Inflight Weather Encounters - ASRS - Aviation Safety ... · Inflight Weather Encounters . ... A...
-
Upload
nguyencong -
Category
Documents
-
view
217 -
download
0
Transcript of Inflight Weather Encounters - ASRS - Aviation Safety ... · Inflight Weather Encounters . ... A...
ASRS Database Report Set
Inflight Weather Encounters
Report Set Description .........................................A sampling of reports from both air carrier flight crews and GA pilots referencing encounters with severe or unforecast weather.
Update Number ....................................................32.0
Date of Update .....................................................December 28, 2017
Number of Records in Report Set ........................50
Number of New Records in Report Set ...............50
Type of Records in Report Set.............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.
National Aeronautics and Space Administration
Ames Research Center Moffett Field, CA 94035-1000
TH: 262-7
MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data
SUBJECT: Data Derived from ASRS Reports
The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.
ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.
Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.
After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.
The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.
Linda J. Connell, Director NASA Aviation Safety Reporting System
CAVEAT REGARDING USE OF ASRS DATA
Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.
Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.
One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.
ACN: 1488242 (1 of 50)
Synopsis C525 Captain reported a track deviation during climb from SLC when they were distracted
by turbulence or a wake vortex encounter.
ACN: 1485675 (2 of 50)
Synopsis Diamond DA40 pilot reported encountering severe turbulence while traversing a mountain
pass. He and all the passengers hit their heads on the ceiling when the seat belts became
ineffective.
ACN: 1481209 (3 of 50)
Synopsis EMB-505 flight crew reported using Captain's authority to circumnavigate an area of
thunderstorms.
ACN: 1477252 (4 of 50)
Synopsis Air carrier flight crew reported descending below the MIA Runway 26R RNAV Approach
profile. The autopilot did not capture the vertical path and the crew did not detect it until
they were low causing a GPWS warning.
ACN: 1476596 (5 of 50)
Synopsis Air Carrier flight crew reported a deviation for weather in oceanic airspace, after deviating
a message was received from ATC that denied the deviation.
ACN: 1476347 (6 of 50)
Synopsis A single engine pilot reported approach control vectored a military aircraft over his aircraft
which the pilot felt was unsafe.
ACN: 1476074 (7 of 50)
Synopsis A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the
repair made by a local mechanic did not have the proper documentation.
ACN: 1476062 (8 of 50)
Synopsis A Maintenance Controller reported that he received a report that a Bombardier CRJ-700
had minor cabin damage due to turbulence, later it was found to have severe cabin
damage.
ACN: 1475960 (9 of 50)
Synopsis SF 340B Captain reported returning to the departure airport after loss of First Officer's
attitude and heading indicators.
ACN: 1475763 (10 of 50)
Synopsis SR22 pilot reported that during cruise the Multifunction Display flickered then he smelled
electrical burning/arching.
ACN: 1474961 (11 of 50)
Synopsis A319 Captain reported descending below the profile on descent to IAD when they
encountered turbulence that may have been a wake encounter.
ACN: 1474872 (12 of 50)
Synopsis Cessna pilot reported being unable to maintain altitude and airspeed due to a downdraft
on approach to COS.
ACN: 1474295 (13 of 50)
Synopsis B767-300 reported that due to weather conditions the aircraft had a hard.
ACN: 1474226 (14 of 50)
Synopsis B737 flight crew reported a rejected takeoff due to a predictive windshear warning.
ACN: 1474198 (15 of 50)
Synopsis Cessna Skymaster pilot reported inadvertently climbing VFR into Class A airspace due to
convective activity. He negotiated with the Center Controller and a Military Controller for a
new IFR clearance away from the convective activity, restricted airspace, and out of the
MOA to his destination.
ACN: 1473844 (16 of 50)
Synopsis C172 pilot reported entering an area of extreme precipitation and severe turbulence while
using NEXRAD XM weather to circumnavigate storm areas.
ACN: 1473689 (17 of 50)
Synopsis Flight crew reported windshear warnings while attempting to land at the COS airport that
resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,
and a successful landing was accomplished.
ACN: 1473122 (18 of 50)
Synopsis Learjet crew reported encountering failures of the Windshield Heat, Autopilot, and
Electronic Attitude Direction Indicator during flight. Crew continued to VMC conditions and
landed uneventfully.
ACN: 1472727 (19 of 50)
Synopsis C172 pilot reported a power loss that led to an altitude deviation that was probably related
to carburetor icing.
ACN: 1472521 (20 of 50)
Synopsis Miami Center Controller reported an aircraft that was in conflict with another and the pilot
did not want to turn away from traffic because of weather.
ACN: 1472510 (21 of 50)
Synopsis Air Traffic Controller and trainee reported a loss of separation between aircraft deviating
for weather.
ACN: 1472483 (22 of 50)
Synopsis CL350 Captain reported using his Captain's authority to avoid thunderstorms during climb.
ACN: 1471766 (23 of 50)
Synopsis
A Bombardier flight crew reported not being aware of the Precision Runway Monitor in use
because it was not advertised on ATIS.
ACN: 1471540 (24 of 50)
Synopsis LR60 Captain reported momentary loss of control after encountering a developing
thunderstorm on descent.
ACN: 1471524 (25 of 50)
Synopsis A General Aviation pilot reported canceling IFR then entering IMC weather without
obtaining a new IFR clearance in a timely manner. The reporter indicated that the delay
was due to staffing issues from ATC.
ACN: 1471374 (26 of 50)
Synopsis E-175 flight crew performed an precautionary landing after troubleshooting pressurization
door issue.
ACN: 1471341 (27 of 50)
Synopsis B737 flight crew reported on approach to DEN they had the wrong runway programmed in
the FMS which caused a deviation on the visual approach.
ACN: 1471135 (28 of 50)
Synopsis A corporate pilot reported turning away from the Mexico ADIZ airspace after being unable
to contact the Center due to frequency congestion.
ACN: 1471074 (29 of 50)
Synopsis M20 pilot reported encountering an updraft which caused him to climb into TPA Class B
airspace.
ACN: 1470687 (30 of 50)
Synopsis Air Carrier Captain reported diverting due to thunderstorms at the destination airport and
fuel concerns.
ACN: 1470661 (31 of 50)
Synopsis B737 Captain reported executing a go-around at MCO after encountering a "microburst
type event" on short final.
ACN: 1470577 (32 of 50)
Synopsis B747 flight crew reported beginning to divert due to weather and minimum fuel but ended
up going to the original destination.
ACN: 1470484 (33 of 50)
Synopsis A Center Controller reported allowing an aircraft to enter Military Operations Areas without
coordination while working special military operations and dealing with weather deviations.
ACN: 1470479 (34 of 50)
Synopsis Two Controllers and two Dispatchers reported a flight encountered severe turbulence
which resulted in injuries to flight attendants and passengers.
ACN: 1470471 (35 of 50)
Synopsis ZNY Center Controller reported the flight plan processing software did not detect that an
aircraft filed a route which reversed course at a fix and into conflict with another aircraft at
the same altitude.
ACN: 1470460 (36 of 50)
Synopsis Orlando TRACON Controller reported an airspace incursion and a loss of separation due to
another Controller being overwhelmed with traffic and weather.
ACN: 1470394 (37 of 50)
Synopsis PA32 pilot reported loss of directional control in gusty crosswind conditions that resulted in
a runway excursion.
ACN: 1469723 (38 of 50)
Synopsis
Air carrier pilot reported difficulty identifying the MUHG Runway 5 displaced threshold
because of the prevailing visibility, the runway marking width, the low contrast from the
surrounding runway surface, and no approach lights.
ACN: 1469614 (39 of 50)
Synopsis B737 flight crew reported that the First Officer experienced erroneous airspeed indications
while flying through heavy rain.
ACN: 1469590 (40 of 50)
Synopsis C90 Approach Controller reported that their sectors became overloaded and unorganized
due to numerous weather related go-arounds combined with a lack of experienced
controllers and supervision.
ACN: 1468984 (41 of 50)
Synopsis An ERJ-175 pilot reported windshear at on final which resulted in a 20 kt increase. Speed
brakes and landing gear were extended to regain a stable profile for landing.
ACN: 1468502 (42 of 50)
Synopsis ZAU Center Controller reported their session was out of control due to traffic and no flow
control from the Traffic Management Unit.
ACN: 1468179 (43 of 50)
Synopsis A flight instructor observer pilot reported not being assertive enough and allowed the pilot,
who was presumably operating under VFR, to proceed to and land at an airport that was
below VMC.
ACN: 1468164 (44 of 50)
Synopsis Atlanta Center Controller reported aircraft being cleared into known weather.
ACN: 1468132 (45 of 50)
Synopsis Turbojet flight crew reported a missed approach due to the winds at ASE. The aircraft
entered an area with a higher MSA due to a higher speed and greater turn radius.
ACN: 1468112 (46 of 50)
Synopsis B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be
expected during arrival, and did not expedite a clearance to the alternate after being
advised of the low fuel state.
ACN: 1467710 (47 of 50)
Synopsis B737 Captain reported departing DEN Runway 34L during variable windshear conditions
and recorded 192 kts at Vr, 209 kts at lift off with indicated airspeeds of 158 kts and 163
kts respectively. The maximum tire speed was exceeded.
ACN: 1467476 (48 of 50)
Synopsis ERJ175 flight crew reported receiving a stick shaker warning when intercepting the glide
slope from above with the speed brakes deployed.
ACN: 1467408 (49 of 50)
Synopsis B737 flight crew reported a weather diversion that resulted in a long delay and difficulties
deplaning the passengers due to airport rules and equipment availability.
ACN: 1467288 (50 of 50)
Synopsis IAD Tower Controller reported that a flight crew missed the taxiway turnoff, turned around
to exit, causing aircraft on final to be sent around. Instruction was too late and aircraft
landed on occupied runway.
ACN: 1488242 (1 of 50)
Time / Day
Date : 201710
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : SLC.Airport
State Reference : UT
Relative Position.Angle.Radial : 220
Relative Position.Distance.Nautical Miles : 8
Altitude.MSL.Single Value : 8000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : S46
Aircraft Operator : Corporate
Make Model Name : Citationjet (C525/C526) - CJ I / II / III / IV
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use.SID : LEETZ6
Airspace.Class B : SLC
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : S46
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Airspace.Class B : SLC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 14000
Experience.Flight Crew.Last 90 Days : 85
Experience.Flight Crew.Type : 2000
ASRS Report Number.Accession Number : 1488242
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While climbing out of SLC via the LEETZ 6 departure we encountered either wake
turbulence from the aircraft ahead or severe environmental turbulence. The auto pilot
disengaged and while hand flying the aircraft trying to keep the aircraft under control we
missed the initial fix, PPIGG, by approximately 1.5 to 2 miles. SLC departure queried us
and advised we were off the departure. They issued a heading to rejoin the departure and
nothing more was said of the situation. There was no loss of separation from other
aircraft. It was a VMC day so we were never in danger of terrain contact with all of that in
full view.
In hindsight, we should have advised ATC of the encounter with turbulence and let them
know we had to deviate to get the aircraft under control. We were so preoccupied with
dealing with the situation that we never advised ATC of our actions.
Synopsis
C525 Captain reported a track deviation during climb from SLC when they were distracted
by turbulence or a wake vortex encounter.
ACN: 1485675 (2 of 50)
Time / Day
Date : 201710
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 11500
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility.Visibility : 50
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Personal
Make Model Name : DA40 Diamond Star
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class E : ZZZ
Component
Aircraft Component : Seatbelt
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 1600
Experience.Flight Crew.Last 90 Days : 15
Experience.Flight Crew.Type : 150
ASRS Report Number.Accession Number : 1485675
Human Factors : Situational Awareness
Analyst Callback : Completed
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.General : Physical Injury / Incapacitation
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
After passing northeast bound through a mountain pass, I warned my passengers to
expect turbulence. We started to experience moderate turbulence and then encountered a
sudden violent drop in altitude. All four of us hit our heads on the roof of the airplane. No
serious injuries, but possible head and spinal issues noted the next day. Two headsets
were broken. The seatbelts did not prevent head strikes and two seat belts became
unfastened. The front right possibly was not securely "clicked" in place and the right rear
came out of floor mount (looks like it was "clicked" into an inaccessible latch under back
seat) and could not be reattached during or after the flight without maintenance
assistance.
Reported the incident as "severe turbulence" to Center, telling them we had struck our
heads on roof of airplane. They were concerned and asked if we needed assistance. Each
controller that followed checked in on how we were doing.
The Diamond seat belts are particularly difficult to fasten securely. They are hard for larger
persons to reach and securely latch and they did not appear to be effective at preventing
head strike. Maybe the lap belts should have been tighter? Wind on the windward side of
the pass at this altitude was about 25-30 knots. I did not notice the wind speed at the
time of the incident on lee side of pass, but noticed it was over 40 knots (tailwind) as we
continued northeast bound toward our destination. We modified course to get farther away
from the mountains for the remainder of the flight.
Callback: 1
The reporter stated the seat belt that the passenger in the right seat was using may not
have been completely fastened because of the difficulty of accessing the buckle. The
reporter stated that in order to ensure that the front seat belts are properly fastened you
need to open the door to gain access to the buckle (especially if you're overweight). The
reporter also stated one of the seat belts for the passengers in the rear seat became
unlatched from the mount (which rendered it ineffective) and had to be reattached by
Maintenance. Reattaching the seat belt required removing the rear seat. The reporter also
stated that due to the low ceiling, the seat belts, as designed, will not prevent you from
contacting the ceiling with your head during turbulence. The reporter stated that he broke
his headset as a result of hitting his head on the ceiling.
Synopsis
Diamond DA40 pilot reported encountering severe turbulence while traversing a mountain
pass. He and all the passengers hit their heads on the ceiling when the seat belts became
ineffective.
ACN: 1481209 (3 of 50)
Time / Day
Date : 201709
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 37000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 37000
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Personal
Make Model Name : EMB-505 / Phenom 300
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Training
Nav In Use : FMS Or FMC
Flight Phase : Descent
Route In Use.STAR : ZZZZZ
Airspace.Class A : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 13000
Experience.Flight Crew.Last 90 Days : 250
Experience.Flight Crew.Type : 850
ASRS Report Number.Accession Number : 1481209
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Analyst Callback : Completed
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Trainee
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 2500
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 70
ASRS Report Number.Accession Number : 1481177
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Instructor/Mentor Pilot was acting [as] PF. During the descent briefing the PF/IP informed
the PIT (Pilot in Training) that the weather over the arrival was deteriorating. XM Weather
and Active Weather Radar was painting numerous cells starting to top at FL400. Literally
the entire area was bubbling up with convective activity creating a dangerous situation.
Descent/Approach briefing completed the THREATS were clearly outlined as Severe
Weather both on the arrival and the wind conditions at the field.
[While cruising] at FL450 the Controller issued a clearance to descend to FL400. PIT (Pilot
in Training) doing the radios advised the Controller to stand by. After conferring with the
IP/PF both pilots agreed it was much safer to stay at FL450. PIT reported to [ATC] that we
wished to stay at FL450 until we passed the worst of the weather. The Controller
DEMANDED a descent. Again the PIT with authorization from the PF/IP advised we were
unable to descend. The Controller then assigned us a heading of 210 and demanded a
descent. The PF/IP made the call to begin the descent and try to help the Controller out.
We accepted the 210 heading and descend to FL350. We heard the Controller ask for an
expeditious descent through FL370. Upon rolling out on the heading of 210 we were
closing in on a large cell. We asked the Controller for a 230/240 heading for weather.
When we turned to that heading, it was obvious we were going to go through the tops of
another cell.
Now unable to get on the radio due to numerous aircraft requesting VECTORS FOR
WEATHER we turned to a SAFE heading of 260 and at first break in the radio, advised the
Controller we now needed a 260 heading for weather. The Controller replied with "You are
not cleared for a 260 heading". We again advised "sir, we need the 260 heading for
weather!" again the Controller said "you are not cleared on to that heading". This left the
crew no option but to [override the Controller] for safety. We immediately took a picture
of the weather radar and view out of the window showing the imminent threat.
Pilots should keep in mind that an XM Weather image may be 20-30 [minutes] old and
that what matters most is the image out of the window and on the weather radar. The
atmosphere had clearly reached a boiling point making safe flight very much in doubt. If
we had the time we would have squawked 7700 prior to making the turn to 260 but it is
always Aviate, Navigate and then Communicate. Didn't have time in a dynamic situation. I
stand behind the decisions we took as a crew to have a safe conclusion to our flight.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
EMB-505 flight crew reported using Captain's authority to circumnavigate an area of
thunderstorms.
