a right hydraulic low
pressure light and loss of right hydraulic system.
Synopsis
MD80 Captain reported a right hydraulic system failure which necessitated a manual gear
extension with a normal landing and a tow off the runway.
ACN: 1415813 (26 of 50)
Time / Day
Date : 201701
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : 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 : Initial Approach
Airspace.Class E : ZZZ
Component
Aircraft Component : GPWS
Aircraft Reference : X
Problem : Design
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 : 1415813
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Detector.Automation : Aircraft Terrain Warning
When Detected : In-flight
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Flight Crew : Took Evasive Action
Result.Aircraft : Equipment Problem Dissipated
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
I was Pilot Flying, when cleared by Approach to descend to 3000. Received an altitude
alert, and responded by executing escape maneuver. Not sure if the aircraft terrain
database is off, my descent was too steep (1000 fpm), or what. There was no imminent
terrain threat, and we were cleared down by ATC.
Executed climb to approximately 3800 feet and notified ATC that we were responding to
an altitude alert. Eventually descended again back to 3000. I would likely just attempt a
more shallow descent if given the same instructions in that area to see if that was why the
alert occurred.
Synopsis
EMB145 First Officer reported a terrain warning after being cleared by Approach to
descend to 3000 feet. Evasive action was taken, but no reason for the warning could be
found.
ACN: 1415788 (27 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 2200
Environment
Flight Conditions : IMC
Weather Elements / Visibility.Visibility : 5
Light : Night
Ceiling.Single Value : 800
Aircraft
Reference : X
ATC / Advisory.CTAF : 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 : Landing
Airspace.Class E : ZZZ
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 : 11000
Experience.Flight Crew.Last 90 Days : 60
Experience.Flight Crew.Type : 4600
ASRS Report Number.Accession Number : 1415788
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 Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 10000
Experience.Flight Crew.Last 90 Days : 75
Experience.Flight Crew.Type : 6000
ASRS Report Number.Accession Number : 1415789
Human Factors : Workload
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Captain hand flew the ILS. Left gusty crosswind and we encountered a big gust in the
flare. Captain performed a manual go-around since the autopilot was not engaged. It was
bumpy during the go-around. From my recollection I selected LNAV at 400 AGL and
bugged clean maneuvering at 1,000 AGL. I told the Captain watch your rate of climb which
I thought was excessive. He pulled back the thrust levers just before we were about to
reach missed approach altitude. From what I recall we exceeded missed approach altitude
by 250-300 ft. Then I noticed the speed slowing rapidly and I called "watch your airspeed"
and shortly thereafter there was stick shaker activation. The Captain pushed the nose
down and simultaneously advanced the thrust levers and recovered nicely. If I remember
correctly I heard one "BANK ANGLE" somewhere during the climb out. We contacted
Center and got vectors for a second approach and subsequent landing.
It felt like everything was happening very fast as if there was excessive thrust, but we
were also very light. I am upset with myself that I cannot recall verifying the 3 go-around
FMA's prior to going heads down and selecting flaps 20 and gear up. Also, I cannot recall if
the autothrottles were engaged at this point. In the future that is what I always intend to
do before selecting gear up, roll mode and bugging clean maneuvering.
Narrative: 2
I was the flying pilot for this ILS. There was a 20 knot crosswind and it was very bumpy.
The tower was closed. Company procedures say not to fly a coupled approach as the
glideslope is unreliable. I was hand flying the approach and elected to go around as a wind
gust made for an unstable landing. Go-around procedures were initiated. The missed
approach altitude was 2200 MSL. Everything was happening very quickly. Shortly after
1000 ft "bug clean maneuvering" the FO called slow airspeed. Airspeed was rapidly
decreasing and I added thrust. We were approaching the missed approach altitude. We
received the stick shaker at this point. I recovered and we finished cleaning up the
aircraft. The second approach was uneventful.
I am not really sure how this got away from me other than it has a low missed approach
altitude.
Synopsis
B757 flight crew reported a go-around from the flare due to a strong crosswind gust. The
airspeed was allowed to get low and the missed approach altitude was overshot.
ACN: 1415751 (28 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : IAH.Airport
State Reference : TX
Altitude.MSL.Single Value : 6500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : I90
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
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Route In Use.STAR : DRLLR5
Airspace.Class B : IAH
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 : 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 : 120
Experience.Flight Crew.Type : 755
ASRS Report Number.Accession Number : 1415751
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Undershoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
While flying the DRLLR 5 arrival into IAH we crossed the BYSUN intersection at
approximately 6500 feet. We should have crossed the intersection at the published altitude
of 6000 feet. This happened for a couple of reasons. First was the distraction of the VNAV
system not completely operating correctly. Every time speed intervene was selected, to
comply with speed changes ATC gave us on the arrival, the autopilot flight director system
would drop out of VNAV into CWS pitch mode. This was written up on arrival into IAH.
Also, we were originally expecting to fly the transition for RWY 26R and we were changed
to the transition for RWY 27 while descending on the DRLLR 5 arrival. This caused us to be
high on the profile and miss the crossing altitude at BYSUN by 500 feet high. While
realizing that we were going to be high on crossing the fix, I tried to contact ATC to tell
them we were going to be high at BYSUN, but the frequency was too congested.
Synopsis
B737 Captain reported descending on the IAH DRLLR5 Arrival for Runway 26R then
assigned Runway 27 and multiple speed adjustments. This resulted in crossing BYSUN 500
feet high.
ACN: 1414698 (29 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : LECM.ARTCC
State Reference : FO
Altitude.MSL.Single Value : 44600
Aircraft
Reference : X
ATC / Advisory.Center : LECM
Aircraft Operator : Corporate
Make Model Name : Citation X (C750)
Operating Under FAR Part : Part 91
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Climb
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)
ASRS Report Number.Accession Number : 1414698
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Undershoot
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Upon leaving LECO, our FMS indicated we would reach FL450 at BERUX waypoint. All
during the climb, the FMS continued to show us reaching our Coast-Out point at FL450 at
the appropriate time. We did attempt to communicate with Madrid radio to get a 360 turn
or vector to give us more time just to have a little margin. Madrid was hard to
communicate with and was reluctant to give us any turns since we initially stated we were
projecting to make the altitude. They also had a sense of urgency about making our time
at the waypoint. In the last 1,000 feet, the temperatures climbed unexpectedly and our
climb deteriorated rapidly; we stagnated at 44,600 and ended up crossing BERUX at this
altitude. We talked with Madrid about our problem and said we could climb very slowly to
45,000. They coordinated our handoff to Shanwick radio. By the time we checked in, we
were at FL450. We requested .80 Mach instead of .83 due to the temperature and they
accepted this new speed for the crossing.
