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

Situational Awareness; Communication Breakdown

Air Traffic Control Time Certified In Pos 1 (yrs) 4.5

ATC Equipment / Nav Facility / Buildings

I was working a combined sector at HUD/DET. I had reports from ZAU that aircraft couldn't hear me/I couldn't hear them; so I was moving from Mains to Standby then finally to BUEC [Back Up Emergency Communications] in attempt to be able to communicate better with the aircraft. We cannot cross-couple at this sector because the western frequency is not usable on the far east side; and we don't like to use 135.72 as an alternate in case we don't switch them early enough and thus lose the aircraft.Additionally; rides had begun to deteriorate and I needed to get all aircraft at FL280 or below (I own from FL240-FL330) or up above FL340. There was a lot of changing altitudes occurring at this time. The sector beneath me (WINDSOR/DRESDEN) was helping me out by climbing aircraft from below and missing my traffic while I attempted to resolve the frequencies after I had reported issues to my supervisor.I switched an aircraft - Aircraft Y - to the next sector (RAV) right on the boundary after a call for them to accept the handoff. There was interference on the frequency during the response; but upon reviewing the tapes apparently Aircraft X took the switch for Aircraft Y. I did not hear it; and had not made the aircraft aware of similar sounding call signs ahead of time. The next sector must have missed the incorrect call sign. They descended Aircraft Y (who was not on their frequency yet; though we didn't know it) from FL260 to FL240. The sector below me had climbed Aircraft Z to FL250 beneath Aircraft X with my approval. We saw FL257 in the datablock. I immediately told Aircraft X to maintain FL260 for traffic with no response. I called again. I attempted to reach Aircraft X several times on frequency with no response.In the meantime; the sector below me stopped the climb of Aircraft Z and turned him 30 degrees left with my approval. I called a safety alert to Aircraft X and told him to turn left and climb if he could hear me. Aircraft Z responded to a TCAS RA.The controller at the sector below me and I were operating under the assumption that Aircraft X was experiencing an emergency and expedited the descent of another aircraft that might have been a problem in the future.I received a call after the traffic was no longer a factor from the sector that had Aircraft X on their frequency to tell me that he'd taken the switch for Aircraft Y. Until that point; I had no idea that there'd been a readback error.Better working frequencies; better communication with foreign aircraft and an attempt by airlines to not have such similar sounding call signs on such similar routes at such similar times. (This is a frequent problem for us with GGN) It would have also helped if either I or the controller at the RAV sector had heard the mistaken call sign of Aircraft X instead of Aircraft Y.

I was the radar position at the low sectors of Windsor and Dresden at ZOB. I worked a departure out of Detroit; Aircraft Z. The controller at the high sector where Aircraft Z was climbing into was having frequency issues along with congestion due to poor rides; so I decided to keep Aircraft Z on my frequency to assist the other controller. Aircraft Z was climbing to maintain FL250; because traffic Aircraft X was level at FL260. I then viewed Aircraft X depart FL260 to descend; in conflict with Aircraft Z at FL250. I issued a descent clearance to FL240 and a turn of 30 degrees right to Aircraft Z to ensure the aircraft would not merge; while not knowing what Aircraft X was descending to; as Aircraft Z was just passing FL240; I thought it best to send the aircraft back down to ensure I kept Aircraft Z below the randomly descending Aircraft X. After control instructions were given; Aircraft Z informed me he got an RA. After I ensured the aircraft was finished with his RA; I gave him follow up control instructions. It turns out Aircraft X had company Aircraft Y on frequency with the high sector. Aircraft X took Aircraft Y frequency switch and descent clearance on the next frequency; leading to the loss of separation and the RA.I think it would benefit the NAS greatly if we did something about our frequencies. We have been having trouble with the same frequencies for years now; along with proof in writing of when there are issues with them. Also; companies should not have aircraft with such similar sounding call signs depart the same airport; with the same route of flight; within minutes of each other. This creates entirely too much confusion for not only the pilots; but the controllers as well. We both have a lot going on in and out of the cockpit and I think a lot of these errors would be drastically reduced if call signs were not so similar in such a fashion.

Cleveland Center controllers reported radio problems along with similar sounding call signs led to and unsafe situation.


Medium Transport; Low Wing; 2 Turbojet Eng

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

Flight Crew Last 90 Days 60; Flight Crew Total 1800; Flight Crew Type 600

ATC Issue All Types; Conflict Ground Conflict; Critical

Flight Crew Executed Go Around / Missed Approach; Flight Crew Took Evasive Action

Tower closed; multiple airplanes in pattern using Runway 14 for favorable winds (170 about 15 knots). I was on short final; less than 200 AGL over clearway for runway. Jet lands straight in on Runway 32. No calls were made from the jet on CTAF announcing position or intentions. Jet landed; I added power and went around; overflying the jet. All other airplanes in the pattern were using 124.125 as the CTAF as published. Brief phone conversation with Houston Approach confirmed that the jet landed straight in apparently on an RNAV 32 approach. Jet would have landed with excess of 10 knots tail wind. ASOS was broadcasting at the time.

