ASRS Database Report Set - Checklist Incidents

ASRS Database Report Set

Checklist Incidents

Report Set Description .........................................A sampling of reports from all aviation arenas referencing checklist issues (design, procedures, distraction, etc.).

Update Number ....................................................31.0

Date of Update .....................................................March 31, 2017

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............13

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: 1427778 (1 of 50)

Synopsis Air Carrier Captain reported that new checklist response procedures and policy are

interfering with cockpit and radio communications.

ACN: 1426650 (2 of 50)

Synopsis A CE-560XLS flight crew reported smoke and fumes on descent so the crew diverted to a

nearby airport. Maintenance found a burned set of wires under the forward left galley

carpeting and believe that to be the smoke's source. The First Officer commented about

the aircraft emergency checklist complexity.

ACN: 1421407 (3 of 50)

Synopsis B777 Captain reported a primary flaps failure and ran the appropriate checklist. They

opted to deviate from the checklist and land with more flaps than the checklist dictated.

ACN: 1420193 (4 of 50)

Synopsis A319 flight crew reported being rushed during takeoff resulting in the non-completion of

the post engine start checklist.

ACN: 1417120 (5 of 50)

Synopsis Dash 8 flight crew and Flight Attendant reported smoke and odor during descent that was

hampered by communication issues, checklist confusion, and high workload.

ACN: 1410057 (6 of 50)

Synopsis MD11 First Officer reported being dispatched with an MEL for number one fuel flow

inoperative. Approaching Top of Descent the number three tank fuel quantity failed

rendering many FMC calculations. QRH procedures were not accomplished due to the lack

of any fuel numbers from the FMC. Numbers returned to normal during descent.

ACN: 1409441 (7 of 50)

Synopsis MD11 flight crew reported a slat disagree indication, they followed the QRH and landed

with a reduced flap configuration and high approach speed. Post flight analysis showed it

was a sensor problem which the QRH did not address.

ACN: 1405499 (8 of 50)

Synopsis B737NG flight crew reported experiencing Yaw Damper and Flap extension failures upon

initial flap selection on approach. Crew reported confusion in attempting to decide which

QRH procedure to use and offered recommended changes to the QRH.

ACN: 1403091 (9 of 50)

Synopsis ERJ-175 Captain reported a Secondary Power Distribution (SPDA) Failure which resulted in

a loss of pressurization, descent and diversion. The Captain reported the QRH could have

been more specific with corrective actions.

ACN: 1402178 (10 of 50)

Synopsis An A320 Captain reported a loss of the "yellow" hydraulic system followed by confusion

with a new bulletin that had not been incorporated in the QRH procedure.

ACN: 1396622 (11 of 50)

Synopsis B767 Captain reported after takeoff an EICAS alerted FWD EQUIP OVHT. The QRH was

completed which extinguished the alert. A short time later the EICAS alerted again so the

Captain diverted to a nearby airport rather than enter oceanic airspace at night.

ACN: 1394752 (12 of 50)

Synopsis CRJ-200 First Officer reported failing to retract the landing gear on departure, interpreted

the gear noise as a possible open panel, and diverted due to reduced performance and

increased fuel burn. The extended gear was noted when performing the landing checklist.

ACN: 1394231 (13 of 50)

Synopsis Air carrier Captain cited distractions that occurred on vectors to a visual approach to

Runway 31 at LGA as contributing to a failure to run the before landing checklist and to

arm the thrust reversers. Landing rollout was uneventful.

ACN: 1388034 (14 of 50)

Synopsis A B737-800 Captain reported suspecting a tire failure during takeoff and was notified in

flight about tire debris on the departure airport runway. During approach, an electronic

QRH index search listed no "LANDING ON A FLAT TIRE" procedure but the procedure was

contained in the document, simply mis-indexed.

ACN: 1386891 (15 of 50)

Synopsis B737-700 flight crew reported taxiing without completing the Before Taxi checklist, due in

part to distraction and confusion with the CPDLC Pre-Departure Clearance procedure.

ACN: 1376117 (16 of 50)

Synopsis The flight crew of a Bombardier CRJ-200 reported when in climb with one pack deferred,

when the other pack failed, they went to the QRH to troubleshoot and neglected to

proceed per the QRC for emergency descent.

ACN: 1374157 (17 of 50)

Synopsis EMB175 flight crew experienced a Bleed 1 overpressure shortly after takeoff with the First

Officer flying. The Captain performed the QRH procedure which lead to idling the number 1

engine and a return to the departure airport. After landing the Chief Pilot suggested that

the Pack 1 switch may have been turned off instead of the Bleed 1 switch as the QRH calls

for.

ACN: 1370202 (18 of 50)

Synopsis B737-NG Captain reported losing both Captain and First Officer control wheel stabilizer

trim switches. He expressed some confusion occurred while trying to interpret the

procedure dealing with the issue.

ACN: 1369678 (19 of 50)

Synopsis B737 flight crew reported rejecting the takeoff due to crossing traffic on the runway.

ACN: 1364992 (20 of 50)

Synopsis PC-12 flight crew reported a rag was left in such a location so as to prevent full retraction

of the flaps after takeoff. The distraction led to failure to retract the landing gear.

ACN: 1360127 (21 of 50)

Synopsis

An MD-80 First Officer reported a engine EGT high temperature which was entered in the

aircraft maintenance log. Following much discussion and disagreement, Maintenance did

not place the engine on a watch list or apply an MEL until after arrival at a maintenance

station.

ACN: 1359757 (22 of 50)

Synopsis Q400 Captain reported departing a high altitude airport using a bleeds off procedure, but

did not reselect the bleeds on until observing the cabin altitude warning light as the cabin

climbed to 9,800 feet.

ACN: 1357903 (23 of 50)

Synopsis B737 Captain reported the FMC execute light was disabled for most of the flight.

ACN: 1357633 (24 of 50)

Synopsis B737 Next Generation flight crew reported the guidance in their manuals was unclear

regarding required inspections following their rejected takeoff.

ACN: 1354679 (25 of 50)

Synopsis B737 flight crew reported they could not comply with MEL procedure to verify leading edge

flap position in flight because they could not see the device from the cockpit.

ACN: 1353675 (26 of 50)

Synopsis A319 flight crew reported an air-conditioning smoke event during descent that was

believed to be caused by the APU and the APU was deferred. On the next leg the odor

became intense and the crew diverted to a suitable airport. The Captain became quite sick

the next day and checked himself into the hospital.

ACN: 1352390 (27 of 50)

Synopsis B767-300 flight crew reported they failed to follow SOP after receiving a takeoff warning

horn on initial throttle application. A late runway change and new performance data

procedures were cited as contributing factors.

ACN: 1351710 (28 of 50)

Synopsis B737 flight crew reported returning to departure airport following the loss of the

pressurization auto mode on the takeoff roll.

ACN: 1349914 (29 of 50)

Synopsis MD83 Captain reported the takeoff was rejected due to the Wheel Not Turning light. The

right hand brake temperature was over 250 degrees.

ACN: 1349875 (30 of 50)

Synopsis During takeoff in a B737-800 the Flight Crew received a "Tail Strike" warning. When

returning to the departure airport the Flight Crew received a "Landing Gear Unsafe"

indications on all three gears accompanied by the audible gear warning.

ACN: 1349031 (31 of 50)

Synopsis An ERJ-175 EICAS alerted BRK LH FAULT and BRK RH FAULT when the landing gear were

lowered. The crew incorrectly decided the EICAS was an advisory alert because it was

colored blue. After landing, overheated brakes required the aircraft be chocked while Fire

Crews cooled the brakes with fans prior to a tow to the gate.

ACN: 1345222 (32 of 50)

Synopsis B737-800 flight crew reported a Flight Attendant informed them of a popping noise as the

flight taxied into position for takeoff. The flight crew did not see any discrepancies and

departed, but were notified by another crew that a tire may have failed. The flight

returned to the departure airport.

ACN: 1343043 (33 of 50)

Synopsis B737NG flight crew was informed by the flight attendants (and indirectly by passengers) of

smoke in the cabin just after takeoff. The aircraft had undergone extensive deicing prior to

takeoff, with the engines shut down, and deicing fluid had apparently gotten into the

pneumatic ducts causing fumes and smoke. The fumes dissipated quickly and the flight

continued to destination.

ACN: 1341900 (34 of 50)

Synopsis MD-83 Captain reported he felt his operational authority was being infringed upon while

dealing with a mechanical issue at the gate prior to departure.

ACN: 1337362 (35 of 50)

Synopsis CRJ-900 flight crew reported experiencing a low fuel state when their destination changed

runway configuration due to shifting winds. The Captain was critical of company fuel

policy.

ACN: 1337057 (36 of 50)

Synopsis EMB-145 Captain reported concern that flight crews are becoming too accepting of wing

anti-ice issues in the fleet.

ACN: 1331434 (37 of 50)

Synopsis MD-80 flight crew experienced a faulty pressurization controller and outflow valve. Flight

diverted to enroute airport.

ACN: 1331374 (38 of 50)

Synopsis A MD-80 Captain reported returning to departure airport after loss of the FMS.

ACN: 1331058 (39 of 50)

Synopsis A MD-88 First Officer reported returning to the departure airport after shutting down the

left engine because of low oil pressure.

ACN: 1330473 (40 of 50)

Synopsis EMB-145 crew deiced at the gate with the APU running. Immediately after takeoff, the

cabin and cockpit filled with smoke and the flight returned to the departure airport. Deice

fluid was suspected as the smoke's source.

ACN: 1329417 (41 of 50)

Synopsis CE-560EP Captain reported the right engine starter failed to disengage and the procedure

to resolve the issue was not in the QRC.

ACN: 1329350 (42 of 50)

Synopsis

A320 Captain reported a "B" Hydraulic System Low Pressure warning appeared on ECAM.

There was no procedure in the QRH to resolve the issue. Pressure indicated normal, but

the aircraft tended to roll to the right for the remainder of the flight. They reset MCDU 1,

to no avail. Turning the hydraulic pump back on the aircraft "jerked" indicating pressure,

but the tendency to roll remained.

ACN: 1327724 (43 of 50)

Synopsis The crew expressed concerns about the BOG VOR-C 31R/31L approach at SKBO, as it is

not in the FMS database and is used infrequently. There were also questions about missed

approach performance.

ACN: 1327347 (44 of 50)

Synopsis CRJ-900 torque links on nose gear were not secured after towing. Aircraft lost nose wheel

steering upon landing.

ACN: 1325805 (45 of 50)

Synopsis Air carrier Captain reported a track deviation departing SKBO because of communication

issues with ATC.

ACN: 1325458 (46 of 50)

Synopsis A CRJ-200 flight crew reported nose wheel steering difficulties during taxi out. The crew

associated the control issues to ice on the ground. After takeoff the gear disagree alerted

with the nose wheel extended. The nose scissor link was found disconnected after landing.

ACN: 1318154 (47 of 50)

Synopsis Air carrier flight crew experienced difficulty communicating with the ground crew during

deice/anti-icing of their aircraft. The first problem was ensuring that the crew deiced the

entire aircraft. Secondly, the crew was not sure if both types were applied as required and

requested. After the flight the crew could find traces of Type I deicing fluid, but not Type

IV anti-icing fluid.

ACN: 1315627 (48 of 50)

Synopsis During the takeoff roll a flight crew receives an advisory message yet continues the

takeoff. Once at altitude it is discovered that the message should have warranted a

rejected takeoff procedure and the crew should have remained on the ground.

ACN: 1315353 (49 of 50)

Synopsis A B757 Primary Flight Display FMA annunciated FLAP LIMIT at the top of descent with flap

handle up but the flap gauge indicating one half degree symmetrical flaps. With Flaps 1

selection EICAS the alerted TE FLAP ASYM and TRAILING EDGE so the QRH was completed

and a normal landing was accomplished with Crash Fire Rescue standing by.

ACN: 1315155 (50 of 50)

Synopsis A B737 Captain charged his iPad during a turnaround preflight and accidently pulled the

landing gear control circuit breaker while removing the charging cable. After takeoff when

the landing gear did not retract and while completing the QRH, the pulled circuit breaker

was reset.

Report Narratives

ACN: 1427778 (1 of 50)

Time / Day

Date : 201702

Local Time Of Day : 1201-1800

Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Altitude.MSL.Single Value : 5000

Environment

Flight Conditions : VMC

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ

Aircraft Operator : Air Carrier

Make Model Name : B737 Undifferentiated or Other Model

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 121

Flight Plan : IFR

Nav In Use : FMS Or FMC

Flight Phase : Climb

Airspace.Class B : ZZZ

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Air Carrier

Function.Flight Crew : Captain

Function.Flight Crew : Pilot Not Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)

Experience.Flight Crew.Total : 9774

Experience.Flight Crew.Last 90 Days : 240

ASRS Report Number.Accession Number : 1427778

Human Factors : Workload

Events

Anomaly.Deviation - Procedural : Published Material / Policy

Detector.Person : Flight Crew

When Detected : In-flight

Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Company Policy

Contributing Factors / Situations : Human Factors

Primary Problem : Company Policy

Narrative: 1

The new procedure of calling out everything that is pushed and display in the cockpit

during a change, makes the cockpit too busy and talking in critical stages of flight, during

climb out it caused three missed radio calls and subsequent instruction. This goes along

with excessive information on arrival and departure briefings, some have gone on for 10

minutes, glossing over what is important and setting a scenario of it getting lost in the

small info.

Synopsis

Air Carrier Captain reported that new checklist response procedures and policy are

interfering with cockpit and radio communications.

ACN: 1426650 (2 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Light : Daylight

Aircraft

Reference : X


Aircraft Operator : Air Taxi

Make Model Name : Citation Excel (C560XL)



Flight Plan : IFR

Mission : Passenger


Flight Phase : Descent


Component

Aircraft Component : Electrical Wiring & Connectors

Aircraft Reference : X

Problem : Failed

Problem : Malfunctioning

Person : 1

Reference : 1



Reporter Organization : Air Taxi


Function.Flight Crew : Pilot Flying




Human Factors : Distraction

Human Factors : Situational Awareness

Human Factors : Time Pressure

Human Factors : Troubleshooting

Person : 2

Reference : 2




Function.Flight Crew : First Officer









Events

Anomaly.Aircraft Equipment Problem : Less Severe

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

Anomaly.Conflict : Airborne Conflict



Result.General : Maintenance Action

Result.Flight Crew : Diverted

Result.Flight Crew : Landed in Emergency Condition

Result.Flight Crew : Took Evasive Action

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

Result.Air Traffic Control : Provided Assistance

Assessments

Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Chart Or Publication


Contributing Factors / Situations : Procedure

Primary Problem : Aircraft

Narrative: 1

While acting as Pilot in Command on a flight we smelled an electrical burning smell

followed by smoke in the cockpit. We were on the RNAV arrival around 12000'. We

executed an emergency descent to ZZZ airport to land. I was the flying pilot in the left

seat while First Officer handled the radios and checklist items. During the emergency

descent we encountered a TCAS RA and complied with it by climbing and turning to our

right towards the north to avoid the VFR aircraft which was not talking to approach.

Approach did advise us of the aircraft since it was on radar. After complying with the RA

we continued with the emergency descent and checklist items prior to landing. We

commenced and complied with the Electrical Fire or Smoke checklist from the CE-560XLS

checklist. Once the checklist directed us place the cabin master and generators to the off

position the smoke subsided but the electrical burning smell was still present. I decided to

deploy the passenger oxygen masks manually due to the continuing burning electrical

smell. We briefed the passengers of the situation and advised them of our plans to

immediately land. We landed and cleared runway 21 on taxiway B/B6 and performed an

evacuation of the aircraft on the taxiway due to the existing electrical burning smell. The

landing was normal and uneventful. We immediately disconnected the ship's battery after

exiting the aircraft. Fire and airport ops met us at the aircraft. Fire performed a search on

the aircraft and advised us that there was no present danger. We had the aircraft [towed]

to the ramp. The crew and passengers suffered no injuries or problems from the event.

Overall I feel as though the First Officer and I acted appropriately and worked well

together as a crew under the circumstances we were dealing with. There are a lot of things

going through your mind when you smell burning and see smoke in an airplane. Our goal

was to get the plane on the ground as soon as possible. I would advise all crew members

to pay close attention to the TCAS before initiating an emergency descent to avoid any

conflicts with other aircraft like we had. I was focused on getting the airplane on the

ground and [the First Officer] was focused on the checklist and radios. The TCAS system

definitely helped to prevent a conflict with the VFR aircraft. Following the appropriate

checklist lead to the turning off of several important switches which eventually put an end

to the smoke. We both have learned positive things from this event and come out of this

as better pilots in my mind.

Narrative: 2

The XLS electrical fire/smoke checklist is complicated. To be honest it is not a well-

organized checklist, nor is it laid out in a way that guarantees that a crew can perform the

checklist error free in a stressful emergency situation. Ideally the right seat pilot needs to

be Pilot Flying (PF), so that the left seat pilot can read and execute the checklist items

since most of the items are on the front left cockpit panel. I believe in this case it was

good idea for PIC to remain PF in left seat, and perform the checklist items as I called

them out with my confirmation for critical items. By remaining PM, it allowed me to be

methodical with the checklist from the right seat and scrutinize each item in order to

ensure that we did not turn off essential systems that we would want available if possible.

(i.e. brakes, speed brakes, TR's). In this situation with time compression, had we run the

electrical fire/smoke checklist to its completion including BATT EMER, we would have had a

significantly degraded our chance of a successful landing, inability to clear the runway to

evacuate, and potentially blown tires/overrun etc.

The TCAS RA portion of this event was not a good situation. Each time that I think about

whether we could have delayed our descent to coordinate with ATC on traffic, I decide that

no we could not. We had no idea that the airplane was not going to be overcome with

smoke, or worse. I believe that an immediate descent and landing was indeed necessary,

and we did so under emergency authority and without ATC direction away from traffic. I

credit the PIC for his quick reaction to the RA in arresting our rapid descent and turning

away from the traffic.

It may be worth noting that I had just returned from recurrent training on the tour

immediately preceding this event. I had reviewed the electrical fire/smoke checklist during

my personal study in recurrent. This may have helped in the decision to recognize that we

needed to stop the checklist prior to step 8, and avoid a more dangerous situation with an

un-needed use of emergency braking.

I do not believe that I would have done anything differently if I had do perform this same

event again. If anything, I would have tried to divide my attention as Pilot monitoring (PM)

between the emergency checklist, and assisting the PF in avoiding traffic using TCAS

before it became a critical issue during our emergency descent. I was contacted by

company managers and a union representative after the fact and I was able to discuss the

event to my satisfaction at the time.

I was assigned flight duty the next day on a different aircraft. I showed a few minutes

early in order to visit the mechanics on our aircraft to see if they had found the source. I

was advised at that time by mechanics that they believed the source was a unprotected

set of wires under the forward left galley carpeting. The wires had burned the plastic non-

stick material under the carpet. I do not know what the final resolution was, as the aircraft

was still in maintenance at the time of my filing this report.

Synopsis

A CE-560XLS flight crew reported smoke and fumes on descent so the crew diverted to a

nearby airport. Maintenance found a burned set of wires under the forward left galley

carpeting and believe that to be the smoke's source. The First Officer commented about

the aircraft emergency checklist complexity.

ACN: 1421407 (3 of 50)

Time / Day

Date : 201702


Place



Environment


Light : Night

Ceiling : CLR

Aircraft

Reference : X



Make Model Name : B777-200



Flight Plan : IFR

Mission : Cargo / Freight

Flight Phase : Initial Approach

Route In Use : Vectors


Component

Aircraft Component : Trailing Edge Flap



Person

Reference : 1










Human Factors : Training / Qualification

Events






Result.Flight Crew : Overcame Equipment Problem

Assessments

Contributing Factors / Situations : Environment - Non Weather Related


Contributing Factors / Situations : Airspace Structure



Narrative: 1

Landing south in ZZZ, ATC near capacity, busy night. Given a number of speed

assignments during our arrival, and we had slowed to 210 kts by 40 NM from field. On

base leg to final, Runway XXL, we were assigned 160 kts. Our ZFW of 505,000 lbs

required 30 flaps to go below 165 kts, so we asked to stay at 165 and were cleared for

that, initially. On dogleg to final, still approximately 20 miles to touchdown, we were

assigned 160 kts to 5 NM final. Lowered the gear and as we selected 30 flaps we got an

EICAS alert "PRIMARY FLAPS FAIL". We ran the non-normal checklist and noted that the

flaps were extending beyond 25 as we read the checklist. By the time we finished the

checklist, we were configured with gear down and flaps 30, with field in sight and

intercepting the glideslope. All indications for the approach were normal, autopilot was

engaged and the aircraft was stabilized. As Pilot Monitoring, I made the decision to

continue the approach as I considered it a safer course of action than discontinuing

approach at that point, especially since we were on final. I elected also to leave the flaps

at 30 instead of trying to raise them to 20 at that point, confident that the aircraft in that

configuration had more than enough go-around performance. FO was pilot flying and

continued the stabilized approach to an uneventful landing.

Submitting this report because after completing the "Primary Flaps Fail" checklist, I

determined it safer to remain in current, stabilized configuration for landing than to try

and raise the flaps via alternate means to the recommended configuration of flaps 20.

Weather was clear and we were confident that the aircraft had more than sufficient go-

around capability.

Our option was to discontinue the approach, request vectors and reset the flaps from 30 to

20. With the traffic load on approach, we determined it safer to continue to landing. I don't

think this type of event can be prevented, as it was an aircraft system malfunction. If the

weather was questionable, or if there was any question of go-around performance due to

terrain we would have definitely discontinued the approach and reconfigured the aircraft.

Synopsis

B777 Captain reported a primary flaps failure and ran the appropriate checklist. They

opted to deviate from the checklist and land with more flaps than the checklist dictated.

