Light Transport; High Wing; 2 Turboprop Eng

Training / Qualification; Situational Awareness

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

Prior to departure; the aircraft was de-iced due to overnight frost buildup. After deicing we began our taxi out and we were informed by the tower that there would be flow control beginning shortly. Upon reaching the runway; while we were being cleared for takeoff; Operations called us regarding our deicing. We called the tower and told them we were not ready to depart.Throughout the discussion both Celsius and Fahrenheit scales were being used concurrently by operations without distinction.  At this point it seemed to both the Captain and I that some error had been made in the math being used by the deice personnel. After further query it was revealed that the 14 degrees referenced was in Fahrenheit; however it was still unclear in the cockpit if there was indeed a problem. It was not effectively relayed that the aircraft had been deiced using the wrong fluid and needed to be deiced again. Soon thereafter operations stated that they had run the numbers again and that we were good. After a short discussion in the cockpit; the decision was made that the flight would depart as the aircraft had been deiced and was clean. Station operations deicing the aircraft with the wrong fluid. Station operations did not effectively communicate that the aircraft had been deiced using the wrong fluid and that we were required to return to be deiced properly.

First Officer reported there was a procedural deviation during preflight deice procedures that was not discovered until they had taxied to the runway. The flight took off even though the reporter realized later they should have returned to the gate for proper deice procedure.


Communication Breakdown; Human-Machine Interface; Troubleshooting

ATC Issue All Types; Aircraft Equipment Problem Critical

Aircraft Equipment Problem Dissipated; Flight Crew Returned To Departure Airport; General Declared Emergency; General Maintenance Action

All communications were normal from the gate through departure. On climb out we did not receive a call from Tower to switch to Departure Control. After several attempts to contact Tower we switched to Departure Control. When we were unable to contact Departure Control we tried several frequencies and were unable to establish communication. 7600 was selected on the transponder and we leveled at the last assigned altitude of 5;000 FT. For some time we tried to resolve the problem by disconnecting all microphones and headsets including those at the observer seats. Both communication radios and both audio select panels were tested. As a last resort we sent an ACARS message to Dispatch advising him of our status and requesting him to contact ATC and advise that we were returning to our departure airport. On base leg we heard a transmission from Tower. At that point both VHF communications radios became fully operational and remained so throughout the landing. Maintenance was unable to duplicate the problem at the gate and all communication functions remained normal.

When they were unable to communicate with ATC after takeoff the flight crew of a B757-200 squawked 7600 and sent an ACARS message to Dispatch requesting them to advise ATC at their departure airport they would be returning. On base leg communications were re-established. No cause for the loss and/or its resurrection was determined by Maintenance.


Confusion; Situational Awareness; Time Pressure

Deviation / Discrepancy - Procedural Published Material / Policy

Prior to starting engines at EGE we loaded the flight plan in the FMS; and then preceded it by the 'Visual [Engine Out] Procedure' with all the waypoints required therein. The problem arose that only the first fix; 'ABCDE' was in the FMS database and the remainder had to be entered using the LAT/LONG. Upon taxiing out and holding short of the runway a quick review of the first fix on the escape maneuver showed it to be well beyond the second and 90 NM from the field. I brought this to the attention of the PNF and he corrected it with the correct fix in LAT/LONG. Subsequent discussion with the Check Airman; as this was a 121.440 check; revealed that ATC had in fact adopted this name for a fix which was in somewhat close proximity to the Company fix. It would seem that some system of verifying waypoint names between the FAA and private operators would go a long way toward avoiding this potentially hazardous situation. If we had the ability to create FAA recognized waypoints for use in the ATC system we could avoid this kind of ambiguity. Operationally; I feel it's too much to ask of the crews to have yet another procedure for verifying the waypoints against LAT/LONG when they exist in the database already. It would seem to be a systemic error rather then operational.

CE560 Captain discovers during taxi that a company designed visual engine out procedure from EGE; which must be entered into the FMC manually; has a waypoint name that is the same as an FAA waypoint. This is corrected by entering Lat/Long; the same as the other waypoints in the procedure which are not in the FMC data base.


FMS Or FMC; GPS; Localizer/Glideslope/ILS Runway 09R

Flight Crew Last 90 Days 134; Flight Crew Total 11700

Communication Breakdown; Confusion; Fatigue

Party1 ATC; Party1 Flight Crew; Party2 Flight Crew

Flight Crew Last 90 Days 206; Flight Crew Total 13901; Flight Crew Type 368

Workload; Fatigue; Confusion; Communication Breakdown

ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Flight Deck / Cabin / Aircraft Event Other / Unknown

Person Flight Crew; Person Air Traffic Control

Air Traffic Control Issued Advisory / Alert

While descending for the ILS 9R; the SBGR approach controller told us to 'descend to 5000 feet; unrestricted descent'. The captain; who was the PM; read back the clearance to descend to 5000 feet. The air traffic controller; who's English was terrible; then repeated the clearance to 'descend to five thousand five hundred; unrestricted descent.' It was very difficult to understand these two clearances. The captain again read back the clearance to descend to 5000 feet. I wasn't sure of the altitude clearance; because of the lack of clear English used by the controller; but I asked the captain to verify if we were cleared down to 5500 or 5000 feet. The captain; who had become very grumpy and agitated after being awake all night while flying down to SBGR barked at me that he was sure the altitude assigned to us was 5000 feet and he set it in the MCP. He seemed certain about the assigned altitude so I took his word for it. Once level at 5000 feet; the controller told us we should have been at 5500 feet.

We heard Approach clear us to 5000 ft and I read back 5000 ft. Radar minimum altitude is 5500 ft. I asked approach for altitude clearance again and he said 5000 ft and I read back 5000 ft again. ATC cleared us to an intercept heading for ILS final and cleared us to 5500 ft. I told him we were previously cleared to 5000 ft.

The Captain of a redeye flight to SBGR heard a clearance to 5;000 feet. The foreign Controller's clearance was actually to 5;500 feet which the flying First Officer heard correctly. When level at 5;000 feet; which the Captain wanted; the Controller commented on the incorrect altitude.


FMS Or FMC; Localizer/Glideslope/ILS Runway 24

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

Flight Crew Last 90 Days 65; Flight Crew Total 5960; Flight Crew Type 2600

Situational Awareness; Training / Qualification

Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT

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

The crew was flying into BHM from the east. A cold front had just passed and was producing some light to moderate rain. The crew was flying in a CE501 which was on loan to them through a lease agreement. The crew was legal and current to be flying in this aircraft. However; it is not the aircraft that they fly on a daily basis.  Approach control gave vectors onto final to intercept the LOC of the ILS Runway 24 approach. The aircraft was approaching the LOC from the east. Approach control gave a final vector and told the crew to maintain 3000 feet until established and cleared them for the ILS Runway 24 approach. PIC believes they intercepted the LOC in proximity to SPATT intersection. Neither crewmember remembers whether the controller gave a distance referenced to any of the fixes along the LOC when cleared for the ILS Runway 24 approach. After about a minute of intersecting the LOC; the PIC decided to descend to GS intercept attitude of 2200 feet. Soon after descending; the controller issued a low altitude alert. The aircraft was between layers and had some visual contact with the ground; based on this the crew was not alarmed and verbally acknowledge the controller. Just prior to intercepting the GS at 2200 feet; the controller asked the crew for their altitude and the SIC responded with 2200 feet. The controller responded back with 'because the low altitude alert goes off below minimum vectoring altitude of 2600 feet'. The aircraft intercepted the GS and landed uneventful.The crew discussed the approach after the flight. The crew is uncertain what caused the low altitude alert; but theorized two possibilities. The PIC could have descended below the stepdown altitude of 2700 feet prior to reaching HUKEV stepdown fix. Another possibility could be a descent rate towards GS intercept altitude that triggered the alert.The aircraft flown was a CE501 on loan; instead of the crew's daily aircraft of CE525A and CE560. The FMS used as long range navigation was a Garmin 400; which the PIC is moderately proficient with. Since the crew was vectored onto final; the SIC programed the Garmin 400 using the Vectors to Final feature to load the ILS Runway 24 approach for situational awareness. One consideration of 'Vectors to Final' feature is that it removes from view any fixes prior to the FAF. In this instance; it removed from view stepdown fixes SPATT and HUKEV prior to FAF LOWGA. Had the stepdown fixes been in view; the crew might have remembered to consider the stepdown altitude at HUKEV.Also; the autopilot is a bit quirky especially regarding climbs and descents. Therefore; it was suggested to the PIC to fly autopilot in pitch mode. Autopilot responds smoother; but requires more attention to descend at a constant VS. With the high workload of an approach especially considering the weather in the vicinity; the PIC may have allowed the descent rate to fluctuate more than intended. This may have triggered the low altitude alert.Contributing factors:Proficiency with aircraft especially avionics and autopilot. Weather distractions.Corrective actions:Thoroughly brief approaches to include step down fixes and altitudes prior to FAF or FAP; even if they aren't anticipated to be used. Always load approaches into FMS to include step down fixes and altitudes prior to FAF or FAP to aid in situation awareness. Constantly maintain situation awareness referenced to your altitude.

CE501 Captain reported receiving a low altitude alert from ATC on approach to BHM.


Small Aircraft; Low Wing; 2 Eng; Retractable Gear

Flight Crew Last 90 Days 175; Flight Crew Total 3800; Flight Crew Type 850

Air Traffic Control Time Certified In Pos 1 (yrs) 22

Automation Aircraft TA; Person Air Traffic Control

We were descending into ACK in VMC while VFR. Passing about 5;500 we visually acquired traffic at our 11 o'clock. The traffic page of our MFD indicated he was at a range of 10 miles. Shortly after we acquired the traffic Cape Approach warned us of the same traffic and said they were westbound at 4;500 FT. Upon passing through 4;500 FT during our descent the conflicting traffic was approximately 4 miles from us at our 11 o'clock position and began to descend. At approximately 2 miles he began a left turn toward us. His aircraft no longer had any relative movement and was coming directly at us. The lights of his aircraft were getting more vivid by the second. The pilot flying and I both pulled back on the yoke to initiate and very steep climb to avoid the other aircraft. During our climb the TCAS alerted us to the traffic. I watched the other aircraft pass below our aircraft from left to right. This situation is another example of why looking outside the aircraft for conflicting traffic is so important.