Flight Instructor reported performing a go-around on short final due to a business jet landing in the opposite direction following an RNAV approach.


Flight Crew Last 90 Days 2.7; Flight Crew Total 119; Flight Crew Type 116

Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Wake Vortex Encounter; Inflight Event / Encounter CFTT / CFIT

Person Air Traffic Control; Person Flight Crew

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

Airport; Human Factors; Environment - Non Weather Related

I contacted Approach and was given vector to land on Runway 35R. This was just after sunset. Conditions were dark; but it was not night by legal definition to log night ops. As I approached the airport; AUS had me turn left to a new heading for spacing to accommodate a MD-80 that was landing in front of me. Once the MD-80 was established on the flight path; I was cleared to land number 2 behind the MD-80. Tower advised me to beware of wake turbulence. At this time; to avoid the effects of wake turbulence; I focused on the MD-80 and attempted to visually fly above its approach path. I experienced some light to moderate bumps; perhaps due to wake turbulence or due to other factors. While attempting to fly visually about the landing aircraft's approach path; I allowed my aircraft to fly well below 35R glidepath. When the MD-80 landed; I looked at the PAPI lights and saw they were all red. I immediately applied more power and began a climb to a safer approach altitude. A few moments after I noticed I was dangerously low; the Tower Controller contacted me and advised me I was low; and asked if I had the airport in sight. I confirmed that I had the airport in sight; and resumed my established approach and made a safe landing. No other mention of the incident was made by ATC. In my evaluation; this incident was the result of a 'black hole' approach - there are very few ground references at night approach AUS from the south. Compounding this issue was my fixation on the landing aircraft's approach path rather than on the runway's PAPI lights. Had I focused first on my position relative to the PAPI indicators; then flying above the landing aircraft's approach path; I would not have allowed my aircraft to descend so far below the glideslope.

C172 pilot reports getting very low during a night visual approach to AUS while following a MD-80 and attempting to remain above its flight path. The reporter detects low position via the PAPI lights and adds power; followed shortly by a low altitude alert from the Tower.


ATC Issue All Types; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Wake Vortex Encounter

Flight Crew Executed Go Around / Missed Approach

In the flare after an ILS approach to Runway 35C at DFW I initiated a go-around due to wake turbulence from the preceding arrival. On glide path at about the 50 ft radio altimeter call out the wings started rocking. I attempted to slightly flatten out the descent angle to rise above the turbulence but the oscillation continued for another cycle. At around 20-30 feet and nowhere near stable due to the buffeting I initiated an autopilot-off go-around. We followed ATC instructions and returned to land uneventfully on runway 35R.In my opinion the event occurred due to poor spacing by the DFW approach facility. We had followed this aircraft on the arrival and in fact were kept 1000 ft higher than normal at SILER due to our tight lateral separation. The ATIS had advertised visual approaches with a 1500 ft reported ceiling but were told to expect the ILS by the Controller. As we joined final we were instructed to maintain 170 knots to a five mile final. The next transmission we received informed us that we had a 40 knot overtake on the aircraft in front of us yet there was no amendment to our previous speed assignment by the Controller. Based on that information I put the gear down with landing flaps and asked the FO to query the Controller whether he still wanted that 170 knots given our closure rate. Of course I knew the answer but when the FO finally got the question out the Controller responded by telling us to reduce to final approach speed; which I was already doing. Basically what happened is the Controller treated us like we were a visual instead of an ILS; even though we were IMC until after passing the FAF. We were never informed what type of aircraft we were following. At some point in the radio exchanges subsequent to our go-around the FO was able to glean that the preceding aircraft whose wake we hit was a B757. By the way this was the return leg of an all-nighter; the second consecutive night in a row for me.It would have helped to have known the type aircraft whose heels we were nipping on final approach. The '170 to five mile final' instruction was unrealistic given our separation and the weather. Not exactly how you want to end an all-night duty period.

A321 Captain reported executing a go-around after encountering wake turbulence during their landing flare in trail of a B757 to DFW airport.


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

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

Person Dispatch; Person Ground Personnel

I received an ACARS message during cruise flight that ZZZ OPS listed a power wheelchair as luggage instead of cargo and they listed 4 slides as COMAT instead of HAZMAT. More emphasis to Operations about the importance and critical safety issues of transporting HAZMAT and correct cargo loads.

B737-700 Captain reported ACARS message during cruise stating Hazmat documentation errors.