I telephoned Shanwick Radio to discuss our situation and ask what could be done better.
The supervisor said that in our situation we should not be afraid to insist that Madrid give
us a turn to avoid entering Oceanic airspace not at altitude. As soon as a flight crew is
aware they may not be at altitude at the crossing, they should attempt to avoid entering
as the primary course of action.
As it turned out, I learned from the supervisor that Madrid did coordinate with Oceanic and
we were accepted at the lower altitude with the understanding we would continue slow
climb to FL450.
For the future, picking a point 30-40 miles out from the Entry Point would be a good
technique to avoid any uncertainty. Additionally, the knowledge that the air traffic
controllers are absolutely obligated to give a deviation to stay out of Oceanic is helpful.
The language/communication difficulty should not deter flight crews from obtaining what
they need.
Synopsis
CE-750 Captain reported they were unable to make assigned altitude at their coast-out
point when the temperature rose above forecast.
ACN: 1414639 (30 of 50)
Time / Day
Date : 201603
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 36000
Environment
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Thunderstorm
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
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : 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 Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1414639
Human Factors : Situational Awareness
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
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Event was caused by unexpected turbulence and inability to maintain airspeed at altitude.
While enroute to ZZZ we encountered a patch of severe turbulence in an embedded storm.
However very little was showing on the radar and there were no prior reports of anything
more than moderate chop. Our speed slowly began dropping off, I increased power and
requested a descent to FL360. We leveled off there but still could not maintain speed, I
requested to descend again to FL340 and increased to Takeoff power. At some point in the
descent we got the stick shaker very briefly. We executed SOP procedures and recovered
uneventfully. All passengers and flight attendants were seated and no injuries were
sustained. Initiate more power and quicker descent faster.
Synopsis
CRJ-700 First Officer reported speed dropped off enough in severe turbulence to trigger a
momentary stick shaker at FL360.
ACN: 1414621 (31 of 50)
Time / Day
Date : 201608
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : BOS.Airport
State Reference : MA
Altitude.MSL.Single Value : 10000
Environment
Weather Elements / Visibility : Cloudy
Light : Night
Aircraft
Reference : X
ATC / Advisory.TRACON : A90
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 Approach
Route In Use.STAR : ROBUC2
Airspace.Class E : A90
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 : 1414621
Human Factors : Confusion
Analyst Callback : Attempted
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
The FMS was occupied by the non-flying pilot. I set the MFD range too broad and the
names of waypoints and altitudes were not clear, and for a brief second I was using the
arrival chart alone for guidance from one waypoint to the next. On the ROBUC2 arrival into
BOS, I was flying and descended to 11,000 ft for waypoint PROVI, and then proceeded to
set 8,000 for ANSLY because at the time the Captain was using the FMS and I set the MFD
to a range that was too broad so the wording was not too clear. I looked over to my iPad
chart for ROBUC2 and it is rather confusing for the arrival into the several runways. The
lines for each waypoint after PROVI take you to different arrivals for the different runways.
For example JOODY takes you to 4R, JAYNA takes you to 15R, and I thought KRANN takes
you to runway 27 and ANSLY for runway 22L but I got those two last mixed up KRANN and
ANSLY. I was supposed to stay at 11,000ft for KRANN. So I was descending close to
10,000 when the captain and I realized the mistake and we expedited a climb back to
11,000 ft. There was no incident or traffic. We proceeded to finish the arrival, landing, and
taxi to gate safely.
Charts with overlapping lines for waypoint to waypoint should be different colors to
differentiate which is the one on the runway specific arrival.
Synopsis
CRJ-900 First Officer reported descending below a transition crossing altitude on the BOS
ROBUC2 Arrival. They attributed the error to missetting the Multifunction Display range
and confusing chart presentation.
ACN: 1414603 (32 of 50)
Time / Day
Date : 201602
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : LGA.Airport
State Reference : NY
Altitude.AGL.Single Value : 1000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Windshear
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
Flight Phase : Final Approach
Airspace.Class B : LGA
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 : 1414603
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Automation : Aircraft Other Automation
When Detected : In-flight
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
[We] encountered windshear on final approach. LGA was reporting IMC conditions on the
current and forecasted weather as well as reporting using runway 13 for arrivals and
departures. Our flight entered IMC conditions around at 12,000'. There was intermediate
light chop till we reached the the outer fix of PAYMI at 3,000'. Here we intercepted the
localizer to begin the ILS approach to 13. Once we reached the final approach fix, STEED,
at 2,000', we began to pick up continuous light to moderate turbulence. Around 1,000', we
encountered a flash of lightning followed shortly by the WINDSHEAR aural warning and
visual display on our PFDs. Immediately, I initiated the windshear recovery maneuver and
was out of the windshear by 3,000'. The published missed for ILS 13 is 2,000', however,
the recovery maneuver demanded more altitude.
Synopsis
CRJ-700 Captain reported executing a go-around after receiving a windshear aural alert on
approach to LGA.
ACN: 1414574 (33 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZME.ARTCC
State Reference : TN
Environment
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.Center : ZME
Aircraft Operator : Air Carrier
Make Model Name : Medium Large Transport
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 : BLUZZ 1
Airspace.Class A : MEM
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
ASRS Report Number.Accession Number : 1414574
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Human Factors : Confusion
Human Factors : Human-Machine Interface
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
This is an issue of bad RNAV arrival terminology. Pilots are directional and when we hear
south transition we naturally fly a southern pattern in our heads. DEN has a different
name for each directional transition which works. MSP has the runway 12 or 30 transition
which works. The FAA needs to update these transitions that have the phrase landing
south//north and just change it to a number, landing 18 transition.