The turboprop was eastbound to ACK receiving VFR advisories. I observed a westbound 1200 code (acft Y) at 4;500 (not in communication with ATC). I issued traffic to the turboprop - 11 o'clock; 5 miles; opposite direction at 4;500. He reported the traffic in site. I observed the westbound traffic descending and updated the turboprop with that trend. He asked if we were in communication with the other aircraft to which I informed him we were not. I told the turboprop pilot it appeared the other aircraft turned toward him and descended to which he replied that was exactly what he did. I immediately informed the FLM.Shortly after acft Y called for advisories.Yesterday I learned that the turboprop pilot had filed a NMAC.

A turboprop pilot and two K90 controllers reported a near miss near ACK in ZBW airspace between one VFR aircraft with flight following and another VFR aircraft with no communications.


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

During my layover; I made an attempt to sleep roughly between the hours of XA00 and XE00; however; I was unable to sleep. Upon arrival into ZZZ; fatigue was severe and I believe micro sleeps were beginning to occur. I spoke with the First Officer about this and he advised me that he was able to get sleep during the day and felt good. I thought I would be able to drive home safely; however; micro-sleep began occurring again. Fortunately; I made it home safely and went straight to bed. After three hours of sleep I woke up sore with a headache and neck ache. I was unable to sleep any further than that day. I placed my fatigue call at a time that would allow crew scheduling enough time to cover the flight that evening.As I have stated in many fatigue reports prior to this; I believe avoiding back to back red eye flights and wake times back-and-forth between day and night would reduce these issues.1. I was unable to get sleep at the hotel. The hotel provided a quiet; comfortable; cool environment for sleep; but I still could not day sleep. 2. None of the fatigue mitigation techniques work for me during WOCL (Window of Circadian Low). 3. Crew scheduling compounds the problem in its current structure.As I have stated in many fatigue reports prior to this; I believe avoiding back to back red eye flights and wake times back-and-forth between day and night would reduce these issues.

A321 Captain reported being fatigued due to lack of sleep and changing day/night flight schedules.


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

Equipment / Tooling; Human Factors; Weather

Took over [a] position and shortly thereafter MDW went below minimums. 2 aircraft entered the hold a 3rd was sent back to [departure airport] and another diverted to ZZZ prior to entering the hold. Also at this time I was having issues with AUS and BNA convective weather and possible diverts as well.SOD (Supervisor on Duty) requested [flight] divert to [ZZZ2 a nearby airport]. Aircraft had 45 minutes of divert fuel on board and ZZZ3 as the alternate. In the process of trying of using the reroute tool swift crashed. This happened at absolutely the worst time. Numerous ACARS messages and calls coming in. Asked my pod mates for help as well.Once [software] was rebooted I attempted to work on a reroute again and [software] crashed for the second time. I had informed [flight] to add ZZZ2 as an alternate; gave him the info and told him to divert to ZZZ2. TAF was showing 400/2 for ZZZ2. In the confusion I didn't realize the METAR at ZZZ2 was showing 300/1; below alternate minimums. I changed [the flights] destination to ZZZ2 and again with the workload and confusion of [software] crashing I neglected to add ZZZ4 as the alternate for ZZZ2. This was by far the busiest I've been and to lose my main tool in the heat of the battle was very stressful.

Dispatcher comments about the issues with their company's flight management system.


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

Aircraft X landed Runway 28R and slowed enough to make [the] turn off on Runway 32. My Trainee instructed pilot to turn right on Runway 32. We observed Aircraft X begin to turn; but then return to centerline and continued down runway. Once trainee saw Aircraft X begin a turn; he quickly cleared Aircraft Y for takeoff before verifying Aircraft X had actually exited the runway. Before I could key up to cancel the takeoff clearance; Aircraft Y rejected the clearance saying he saw the other aircraft still on the runway. I told Aircraft Y to cancel takeoff clearance and hold position. Aircraft X then missed the next turnoff and moved very slowly down the runway. Aircraft X asked us which exit he was supposed to make. As this was happening; [the] Trainee decided the next arrival was too close to get Aircraft Y airborne; [and] he instructed Aircraft X to turn right and exit runway at C12. Aircraft X was instructed to exit at C5 and contact Ground. Aircraft Y was not exiting the runway quickly enough; so Trainee told Aircraft Z to go-around. Trainers and trainees must do a better job of scanning runways and verifying arrivals have exited prior to issuing takeoff clearance to subsequent aircraft.

PBI Tower Controller/Instructor reported a runway incursion involving an arrival not exiting the runway quick enough; a departure cleared for takeoff; and an arrival having to be sent around.


Communication Breakdown; Situational Awareness

Party1 Flight Crew; Party2 Ground Personnel

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

We were preparing to operate [the] flight.  The Ramp Lead came to the flight deck to give us the Load Sheet; and asked if we had brought the aircraft in from ZZZ.  I told him that we had operated that flight.  He then informed us that the ramp personnel in ZZZ had not unloaded the aft cargo compartment when the aircraft arrived in ZZZ; as there were 13 ZZZ tagged checked bags in the aft cargo compartment that he discovered when we arrived in ORD. This caused us to operate ZZZ-ORD; with 390lbs of undocumented bags in the aft cargo compartment.  Not knowing these bags were onboard then caused us to have inaccurate weight and balance information for this flight; including an inaccurate takeoff trim setting.Suggest having the ramp personnel double check the aft cargo compartment when an aircraft arrives at the gate.

EMB-170 Captain reported ramp personnel discovered bags had not been unloaded from the aft cargo pit at the previous airport. This caused the aircraft to operate with 390 lbs of undocumented bags on the flight to ORD.


Inspection; Installation; Repair; Testing; Work Cards

Communication Breakdown; Time Pressure; Workload

Company Policy; Human Factors; Staffing; Procedure

Here is [the] actual times it takes to perform the 600fh (Flight Hour) inspection and 12 month inspection on a CRJ 200. Man-hours attributed to both inspections need to be adjusted as they are not close to the actual time needed to perform these inspections. We are creating a safety issue with such a differential between the allotted time and the actual time of the inspections; causing mechanics to work at extremely quick and rushed speeds on this aircraft and others to be able to get the check as finished as possible in the overnight maintenance period. Again; there is a great need to adjust the hours given for these inspections; please pursue this issue and help make our aircraft as safe and compliant as they need to be.During last night; I recorded the amount of time each person spent on each a 600fh inspection and a 12-month check on a CRJ200. For the 600fh check; planning allows us 13.8 man-hours to perform the inspection. This is an extremely low amount of time because this inspection is very deep in depth and took us 49.25 man-hours to perform last night. On the 12 month inspection; the allotted man hours was 7.0. The actual time it took was 14.5 man-hours and in addition to that we still have to fix the issues that are found during these inspections. The company is so busy trying to obtain more planes and get more work done that they refuse to recognize that we do not have manpower to fix everything.My mechanics for the night felt rushed due to this extremely large amount of work that is being issued to us with the shortest amount of manpower allotted to them. Both of these inspections take at least two times longer to perform than we are allotted to take.We need to re-evaluate our times spent on inspections; especially the non- frequent inspections like the two mentioned above. Anything to keep the leads and mechanics from rushing around (and very possibly not performing their job to the best of their ability) to make our planes safe and compliant.

CRJ-200 Maintenance Technician reported that allotted time is insufficient to allow safe and proper inspections on the aircraft fleet.


Aircraft Equipment Problem Critical; Inflight Event / Encounter Fuel Issue

Flight Crew Returned To Departure Airport; General Declared Emergency

While climbing through 12;000 FT on departure; we received a FUEL LOW LEVEL 1 message warning with the wing tank 2 indications going to zero. We immediately turned back toward the airport for an emergency landing after running the fuel low level QRC. We made an uneventful landing and proceeded to the gate after being inspected for fuel leaks by the ARFF (Airport Rescue and Fire Fighters) equipment. We received an erroneous indication of no fuel in the number one wing tank and returned to the departure airport.

The pilots of an Embraer 145 received an erroneous low fuel warning during climb and observed one fuel quantity indicator going to zero. The crew turned towards the departure field; ran the low low level checklist; and made a safe landing.


Maintenance Airframe; Maintenance Powerplant

Maintenance Powerplant; Maintenance Airframe

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Maintenance; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor

Aircraft In Service At Gate; Routine Inspection

On Date aircraft XXX had fumes/smoke in the cockpit smell noticed by the flight crew.The event occurred due to a razor blade that was left inside CBP1 possibly during a visit to ZZZ for the ADS-B modification in the middle of month of 2019 and I could have possibly left it there during the installation of breaker CBP1-XX during the mod. Due to the length of time between when possibly leaving a razor blade and when it was discovered I cannot recall whether or not I used a razor blade in the area. But; typically; when I do wiring work I don't use razor blades to cut tape or remove wiring insulation. As we usually have the equipment to remove fiberglass tape (a wire spoon and flush cutters or just peeling it off by hand;) and wiring insulation (standard wire strippers and the twisted pair stripping tool). Reflecting on the experience I would hope that even during the crunch time of the push to finish the ADS-B modifications on all our aircraft before the deadline that I would have continued to practice strict FOD control.My suggestion is to not use lose razor blades when doing work on wires unless absolutely necessary; and to practice strict FOD control and to perform detailed FOD inspections before every panel close-up.

