Multi-Engine Turbojet Aircraft Upsets Incidents

ASRS Database Report Set

Multi-Engine Turbojet Aircraft Upsets Incidents

Report Set Description .........................................A sampling of reports concerning turbojet uncommanded control surface movement and unusual aircraft attitudes.

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

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

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

Number of New Records in Report Set ................18Type of Records in Report Set.............................For each update, new records received at ASRS will

displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

Report Synopses

ACN: 1413522 (1 of 50)

Synopsis CL30 pilot reported the aircraft rolled suddenly left and right exceeding 30 degrees of bank

after encountering wake turbulence on approach to MEM.

ACN: 1411822 (2 of 50)

Synopsis EMB-135LR First Officer reported diverting to an alternate after experiencing difficulty

controlling the aircraft when the stabilizer pitch trim failed in the nose down position.

ACN: 1411370 (3 of 50)

Synopsis EMB-175 crew reported rejecting the takeoff at 90 knots after experiencing an

uncommanded left yaw. Control was regained and after returning to the gate for a

maintenance inspection, the crew departed normally in the same aircraft.

ACN: 1408667 (4 of 50)

Synopsis CRJ-900 Captain reported returning to departure airport after experiencing inflight

catastrophic failure of the left engine.

ACN: 1408242 (5 of 50)

Synopsis G550 First Officer reported a wake turbulence encounter at 17,000 feet while ten miles in

trail of an A380 that resulted in a 20 to 30 degree roll and a loss of 200 feet.

ACN: 1406591 (6 of 50)

Synopsis Embraer Lineage 1000 flight crew reported the Captain was having difficulty with pitch

control after takeoff. Control was reestablished using the F/O's pitch trim switch. After

returning to the departure airport it was discovered the Captain's pitch trim switch was

installed upside down.

ACN: 1403525 (7 of 50)

Synopsis B737-700 flight crew reported they descended below the glide slope on approach to MROC

airport, runway slope was cited as contributing to the optical illusion.

ACN: 1398994 (8 of 50)

Synopsis EMB145 flight crew experienced a SPOILER FAIL message with a SPLRS OPN inscription on

the EICAS on downwind. QRH procedures were followed and at some point during the

procedure the spoilers were noted to be down. The approach was accomplished using QRH

flap setting and approach speed for the anomaly to a successful landing.

ACN: 1396133 (9 of 50)

Synopsis B767-300ER flight crew reported the aircraft started to roll when the First Officer released

the brakes at the gate. The Captain, who had left the cockpit, thought the chocks were in

place and told the First Officer to release the brakes.

ACN: 1394863 (10 of 50)

Synopsis McDonnell Douglas Trijet Captain reported Number Three engine failure in cruise at FL350.

Flight diverted to a suitable field that was at an appropriate distance and directly ahead.

ACN: 1393496 (11 of 50)

Synopsis EMB145 flight crew reported they experienced multiple failures due to a faulty pressure

switch.

ACN: 1393474 (12 of 50)

Synopsis B747 pilots and flight attendants reported their perspective of an engine failure climbing

through FL230. Flight returned to the departure airport.

ACN: 1392802 (13 of 50)

Synopsis A319 Captain reported that during pushback, the tug driver called for brakes set rather

than breakaway when the tow bar became disconnected.

ACN: 1391224 (14 of 50)

Synopsis BE-400XP flight crew reported returning to the departure airport due to a roll trim

runaway.

ACN: 1391073 (15 of 50)

Synopsis

Falcon 2000 Captain reported an uncommanded 60 degree roll resulted from a wake

turbulence encounter descending through 14,000 feet on arrival into IAD despite being 16

miles in trail of a B777.

ACN: 1390685 (16 of 50)

Synopsis CRJ-900 flight crew reported the aircraft entered an uncommanded 45-degree bank after

encountering wake turbulence in trail of an A319 departing PHX.

ACN: 1390662 (17 of 50)

Synopsis EMB-145 Captain reported a possible pitch trim failure or runway trim during rotation with

the First Officer flying. Flight returns to the departure airport.

ACN: 1383903 (18 of 50)

Synopsis Lear 31A Captain reported a wingtip strike occurred on landing when roll authority was

compromised in the landing flare perhaps from ice accumulation on the wing.

ACN: 1370694 (19 of 50)

Synopsis An air taxi Captain reported receiving confusing taxi instructions to a different runway than

originally issued. Once airborne the aircraft was issued headings to an airway not

contained in their flight plan.

ACN: 1370332 (20 of 50)

Synopsis CRJ-900 Captain reported encountering windshear on takeoff from TYS with no windshear

warning provided.

ACN: 1365938 (21 of 50)

Synopsis EMB-145 First Officer reported a failure of the aircraft's pitch trim system during climbout.

All appropriate abnormal checklists were accomplished and the crew returned to the

departure airport, where an uneventful landing was accomplished.

ACN: 1365880 (22 of 50)

Synopsis

B757 First Officer reported encountering wake turbulence in 9-mile trail of a B787 on

descent.

ACN: 1362047 (23 of 50)

Synopsis B737-800 First Officer reported the aircraft yawed to the right at FL380 with Autopilot B

engaged. Substituting Autopilot A solved the problem.

ACN: 1359975 (24 of 50)

Synopsis B737 flight crew reported a split flap indication (25 and 30 degrees) with no rolling

tendency and no flap asymmetry indication. A go-around was initiated and the flap lever

was moved to 15 and the flaps both moved to 15. QRH procedures were accomplished and

a flaps 15 landing ensued.

ACN: 1359365 (25 of 50)

Synopsis A320 Captain experienced electrical anomalies during climb to FL350 which resulted in the

intermittent blanking of his PFD, ND and the upper ECAM display. With low ceilings at their

destination, the crew elects to return to their departure airport. The First Officer's displays

remain normal and he becomes the pilot flying for the approach and landing.

ACN: 1359125 (26 of 50)

Synopsis HS125 flight crew on a ferry flight reported experiencing flight anomalies created by an

unfastened panel on the engine pylon.

ACN: 1358171 (27 of 50)

Synopsis B737-800 flight crew reported rejecting the takeoff when the Captain's side window

opened.

ACN: 1357579 (28 of 50)

Synopsis A330 First Officer reported the flight crew chose to divert to an alternate airport after

noticing abnormal uncommanded aileron movement.

ACN: 1357484 (29 of 50)

Synopsis

B737 Captain reported encountering severe mountain wave in the vicinity of PUB that

resulted in speed and altitude excursions.

ACN: 1348361 (30 of 50)

Synopsis MD-80 Captain reported an overspeed in climb that he felt was related to a recent change

in procedure that calls for a high speed climbout.

ACN: 1348155 (31 of 50)

Synopsis A regional jet flight crew reported experiencing a minimum fuel condition due to ongoing

delays at the destination airport, which were attributed to multiple runway changes. They

also cited their company's fuel policy as a contributing factor to their fuel situation.

ACN: 1338459 (32 of 50)

Synopsis B737 Captain reported his aircraft rolled right and descended after encountering wake

turbulence in trail of a B777 at FL340.

ACN: 1336081 (33 of 50)

Synopsis Air carrier First Officer reported an uncommanded roll shortly after takeoff due to the

exhaust stream from a parked aircraft with engines running pointed toward the departure

runway.

ACN: 1328335 (34 of 50)

Synopsis EA50 pilot reported deviating from his cleared track departing FFZ when he experienced

FMS issues.

ACN: 1327278 (35 of 50)

Synopsis Air carrier flight crew reported being distracted during takeoff roll by a bird which emerged

from inside the cockpit. Aircraft control was maintained at all times and the bird

subsequently disappeared for the remainder of the flight.

ACN: 1324001 (36 of 50)

Synopsis

B757 Captain reported experiencing an uncommanded 45 degree bank angle at FL370 that

the reporter felt was related to jet stream activity.

ACN: 1321647 (37 of 50)

Synopsis EMB-145LR Captain reported the aircraft swerved suddenly during the takeoff roll possibly

due to wake turbulence from a landing aircraft on an adjacent runway.

ACN: 1317768 (38 of 50)

Synopsis A B757 flight crew experienced a dual generator failure during the takeoff roll and rejected

the takeoff.

ACN: 1317459 (39 of 50)

Synopsis B737-700 flight crew reported experiencing an uncommanded roll during flap extension on

approach. Flight landed with flaps set to position 5.

ACN: 1317203 (40 of 50)

Synopsis B757 First Officer reported a track excursion while on autoflight for unknown reasons.

ACN: 1316669 (41 of 50)

Synopsis The B737 crew experienced an autopilot and autothrottle disconnect at glideslope

intercept, which led to an unstable approach. The Captain elected to land.

ACN: 1313853 (42 of 50)

Synopsis B777 flight crew reported two flight attendants were injured when they encountered

probable wake turbulence at FL280 from a crossing aircraft at FL300.

ACN: 1312744 (43 of 50)

Synopsis Air Cargo Captain reported speed and track deviations related to fatigue issues.

ACN: 1311216 (44 of 50)

Synopsis

G-V Captain reported a wake turbulence encounter at FL320 that resulted in an

uncommanded 40 degree bank.

ACN: 1306332 (45 of 50)

Synopsis B757-200 flight crew reported diverting to a nearby alternate when they experienced

violent nearly uncontrollable rolls in climb at FL270 from a malfunctioning yaw damper.

ACN: 1305550 (46 of 50)

Synopsis A CRJ-700 crew experienced an uncommanded rudder input at cruise and diverted as per

the QRH. A Contract Mechanic and Company Maintenance Control diagnosed the system

and concluded an autopilot fault. However, this autopilot has no rudder input.

ACN: 1304387 (47 of 50)

Synopsis BAE125-850XP First Officer reported possible flight control icing, which led to an altitude

excursion at FL400.

ACN: 1302352 (48 of 50)

Synopsis CRJ-700 flight crew reported they deviated from cleared departure track out of LGA when

they were distracted at a critical time.

ACN: 1300945 (49 of 50)

Synopsis B767-300 flight crew experiences a sudden engine failure at 700 feet AGL after takeoff.

The engine is shut down and the flight returns to the departure airport for an overweight

landing. ARFF reports fluid leaking from the shut down engine and three of the four tires

on that truck deflate due to temperature.

ACN: 1299693 (50 of 50)

Synopsis A First Officer and Check Pilot reported a sudden, unexplained shutdown of the right

engine on a CRJ-700 aircraft during the landing rollout on a training flight. The Check Pilot

noted he never saw the FO pull the right engine shut-off trigger and only observed the

First Officer's hand on top of the power levers.

Report Narratives

ACN: 1413522 (1 of 50)

Time / Day

Date : 201612

Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : MEM.Airport

State Reference : TN

Altitude.MSL.Single Value : 3000

Environment

Flight Conditions : IMC

Weather Elements / Visibility : Rain

Weather Elements / Visibility : Turbulence

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.TRACON : M03

Make Model Name : Challenger 300

Crew Size.Number Of Crew : 2

Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 18L

Flight Phase : Initial Approach

Airspace.Class B : MEM

Aircraft : 2

Reference : Y

ATC / Advisory.TRACON : M03

Make Model Name : Commercial Fixed Wing


Flight Plan : IFR

Flight Phase : Final Approach

Airspace.Class B : MEM

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Corporate

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1413522

Human Factors : Situational Awareness

Analyst Callback : Attempted

Events

Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control

Anomaly.Inflight Event / Encounter : Wake Vortex Encounter

Detector.Person : Flight Crew

Were Passengers Involved In Event : Y

When Detected : In-flight

Result.Flight Crew : Regained Aircraft Control

Result.Flight Crew : Took Evasive Action

Assessments

Contributing Factors / Situations : Environment - Non Weather Related

Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure

Primary Problem : Ambiguous

Narrative: 1

We were on the Runway 18L localizer north of REISE intersection at 3000 ft and cleared

for the ILS RW 18L approach. We were configured with flaps 10, gear up, and flying

approximately 180 KIAS in IMC with rain and light to moderate turbulence. Wind was out

of the southwest at 50-60 knots at 3000 ft. Autopilot was engaged. The airplane suddenly

rolled right, then left exceeding 30 degrees of bank each way. The autopilot remained

engaged, and came back to wings level. About 3 seconds later, it happened again with

high roll rates and bank angles nearing 45 deg. I disconnected the autopilot and initiated a

climb out of wake turbulence. We were able to re-establish and fly the approach to landing

without further incident. We reported it to ATC and asked ATC what type of plane we were

following. They said we were #1 for 18L, but there was traffic for the parallel runways.

ATC was busy, so we didn't query any further. Our 2 passengers were pretty shaken up

about it, but we calmed them the best we could. I contacted MEM Approach Control by

telephone and reported it to him. He said they would review the tapes.

Synopsis

CL30 pilot reported the aircraft rolled suddenly left and right exceeding 30 degrees of bank

after encountering wake turbulence on approach to MEM.

ACN: 1411822 (2 of 50)

Time / Day

Date : 201612


Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Environment

Flight Conditions : VMC

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ

Aircraft Operator : Air Carrier

Make Model Name : EMB ERJ 135 ER/LR


Operating Under FAR Part : Part 121

Flight Plan : IFR

Mission : Passenger

Nav In Use : FMS Or FMC

Flight Phase : Cruise

Airspace.Class A : ZZZ

Component

Aircraft Component : Horizontal Stabilizer Trim

Aircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1



Reporter Organization : Air Carrier

Function.Flight Crew : First Officer




Events

Anomaly.Aircraft Equipment Problem : Critical



Result.Flight Crew : Overcame Equipment Problem

Result.Flight Crew : Diverted

Assessments

Contributing Factors / Situations : Aircraft

Primary Problem : Aircraft

Narrative: 1

The Captain and I were cleared to "Descend Via" the Arrival and the plane suddenly rolled

to the right at a very rapid rate and pitched down as well. I immediately pressed the

"quick disconnect" button and held it. The Captain said, "That's just wake" and then I told

him it put us in a nose low trimmed attitude. The plane was in a Nose Down trim and

maintaining altitude was not possible and we continued to descend. The Captain alerted

ATC that we were still descending and wouldn't be able to make the altitude gates. The

Master Warning messages for both the main and backup trim were present. The Captain

ran the QRH while I continued to fly the plane. After the reset was unsuccessful we

[advised ATC] and asked to get direct to nearest airport and they gave us a vector [to the

alternate airport] for the ILS. We set up the approach and briefed it accordingly. My arms

and thumb were worn out and fatigued so the Captain relieved me and continued the

approach to landing via an ILS in IMC.

The training I received in initial was crucial for the happy outcome in this event. I would

encourage the training department in recurrent to give this problem without pre-briefing it

so that it gets ingrained how quick and dangerous it is.

Synopsis

EMB-135LR First Officer reported diverting to an alternate after experiencing difficulty

controlling the aircraft when the stabilizer pitch trim failed in the nose down position.

ACN: 1411370 (3 of 50)

Time / Day

Date : 201612


Place



Altitude.AGL.Single Value : 0

Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ


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



Flight Plan : IFR

Mission : Passenger

Flight Phase : Takeoff

Person : 1

Reference : 1




Function.Flight Crew : Captain




Human Factors : Workload


Human Factors : Time Pressure

Human Factors : Troubleshooting

Analyst Callback : Completed

Person : 2

Reference : 2




Function.Flight Crew : Pilot Not Flying









Events

Anomaly.Ground Event / Encounter : Loss Of Aircraft Control

Anomaly.Inflight Event / Encounter : Weather / Turbulence


When Detected : Taxi

Result.General : Maintenance Action

Result.General : Release Refused / Aircraft Not Accepted

Result.Flight Crew : Rejected Takeoff


Result.Flight Crew : Returned To Gate

Assessments


Contributing Factors / Situations : Airport

Contributing Factors / Situations : Weather


Narrative: 1

On the takeoff roll as we passed 90 knots we experienced a momentary loss of control, the

airplane pulled hard to the left. I had to apply a lot of right rudder in order to keep the

airplane on the runway.

As I was fighting to keep the airplane on the runway I called for the abort. The abort was

executed in accordance with Aircraft Operating Manual (AOM). We pulled off the runway

and asked City Operations to inspect our tires, my first thought was that we had blown a

tire. After getting our tires inspected and verifying brake temperature I called our

dispatcher and spoke with our Chief Pilot in accordance with FOM, we then coordinated a

gate return. I spoke with maintenance and did the required logbook entry.

Callback: 1

The reporter stated that station maintenance inspected the aircraft, but found no

anomalies. The reporter suspected that the aircraft may have hydroplaned on the wet

runway and been affected by a large aircraft landing on the parallel runway. They did

depart later with no problems.

Narrative: 2

Passing 90 KIAS on the takeoff roll, the aircraft experienced an uncommanded left yaw.

The PIC reacted with right rudder, but felt this constituted loss of aircraft control and

aborted the take off in accordance with Aircraft Operating Manual (AOM). We exited the

runway and asked City Operations for an external inspection of the aircraft. City

Operations reported that they did not observe any damage or abnormalities with the

aircraft. After coordinating with Operations, Dispatch, and the Chief Pilot, we returned to

the gate in accordance with FOM.