ACN: 1420193 (4 of 50)

Time / Day

Date : 201701


Place



Altitude.AGL.Single Value : 0

Environment


Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ


Make Model Name : A319



Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Component

Aircraft Component : Air Conditioning and Pressurization Pack


Problem : Improperly Operated

Person : 1

Reference : 1







Experience.Flight Crew.Type : 1399




Person : 2

Reference : 2












Events

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





Assessments



Primary Problem : Human Factors

Narrative: 1

We departed the gate on time, and elected to not start the number 2 engine until we had

a better idea of takeoff time. We briefed the expected taxi out and were given a taxi

clearance slightly different than expected. Shortly after we began taxi, Captain (CA)

ordered start of Number 2 engine. I initiated the engine start, and while the engine was

starting, we were told to cross the runway and monitor tower. As we crossed the runway, I

switched to tower frequency and immediately was told we were next for takeoff and

shortly after cleared us to line up and wait with aircraft on 5 mile final. The CA stated that

he was unsure of where the taxi line was in relation to "the block" as there was another

aircraft in the block. I looked up to assist, got distracted from my duties, and did not

complete the after engine start flow (APU bleed off, APU off, GEN 2 on, PACK 2 on, the

before takeoff checklist was completed. At that point, we were advised there was an

aircraft on 2.5 mile final. After takeoff, once established on the RNAV SID, I realized my

error and advised the CA before turning on generator, pack, and shutting off APU.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

A319 flight crew reported being rushed during takeoff resulting in the non-completion of

the post engine start checklist.

ACN: 1417120 (5 of 50)

Time / Day

Date : 201701


Place



Environment

Flight Conditions : IMC

Light : Daylight

Aircraft

Reference : X



Make Model Name : Dash 8 Series Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Air Conditioning Compressor



Person : 1

Reference : 1











Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew


Communication Breakdown.Party2 : ATC

Analyst Callback : Completed

Person : 2

Reference : 2














Person : 3

Reference : 3


Location In Aircraft : General Seating Area

Cabin Activity : Safety Related Duties


Function.Flight Attendant : Flight Attendant (On Duty)

Qualification.Flight Attendant : Current



Events


Anomaly.ATC Issue : All Types



Detector.Person : Flight Attendant

Were Passengers Involved In Event : Y



Result.General : Evacuated



Result.Air Traffic Control : Issued New Clearance

Assessments





Narrative: 1

On descent I smelled an odor that appeared to be coming from the lavatory. It became

stronger and stronger, and smelled like an electrical smoke. Very shortly after, I noticed it

becoming hazy in the cockpit quite quickly. There were no caution lights, master warning,

nor was the lavatory smoke detector going off. We donned the oxygen mask and smoke

goggles, and at that time the flight attendant called us. I was informed there was smoke in

the cabin as well. I asked the flight attendant to try to locate a fire if able. The flight

attendant was unable, I told him/her we had about 10 minutes until landing, bracing

signals, and also that we were to evacuate the aircraft upon landing. We transferred

controls to my side knowing that load shedding would shut down the FO's instruments. We

ran the smoke in aircraft checklist, while doing that I [advised ATC] and asked [for]

priority to land. The pilot not flying ran the checklist leaning towards electrical smoke

because it had a electrical smell. The smoke didn't appear to be disappearing yet getting

any worse. Due to the lack of time and low altitude, I was unable to inform dispatch or

operations. Landing was imminent so we proceeded to land and evacuate on the runway.

The evacuation went quickly and smoothly, and there were no injuries.

The checklist for smoke is quite the long checklist with many trees. Being so close to

[destination airport] and at a low altitude, problem solving isn't timely. Having a quick

checklist such as load shedding, dumping pressurization and land immediately would be

fantastic to be used only when over an airport in which you can land at and at a low

altitude.

Callback: 1

Reporter indicated the source of smoke and odor was a failed air cycle machine. He added

that in hindsight it may have been more appropriate to have run the pneumatic smoke

checklist. Reporter described the conditions after the load shed as no navigation in IMC

with trouble communicating with the First Officer with oxygen masks on. Additionally, ATC

communication was hampered by attempts from the Flight Attendant to call the cockpit.

Also, ATC did not understand the situation and that changing runways increased the flight

crew workload.

Narrative: 2

During descent to land an odor was detected in the cockpit which seemed to be electrical

in nature. No warning or caution lights were observed. Very shortly faint smoke was

detected in the cockpit at which point the captain and I switched flying duties so that I

could run the emergency checklist. While the captain flew I ran the smoke in aircraft

checklist while he took over communications with ATC. Based on the smell I followed the

electrical side of the checklist. With the close proximity of the airport we prepared to land

in accordance with ATC requests. After landing we evacuated the aircraft on the runway.

The flight attendant and emergency responders were prompt and efficient in their actions.

No passengers were injured in the evacuation.

Smoke in aircraft checklist needs to provide for unknown source of smoke. Choices are

only given for electrical or pressurization.

Narrative: 3

Prior to final approach I smelled smoke coming from the cabin. I sniffed around for the

source and came to no conclusion. Within 30 seconds I noticed that the cabin became

hazy and still no smoke detectors going off. I called the captain and informed him and he

said yes we were [running checklist] for smoke and said we have 7 minutes to land the

aircraft and I planned on bracing and evacuating on the runway. He then asked me to try

to find a source which I was never able to find. Upon landing we evacuated out of all

emergency exit doors and organized passengers to the side of the runway. No injuries

occurred and it was an efficient evacuation.

Synopsis

Dash 8 flight crew and Flight Attendant reported smoke and odor during descent that was

hampered by communication issues, checklist confusion, and high workload.

ACN: 1410057 (6 of 50)

Time / Day

Date : 201612


Place

Locale Reference.ATC Facility : ZOA.ARTCC

State Reference : CA


Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZOA


Make Model Name : MD-11



Flight Plan : IFR


Flight Phase : Cruise

Airspace.Class A : ZOA

Component

Aircraft Component : Fuel Quantity-Pressure Indication


Problem : Failed

Person

Reference : 1








Events


Anomaly.Inflight Event / Encounter : Fuel Issue

Detector.Automation : Aircraft Other Automation




Result.Aircraft : Equipment Problem Dissipated

Assessments


Contributing Factors / Situations : Manuals


Narrative: 1

In cruise flight at FL360, shortly after completing the descent and approach brief, we

received a "Fuel Quantity Fault" alert. This was quickly followed by the fuel system

reverting to manual and the display of a "Select Fuel Manual" alert. The synoptic page

indicated the number 3 main tank fuel quantity had failed and was replaced with an amber

x. The reversion to manual fuel management brought on all tank pumps. We also noticed

the loss of prof [descent profile] indications, as well as the loss of numerous values in the

FMC and on the speed tape.

We ran the QRH for fuel quantity fault because it was the initial fault that began this series

of events. The checklist directs the crew to calculate the fuel remaining in the affected

tank by subtracting the fuel used from the departure fuel for the flight. With the

dispatched MEL for #1 Fuel Flow, the fuel used on # 1 engine was blank and therefore

there was no way to do this as directed. The only option to estimate the fuel in the tank

was by referencing the other main tanks knowing the fuel should have been in balance

prior to the fault. We were tank to engine on the fuel flow, so they should be relatively

similar.

Since it was referenced in the QRH, we checked the UFOB on the init page and it was

blank. This explained the loss of prof as the FMS had no UFOB value, hence no aircraft GW

to calculate speeds and profiles. Even after calculating the estimated onboard fuel and

trying to initialize the UFOB in the FMS, the FMS would not accept the value. This was

because there was no fuel used indications for the FMS to use to update the Fuel on Board

and Ground Weight as fuel was burned to provide accurate data for speed and decent

calculations.

Unable to get any profile information from the FMS, we reverted to manual flying of the

descent using 3 to 1 planning and using the VVI and remaining time to turn points to

gauge our progress. Due to lack of approach speed info from the FMS, we used the QRH

approach tables to calculate the approach speed. To confirm the value was accurate, we

would be referencing the AOA as we carefully slowed to approach speed.

As we approached top of descent, center slowed us down to 250 knots. We began our

descent as soon as cleared and were looking good on the STAR profile. However, center

leveled us off for traffic at FL190 and kept us there for some time. By the time center gave

us clearance to continue the descent, we could not make the subsequent restrictions. We

informed center and they acknowledged, telling us to rejoin the profile as soon as possible

from above. We rejoined the profile at about 6000 feet.

Descending through about 7000 feet, the #3 main tank indication returned to normal and

we got the FMS information back. We found that our fuel estimate was very close and the

approach speed was as well. We flew a visual approach and landed uneventfully.

The QRH procedure for Fuel Quantity Fault should be amended to include the scenario of

having a fuel flow inoperative. It creates numerous issues for the descent and landing. We

had enough time in cruise to evaluate the situation before beginning descent, but if

someone had this problem on descent on a clear day with little fuel, a crew could be

pressed by their fuel state before having enough time to diagnose something they've

never encountered. A clear definition of this specific situation in the QRH could be critical.

The flight landed in VFR conditions at the diversion airport and taxied to the gate without

further incident. The primary cause of this event was an aircraft component malfunction

that resulted in an uncontrollable cabin altitude.

Synopsis

MD11 First Officer reported being dispatched with an MEL for number one fuel flow

inoperative. Approaching Top of Descent the number three tank fuel quantity failed

rendering many FMC calculations. QRH procedures were not accomplished due to the lack

of any fuel numbers from the FMC. Numbers returned to normal during descent.

ACN: 1409441 (7 of 50)

Time / Day

Date : 201612


Place




Environment


Weather Elements / Visibility : Turbulence

Weather Elements / Visibility : Windshear

Weather Elements / Visibility : Icing

Aircraft

Reference : X






Flight Plan : IFR






Component

Aircraft Component : Flap/Slat Control System



Person : 1

Reference : 1








Person : 2

Reference : 2




Function.Flight Crew : Check Pilot



Person : 3

Reference : 3








Events






Assessments




Narrative: 1

I was the pilot flying and we were being vectored for a visual approach for Runway XYC.

There were gusty winds (20G30) with wind shear advisories in effect. I began configuring

the airplane at 3000 ft with localizer intercept. At flaps 15 degrees, both the Captain and I

saw intermittent flashes of the master caution light but were not sure of the cause. Flaps

were lowered to 22/EXT and we received a steady master caution light with a resultant

SLAT DISAG yellow box. There was no concurrent airplane controllability issues with the

SLAT DISAG light. We requested a go around. Tower gave us a vector to 180 degrees and

a climb to 4000 ft. I was still pilot flying as the Captain assessed the situation, and pulled

out the QRH. We followed the checklist as well as re-configured a second time to assess if

this was a onetime event or if the SLAT DISAG light would return. It repeated the exact

same sequence that it did when I was configuring on final to RWY XYC. Flaps 15,

intermittent master caution light, followed by Flaps 22/EXT steady caution light and SLAT

DISAG light. The checklist was a little confusing as it was driving us to a Flaps 22/EXT

landing which didn't make sense to us since the SLAT DISAG illuminated at flaps 22, so

the captain asked that I back her up by reading the checklist and confirming that was in

fact what the checklist said. I transferred control of the airplane to her and also came to

the same conclusion that she did. We had a check airman on board and he also backed us

up on the checklist. We all agreed that a flaps 22/RET landing was the checklist that

needed to be done instead since the SLAT DISAG light illuminated steady at flaps 22, so

we complied with the QRH and did those procedures. We [advised] ATC, asked for RWY

XYR as it is the longest runway, used the tables to determine Vref/Vapp. We were at

320000 LBS landing weight and the Takeoff and Landing Performance Assessment (TALPA)

codes for RWY XYR were 5/5/5 (WET). We determined our landing rollout distance to be

approximately 9500 or so. Vref was 188. Vapp 192. We discussed the sight picture of a

flaps 22 landing and the increased rate of descent that would be normal for that type of

landing. We discussed a go around in the event of wind shear and a go around in the

event of an unstable approach (two different procedures). The captain brought the jump

seater up to the cockpit who was an off duty mechanic to see if he had anything to add.

The Line Check Airman was also integral to our discussions and checklist application and

was a huge asset to our cockpit teamwork. Landing was uneventful. We taxied clear of

RWY XYR then hold short of RWY XYC. We were then cleared across XYC to the ramp. The

fire trucks followed us to the gate.

Sensor failure of the SLATS.

Not really sure that this is an applicable section. Stuff breaks, wears out and gets dirty.

That is life. However, the SLAT DISAG checklist should be cleaned up just a little, to

perhaps include a potential sensor failure option.

Narrative: 2


Narrative: 3


Synopsis

MD11 flight crew reported a slat disagree indication, they followed the QRH and landed

with a reduced flap configuration and high approach speed. Post flight analysis showed it

was a sensor problem which the QRH did not address.

ACN: 1405499 (8 of 50)

Time / Day

Date : 201611


Place




Environment


Light : Night

Aircraft

Reference : X



Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR





Component




Person : 1

Reference : 1










Human Factors : Confusion


Person : 2

Reference : 2












Events







Assessments



Primary Problem : Manuals

Narrative: 1

The First Officer (FO) and I were on a visual approach on the last leg of a four-day trip,

landing after midnight and over an hour late. While slowing and configuring for the

approach as I moved the flaps to 5 the yaw damper kicked off and I noticed immediately

that the flaps were not tracking. A visual check, gauge check, and leading edge lights

check indicated no movement. At this time I took control of the aircraft to bring it back to

220 knots, level off and assess the problem. There were no additional indications of failure

of any kind. It was unclear if the flap needle had moved at all. I then asked the FO to

break out the QRH. We [advised ATC] and asked for delay vectors away from terrain which

also required a climb to 8000 feet. Upon inspection of the QRH, it was unclear to both of

us which checklist we should be following. The first checklist listed is the All Flaps Up

Landing. This checklist, however, does not offer up a solution but points to another

checklist, the Trailing Edge Flaps Up Checklist, and does not direct you to a page.

Returning to the index page you have the Asymmetry which did not fit the situation and

Trailing Edge Flap Disagree checklist that at the time, didn't seem right either. By this

point we had already bored holes in the sky for ten minutes. I knew from training and

experience that I should be looking to use the alternate flap switch. Looking to the Trailing

Edge Flaps UP Landing Checklist I keyed in on the Alternate Flaps Master switch statement

and put the checklist down. The Alternate Flaps switch worked, and as a team, with the FO

flying, proceeded to move the flaps one setting at a time to make sure we had correct

movement and no asymmetry. With successful movement to include lights and indicators

and the fact that we were in VFR conditions I was satisfied with the result. I took back

control of the aircraft from the FO and told ATC that we were ready to land. From that

point we proceeded to continue to configure and land with a flaps 30 landing. At the time I

believe both of us were satisfied with the result, but both of us were frustrated with the

amount of time and effort it took to figure out the solution.

It was only after a discussion of the incident a few days later that I realized I had missed

some key steps in the checklist and that I actually hadn't continued or finished the

checklist. In the VFR conditions we had this solution seemed appropriate, but if the

weather had been different or if I had lost an engine on final approach I would have

caused myself some additional problems due to the position of the flaps at 30 for landing.

My frustration with the QRH on this particular problem became clear to me which caused

me to revert back on my knowledge of systems, but in my haste to solve the problem I

also forgot some key concepts in using the checklist which I attribute to fatigue. The FO on

this flight was relatively new and therefore didn't have a lot experience to call on for this

particular event, but was having the same problem I was, matching our indications to the

proper checklist. I believe it would be helpful to rewrite the flap checklists into one

checklist that then direct to follow-on checklists as you proceed through it. Also using page

numbers would be helpful as opposed to just telling you to reference a title. In this

particular malfunction the factors to consider and obvious solutions should be printed right

up front rather than further down in the checklist as they would be the same for all of the

different types of flap malfunctions.

Narrative: 2

While I flew, the Captain ran the QRH and then briefed the landing as flaps 30 via the

alternate extension. The Captain then took the flight controls while I operated the

alternate flap switch and we proceeded to land. My unfamiliarity with the QRH caused the

CA to run the procedure as we were beginning to get close to min fuel. This caused several

flight control changes and added to the overall complexity of the situation as we changed

the Pilot Monitoring and Pilot Flying roles a few times. The biggest mistake I made was not

speaking up. I had pulled the computer out anticipating a change in the planned landing

flaps. After being briefed on a flaps 30 landing I stowed it and focused on executing the

briefed approach and never asked for clarification on the procedure followed in the QRH.

Synopsis

B737NG flight crew reported experiencing Yaw Damper and Flap extension failures upon

initial flap selection on approach. Crew reported confusion in attempting to decide which

QRH procedure to use and offered recommended changes to the QRH.

ACN: 1403091 (9 of 50)

Time / Day

Date : 201611


Place




Aircraft

Reference : X

ATC / Advisory.Center : ZZZ


Make Model Name : EMB ERJ 170/175 ER/LR



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZZZ

Component : 1

Aircraft Component : Electrical Distribution


Problem : Failed

Component : 2

Aircraft Component : Fuel Distribution System



Person

Reference : 1








Events

Anomaly.Aircraft Equipment Problem : Critical







Assessments




Narrative: 1

As we were climbing through FL280 we received a FUEL FEED 1 FAULT message. Within 15

seconds we then received a SPDA FAIL MESSAGE. While looking in the QRH the SPDA FAIL

message told us that we could expect both thrust reversers to be inoperative. What

followed is where the QRH grossly failed us. As I began to look at the fuel synoptic page to

see what was happening with the fuel system, and noticing that the Electric Fuel Pump A

was in operation, the FO said that the cabin was climbing. I then realized that I too noticed

the pressure change. I immediately went to the ECS synoptic page and saw that BOTH

engine bleeds were closed! I looked at our altitude and saw that we were now climbing

through FL300. I told the FO that we needed to descend immediately and I called ATC to

tell them that we had lost pressurization and that we needed an immediate descent.

I then put my O2 mask on and the FO followed my lead. I then pressed the cabin EMER

button and told the flight attendants that we were losing pressurization, we couldn't get it

back and hat we were making a emergency descent. I then pulled out the QRC and began

to follow the EMERGENCY DESCENT checklist. During the checklist ATC gave us a descent

to FL240 on our current heading and then FL190 with a turn off course to the right. When

the checklist was complete I quickly sent a message to dispatch saying that we had a

"SPDA FAIL lost press EMER descent." At this time the FO suggested a diversion. ATC was

thinking the same thing and we made a turn direct to ZZZ. We then made preparations to

land in ZZZ. Dispatch messaged us and also told us to divert to ZZZ, I replied that we

were.

We continued the descent to 10,000 and lower as ATC cleared our traffic. We then came

off O2 and I started the APU. I made an announcement to the passengers describing the

situation and of our intentions. We then noticed that we would be landing overweight. We

were at 76.6 and needed to get down to 74.9. Given that the aircraft was in a relatively

normal state, other than the pressurization and the AC Fuel Pump being on, that we could

take 15-20 minutes to burn off the fuel to make landing weight and to not add another

issue to our situation. So we circled the ZZZ airspace at 6,000 at 200 KIAS with Flaps 2.

I finally had the time to consider using the APU as the bleed source! This is where the QRH

failed me a second time - it would have been MUCH more helpful if the QRC told you to go

to NAP-4 which could have then reminded me that I could use the APU bleed at 15,000 ft

and below. I came to this conclusion on my own but we would have been in a much better

situation if I had been reminded earlier. There was just too much going on and other linear

thoughts taking my attention preventing me to think outside the box.

The first time the QRH failed us was with the SPDA FAIL procedure. The notation in the

procedure is incomplete and, in our situation, completely wrong. The SPDA that we lost

had the bleed valve control on it. Because the bleed valves failed closed we lost pressure

at the leak rate. The SPDA procedure should have a decision tree to determine which

systems had failed and what actions should be taken. Had I had time to think outside the

box I would have gone to the BLEED FAIL checklist in the QRH which would have had me

turn on the APU and

used the APU bleed below 15,000 ft.

In conclusion, we executed the emergency descent procedure, notified all parties, used the

O2 masks as trained, diverted and even kept the cabin altitude from reaching the mask

deployment altitude.

Synopsis

ERJ-175 Captain reported a Secondary Power Distribution (SPDA) Failure which resulted in

a loss of pressurization, descent and diversion. The Captain reported the QRH could have

been more specific with corrective actions.

ACN: 1402178 (10 of 50)

Time / Day

Date : 201611


Place




Environment


Aircraft

Reference : X






Flight Plan : IFR




Component

Aircraft Component : Hydraulic Main System


Problem : Failed

Person

Reference : 1













Communication Breakdown.Party2 : Maintenance

Events







Assessments




Narrative: 1

During cruise flight, we received a HYD Y RSVR LO LVL ECAM. As Pilot Flying, I kept

aircraft controls and ATC communications and directed First Officer (FO) to accomplish the

ECAM and then QRH procedure. Yellow hydraulic quantity was confirmed low and ECAM

actions expeditiously accomplished. Resulting System Status after procedural completion

was Y ENG 2 PUMP LO PRESS, Y SYS LO PR, and BRK Y ACCU PR MONITOR. Crew duties

were assigned and FO was given aircraft control and ATC duties while utilizing our Dead

Head (DH) FO in jump seat as backup eyes and ears while I initiated a Dispatch Call Me for

coordination with dispatch and [maintenance]. Radio communications via ARINC were

problematic (spotty reception, dropped calls, bad audio quality) during the entire

coordination exercise. While radio patch was ongoing, we received another ECAM. This

time it was HYD Y RSVR OVHT. We discussed, as a crew, whether the new flight manual

bulletin applied as we were faced with ECAM screen showing Y HYD ENG PUMP LO PR

followed by HYD RSVR OVHT (Special). We decided that bulletin did not apply as the LOW

PRESS ECAM was a subsequent result of the initial RSVR LO action items and did not occur

on opposite systems. We completed the appropriate HYD Y RSVR OVHT ECAM action items

and QRH.

We finally received an acceptable radio patch and coordinated with [maintenance] and

Dispatch regarding the applicability of the new bulletin procedure. Both dispatch and

[maintenance] seemed unfamiliar with the new bulletin, but once they researched the

reference provided, agreed that the new FM (special) procedure didn't apply. Power

Transfer Unit (PTU), Engine Pump and Electric Pump were confirmed to be off by multiple

means and determination was made that the continued overheat indication resulted from

delayed heat transfer on the low yellow system reservoir occurring after the PTU was

turned off per the initial ECAM procedure.