On date the crew of Aircraft X reported fumes in the cockpit. An AMT discovered a loose razor blade located behind circuit breaker panel 1. Records indicate that panel had work done inside on date. This event has been brought to my attention due to my participation in ADSB mod which the work was completed. Due to the length of time from when the work was accomplished until now; unfortunately I can not provide details on exact situation. I can say that I was the RII In the process and I understand the seriousness of the situation and would not have allowed a loose razor blade to be left in the circuit breaker panel. I did not see a razor blade in the panel when it was closed. AMT found razor blade after fumes noted in cockpit. The event was caused by a Razor blade left in CBP-1.

Air Carrier Lead Technicians reported being notified that they may have inadvertently contributed to a fume event by leaving FOD on an aircraft they repaired.


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

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

While flying the VANZE arrival into Memphis; we were vectored off the arrival and allowed to deviate left and right to avoid major thunderstorms in the Memphis area. After clearing a cell; we were told to proceed to SUZEE and resume the arrival. We were level at 10;000 ft.; about 3 miles from SUZEE; we started a slight descent; to adhere to the altitude restrictions of the arrival. Memphis approach was extremely busy vectoring aircraft on/off the arrivals and SIDS. We noted an aircraft 5 miles away and climbing and no factor. We stopped our descent at 9;500 ft. and were told to maintain 10;000 ft. for the traffic. We continued the arrival with no other issues. [There was] congestion on the radio and thunderstorms in the area.

Air Carrier Captain reported an airborne conflict following ATC clearance.


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

Flight Crew Last 90 Days 130; Flight Crew Total 16000; Flight Crew Type 1100

Flight Crew Diverted; Flight Crew Inflight Shutdown; Flight Crew Landed in Emergency Condition; Flight Crew Took Evasive Action

At cruise altitude of 3;500 FT on a VFR flight; the engine failed. I immediately informed TRACON who turned me over to a nearby Tower and I landed on Runway X. This action was the safest course of action at that moment in time. Aside of the engine failing; there was no damage to property or injury to anyone.

A C172's engine failed while cruising at 3;500 FT so the pilot; in contact with a TRACON; was turned over to a nearby Tower where a safe landing was completed.


Flight Crew Last 90 Days 250; Flight Crew Total 16000; Flight Crew Type 4000

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

Automation Aircraft Other Automation; Person Flight Crew

Flight Crew Diverted; Flight Crew Landed As Precaution; General Maintenance Action

Just after a normal takeoff; received the ECAM 'AIR ENG1 BLEED ABNORM PR.' This is a special ECAM and requires us to go to the QRH instead of running the ECAM checklist. After reaching a suitable altitude; I ran the QRH with the Captain backing me up on any switches being moved. Secured the bleed via the checklist; then once on with ORD center; we started to evaluate our situation. The Captain was new to the plane. He was concerned there might be an issue with what maximum altitude we could fly at with only one bleed running two packs.  He was also concerned that we might not be legal to continue over the Rockies in this configuration. I have been on the plane for a long time; but had not had this come up and I was unsure as well. I was still the pilot monitoring so I sent off some messages to Dispatch and sent in the MEL to Maintenance Control. We got nothing back from Dispatch; or Maintenance Control; except the auto print out of our write up. The Captain had me tell ATC that we would like 20;000 as a cruise altitude for now as we worked what we thought would be a minor issue. After 15 minutes; we had not heard anything from anyone via ACARS. So the Captain gave me the plane while he looked for a frequency to try to get in touch with Dispatch. We had some very specific questions that we needed to find answers to. Was there a restriction on our cruise altitude with only one bleed? Could we go past the Rockies with only one bleed? Did they want us to go back to departure airport if we could not continue to destination? The Captain could not find any frequency. It was now 20 minutes into the flight; and we still had no contact with Dispatch. Finally; we got a frequency. The Captain tried that frequency; but could not maintain the connection.  Each time he would speak to Dispatch the line failed. He kept trying to get a connection; but each time it failed. This went on for about 20 minutes; meanwhile we continued on our flight plan. We still had not received our MEL from Maintenance Control; or any answers to our questions with one bleed. Now it was about a half hour into the flight; and our gas was getting critical to make it to destination if we did not climb. Finally got a message from Maintenance Control; and they were saying that they showed our bleed valve was closed and why did we close it? We did not close the bleed; it closed on it's own. We made sure we ran the proper checklist and had not missed anything. The procedure does not have us close the bleed; but Maintenance Control was insistent that we did as they showed it closed and it should be open. But nothing was communicated as to our questions about this flight. They only cared about why we closed the bleed; and Dispatch still had not given us anything concrete about our other questions. Now it was about 40 minutes into the flight; we were still at 20;000 and even if we had been able to climb to flight plan altitude; we would most likely not have enough gas to get to destination. But we still had no viable way to contact Dispatch; as they still had not responded to our questions via ACARS. Finally; the Captain got a working patch to Dispatch; who also had Maintenance Control patched in. The only thing they cared to talk to us about was why the bleed was closed and what had we done to close it. The Captain kept saying to them we did NOT close the valve; but they were adamant that we had; or implied that we had run the wrong checklist. The Captain mentioned to me earlier that he had seen the bleed fault light at the same time we got the ECAM.  It had since extinguished sometime while I was running the QRH or before.  I did not see it and it was not on or indicated on the ECAM message page; but the valve was closed via the schematic on the bleed page. So now the Captain was thinking that maybe we had something more wrong with this plane than just the over pressurized bleed. [At this point] continuing to destination was not possible.  We needed to go back or divert. Again; Dispatch did not have any guidance for us.  They said go back; then came back and said no; go to ZZZ as there was a spare plane there.  Then they came back and said the Captain could use his emergency authority to do what he wanted. We were on our own. Only 15 minutes to ZZZ; and not sure about the real status of the plane; so the Captain said how would I feel about diverting into ZZZ. It was a CAVU day; we had a long runway; but we were a bit over max landing wt. Our choices were to hold for an hour; or land overweight.  We reviewed the Overweight Landing Checklist; evaluated the performance; and thought the best idea was to land now. So we did; and taxied into the gate uneventfully. Once at the gate we were met by a Mechanic and a Flight Manager. The Mechanic had already done some research and had inspected the bleed before coming up to the cockpit. He said that valve had been replaced overnight and that it was leaking a lot of hydraulic fluid and he suspected it had been installed incorrectly. So we did in fact have other issues with this plane; as the Captain had surmised. The Flight Manager heard all of this; said we made the right call and that if we felt up to it; there was a spare and that we could be ready to proceed within the hour and that is what we did.

A320 First Officer experiences an ECAM for 'AIR ENG1 BLEED ABNORM PR' shortly after takeoff. QRH procedures are complied with; which included turning off the associated bleed valve. Questions arise concerning continuing the flight over the Rockies and climbing to higher altitude with one bleed system powering two packs. The crew elects to divert for maintenance; land overweight and continue to their original destination with another plane.


Flight Crew Last 90 Days 198; Flight Crew Total 12220; Flight Crew Type 5284

Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural FAR; Flight Deck / Cabin / Aircraft Event Other / Unknown

Environment - Non Weather Related; Aircraft; Procedure

The cabin reading lights at row 9 and 10 as well as the first 3 rows of coach would not turn off.  [Maintenance Control] was consulted and several resets by the purser were tried; nothing worked.  I was told again by [Maintenance Control] that it was a known and constant problem; I've written this up before.  In the process of the resets; it caused the pilots bunk reading lights to cycle on and off; disturbing the resting pilots crew rest.  That makes that rest area not a class 1 facility; and a violation of FAR 117 rules.  This must get fixed in a timely fashion or crews might not take aircraft with this known problem.

Captain reported several rows of cabin lighting would not turn off. The reset procedure caused the crew rest area lighting to cycle on/off; impinging FAR 117 rest requirements. This was reported as a chronic occurrence.


B787 Dreamliner Undifferentiated or Other Model

Airport; Company Policy; Human Factors; Procedure

Airline supertug 1 was repositioning a B787 from the ZZZ Hardstand (Terminal X) to Ramp Exit XX. As the supertug was backing onto the ramp area; Aircraft X was observed entering the XX Alleyway and taxiing around the aircraft under tow (which was still in motion) to Gate XXB in what seemed to be an unsafe maneuver; for which the supertug Operator had to stop abruptly to avoid contact with Aircraft X. While it is true that the XX Alleyway is uncontrolled; the Aircraft X Flight Crew should have stopped and contacted FAA Ground as the primary overseer of all ground movement.

Dispatcher reported a B787 was under tow and an A320 taxied around the towing aircraft.


Maintenance Powerplant; Maintenance Airframe

Maintenance Lead Technician 5; Maintenance Technician 16

Situational Awareness; Troubleshooting; Fatigue; Confusion; Communication Breakdown

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

Chart Or Publication; Human Factors; Manuals

October 2013; I had B757-200 aircraft Work Package that included troubleshooting (T/S) of the Auto Speed Brake System. I found that the Auto Speed Brake actuator was at fault. I checked the RII list to see if the replacement of the actuator was RII; and per RII list 27-62-02 it does not.  I printed out the Aircraft Maintenance Maintenance Manual (AMM) reference 27-62-02-022 and read the instructions. Because I was tired and had already checked the RII list; I missed the paragraph in the AMM that said the Auto Speed Brake mechanism had to be removed to change the actuator and that requires an RII Inspection. I replaced the actuator with no problems and all tests were good and the aircraft went back into service with no problems. I feel that this mistake was because I was too tired and the AMM included a note that was opposite to what the RII list has. There is no need to remove the mechanism to replace this actuator and that threw me off too; but the mechanism needs an RII.  I know that the AMM takes preference over all other documents and I made the mistake of not reading the AMM carefully enough; that will never happen again.