Synopsis

EMB-175 crew reported rejecting the takeoff at 90 knots after experiencing an

uncommanded left yaw. Control was regained and after returning to the gate for a

maintenance inspection, the crew departed normally in the same aircraft.

ACN: 1408667 (4 of 50)

Time / Day

Date : 201612


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment

Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 900 (CRJ900)

Mission : Passenger

Flight Phase : Climb

Airspace.Class E : ZZZ

Component

Aircraft Component : Turbine Engine


Problem : Failed

Person

Reference : 1








Events



Were Passengers Involved In Event : Y


Result.Flight Crew : Inflight Shutdown

Result.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Landed As Precaution

Result.Air Traffic Control : Provided Assistance

Assessments



Narrative: 1

At show time, the crew shows to a cold soaked, dark airplane. Neither electrical power, nor

cabin heated air were connected to the airframe. The temperature outside was minus two

degrees celsius, below freezing. The cabin and cockpit seemed in total chaos as switches

and items seemed out of place, order and positions. In short, the airplane was not ready

to be presented to the crew.

In the cockpit we found several switches out of position, but running through procedures

and checklists, it was all quickly found and put back to proper positions, places, and order.

Boarding started at an appropriate time and aside from a slightly chilly cabin, we would

have been out of the gate on time if it wasn't due to the jet-bridge breaking on us. After

departure from the gate, it was all normal.

All appropriate checklists completed, and passing 17,000ft, a loud bang was heard from

the rear of the airplane. It was both, felt and heard in the cockpit. A continuous vibration

followed and propagated through the entire airframe until the engine was secured. All

engine indications where normal prior to this event. As the event occurred, we could

confirm both by feel and engine indications that we had suffered a catastrophic engine

failure. The left engine gauges confirmed a sudden N1 and N2 drop to minimum

performance, further solidified by a left yaw motion. The ITT and Fan Vibration gauges

also confirmed engine failure as they quickly moved towards and beyond their respective

red lines.

After confirming the nature of the event as a Catastrophic Left Engine Failure, I decided to

bring the airplane immediately back to [departure airport] for landing. In what seemed like

a matter of 2 minutes, I passed the radios to First Officer (FO) with instructions to take us

back, I communicated [the issue] to ATC, yielded control of the airplane to FO, and talked

to [the] Flight Attendants (FA) about our situation and intentions. After communicating to

my immediate crew, I proceeded to address the passengers and alert the rest of our

ground crew about the situation commencing with Dispatch via ACARS.

Having freed myself from as many duties as possible, I followed procedure with the

Emergency Checklist Card, Severe Engine Damage (In Flight), followed as directed by the

QRH In-Flight Engine Shutdown, and later the Single Engine Approach and Landing

checklists. All emergency and non-normal checklists completed, I followed up with FO,

then with [the] FA's and the passengers.

After communicating with everyone for a second time, I proceeded with all normal

checklists and procedures. Upon conclusion, we were already on final approach at the

same runway we took off from. We landed normally with flaps at 20 Degrees, as per non-

normal procedures. Then we executed a gradual deceleration and stop, exiting near the far

end of the runway towards the terminal. After exiting the runway I communicated with the

FAs, then the passengers, then back to FO who I left communicating with ATC, and

Operations. From here we taxied uneventfully back to the same departure gate and

deplaned the passengers.

In conclusion, all pertinent checklists were completed in a timely fashion as per

procedures. All crew members, including ground crew members and personnel were

briefed, debriefed and communicated. We successfully and safely landed with no evident

crew induced damage to the airframe, or injury to passengers.

Captain decisions and crew action results:

One overweight landing at 76,100 pounds.

One overheated brake condition:

Left Main Outboard gauge white at 07

Left Main Inboard gauge white at 06

Right Main both gauges green

A safe return of all passengers uninjured to the gate.

A safe return of the airframe to an outstation without any evident damage induced by the

crew.

Synopsis

CRJ-900 Captain reported returning to departure airport after experiencing inflight

catastrophic failure of the left engine.

ACN: 1408242 (5 of 50)

Time / Day

Date : 201612


Place

Locale Reference.Airport : IAD.Airport

State Reference : DC


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZDC

Aircraft Operator : Government

Make Model Name : Gulfstream V / G500 / G550



Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : HYPER7

Airspace.Class E : ZDC

Aircraft : 2

Reference : Y



Make Model Name : A380



Flight Plan : IFR

Mission : Passenger





Person

Reference : 1



Reporter Organization : Government



Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Multiengine


Qualification.Flight Crew : Flight Instructor

Experience.Flight Crew.Total : 6200

Experience.Flight Crew.Last 90 Days : 100

Experience.Flight Crew.Type : 300



Events







Result.Air Traffic Control : Issued New Clearance

Assessments




Narrative: 1

[We were] level at 17,000 feet in cruise flight near LRP at 300 KIAS. ATC informed the

crew that they were ten miles in trail of an A380. A few minutes earlier, the G550 had

been cruising at 320 KIAS when ATC ordered a speed reduction to 300 KIAS to maintain

required separation with [the A380]. Crew complied with the speed reduction. [The A380]

was visible in the distance out of the cockpit windows. The G550 suddenly entered a 20 to

30 degree uncommanded right roll at 10-20 degrees per second. The left seat PF copilot

disengaged the autopilot and corrected roll using left roll input and turned on the seatbelt

sign. The G550 returned to level flight with about 200 feet of altitude loss. The Captain, as

right seat PM, then alerted ATC to the wake turbulence encounter and requested a turn

and descent. ATC then provided a vector to the right [to] take the G550 out of a trailing

position between [the A380]. No significant G forces were experienced during the upset or

recovery and there were no injuries or damage. Management was notified upon landing.

Synopsis

G550 First Officer reported a wake turbulence encounter at 17,000 feet while ten miles in

trail of an A380 that resulted in a 20 to 30 degree roll and a loss of 200 feet.

ACN: 1406591 (6 of 50)

Time / Day

Date : 201611


Place




Environment


Weather Elements / Visibility.Visibility : 10

Light : Daylight

Ceiling.Single Value : 12000

Aircraft

Reference : X


Aircraft Operator : Corporate

Make Model Name : Embraer Lineage 1000 (EMB190BJ)



Flight Plan : IFR

Mission : Personal


Route In Use : Vectors

Route In Use : Oceanic

Airspace.Class D : ZZZ

Component

Aircraft Component : Elevator Trim System


Problem : Improperly Operated

Person : 1

Reference : 1















Human Factors : Confusion

Human Factors : Distraction

Person : 2

Reference : 2














Events


Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Deviation - Procedural : Maintenance








Assessments


Primary Problem : Procedure

Narrative: 1

Took off and after about 1200 feet noticed that it was difficult to lower the nose of the

aircraft. By 1600 feet started making a left turn to heading 300 and realized that

something was wrong with the trim of the aircraft. Asked the right seat pilot to help me

force the control wheel down to keep the airspeed. Looked at the pitch trim indicator and

saw it almost full nose up. Thought to myself we were having a pitch trim runaway. Called

pitch trim runaway memory item. First Officer went for the procedure but went back to the

control wheel to help push nose down to avoid stall. First chance I had I performed the

memory item for pitch trim runaway and followed with the remainder of the procedure.

Called out loud "pitch trim runaway", FO went for the QRH in the center console and went

back to help push the control wheel down. FO places the QRH on the top of glare shield.

[Advised ATC] and asked for time to troubleshoot. After pitch trim runaway procedure

realized that the problem remained, airplane is still trimmed full nose up and slow in

airspeed. By then I left my controls to try the procedure again. I let go of the control

wheels, reset the system, called briefly the FA to prepare for landing when FO realizes that

he can now control the airplane and the trim system is working. After that FO says that he

has control of the airplane and that the trim system was working at that time.

Got control of the aircraft at about 7500 feet. Headed back to the departure airport and

landed. Maintenance from Embraer and our company went to check the aircraft and

detected that the Captain pitch control switches were found installed wrong. Switches were

commanding nose up and down inverted. Luckily after we got control of the aircraft with

the autopilot, I took control of the airplane to land and never touched the pitch trim

switches again all the way to the runway. Had I touched those switches again problem

would come back in worst scenario and closer to the ground.

Narrative: 2

We were cleared to takeoff, fly runway heading to 9000 ft, and were given a left turn to

300 degrees. Due to the departure procedure we waited until 1600 ft to make our turn.

The pilot flying starting a left turn to 300 degrees during the climb and noticed the trim

was causing the aircraft to pitch up, and as he climbed higher it was climbing at a higher

pitch and it was getting uncontrollable and slow on airspeed. He requested help from me

to pitch the aircraft down. I assisted him and tried trimming down but my trim switch

must have been momentarily blocked from his trim switch, as it has priority over my

switch. After he ran the procedure, my switch still was not working, then suddenly my

switch freed up and I started trimming down and I got control of the aircraft and leveled

off. We [advised ATC] and returned back to the [departure airport] for the ILS approach.

The PF then requested the controls back and we landed safely.

The aircraft was just in for a maintenance inspection and the trim switch on the left side

was put in upside down, which caused reverse command from what the switch would

normally do. The factory mechanic found this out and also mentioned that some type of

block was being installed to prevent this, but it could still be forced in upside down.

Synopsis

Embraer Lineage 1000 flight crew reported the Captain was having difficulty with pitch

control after takeoff. Control was reestablished using the F/O's pitch trim switch. After

returning to the departure airport it was discovered the Captain's pitch trim switch was

installed upside down.

ACN: 1403525 (7 of 50)

Time / Day

Date : 201611


Place

Locale Reference.Airport : MROC.Airport

State Reference : FO


Environment

Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : MROC


Make Model Name : B737-700



Flight Plan : IFR

Mission : Passenger

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


Person : 1

Reference : 1











Human Factors : Physiological - Other

Person : 2

Reference : 2










Human Factors : Physiological - Other

Events

Anomaly.Aircraft Equipment Problem : Less Severe


Anomaly.Deviation - Procedural : Clearance


Anomaly.Inflight Event / Encounter : Unstabilized Approach

Detector.Automation : Aircraft Other Automation




Assessments



Primary Problem : Human Factors

Narrative: 1

After an uneventful flight we were on final approach on the ILS Runway 7 (I was the Pilot

Flying). While on glidepath and on localizer at approximately 4900 ft we encountered

moderate turbulence and at the same time the autopilot suddenly disconnected, the FMA

(Flight Mode Annunciator) indicated CWS (Control Wheel Steering) for both pitch and roll,

and both Flight Directors were lost. We were at this point in visual conditions with the

runway in sight so I elected to continue the approach visually.

A few seconds later we heard the "Glideslope" aural warning and realized we were indeed

below the glidepath. Looking out the window, we both commented that even though we

had the glideslope warning, we appeared to be high, so we continued the visual approach

using visual cues and landed normally on the touchdown zone.

After the flight and upon further review of all available information, I found a note on the

MROC route brief that warned of the potential for optical illusion due to upward slope on

Runway 7. At that point I realized that due to the compounding factors (moderate

turbulence, sudden loss of A/P, loss of Flight Director, etc.) we might have been below

glidepath for a portion of the approach.

I have been to [MROC] several times before (although never at night) and I can say that

the illusion is much more pronounced at night time.

In my opinion, the note should be added to the airport information page under the arrival

notes.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

B737-700 flight crew reported they descended below the glide slope on approach to MROC

airport, runway slope was cited as contributing to the optical illusion.

ACN: 1398994 (8 of 50)

Time / Day

Date : 201610


Place




Environment


Light : Dusk

Aircraft

Reference : X






Flight Plan : IFR



Airspace.Class C : ZZZ

Component

Aircraft Component : Spoiler System



Person : 1

Reference : 1









Person : 2

Reference : 2








Events





Result.Flight Crew : Executed Go Around / Missed Approach

Result.Flight Crew : Landed in Emergency Condition

Result.Aircraft : Equipment Problem Dissipated

Assessments



Narrative: 1

After being cleared for a visual approach I turned the base leg, called for flaps 9, and after

leveling at 3000, set the altitude for the first approach fix. Decelerating through 200 and

slightly above glideslope, I selected approach mode and pressed the Quick Disconnect

Button to hand-fly the approach.

At that time, the caution message SPOILER FAIL displayed and the Spoiler indication

showed open with the lever closed. I added power to somewhere in the area of 78% N1

and we were maintaining altitude and airspeed at 200 KIAS. I told the Captain (CA) that I

was going to maintain 3000 feet and then I kept the plane straight and level to gauge any

new handling characteristics. The CA took the controls and informed the tower then flew a

ground track over the runway with the intention of making a pattern to land.

After running the QRH procedure, we flew a pattern planning to land visually with gear

down and flaps 22 per the QRH. The Spoiler indication was open for some time. While

maneuvering, the CA pointed out that the spoilers showed closed, and I told him I would

be scanning them in the event they deployed again. Our pitch/power settings for landing

were normal for that configuration. The flight concluded uneventfully.

I believe that the spoilers did actually deploy without command on the initial indication. I

believe that they slowly "bled" back down during the second visual pattern as a result of

the QRH procedure. CA feels he wasn't certain how much they actually deployed because

at no point in his pattern did he feel an acceleration that would be typical of the spoilers

closing in normal operation. I agree there was not a surge like he mentioned, but I think

they clearly deployed at least partially due to the power settings I used to maintain

equilibrium after the initial indication.

The spoilers deployed independently of command during the approach phase of flight. This

worked well as a crew because I had recently reviewed this QRH procedure in training and

felt very proficient at it. I have always remembered this one because of the CB collars that

are already in place, and I had imagined this condition would be more dire than it was. I

assumed it was a bigger deal than it was and I think that was the best position for us to be

in.

In this situation we did not have a fuel issue in clear weather, next to the runway, with

other airports nearby. I can think of a couple flights this last summer while maneuvering

around thunderstorms that, if this same deployment had unexpectedly happened,

continuing to an unexpected alternate with only the planned 1701 LBS of reserve and

spoilers stuck open would have been a really undesirable situation to have flight planned

our way into. I will be much more aware of the potential for an unexpected higher fuel

burn to an alternate based on something like this.

Narrative: 2

On downwind, 3000 feet and 200 KIAS, received SPOILER FAIL message with a SPLRS

OPN inscription on the EICAS display. The CA, Pilot Monitoring (PM), took control of the

aircraft, becoming Pilot Flying (PF). The CA (PF) directed the First Officer (PM) to perform

the UNCOMMANDED SPOILER DEPLOYMENT IN FLIGHT checklist. Simultaneously the CA

informed Tower, and advised them we would join final at present altitude (3,000 feet) and

required a box pattern to perform the necessary checklists. At the beginning of the QRH

arrival checklist it directs the flight crew to apply 1.35x factor (spoiler open) to Flaps 45

landing data, and configure for a Flaps 22 landing. Runway (light winds) had sufficient

length for this emergency. The SPLRS inscription later changed to CLD, which only

requires to apply a 1.27x factor, but the CA elected to keep the original more conservative

factor of 1.35 in place. The PF landed the aircraft normally.

Airport is in a "valley" aligned with, with ridges on both sides and with rising terrain into

the approach for landing west. Weather was dusk. Flight control problems are by nature

unpredictable in their effect and thus their severity, as opposed to a generator which

either works or it doesn't.

Should teach our crews a rule of thumb of the possible QRH landing data penalty factors.

Most are under 2x, except Dual Hydraulic Failure (2.86). Both times I had to apply these

factors, my knowledge of these rules of thumb provided a significant time cushion and

allowed an initial determination that the destination runway was still sufficient in length

despite the emergency condition. Need to periodically emphasize that the QRH is applied

to FLAPS 45 settings in Aerodata, NOT Flaps 22. Some FOs will select Flaps 22 AND apply

the QRH penalty, i.e. a double penalty.

Synopsis

EMB145 flight crew experienced a SPOILER FAIL message with a SPLRS OPN inscription on

the EICAS on downwind. QRH procedures were followed and at some point during the

procedure the spoilers were noted to be down. The approach was accomplished using QRH

flap setting and approach speed for the anomaly to a successful landing.

ACN: 1396133 (9 of 50)

Time / Day

Date : 201610


Place

Locale Reference.Airport : ZZZZ.Airport



Aircraft

Reference : X


Make Model Name : B767-300 and 300 ER



Flight Plan : IFR

Flight Phase : Parked

Person : 1

Reference : 1









Person : 2

Reference : 2








Events


Anomaly.Ground Event / Encounter : Other / Unknown


Detector.Person : Flight Attendant

When Detected : Aircraft In Service At Gate

Result.General : Physical Injury / Incapacitation

Result.Flight Crew : Became Reoriented

Assessments



Narrative: 1

After arriving and completing the shutdown checklist I stepped out on the airstair to see if

the chocks were in. I thought the chocks were installed and told the first officer to release

the brakes and the aircraft started to roll. The aircraft rolled about 6 feet, a flight

attendant and myself screamed to the first officer to set the brakes and he did. No one

was hurt and no damage was done to the aircraft.