ACN: 1477252 (4 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : MIA.Airport
State Reference : FL
Altitude.MSL.Single Value : 1300
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Thunderstorm
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : MIA
Aircraft Operator : Air Carrier
Make Model Name : Widebody Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Nav In Use : FMS Or FMC
Nav In Use : GPS
Flight Phase : Final Approach
Route In Use.Other
Airspace.Class B : MIA
Component
Aircraft Component : Autoflight System
Aircraft Reference : X
Problem : Improperly Operated
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1477252
Human Factors : Distraction
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1477254
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Automation : Aircraft Terrain Warning
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Uneventful descent into Miami while avoiding thunderstorms. Vectors to intercept final
course for RNAV/GPS Rwy 26R. We kept the speed up to get on the ground before a series
of thunderstorms got to the airport and received shortened vectors to final inside the
NAYIB fix on the approach. On final and after confirming FMS speed, Nav, and profile MDA,
while consulting with each other about rain showers close to the airport, we noticed that
the airplane was descending below the profile glidepath and I disconnected the Autopilot
to arrest the descent.
We descended to 1300, below the minimum 1500 ft for that portion of the approach before
the Final Approach Fix ZARER. We immediately started a correction back to published
altitude. At that point we received a yellow GROUND PROXIMITY alert for several buildings
2 to 3 miles in front and on both sides of the approach course. After confirming we were
well clear of all obstacles and still in a safe position for landing we opted to visually
continue the approach and landing.
Distraction with weather during the approach. Clarify before the approach the duties (i.e.
who will be looking at the radar and who will be closely monitoring the instruments).
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Air carrier flight crew reported descending below the MIA Runway 26R RNAV Approach
profile. The autopilot did not capture the vertical path and the crew did not detect it until
they were low causing a GPWS warning.
ACN: 1476596 (5 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : KZAK.ARTCC
State Reference : CA
Altitude.MSL.Single Value : 33000
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
ATC / Advisory.Center : KZAK
Aircraft Operator : Air Carrier
Make Model Name : Widebody Transport
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Cargo / Freight
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Route In Use : Oceanic
Airspace.Class A : KZAK
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1476596
Human Factors : Communication Breakdown
Human Factors : Time Pressure
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1476603
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
About 3+26 into flight at FL330, after passing N46E170, we encountered moderate to
severe turbulence with associated "pop-up" radar returns beneath the aircraft. We couldn't
see as we were at the cloud tops. As Pilot Monitoring, I sent SF Radio [ARINC] a message
requesting left deviation for weather; we had radar indications that prevented a right
deviation. SF Radio's response wasn't timely enough and we decided to deviate left off of
our Strategic Lateral Offset Procedure. We reviewed the Long Range Navigation (LRN) for
weather deviations and were aware of parameters and altitude requirements of a deviation
off course for weather. Our left deviation kept the aircraft at a safe distance away magenta
indications on the radar. SF Radio replied with "unable deviation left due to traffic." By this
time we had already deviated left. Upon receiving this message the flying pilot turned right
to return on course, while avoiding weather. SF Radio sent another message indicating
they showed us off course. We replied that we were back on course.
Intent is to communicate why we deviated for weather and that the crew was aware of off
track deviation procedures.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Air Carrier flight crew reported a deviation for weather in oceanic airspace, after deviating
a message was received from ATC that denied the deviation.
ACN: 1476347 (6 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : A11.TRACON
State Reference : AK
Altitude.MSL.Single Value : 600
Environment
Weather Elements / Visibility : Fog
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Windshear
Weather Elements / Visibility.Visibility : 3
Ceiling.Single Value : 1700
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : A11
Aircraft Operator : Personal
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Descent
Route In Use : VFR Route
Airspace.Class C : ANC
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : A11
Aircraft Operator : Military
Make Model Name : Military
Mission : Training
Nav In Use.Localizer/Glideslope/ILS : ILS Runway 6
Flight Phase : Initial Approach
Route In Use : Vectors
Airspace.Class C : ANC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 11000
Experience.Flight Crew.Last 90 Days : 201
Experience.Flight Crew.Type : 4200
ASRS Report Number.Accession Number : 1476347
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 600
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Procedure
Primary Problem : Airspace Structure
Narrative: 1
I was approaching Anchorage from the north in an ADS-B in/out equipped [aircraft]. I
called Approach for radar services for routing for landing. I was given an immediate Part
93 Deviation in the PAMR segment. Weather was raining, fog, getting dark with few clouds
and 600-700, and rain obscuring visibility to 3-5 miles. Heavy wind and windshear
occurring with the traffic at ANC being routed in for the ILS for Runway 15. There was
significant traffic using Approach and I was watching the flow of the vectoring to the ILS
and handoff to the Tower. Heavy jet traffic was reporting wind shear and turbulence. I was
low at 600 feet as I had little wind and below the ground surface shear point.
Also in the mix was a [military aircraft], which was doing practice approaches and the
TRACON controller twice told traffic that the [military aircraft] was doing "Touch and go's"
and then corrected that to missed approaches. He was vectoring the [military aircraft]
around very non-standard with tight turns and low altitudes. When I was approaching the
[military aircraft] was returning to PAED on a visual. The ATC controller gave him a
weather report of heavy precipitation between the [military aircraft] and PAED in the area
which I was at the time. I am not sure if it was requested by the [military aircraft] or
suggested by the controller, but the [military aircraft] was then cleared for the ILS on
Runway 6 at PAED. The controller vectored the [military aircraft] onto the ILS INSIDE THE
FAP! His clearance also said to maintain 1600 feet until established on the ILS. The
controller then cancelled my FAR Part 93 deviation in and handed me off to my Tower with
a "caution wake turbulence" warning. I switched to Tower and now had a visual on the
[military aircraft] that was, according to my ADS-B, less than 800 feet vertical separation
and he was coming right over me. I would like to see the track but it appeared that the
[military aircraft] was below the ILS glideslope. I took evasive action by wide open throttle
and full dive to the water to try to get east of the [military aircraft] and get the largest
amount of vertical separation. I think this was way too much "cowboy" action by the
TRACON controller and put lives in danger. If the [military aircraft] wanted to go IFR and
ILS approach into PAED why the heck he was not vectored out to join at an IAP or outside
the FAP!
This did not need to happen. There was no emergency or rush to put the [military aircraft]
back into PAED that was communicated on the frequency I was on. Doing "touch and go's"
or even the missed practice approaches that they really were at ANC at a time of heavy
traffic flow and difficult conditions of wind shear, turbulence and low weather was
questionable as the ILS was stacked up with traffic. What makes the air traffic work well in
this area is that the flows of traffic at all of the airports is usually predictable, and with
ADS-B even a "little general aviation guy operation" like me can get a good sense of where
the traffic is and will be due to the normal approach/departure flows out of the airports.
This was a fly in the ointment and seemingly only the TRACON controller and the USAF
flyboys knew what was going to be coming next. I am available to discuss this, although I
am flying commercially and not contactable much of the day until I return.
Synopsis
A single engine pilot reported approach control vectored a military aircraft over his aircraft
which the pilot felt was unsafe.
ACN: 1476074 (7 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 14000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Airspace.Class G : ZZZ
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Repair
Component
Aircraft Component : Stabilizer Fairing
Aircraft Reference : X
Problem : Improperly Operated
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Student
Experience.Flight Crew.Total : 144
Experience.Flight Crew.Last 90 Days : 19
Experience.Flight Crew.Type : 6
ASRS Report Number.Accession Number : 1476074
Human Factors : Training / Qualification
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Object
Detector.Person : Maintenance
Detector.Person : Flight Crew
When Detected : Routine Inspection
Result.General : Maintenance Action
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
During an authorized long distance cross-country student solo flight, attempted landing at
ZZZ on runway 18. Wind was >10 knots with gusts from 260 degrees. Had 25 degrees
flaps. As the plane was about to touch down, a wind gust blew plane from right to left and
past the edge of the runway. Was unable to maintain alignment with the runway. Executed
a go-around and as power was brought in, the nose began to raise up slightly and as such
the tail lowered. The left endcap of the stabilator struck a runway light. The impact was
felt in the yoke. Remained in the pattern, and landed on runway 18. Had the plane
refueled. Inspected the plane for damage. The left plastic stabilator endcap had a hole in it
on the leading edge.
Filled out an incident report at the airport terminal to report the damage to the runway
light. An aircraft mechanic was available to effect a repair by fabricating and attaching a
sheet metal patch. The plane was inspected for additional damage, none was found. Upon
completion of the temporary repair, the plane was returned to service. The mechanic did
not provide documentation for the repair other than a description on the cash receipt. I
was ignorant of the fact that this is improper maintenance record keeping and
subsequently learned that the aircraft should not have been placed back in service without
proper documentation. The details described in this report were reported to the FBO/owner
of the aircraft upon return two days later.
The incident could have been avoided by selecting another airport prior to the flight when
it was learned from a NOTAM that [other] runways [at ZZZ] were closed. The airport was
chosen specifically because it offered multiple runways. This fact was missed because of
fixated focus on local weather for making the go/no go decision for the flight and was not
noted and added to the plan of flight. The fuel burn rate was over-estimated and there
was more than adequate fuel available to have deviated from the plan of flight to another
airport. The cross wind component was at the margin of my skill level and surpassed by
the gusts, so upon listening to AWOS another opportunity to deviate was missed. The FAR
requirements for signed documentation for returning an aircraft to service following a
repair should have been known (43.9, 91.407).
Synopsis
A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the
repair made by a local mechanic did not have the proper documentation.
ACN: 1476062 (8 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 700 ER/LR (CRJ700)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Parked
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Repair
Component
Aircraft Component : Cabin Furnishing
Aircraft Reference : X
Person
Reference : 1
Location Of Person : Company
Reporter Organization : Air Carrier
Function.Maintenance : Other / Unknown
Qualification.Maintenance : Powerplant
Qualification.Maintenance : Airframe
ASRS Report Number.Accession Number : 1476062
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Maintenance
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Illness
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Maintenance
When Detected : Routine Inspection
Result.General : Physical Injury / Incapacitation
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Procedure
Narrative: 1
Flight diverted to ZZZ for medical emergency [and] it was reported that the flight
attendant fell when turbulence was encountered. The flight attendant and 2 passengers
were transported to the hospital. The Dispatch Supervisor asked the Captain on a recorded
phone line if the turbulence was severe and the Captain said No it was not severe. I picked
up a roll over call from an open desk the Captain called and reported a broken armrest
they were going to reposition the Aircraft to ZZZ1. After talking with the supervisor it was
decided to defer the whole seat and have ZZZ1 Maintenance repair it when it arrived since
there was going to be no passengers on the flight. When the flight arrived in ZZZ1 I had
arranged for Maintenance to meet the flight and repair the armrest. The Captain called in
and talked to another Maintenance Controller and told him on a recorded phone line that
he did in fact have a severe turbulence event prior to diverting to ZZZ with the medical
emergency. It was reported to us by the Line Mechanic in ZZZ1 that in the lav there was
blue juice on the ceiling and walls also there was soda pop on the ceiling in the main cabin
area. None of this was reported to us in ZZZ by the crew. From what was reported to Line
Maintenance it sounds like the beverage cart went airborne hit the Flight Attendant and hit
[a] seat causing the damage. ZZZ1 Maintenance took some pictures showing the extent of
the damage seatback pockets were filled with soda cans and bottles of alcohol that were
picked up off the floor by passengers.
The captain flat out lied on how bad the turbulence was. I don't know if deferring the
whole seat was the right decision with it going to be a reposition flight and no passengers
it was the easiest thing to do after discussing it with the Supervisor. If the Captain would
have been honest about what happened we would have gone in a completely different
direction.
I trusted that the information that was given to me was correct and that the Captain was
being honest on what happened. I don't know if I had asked the questions again if he
would have given the same answers. I think the Crew did not want to get stuck in ZZZ.
First and foremost if the Captain would have been honest in ZZZ and told us he had
severe turbulence we could have handled the Inspection there.
It is getting tougher to work shorthanded in Maintenance Control and try to cover more
than 1 desk, if the same crew calls in more than once they can end up talking to multiple
Controllers. Even though all the questions had been asked I should have asked them
again.
Synopsis
A Maintenance Controller reported that he received a report that a Bombardier CRJ-700
had minor cabin damage due to turbulence, later it was found to have severe cabin
damage.
ACN: 1475960 (9 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 6000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : SF 340B
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Airspace.Class E : ZZZ
Component : 1
Aircraft Component : Attitude Indicator(Gyro/Horizon/ADI)
Aircraft Reference : X
Problem : Failed
Component : 2
Aircraft Component : Compass (HSI/ETC)
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1475960
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Returned To Departure Airport
Assessments
Contributing Factors / Situations : Equipment / Tooling
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
After departure, 15 minutes into flight, we leveled off at 6,000 ft, entered IMC conditions
and light to moderate rain. First Officer's Electronic Attitude Direction Indicator (EADI) and
Electronic Horizontal Situation Indicator (EHSI) screens went black. Captain's screens also
flickered on/off at the same time. The First Officer's screens did not come back on right
away. Minutes later FO HSI screen did come back on but ADI did not. Controls were
handed over to me immediately and we requested a return back to [departure airport] and
out of IMC conditions. Landed with no incident.
Synopsis
SF 340B Captain reported returning to the departure airport after loss of First Officer's
attitude and heading indicators.
ACN: 1475763 (10 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 10000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 1600
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Personal
Make Model Name : SR22
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class E : ZZZ
Component
Aircraft Component : Navigational Equipment and Processing
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 1905
Experience.Flight Crew.Last 90 Days : 28
Experience.Flight Crew.Type : 1260
ASRS Report Number.Accession Number : 1475763
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
In cruise, having just passed over ZZZ airport. Was navigating to fly through a wide gap in
thunderstorms approximately 40 nm south of position. Noticed the Avidyne Multifunction
Display (MFD) flicker, followed immediately by the smell of electrical burning/arcing.
Elected to turn 180 deg immediately and informed ATC my intention to land at ZZZ with
priority handling. I had my copilot get the ATIS for landing information while I descended
rapidly through the OVC layer. No fire, no smoke. Display remained on during descent, but
smell continued. Due to altitude and short distance to ZZZ, I overshot airport and had to
spiral back, all in IMC. Broke out of OVC on downwind to runway, saw runway and landed
visually. Was able to taxi to the ramp and shut down without further incident. Call made to
ZZZ tower as requested.
In hindsight, I could have pulled the breaker for the MFD and relied on my GPS or iPad for
navigation to ZZZ. The display continued to function without smoke, however, and I used
it to locate the airport as I spiraled down in IMC.
Synopsis
SR22 pilot reported that during cruise the Multifunction Display flickered then he smelled
electrical burning/arching.
ACN: 1474961 (11 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : IAD.Airport
State Reference : DC
Altitude.MSL.Single Value : 22000
Environment
Light : Night
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Carrier
Make Model Name : A319
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use : GPS
Flight Phase : Descent
Route In Use.STAR : CAVLR3
Airspace.Class A : ZDC
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZDC
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Flight Phase : Descent
Airspace.Class A : ZDC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1474961
Analyst Callback : Attempted
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Weather
Primary Problem : Ambiguous
Narrative: 1
On the CAVLR3 arrival into IAD at FL220 we were cleared to "descend via". The FO was
flying [and] he put 6000 ft in the altitude window. I went off COM1 to say goodbye to
passengers and give arrival brief. We encountered some turbulence and autopilot
disengaged. I came back to COM1 and noticed we were below profile and the FO was
correcting manually. Exact altitude loss unknown, recaptured profile. No word from ATC.
PIREP: possible mountain wave or wake turbulence.
Unknown or possible attention to aircraft trailing. Also weather could have been a factor.
Suggest offsetting further from aircraft ahead? Possibly intervene sooner.
Synopsis
A319 Captain reported descending below the profile on descent to IAD when they
encountered turbulence that may have been a wake encounter.
