Light Transport; Low Wing; 2 Turbojet Eng

Air Traffic Control Time Certified In Pos 1 (yrs) 21

Air Traffic Control Time Certified In Pos 1 (yrs) 9

Confusion; Situational Awareness; Communication Breakdown

Party1 Flight Crew; Party1 ATC; Party2 Flight Crew; Party2 ATC

ATC Issue All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew FLC complied w / Automation / Advisory

Working an arrival sequence. Waiting on Aircraft X to check on to descend from 34000 feet to 31000 feet. Aircraft Y checks on at 33000 feet. My attention was on Aircraft X to descend to get down under traffic. I inadvertently issued descent clearance to Aircraft Y on his initial check on to 31000 feet thinking it was Aircraft X. Aircraft Z was westbound at 32000 feet. Aircraft Y reported a TCAS Alert and that he was going to stop his descent; I advised him to please stop his descent and maintain 33000 feet. At the time I believed it was a pilot deviation on Aircraft Y until Aircraft X finally checks on at 34000 feet.Needed to exercise more patience to issue a clearance; and make sure it is to the correct aircraft.

I was the supervisor in charge of the area. Two sectors were combined. Combining these sectors at this time of night is not unusual during this time of the year. Traffic was moderate and fairly complex. Predicting traffic complexity in these sectors is difficult. In order to predict traffic volume for these sectors I look at the En Route Decision Support Tool (EDST) to see what mix of overflight and arrival traffic is coming and look at the departure list in our low altitude sectors to try to predict the volume of departure traffic. Traffic was departing slowly from ZZZ that night. The monitor alert function does not work for these sectors and hasn't since I returned to the center two years ago. It is a known problem. The radar controller had over 25 years experience and is a Controller-In-Charge and Instructor. There was training on the Radar Assist position. The Radar Assist position Instructor also has over 25 years experience. I check on these sectors regularly if I have them combined on evening shifts and did not feel the volume or complexity was an issue. I heard the radar controller question a flight crew. The controller sounded pretty upset. He asked for the pilot deviation phraseology card we keep at the supervisors' desk. He had two same company flights on frequency and said that one of them took the other's clearance even though the flight numbers were not close. He told me Aircraft X got a TCAS RA from a flight beneath him. The Radar Assist position printed out strips on the Aircraft X and Aircraft Y flights. I took the strips to the watch desk and advised the operations manager of the situation. The operations manager enters reports and takes calls from the pilots. As I returned to the area I was advised by a supervisor from the area handling the Aircraft Y flight that they had responded to an RA as well. I relieved the radar controller with the next person back from break so he could fill out a TCAS questionnaire and [safety report] prior to leaving for the night. I learned from the operations manager that reviewed the FALCON and audio shortly afterwards that the controller issued the descent clearance to the wrong flight. The controller was over 9 hours into a 10 hour shift on his second evening shift of the week at the time of the incident. A review of the Radar Assist position audio indicated they were on a landline coordinating when the clearance was issued to the wrong aircraft. I'm not sure what I can do differently to prevent something like this from re-occurring. I will encourage controllers I work with to issue traffic more often even if it is not required by merging target procedures. In this case the targets did not merge. Their closest proximity was around 2 miles. I feel that had Aircraft X been issued traffic they would have questioned the subsequent descent clearance. The next time I take a familiarization trip I will encourage the flight crews to take a quick glance at their TCAS when issued an altitude change en-route. Splitting the sectors would have meant that the radar controller would have been on position even longer at the end of his day. I have already been questioned about my staffing of the area. That is the first thing the facility looks at whenever there is an incident. Specifically the facility looks at how many controllers were on break that could have been staffing more radar positions or Radar Assist positions. I feel that staffing the area appropriately means finding a good balance between having enough positions open that the controllers are not too busy and not having so many open that they are not engaged. I also think that over-staffing the area and leaving controllers on position longer as a result has risks. That being said I will have to staff the area more conservatively for a while as I am anticipating getting a performance discussion as a result of this incident. I stay in the area a lot and ensure I am in the area during peak traffic periods. I feel this is my responsibility as a supervisor but also means I am more at risk for being counseled on how I staff the area.

While waiting for an aircraft to check in on frequency; another aircraft of the same company checked on to the frequency at 33000 feet. The Controller inadvertently descended this aircraft to 31000 feet resulting in a TCAS alert for conflicting traffic. The Controller then advised the descending aircraft to maintain 33000 feet.


Automation Aircraft Other Automation; Person Flight Crew

Flight Crew Landed in Emergency Condition; General Declared Emergency; General Maintenance Action

On climbout/normal departure passing approximately 13;000 feet MSL; the 'B' hydraulic system engine 2 pump low pressure light illuminated.  The QRH was complied with.  A minute or two afterward; the 'B' system electric pump low pressure light flickered and then remained illuminated.  We checked the hydraulic gauges and noted the 'B' system needle was erratic and then settled between 1/4 and 1/2 full.  The First Officer continued flying and communicating with ATC.  The flight attendants were notified.  I addressed the QRH for the 'B' system failure.  We initially leveled off at 16;000 feet MSL and then continued to FL220.  Coordinating with Dispatch and Maintenance; the 'A' and standby hydraulic systems functioning normally and after working through our malfunction; being near the halfway point; I decided to continue to our destination and a longer runway.  The QRH checklist was completed and reviewed and a request was made with Approach Control to have emergency equipment standing by as a precaution.  Transfer of control of the aircraft was accomplished; landing and go-around procedures reviewed; and an uneventful flaps 15 recovery was made.  Maintenance was at the gate to receive the aircraft.

On climbout; passing approximately 13;000 feet MSL; the 'B' hydraulic system engine 2 pump low pressure light illuminated.  The 'A' autopilot was engaged and the QRH was complied with.  One to two minutes later; the 'B' system electric pump low pressure light flickered and then remained illuminated.  The 'B' hydraulic gauges were erratic and the 'B' system needle settled at 3/8 full.  I flew and communicated with ATC while the Captain notified the flight attendants and ran the QRH.  We initially leveled off at 16;000 feet; but continued up to 22;000 feet for a better ride. The Captain coordinated with Dispatch and Maintenance who agreed that the best course of action was to continue to our scheduled destination (about halfway there at this point; clear weather and longer runway as opposed to returning with TRW in area).  Requested emergency equipment standing by as a precaution.  On vectors to final; the Captain took control of the aircraft for the approach and landing.  Uneventful flaps 15 landing was made. Taxied normally to the gate leaving flaps in 15 position.  Maintenance met the aircraft at the gate.

B737-300 flight crew experiences the loss of the B hydraulic system during climb.  After securing both pumps the flight continues to destination (short flight) for landing with the B system inoperative and the flaps at 15 degrees.


Party1 Dispatch; Party2 Ground Personnel

Deviation / Discrepancy - Procedural Weight And Balance; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Hazardous Material Violation

ZZZ hub failed to advise that there was dry ice loaded in forward belly so that appropriate over burn could be applied. Cause: Hub didn't do their part; I don't know why. Other-action-taken: Ran new numbers applying the .4 percent over burn and sent to crew as release amendment and documented issue in shift note.

Air Carrier Dispatcher reported Load Planning failed to notify Dispatch that dry ice was loaded on aircraft prior to departure.


Flight Crew Air Transport Pilot (ATP); Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 60; Flight Crew Total 4500; Flight Crew Type 650

Confusion; Distraction; Situational Awareness

Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Altitude Overshoot; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Issued Advisory / Alert; Aircraft Equipment Problem Dissipated; Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem; Flight Crew Took Evasive Action

We were departing and after takeoff from Runway 15 assigned a heading 050 and climb and maintain 2;000 FT. After taking off the Captain was making a left turn from runway heading 15 to a heading of 050 and climbing to assigned altitude of 2;000 and had just completed the Takeoff Checklist. This would have been around 1;500 FT. At this time airplane began to lose power instantly and the Captain was concerned for the loss of both engines. The Captain started a left turn back to the airport and was climbing for altitude. After approximately 20 seconds to 45 seconds he was able to figure out that we had an inadvertent activation of the APR system on both engines. When I deactivated the APR system both engines did a large roll back on power; causing the feeling of losing both engines. At that point we were at altitude of about 2;800 FT and a heading of about 030. The Captain was turning back to the assigned heading and starting to head back down to the assigned altitude. The Controller made contact with us and said we were supposed to maintain heading of 050 and altitude of 2;000 FT and now climb and maintain 5;000 and contact Approach. After contacting Approach the Controller cleared us to climb and then gave us a phone number to call. We did not have any aircraft conflicts or TCAS advisories. We continued on with flight and contacted when we landed.

An HS-125-800 APR (Auto Performance Reserve) system was in inadvertently activated and at about 1;500 FT the First Officer turned the System OFF which caused a surprise power reduction similar to a dual engine failure. The Captain initiated a return to land but when he realized what had happened continued the departure.


Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance

Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Aircraft; Environment - Non Weather Related

While cruising at FL320; I noticed the 'APPR 2 NOT AVAILABLE' advisory repeatedly showing up on ICAS; followed by the ALT flag on my Primary Flight Display (I was the pilot flying). We were enroute via Q40 in the vicinity of Meridian (MEI). This message called for 'crew awareness ' in accordance with our Quick Reference Handbook. For a few seconds we began to experience altitude variations on the plus and minus sides thus making it impossible to maintain assigned altitude. I asked [the Captain] to request a lower altitude so we could leave RVSM in view of the problem we were experiencing. We were cleared to FL280 and although the advisory would show up once more; the aircraft maintained altitude and no further issues appeared.Shortly after; we heard on the radio another aircraft also requesting altitude change as they could not maintain their assigned altitude either; in the same area we experienced our problem. A few moments later; we heard a [a third] flight asking the Controller if he had knowledge of any problems in that area as they lost their Autopilot and several others systems and were unable to maintain altitude. I think that same flight landed after us and there were firetrucks waiting for its arrival.We discussed the problem during the flight and wondered if this issue was related to a 5G network implementation or something similar. We don't know. I noticed in the area around the fix MISLE; there are several tall antennas; around the area we had this problem. Perhaps look into this 5G network issue more closely and how it possibly affects aircraft at high altitude.