Narrative: 2

Shortly after completing the shutdown checklist the Captain came back in the cockpit and

told me to release the brakes. I did so and went heads down to fill out the logbook. A

matter of seconds later I heard a commotion in the back and someone said "hit the

brakes". I looked up and saw that we were rolling backward. I immediately slid forward on

the seat and hit the brakes. It was rather abrupt and one of the flight attendants hurt his

back during the sudden stop. I checked with the purser afterward to ascertain if anyone

had been hurt. They said no one had. It wasn't until about an hour later that the Captain

and I learned about [the flight attendant] hurting his back. No damage to the aircraft.

I've seen many Captains verbally state "parking brake released (pause) we're not

moving". I think I will be adopting this down the road.

Synopsis

B767-300ER flight crew reported the aircraft started to roll when the First Officer released

the brakes at the gate. The Captain, who had left the cockpit, thought the chocks were in

place and told the First Officer to release the brakes.

ACN: 1394863 (10 of 50)

Time / Day

Date : 201610


Place




Environment


Aircraft

Reference : X



Make Model Name : Widebody, Low Wing, 3 Turbojet Eng



Flight Plan : IFR



Component



Problem : Failed

Person

Reference : 1








Events



Were Passengers Involved In Event : N




Assessments



Narrative: 1

At FL350 we suddenly heard a muffled Boom, felt a momentary heavy vibration, and felt

the airplane yaw to the right. The number 3 engine began to immediately roll back. We

complied with the QRH procedures and landed at ZZZ airport which was directly in front of

our aircraft and on a perfect 3 to 1 aircraft descent ratio. The decision to go to ZZZ set us

up for an expeditious route/descent into a suitable airport while allowing us to manage our

airmanship and appropriate checklists.

Synopsis

McDonnell Douglas Trijet Captain reported Number Three engine failure in cruise at FL350.

Flight diverted to a suitable field that was at an appropriate distance and directly ahead.

ACN: 1393496 (11 of 50)

Time / Day

Date : 201610


Place




Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Rudder



Person : 1

Reference : 1








Person : 2

Reference : 2









Events








Assessments



Narrative: 1

At approximately 23,000 feet, during the beginning of climb and in very light chop, we

received EICAS messages AUTOPILOT FAIL, YAW DAMPER FAIL and SPS/ICE SPEEDS (as

we had just entered very light icing conditions). We ran the AOM-1 abnormal procedure for

AUTOPILOT FAIL. As directed by the procedure, we informed ATC we were no longer RVSM

compliant and would need to be held below FL290.

After this, we received the EICAS message RUDDER SYS 1-2 INOP. We ran the RUDDER

SYS 1-2 INOP abnormal checklist, which led us to turn off RUDDER SYS 1 and 2. As we

continued the procedure it led us to turning off RUDDER SYS-1. When we turned off

RUDDER SYS-1 it caused an uncommanded yaw movement to the right. We then re-

selected RUDDER SYS-1 ON, and yaw movement went back to normal with RUDDER SYS-2

INOP message remaining. We diverted to and landed at the nearest suitable airport.

Normal landing was successfully completed, and all crew and passengers deplaned under

normal conditions. Per maintenance, a pressure switch failure occurred.

Narrative: 2


Synopsis

EMB145 flight crew reported they experienced multiple failures due to a faulty pressure

switch.

ACN: 1393474 (12 of 50)

Time / Day

Date : 201610


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC



Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ


Make Model Name : B747 Undifferentiated or Other Model



Flight Plan : IFR

Mission : Ferry


Component



Problem : Failed

Person : 1

Reference : 1











Person : 2

Reference : 2










Person : 3

Reference : 3


Location In Aircraft : Galley

Cabin Activity : Service


Function.Flight Attendant : Flight Attendant (On Duty)

Qualification.Flight Attendant : Current

Experience.Flight Attendant.Total : 27


Person : 4

Reference : 4


Location In Aircraft : Galley

Cabin Activity : Service


Experience.Flight Attendant.Total : 18


Events








Assessments



Narrative: 1

Climbing through FL230, the aircraft experienced moderate to severe vibrations followed

by an audible bang. The relief pilot announced "engine failure." I looked at the engine

instruments and noted the EGT in red indicating 700 degrees with minimal N1 and N2

rotation.

The captain compensated for the loss of thrust with coordinated rudder and aileron. The

captain then delegated crew duties and the relief pilot and I secured the engine via the

Engine Severe Damage Separation checklist in the QRH.

The captain handed the aircraft and ATC communications over to me, while he and the

relief pilot contacted dispatch, coordinated with flight attendants, and formulated a plan

for a return to a nearby airport.

After getting a briefing from dispatch, it was determined that ZZZZ was the nearest

suitable airport. We proceeded direct to ZZZZ. ATC allowed us to make a straight-in ILS

approach. A normal 3-engine approach and landing was made by the captain.

After exiting the runway, local ARFF crews checked for an engine and/or brake fire. There

were none.

Normal shutdown and securing procedures were preformed. Maintenance was notified of

the technical problem. The captain spoke with local authorities and the Chief Pilot.

Overall the engine problem was a non-event. I believe we handled the problem

professionally and in accordance with Company procedures. We debriefed and critiqued

our performance and decided we handled the engine failure like we practiced in the

simulator during training events.

Narrative: 2


Narrative: 3

On our ferry flight we had the number 4 engine go out at 23,000 ft. I felt a jolt and right

after that the captain made an announcement for the mechanic to come to the cockpit.

After that he made another PA announcement for the purser to come to the cockpit. Our

purser got all the information from the captain that we had an engine failure and are

landing in 15 to 20 min and to be prepared. Purser called for a briefing and relayed the

message. I was at door 1R and made sure all carts were stowed, galley secured, and did

my silent review. We landed safe and disarmed our doors.

Narrative: 4

After our climb out, I do believe seatbelt sign was off, 10,000 was chimed by captain, our

purser and I, were in upper deck galley setting up trays for their meal service, when

suddenly we heard a loud noise, not a boom, but a thud type noise, and we almost lost

our footing, as aircraft lurched sideways to the left, we had to hold on to keep from falling,

we said that didn't feel like regular turbulence, but kept setting up trays, then captain

called for one of our mechanics, we had 2 mechanics and 2 ops guys on board, as is with

all charter flights, to come to the cockpit. They talked a bit, then FO came out to look at

number 4 engine, out many windows in upper deck, then back to cockpit. They said that

#4 seized up, called for the purser to come to cockpit, for all of us to get out our books

and plan for a possible evacuation. The purser went up and we were told that #4 was not

working, seized up and we were going back. One of our crew said that there was smoke

coming out of the engine, I did not see this, as I was nearest to cockpit. The captain was

flying aircraft at this time and being very busy, just said that we were not expecting an

evacuation at this time, but be prepared, we were given a direct line to land in ZZZZ.

When we landed we were sent to a remote area, following a follow me truck. We had a

beautiful landing, the captain had said we should be landing in about 15 minutes, and we

did. As to why this happened, I have no clue, mechanics inspect engines each time they

land and before departure, they maintain engines on all charter aircraft, they had no idea

as to what happened either. We were all very happy with the cockpit and how they

handled the situation.

Synopsis

B747 pilots and flight attendants reported their perspective of an engine failure climbing

through FL230. Flight returned to the departure airport.

ACN: 1392802 (13 of 50)

Time / Day

Date : 201610


Place




Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Ramp : ZZZ





Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Person

Reference : 1











Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Ground Personnel

Events




When Detected : Pre-flight


Assessments




Narrative: 1

Airplane we were taking arrived at gate XA:25. Our flight was due out at XB:05. The

Pushback coordinator on the headset called ready for pushback around XB:03. I told him

standby. FO read the before push checklist and called ramp for clearance. Our clearance

was received and I released the brake and told coordinator "brakes released cleared to

push." He acknowledged. My head was down as I was watching the FO put in our final

weights. I looked up and we were slowly moving backward in what seemed like a nice

smooth push. All of a sudden I hear coordinator say "set the brake, set the brake." I found

it difficult to set the brake while we were being pushed back, so I hesitated for a second

until I saw the back part of the tug start to appear in my forward window and realized we

weren't being pushed at all. I stopped the airplane and set the parking brake. It was a

little bit of a jolt but luckily we weren't moving fast enough to injure anyone or tip the

airplane on its tail. There seemed to be some confusion among ramp personnel as to why

the tow bar came loose. I personally think when I released the brake that the tow bar

appeared to be connected but wasn't. Thus we just began to slowly roll back. If in fact it

did disconnect during the push, the tug probably only moved a foot or two forward. They

reconnected the tow bar properly, we started the pushback protocol over, and completed

it normally. I reminded the coordinator that it is imperative you use the term "breakaway"

and not "set the brakes" if that ever happens again. It was counterintuitive for me to "set

the brakes" while the airplane was in motion during what I thought was a normal

pushback.

Synopsis

A319 Captain reported that during pushback, the tug driver called for brakes set rather

than breakaway when the tow bar became disconnected.

ACN: 1391224 (14 of 50)

Time / Day

Date : 201609


Place



Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ

Make Model Name : Beechjet 400


Flight Plan : IFR



Component

Aircraft Component : Aileron Trim System



Person : 1

Reference : 1







Person : 2

Reference : 2







Events







Assessments



Narrative: 1

During climb out we had an uncommanded roll trim runaway. After completing all

necessary checklists we were unable to rectify the situation. We returned to our departure

airport and landed the aircraft uneventfully with a significant amount of roll control input

from the pilot.

Narrative: 2

During climb out the control yoke began to deflect to the side, I noticed the roll trim was

in a runaway condition. We executed memory items and checklist items and were unable

to fix the problem. We [advised ATC] and returned to the airport. During arrival the

Captain said he would execute the landing I transferred the controls & we landed

uneventfully.

Synopsis

BE-400XP flight crew reported returning to the departure airport due to a roll trim

runaway.

ACN: 1391073 (15 of 50)

Time / Day

Date : 201609


Place

Locale Reference.ATC Facility : ZDC.ARTCC

State Reference : VA


Environment



Light : Daylight


Aircraft : 1

Reference : X


ATC / Advisory.TRACON : PCT


Make Model Name : Falcon 2000



Flight Plan : IFR

Mission : Ferry


Flight Phase : Descent



Aircraft : 2

Reference : Y






Flight Plan : IFR




Airspace.Class E : ZNY

Person

Reference : 1














Events





Result.Flight Crew : Requested ATC Assistance / Clarification



Assessments




Narrative: 1

Descending on HYPER7 arrival in VMC conditions, smooth air, and winds (at our altitude)

nearly nil. Just as [ZDC] called to assign hand-off to POTOMAC TRACON we were jolted by

wake turbulence. The airplane suddenly rolled 60 degrees to the right. SIC/PF

disconnected autopilot and stabilized the aircraft. As quickly as the encounter occurred, it

was over. ATC called to repeat the freq change. I replied, including report of wake

encounter. By the time I switched to POTOMAC they were calling us. I checked-in and

acknowledged the new descent clearance (to 10,000 ft). After investigating TCAS (in

BELOW mode to see aircraft at our altitude and below that might be on the arrival ahead

of us) I asked ATC to identify the type aircraft ahead of us (the only one I could see, now

over HYPER intersection). It was a B777, also flying the profile STAR. After communicating

our wake encounter, TRACON issued vectors to take us off the STAR and away from the

path of the proceeding aircraft. Minutes later the POTOMAC controller inquired about the

incident, flight conditions, aircraft damage, and whether anyone was hurt. That was good.

The heavy was nearly 16nm ahead of us. That seems to be plenty enough separation to

avoid a wake encounter. Even with winds aloft nearly zero, the standard rules regarding

descent and dissipation of wake did not keep us from getting violently tossed. I am not

aware of minimum separation requirements for enroute and arrival aircraft, but it was

insufficient for these conditions.

Callback: 1

Reporter had no additional comments.

Synopsis

Falcon 2000 Captain reported an uncommanded 60 degree roll resulted from a wake

turbulence encounter descending through 14,000 feet on arrival into IAD despite being 16

miles in trail of a B777.

ACN: 1390685 (16 of 50)

Time / Day

Date : 201609


Place

Locale Reference.Airport : PHX.Airport

State Reference : AZ


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : PHX





Flight Plan : IFR

Mission : Passenger


Flight Phase : Initial Climb

Airspace.Class B : PHX

Aircraft : 2

Reference : Y

ATC / Advisory.Tower : PHX





Flight Plan : IFR

Mission : Passenger



Airspace.Class B : PHX

Person : 1

Reference : 1









Person : 2

Reference : 2









Events

Anomaly.Deviation - Track / Heading : All Types








Assessments




Narrative: 1

Taking Runway 7L behind an A319 or similar size type, with traffic on a 5 mile final for

same runway. We were given a departure clearance as the Airbus was rotating on

departure. I discussed a 5-10 degree course heading to the right if needed. As we rotated

and started climbing, the FO kept the speed back (under 200 KIAS) as we were

approaching acceleration altitude still at 8 degrees flaps, we encountered an un-

commanded roll of approximately 45 degrees to the left. Disconnecting the autopilot, it

was a couple seconds before full control was regained. I advised PHX tower of our

deviation off course for wake turbulence. We resumed our departure course crossing near

(south) SPRKY intersection.

Towers use of visual separation does not always provide a good margin of safety on

departures.

Narrative: 2

Taking off on a normal flexing flaps 8 takeoff from 7L. I was pilot flying. Before we took off

an Airbus 319 was taking off 7L as we were given the command to line up and wait.

Shortly thereafter we were cleared for takeoff. On initial climbout I kept the speed under

200 kts to ensure a steeper angle of attack to out climb the Airbus' wake turbulence. We

had talked before about a right deviation if needed but both of us found the flight angle

acceptable. Around 800 feet we encountered a light jet wake turbulence and an

uncommanded left bank while the autopilot was engaged. Suddenly the aircraft banked

harder left. As we were passing through 30 degrees of left bank I clicked the autopilot off

to take manual control. I had full right deflection of the yoke as the plane passed through

45 degree bank. The plane was at 45 degrees plus angle for a few seconds until full control

was established. After this we made a right deviation to parallel the other jet's course and

continued the climb. We contacted ATC however received no response.

Not much you can do except lengthen the time between departures. However in this case

the separation was normal.

Synopsis

CRJ-900 flight crew reported the aircraft entered an uncommanded 45-degree bank after

encountering wake turbulence in trail of an A319 departing PHX.

ACN: 1390662 (17 of 50)

Time / Day

Date : 201609


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Component




Person

Reference : 1










Events






Assessments




Narrative: 1

Shortly after rotation on takeoff, the aural warning system sounded "trim, trim" with an

aural ding. No EICAS message was presented. The FO reported to me that he did not use

any trim, and I reported to him that I had not touched the controls. We continued to climb

out on the departure. I noticed the FO was struggling with the trim, pushing nose down

with a lot of effort. We received multiple heading changes and altitude changes. At the

same time I was trying to finish the takeoff checklist. My FO told me he had no trim

control, and that he had excessive nose up pressure. He asked me to try my trim, which I

did, and it had no effect. We then knew the main pitch trim system was malfunctioning.

We did not receive any messages on the EICAS, so I looked up the QRH section pertaining

to flight controls. My FO continued to struggle with the pressure. We both agreed that we

should get the aircraft back on the ground as soon as possible. I then tried to find the QRH

section that best pertained to our situation, but still unclear as to whether it was pitch trim

runaway, or pitch trim inoperation. I tried to follow that later, since my FO wasn't positive

it was runaway, but he thought that it might be. I tried to follow the pitch trim inop QRH,

but ran out of time to complete it. We were already being vectored onto approach, and I

had to get the NAV equipment set up, and get the landing information. I did TEST the

flight attendant, telling her of our situation, and that we were going back to land. We then

landed uneventfully, and taxied to the gate with no further situations. During the

approach, I assisted the FO with the backup trim at his request. This worked very well.

Synopsis

EMB-145 Captain reported a possible pitch trim failure or runway trim during rotation with

the First Officer flying. Flight returns to the departure airport.

ACN: 1383903 (18 of 50)

Time / Day

Date : 201608


Place




Environment


Weather Elements / Visibility : Icing



Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ

Aircraft Operator : Government

Make Model Name : Learjet 31



Flight Plan : IFR

Mission : Passenger

Flight Phase : Landing

Route In Use : Direct


Person

Reference : 1



Reporter Organization : Government










Events


Anomaly.Ground Event / Encounter : Ground Strike - Aircraft





Result.Aircraft : Aircraft Damaged

Assessments



Primary Problem : Weather

Narrative: 1

The event occurred on a Part 91 flight to ZZZ. The event aircraft was a Learjet 31A.