In concluding the coordination call, it was determined that [advising ATC of emergency

condition] was not necessary. With information from both Dispatch and [maintenance], it

was determined that the Dispatcher's calculated landing distance matched that calculated

by our DH pilot (in jump seat) and the supplied weather and field conditions posed no

significant issues. In conjunction with the remaining hydraulic system redundancies (and 3

member crew), it was determined safe to continue to [destination] for an uneventful, non-

emergency, landing.

However, this entire exercise illuminated some Problems of Note:

1. The placement of Bulletin (special) outside the QRH made it difficult to find.

2. Lack of familiarity with / confusion with the new procedure at crew, [maintenance] and

Dispatch levels led to a delay in determining procedural applicability.

3. Lack of adequate clarifying / descriptive notes in two procedures (QRH and FM

Procedure (special)).

Recommendations:

1. Expeditiously place FM special procedure in the QRH where it should properly reside.

2. Add clarifying Notes.

i.e. A Note in HYD Y RSVR LO LVL QRH indicating that a Hydraulic Overheat may result

after procedure completion and include a reference to the proper OVHT QRH.

i.e. A new Note, or a remark in Condition language of the special procedure, that

clarifies/emphasizes/highlights the procedure is only to be run for a condition of Hydraulic

Pressure loss followed by Overheat on OPPOSITE systems.

Synopsis

An A320 Captain reported a loss of the "yellow" hydraulic system followed by confusion

with a new bulletin that had not been incorporated in the QRH procedure.

ACN: 1396622 (11 of 50)

Time / Day

Date : 201610


Place




Environment


Light : Dusk

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Route In Use : Oceanic


Component

Aircraft Component : Aircraft Cooling System



Person

Reference : 1

















Events


Anomaly.Deviation - Procedural : Maintenance








Assessments




Narrative: 1

Climbing out we experienced a FWD EQUIP OVHT EICAS message. I instructed IRO to be

ready with QRH after we finished after takeoff clean up duties. FO was PF and IRO and I

worked the QRH to fix the issue, which resulted in us having to go to STBY position on

equipment cooling. Then a few minutes later the EICAS message returned and we ran the

QRH again (please leave the hard copy QRHs in the cockpits; far superior product to use

when things are getting busy!). This resulted in us going to OVRD on the equipment

cooling selector.

We continued our route of flight, and I began to think through the possible implications of

operating in OVRD, using pressure differential to keep my displays and navigation and

communication "alive", should we lose cabin pressure over a hostile environment, such as

the oceanic airspace at night, with no airport within a couple of hours around our mid-

point. My ETOPS flights are planned with a fuel contingency to ensure I can make it to a

suitable ETOPS alternate in the event of both an engine failure and depressurization, so we

are always prepared and equipped to handle that worst case scenario. But what if I have

lost my cockpit displays - EFIS (Electronic Flight Instrument System)/CDU etc? I might not

be able to communicate and navigate the plane to an airport for a safe landing. I also lost

all SATCOM communication facilities during this event by the way. VHF ACARS datalink

continued to work for my immediate purposes, but I would lose that over the ocean. I

instructed Dispatch to contact me through ARINC for a phone patch with Maintenance

Control to determine best course of action.

Maintenance Control did not seem to appreciate how easy it might be to end up with a loss

of cabin pressure, saying I would need "multiple system failures" to end up depressurized.

I pointed out that I only needed an uncontained engine failure to end up depressurized

and how long would I have my suite of flight, navigation and communication instruments

and tools at my disposal. Maintenance Control said I would have these for at least 90

minutes after loss of pressure, but the non-normals, FWD EQPT COOLING checklist,

suggests that any avionics, and electronics, to include displays, not powered by the

standby busses, ARE SUBJECT TO IMMINENT FAILURE - my capitalized emphasis. If that

were indeed to happen, the aircraft and all aboard could quickly be in peril. Clearly we

were not having a meeting of the minds. After further discussion, I indicated that in my

opinion we were not going to be able to safely continue the flight and that I intended to

divert to a safe landing while still able, prior to oceanic airspace entry and the potential

threats associated with it. Dispatch instructed me to take the aircraft to an enroute airport

where maintenance could assist. (There is a history of equipment cooling problems with

this particular aircraft by the way)

ATC facilitated our routing to an enroute alternate but we experienced extensive vectoring

delays at low level going into the divert airport. The cloud base was lowering, and then at

about 1.0 pressure diff, we experienced (and had expected at some point) a total loss of

equipment cooling. I then elected to use my Captain's Emergency Authority to return the

EQPT COOLING switch to the NORM position, which recovered some cooling. We were able

to complete the ILS to a normal landing at the divert airport. The aircraft was worked on

by maintenance and we took off for our filed destination, having waived the FAR 117 by

the allowable 2 hours. No further issues were noted on the flight. Kudos to the divert

airport's maintenance for their diligence in fixing the aircraft.

Synopsis

B767 Captain reported after takeoff an EICAS alerted FWD EQUIP OVHT. The QRH was

completed which extinguished the alert. A short time later the EICAS alerted again so the

Captain diverted to a nearby airport rather than enter oceanic airspace at night.

ACN: 1394752 (12 of 50)

Time / Day

Date : 201610


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 200 ER/LR (CRJ200)



Flight Plan : IFR

Mission : Passenger

Flight Phase : Initial Climb


Component

Aircraft Component : Landing Gear



Person

Reference : 1








Events





Were Passengers Involved In Event : N




Assessments





Narrative: 1

On departure CA called for AP at about 600-800 ft. I engaged the AP. As we accelerated

through 200KIAS, we both noticed a loud noise that we could attribute to increased

airspeed, as though the noise was coming from airflow over an open panel on the aircraft.

I assumed, and the captain agreed it was likely the Headset and Nose Gear Door switch

panel. We continued our climb out following the SID. CA had called for "flaps up, climb

thrust, after takeoff checklist." I conducted my flow/procedure. After completing the

procedure, I read through the checklist silently and then called "After Takeoff Checklist

Complete." Around 4,000-8,000 MSL, or around 3-5 minutes after takeoff, the AP

disconnected on its own. CA re-engaged the autopilot. Within a minute, the AP

disconnected again. We tried to troubleshoot why it was disengaging, as we had no EICAS

message or other indications as to why our autopilot wouldn't engage. We tried engaging

the AP on my side, and we tried disconnecting the AP from my side (occasionally the

disconnect button on the control wheel will get stuck). After a few attempts at re-engaging

the autopilot and the autopilot disconnecting, CA chose to hand-fly the aircraft. In addition

to this, we noticed that my (FO's side) FMS needles had disappeared from my PFD. I

cycled my NAV selector to "green needles" and back to FMS and the FMS course re-

appeared. A few moments later my FMS needles disappeared.

Passing through 10,000 feet I switched the "No Smoking" sign switch to signal to our

Flight Attendants (FA) that we were through 10,000 feet. The switch did not chime. I tried

the "Fasten Seatbelts" switch which also did not chime. I transferred the radios to the CA

and called the flight attendants and advised that we were through 10,000 feet. It was at

this point we began to notice we had extremely diminished climb performance and were

not able to accelerate past 260-270KIAS. We advised ATC we needed to level off, and

leveled off at 12,000 feet. We knew something was wrong, but we could not figure out

what. CA asked me to begin reviewing all of the system status pages to see if there were

any other indications to give us a clue as to why we did not have any climb performance.

After reviewing the systems, we began communicating our issue with Dispatch. We

advised Dispatch of our new altitude and that we were suffering performance loss. We also

advised that the autopilot would not stay engaged. We began calculating our fuel burn as

discovered we were burning about 400lbs of fuel every 5 minutes, or about 4,800 lbs. an

hour. With about 5,000 lbs. of fuel and about 40 minutes of flight time remaining, we

decided it was best to divert. At this point, we had resolved that a panel of some sort on

the aircraft was hanging open and needed to focus on diverting as our fuel burn rate would

not permit us to continue much longer. I called the FA and advised him of our problem and

that we would be landing in about 15 minutes and this was a non-emergency situation. I

then made a PA to the passengers in the cabin advising them that we believed we had a

loose panel on the aircraft and that it was degrading our fuel burn and performance to the

point that we would not be able to make it to ZZZ. CA continued to hand-fly while I

prepared the performance numbers and FMS for the arrival.

Upon entering final, CA called for "Gear Down." At this point, I reached for the gear handle

and noticed that it was down. I verified the indications on the EICAS which confirmed

down and three green. We immediately realized our mistake which was that I had never

selected the gear up on departure. I am not sure what to attribute this mistake to other

than complacency and distractions. On departure, I do recall reaching for the gear handle.

I believe I became distracted by reaching for the "SPEED" mode button and "NAV" button.

We became distracted by the noise generated by the gear and attributed it to an open

panel instead. We further became distracted by an autopilot that wouldn't stay engaged

and having to hand-fly the aircraft. It was a "tunnel-vision" situation where we became

fixated on only one possible problem while dealing with other small, seemingly

unassociated problems. We were becoming worried and baffled as to what was wrong with

the aircraft. The max gear extended speed was exceeded by approximately 10-20KIAS.

There was also a flap over-speed on final and the thrust reversers were not armed for

landing (I don't recall completing the landing checklist). This can be attributed to our state

of embarrassment and distraction by discovering our mistake on final.

While I did read the checklist and look through the flight deck to verify (I was more

concerned with making sure the APU had shutdown, the bleeds were switched, the CARGO

AIR switch was in the correct position, and the Thruster Reversers were disarmed), I failed

to notice that the gear indicated Down and Three Green. To prevent this from happening

again, I will need to pay particular attention to all of my checklist items. It is one thing to

miss a flow, it is another to read and verify a checklist and still miss an item - that is what

the checklist is for. Additionally, once an issue is discovered in-flight, you must also sit

back and review even the most basic reasons why a problem is occurring. We failed to

notice that our gear was down for the entire hour we were in flight. We were very focused

on other possible issues, and failed to sit back and evaluate the big picture.

Synopsis

CRJ-200 First Officer reported failing to retract the landing gear on departure, interpreted

the gear noise as a possible open panel, and diverted due to reduced performance and

increased fuel burn. The extended gear was noted when performing the landing checklist.

ACN: 1394231 (13 of 50)

Time / Day

Date : 201610


Place

Locale Reference.Airport : LGA.Airport

State Reference : NY


Environment


Aircraft

Reference : X

ATC / Advisory.Tower : LGA


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



Flight Plan : IFR

Mission : Passenger

Flight Phase : Landing

Route In Use : Visual Approach

Component

Aircraft Component : Turbine Engine Thrust Reverser



Person

Reference : 1











Events






Assessments




Primary Problem : Procedure

Narrative: 1

We were expecting the Expressway Visual into Runway 31 in LGA. We were coming in on

the KORRY3 Arrival from the north and at the end of the arrival we were told we would be

getting a right turn. It wasn't clear at the time, but they meant a right base to final for 31

and no longer a turn to eventually join the Expressway Visual to 31.

We were still fairly high and getting step downs and precise speeds on our vectors toward

the final for 31. This is from the area where there was all the information published about

the crane which was in my mind and further distracting as I wasn't fully aware of its

current position due to my lack of flying into LGA recently.

I'm a fairly junior Captain and still on high minimums and this was my first leg with the

First Officer flying. He was less than a year into the company and although having done a

great job so far it was still on my mind to keep a good eye on his flying and situational

awareness.

As we approached the final approach course we were given instructions to look for traffic

that we were to follow. This traffic was on the expressway visual. We didn't initially see

this traffic. On the second call out from ATC the traffic came into sight and we called it in

sight and were cleared for the visual. We were still high and fast and tight on that traffic.

I immediately asked if the First Officer wanted the gear down and flaps 30 and he called

for it and we continued to slow to final approach speed.

We received our handoff to LGA Tower right after this and upon initial contact we weren't

given landing clearance so we continued. We were stable and on speed by 1,000 feet and

on the 1,000 foot call I stated "no landing clearance". We were still tight on space with the

prior aircraft at this point. Closing in on 500 feet we received the landing clearance from

ATC and I restated clear to land to the First Officer and verified the landing nose light was

on and that we were fully configured.

Upon touchdown the First Officer attempted to deploy the thrust reversers and stated they

would not deploy. We were slowing down sufficiently and were able to get off prior to the

intersection of Runway 4/22. When I took the controls I also attempted to deploy the

reversers to see if I would have any success. I didn't have any so as I looked around to

see what the issue was. It was clear to me that I never armed the reversers prior to

landing which then also made me realize I never ran the before landing checklist.

Synopsis

Air carrier Captain cited distractions that occurred on vectors to a visual approach to

Runway 31 at LGA as contributing to a failure to run the before landing checklist and to

arm the thrust reversers. Landing rollout was uneventful.

ACN: 1388034 (14 of 50)

Time / Day

Date : 201609


Place




Environment


Light : Dawn

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Flight Phase : Takeoff

Component

Aircraft Component : Main Gear Tire


Problem : Failed

Person

Reference : 1











Events







Result.Flight Crew : Became Reoriented

Assessments





Narrative: 1

Just before liftoff I felt a rumble and I wondered about the tires. At that [same] time I saw

an intersecting runway go by so I attributed the rumble to an uneven intersection.

Approaching our destination I received an ACARS message that tire debris was found on

our departure runway. I [advised ATC], followed QRH procedure, briefed flight attendants,

and briefed passengers. On landing there was a strong rumble as we decelerated and I

then knew for sure we had a blown tire. After stopping fire rescue confirmed the blown tire

and we were towed to the gate.

I would like to make special note that when I looked in the electronic QRH there is no

mention of landing on a flat tire procedure. That same page in the paper QRH does list the

procedure. This needs to be corrected quickly. This initially caused me to believe there was

no procedure. Only as a last resort when I searched the electronic QRH for the key word

"tire" did I find the procedure.

Synopsis

A B737-800 Captain reported suspecting a tire failure during takeoff and was notified in

flight about tire debris on the departure airport runway. During approach, an electronic

QRH index search listed no "LANDING ON A FLAT TIRE" procedure but the procedure was

contained in the document, simply mis-indexed.

ACN: 1386891 (15 of 50)

Time / Day

Date : 201609


Place




Environment

Flight Conditions : Mixed

Weather Elements / Visibility : Thunderstorm

Aircraft

Reference : X



Flight Plan : IFR

Flight Phase : Taxi

Person : 1

Reference : 1











Person : 2

Reference : 2











Events



When Detected : Taxi


Assessments




Narrative: 1

Due to thunderstorms in the area, the pushback was delayed and performed without

headsets. During pushback, Ground Control told us to contact Clearance Delivery for

possible routing change. We completed the pushback/engine start and cleared off the

Ground Crew. We contacted Clearance Delivery and they informed us of a new Controller

Pilot Data Link Communications (CPDLC) clearance we needed to acknowledge. Due to

weather on the departure corridor, we spent approximately five minutes and multiple

different clearance changes before we received our final clearance and sorted out the

CPDLC confusion. We then performed a waypoint by waypoint review of the clearance to

ensure we had all proper points. We were satisfied we had the correct routing and called

for taxi. During taxi out we realized we had not performed the Before Taxi flows or done

the Before Taxi Checklist, flaps were not set. I stopped the aircraft; we performed the

flows and checklist and confirmed the aircraft was properly configured. The rest of the

flight was uneventful.

The complexity and confusion of the multiple clearance changes put us out of the normal

flow of operation. We just need to be more vigilant to checklist discipline when our normal

triggers are interrupted.

Narrative: 2

There was confusion with the Controller Pilot Data Link Communications (CPDLC)

procedures on reroutes and accepting and rejecting clearances. We tried following the

Company procedures, but even the Tower was agreeing the process was not working, so

we had to get a verbal clearance. I think both groups need more time with the new

process.

Synopsis

B737-700 flight crew reported taxiing without completing the Before Taxi checklist, due in

part to distraction and confusion with the CPDLC Pre-Departure Clearance procedure.

ACN: 1376117 (16 of 50)

Time / Day

Date : 201607


Place




Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Maintenance Status.Maintenance Deferred : Y

Maintenance Status.Released For Service : Y

Component

Aircraft Component : Air Conditioning and Pressurization Pack

Manufacturer : Bombardier


Problem : Failed

Person : 1

Reference : 1










Person : 2

Reference : 2










Events



Anomaly.Deviation - Procedural : MEL



Result.Flight Crew : Returned To Departure Airport



Assessments




Narrative: 1

We had been sitting at ZZZ for quite a while waiting out an ATC delay. When we started

boarding, I noticed that our left pack had turned off with no associated caution messages.

I selected the L PACK switch to off and then back on and the pack turned back on. Shortly

thereafter though, we heard a whirling sound and the pack temperature rose taking the

pack offline with a little puff of smoke from our vents and a "hot" smell. Meanwhile we

were issued a further delay of 2 1/2 hours so we deplaned and I contacted maintenance

and dispatch to get the pack deferred and issue a new release. While we were in the

process of the deferral, ATC called and said that we could go when we were ready so we

boarded up again, got some additional fuel for the lower cruising altitude and then

departed. Prior to the departure, the First Officer (FO) and I reviewed the MEL TR

associated to the deferral and the special procedure for transferring bleeds from the APU

to the engine. In the TR there is a requirement to reduce the thrust to 60% N1 prior to

transferring bleeds so we made the decision to delay the bleed swap until we were clear of

the terrain in the area. The only requirement of the TR is that it must be completed prior

to 15,000 feet. Around 5-6,000 we transferred the bleeds per the TR with no issues. As we

were passing through around 20,000 feet I went on to the PA to turn off the seat belt sign.

As I was talking, I noticed that the airflow from my vent was gone. I looked at the

Environmental Control System (ECS) page and noticed that the R PACK was off, but there

were no caution messages as to why the pack went offline. We began a rapid descent and

[advised] ATC. We were issued a clearance to 10,000. I transferred controls to the FO and

made a PA announcement to the passengers. When I came back, I made the mistake of

going to the QRH to try to figure out what was going on with the pack instead of referring

to the QRC for emergency descent. After we reached 10,000 we turned around back to

ZZZ and started the APU. Since there were no caution messages associated with the pack

going offline, I made the decision to try the pack using the APU bleed air. It turned on and

worked normally so we decided that since we had pressurization and air conditioning that

we would hold for a while to burn off some fuel because we were significantly over max

landing weight. After arriving at the gate and during the debrief we identified that we

should have run the QRC which would have included dropping the passenger O2 masks.

The root cause was not adhering to the new SOP of using the QRC first. The confusion of

the pack going off with no apparent reason distracted my attention to the pack issue

instead of the descent.

For me, I'm going to make it an important part of my future IOE trips to get into the QRC

with students and run through some scenarios to become more familiar with the items on

the list as well as trying to incorporate it into my daily thought process.

Narrative: 2


Synopsis

The flight crew of a Bombardier CRJ-200 reported when in climb with one pack deferred,

when the other pack failed, they went to the QRH to troubleshoot and neglected to

proceed per the QRC for emergency descent.

ACN: 1374157 (17 of 50)

Time / Day

Date : 201607


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Pneumatic System



Person : 1

Reference : 1











Person : 2

Reference : 2









Events









Result.Air Traffic Control : Issued New Clearance

Assessments





Narrative: 1

After departure climbing through roughly 500 ft AGL we received a Bleed 1 overpress

Caution EICAS message. The climbout was continued and the aircraft configuration

cleaned up, then a positive transfer of radios was initiated to give the FO the controls and

radios. As the PIC I ran the QRH for the Bleed 1 overpress EICAS message. At the time I

felt that I followed the QRH procedures word for word which led for the throttle on engine

number 1 be brought to idle and the single engine approach and landing procedures to be

accomplished. We asked for vectors to be close to [the] airport. The first officer continued

to fly and handle the radios while I conducted the single engine approach and landing

checklist, followed by the overweight landing checklist and all other appropriate checklists.

The flight attendants and passengers were briefed on the situation as well as all QRH items

being accomplished before preceding for a safe landing.

After the successful landing, taxi in and deplaning I contacted the chief pilot on call to

discuss the situation. While discussing the QRH there was doubt raised that I might have

inadvertently "pushed out" the Pack 1 button instead of Bleed 1 as the QRH called for. I

cannot put any assurance into the fact that I did or did not press the Pack 1 instead of

Bleed 1. By the time this doubt was raised maintenance was already on board and the

landing configuration of the overhead panel had been changed. The maintenance

personnel onboard the aircraft ran a test on the MFD and found there was a fault detected

in the bleed system of the number 1 engine.

I feel that in the QRH procedures that lead to degraded aircraft performance there should

be a "confirm" item listed in the procedure when dealing with turning off critical items This

QRH procedure does not call for any confirmation of any kind even when it asks to reduce

the thrust to idle on an engine.

Narrative: 2

I was the Pilot Flying. During the crew briefing, the Captain stated "If we have a problem

you fly, I fix". During initial climb at approximately 500 feet, master caution went off, and

the Captain announced "BLEED 1 OVERPRESSURE". I acknowledged, he silenced the

warning, and we continued. The Captain transferred the radios to me and began running

the QRH. At his command, I requested with ATC to stop the climb at 10,000 feet and for

vectors back. ATC instructed us to descend to 5,000 feet and provided vectors to the

airport.

The QRH procedure did not succeed in clearing the caution message, and led to the Single

Engine Approach and Landing procedure, at which point the Captain instructed me to

inform ATC and request emergency services standing by, which I did. We accomplished

the Single Engine Approach and Landing checklist, followed by the Overweight Landing

checklist. Following that, the Captain transferred the controls to himself. We accomplished

all applicable normal checklists, and executed an uneventful single engine approach and

landing. We stopped on the runway, had emergency services inspect and clear the aircraft,

and taxied to the gate under our own power without further incident. At the gate we were

met by maintenance personnel, and after deplaning the passengers we turned over the

aircraft to them.