On the Q40 airway between the MISLE nav/fix and BFOLO nav/fix we experienced the 'Approach 2 not available' cyan message on ICAS which indicates crew awareness per the Quick Reference Handbook. Shortly thereafter we experienced attitude; airspeed and auto throttle fluctuations. We notified ATC and requested FL280. We then got permission to leave RVSM. Using the FPA mode and disconnecting the auto throttles we descended to FL280. Although the advisory message appeared once more on the ICAS; everything appeared normal at FL280.Shortly after we heard [another aircraft] report the same issue to ATC. They also had issues maintaining airspeed and altitude and also requested leaving RVSM. We switched Controllers afterwards and then heard [a third aircraft] reporting the same issue except they had more severe fluctuations including the loss of autopilot. Our flight was uneventful at FL280. I reached out to [the third aircraft] to ask of their approximate location and occurrences and it appeared that they had lost their autopilot and some other messages appeared on their screen as well. They were also on the Q40 airway and experienced issues in the same area north of Tuscaloosa Alabama near MEI. [The third aircraft requested special handling] and was number two to land.

Air carrier flight crew reported autoflight anomalies in cruise flight in the vicinity of MEI VORTAC; citing 5G interference as possibly contributing.  Reporter noted that two other air carrier flights in the same area were experiencing similar issues.


Automation Aircraft RA; Automation Aircraft TA

Human Factors; Environment - Non Weather Related

On our initial climbout of Las Vegas airport we were cleared to takeoff from Runway 26R. I don't remember if ATC told us about a traffic on the far end of the runway or not; anyhow we were cleared for takeoff. After rotation we raised the landing gear and before we could raise the flaps we had a TA for traffic that was initially 800 feet below us but the distance was closing in; my First Officer (FO) promptly turned on the remaining lights and started to look for the traffic. Considering the pitched up attitude and the night environment of Las Vegas strip it was hard to visually acquire the traffic.  Few seconds later the Traffic Alert (TA) became an RA and I was commanded to climb. I think I was at about 150 KIAS; I made sure to have enough speed to climb without stalling the plane; I did; so I pitched up the plane and followed the command bar. My FO quickly called the Tower to let them know about the event and everything was quickly concluded with no disruption for the flight. The event was concluded in a matter of a few seconds and I think we came within 500 feet vertically from the other traffic. I think it was an helicopter but I'm not sure. I don't know if the other traffic did not respect the Tower instruction or if the separation was not enough; but I don't think I did anything wrong to cause this event.

EMB-175 Captain reported an airborne conflict with another aircraft departing LAS.


Flight Crew Commercial; Flight Crew Flight Instructor; Flight Crew Multiengine; Flight Crew Instrument

Flight Crew Last 90 Days 152; Flight Crew Total 2022; Flight Crew Type 155

Ground Event / Encounter Object; Ground Excursion Runway; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Object

Aircraft Aircraft Damaged; General Maintenance Action

I decided to land at the uncontrolled airport to the north [on Runway 34]. The winds were out of the northeast between 30 and 40 knots on the ground. At this airport moderate or greater mechanical turbulence can be expected below 1;500-2;000 feet when there are strong winds out of the northwest or northeast quadrants; I expected this. From my 4;500 foot cruise altitude; I began a stabilized descent to pattern altitude; the entire descent was in smooth air. I overflew the airport at 1;000 feet still in unexpectedly smooth air and made a left turn to enter the left downwind. The initial descent in the traffic pattern was also in smooth air. However; about half way through base leg turbulence began to develop. The turbulence was not consistent with what one might expect from the reported wind condition. In my experience; it was more consistent with a 20 knot surface wind. I rolled out on final in a stabilized descent and the VASI indicated I was on glidepath. My alignment with the runway was slightly left of the left-side runway edge lights as a result of the right crosswind so I corrected by increasing the crab angle of the aircraft farther to the right; the aircraft began drifting back towards the runway center. When I crossed the runway threshold; I was over the left side of the runway and transitioning from a crab to a forward slip. The aircraft was still drifting right towards the center of the runway once the forward slip was established; and I intended to continue drifting to the center of the runway and then execute a normal crosswind landing. However; the aircraft touched down prematurely on the left side of the runway. Since I had not started the landing flare the impact was firm and resulted in a bounce. I increased right rudder to maintain directional control and added power to prevent a porpoise and soften the subsequent touchdown. As the pitch attitude lowered; the runway came back into full view; and the aircraft made contact with the runway again; it was clear that the aircraft was now being blown back to the left and was nearing the edge of the runway. I input full right rudder; increased right aileron; and began to increase power to try and keep the aircraft on the runway; however; the limited response time and strong crosswind kept pushing the aircraft left. The airframe and/or propeller began striking the runway edge lights; and I elected to close the throttle and not attempt a go around and aggravate an already bad situation. Instead; I tried to keep the aircraft on the runway as long as possible and slow the airplane as much as possible. Eventually the left main caught the soft snow on the side of the runway and the airplane turned to the left and came to a rest and the bottom of the small embankment on the side of the runway.

A C-207 pilot landing at night with strong gusty crosswinds on a lighted but questionably maintained gravel airstrip in Alaska lost control of the aircraft and exited the left side of the runway; striking runway edge lights with the aircraft and/or the propeller while doing so.


Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP)

Distraction; Situational Awareness; Confusion

Deviation / Discrepancy - Procedural Published Material / Policy

Environment - Non Weather Related; Human Factors; Procedure

I was PM for this leg back to ZZZ1. We were cleared for takeoff on Runway XX; lined up on the runway; and I gave the controls to the FO. He set the thrust levers to CLIMB and called 'set thrust.' I checked the stack and verified the N1 indications were in the carats and stated 'thrust set.' I failed to push the thrust levers into the TOGA detent and neither of us noticed. The remainder of the takeoff was uneventful. When performing the after takeoff flow I realized that the thrust levers were already in the climb detent.This was my first trip on the type aircraft since being checked out earlier this month. I have exclusively flown the different version of aircraft type for the last X months and have not become accustomed to setting the thrust in Aircraft X compared to the previous type aircraft. I was a type Y aircraft FO before upgrading into this type aircraft so my time in all three variants is very limited. I had only done three legs in this type aircraft as PM before today; the rest of the legs being as PF to practice landings. My habit of pushing the thrust levers past the climb detent and into the TOGA detent has not been set yet; as for the majority of my legs I was only setting them to CLIMB; then the PM pushing them up to TOGA before I put my hand back.I need to fly this type aircraft more often to become/stay proficient. It also would have been better to do OE in this type of aircraft sooner to start those habits earlier and not get into such a groove in only the other type aircraft. I guarantee I will never make the same mistake again as it was quite a shock when I realized what I had/had not done.

Air carrier Captain reported failing to push the thrust levers into the TOGA detent before takeoff.


Small Aircraft; Low Wing; 1 Eng; Fixed Gear

Air Traffic Control Time Certified In Pos 1 (yrs) 6

Situational Awareness; Communication Breakdown

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance

Aircraft X was a departure filed at a final altitude at 6000 feet. The filed altitude was too low for this destination and was amended by the departure controller to 11;000 feet. The aircraft departed and was told leaving 4200 feet proceed on course. The aircraft leveled at 6000 feet and had entered a higher MVA (Minimum Vectoring Altitude) when I realized he had leveled at which point I had the aircraft execute an expedited climb to the appropriate altitude and sent him off to the next sector without any incident.In addition to being more vigilant myself during times of low traffic volume I would recommend that the tower issue more appropriate altitudes for direction of flight on the ground.

EUG TRACON Controller reported an aircraft that should have been climbing to 11000 feet leveled off at 6000 feet which was below the MVA.


Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP); Flight Crew Flight Instructor

Flight Crew Last 90 Days 50; Flight Crew Total 8600; Flight Crew Type 25

Flight Crew Last 90 Days 25; Flight Crew Total 13800; Flight Crew Type 600

Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Provided Assistance; Flight Crew Regained Aircraft Control; Flight Crew Took Evasive Action

Level at FL350 en route we were on a vector from ATC to avoid the area of buildups ahead of us. We were in instrument conditions when we started to encounter severe turbulence with downdrafts that decreased our altitude to about 34;650 FT on the altimeter. I was going to disconnect the autopilot; but the PIC advised against it and said to let it ride it out and then he informed ATC that we were unable to maintain our RVSM assigned altitude of FL350. ATC then assigned us a block altitude of FL340-350 and advised us we should be exiting the weather soon. Our onboard weather avoidance equipment did not show any activity at our altitude and position and because of the IMC conditions we were unable to visually locate any activity. Shortly thereafter we exited the weather in to VFR conditions.

One minute severe turbulence; altitude variations up to 400 FT; advised ATC unable to maintain RVSM separation and requested /received clearance to deviate 30 degrees left to avoid turbulence area. Turbulence stopped after one minute and normal operations resumed; no other problems noted.

A CE-501 encountered severe turbulence for one minute at FL350 and advised ATC they were unable to maintain RVSM because of altitude variations up to 400 FT.


