ASRS Database Report Set - Altitude Deviations

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.

Report Synopses

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.

Report Narratives

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




Function.Flight Crew : Captain

Function.Flight Crew : Pilot Not Flying





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


Place

Locale Reference.Airport : SLC.Airport

State Reference : UT


Environment


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



Flight Plan : IFR

Mission : Personal

Nav In Use.Localizer/Glideslope/ILS : Runway 34L


Route In Use : Vectors

Airspace.Class B : SLC

Person

Reference : 1



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



Human Factors : Other / Unknown

Events


Anomaly.Deviation - Procedural : Clearance

Anomaly.Inflight Event / Encounter : Weather / Turbulence

Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control






Result.Flight Crew : Returned To Clearance

Result.Flight Crew : Regained Aircraft Control

Result.Flight Crew : Executed Go Around / Missed Approach



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


Place

Locale Reference.Airport : CYHM.Airport

State Reference : ON


Environment

Weather Elements / Visibility.Visibility : 2.5

Light : Night

Ceiling.Single Value : 300

Aircraft

Reference : X

ATC / Advisory.Center : CZYZ


Make Model Name : Widebody, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Cargo / Freight

Nav In Use.Localizer/Glideslope/ILS : Runway 12


Person

Reference : 1




Function.Flight Crew : Relief Pilot



Human Factors : Confusion

Human Factors : Training / Qualification

Analyst Callback : Attempted

Events

Anomaly.Deviation - Altitude : Overshoot

Anomaly.Deviation - Procedural : Published Material / Policy



Were Passengers Involved In Event : N


Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Chart Or Publication


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


Environment



Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger


Airspace.Class C : ZZZ

Person

Reference : 1











Events




Detector.Automation : Air Traffic Control


Detector.Person : Air Traffic Control


Result.General : Maintenance Action

Result.Flight Crew : Overcame Equipment Problem


Assessments




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


Place

Locale Reference.Airport : RNO.Airport

State Reference : NV

Environment

Flight Conditions : Mixed

Weather Elements / Visibility.Visibility : 6

Light : Dusk


Aircraft

Reference : X

ATC / Advisory.Tower : RNO


Make Model Name : B737 Undifferentiated or Other Model



Mission : Passenger


Route In Use.Other

Airspace.Class C : RNO

Person

Reference : 1









Events

Anomaly.ATC Issue : All Types






Assessments


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


Place

Locale Reference.ATC Facility : ZMA.ARTCC

State Reference : FL


Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZMA




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


Human Factors : Communication Breakdown

Human Factors : Distraction



Communication Breakdown.Party1 : ATC

Communication Breakdown.Party2 : Flight Crew

Person : 2

Reference : 2

Location Of Person.Facility : ZMA.ARTCC



Function.Air Traffic Control : Instructor

Function.Air Traffic Control : Handoff / Assist










Events

Anomaly.Conflict : Airborne Conflict






Result.Air Traffic Control : Provided Assistance

Assessments




Contributing Factors / Situations : Staffing


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


Place

Locale Reference.Airport : LVK.Airport

State Reference : CA


Environment


Weather Elements / Visibility : Fog



Aircraft

Reference : X

ATC / Advisory.Tower : LVK

Aircraft Operator : FBO

Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : IFR

Mission : Training

Flight Phase : Final Approach


Airspace.Class D : LVK

Component

Aircraft Component : Pitot-Static System


Problem : Malfunctioning

Person

Reference : 1



Reporter Organization : FBO

Function.Flight Crew : Instructor

Qualification.Flight Crew : Flight Instructor








Human Factors : Troubleshooting




Events







Result.Flight Crew : Returned To Departure Airport


Result.Flight Crew : Became Reoriented


Assessments




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


Place

Locale Reference.Airport : PHX.Airport

State Reference : AZ


Environment


Weather Elements / Visibility : Rain

Light : Night

Aircraft

Reference : X

ATC / Advisory.TRACON : P50


Make Model Name : Regional Jet 700 ER/LR (CRJ700)



Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 7R


Airspace.Class B : PHX

Person

Reference : 1













Events



Anomaly.Deviation - Track / Heading : All Types



Anomaly.Inflight Event / Encounter : Unstabilized Approach



Result.Flight Crew : Requested ATC Assistance / Clarification



Assessments






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


Place

Locale Reference.Airport : NQI.Airport

State Reference : TX

Relative Position.Angle.Radial : 110

Relative Position.Distance.Nautical Miles : 6


Environment

Flight Conditions : VMC


Light : Daylight


Aircraft

Reference : X

ATC / Advisory.Tower : NQI

Aircraft Operator : Military

Make Model Name : Military Trainer



Flight Plan : IFR

Mission : Training

Flight Phase : Initial Climb


Route In Use : Direct

Airspace.Class D : NQI

Person

Reference : 1



Reporter Organization : Military









Human Factors : Workload

Human Factors : Time Pressure



Events










Assessments




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


Place

Locale Reference.ATC Facility : ZME.ARTCC

State Reference : TN


Environment



Light : Dawn


Aircraft

Reference : X

ATC / Advisory.Center : ZME

Aircraft Operator : Corporate

Make Model Name : Medium Transport, High Wing, 2 Turboprop Eng



Flight Plan : IFR

Mission : Passenger

Flight Phase : Descent


Airspace.Class E : ZME

Person : 1

Reference : 1



Reporter Organization : Corporate












Person : 2

Reference : 2









Events






Miss Distance.Vertical : 2000





Assessments



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


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


Place

Locale Reference.ATC Facility : BTV.TRACON

State Reference : VT


Aircraft

Reference : X

ATC / Advisory.TRACON : BTV





Flight Plan : IFR

Mission : Passenger




Airspace.Class C : BTV

Person

Reference : 1

Location Of Person.Facility : BTV.TRACON


Function.Air Traffic Control : Approach


Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 4.0



Events









Assessments


Contributing Factors / Situations : Equipment / Tooling



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


Place

Locale Reference.Airport : RNO.Airport




Environment

Flight Conditions : Marginal

Weather Elements / Visibility : Cloudy


Light : Night


Aircraft

Reference : X

ATC / Advisory.TRACON : NCT

Aircraft Operator : Air Taxi

Make Model Name : Citation II S2/Bravo (C550)



Flight Plan : IFR

Mission : Ferry



Airspace.Class E : NCT

Person : 1

Reference : 1



Reporter Organization : Air Taxi





Qualification.Flight Crew : Flight Engineer







Human Factors : Human-Machine Interface

Human Factors : Fatigue


Person : 2

Reference : 2



Reporter Organization : Air Taxi













Events






Result.Flight Crew : FLC Overrode Automation


Assessments





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


Place




Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ


Make Model Name : B737-700



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZZZ

Person : 1

Reference : 1









Person : 2

Reference : 2








Events







Assessments



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


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


Place

Locale Reference.ATC Facility : ZOA.ARTCC



Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZOA


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Retractable Gear



Flight Plan : IFR

Mission : Personal


Airspace.Class E : ZOA

Person

Reference : 1

Location Of Person.Facility : ZOA.ARTCC




Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 3.3




Events











Assessments



Contributing Factors / Situations : Company Policy



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


Place

Locale Reference.ATC Facility : ZDC.ARTCC

State Reference : VA


Environment





Light : Daylight


Aircraft

Reference : X

ATC / Advisory.Center : ZDC


Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior



Flight Plan : IFR

Mission : Personal


Route In Use.Airway : V143

Airspace.Class E : ZDC

Component

Aircraft Component : Engine



Person : 1

Reference : 1








Qualification.Flight Crew : Flight Engineer









Person : 2

Reference : 2





Qualification.Flight Crew : Private








Events













Assessments



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


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


Place

Locale Reference.ATC Facility : ZDC.ARTCC

State Reference : VA


Environment


Light : Dawn

Aircraft

Reference : X

ATC / Advisory.Center : ZDC


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZDC

Person

Reference : 1









Events


Anomaly.Deviation - Altitude : Crossing Restriction Not Met







Assessments




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


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS



Airspace.Class B : ZZZ

Component

Aircraft Component : Autopilot



Person : 1

Reference : 1









Person : 2

Reference : 2







Events




Anomaly.Deviation - Speed : All Types



Detector.Automation : Aircraft TA








Assessments




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


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


Place

Locale Reference.Airport : LAX.Airport



Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZLA


Make Model Name : A321



Flight Plan : IFR

Mission : Passenger



Route In Use.SID : LOOP9

Airspace.Class E : ZLA

Person

Reference : 1










Events

Anomaly.Deviation - Altitude : Undershoot










Assessments





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


Place

Locale Reference.ATC Facility : KZAK.ARTCC

State Reference : AK


Environment


Weather Elements / Visibility : Thunderstorm

Aircraft

Reference : X

ATC / Advisory.Center : KZAK


Make Model Name : B787 Dreamliner Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1