Flight Crew Last 90 Days 225; Flight Crew Total 10700; Flight Crew Type 2100

Time Pressure; Confusion; Communication Breakdown; Workload

Flight Crew Last 90 Days 40; Flight Crew Total 12000; Flight Crew Type 1500

Workload; Communication Breakdown; Time Pressure

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

Flight Crew Became Reoriented; Flight Crew FLC Overrode Automation

Departing a morning turn to ZZZ; we experienced an EPR (Engine Pressure Ratio) engine probe heat failure on the no. 2 engine. The deferral resulted in split automation with the loss of ATS and also required the engines to operate in N1 mode. The leg to ZZZ was uneventful.  Departing ZZZ on 26R the PDC assigned the Indie1 Departure; runway heading; and climb to 4;000 feet. I was the Pilot Monitoring (PM) in the left seat. The Pilot Flying (PF) had limited recent flying experience. Our aircraft was very light with 15;000 lbs. of payload.  At the runway after an extended delay for arrivals we were cleared to line up and wait with traffic on a 9 mile final.After sitting in position for an inordinately long period of time under an 800 foot overcast we became increasingly anxious. We sat transfixed on the TCAS looking for arriving traffic behind us. Tower then cleared us for T/O. Fly runway heading maintain 2;000 feet. I repeated the clearance and set 2;000 feet in the MCP and we commenced the T/O. Passing 1;000 feet I called passing 1;000 feet for 2;000 feet. The PF called for climb thrust at the same time Tower handed us off to departure. Rapidly approaching 2;000 feet the PF realized the autopilot couldn't negotiate the L/O so he attempted to intervene with V/S. Passing 2;150 feet I said disengage the autopilot. He complied and stopped the climb at 2;250 feet but then over corrected while trimming. I called for control of the aircraft as he descended through 1;800 feet and stopped the descent at 1;700 feet.

The flight was scheduled to ZZZ. I had operated as the First Officer (FO) on the previous leg as Pilot Monitoring (PM) so that a Check Airman could accomplish a line check on the Captain Pilot Flying (PF). On the incident leg I occupied the jump seat to give a 24 month observation to the (Check Airman) who was now flying from the right seat (PF). The aircraft was operating under MEL 30-XX-XX-X EPR ENG PROBE HEAT P&W ENGINES which forced the crew to operate the engines in N1 mode and deactivated the auto throttles. The crew thoroughly briefed the N1 setting procedure and reviewed the procedure just prior to takeoff. The flight was given a clearance to line up and wait on runway 26R and was advised there was an inbound aircraft for that runway 9 miles out. The delay in position was long and somewhat uncomfortable as the crew was concerned about the proximity of the inbound aircraft. The takeoff clearance was received '[Flight No.] cleared for takeoff; fly runway heading; maintain 2;000 feet' As soon as the words 'Cleared for takeoff' were spoken the PF advanced the throttles to 60% N1 per the MEL procedure. The PM correctly read back the clearance including the cleared altitude of 2;000 feet (PDC clearance altitude was 4;000 feet). The PM set 2;000 feet in the MCP Altitude window and pointed to it but the FO was already advancing the throttles and never acknowledged the new altitude clearance. The takeoff roll was uneventful. The Captain made the 2;000 foot for 3000 foot call and the FO responded (I don't recall his exact words) As the aircraft climbed thru 1500 feet the FO called for Autopilot 2 to command. The Captain selected the autopilot on at 1;700 feet-1;800 feet. The rate of climb was quite high and the aircraft climbed thru 2;000 feet. The captain called out 'level off' to which the FO responded by attempting to select V/S on the MCP panel. At approximately 2200 feet the autopilot was disengaged (I believe by control column forward pressure but I do not know which pilot force caused disconnect). The pitch over was somewhat dramatic and a descent initiated. At this point the Captain responded to a radio call. The FO allowed the aircraft to descend thru 2;000 feet and I called out '2000 feet' The FO responded by reaching up for the MCP panel and appeared confused. I yelled '[Name] you are manually flying'. The FO responded by reducing the rate of descent (It was 1;000-1;200 feet per minute) to near level flight. At this point we were approximately 300-400 feet low. Some conversation occurred between the Captain and the FO; the result being that the Captain assumed control of the aircraft and manually climbed to and leveled off at 2000 feet. (During de-brief the FO claimed the Captain asked if the FO would like to the Captain to fly; from my seat I only heard the FO say 'You have the aircraft') The remainder of the flight was uneventful. Factors contributing to event - Mixed automation (No auto throttles) - Engine Power setting by N1 vice EPR - FO's perceived time pressure to start takeoff roll - Non-compliance with SOP (Alt setting procedure) - Communication- Captain did not ensure FO acknowledgement of cleared altitude - Early level off - Reluctance to turn off automation - Auto-pilot mode confusion - Over reliance on auto-pilot (Attempting to engage the auto pilot in descent below cleared altitude)

An A300 flight crew experienced an altitude deviation while attempting to level off at 2;000 feet. The pilot flying co-pilot did not acknowledge the change in the initial level off altitude from 4;000 feet to 2;000 feet. This combined with a light loaded aircraft and his relative inexperience combined to cause the event. The Captain took control of the aircraft and performed the level off.