We had an hourly ATIS less than 40 minutes old, we briefed that information. MEM
changed their configuration and ATIS with no notice to arrival aircraft 150 miles out. Flying
into Memphis, I received the ATIS when issued in the hour. Landing Runways 36L 36R and
27. We briefed Runway 36R and entered the correct arrival for that runway into the FMS
and reviewed the southern transition and all of the altitude boxes and speeds.
20 minutes later, Memphis Center issued clearance, descend VIA Bluzz One arrival landing
south transition. Knowing we just reviewed and briefed Runway 36R, I glanced at my chart
and confirmed Bluzz arrival south transition fixes and altitudes. 10 minutes later ATC
issued direct to a fix that was located on the landing south transition. I told him the fix
was not on our route, we have the southern transition. He said MEM is landing Runway 18.
Finding our error, we expedited to the fix and altitude advising ATC, we missed the
crossing restriction by 2000 feet. We advised ATC that our ATIS said landing 36, he replied
that they changed the configuration and ATIS more than 20 minutes ago. Update RNAV
arrivals and make consistent with other major airports.
Synopsis
A pilot reported not receiving the latest ATIS information for an airport and did not have
the fix they were cleared to programmed in their FMS.
ACN: 1414567 (34 of 50)
Time / Day
Date : 201607
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 4000
Environment
Weather Elements / Visibility.Other
Aircraft
Reference : X
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Crew Size.Number Of Crew : 2
Flight Phase : Landing
Component : 1
Aircraft Component : Aileron Control System
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : Spoiler System
Aircraft Reference : X
Problem : Malfunctioning
Person
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 : 1414567
Human Factors : Workload
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Weather
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
Low time First Officer (1st flight after IOE) was flying visual. We were cleared for a visual
approach. It was little high and fast so I suggested to him to slow down and start to
configure. As he was extending the flight spoilers, Inboard Spoilerons, Outboard Spoilers
Caution Message came on. I ran the QRH, stowed the flight spoilers according to the QRH
procedure. At FAF, gear was extended, flaps were extended to 30. At this time, we
encountered gust wind to cause aircraft nose to be pushed down which caused an
unstabilized approach. It was too fast. I told First Officer (FO) to Go-Around but he
insisted that he can land. I told him "my airplane" took over the control and Missed
approached. As I was going around, I could not get First Officer to do anything. He was
frozen. I had to configure the airplane for Go-Around. By the time I engaged the auto pilot
and asked for HDG for a vector to come around, I was at 4,000 instead of 3,000 missed
approach altitude. I reported to tower that we missed approach with current altitude. Then
they assigned us 4,000 instead of 3,000. They cleared us to land via traffic pattern. We
configured and landed safely.
I should have executed the Go-Around procedure earlier. Go-Around and run the QRH and
fix the problem in order to have a stablized approach. That would have given us more time
as a crew especially having low time pilot.
Synopsis
CRJ-700 Captain reported an altitude overshoot on go-around due to a spoileron/outboard
spoiler malfunction.
ACN: 1414402 (35 of 50)
Time / Day
Date : 201701
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : I90.TRACON
State Reference : TX
Altitude.MSL.Single Value : 12000
Environment
Flight Conditions : VMC
Aircraft
Reference : X
ATC / Advisory.TRACON : I90
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Operating Under FAR Part : Part 121
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use : GPS
Flight Phase : Final Approach
Route In Use.STAR : MSCOT4
Airspace.Class B : I90
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.Type : 6269
ASRS Report Number.Accession Number : 1414402
Human Factors : Confusion
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
Center told us to descend VIA the MSCOT4 for 26R transition into IAH. Switching to
approach they told us descend and maintain 12,000. After switching to another approach
controller, he told us we were cleared for the 26L transition. We are now approaching
MSCOT which has an altitude of 10,000 and I asked the controller if he still wanted us at
12,000. He said cleared for the 26L transition. After passing MSCOT the controller said we
were supposed to be at 10,000. I said we were cleared for the 26L transition, but not to
descend VIA. He then told us to descend to 7,000 and said, "When I clear you for the
transition that also means descend via".
Synopsis
Air carrier Captain reported confusion with expected altitude on descent clearance from
Houston Approach.
ACN: 1413426 (36 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 38000
Environment
Weather Elements / Visibility.Other
Aircraft : 1
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B787 Dreamliner Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Mission : Passenger
Flight Phase : Cruise
Aircraft : 2
Reference : Y
Make Model Name : B777 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
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)
Experience.Flight Crew.Total : 15700
Experience.Flight Crew.Type : 835
ASRS Report Number.Accession Number : 1413426
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
The Captain and I had returned from break to relieve the flying crew about 1 hour and 45
minutes prior. Had just turned off the center fuel tanks, when about 5 minutes after that
heard the warning sound go off which sounded like the autopilot disconnect button. We
immediately looked at the instruments and noticed the airspeed was in the red zone and
our altitude was off by - 500 feet. The Captain reduced the throttles but airspeed
continued to increase, so opened the speed brakes slightly. I noticed that yellow slash bars
were indicated on both LNAV and VNAV. I told the Captain no LNAV or VNAV, engines look
fine. The Captain disconnected the autopilot while continuing to get the airspeed under
control and regain our altitude back to FL 380. I reset the flight directors selected heading
select and V/S +300. I then reengaged LNAV/VANV and informed the Captain that these
systems were available again.
The Captain turned on the seatbelt sign as a precaution. We were both stunned as to what
had happened, because the ride was smooth and had no bumps or chop at all. I
immediately got on the radio and told another aircraft behind us (one that we had been
communicating with and passing pirep information), that we had just experienced
something very, erratic and strange. As I was making this call, a printer message came
across the printer about a B777 that had experienced severe wave turbulence at FL 350 in
same vicinity we had just traveled. I relayed this info to the aircraft behind us. They
informed us yes they had just encountered the same and gained 1000ft, and 50kts. There
were other aircraft in the area who later confirmed they experienced the same wave,
however, were better prepared to handle it due to our detailed pireps and were very
appreciative.
We sent a message to dispatch. Dispatch did not show any unusual activity such as
horizontal windshear or unusual jet streams in the area so was very surprised to get our
prep/report. We later learned that aircraft north of our track did not experience the wave
action, but aircraft just south of us did.