Enroute altitude was FL400. Descent was initiated 90 NM from ZZZZZ intersection, the

initial approach fix for the RNAV (GPS) RWY XX approach to ZZZ. Descending through

FL180 I turned on the nacelle heaters, but did not turn on the wing and stab heat, as I

anticipated a short descent through a shallow cloud layer to above freezing temperatures.

The approach proceeded normally, with the aircraft in the landing configuration and the

before landing checklist completed prior to glide path intercept. The aircraft entered the

cloud tops at approximately 1500 MSL and exited the bases at approximately 900 MSL.

There were no indications of ice accumulation on the normal reference area during

descent. During the landing flare (less than 10 ft AGL), as the flying pilot applied right

aileron to counteract the right crosswind, the left wing abruptly dropped. I immediately

took the controls, applying full right aileron as the left main landing gear contacted the

runway, followed closely by deployment of spoilers, thrust reversers and brakes to return

the aircraft to the runway centerline.

Upon exiting the aircraft, I observed a small amount (less than 1/4 inch) of rough, rapidly

melting ice on the leading edges of the wings. Inspection revealed that the trailing edge of

the left wingtip had contacted the runway surface, causing abrasion to the contact area. I

believe the combination of the small amount of ice, aileron deflection and mechanical

turbulence from buildings on the upwind side of the runway caused the left wing to stall at

a higher than normal airspeed, resulting in the uncommanded left roll. Contributing factors

include my failure to turn on the wing and stab heat prior to entering the cloud layer.

Synopsis

Lear 31A Captain reported a wingtip strike occurred on landing when roll authority was

compromised in the landing flare perhaps from ice accumulation on the wing.

ACN: 1370694 (19 of 50)

Time / Day

Date : 201607


Place

Locale Reference.Airport : JFK.Airport

State Reference : NY


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : JFK


Make Model Name : Learjet 35



Flight Plan : IFR

Mission : Passenger



Route In Use.Airway : V16

Route In Use.SID : SKORR3

Airspace.Class B : JFK

Person

Reference : 1

















Communication Breakdown.Party1 : ATC


Events

Anomaly.ATC Issue : All Types




Miss Distance.Horizontal : 4

Miss Distance.Vertical : 500


When Detected : Taxi




Assessments


Contributing Factors / Situations : Airspace Structure




Narrative: 1

This was a very bizarre incident. In 12000 hours of professional flight time, I have never

experienced an occurrence like this one. After a very thorough and detailed departure

briefing with my copilot, we were given taxi instructions to taxi to runway 4L at JFK.

During the taxi, we were instructed by ATC ground control to taxi via KE and left on Q to

hold short of N. Then we were instructed to follow a B777 on Taxiway B and to monitor the

Tower frequency. We were then instructed by the Tower to turn right on MB and then turn

right onto Runway 31L and lineup and wait. The Tower controller was speaking so fast that

his words were all mixed together and hard to understand. I responded with, "It sounded

like you said to turn left on MB, but the runway is to our right." He then repeated his

instructions more coherently so that we were able to understand him.

Then suddenly within a few seconds of the lineup and wait instruction, we were given

cleared for immediate takeoff on Runway 31L. We were completely taken by surprise as

ATC never told us to expect Runway 31L, and never asked us if we could accept a Runway

31L intersection departure from intersection MB. Then, again within seconds, as we are

running our Lineup Checklist prior to adding power for takeoff, the tower asked us if we

are going to takeoff. I had to stop the Lineup Checklist to respond to him that we were

running our Lineup Checks and would then start the takeoff roll. We didn't even have a

chance to realize that we were departing on a runway other than the one we had briefed

for the RNAV SID. So without knowing what heading we were expected to fly, when

handed off to departure, I immediately informed him that we were flying Runway heading,

at which the departure ATC instructed us to make an immediate left turn to some heading.

Then within a very short time, we were told to fly heading 180 degrees to intercept V16. I

read the clearance back and quickly realized that V16 was not on our clearance until much

farther down the flight plan well beyond the RNAV SID. Not wanting to wander into the

path of other aircraft, I joined the departure course hoping that it was also part of V16

until I could get in contact with ATC as he was somewhat busy with other traffic. We were

then instructed by ATC to turn left as we were not flying the course they instructed us to

fly. ATC then asked us if we were flying V16 and I told him that we understood that we

were to join and fly the RNAV SID and that if he wanted us to join V16 he would need to

tell us what fixes delineated the section of airway he wanted us to join. ATC asked us if we

were familiar with V16 and I said that we were not. He then assigned us a heading to fly

before clearing us direct to a fix on our flight plan.

After being switched to another frequency, we were told that we had deviated and caused

a traffic conflict and that we should expect a phone call at our destination. It should be

noted that our flight plan did not include V16 until about another 30 miles further along

our flight plan clearance. All of this occurred immediately after takeoff, before we even had

a chance to run our after takeoff check list. As of this writing, we have not received

instructions to call any ATC facility.

Synopsis

An air taxi Captain reported receiving confusing taxi instructions to a different runway than

originally issued. Once airborne the aircraft was issued headings to an airway not

contained in their flight plan.

ACN: 1370332 (20 of 50)

Time / Day

Date : 201607


Place

Locale Reference.Airport : TYS.Airport

State Reference : TN


Environment


Weather Elements / Visibility : Windshear

Light : Dawn

Aircraft

Reference : X

ATC / Advisory.Tower : TYS





Flight Plan : IFR

Mission : Passenger


Airspace.Class C : TYS

Person

Reference : 1










Events

Anomaly.Deviation - Speed : All Types






Assessments




Narrative: 1

Pushed back and called ATC for taxi [who then] cleared us to runway 5R for departure.

Airbus just landing 5R. Taxied to 5R, [another] Airbus landed on 23L. [The second Airbus]

cleared the runway and we were given take off clearance 5R, turn right to 070, climb 6000

ft. We had a deferred left thrust reverser so taking the runway I again briefed an aborted

takeoff with one thrust reverser. As we got to V1 and then rotate I pitched up to the flight

director, called for the gear up, and heading 070. Suddenly my airspeed started to

degrade so I started to pitch down. We [then] received a windshear warning with the red

eyebrow arrows [so] I started to pitch up to the bars and it went away. I thought it was a

malfunction since we had no warning. The first officer called out airspeed and I did not call

out for max power. The first officer noticed 25 knots of tail wind, we got to about 700 feet

before we saw positive performance.

Suddenly having a windshear with no warning [early in the morning] can certainly bring

about confusion. I believe if the two other aircraft could have provided a clue to the tower

to pass on a degraded performance on landing we would have [taken a] delay and held off

the runway till we got more information. As it was we were taking off with calm wind and

no thunderstorms anywhere near the airport [so] we figured a normal takeoff but once

again we found that normal is just a setting on a washing machine. As far as preventing

this event we should have called max power and as it [happened] with no clues to what is

going happen next was the big problem. We tried to stay SOP but this got thrown in and

caused confusion.

Synopsis

CRJ-900 Captain reported encountering windshear on takeoff from TYS with no windshear

warning provided.

ACN: 1365938 (21 of 50)

Time / Day

Date : 201606


Place



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Airspace.Class B : ZZZ

Component




Person

Reference : 1












Events


Anomaly.Deviation - Altitude : Excursion From Assigned Altitude









Assessments



Narrative: 1

I was pilot flying on leg 4 on day 2 of a 3 day trip. It was visual conditions departing on

time. Immediately after takeoff while re-trimming we hear "ding" "trim" then saw a red

warning of PTRIM MAIN INOP. I continued to maintain control of the aircraft on the RNAV

departure. I noticed trim wasn't working correctly. Captain (CA) maintained radios and got

out QRH to start procedure. We had to get ATC to let us level out. We ran the QRH. If it

failed but Auto Pilot (AP) would still engage then we could continue? AP did engage and did

appear to be working. CA then got dispatch and maintenance on [commercial radio] while

I monitored flight. After explaining all we had done then looking at whether or not a reset

may not be successful in destination we decided to turn back. Once we started to return

the aircraft began an uncommanded climb from 2900. I then disconnected AP and used

backup trim to get aircraft back in control. AP was used again in descent. Aircraft was out

of trim and additional messages, AUTO TRIM FAIL and AP ELEV MISTRIM were presented.

I told CA I wanted no delays and wanted to [advise ATC]. So we did and proceeded

directly to the airport for the visual to runway 26L. Landed uneventfully.

Threats, Long duty day after min rest, previous day had maintenance issue and gate

return.

Immediately land and deal with indications on the ground. Do not continue flight with a

master warning.

Synopsis

EMB-145 First Officer reported a failure of the aircraft's pitch trim system during climbout.

All appropriate abnormal checklists were accomplished and the crew returned to the

departure airport, where an uneventful landing was accomplished.

ACN: 1365880 (22 of 50)

Time / Day

Date : 201606


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X






Flight Plan : IFR

Mission : Passenger




Aircraft : 2

Reference : Y



Make Model Name : B787 Dreamliner Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger




Person

Reference : 1












Events




Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

On arrival into ZZZ, we encountered the wake of a preceding B787 that was reported to be

9 miles ahead. We were descending VIA the arrival in VERY smooth air above the haze

layer right at ZZZZZ intersection. Our speed was 220 assigned. The aircraft made 3

uncommanded rolls of approximately 5-10 degrees. The rolls were less than 1 second each

and were consecutive (LRL or RLR--not sure). It also felt like yaw and pitch accelerations,

but not very much magnitude. After the encounter, the air was still smooth, but we

descended into the haze layer shortly afterwards (30 seconds or so) where it was

intermittent light turbulence. The autopilot and autothrottles remained on. We all

remarked that it was a wake encounter and I called ATC and asked what we were

following. He said it was a B787 9 miles in front of us. We had heard him get 210 knots

earlier and we were at 220 assigned. At about 4 miles a minute groundspeed, we were

about 2 minutes behind him and because of the STAR, should have been at the same

altitude/descent profiles at that crossing restriction (ZZZZZ intersection 7000 ft). I am not

sure what the winds were but it was very smooth just above the haze layer.

ATC offered to let us fly higher on the arrival, but by that time, we were in the haze layer

where it was intermittent light turbulence and that should have broken up the wake

quicker. We didn't feel that an offset would help, either, once we entered the haze layer.

The wind vector there showed a SW crossing headwind and it was bumpy. The encounter

was more than light turbulence in roll accelerations, but was smoother in vertical g load. I

am not sure if there was much, if any, pitch change due to the wake encounter, but it was

very characteristic of wake encounters. We continued the arrival to a visual behind the

heavy and kept track of the crosswind on final to mitigate the chance of another

encounter. We had a 10 knot crosswind on final (although a slight tailwind component)

and felt that the wake would be well east of us. We did monitor that we had almost 5nm

on final (TCAS estimate).

If I were "rating" this encounter, I would say it was a "minor" severity event. These things

happen, and the wake had decayed to a point where it was manageable for us, a B757. I

wouldn't have wanted to hit that in an RJ or even a short coupled B737 or A319. We were

about 172k pounds. That said, a cup of coffee would have spilled, and flight attendants

could have been injured (they were not). If a passenger had been up getting things

into/out of the overhead, it could have been an injury (it felt a bit like a very tight "dutch

roll").

Callback: 1

Reporter stated the incident would have been more severe for a smaller aircraft.

Synopsis

B757 First Officer reported encountering wake turbulence in 9-mile trail of a B787 on

descent.

ACN: 1362047 (23 of 50)

Time / Day

Date : 201606


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Autopilot



Person

Reference : 1








Events







Assessments



Narrative: 1

In cruise flight at FL380, .78 Mach, autopilot CMD B engaged, the jet suddenly began

"driving" or yawing to the right. I would describe the motion as more of a constant drive

and definitely not a "snap" movement. I immediately grasped the yoke and attempted to

return the nose of the jet back to its original position. Concurrently, I scanned the

instruments/lights for any signs of an engine rolling off or other indications pertaining to

this unexpected movement (hydraulics, yaw damper, etc.). The CA (pilot not flying) felt

the jet move and asked me what I was doing; my response was that I was not making any

inputs to the jet to cause this drive/yaw and that my feet were flat on the deck when this

motion ensued. As the drive deepened the jet started to roll to the right. I immediately

clicked off the autopilot while simultaneously announcing my action. I manually flew the

jet back into our original state (.78 at FL380). I believe we may have gained/lost +/- 60

feet but I don't recall how many degrees of heading changed; I'm also not certain how

much we rolled but I'm guessing it was around 5 degrees when I reacted. After some

discussion, the CA elected to engage autopilot CMD A. The flight proceeded normally with

no further anomalies.

It was night, no turbulence or chop, and no "heavies" nearby that might have generated a

wake turbulence event. The CA requested maintenance meet us at the jet for a debrief.

After we debriefed the maintainer and after the passengers had deplaned, two of our flight

attendants (the number 1 and one from the back) asked us "what the heck happened back

there." They went on to describe their experience similar to the sensation of being on a

boat. A yawing, mushy feeling of working through waves, etc. Both also declared being

somewhat disoriented by the motion, perhaps due to inner ear fluid movement. After the

flight attendants were debriefed by the CA and myself, we surrendered the jet to

maintenance, deplaned and concluded our sequence.

Synopsis

B737-800 First Officer reported the aircraft yawed to the right at FL380 with Autopilot B

engaged. Substituting Autopilot A solved the problem.

ACN: 1359975 (24 of 50)

Time / Day

Date : 201605


Place

Locale Reference.ATC Facility : ZZZ.Tower



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Trailing Edge Flap



Person : 1

Reference : 1









Person : 2

Reference : 2









Events





Result.Flight Crew : Executed Go Around / Missed Approach

Assessments




Narrative: 1

While being vectored for the approach we began our final configuration for landing.

Approaching the outer marker in a shallow descent passing 2000 ft MSL I commanded for

the flaps to be set at 30 degrees and we began the Before Landing Checklist. The F/O

(First Officer), who was the PM (Pilot Monitoring), read flaps, and I responded "flaps," as I

looked over at the flap gauge. We both verified on the flap gauge that the left flap was

indicating 30 degree, while the right flap was still at the 25 degree indication. There was

no indication of uncommanded roll, or yaw of the aircraft.

We immediately decided to discontinue the approach and requested vectors or a holding

pattern so we could run a checklist. We were cleared initially to 1500 ft MSL, and then up

to 4000 ft. Climbing through approximately 1200 ft MSL, I reengaged the autopilot to get

an additional level of automation working for me, so I could concentrate on the situation at

hand. We pulled out the QRH, and ran the Trailing Edge Flap Asymmetry Checklist from

the QRH.

We completed the QRH Checklist and ran landing performance numbers for landing with

flaps set at 15 degree. At this point the aircraft was taken care of, so it was time to notify

the Company, the F/As (Flight Attendants) and the Passengers. The Pilot monitoring took

care of these duties while I, as the PF (Pilot Flying), maintained radio communications with

Air Traffic Control, and flew the aircraft. After all external notifications were done and

checklists were complete, we requested vectors back to the approach course for landing.

The approach and landing were uneventful, and we arrived with Maintenance waiting for

us at the gate. I contacted Dispatch, and the Chief Pilot on Duty, by telephone, and spoke

with Maintenance Personnel while my F/O briefed the Crew that was to take the aircraft.

The aircraft was subsequently taken out of service for Maintenance, and my F/O and I

proceeded to another gate and pressed on with our day.

By using automation to lighten our workload, dividing up tasks and working together as a

team to diagnose and address a mechanical situation, using the appropriate checklists,

and letting other members of the Company Team know what was going on, an abnormal

situation was handled in a methodical and professional manner by everyone involved.

Narrative: 2

During a visual approach, the PF (Pilot Flying) called "Flaps 30, Before Landing Checklist."

We performed the checklist per normal procedure, and as the PM (Pilot Monitoring) was

aurally stating "FLAPS", we both noticed that the Left flap was indicating 30, while the

Right flap was indicating 25. Both indicators aligned with the index marks at each of the

flap positions respectively.

As the flaps were set to the final setting, neither of us noticed any rolling tendencies and

the aircraft appeared quite stable. The PF took the safest course of action by electing to

discontinue the approach, and requested the PM to notify the Tower. Tower was notified

that we were going around, and we were instructed to fly runway heading. I cannot recall

the altitude we climbed to initially (either 3000 ft or 4000 ft). During the normal go-

around maneuver, flaps 15 was selected, and the flaps correctly retracted to the selected

detent.

We then were switched to Departure, where we were given box vectors within the terminal

area, in order to complete the appropriate QRH Checklist (Trailing Edge Flap Asymmetry),

and return for landing. VREF - 146 IAS & VTARGET-151 IAS based on an approximate

landing weight of 113 pounds. After the QRH Checklist was completed, the PM notified the

F/As as to the situation at hand, that we expected a normal approach and landing, and the

amount of time to landing.

Also, an announcement to the Passengers was made to notify them of the basic condition,

and that we would be performing a checklist to allow us to return for landing. Ops was also

notified. Finally, we advised Approach Control that we were ready to proceed inbound for

landing. A flaps 15 approach and landing was conducted at a nominal touchdown rate of

descent, with an approximate brakes speed of 140 IAS. The aircraft turned off and taxied

to the gate where a normal deplaning occurred, and Maintenance was waiting.