A Lead Aircraft Maintenance Technician (AMT) was informed he missed a required RII Inspection of an Auto Speed Brake mechanism after replacing an Auto Speed Brake actuator on a B757-200 aircraft. Technician noted that fatigue; along with a misunderstanding of a 'Note' in the Aircraft Maintenance Manual (AMM) procedures contributed to the missed RII requirement.


Small Transport; Low Wing; 2 Turbojet Eng

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

Flight Crew Last 90 Days 45; Flight Crew Total 14550; Flight Crew Type 1250

Communication Breakdown; Confusion; Situational Awareness

Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway

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

Environment - Non Weather Related; Airport; Human Factors

After deplaning passengers; we called Ground Control for taxi clearance for our IFR return flight to home base. The following clearance was received; 'Taxi to Runway 34L via Bravo; Alpha; Runway 11. Hold short of Runway 34L at Runway 11.' While taxiing southbound on Alpha; approaching Runway 11; I switched to Tower frequency (as directed by Ground Control) and the pilot flying initiated a right turn onto Runway 11. While looking for the standard runway-hold signage that would be expected at the termination of the runway; we overheard Tower say; 'takeoff clearance canceled; there is a jet that Ground isn't talking to that just entered (past the hold short line).' We immediately stopped the aircraft (still about 50 FT from the Runway 34L edge paint); called Tower and was instructed to 'just make a 180 and get back behind the hold-line.' Remarkably; the hold line at that position on the airport is unlike the other (expected) hold lines. It merely stretches across just the runway position; and in-line with the right edge of Taxiway Alpha. The line itself is difficult to see when approaching from the north since the runway is slightly higher than the taxiway. Also; one would expect to see the red signage associated with hold-short instructions for a runway. See the diagram of the runway; depicting the hold line on the runway and how easily an aircraft can make the turn onto Runway 11; and be immediately beyond the hold line. There is no signage for holding at Runway 34L from Runway 11 (29).

A pilot reported that the PAE Runway 34 hold short line on Runway 11 is not clearly presented when approaching from Taxiway D because the hold line only extends the width of Runway 11 and may not be seen when entering from Taxiway D.


When I came in to work this morning; a 767-300 was parked in [the hangar] on an angle and not on approved lines in the bay. This aircraft was parked here for a jack job due to the back of the bay not being level enough for use of the tail jack. While I understand why the company is parking the aircraft on this angle; it is not an approved parking area in the bay; and it is not marked as such. I have brought this concern up before; and asked for the hangar to be lined for this specifically; but to no avail. With the advent of the [compliance] class; and the video of the jacking incident being prominently displayed in the class; one would think that the company would adhere to strict jacking rules. I have [submitted] pictures to the [company]; and believe that this should be corrected; prior to a mishap on a jacking job.  Either mark the bay properly; or stop jacking aircraft in this position.

A Maintenance Technician is concerned that non-standard procedures are being used when jacking aircraft in a hangar.


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

Air Traffic Control Provided Assistance; Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory

I was PM (Pilot Monitoring) on flight. It was daylight VMC. We were cleared to takeoff from Runway 10L and fly runway heading to 5;000 feet. At 1;000 feet we got an RA. The TCAS showed a yellow circle with -02 next to it. The aircraft was almost right below us. First Officer increased our climb rate. ATC told us to turn right to a 180 heading. The RA went away and we continued the flight. ATC later said Aircraft Y took off on Runway 9R and was instructed to turn to a heading of 330; but turned into us on a 230 heading. The rest of the flight was uneventful. Aircraft Y turned the wrong direction on their initial climb.

Air carrier Captain reported an NMAC during departure from ORD airport.


Confusion; Distraction; Human-Machine Interface; Troubleshooting

Aircraft; Chart Or Publication; Human Factors; Procedure

Shortly after takeoff on Runway 4R at BOS on the BLZZR 1 RNAV Departure; we received a route discontinuity between BUOYY and BSQUE. Three attempts were made to close the discontinuity before it closed. We remained on the LNAV course throughout departure. Preflight route/departure briefing verified all correct points for procedure; and no discontinuities existed. There is a Safety Alert in our chart manuals; along with a note on the cover page of the trip weather package; drawing attention to route discontinuities occurring from Runways 15R and 22L/R between points BRRRO and CHWDH and a warning to not accept these procedures with a discontinuity. The purpose of this report is to alert Flight Operations that this anomaly is occurring on other runways not included in the Safety Alert or weather package cover note. Dispatch was contacted once we got to cruise altitude to pass this information along to flight crews departing BOS. My Chief Pilot and Union Safety Representative were also given a courtesy call to inform them of the issue.I believe the company should suspend RNAV departures out of BOS until the cause for these discontinuities is discovered.

This problem is not runway specific; as it happened to us as well on Runway 4R. We attempted to close the discontinuity three times to no avail. The aircraft would no longer fly the route and eventually entered bypass on the fix in question.

The flight crew of a B737-700 encountered an unexpected route discontinuity between BUOYY and BSQUE on the line selected BLZZR RNAV SID off Runway 4R at BOS.


Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented

Environment - Non Weather Related; Human Factors

Runway 9 Left Novss7 departure - normal take off; gear up and at around 7 hundred feet AGL I called 'speed mode NAV mode' at about the same time we encountered wake turbulence (plus 20 degree roll). I remained 'hands on' the controls to counter roll motions. ATC queried us as to our heading and at that point we became aware that we were not tracking the departure nor was the auto pilot on. ATC gave us a heading and shortly after that they gave us direct to waypoint GRITZ. There was no TCAS alert so we are assuming there was no traffic conflict.Two threats:1) our take off roll and initial climb was complicated by the fact that the sun was directly in our eyes. 2) distraction due to wake turbulence.Errors:1) Monitoring pilot did not verify the NAV mode on (due to sun in his eyes?)2) Flying pilot did not maintain proper track (distraction due to wake turbulence?)This is another case where both pilots started to assume the same roles - aircraft control was in question due to the wake turbulence so both pilots were focusing on aircraft control and no-one was monitoring the flight path or the autopilot. This is another reminder that each pilot ought to focus on his/her own role as pilot flying or pilot monitoring. NOTE: neither pilot was using their EFB at this time.

While taking off from 9R into bright blinding morning sun; the Captain and I were executing a routine departure.  The Captain and I stated out standard callouts; at 600 feet Captain requested autopilot; at that time we got into I'd say moderate wake turbulence from the Aircraft ahead of us; not bad; but it got both of our attentions because the Aircraft rolled 15-20 [degrees] and just stayed there riding the vortex. He placed his hands on the controls and flew with the Autopilot; both of us expected it to kick off; when it didn't we were surprised and commented that we thought it would kick off as that was some strong wake turbulence.  At that time I resumed my duties of completing the climb checklist.ATC then called asking our heading. I replied 095 and they informed us we were supposed to be in the NOVSS and gave us a heading and verified following traffic had visual on us; after another vector we were given 'resume the departure'Our threats were; we even discussed them; that the sun was going to be bright in the windshield; the close departure with the 737. I think what happened is when I went to hit NAV I hit heading and because of the sun I didn't notice the wrong lights on the Flight Control Panel (FCP).  When I should have called FMS off the FMA we were in the wake turbulence and I was watching that the Captain had control of the Aircraft.My learning factors are to be more vigilant at which button I press on the FCP and try to also do my Pilot Monitoring duties during an event in which the Aircraft is in an undesired state.

A CRJ900 flight crew reported a deviation from cleared departure route when they were distracted by the bright early morning sun and a wake turbulence encounter departing ATL in trail of a B737.


Flight Crew Last 90 Days 450; Flight Crew Total 25000; Flight Crew Type 2773

Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

While I was sleeping during my break an altitude deviation occurred. The relief pilots were in Russian airspace. They were assigned a cruise altitude in Meters. They misread the feet to meters chart and set an incorrect altitude. As they descended a thousand feet below their actual cruise altitude assignment ATC intervened. They then climbed back to the correct altitude.

B787 Captain reported that a conversion error between meters and feet resulted in an altitude deviation.


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

Automation Air Traffic Control; Person Air Traffic Control

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

Procedure; Airspace Structure; Human Factors

The Tower Local control positions were de-combined. Traffic was easterly operations. I was monitoring Local North. A VFR B350 was awaiting departure. I received a point out of a flight of two H60s that were transitioning from West to East that would definitely effect any North field traffic. I also anticipated the Helicopters to be traffic for any departures on the Northside. The Local North Controller issued traffic to the B350 that had departed referenced the H60s and a Cherokee. The B350 reported the Helicopter traffic in sight. Once I heard that the conflict appeared to be resolved; I resumed to assigning duties for the position rotation. The controller switched the B350 and advised TRACON that they were looking for the traffic.I was not aware of a Cessna inbound. The C172 was on the South Local Controller frequency. At the time; the ATM (Air Traffic Manager) was in the cab talking to other controllers about other things; and during the occurrence he was standing directly behind the two controllers on position watching them work; obstructing my view. If he saw something peculiar; he could have brought it to the attention of any one of us at the time. After the fact; the ATM discussed with me that the B350 did not have the Cessna in sight. I assume this was after he reviewed the audio. I explained to him that I was not aware of the C172 until after the audio and Falcon replay. Prior to this revelation; the North controller had called the Cessna a Cherokee but DID give the traffic call. I heard the collision alert; which alarmed well after the B350 was switched to the sector. I heard externally the South Controller give traffic alerts to a Cessna that appeared to be not answering. The controller was making transmissions to provide the traffic. The controllers (and I am not sure if they did; you cannot hear from my distance) could have coordinated the Cessna and B350 intentions. If I had known in time about the Cessna; I could have suggested to the Local South controller to give a suggested VFR heading i.e. (for more positive control) vice the 'turn southbound' instruction. I would recommend a group review of the situation with all parties involved to discuss; learn and prevent any possible future re-occurrence.Having an ATM in the cab and talking to other controllers; and then literally standing behind the local controllers watching them; while they were working traffic during that event; may have been a contributing Human Factor to their performance. Especially when they are working [non]- standard operation.