Synopsis
B787 First Officer reported a severe wave encounter at FL380 which resulted in an
overspeed and uncommanded 500 foot climb.
ACN: 1413229 (37 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZNY.ARTCC
State Reference : NY
Altitude.MSL.Single Value : 35000
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZNY
Aircraft Operator : Air Carrier
Make Model Name : A330
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class A : ZNY
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZNY
Aircraft Operator : Air Carrier
Make Model Name : B737-800
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 : ZNY
Aircraft : 3
Reference : Z
ATC / Advisory.Center : ZNY
Aircraft Operator : Air Carrier
Make Model Name : B757-200
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZNY
Person
Reference : 1
Location Of Person.Facility : ZNY.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Function.Air Traffic Control : Instructor
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 4
ASRS Report Number.Accession Number : 1413229
Human Factors : Communication Breakdown
Human Factors : Confusion
Human Factors : Distraction
Human Factors : Human-Machine Interface
Human Factors : Time Pressure
Human Factors : Training / Qualification
Human Factors : Workload
Human Factors : Situational Awareness
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Primary Problem : Procedure
Narrative: 1
I was training someone on the non radar sectors of 87 and 89, and decided due to the
amount of weather and deviations to split the sector as the trainee couldn't keep up with
the flow of traffic at the time. We decided to stay with the south sector as that was the
busier of the two and had the weather and deviations, more complexity that would be
good for him to see. Before we split the sectors, I took control of the sector and gave a
position relief briefing to my relief, and had explained to him that Aircraft X was requesting
higher than what he was currently at (FL350). There were multiple aircraft head on with
Aircraft X at FL360 so in my opinion, a climb clearance was not possible with the time
constraint that he needed to be level.
As soon as myself and the trainee sat down and started back to working on the south side,
the controller who took the north sector sent a clearance to Aircraft X to climb to FL370.
Aircraft X was connected via Controller Pilot Data Link Communications (CPDLC) and
Automatic Dependent Surveillance (ADS), so he felt that there was enough time to issue
the clearance and have the plane be level before the conflict started. A clearance was sent
at XX+00 to be level at FL370 by XX+2, which I feel was unsafe to issue a climb clearance
to be level in two minutes. The pilot did not respond to the clearance right away as there
may have been a lag in the time the clearance was sent to when it was received. When
the controller did not receive a wilco from the pilot, he sent a new message at XX+3 to
disregard the climb clearance and to maintain FL350. Five seconds later the pilot sent a
wilco message, followed by a second wilco at XX+3.35. Therefore it was uncertain what
the aircraft was actually doing.
Because the controller cleared him to maintain FL350, there was no conflict window that
popped up when Aircraft X sent a downlink at XX+4:15 that the plane was at 36,172. The
controller received a trial probe error because the plane was profiled at being at FL350.
This is when I stopped training and kicked the trainee out as I tried to figure out what the
other controller was doing. The downlink we received at XX+4:15 said the aircraft was at
36,172, but had a vertical rate of -688 feet per minute, so the pilot was confused by the
multiple quick clearances and had already been through FL365 and descended back down.
The controller at sector 87 then sent a message to Aircraft X at XX+04:33 asking if the
pilot was climbing to FL370, and then attempted to get a phone patch with the pilot to
clarify the clearance. As he was attempting to get the phone patch, it appeared that
Aircraft X had been in level flight at FL360 for over 4 minutes, with the head on traffic. At
this point I told that controller to just send him a climb clearance instead of waiting for the
patch as it would be quicker since he was connected via CPDLC, just anything to get him
out of FL360.
It took two minutes for the controller to decide to climb Aircraft X to FL370, and the
clearance should have included immediately so the plane would get to a safe altitude. I
could not legally descend Aircraft Y to FL340 as Aircraft X was profiled to be at level flight
of FL350. According to the ADS reports from the plane, Aircraft X had been level at FL360
from XX:03 until XX:08:21 when the pilot reported level at FL370.
The conflict between Aircraft X and Aircraft Y started at XX:04, but because of the
controller's change of clearance, the conflict did not appear on my screen until XX:06:49
when the loss of separation had already begun. The second conflict with Aircraft Z started
at XX:15, and there was a third aircraft on that route northbound also at FL360, but I do
not recall the call sign.
I issued the brasher warning to Aircraft X as soon as he entered my airspace as there was
a loss of separation. I do not know for sure if Aircraft X was really level at FL360 for four
minutes or if he had descended back to FL350, however the ADS reports showed him
FL360. The delay between the ADS reports made this more confusing.
I would suggest to never, ever send a clearance if there is such a short time frame for the
plane to be level. This was a "safe" clearance, but a stupid one to make. If this was a
radar sector, I still would not issue a clearance like that, but especially in non-radar where
you don't have accurate positions it was completely unsafe in my opinion. Also the
controller should have added to the clearance, "if unable climb by time issued, maintain
FL350 and advise". The pilot was confused by the multiple clearances sent so closely
together, especially for someone whose first language is not English.
Synopsis
ZNY Controller reported of an unsafe situation when a fellow Controller climbed an aircraft
to avoid a loss of separation. The other Controller climbed the aircraft in what the reporter
thought was too short of a time period.
ACN: 1413202 (38 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 2700
Environment
Flight Conditions : VMC
Work Environment Factor : Temperature - Extreme
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Personal
Make Model Name : PA-31 Navajo/Chieftan/Mojave/T1040
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use : Visual Approach
Route In Use : Vectors
Airspace.Class E : ZZZ
Component : 1
Aircraft Component : Aircraft Heating System
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : GPS & Other Satellite Navigation
Aircraft Reference : X
Problem : Malfunctioning
Component : 3
Aircraft Component : Autopilot
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 5445
Experience.Flight Crew.Last 90 Days : 78
Experience.Flight Crew.Type : 583
ASRS Report Number.Accession Number : 1413202
Human Factors : Workload
Human Factors : Distraction
Human Factors : Situational Awareness
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
Were Passengers Involved In Event : Y
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Diverted
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Landed As Precaution
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Very early we lost the cabin heater, but decided with the length of flight we would make
the flight. It was bitter cold in the cabin. Also the two panel mount GPS unit screens
started hazing over becoming difficult to read. At that point I requested from a deviation
to go to [a nearby airport]. At that point we were given radar vectors and at some point a
new altitude. We had been at 7,000 ft. As we descended we were in VFR conditions. [ATC]
told me to expect radar vectors for the ILS Rwy 23 and I was cleared down to 2,700 ft.