Maintenance Airframe; Maintenance Powerplant

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Object

Company Policy; Staffing; Human Factors; Environment - Non Weather Related

I was contracting under Company contracting company to Air Carrier X for line maintenance at ZZZ airport. Last night we were sent to the Air Carrier Y's hangar to do an engine wash on a CRJ-900 aircraft.We had two scissor lifts around the #1 engine to install a vinyl water trap to said engine to collect the solution used to wash the engine blades and deposit it into a container placed under it. We were on the ramp working at night without adequate lighting conditions installing it. Instead of doing this procedure in a well-lighted hangar; they decided not to move it in and do it on the ramp. I positioned my lift at the aft of the engine and was positioning the vinyl covering over the aft engine tailpipe section. I misjudged by an inch and as I came up the railing of the lift just caught the underside of the tailpipe causing a dent in it.I took photos and promptly reported it to my Supervisor [Person #1]. He told me to make a report and take pictures of damaged section. Once back to the office; I was instructed to fill out a logbook entry for Aircraft X in the logbook stating damage dimensions; etc. so that appropriate action could be taken. Today when I showed up for work; the day-shift line Supervisor [Person #2] asked for my badge; as since I was just a contractor; I must be let go for damage to the aircraft.I have always been told to report damage or accidents promptly to management for safety reasons. I; personally; know that hundreds of lives are at stake and should report any damage incurred during maintenance procedures. The night-shift Supervisor [Person #1] was chastising me and my partner last night for not getting the fan blades removed from another aircraft within an hour of starting when the same procedure a couple of days before took us four and a half hours to remove and replace. It took us time to get to the hangar on the other side of the airport; set up tables; get equipment required for the procedure; etc. before we could even start.These people want to rush the mechanics on very critical jobs and it's very unsafe. Especially since we are expected to work 13.5 hr. shifts then get up and do it again! This is the first time in all the years I've been an A&P mechanic that I've ever had this type of accident. Very surprised that doing the right thing for safety purposes would lead to termination of your job. Guess that honesty doesn't pay in the end.

Maintenance Technician reported being let go after using scissor lift which contacted CRJ-900 engine tail pipe causing damage.


Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Air Transport Pilot (ATP)

Aircraft Equipment Problem Critical; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Automation Aircraft Other Automation; Person Air Traffic Control

Flight Crew Overcame Equipment Problem; General Maintenance Action

After landing and taxiing towards our parking spot the we got indications of an APU fire. The APU was running and supplying electrical power to the aircraft. Almost simultaneously with the fire warning ground control called and said [they] could see smoke coming from the tail of the aircraft. The Captain stopped the aircraft set the brakes and called for the APU FIRE QRC. We ran the items and the fire was immediately extinguished. We then called for fire department support and was happy to see them already at the aircraft as the Ground Control called them for us. After confirming the fire was out; we taxied into our spot and shut down the aircraft.   It was great to see how fast the Ground Controller was there to confirm our fire suspicions and to call local fire rescue for us. [Other personnel] were on the scene so fast that if an evacuation would have been necessary; they would have been a great help to us.

On taxi to freight facility after landing got a APU fire warning closely followed by ZZZ Ground informing us that there was smoke coming from the tail area of the aircraft. Stopped the jet; asked ATC to roll the fire equipment and completed the APU FIRE QRC followed by the QRH. We discharged one fire retardant bottle. The fire warning went away and ground personnel indicated there was no further evidence of fire. We taxied to parking spot and shut down.   Did not [request priority] as we were already on the ground and required no priority handling. We did call immediately for fire trucks to come to our location.Simulator training works well and prepared us for the event. Cannot overstate the great help available from the ground controller and fire department.

B737-700 flight crew reported that an APU fire began during taxi and was extinguished after the crew ran the applicable procedure.


Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Maintenance

[Maintenance Technicians] were working off of EMB 175 Maintenance Manual 32-11-05 to install the side stay on the left hand main landing gear. The side stay upper section was already installed; and the lower section was sitting on a table behind the left wing. According to the manual; you place the lower section into position and slide the pin through into the upper section; lower section; and the down lock arm and torque the through bolt. The manual does not state that the orientation of the grease fittings is of any consequence. If it had; this problem would not have occurred. I also referred to images attached to the Aircraft Maintenance Manual; and nowhere is there even an image showing the correct orientation. I would like to see [part orientation information] added to the Maintenance Manuals in the near future to stop this from occurring again.

The Aircraft Maintenance Manual did not provide the part detail sufficient to prevent the incorrect orientation and subsequent damage to landing gear components.


Aircraft Equipment Problem Less Severe; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Provided Assistance; Aircraft Aircraft Damaged; Flight Crew Landed As Precaution; Flight Crew Overcame Equipment Problem; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Departure Airport; General Maintenance Action

Departing PHL during climb out Passing 6;000 ft. to 12;000 ft. we experienced heavy rain with moderate turbulence and possible hail that resulted on a cracked [right] windshield panel (First Officer window). The breakage of the window activated an ECAM message related to the window heat. QRH procedures were performed. Due to the broken outer windshield we decided to divert back to the departing airport (PHL) circumnavigating the weather on the west side an landing VFR on Runway 9R 20 minutes later. There was no need to request priority handling due to the fact the inner panel of the windshield was intact.[The] previous aircraft being vectored in front of us reported turbulence also; but there was no place to deviate [at] that point since ATC was vectoring us between two precipitation cells.I was flying a basic A319 with a basic radar. If our radar would be one of the enhanced newer 320 or 321 with an advance radar with a better resolution we would have avoided this high precipitation and moderate turbulence area.

Radar vectors on climb out from PHL runway 09L. Climbing through 6000 feet; given vector following previously departing traffic through a gap in two weather systems. Assigned climb to 12000 feet; previous departing aircraft ahead of us reported moderate turbulence on climb out. Shortly afterwards encountered moderate turbulence and the right windscreen cracked; accompanied by a failure of the right windscreen anti ice system. FO visibility not impaired through right windscreen. Exited the weather and leveled off at 12000. Requested descent to 10000 and vectors back to PHL. Completed ECAM actions and QRH follow ups; contacted dispatch and PHL operations. Coordinated with ATC to descend and vector around the backside of the weather to the west and returned to PHL 09R.[The] weather in the terminal area south east of the airport developed faster than expected. The weather radar in the older 319s does not have the same fidelity and clarity that the newer aircraft weather radar systems have.

A319 flight crew reported a windshield crack that resulted in a return to the departure airport.


Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem

After a normal landing; the flight control annunciator illuminated during taxi to gate. Looked up and both hydraulic B switches were off and engine heat was on. Turned hydraulic B switches on and engine heat off. I assume this occurred during after landing flow as there were no amber lights on during approach or with a master recall. Approach and landing felt normal.

While taxiing in; the Captain noticed the Feel Diff Press caution light was illuminated and the #2 hydraulic pressure was low. He then noticed that both #2 hydraulic pump switches were off. I believe that on my after-landing flow I reached up to turn off the engine anti-ice switches; but grabbed the hydraulic pump switches by mistake. When we turned on the hydraulic pumps; the caution light extinguished and the system operated normally. In my mind; there is a slight chance the pumps were turned off in flight; but this seems unlikely because I don't remember intending to turn off the anti-ice until after landing.My insufficient attention to detail in confirming the correct switches was the main cause of the problem. I had also forgotten to wait to do the after-landing flow until after crossing all runways with taxi instructions received and understood. I will remember from this event to wait until the appropriate time to perform procedures; and to always visually confirm every switch before moving it.

After a normal landing the flight control annunciator illuminated during taxi to gate. Upon checking the overhead both hydraulic B switches were found off and engine heat was on. The First Officer believes he may have made a mistake on the after landing flow.


Any Unknown or Unlisted Aircraft Manufacturer

Flight Crew Last 90 Days 237; Flight Crew Type 3000

Flight Crew Last 90 Days 320; Flight Crew Type 4950

Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude

Air Traffic Control Issued Advisory / Alert; Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory

On the RMBLR Departure out of Atlanta; ATC leveled us off at 8;000 FT MSL. While at 8;000 FT MSL; another aircraft was vectored over us at approximately 8;500 FT. ATC did not call out the traffic to us. We received an RA 'Descend Now' Advisory. I complied with the advisory and started a 2;000 FPM descent into the green arc on the VSI. I descended to approximately 7;600 FT and the Resolution Advisory ceased. We informed ATC of the event and then climbed back up to our assigned altitude. We believe the other aircraft's descent rate caused our system to trigger the RA.

Prior to our departure from ATL; Tower changed our altitude clearance from 10;000 FT to 8;000 FT without explanation. Departure Control also verified that our clearance was 8;000 FT. As we leveled at 8;000 FT; we received first a caution; then a descend command from our TCAS to which the First Officer; as the pilot flying; responded. I called our TCAS directed descent to Departure and they responded with a traffic callout of VFR traffic at 8;500 FT. When the TCAS reported 'Clear of Conflict;' we returned to 8;000 FT.I have never seen 500 FT of separation in level flight not cause a TCAS RA. 500 FT of separation satisfies everything except the TCAS. Controllers should be made aware of this issue; and the TCAS logic that requires an RA in this situation should be re-examined. In the interim; pilots should continue to respond to the RA as we have been trained.

B737 flight crew leveling at 8;000 FT experiences a TCAS RA due to VFR traffic at 8;500 FT and descends.