Local positions were split. Local North controller asked if I could take a Cessna 172 inbound for touch and go. I agreed and the Cessna was switched to me the Local South position. Upon contact; I saw a King Air 350 climbing off and instructed the Cessna to turn south for that traffic. I made a few traffic calls; the final one being a traffic alert. The King Air was already transferred to approach control. The Cessna never saw the King Air. They passed over each other and it appeared to both be at 3400 feet. The only thing would maybe to have kept King Air on frequency until traffic had passed by other controller.

ATC Tower Supervisor and Local Controller reported a NMAC.


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

On approach; joining final and pilot flying called for Flaps 5. Got TE Flaps disagree; put flaps back to one and reselected Flaps 5. Got TE Flaps disagree again. Ran QRH for Trailing Edge Flaps Disagree; declared emergency with ATC and landed Flaps 1. Trailing edge flaps would not extend.

A B767 TE Flap Disagree occurred during approach when flaps are selected from one to fove. QRH procedures are complied with; an emergency declared and a trailing edge flaps up landing was made.


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

Flight Crew Inflight Shutdown; Flight Crew Requested ATC Assistance / Clarification; General Maintenance Action

Right engine FAIL warning and N1 RPM rollback on descent through 10;000 feet. Crew acknowledged; PF (SIC) continued to fly. Crew accomplished emergency checklist E-1(2) Fail. No auto-relight in Region 1 (best chance of inflight start). N2 and oil pressure decreased to zero with N1 windmilling. Crew discussed briefly and elected not to attempt restart due to time required and available. The engine had failed for an unknown reason and system would not auto-restart--something in the #2 powerplant system appeared to have failed. Also; aircraft was light (~8800 lbs) and in a good position for a normal approach path and landing. Therefore rather than complicating the situation; crew judged as the best course of action continuing the approach single-engine. PF executed a smooth approach and landing; and exited as instructed. Fire services inspected the aircraft and reported no fires or leaks. We shut down the #1 engine and were towed in to the FBO.

EMB-500 flight crew reported a normal landing followed the failure of the right engine during descent.


Distraction; Situational Awareness; Training / Qualification

Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Weather / Turbulence

We were dispatched without an alternate. Enroute; the weather at IAD did not improve as forecast and was below alternate requirement mins on arrival. Despite my best efforts to save gas; we were going to land 1000lbs down from the flight plan at Dulles; assuming one approach to a landing. During the descent; the FO and I agreed that if we had to go around; the safest action would be to divert to BWI and we told Dispatch this via ACARS during cruise.Traffic in Dulles was packed and ATC gave us min spacing to the point we were worried we would have to go around being too close to plane in front of us and behind us. The FO and I discussed this and I varied my speed and configuration to prevent this since a divert would put us below 45 mins of fuel. We put the gear down and I called for the landing checklist 2 miles prior to the marker. I delayed final flaps intentionally since I was concerned about the fuel burn and was doing my best to comply with ATC's speed instructions while also trying to maintain spacing with the airplane in front of us. Inside the marker; ATC told me to increase speed by 10 knots which I did. This is the same time I'd normally call for Flaps 30. To be honest; I'm not sure whether or not I called for this; even though it's part of my normal habit patterns. We were distracted due to our spacing concerns; without a doubt. We were both also concerned increasingly concerned with how a go around would affect our fuel state. We popped out of the weather around 1000 feet AGL with the visibility at about 2 miles with fog. Shortly after that we got the GPWS 'Too Low Flaps' warning. I called for flaps 30 and the approach was stable so I continued and we landed without incident inside normal touchdown parameters.After the flight we debriefed this incident and I told the FO that I felt it was safer to land; than to divert into an unknown situation to BWI and land with less than 45 minutes of gas; assuming everything went perfectly. He agreed. However; I also pointed out that I deviated from procedures and that this is not something to be taken lightly. The flight manual calls for a go around. We also debriefed ourselves on checklist discipline and talked about not putting the list away until it's complete. I take responsibility for the checklist/configuration/speed errors as the Captain particularly since my FO is brand new. We did our best to thoroughly complete the debrief with honest self-critique; so that these errors do not happen in the future. In the end; I think what I did (deviating from the FM) was the best course of action and the safest way of recovering from our errors and landing the airplane in the safest condition possible; considering fuel and weather.

[Report narrative contained no additional information.]

B737 flight crew reported they continued the approach to a landing even though they selected final flaps below 500 feet AGL.


Citationjet (C525/C526) - CJ I / II / III / IV

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

Flight Crew Last 90 Days 400; Flight Crew Total 4100; Flight Crew Type 1000

Aircraft Equipment Problem Less Severe; Flight Deck / Cabin / Aircraft Event Smoke / Fire / Fumes / Odor; Ground Event / Encounter Loss Of Aircraft Control

Person Air Traffic Control; Person Flight Crew

Aircraft Aircraft Damaged; Flight Crew Rejected Takeoff

We received takeoff clearance; proceeded onto the runway and applied power smoothly. The First Officer made all required callouts to indicate gauges green; takeoff power set; airspeed alive; 70 KTS cross check; V1; Rotate.Upon rotation the airplane experienced a loss of directional control and pulled to the right. The airspeed dropped below V1. The Captain called for the abort; started to brake; pulled power to idle and called for ground flaps. Captain advised 'no brakes.' At this point Tower advised there was smoke coming from the aircraft. The aircraft continued to the right of center line and the Captain advanced the right power lever to maintain directional control. Differential thrust was implemented to keep aircraft on the runway. The First Officer announced the aborted takeoff on Tower frequency and the end of the runway was nearing fast. The Captain intentionally pulled the emergency brake lever to try and gain symmetrical control of the aircraft. The aircraft started slowing quickly and the aircraft came to rest approximately 800 feet short of the runway end.The First Officer then advised Tower that the aircraft was unable to move under its own power and required assistance. The engines were shut down and all occupants evacuated. Fire rescue extinguished the two fires on the main landing gear.Corrective actions:Runway abort procedures prescribed by manufacturer.Recognized directional control loss and improvised by intentionally blowing the left tire. The slow brake pulls were exacerbating the directional control issue and the PIC intentionally pulled the brake handle to blow the left tire.Evacuation procedure was executed and the passengers and crew moved a safe distance.Fire rescue extinguished fires on main landing gear.

CE-525B Captain reported rejecting the takeoff following loss of directional control on takeoff roll.


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

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

A runway change was initiated to switch from a RWY31L to a RWY2 configuration due to winds. Training was in progress at the FD/GC (Ground Control) position. Coordination was initiated with P80 as the afternoon departure phase from the based flight school started. Multiple aircraft were already taxied with information to RWY 31L as the new ATIS was being recorded for a RWY 2 Configuration. The recording of the ATIS took longer than expected causing both ground and airborne aircraft to check in with no ATIS information. The combination of chronic equipment error (partial/incomplete recordings) and excessive phraseology on the ATIS recording further delayed the ATIS broadcast which led to aircraft taxing and entering the airspace without the proper information. The new interpretation of 7110.65 2-9-2 requires the issue of the complete ATIS broadcast if the ATIS was unable to be received. Adherence to the new standard created an excessive burden on the controller and an unsafe situation. The design of the tower cab prevents or hinders access to the ATIS terminal during normal staffing conditions limiting assistance from other controllers. An Automated ATIS would greatly reduce controller workload and reduce the time required to disseminate new information.

HIO Tower Controller reported a problem with the ATIS recording equipment and the new requirement to transmit the full ATIS information when the recording is not available.


Flight Crew Private; Flight Crew Instrument; Flight Crew Multiengine

Flight Crew Last 90 Days 70; Flight Crew Total 2250; Flight Crew Type 310

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

Flight Crew Last 90 Days 160; Flight Crew Total 11273; Flight Crew Type 765

Ground Event / Encounter Person / Animal / Bird

Aircraft Aircraft Damaged; Flight Crew Overcame Equipment Problem; General Maintenance Action

VMC conditions; winds basically calm. Cleared by ATC for RNAV GPS approach and announced on CTAF. Runway clear and no obstacles visible during final. Right at touch down; I suddenly saw a deer emerging from the dark and crossing from the left under the aircraft. Initially unclear if or where the deer hit the aircraft. Pilot Flying brought aircraft to a controlled stop and taxi to ramp with no issues. Warned other aircraft on CTAF about the incident and possibility of a deer on the runway. After engine shut down identified multiple damage areas to the fuselage below the aircraft. Incident was unavoidable and Pilot Flying handled situation calmly and professionally. It was important to warn other aircraft on CTAF. Critical for [the airport] to upgrade their deer fencing and protection.

The flight itself went as planned and there were no issues. I was flying a visual approach and tracking the GPS approach for guidance only. Upon landing and right before touchdown a deer ran out of the woods on to the runway causing a deer strike. I maintained the center line directional control of the aircraft to a full stop. There was no further damage to aircraft from the deer strike except what was caused from the impact of the deer.

Phenom 300 flight crew reported deer strike on landing; resulting in damage to the aircraft.


Party1 Flight Attendant; Party2 Flight Crew; Party2 Ground Personnel

Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Other / Unknown

Company Policy; Procedure; Human Factors

I have worked many 737 flights where the aircraft is getting 'shut down' for an overnight in the arrival station. When the flight deck shuts down the aircraft while we are still deplaning passengers and leaves for their layover; it leaves the cabin crew in an unsafe position due to the inability for us to use the cabin inter phone or PA in the event of any type of emergency in the aft section of the aircraft. In essence; we have no way to communicate with the front of the aircraft other than use of the megaphone. In addition; the cabin temperature rises rapidly once the air flow is discontinued making it a health/safety issue for the 100 or more passengers still waiting to deplane.