The Captain then proceeded to call the Duty Chief Pilot, while I performed the postflight

inspection that did not reveal any externally observable anomalies. When I came back to

the aircraft, the Captain informed me that during his call with the Duty Chief Pilot, doubt

had been raised as to whether the Pack 1 button had been pushed instead of Bleed 1

button during the execution of the QRH procedure for BLEED 1 OVERPRESS. I cannot

ascertain which button was pushed, as I concentrated on flying the airplane and handling

the radios.

The possibility exists that the Pack 1 button was pushed instead of Bleed 1, and if indeed

true, this may have led to the caution message not clearing, and the subsequent single

engine approach and landing. Therefore, I believe the QRH procedures need to be modified

to add second crewmember verification to the actions that lead to significant consequences

and degraded aircraft performance. This would be similar to existing crew verifications for

critical control movements, such as fire handles and the thrust lever during engine

shutdown procedures. For the example, in this QRH procedure the Bleed 1 button is not

verified by the second crewmember, nor is the thrust lever movement to idle that leads to

the single engine approach procedure.

Synopsis

EMB175 flight crew experienced a Bleed 1 overpressure shortly after takeoff with the First

Officer flying. The Captain performed the QRH procedure which lead to idling the number 1

engine and a return to the departure airport. After landing the Chief Pilot suggested that

the Pack 1 switch may have been turned off instead of the Bleed 1 switch as the QRH calls

for.

ACN: 1370202 (18 of 50)

Time / Day

Date : 201607


Place

Locale Reference.Airport : ZZZZ.Airport

State Reference : FO


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ





Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Horizontal Stabilizer Trim



Person

Reference : 1












Events





Assessments





Narrative: 1

Shortly after takeoff we lost both the Captain's and First Officer's control wheel stabilizer

electric trim. We stopped our climb and leveled at 14000 ft to troubleshoot the problem.

The First Officer could not find an exact match for failure of only the control wheel trim

switches. The closest procedure was "Electric stabilizer trim inoperative." This procedure

deals with a failure of BOTH the control wheel and autopilot electric trim. Reading through

this procedure we opted to turn on the autopilot to test whether the electric trim worked in

the autopilot mode. It did work, so now we knew we had electric trim through the

autopilot and manual trim though the trim wheel. We called dispatch and maintenance and

all agreed that we could safely proceed to our destination.

Enroute we began going further into the systems and procedures to determine how we

would conduct the approach and landing. Here is where I feel there needs to be a

clarification and procedure for a complete failure of the control wheel stabilizer electric

trim system. We originally thought of doing an autoland which would allow the aircraft to

maintain electric trim throughout the landing. However, we looked up MELs related to the

control wheel trim failure and found MEL 2709 which deals with a failure of just one of the

control wheel switches. In that MEL it restricts the plane to CAT I no autoland. Even

though we were not sure why the plane would be only CAT I, we decided that we should

not use autoland in our situation. Next we went back to the QRH procedure for Electric

Stabilizer Trim Inoperative and in the objective section of the procedure we noted that it

could be used for landing the aircraft using manual trim, which would be our situation. We

decided the best course of action would be to use the autopilot and configure the aircraft

for landing, get on speed, and then turn the autopilot off and use the QRH procedure for

the remainder of the approach and landing. The procedure would require a flaps 15

landing and turning the Stab Trim Cutout switches to Cutout, then using manual trim.

[Dispatch] did send us a recommended procedure via ACARS that he vetted through the

737 fleet. They suggested what we had planned. However they also suggested turning

both Stab Trim Cutoff switches to Cutout and then back on as a sort of reset. We decided

that putting the autopilot stab trim cutout switch to cutout before final configuration was

not the best move since it could eliminate the only source of stabilizer electric trim. We did

however cycle the main electric switch to cutout and back on when we were level on the

arrival and the control wheel trim did start working. However I cannot be certain if that is

what reset the system or it was something else because I did not try the control wheel

switches before I put the switch to cutout. We continued the arrival and landed using

normal procedures.

The purpose of this report is to point out an ambiguity of what to do if this malfunction

happens again. There needs to be a procedure that clarifies what a crew should do in this

situation. In particular whether to reset the Cutout switches, either both or just the

affected side, and how to configure the aircraft for landing.

Synopsis

B737-NG Captain reported losing both Captain and First Officer control wheel stabilizer

trim switches. He expressed some confusion occurred while trying to interpret the

procedure dealing with the issue.

ACN: 1369678 (19 of 50)

Time / Day

Date : 201607


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1











Person : 2

Reference : 2











Events


Anomaly.Conflict : Ground Conflict, Critical

Anomaly.Ground Incursion : Runway



Result.Flight Crew : Rejected Takeoff

Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

At approximately 90kts on takeoff, tower directed us to "discontinue takeoff" due to other

aircraft passing the hold short line, but had not entered the runway. Executed rejected

takeoff procedure with no issues and exited the runway. FO reviewed rejected takeoff

section in QRH then used the brake cooling chart and determined we were in the "cooling

recommended section" with a thirty minute cooling time. Taxied to gate.

Maintenance completed their inspections with no issues found, and also determined a 30

min cooldown time of the brakes. Maintenance signed off the AML. Approximately one hour

after gate arrival we pushed back and continued flight.

Narrative: 2


Synopsis

B737 flight crew reported rejecting the takeoff due to crossing traffic on the runway.

ACN: 1364992 (20 of 50)

Time / Day

Date : 201606


Place




Environment


Weather Elements / Visibility : Fog

Weather Elements / Visibility.Visibility : 10

Light : Night

Ceiling.Single Value : 1200

Aircraft

Reference : X



Make Model Name : PC-12



Flight Plan : IFR

Mission : Passenger



Airspace.Class D : ZZZ

Component : 1




Component : 2

Aircraft Component : Landing Gear



Person : 1

Reference : 1






Qualification.Flight Crew : Multiengine

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Instrument






Person : 2

Reference : 2












Events


Anomaly.Inflight Event / Encounter : Other / Unknown




Assessments




Narrative: 1

On initial climb just before penetrating overcast layer we received a warning that the flaps

failed to completely retract. Continued climb out Captain ran QRH to attempt correct

condition (unsuccessful). Continued departure as aircraft was feeling normal. After the

required wait time a second attempt to correct the condition was performed but again

unsuccessful. After discussing the flap situation and aircraft performance with ground

based company personnel the decision was made to continue the flight to destination and

land with flaps in current position.

On approach to [destination airport] in preparation for landing in visual condition on final

approach we noticed the landing gear lights were indicating three green with the landing

gear lever in the up position. A request to go around in the pattern to assess the landing

gear indication was made. Once the landing gear position was verified by seeing the main

struts on both left and right side from cockpit the landing was made.

Narrative: 2

[During climb] "Flaps" annunciator came on. Flaps stuck at 3 degrees. Ran checklist, but it

did not correct problem. Called Operations. After much discussion, Operations wanted us

to continue provided we thought the plane was safe. We thought the plane was safe to fly,

so we continued.

Upon approach, we 'discovered' that the gear was still down. We went around to sort out

what was happening. The gear was down with three green, so we landed.

The flaps failed due to a rag being left in the actuator. Instead of trying to help out the

company by continuing the flight, I should have turned back and landed. If I did then I

wouldn't be writing this. The gear circuit breaker was popped and we did not catch this on

the preflight. Contributing to this is the fact that we had a scheduled 25 minute turn with

an airplane swap. Instead of trying to maintain the schedule, we should have taken our

time to do a thorough job. Fixation of the problem was also a contributing factor to the

gear issue.

Synopsis

PC-12 flight crew reported a rag was left in such a location so as to prevent full retraction

of the flaps after takeoff. The distraction led to failure to retract the landing gear.

ACN: 1360127 (21 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Daylight

Aircraft

Reference : X


ATC / Advisory.Ramp : ZZZ


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



Flight Plan : IFR

Mission : Passenger

Flight Phase : Parked


Maintenance Status.Maintenance Deferred : Y

Maintenance Status.Records Complete : N

Maintenance Status.Released For Service : Y

Maintenance Status.Required / Correct Doc On Board : N

Component

Aircraft Component : Turbine Engine




Person

Reference : 1















Communication Breakdown.Party2 : Ground Personnel

Events





When Detected : Aircraft In Service At Gate





Assessments






Narrative: 1

On this flight we had an engine EGT read a high temp. More specifically our number 2

engine EGT got to 604C. We did a FLEX 30 takeoff so no limitations were exceeded

however referencing QRH due to note 4 we needed to make a logbook entry. We called at

a safe altitude and gave them the parameters, since they were in limits to continue flight

we continued to our filed destination and maintenance met us at the gate. When

maintenance came back from their inspection with the logbook we saw that they had

deferred the Automatic Reserve Thrust (ART) system as maintenance control had told him

to do. Referencing the bulletin issued, this was an improper and old procedure. When

brought to the mechanics attention he became nervous he was sent improper paperwork

to follow as he found out later he was sent the previous years procedure.

The Captain (CA) and I followed up with the duty pilot. He then told us deferring the ART

was a good procedure since the plane wouldn't be going on the Maximum Takeoff

Performance (MTOP) until it got back to a maintenance station after battling with him that

the bulletin applied we asked to talk to the fleet manager. Once we got in touch with the

[company] Manager, that Manager assured us that this was NOT ok. They were no longer

to defer the ART as it's a working system per the bulletin previously mentioned. Then I

inquired about a [previous] MEL as I needed it the last 3 times I put an engine on the

MTOP. Now all the sudden I was informed by the fleet manager that it was not needed. We

took off and flew to our planned destination, uneventfully.

I have had 4 engines put on the MTOP and have had 4 different procedures to place them

on the MTOP so far. There needs to be information sent to the pilot group of what we must

do and or see to properly place an engine on MTOP (I.e no ART deferral, whether or not

we need a deferral, what has to be on the release, etc) so it's the same every time. Also,

maintenance needs to have a standard procedure to place an engine on the MTOP to follow

every time we do this so its the same on their end as well. Also, I have had 2 encounters

with the duty pilots and both times I have received wrong information from them in favor

of getting the airplane off the ground. The duty pilots need to make safety a bigger priority

than getting the airplane off the ground, which seems to be the case with all the

departments. Were more worried about completing the flight than being legal and safe.

Synopsis

An MD-80 First Officer reported a engine EGT high temperature which was entered in the

aircraft maintenance log. Following much discussion and disagreement, Maintenance did

not place the engine on a watch list or apply an MEL until after arrival at a maintenance

station.

ACN: 1359757 (22 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Daylight

Ceiling : CLR

Aircraft

Reference : X



Make Model Name : Q400



Flight Plan : IFR

Mission : Passenger


Airspace.Class E : ZZZ

Component : 1

Aircraft Component : Pressurization Control System



Component : 2

Aircraft Component : Pneumatic System Control



Person

Reference : 1









Human Factors : Human-Machine Interface







Events







Assessments






Narrative: 1

Departed out of [a high altitude airport], clear day, smooth air, at 12,000 ft got a Cabin

Press warning light. On the ground my FO and I had talked about doing a [normal] TOP

(Takeoff Performance) vs [maximum] TOP takeoff. We decided on NTOP and I had missed

that both procedures were with bleeds off. Immediately knowing I had forgotten to turn on

the bleeds, I quickly turned them on. I pulled out the emergency action card and

proceeded to read through the Cabin Press emergency procedure. Cabin altitude was

stable at 9.8 and not rising (nor was it descending). We slowed our rate of climb hoping

the cabin controller would catch up while I continued with the Pressurization Fail Checklist.

This led us to the Manual Pressurization checklist. I manually controlled the pressurization

and was able to bring the cabin alt back down to 8,000 feet before switching it back to

auto mode and allowing the cabin controller to do the work for us.

There were some decisions I did not make due to the knowledge of the system and that

the event was due to pilot error. The first was not calling Oxygen/Don Masks. My

reasoning was that the cabin was stable at 9.8 and not climbing any more once the bleeds

were turned on and I did not want the extra distraction of masks while trying to get the

pressurization under control. The second was not declaring an emergency with ATC. My

reasoning was once again I realized that the cabin press warning was due to pilot error.

Since I had flown the aircraft the whole day, I figured I could get the cabin pressure under

control. I also did not want to take the people back to the out station we just departed and

the subsequent delays with maintenance that would happen there. Both oxygen/Don

masks and declaring an emergency were in my back pocket and I was prepared to execute

them but had felt that doing so at that time was jumping the gun. There was a bit of

distraction for me in making those decisions. I was confused as to why the cabin controller

wasn't automatically bringing the cabin altitude back down once the bleeds were turned on

(past experience this had not happened). There was a part of me that yelled to follow our

emergency memory items and yet the other part that rationalized following our checklists

would alleviate my mistake to declare an emergency and declaring an emergency would

add more complications. Due to the conflict in my mind I did miss a few radio calls from

ATC and instead of requesting a lower altitude to run checklists, I accepted a climb to a

higher altitude. My decisions were based on the observation of the cabin not further

climbing, eventually getting the pressurization under control manually, the social impact of

forgetting the bleeds, passenger inconvenience, and knowing I could declare an

emergency if I noticed the cabin getting out of control.

For bleeds off takeoff, I need to come up with a better way to remind myself that the

bleeds were turned off for takeoff and to turn them on at 400 feet. The cause was doing

something that is not a normal procedure. During winter it is easier to remember turning

the bleeds back on due to icing conditions and our deice equipment being ALL ON. On a

clear day it is easier to get distracted. There is no normal procedure to verify that the

bleeds are ON at 400 ft. We do have the after takeoff checklist which I will now physically

touch the bleeds and ensure they are on, but it's easy sitting in the left seat to look up and

assume they are on (since they always are, right?). I also noted during the climb that the

pressurization did not look correct. The altitude indicated 8,000, the rate was climbing at

500 ft per minute, and the differential was low, not climbing at all (usually it's the other

way around). I stared at this for a while trying to figure it out but determined that it was

at 8,000 feet because we took off at an airport at 7,000 feet elevation. Had I verified

bleeds were ON physically while accomplishing the after takeoff checklist or if I had further

investigated the abnormality with the pressurization (maybe even bringing my FO in the

loop and my concern), we would not have had a cabin press warning light.

Synopsis

Q400 Captain reported departing a high altitude airport using a bleeds off procedure, but

did not reselect the bleeds on until observing the cabin altitude warning light as the cabin

climbed to 9,800 feet.

ACN: 1357903 (23 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Dawn

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : FMS/FMC


Problem : Design

Person

Reference : 1
















Events



Anomaly.Deviation - Procedural : FAR





Assessments





Narrative: 1

On this flight, the FMC execute light was disabled for most of the flight. This report

addresses the failures of the flight manual, cross checks, or Maintenance Control to

address any type of correction for this. It is presumed that reloading the approach, which

was done just prior to descent, corrected the issue, and that loading the arrival and

departure prior to the winds actually caused the issue, but that is indeterminable. After the

route was loaded on this flight, a RTE DATA prompt was not available, so the rest of the

box was loaded, including both the departure and arrival. After that, the prompt appeared

and the winds were loaded. The final weights and takeoff data required manual loading

and after takeoff, it appeared that the execute light did not work. After exploring the

system, it was discovered that portions of the FMC would execute, but not others. The

navigation system worked properly, and we were able to stay on our route in RVSM

airspace. The impact would have involved either using conventional navigation in the

terminal area, or not being able to modify our arrival in the terminal area. After consulting

the book and QRH, we could find nothing addressing this issue.

We contacted Maintenance Control regarding this issue. It took nearly 30 minutes to get a

response, and only after prompting from Dispatch. Their response was disappointing,

especially since this seems like an issue that may have occurred on numerous occasions

before. Their support was also inaccurate, referring to a route purge prompt, which did not

exist. However, they did inspire us to try reloading the approach and arrival, but not on

their accord, only on our connection of the differing solutions.

The book and QRH did not present an easy to find solution to this issue. With hundreds of

pages of NORMAL procedures, and charts that few can understand, the book is a lot like

searching a 5 year old's Lego box for the Luke Skywalker light sabre. Perhaps I am

revealing my ignorance here, but a response like, "ya, that's clearly covered" doesn't help

me with this or especially the next problem that may occur. If there is something that

actually addresses this particular issue, I could not find it with multiple searches and

looking in the book for over an hour. We need a useful manual, and a section of system

anomalies that is easy to find.

Flying this aircraft requires a great deal of colloquial knowledge, with differences in the

FMC and LNAV/VNAV systems creating many issues. Burying them in the book only makes

us bury them, and thus not report them when we fly. This is one more of those issues.

With all of these little secrets in each model aircraft, the error rate increases greatly. I'm

sure this isn't the first time that my issue has occurred, but my interaction with

Maintenance Control and the book would suggest otherwise.

The following items should be reviewed:

1) The flight manual needs to show this as an anomaly, make it searchable in the book,

and ensure it is trained and noted regularly so we all know where to find these issues.

2) Maintenance Control needs the right personnel to provide prompt assistance that is

accurate and doesn't take 30 minutes to address, even when there is a shift change. An

acknowledgement of receipt of the message and a standby should be required, so we

know we aren't being ignored.

3) The loading of the FMC should be fixed so it is does not inhibit the EXECUTE light. It

shouldn't matter how the FMC is loaded.

4) Further training could be addressed in perhaps a recurrent LOE, where anomalies are

addressed.

Synopsis

B737 Captain reported the FMC execute light was disabled for most of the flight.

ACN: 1357633 (24 of 50)

Time / Day

Date : 201605


Place

Locale Reference.Airport : SJC.Airport



Environment


Aircraft : 1

Reference : X

ATC / Advisory.Tower : SJC





Flight Plan : IFR

Mission : Passenger


Aircraft : 2

Reference : Y





Flight Phase : Taxi

Person : 1

Reference : 1











Person : 2

Reference : 2










Events

Anomaly.Conflict : Ground Conflict, Less Severe


Anomaly.Ground Incursion : Runway

Detector.Person : Air Traffic Control

When Detected.Other


Assessments




Narrative: 1

On taxi out for takeoff with all takeoff checklist items complete and approaching the

departure end of Rwy 30R I noticed a B737 on short final for Rwy 30L. As we turned

toward the runway, tower cleared us for takeoff. As we started our takeoff roll I noticed

[the B737] clearing runway 30L downfield at a very high speed but saw that he stopped

short of our runway as I continued the takeoff roll. At approximately 100 knots B737 pilot

self-disclosed to the tower that he was over the hold short line for runway 30R (our

runway). The tower immediately told us to stop our takeoff, which I did. I can't remember

the phraseology that the tower used but it was very clear to me that he wanted us to

discontinue our takeoff.

I closed the power levers, Rejected Takeoff engaged, the auto spoiler deployed, I deployed

both reversers and we cleared the runway at taxiway H. Once clear of the runway I made

a brief PA to inform the passengers why we stopped the takeoff and assured them that

everything was OK.

We received clearance to sit on taxiway Y between taxiways H and J. Our (pilots)

discussion as to our next steps took us into [the flight manual] Rejected Takeoff. We called

SJC Ops and told them we might have to return to the gate and have maintenance look at

the aircraft. They informed us that [the company] only has contract maintenance at SJC

and that they would contact them.

Knowing that if we went back to the gate we would probably be delayed a couple of hours,

I made the decision to contact dispatch and maintenance to see if we needed to go back to

the gate. While in conference with Dispatch and maintenance, we ended up in the Brake

Cooling Chart. When you enter the chart with the situational data the chart leads you to

the lower left hand block that says "No special procedures required". With this completed,

we determined that nothing else was required and I got confirmation from all parties that

we were all comfortable with this determination and we departed SJC and landed in

[destination] without any further incident.

During the flight to [destination] while doing self evaluation and review the First Officer

and I found in the Maneuvers Section of the QRH (which I believe is mainly a "training"

not an "operational" document) the Rejected Takeoff section. In that section it has a sub-

paragraph titled Maintenance Inspection. It says, "Following any rejected takeoff above 80

knots, heavy weight reject, or if maximum braking was used, the tires, wheels, brakes,

etc., must be inspected by Maintenance prior to any subsequent takeoff." This singular

statement is the reason why I am submitting this report.

Upon landing at [destination] I made an Aircraft Maintenance Logbook entry with the

pertinent data regarding the rejected takeoff and requested maintenance meet me at the

aircraft. I waited at the aircraft until maintenance completed their inspection. The

maintenance supervisor informed me that no maintenance discrepancies associated with

this rejected takeoff were found.

If it is the company's desire to have the aircraft inspected prior to the next takeoff after a

high speed abort than there should be a reference in the QRH in the index titled "Rejected

Takeoff". That index reference should lead us to the statement "Following any rejected

takeoff above 80 knots, heavy weight reject, or if maximum braking was used, the tires,

wheels, brakes, etc., must be inspected by Maintenance prior to any subsequent takeoff."

Additionally, that statement should be put into [the flight manual] Rejected Takeoff. What

is written there now is confusing and in my opinion open to interpretation.

Narrative: 2


Synopsis

B737 Next Generation flight crew reported the guidance in their manuals was unclear

regarding required inspections following their rejected takeoff.

ACN: 1354679 (25 of 50)

Time / Day

Date : 201605


Place

Locale Reference.Airport : OAK.Airport



Environment


Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Component

Aircraft Component : Flap/Slat Indication



Person : 1

Reference : 1









Person : 2

Reference : 2









Events







Result.Flight Crew : Returned To Gate

Assessments



Contributing Factors / Situations : MEL

Primary Problem : MEL

Narrative: 1

After pushback, we ran the Before Taxi Checklist. Setting flaps to 1 we did not get a green

light, only a flap transit light. We noticed that the number four leading edge device was

not showing transit position on the overhead panel but did show green overhead along

with the rest of the flaps/slats. We ran the QRH, but as we read the QRH the transit light

went out and the green LE Flaps EXT illuminated. We had all green on the overhead and

green light on the forward panel. We continued our taxi and during taxi the forward green

light went back to amber in transit again.