Person : 2

Reference : 2










Person : 3

Reference : 3


Location In Aircraft : Crew Rest Area


Function.Flight Crew : Relief Pilot






Events










Assessments




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


Place

Locale Reference.Airport : SJC.Airport




Environment




Light : Night


Aircraft

Reference : X

ATC / Advisory.TRACON : NCT


Make Model Name : Large Transport



Flight Plan : IFR

Mission : Passenger




Route In Use.STAR : FRLON2

Airspace.Class B : SFO

Person : 1

Reference : 1












Person : 2

Reference : 2










Events









Assessments





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


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


Place

Locale Reference.Airport : PHX.Airport

State Reference : AZ


Environment


Light : Daylight

Aircraft : 1

Reference : X



Make Model Name : Large Transport



Flight Plan : IFR

Mission : Passenger



Route In Use.SID : KATMN5


Aircraft : 2

Reference : Y


Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer


Person : 1

Reference : 1














Person : 2

Reference : 2













Events






Detector.Automation : Aircraft RA




Result.Flight Crew : FLC complied w / Automation / Advisory


Assessments




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


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


Place

Locale Reference.ATC Facility : ZDV.ARTCC

State Reference : CO


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZDV


Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger



Airspace.Class A : ZDV

Aircraft : 2

Reference : Y



Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1

Location Of Person.Facility : ZDV.ARTCC


Function.Air Traffic Control : Trainee


Qualification.Air Traffic Control : Developmental




Person : 2

Reference : 2










Person : 3

Reference : 3













Events












Result.Air Traffic Control : Separated Traffic

Assessments






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


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


Place

Locale Reference.Airport : PIT.Airport

State Reference : PA


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : PIT


Make Model Name : Regional Jet 900 (CRJ900)



Flight Plan : IFR

Mission : Passenger


Route In Use : Visual Approach

Airspace.Class B : PIT

Person

Reference : 1








Events










Assessments



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


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


Make Model Name : Medium Large Transport



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1








Events










Assessments




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


Place




Environment


Light : Dusk

Aircraft

Reference : X



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



Flight Plan : IFR

Mission : Passenger



Airspace.Class E : ZZZ

Component

Aircraft Component : Hydraulic Main System


Problem : Failed

Person

Reference : 1








Events








Result.Flight Crew : Landed in Emergency Condition


Assessments



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


Place




Environment

Light : Daylight

Aircraft

Reference : X



Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : GPWS


Problem : Design


Person

Reference : 1








Events







Result.Aircraft : Equipment Problem Dissipated

Assessments


Contributing Factors / Situations : Airport



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


Place




Environment



Light : Night


Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ





Flight Plan : IFR

Mission : Cargo / Freight

Flight Phase : Landing


Person : 1

Reference : 1












Person : 2

Reference : 2













Events





Detector.Automation : Aircraft Other Automation






Assessments





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


Place

Locale Reference.Airport : IAH.Airport



Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : I90





Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : DRLLR5

Airspace.Class B : IAH

Component

Aircraft Component : FMS/FMC



Person

Reference : 1














Events








Assessments





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


Place

Locale Reference.ATC Facility : LECM.ARTCC



Aircraft

Reference : X

ATC / Advisory.Center : LECM


Make Model Name : Citation X (C750)


Flight Plan : IFR



Person

Reference : 1









Events









Assessments




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


Place




Environment


Weather Elements / Visibility : Thunderstorm

Aircraft

Reference : X






Flight Plan : IFR




Person

Reference : 1









Events







Assessments




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


Place

Locale Reference.Airport : BOS.Airport

State Reference : MA


Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.TRACON : A90


Make Model Name : Regional Jet 900 (CRJ900)



Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : ROBUC2

Airspace.Class E : A90

Person

Reference : 1









Analyst Callback : Attempted

Events









Assessments





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


Place

Locale Reference.Airport : LGA.Airport

State Reference : NY

Altitude.AGL.Single Value : 1000

Environment



Aircraft

Reference : X

ATC / Advisory.Tower : LGA





Flight Plan : IFR

Mission : Passenger


Airspace.Class B : LGA

Person

Reference : 1








Events









Assessments



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


Place

Locale Reference.ATC Facility : ZME.ARTCC

State Reference : TN

Environment

Ceiling : CLR

Aircraft

Reference : X

ATC / Advisory.Center : ZME


Make Model Name : Medium Large Transport



Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : BLUZZ 1

Airspace.Class A : MEM

Person

Reference : 1













Events










Assessments





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


Place




Environment

Weather Elements / Visibility.Other

Aircraft

Reference : X



Flight Phase : Landing

Component : 1

Aircraft Component : Aileron Control System



Component : 2

Aircraft Component : Spoiler System



Person

Reference : 1











Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown










Assessments





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


Place

Locale Reference.ATC Facility : I90.TRACON



Environment


Aircraft

Reference : X

ATC / Advisory.TRACON : I90




Mission : Passenger


Nav In Use : GPS


Route In Use.STAR : MSCOT4

Airspace.Class B : I90

Person

Reference : 1















Events







Assessments




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


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment

Weather Elements / Visibility.Other

Aircraft : 1

Reference : X


Make Model Name : B787 Dreamliner Undifferentiated or Other Model



Mission : Passenger


Aircraft : 2

Reference : Y



Person

Reference : 1










Events






Assessments



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


Place

Locale Reference.ATC Facility : ZNY.ARTCC

State Reference : NY


Aircraft : 1

Reference : X

ATC / Advisory.Center : ZNY


Make Model Name : A330


Flight Plan : IFR



Airspace.Class A : ZNY

Aircraft : 2

Reference : Y






Flight Plan : IFR




Aircraft : 3

Reference : Z





Flight Plan : IFR




Person

Reference : 1

Location Of Person.Facility : ZNY.ARTCC



Function.Air Traffic Control : Instructor















Events








Assessments





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


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Work Environment Factor : Temperature - Extreme