ATC Issue All Types; Airspace Violation All Types; Conflict Airborne Conflict; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Issued New Clearance; Air Traffic Control Separated Traffic

Leveled a B737 at FL220 and stopped a Citation V at FL230. They were separated. Handed the Citation V off to Sector 60 and they descended the Citation V down to eleven thousand right on top of my B737 without control. In response; I climbed my B737 to FL270 in order to avoid a mid air collision. Possibly evaluate and establish some procedures that may include a 'Look and Go' option that could enhance the current operation with minimum coordination. All too often; Sectors in close proximity rely on verbal confirmation to a request; but do not have anything concrete or an established procedure in an SOP.

ZME Controller described a loss of separation event when an aircraft handed off to an adjacent sector was descended without coordination; the reporter suggesting some type of 'Look and Go' coordination procedure be established.


Medium Large Transport; Low Wing; 2 Turbojet Eng

FMS Or FMC; GPS; Localizer/Glideslope/ILS Runway 6

Party1 Dispatch; Party2 Flight Crew; Party2 ATC

Workload; Confusion; Communication Breakdown

Party1 Flight Crew; Party2 ATC; Party2 Dispatch

ATC Issue All Types; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance

Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Requested ATC Assistance / Clarification

Airport; ATC Equipment / Nav Facility / Buildings; Human Factors; Procedure

Prior to push I was notified by the crew about the GS on Runway 6 being NOTAM'd OTS at FPO/MYGF. I asked the CA if he wanted me to send him the NOTAMs packet via acars I would do so; but the only thing that I saw regarding the Glideslope at the destination was that it would be OTS only during the hours of construction which this would not be affected by. We both agreed that the flight could be completed safely and proceeded on with the flight. At this point; since I was not asked to send the packet of NOTAMs I was under the assumption that the CA was simply asking verification on the situation. Once on the ground I received a call from the CA who told me that Nassau Center instructed them to intercept the the GS while on the ILS and was cleared for approach; and it was at this point that they realized the GS was OTS. When they brought this up to someone on the ground they were told that it was in fact not operational. I'm not sure if the information given by [our software] is inaccurate or if the NOTAM simply hasn't been generated.Going off of the information available to us; I don't necessarily feel that myself or the crew did anything wrong in this situation. From the NOTAMs available to me; I didn't see any potential issues; and the crew was instructed to intercept the GS from Nassau Center while on approach.

After being cleared for the ILS 06 approach we captured the glideslope and started descending earlier than we should have. We realized we were too low on the approach around 900 feet and started to climb back to around 1300 feet to intercept a normal glide path. We notified Tower the GS was not working. They said they know. We verified with the paperwork and dispatch that the GS was not NOTAMed out today. We were also cleared for the ILS 06 Z approach.

Air carrier Captain and Dispatcher reported that after commencing the MYGF Runway 06 ILS the Captain discovered the glideslope was out of service and ATC confirmed. The flight crew and Dispatcher referenced the NOTAM before departure which stated the glideslope would not be OTS at the time of their arrival.


Flight Crew Air Transport Pilot (ATP); Flight Crew Multiengine; Flight Crew Instrument

Human-Machine Interface; Situational Awareness; Workload; Time Pressure

Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Issued Advisory / Alert; Flight Crew Took Evasive Action

Abeam the airport level at 8000 ft.; the Captain prompted me to start slowing; I activated the approach speeds in preparation for configuration and descent. I added a last second briefing item about configurations and we got a descent clearance in the middle of that briefing. I misunderstood the descent clearance as 4000 ft.; instead of 5000; I consequently set 4000 in the altitude selector. We got a vector during the descent as expected; we got ICE Speeds as we broke out of the overcast; about 5000 ft. and the Captain was entering those and cleaning up the FMS for the approach. I was heads-up and saw the city lights so I had no cause for concern. At 4500 ft. ATC gave us an ALT Alert; low altitude; climb 5000. I used the TCS (Touch Control Steering) button to override the automation and asked the captain to set 5000 ft. and we climbed back up. There was no GPWS alert and the ground was in visual reference. The rest of the approach proceeded without incident. As the aircraft was slowing I remembered the that I had not briefed when I would call for 'gear down/flap 3; and when I would be fully configured for landing; due to the non-standard RA readings to [Runway] XXR - where the TDZE is elevated from the terrain west of the threshold. I asked the Captain to verify my math and confirm if by 4300 ft. (1500AFE) would be gear-down/f3 altitude; which is notably before to FAF ZZZZZ; and landing config just after ZZZZZ. A similar briefing as I would give in ZZZ1; but I had forgotten to do this in the original briefing. As the Captain was verifying this for me we got a descent clearance; 'descend 5000'; that I heard at the time as 'descend 4000'. We began descending and I was expecting a vector any moment. We were leaving 8000 ft. and we were NW of ZZZ; and the vector would take us away from terrain; so in the task saturation of entering ice speeds at the same time as getting a vector; I failed to recognize that the altitude I had set was 4000 and the final approach altitude was actually 4100. That would usually make me question what I thought I heard. We broke out of the clouds it was VMC and I had even less concern because our vector was taking us inside of ZZZZZ1. I am pretty sure that when I was asking the Captain earlier to double check the configuration altitudes; we both got 4000 stuck in our heads; because that was about where the configs would be taking place. Seeing the city and having the tasks completed helped me relax; but I still did not catch that we had set the selector 100 ft. lower than the final segment altitude; which would usually be a red-flag that I had misunderstood something and need double check. The Tower alerted us that we were low and we promptly corrected as the Captain set 5000 ft. and I TCS'd to initiate the climb. Adding somewhat complex briefings during a final segment of STAR to approach caused misunderstanding of the clearance and at the same time degraded my situational awareness of clues that would alert to a misunderstanding. As so often does; it went from a gradual deceleration for configuration; to everything happening at once; distracting us with ice speeds; vectors and FMS management; especially the PM (Pilot Monitoring) can become severely task saturated in an instant. Even though I was intending to cover the late addition to the briefing while things were still relatively quiet; I distracted the captain and myself by doing so at that time. If I recognize that I have omitted something from the briefing; I should transfer controls; and abbreviate the points I need to address. At the [time] I brought it up; I was trying to abbreviate it and I thought we had sufficient time; which quickly changed. Verifying altitudes that are assigned with charted altitudes as a cross-reference needs to become a habit of mine; so that I don't ever set an altitude 100 ft. lower than FAF altitude again.

ERJ-175 First Officer reported receiving a low altitude alert from ATC when the aircraft descended below the Final Approach Fix (FAF) as a result of the First Officer having set an incorrect FAF altitude.


While on arrival; cleared to descend from 8000 FT to 7000 FT and slow to 210 KTS. Observed on TCAS the aircraft 10 miles ahead of us encounter traffic climbing to their altitude. A resolution advisory was declared by Aircraft Z with subsequent change in TCAS readouts by both aircraft. Transmissions by Aircraft Z asking clarification of positive control of the intruding Aircraft Y led me to believe it was a VFR aircraft attempting to fly very near the base of the clouds which we were flying in. Subsequently the intruder Aircraft Y (which had descended to 6000 FT after its near encounter with Aircraft Z); was seen approaching our flight on TCAS. At approximately 5 miles and closing; the intruder Aircraft Y display showed a climb from 6000 FT which would place Aircraft Y in the clouds which we were then flying through. FO queried ATC and requested a turn which ATC granted; a right turn to 090. I turned the heading knob to 090 and pulled; starting the right turn and immediately recognized a rapidly devolving situation. Pressing the autopilot instinctive disconnect button I steepened the bank to 45 degrees and began a climb while commanding 'flight directors off.' At about the same time a RA was alerted by TCAS; followed by the command 'Monitor vertical speed.' We climbed at approximately 2000-3000 FT per min for about 15-20 seconds before the TCAS reported 'Clear of conflict.'; at which time we leveled off (about 8000 FT); and notified ATC of our ability to resume the arrival. No further incidents occurred. The closest distance I saw displayed was 0 miles and 300 ft. Recognizing the possibility that the intruder  Aircraft Y did not have TCAS or would not respond properly to a TCAS event; I chose to continue the turn while climbing; in order to gain 'angles off' the intruder's heading. I believe this to have been the proper course of action. FO made telephone contact with the ATC controller on duty at the time of the incident and was told the Aircraft Y was flying VFR and the proper authorities had been notified to meet him upon arrival. A VFR pilot was attempting to penetrate IMC conditions in order to gain 'VFR on top'; without proper communications and subsequent authorization. In doing so he unwittingly flew his aircraft opposite direction to a major arrival route into one of the busiest airports in the nation. All VFR pilots flying in the vicinity of major airports and their arrival/departure corridors need to be made aware of the risks involved regarding separation of general aviation and commercial/business aircraft. All too often; a VFR pilot wanders into the path of a large aircraft and the events mentioned here happen all over again.

A320 crew experienced an NMAC while on initial descent for approach and landing.  Crew experienced an RA after receiving evasive heading change from ATC. After clear of conflict crew continued the approach and landing.


Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance

CLT ramp personnel dropped Cargo Load Report (CLR) off in cockpit and the CLR stated: 57 standard check; 0 heavy checked and 11 gate checked bags in the forward cargo hold. 0 bags loaded in the aft cargo hold. The number seemed reasonable to me so it didn't raise any red flags in my head. After landing; I went down on the ramp to find out why the gate checked bags were not off loaded. I noticed ramp offloading 23 bags from the aft cargo hold that were a mix of gate and checked bags. I went back on aircraft to verify what was on the CLR. The CLR was filled out incorrectly.The person filling out the CLR [should] physically verify bags [are] or [are] not in each cargo hold.  [Then] the crew [should] physically check cargo holds if they think the CLR might be in error.