Communication Breakdown; Time Pressure; Training / Qualification; Workload; Distraction

Party1 Flight Crew; Party2 Dispatch; Party2 Ground Personnel

Automation Aircraft Other Automation; Person Flight Crew

Flight Crew Inflight Shutdown; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Landed in Emergency Condition; Flight Crew Returned To Departure Airport; General Declared Emergency

I initially was the pilot flying. Passing through 10;000 FT I called for 'props 850; climb checklist below the line.' Shortly after that I noticed high oil temp on #1 engine. We immediately leveled off at 12;000 FT and notified ATC. The Captain pulled out the QRH and read it. I reduced the power 20% to about 68-70% torque. We started the clock for 10 minutes. Next we notified the flight attendants of a potential engine shut down. We tried to text Dispatch several times of the problem. For a while we had a VHF no comm. I tried to get Departure Operations and could not reach them. 10 minutes expired. We completed the QRH which led us to the engine shutdown QRH procedure. I disengaged the autopilot and we shut down the engine per Company procedures. The Captain declared an emergency. I turned the airplane back to the departure airport. We were given direct. Then we received a message saying to monitor the temperature for 2 minutes and it could be an indication failure. At that point we had already shut the engine down. The Captain made a PA. We swapped controls [and] then re-engaged autopilot. We asked for 15R. We were given direct the outer marker. I called the flight attendants and gave them the emergency brief. I told them we shut down the engine as a precaution; about 20-30 from landing; stay on the airplane do not evacuate after landing we will be towed to the gate; and no special bracing. We set up the approach and the Captain briefed it. We were given 10;000 FT. We descended; and completed single engine QRH descent and approach checklist. I used the FMS and sent the landing data and never got numbers back. We used the speed cards for 62;000 LBS. I sent a text message to Dispatch telling them we were using 15R; landing weight 61;500 with an LDF of 1.4. We got no response. I called Operations several times with no response. Then I heard another airplane call Operations with times and I asked them to relay the LDF 1.4 message and I got no response. Then we were given 4;000 FT. We descended. The Captain and I discussed that our normal landing distance is around 4;400 FT. With an LDF of 1.4 it is less than 7;500 FT. 15R is 10;000 FT long. We were within limits. Then given 3;000 FT; we descended. The Captain called for flaps 5. I put flaps 5. We want to blue needles. Localizer captured. I called 'runway in sight' and the Captain said 'landing.' Glide slope alive. The Captain disengaged the autopilot and called for gear down. Then he said flaps 15 single engine before landing checklist. I completed the checklist out loud with him. He followed the localizer and glide slope down and landed on the centerline. He exited the runway to the left. Then we completed the after landing and parking checklist [and] were towed to the gate.

After a Q400 #1 engine oil reached 124C the QRH directed an engine shutdown. An emergency was declared and the flight returned to the departure airport.


Air Traffic Control Time Certified In Pos 1 (yrs) 5

Situational Awareness; Distraction; Communication Breakdown

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

Aircraft X was given a heading of 110 to join the localizer; maintain 2;000 feet until established and cleared for the ILS 13R approach at HOU. The pilot read back 'one one thousand; maintain 2;000 feet till established on the ILS 13 cleared ILS 13.' I remember him saying the one one thousand which of course was wrong; but I was fairly certain he meant 110 heading. He did state the altitude to maintain correctly so I did not make a new transmission to get a different read back. I switched him to HOU Tower when he was at 019. Since he was the last aircraft for a few minutes; I remember taking a drink of my water and standing up to stretch my legs. The LA (Low Altitude) alert sounded and I quickly called HOU Tower for them to issue the MSA alert.  The aircraft had descended to 010 on the localizer 1.5 miles from the FAF.  The crossing altitude for the FAF is 020 and the MVA in the area is 020 and the MVA in the area is 2;000 feet. I did not notice his quick descent since the few seconds had elapsed from when I switched him to the Tower.Maintain a steady scan of all aircraft at all times until they are safely outside the area of my responsibility. Make sure every read back is 100% accurate; 100% of the time.

Houston TRACON Controller reported a partially incorrect readback which lead to an aircraft descending below the MSA in the area.