ACN: 1474872 (12 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : COS.Airport
State Reference : CO
Altitude.MSL.Single Value : 8500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
Aircraft Operator : Personal
Make Model Name : Cessna Single Piston Undifferentiated or Other Model
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Cruise
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
ASRS Report Number.Accession Number : 1474872
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Flight to COS on an IFR flight plan. After crossing LUFSE at 9000 ft we turned south on
V389 after calling COS approach on 124.0, we were told to expect 'vectors for the Visual
17R' into COS. On V389, approximately 15 NM north east of COS, we received the first
vector of heading 230 for the Visual 17R. About 8 NM ahead we could see light rain shafts,
that we associated would have some downdrafts. I requested a left deviation of 20
degrees to avoid the rain shaft. During the deviation of 20 degrees we started to
experience downdrafts. The aircraft began pitching up to around 8 degrees nose up and
began decreasing in airspeed. Full power was already applied and aircraft slowed to
around 66 KIAS and was unable to hold altitude, at the same time the autopilot was
disconnected and straight and level flight was maintained. The aircraft continued to pitch
up to what was around 12 degrees. I made COS Approach on 124.0 aware that we were
descending in what occurred to be a downdraft at the altitude of 8800 ft, during which our
VSI indicated a descent at 1400 FPM. The aircraft stall warning briefly sounded. I was told
by approach to maintain 9000, and I continued to tell approach we were unable to
maintain 9000 with the current situation at hand. They understood and told us that the
minimum enroute altitude was 9000 and to turn to heading 150 for an emergency vector.
We complied with Approach's instructions and began the turn, which was about the time
the downdraft ceased, we were able to maintain level flight at 8500 and continue the climb
back to 9000. At 8500 feet we cancelled our IFR flight plan because we could maintain our
own terrain and obstacle clearance and were in VFR conditions. The rest of the flight was
continued without incident under VMC with flight following with approach to COS.
Corrective action was taken on the event during the loss of altitude due to weather.
Cancelling IFR earlier during the loss of altitude would have relieved the controller of
having to issue emergency vector due to altitude below MEA. If on an IFR flight plan,
consider flying higher than the MEA assigned for the routing to account for unknown
variables, such as weather.
Synopsis
Cessna pilot reported being unable to maintain altitude and airspeed due to a downdraft
on approach to COS.
ACN: 1474295 (13 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B767-300 and 300 ER
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Mission : Cargo / Freight
Flight Phase : Landing
Route In Use : Visual Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1474295
Events
Anomaly.Ground Event / Encounter : Other / Unknown
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
First Officer flying a visual approach. Winds on ATIS during descent planning was reported
17010. When cleared to land tower reported wind 170 at 14 G 22. Approach seemed
stable in the gusty conditions. At about 50 FT, the auto throttles were disconnected.
Aircraft had a hard landing and bounced. At this point Captain took aircraft and landed. No
problem stopping aircraft in remaining runway. Logbook write up was completed and was
informed by mechanics that no damage was found from the landing.
Synopsis
B767-300 reported that due to weather conditions the aircraft had a hard.
ACN: 1474226 (14 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Weather Elements / Visibility : Windshear
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-700
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1474226
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1474545
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Flight Cancelled / Delayed
Result.Flight Crew : Returned To Gate
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Just prior takeoff we received a wind shear alert of 20 knots off the end of the runway. We
declined our takeoff clearance, and ran performance weight and balance for wind shear.
While waiting for our numbers, another airline departed to the northwest without issue.
After reconfiguring for a precautionary takeoff profile with performance weight and balance
numbers and briefing the potential for wind shear, we were cleared for takeoff with a 330
heading to avoid the cell off the end of the runway. While taking the runway, Tower issued
another 20 knot wind shear alert. Seeing the cell off the end of the runway both visually
and on radar, and seeing a clear path to the northwest, we decided to depart with the
added margins afforded by the precautionary takeoff profile.
At about 90 knots, we received the PWS (Predictive Wind Shear) warning "wind shear
ahead." I announced, "Reject, I have the aircraft." Autobrake Disarm illuminated, and we
brought the aircraft to a relatively gentle stop with TRs (Thrust Reversers) and speed
brakes. We cleared the runway and briefed the FAs (Flight Attendants) and the
Passengers. We ran performance weight and balance Brake Cooling numbers, coordinated
with Dispatch, Chief Pilot on Call, Maintenance Control, and determined that after brake
cooling, we would be safe to depart with a revised fuel load to reflect the new conditions.
In hindsight, we did some things well and others we did not. Having had to reject for PWS
Warning, the red flags were certainly there to not takeoff in the first place. But, we were
wise to refuse our initial takeoff clearance so that we could acquire wind shear takeoff data
from performance weight and balance. The reject decision was assertive and decisive, and
transfer of control went well. However, the FO (First Officer) debriefed that it was difficult
to hear my reject call over the wind shear warning. Also, he mentioned that he might have
inadvertently hit the brakes when I rejected the takeoff, which could explain the autobrake
disarm (we did not get the max braking of the RTO (Rejected Takeoff).
After turning off, while we did brief the FAs immediately and then the Passengers, we
neglected to reference the QRH for the RTO. Additionally, I did not announce to "Remain
seated." I believe a contributing factor was that the reject was relatively benign due to the
RTO autobrake not taking over and being only at 90 knots. It wasn't the "screeching halt"
we've practiced many times. Once off the runway, the FO was quick to suggest releasing
the brakes, and we ran the performance weight and balance brake cooling numbers,
contacted Dispatch, and conferenced with the Chief Pilot on Call, Maintenance Control to
ensure that we did not have to return to the gate, and that we could continue for takeoff
after brake cooling with fuel onboard.
Maintenance did ask if our performance computer showed a "high energy" stop. We
informed them that we no longer use the performance computer. I tried to look up what
the performance weight and balance would say in that case, but was unable to find an
example. Also, once we had new numbers for takeoff, we found that there really isn't a
procedure for takeoff after an RTO. We ran all checklists from Before Start through Before
Takeoff as a precaution (rearming the autobrake, for example). I was happy with how we
used CRM throughout the process.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737 flight crew reported a rejected takeoff due to a predictive windshear warning.
ACN: 1474198 (15 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : TWF.Airport
State Reference : ID
Relative Position.Angle.Radial : 210
Relative Position.Distance.Nautical Miles : 65
Altitude.MSL.Single Value : 17500
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZLC
Aircraft Operator : Personal
Make Model Name : Cessna 337 Super Skymaster
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Nav In Use : GPS
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class A : ZLC
Airspace.Class E : ZLC
Airspace.Special Use : JARBRIDGE MOA
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 2192
Experience.Flight Crew.Last 90 Days : 22
Experience.Flight Crew.Type : 594
ASRS Report Number.Accession Number : 1474198
Human Factors : Situational Awareness
Events
Anomaly.Airspace Violation : All Types
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Deviation - Procedural : FAR
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : VFR In IMC
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Exited Penetrated Airspace
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Provided Assistance
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Was VFR enroute to BZN at 15500 feet with flight following talking to SLC Center on
134.1. I contacted SLC Center and communicated I was going to climb to 17500 feet as I
was approaching clouds ahead. As I was climbing up over the clouds my climb was
accelerating upward due to convective activity and I was contacted by SLC who saw that I
had climbed above 17500 and in fact had exceeded 18000 and was therefore in Class A
airspace. I saw that it looked like I could descend back lower heading to the west but I
decided I should request an IFR clearance to be able to fly in Class A airspace and climb
higher. Before I could call I was contacted by SLC and told that I was to contact the
military frequency for Jarbidge and was given a clearance direct to Mountain Home. I
turned to the left toward Mountain home and contacted the military facility. I believe the
frequency was 118.05. I contacted the military facility and was told that I needed to
descend to a lower altitude. I told the controller that it looked like I would be able to
descend up ahead. I failed to tell the controller about the convective activity I was
experiencing and that I was above the clouds. However due to the aggressive convective
activity of the storm building beneath me, I then asked the controller for an IFR clearance
to BZN and was told that this was not possible within the military airspace that I was now
in. I was called back by the military controller and told to contact SLC Center again and
they were going to work something out for me. I contacted SLC Center again and I was
given an IFR clearance to 21000 to BZN with vectors. I was given a heading of 070 which I
could see was to fly me to the east out of the MOA. However I replied that I was unable to
turn to the east due to a large buildup/ thunderstorm to the east on my right side. I
continued to turn east as much I was able to and soon got on a heading of 070. In the
process, the convective activity pushed me up beyond 21000 and I was contacted to get
back down to my assigned altitude. In the middle of dealing with maneuvering around the
thunderstorm to the east during the climb and the convective activity my engines were
overheating due to the decreased cooling effect of the thinner air. At the same time all of
this was going on I was managing changes to cowl flaps, mixture, power settings and
airspeed to get the engine CHT temperatures under control. In the middle of this the
convective activity was now pushing me down lower and I requested to descend to 19000.
The convective activity carried me down below 19000 and I was again contacted and had
to climb back up to the assigned altitude of 19000. I could see that I was staying south of
restricted area R3204A and B as I exited the MOA.
I realized that I should have executed a 180 degree turn when I was pushed above 17500
feet to get out of the convective area that I had flown into. Then I could have requested
an IFR clearance up to a higher altitude prior to beginning my flight. I had in fact filed an
IFR flight along the route I was flying and should have activated that flight plan when I
took off so that I could have easily requested a change in altitude when I encountered the
bad weather south of TWF. I am very thankful for the assistance of the controllers that
helped me manage this difficult weather situation that I flew into. I plan to get more
training to learn how to handle higher altitude VFR to IFR transitions. My experience with
IFR flight at high altitudes has been new learning to fly the pressurized Skymaster. I also
realize now that military controllers are not trained to handle IFR traffic for separation
since their job is to manage military aircraft that are trying to intercept one another.
Synopsis
Cessna Skymaster pilot reported inadvertently climbing VFR into Class A airspace due to
convective activity. He negotiated with the Center Controller and a Military Controller for a
new IFR clearance away from the convective activity, restricted airspace, and out of the
MOA to his destination.
ACN: 1473844 (16 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZFW.ARTCC
State Reference : TX
Altitude.MSL.Single Value : 7000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Hail
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility.Visibility : 0.5
Light : Daylight
Ceiling.Single Value : 5000
Aircraft
Reference : X
ATC / Advisory.Center : ZFW
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Training
Flight Phase : Cruise
Route In Use.Other
Airspace.Class E : ZFW
Component
Aircraft Component : Engine
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Flight Instructor
ASRS Report Number.Accession Number : 1473844
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Took Evasive Action
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Myself and another pilot had made the flight on an IFR flight plan. On the way up to
Kansas, thunderstorms were to the west of us, but we flew east of them without any
issue. Upon arriving in Kansas, we picked up another pilot who was also instrument rated,
and he and I flew in the front seats on the way back, with the previous pilot sitting in the
backseat. We flew VFR to an airport in northern Oklahoma without issue, where we fueled
the airplane. We then filed an IFR flight plan and continued our trip back home. The initial
line of thunderstorms had passed through to the east of our route, but another line was
building over Oklahoma City. We deviated several times to avoid areas of moderate and
heavy precipitation by using ATC suggestions and XM weather (NEXRAD). After
successfully navigating the storms for some time, we were passed to Fort Worth Center.
We requested a few deviations to the right by using the XM radar in order to go around
the building storms on the back side. At this time, it had been at least 30 minutes since we
had received an advisory from ATC for moderate to heavy precipitation. We had found a
gap in the storms that was showing on our XM radar to be green and yellow areas. After
10 minutes or so in this area, the radar updated and showed us rapidly approaching a pink
area of extreme precipitation. Unable to avoid it quickly enough, we flew into the
precipitation and experienced extreme precipitation, severe turbulence, light hail (pea
sized at most), and heavy downdrafts. After flying in the extreme precipitation for 20
seconds or so, we experienced a momentary loss of power which we expect to be due to
the ingestion of water in the engine intake. We informed ATC that we were experiencing
"engine troubles" and severe turbulence, and got radar vectors out of the storm. After
exiting the precipitation, the engine power resumed and we continued the flight without
issue.
Synopsis
C172 pilot reported entering an area of extreme precipitation and severe turbulence while
using NEXRAD XM weather to circumnavigate storm areas.
ACN: 1473689 (17 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : COS.Airport
State Reference : CO
Altitude.AGL.Single Value : 1000
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Windshear
Light : Daylight
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Landing
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1473689
Human Factors : Time Pressure
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
ASRS Report Number.Accession Number : 1473689
Human Factors : Time Pressure
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
The flight started normally. My First Officer (FO) and I discussed the weather surrounding
COS before and during the flight. Noticeable virga was on the approach end about 10
miles north of 17L. The airport was not reporting windshear or wind gusts on the last
ATIS. A flaps 45 landing was used on the first approach. A red wind shear appeared and
we executed a go-around. I am not sure, but we may have gone over 200 kts during the
go-around in Class C. The weather was still VFR for COS and the storms were moving
away from the airport. The weather had thunderstorm activity between COS and our filed
alternate. A quick discussion of our options resulted in another attempt to land at COS. On
the second approach, we used a flaps 22 landing. Another red windshear appeared and we
once again executed another go-around. Our best option still appeared to be another
attempt to land at COS, but on the third attempt I flew the approach. For the third time,
we got another windshear warning that quickly went away along with a soft "sink rate,
sink rate".
With the fuel running low, a flight to KDEN would have put us in a min fuel status and
there was weather that would require additional vectors off course. On all three
approaches, the windshear felt minimal and I did not expect to get a windshear message
with the storms at its distance away from the field. Although we were told the storms were
moving away from the field, I did not want to risk having the storm change directions and
further limit our options. Also, the windshear message went away and I adjusted the
aircraft to not allow another sink rate aural message. After quickly reviewing our options,
we agreed to continue the approach and land in the interest of safety. The aircraft was
fully configured above 1000 AGL and no aircraft limitations were exceeded, although I was
fast on the approach.
The threats included windshear, thunderstorms in the vicinity, thunderstorms enroute to
our filed alternate, thunderstorms approaching our filed alternate, a high workload
environment, and a steadily decreasing amount of fuel.
Narrative: 2
After a normal flight with myself as pilot flying, during our arrival brief the Captain and I
briefed the possibility of a go around due to a small thunderstorm north of the COS airport
and the steps involved in go around. Our alternate was DEN with thunderstorms expected
in the vicinity. As we approached the field, still with approach control, we visually saw the
thunderstorm which was about 6 miles north of the 17L runway. Approach informed us
about the thunderstorm as well and said no aircraft had any issues with getting in and no
unusual weather alerts were given. It was my leg to fly, the Captain and I briefed the risks
and that we would need to be fully configured early to avoid an unstable approach. This
would be a flaps 45 landing. Flaps 8 was called for early and then gear down and flaps 22
was called for on our extended left base and inside outer marker. Turning final, I asked for
flaps 45 and landing check. I was a little high and corrected and was stabilized by 1000
feet, I believe about 1 to 1.5 miles from the end of runway we received a Windshear red
alert, thus we executed a go-around. We climbed out to our assigned altitude and
reconfigured, briefed what happened and I quickly asked either the tower or the approach
control, what direction the thunderstorm was moving, they said storm was basically
moving ENE away from the field. The Captain and I briefed the approach and landing
again, believing that it was safe to execute another approach and landing, but instead
using flaps 22. We executed the approach with the same result, a Windshear almost in the
same spot. We executed a go around and after a quick discussion and review of the
weather and weather at the alternate, I transferred the controls to the Captain so he could
execute the approach in the interest of safety. We briefed the weather/risks, approach and
landing, and executed a flaps 22 landing with the same results, a Windshear warning,
however, the warning was only on for a matter of maybe 2 seconds and went away then a
soft sink rate, however quickly went away. After a quick discussion we both felt the safest
option was to land the aircraft. The short final was stable, however fast (which was
briefed) and we landed with no further issue. At no time did I feel nervous or that we were
operating in a unsafe manner. I believe the Captain acted and operated in the most
professional manner. Threats included windshear, thunderstorms in the vicinity,
thunderstorms enroute to and at our alternate, a high workload environment and a always
decreasing amount of fuel. After first approach and go around we could have diverted to
our alternate, however before we even left ZZZ I checked the radar and Denver had
thunderstorms building to the west and south west and also Pueblo would normally be a
good alternate but they had storms as well. We could have diverted to the alternate with
the same results, but with landing with even lower fuel. We could have executed a hold
but, according to controllers, the storm was not moving much.
Synopsis
Flight crew reported windshear warnings while attempting to land at the COS airport that
resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,
and a successful landing was accomplished.