We notified Maintenance Control and returned to the gate. MEL Leading Edge Slat

Indications Forward Panel and number four slat was applied. We read the MEL and began

our second pushback. In the MEL, the list of procedures section A is to verify leading edge

slat position for the inoperative indication before each takeoff and landing. Then the MEL

has a note to use the wing illumination light to verify normal operation of leading edge;

which (to me) means that I must visually see the slat from the cockpit. My First Officer

could not see slat number four from the cockpit view. He could see slat number five and

number six. I looked out my window and I also could not see slat number three (it's slat

three on the number one engine that corresponds to the number four slat on the number

two engine) from my vantage point on my wing. The MEL goes on to say all indications on

the overhead annunciator panel must be operating normally. The MEL says all items must

be complied with so we both concluded that we could not comply with the MEL so we

returned to the gate.

The only way my First Officer could possibly see the number four slat was by opening his

window and sticking his head out to verify. We knew we would be unable to do this in

flight. The other option was to go back and look through the passenger window, but on

landing you're in a critical phase of flight; so we concluded that was not an option either.

My Dispatcher, Chief Pilot on Call, and Maintenance Control were notified as to our

decision. My opinion is the MEL should be fixed. If the number four slat is affected, this

MEL cannot apply or verify the slat position using the overhead only.

Narrative: 2


Synopsis

B737 flight crew reported they could not comply with MEL procedure to verify leading edge

flap position in flight because they could not see the device from the cockpit.

ACN: 1353675 (26 of 50)

Time / Day

Date : 201605


Place




Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : APU



Person : 1

Reference : 1








Human Factors : Physiological - Other

Person : 2

Reference : 2








Human Factors : Physiological - Other

Events



Anomaly.Flight Deck / Cabin / Aircraft Event : Illness




Result.General : Flight Cancelled / Delayed

Result.General : Physical Injury / Incapacitation




Assessments





Narrative: 1

Day 1

Once starting down my FO noticed an oily type smell. Moments later I smelled it, too. It

was not intense, just a noticeable oily type smell. This occurred occasionally all the way

down to landing, including taxi in. Neither one of us where too concerned about it but we

felt it was enough to call Mx. We described the events to Mx who then dispatched our

contract mechanic to the airplane. A mechanic came out to the airplane and did an

inspection to see if there are any leaks. He did not see anything that would cause an odor

that we described. At that point we decided to start boarding. When the first three elderly

passengers were seated I noticed the temperature in the cabin was 84 degrees and I

decided to start the APU to begin cooling down the cabin. When I turned the APU bleed to

on, my FO and I received a significant blast of oily smell. I immediately turned off the APU

bleed and the APU. I instructed the gate agents to stop boarding and then deplane the

three passengers who had finally settled in. I then called Mx back and explained what we

encountered. It took about 3 hours for the contract Mx personnel to do what they needed

to clean the packs and attempt to find the source of the problem. They asked me and my

FO if we could do an engine run up at the gate to see if we could isolate if it's coming from

Pack 1, or Pack 2, or Bleed 1, or Bleed 2. We ran through each scenario starting with

engine 2 and then each scenario with engine 2 with a mechanic in the cockpit. We did not

experience any smell. After we shut engine number 1 down, the mechanic turned the APU

bleed on and we again got a significant blast of oily smell. Both my FO and I put on our O2

masks and open the windows. It seemed safe to conclude the source was the APU bleed.

Mx deferred the APU bleed. Looking back, Mx did not burn the packs off after the MEL

deferral as they did before to troubleshoot the problem, therefore we took the airplane

with re-contaminated packs.

We boarded the airplane and were on our way. We detected no odor on the taxi out and

takeoff. We did notice a little bit of smell on the climb only once for a short period of time.

45 minutes into the flight at cruise we again detected the oily smell, but nothing

significant. It came and went occasionally for approximately 10 minutes until we again

receive a significant blast. My nose began to burn. We put on our O2 mask. I wore my O2

mask for approximately 2 minutes and then took it off to see if the odor dissipated. I could

not detect the smell and my FO took his mask off. He could not detect anything. About 2

minutes after that we received another blast of oily smell at which time we both put our

mask back on and advised ATC, and diverted to the nearest suitable airport. I was the

flying pilot, and my FO ran the QRH for smoke/fumes during the descent.

Upon landing we both opened our windows with our O2 mask off, breathed fresh air and

taxied to our gate. After doing our routine post flight requirements for such an event, we

left the airplane for the terminal. My FO whistled using his fingers at a young boy running

away from his parents. He said his fingers tasted terrible, like hydraulic fluid. I called Mx

to let them know what he had experienced to help them diagnose the problem. When we

got to the hotel, my FO and I went out to dinner. I had a strong oily taste and my nose

felt burned. We split the same meal together and had a couple beers. We returned to the

hotel and went to bed.

Day 2

I woke up feeling sick [very early in the morning]. I went to the bathroom and had

diarrhea, then vomited. I went back to bed feeling much better. I slept for about 2 hours

and woke up feeling bad. From this point on I begin to lose track of time and can give only

approximations of time and events, other than phone/text records. I called the duty

manager and told him I'm not feeling good, I had a strong headache and that I threw up.

The duty manager told me to call crew scheduling to call in sick and that he would start

the OJI paperwork. He also told me he would get a phone number to the Nurse Line, which

the company uses for sick employees and would call me back. I also called STAT-MD,

spoke to a doctor and explained what happened. The doctor advised me to go to an

emergency room. The duty manager called me back with the number and I told him what

STAT-MD recommended. He said that's good, that he has no medical expertise and for me

to do what I think is best, whether or not to go to the emergency room or call the hotline.

I said ok and called the Nurse Line. While being held online for someone to answer I

vomited again. At that point I decided to call 911. I told my FO what I was doing and he

asked if he should come with me. I said yes, and that I would meet him downstairs in the

lobby. I could not receive phone service on the elevator and called 911 in the lobby. By

the time I reached the lobby I was having a difficult time concentrating while on the phone

with 911, felt nauseous, walked out the front door and started to vomit several times

outside the lobby door while finishing up my phone call with 911. About this time my FO

appeared. The ambulance arrived and I sat in the back waiting for another ambulance to

arrive who would take me to the hospital. I was feeling sick again while the EMT's were

checking my vitals and was handed a bag to throw up. I vomited several times again. My

FO said that it reeked like the same smell we had on the plane. The EMT said he smelled

it, too. My FO asked him what it smelled like to him and the EMT said it smell like a

petroleum product. The oily taste was intense in my mouth. I also began to have an

intense headache.

I was admitted to the hospital and it took, I believe, 3 hours for them to get the vomiting

to stop and the intense headache to subside. The last time I vomited the oily taste was the

most intense during the entire event. I was given a CT scan of my head because of my

headache and chest X-ray of my lungs. I began to feel better that afternoon and evening,

although I still had the bad, oily taste in my mouth.

Day 3

The next morning, I felt much better and most of the oily taste in my mouth was

dissipating. The rest of the day I felt wiped out and every once in a while I would get the

oily taste in my mouth and a mild headache. Returned home that evening.

Day 4

No headache, but have a slight oily taste in my mouth. The best way to describe the oily

smell/taste: Like sucking on a penny or a coin when we were kids. [We should have]

specific training for this kind of event. I heard the source of the problem was an overfilled

oil reservoir for the APU, which was subsequently sucked into the APU, APU bleed system

which then in turn the packs. Maybe APU oil quantities should be verified by two people

knowing the toxicity of oil and the potential harm, just as both pilots verify altitude

changes in the cockpit.

Narrative: 2

During descent, the captain and I noticed an oily metallic smell in the cockpit. It was

different than the usual airbus smells. It did not alarm us at that time. It occurred from

about 27,000 feet down to landing and was intermittent.

We called MX control and they dispatched a mechanic over. During the deplaning process

while I was heading out to do the post flight, a passenger was talking and triggered me to

ask them if they smelled anything. They said yes, it was strong and bad. They were in row

23. I made that aware to the captain and performed a postflight. During the postflight, I

opened as many hatch's as I could and I noticed the smell strongest in the yellow

hydraulic bay on the A/C right. I also noticed it in the forward portion of the aft cargo bin.

When I returned to the cockpit, the MX person was there. We told him all of the

information that we had, he walked through the cabin and we also re-checked the

hydraulic bays. He smelled something there and stated that there was a lot of anti-

corrosion spray and when it gets wet, it will smell. Other than that he said the plane

smelled like an Airbus. We did not enter anything into the logbook at that time. We started

boarding the A/C and when the cabin became too warm, we started the APU. There were

about 3 people on at that time. When the APU bleed was turned on, the smell was intense.

We stopped boarding, called MX and put an entry in the logbook. Two MX persons showed

up and they smelled the fumes. While we waited they consulted with MX Control. They

burned out the packs. Then asked us to help them do engine runs and we complied. We

were trying to determine the source of the fumes. There were none noticeable on Engine 1

or 2. When the APU bleed was tested, the fumes were intense again. While they were

trouble shooting, we sat in the cockpit for a while and eventually put on our O2 masks for

the rest of the engine runs.

We were told we were removed from trip and limo to ZZZ1. While heading for the limo we

got a call that the plane was fixed. We were notified that they deferred the APU bleed,

which was the source of the contamination/fumes. The Captain and I discussed it and

chose to fly the plane. Since we smelled the fumes only in descent we assumed they were

only intermittent, there was no irritation, we agreed that if we smelled fumes again we

would write it up again. We used an external pneumatic air cart to start the a/c and a

cross bleed start from engine 1 to 2. The APU bleed was not used after being deferred.

In cruise flight, 36,000 feet, we started noticing the smell again in the cockpit. The odor

was intensifying. We discussed our options, deemed that we were diverting to ZZZ (~160

miles west). We also discussed how to advise the already angered or irritated passengers

that we were heading to ZZZ. During [the Captain's PA] statement to the PAX, the fumes

became an irritant and became the most intense we had encountered. My eyes started

burning along with my throat. The Captain's throat and nose started burning. We placed

our O2 masks on and sent a quick note to dispatch and advised ATC. We were cleared

direct. Being the PNF, I went through the Smoke/Fumes checklist and since we didn't need

to troubleshoot I performed the smoke fumes removal portion once below 10k. The A/C

landed safely.

Two factors come to mind here. First, I talked with MX control the next day and was

advised that they had determined that the APU oil was over-serviced. Second factor: MX

Pack Burn/Troubleshooting Procedures. The packs need to be burned out before returning

the A/C to service. In our case they were burned out to troubleshoot and the APU bleed

was determined to be the cause. After the troubleshooting and the deferral of the APU

bleed, the bleed system was not cleaned or burned out prior to the A/C being returned to

service. Also, in the SMOKE/FUMES removal checklist, REMOVAL of SMOKE/FUMES, if no

fuel vapors: PACK FLOW HI. In this case, it may have or it certainly could make the bleed

fumes worse.

Synopsis

A319 flight crew reported an air-conditioning smoke event during descent that was

believed to be caused by the APU and the APU was deferred. On the next leg the odor

became intense and the crew diverted to a suitable airport. The Captain became quite sick

the next day and checked himself into the hospital.

ACN: 1352390 (27 of 50)

Time / Day

Date : 201604


Place

Locale Reference.Airport : LAX.Airport



Environment



Light : Dusk


Aircraft

Reference : X

ATC / Advisory.Tower : LAX


Make Model Name : B767-300 and 300 ER



Flight Plan : IFR



Flight Phase : Taxi


Person : 1

Reference : 1














Person : 2

Reference : 2














Events






Assessments




Narrative: 1

Preflight and pushback with normal engine start was accomplished with no threat or

stress. This was the second flight using [a new performance procedure] for both me and

the first officer. Our planned runway was 25R at intersection F. We received a taxi

clearance for 25L (Alfa hold short of Foxtrot). I asked for flaps 5 and we start moving.

Then LAX ground control told us taxi 25L left, but to have the numbers ready for 25R at

Foxtrot intersection. I briefed the takeoff and called for before takeoff checklist. We both

pointed to flap indicator and responded 5. First Officer started reconfigure for 25L. He

finished reconfiguration when we were holding short of taxiway Foxtrot. We both verified

the change in runway by using the QRH procedure for "takeoff runway or performance

procedure change". We then got clearance to hold short of 25L. 25L was a landing runway

and their intention was to have us take off after two landing aircraft. We got clearance to

taxi in position and hold with reminder of aircraft on final. When we got the clearance for

takeoff I advanced the power levers and pushed N1. Immediately we got the FLAP

configure warning. I reached quickly for flap lever to verify it was in its detent. The flap

lever was not in the detent and I moved the flap lever to flaps 5 quickly. The configure

warning silenced quickly and we proceeded with a normal take off. Before rotation speed I

looked at the flap indicator to verify that it was 5 and then executed a normal take off and

departure. In hindsight I should have never reached for the flap lever. Instead I should

have initiated a rejected take off. When we got a runway change with our taxi clearance I

should have asked the ground control if it would be possible to stop on the taxiway and

accomplished runway change procedure. The stress factor went from none to very high

when we got the runway change and a short taxi with the new performance procedures on

a very busy airport. How we both miss-read the flap indicator on the before takeoff

checklist I have no idea, maybe we were too occupied in our minds with the new

performance procedures.

Narrative: 2


Synopsis

B767-300 flight crew reported they failed to follow SOP after receiving a takeoff warning

horn on initial throttle application. A late runway change and new performance data

procedures were cited as contributing factors.

ACN: 1351710 (28 of 50)

Time / Day

Date : 201604


Place



Environment


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component




Person : 1

Reference : 1











Person : 2

Reference : 2










Events








Assessments




Narrative: 1

Caution light on Takeoff.

Pressurization Auto Fail.

Green ALTN illuminated.

Pressurizing normally in Alternate mode.

Continued climb while running QRH procedure.

We got to spot in procedure that did not make sense to us. Alternate was working

normally but the procedure directed to manually operate the outflow valve because Auto

Fail light was still illuminated. We re-ran the checklist twice to double check and make

sure we were not making a mistake.

Not seeing need to manually operate the outflow valve, we contacted Dispatch and

[Maintenance] for additional guidance. Maintenance control also concurred with my

reluctance to manually operate outflow valve while alternate was working. [Maintenance]

was able to produce an older version of the checklist and stated that it read differently

than our current version but could not recommend following that because even though we

don't know why, it was revised for a reason. He would not say that it is ok to continue

climbing and continuing on a four hour flight with functioning alternate mode.

Dispatch then got [Chief Pilot] on the line and reviewed the checklist with me as well and

came to the same conclusion. We agreed that the best course of action would be to

"pause" the checklist where we were and return to [departure airport]. We left the

pressurization controller in alternate mode and returned for an uneventful overweight

landing.

Used emergency authority to "pause" the checklist and to make overweight landing.

Some unresolved issues are:

Why would a procedure direct you to go to manual mode with a functioning alternate

mode?

I used ACARS to get hold of Dispatch. I got two messages from Dispatch stating they were

trying to make the connection through [communications] but "we're having issues". After

what seemed like nearly 10 min, I called [Company Radio] and had them call my

Dispatcher directly.

During this time, we were getting further and further away from [departure airport]. We

previously had decided to continue towards destination with the hopes of resolving the

fault and being able to continue. Ultimately, this was not the case and we ended up over

200 miles away from [departure airport] before turning around.

Although it was not critical for this flight, other than burning more fuel, it was a very time-

consuming process to establish contact. If it had been a more serious in-flight emergency,

the delay in making contact may have been more critical and should be addressed.

Narrative: 2


Synopsis

B737 flight crew reported returning to departure airport following the loss of the

pressurization auto mode on the takeoff roll.

ACN: 1349914 (29 of 50)

Time / Day

Date : 201604


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Brake System

Manufacturer : McDonnell Douglas



Person

Reference : 1












Analyst Callback : Completed

Events




Anomaly.Deviation - Procedural : FAR




Result.General : Release Refused / Aircraft Not Accepted


Result.Flight Crew : Returned To Gate

Assessments


Contributing Factors / Situations : MEL



Narrative: 1

The takeoff was rejected due to the Wheel Not Turning light illuminating between 50 and

60 KIAS. After taxiing clear of the runway, I spoke to the Lead Flight Attendant (FA), and

then to the passengers. During this time, the first officer ran the Quick Reference

Handbook (QRH). At this time, the right inboard brake was over 200 degrees, while the

other three were at or below 100 degrees. We returned to the gate. The right inboard

brake temperature had continued to climb, eventually settling at about 250-260 degrees.

The right outboard was at about 125 degrees. The two left brakes remained at about 100

degrees. We were boarded by a mechanic who asked me the details of the event. He

returned several minutes later and informed me that he planned on deferring the Wheel

Not Turning light and, potentially, the brake temperature display. I literally thought he was

playing a joke on me. It quickly became apparent that he was not. His contention was that

I had a failure of two separate indicating systems at exactly the same time, and that both

indications were "unrelated." He offered no explanation for the heat emanating from the

right main - he only stated that the tires "had no flat spots." I informed him that I would

refuse the aircraft if he took that course of action. He then went on to tell me that the MEL

allows him to do this if there are no anti-skid messages. I informed him that I didn't recall

seeing any messages, but was also very clear that a pilot is not looking for these during

the process of rejecting a takeoff. I ran the anti-skid test at the gate, and the aircraft

failed the test: RIGHT OUTBD ANTI-SKID remained illuminated. This was interesting

because the LEFT inboard brake was running hot, yet the anti-skid system detected a fault

on the RIGHT inboard brake. I asked him for the logbook to enter this new condition as a

separate write-up. He informed me that he had the logbook and that he would do it. After

following up with the captain who was assigned this aircraft several hours later, it was, in

fact, NOT entered in the logbook.

When an aircraft has an obvious legitimate issue, the course of action should not be to

immediately defer the indicating system(s) in order to simply "move the aircraft" as

quickly as possible. This is one of the most egregious instances of this I have ever seen.

This is absolutely unacceptable. In the future, I will also seek out the logbook when a

discrepancy occurs and see with my own eyes that it was actually recorded accurately and

legally per the FARs.

Callback: 1

The reporter stated that this warning light comes on when a MLG wheel is turning 20%

less than the other wheels. He also stated that he could actually feel the excessive heat

coming off the RH inboard Brake. The reporter stated this issue has also happened on

other aircraft of this type, this is not a unique occurrence. The reporter also stated that

Maintenance argued with him about the issue and wanted to defer it along with an Anti-

skid problem.

Synopsis

MD83 Captain reported the takeoff was rejected due to the Wheel Not Turning light. The

right hand brake temperature was over 250 degrees.

ACN: 1349875 (30 of 50)

Time / Day

Date : 201604


Place

Locale Reference.ATC Facility : ZZZ.Tower


Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component : 1

Aircraft Component : Fuselage

Manufacturer : Boeing


Component : 2

Aircraft Component : Landing Gear Indicating System

Manufacturer : Boeing


Person : 1

Reference : 1








Person : 2

Reference : 2









Events



Anomaly.Ground Event / Encounter : Ground Strike - Aircraft





Result.Flight Crew : Landed As Precaution


Assessments




Narrative: 1

Captain is Pilot Flying (CA-PF), First Officer is Pilot Monitoring (FO-PM). On take off we

received a tail strike annunciation that extinguished after clean up. Although the winds

were gusty on takeoff, we did not suspect an actual tail strike. The flight attendants did

not hear anything unusual and we did not see or feel anything unusual. In consideration of

the Quick Reference Handbook (QRH) guidance to land at the nearest suitable field and

out of an abundance of caution, we elected to return to our departure airport for a

maintenance inspection which confirmed a tail strike did not occur.

During the return, with the flaps up, gear up/handle off, and speed brake deployed, we

received unsafe gear indications on all three gear accompanied by the audible gear

warning. The hydraulics were all normal and there were no other abnormal indications at

that time. The gear warning preceded any gear/flap changes and resolved on its own,

possibly in correspondence with retracting the speed brake.

We landed uneventfully and maintenance inspected the aircraft. In addition to confirming

there was no tail strike event maintenance discovered a significant hydraulic leak of the A

system in the left main gear wheel well. Maintenance identified and fixed a loose hydraulic

fitting and reviewed the aircraft history of false gear warnings. After several hours of

troubleshooting the aircraft was returned to service.

During this event, there was not enough information available to us to facilitate decision

making. The QRH describes the tail strike annunciation as an indication of a possible tail

strike but Vols 1 and 2 describe the tail strike annunciator as a warning for a potential tail

strike triggered by specific parameters. Despite a thorough review of the QRH checklist,

we could not discern if the tail strike annunciation by itself compelled a return when there

was no other evidence or suspicion of a tail strike. In this event, it is possible the tail strike

annunciation functioned as a warning and not an actual tail strike, but we have no way to

know definitively based on the information in the QRH. It is my strong recommendation

that Vol 1, Vol 2 and QRH guidance be expanded to include more information on how the

tail strike annunciation operates (i.e. stays illuminated, extinguishes after a time,

parameters, warning vs actual, etc.) and whether crews must land at the nearest suitable

field for an indication alone.

During the return, the audible gear warning was extremely distracting at a very busy time.

Had the unsafe gear indication not resolved, we would have needed to run a complicated

QRH procedure in a high traffic density area with a loud buzzer that we are unable to

silent. This buzzer will move any crew from the yellow to the red or worse simply because

it will not silence. This is an unacceptable risk. Many other large aircraft have the ability to

silence the audible gear warning horn and clearly safe procedures can and must be

developed to add the gear warning silence capability on this aircraft.

Finally, there still remains a question of whether the three events, tail strike annunciation,

unsafe gear warning, and confirmed hydraulic leak are related in any way. At the first

moment of the gear warning, we began to speculate if that could be related to the tail

strike annunciation. Had the unsafe gear indication not resolved, the QRH procedure would

require the gear handle to be placed in the up position, thereby pressurizing the up line.

But, depending on the specific location of the confirmed hydraulic leak, that could have

depleted the A system hydraulic fluid. These events could have developed in a number of

different ways but we were fortunate to only contemplate those possibilities at ground

speed zero.