Trying to load the ILS was almost impossible as by this time the GPS screens were almost
unreadable. I was flying on autopilot, descending, trying to load the ILS and visually
searching for the airport. It was during this time the auto pilot failed and not noticing it at
first, I descended below the assigned altitude of 2,700 ft. I remember being at 2,400 ft
and I might have been momentarily a little lower. With the help and guidance from [ATC] I
did recapture my altitude and I was able to spot the airport for a visual approach and
landing.
On the ground I reset the cabin heater (can only be done on the ground) but elected to
spend the night and fly to [our destination] in the morning when VFR conditions were
forecasted. We wanted VFR daytime flight conditions to check out the avionics. On Friday
morning we had clear skies and we flew back VFR. The heater worked and with a warm
cabin, the GPS units as well as the autopilot worked perfectly.
Synopsis
PA31 pilot reported while flying during extreme cold conditions, an inoperative cabin
heater caused the cabin of a twin piston aircraft to become abnormally cold. Pilot stated
this resulted in difficulty reading the GPS screens, failure of the autopilot, and the need for
ATC assistance with a diversion.
ACN: 1413139 (39 of 50)
Time / Day
Date : 201612
Place
Locale Reference.Airport : SJU.Airport
State Reference : PR
Altitude.MSL.Single Value : 520
Environment
Flight Conditions : VMC
Aircraft
Reference : X
ATC / Advisory.Tower : SJU
Aircraft Operator : Air Carrier
Make Model Name : Airbus Industrie Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Route In Use.SID : ACONY 2
Airspace.Class C : SJU
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)
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
ASRS Report Number.Accession Number : 1413139
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Workload
Human Factors : Time Pressure
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft RA
Detector.Automation : Aircraft Terrain Warning
Detector.Automation : Aircraft TA
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
Primary Problem : ATC Equipment / Nav Facility / Buildings
Narrative: 1
During takeoff from SJU on the ACONY2 departure after making a left hand turn out of 520
ft we had a near midair with a general aviation aircraft. When we started the left turn I
saw the aircraft flying into [our path] and I immediately told the first officer to turn right
and descend. At that point the other aircraft appeared to start a climb. The other aircraft
then passed over top of us. It was after we had already start our maneuver that the TCAS
RA commanded a climb to which we couldn't comply with at that point. Seconds after
passing the other aircraft we received a GPWS alert because we were so low to the water
with a high descent rate. No Pax injured and no aircraft damage.
Synopsis
Airbus Captain reported an NMAC after departure from SJU. He received a RA to climb
which could not be complied with due to aircraft performance limitations.
ACN: 1412991 (40 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZZ.ARTCC
State Reference : FO
Altitude.MSL.Single Value : 31000
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B777 Undifferentiated or Other Model
Crew Size.Number Of Crew : 3
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
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.Total : 10617
Experience.Flight Crew.Type : 1973
ASRS Report Number.Accession Number : 1412991
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
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 : Requested ATC Assistance / Clarification
Result.Flight Crew : Regained Aircraft Control
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Preflight planning included Dispatch who relayed 3 separate areas of potential turbulence.
The flight was planned initially at FL270 to avoid the first large area of forecast LT-MOD
Turbulence. ATC assigned us FL310 "due traffic". Flight Attendants were briefed to remain
seated until we called.
Once airborne ATC advised us there were no adverse reports FL310-350. We were
experiencing continuous light chop from approximately 12,000-FL27.5. Once level at
FL280 we experienced nothing more than occasional light chop. ATC again said no adverse
reports FL310-350. I had [the relief officer] call Purser so they could start service and
secure barrier to allow [the relief officer] to exit cockpit. This occurred approximately 46
minutes after takeoff. We continued to climb to FL310. Autopilot engaged LNAV/VNAV.
Shortly after level off at FL310 we encountered the first of 2 separate turbulence
encounters. The first started as a gentle climb and slight right turn, followed immediately
by an immediate left roll and negative pitch change. The autopilot disconnect horn
sounded as well as Master Warning and Auto Pilot (AP) on Electronic Attitude Director
Indicators (EADI). Associated with the violent nature of the event my eyeglasses were
knocked from my face. I immediately grasped the control wheel with both hands to return
the aircraft to level flight. Altitude fluctuated from -300 feet to +600 or 800 feet.
Under the circumstances I cannot honestly say what the exact deviations were. I ordered
the First Officer (FO) Pilot Monitoring (PM) to command the Flight Attendants (FA) to "be
seated immediately". I was able to return the aircraft to wings level and FL313 when the
second and largest of the two jolts of severe occurred. The aircraft again violently pitched
up, rolled left, then right, with very little response from the control wheel inputs. I noted
approximately 35-40 degrees of left bank and -5 degrees of pitch at one point. It really
felt like much more at the time, and actually might have been. The second encounter was
quite violent and it was difficult to accurately see the instrument panel.
We reported the encounter to [ATC]. There was a bit of a language issue as to what we
had encountered as well as trying to get a clearance to a lower altitude. Compounding this
was [another air carrier] flight trying to get a different altitude after hearing our report.
We were then cleared to FL280. Once we were established in smoother air I made a PA to
FAs to "take your jump seats and check in". Purser reported that there were no injuries.
We contacted Dispatch via SATCOM and reported the severe turbulence encounters.
[Maintenance] was patched through as well. The decision was made to continue as
schedule.
Synopsis
B777 Captain reported encountering severe turbulence in departure climb.