[Report narrative contained no additional information.]

ERJ-170 flight crew reported they discovered after arrival that the load manifest they departed with was not accurate.


Flight Crew Last 90 Days 180; Flight Crew Total 27000; Flight Crew Type 4500

Confusion; Human-Machine Interface; Communication Breakdown; Situational Awareness

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Other / Unknown; Inflight Event / Encounter Fuel Issue

Flight Crew FLC Overrode Automation; Flight Crew Overcame Equipment Problem

Aircraft; Chart Or Publication; Human Factors; Procedure

As I've previously reported on many occasions; the FAA insists upon creating and utilizing charted arrival procedures which have no 'end point.' Our FMC interprets this lack of an end point to add approximately 90 miles; 1;000 LBS of fuel burn and as much as a 30 minute longer ETA into the FMC arrival calculations. Once again; on my arrival at ORD this afternoon; the FMC displayed a 50 mile error; 1;000 LBS landing fuel discrepancy; and 20 minute arrival time error. Upon discovering and verifying this error in flight; I requested and received a clearance change eliminating the BULLZ 3 arrival and adding the Janesville 5 arrival; thus eliminating the multiple errors.

The reporter compared the BULLZ and JANESVILLE arrivals to illustrate the problem. The JANESVILLE STAR; for arrivals from the west; shows a last 36 NM leg from KRENA direct to ORD. A balloon note pointing at the airport advises flight crews to 'expect radar vectors; etc.' Until a runway is selected the FMC computes the route distance; fuel burn; etc. just to the airport via KRENA. The BULLZ STAR; on the other hand; also contains routes from the west but ends with fixes comprising downwind legs which take the aircraft some distance east of the airport before concluding with a continued downwind heading and the 'expect radar vectors...' balloon note. Reporter advises that; while en route and until a landing runway is selected; the FMS appears to 'assume roughly 90 NM of additional flight distance and associated fuel burn beyond the last downwind waypoint.The problem he associates with this predictive FMC methodology occurs when a flight is: 1. dispatched with minimum fuel reserves; and 2. en route weather or other delays unexpectedly increase the en route flight time. When those two factors co-exist the FMC computed arrival fuel will be reduced and; if the reduction is great enough; may force the flight crew to consider diverting for fuel prematurely.

A B757-200 Captain expressed his concern that the programing by which FMCs determine ETAs and arrival fuels is inordinately affected by the manner in which the selected STAR is constructed; some prescribing a direct route from the last fix direct to the airport and others ending at downwind legs from which the FMC assigns a conservative longer enroute time and applies the commensurate additional fuel burn to the predicted arrival fuel.


Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Provided Assistance; Flight Crew Returned To Clearance

Procedure; Equipment / Tooling; Human Factors; Aircraft

Aircraft X was IFR at 8;000 5NM W of TALLI intersection. Aircraft X advised that his ACARD went out and came back then went out again. Aircraft X said that he did not need to declare an emergency he just needed to descend to VFR conditions to see what the problem with his equipment was. I descended Aircraft X to 7;000 and then gave him a turn to 320 and continued his descent to 6;000. Aircraft X had some VFR conditions in the area and wanted to continue descent to avoid the clouds. I gave Aircraft X descent to 4;000 and advise me if he needed any other assistance to remain in the VMC conditions during his descent. He then asked to descend to 3;500 and the MVA in the area that was 3;700; I told him about the MVA and descended him to 3;700. I verified that the MVA was at 3;700 and gave Aircraft X the altimeter due to his altitude showing him descending below 3;700 on the scope. Aircraft X responded that he was climbing back up to 3;700 and wanted vectors towards [a nearby] airport. I gave Aircraft X a heading of 150 and maintain 3;700. Position Relieve briefing was started at this time and I gave the next controller all the information about Aircraft X and his intentions to remain in VMC conditions. Before the end of the position relief briefing I gave Aircraft X a heading of 180 and maintain 3;700; vectoring him towards an area with an MVA of 3;400 if he needed to descend anymore. I stayed in the TRACON to see if the next controller needed any assistance with the position.No recommendations to prevent the re-occurrence of this event due to it being an equipment malfunction.

AVP TRACON Controller reported an IFR aircraft with avionics trouble descending below the Minimum Vectoring Altitude.


Aircraft Equipment Problem Less Severe; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Maintenance

After working to resolve several avionics problems with the aircraft involving the Thrust Management/Autothrottle system and the Takeoff Speed display; we attempted a normal takeoff. Upon reaching somewhere between 65 and 75 KIAS on my (Captain-pilot flying) side; the First Officer (FO) called '95 Knots.' I immediately performed a Rejected Takeoff and exited the runway. We did note that there was an airspeed discrepancy as we slowed. It appeared that the FO's was incorrect; as it did not seem as if we had enough time to accelerate to 95 KIAS compared to other takeoffs. After exiting the runway; all checklists and procedures were complied with and brake energy charts were cross-referenced. We taxied back to parking.

A B757-200 Captain rejected the takeoff at about 70 KTS when the First Officer called 95kts. Maintenance had worked avionics issues to resolve an autothrottle system and takeoff speed display anomalies.


Confusion; Training / Qualification; Situational Awareness

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Unstabilized Approach

Flight Crew Regained Aircraft Control; Flight Crew Executed Go Around / Missed Approach

Weather; Human Factors; Procedure; Company Policy

IOE (initial operating) student was attempting a flaps 22 landing. During the approach; gusty winds from outer bands of an approaching hurricane contributed to an unstable approach and generating two glide slope EGPWS annunciations. We initiated a missed approach and were put in sequence to reattempt the approach. The vectors from the second approach brought us in above the glideslope. We engaged the vs (vertical speed) mode initially at 1;200 feet per minute (per GOM) and then 1;000 feet per minute as we closed in on the glide slope and stabilized approach criteria. The student had NAV armed; not APP; which as PM (pilot monitoring) I should have caught. My attention was briefly diverted to reassessing our fuel; which was 200 pounds over final divert at the final approach fix. At 1;000; instruments cross checked; the GS (glideslope) was exact (though not captured). At this point; we had been in visual conditions for several minutes. The runway did not have visual guidance (PAPI nor VASI); I looked out the window to verify the runway was clear; of which I annunciated. At approximately 700 feet AGL; we fell below the glide slope; generating additional glide slope EGPWS annunciations. Due to the winds; fuel nature; incoming weather; and diversion airport expecting similar conditions; I used my command authority to take control of the airplane; reestablish ourselves on the glide path; and land without further incident.

EMB-145 Captain reported an unstabilized approach due to gusty conditions.


Communication Breakdown; Confusion; Other / Unknown

Party1 Flight Crew; Party2 Ground Personnel; Party2 Other

Deviation / Discrepancy - Procedural Published Material / Policy

Environment - Non Weather Related; Company Policy; Human Factors

Due to the world pandemic; national health emergency; and concept of social distancing; I decided for the safety of our passengers and flight attendants not to do a cabin service during our flight. I had the same flight attendants the day before and we discussed how we could best; and safely; manage our long flight to ZZZ1. As I approached the ZZZ Operations Agent; I presented the idea to him and asked him if he was comfortable making an announcement to the passengers to encourage the purchase of drinks or snacks as needed for the long flight. He seemed to understand and was willing to make an announcement.Once down the jetway; I was approached by two ZZZ station managers who expressed concerns with it not being company policy and that it might panic our passengers. I assured them that I understood and if they were not comfortable making the announcement; that was fine. One of them suggested that a modified announcement could be made to encourage getting something to eat for the long flight. I agreed and said it was their call on how to handle it. During my preflight preparations for the flight to ZZZ1; I received a call from the Chief Pilot on call. He asked if I had permission from someone at Company for what I was doing.I shared with him the timeline of how over the last four days I had tried to get Company approval; and also discussed my reasoning. He did not agree and said it was not Company policy. I reminded him that this was a national emergency. My understanding of the conversation's conclusion was that I have Captain's authority to do what is safe for the flight; but need to be ready to explain what I did. I told him that I understood. The flight to ZZZ1 was uneventful and we passed out cans of water at the halfway point. The passengers seemed very appreciative of our efforts and approach to the pandemic upon deplaning.

Air Carrier Captain reported the crew made the decision to suspend in-flight service for COVID-19 social distancing reasons contrary to company policy.


Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP); Flight Crew Flight Instructor

Flight Crew Last 90 Days 60; Flight Crew Total 3073; Flight Crew Type 2000

Human-Machine Interface; Training / Qualification

Aircraft Equipment Problem Critical; Inflight Event / Encounter Fuel Issue

Flight Crew Landed in Emergency Condition; General Maintenance Action; General Declared Emergency

I was on a training flight with a student pilot who does not yet have a student pilot certificate.  This was our ninth flight together during which we practiced landings; steep turns; VOR course intercepts; and navigation. After completing our training for the day; we were departing the training area and on our way back to the airport.  While listening to ATIS outside of the Bravo airspace we had engine trouble which led to engine failure.  At the first sign of engine trouble the flight time was at 1.6 hours. We began the flight with an estimated 2.5 hours fuel on board (~20 gallons).  I estimated that at the time of engine failure we had used approximately 14 gallons of fuel and had approximately 6 gallons of fuel remaining or at least another 45 minutes of fuel aboard.  Nonetheless; I assumed control of the aircraft and turned back [toward a nearby airfield we had just passed].  We declared an emergency due to engine failure and landed the aircraft in a farmers plowed dirt field.  There were two souls on board; neither of whom received any injuries.  Also; no damage occurred to the aircraft.  The following day a Mechanic from the FAA inspected the aircraft on the field and found no mechanical problems with the aircraft and presumed the engine failure occurred due to fuel starvation.  Fuel was added and the aircraft was flown under its own power off the field back to base.  It was then returned to service.I believed that a fuel leak could have been a contributing factor to the incident as I am certain we began our flight with approximately 20 gallons aboard.  I was shocked to know that the engine failure occurred due to a lack of fuel.  We had only been in flight for 1.6 hours and the aircraft only burns approximately 6.9 gallons per hour.