Narrative: 2


Synopsis

During takeoff in a B737-800 the Flight Crew received a "Tail Strike" warning. When

returning to the departure airport the Flight Crew received a "Landing Gear Unsafe"

indications on all three gears accompanied by the audible gear warning.

ACN: 1349031 (31 of 50)

Time / Day

Date : 201604


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Normal Brake System



Person : 1

Reference : 1















Person : 2

Reference : 2
















Events









Result.Flight Crew : Requested ATC Assistance / Clarification

Assessments






Narrative: 1

At or about 2,000 feet AGL we got 2 EICAS messages and the auto brakes clicked off. The

messages were RH brake fault and LH brake fault. I was the pilot flying so I took the

radios and the captain checked the QRH. Upon checking the QRH the captain did not

believe that a go around was necessary. He stated that the QRH had a ground reset

procedure and there was a note that said to expect asymmetrical braking on landing. He

also stated that it said if appropriate see the next page. I agreed that in that case a go

around was not necessary and we could land normally knowing that we had almost twice

the amount of required landing distance even if there was an issue. I had repeatedly

considered going around but I was thrown off by fact that the messages were blue in

color. That was one of the main reasons that I agreed with the captain's assessment. After

landing and relooking at the QRH we realized our error, the QRH says to accomplish the

checklists not "when appropriate". Upon landing in the rush of talking on two different

frequencies and accomplishing the necessary after landing items I delayed looking at the

status page to check the brakes. Upon reaching the ramp, we got a brake overheat

message. The Captain immediately stopped the aircraft and asked me to call for fire

trucks. I did so and then ran the QRH for Brake overheat. I then informed ops of the fact

that we needed to be chalked and eventually towed in. The captain let the flight

attendants and the passengers know of the situation and to remain seated. I sent a

message to dispatch informing them. The fire department arrived and cooled the brakes

with fans and we were towed to the gate with no further incident.

This could have been prevented by being more conservative with our decision after the

fault appeared. It was a rushed process that led to a faulty decision. Colors of indications

are very prominently relied on in our training, I will not, focus so much on the color of the

message from now on but will simply make the cautious decision to go around and dig

deeper if something like this ever happens again.

Narrative: 2

I gave the radios to the First Officer (FO) while I checked the QRH. The QRH had a ground

reset procedure, to expect asymmetrical braking, and directed me to reference page 13-10

when appropriate. In a rush on short final I believed this meant if needed. The FO asked if

we were good to land. I decided that since the messages were advisory and they were

faults, I assumed that only one channel of the brake control modules were inoperative we

would have normal braking and we had nearly twice the amount of runway as our factored

distance so I said yes. As I taxied into the ramp area the BRAKE OVERTEMP message

illuminated. I stopped, did not set the brake, and had the FO run that checklist and check

the brake temps. The outboard brakes were hot the inboard brakes were indicating a little

more than the outside temperature. We had the ground crew hook the plane up to the tug

so we could release the brakes. We also had the fire crew inspect the plane with their

thermal imaging equipment. The fire crew also put fans by the wheels to help cooling.

Had I told the FO to just "go around" I would have handled the situation appropriately. If I

did not rush the decision, I would not have made the error of not doing the checklist

properly.

Synopsis

An ERJ-175 EICAS alerted BRK LH FAULT and BRK RH FAULT when the landing gear were

lowered. The crew incorrectly decided the EICAS was an advisory alert because it was

colored blue. After landing, overheated brakes required the aircraft be chocked while Fire

Crews cooled the brakes with fans prior to a tow to the gate.

ACN: 1345222 (32 of 50)

Time / Day

Date : 201602


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Flight Phase : Taxi



Component

Aircraft Component : Main Gear Tire


Problem : Failed

Person : 1

Reference : 1
















Communication Breakdown.Party2 : Flight Attendant

Person : 2

Reference : 2
















Communication Breakdown.Party2 : Flight Attendant

Events




Detector.Person : Observer








Result.Aircraft : Aircraft Damaged

Assessments





Narrative: 1

Flight started out with me doing the preflight of the aircraft. I did not notice any anything

unusual about the main gear tires. Tires 1 and 2 were worn but no deep cuts or cord

showing and there was still a tread groove around both tires. Tires 3 and 4 looked to be

fairly new with deep tread still left on them. I complete the pre-flight and all my other

duties before departure. The taxi out was long but normal as we were headed to RWY XXL

for departure. We were holding short of RWY XXL and tower cleared us onto the runway

and also cleared us for takeoff. The Captain added power and we started to roll across the

runway hold short line. Just about the time we crossed over the hold shot lines the fight

attendant called from the back. I picked up the phone and asked the flight attendant

what's up. The flight attendant stated that "she heard a popping noise". I asked her if it

was still doing it and she said no it just did it once. I told the Captain what the flight

attendant had said. The Captain asked me if I heard anything. I said "no" I just heard us

crossing the hold short recessed lights. The Captain said "I did not hear anything either". I

told the flight attendant that I only heard us crossing the hold short taxi lights. The flight

attendant said okay. The Captain and I looked over all the engine gauges and overhead

panels. The Captain asked me if I think everything look good and I said yes. He said okay

then let's go. The Captain had started to push up the power levers at about the same time

we looked everything over to make sure we had no indications of a problem.

So by the time he asked me if I thought everything looked good, the engines were spooled

at about 40 percent and stable. We then started the takeoff roll down the runway.

Everything was normal about the acceleration up to 100 knots. I called 100 knots. Still

everything was normal about the aircraft as we kept accelerating towards V1 speed. I

called V1 then rotate. Again, everything was normal about the takeoff rotation and lift off.

I called positive rate and the Captain called for the gear up. Just after the gear was in the

wheel well I heard the aircraft behind us call tower. The aircraft in position and holding

behind us on RWY XXL said to the tower "I think the airplane that just took off may have

blown a tire". The Captain and I looked at each other and said that must be us. About that

time the tower called and said "Flight XXXX did you hear that?" I acknowledged the tower

and said "yes". By this time we are at about 400 ft and we went to heading select and

started a left turn on the departure. We continued climbing to 1000 ft and started to clean

up the airplane and accelerated to 250 knots. We then switched to departure and told

them that we wanted to stay at 4000 feet and that we may have blown a tire on takeoff.

The Captain and I both agreed that we should not continue the flight. We had no idea

whether it was the left side or right that had blown or if it was one or even two tires that

had blown. The Captain said to me "will you fly?" I said I have the aircraft and switched

the flight director over to my side. The Captain said "I will contact the company,

maintenance, flight attendants and talk to the people." Meanwhile I flew the airplane and

talked to ATC. I asked ATC if we could fly out to the southeast somewhere and hold. They

gave me the identifier to the ZZZ VOR and cleared us direct to the VOR and hold. So that

is what we did. The Captain looked at the QRH but there was nothing for a blown tire. He

then called Maintenance and they told him that they were not pilots and to look at the

QRH. The Captain told MX that there was no procedure for a blown tire and tried to get

some information from MX to help us determine what tires may have blown. He asked

Maintenance to check with airport OPS to see if they could tell even which side had blown

based on tire rubber on the runway. We came to the conclusion after some time that it

was the left side that had blown but we still did not know if it was one or both of the tires.

The Captain briefed the flight attendants as if we had blown both tires and we may have to

evacuate the aircraft if we go off the runway. The Captain made a PA to the passengers as

to what had happened. We knew that we had to do an overweight landing. The Captain

asked Maintenance about landing overweight with only one tire. They said it should be

okay. We decided to land on Runway YZ with flaps 40 and brakes 2. We landed safely and

rolled to the end of Runway YZ. The fire department checked the brake temperatures and

said it looks like both tires are still inflated. The fire department asked if we could clear the

runway and shut down the number one engine. The fire department then took a closer

look at the tires. They thought it would be okay to continue to the gate. We taxied the

aircraft to gate. Back at the gate I looked at the tire and indeed it had lost tread, and was

damaged, but was still inflated.

I have subsequently learned that there may be discrepancies in reports about the

sequence of events regarding communication with the flight attendant and the report of

hearing the popping noise. I am reporting the sequence to the best of my recollection. I

am certain that the Captain and I did not believe we had an actual tire problem before

taking off, and only knew of the tire problem once we got the radio report from the other

aircraft behind us.

Narrative: 2

I received communication that there potentially may be, discrepancies in reports

addressing a tire failure on takeoff roll. I am unable to address other crew member's

recollection of events. After receiving takeoff clearance, aircraft was maneuvered to take

off position, throttles advanced to prescribed take off setting, and departure roll began.

During the takeoff roll and accelerating, FA's "chimed" the flight deck. Speed would be

estimated at 80 KTS and accelerating. ALL indications NORMAL. At this point in the takeoff

roll - I did not feel it appropriate to answer the call due to pilot flying duties. I stated to

the First Officer, we would address the call at a safe altitude. Normal take off.

We began a left turn at approximately 400+ ft and the First Officer then got in contact

with the Flight Attendants. They informed him they had heard a "bang". He inquired to

obtain more specifics. At that time, the aircraft holding short made a radio transmission

that they believed the departing aircraft (ours) may have blown a tire. With this

information received, the flight crew informed ATC that we would like to be vectored away

from ZZZ to obtain more information from Company and maintenance. Maintenance

personnel were extremely helpful. We held approximately 45 miles southeast of the airport

to burn fuel to reduce landing weight and coordinate return to ZZZ. Flight attendants,

passengers, Company, dispatch, ATC, and maintenance all worked together to coordinate

an uneventful return to the airport. Equipment [was] requested. Uneventful landing in

ZZZ. Fire department inspected landing gear. Maintenance inspected landing gear. It was

determined that it was safe to taxi aircraft to assigned gate.

Synopsis

B737-800 flight crew reported a Flight Attendant informed them of a popping noise as the

flight taxied into position for takeoff. The flight crew did not see any discrepancies and

departed, but were notified by another crew that a tire may have failed. The flight

returned to the departure airport.

ACN: 1343043 (33 of 50)

Time / Day

Date : 201603


Place

Locale Reference.Airport : DEN.Airport

State Reference : CO

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : DEN





Flight Plan : IFR

Mission : Passenger



Airspace.Class B : DEN

Component

Aircraft Component : Pneumatic System


Person : 1

Reference : 1










Person : 2

Reference : 2











Events




Detector.Person : Passenger





Assessments




Contributing Factors / Situations : Weather

Primary Problem : Ambiguous

Narrative: 1

After an approximate 30 minute deicing process, with the engines shut down (needed the

landing gear deiced and there was a lot of snow and ice on aircraft from prior day's snow

storm), we taxied to Runway 8. Captain was Pilot Flying. On our takeoff roll, just prior to

V1, I seemed to notice a mist in the cockpit. I called V1, and Rotate at the appropriate

speeds when I smelled smoke. I noticed the mist, which turned out to be smoke, getting

thicker in the flight deck.

As we rotated and climbed out, I could hear "Fire, fire, fire" from the Passengers in the

cabin. Simultaneously, the Flight Attendants (FA) were calling to the cockpit. The Captain

and I quickly ascertained that the odor was deicing fluid and that was causing the smoke.

I answered the FAs call and they told me about the smoke. I told them that it was the

deicing fluid but to call me if they saw flames or it got worse.

I then made a PA telling the Passengers that the smoke was caused by the deicing fluid

coming through the vents of the aircraft and that everything was under control. I checked

on with Departure and then donned my O2 mask. We continued the climb, discussed

turning around, but both agreed that it was deicing fluid and the cabin was clearing out, so

we continued our eastward climb. When time permitted, we proceeded with the "smoke,

fire, fumes" checklist. I wish we had some type of procedure to help mitigate this from

happening. I think that a PA message to the Passengers, mentioning the possibility this

happening, would helped lessen their panic.

Narrative: 2

We had an originator out of DEN, with a lot of ice on the aircraft from the previous night's

winter storm. I had the deice Crew take extra care in getting all the ice off the aircraft.

They spent approximately 30 minutes deicing the aircraft. After deice, we taxied to Depart

Runway 8. On take-off we had fumes with the distinct smell of deice fluid throughout the

cabin and cockpit.

Passengers were concerned and we were chimed by the FAs that some fumes were in the

cabin. The First Officer immediately made a PA to assure the passengers that the smell

was from the deicing fluid. I had him put on an oxygen mask as a precautionary measure.

We went to high on the packs to clear out the fumes. We went through the Smoke, Fire,

Fumes QRH Checklist. We flew on to destination uneventfully.

Synopsis

B737NG flight crew was informed by the flight attendants (and indirectly by passengers) of

smoke in the cabin just after takeoff. The aircraft had undergone extensive deicing prior to

takeoff, with the engines shut down, and deicing fluid had apparently gotten into the

pneumatic ducts causing fumes and smoke. The fumes dissipated quickly and the flight

continued to destination.

ACN: 1341900 (34 of 50)

Time / Day

Date : 201603


Place




Environment

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Pneumatic Ducting



Person

Reference : 1








Events





Result.General : Flight Cancelled / Delayed


Assessments




Narrative: 1

Ten minutes prior to pushback, had a tail compartment overheat warning. Very abnormal

with cool outside temps. Performed QRH emergency procedure, shut down air and APU

which was providing it. Warning stopped at shutdown of APU. With over twenty years

experience on this type aircraft, and fully knowing this aircraft a day prior provided me

with a right air condition temp high light and had issues with Airfoil Ice needing excessive

power to get proper temps both on right side, I believe a bleed air problem existed with

this aircraft that just came out of a heavy check. Upon Maint arrival with a fully loaded

aircraft they lowered the stairs of this aircraft and attempted to start APU and trouble

shoot aircraft with passengers on board. Sitting in the left seat as Captain of this flight I

stated "NO" and advised that if they wanted to trouble shoot a possible bleed air leak that

we needed to deplane passengers. This request was not received well and was met with

resistance as maintenance and ramp worried about on time. Maintenance in a

condescending confrontational tone stated "just fine go ahead and deplane".

Suddenly Ramp operations called and said that someone in Customer Operations said to

override the Captain and not to deplane. As a Captain I have never experienced such an

event. The Captain is in charge of all passengers, crew, and their safety while on board. At

this point I realized I was losing control operationally speaking of the safety of my crew

and passengers and advised the ramp that if they did not deplane prior to trouble shooting

a Tail Comp Over Heat warning with cool ambient outside temps that I needed to be

replaced or relieved as the Captain. Ten minutes later they chose to swap aircraft.

The Pilot in Command should not be interfered with when performing the duties of his or

her position especially regarding the safety of their passengers and crew. Maybe Customer

Operations needs to communicate directly with Dispatcher and Captain involved with said

scenario before circumnavigating their authority to keep passengers as safe as possible.

Hire more experienced personnel in customer ops.

Synopsis

MD-83 Captain reported he felt his operational authority was being infringed upon while

dealing with a mechanical issue at the gate prior to departure.

ACN: 1337362 (35 of 50)

Time / Day

Date : 201603


Place



Environment



Weather Elements / Visibility : Turbulence

Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 900 (CRJ900)



Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1








Person : 2

Reference : 2








Events



Anomaly.Inflight Event / Encounter : Weather / Turbulence





Assessments




Narrative: 1

We departed with very close to our ramp fuel number (i.e. far above our takeoff fuel

number). An alternate was not required, and none was on our flight plan. We were

planned to land with approximately 3300lbs of fuel, a typical number for flights that do not

require an alternate. Winds were out of the east, and [destination] was in a northbound

operation. The final was a long one, probably 20-25 miles, with many airplanes in line to

land. We experienced continuous moderate turbulence as we entered clouds and

precipitation to the south of the field. As we were cleared for the approach and switched to

tower, we noticed airplanes were being broken off the approach. As we listened further,

we found out the winds had picked up and now exceeded the tailwind limitation of the

airplane, and they were giving airplanes instructions to track the localizer, then giving

them headings to put them in line for landing to an as-yet undetermined runway. At this

point we were at roughly 3100lbs of fuel, and I begin thinking about a diversion. Given the

deteriorating weather to our south, lack of alternate fuel, and relative distance of possible

alternate airports I decided the safest option would be to continue in the pattern. I'm sure

dispatch was quite busy, because they were little help in putting together a plan. They

didn't give us the weather I asked for.

We made a minimum fuel declaration as our fuel dropped to reserve, as several other

flights were doing. We continued northbound in line to land in IMC, icing conditions and

continuous moderate turbulence. At this point we were also addressing a R REV UNSAFE

caution message per the QRH. As ATC required us to maintain 170 knots, we had no

choice but to fly with the flaps extended. I was able to safely raise them to 8 degrees to

minimize drag on the airplane. The First Officer and I, with the helpful assistance of our

jumpseater, continually evaluated our fuel situation versus our position and formulated

alternatives. As our fuel dropped below reserve to less than 30 minutes remaining, I

[advised ATC] for low fuel, and told ATC in the event of a go-around or missed approach

that I would proceed directly to [a point] just south of the airport, and land straight-in

there. We had yet another 25 mile final where we touched down. Just as we were touching

down on the mains, we received a LOW FUEL caution message. We landed with 1200lbs of

fuel, barely enough for a go-around.

It became obvious that we would be in a fuel-critical situation when we were broken off

the approach and shuffled back into line. It took ATC several minutes to formulate a plan

themselves; they could not give everyone a runway to expect immediately, or a time

estimate, which caused us planning difficulty as well.

A combination of factors caused this low fuel event, but I believe the overriding cause is

the company's current fuel policy. Our flight plan was perfectly legal, with a very typical

Fuel over Destination number for our landing, approximately 3300 pounds. If we depart

very close to our Ramp Fuel number, fly our flight planned speeds with no deviations and

a "normal" approach and landing, we land remarkably close to that number. This number,

however, gives us very little leeway for off-nominal situations. Other causes of this low

fuel emergency were the wind shift itself, along with the airport's last-minute switch to a

northbound operation and subsequent re-alignment of traffic toward the opposite direction

runway. Holding us at 170 knots required us to be in a high drag situation with flaps

extended. My declaration of minimum fuel, which should ostensibly protect us from any

undue delay, was most likely ineffective due to the high number of [Company] airplanes

declaring minimum fuel, and did not serve to expedite our return.

Once we were told to expect to break off the approach, we began assessing our fuel

situation. We had noticed deteriorating weather to the south of our position, and we were

already in moderate rain and turbulence. I asked for [alternate] weather and to see how

the radar looked, but only got a METAR. I wasn't sure I could make it straight to [the

alternate] without deviating around weather, and it looked like we would be able to land

back in [destination] without too much of a delay at that point. I then examined the

possibility of going [somewhere else], where I knew the weather was acceptable, but our

fuel calculations showed us arriving at those airports burning into emergency fuel. I

decided to stay in the pattern because I know the local area quite well, and know of

several suitable general aviation airports in the area with long-enough runways in case of

a dire emergency. We could have descended just a little bit and been in VMC, so I wasn't

worried about an instrument approach to an unfamiliar airport. We did everything we

could to minimize drag on the airplane; speeding up and raising flaps completely wasn't a

viable option, because we would have had to be broken out of the line. With other

airplanes in the same situation, that would not have helped anyone.

I believe beyond a shadow of doubt that our current fuel policy should be critically re-

examined. There is an axiom in aviation that "what is legal is not always safe," and it

would serve us well to heed that caution. Our critical fuel situation may have been caused

by an unusual combination of factors this time, but I don't believe it is unique to our

specific scenario. It is an unrealistic expectation to assume a return to landing from a go-

around or missed approach will be immediate; ATC will work you into the pattern where

they can, but other aircraft need to land, too. Sometimes there are other complicating

factors: Something malfunctions late into the approach that requires a missed approach

and attention from the QRH, or several airplanes have to go around due to unexpected

windshear. I believe that our target Fuel over Destination numbers for the hubs should be

revisited and revised upwards significantly. It's not always a simple case of diverting for

extra fuel if we find we won't have a good margin--in our specific case that was not

realistic. Additionally, I find that the assumptions used to calculate Takeoff Fuel are

unrealistic in most scenarios without alternates, and takeoff should usually not be

attempted at that number. In our specific case, we even took off close to ramp fuel. I even

went above and beyond the company's usual fuel saving policies on this flight. As we

pushed back from the gate and received a 30-minute wheels up delay, I elected to sit with

only the APU running. We started one engine to taxi to the runway and arrive at the

runway just in time to take off, and started the other one very close to our takeoff time. If

I had started an engine when we pushed back from the gate, it might have changed our

scenario completely, and not for the better.

Furthermore, there is a feeling amongst the pilot group that at least one dispatcher and/or

coordinator have pushed back against pilots requesting extra fuel in special circumstances,

which can discourage many pilots from requesting extra fuel when they think they might

need it. I feel it is incumbent upon the Company to create an atmosphere where such

requests are not viewed as wasteful, but rather indicative of good judgement. Dispatchers

and pilots alike should be encouraged to take the steps necessary to ensure flight safety

without fear of retribution or any other deleterious action from the Company.

It is my honest and very real fear that if the Company does not take action to revisit the

fuel policy and create a positive atmosphere for pilots and dispatchers to ensure good

margins for safe flights, especially when we have so many new employees coming online

without much experience, then we stand the risk of losing an airplane.

Narrative: 2


Synopsis

CRJ-900 flight crew reported experiencing a low fuel state when their destination changed

runway configuration due to shifting winds. The Captain was critical of company fuel

policy.

ACN: 1337057 (36 of 50)

Time / Day

Date : 201602


Place



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR




Component

Aircraft Component : Aerofoil Ice System



Person

Reference : 1








Events


Anomaly.Inflight Event / Encounter : Unstabilized Approach




Assessments





Narrative: 1

We briefed and set up for a CAT II in icing conditions into ZZZ and conditions were

forecast to improve and did in fact improve some prior to our landing but we stayed in a

CAT II configuration to landing. In the descent we got multiple caution messages starting

with (I think) wing Anit-Ice (A/I) fail, bleed low temp, A/I low capacity and the #1 bleed

temp was "amber". This happened a few times while we were powered back trying to

configure for landing. First Officer attempted to add power (per the company message and

also the QRH) to fix the problem but then we were not able to configure for a stabilized

approach. These caution messages would come and go with icing conditions. At some

point we stopped trying to manage the A/I failure versus the energy of the aircraft to get

configured for a stabilized approach. I think we may have gotten the Ice condition A/I

inoperative warning at this point. We landed, I wrote of the failures in the logbook

explaining that 1: it happens in flight when you are powered back and 2: increasing thrust

(as much as we could in a descent trying to configure to land) did not fix the problem.