ACN: 1412876 (41 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZDV.ARTCC
State Reference : CO
Altitude.MSL.Single Value : 23600
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZDV
Make Model Name : Challenger 300
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 : Descent
Airspace.Class A : ZDV
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 : 1412876
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 : 1413140
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Were Passengers Involved In Event : Y
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Descending out of cruise altitude reports of continuous moderate turbulence by other
aircraft around the front range of the Rocky Mountains was noted and the crew was also
advised by ATC. The second in command left the flight deck and advised the passengers of
the turbulence and secured the cabin. The crew requested a slower airspeed and 230
knots was assigned. The weather in the descent was clear with no clouds and unlimited
visibility. The aircraft was cleared to descend to FL240 and was on an assigned heading
due to traffic volume. Turbulence began around FL260 and increased in intensity around
24,500 feet. The airspeed began to become erratic with plus or minus 30 knots and as the
turbulence increased the autopilot was unable to capture the altitude of FL240 assigned.
At around 23,600 feet the autopilot was disconnected and the PIC maintained control of
the aircraft. Air traffic control was advised that severe turbulence was encountered and
cleared the aircraft to FL230. Leveling off at FL230 the turbulence ended and the aircraft
landed without further incident. There were no injuries to the passengers. Several glasses
had broken, three in the galley cabinet and one in the cabin, and one panel of oxygen
masks dropped.
Narrative: 2
The air was smooth as we continued our descent through FL240. However as we continued
below FL240, both the Pilot Not Flying and I noticed the aircraft tail starting to lift and the
autopilot attempted to correct the pitch attitude by increasing the pitch to a more nose up
attitude since we were descending in Vertical Speed mode. At about 23,600 feet we
encountered a severe downdraft which caused us to descend through our assigned altitude
(FL230). The downdraft was immediately followed by a tremendous updraft and the
aircraft ballooned upwards at about 2000 feet a minute and then another violent
downdraft. During the descent, the airspeed began increasing rapidly, so I reduced the
thrust setting in an attempt to control the airspeed. However, we then encountered a
second updraft and the plane pitched to a high angle of attack and due to the thrust
reduction the airspeed diminished very quickly. It was at this point that I pushed the
thrust levers to Takeoff Power and disconnected the autopilot. We regained our airspeed
instantly and climbed out of the mountain wave.
Synopsis
CL-30 flight crew reported encountering severe turbulence in descent over the front range
of the Rockies.
ACN: 1412795 (42 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : BTV.Airport
State Reference : VT
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Icing
Weather Elements / Visibility : Windshear
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : BTV
Aircraft Operator : Air Carrier
Make Model Name : Medium Transport
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 : Final Approach
Airspace.Class C : BTV
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 : 1412795
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 : 1412790
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Automation : Aircraft Other Automation
When Detected : In-flight
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Aircraft X [operating] to CYUL with divert to BTV. I (Captain) was pilot flying. On arrival to
Montreal 24L the aircraft in front of us reported poor braking action and sliding on the
runway so we went missed. They were going to put us number four in line to try again for
24R but considering fuel and weather we decided to immediately divert to BTV. It was
very windy and turbulent on approach into BTV. On the approach at around 1000 feet we
got a red wind shear and went missed. During the execution of the wind shear missed the
stick shaker went off for a split second and went away due to the turbulence, and we got
the Autopilot fail message. We came back around for another attempt, at this point we
were at about 1900 Fuel on Board (FOB) and options were dwindling. On the next attempt,
at about 1000 feet, we got the red wind shear again. Considering that the wind shear was
not associated with a thunderstorm, our fuel situation, other possible alternates within
range likely to also have wind issues, and the reasonably high altitude of the wind shear
warning, I used my captain's authority to disregard the wind shear warning and continue
the approach. I put her down safely in BTV. We refueled and continued on to Montreal.
BTV was a terrible alternate. The TAF did not look so bad but it was bad when we got
there. More fuel would have been nice to have. I overshot our missed approach altitude of
3000 feet by 3 or 400 feet because I was and fighting the turbulence with no autopilot as
it kicked off with the shaker and troubleshooting that was at the bottom of my list of
importance. Threats were mountains, winds, wind shear, runway icing in CYUL, bad
options for other alternates, and minimal fuel.
It would be nice to not always be so tight on fuel, it seems like the company often gives us
the minimum required by law and you can quickly run out of options. We diverted
immediately from Montreal and still were in a bad spot at BTV. I believe I made the
correct decision in disregarding the wind shear alert on the second approach and landing
the plane, we would have been well into reserve fuel if I went missed again. I don't
remember the winds now I'm tired and did 3 more legs after that, but it was windy,
significantly windy, and we should be more mindful of that when choosing alternates
especially at the dispatch level and also at the pilot level. And if I had more fuel I would
have gone missed again and not disregarded the second red wind shear alert. And the
dispatcher did a good job dealing with the situation with us, it was just a bad alternate.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Air carrier flight crew reported a diversion to BTV after runway conditions deteriorated at
CYUL. Captain reported BTV was not a very good alternate, but due to their fuel state
elected to successfully land even though he received a wind shear alert on the second
approach.
ACN: 1412626 (43 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : SAN.Airport
State Reference : CA
Altitude.MSL.Single Value : 1200
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : SAN
Aircraft Operator : FBO
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Climb
Route In Use : VFR Route
Airspace.Class B : SAN
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 575
Experience.Flight Crew.Last 90 Days : 30
Experience.Flight Crew.Type : 40
ASRS Report Number.Accession Number : 1412626
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Human Factors : Confusion
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : FAR
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was doing the San Diego Bay tour at 800 ft MSL. After reporting my 180 degree turn
over the Coronado Bridge during the bay tour with a student, I was cleared for the SAN
Delta transition at 1500 ft MSL to travel northbound to MYF. I misunderstood the clearance
to be 500 ft MSL. I started a descent to 500 ft MSL when Lindbergh Tower instructed me
to climb immediately. I crossed SAN at 1200 ft MSL and was instructed to continue to the
Mission Bay VOR. I am a new flight instructor and new to San Diego.
I had practiced the bay transition earlier in the morning with another instructor with no
problems and I understand my mistake. After conversing with the Director of Operations
at my flight school, we have agreed that I will receive more training on the transition and
the San Diego airspace, and I will give a safety briefing at the next pilot meeting about the
event.
Synopsis
A flight instructor reported misunderstooding the clearance altitude while on a San Diego
Bay tour. They descended to 500 feet until ATC corrected them and they climbed to
assigned crossing altitude.