B737 Flight Attendant reported that the aircraft was shut down; on multiple occasions; prior to deplaning all the passengers.


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

Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Unstabilized Approach

Flight Crew Overcame Equipment Problem; Flight Crew Returned To Clearance

We were on the approach to LGA ILS04. We got vectored onto the loc and began our descent. I began a quick descent so I wouldn't be too high and stayed below the glide slope on the approach; which is the reason it never captured. After descending through the FAF we broke out of the clouds but got a 'glide slope' warning twice. The autopilot was disconnected and the plane leveled off. Shortly after ATC gave us a 'low altitude alert'. The approach was continued visually and we landed. Cause: When we got vectored we were at 7000' and needed to descend to 2700 per the approach. I felt as though I was being brought in high so I began a quick descent and stayed below the glide slope; which is the reason it never captured and initially caused confusion. Because of this I stayed in vertical mode during the descent which was too high for the approach and caused us to get a 'glide slope' warning. We were clear of the clouds and had the runway in site and decided to land. Suggestions: We should have been more aware of our altitude and descent rate on the approach. We should have completed a go around upon getting the glide slope warning as well as the low altitude alert from ATC.

We were on an ILS approach in LGA; and we were low on the approach which is why the glide slope never captured. We then got the runway in sight; and then heard 'glide slope' 'glide slope'. We disconnected the autopilot and leveled off. ATC then advised us that we were low when we had already correctedCause: We didn't want to be high on the approach which is why the glide slope never captured. The plane then would have just stayed in vertical mode instead of following the glide path downSuggestions: When we initially realized that we were unstable; we should have gone around and tried the approach again.

EMB-140 fight crew reported flying an unstable approach which resulted an EGPWS and ATC low altitude alert.


Flight Crew Last 90 Days 200; Flight Crew Total 15865; Flight Crew Type 1272

Confusion; Situational Awareness; Workload; Communication Breakdown

Party1 Flight Crew; Party2 Flight Crew; Party2 ATC

ATC Issue All Types; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural FAR

Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented; Flight Crew Requested ATC Assistance / Clarification

Climb from FL390 to FL410 possible altitude deviation.I was on lavatory break returning to the cockpit thus not on the flight deck as the aircraft left FL390 for FL410. When I initially called for re-entry to the cockpit while awaiting the flight attendant to set up the cart for 'blocking' via interphone. My First Officer asked if I wanted to climb to the FMC recommended FL410; it was my leg. I said yes it was smooth. It took a minute or two to set up the door 'block'. As I entered at approximately 38;900 feet ATC asked 'who cleared you to 410?' He then cleared us to FL 410 in the same transmission there was no traffic conflict that we were aware of I noted the time as approximately XA:27.I inquired with ATC if we needed to contact anybody about 'this' since I was clear the 41;000 feet was in the 'ALT' window and did not think my First Officer would have put it there without a 'clearance' to do so. Controller stated that they were researching the tapes and querying the Controller about a possible Controller Pilot Data Link Communication (CPDLC) clearance being issued they might not be aware of. It was curious that the Controller knew and stated we were going to 41;000 verses 'why are you in a climb' or 'say altitude'. My thought at the time is he may not be sure if he or did or didn't already clear us. I realize the Automatic Detective Surveillance (ADS) lets him see the 'ALT' window.

A B787 Captain left the flight station for short break and upon return noted the aircraft climbing to FL410 from FL390. Uncertain about the clearance; he inquired and was then cleared to FL410.


Flight Crew Last 90 Days 20; Flight Crew Total 150; Flight Crew Type 50

Aircraft Aircraft Damaged; Flight Crew Returned To Departure Airport; General Maintenance Action

After a thorough preflight and takeoff run-up; pilot departed in clear conditions with no indication of problems. At nearly 900 FT; Tower assigned pilot heading of 210 and transferred to Departure frequency. Before contacting Departure; while turning; the front latch of the passenger door unlatched and bent rearward. At this point; pilot returned to Tower frequency and requested landing. Approximately 30 seconds after; the rear latch also became unlatched causing door to open upward to fully open position. Pilot was cleared to land and proceeded to land and taxi back to the FBO ramp without further complications. Upon further inspection; pilot noticed missing Plexiglas from passenger window and door frame damage; but is unsure of exact phase of flight in which damage occurred. It is important to note that we have experienced similar situations where the door has opened during takeoff roll or shortly after takeoff in this type aircraft.

The reporter stated that the aircraft manufacturer shipped modified door latches and the existing ones were replace in a matter of days. The door latch weakness is a known issue and is the object of a service bulletin.

Both passenger door latches of a C162 failed after takeoff; allowing the door to fully open upward. At some point the Plexiglas window separated from the door. The aircraft returned to the airport.


Flight Crew Overcame Equipment Problem; General Maintenance Action

After takeoff we retracted flaps on schedule and verified flaps in up 0 degrees position before selecting autobrakes off and gear handle to off position. After two hours in cruise we noticed a slight rolling moment followed by the illumination of the LE FLAPS TRANSIT amber annunciator light. Flaps indicated 1 degree with flap handle in the 1 degree position. This action was uncommanded by either pilot. The airspeed indicated 244 knots and at no time exceeded upper airspeed limit. Aural airspeed warning/overspeed was not heard. We then moved flap handle back to 0 degree position and the flaps again indicated 0 degrees. During approach we extended flaps from 0 to 1 degree and found the flap handle was difficult to move out of the 0 degree detent. It felt as though there was resistance to its movement. Selecting other extension positions was normal with no resistance. After landing and clearing runway; selected flaps up. Again; flap handle was difficult to position in the 0 degree detent/gate. We called Maintenance Control after gate arrival and explained what had happened. They advised there was no reported history of this problem on the aircraft and that there was no required flap inspection since a flap overspeed warning had not been detected. They advised that Maintenance would visually inspect the flap components and would operate/cycle the handle to verify its operation based on the logbook entry and what had happened. We made a logbook entry explaining the uncommanded extension and difficulty in operating the flap handle in and out of the 0 degree gate. We also made reference to the fact that the flaps had extended above FL200. Later; a representative recommended filing this report based because the flaps were extended above FL200. I suspect; based on the binding/resistance felt in operating the flap handle at this position; it had never fully seated in the 0 degree gate and that the flap handle migrated from 0 to 1 degree position over the course of two hours.

After clearing the runway and retracting flaps; I noticed that the flap handle had resistance the last 1/2 inch of travel before entering the 0 degree detent.

A B737NG flight crew was surprised when; while at cruise; the flaps extended to the one degree detent; apparently the result of resistance to fully engage the zero degree gate during retraction.


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

Flight Crew Last 90 Days 60; Flight Crew Total 500; Flight Crew Type 300

Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Loss Of Aircraft Control; Ground Excursion Taxiway

Instructor landing with a student pilot after a short cross country. Approach speed and path were good. Touchdown was a little hard. Told the student to turn left on Taxiway G. He still had too much speed but began the turn after a slight delay. We began to skid as we turned sharply and I took flight controls. When I did; I noticed there was some power still in. I reduced power; brought the yoke back; and aimed between the taxiway lights. Once straightened out; I applied brakes and stopped in the grass to the right of Taxiway G before the hold short. I contacted Tower and they told me to wait for emergency vehicles. There was no damage to the aircraft nor injuries. After an inspection by the fire department; [the FBO] towed us back out onto the runway. We started up again; contacted Tower; went to Taxiway F; contacted ground; and taxied back to [the FBO].

C172 flight instructor reported a runway excursion after landing.


Flight Crew Last 90 Days 200; Flight Crew Type 550

Human-Machine Interface; Situational Awareness

Flight Crew Last 90 Days 270; Flight Crew Type 11000

Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation - Altitude Crossing Restriction Not Met; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Clearance

Approaching the Arrival; we were directed by ATC to cross ZZZZZ intersection at or above FL300. Normal crossing depicted for the ZZZZZ intersection is FL240-FL320. We discussed and loaded the FMC by first erasing the preloaded speed/altitudes and loading only 280 for speed. The FMC Update 13 (U13) software calculated a crossing of approximately 28750 confirming we would be able to meet the follow on restrictions; if cleared; with a little work. Next we loaded 280/30;000 ft; verified VNAV path; Top of Descent; etc. We were satisfied with the setup. We anticipated a clearance of 'cross ZZZZZ intersection at or above FL300 and then descend via the Arrival'; which were given halfway through our descent to ZZZZZ intersection and placed the bottom altitude of the arrival in the MCP with verification of VNAV PATH. As we monitored the automation on descent we started to notice an erratic action of the autopilot attempting to stay on path with pitch and the airspeed was 20-30 knots fast. I deployed speedbrakes smoothly for a few thousand feet to aid in the controllability and attempt to return the speed to 280. As we approached FL300 in an idle descent; we both felt we were going to cross at FL300 and; with past experience; that the aircraft would go to VNAV Speed if unable and slow its descent. Instead; the aircraft stayed in VNAV PATH idle descent and before I could slow the descent; I noted a deviation 29;600 ft approximately 0.3 from ZZZZZ intersection. The VNAV continued the high speed issue causing deployment of speedbrakes at different times through the rest of the descent and pitch and path seemed erratic; even though it stayed in VNAV PATH. Overall; it was having a difficult time. We had a shared mental model and were truly attempting to be in 'its head'; but it was giving mixed signals. We had no other altitude crossing issues until flying final on the RNAV Y Runway XXL and it attempted to stop at 1800 ft in path and cause us to go high. We recognized it; I disengaged the automation; re-acquired path; and hand flew the rest of the approach without incident. The indications were odd; showing us low per VNAV; by approximately 500 ft; yet visually on glideslope. At about 150 ft AGL; the indications returned to a VNAV 'on path' norm. U13 software: It seemed inaccurate and misleading during this VNAV descent. If this were IMC; the indications and actions of the software would have intensifying confusion and result in task saturation. On final; if IMC; it would have caused a go around without the VMC references. These issues in the software are a cause for concern and need further attention. In reference to the altitude deviation: In hindsight; I could have put some back pressure on the yoke and been more aggressive to attempt to prevent the deviation as I did later with the anomaly on final.