Synopsis

B737 flight crew reported a split flap indication (25 and 30 degrees) with no rolling

tendency and no flap asymmetry indication. A go-around was initiated and the flap lever

was moved to 15 and the flaps both moved to 15. QRH procedures were accomplished and

a flaps 15 landing ensued.

ACN: 1359365 (25 of 50)

Time / Day

Date : 201605


Place




Environment

Flight Conditions : Mixed

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Electrical Wiring & Connectors



Person

Reference : 1










Events







Assessments



Narrative: 1

About 20 minutes into flight while climbing through 32,000 feet to get to 35,000 feet we

heard a clicking noise coming from behind the circuit breaker panel and I noticed the

Captain PFD and ND flicker a few times. I suspected we might have a generator issue as I

had noticed in the logbook that an IDG had recently been changed on one of the engines

but I was not sure which one. We were not issued any ECAM messages. The electrical

page did not show anything abnormal except a possible high voltage on the left side TR

(no amber indications). We were flying to ZZZ which had weather right at minimums so I

attempted to start the APU. Starting the APU resulted in an APU auto shutdown. The

electrical issues continued and became steadier so I told the First Officer I thought we

should divert back. As we began the diversion the problem continued to get worse. I gave

the controls to the First Officer because my PFD/ND were going blank so often that they

were unusable. We were unsure which checklist to use as I attempted to look through the

QRH. No checklist applied to our issue. I did run a diversion checklist.

The problem continued to get worse. The lower ECAM displayed multiple messages and the

overhead panel displayed multiple lights flashing on and off in sequence with the clicking

noises heard from behind the circuit breaker panel. The Captain's PFD/ND and upper ECAM

were mostly unusable. Multiple systems were shutting off and turning back on again. The

autopilot and autothrust failed. The First Officer's PFD and ND stayed useable for most of

the flight but would flicker on occasion. The First Officer's MCDU was useable but the

captains MCDU was not. We were in visual conditions all the way back.

When we put down the landing gear it appeared the aircraft went into alternate law

however this was intermittent. "Use manual pitch trim" was displayed in amber on the

FMA. I observed the trim wheel moving. The flaps and slats worked and the aircraft was

controllable for the approach and landing. Communication with ATC was intermittent due

to the electrical issues. Some uncommanded movement of the rudder was felt by the First

Officer and I noticed some clicking on the rudder pedals during taxi but the aircraft

remained controllable at all times.

After parking and shutting down engine #1 all the electrical issues went away. We

considered shutting off the left generator in flight but there was not enough data available

to support that decision. Also the APU would not start.

Callback: 1

The reporter stated that he believes that Maintenance replaced the generator control panel

to return the aircraft to service. He also discovered after the flight that the QRH does have

a checklist to cover the situation but it is not located in the electrical section. It is in the

section concerning displays.

Synopsis

A320 Captain experienced electrical anomalies during climb to FL350 which resulted in the

intermittent blanking of his PFD, ND and the upper ECAM display. With low ceilings at their

destination, the crew elects to return to their departure airport. The First Officer's displays

remain normal and he becomes the pilot flying for the approach and landing.

ACN: 1359125 (26 of 50)

Time / Day

Date : 201605


Place



Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : HS 125 Series



Flight Plan : IFR

Mission : Ferry




Component

Aircraft Component : Cowling/Nacelle Fasteners, Latches



Person : 1

Reference : 1









Person : 2

Reference : 2









Events







Result.Aircraft : Aircraft Damaged

Assessments




Narrative: 1

Aircraft experienced gradual, uncommanded left roll/yaw at 16,000 ft and 300 KIAS, level

flight, while vectored direct for the Arrival. Continuous light vibration felt throughout

airframe. Slip/skid (ball) indicator displaced completely to the left of center (unusual for a

left yaw situation). No unusual engine or flight control malfunctions or abnormalities

indicated on the MFD/PFD/MWS.

Slowed to 250 KIAS, disengaged Auto Pilot (AP)/ Yaw Damper (YD), and centered the ball

by displacing rudder trim 2 indications to the left. Coordinated diversion with ATC. Aircraft

remained stable with rudder trim 2 indications to the left, rudder pedals difficult to move

as if Yaw Damp still engaged, and vibrations still noticeable. Flew stable visual approach.

ATC arranged for emergency vehicles to be on standby. Landed with no complications.

On post flight, discovered a fastener on the leading edge of an accessory panel, on the

underside of the left engine pylon, became loose and allowed for the leading edge of the

panel to be forced aft. Although it was understandable that the panel could cause the

aircraft to yaw left, it was confusing as to why the slip/skid (ball) indication was indicating

to step on the left pedal and add left trim. Notified ACP, maintenance and steward on

duty.

Narrative: 2


Synopsis

HS125 flight crew on a ferry flight reported experiencing flight anomalies created by an

unfastened panel on the engine pylon.

ACN: 1358171 (27 of 50)

Time / Day

Date : 201605


Place




Aircraft

Reference : X





Mission : Passenger


Component : 1

Aircraft Component : Cockpit Window



Component : 2

Aircraft Component : Headset


Person : 1

Reference : 1











Person : 2

Reference : 2










Events




When Detected.Other


Assessments




Narrative: 1

I was the Pilot Monitoring (PM) for takeoff. Shortly after initiating the takeoff roll, my

sliding window rolled back. When this happened, the window caught my headset wire and

twisted the headset on my head. I turned to check the wire was free, and was then

readjusting it, when suddenly my First Officer (FO) asked me something about my

window. I was not sure, (due to noise and headset position) but I believe it was something

to the effect of if I was closing the window. I responded no. He immediately announced

and conducted a rejected takeoff. I was quite surprised he didn't simply continue the

takeoff as the window could easily have been closed once safely airborne.

Nonetheless, I felt it was prudent, under the circumstances, to simply take control of the

aircraft and complete the rejected takeoff. The reject was uneventful, and we cleared the

runway as requested by Tower. After arriving at a designated stopping point, I reviewed

the rejected takeoff procedure in the QRH. We also looked at brake cooling requirements

in the [flight computer]. On this note, I asked my FO (since I did not see it myself) what

speed he initiated the reject at. He said 75 knots. I believed it was actually at a slightly

higher airspeed, and therefore checked the [flight computer] for speeds of 85 and 90

knots. 85 knots showed 0 brake cooling time required. 90 knots showed nine minutes

required, which by then, we had.

I then checked minimum takeoff fuel, which was not a problem. I informed Dispatch of

what had occurred, and of our intention to continue. The reply via ACARS was "Ok." We

re-accomplished both the Before Push and Before Takeoff Checklists and departed without

further incident.

Preventative Measures: Two big lessons learned here are as follows: First, I should have

announced loudly and clearly "Continue." Yes it was a bit noisy, and my headset was

twisted on my head as a result of the window knocking the wire; however, I could easily

have communicated in a loud enough voice to be heard. In all honesty, while I am aware

that for any anomaly (particularly above 80 knots) this communication is required, due to

the distraction with my headset, and the fact it didn't even cross my mind he would decide

to reject, I did not say "Continue."

Second, I must, in the future, be more "assertive" when checking my window during pre-

flight. As a matter of explanation, I do (and believe I did in this case check the window).

However, as I have observed by many, my technique has never been to bang on the

handle with the side of my fist. Generally, I have always, (unless it appeared the window

was not correctly closed for whatever reason) simply tapped on the handle while visually

determining it is closed. In this case, there seemed no visual indication the window was

not properly closed, yet it obviously was not completely locked in place. I will be much

more cognizant of this possibility in the future and intend to check it by physically grasping

the handle and checking to see it is secure in the locked position.

Narrative: 2

Takeoff [in a] fully loaded -800, flaps 15, First Officer (FO) Pilot Flying (PF). Thrust set at

102.2% N1. As the aircraft started to move, the Captain's side window opened abruptly.

The Captain's response was to shut the window, as FO continued takeoff roll. Captain

remained distracted by open window and now has his back toward the FO. Captain stated,

"I can't close the window!" No [risk management] input, no callouts, no situational

awareness on the part of the Captain. Just complete distracted obsession with closing the

side window.

As PF, I am now also very distracted at all of this, the engine noise at 102% made hearing

the Captain difficult, but still nothing heard except not being able to close the window. I

was expecting to hear "reject," since we were still in the low airspeed regime, but that call,

or the continue call, never happened. I opted to abort on my own. Mind you, it's [a short

runway], and we are accelerating at full power. A decision needed to be made in seconds.

I said, "I'm aborting the takeoff," thrust levers to idle, reverse thrust.

My honest "guess" was airspeed below 80, but in all honesty I couldn't tell, as this all

occurred very quickly, and the distraction was more than I expected. I notified ATC of the

aborted takeoff. The Captain now faced forward, and realized I performed an aborted

takeoff and asked me "why?"

He took the controls. ATC asked us to accelerate to exit at the high speed taxiway. We

complied. ATC asked why we aborted. I told them about the window. On the taxiway, the

Captain again attempted to close his window, while I notified the Flight Attendants (FA),

and made a PA announcement to the passengers. Finally, the Captain got his window shut.

We taxied to the pushback location abeam the gates. The Captain checked the QRH, while

I worked the OPC for brake cooling. I asked the Captain about fuel, and we had enough to

continue. We ran the checklist from "Before Taxi" to "Departure Checklist" again. No brake

cooling was required, so we departed. Take off and flight uneventful.

Preventative Measures: Perhaps a place on the checklist to check Windows; "Doors and

Windows." Response "closed" or "secure." Just a reminder to check them. I really expected

the Captain to abort immediately, after the window opened. We were below 45 knots, as

the airspeed tape didn't even move yet. What's the problem with stopping and fixing this

issue on the taxiway, and then departing? Are we really that pressured to be on time, or

avoid paperwork?

Synopsis

B737-800 flight crew reported rejecting the takeoff when the Captain's side window

opened.

ACN: 1357579 (28 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR




Component

Aircraft Component : Aileron Control System



Person

Reference : 1








Events


Anomaly.Inflight Event / Encounter : Other / Unknown






Assessments



Narrative: 1

During climb and cruise we had what we thought was continuous light chop. The chop did

not subside and it seemed to us that the aircraft's pulsating/bumping movement was too

rhythmic, too steady to be turbulence. We had flown the aircraft 3 legs already with no

anomalies.

My first concern was the rudder as the movement had a fishtail quality to it. ECAM F/CTL

(flight control) page indicated ops normal on the rudder. However, the Captain noticed

that the indicator (carrot) on the left outboard aileron was moving up and down

rhythmically over a short range. The other seven aileron actuator indicators were near

motionless. Flight control computers appeared normal, as did Yellow and Green hydraulics

that powered the aileron.

Convinced that we had a bad left outboard actuator we opted to [advise ATC] and land

before the unit degraded further. The pulsing stopped upon flap extension during approach

and landing and taxi was uneventful.

Synopsis

A330 First Officer reported the flight crew chose to divert to an alternate airport after

noticing abnormal uncommanded aileron movement.

ACN: 1357484 (29 of 50)

Time / Day

Date : 201605


Place

Locale Reference.ATC Facility : ZDV.ARTCC

State Reference : CO


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZDV


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR



Airspace.Class A : ZDV

Person

Reference : 1










Events








Assessments


Primary Problem : Environment - Non Weather Related

Narrative: 1

At FL410 we were cruising with very light Mountain Wave (MTW) at 52 NM west of Pueblo

(PUB) VOR, we then heard (other carrier) request altitude block and deviation for severe

mountain wave encounter at FL390, altitude plus or minus 200 feet, airspeed plus or

minus 30 knots. The location of encounter was at 45 NM west of Pueblo crossing the

Rockies. I did notice very slight variations at FL410, when suddenly this wave hit us (45

NM west of PUB), full strength the airspeed went straight beyond the barber poll 10 knots

into VMO/MMO [maximum operating speed]; speed attained was 252 KIAS or Mach .83.

I did everything in my power to abate the acceleration, ATS-OFF, Power Idle, and SPEED

BRAKES FLIGHT DETENT. Our altitude variation was over 50-180 feet, Denver ARTCC gave

us a 30 degrees offsite vector to the right with a block altitude FL410-390, and we

reported the severe mountain wave. I used Control Wheel Steering Pitch to maintain level

attitude, thereafter over PUB the event receded. It lasted only four seconds, but was

definitely severe and unforecasted at that location. Both Maintenance and Dispatch were

advised and a write up was entered.

Preventative Measures: Better MTW forecast and predictions. Alternate routing. But the

MTW was unpredictable and very localized, seemed in the wake of Pike's Peak.

Synopsis

B737 Captain reported encountering severe mountain wave in the vicinity of PUB that

resulted in speed and altitude excursions.

ACN: 1348361 (30 of 50)

Time / Day

Date : 201604


Place

Locale Reference.Airport : LAS.Airport

State Reference : NV


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : L30


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



Flight Plan : IFR

Mission : Passenger


Route In Use.SID : SHEAD 9

Airspace.Class E : L30

Person

Reference : 1










Events






Assessments

Contributing Factors / Situations : Company Policy


Primary Problem : Company Policy

Narrative: 1

The FO was the PF and I was the PM. Flying out of LAS on the Shead 9 departure ATC

instructed us to level off at 11000 feet instead the usual FL 190 for this departure. Our

new standard operating procedure is to use Cost Index 70 in the FMS which will climb the

plane at 335 KIAS once above 10000 until transitioning to Mach speeds at around FL250

or so. The plane was on autopilot with the FMS in VNAV. After passing 10000 feet the

airplane pitched down to accelerate to 335 KIAS. Once leveling at 11000 the FMS retarded

the autothrottles from climb power to a power setting that would maintain 335 KIAS. Our

VMO is 340 KIAS. So the barberpole and the airspeed indicator needle are almost on top of

each other while in this now "normal" mode. Subsequently ATC cleared us to FL190. I set

the altitude in the altitude pre-selector and the PF engaged the FMS in VNAV climb. The

autothrottles advanced and the aircraft started to pitch up, however, the autothrottles

added the power quicker than the autopilot did the pitching up. I was not "glued" on the

airspeed indicator since the airplane was in the proper automation mode and I was busy

attending to other duties as well (climb-check at 10000, entering proposed times in the

flight-plan log, adjusting cabin temperatures, verifying correct modes on the FMA,

changing the frequencies on Com 2 etc.) I was alerted by the overspeed clacker that we

must have accelerated to our VMO. I looked at the airspeed indicator and saw both

needles on top of each other. The PF promptly adjusted the climb speed on the DFGS to

320 KIAS in order to maintain a more acceptable buffer to our VMO in deviation from our

SOP guidance. I made a logbook entry upon arrival [and] no discrepancies were found.

Our new procedure puts our climb speed with 335 KIAS awfully close to our VMO on every

flight from approx. 10000 MSL until the mid-20s flight levels. That is a long time and gives

the airplane ample opportunities to "accidentally" accelerate to our VMO be it due to

sluggish autopilots, binary autothrottles that know only full forward or aft, sudden

turbulence, windshear, wake turbulence, gusts, inversion layers, embedded convective

activity etc. etc. Ever since that procedure was implemented "every" single FO that I have

flown with since modifies the FMS to climb out at a slower speed than commanded. And

while I agree that this is a good idea it also violates our standard operating procedure.

Why are we implementing a procedure that virtually no pilot feels comfortable following

ever on any single flight? And if you do follow it then you better stay glued to the airspeed

indicator in order to avoid overspeeds while neglecting other duties and a proper scan of

all other flight instruments.

It is my recommendation to implement [the new procedure] for cruise only and use a

more conservative Index for our climb profile. I will from now on override the FMS on

every single climbout in order to maintain a safe buffer between our actual airspeed and

VMO and 335 KIAS is not the number I shall use as it is too close to our overspeed limit

considering the capabilities of our equipment and the fluid dynamics of the ever changing

atmospheric conditions. Given the choice of following a newly implemented procedure or

maintaining a safe airspeed I believe it is in the best interest of safety to do the latter.

Synopsis

MD-80 Captain reported an overspeed in climb that he felt was related to a recent change

in procedure that calls for a high speed climbout.

ACN: 1348155 (31 of 50)

Time / Day

Date : 201604


Place

Locale Reference.Airport : DCA.Airport

State Reference : DC

Environment



Ceiling : CLR

Aircraft

Reference : X



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



Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : FRDMM3

Airspace.Class B : DCA

Person : 1

Reference : 1










Person : 2

Reference : 2










Events

Anomaly.ATC Issue : All Types



Anomaly.Inflight Event / Encounter : Fuel Issue






Assessments


Contributing Factors / Situations : Equipment / Tooling


Primary Problem : Company Policy

Narrative: 1

Upon pushback and normal startup at the departure airport, upon taxi out, ground advised

us of a ground hold into destination airport. We parked on a taxiway and elected to

shutdown both engines, due to the length of the projected ground stop and due to the fact

that the fuel margin between planned and required was so slim. Once finally released

departure was normal. Prior to reaching the initial point for the FRDMM3 arrival, we were

vectored off the arrival. We were then cleared to LETZZ a little further down the arrival

and told to descend via the arrival. This is where things started to become so busy and

confusing.