ACN: 1412623 (44 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 8000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 2500
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Personal
Make Model Name : Skylane 182/RG Turbo Skylane/RG
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class E : ZZZ
Component
Aircraft Component : Electrical Power
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 675
Experience.Flight Crew.Last 90 Days : 50
Experience.Flight Crew.Type : 14
ASRS Report Number.Accession Number : 1412623
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed As Precaution
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft
Narrative: 1
Experienced electrical issue during cruise flight on an IFR flight plan in IMC. I immediately
shut off the master switch [and] that stopped the smoke. In the meantime, I flew out of a
cloud and recognized the surrounding area. Being in visual conditions, I stayed in visual
and continued to execute a precautionary landing at [a nearby airport]. I turned the
master back on momentarily to allow me usage of the aircraft's flaps, and heard Center
calling me multiple times. I responded and told them I had an issue in the cockpit at which
point they asked if I was declaring an emergency, and I responded (seeing how I was on
final) with no. After this occurrence, I promptly shut the master off to ensure that a fire
would not start. Once on the ground, I immediately called the operations desk at Center
and explained what had happened. My deviation decision from ATC instructions was made
at a point where I did not have communication with Center and due to not knowing the
cause I decided it was best to execute a precautionary landing while remaining in visual
conditions. Ultimately, the result of the incident ended as a non-event in the form of a
precautionary landing.
Synopsis
C182 pilot reported smoke in the cabin while on an IFR flight plan, and electing to divert to
a nearby airport without notifying ATC.
ACN: 1412163 (45 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 24000
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Corporate
Make Model Name : Turbo Commander 690 Series
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class A : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Single Pilot
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 25200
Experience.Flight Crew.Last 90 Days : 35
Experience.Flight Crew.Type : 6000
ASRS Report Number.Accession Number : 1412163
Human Factors : Situational Awareness
Human Factors : Fatigue
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was 11 hours into a 12 hour duty day flying single pilot on a positioning leg. The previous
three legs had all had some stress due to weather. I was in level flight cruise in VMC on
autopilot. I was trying to catch up on paperwork and had the flight log binder propped on
the control yoke. I heard the autopilot disconnect warning but it didn't immediately
register on my brain. A few seconds later I looked up and the airplane was in a right wing
down nose down attitude. I immediately rolled wings level and pitched back up to regain
my assigned altitude. The binder had hit the trim switch which disconnected the autopilot
and possibly added some nose down trim. The only reason I can think of for not reacting
sooner to the autopilot disconnect warning is fatigue. I had had two long days in a row.
Synopsis
Aero Commander 690 pilot reported an altitude deviation occurred when the autopilot was
inadvertently disconnected.
ACN: 1412041 (46 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : PDK.Airport
State Reference : GA
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Cloudy
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : PDK
Make Model Name : Light Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Phase : Final Approach
Airspace.Class D : PDK
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1412041
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1412478
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Altitude : Undershoot
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Speed : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
I can honestly say that this is the first time in years that this was NOT a fatigue related
issue.
We were given the VOR DME-D approach, circle to land. The weather was reported at 700'
overcast. We were vectored inside of, to the east of JUDYY at 3000'. Cleared for the
approach, we were just approaching LIPPY, descending just above 2,600'. I was fully
configured and on speed, with autopilot engaged. As we approached 1700' the tower with
alarm in his voice stated, Aircraft X check your altitude immediately! Something to the
effect of level off or climb and he said it 3 times. I was totally freaked out. My Adrenalin
shot through the roof. This set me up for a chain of events. I believe it totally flustered the
Pilot in Command (PIC) as he stammered on the radio as our minds were racing about
what the hell just went wrong. I glanced at my Ipad and verified we were good for 1600',
kicked the autopilot off in preparation for a go around. I was very confused for a period of
time. It was clear we were not going to see the airport and I hit the go around button and
at about the same time tower asked incredulously did we not see the airport as we were
approaching the airport.
He told us to climb to 3,000' Runway heading. I started the go around but neglected to
command flaps 15. The captain failed to say positive rate and at this point with my head
still trying to wrap myself around what the heck had just transpired I failed to "FLY THE
AIRPLANE" properly, better said, I got behind the airplane. Finally the captain call positive
rate and I said gear up, flaps 15 and now I'm approaching 3,000' too fast. We had pax on
board so in an effort to not float them in their seats, I cut power and started pushing over
gently. I should have been more aggressive, but we exceeded 3,000' by approximately
250'. ATC advised us to maintain 3,000. The captain is now hollering at me, making it
worse. Now my speed is decaying down to approximately ref speed and the captain said,
autopilot on. I relaxed pressure assuming this was the case. It was NOT ON!!! So now with
speed back under control we are going through 3,000 the other way! The captain is
frustrated by this point and says, "my controls" and I felt at this point it made sense for
him to do this, rather than tr to discuss what happened and just make a bad situation
worse. I believe we went 200' below 3,000 feet before we got it all straightened out.
Once stabilized we asked for and received the ILS approach to 21L. We broke out about
100' above ILS minimums. We were set up for failure because the cloud bases were no
where near making a successful circle and I still have no idea why the controller started
hollering at us about the approach. We never went below mins, and in fact he started
hollering 100' above mins.
I wished I had just gone straight to flying the airplane and tuning everything else out, but
because this was a very unusual situation I was trying desperately to figure out what was
wrong so I didn't kill us. I guess in hind-site I would rather be too high than too low.
The only thing I can guess at this point is that perhaps he felt my descent rate was too
high? I believe were in the descent at about 1,100' per minute, prior to leveling off.
Narrative: 2
While on the VOR DME-D circle to land 03R, we received a low altitude alert from ATC. We
were inside the Final Approach Fix (Lippy) and descending to the MDA of 1600. Passing
1700 we received a low altitude alert from PDK Tower. We confirmed the current altimeter
setting of 30.47 with Tower and the verified the MDA of 1600 feet on the approach plates.
There were no NOTAMs associated with this instrument approach. Nor did we read back
any instructions that placed any limit on our altitude.
I am unsure as to why we received a low altitude alert. The pilot flying did not have an
excessively high rate of descent from the FAF to MDA (about 1000' fpm).
Synopsis
Aircraft reported while on final approach the Tower frantically called to "CHECK
ALTITUDE", which set the crew up for a chain of events that led to a go-around.