ACN: 1473122 (18 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 8000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Thunderstorm
Light : Daylight
Ceiling.Single Value : 5000
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Taxi
Make Model Name : Learjet 36
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 135
Flight Plan : IFR
Flight Phase : Descent
Route In Use : Direct
Airspace.Class E : ZZZ
Component : 1
Aircraft Component : Window Ice/Rain System
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : Attitude Indicator(Gyro/Horizon/ADI)
Aircraft Reference : X
Problem : Malfunctioning
Component : 3
Aircraft Component : Autopilot
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Taxi
Function.Flight Crew : Captain
Qualification.Air Traffic Control : Fully Certified
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Flight Engineer
Experience.Flight Crew.Total : 10000
Experience.Flight Crew.Last 90 Days : 60
Experience.Flight Crew.Type : 200
ASRS Report Number.Accession Number : 1473122
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Speed : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
Activated Windshield Heat (WSH) ten minutes prior to top of descent. Seconds later,
annunciator panel illuminated "WSH overheat" accompanied by strong odor throughout
aircraft. Deactivated WSH until Overheat (OH) light extinguished. Re-activated WSH. WSH
OH light illuminated again. Despite repeated attempts to sustain normal operation, WSH
OH light re-illuminated at even minimal settings. Descending through FL240 autopilot
disconnected. Attempts to reconnect accompanied by un-commanded right roll. With left
windshield occluded, storm clouds interspersed throughout flight path, and the AP inop,
considered switching pilot flying (PF) and pilot monitoring (PM) duties with SIC, whose
windshield was clear, possibly due to absorbed heat radiating from glare-shield (black)
after prolonged flight with sun on right side of aircraft. Prior to assigning aircraft control to
SIC, checked to confirm normal operation of right side flight instruments: noted SIC's
EADI (Electronic Attitude Direction Indicator) indicated "Fatal Failure." Aircraft type does
not provide for electronic switching to bootstrap gyro signal from opposite side to inop
side. Elected to retain aircraft control and PF duties until descended into continuous VMC.
SIC performed PM duties and provided visual guidance to avoid cumulonimbus clouds
(CBs). Slowed AC to 250 kts at 10,000 ft. At approximately 6,500 ft MSL, observed
airspeed indication had increased to 280 kts. Corrected and continued flying by instrument
reference until descending to approximately 2,500 ft (1,000 ft above pattern altitude), and
continuous VMC, in vicinity of [the airport]. Then asked SIC to take controls for landing.
Synopsis
Learjet crew reported encountering failures of the Windshield Heat, Autopilot, and
Electronic Attitude Direction Indicator during flight. Crew continued to VMC conditions and
landed uneventfully.
ACN: 1472727 (19 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZDV.ARTCC
State Reference : CO
Altitude.MSL.Single Value : 12000
Environment
Flight Conditions : Marginal
Light : Dawn
Aircraft
Reference : X
ATC / Advisory.Center : ZDV
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Flight Phase : Cruise
Airspace.Class E : ZDV
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : Single Pilot
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Commercial
ASRS Report Number.Accession Number : 1472727
Human Factors : Situational Awareness
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
[My aircraft] started to descend due to loss of power. I was level at 12,000 ft, at 2600
RPM, air temp was 12C and when a light drizzle of rain started, the temperature dropped
to 4C. I noticed a noise change in the engine, dropping down to 2200 RPM. This happened
right after a light drizzle of rain started. The airspeed went from 93 knots indicated, and
was dropping below 60 knots indicated. At 75 knots, I disconnected the autopilot to make
sure the aircraft wouldn't stall, then reported to ATC that we were unable to maintain
12,000 ft, and needed vectors and a lower altitude immediately. The aircraft lost
approximately 400 ft before the engine began to produce max power and was able to
maintain altitude. I noticed the power came back after I was clear of the light drizzle rain.
I would suspect induction ice was the cause of this event.
Synopsis
C172 pilot reported a power loss that led to an altitude deviation that was probably related
to carburetor icing.
ACN: 1472521 (20 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZMA.ARTCC
State Reference : FL
Altitude.MSL.Single Value : 35000
Environment
Light : Dusk
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZMA
Aircraft Operator : Air Carrier
Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Route In Use : Vectors
Airspace.Class A : ZMA
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZMA
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Route In Use : Vectors
Airspace.Class A : ZMA
Person
Reference : 1
Location Of Person.Facility : ZMA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Instructor
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1
ASRS Report Number.Accession Number : 1472521
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Human Factors : Distraction
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Aircraft X was deviating left from ORL and over INPIN area at FL350. INPIN is a common
arrival fix that aircraft are descending to FL270. Aircraft Y was southbound at FL350 and
the data block showed FL270. He was in the hand off flash to us. We called J86 ZEPHYR
and pointed out Aircraft X deviating left to VQQ. They did not reference traffic. As we saw,
Aircraft Y was on an intercepting heading to Aircraft X, my trainee instructed Aircraft X to
fly heading 360 for traffic. Aircraft X responded that he was unable and that it would put
him in weather. Trainee reissued the clearance and said "Unable weather deviation, fly
heading 360 for traffic." The pilot again responded that he was unable. I keyed up and told
Aircraft X, "Understand you are [exercising your emergency authority], if not, fly heading
360." He responded that he was not, and that he was in the turn. I called traffic at 11:00
and 5 miles southbound, same altitude. Aircraft X never had the traffic in site. After
clearing traffic, we re-cleared him to deviate and issued the frequency change to ZJX.
I would like to start issuing briefs to other pilots about the necessity to follow a controller's
instruction. Whether or not they want to argue it is fine, but they should be complying by
the instruction first - and then they can question it. The current attitude of, "I'm not going
to do that so issue me something else" is extremely hazardous and will eventually result in
a LoSS (Loss of Standard Separation) or worse.
This issue of assigning aircraft routes through weather goes back to my other reports, we
continually assign routes that go through weather and expect pilots to deviate when they
get close to the weather. This is also hazardous; we should not be assigning any routes
close to the weather, to alleviate this from even being a problem. By assigning these
routes, we open ourselves up to the problems such as above.
Synopsis
Miami Center Controller reported an aircraft that was in conflict with another and the pilot
did not want to turn away from traffic because of weather.
ACN: 1472510 (21 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZMA.ARTCC
State Reference : FL
Altitude.MSL.Single Value : 35000
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Cloudy
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZMA
Aircraft Operator : Air Carrier
Make Model Name : Large Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Airspace.Class A : ZMA
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZMA
Aircraft Operator : Air Carrier
Make Model Name : Medium Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Airspace.Class A : ZMA
Person : 1
Reference : 1
Location Of Person.Facility : ZMA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Instructor
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1.5
ASRS Report Number.Accession Number : 1472510
Human Factors : Fatigue
Human Factors : Training / Qualification
Human Factors : Workload
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Facility : ZMA.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Developmental
ASRS Report Number.Accession Number : 1472505
Human Factors : Training / Qualification
Human Factors : Workload
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Air Traffic Control
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Separated Traffic
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Company Policy
Narrative: 1
I was the Instructor at the time of this incident. We had a Handoff/Assist positon. Aircraft
X was level at 35000 feet deviating slightly left of course for weather. Aircraft Y was slow
climbing out of 33000 feet to 37000 feet. Aircraft X was indicating approximately 460
knots groundspeed with Aircraft Y indicating 375-380 knots. Aircraft Y was approximately
6 miles diagonally behind the Aircraft X. Vector lines also concurred with this, showing that
they would be 6 miles apart in 1 or 2 minutes. I assessed this situation and agreed with
what the vector lines and ground speeds were showing. Consistent to my training, Aircraft
Y should pass directly behind at 6 miles from Aircraft X. As Conflict Alert activated, my
trainee was working on another issue south of this situation which my trainee resolved.
He looked at this situation. I told him to turn the Aircraft Y 20 degrees right of course to
run behind Aircraft X. As Aircraft Y was climbing through 34100 feet the trainee asked me
if he should descend him back down to 34000 feet. I told him "no", as this instruction
would induce confusion with the pilot and would not solve the conflict possibly causing him
to speed up more by the time it's finally understood. Aircraft Y passed behind Aircraft X at
4.93 miles, resulting in a loss between the two aircraft. I take responsibility for my
actions, and admit that I misread the situation.
During this entire event, the sector had a full En route Decision Support Tool (EDST) and
the sector's Monitor Alert Parameter (MAP) number was at the original number of 18. The
actual value was borderline to this number, at 17-18 the whole time. Future 15 minute
increments were showing red. This MAP value does not change when there's weather,
which I believe is a safety issue as it lulls people into a false sense of security. Based on
that logic, we can work the same amount of planes with 100% weather as if we had 0
weather. There was a significant line of weather developing causing numerous deviations
and frequency congestion. The volume of traffic for this sector was significant even
without the weather in the north side of the sector. Routes were closed to our northeast,
and then reopened, which resulted in a significant increase of over flights to our sector.
The Q routes were closed, which resulted in aircraft going over a fix that would have
normally exited our sector significantly faster. Throughout this whole event, no Traffic
Management Issues (TMI) were applied to our sector to reduce the traffic volume, and
help alleviate our congestion. The Supervisor recognized how complex that it was, and
said "If you need help, your tracker is right behind you, just grab him." He was looking out
for the situation, whereas Traffic Management Unit (TMU) failed to help our sector from
becoming too complex.
Compounding the situation, both the trainee and I were 'assigned to duties' since XA00.
This occurred 2 hours and 17 minutes without being offered a break away from the
operational area.. We both were plugged in for approximately 30 minutes, took a 30
minute break, and went to our mandated team training. From XA00-XB00, we were in our
mandated briefing and training, and then told to report to the floor. We were plugged in at
this sector from XB00 to XC55, a 1 hour and 55 minute plugin, but being assigned to
duties for more than 2 hours and 55 minutes without a mental break or rest. Supervisors
in the area do not believe that "being assigned to training" is the same as being plugged in
at a sector, but both are mentally taxing. I believe that I was not as responsive as I would
have been within the first hour, even two hours, of working this sector. I believe that this
length of plug in negatively affected the trainee's decision making as well.
Throughout the whole summer, we are forced to push aircraft through small gaps in
extreme precipitation and convective activity. Unfortunately, this is an example of that.
Because of this, workload greatly increases exponentially in the sector as aircraft are
deviating that normally we can run parallel, and they're dangerously close to convective
weather activity. There continue to be no plans to fix this, or change this, we just continue
to run aircraft through the weather until something terrible happens.
I would require that the MAP value changes to reflect the current conditions in the sector,
as required by the Order. We currently do not do this. As such, when the sector is
borderline RED or Yellow TMU should have to advise the supervisor what actions they have
taken in order to resolve it. If the sector is already inundated with weather, the more
significant the plans should be in order to alleviate it. For example, once some of the
routes opened back up in this case, they could have offered the routes to about 10
aircraft, which would have significantly reduced the workload in this sector at the time of
the incident.
Additionally, when there is weather, especially developing lines of severe weather, as this
was, plans should be drawn up on how they will change the departures as the weather
progresses. This should be done at TMU and at the management level, so that the sector
team, who is already extremely inundated with problems, does not have to worry about
this. All they have to do is turn around and tell a Supervisor, "Hey this isn't working,
what's the next plan?" Currently, this happens, and then it's up to the sector team to
devise a new plan. If the opposite was true, then the following aircraft could already be
executing the next few plans, without sector overload.
We routinely get away from the idea of keeping aircraft away from severe weather,
instead, we run aircraft as close as 3 or 4 miles away from heavy precipitation as seen in
the situation above with BOTH Aircraft Y and Aircraft X. When weather is developing, we
need to move our traffic away from the precipitation to the recommended 20 miles.
Aircraft should not be allowed to depart on routes that take them less than that separation
(20 miles) to the weather. If they deviate that direction, that is their choice, but we are
setting ourselves up for failure by letting them depart on routes that are filed through
areas of extreme precipitation and convective activity.
I would also suggest significantly briefing supervisors on fatigue requirements, and the
mental impairment caused when controllers are on position/assigned duties for more than
2 hours. The cognitive process breaks down, and results in judgment errors that normally
wouldn't happen when the controller is fully rested.
Narrative: 2
[Report narrative contains no additional information.]
Synopsis
Air Traffic Controller and trainee reported a loss of separation between aircraft deviating
for weather.
ACN: 1472483 (22 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ALM.Airport
State Reference : NM
Altitude.MSL.Single Value : 17000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Hail
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Windshear
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZAB
Aircraft Operator : Corporate
Make Model Name : Challenger 350
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use.SID : CRONA2
Airspace.Class E : ZAB
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 8000
Experience.Flight Crew.Last 90 Days : 90
Experience.Flight Crew.Type : 2500
ASRS Report Number.Accession Number : 1472483
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Airspace Violation : All Types
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
We departed ALM on the CRONA2.CNX departure. After being cleared to 17000, it became
apparent that thunderstorms had moved over the departure route and that deviations
would be necessary. We were told that deviations right of course were approved. Most of
the weather was located to the right of us so we asked for deviations left and/or higher.
We were informed that we were unable to deviate left due to military airspace and unable
higher, due to military airspace. We entered a small area of what appeared on the radar to
be moderate precipitation but was in fact an area of moderate to severe turbulence and
precipitation. We repeatedly asked for higher, or deviations to the left due to weather. The
Controller denied the requests, giving us only clearance to enter into weather that
appeared more severe. We could see that the weather off to our left was clear.
We were handed off to another Controller [who] upon asking, gave us a deviation to the
left. We turned left to avoid a very large storm directly in front of us. Turning to the right
would have put us into equally severe weather. Upon making the left turn, the Controller
informed us to return to the previous frequency. On calling back to the previous frequency
we were again told that there would be no left deviations and an "immediate 040 degree
heading" was ordered from the Controller. This would have put us directly back in conflict
with weather that could have damaged the aircraft or caused injury or death to the
occupants. The Controller was argumentative and insisted that we turn immediately back
towards the storm. At this time, I took the radio and informed the Controller that we were
going to turn to a heading and if I needed to declare an emergency, that I would. We
asked for a number to call to have a discussion with a ZAB supervisor.
Synopsis
CL350 Captain reported using his Captain's authority to avoid thunderstorms during climb.
ACN: 1471766 (23 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZZZ.TRACON
State Reference : US
Environment
Flight Conditions : IMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 200 ER/LR (CRJ200)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1471766
Human Factors : Time Pressure
Human Factors : Workload
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1471767
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
As we began to get vectors off the arrival due to weather, approach control assigned us a
different runway than we had brief and expected. The new approach was the ILS PRM
(Precision Runway Monitor) 27L into ZZZ. Seconds after the runway change we were
assigned direct ZZZZZ and cleared for the approach. This gave us no time to brief the new
approach and due to that we forgot to put in the monitor frequency. We continued on the
approach.
During the approach the first officer had trouble switching from white needles to green
needles. This caused us to deviate from the localizer. The captain realized the mistake
shortly after and made the first officer correct before we were 1 dot off the localizer so we
continue the approach and landed safely
The cause of this was lack of briefing a possible PRM approach. We had brief both runways
but we were not aware that PRM's were in use due to the fact they were not advertised on
the ATIS. The slight deviation on the localizer was due to task saturation on the first
officer's part.
[ATC] should start advertising PRM approaches when they are actually using them. As
pilots we should recognize the threat that ZZZ sometimes is using PRM approaches even
though they are not advertised.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
A Bombardier flight crew reported not being aware of the Precision Runway Monitor in use
because it was not advertised on ATIS.
ACN: 1471540 (24 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Altitude.MSL.Single Value : 20000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Windshear
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Icing
Weather Elements / Visibility : Thunderstorm
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
Make Model Name : Learjet 60
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Descent
Route In Use.STAR : GIBZ2
Airspace.Class A : ZDC
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 3300
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 410
ASRS Report Number.Accession Number : 1471540
Human Factors : Situational Awareness
Events
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
I was Pilot in Command (PIC) and Pilot Monitoring (PM). First Officer (FO) was Pilot Flying
(PF). Forecast called for a possibility of scattered afternoon thunderstorms.
Descending on the arrival, ADS-B weather showed scattered small-but-developing
thunderstorms. Turned on aircraft weather radar and it showed the same. PIC radar was
tilted down and SIC radar was tilted up to get a full picture of the weather. Both ADS-B
and radar showed small cells left and right of our arrival route, but nothing directly along
our route. No other aircraft had reported turbulence beyond light chop.
Below us was an undercast. We turned on nacelle heat and stab/wing heat several minutes
prior to entering the cloud layer. We were indicating approximately 300 knots, slowing to
280 knots as required by the arrival. Upon entering the cloud layer, the windscreen was
instantly caked in ice and the aircraft was rolled approximately 40 degrees left and pitched
nose down. The PF disconnected the Autopilot, established a level attitude, and brought
power to idle. After 10-20 seconds the turbulence ended and the flight continued as
normal.
We made a PIREP of severe turbulence to ATC. After landing we inspected the aircraft and
found no visible damage. No injuries occurred. Maintenance was notified. Further
inspection revealed no structural damage to the aircraft.