An instructor pilot and his student suffered engine failure due to fuel starvation.  They had estimated they had 2.5 hours of fuel on board at departure; yet the engine failed only 1.6 hours into the flight.


Flight Crew Diverted; Flight Crew Landed in Emergency Condition; General Declared Emergency

During our approach after selecting Flaps 20 on a visual approach; the Status message SLAT/FLAP MAINTEN message appeared on the EICAS. A Go around was executed. The QRH was referenced and the procedure completed. We elected to divert to land at an airport with longer runways; and with crash and rescue services. The company was contacted and the proper coordination was made. An emergency was declared with ATC as a precaution. The QRH directed us to do a zero flap landing procedure. A landing assessment was completed by the crew. Company decided that PIC should make the landing. Landing was uneventful. No evacuation was necessary.

G200 First Officer reports a diversion to an airport with a long runway after a status message SLAT/FLAP MAINTEN appeared on the EICAS during approach.


Training / Qualification; Situational Awareness

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

On arrival into MROC while dodging buildups and thunderstorms; we were cleared to fly the VOR DME Runway 07 to transition to the (RNAV-F) Runway 25 after TOMAS to land on runway 25. Neither pilot had ever accomplished this combination approach/circle VFR maneuver before. We broke out of the weather and maintained VFR from CYRUS inbound at 4;000 feet. At the time we were Flaps 10 and 160 knots. We should have been fully configured per company policy as we were actually 1;000 feet AGL. The normal urgency was not present as we were not yet abeam the field straight and level on downwind and we were more concerned with the approach being flown correctly; our situation awareness with respect to the mountains and the weather. As the 1;000 foot annunciation sounded; I directed the First Officer to climb up 200 feet to place us above 1;000 foot AGL and we established final configuration in straight and level flight; well before midfield downwind. I felt this was the more prudent course of action rather than executing a missed approach into weather and mountainous terrain in all quadrants from this unfamiliar location. We maintained VFR throughout the misstep and correction and the remainder of the approach and landing was normal.We should have executed the VOR DME approach as if we were landing on runway 07; configuring the aircraft correctly; rather than flying the approach as if it were the feeder to the RNAV approach. We thoroughly debriefed the event after landing.

Air carrier flight crew reported not fully configuring the aircraft at the appropriate time per company procedures during a circling maneuver off the VOR DME Runway 07 at MROC to land Runway 25. The procedure calls for the pattern to be flown at 4;000 MSL which is less than 1;000 feet AGL.


Large Transport; Low Wing; 2 Turbojet Eng

ATC Issue All Types; Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude

Automation Aircraft TA; Person Flight Crew

Flight from SAN. Climbing on the POGGI 5 RNAV departure. Out of 12;000 feet on our way to assigned altitude of 14;000 feet the departure controller queried whether we could maintain current rate of climb all the way to 14;000 which we answered yes. Current rate was 2200 FPM and I selected VS to maintain the climb as requested. A traffic TA was activated for an aircraft preparing to drop skydivers at our 11 o'clock and approximately 5 miles. As we leveled at 14;000 feet I decided this traffic might be a factor and disengaged the autopilot and began a climb just as the TCAS entered the RA mode of 'monitor vertical speed'. The captain notified ATC we were climbing for traffic; and we were issued a higher altitude. The captain had the other aircraft in sight and said it was no factor. Once clear of the conflict; the flight continued normally with no further comment from ATC.It all happened pretty fast; but this seems to be a poor setup for the departure. If the skydiving operation is known to be near this departure corridor; a minimum altitude on the SID which is above the known drop zone at a point before reaching the drop zone would ensure this doesn't happen again. Also; I believe the controller probably meant to issue us an altitude assignment of 15;000 but had only given us 14;000. 15;000 would have avoided this issue all together and is actually published as the top altitude on the SID.

We were cleared to 14;000 feet climbing out on the Poggi 5 departure from SAN departure control. While passing 12;000 feet ATC asked us if we could hold our current climb rate through 14;000. We replied 'yes' and continued our 2;200 FPM on our climb. Approaching 14;000 feet I saw an aircraft indicating our altitude on the TCAS. I contacted ATC and asked if he wanted us to climb higher. He replied with climb to FL230. I then saw the traffic just as the TCAS RA went off telling us to monitor our vertical speed. The FO took over and manually continued the climb which kept us within the RA parameters. The other aircraft was in sight and was never a factor in our climb. ATC then switched us to another frequency without further comment.

Air carrier flight crew experienced an airborne conflict and TCAS RA after level-off following the POGGI 5 RNAV departure procedure. Conflicting aircraft was preparing to drop skydivers from the same altitude. ATC issued clearance for a higher altitude.


ATC Issue All Types; Deviation - Altitude Overshoot; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Weather / Turbulence

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Returned To Clearance; Flight Crew Executed Go Around / Missed Approach

Descending around thunderstorms; Tower told us to slow to approach speed for a departing aircraft. Notified by Tower approaching 1000 feet of abrupt wind shift which would give us a 17 knot tailwind. The airplane in position on the runway requested the winds again and decided not to launch. We realized the winds were out of limits for our approach; and notified tower around 1000 feet AGL of our intention to go around. Tower said that we didn't need to do that; but just to climb to 2500 feet and continue; but go around was already initiated using TOGA levers. The pilot monitoring was changing the altitude from the 3500 feet we had previously set for a visual missed to 2500 feet as assigned as I was trying to hit altitude hold. Signals got crossed and I elected to hand fly as the airplane was now climbing quite rapidly. There was some confusion on the radio as to what heading we were to fly and how the controller wanted us to return to land in the opposite direction; and the distraction of trying to get the airplane out of [go around] mode (heading select) led to an overshoot of 500 feet on the level off. We were VMC with no separation issues; and Tower did not comment except to clear us back down to 2500 feet. The Tower Controller was then pushing us to initiate a teardrop or switch back to approach for an extended downwind. PM asked for a 6 mile final; but even after we reconfigured quickly with maximum drag; we were just barely stable at 500 feet for the landing. We realized after landing that the approach speeds were not reset for the higher wind component (17 knots) on final.Expectation bias on the initial missed approach. I was thinking about a normal go around; but the Controller wanted us to perform a discontinued approach. We were already throttled up and climbing when the controller asked us to level off at a lower altitude. Too many hands were working the glare shield controls [MCP] at once; and altitude hold was not selected in a timely manner. Hand flying was then the best option; but I lost situational awareness when the conversation became about heading and missed the level off. We then let ourselves be talked into a shorter approach than we wanted after the missed approach; causing us to feel rushed to land.Decide on a course of action and stick with it. If it's going to be a normal go around; then do that. If it's going to be a discontinued approach; then make it clear to the other crewmember who will be pushing the buttons. If more time is needed after an unusual event (i.e.: go around) to get set up for another try; then take the time and don't let ATC rush the process. Above all; fly the airplane!

B757 Captain experienced a wind shift during approach; necessitating a go-around. The Tower wanted the crew to remain in the pattern at 2500 feet but a TOGA had already been initiated and the altitude was exceeded before thrust could be reduced.


Inflight Event / Encounter Wake Vortex Encounter

Environment - Non Weather Related; Procedure

On arrival into Seattle ATC advised we were following a heavy 767. They made approach and landing on [Runway] 34R; and we landed 34L. On arrival just past FOOTT intersection I shallowed our descent rate; and re-VTO'ed (vertical guidance to waypoint) with a 3.4 degree glide path to remain above the heavy. Cleared for the visual I disengaged autopilot; and intercepted slightly wide and high on glide path. Wind was out of the east at about 15 kts; which I knew could push their wake into us. At about 4;000-5;000 ft we got substantial roll to the right; and slight pitching. We countered the roll and continued. The FA's (flight attendants) were seated and we heard no passenger complaints; though one of the forward passengers asked what that was; which I told him was wake turbulence. Even with my precautions of trying to stay above and wide; slowing a little more for better separation; and asking for more spacing from ATC; who was trying to keep us fast.

Medium Large Transport Captain reported encountering wake turbulence on arrival to SEA in trail of a B767.


Dash 8 Series Undifferentiated or Other Model

Fatigue; Situational Awareness; Workload

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy

Aircraft Aircraft Damaged; General Maintenance Action

Incorrect / Not Installed / Unavailable Part; Human Factors

I changed three main tires on aircraft that night. [I] had the work card with me. I just got complacent and just made sure the Number-4 tire had the inner bearing on and didn't look at the outer [bearing] on. I must have gotten two inner [bearings] from [Parts] stock. Upon landing; the brake seemed to fade in ZZZ1; [so Maintenance] took off the wheel and found that two inner bearings were installed [at the outer bearing position]. I was complacent and didn't make sure the outer bearing was the outer bearing. The one from stock wasn't an outer bearing. Not really sure; I think the Main Landing Gear (MLG) Shock Strut was changed; the tire was [replaced]. Was my fault; I need to take my time and look at both bearings. Aircraft damage.

An Aircraft Maintenance Technician (AMT) was informed he had installed an inner wheel bearing at the outer wheel bearing position for # 4 Main tire on a DHC-8 aircraft. Brakes seemed to fade upon landing after Mechanic had replaced three main tires.