ACN: 1411417 (47 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : DCA.Airport
State Reference : DC
Altitude.MSL.Single Value : 9400
Aircraft
Reference : X
ATC / Advisory.TRACON : PCT
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 : Initial Approach
Route In Use.STAR : CAPSS TWO
Airspace.Class E : PCT
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1411417
Human Factors : Workload
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Equipment / Tooling
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
Descending on the CAPSS2 RNAV arrival into DCA. Airplane crossed HOYAS about 400 feet
high. This particular STAR gave the FMC a lot of problems. Multiple alerts displayed,
unnecessary airspeed changes and finally an impossible descent rate to make the HOYAS
altitude restriction were all part of the descent from WAVES. Between HOYAS and CAPSS
the FMC reverted to VNAV speed and simply left the path. The VNAV path alternated
between an add power segment back to a flight idle, speed brakes segment several times.
A better solution for the FMC is to simply average the path. Is this RNAV arrival too
complex for the FMC brain? The promise of a reduced cockpit workload by using
VNAV/FMC RNAV descents is elusive. Cockpit workload in this situation is increased due to
crews having to constantly monitor, intervene, and fix VNAV issues.
Synopsis
B737 Captain detailed problems associated with a DCA RNAV arrival relative to FMC
capabilities and increased workload imposed on flight crews.
ACN: 1411411 (48 of 50)
Time / Day
Date : 201612
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : DFW.Airport
State Reference : TX
Altitude.MSL.Single Value : 6500
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : D10
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
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use : GPS
Flight Phase : Descent
Route In Use.STAR : VICTRY2
Airspace.Class B : DFW
Component : 1
Aircraft Component : Aero Charts
Aircraft Reference : X
Component : 2
Aircraft Component : Electronic Flt Bag (EFB)
Aircraft Reference : X
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 : 1411411
Human Factors : Human-Machine Interface
Human Factors : Workload
Human Factors : Confusion
Human Factors : Distraction
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Chart Or Publication
Primary Problem : Chart Or Publication
Narrative: 1
DFW VKTRY RNAV Arrival, Set 7,000 instead of 5,000. End of arrival procedure on the
upper left hand of the page confusing. Enlarging page to read fine print and upper left
page disappears. Fatigued at the end of long day flying with First Officer that hadn't flown
in 14 years. Single pilot operations.
Suggestions: Put the end of the procedure at the end of the page. When "cleared to
descend via" the pilot could respond "cleared to descend to 5,000 feet via the VKTRY."
Synopsis
B737NG Captain reported flying the DFW VKTRY 2 RNAV Arrival "DESCEND VIA" set 7,000
feet as the final procedural altitude verses 5,000 feet, because after enlarging the
procedure on the EFB, the Runway Transition was not visible in the upper left corner,
opposite direction from the lower right final procedures' termination.
ACN: 1411410 (49 of 50)
Time / Day
Date : 201612
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZDV.ARTCC
State Reference : CO
Altitude.MSL.Single Value : 30500
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
ATC / Advisory.Center : ZDV
Aircraft Operator : Air Carrier
Make Model Name : Airbus 318/319/320/321 Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : GPS
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 : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1411410
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
In cruise at FL290 crossing over the front range of the Rockies just north of Denver. Desire
climb for fuel conservation and inquire with Denver Center about rides at FL310. Rides
reported good and subsequently given climb to FL310. Climbing out of FL305 encountered
severe mountain wave turbulence causing immediate airspeed increase above limits and
uncontrollable climb. Disconnected autopilot and attempted immediate correction. Topped
out at FL330, then corrected back to FL310. Reported event to ATC, Dispatch, and
Maintenance Control with Aircraft Maintenance Log (AML) write up.
Synopsis
Airbus Captain reported encountering a mountain wave during a climb from FL290 which
oversped the aircraft during an uncontrollable climb to FL330.
ACN: 1411389 (50 of 50)
Time / Day
Date : 201612
Place
Locale Reference.Airport : SNA.Airport
State Reference : CA
Altitude.MSL.Single Value : 1600
Environment
Weather Elements / Visibility : Rain
Aircraft
Reference : X
ATC / Advisory.Tower : SNA
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
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 2L
Flight Phase : Initial Approach
Airspace.Class C : SNA
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 : 1411389
Human Factors : Confusion
Human Factors : Situational Awareness
Human Factors : Workload
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft Terrain Warning
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : FLC complied w / Automation / Advisory
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Flying SNA received ATIS for landing prior to descent into Orange County, weather
reported VFR 3,500 scattered. The only thing that made the approach different than usual
was landing on 2L. We briefed a visual approach to 2L with LOC Back Course as a backup.
As we were vectored for the approach I had the aircraft stable at 170 knots 1,600 feet, at
the final approach fix we were fully configured gear down flaps 40 with all checklist
completed. We were surprised that we were still in the clouds (marginal weather) I figured
we'd pop out and the airport would be in sight as soon as we started down. I made the
mistake of a too aggressive descent rate that put us in a low position too far from the
airport. I notice a FMC disagree light called it out to my First Officer when we then got a
terrain warning and immediately executed a missed approach. Tower told to us fly runway
heading and would be vectored for a right downwind RNAV 2L Approach, I also let them
know that the visibility was much worse that reported and moderate rain. At this point we
briefed the RNAV approach flew it all the way down to minimums when we finally got the
runway in sight and landed safely.
A couple of things that contributed to the situation was we both did not sleep well and
both of us were a little tired. Also we noticed at 1,600 we were still in the clouds even
though it didn't appear that bad and that we would pop out I should I have executed the
missed approach there. I have been with this airline for [many] years and a Captain for
[almost as many] and I have never had anything happen to me like this and was a definite
slap to my ego. I consider myself a pretty good guy and a very good pilot and always take
responsibility for my crew and aircraft at all times while on duty or off duty!
Inaccurate ATIS report and not planning a full approach to minimums and fatigue.
Synopsis
B737NG Captain reported flying a visual approach with LOC Back Course back up to SNA
Runway 2L, executed a missed approach at an EGPWS TERRAIN Warning in weather far
worse than reported on ATIS. The second RNAV 2L approach was flown to minimums for a
successful landing.