I suspect we flew through the top of a developing thunderstorm that was embedded in the
undercast, and that had formed quickly enough that ADS-B had not yet shown the cell,
and that was below our radar as we approached it, even though my radar was tilted down.
This incident just reiterates the need to use extreme caution when flying in the vicinity of
convective activity, even if the cells appear "scattered," "small," and "weak."
Synopsis
LR60 Captain reported momentary loss of control after encountering a developing
thunderstorm on descent.
ACN: 1471524 (25 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : D10.TRACON
State Reference : TX
Altitude.MSL.Single Value : 2500
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility : Rain
Weather Elements / Visibility.Visibility : 10
Light : Night
Ceiling.Single Value : 2500
Aircraft
Reference : X
ATC / Advisory.Center : ZFW
ATC / Advisory.TRACON : D10
Aircraft Operator : Personal
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Cruise
Route In Use : VFR Route
Airspace.Class E : ZFW
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
ASRS Report Number.Accession Number : 1471524
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : VFR In IMC
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Exited Penetrated Airspace
Result.Flight Crew : Became Reoriented
Result.Air Traffic Control : Provided Assistance
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Staffing
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
During a round-robin IFR cross country training flight at night, I made the decision to
cancel IFR while midway through our second leg. Center was advising us of moderate to
extreme precipitation along our route of flight. Our aircraft was equipped with a storm
scope and we were able to see the cumulus clouds ahead as the moonlight shone around
it. There were no signs of lightning visually or on the storm scope, so I made the decision
to continue underneath the weather Center was depicting.
Not wanting to get involved with even the mere possibility of embedded convective
weather, and knowing from our first leg that the cloud bases were between 2,500 and
3,000 feet I elected to cancel IFR, descend below our Minimum Enroute Altitude (MEA) to
3,000 feet and continue receiving flight following from Center. We would not have been
able to remain IFR at 3,000 feet due to the MEA and Center's Minimum IFR Altitude in this
area. We would then descend to 2,500 feet to maintain VFR cloud clearance requirements.
Center transferred us to Approach, and shortly thereafter, we had an inadvertent
encounter with IMC at 2,500 feet. I informed the Approach controller that we would need
to pick up IFR again, and he advised us to standby because he needed to call Center for
permission to make that change, as we were still not inside the Approach airspace
boundary. About 2 minutes later, we popped out of the cloud and were back in VFR
conditions. I cancelled the request to pick up IFR. The controller acknowledged that,
advising us that Center wouldn't pick up his landline call and therefore he would probably
not have been able to issue the clearance for another several miles when we entered his
boundary.
This speaks to a larger issue about staffing at Center and TRACON. It seems [in the
evening] both facilities staff with a lower-than-acceptable number of controllers. This
makes it hard to receive otherwise simple services like changing a VFR aircraft to IFR
status. We were already "in the NAS" from our previous IFR clearance, squawking our NAS
flight plan code, and yet the Approach controller couldn't get Center to pick up a simple
call to request permission to change us back to IFR. Insofar as I'm concerned, Approach
and Center should be staffed just as well at night as both seem to be staffed during the
day. In most cases I hear more traffic flying with these two facilities at night than I do
during the day. I fly at all hours of the day and night and find the most hectic hours [in
the latter half of the evening], when one controller will be combined on multiple sectors
and frequencies.
I accept responsibility for the inadvertent IMC encounter. I elected to remain in IMC rather
than descend out of the cloud thinking we would be able to switch back to an IFR
clearance without a problem. The fact that it was night time contributed to my decision to
remain at 2,500 feet rather than descend lower. Had we continued to be unable to receive
a new IFR clearance, I would have descended out of the cloud and back into VFR
conditions. We exited the cloud and were back in VFR conditions before that option
crossed my mind.
Synopsis
A General Aviation pilot reported canceling IFR then entering IMC weather without
obtaining a new IFR clearance in a timely manner. The reporter indicated that the delay
was due to staffing issues from ATC.
ACN: 1471374 (26 of 50)
Time / Day
Date : 201708
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 36000
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 170/175 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use : Direct
Airspace.Class A : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1471374
Human Factors : Distraction
Human Factors : Physiological - Other
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Air Traffic Control : Enroute
Function.Flight Crew : Check Pilot
Function.Flight Crew : Captain
ASRS Report Number.Accession Number : 1471375
Human Factors : Physiological - Other
Human Factors : Human-Machine Interface
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed As Precaution
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Upon climbing through FL360 to FL380 we received an Engine-Indicating and Crew-
Alerting System (EICAS) warning "DOOR Passenger AFT OPEN". We [reset] warning and
called the Flight Attendant (FA) to determine status of door. They stated that it was closed
and secure yet the top right green indicator had some white area in it that was not
normal. We checked the Quick Reference Handbook (QRH) for required actions. We
continued to climb to assigned FL380. After leveling off at FL380 we were encountering
light to moderate chop turbulence. The warning message came one again. We called again
to confirm with the same answer. We requested lower as the door was still indicating
unsafe. As we descended we noticed that the differential pressure was 8.3. We referenced
the QRH for proper differential pressure for that altitude and determined that the aircraft
was indicating a high differential pressure for the altitude we were flying. At this time you
could feel the pressure on our ears and the Captain asked me if I could feel this as well. I
confirmed the discomfort. The warning was still on and had unreliable pressure readings
combined with physical discomfort from the pressure. The Captain stated "I think we need
to get lower and divert". This also was confirmed by the QRH if we lost cabin pressure. I
confirmed the need to divert. We descended to 14,000 ft. We continued to have pressure
fluctuations during the descent. Aircraft was inspected by contract maintenance and
deferred. Captain suggested we fly back at 10,000 ft to avoid issues if the pressurization
failed. We did so attempting to manage pressure manually and automatically [to ZZZ1].
The aircraft continued to have increase and decreased differential pressure for the flight
[to ZZZ1]. Unknown cause for event. The warnings and pressure issues may have been
caused by the door open indications.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
E-175 flight crew performed an precautionary landing after troubleshooting pressurization
door issue.
ACN: 1471341 (27 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : DEN.Airport
State Reference : CO
Altitude.MSL.Single Value : 7000
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : D01
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use : GPS
Flight Phase : Final Approach
Route In Use : Visual Approach
Route In Use.STAR : ZPLYN3
Airspace.Class B : DEN
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 3581
ASRS Report Number.Accession Number : 1471341
Human Factors : Distraction
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 2459
ASRS Report Number.Accession Number : 1471638
Human Factors : Confusion
Events
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Approaching Denver we had loaded and briefed the ZPLYN 3 arrival and planned on the
16L ILS as our best guess of what approach we would receive. ATIS was advertising 16L,
17R and 17L. We also briefed the Class B airspace and altitudes using the fix page to
ensure we remained above the floor of the class B if we received a visual approach
clearance. After checking in with approach control, we were told to expect the visual to
17L. At about the same time we encountered moderate turbulence in the descent and I
made the PA for the flight attendants to take their jumpseats. While we both started to set
up the necessary changes to the localizer frequency and minimums for 17L, approach
control instructed us to maintain 280 kts whereupon the FO, who was the pilot flying,
began making the changes to multiple legs of the arrival to maintain our speed while
descending in VNAV. While he was making the changes I was asked for and gave a PIREP
on the weather and ride during the descent. I believe it was these distractions that led us
to forget to change the runway in the FMC. We did a quick mini-brief on the runway
change but did not catch the fact we still had the ILS 16L loaded in the FMC. Within
minutes we were descended to 7000, given a turn off the arrival and asked if we had the
airport in sight. We both agreed and we're given a heading of 200 to join the final for 17L.
Things were happening quickly. The FO slowed the aircraft, descended and began calling
for flaps and the approach checklist which I completed. I also, distracted myself and the
FO a bit by talking about the floor of the class B and being careful not to descend below it.
I noticed that just as we were about to cross the final of 17L and asked the FO to arm the
approach mode. By the time he did so, we had crossed the final approach course of 17L
and the aircraft flew through the localizer. The FO seemed unsure what was happening so
I took the aircraft, disengaged the autopilot and turned the aircraft back toward 17L. The
turn was made between the final approach courses of 17L and 17R. At about the same
time, ATC queried us about the overshoot and I explained we were maneuvering back
towards the 17L final. At no time was there a conflict with other traffic. It was then that
the FO verbalized he had been looking at 17R (believing that he was seeing 17L) and he'd
been further convinced he was not on final yet because the final approach course line on
the MFD was actually showing 16L - much farther to the west than the 17L final. This
resulted in his delay in arming the MCP approach mode. Once established back on the 17L
final, the FO resumed flying the aircraft and configured for landing within required visual
approach criteria. We confirmed the runway again with the localizer, glideslope and our
eyeballs using the taxi chart and a normal landing was made.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737 flight crew reported on approach to DEN they had the wrong runway programmed in
the FMS which caused a deviation on the visual approach.
ACN: 1471135 (28 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZLA.ARTCC
State Reference : CA
Altitude.MSL.Single Value : 11000
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 20000
Aircraft
Reference : X
ATC / Advisory.Center : ZLA
Aircraft Operator : Corporate
Make Model Name : Small Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Flight Phase : Descent
Route In Use : Vectors
Airspace.Class E : ZLA
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 1350
Experience.Flight Crew.Last 90 Days : 60
Experience.Flight Crew.Type : 60
ASRS Report Number.Accession Number : 1471135
Human Factors : Confusion
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Airspace Violation : All Types
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : FAR
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Flight Cancelled / Delayed
Result.Flight Crew : Requested ATC Assistance / Clarification
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Another pilot and I on board experienced an incident with L.A. Center while approaching
the San Diego International Airport. The incident occurred when L.A. Center assigned our
aircraft to fly direct to the IFR fix, JONDA then direct to the San Diego International Airport
(SAN), which was our final destination. JONDA (IFR Fix) is located 55 nautical miles
southeast of the San Diego International Airport just north of the Mexican/USA border.
Our aircraft was flying on a heading direct to JONDA (IFR fix) from the north. L.A. Center
then told our aircraft to maintain present heading once we were approximately 10 nautical
miles north of JONDA (IFR Fix). Our aircraft along with multiple other aircraft approaching
the San Diego International Airport were trying to maneuver around a large wall of
thunderstorms that were located to the east of the San Diego County area.
L.A. Center had most of the aircraft approaching the San Diego International Airport fly
south close to the border of Mexico to deviate around the thunderstorm cells, then head
inbound to the San Diego International Airport. While our aircraft was quickly approaching
JONDA, maintaining our southerly heading to the Mexican border, our L.A. Center
frequency became highly saturated with radio calls. Our L.A. Center controller kept getting
stepped on while making transmissions to other aircraft. Also, two to three aircraft were
calling at one time to get a hold of our L.A. Center Controller. Our controller even stated
that two aircraft are calling at once and to say again because he did not receive the
transmissions clearly from those two other aircraft. Our aircraft was still maintaining our
present southerly heading that L.A. Center told us to fly, but we were quickly approaching
the ADIZ borderline between Mexico and the United States. My other pilot and I tried
reaching our L.A. Center Controller multiple times, but our transmissions kept getting
blocked by other aircraft and the L.A. Center Controller together.
We tried approximately 20 attempts to get a hold of our L.A. Center Controller, but were
not able to. We started calling our controller once we were about 5 nautical miles to the
North of JONDA (IFR fix) because we knew we were getting close to the ADIZ. The other
pilot and I thought that the controller became too saturated with radio calls and forgot
about our aircraft and our current position of our aircraft, which was very close to the
ADIZ. Once we passed JONDA (IFR fix) on our assigned southerly heading, we were now 5
nautical miles from the North of the ADIZ and were soon going to pass the ADIZ without
any sort of clearance or permission to cross the border of Mexico since our aircraft's final
destination was San Diego International Airport, a United States domestic destination.
Myself and other pilot kept trying and trying multiple times now, once we were quickly
approaching the ADIZ, but the L.A. Center frequency was still very saturated with
communication amongst the Controller and several other aircraft. Approximately 2-3
nautical miles north of the Mexico/United States ADIZ, myself and other pilot both decided
to deviate and make a turn to the right on a westerly heading to avoid crossing the ADIZ
from the north in VFR flight conditions. Once rolling out on the westerly heading we tried
calling L.A. Center two-three more attempts and after the third attempt we were able to
get a hold of the controller. We told the controller that we had to make a right turn to the
west to avoid crossing the ADIZ into Mexico and tried multiple times calling on the
frequency, but it was too saturated with transmissions between other aircraft and the
controller.
The L.A. Center controller then acknowledged to us that he was capable of having aircraft
cross the ADIZ due to the thunderstorms in the area, but myself and other pilot had no
knowledge of that information and were never communicated that information until after
we made the turn to the westerly heading to avoid the penetration of crossing the ADIZ.
L.A. Center then told us to fly on a heading of 255 degrees and expect radar vectors to
San Diego International from that point. Our aircraft then was assigned a different Air
Traffic Control frequency and made it safely to our destination of the San Diego
International Airport.
Synopsis
A corporate pilot reported turning away from the Mexico ADIZ airspace after being unable
to contact the Center due to frequency congestion.
ACN: 1471074 (29 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : TPA.Airport
State Reference : FL
Relative Position.Angle.Radial : 300
Relative Position.Distance.Nautical Miles : 24
Altitude.MSL.Single Value : 6400
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Windshear
Weather Elements / Visibility.Visibility : 3
Light : Daylight
Ceiling.Single Value : 4000
Aircraft
Reference : X
ATC / Advisory.TRACON : TPA
Aircraft Operator : Personal
Make Model Name : M-20 F Executive 21
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Descent
Route In Use : Direct
Airspace.Class B : TPA
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 2800
Experience.Flight Crew.Last 90 Days : 0
Experience.Flight Crew.Type : 2000
ASRS Report Number.Accession Number : 1471074
Human Factors : Situational Awareness
Human Factors : Training / Qualification
Events
Anomaly.Airspace Violation : All Types
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
I had not flown for several months and was getting practice in. As I tried to get to BKV I
found myself hemmed in by building cumulonimbus, rain, and thunderstorm activity. I was
unable to make BKV and updrafts and cloud tops pushed me above the class B veil beyond
6,000 ft to 6,400 about. I had relied on my Garmin weather in cockpit, but it was not
depicting actual conditions. I will not rely on this instrument again.
Synopsis
M20 pilot reported encountering an updraft which caused him to climb into TPA Class B
airspace.
ACN: 1470687 (30 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZOB.ARTCC
State Reference : OH
Environment
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Windshear
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZOB
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Approach
Airspace.Class A : ZOB
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1470687
Human Factors : Time Pressure
Events
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Original flight scheduled to ROC, diverted to ZZZ due to TRs at ROC. At the folder noticed
fuel was about 10.3 at ROC no alternate with lots of weather in route. I added 3k. After
takeoff ATC leveled us at 310 initially. They said this would be a final. Sent [Operations] a
msg. After a bit they gave us 330 as a final. Enroute we have to deviate for WX quite a bit.
On arrival several thunderstorms in the area. We flew over ZZZ and it looked fine. Noticed
the radar displayed strong storms east and southeast and south of ROC and closing in on
the airport. We were getting vectors for the approach and handed off to tower. We were
on a right dogleg and Tower reported winds gusting to 30 and the last jet that attempted
to land was an Airbus 319 that reported +\- 15 and a 600 ft loss on final. I could see the
strong rain down shafts and lightning almost at the field and discontinued the approach. At
this point we had about 11k on gas. I knew ZZZ was clear and I decided to go. ZZZ is a
very short flight from ROC. The FO (First Officer) was flying and I was getting our
clearance to ZZZ as well as diverting the box, loading the app, getting ATIS, working the
radar, and doing landing data. We landed and I called [Operations] then because I just flat
didn't have time to tell them in flight, very time compressed. We blocked in with 8.9 fob
(Fuel on Board). 1900 lbs above emergency fuel, glad I added 3k.
Synopsis
Air Carrier Captain reported diverting due to thunderstorms at the destination airport and
fuel concerns.
ACN: 1470661 (31 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : MCO.Airport
State Reference : FL
Altitude.AGL.Single Value : 200
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Rain
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : MCO
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 35R
Flight Phase : Final Approach
Airspace.Class B : MCO
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1470661
Events
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
While conducting the ILS 35R approach into MCO, deteriorating weather conditions
mandated a missed approach. The missed approach was executed without incident. There
were storm cells around MCO but the field was VFR and normal operations/landings were
being conducted to 35R (9001 ft). Wind was approximately 45 degrees off the nose 15
gusting to 25 (approximately). Left to right crosswind. As we joined the localizer the
aircraft landing reported the first 1000 ft of runway was wet. We were cleared to land, #2.