ATC notified everyone at least 3 to 4 times that runway directions had changed at National

even though National had not published a new ATIS. They were landing south one minute

and north the next, requiring multiple FMS changes and entries.

This is when things started stacking up for ATC. ATC gave us a hold as published 3 miles

prior to the fix they wanted to hold at, which does not allow a proper FMS entry nor even

the ability to scramble and determine the hold via green needles without passing over the

fix. After informing them that it was too close to the fix, they then vectored us off the

arrival and holding fix.

At this point we had sent a [message] to Dispatch and told them we were being held. We

received back that minimum fuel was approximately 3,000 LBS. At this point we had

roughly 3,200-3,300 pounds and that we could only take one turn in the hold if that. We

declared minimum fuel. At this point we were roughly over IAD with 3,100 LBS of fuel.

ATC then gave us a heading for the river and a descent. After being cleared for the river

visual, they turned us off the approach again! We had started to configure at the point, we

were approximately at Flaps 2 with the gear down and around 210 knots and slowing.

After the turn we encountered a turbulent patch of air that [over sped] the flaps by a few

knots for 1 second. We were then turned back and recleared the river visual. Landing

phase was uneventful, turned off the runway with the fuel indications just beginning to

turn amber.

A determination should be established as to why National decided to change runways so

many times during light and variable wind conditions which in turn stacked up arriving

traffic. As well as the margins for fuel have become so stringent that it almost forces an

emergency situation anytime undue and unplanned delays occur, even in a CAVU day.

Narrative: 2

We are not being given enough fuel. This fuel program looks fine on paper, but it doesn't

work. Yesterday we boarded on a perfectly clear day. I didn't save the release to give you

exact numbers, but we had the "planned fuel" that Dispatch gave us. We pushed back

from the gate and started both engines because the departing runway was right behind

us. When Ramp Control turned us over to ground, ground informed us we were in a

ground stop for DCA and long story short it would be about a 25 minute delay. We shut

down both engines, leaving the APU on as our air/electrical source. We contacted Dispatch

and [departure] operations to tell them what was happening. They informed us Center was

the culprit and it was a volume issue.

Finally Ground released us and we started the engines and headed to the runway. The

time from Ground releasing us until the takeoff roll was about four minutes so we didn't

have the engines running for an absurd amount of time. When we crossed the hold short

line we were above the Minimum fuel by about 600 LBS if memory serves me. It may have

been a little more. Either way it was legal and above minimum fuel.

As soon as we were turned over to Departure Control we were given a twenty degree turn

off course. At this point we would be landing with 3,500 LBS of fuel. Center got us on

course only to turn us off course again. Landing fuel would now be 3,400 LBS. [Next]

Center does the same thing. Constant turns and they inform us that Runway 19 is in use

at DCA despite the fact that the ATIS is showing Runway 1. More turns, fuel now 3,300 at

arrival in DCA. I recognize the 2660 rule for declaring minimum fuel (or the reserve plus

the alternate fuel if it is more). But we have no alternate today and the weather is fine. My

mind cannot comprehend why the vectoring.

We check on with Potomac and they tell us the runway is now 1. They are vectoring the

people around us and then they announce holding. He told us to hold at ALWYZ, but I told

him he was too late on the assignment as ALWYZ now sequenced beyond us. He gave us a

south heading and an Expect Further Clearance (EFC) about twenty minutes from now. I

immediately could tell that would not work and informed him we would be diverting.

Dispatch gave us a minimum fuel of 3,004 LBS from where we were to DCA and IAD as an

alternate. We are now scheduled to land at DCA with 3,000 LBS so I told him we would be

diverting to IAD unless he could get us right in to DCA. He says he can and began heading

us east bound. I declared minimum fuel and he told me we were number one for DCA and

we were getting right in. He then switched us to another frequency and this controller said

he was aware we were minimum fuel and we were getting right in. Then he tells us to turn

90 degrees off course. At that point I told him he had ten seconds to figure out what he

was doing. He told us they had switched runways again to Runway 19. This is the fourth

runway change! Then he turns us back toward the river and clears us for the river visual

Runway 19. At this point we are showing 2,900 LBS on landing. As we configure for the

river visual and cross over the American Legion Bridge, he suddenly tells us to turn left

heading 150. I yelled at him. I don't know what I said, but he became nervous and then

gave us a 240 heading. At this point we had a flap over speed with flaps at 2 and speed at

210. It jumped to like 218 for like one second. I don't know how it happened, because

there was so much going on.

Finally he re-clears us for the approach and we landed with around 2,800 LBS. By the time

we got to the gate we were in amber.

I am concerned about this fuel program we have adopted. I feel it has compromised

safety. I have no idea what Potomac Approach was doing, but things happen and if we

would have only had 1,000 more LBS this would have been a non-issue. Our dispatcher

told me, "I will give you more fuel anytime you ask." Again, we were legal per the release,

(which is honestly my only measurement) but we are not given much room for errors or

for unpredictable events.

We wrote up the flap over speed.

Giving us more fuel would have helped a lot.

Synopsis

A regional jet flight crew reported experiencing a minimum fuel condition due to ongoing

delays at the destination airport, which were attributed to multiple runway changes. They

also cited their company's fuel policy as a contributing factor to their fuel situation.

ACN: 1338459 (32 of 50)

Time / Day

Date : 201603


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X






Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZDC

Aircraft : 2

Reference : Y






Flight Plan : IFR

Mission : Passenger



Person

Reference : 1










Events







Assessments



Narrative: 1

Twenty miles in trail of a B777 [at FL340], we got an uncommanded aircraft roll to the

right and altitude loss from wake turbulence.

Callback: 1

Reporter stated wake encounter was in the vicinity of ORF at FL340.

Synopsis

B737 Captain reported his aircraft rolled right and descended after encountering wake

turbulence in trail of a B777 at FL340.

ACN: 1336081 (33 of 50)

Time / Day

Date : 201602


Place

Locale Reference.Airport : SMF.Airport

State Reference : CA


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : SMF


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



Flight Plan : IFR

Mission : Passenger


Airspace.Class C : SMF

Aircraft : 2

Reference : Y

ATC / Advisory.Ground : SMF





Flight Plan : IFR

Flight Phase : Taxi

Person

Reference : 1









Events

Anomaly.Inflight Event / Encounter : Other / Unknown





Assessments





Narrative: 1

I was PM. On taxi out I noticed Aircraft Y parked just clear of 34L, on Taxiway A8. We

proceeded normally for takeoff, completed checklists, and received takeoff clearance for

34L. Aircraft Y was still parked on Taxiway A8 facing east. Our takeoff roll was normal and

we started rotation approximately around Taxiway A10. Passing Taxiway A8, our aircraft

experienced an abrupt left roll due to the jet blast of Aircraft Y. We were approximately

50-100 ft in altitude. Passing 1000 ft, we configured for climb and I mentioned to the

Captain that "I knew that was going to happen." Tower gave us the handoff to departure.

Before switching frequencies, I mention to Tower that even though I assumed Aircraft Y

was at idle power, we received a significant jet blast induced roll at rotation. I also

mentioned that A8 wasn't the smartest place to park Aircraft Y.

I noticed this hazard on taxi out and minimized its significance. I had experienced a similar

situation in a different aircraft over 10 years ago. I failed to mention the hazard to the

Captain and/or Ground Control. I write this ASAP to highlight the hazard for SMF Ground

Control and general Pilot awareness.

Synopsis

Air carrier First Officer reported an uncommanded roll shortly after takeoff due to the

exhaust stream from a parked aircraft with engines running pointed toward the departure

runway.

ACN: 1328335 (34 of 50)

Time / Day

Date : 201601


Place

Locale Reference.Airport : FFZ.Airport

State Reference : AZ


Environment


Light : Daylight

Ceiling : CLR

Aircraft

Reference : X

ATC / Advisory.TRACON : P50

Aircraft Operator : Personal

Make Model Name : Eclipse 500



Flight Plan : IFR

Mission : Passenger



Route In Use.SID : SACAT 1

Airspace.Class D : FFZ

Component

Aircraft Component : FMS/FMC



Person

Reference : 1



Reporter Organization : Personal

Function.Flight Crew : Single Pilot









Events








Assessments




Narrative: 1

Was given the Sacat 1 Departure off of FFZ using runway 22L, approximately 1000 ft AGL

got several CAS warnings, uncommanded trim, landing gear aural warning, and air data

computer fail, the programmed route and navigation was unreliable also. I did not want to

inadvertently fly into Sky Harbor's approach paths and airspace and was assessing the

situation for a possible return to the airport of departure. I made a left turn back towards

the airport of departure and advised the controller that I was having some issues and

requested a heading. The controller gave me direct to Mrbil and to climb to 5000 ft which I

was able to program into the FMS and I was also able to resolve the uncommanded trim

problem. I was in VFR conditions at the time of the deviation and was aware of the terrain

and other traffic.

Synopsis

EA50 pilot reported deviating from his cleared track departing FFZ when he experienced

FMS issues.

ACN: 1327278 (35 of 50)

Time / Day

Date : 201601


Place

Locale Reference.Airport : MTPP.Airport



Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : MTPP


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



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1










Events

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


Anomaly.Ground Event / Encounter : Person / Animal / Bird





Assessments



Narrative: 1

FO was PF. During takeoff roll at MTPP right at rotate speed, a bird in the cockpit suddenly

flew from the Capt.'s left side to cross in front of the Capt., across the window, bumping

off the window/glare shield in front of me, and then headed right toward my face, causing

me to lean out of the way as it brushed by my face while I was pulling the aircraft nose up

through rotation. Aircraft control was not compromised. The bird passed by me, and we

were unable to locate it for the duration of the flight. Presumably it escaped our view in a

small crevasse and perished.

Prior to departing ZZZ for the MTPP turn, the aircraft was on the ground for three days. It

was towed from the maintenance hangar to our gate. As I boarded the aircraft for preflight

duties at ZZZ, ground personnel was attempting to remove a pigeon from the cabin and

apparently succeeded. The electronic maintenance log indicates that a pigeon was

removed from the aircraft, but unclear to me whether that entry refers to the preflight

pigeon or our inflight bird of unknown species. We were aware of no other in-the-aircraft

bird activity.

On the ground in MTPP, ground personnel secured the jet bridge door in the open position

throughout the ground time. There is a remote possibility the bird joined us from there

too. Regardless of where our avian friend originated that day, it most likely entered the

aircraft through open doors, especially if the aircraft was left open for days prior to the

flight. As such, I recommend the review of the existing guidance for leaving aircraft doors

open for extended periods of time and determine if the guidance is inadequate, or simply

not followed in this event.

Synopsis

Air carrier flight crew reported being distracted during takeoff roll by a bird which emerged

from inside the cockpit. Aircraft control was maintained at all times and the bird

subsequently disappeared for the remainder of the flight.

ACN: 1324001 (36 of 50)

Time / Day

Date : 201601


Place

Locale Reference.ATC Facility : KZAK.ARTCC

State Reference : HI


Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : KZAK





Flight Plan : IFR

Mission : Passenger


Route In Use : Oceanic

Airspace.Class A : KZAK

Person

Reference : 1








Events





Result.General : None Reported / Taken

Assessments


Primary Problem : Weather

Narrative: 1

160 nm east of waypoint DUSAC over the Eastern Pacific we experienced a quick moment

of severe turbulence which caused the aircraft to bank as much as 45 deg. Altitude FL370.

Mach .80. Wind 260 @ 110. VMC on top. Layer 4,000 feet or more below us. LNAV/VNAV

on. Autopilot on. Seat belt sign on due to continuous light chop.

Aircraft slowly began to roll (similar to a mountain wave event) which got our attention.

Seconds later aircraft began to bank right excessively and rapidly. Autopilot and

Autothrottle were disengaged and a recovery to straight and level flight was achieved.

Recovery was smooth and forceful but not abrupt. Bank angle may have reached as much

as 45 deg right. Airspeed remained within limits. Descent was arrested manually before -

300 feet. No significant sink rate. Engine instruments normal. No ECIAS or STATUS

messages.

After autopilot reengaged and flight seemed normal, FO called FAs to make sure both they

and pax were okay. No reported injuries. A few minutes later I made a passenger

announcement. No one seemed to care. It just felt like turbulence to them. There were

two aircraft below us at 360 and 350 about 10-20 miles ahead. There was another aircraft

(likely a 737-800) 2,000 feet above us but far enough ahead to be out of TCAS range. In

my professional opinion (25+ years) this was not a wake turbulence event. A blind

announcement was made on guard. As air was again relatively smooth, returned to Mach

.80 speed and continued flight with no further incidences. Normal landing in HNL. No

apparent damage on walk-around.

I think this was a case of wrong place at wrong time. According to WX charts, we were

likely in the vicinity of the crossing of a 120 kt. jet stream at both FL340 and FL410.

Synopsis

B757 Captain reported experiencing an uncommanded 45 degree bank angle at FL370 that

the reporter felt was related to jet stream activity.

ACN: 1321647 (37 of 50)

Time / Day

Date : 201512


Place

Locale Reference.Airport : ORD.Airport

State Reference : IL


Environment

Weather Elements / Visibility : Icing

Weather Elements / Visibility : Snow

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : ORD





Flight Plan : IFR

Mission : Passenger


Aircraft : 2

Reference : Y

ATC / Advisory.Tower : ORD





Flight Plan : IFR


Person

Reference : 1








Events








Assessments




Narrative: 1

[We] encountered uncommanded swerving during the high speed regime of takeoff.

Around 110kts, 24kts below V1, the plane experienced a higher than normal vibration

possibly in the nose wheel and a sudden swerve to the right. I was pilot flying and called

the abort. During the deceleration, control was regained and kept the plane returned to

centerline. The procedure was performed as briefed and as previously practiced in the sim

by complying with the immediate action items. Once stopped, we ran all appropriate

checklists, coordinated with the cabin crew, and established a plan of action. The decision

was made to not attempt to taxi with snow and ice covering taxiways. We requested to

remain on the runway until a tug could pull our aircraft back to a gate. O'Hare Tower,

Maintenance, Dispatch, Cabin crew and passengers were all kept in the loop and aware of

the plan of action. It took about 40 minutes for a tug to hook up to the plane. We gate

returned and had all luggage reloaded to a new aircraft that was available to use as a

swap. The flight continued with the new aircraft with no other abnormal occurrences.

There was winter weather affecting operations. O'Hare tower when clearing us for takeoff

requested [us to] expedite due to spacing with a landing aircraft on 28C. Other than the

uncommanded swerving, there were no other signs of any mechanical issues that were

obvious to the pilots. The swerving could have been caused by wake turbulence from the

aircraft landing 28C. Unsure of the cause, I opted to be tugged back to the gate rather

than taxi with snow and ice on taxiways.

Synopsis

EMB-145LR Captain reported the aircraft swerved suddenly during the takeoff roll possibly

due to wake turbulence from a landing aircraft on an adjacent runway.

ACN: 1317768 (38 of 50)

Time / Day

Date : 201512


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Cargo / Freight


Component

Aircraft Component : AC Generation


Problem : Failed


Person : 1

Reference : 1











Person : 2

Reference : 2










Events







Assessments



Narrative: 1

During the takeoff roll, after calling "Standard Power set" and before the "80 Knots call"

our aircraft experienced a sudden and simultaneous complete electrical failure except for

the emergency/standby battery bus. All we heard in the cockpit was a 'clunk' followed by

complete dark cockpit except for the standby ADI and left radio and one IRU. The Pilot

Flying immediately performed a Rejected Takeoff (RTO) as I called the problems. Using

the remaining radio I called tower and informed them we were aborting and asked if they

could see us. They informed us we were completely 'dark'. As we came to a stop on the

runway the Captain and I analyzed the situation and determined we should start the APU

to get some taxi lights and outside visibility for safety. We accomplished this, got the

utility bus back on line, and with the towers permission taxied back to the ramp area.

This event was caused by the simultaneous coming off line by both generators leaving

battery power only. I have heard that there was a catastrophic failure of one Integrated

Drive Generator (IDG) which caused a surge knocking the other generator off line.

Speaking to our fleet experts after the event I was informed that what we experienced

was 'impossible' but yet it happened. If it had happened 10 seconds later we would have

been airborne with no checklist procedures to follow. Prior to turning the APU on we

confirmed we had no indication of fire with the tower and could not smell any

smoke/fumes. However the maintenance personnel said there was indication of 'burning'

electrical parts. Again, our experts have told us the chances of having a simultaneous dual

gen failure with no warnings is 'impossible' but I would think exploring the art of the

possible is perhaps needed.

Callback: 1

The First Officer expressed his concerns about the lack of a checklist procedure for a dual

generator failure and the response that "it can't happen."