Air Traffic Control Time Certified In Pos 1 (yrs) 14.5

Workload; Troubleshooting; Distraction; Confusion; Time Pressure

Airspace Violation All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence

Weather; Airspace Structure; Human Factors

I climbed Aircraft X to FL400. Based on aircraft performance; I expected the aircraft to be level by the boundary. There were a lot of deviations and rerouted aircraft in my sector adding a lot to the complexity of the sector. I didn't notice Aircraft Y coming northbound at FL390. I switched Aircraft X to ZTL. When the conflict alert activated; I saw that the only solution was to turn Aircraft Y to the right. I turned 20 right and called the BADIN sector right away to tell them. I called several times and they never picked up the line. No separation was lost (due to my turn) but I never officially got permission to turn in their airspace.TMU has to come up with better plans than to constantly keep traffic in Area 5 when there is weather. The complexity of the sectors go through the roof with their asinine ideas to get traffic through with virtually no restrictions. I was so distracted by the huge departure push over MOL that I missed a simple thing.

ZDC Controller reports of a airspace deviation that is caused by flight deviations and traffic workload in the sector.


Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 115; Flight Crew Total 290; Flight Crew Type 225

ATC Issue All Types; Airspace Violation All Types; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Became Reoriented; Flight Crew Exited Penetrated Airspace

Myself and two close friends flew to BKL for the day to [attend an event]. After arriving back at the airport; I paid for the fuel; did my preflight inspection; got the ATIS (which made no mention of any TFR in effect); spoke to ground (who also made no mention of a TFR); who then handed me off to tower (who also made no mention of a TFR in effect over the airport from surface to 3;000 feet AGL).After receiving clearance for takeoff and a left hand turn towards my destination; I asked the controller for permission to circle momentarily around a local yacht club which was approximately two miles west of the airport. He replied that it was 'up to me.' While over Lake Erie; approximately half a mile from shore; I descended to 800 feet AGL so my passengers could take a photo of the yacht club. At that moment I heard a transmission from an unidentified source (either the tower or another aircraft on the frequency) informing me that I was in an active TFR. I immediately started a climbing righthand turn out over the lake to get out of it as soon as possible. Following that; I requested for a frequency change; and contacted Cleveland approach; who gave me a transponder code and initiated flight following to the destination.The main contributing factors were that I had not received an adequate preflight VFR briefing. I understand that FAR 91.103 states that I must become familiar with all available information for the flight. We were in a hurry to get home and I knew it would be VMC the entire flight; so I omitted a preflight briefing; and as a result; I departed from a controlled airport that was under a TFR.

A C172 pilot reports departing BKL and discovering airborne that the airport is under a TFR. There was no mention of the TFR on ATIS; Ground; or Tower. The NOTAMS were not checked.


Human-Machine Interface; Fatigue; Distraction; Confusion; Communication Breakdown; Workload

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

ATC Issue All Types; Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Became Reoriented; Flight Crew Took Evasive Action; Flight Crew Returned To Clearance

Procedure; Environment - Non Weather Related; Human Factors; Aircraft

We were cleared by LAX Center direct BLH as filed. We were filed for the BLH GEELA6 RNAV arrival. I had programmed the FMC for the Runway 7L transition; since Runway 7R was closed by NOTAM KPHX A0865/13 201308/0500 201308/1400 and our arrival time was during that entire period. This NOTAM was the first contributing issue to this incident; as I interpreted it as meaning that the Runway was going to be closed continuously for 3 days; rather than the usual night time closings of various PHX runways. If the runway was going to be closed each night but open in the morning; I expected the NOTAM would say (as it usually does) RWY 07R/25L CLSD DAILY 0500-1400 WEF 201308/0500 201308/1400. We had completed the arrival verification procedure before top of descent; and had been cleared direct to SCOLE. After starting our descent to cross SCOLE at FL250 we received the latest PHX ATIS which showed arrivals on Runway 7R. I attempted to load the 7R transition by selecting GEELA6/BLH/ILS 7R and had to do it several times before the route looked satisfactory and discontinuities were removed. During each unsuccessful attempt the autopilot was transitioning back and forth from VNAV PATH to VNAV SPD; with changing VTK ERROR information and autothrottle activity. My difficulty was probably caused by our direct clearance to SCOLE (bypassing BLH) combined with my fatigue level; having been up all night. The net result was that my task loading went up very rapidly and my ability to figure out what I was doing wrong deteriorated. We did not have the chance to do a complete 2-pilot arrival verification procedure again after changing to the 7R transition because in very short order we got a frequency change to ABQ Center; crossed SCOLE properly at 280 knots and FL250; received and read back a clearance to descend via the GEELA 6 arrival 7R transition; set 4000 in the altitude window; and noted that we were high on the profile and the autopilot was correcting with a significant pitch down. My First Officer (Pilot Monitoring) then asked; 'Where did SPINK go? We need to cross at or above 240.' I didn't see SPINK on the HSI; although I thought we had not yet crossed it. We were rapidly approaching FL240. I selected ALT HOLD and saw that SPINK had apparently dropped out of the active route. I didn't think I had time to reload the route so I selected direct to SPINK; saw that it was about two miles ahead of us; and executed it. The aircraft was in a steady pull up and had leveled at FL236 as we passed SPINK. The execution occurred too close to SPINK; because as soon as we passed it the FMC drew a right circle back to SPINK; the aircraft rolled into a turn to the right; and the active route ahead disappeared up to GEELA. I went into HDG SEL then direct to SNRRA and on the way was able to successfully reload and verify the entire route with no further issues. Apparently I had not properly loaded the BLH transition; so the route I had executed was from SCOLE direct to GEELA. Distraction and sudden workload increase occurred just as we needed to complete another arrival verification. My First Officer clearly saved the day with good monitoring; I'm sure we would have crossed SPINK significantly lower if he hadn't caught the mistake. ATC did not comment on our altitude or minor course divergence.Fatigue; distraction; and a change to a different RNAV arrival transition caused me to fail to resolve FMC route change issues fast enough to prevent crossing an altitude restriction 400 FT too low. I could have avoided the issue altogether by not attempting to change the runway transition until much later (for example; approaching CAGOR); when our ground speed was much lower; we had more time; and ATC had made a final decision on our runway assignment. In retrospect; as soon as my task loading spiked I should have said; 'I have the aircraft and the radio; would you verify the route right now?' I think that would have divided the workload and managed the distractions and task loading more effectively. It might be worthwhile to check NOTAM KPHX A0865/13 to see if it is coded correctly; since that's what set me up to begin with. Regarding the fatigue issue; it is my opinion that most if not all of us flying schedules that require us to stay up all night are always in a degraded condition. Operating this way is the norm; and the effects of the fatigue do not become obvious until things go wrong. This isn't going to change with the new flight/duty time FAR; solving the problem will require the company to stop building pairings that clearly violate safe scheduling practices that have been well researched and publicized for years. The schedule I fly is legal under the new FARs. It is; however; as my doctor puts it; 'just crazy.'

A fatigued Captain described the complexity and confusion around a PHX RNAV runway transition change after the initial descent began which resulted an altitude constraint overshoot after the constraining waypoint dropped from the FMS during programming.


Party1 Maintenance; Party2 Ground Personnel

While in flight deck area we were advised by maintenance personnel that they were working on a tire change. They had the cockpit placarded against using systems and verbally requested we not board or use the APU. We relayed this information to our flight attendants. After about 20 minutes the lead flight attendant notified us that the gate agent had received word from maintenance that we could begin boarding and that it was in process. About one minute later a maintenance worker came into the flight deck and wanted to know why we had begun to board when he had previously told us not to. He said someone could get killed. The Captain advised him that we were told by the lead flight attendant that the gate agent said maintenance had told her it was ok to board. I then left the flight deck and went to the gate to speak with the agent. I notified the agent that they were not to board. Maintenance was still changing a tire and the plane was on jacks and the maintenance crew said someone could be hurt or killed if the jack failed.I feel that there is too much pressure to get the plane out on time. If the gate agent had spoken with the cockpit crew or field maintenance with his boarding concerns instead of relying on a third party to expedite boarding he would have realized that by boarding passengers he could negatively affect safety. There was clearly a placard in the flight deck and maintenance personnel were on the ground and in and out of the aircraft several times.There needs to be better communication between the agents who are always pushing to board; the mechanics who need time to do their job; and the pilots who are trying to complete their preflight duties while coordinating with all the parties. Ground maintenance should be the ones to notify the tower when they are done.  Ground maintenance should then contact the flight crew to say they are going to allow boarding. Then the agent should be notified to board. Why are we in a hurry to get someone hurt?  Maintenance needs to be done and done safely. The flight was already late. Boarding should NOT be the priority. Safety should be the priority and the flight crew should be notified directly by maintenance before an agent begins boarding.

Air Carrier First Officer reported a gate agent started to board a flight even though Maintenance had requested the aircraft not be boarded until a tire change was completed.