B737 flight crew reported the aircraft automation had an erratic action with the autopilot trying to stay on path.


Communication Breakdown; Situational Awareness; Confusion

Party1 Maintenance; Party2 Other; Party2 Maintenance

Manuals; Aircraft; Chart Or Publication; Human Factors

In the Cessna CE-560XL Maintenance Manual 27-90-30-720; Step (D); Monel rivets are said to be identified 'by dimple heads'. Industry uses 'Double Dimple' as the head marking for Monel MS20615M rivets. Rivets with one dimple would be standard aluminum alloy rivets and would be unsuited for the elevator location described in the above reference. Suggest the Maintenance Manual reference needs revising to have the Mechanic inspecting for 'Double Dimple' heads; not 'Dimple heads'.

A Technician reports that in the Cessna CE-560XL Maintenance Manual 27-90-3--720; Step (D); Monel rivets are said to be identified 'by Dimple heads'. Industry standards use 'Double Dimple' as the head marking. Maintenance Manual needs revising to have the Mechanic check that 'Double Dimple head' Monel type rivets are installed in the Elevator area; not 'Dimple heads'.


Deviation / Discrepancy - Procedural Other / Unknown; Flight Deck / Cabin / Aircraft Event Other / Unknown

Flight Crew Took Evasive Action; General Flight Cancelled / Delayed

I checked in at the gate for flight approximately 35 minutes before departure. The gate agent said that there were no specials and no jump seat requests for the flight. I continued to the aircraft; briefed the flight attendants and began my preflight. The First Officer was just beginning to go out and do the preflight duties. While in the middle of my preflight I saw a figure out of the corner of my eye entering into the flight deck; nothing was said and suddenly there was a hand holding FAA credentials in front of my face. I recognized the standard FAA ID and looked up to see an FAA Inspector looking at me. I asked him if he was with the FAA and looking to ride on our flight and he said yes. I told him that I was in the middle of my preflight and if he would be kind enough to stand in the passageway inside the cockpit that I would be able to give him all of the documents that I was sure he needed to see and then prepare for him to ride in the jump seat. He asked where he could put his bag and I said there was plenty of room inside the cockpit and to put it under the second jump seat on top of my bag carrier and he did so. I then continued my preflight and noticed that he was now pulling down the jump seat that he was going to sit in. I looked back at him and asked him to not pull the jump seat out that I still had to go to the cabin. This seemed to make him upset and he said that he was only trying to figure out how to plug in the headset. During this conversation he said that the jump seat was 'his' and that he was here to observe our flight. He also said that 'this was not his first rodeo' and that he had been doing this for a long time. I advised him that I was fully aware of his right to observe our flight and we would cooperate with the endeavor. When finishing an interrupted; and I felt incomplete preflight (later I learned that I had left the galley power off); I left my credentials on the center console and told him that he was free to look at them and record their information and went back to greet the passengers and make the PA for the flight. When I returned to the cockpit I gathered my credentials and took my seat. At this time he made a point of taking out a notebook and putting his leg on the jump seat behind the Captain's seat and writing notes on the pad. He informed me that he was writing down information that was going to be used in his report. I asked him what type of information that would be and he said that he was writing down information about how I was resisting him and his efforts to observe our flight. I assured him that I was not resisting his efforts but rather I was in the middle of my preflight duties and he put his ID in front of my face without saying anything. He told me that this was how he was taught to do in his training and that he was leading with his ID. I calmly advised him that he could have said hello and introduced himself while showing me his credentials. During this time he had taken the jump seat and strapped himself in. His hostile attitude and demeanor was intimidating to me and I asked him what his purpose was to tell me that he was writing things down. He advised me that in ten years he had never been treated like this; (I wanted to tell him that in 31 years and hundreds of FAA jump seat inspections that I had never been treated like he was treating me; but I did not say it). He said if I wanted he could take the next flight but if he did so he implied that I would be in trouble for causing him difficulty. I assured him that he was welcome on this flight. He said in a terse manner that he would sit in the seat and not say anything for 3 hours. I told him that was not my request and that once we got going that I would be happy to speak with him and that I was sure he would have good things to tell us. He then asked again if he should take another flight and I said again that was not necessary; but he said well I guess I will take the next flight. He then unstrapped himself fromthe jump seat; gathered his bag and left the aircraft. At this point I called the Flight Office Department to explain to him what had just happened and that I would not be able to take the flight. Worrying about the threat that FAA Inspector had made to me would have distracted me from my proper duties and that I would have been worrying about his report and what he was going to say. His lack of courtesy and respect were very disconcerting to say the least and was not conducive to a safe flight. Improper FAA inspection of scheduled airline flight.

B737 Captain takes exception to the manner an FAA Inspector uses to enter the cockpit during preflight and announce he will be conducting a line check. Eventually the Inspector elects to leave and the Captain elects to remove himself from the flight.


Boeing Company Undifferentiated or Other Model

Aircraft Automation Overrode Flight Crew; General Evacuated; General Maintenance Action

About 12 minutes prior to departure; approximately one minute after switching from external power to APU power; APU auto shutdown. APU FIRE Light illuminated with EICAS APU FIRE warning; FIRE BELL and FIRE BOTTLE auto discharge. Ground Control was contacted for CFR to respond and passenger deplaned right away via jet bridge. No fire (per CFR). Maintenance performed inspection; MELed APU and we departed. Upon switching to external power [after arrival]; APU FIRE Light illuminated with EICAS APU FIRE warning and FIRE BELL. Ground Control contacted to inform of situation and for CFR to respond. Operations and Maintenance also contacted. No Fire. Maintenance then took aircraft. There is nothing that we could do to change this. Maintenance [at the departure airport] said that a spike in a power card (or something like that) was the cause. We would not assume anything after arrival and it was absolutely required to call CFR. We also had no fire bottle at that time.

Widebody First Officer experiences an APU fire warning with auto shut down and fire bottle discharge during preflight. The passengers are evacuated through the jet bridge; but CFR finds no evidence of fire. The APU is MEL'ed and the flight departs for North America. Upon gate arrival; with the APU off and switching to ground power; the scenario repeats.


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

Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; General Flight Cancelled / Delayed

We were cleared for takeoff on RWY XXL. With a clearance for a right turn [on course]. The tower handed us off to Departure and the last transmitted clearance we heard was for another right turn heading. We could not hear; nor could we transmit on the last assigned and guard frequency. To avoid penetrating into any other airport's airspace from the last assigned heading; we decided to turn towards [an open area] to troubleshoot. We were squawking 7600 on the transponder. For a brief moment; we were able to hear TRACON on guard frequency. The controller told us to climb to 10;000 ft. Initially started to climb to 10;000 ft. The Captain for a brief moment was able to transmit on guard frequency advising the controller of the radio failure; at which the controller told us to descend to 3000 feet and that we were cleared for the approach into ZZZ for RWY XXR. Again; we were not able to further communicate with ATC and came in for an overweight landing on RWY XXR. After vacating the runway; we were met by emergency vehicles and called our company operations via cell phone and requested they send a follow-me car so that we could head back to our ramp. Upon; returning to the gate; aircraft maintenance discovered there was an internal failure that caused both VHF radios to become inoperative. The maintenance supervisor confirmed that it was not a 'stuck' or 'hot' mike. When we returned to the gate; aircraft maintenance advised there was an internal failure that caused both VHF radios to become inoperative. Research the maintenance records; failure modes; and history of the installed equipment.

During execution of ZZZ departure from RWY XXL all VHF communication was lost. Last contact was brief check in with Departure. Code 7600 was set in mode 3 and we attempted to establish communication with ATC. Approximately 3 minutes later Center came through on VHF 2 121.5. After a short explanation of our situation we were cleared for a visual approach to RWY XXR at ZZZ. Communication was again lost. An uneventful approach and overweight landing was landing was accomplished and code 7700 was now set in mode 3. A follow me truck guided us back to gate. VHF 1 malfunction affecting all 3 VHF radios.

B757 flight crew reported VHF 1 malfunctioning on departure and returning to land.