Narrative: 2

During the Takeoff roll on above 40 KIAS and below 80 KIAS we lost all electrical power

simultaneously except for battery power. We were able to exit the runway safely after the

Rejected Takeoff (RTO). We started the APU and performed the applicable QRH procedures

to include referencing the Brake Cooling Chart.

Synopsis

A B757 flight crew experienced a dual generator failure during the takeoff roll and rejected

the takeoff.

ACN: 1317459 (39 of 50)

Time / Day

Date : 201512


Place




Environment

Flight Conditions : Mixed


Light : Dusk

Aircraft

Reference : X






Flight Plan : IFR



Component

Aircraft Component : Trailing Edge Flap



Person : 1

Reference : 1










Person : 2

Reference : 2









Events








Assessments



Narrative: 1

The flight was unremarkable until configuring the flaps [for] landing. We were cleared for

an ILS approach to 4R. The aircraft was stabilized on glideslope and on course at 170

knots approximately eight miles from the runway. I was the Captain and the First Officer

was the Pilot Flying. The aircraft was cleared to land and was configured with the flaps set

to five and the landing gear down. The Pilot Flying (PF) asked for flaps 15. As I moved the

flap lever from the five detent to 15, the aircraft experienced a sudden un-commanded roll

to the right. The First Officer (FO) disconnected the autopilot as the aircraft rolled through

30 degrees of bank. At the same time I moved the flaps back to the five detent. The FO

recovered to a wings level attitude and I informed Tower we needed a heading and

altitude as we had to break off the approach. Tower told us to climb to 3000 feet and

contact Approach Control.

Once the aircraft was climbing, we decided to raise the gear but keep the flaps down. I

asked the FO to take over the radios and continue flying while I worked the QRH. We

briefly discussed what we thought the problem was, and what could have caused the roll.

We briefly considered wake turbulence, but decided it was more likely a flap malfunction

or failure as we were not close to the preceding aircraft on final. It took me a few minutes

to decide which checklist to run from the QRH. (Most of the excellent information that was

in the old QRH is difficult to find as it is not tabbed by system.). I knew that the older

model 737s have an un-commanded roll QRC checklist, but the -700 QRH does not

address this. I did find a reference to un-commanded roll at the beginning of the Trailing

Edge Flap Asymmetry Checklist. It was only one bullet point, but I decided this checklist

was the best one to use for an un-commanded roll after flaps are moved. We ran all of the

items for the checklist through the "Before Landing" portion. I also notified the Flight

Attendants and Passengers, sent an ACARS message to Dispatch, [notified] ATC. The FO

gave me control of the aircraft on a ten mile left downwind. He then reviewed the QRH to

make sure everything was accomplished correctly. We finished configuring the aircraft and

left the flaps at five for the landing.

I have never landed less than 30 flaps, except for in the simulator, so I was not sure what

to expect. I used the HUD on final, and had to keep the thrust levers near idle to keep

from getting fast on glidepath. The flare and touchdown didn't seem very different from a

flaps 30 landing. We taxied clear and told Tower we did not need any further assistance.

We taxied to the gate and finished the shutdown and parking procedures like any other

flight, except we opted to keep the flaps at five in case they were damaged. I did call

Dispatch and Maintenance Control and entered the flap discrepancy in the logbook. One

thing I did not do was pull the cockpit voice recorder circuit breaker. (I did not look at the

event reporting chart until after I was at the hotel and did not realize I was supposed to.)

As far as prevention goes, I do not have a suggestion. However; training for the event and

QRH guidance could be improved. It was very stressful trying to find un-commanded roll

guidance in the -700 QRH. I did not feel it was appropriate to study the AOM while burning

what little gas we had left with the flaps stuck down. Perhaps a blurb could be entered in

the flight control tab directing the Pilot to various conditions that might cause the roll. Also

if it is important for me to pull the circuit breaker on the CRV maybe Company could

emphasize this during training, or have Maintenance Control and/or Dispatch help remind

the pilots.

Narrative: 2


Synopsis

B737-700 flight crew reported experiencing an uncommanded roll during flap extension on

approach. Flight landed with flaps set to position 5.

ACN: 1317203 (40 of 50)

Time / Day

Date : 201512


Place

Locale Reference.Airport : LAX.Airport


Environment

Flight Conditions : Marginal

Light : Night

Aircraft

Reference : X

ATC / Advisory.TRACON : SCT





Flight Plan : IFR

Mission : Passenger


Nav In Use.Localizer/Glideslope/ILS : Runway 24R


Route In Use.STAR : RIIVR 2

Airspace.Class B : LAX

Person

Reference : 1











Events





Detector.Person : Air Traffic Control



Result.Flight Crew : Returned To Clearance

Assessments



Narrative: 1

I was the pilot monitoring. We flew the RIIVR 2 STAR and were cleared for the ILS to 24R

into LAX. We were on a very long final having previously completed all our checklists and

briefings and after we reviewed the waypoints in the FMS crosschecked with the charts. All

of a sudden the aircraft rolled to the left with the autopilot on in a way that was deliberate.

We were in LNAV and VNAV performing "VNAV to the feather." Prior to the roll we were

centered on the lateral course and centered on the vertical path. I noticed that the aircraft

banked to the left and I saw the "noodle" or white lateral course indicator curve in a circle

to the left on the map display. I said something to the Captain and then almost

immediately ATC asked us if we were on course. I replied that our RNAV system banked to

the left on its own. Then the Captain went into heading mode and armed the localized to

capture. That put us back on course and we continued the approach and landed normally.

It all happened very quickly but I would guess that we were still "established" on the LOC

course the entire time especially considering how far away from the runway we were.

I don't know why this occurred. The roll was not associated with an automation mode

change and the FMS points had been verified using the appropriate charts. I was

impressed by how fast ATC noticed a slight course change and asked us about it. It may

have been wake but it was so smooth and deliberate of a roll that my impression is that

this was not wake turbulence.

Synopsis

B757 First Officer reported a track excursion while on autoflight for unknown reasons.

ACN: 1316669 (41 of 50)

Time / Day

Date : 201512


Place




Environment

Flight Conditions : Marginal

Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


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



Component : 1

Aircraft Component : Autopilot



Component : 2

Aircraft Component : Autothrottle/Speed Control



Person : 1

Reference : 1









Human Factors : Fatigue





Person : 2

Reference : 2














Events





Assessments




Narrative: 1

We were established on the localizer to the ILS approach. As we were approaching the FAF

with the glide slope indication of a half dot above the aircraft, I as the Pilot Flying, called

for gear down and flaps to 15. At the point that I thought the Pilot Monitoring lowered the

gear, the autopilot and auto throttles suddenly disconnected. At that point, I tried to figure

out why and didn't noticed that I went through the glide slope to being above the glide

slope. I then applied correction to recapture the glide slope. When I adjusted pitch and

power to capture glide slope, I then noticed that the flight director was not showing in the

PFD. Having directional information still showing in the HUD and having clear sight of the

runway, runway lights and approach light, I elected to continue with hand flying using the

HUD and PAPI lights. I then began to notice that I was getting below the glide slope and

began to correct too much and went above it again. By 1000 feet, I elected to continue

because I still had the runway environment in sight and was correcting back to the glide

slope. By 500 feet, I was still correcting to the glide slope that was below the aircraft, and

because airspeed was under control and still in visual conditions, continued to correct pitch

to catch glide slope and then got an aural "SINK RATE" announcement. Made necessary

pitch adjustment, landed under better control in touchdown zone. I know, in hindsight,

that I should have gone around on a couple of locations on the approach because I was

not stable. I fully admit that my false sense of desire to salvage the unstable approach

caused me to make the poor decision to not go around throughout the approach.

Narrative: 2

I was the Pilot-Monitoring in a B737. We were given a RNAV Arrival, and then we were

vectored to intercept the LOC for the approach. Our set up for the approach was good and

we were "in the green".

The Captain was the Pilot Flying at the time. Approaching the FAF we had the autopilot

and the auto throttles on. Airspeed was approximately 180 KIAS with the flaps at 5. The

LOC was captured and the Glideslope was alive. At 1/2 dot below the glideslope the CA

called for "Gear Down" and just as I reached up to extend the gear, the autopilot and auto

throttles disconnected, and the PFD flight director command bars went out of view. I

extended the gear and we set the flaps to 15. I experienced the "swimming in glue"

feeling of trying to understand what had happened to our well set up approach.

The CA continued flying raw data, hand flying the aircraft and throttles with no flight

directors. I began calling out deviations, LOC tracking and airspeed were good, but

glideslope tracking was problematic. I called "Glideslope" when initially we were slightly

low (approx. 1/2 dot) and then called "Glideslope" again as we became one and then 2

dots high.

Our before landing checklist was complete and we were fully configured before 1000 feet

AGL. We still did not have flight director guidance on the PFD's and the captain was hand

flying the airplane and the throttles. The CA called for me to reset the flight director

switches, but we still couldn't make the flight directors work for us. At this point we had

the runway in sight and we were still too high. The captain called correcting but in

hindsight I should have called for a go around. We were too high and we were descending

too rapidly, it was not a stabilized approach.

Synopsis

The B737 crew experienced an autopilot and autothrottle disconnect at glideslope

intercept, which led to an unstable approach. The Captain elected to land.

ACN: 1313853 (42 of 50)

Time / Day

Date : 201511


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X






Flight Plan : IFR

Mission : Passenger



Aircraft : 2

Reference : Y






Flight Plan : IFR



Person : 1

Reference : 1











Person : 2

Reference : 2











Events





Result.General : Physical Injury / Incapacitation



Assessments



Narrative: 1

We were level at FL280 with a smooth ride. The seat belt sign was off with no complaints

from any other traffic. Quite suddenly, we experienced a very slight roll momentarily,

followed by a couple of sudden moderate jolts. I reached up as quickly as I could to turn

the seat belt sign on. We were then immediately back to smooth air again. We told ATC of

our encounter and if there were any complaints out there. He responded that there were

no complaints all afternoon. We did notice that there was TCAS traffic about 17 miles

ahead and 2,000 ft. above us in a crossing pattern. I can only surmise that we possibly

encountered wake turbulence from that aircraft in front of us, as I have no other plausible

explanation. I called the cabin to check on everybody and found that two flight attendants

had been injured. Our Chief Purser headed to the back of the cabin to find out what

happened. In a little while he called back to tell us that one flight attendant had bruised

his arm or elbow during the event, and another flight attendant had a more substantive

injury. During the turbulence encounter, one of the large serving carts fell over onto her

foot creating an extremely painful injury.

Chief Purser then followed protocol and solicited onboard medical personnel. He wound up

with a paramedic, a nurse, and of all things, a podiatrist. They began attending to the foot

injury, while the Purser initiated a call to Medlink from the back cabin. As they were

working the problem in the back, I was giving Dispatch a heads up on what was taking

place. I advised that we were still waiting to find out about the seriousness of the problem,

and to be prepared for a possible diversion.

We finally heard back from [Chief Purser] and was told that [the foot] injury could be

some sort of fracture but really unsure of that. We were also told that she would definitely

be out of commission for the rest of the flight, with having to keep her foot elevated with

ice application and ibuprofen for pain and swelling. The docs all had decided that it would

probably be safe for continuing on to [destination].

I was concerned that such a long flight at high altitude could cause swelling issues and

pain beyond necessary. [Chief Purser] questioned her a bit more about her uneasiness to

continue, and found that she had just successfully battled cancer with a routine of

chemotherapy. When the onboard docs heard that, they immediately changed their minds

about continuing on. They didn't want to take any chances with possible blood clotting or

other complications. That then made the decision to divert quite easy and prudent. After a

quick call with Dispatch, we decided to divert to [a nearby airport].

Clearance was given right away to proceed direct to [the divert airport]. We proceeded

with the diversion, and began following our own protocol with the FOM [QRH] Diversion

Guide. We also made an announcement to our passengers about what was taking place

and why. At this point, we were about 30 minutes or so from [landing], and began

dumping fuel as we needed to lose 100,000lbs of weight to get down to max landing

weight.

There was medical personnel standing by upon landing. We blocked at gate and medical

personnel came aboard right away and headed back to attend to our injured flight

attendants. Both flight attendants were taken off the aircraft for medical evaluation.

Many thanks to all involved for a successful outcome to this event.

Narrative: 2


Synopsis

B777 flight crew reported two flight attendants were injured when they encountered

probable wake turbulence at FL280 from a crossing aircraft at FL300.

ACN: 1312744 (43 of 50)

Time / Day

Date : 201511


Place

Locale Reference.Airport : ZGGG.Airport


Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZGZU


Make Model Name : Light Transport



Flight Plan : IFR



Route In Use.SID : VIBOS1A

Person

Reference : 1










Events










Assessments



Narrative: 1

This is two events that are rolled into one. It was the 9th day of an around the world trip.

My pairing had just been revised and I was flying the first leg with a new first officer.

Everything was going smoothly until all of the sudden we were behind when closing up the

jet and getting ready for pushback. Prior to receiving the clearance I had entered the

Vibos1g departure off of runway 01 at ZGGG and briefed it and made a mental note to

verify that it was correct when we received the departure clearance. When we got the

clearance we were given the Vibos1a and I guess I got confused and assumed that that

was the one I had entered and briefed. After takeoff, the departure controller started

asking us what departure procedure we were on and there were a couple of transmission

before we figured out what he was asking. He said we were west of course, which didn't

make any sense to us. By the time we figure out what he was saying to us it was too late

and he started vectoring us.

We switched the FMS to the Vibos1a departure right as he started vectoring us. It was

executed but never cleaned up so a disconnect was created after the first point on the

Vibos1g - gg418. After it was executed, the speed restriction was deleted for the turn so

the airplane started to accelerate. We cleaned it up as we passed gg418 and commenced

the turn to the assigned heading of 270. As we passed gg418 and hit the disconnect, the

aircraft reverted to v/s and was in a high enough nose attitude that as we raised the flaps

we entered stick shaker. I disconnected the autopilot and recovered the airplane. We

continued to climb the entire time but it took a few seconds before we got the flight

directors off/on to get a pitch bar back. We went back on the autopilot and the rest of the

flight was uneventful.

It was entirely my fault for entering and then not verifying the correct departure

procedure. That led directly to a chain of events that caused the stick shaker activation. I

made another mistake of going heads down to look at what was entered in the FMS and

left the autopilot unattended at exactly the wrong time and missed the events unfold as

we raised the flaps. I looked up just in time to see our airspeed deteriorate into the foot.

Cumulative fatigue was involved as I do not sleep well on east bound around the world

trips. I did not realize how tired I was until we got to the hotel and slept solidly for 4 hours

but then tossed and turned for several more. I didn't think I was going to sleep at all when

we first got there.

More attention to detail prior to closing up and taxiing. The sudden rush we experienced

just prior to departure could easily have been prevented by just saying "slow down."

Maybe then we would have caught the incorrect departure procedure. I will also not get

complacent and go heads down when I'm the pilot flying - "like we are told repeatedly in

training!" On the fatigue issue, I have been trying to just sleep whenever my body says

too, but I'm still not doing well on east bound long haul trips. West bound I seem to do

much better.

Synopsis

Air Cargo Captain reported speed and track deviations related to fatigue issues.

ACN: 1311216 (44 of 50)

Time / Day

Date : 201511


Place

Locale Reference.ATC Facility : ZOA.ARTCC



Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZOA


Make Model Name : Gulfstream V / G500 / G550



Flight Plan : IFR

Mission : Passenger



Airspace.Class A : ZOA

Aircraft : 2

Reference : Y

ATC / Advisory.Center : ZOA

Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer

Flight Plan : IFR


Airspace.Class A : ZOA

Person

Reference : 1












Events





Assessments



Narrative: 1

Were you aware of the other aircraft before the event? NO X

If so, how? Visual 0 ATC Traffic Advisory 0 TCAS 0 Other 0

What was the position of the OTHER AIRCRAFT, when you encountered wake turbulence?

Level

Flight Level Unknown?

Climbing

Descending

Opposite direction

Unknown Feet above?Unk Miles past

Same direction

Unknown Feet above?Unk Miles in front

Converging

Unknown Feet above?Unk Miles away

Crossing

Unknown Feet above ?Unk Miles in front

Briefly characterize the magnitude of the wake turbulence:

Moderate

Did you experience VERTICAL ACCELERATION?

?YES NO X

What was the change in ALTITUDE? No

What was the change in aircraft ATTITUDE? Estimate angle of change in:

?PITCH 0 ROLL 40 degrees right YAW 0

Was there buffeting? NO X

Was there stick shake? NO X

Was the autopilot engaged? YES X

Was the auto throttle engaged? YES X

Synopsis

G-V Captain reported a wake turbulence encounter at FL320 that resulted in an

uncommanded 40 degree bank.