Flight Crew Last 90 Days 103; Flight Crew Total 11000; Flight Crew Type 2500

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue

Flight Crew Diverted; Flight Crew Landed in Emergency Condition

I was the Relief Pilot on the flight. At the time of the discovery of the issue at hand; I was in the back of the aircraft on break. When I arrived on the Flight Deck the Number 2 Fuel Tank showed 4;800 LBS; the Number 1 Tank at 12;800 [LBS] and [quantity] unknown on the Number 3 Tank; as it was dispatched with Number 3 Fuel Tank Indicator inoperative equals Manual Fuel Procedures. After takeoff; all the appropriate procedures took place for Manual Fuel and monitored throughout the flight until the above occurrence. After coming to the Flight Deck; after being called up for a potential problem for fuel; the crew was running the Fuel Leak Checklist for the Number 2 Tank and had Number 2 isolated. I helped them finish the checklist and we had ascertained that Number 2 did not have a fuel leak; but the fuel started increasing in the tank so we opened the cross-feeds [valves] to protect the engines and pressurize the manifold. At this point we felt that the actual fuel readings that we were seeing could be incorrect due to the fact that the fuel in Number 1 and Number 2 fuel tanks were very erratic; Number 3 fuel [quantity] was unknown. We called Company to advise [them] of the problem and we continued to work the fuel issue; there again not having any idea of what fuel quantity we had in Number 3 tank; but up to that point felt that it equaled Number 1's fuel quantity and Number 2 continued to decrease. The fuel state [status] became critical for Number 1 and Number 2 fuel tanks and we elected to divert while talking to Company and ATC Center to ZZZ for fuel concerns due to a possible fuel leak which was directed by the checklist. We continued to work the fuel problem up to a safe landing in ZZZ1. We felt the tank quantities indications were possibly incorrect.

[We were] operating [City Pair] on an MD-11. Operating the Fuel System in Manual Mode due to a MEL; Number 3 [Fuel Tank] Indicator inoperative. We passed ZZZZ and made a fuel check and determined by manual procedures that we were 2;500 LBS above schedule. Looked at tank quantities and noted the Center Main Tank (Number 2) at 4;600 LBS. Initially reviewed the Manual Fuel Procedures (MFP) in the Aircraft Operating Manual to insure switches were in the correct positions. Immediately questioned and discussed the possibility of a fuel leak; ran the checklist and isolated the Number 2 Tank. We opened the cross-feeds [valves] to protect the running engines. With the Number 2 Tank isolated; the quantity in that tank increased and the Number 1 Tank was decreasing at a faster rate than we thought was normal. We assumed the Number 1 and Number 3 Tanks were together in quantity and to this point were operated in the same manner to keep those quantities the same. The quantity in the operating tanks were at levels lower than where we expected them to be; so we called Operations on the SAT phone to discuss our options. While talking to Maintenance and Dispatch; fuel in the operating tanks reached emergency level so I declared an emergency and diverted to ZZZ1. I flew the airplane and handled communications. My First Officer and Relief Pilot set up the approach. I elected to stay high on our descent into ZZZ1 in case of engine flameout. I joined the final on profile and noticed a lot of rudder was needed to maintain centerline. I questioned if we lost the Number 3 Engine and their response was no; all operating normally. Landed and parked with no other abnormalities.

Three pilots describe their efforts to determine the actual fuel quantity on board an MD-11 aircraft during cruise flight after fuel indications in Number 1 and Number 2 Fuel Tanks became erratic while Number 3 Tank quantity was unknown due to being deferred 'inoperative.' Emergency was declared due to critical fuel status; aircraft diverted.


Large Transport; Low Wing; 2 Turbojet Eng

Party1 Flight Crew; Party2 Dispatch; Party2 ATC

Party1 Flight Crew; Party2 ATC; Party2 Dispatch

Deviation / Discrepancy - Procedural Published Material / Policy

Person Flight Crew; Person Air Traffic Control

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification

Procedure; Chart Or Publication; Company Policy

When cleared for takeoff; we were assigned the HITAG1 departure. We queried the Tower Controller and said we had the WINCO1 RNAV loaded causing him to cancel takeoff clearance. We asked if we should load HITAG1 and he instead issued runway heading to 5;000 FT. For vectors. He said he would contact our company as this change is being missed on PDC. After reviewing the PDC; we confirmed no change bars or route change advisory as listed in FOM guidance; however; in the text at bottom; the HITAG1 was referenced. Communication discrepancy between ATC and crew via PDC. Non-standard format for DP change instructions. ATC should use standard route change format or not send PDC to issue alternate clearance instructions. As a crew; we should have queried the irregular format.

After we had been cleared 'line up and wait' on Runway 8R; we were then 'Cleared for takeoff; RNAV HITAG.' I inquired that we were assigned the WINCO1. We were told that our takeoff clearance was cancelled. We immediately looked at our PDC and there were actually no change bars from our filed routing; but we both missed that HITAG1; WINCO transition was also listed on the PDC. We said we could load the HITAG if needed; and the Tower Controller said not to worry about it; 'cleared for takeoff; runway heading 090' and he would take it up with the company. Non-standard PDC route change; and for some reason both the Captain and myself missed the HITAG1 even being referenced in the notes. Had we noticed; we would have had to inquire with Clearance Delivery as there were two different SIDs referenced.