Flight Crew Instrument; Flight Crew Flight Instructor; Flight Crew Air Transport Pilot (ATP); Flight Crew Multiengine

Flight Crew Last 90 Days 30; Flight Crew Total 6000; Flight Crew Type 600

Airspace Structure; Procedure; Human Factors

I departed MYF VFR and prior to departure asked to get a handoff to Socal Approach. Ground control advised that I ask for an early handoff. Tower cleared me for a takeoff on 28R and a right downwind departure. On the downwind I asked for an early frequency switch but was not granted one due to two traffic calls. Once I departed the airspace to the east I needed to make a 360 degree turn while I contacted Gillespie Field Tower to transit their airspace from 1800 feet in a climb. I told MYF tower I was doing the 360. SEE tower they granted permission for the transit and once I flew out the top of their airspace I checked off and called Socal Approach. In the area the airspace for aircraft transit; not in radio contact is between 2400 feet and 4800 feet so the airspace is compressed. As I checked on with Socal I heard the conflict alert in the background and saw a twin in my 1 o'clock position; opposite direction; descending. As I broke left the controller asked me about the conflict alert and I commented that 'I just saw the aircraft go by'. I am not sure if the other aircraft; a twin going into MYF; saw me or maneuvered. In any event we passed each other about 200 feet horizontally (the twin to my right) and maybe 100 feet vertical (the twin above me) with a closure rate of about 250 KIAS. The controller commented that it was a twin engine aircraft going into MYF. Controller then granted me clearance through the class B and I continued on course to Julian (JLI) VOR thence to PRC. My observation is that the compressed flyway over top of SEE requires significant vigilance as it requires aircraft approaching MYF from the East to level off above Gillespie Field; and Eastbound aircraft departing MYF to climb through that same hole. In the future I will file IFR to attain more complete ATC services from Socal Approach.

C177 pilot reported an NMAC with a light twin during departure from MYF.


ATC Issue All Types; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Speed All Types; Deviation - Track / Heading All Types; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Wake Vortex Encounter

Description===========Type Incident:  Aircraft UpsetWe were descending to DFW.  As we flew through about 8500ft. and about 10nm below and behind an A-380 Super Jumbo; we encountered strong wake turbulence.The aircraft started a fast and aggressive roll to 30 degrees right bank.  The autopilot disconnected and I told the First Officer (FO) who was Pilot Flying (PF) to 'Grab It!'  He immediately started a wings-leveling correction effort; and fought to maintain it and started a climb.  I directed him to turn right in the direction of the upwind side.As we climbed and turned upwind we exited the wake turbulence area.  I'm uncertain exactly how much we deviated in altitude and heading and speed during the event.  But I'm certain it wasn't too excessive and we returned to our cleared descent to 5;000 feet as soon as we could.  We were both alert and prepared in advance for the possible wake encounter.  This helped us to react quickly and decisively to correct the upset event.  ATC was notified of the event and I recommended a minimum of 20nm in flight separation for following an aircraft of that size. The controller indicated he would pass it on to the previous controller that had maneuvered us within 10nm of the A-380 with previously assigned vectoring.  Our subsequent descent and landing to RWY 13R was uneventful.SuggestionsAs noted above; I recommended strongly to ATC that they provide an absolute minimum of 20nm in-flight separation for narrow body aircraft when following a Super Jumbo sized aircraft like an A-380.I hope they took my suggestion very seriously.  I'll know they did if they change their vectoring procedures in the future to provide my recommended minimum separation suggestion.  I would hope they follow up with me about their future intentions in that regard...

B737-800 Captain reported encountering wake turbulence in trail of an A380 on approach to DFW. Reporter recommended in-trail separation of smaller transport aircraft behind Super Jumbo aircraft be raised to 20 miles.


Flight Crew Air Transport Pilot (ATP); Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Flight Instructor

Flight Crew Last 90 Days 50; Flight Crew Total 4900; Flight Crew Type 200

ATC Issue All Types; Conflict NMAC; Deviation / Discrepancy - Procedural Clearance

Tower vectored me into a NMAC on final to 34R at HEF. I was on an IFR flight plan to HEF in VMC. I had been told to expect a visual approach at HEF. When I saw it; I advised Potomac Approach I had the airport in sight. They approved my frequency change. I complied. I contacted Tower and let them know I was at 1500 ft five miles southwest of the field. Tower cleared me 'for a Visual Approach; Runway 34R; advise on two mile final.' I echoed the clearance. A few seconds later; Tower asked me to 'dogleg left then right.' I read back and complied. Then a few seconds after that; Tower cleared me 'direct to the numbers.' That flight path meant I was going to cross short final for Runway 34L. So I immediately added 34L's final approach path into my scan; and I stayed at traffic pattern altitude in order to potentially avoid any traffic for that runway. I repeated the change in routing and complied. That's when I saw the Cessna on downwind to 34R. I called it out to Tower; adding 'no factor.' I was still 'direct to the numbers'; crossing what would have been the point where an aircraft turning left downwind to base for 34L would do so when a Cessna Skylark appeared to be hovering directly in front of me right at my altitude; about 100 ft away. I had enough time to confirm the Skylark's flight path was for 34L and not my runway 34R before I dove slightly away and to the right behind the Skylark. I mentioned to Tower that I was no longer 'direct to the numbers'; that I'd squared up my base to avoid landing traffic on 34L. Tower thanked me. I landed without incident. On the taxi out before switching me to Ground; Tower thanked me again for my 'help with that situation.' I'm writing this report because I feel it might help educate HEF Tower controllers and help improve their situational awareness. My understanding is HEF is a training facility. Mistakes get made at such facilities. No problem. I do believe this was Tower's mistake. My understanding is; per the AIM; that I am just as protected (ATC responsible for separation) on a Visual Approach when on an IFR flight plan; as when on any other charted approach. Failure to adequately separate me from 34L traffic; or at least notify me of that traffic was a mistake that could have been fatal if I had been a less experienced pilot. It might be better in the future not to clear an aircraft approaching from the southwest for 34R 'straight to the numbers' when the flight path will take it across the downwind and base legs for 34L; as my flight path did. That directive put me inside the pattern for 34L. That's why the NMAC occurred.

PA-30 pilot reported a NMAC while on approach to Runway 34R at HEF.


Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Hazardous Material Violation; Flight Deck / Cabin / Aircraft Event Passenger Electronic Device

Person Gate Agent / CSR; Person Flight Attendant; Person Flight Crew

General Maintenance Action; General Work Refused

During boarding; ground personnel brought to our attention that a bag was smoking. Upon further inspection; the portable battery was smoking and burning the contents in the bag. During this time I was in the cockpit setting up the FMS and doing my pre departure duties. I never saw the bag. I was told about it from the Captain. He said the contents were disposed of and all electronics were out of the bag prior to putting it in the baggage compartment. Flight went on with no further incidents. Cause: The passenger did not remove the portable battery from the bag. Suggestions: I didn't think anything of the situation after it was resolved. After we got to the hotel; the Captain said if he had to do it over again; he would have called the Chief Pilot. I agreed.

CRJ-900 First Officer reported a smoking portable battery in passenger bag. Contents were disposed and all electronics were removed from bag. Uneventful flight completed.


Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Air Transport Pilot (ATP)

Workload; Confusion; Situational Awareness

Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP)

Flight Crew Last 90 Days 55; Flight Crew Total 22500

Situational Awareness; Workload; Confusion

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT

Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Returned To Clearance

While descending via on the DSNEE 4 RNAV arrival into SNA we were given a set of instructions approximately 5 miles from the DSNEE fix. I remember it as being; Aircraft X; after DSNEE; slow to 190 kts. and descend and maintain 6;300 ft. I repeated this instruction back to ATC and I believe my partner repeated it to me. He dialed in 6;300 ft. and we continued our descent to cross DSNEE at 8;000 ft. before descending further. As we crossed DSNEE; he switched from VNAV to vertical speed for the next descent as expected. He also hit the heading button and moved our heading bug to 190 which I did not expect. I questioned whether I had misunderstood ATC instructions. I immediately contacted ATC to query the heading and almost simultaneously a different controller jumped on the frequency to instruct us to climb back to 8;000 ft. and immediately make a right turn along with a low altitude alert as there was terrain nearby. We did so and continued normally to SNA. When we got on the ground and the aircraft was secured; my partner and I debriefed what had just happened. He was confused as to the series of events until I explained to him the instruction was for 190 kts.; not a heading of 190. He then fully understood what had happened. Great job by ATC to immediately notice we were off track and to issue new instructions. While this event happened visually and we had terrain in sight; it could have had bad consequences at night or in IMC without their quick response.We were in a fairly busy segment of flight and were given a fairly complex series of instructions. Somewhere in that quick 5 miles; we; as a crew did not communicate properly. While myself and ATC were on one page; my partner was on another. Things happened very fast leading up to the deviation; I had no reason to think he had misunderstood the instructions. I should have been listening more carefully when he repeated them back to me; but In this case I think he did repeat the right instructions back to me; but executed them differently. In the future; I think I will try to write down instructions when they are given in a situation like that. We have a lot going on; and sometimes it is possible to miss or misinterpret an instruction when it was given to be done at a point further down the line. I know I have missed a few and my partner has caught it in situations like this. Usually more along the lines of fly Heading xyz or descend to xyz after an intersection 5 minutes or so down the road.

We were established on DSNEEE4 arrival approaching DSNEE intersection. We had been given numerous vectors off STAR for aircraft separation then cleared back to STAR fixes. Airspeeds were also assigned different from STAR. Several minutes prior to DSNEE we were given a heading of 190 and altitude of 6;300 ft. to take after DSNEE. We were in absolutely clear weather with all terrain; traffic and SNA in sight. At DSNEE I turned to 190 degrees heading as assigned and commenced descent. Very shortly thereafter another controller intervened with a new heading of 280 degrees and to return to 8;000 ft. immediately. I complied immediately but at no time was there any EGPWS warning and the terrain was clearly in sight well below us. Shortly afterwards the previous controller came back on frequency with headings and altitude assignments. We continued uneventfully to landing at SNA.

Citation 560XL flight crew reported a confusion between an altitude and heading assignment that resulted in a clearance deviation and CFTT.