Maintenance took the aircraft and eventually cleared the logbook with a "could not

duplicate" entry in the logbook.

My primary reason for reporting this is that due to company guidance (Anti-Ice System

Failures company message) and QRH procedures that instruct you to add power (up to the

detent I guess, there is no min or max defined?) pilots and mechanics are becoming numb

to anti-ice system failures as this issue is far more common in the last few years than it

has been in the preceding decade or so. I fear we will eventually ice up an aircraft and

stall it on the descent because pilots believe these messages are the new "normal".

The company message says to direct questions to [a Company resource], and when he

returned my call he told me that, one, he is not an ERJ pilot so he's not current on the

system, and two, he is directed to publish that same company message every year to

prevent nuisance write ups. He did seem very concerned and passed my concern on.

The aircraft must be certified for known ice EVEN AT IDLE THRUST, correct? Per the QRH if

you add thrust and it goes away (how much thrust, all the way to the detent, hard to do in

a descent which is the primary time when the issue happens!) it is not a problem and

should not be written up. In this case I wrote up that it happens in flight and adding thrust

did not solve the problem (bleed temp indicator still amber, multiple caution messages

etc), and the maintenance action was to test the ice system (I assume via an "A" test, and

conclude that they "could not duplicate" return to flight. Of course they could not duplicate

it because they did not duplicate the conditions. (OAT at -degrees c, thrust near idle,

actual moderate icing etc).

I've talked to multiple pilots and other check airman about this issue and there are several

common threads. One, is that the problem is more common now than it used to be. Two,

it doesn't get written up because of the company message implying that it's not a "real"

issue and more of a nuisance problem. Three, many pilots believe there is no risk with an

icing failure because it's just an indication problem now, so they neither write it up nor

take action to avoid icing. Four, most of us agree that the QRH procedure is not a realistic

fix because, either you cannot add thrust (and continue to descend or configure) or often

times you have to add so much thrust that you'd have to abandon the arrival or approach.

How can there not be a defined minimum N2 that the icing system should operate at?

Five, maintenance is aware of the company message as well, so pilots are slowly being

trained that if they write it up maintenance is just going to go do an ice test and ops check

it good anyway so why bother to write it up?

I do know that [I saw] a chart that showed that these failures were going down over time.

I think that the question was left at "is the rate going down based on actual failures or on

reported failures?" and the answer was the "reported failures" are going down. That makes

sense to me because I've now talked to many pilots who consider A/I failures (that

eventually clear at some point) not worthy of a write up in the logbook per the company

message.

Another thought I had is that the A/I valves are not getting exercised via the ice test as

much as they used to since we switched to a logbook where we no longer log the ice test

as complete. How does a crew know whether or not it's first flight of the day on aircraft

particularly leaving a hub? I would guess that this test get inadvertently skipped far more

often now that we no longer log the ice test and therefore the valves get less "exercise".

I should have done this report every time this happened to me over the last few years so

there would be a better record of it. So I guess I have to be more vigilant to be more vocal

over issues like this where I think the airline could have a horribly bad outcome with a stall

in icing conditions.

Synopsis

EMB-145 Captain reported concern that flight crews are becoming too accepting of wing

anti-ice issues in the fleet.

ACN: 1331434 (37 of 50)

Time / Day

Date : 201408


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component : 1




Component : 2

Aircraft Component : Pressurization Outflow Valve



Person

Reference : 1








Events



Anomaly.Inflight Event / Encounter : Other / Unknown





Result.Flight Crew : FLC Overrode Automation




Assessments





Narrative: 1

About 1hr 15min into the flight at FL330, the cabin pressurization controller began acting

erratically. This was also accompanied with rapid pressure fluctuations that could be felt in

the ears. The cabin ALT began climbing at an approximate rate of 1500 fpm initially and

later would increase further. We initiated the procedure "Cabin Pressure off Schedule or

Erratic". We selected the pressurization controller to STBY with no change that corrected

the problem. The outflow valve control wheel appeared to be sticking or stuck and every

time the automatic system would recoil, the outflow valve would stick in a position more

open than the last. We selected the system to manual and manually attempted to move

(muscle) the control wheel forward to close the outflow valve. We were unsuccessful in

being able to position the outflow valve in a closed position sufficient to maintain cabin

pressure. While attempting to manually close the outflow valve we were approaching a

cabin ALT of 9000-10000 ft. Prior to reaching step #3 on the QRH, the "Cabin ALT" Master

Warning illuminated. We elected to stop performing the steps and performed the memory

items required for a "Cabin ALT/ Rapid Depressurization" followed by "Rapid Descent". The

FO was PF with the autopilot on. We donned our Oxygen masks and established

communication with ATC. I took control of the aircraft, [advised ATC], and initiated an

emergency descent. During the descent while running the QRH, we ensured the blue

"Cabin O2 On" was illuminated. We elected to turn towards and divert. When approaching

10000 ft we removed our oxygen masks, and I made a call to the FA's and briefed them

followed by a clear PA to the passengers stating what had happened, that we were at a

safe altitude to remove oxygen masks, and that we were diverting.

Once below 10000 ft all operations/ communications were normal, as well as a normal

landing. We contacted dispatch via [commercial radio] around 10000 ft to inform them of

our situation. We taxied to the gate and deplaned. Passengers were in good spirits as they

deplaned and no injuries were noted. Once on the ground, movement of the outflow valve

was still restricted even with no air load on the valve. Two logbook entries were made.

One for the loss of cabin pressure and one for 3 POB's that were used by the FA's. All

aircraft emergency equipment appeared to operate normally. The FA's assisted a special

needs passenger and an infant with the donning of their oxygen masks. After the flight

deplaned, our FA's went above and beyond the duty to assist a special needs teen to make

accommodations to catch a Flight later that night. Prior to our crew deplaning, we had a

formal debrief as a crew in its entirety about the event.

This aircraft had been recently painted. This aircraft had a similar problem before. They

returned to the airport of origin when they were unable to pressurize. Ensure outflow

valves (scoop) are painted properly (or NOT painted over at all).

Synopsis

MD-80 flight crew experienced a faulty pressurization controller and outflow valve. Flight

diverted to enroute airport.

ACN: 1331374 (38 of 50)

Time / Day

Date : 201412


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : FMS/FMC



Person

Reference : 1







Events








Assessments




Narrative: 1

Upon arrival at the aircraft there were some issues that were still being worked on and

eventually the mechanics were able to resolve the FMS position issues. The aircraft pre-

flight was completed and the aircraft was ready for flight. We took off and within the first

hour ATC began to query about our heading. After checking our heading with the mag

compass we could see there was a discrepancy. After consulting the QRH it was clear this

was not a heading fail situation. We checked the FMS and it had lost its position. From that

point we changed over to flying from VOR to VOR and disregarded the FMS indication. We

had full map and heading information but it was incorrect. Eventually ATC called about our

heading again and we checked the heading with the wet compass and it was off. We

placed both Captain and First Officer compasses in Non-Slaved mode and made

adjustments in relation to the wet compass. After navigating through a line of weather we

contacted Dispatch and informed them of the issues and their instructions were to turn

around and go back to [departure airport]. We advised them we could make [destination]

but were told to turn around and go back. We made the 180 turn and asked for the fuel

burn at our present position. Dispatch informed us that we would have approximately

6,800 lbs upon landing. [Later] I called dispatch again for an update and they informed us

that we would be landing with 5,600 lbs. In addition to this we noticed that our wind

indicator was showing 191 kts Headwind (HW) and when we made the 180 back the

indicator still showed 191 kts HW.

Plan that a plane coming out of extensive maintenance will most likely have issues. It is

better to work out the issues rather than expecting to use the aircraft. Assign a Team to

shake down the aircraft issues quickly. Don't release the aircraft to the line until the Team

has given the green light.

Synopsis

A MD-80 Captain reported returning to departure airport after loss of the FMS.

ACN: 1331058 (39 of 50)

Time / Day

Date : 201407


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Turbine Engine



Person

Reference : 1








Events




Result.Flight Crew : Inflight Shutdown



Assessments




Narrative: 1

Level at 11,000 feet [after departure] and accelerating, the L OIL PRESS LO annunciator

illuminated. I noted the Oil Pressure to be 35 PSI at this point and decreasing rapidly. I

was the Pilot Flying, and at this time I took the radios so Captain (CA) could run the

appropriate checklists. I requested return to [departure airport].

Complied with QRH OIL PRESSURE LOW. Step 2a says "with oil pressure less than 35 PSI

and OIL PRESS LO Annunciator, Engine Shutdown Required. Refer to Engine

failure/shutdown procedure this section". Complied with QRH ENGINE

FLAMEOUT/SHUTDOWN/FAILURE. Secured the Left engine as oil pressure was dropping

through about 10 PSI. CA notified the cabin crew with the nature of the [situation] and to

prepare the cabin. He also addressed the passengers that we would be returning to

[departure airport] due to mechanical issues.

As the pilot flying, I got the weather and decided [on] the best suitable runway. I flew a

visual approach, single engine. We ran all appropriate single engine approach and landing

checklists. Emergency vehicles met us on the taxiway, where we told them we could taxi

to the gate. They followed us there for safety purposes. Upon arriving at the gate, we

were met by mechanics, who further informed us that a Chip Detector had "blown" and we

had lost all oil.

QRH phraseology changes from one procedure to the next. Needs to be uniform for faster

compliance.

When referring to a procedure in the QRH that should be followed next, it would be helpful

to have the procedure number for faster look up.

Synopsis

A MD-88 First Officer reported returning to the departure airport after shutting down the

left engine because of low oil pressure.

ACN: 1330473 (40 of 50)

Time / Day

Date : 201602


Place




Environment


Weather Elements / Visibility : Snow

Light : Daylight

Aircraft

Reference : X



Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1












Person : 2

Reference : 2











Events


Anomaly.Deviation - Track / Heading : All Types

Anomaly.Deviation - Procedural : Clearance









Assessments






Narrative: 1

Upon departing, we deiced with the APU running and taxied out to the runway with high

overcast skies. The light snow had stopped and the runways were clear. We were cleared

for takeoff with a left turn to 160. Upon climb out through 200 to 300 feet I noticed a

smell and white smoke started pouring out of the side vents. We quickly ran our Cabin

Smoke Memory items and then ZZZ tower was calling us to make the turn that had been

assigned to us. At the same time, the FA started calling us to advise us of smoke in the

cabin. We went back to basics of Aviate, Navigate, Communicate and we went through the

normal callouts through our masks to get the gear and flaps up and do the after takeoff

configuration. I responded to tower that we [had] smoke in the cockpit that our plan was

to air return and to please stand by. We backed up our memory items with the QRH and

took ATC's request to turn left to 160 as the FO asked for autopilot to reduce the

workload. Then ATC switched us to departure. He requested our FOB and Souls aboard. I

asked him to stand by. We completed the after takeoff checklist and got started on the

QRH. We completed the Cabin Smoke QRH and then called back to the FA. The FA said

there was smoke in the cabin and we confirmed that we had it in the cockpit too. I gave

the FA a quick briefing saying that we also had smoke in the cockpit that we were already

getting vectors to come back to land at ZZZ. I stated that we would be on the ground in

less than 10 minutes and I did not expect an evacuation of the jet and that we would taxi

back to a gate and deplane there.

After we had talked to the FA, I got back with the controller to give him Souls on Board

and Fuel aboard. I also requested that they roll the trucks. At this point I went heads down

to reconfigure the ACARS for the diversion and get landing data but the ACARS was giving

me trouble in requesting landing data back to ZZZ even though we had changed the

destination back to the departure airport. We were cleared down to 3000, given a final

vector and cleared for the ILS. I decided that it was safer to come back heads up to focus

on the flight and back up the FO instead of trying to get numbers from ACARS and flipping

pages in the [FMS] to get the weights manually. I verbalized that the ACARS wasn't

cooperating and that I didn't have time to get the landing numbers in from the [FMS] but I

checked the landing weight and that we would be landing about 100lbs overweight. The

FO acknowledged and stated he would fly above the white arc and aim for a very smooth

landing. We landed normally and came to a stop after clearing the runway. We completed

the after landing and called the FA to remind them to remain seated. By this time we had

been handed off to a ground frequency and were talking to the fire trucks in front of us.

The smoke had dissipated completely with only a lingering odor. We expressed our

intentions to the fire crews that we were going to head back to the gate and deplane there

but first they requested to walk around and look for anything obviously wrong. We

confirmed and indicated to them that we had no heat or fire indications and the only thing

we had seen was smoke. While the fire trucks inspected the jet, I made a passenger

announcement, stating that we had had some smoke in the cockpit which could have been

deice fluid burning in the A/C units but that we were not sure. I stated the firetrucks were

doing an exterior inspection and when they gave us the green light, we were going to taxi

back to the gate and deplane the aircraft. I further stated that we would keep them in the

loop when we learned more about the status of the flight. The fire department escorted us

back to the gate that [company] had assigned us and we deplaned the aircraft. The fire

crew came on to look for signs of fire and said that they found none. After we completed

all normal checklists, we called maintenance and wrote up smoke in the cockpit, low O2

from the oxygen that we had used and overweight landing and we left the jet with the

Maintenance crew.

One major threat was the state of flight when the smoke event occurred. It was

immediately after takeoff in a high traffic environment. If I had known that the smoke was

going to stop fogging the cockpit and eventually dissipate I think an error that I committed

was not asking for a few more vectors so that we had more time to finish inputting the

landing data. However, as the source of smoke was unknown to us, I felt an urgency to

get back on the ground as quickly and safely as possible. In the future I will be a little

more thorough in my per-departure brief about air return weights and whether or not we

will be overweight if we have to do an air return. I realized as we were coming back that I

wasn't sure if we were going to be overweight until I checked the performance page and

that surprised me. I also wish I had remembered to make the turn to 160 but the smoke

really surprised me. Finally, I don't know if there was a connection between the APU

running and smoke getting into the packs but in the future I am going to take the

recommendation of deicing with an engine running and the APU down as a hard rule.

Narrative: 2


Synopsis

EMB-145 crew deiced at the gate with the APU running. Immediately after takeoff, the

cabin and cockpit filled with smoke and the flight returned to the departure airport. Deice

fluid was suspected as the smoke's source.

ACN: 1329417 (41 of 50)

Time / Day

Date : 201602


Place

Locale Reference.Airport : BUR.Airport



Environment


Aircraft

Reference : X


Make Model Name : Citation Excel (C560XL)



Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Engine Air Starter



Person

Reference : 1










Events






Assessments





Narrative: 1

While starting the right engine, the GPU went offline aborting the start. I followed the QRC

for abnormal start and secured the engine. I had the ground crew remove the GPU and

started the left engine on battery power. After limitation wait time, I started the right

engine using generator assist. The right engine started, but the starter would not

disengage. I again followed the abnormal start QRC, but while the engine shut down, the

starter would not disengage. I used the right engine fire switch to secure the engine.

The Encore+ QRC does not have, nor points to the more expanded abnormal start

procedure that exists in the QRH. That procedure would have most likely resolved the

stuck starter without having to use the engine fire switch. I did not think of this procedure

as I was concerned about major damage or even an engine fire with passengers on-board.

I suggest that the full engine start malfunction procedure be incorporated in the QRC, or

at the very least, the QRC point to the appropriate section in the QRH should the QRC

actions not resolve the abnormal start.

Synopsis

CE-560EP Captain reported the right engine starter failed to disengage and the procedure

to resolve the issue was not in the QRC.

ACN: 1329350 (42 of 50)

Time / Day

Date : 201602


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Indicating and Warning - Hydraulics



Person

Reference : 1











Events








Assessments




Narrative: 1

We were at FL320 and got a HYD B LO PR ECAM with no [Blue Advisory] items but got the

chime. Since we were stabilized at cruise altitude and I was already the PF I continued to

fly and took the radios as the FO began to search the Quick Reference Handbook (QRH)

for the procedure. As I followed him through the index we both soon realized that there

was no such procedure listed in the QRH. We then checked the Flight Manual (FM) and

found the same - no procedure for the Electronic Centralized Aircraft Monitoring (ECAM)

we showed. I then had the FO send a Dispatch CALL ME so we could talk to Maintenance

Control (MC). The Airbus controller spoke as I monitored at low volume as to maintain ATC

watch. The controller was "dumbfounded" as to why there was no direct procedure as he

had us check the status of the Electric Blue pump (had no fault light indication), HYD page

(amber arrow and amber "BLUE" shown), BLUE system pressure was 2850 PSI, and F/CTL

page (amber B indications). He finally decided that it would be prudent for us to run the

HYD B ELEC PUMP LO PR (QRH 130.1) as it was the closest procedure - which we

accomplished. After fully following 130.1 we signed off with MC and Dispatch as he could

not think of any other options to work from. Upon clearing the pages - when the FO

arrived at the Status page the first step showed to turn the BLUE ELEC pump back to auto

for approach which was NOT part of the 130.1 procedure. We once again contacted MC for

clarification and he recommended doing this - just in case the pump "failure" was

erroneous and we re-established Blue system pressure for approach and landing.

After leaving him once again, within two minutes (approx) we received a F/CTL ELEC1

FAULT and followed the QRH procedure which called for a reset of ELEC 1. When we turned

it off the aircraft began a slight (less than 5 degree) roll to the right and stayed that way

throughout the remainder of the flight. We reset Elevator/Aileron Computer (ELAC) 1 after

5 seconds to no avail - as the message remained. I elected not to call MC for a third time

as we believed this to be a related failure (which was in fact MC's opinion as well after we

called to debrief them after landing). After finishing all procedures and calls I elected to

call the Purser to inform her that the aircraft was flying normally but we did have a

hydraulic issue. I asked her to review procedures for evacuation with her partners just in

case the situation deteriorated and gave her an estimated time until landing (TEST). As we

quickly approached the Top of Descent I began to quickly brief the RNAV arrival to

transition to a visual approach. In our haste, the FO and I failed to confirm this in the

Multipurpose Control Display Units (MCDU), and had the ILS in instead. I didn't catch it

until shortly after the final fix and had him quickly enter the FMS visual procedure - we

were slightly SW of course and corrected back to the FMS course expeditiously. I then

asked the FO to turn the BLUE ELEC pump back on and the aircraft "jerked" momentarily,

which signified to me that in fact there was some pressure provided of course - although

the 5 degree right bank continued. I elected NOT to declare an emergency based on the

GREEN and YELLOW systems being normal, a "return" of BLUE system, no fault lights or

overheats noted on any HYD pumps or systems, and positive aircraft control. By the way, I

had been hand flying (auto thrust still on) since around 12,000 feet as to get a feel for

aircraft control relatively early. Again, except for the bank the aircraft flew relatively

normally - under the circumstances. I also made sure to configure early as we were

expecting slow slat movement as per QRH 130.1. We were soon cleared for the approach,

configured the aircraft, stabilized the approach early, and landed normally. Upon reaching

the Gate and completing all checklists I then called Maintenance Control via Dispatch to

debrief him fully. By the time we landed MC had already sent email(s) to various

departments documenting the issue(s) and said they would follow up with us if need be.

Lastly I would be remiss if I failed to mention the exemplary work displayed by my New

Hire FO. All crewmembers and MC displayed true skill and professionalism which ultimately

contributed to a safe outcome.

Synopsis

A320 Captain reported a "B" Hydraulic System Low Pressure warning appeared on ECAM.

There was no procedure in the QRH to resolve the issue. Pressure indicated normal, but

the aircraft tended to roll to the right for the remainder of the flight. They reset MCDU 1,

to no avail. Turning the hydraulic pump back on the aircraft "jerked" indicating pressure,

but the tendency to roll remained.

ACN: 1327724 (43 of 50)

Time / Day

Date : 201601


Place

Locale Reference.Airport : SKBO.Airport


Environment


Aircraft

Reference : X

ATC / Advisory.TRACON : SKBO


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Passenger

Nav In Use.VOR / VORTAC : BOG


Person : 1

Reference : 1










Person : 2

Reference : 2










Events








Assessments


Contributing Factors / Situations : Airport






Narrative: 1

Bogota approach cleared us for the VOR-C approach, to land on Runway 31R, due to

northerly winds at SKBO. All FMC approaches are for landing Runway 13. The iPad has a

VOR-C Jeppesen chart but would have required QRH raw data approach procedures.

ATC refused my requests to land south with a tailwind.

I made the decision that to fly the VOR-C procedure in IMC was unsafe for the following

reasons:

-I have never practiced nor flown a raw data approach in almost 5,000hrs of 737 time.

-SKBO is a mountainous terrain airport designated as special per 14 CFR 121.445. Flying

approach procedures IMC into this airport, that I have never used, is unsafe.

-The engine out missed approach for Runway 31L requires the existence of a "route 2" in

the FMC, per jeppesen page 10-7e-2, that cannot be flown legally on non-route 2 equipped

aircraft. I am quite sure we have not even taken delivery on any route 2 equipped

737's...........this issue needs to be addressed on our fleet since, apart from this event, the

missed app procedure for ALL runways requires a route 2, installed in the FMC, to perform

the Single Engine missed approach correctly.

-The VOR missed approach to the northeast via ZIP VOR, although at first glance might be

ok for Single Engine missed approach, I was not comfortable not having specific 10-7 page

guidance indicating a Single Engine missed was safe in that direction from the missed app

point that was located a couple of miles east of the airport.

I informed ATC that I would only accept the VOR-C procedure if we could maintain VMC

from the Minimum Vectoring Altitude (MVA) on the approach to landing.

We were able to maintain VMC and fly the VOR-C as published to a circle and land on

Runway 31L.

ATC informed the Aeronautical Civil authorities of our difficulties accepting the approach.