A crew preparing to depart MIA had its takeoff clearance canceled after ATC asked them to confirm they were assigned the HITAG1 SID but the WINCO1 RNAV was loaded in the FMS.


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

Environment - Non Weather Related; Human Factors

While descending through 19;200 feet MSL on the ORW7 arrival into BOS; I saw what I thought was a balloon coming towards our aircraft. A few seconds later as we flew directly under it; missing it by about 10-20 feet; we noticed it was a drone. It was directly above my windshield (the FO side) and probably about 2 feet wide. We were approx 24NM west of PVD VOR.  I immediately notified BOS center and they proceeded to vector other aircraft away from that area. BOS center gave us their number to call them on the ground for further information. I called and spoke with BOS center managent and provided the information [they] requested in addition to my contact information.

We were flying the Norwich 7 (ORW7) arrival into BOS and we were approximately 24 miles west of PVD on the arrival near the OUTTT intersection. I was the Pilot Flying but was heads down at the moment while I was giving a PA announcement to the passengers. As we were passing through FL192 in the descent I looked up and saw what appeared to be a black drone directly in front of us at the same altitude. I saw the drone out of the FO's windshield and it quickly passed over the top of us. It appeared to be 18-24 inch in diameter; oval shaped; solid black in color; and I believe it missed our aircraft by about 20-50 feet.The FO was certain it was a drone. She reported to me that she saw what appeared to be a propeller on the top of it and something else hanging below it (possibly a camera). We reported this to BOS ARTCC who immediately began to vector other aircraft away from that area. The FO had a much better and longer visual look at the object and was certain it was a drone. BOS ARTCC asked us to call them on the phone after landing which we did. They said a report would be filed on their end. I also reported this to the Chief Pilot. Possibly a high altitude drone.

ERJ-190 flight crew reported a NMAC with a Drone during the descent phase of flight.


FMS Or FMC; GPS; Localizer/Glideslope/ILS ILS 05R Z

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

Flight Crew Last 90 Days 108; Flight Crew Total 6699; Flight Crew Type 5877

Distraction; Situational Awareness; Time Pressure; Troubleshooting

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

Aircraft; Chart Or Publication; Software and Automation

Fix CI051 came up when approach ILS 05R Z entered into FMGC.  Fix is not on that approach; nor any approach into MMMX. Fix MX901 which is on the approach was not in the FMGC. This is not noted on NOTAMs. If pilots are not careful and neglect to delete CI051 and add MX901 with an altitude constraint  prior to being cleared the approach they would not comply with a clearance and potentially 'jam' themselves on this approach.

Air Carrier Captain Line Check Airman reported the aircraft database for the MMMX ILS 05R Z does not match the approach chart.


Confusion; Situational Awareness; Communication Breakdown

ATC Issue All Types; Conflict Airborne Conflict

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

I accepted a hand off on a BE40 landing ZZZ. Because he was a Lifeguard; I was trying to give him expeditious service to Runway 6 at ZZZ; as I was not overly busy when I formulated my plan. A few other aircraft came into the picture; including a departure from ILG landing ZZZ1 and requesting practice low approaches at ZZZ1; which we do not do. I got into a conversation with that pilot that may have distracted me from implementing my plan as I had envisioned it. I also misjudged what another sector would do and got myself in a position that I had to try to expedite the descent for the BE40 and vector to avoid traffic that I had not anticipated. I had expected the North satellite controller to leave ZZZ1 arrivals at 50 so I could get the lifeguard underneath at 40 to land straight in to Runway 6. The controller did not do it and ran the traffic more to the SOP at ZZZ1 and I was left scrambling to try for separation. At the same time another aircraft had not descended as quickly as I hoped. It was a plan that would have worked out if I had been able to complete needed coordination; but I didn't. I think I should have worked my traffic closer to the SOP operations here rather than trying to provide expeditious service without complete coordination.

TRACON Controller described a conflict event when the planning for the expedited handling of a Lifeguard aircraft was interrupted by several unexpected adjacent controller actions making the aforementioned planning ineffective.