Light : Night

Aircraft

Reference : X



Make Model Name : PA-31 Navajo/Chieftan/Mojave/T1040



Flight Plan : IFR

Mission : Passenger


Route In Use : Visual Approach



Component : 1

Aircraft Component : Aircraft Heating System



Component : 2

Aircraft Component : GPS & Other Satellite Navigation



Component : 3

Aircraft Component : Autopilot



Person

Reference : 1

















Events





Were Passengers Involved In Event : Y



Result.Flight Crew : Diverted


Result.Flight Crew : Landed As Precaution


Assessments





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


Environment


Aircraft

Reference : X

ATC / Advisory.Tower : SJU


Make Model Name : Airbus Industrie Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger

Flight Phase : Takeoff

Route In Use.SID : ACONY 2

Airspace.Class C : SJU

Person

Reference : 1















Events

Anomaly.Conflict : NMAC



Detector.Automation : Aircraft RA


Detector.Automation : Aircraft TA



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


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC



Environment



Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Person

Reference : 1










Events











Assessments



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


Place




Environment



Light : Daylight

Aircraft

Reference : X


Make Model Name : Challenger 300



Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1







Person : 2

Reference : 2







Events




Were Passengers Involved In Event : Y




Assessments



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


Place

Locale Reference.Airport : BTV.Airport

State Reference : VT

Environment

Flight Conditions : Marginal


Weather Elements / Visibility : Icing


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : BTV


Make Model Name : Medium Transport



Flight Plan : IFR

Mission : Passenger



Airspace.Class C : BTV

Person : 1

Reference : 1








Person : 2

Reference : 2








Events





Anomaly.Inflight Event / Encounter : Fuel Issue



Assessments

Contributing Factors / Situations : Company Policy



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


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


Place

Locale Reference.Airport : SAN.Airport



Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : SAN

Aircraft Operator : FBO

Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior


Flight Plan : VFR

Mission : Training


Route In Use : VFR Route

Airspace.Class B : SAN

Person

Reference : 1



Reporter Organization : FBO













Events


Anomaly.Deviation - Procedural : FAR






Assessments



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


Place




Environment


Weather Elements / Visibility : Haze / Smoke


Light : Daylight


Aircraft

Reference : X



Make Model Name : Skylane 182/RG Turbo Skylane/RG



Flight Plan : IFR

Mission : Personal




Component

Aircraft Component : Electrical Power



Person

Reference : 1















Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor






Result.Flight Crew : Diverted

Result.Flight Crew : Landed As Precaution

Assessments




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


Place




Environment


Light : Dusk

Aircraft

Reference : X



Make Model Name : Turbo Commander 690 Series



Flight Plan : IFR

Mission : Ferry




Person

Reference : 1















Human Factors : Fatigue

Events








Assessments



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


Place

Locale Reference.Airport : PDK.Airport

State Reference : GA


Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : PDK

Make Model Name : Light Transport, Low Wing, 2 Turbojet Eng




Airspace.Class D : PDK

Person : 1

Reference : 1



Reporter Organization : Fractional










Person : 2

Reference : 2



Reporter Organization : Fractional








Events










Assessments




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


Place

Locale Reference.Airport : DCA.Airport

State Reference : DC


Aircraft

Reference : X

ATC / Advisory.TRACON : PCT





Flight Plan : IFR



Route In Use.STAR : CAPSS TWO

Airspace.Class E : PCT

Person

Reference : 1








Events








Assessments


Contributing Factors / Situations : Equipment / Tooling




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


Place

Locale Reference.Airport : DFW.Airport



Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : D10





Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Route In Use.STAR : VICTRY2

Airspace.Class B : DFW

Component : 1

Aircraft Component : Aero Charts


Component : 2

Aircraft Component : Electronic Flt Bag (EFB)


Person

Reference : 1












Events








Assessments


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


Place




Environment



Aircraft

Reference : X



Make Model Name : Airbus 318/319/320/321 Undifferentiated



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Person

Reference : 1











Events











Assessments



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



Environment

Weather Elements / Visibility : Rain

Aircraft

Reference : X

ATC / Advisory.Tower : SNA





Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 2L


Airspace.Class C : SNA

Person

Reference : 1














Events













Assessments





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.

ASRS Database Report Set - Altitude Deviations

Documents

Transcript of ASRS Database Report Set - Altitude Deviations