We were met and debriefed by 3 representatives of the Aeronautical Civil agency. I

explained to them our procedures, my concerns and the FMC database issue.

Narrative: 2


Synopsis

The crew expressed concerns about the BOG VOR-C 31R/31L approach at SKBO, as it is

not in the FMS database and is used infrequently. There were also questions about missed

approach performance.

ACN: 1327347 (44 of 50)

Time / Day

Date : 201601


Place




Environment





Light : Daylight


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Route In Use : Direct

Airspace.Class C : ZZZ

Component

Aircraft Component : Nosewheel Steering


Problem : Failed

Person

Reference : 1






Qualification.Flight Crew : Instrument


Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Multiengine





Human Factors : Other / Unknown

Events






Assessments





Narrative: 1

The airport had had snow most of the night and our aircraft had been type-1 deiced prior

to crew arrival as well as having been re-positioned from the arrival gate the night before.

The First Officer reported a satisfactory preflight inspection and also that we would require

deicing as there were frozen solid remnants of the earlier deicing event adhering to the

aircraft at various spots. Outside temperature was about plus ten degrees Fahrenheit and

the snow was tapering off at that point.

After passenger boarding and engine start and the second deicing, we began taxi.

Immediately it was apparent that nose wheel authority was minimal, but there was some.

Main brakes were a little better; we eventually reported poor braking conditions to the

Tower. That said, purely for the nose wheel it was between poor and nil. There were no

abnormal messages or indications. Aside from that fact, operation up to and prior to

takeoff were normal.

At liftoff, there were messages for nose door open, gear disagree. The nose gear indicated

extended while the two main gear indicated retracted. There was a slight abnormal

vibration which seemed to confirm the nose gear was extended as indicated.

The aircraft was otherwise performing well and we continued climb out with the intent of

running checklists and assessing options. We arrived on top of the overcast with clear sky

above at roughly 13,000 MSL. I leveled off for cruise at 15,000 MSL. We ran the QRH

checklist for gear disagree up to the point of pulling the manual gear extension handle. It

was not clear just where, at that point, we would be landing. And there was little point in

immediately attempting main gear landing without first deciding just where the landing

would be.

Originating airport surface conditions were alarming to me. We had reported poor braking

and that was mostly for the effect that the brakes had, however, for the nose gear it was

much more like nil. At moments taxiing out, I was concerned the aircraft might brake

traction and begin sliding downslope. Returning to this airport was, for me, the last choice.

In the area, I was generally aware of other possible airports. After advising Center of our

condition, in due course we were provided weather for other airports none of which were

suitable.

Early in cruise, we checked fuel status. Current consumption, even at lowered altitude,

indicated about an hour and a half remaining even continuing all the way on to our filed

destination. There was about a 50 knot tailwind. We were indeed much lower than filed,

but the QRH airspeed mandated flying at or less than 200 KIAS, which was an unsafe

airspeed for cruising much higher than the low twenty thousand feet altitude regime at

most. Depending on interpretation of SOP speed guidelines, it could have been said we

were already higher than allowed for normal operation, which we were not in. That said,

the overall situation was not an emergency, but rather an abnormal one in my

assessment. The priority was not to land as soon as possible, but to identify a suitable

airport, run the QRH to extend the main gear, and land there with sufficient fuel.

I'd elected to head initially on flight plan route, towards our original destination, while

prosecuting the plan to find suitable landing spot. I informed Center that we were

committing to land at our filed destination.

Arriving in the destination area, it was CAVU. We descended to 10,000, performed the

remaining QRH which dropped the remaining gear with three down and locked at that

point, with an hour and a half of fuel. We then accepted vectors to a landing. During

rollout below 60 knots, there was a severe nose wheel shimmy that remained until at taxi

speed.

We cleared the runway with no nose wheel steering authority at all, it was inoperative.

Emergency equipment was standing by even though [we did not request any]. Upon

inspecting the aircraft, they indicated that the nose wheel appeared to have some

apparent problem. We made calming passenger announcements and waited for a tow

vehicle. Eventually, instead, passenger transfer busses were brought to the aircraft and we

deplaned all passengers and they were transported to the terminal.

With the main cabin door open, we were able to view the condition of the nose gear. The

tires were badly worn, but not deflated. Most concerning, though, was that the torque

links were not connected and were not damaged either.

During the preflight, the torque links appeared in a normal state to the FO as well as the

pushback and deicing crews. I can only account for any steering authority by theorizing

that the links had been pushed and frozen together in a manner that was not obvious and

remained so until nose strut extension at liftoff. A most unusual situation. I've

recommended that our Company provide training containing photographs of this "close,

but not quite" condition in standard pilot preflight syllabi.

Synopsis

CRJ-900 torque links on nose gear were not secured after towing. Aircraft lost nose wheel

steering upon landing.

ACN: 1325805 (45 of 50)

Time / Day

Date : 201601


Place

Locale Reference.Airport : SKBO.Airport


Relative Position.Distance.Nautical Miles : 2


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : SKBO


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



Flight Plan : IFR




Route In Use.SID : ZIPAQUIRA 9G

Person

Reference : 1















Events






Result.Flight Crew : Returned To Clearance


Assessments




Narrative: 1

My first officer and I were all set to depart off of runway 13L with all briefs completed and

during pushback ground control advised that they had a new routing for us. We stated that

we would call them back and continued with the push back and start. Once we were under

way and all checks were completed we indicated that we were ready to copy the new

clearance. The clearance was actually a change of the runway to runway 31L which is

seconds away from our ramp as well a new clearance was issued. We both listened in

which is always a bit difficult with the accent, but we were both 100% certain that we

received the Zipaquira 9G and I was certain that the FO read back the Zipaquira 9G. We

worked hard to slow things down and spent a considerable amount of time going over

everything from start to finish, as well we referenced the QRH for guidance for the runway

change. On the departure while waiting to turn right to intercept the course the controller

stated [Air Carrier X] turn left. Knowing that we had terrain the FO asked for a specific

heading and the controller went silent. Soon he responded with a specific right turn

instruction and then mentioned that we were given the Zipaquira 9F. Bogota has four

departures with Zipaquira, the Zipaquira 5J, Zipaquira 2H, Zipaquira 9G and Zipaquira 9F.

We continued the flight to [the destination].

Synopsis

Air carrier Captain reported a track deviation departing SKBO because of communication

issues with ATC.

ACN: 1325458 (46 of 50)

Time / Day

Date : 201601


Place




Environment


Weather Elements / Visibility : Cloudy




Light : Daylight


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Gear Extend/Retract Mechanism



Person : 1

Reference : 1












Person : 2

Reference : 2















Events



Anomaly.Ground Event / Encounter : Loss Of Aircraft Control








Result.Aircraft : Aircraft Damaged

Assessments





Narrative: 1

We took off after all operations were normal during preflight, pushback, and de-ice. I was

the PM, and we had [another] carrier's captain jumpseating. On the taxi out, I noticed that

the ramp appeared to be contaminated with snow, and the captain had trouble steering.

We reported braking action as poor, and asked to back taxi on the runway to confirm the

reported braking action of good was true. It was, we had good braking action on the

runway. The plane didn't turn quite as well as usual when turning into position for takeoff,

and the captain stated it was probably slush picked up from the contaminated ramp. The

visibility was roughly 2 miles, with 400 ft. overcast. After back taxiing, turning around, and

taking off, I selected the landing gear up, and we received a triple chime, with GEAR

DISAGREE and NOSE GEAR DOOR messages. After maintaining positive control of the

airplane, we brought out the QRH and ran the associated procedures. On ED1, the landing

gear status showed both main gear up, and the nose gear down. The captain stated early

into the situation that he didn't like the idea of going back to the departure airport, as

there was low visibility and ceilings, snow piled on the edge of the runway, and we weren't

guaranteed controllability when we landed.

The tops were roughly 13,000 feet, and we climbed to 15,000 feet. We thought the

proximity sensors might have frozen slush on them, and our hope was to stay in warmer

air to melt it and have operational control of the gear. Our attention then turned to where

to go. I checked with ATC for airports in VMC, with little crosswind and was given a few.

There was a solid overcast below us that was reported to clear the further south we went.

After discussing each, we decided we had enough fuel to reach our filed destination with

an hour of fuel remaining, and that was an appropriate airport due to the long, wide

runways, weighing less upon landing, and better rescue services, if needed. Our

jumpseater said, while he had no operational control over the flight, he agreed with the

decision. We flew to our filed destination with no changes in situation, and held to

complete all QRH procedures, got three green landing gear indications, and proceeded to

land.

The landing and rollout were normal, until we slowed. After slowing to approximately 60

knots, the plane started to vibrate, and nose wheel steering was not possible. We were

able to taxi off the runway and stop, at which point the passengers were deplaned and

bussed to the terminal, and we were towed to a gate. When we had stopped, maintenance

came to tow us in, and reported that our torque links were not connected. Their estimation

was that when the weight came off the nose strut, it extended and caused the PSEU to

fail. The maintenance personnel said that sometimes the connection of the torque links will

appear to be connected, but aren't fully locked.

While performing the preflight, I looked at the torque links, and they appeared to be

connected. If what the maintenance personnel in the destination stated was true, that the

torque links can look locked, but aren't, a suggestion to keep this from happening again is

to paint the pin part of the lock a neon color, so it's easily visible if it isn't locked all the

way. Another suggestion is to stress to flight crews to not be complacent in preflight/post

flight inspections. If the torque links were the cause of this situation, it is a good example

of not catching a problem on the ground, and having it turn into a larger problem in flight.

Narrative: 2

The aircraft preflight was reported as without any discrepancies but the aircraft had been

already repositioned from the last evening gate and had also been deiced before our

arrival. Light snow and ice on portions of the fuselage dictated another deicing after

pushback. Steering on taxi had seemed sluggishly effective consistent with surface

contamination.

Approaching our destination, the QRH procedure resolved the gear disagree and a normal

approach and landing followed except that slowing through about 60 knots, a severe

nosewheel shimmy occurred that continued until slowing to taxi speed. Nose steering was

inop. Emergency vehicles had stood by and the personnel inspected the aircraft exterior

and found the nose tires badly worn to cord but not deflated. Maintenance personnel

stated that the torque links were not connected, however they were not seen so before.

We believe its possible ramp personnel repositioned the aircraft, and afterwards aligned

the torque links but did not lock them. In the adverse weather, the low experience FO did

not detect this. Additionally, our pushback crew did not. I suggest pictorial diagrams of the

final pretaxi necessary torque link configuration be added to pilot and ramp agent training

and manuals.

Synopsis

A CRJ-200 flight crew reported nose wheel steering difficulties during taxi out. The crew

associated the control issues to ice on the ground. After takeoff the gear disagree alerted

with the nose wheel extended. The nose scissor link was found disconnected after landing.

ACN: 1318154 (47 of 50)

Time / Day

Date : 201512


Place

Locale Reference.Airport : ORD.Airport

State Reference : IL


Environment



Light : Dusk

Aircraft

Reference : X


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



Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Person

Reference : 1










Communication Breakdown.Party2 : Ground Personnel

Events



When Detected : Routine Inspection


Assessments




Narrative: 1

While doing the pre-flight walk around I noticed ice attached to the leading edge of the

horizontal stabilizer. But it wasn't snowing yet. I let the ground crew and the Captain know

that we would have to deice. The company contacted ops to let them know we would have

to deice the aircraft. That was after trying several times to contact "Ice-man" on the

assigned frequency. We configured the plane for deicing following the procedure on the

"QRH". We read it carefully especially since it was our first time deicing this season. When

we were ready to be deiced we told the deicing crew that we need fluid types I and IV and

they acknowledge it. At some point the deicing crew said that we had some more ice on

the fuselage and asked us if we wanted that removed as well. That situation made us feel

a bit uneasy. So we told them that we needed to be fully deiced with fluid types I and IV.

After a few more minutes the deicing crew told us that they were done and gave us the

times. But they hadn't deiced the nose of the plane so we asked them about it. And they

said that it was their mistake and they then deiced the nose. After that they left and didn't

answer our calls. By then it had stopped snowing. It stopped snowing around the same

time that the deicing started. Since it was an awkward situation we asked our rampers to

do a tactile check and a visual inspection of the aircraft for any signs of ice. And after

doing the check they said everything looked good and that the plane seemed fully deiced.

We finished the flight without any problems. But after we landed while I did the post-flight

check I couldn't find any traces of type IV fluid. I could see type I leftovers, but no type

IV. And you can usually find some traces after the flight.

We are not sure if both types were applied. And we felt that communication with "Iceman"

was difficult. We followed the written procedure but it seemed like the deicing crew

sometimes had no idea of what we were talking about. That was our impression at least.

We did what we deemed necessary at the time in order to make sure the plane was free of

ice and snow and not to put safety at risk. If the rampers would've said that we still had

ice or snow on the aircraft we would requested to be deiced again. I understand that every

year there are some issues with deicing at the beginning of the winter season. Maybe

initially the deicers could be supervised a little more closely. Especially if they have new

hires.

Synopsis

Air carrier flight crew experienced difficulty communicating with the ground crew during

deice/anti-icing of their aircraft. The first problem was ensuring that the crew deiced the

entire aircraft. Secondly, the crew was not sure if both types were applied as required and

requested. After the flight the crew could find traces of Type I deicing fluid, but not Type

IV anti-icing fluid.

ACN: 1315627 (48 of 50)

Time / Day

Date : 201512


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Medium Large Transport



Flight Plan : IFR

Mission : Training



Component

Aircraft Component : Indicating and Warning - Fuel System


Person : 1

Reference : 1










Person : 2

Reference : 2











Events





Result.Aircraft : Equipment Problem Dissipated

Assessments




Primary Problem : Chart Or Publication

Narrative: 1

We were starting the number 2 engine at the beginning of 16R in ZZZ. While starting the

engine tower called and cleared us for takeoff. We had been waiting for our EDCT

(Expected Departure Clearance Time) time to ZZZ1 and were being released a little early.

I responded that we were just starting our second engine and that we would need a bit.

Tower said that's fine but that we were still cleared for takeoff when ready. I let the

aircraft roll up to the runway while we were in the engine start. After the checklists were

complete and the needed warm up time we took the runway. It was the FO's (First

Officers) leg so once lined up I said "your controls". We were doing a rolling takeoff. Just

as he was about to, or had pushed the power up we got an advisory message that said

"fuel feed 2 fault". As it was not a warning or caution or any other item we had briefed for

a rejected takeoff I told him to continue. Once at a safe altitude and cleaned up after

takeoff I ran the QRH for the message that remained. The QRH said "Don't takeoff" end of

procedure.

I don't really have an answer for this. From the folks I've talked to more about this the

advisory message we received should have come on sooner or not at all till after we were

above a certain altitude.

Narrative: 2

Cleared for takeoff, I advanced thrust for takeoff. As we started rolling we got a fuel pump

something status message (not a warning or caution or anything we should abort for). I

called it out. Captain says continue. I did. After cleaning the plane up CA (Captain) pulls

out the QRH to read up on that status message. It ends with "DO NOT TAKE OFF". Got to

ZZZ1 where MX cleared the message.

One cannot memorize all status messages. As it wasn't a warning or caution or anything

that affected the safe outcome of flight the CA decided to continue. It was not an abort

worthy item per the sop as such we continued. If it should be then it should be added to

the SOPM.

Synopsis

During the takeoff roll a flight crew receives an advisory message yet continues the

takeoff. Once at altitude it is discovered that the message should have warranted a

rejected takeoff procedure and the crew should have remained on the ground.

ACN: 1315353 (49 of 50)

Time / Day

Date : 201512


Place




Environment

Light : Night

Aircraft

Reference : X






Flight Plan : IFR






Component

Aircraft Component : Flap Control (Trailing & Leading Edge)



Person : 1

Reference : 1













Person : 2

Reference : 2











Events


Anomaly.Deviation - Procedural : Maintenance








Assessments




Narrative: 1

At FL380 and just prior to top of descent for a heavy-weight night landing, we received a

PFD FMA of "FLAP LIMIT" and noted that the flap gauge indicated 1/2 with symmetrical

needles and of course the flap handle was in the up position. We slowed the aircraft below

the flaps 1 speed limit and the FMA went away. We also noted a status message of

"FLAP/SLAT ELEC". We continued descent at slow speed and then attempted to configure

for landing. Once we selected flaps 1 we immediately received the EICAS message "TE

FLAP ASYM" and a "TRAILING EDGE" Discrete light and the flap gauge showed both

needles 1/2 way between up and 1 with the Flap handle in the 1 detent. After consulting

QRH and having already had this issue in this aircraft previously, our assessment that a

heavy-weight, slats-deployed, flaps-up landing would be required. We requested CFR

standing by. I was conducting new hire IOE and the student was PF during this leg and I

elected to have the student remain PF until we accomplished all checklist items and then I

took over PF duties for the landing phase. Landing was uneventful and we had CFR follow

us to the gate and they remained with the plane while the brakes continued to cool. This

was the 3rd occurrence of this flight control malfunction in this aircraft.

Note: New Hire IOE FO did an outstanding job in all aspects of his duties during this event.

Unknown (reoccurring) aircraft system malfunction with this AC.

Narrative: 2

I was the PF while operating flight during my IOE training. Shortly before starting our

descent for landing we noticed the SPD FMA changed to FLAP limit FMA. After that the Line

Check Airman (LCA) pointed out that the flaps indication was out of the "up" position. The

Status message "flap/slat elec" was displayed on the status page. It was obvious to us

that the airplane believed some flaps were out. We decided to slow down to 230 knots

below the flaps 1 speed.

We were aware this was a reoccurring problem with Aircraft so we decided to extend flaps

early in case it progressed to an additional fault. I called flaps 1 early on the approach and

that is when we got the "TE flap assym" EICAS Caution message. The LCA accomplished

the QRH and briefing the plan of action we did a positive exchange of controls. I finish the

before landing Checklist and the LCA did the landing. The landing was really good and the

aircraft stop with no difficulty. We ask the Fire department to follow us to the gate as one

of the brakes was indicating warmer than normal.

Reoccurring system malfunction with Aircraft.

Synopsis

A B757 Primary Flight Display FMA annunciated FLAP LIMIT at the top of descent with flap

handle up but the flap gauge indicating one half degree symmetrical flaps. With Flaps 1

selection EICAS the alerted TE FLAP ASYM and TRAILING EDGE so the QRH was completed

and a normal landing was accomplished with Crash Fire Rescue standing by.

ACN: 1315155 (50 of 50)

Time / Day

Date : 201512


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Tablet



Person : 1

Reference : 1













Person : 2

Reference : 2










Events









Assessments




Narrative: 1

This situation was not a compliance or violation event, but a general information event.

During our ground time, both the First Officer (FO) and I were charging our iPads. I

remember seeing the charging cord against the circuit breaker (CB) panel behind the FO's

seat because of the way I had my iPad seated. I believe that at some point by moving the

cord, it inadvertently pulled one of the landing gear CBs. Unfortunately, I did not catch this

before I took my seat for pushback.

I was the Pilot Flying and right after takeoff, I called for the landing gear up. The FO raised

the gear handle but only went to the mid-position. Things got a little busy then. I

continued to fly the plane and the FO requested a level off. I was thinking back to the cord

next to the CB during our ground time. In the past, I have had a couple of times where

the seatbelt shoulder harness had pulled the landing CB and figured out that was what had

probably happened to us with the charging cord.

We started to run the checklist for Landing Gear Will Not Retract. I looked back and saw

that the CB was out. I then pushed the breaker in and directed the FO to retract the gear

which did come up at that time. We then continued the climb and proceeded with the

flight. Upon arriving, we did notify Maintenance and filled the logbook out with an Info

Only write-up since we did reset a CB. We explained to them what had happened and that

I was fairly certain that at some point the charging cord must have snagged the CB and

pulled it out.

In the future I will continue to do a thorough check of the CB panel before I take my seat,

especially with the charging cord hanging across the FO panel.

Narrative: 2

While on the ground, Captain plugged his EFB into recharge cable. At one point, I moved

the cable to run behind my seat. Captain unplugged his EFB and I took the cable and

rerouted and plugged it into my EFB for a few minutes. Before pushback, I unplugged the

charging cable and stowed it. Pushback, engine start, and taxi to the takeoff runway were

uneventful.

Captain was Pilot Flying. After liftoff, Captain called for landing gear up. Upon moving the

handle, it would not go past mid-point and both red and green lights were illuminated for

all gear. We agreed to continue initial climb and clean up then work on gear issue once

level. Thinking that we would need a little time to consult QRH and troubleshoot, I

requested a turn downwind and level off from Tower. They gave us a heading and altitude

and then switched us to Departure frequency. At the same time, I was looking for the

correct checklist in the QRH.

The Captain leveled the aircraft (at assigned altitude of 3000 feet) and engaged the

autopilot about the same time I located the "Landing Gear Lever Will Not Move Up After

Takeoff" Checklist in the QRH. Just as I started to read this checklist, the Captain stated

that one of the landing gear circuit breakers with a blue collar was out. He also said that

he felt it probably got pulled by the EFB charge cord and that he would reset it. Upon

reset, he asked me to raise the gear handle and it raised to up position and the gear fully

retracted.

At that point we agreed that the issue was corrected and we should continue to our filed

destination. The remainder of the flight was uneventful. Upon arrival, the Captain called

for Maintenance, informed them of what had happened, and documented the circuit

breaker reset in the aircraft logbook.

Make sure Crews are aware of the hazard of the EFB charging cable pulling a CB and are

always checking circuit breakers during/after charging cable use. I read through the

"Landing Gear Lever Will Not Move Up After Takeoff" Checklist. There is no direction to

check the status of landing gear system circuit breakers. Why? Perhaps this checklist

content should be reviewed and updated.

Synopsis

A B737 Captain charged his iPad during a turnaround preflight and accidently pulled the

landing gear control circuit breaker while removing the charging cable. After takeoff when

the landing gear did not retract and while completing the QRH, the pulled circuit breaker

was reset.

ASRS Database Report Set - Checklist Incidents

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Transcript of ASRS Database Report Set - Checklist Incidents