Small Aircraft; High Wing; 1 Eng; Retractable Gear

Flight Crew Instrument; Flight Crew Private

Flight Crew Last 90 Days 2; Flight Crew Total 650; Flight Crew Type 400

Flight Crew Rejected Takeoff; Flight Crew Took Evasive Action

I received my IFR release with a 2 minute void time. Although I had heard the pattern traffic call 'turning base' there were no subsequent calls. I checked final and saw no traffic. I announced my departure and entered Runway XX. As I started to roll; the other pilot radioed 'hold position; hold position.' He further stated that he was on short final and was initiating a go-around. On my climb out he asked if I was on frequency. I replied and he told me that I had essentially cut him off. Although I never saw him; or heard him call 'turning final;' I apologized and we each went our own way.Contributing factors on my part include: about 2 hours experience in the last 90 days due to COVID; the 2 minute release window; my unconfirmed belief that I could depart without impacting the other aircraft.Corrective actions include: Asking ATC for a longer release window; calling for a position report from the other aircraft prior to entering the runway; accepting the release voidance and rescheduling the release.Human performance consideration: I believe that I experienced a form of 'get-there-itis.' It felt urgent to depart before reaching the 2 minute void time and that urgency affected my judgment. In truth; there was no rush and I could have taken one or more of the previously identified corrective actions. I will do so in the future.

Pilot reported calling on radio for traffic and attempting to depart in a 2 minute window; when an aircraft on final requested pilot to hold position; but ultimately had to go-around.


Air Traffic Control Time Certified In Pos 1 (yrs) 3.5

Situational Awareness; Confusion; Human-Machine Interface

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

ATC Equipment / Nav Facility / Buildings; Weather; Procedure

I was working a sector. I was talking to two aircraft at the time. This aircraft was going to ZZZ airport. These aircraft get descended to 11000 feet and handed off to TRACON. Around the middle of my sector; after TRACON took radar handoff; all of my information disappeared. The entire data block; flight plan etc. The aircraft became a Mode C intruder on the previous assigned code. Upon my further investigation I found the exact same call sign; a departure leaving ZZZ1 airport. I asked the pilot about why he thought company would do that to which he told me that his flight was delayed due to maintenance. I would assume that the pilot called this in to company because about 5 minutes later the call sign of the other aircraft; the ZZZ1 departure was changed by the company. At this point it made no difference because my flight plan information was already gone. TRACON still had their information. Further investigation by my supervisor led to the discovery that TRACON; unable to depart the flight plan in the system (obviously because one was active) removed strip with logic override; which led to my information disappearance. Had this happened with the sector busy it could've been disastrous. This happens to us all the time in the summer during SWAP (Severe Weather Avoidance Program). Flights get delayed; same call signs are still inbound to the metro area and the outbound flight gets airborne. We always change the call sign. I really don't understand why the airlines use a certain call sign multiple times per day. There must be enough call sign numbers to have a different number for every flight every day.  In SWAP this adds complexity and an extreme amount of workload to an already busy sector. Being able to remove strips would make it much easier; but someone somewhere would lose all their information. I would recommend that the companies use a call sign for one flight only.

ZNY ARTCC Controller reported a TRACON Controller entered a remove strip message on a flight plan. The Controller had to override the flight plan control to enter the message. An aircraft with the same call sign was active in ARTCC airspace. The data tag on the ARTCC Controllers radar disappeared from the display.


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

Flight Crew Last 90 Days 70; Flight Crew Total 14000; Flight Crew Type 250

Workload; Communication Breakdown; Time Pressure; Physiological - Other; Fatigue

Flight Crew Commercial; Flight Crew Multiengine

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

On post flight inspection in ZZZ Captain noticed an oil seepage on the left side of engine cowling. Discovered that the oil Dip Stick was missing. Reported same to Maintenance Control; Chief Pilot; Chief Training Captain; and Director of Operations. New stick was installed and oil added. One (1) quart brought engine to Full Cold mark. Maintenance ran engine and released aircraft back into service. Completed the next four (4) flights without any issues. Day before; Date1; 3 leg Deadhead; XA:35 to XK:45 ; 9 1/2 hours on duty. DH (Deadhead) was moved up Date2 by 6 hours. During DH I was informed that my Copilot would not be arriving until XR:30 and I was expected to pick him up at ZZZ1 airport. Scheduled to report Date3 at XX:55. I informed Operations that would not be adequate rest for either of us. Copilot was told to stop in ZZZ and join me the next morning on my arrival there. I filed flight plans accordingly. That evening I was rescheduled again; adding 2 more flights and reporting at XX:15 . Reposition part 91; No Autopilot; from ZZZ1 to ZZZ2. Pick up new Copilot and fly passengers to ZZZ then change copilots and fly ZZZ; ZZZ3; ZZZ; ZZZ2; ZZZ1. arriving at YM:30; 15.5 hours duty. During preflight I missed the missing Dip Stick. Dark; tired; cold; plane just released by Maintenance for service; running late. Dip stick was later found in hangar where 2 Mechanics left it the night before. Why they removed it to hangar I do not know.I was told to fly the remainder of my day when incident occurred with Management's full knowledge that it was my mistake during preflight to catch missing dip stick. They also had me to fly with minimum rest the next day 4 passenger flights; and then 3 DH flights home to ZZZ4. I was informed during my DH that I was being investigated and to remain home until called back to work. I [reported] company Incident/Debrief within 24 hours of being asked to. Company routinely reschedules pilots into situations where they are late; little sleep; no food. Pushed to fly single pilot many times.