The aircraft immediately ahead of us landed and reported that the first 4000 ft of the
runway was now wet, but no other issues. There was a storm cell approaching the field.
Approaching the final approach fix we could still see the runway (approximately 6 DME).
Fully configured, checklist complete, stable at 1000 AGL, stable at 500. Visibility rapidly
started to deteriorate after the 500 ft stable call. Heavy rain. No longer VFR, but all
approach lights and runway lights were visible. At approximately 200 ft a very strong and
sudden gust of wind left to right pushed us well right of centerline. The Captain (pilot
flying) called for and initiated a go-around. Aircrew initiated the go-around without
incident. Multiple aircraft on the localizer behind us immediately broke off their approaches
as well.
I believe the gust of wind that drove us off centerline was microburst type event. It had no
headwind component to it, only crosswind, and it was very sudden. To avoid a recurrence,
the only suggestion would to be to recognize the threat of weather earlier and discontinue
(or never start) the approach sooner.
Synopsis
B737 Captain reported executing a go-around at MCO after encountering a "microburst
type event" on short final.
ACN: 1470577 (32 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 700
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Windshear
Weather Elements / Visibility : Rain
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B747 Undifferentiated or Other Model
Crew Size.Number Of Crew : 3
Operating Under FAR Part : Part 121
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Final Approach
Route In Use : Vectors
Airspace.Class B : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 8226
Experience.Flight Crew.Type : 1110
ASRS Report Number.Accession Number : 1470577
Human Factors : Time Pressure
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Relief Pilot
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 9206
Experience.Flight Crew.Type : 6686
ASRS Report Number.Accession Number : 1470564
Person : 3
Reference : 3
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Total : 15504
Experience.Flight Crew.Type : 13801
ASRS Report Number.Accession Number : 1470561
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
We were on the approach to ZZZ, about 18 mile final and were watching a large storm cell
over the airport. As we got closer ATC issued a micro burst alert for 50 knot wind gains
and losses on final. We elected to abandon the approach and since the cell appeared to be
moving quickly across the field, we elected to have delay vectors to evaluate the rapidly
changing weather. We had about 1+20 minutes of fuel remaining. We were sent on a
heading to ZZZZZ and switched to ZZZ1 approach. The controller there had clearly lost
the picture of his traffic situation and did not answer our initial transmissions. We
continued to have difficulty establishing communication with approach. The IRO
(International Relief Officer) was communicating with dispatch to change our alternate to
something closer to our current position than ZZZ2, but were told that none of the local
area airports were suitable. We evaluated our fuel state and determined that we needed to
divert to ZZZ2 without delay to arrive with sufficient fuel. Again, the controller seemed to
not hear our transmissions and at one point made a blind broadcast to us by our
transponder code. We finally got a heading to ZZZ2 after declaring minimum fuel. In
addition, we had to deviate around scattered cells as we headed to ZZZ2. We were
switched to ZZZ approach as we had to go by ZZZ on our way to ZZZ. The controller
informed us that Runway XYR was available for landing if we wanted it. We evaluated the
situation and saw a large gap between cells that would allow a visual approach. We were
vectored till we saw the airport and were cleared for a visual approach to XYR. I noticed
the First Officer appeared to have the wrong runway in sight and was slightly high on the
approach. He reported XYR in sight and I was providing verbal corrections to position us
for the visual approach. We had to maneuver around a rain shower between us and the
runway and I noticed we were trending to low when we got a below glide slope alert. We
immediately corrected back to course and because of our position on an angling left base,
we needed to make a turn to line up with the runway at 700 feet. My normal reaction is
not to try to salvage a bad approach, but to go around and do it again. I felt that
considering our fuel state, about 40 min remaining, and the rapidly changing weather we
needed to land rather than go around, and that we could do it safely. The approach
resembled the IGS [Instrument Guidance System] into the old Hong Kong airport. We
were lined up and on speed at 400 feet and the wind at the airport remained less than 5
knots. We landed exactly in the touchdown zone and taxied to the gate without further
incident.
Narrative: 2
[Report narrative contained no additional information.]
Narrative: 3
[Report narrative contained no additional information.]
Synopsis
B747 flight crew reported beginning to divert due to weather and minimum fuel but ended
up going to the original destination.
ACN: 1470484 (33 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZMP.ARTCC
State Reference : MN
Altitude.MSL.Single Value : 6000
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZMP
Aircraft Operator : Air Carrier
Make Model Name : Medium Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Route In Use : Vectors
Airspace.Class E : ZMP
Aircraft : 2
ATC / Advisory.Center : ZMP
Aircraft Operator : Military
Make Model Name : Military
Flight Plan : IFR
Flight Phase : Cruise
Route In Use : Vectors
Airspace.Class E : ZMP
Person
Reference : 1
Location Of Person.Facility : ZMP.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Approach
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 8.0
ASRS Report Number.Accession Number : 1470484
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Confusion
Events
Anomaly.Airspace Violation : All Types
Anomaly.ATC Issue : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Separated Traffic
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
APN complex hot with large force exercise. Multiple airspaces, including a temporary
Military Operations Center (MOA), with bases as low as 5,000. Building weather with
deviations. First, Aircraft Y was direct to APN level at 5,000. I had moved Aircraft Y from
nonradar conditions at 4,000 to 5,000 for an unusual departure from GOV Tower, which I
had wrongly thought (as it turns out) was departing Runway 14 (he actually departed 32).
Aircraft Y then progressed into the temporary MOA (5,000 to 27,000) when APN Approach
called (upon taking their handoff), and asked whether I was going to move him down to
4,000 to avoid the airspace. I then descended Aircraft Y to 4,000. He barely entered the
lateral confines at approximately 4,500.
Sometime around the same time, APN Approach handed me Aircraft X, opposite direction,
at 5,000. I knew the airspace (Garland MOA) was active at 6,000, but simply forgot. I may
have seen the "6,000 to 23,000" associated with the MOA on the screen and used 6,000
instead of 500 to 1,000 feet below. Upon exiting APN airspace, I climbed the aircraft to
6,000, partly to avoid any potential conflict with Aircraft Y going the opposite direction.
Not that they were in conflict at the time, but I was busy and expected deviations from
both. Aircraft X was in the airspace for at least 20 to 30 miles. I realized my mistake after
the phone call about Aircraft Y from APN Approach. By this time, Aircraft X was nearly
clear, and elected to keep him there for another 5 miles until I could climb the aircraft on
course.
I was busy, and just lost the flick. There is no other excuse, it was probably my worse
session in quite some time, other than my mistake that happened here. A D-side was
provided a short while after. I should have asked for a D-side. This would have helped
immensely.
Synopsis
A Center Controller reported allowing an aircraft to enter Military Operations Areas without
coordination while working special military operations and dealing with weather deviations.
ACN: 1470479 (34 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.ATC Facility : ZBW.ARTCC
State Reference : NH
Altitude.MSL.Single Value : 28000
Environment
Weather Elements / Visibility : Turbulence
Aircraft
Reference : X
ATC / Advisory.Center : ZBW
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Descent
Route In Use : Direct
Airspace.Class A : ZBW
Person : 1
Reference : 1
Location Of Person.Facility : ZBW.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 7.5
ASRS Report Number.Accession Number : 1470479
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Human Factors : Distraction
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Person : 2
Reference : 2
Location Of Person : Company
Reporter Organization : Air Carrier
Function.Dispatch : Dispatcher
Qualification.Dispatch : Dispatcher
ASRS Report Number.Accession Number : 1472867
Person : 3
Reference : 3
Location Of Person.Aircraft : X
Reporter Organization : Air Carrier
Function.Dispatch : Dispatcher
Qualification.Dispatch : Dispatcher
ASRS Report Number.Accession Number : 1472868
Person : 4
Reference : 4
Location Of Person.Facility : ZBW.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 3
ASRS Report Number.Accession Number : 1470479
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.ATC Issue : All Types
Anomaly.Flight Deck / Cabin / Aircraft Event : Illness
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Physical Injury / Incapacitation
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Aircraft X was on route direct to MANTA intersection and then an arrival into PHL
descending to FL280. I had plugged into Sector 31 as the radar controller a couple of
minutes prior to the aircraft checking on, and was informed by the previous controller that
there were some weather deviations, but surprisingly no bad rides.
I issued the weather to Aircraft X and received no response. No more than two minutes
later I issued a descent clearance to Aircraft X to cross 35 miles north of MANTA at FL200,
no response and I issued it one more time. The pilot read back the clearance and then
reported moderate turbulence descending from FL300-280 five miles behind. I thanked
him for the report. At this point I was relieved from position to take over as CIC
(Controller In Charge) in the area. A couple of minutes later, the new Sector 31 Controller
advised me that Aircraft X encountered moderate to severe turbulence and that there were
injuries on board the aircraft. The aircraft was switched to ZNY for more expedient routing.
Narrative: 2
Aircraft X was flight planned through a FPG (Flight Planning Guidance) that had light-
moderate-occasional Turbulence from FL280-FL340. Flight was planned to descend to
FL280 at LFV. There was an FPG in the area, if I remember it started just prior to LFV. I
had no reports of bad or good rides reported by other Flights in the area.
There were no SIGMETs or PIREPs in the area, from other flights traversing the area in
question.
Narrative: 3
The flight encountered severe turbulence resulting in injuries. Captain reported the
incident via radio and requested paramedics and ambulances meet the flight upon arrival.
The flight submitted a PIREP to ATC.
HTO UUA /OV HTO090025/TM XA44/FL280/TP [Commercial Fixed Wing] /TB MOD-SEV/RM
2 SEV BUMPS ASSOC W/ AREA OF WX, INJ PASS AND CREW CORR FOR TYPE UUA
The flight crew then requested FA supervisors meet the flight via ACARS.
VIA ops, I requested paramedics and ambulances meet the flight upon arrival due to
possible 10 passengers and 7 flight attendants injured. The crew reported that the seatbelt
sign had been on for 40 minutes before the turbulence was encountered.
Narrative: 4
I was made aware today, that on the last session of my shift yesterday, Aircraft X
encountered moderate to severe turbulence as it was leaving my sector, while already
talking to the following controller. There were numerous thunderstorms in the area and I
had been calling the weather to other aircraft in my sector. I cannot recall if the
precipitation that Aircraft X encountered was in my sector or not, and I have not seen the
radar playback to know if it did indeed fly directly through heavy/extreme precipitation. I
was told that I did not call the weather to this aircraft and for that, I am reporting myself.
I would like to see this become a training item for controllers to again remind about the
serious need to call the weather. I believe many of us get complacent because we see
aircraft all the time fly directly through what appears to us to be extreme precipitation.
This should help reinforce the need to call weather all the time.
Synopsis
Two Controllers and two Dispatchers reported a flight encountered severe turbulence
which resulted in injuries to flight attendants and passengers.
ACN: 1470471 (35 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZNY.ARTCC
State Reference : NY
Altitude.MSL.Single Value : 41000
Aircraft
Reference : X
ATC / Advisory.Center : ZNY
Aircraft Operator : Fractional
Make Model Name : Medium Large Transport
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Cruise
Airspace.Class A : ZNY
Person
Reference : 1
Location Of Person.Facility : ZNY.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Handoff / Assist
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 13
ASRS Report Number.Accession Number : 1470471
Human Factors : Situational Awareness
Human Factors : Human-Machine Interface
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : FLC Overrode Automation
Assessments
Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
Contributing Factors / Situations : Equipment / Tooling
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : ATC Equipment / Nav Facility / Buildings
Narrative: 1
I was working the handoff position at the sector. There was a lot of weather deviations and
route closures. Aircraft X had a flight plan which took them backwards. The pilot did not
question the route and I did not catch the fact that the routing took them backwards.
Aircraft X was coordinated with the adjacent sector who also did not catch that the routing
would take this flight backwards. ATOP probed the flight as if he was going reverse course
at a fix. The flight did not reverse course and came together with another flight at 41000
feet.
ATOP should have a logic check when a flight reverses course like this. Also the pilot didn't
fly flight plan.
Synopsis
ZNY Center Controller reported the flight plan processing software did not detect that an
aircraft filed a route which reversed course at a fix and into conflict with another aircraft at
the same altitude.
ACN: 1470460 (36 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : F11.TRACON
State Reference : FL
Altitude.MSL.Single Value : 5000
Environment
Flight Conditions : Mixed
Weather Elements / Visibility : Thunderstorm
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : F11
Aircraft Operator : Air Carrier
Make Model Name : Widebody, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 129
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Approach
Route In Use : Vectors
Airspace.Class B : MCO
Person
Reference : 1
Location Of Person.Facility : F11.TRACON
Reporter Organization : Government
Function.Air Traffic Control : Approach
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 2.5
ASRS Report Number.Accession Number : 1470460
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : ATC
Events
Anomaly.Airspace Violation : All Types
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Staffing
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Aircraft Y was being worked by the STN controller on a 160 heading and clipped the corner
of my airspace on final (ARM sector), right where Aircraft X was descending out of 6,000
for 4,000. Aircraft Y entered my airspace without a point-out. The STN controller was busy
and had several areas of thunderstorms affecting his airspace. Aircraft Y passed less than
5 miles behind Aircraft X, a heavy with 700 feet of altitude. There was several significant
areas of precipitation affecting the entire airspace and every sector was overwhelmed
including the supervisors. There was not enough staffing to staff hand-off positions and
coordinator positions. Supervisors were having to work Coordinator positions for the MCO
departure sectors and arrivals sectors and were not able to keep an eye on other sectors
than may need attention.
I recommend adequate staffing levels to staff coordinator and hand-off positions so that
supervisors are not having to stand behind just 1 sector to coordinate for an extended
period of time and they can keep an eye on the entire operation. It is a known issue that
F11 experiences significant thunderstorms every afternoon during the summer months and
staffing was decreased instead of increased to allow for necessary positions to be staffed.
Synopsis
Orlando TRACON Controller reported an airspace incursion and a loss of separation due to
another Controller being overwhelmed with traffic and weather.
ACN: 1470394 (37 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Turbulence
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Personal
Make Model Name : PA-32 Cherokee Six/Lance/Saratoga/6X
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Airspace.Class D : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 173
Experience.Flight Crew.Last 90 Days : 16
Experience.Flight Crew.Type : 32
ASRS Report Number.Accession Number : 1470394
Human Factors : Training / Qualification
Events
Anomaly.Ground Excursion : Runway
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected.Other
Result.Flight Crew : Regained Aircraft Control
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
It was a warm afternoon, windy out of the northwest (after landing I approximated the
crosswind at 13 knots with winds around 350 at 20 knots). I was in a stable traffic pattern,
turned onto final and had to crab the plane to line up with the runway due to the winds. I
had a smooth landing on centerline at a higher than normal speed due to the gusting wind
conditions, then the plane quickly veered off to the right, exiting the runway, and I was
able to quickly stop it on the grass next to the runway. Tower inquired whether I needed a
tow. The engine was running normally, there were no engine warning lights or unusual
sounds so I requested and received permission to taxi back onto the runway and then exit
off at the normal taxiway.
I performed a thorough inspection of the aircraft afterwards and there was no damage to
the aircraft or obvious wear changes to the tires. A mechanic examined the plane the next
day and no obvious damage was noted. No damage to the airport environment was noted.
The runway excursion was the result of a high crosswind and my delay in correcting for it.
I was reminded of the importance and difficulty in maintaining crosswind correction during
all phases of aircraft movement and was too slow to respond given the very windy
conditions at the airport. I am unfamiliar with this airport and need more experience with
this airport environment and its windy conditions. I plan on working with a local CFI to
improve on these skills.
Synopsis
PA32 pilot reported loss of directional control in gusty crosswind conditions that resulted in
a runway excursion.
ACN: 1469723 (38 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : MUHG.Airport
State Reference : FO
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Thunderstorm
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : MUHG
Aircraft Operator : Air Carrier
Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Nav In Use : GPS
Nav In Use.Localizer/Glideslope/ILS : Runway 5
Flight Phase : Initial Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1469723
Human Factors : Distraction
Human Factors : Confusion
Human Factors : Workload
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Weather
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Airport
Primary Problem : Airport
Narrative: 1
We stayed offshore to avoid thunderstorms on the arrival. About 20 miles out from the
airport we proceeded to DME 8.5 on the approach course to avoid thunderstorms over
BEMUV. We shot the LOC Runway 5 approach because the glideslope was not available
due to the DTHR for Runway 5. We were not able to acquire the displaced runway
threshold (DTHR) marking until 2.5 miles out on the approach. The runway marking isn't
wide enough and has almost no contrast to the surrounding runway surface. The marking
for the DTHR is about 200 ft northeast of Taxiway B. My local knowledge of where the
DTHR was made the difference in continuing the approach. We departed at dusk with the
runway lights on and the DTHR was clearly marked. The lack of approach lighting and an
almost invisible DTHR would result in a missed approach in IFR weather conditions.