ACN: 1306332 (45 of 50)

Time / Day

Date : 201510


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR




Component

Aircraft Component : Autoflight Yaw Damper



Person : 1

Reference : 1










Person : 2

Reference : 2







Events









Assessments



Narrative: 1

Climbing through FL270 the aircraft started violently rolling left and right, uncommanded,

and very near uncontrollably. There were no associated messages on the EICAS panel nor

were there any lights illuminated on the overhead panel. What needs to be emphasized

here is that it was very difficult to maintain control of the aircraft and there were no

associated messages notifying us of a problem. We leveled off at FL270, slowed to 250

knots, notified ATC of our deviations and basically just worked to keep the aircraft straight

and level. Quickly, the FO and I determined that the first thing we should do was to isolate

the yaw dampers. After turning the right one off the problem persisted so we switched it

back on and tried the left one. Once it was switched off the problem stopped. At that

point, we notified ATC that we would be remaining at FL270 and would be returning to

normal speed. I called maintenance control and Dispatch to bring them up to speed on our

issue. Maintenance just told us to follow our QRH procedure of which there was none due

to not having any associated EICAS message, and Dispatch asked us if we felt comfortable

continuing on to [a nearby alternate], [to] which I replied yes because we were already

halfway there and had 95 knots of wind on the tail. The rest of the flight was uneventful.

Once on the ground, the mechanic meticulously followed his maintenance procedures

inspecting the aircraft for stress and damage and informed us that maintenance

engineering had pulled the data which apparently did not show a problem with the yaw

damper nor were any exceedences recorded. He ended up deferring the left yaw damper

and we pressed on to [destination].

Narrative: 2

[Report narrative contained no additional information].

Synopsis

B757-200 flight crew reported diverting to a nearby alternate when they experienced

violent nearly uncontrollable rolls in climb at FL270 from a malfunctioning yaw damper.

ACN: 1305550 (46 of 50)

Time / Day

Date : 201510


Place




Environment


Light : Dusk

Aircraft

Reference : X



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



Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Autoflight Yaw Damper



Person

Reference : 1








Human Factors : Training / Qualification





Communication Breakdown.Party2 : Maintenance

Events



Anomaly.Deviation - Procedural : Maintenance




Result.General : Release Refused / Aircraft Not Accepted




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

Assessments





Narrative: 1

Normal flight until we were level at FL260. We felt something that we weren't sure what it

was. It felt like a yaw to the right, but we were in a turn to the left. We called the flight

attendants and asked them if they felt anything weird in the back. They said "no" so we

continued. About 10-12 minutes later we are in level cruise 320kts. The aircraft yawed 3/4

of the brick on the slip indicator to the right. This time the flight attendants felt it and we

knew it was un-commanded yaw. We ran the immediate action item and complied with the

QRH. Land at Nearest Suitable Airport. We [advised ATC] and proceeded to a nearby

airport.

After getting safely on the ground talking to the CFR people and deplaning, we called

maintenance (Mx) control. They in turn called out a local mechanic. He showed up to the

plane with little or no idea of what he was there to do. He asked me if I would mind

swinging the rudder full deflection from left to right using only one hydraulic system at a

time. So, system 1 only on back and forth the same for 2 and then 3. I'm not sure if it's a

coincidence or if he caused this problem by not referencing a task sheet so, I couldn't be

sure if this was an approved procedure or not. But it caused several faults that weren't

there before. Since there was no task sheet that the mechanic had for this procedure it

was unclear if this was normal for this procedure or not, but now we have SSCU 1 and

SSCU 2 fault status messages. He returns to the cockpit with "hey guys great news the

rudder travel is free and clear. You're good to go." The mechanic performing the test of

the rudder with no use of a task sheet made me a little suspicious. Now he has to deal

with the SSCU faults. He is on the phone with MX control. They start performing SPOST

test. The system will not test. They have tried doing this test 4 times. MX control tells the

local mechanic to re-rack the SSCU boxes in the avionics bay. They shut the plane down,

re-rack and restart. The system resets and test correctly. They are all patting themselves

on their backs. Nothing has been done about the yaw damper at all. To be extra vigilant

after one emergency and to prevent another. I ask the local mechanic if he minds showing

me the task sheet that he was given by our company. There wasn't one. Nothing. In the

name of safety, I asked him to please call maintenance control back and have him fax

over the task sheet for testing the yaw damper. After a while he appears with it and

proceeds to run the test on the yaw damper. Finally.

After all of this, I am informed that they tested okay and that they were going to defer the

autopilot system. I asked why? This is a 2 axis autopilot system. That's not going to

correct the problem. We still have the FCC giving signals to the yaw damper servos. After

learning what they are planning to with this aircraft I called [an expert] from [a division of

a manufacturing company]. I called him to confer with him about the aircraft systems.

Just to confirm my thoughts. He offered to speak with MX control to tell him that the route

that he was taking was not the correct. MX control and [the expert] spoke. I then spoke

with [the expert] and he said that he helped point the MX controller in the right direction. I

thought that was the end of the issue. I then have the captain's phone given to me. It's

MX control. He is still going to defer the autopilot against the recommendations of [the

expert]. Then he explains how he had a conference call with someone in engineering,

operations, and Quality assurance. He feels that his work is the best resolution.

At this time I have a major concern I feel like the maintenance controller has a very large

educational gap of our aircraft systems and is trying to use his limited knowledge to try to

strong arm us into flying an unsafe plane. I called [the expert] back he and I are on the

same page he said that he would not take this plane if he were on it. I am of the same

mindset. He then calls [company] and we decided to refuse the plane. [Company] called

the Captain and told him he would back our decision not to operate the aircraft. We did

accept the 2 hour extension to operate the relief flight, but scheduling gave that flight to

the fresher inbound reserve pilots.

My question is why does maintenance think that deferring the autopilot (which does not

disable the FCC's or YD's) would make it safe to dispatch an airplane that had already

experienced a rudder hard over in flight? Shouldn't they have disabled the YD controller?

The threat that mainly exposed itself was the fact that the person in maintenance control

needs further education on the CRJ7/9 systems. I cannot say that this will or cannot

happen again to an aircraft in our fleet. I do hope that this event has shown the weakness

in some of our procedures. Maybe there can be something done about that.

Synopsis

A CRJ-700 crew experienced an uncommanded rudder input at cruise and diverted as per

the QRH. A Contract Mechanic and Company Maintenance Control diagnosed the system

and concluded an autopilot fault. However, this autopilot has no rudder input.

ACN: 1304387 (47 of 50)

Time / Day

Date : 201510


Place




Environment

Light : Daylight

Aircraft

Reference : X


Aircraft Operator : Air Taxi

Make Model Name : BAe 125 Series 800



Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Aeroplane Flight Control



Person

Reference : 1



Reporter Organization : Air Taxi





Events








Assessments




Narrative: 1

At FL400, two hours after takeoff, the First Officer's control stick began several forward

and aft movements as it attempted to trim to maintain altitude. Suddenly, without the

autopilot disconnecting, the nose pitched up and [the aircraft] began an immediate 1500

foot per minute climb. The First Officer disconnected the autopilot but the aircraft reached

between FL404 and FL405 before the climb was stopped. We immediately notified ARTCC

of the altitude diversion and requested a lower altitude to FL280 (out of the RVSM

airspace). The autopilot was not reconnected.

We noticed the pitch trim to be extremely difficult to operate with "catches" in the control.

Extreme stiffness and then a "catch" then stiff movement again. The aileron trim was not

moveable, frozen in position. On landing we noticed the aileron trim seemed free, and the

pitch trim was easily operated.

Speculation may lead to an iced control system. Weather in departure airport was light

rain, overcast at 2100 feet, winds 180/15 with 10 miles visibility and 30.17 inches of

mercury. We did encounter rain on the climbout, but had been clear at FL400 for over an

hour. The temperature at FL400 was -40C.

Complete a maintenance inspection and determine the cause of the flight control/trim

malfunction.

Synopsis

BAE125-850XP First Officer reported possible flight control icing, which led to an altitude

excursion at FL400.

ACN: 1302352 (48 of 50)

Time / Day

Date : 201510


Place

Locale Reference.Airport : LGA.Airport

State Reference : NY

Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : LGA





Flight Plan : IFR

Mission : Passenger



Route In Use.Other

Airspace.Class B : LGA

Person : 1

Reference : 1










Person : 2

Reference : 2










Human Factors : Training / Qualification

Events










Result.Air Traffic Control : Issued Advisory / Alert

Assessments



Narrative: 1

We experienced a lateral deviation while departing LGA Runway 13 on the Whitestone

Climb. We had just started a four day trip and since I had flown the first leg into LGA, this

was the FO's leg as pilot flying. The FO was not familiar with LGA operations so there was

a lot to discuss during our quick turn at LGA. Although our time was compressed, we

discussed everything as thoroughly as possible at the gate.

We pushed back and I taxied slowly so we would have enough time to prepare for

everything else that needed to be addressed. Since we hadn't reviewed the complex single

engine-out procedure at the gate, it took quite a while to find and brief the procedure on

the new EFB but all duties were completed before we reached the runway.

On takeoff the FO over-rotated which was alarming and caused a steep nose up attitude

and possible tail strike situation. I called for a reduction in pitch and monitored the pitch

angle. While my attention was being diverted the FO called for "NAV mode" and I

mistakenly selected "heading" on the FMS control panel. While the FO was attempting to

correct the pitch he called for "autopilot on". The autopilot was selected on but the pitch

was still so high the trim runaway clacker sounded. I had never heard this warning before

with the auto pilot on and this caused further concern.

During this time the aircraft remained on the 180 degree heading while climbing 2,500

feet per minute. This was happening while we were trying to get the pitch, v/s, flaps, and

now increasing air speed under control. We should have been turning to a 40 degree

heading but were still flying 180 degrees. The tower informed us of our mistake and then

gave us a north bound vector.

There was no known conflict and the rest of the flight was uneventful.

Threats were:

- The unique operating environment that LGA presents.

- The fast pace of operations at LGA.

- Multiple complex procedures at LGA.

- The lack of the FO's experience and familiarity.

- My lack of recent experience flying with a new hire pilot.

Errors include:

- FMS entry mistake and lack of recognition by myself.

- Over rotation on takeoff and lack of experience by the FO.

Undesired state:

The aircraft remaining on a 180 degree heading instead of turning to 40 degrees.

LGA requires that both pilots bring their "A" game and operate at 100% all of the time. I

will have to up my game when operating into LGA. I need to always select the correct

modes on the FMS and I must be especially vigilant when flying with an inexperienced FO.

The company could possibly prevent this from happening by providing more training or

exposure to new hires.

Narrative: 2

[Report narrative contained no additional information].

Synopsis

CRJ-700 flight crew reported they deviated from cleared departure track out of LGA when

they were distracted at a critical time.

ACN: 1300945 (49 of 50)

Time / Day

Date : 201510


Place



Relative Position.Angle.Radial : 080

Relative Position.Distance.Nautical Miles : 1


Environment



Light : Night


Aircraft

Reference : X



Make Model Name : B767-300 and 300 ER


Flight Plan : IFR



Airspace.Class C : ZZZ

Component



Problem : Failed

Person : 1

Reference : 1










Person : 2

Reference : 2











Events








Assessments



Narrative: 1

The takeoff was done by the Captain. Due to the heavy weight of 365,000 lbs and obstacle

departure procedure we elected to use a maximum thrust takeoff setting. Takeoff roll and

rotation was normal. At 400 feet we selected LNAV and commenced the right turn for the

departure. At approximately 600-700 feet AGL, in the right turn, there was a slight jerk to

the left and the aircraft stopped turning. We both verified the left engine had quit. The

engine failure was sudden and without warning. There were no abnormal indications prior

to the engine failure. After verifying what happened we were over our turn point for the

special engine out procedure. Heading select was called for and we continued the right

turn. At this point we contacted ATC and advised them of our intention to fly the 206

heading. We continued the climb to level off height and began to speed up and clean up

the aircraft. At this time we also confirmed that the left engine had flamed out. We

coordinated with ATC for a higher altitude and began to run the "Engine failure/Shutown"

checklist.

We both agreed that attempting a restart would be time consuming and distracting, and

going to [destination] was obviously not an option anymore. We made the decision to land

single engine back in ZZZ. After finishing the "Engine failure/Shutdown" checklist we

consulted the Non-Normal Configuration Landing Distance Table. We were going to land at

approximately 360,000 lbs, about 32,000 lbs over weight. We had virtually no center tank

fuel to dump and we were still feeding the good engine with what was left in the center

tank which was about 3,000 lbs. We asked for and were given the longest runway for

landing which gave us about 2,000 feet more runway for the overweight landing. The

approach and landing were uneventful. Manual brake usage was used on rollout and were

what I would describe as minimal. Deceleration was normal with maximum reverse thrust

used on the right engine. After turning left we informed the tower we would let the fire

crew examine the left engine. At this time we were informed by fire crew that there was

fluid leaking out of the left engine. Also at this time fire crew notified us of smoking left

brakes. Not wanting a pool of fuel by the hot brakes we cleared the fire crew away and

continued the taxi, very slowly, East towards the ramp to cool the brakes. The hottest

brake temperature we saw on the left was one 9 and three 8's. The right side was mostly

5 and 6. While taxing we were informed that the leak was still there. With brakes as hot as

they were, the possibility of fuel leaking and the potential for thermal plug discharge, we

elected to stop the aircraft and chock the aircraft. While waiting for ground support the

brakes cooled to reasonable levels. That's when the thermal plugs started to blow. The

brake temperatures at this time were one 7 and three 6's. We lost 3 tires on the left side

while waiting for ground support.

Narrative: 2

[Report Narrative Contained No Additional Information.]

Synopsis

B767-300 flight crew experiences a sudden engine failure at 700 feet AGL after takeoff.

The engine is shut down and the flight returns to the departure airport for an overweight

landing. ARFF reports fluid leaking from the shut down engine and three of the four tires

on that truck deflate due to temperature.

ACN: 1299693 (50 of 50)

Time / Day

Date : 201510


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Training


Maintenance Status.Maintenance Deferred : N

Maintenance Status.Released For Service : Y

Component : 1

Aircraft Component : Throttle/Power Level

Manufacturer :


Component : 2

Aircraft Component : Thrust Reverser Control

Manufacturer :


Component : 3

Aircraft Component : Powerplant Fuel Control

Manufacturer : GE CF-34


Person : 1

Reference : 1









Person : 2

Reference : 2





Function.Flight Crew : Check Pilot






Events





When Detected.Other


Assessments



Narrative: 1

We were on approach to landing Runway 27. I was pilot flying. The approach was normal,

in the flare I brought the thrust levers to idle at the appropriate time. The left thrust lever

stopped at idle and the right continued slightly. When I went to deploy reverse thrust, the

left reverser deployed and the right thrust lever went back a little bit more. The Captain

took control of the airplane when only the left reverser deployed. After we were pulled off

the runway, I saw the right engine was in shutdown and the engine was spooling down.

We stopped on the parallel taxiway and restarted the engine before taxiing back to the

gate.

Narrative: 2

First Officer (FO) was the Pilot Flying and I was the PM giving instruction. Approaching

Runway 27 everything looked really good, FO was doing a good job keeping airspeed and

keeping the aircraft on glideslope. Touchdown was firm and on centerline and well within

our standards. I was guarding the flight controls with my feet on the rudder pedals and

hand on the yoke. My right hand was down low on the lower pedestal just in case I needed

to take over and add power. After main wheels touchdown FO brought the nose wheel

down nice and gentle. On the roll out, FO deployed thrust reversers with only the left

deploying. I looked down at the switches and both reversers where armed. Rolling down

the FO told me there was a split on the power levers and it was then that I realized the

right engine was shut down. I took over the controls and taxied off the runway. I never

saw the FO pull the [shut-off] trigger and I always saw his hand on top of the power

levers. I really do not know how the right engine shut down. I really cannot say what the

cause of this was, since Standard Operations Procedures (SOP) was followed. FO or I

never pulled the trigger to shut down the engine. FO and I retraced our steps and could

not come up with an explanation on what could have caused the right engine to shut down

while on the rollout.

Callback: 2

Reporter stated the First Officer was in training and transitioning from Turboprops to their

CRJ-700 aircraft. The aircraft and FO were performing just fine when the right engine

suddenly shutdown. He has thought over and over again about the sequence of steps they

had accomplished prior to the engine event and cannot find any reason for the shutdown

except for an inadvertent contact with the shut-off trigger handle (switch) on the lower aft

side of the engine throttle lever. All the more frustrating because the First Officer had

performed very well and neither he, nor the FO could remember ever touching the shut-off

trigger. Since the right engine restarted without any problems and no EICAS fault

messages appeared, the possible movement of the right engine shut-off trigger seems to

be the only plausible explanation.

Synopsis

A First Officer and Check Pilot reported a sudden, unexplained shutdown of the right

engine on a CRJ-700 aircraft during the landing rollout on a training flight. The Check Pilot

noted he never saw the FO pull the right engine shut-off trigger and only observed the

First Officer's hand on top of the power levers.

Multi-Engine Turbojet Aircraft Upsets Incidents

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