Flight Crew Commercial; Flight Crew Instrument

Flight Crew Last 90 Days 6; Flight Crew Total 1587; Flight Crew Type 262

Situational Awareness; Confusion; Fatigue

Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Other / Unknown; Ground Incursion Runway

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

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

I was by myself; in effect test-flying/ferrying my aircraft back to...my home base.... I am [over 60] years old and retired. My habit is to sleep at night around seven hours; awakening [early in the morning]; then I almost always look forward to a 30-minute nap after lunch. On this day I woke as usual; felt I had a good night's sleep. It was a two hour drive to [the airport]. After lunch and paperwork was done; I had around a half-hour to grab a nap before I flight planned to lift off.... I went to find a place to rest. What I found was the general aviation terminal.... The only rest facility consisted of a narrow couch with no pillows; located in a room across from the training office of a local flight school. I was treated to the racket of an instructor and student discussing their cross-country trip plans and assorted small talk. After minutes of this I gave up on the idea of a nap. I went out to the plane and flew off. The 45 minute trip home was uneventful; except for the usual afternoon turbulence on the ILS localizer course. And; as usual; we were contending with F-16 and commercial traffic at that hour.... So; here I am at [60 plus] years old; deprived of a nap; changed at the last moment from [the left to the right runway] with an F16 behind me; also cleared to land. I managed to land safely in a quartering tailwind. Tower instructed me to exit at A-11; and I did so. Note that there is a rather limited strip of taxiway spanning the distance between [the left and right runways]; in the center of which is a more confined area designed to hold a general aviation-sized aircraft awaiting clearance to taxi across to A.... I just had a moment when I lost focus (my mistake) and only pulled-up to the [right runway] exit bars (i.e. dashed lines on my side);instead of crossing those bars and holding at the stop bars (solid bars on my side) for the [left runway]. Fortunately; there appeared to have been no other aircraft after me using [the right runway] while this went on. The Tower Controller saw what I had done by stopping short of the [the right runway] exit bars; called me up to instruct me where I needed to be; and I promptly complied with the instruction. I know very well to pull into this hold short area when exiting [the right runway].... I am very sensitive to safety issues. I believe my mistake was a function of my getting older; in combination with a few more distractions than I like to deal with at any one time; and my having been deprived of a restorative nap prior to leaving.... Take a page from a current hot topic in the US workplace. Set aside 'NAP ROOMS' at general aviation or FBO terminals; places with quiet; subdued lighting; and at least a lazyboy recliner if not a bed or broad sofa with a few pillows. These kinds of arrangements are a real potential life-saver for folks like me and with an aging population of pilots; likely others.

After landing on the right parallel runway; an older M-20 pilot was cleared to hold between the runways; but failed to fully clear the right parallel until prompted by the Local Controller. Pilot cited the lack of a nap prior to flight as a contributing factor.


Flight Crew Last 90 Days 181; Flight Crew Type 11000

Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway

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

We were cleared by Ground to 'taxi via the terminal ramp to Runway 33'. As we turned left around the terminal it was a very tight squeeze between left wing and terminal. Captain kept aircraft centered on yellow line and we were both watching carefully for obstructions including tugs and baggage carts. As we neared Runway 33; the yellow taxi line just disappeared so we stopped to figure out how to proceed. At that time; an RJ on short final executed a go-around at about 50-100 feet AGL. We realized it was because of our location; though Ground Control said nothing to us. I switched to Tower and asked if we caused the go-around. Tower replied yes and said we were supposed to hold short at hold bar abeam terminal before the left turn. He told us to then taxi via Runway 33 and Runway 8; then exit abeam Gate A2 and contact Ground. Upon contacting Ground; I asked if we misunderstood something from our taxi clearance. Controller said we were instructed to 'taxi via terminal ramp to Runway 33; stop at hold bar'. I explained that no mention was made about any hold short bar and none about that was read back by me. Controller said it's very confusing because they rarely issue the clearance to depart Runway 33; and that the hold bar is unlit and difficult to see. Nothing further was said. When taxiing to Runway 15; we are always told to taxi up and hold short of 8-26. We understood the lighted hold bar to apply to 8-26 only. The taxi instructions (with no mention of any hold bar) combined with the close proximity of numerous obstructions requiring eyes outside and to the left made this situation very difficult and our outcome likely. ATC made no stink whatsoever which tells me they know their instructions led us right into the trap.

Departing BUR; Ground Control directed us to 'taxi to Runway 33 via the terminal ramp'. We were expecting 15; so we delayed taxiing until we reprogrammed the FMC; and re-briefed the departure. Per the ATC instructions; I taxied west on the terminal ramp in the direction of Runway 33. Due to the proximity of the terminal building and ground equipment; I proceeded very slowly and deliberately. Also; I have never departed Runway 33 and was unfamiliar with that area of the airport. I turned south following the taxi line initially and stopped when I didn't see a taxi line or any familiar signage. No one said a word to us as we taxied. At this point; the First Officer (FO) switched to the Tower frequency. We were informed that we had crossed a hold short line. I never saw the line. Eventually we were given instructions to taxi back to the terminal ramp in front of the Company gates and contact Ground Control. The FO asked the Ground Controller if we had missed something. Controller replied that they had instructed us to' taxi via the terminal ramp and hold short of the second hold short line'. Neither of us recall that instruction. That is not what the FO read back either. Controller further stated that it is easy to miss at night especially if you are unfamiliar. The Ground Controller then had us taxi west on the ramp again and hold short of Runway 33. This time I saw the hold short line because I was searching for it. I believe we didn't see it the first time because it was dark; the line was unlit; it is located in a confusing location; and we were so focused on not hitting anything while moving in cramped; unfamiliar territory. We were then instructed to back-taxi on Runway 33 and cleared for takeoff. First; I have to be more vigilant while taxiing and reviewing my charts. Although I felt I had done what was necessary to mitigate the risks (chart review: 10-7; 10-9; briefs; hyper focus); I still missed it. I did not see the safety alert until after the event. Had I reviewed that chart; this would not have happened. I believe this is one of the challenges of the EFB as well. Previously; the red bordered safety alert page would have stood out. Today; unless you specifically select a chart for review; you have no idea. Lesson learned. Secondly; I think the Burbank Ground Controllers could do a lot more while issuing instructions during this configuration. Since this is not the 'Normal' departure runway; ATC should alert Crews to the difficult to see hold short markings and the non-standard takeoff procedure (back-taxi into position). If the Controller had said 'taxi straight ahead and hold short of Runway 33. Expect to back-taxi for takeoff'; Crews would then be alerted that the hold short is not at the departure end of the runway. Further; I think the airport should make the hold short line for Runway 33 lighted just like the 8-26 hold line. This would make it very difficult to miss; particularly at night. I also think the 10-7 page should address this scenario specifically for Runway 33 departures. The 10-9 page should have either a note or a hot spot designation that shows you can't turn the corner without crossing a hold line. Those chart additions might serve as another layer to the safety alert given that it is more likely to be in view while taxiing.

B737 flight crew reports being cleared to taxi via the ramp taxiway to Runway 33 at BUR for a night departure. The Runway 33/15 hold bars on the ramp taxiway are inadvertently crossed causing an aircraft landing Runway 33 to go-around.


Piper Single Undifferentiated or Other Model

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

Flight Crew Last 90 Days 115; Flight Crew Total 611; Flight Crew Type 46

My student and I were returning from our cross country flight. We had radar flight following with Salt Lake City Center. They handed us off to Salt Lake City Approach who then handed us off to PVU Tower. I reported to PVU tower we were 9.0 NM SW of the airport and we were inbound for landing. Our altitude was 6;500 MSL; consistent with local arrival procedures. PVU tower had us proceed to the CREEK and report the CREEK; and issued the following traffic advisory: 'Traffic 1 o'clock and 4 miles; northbound; altitude 6;000; type unknown' and that they weren't talking to this traffic. I told my student to remain at 6;500 to allow that traffic to pass below us. About 3-4 miles later; PVU tower said that traffic was now '12 o'clock less than a mile; altitude 6;300'. The airplane blended in well with the terrain and we never saw it until it was at our same altitude 11 o'clock and about 500 feet away laterally. I reported that traffic in sight. Tower asked us what type of aircraft it was; and I told them it was a Piper; possibly an Arrow or Saratoga; and that they were departing toward FFU. The airplane was close enough that I could almost make out the tail number; but I was unable to due to the fact it was only a hazard for a short moment of time. We informed tower that it got within 500 feet of us. The aircraft never did show up on their screen; and it would have if the airplane contacted Salt Lake City Approach and received a transponder code. My student and I were actively looking for this traffic from the moment of the first traffic advisory from PVU tower.

DA40 instructor pilot reported NMAC with another light aircraft in the vicinity of PVU.


Air Traffic Control Time Certified In Pos 1 (yrs) 12.0

Communication Breakdown; Confusion; Physiological - Other; Situational Awareness

ATC Issue All Types; Deviation / Discrepancy - Procedural Other / Unknown; Flight Deck / Cabin / Aircraft Event Illness / Injury

Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance; Flight Crew Requested ATC Assistance / Clarification; General Physical Injury / Incapacitation

Aircraft X was direct for the arrival in to ZZZ. This route put the aircraft in a direct conflict with many westbound departures; so I turned the aircraft to a 080 heading to provide lateral separation. Aircraft X was level at 17;000' which was fine with me until I got it north of the westbound departure track. When the aircraft was in the vicinity of the Hinkley airport the pilot requested lower. I asked what altitude and he requested 12;000 (maybe 11;000?). There was some insistence in his tone so I coordinated with West Departures at C90 to get him lower. The controller I spoke to questioned the APREQ; but I made it clear that I thought that the pilot really did need lower. They approved 15;000' on the current heading and gave me a freq. I then shipped the aircraft to C90 and I observed the aircraft descend to 14;000'.C90 then called me back on the land line asking what was up with giving them someone low flying through their airspace. They also said that the pilot told them that he did not want lower. I made it very clear that yes; the pilot did request lower and even stated that he would like 12;000'; maybe 11;000' and that I would not have called them about it if the pilot didn't ask. A different C90 controller called me back later and asked if I would work the aircraft at 14;000' northbound and I said I gladly would. Aircraft X checked back in on my frequency and again requested lower. I asked the pilot to 'say again request' and he said he wanted lower. I then questioned the pilot saying that he requested lower but then said he didn't want lower with TRACON and now he's requesting lower again. Then pilot then very firmly stated that he never requested lower. So then I confirmed that he wanted to stay at 14;000' and the pilot said that he wanted lower; 10;000.' I then immediately called C90 and said something isn't right with this pilot and that we need to get him lower. They said they'd call me back. They did quickly and said to send him direct ZZZ and descend to 7;000' which I did. The aircraft was then shipped to C90 with no incident.No recommendations; it was just a very strange event that I thought needed to be noted.

ZAU Center Controller reported an aircraft repeatedly requested lower altitudes than said they didn't request lower altitudes so the Controller descended the aircraft suspecting the pilot was suffering some sort of illness.