Synopsis
Air carrier pilot reported difficulty identifying the MUHG Runway 5 displaced threshold
because of the prevailing visibility, the runway marking width, the low contrast from the
surrounding runway surface, and no approach lights.
ACN: 1469614 (39 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 33000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Rain
Light : Daylight
Ceiling.Single Value : 36000
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-700
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Climb
Airspace.Class A : ZZZ
Component
Aircraft Component : Pitot-Static System
Aircraft Reference : X
Problem : Malfunctioning
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 46
ASRS Report Number.Accession Number : 1469614
Human Factors : Troubleshooting
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1469624
Human Factors : Troubleshooting
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : FLC Overrode Automation
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Weather
Primary Problem : Aircraft
Narrative: 1
As Pilot Flying, we were navigating around moderate to heavy precipitation using heading
select and climbing to FL330 using VNAV. During the climb, I realized I had bad air data,
as the airspeed suddenly displayed in the 130 knot range along with other erroneous
readouts. At the same time I was trying to diagnose the situation, the Captain noticed the
autopilot had commanded a descent. Realizing my computer was receiving bad data,
controls were quickly transferred to the Captain, who turned off the automation and began
to hand fly.
In regaining positive aircraft control, our flight altitude reached 33,100 ft, but
simultaneously we were also given a new heading and altitude clearance of FL390. The
autopilot was commanded back on and the flight continued a normal climb using the
Captain-side air data. During the climb, we discussed the situation and determined the
First Officer static port had iced over and caused my computer to display wrong
information. The system returned to normal once clear of the precipitation, and the aircraft
control was later returned to the First Officer side after verifying read outs on both sides
corresponded with each other.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737 flight crew reported that the First Officer experienced erroneous airspeed indications
while flying through heavy rain.
ACN: 1469590 (40 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : C90.TRACON
State Reference : IL
Environment
Flight Conditions : Marginal
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : C90
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Flight Phase : Climb
Flight Phase : Descent
Flight Phase : Initial Approach
Flight Phase : Cruise
Route In Use : Vectors
Airspace.Class B : ORD
Person
Reference : 1
Location Of Person.Facility : C90.TRACON
Reporter Organization : Government
Function.Air Traffic Control : Approach
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 19
ASRS Report Number.Accession Number : 1469590
Human Factors : Time Pressure
Human Factors : Training / Qualification
Human Factors : Workload
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.General : Flight Cancelled / Delayed
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Provided Assistance
Result.Air Traffic Control : Issued Advisory / Alert
Result.Air Traffic Control : Separated Traffic
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Staffing
Contributing Factors / Situations : Weather
Primary Problem : Procedure
Narrative: 1
I was vectoring when level 5 weather popped up near the west side of the airport. We
were on west flow. I asked if we should really keep going into 3 full runways with weather
like this. The response was "the tower says it doesn't look that bad out the window".
Everyone started to go around. We had nowhere to go with all these planes with weather
and so many in the airspace. No preemptive strike to help the situation. I believe part of
the problem is that there were younger people, while all very skilled, were not sure what
to do with the situation without getting in trouble or feeling they might. There were only
CICs being utilized rather than a supervisor being in charge of the front line.
There was an OM on duty, although, one, I'm not sure if he was in the room, and two, he
has really no idea what's going on. There were so many go arounds and no instructions as
to what to do with all of them, i.e. another runway, divert, etc. Many were minimum fuel.
It was very frustrating and stressful. It seemed like survival of the fittest rather than any
coordination or instruction being given. Also, monitors were never called for with extreme
weather, even after everyone started going around.
A supervisor should be in charge of the front line when there is only one in the room.
Coordination should be done to lessen the arrivals with extreme weather in the area. CICs
should be made aware that they can do what they need to for the safety of the aircraft
coming rather than the "who am I going to be in trouble with" rather than slowing fixes
and holding or coming off a runway, or two for that matter, with extreme weather. CICs
are put in a bad position because they are unsure of what they can and can't do. Same as
unsupervised mid shifts.
Synopsis
C90 Approach Controller reported that their sectors became overloaded and unorganized
due to numerous weather related go-arounds combined with a lack of experienced
controllers and supervision.
ACN: 1468984 (41 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : ZZZ.Tower
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Turbulence
Weather Elements / Visibility : Windshear
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 170/175 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : GPS
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1468984
Human Factors : Workload
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Over the 10 DME fix on the ILS, we had a strong rain shaft at an 8 DME from the runway
that we had to fly through which looked like it was stable but had very strong 20Kts+
windshear gain. Before we entered the PF (Pilot Flying) determined to try to get configured
partially for the approach which is also SOP and I had no objections we selected Flaps 1 at
210kts and after they were set we entered the rain. As we descended I called out rising
airspeed, at that time the PF already had Spoilers deployed and thrust levers at IDLE, he
called for the gear after we couldn't stabilize the airspeed and reached around 237 kts
before the gear was able to assist in slowing the aircraft. The flaps continued to work for
the rest of the approach and had no issues getting on the ground. The weather was due to
the developing Nor-Easter in the area and we were the first aircraft to report the 20kt+
gain on final.
We could've called for the gear sooner when I noticed the speed increase but not sure if
that would have even stopped the gain it jumped quickly and suddenly from 210 to 228 to
238.
Synopsis
An ERJ-175 pilot reported windshear at on final which resulted in a 20 kt increase. Speed
brakes and landing gear were extended to regain a stable profile for landing.
ACN: 1468502 (42 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZAU.Airport
State Reference : IL
Aircraft
Reference : X
Make Model Name : No Aircraft
Person
Reference : 1
Location Of Person.Facility : ZAU.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 25
ASRS Report Number.Accession Number : 1468502
Human Factors : Workload
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
Result.Air Traffic Control : Separated Traffic
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Staffing
Primary Problem : Staffing
Narrative: 1
I returned from a break and looked at the "numbers" for BAE sector and showed a yellow
26 or 28, I can't remember. I saw there was no one on break and was assigned BAE sector
to let that controller go home. I asked the Supervisor about the lack of staffing and the
high traffic count coming up at BAE. [The Supervisor] said hold-overtime was not
approved. I plugged in at BAE and was getting busy. I had asked for a D-side. It was
getting much worse and needed help right away. I asked at least 5 times for a D-side. It
took maybe 15 minutes or so before I got one. The sector was near out of control. We had
[a nearby sector] traffic from the low side. It was humid and aircraft were not climbing.
Swap north was getting out of hand and departures opposite direction was a problem too.
Most aircraft were complaining about chop/turbulence and was tying up the freq. I stopped
taking hand-offs here and there from the low side and he couldn't take my hand-offs as a
result.
Where is flow in all this! How about hold-overtime! We had plenty of people that went
home. I never complain about working busy periods, I enjoy it. And I understand we need
to move aircraft but this was a totally unsafe situation. I ended up 2.5 hours on the
position. I completely lost track of time so times are approximate. Please really look into
this.
Better flow! Better management with traffic volume forecast!
Synopsis
ZAU Center Controller reported their session was out of control due to traffic and no flow
control from the Traffic Management Unit.
ACN: 1468179 (43 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : FOD.Airport
State Reference : IA
Relative Position.Angle.Radial : 010
Relative Position.Distance.Nautical Miles : 2
Altitude.MSL.Single Value : 800
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 800
Aircraft
Reference : X
ATC / Advisory.CTAF : FOD
Aircraft Operator : Personal
Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Descent
Route In Use : Direct
Airspace.Class E : FOD
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Other / Unknown
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 800
Experience.Flight Crew.Last 90 Days : 20
Experience.Flight Crew.Type : 40
ASRS Report Number.Accession Number : 1468179
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Other
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Passenger
When Detected : In-flight
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Flying as an "extra set of eyes" for a pilot friend while enroute to Oshkosh, we
inadvertently flew into a class E surface airport with weather below VFR minimums. When
approximately 10-15 miles west of FOD, we picked up the AWOS weather and observed
the field was barely above VFR minimums: 1000 ft Broken, 10 SM visibility. I pointed out
to the pilot that there was an airport 10 miles northwest of our position that was reporting
VFR, in case FOD went below minimums. The pilot elected to continue to FOD to take a
look. After descending, we picked up the AWOS again and observed the clouds were now
at 800 ft broken. Already being below the clouds and 2 miles from the airport, the pilot
elected to continue and land at FOD. Looking back, this was probably the safer option at
that point, already being under the cloud deck, but we never should have gotten to that in
the first place. The landing was uneventful and we waited on the ground until the weather
raised back to VFR minimums, and departed for the rest of our trip.
Lessons learned: I should have been more forceful with the pilot on the suggestion of
going to the alternate airport that was VFR. The pilot may not have understood that FOD
was class E and the weather minimums associated with class E. It was ignorant to proceed
into deteriorating weather, when a viable alternate was so close.
Synopsis
A flight instructor observer pilot reported not being assertive enough and allowed the pilot,
who was presumably operating under VFR, to proceed to and land at an airport that was
below VMC.
ACN: 1468164 (44 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : ZTL.ARTCC
State Reference : GA
Altitude.MSL.Single Value : 2400
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Thunderstorm
Weather Elements / Visibility : Rain
Aircraft
Reference : X
Aircraft Operator : Military
Make Model Name : Military
Operating Under FAR Part : Part 91
Mission : Tactical
Flight Phase : Initial Approach
Route In Use.STAR : Raggz1
Person
Reference : 1
Location Of Person.Facility : ZTL.ARTCC
Reporter Organization : Government
Function.Air Traffic Control : Enroute
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Radar : 23
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 23
Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 7
ASRS Report Number.Accession Number : 1468164
Human Factors : Situational Awareness
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Weather that was depicting heavy to extreme precipitation impacted the Tiroe sector ZTL.
The area of convective activity covered a 90 mile radius in the sector. There was no "clean
air" we had aircraft inbound to ATL deviate to avoid the heavy thunderstorms. They
deviated into the south departure sector and also the west departure sector. It was not
possible for them to join the arrival from the south west. We coordinated headings with
ATL approach A80.
Our Traffic Management Unit (TMU) was informed by our Controller in Charge (CIC) that
aircraft were requesting different arrival fixes. The other 3 arrival fixes and sectors in ZTL
airspace had no weather at all. 2 Air carriers demanded a new arrival for safety. Our TMU
responded by saying the air carriers could deviate. So we vectored aircraft to deviate
north and rejoin the arrival when able. When the aircraft reached the Transfer Control
Point (TCP) however the controllers at A80 said they had no knowledge of this plan and
did not agree to it. Lack of communication between our TMU and A80 put the flying public
safety at risk.
Our TMU said that they put out a re-route to put the arrivals on other arrivals. However
the aircraft were still purposely being routed into known convective activity on the arrival
into ATL. No proactive measures were taken by our TMU to off-load arrivals to safe arrivals
with no convective activity. The flying public was put at risk by this lack of action and
planning. In the future when an arrival sector is covered in convective activity the aircraft
should be re-routed to other arrivals.
This was another example of how our management and TMU do NOT work to help the
controllers of ZTL.
Synopsis
Atlanta Center Controller reported aircraft being cleared into known weather.
ACN: 1468132 (45 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ASE.Airport
State Reference : CO
Altitude.MSL.Single Value : 10000
Environment
Flight Conditions : IMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.TRACON : ASE
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 15
Flight Phase : Climb
Airspace.Class E : ASE
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1468132
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1468135
Events
Anomaly.Deviation - Procedural : Weight And Balance
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Enroute to ASE we sent for landing data for Rwy 15 on a wet runway and the winds were
roughly 270/12G19. The data came back and said we didn't have the required runway
length necessary. We immediately asked dispatch to run the numbers as well and then
referenced the flight release. Dispatch came back initially and said we should be good but
they were going to check with their boss. The flight release said that we had more than
enough runway. We decided to continue the approach. Somewhere around XTREM or
TIKET we received a message from dispatch that said,"not legal to land, sorry." We
executed the missed approach and started our climb to 14200 feet. Because of our speed
and altitude I called for VfTO (Final Takeoff Speed) because we didn't have too far to climb
and I didn't want to blow through our missed approach altitude. As we leveled we noticed
the FMS didn't sequence. We verified on the FMA we were in GA mode but it wasn't
sequencing. At that point we identified RIKOC and realized we were already passed it and
turned immediately to a heading of 300. Because we exceeded 190 knots we had a wider
turning radius and exceeded the 13.5 DME arc from DBL when we were intercepting the
303 course outbound. Because of the wide turn tower told us the MSA was 16000 feet and
cleared us to maintain 16000 ft. We complied immediately. We only had 4100 lbs of fuel
onboard and decided to divert to ZZZ. We requested direct to the airport and asked
dispatch for the fuel burn and informed them of our intentions. They responded that ZZZ
isn't a legal alternate because the tower is closed and we need to go to DEN. We started
the turn towards DEN and then received word that ZZZ tower was open and we were good
to go. We proceeded to ZZZ and landed without incident.
I think that an 11 hour duty day is too much. There are too many factors that can get you
behind and make it impossible to catch up without rushing. I think it would also be
beneficial to do more training on the missed approach procedure for the LOC Rwy 15 from
earlier on in the approach. It changes things quite a bit. We need to refine the new data
because it is spitting out data that seems completely and utterly inaccurate and will
completely tie our hands and create situations like this. That being said there was certainly
mistakes made on my part that I haven't made before on this missed approach procedure.
We had already briefed it three times that day but could have been more thorough. Many
of the small but important details that were missed I think were due mostly to a long duty
day with many distractions that took a toll on us mentally. We did identify our long day as
a threat in the WANT briefing but didn't realize how big of a threat it was.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Turbojet flight crew reported a missed approach due to the winds at ASE. The aircraft
entered an area with a higher MSA due to a higher speed and greater turn radius.
ACN: 1468112 (46 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZSPD.Airport
State Reference : FO
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZSHA
Aircraft Operator : Air Carrier
Make Model Name : B787 Dreamliner Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Descent
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Relief Pilot
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1468112
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.ATC Issue : All Types
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Flight Crew : Diverted
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
I was the [relief pilot] on this flight. Just before the landing, the crew returned from break
we updated weather and everything looked normal for arrival and landing into ZSPD. Once
the landing crew got in their seats, PVG approach started to give us a speed reduction and
then eventually a delay turn to the north. Approach was very vague on the reason other
than traffic. We flew north for some time and queried why. Eventually they turned us back
towards arrival and we were told number 2 for landing and the reason was weather. Our
weather radar wasn't painting anything that caused us concern. Our fuel by this time was
getting close to bingo however we were assured that they will get us right in as we told
approach fuel was critical. Once on the arrival the controller said 35 minute delay. This
was not going to work for us so we told controller we will fly direct to our alternate of
ZZZZ. He gave us a vector that was not direct and held us at a lower altitude. We then
[advised ATC] and flew direct ZZZZ and continued our climb.
This was caused by a communication problem with the controller. It was late into the
arrival before we realized it was a weather delay. The controller did not understand our
fuel situation and continued to lead us on. Even after we [advised them of the severity of
the situation] he tried to vector us and keep us down low. Unacceptable considering our
fuel state. Controllers in Shanghai need to understand how to communicate with English
carriers. The need to be very clear on the reasons for delays and real time expected
delays. Dispatchers can help by being more proactive with information on flow into
Shanghai and expected delays. As we pass the South Korean Peninsula it would be nice to
know how things are looking on the arrival. It's easier to stop in Incheon for fuel than
ZZZZ.
Synopsis
B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be
expected during arrival, and did not expedite a clearance to the alternate after being
advised of the low fuel state.
ACN: 1467710 (47 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : DEN.Airport
State Reference : CO
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Windshear
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : DEN
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Takeoff
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1467710
Human Factors : Workload
Human Factors : Confusion
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Troubleshooting
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Weight And Balance
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Requested ATC Assistance / Clarification
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
Dispatch remarks field on SABRE flight plan for Flight DEN-ZZZ said, "planned bleeds off
takeoff at 37 degrees off longer runway for best ATOG (Allowable Takeoff Gross Weight)".
The Planned Weight/Maximum Allowable weights on the flight plan were 160446/166777
lbs. Release 2 was issued due to ZFW increase of 1800 pounds. The takeoff data requested
at the gate was for runway 34L, bleeds off, planned TOW 161,300 lbs. SABRE returned a
flaps 1 setting with max EPR (Engine Pressure Ratio) V1, Vr and V2 of 145, 158, 163. We
had a discussion about the fact that the takeoff data message showed a reduced EPR line
as a legal option. We decided using reduced EPR with bleeds off seemed ill-advised. Had
we used this option, our v-speeds would have been higher at 152, 162, 166.
On taxi out, we requested final takeoff data for runway 34L TOW 161,000 lbs. Again
SABRE sent us flaps 1 with a reduced EPR option. We elected to use max EPR with its
enhanced performance and lower v-speeds. I mentioned to the FO that in the previous
three weeks out of Denver, we had been unable to extract anything other than flaps 1
bleeds off on runway 34L. An error was all we got, bleeds off, if other flap settings were
requested. I also mentioned that I thought we had been very close to exceeding tire speed
each time.
In line for takeoff, ATC reported windshear and shifting winds on our runway. An aircraft
gave a PIREP after takeoff that tailwinds were 16 kts until liftoff, when then shifted to a
four kt headwind. The windsock was initially hidden by an aircraft body, but as we
approached the number two position in line for takeoff, we saw very clearly that the sock
showed a variable tailwind of 5-15 kts. We called up data for 34L with winds at 160/10.
SABRE offered us flaps 5 bleeds off, with 10 kt tailwind. V-speeds were 134, 152, 157. We
reset takeoff data and re-ran the checklists. The company aircraft ahead of us refused
takeoff until more favorable winds developed. Tower seemed miffed at their reluctance to
go, saying, "I said 25 kt GAIN on runway." In fact, as we waited in line, ATC was
consistently reporting "wind shear alert, 25 kt gain on the runway." Sometimes the
verbiage was "...25 kt gain over the numbers" for the landing runway 35R. At any rate,
the aircraft in front was eventually satisfied the winds were acceptable. Tower cleared
them for takeoff, reporting 34L winds as 360/9. Interestingly, the windsock clearly showed
a tailwind. We were cleared for takeoff, with winds reported at 070/4. The windsock
showed a slight tailwind. I had asked the FO to note our ground speed on liftoff. I was
watching them also. At the Vr call, groundspeed was 192. At liftoff, groundspeed was 209.
Rotation rate was normal, and the pitch at takeoff was 4.8. We wrote a logbook entry for
the tire over speed.
Clearly, the allowable TOW on both the SABRE flight plan and takeoff data messages do
not take tire speeds into account. Had we carried the max allowable weight of 166,777 lbs
(per flight plan), or 167,900 per takeoff data message, our tire speeds would've exceeded
tire speeds even more. We mitigated our v-speeds as best we could (most of the time, out
of Denver, only flaps 1 will work, but today we got lucky, I guess). Also, had we use
reduced EPR (an option given us, but not appropriate considering the windshear), our v-
speeds would've been higher. I don't see how B737s can takeoff during summertime out
of Denver (or any high altitude airport) at these "allowable" weights without grossly
exceeding tire speed. In fact, I am sure tire overspeeds are routine.
Synopsis
B737 Captain reported departing DEN Runway 34L during variable windshear conditions
and recorded 192 kts at Vr, 209 kts at lift off with indicated airspeeds of 158 kts and 163
kts respectively. The maximum tire speed was exceeded.
ACN: 1467476 (48 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Turbulence
Ceiling.Single Value : 1800
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : EMB ERJ 170/175 ER/LR
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Initial Approach
Airspace.Class B : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 7530
ASRS Report Number.Accession Number : 1467476
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1467014
Human Factors : Confusion
Human Factors : Distraction
Human Factors : Training / Qualification
Events
Anomaly.Deviation - Speed : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Descending through the ZZZZZ fix on the ILS approach, the First Officer (FO) was
maintaining a speed of 210 Knots using Full Boards. We hit turbulence while descending
through the clouds and the load factor increased and quickly the speed dropped and the
stick shaker came on. I quickly called for the command of the controls and the FO quickly
removed his hands from the controls. I then added power and lowered the nose and
removed the boards to close and thus regain full control authority. I then re-intercepted
the Glide Slope and then gave the controls back to the FO. I then continued with the gear
and flap settings and by the 1000 feet call all was configured and by 500 was stable and
the landing was spot on.
I believe that I have been noticing a trend where the FOs do not really understand the use
of flight boards, especially when inputting full amount. They seem to fixate on the descent
and omit the visual indications such as the yellow band and incremental Pitch Limit
Indicator (PLI). For some reason, these visual indications are either omitted or not used as
an impending warning to probable events such as a stall. I notice that in almost every
flight I have to discuss the use of Boards or in some cases I have had to assist in closing
boards because the yellow band turned RED.
In some cases FOs have taken the assist personally and have increased tension in the
cockpit because in their perception the assist was taken as intrusion. I further believe that
CRM has been taken out of context and has made FOs the premier Flying pilot that "is the
sole manipulator of controls." For example, I had an FO, recently, who thought that having
an EMB 190 type certificate made him loggable PIC when flying.
They seem to look at themselves as PIC rather than first officers who are still flying and
assisting the Captain. I believe this false sense of understanding, hierarchy, has misguided
FOs and thus relied on a false sense of a pilot who never has the need to ask questions.
I think that during training or Initial Operating Experience (IOE), the FO needs to be
reminded of the need to keep learning and that just because they passed IOE is by no
means an excuse to overlook the Captains experience. CRM should be shared information
that allows for Safety but in some cases new FOs are relying less on sharing and more on
acting as individuals in command authority when the sole manipulator of controls.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
ERJ175 flight crew reported receiving a stick shaker warning when intercepting the glide
slope from above with the speed brakes deployed.
ACN: 1467408 (49 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0001-0600
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Weather Elements / Visibility : Thunderstorm
Light : Night
Aircraft
Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Parked
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 675
ASRS Report Number.Accession Number : 1467408
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1467432
Events
Anomaly.Deviation - Procedural : Other / Unknown
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
Were Passengers Involved In Event : Y
When Detected : Aircraft In Service At Gate
Result.Flight Crew : Diverted
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Ambiguous
Narrative: 1
EDCT (Expected Departure Clearance Time) already in place for PHL. We discussed current
weather/fuel state. Ops affirmed EDCT time and need for the gate. Dispatcher affirmed
weather forecast and lack of alternate required (we were prior to forecast storms even
with our delay) but we had contingency fuel to hold/divert if contingency arose. Enough
for deviations but not likely a lengthy hold. Pushed and held in pad for approximately 25
minutes. Takeoff and flight through Western PA uneventful with some deviations for
weather. Fuel burn matching Dispatch and continued flight deck efforts to fly efficiently
while monitoring PHL. Saw cells via radar on arrival corridor but not on the field.
Started hearing about arrivals 2-3 aircraft ahead of us going into hold and reviewed
options for hold/divert if needed. IAD, BWI and others eliminated for obvious
weather/saturation issues. PIT, ZZZ, EWR all discussed and weather obtained. No NOTAMS
onboard for any of these due to not being an alternate. Asked dispatcher about those
fields as well as supportability for 737-900 in ZZZ (most specifically the ability to takeoff
with fuel/pax load). I have not been to ZZZ but looked adequate as I reviewed with the
Captain. Dispatcher recommended ZZZ or EWR. Queried ATC about EWR or ZZZ being ok
for flow and weather. Was told EWR would not be good for flow but ZZZ was ok. Found
ZZZ in JeppFD-Pro and looked at Weather flow we had seen/expected. Of note, no 10-7
page but manual lists as category R for 737. ZZZ was north of the problematic weather
and close enough to quickly get into PHL or deplane passengers if needed. No known
issues as we could see it with any supportability. Landed at ZZZ without incident and went
to the ramp area. ZZZ ATC asked of our intentions--we stated a refuel and go if
weather/ATC allowed but we weren't sure if/when that would happen. We were marshaled
by contract maintenance support to the southern tip of the ramp. Shut down,
accomplished appropriate checklists, door opened with air stairs. Safe divert arrival and
times passed to company.
We were parked in the corner of the ramp, between 500 and 600 feet from gate where we
would ultimately deplane. Some passengers immediately expressed an interest to deplane
given proximity to PHL. Refuelers and air stairs were prompt. We were initially told
approximately an hour until a bus available but the local personnel were working on it
while we looked into legality/security from the Company standpoint. We had some
concerns/questions about checked bags continuing without their associated passengers in
the aircraft and wanted to consult with Operations and our publications. Stipulation would
be no checked bags removed and those that deplaned would not get back on. We were to
ask about how many wanted off and provide a number for accountability and load
planning. The Captain passed this to the passengers and continued to make calls toward
that effort.
Simultaneously worked with dispatch to obtain new flight plan and determine refuel
amount. Gas provided but receipt was not on standard sheet. Provided that printout and
fueler went with air stairs and paperwork to another flight that had also diverted. No
frequencies or phone numbers for operations but eventually obtained them from a
dispatcher who happened to be onboard our aircraft. Took at least 20 minutes to hear
from anyone. The other flight appeared a priority. Ops/ramp Member hooked back up. We
passed 55 people wanted off. Also learned from security/police that no one could walk
across the ramp, that transportation was required. Local operations also given official
on/in times for planning purposes.
We were still under the impression productive efforts were being made to obtain
transportation. We made it clear to multiple ZZZ personnel that any options were fine--
multiple trips via minivan vs one size fits all bus if it would enable deplaning sooner than
later. The next time the stair came up some 30 minutes later we were told by Contract
lead no one could deplane due to lack of a tail stand per her supervisor who was not yet
present but allegedly coming into work. We asked about deplaning from back to front, or
even using the aft doors, as this was beginning to take on a sense of urgency. The lead
stated that her supervisor would not allow it until at the 3 hour point when we had to per
DOT (Department of Transportation) guidelines. This seemed to drive a reduction in
timeline management by local operations who felt they had more time to devise a viable
solution, but didn't seem to think how long it would take to execute a plan for 55-181
souls depending on the situation. Security officer reinforced that under NO circumstances
were people walking across the ramp despite the fact that he personally understood our
plight. We received no completed fuel sheet so I approximated using fuel levels in our
tanks and total gallons (provided on the original sheet so we could insert into ACARS).
Completed the walk around and continued to make any available pre-flight preparations if
there was a break in the weather. However efforts continued to accommodate passengers
wishing to deplane, particularly between Captain and Operations.
PHL continues on a ground stop and storms continue from the east. Also told that ATC is
not taking flights above 10K over ZZZ. Our assessment remained that a second divert was
very likely given the weather and it was not fair to passengers to do that. CA made
numerous calls to dispatch and Operations relaying situation. Local ops was non
responsive about deplaning or transportation updates, making it nearly impossible to
make PA announcements to the passengers but the Captain did his best. No information
provided by dispatch or ATC about whether anyone was able to land in PHL so we had to
go with our judgment as pilots looking at the radar and the forecast coupled with ground
stop information. We were told of an extended PHL ground stop until at least 45 minutes
from now so we turned our primary attention to deplaning passengers. Captain passed this
plan to Operations as best as I can recall.
Throughout tarmac delay, the passengers had appropriate temperatures, food, water, and
lav access at all times. Flight attendants did a great job accommodating while informing us
of questions/concerns. While on a lav break, I personally and publicly inquired about
temps and engaged with a couple customers up in first class area. The only thing they
could not do was deplane, which was increasingly frustrating to them and us. We provided
updates every 10-15 minutes but those often were that we were waiting back for answers.
Near the end of our delay we were informed one passenger was suffering a panic attack,
but that apparently subsided with interaction from the flight attendant and the security
official who happened to be on the aircraft at the time (second/final air stair usage in
remote parking). No Medlink or other efforts seemed warranted other than expediting the
stalled deplaning process. We also anticipated there would be a crew duty day limitation
about the time the weather could break and discussed those ramifications as well. That
information was passed to Operations and scheduling. Just prior to timeout and as we
were approaching the 3 hour point, We received word that ATC approved us to go quickly
to PHL but there was a 40K cell 5-10 miles west of their field, making successful arrival to
PHL unlikely. We focused our efforts on deplaning passengers discussing the need to
deplane if departure was doubtful at 2+15.
Due to inaction from ZZZ ops/security, Captain directed that we would move the aircraft
to gate. Despite ops understanding this final decision, and no other activity on the ramp, it
took 15 minutes to get the airstairs removed so we could safely start engines. We
accomplished checklists, sat passengers, started both engines and taxied to the gate.
Then, jet bridge broke and would not extend to the aircraft front door. We had to reseat
everyone again and push back the aircraft 3-5 feet to use the same air stairs walking
across the same ramp, some 175 yards closer. In total, it took 45 minutes from decision
to move the aircraft to deplaning passengers.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
B737 flight crew reported a weather diversion that resulted in a long delay and difficulties
deplaning the passengers due to airport rules and equipment availability.
ACN: 1467288 (50 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0001-0600
Place
Locale Reference.ATC Facility : IAD.Tower
State Reference : DC
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : Marginal
Weather Elements / Visibility : Windshear
Light : Night
Aircraft : 1
Reference : X
ATC / Advisory.Tower : IAD
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Taxi
Aircraft : 2
Reference : Y
ATC / Advisory.Tower : IAD
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Landing
Airspace.Class B : IAD
Person
Reference : 1
Location Of Person.Facility : IAD.Tower
Reporter Organization : Government
Function.Air Traffic Control : Local
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1
ASRS Report Number.Accession Number : 1467288
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Fatigue
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Human Factors : Human-Machine Interface
Communication Breakdown.Party1 : ATC
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Ground Conflict, Less Severe
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Ground Incursion : Runway
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Air Traffic Control
Detector.Person : Flight Crew
When Detected : Taxi
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Contributing Factors / Situations : Staffing
Primary Problem : Procedure
Narrative: 1
I was working LC1 [Local1], LC2, and LC3 combined at the time of the event. The position
was combined at LC3 which faces the west side of the airport. This configuration makes
working the east side of the airport (RWY1R/19L) difficult. I also had planes on 2 separate
frequencies 120.1 which is LC1 frequency and 134.42 which is LC3 frequency. This also
creates confusion and potential for transmissions being stepped on.
There was weather in the area with a thunderstorm over the airport. This added
complexity and extra focus necessary to issue weather updates, wind shear alerts, and
RVR [Runway Visual Range] readings. I have received many briefings in the last year
stressing how important weather dissemination is. This was my major focus during this
event which could have lead me to get tunnel vision.
I had Aircraft X number 1 for RWY 1R and Aircraft Y number 2 for RWY 1R. Both planes
were cleared to land and given weather advisories. I was working a departure in position
on RWY 30 that was given weather information and was holding in position looking at the
weather and deciding if they were able to depart. My attention was on the weather and
trying to give accurate information and watching the TDWR [Terminal Doppler Weather
Radar] for new wind shear readings because it was continuously changing. Aircraft X had
safely landed and missed the last high speed exit (K2) so I instructed them to turn left J1.
At this time Aircraft Y was on a 1.5 mile final and with the speed of Aircraft X continuing
down the runway I did not think timing would be a factor. The visibility was drastically
reduced and the end of the runway was not visible from the tower. I was relying now on
the ASDE-X [Airport Surface Detection Equipment] to insure that Aircraft X had cleared the
runway. I saw what I believed to be Aircraft X committed to the K1 exit while Aircraft Y
was short final and I allowed them to continue. The Controller in Charge saw Aircraft X's
target still on the ASDE-X now at J1 and instructed me to send Aircraft Y around.
I issued go around to Aircraft Y and it was too late he had already crossed the landing
threshold and responded that they "had already touched down". I then realized my
mistake of issuing Aircraft X to turn off the runway at J1 instead of K1 which caused
confusion to the pilot because J1 is 500 feet farther down the runway. I believe Aircraft X
was exiting the runway at K1 and realized he made the wrong turn and then turned back
to comply with my exiting instructions of J1.
This event happened because of an incorrect runway exiting instruction, weather at the
airport, the position being combined due to lack of staffing and not recognizing a
developing situation due to fatigue.
I recommend that when weather is a factor and adds complexity to workload that LC1 be
separate from LC2 and LC3 and worked from the proper position in the tower. The tower
was improperly staffed and I believe with holdover overtime this event could have been
prevented.
Synopsis
IAD Tower Controller reported that a flight crew missed the taxiway turnoff, turned around
to exit, causing aircraft on final to be sent around. Instruction was too late and aircraft
landed on occupied runway.