I was SIC (Second In Command) during the relevant day. The day began with the PIC (Pilot In Command) flying single-pilot from ZZZ1 to ZZZ2. At ZZZ2 I joined the active crew (PIC) for one leg on the same aircraft - flying ZZZ2 to ZZZ: I waited inside the terminal at ZZZ2 for the plane to arrive from ZZZ1. After the plane landed I met the PIC inside the terminal; and heard him say 'we just need fuel' to the Gate Agent. Upon hearing this I took my belongings from the office; exited the terminal to the plane to supervise fueling. The PIC did not instruct me to perform any checks on the plane. After fueling completed I performed a 'walk-around' of the plane to check externally. I took the fuel sump to check the fuel; poured it out and returned the fuel sump to the pod. Per company FOM pre-flight checks are delegated by Captain to FO (First Officer); this was my first time joining an active crew from another base mid-day; and pre-flight was not discussed. As part of pre-flight checks; oil level is typically checked in the first flight of the day (or when switching aircraft) - since I was joining an active crew that had already completed the first flight of the day on this plane I did not proactively check oil.After fueling completed I entered the terminal; saw the PIC at the entrance; told him I was going to wash my hands. After washing my hands I signed the manifest and we exited the terminal to the plane. We boarded the plane and flew to ZZZ. During the post-flight inspection in ZZZ we saw oil on the side of the aircraft coming from the engine; opened the cowling and discovered the dipstick missing. Later on it was discovered that the dipstick was left where the plane originated in ZZZ1 by the Mechanic who added oil to the engine the evening prior and apparently did not return it.The missing dipstick was not discovered by the PIC in pre- or post-flight of the first leg prior to me joining; and I did not discover the dipstick missing before I joined the subsequent leg of flight. No issues occurred in flight (no lights turned on/no engine issues) and to my understanding the engine was not damaged.While many human factors contributed to this chain of events; it is my personal responsibility to proactively ensure a safe and airworthy aircraft regardless of whether PIC instructed me to perform certain checks or not. Additionally; I believe there is a lack of clarity in company procedure for pilot joining an active crew (what checks need to be performed). In my prior experience flying I checked oil (and performed all other exhaustive pre-flight checks) on the first leg of every day and on the first leg of a new aircraft. In this situation the plane was on the ground for [about] 15 minutes including fueling and boarding of passenger and when the PIC said 'we only need fuel' I did not challenge him and question whether he performed pre- and post-flight checks prior to me joining. On a personal level; in the future I will be proactive regarding any aircraft I fly in; questioning the PIC and will not assume the pilot flying with me has completed any checks; regardless of seniority. On a company procedures level; I think clarity regarding required checks for crews that partially change throughout the day (whether regarded as new crew/day or same crew/flight day) will be helpful. Generally; communication between crew members is key to prevent assumptions and minimize human error.I cannot speak to the human factors from which the issue originated - what caused the Mechanic to forget to replace the dipstick or what occurred during the pre-flight checks of the PIC in ZZZ1.

C208 Flight Crew reported engine oil dipstick missing during post flight inspection.


Any Unknown or Unlisted Aircraft Manufacturer

Flight Crew Last 90 Days 15; Flight Crew Total 475; Flight Crew Type 192

ATC Issue All Types; Ground Event / Encounter Ground Strike - Aircraft; Ground Incursion Runway

Air Traffic Control Issued Advisory / Alert

I had my aircraft parked at the self-service pumps and was about to begin fueling when I caught a landing aircraft in the corner of my eye in the midst of a bad porpoise. The aircraft came down hard on its nosewheel; which separated from the aircraft as it skidded to a stop on its nose a few hundred feet from where I stood. The occupant was not exiting the aircraft and the master switch was still engaged; as evidenced by the rotating beacon.Judging that I was the closest person available to render immediate assistance; I ran towards the aircraft along with my flying partner; who has been certified in wilderness first aid. I was aware that I was entering the movement area and did use extreme caution; carefully supervising my partner as well. We arrived on scene first; almost a minute before the emergency vehicles. As soon as it was clear the occupant was unharmed and there was no risk of fire; we immediately left the scene.Another person who followed us out to the aircraft with a handheld radio was admonished by the controller for entering the area without permission and it was suggested that we may have violated a regulation. I believe that under the circumstances; we acted upon the correct instinct to render immediate assistance. As a pilot I understand the hazards that exist in the movement area and did my best to mitigate any risks as I entered with my partner. We retreated to the non-movement area immediately when it was apparent that we were not needed to help.The decision to enter the safety area was not taken lightly; but I felt it was correct at the time. I am sensitive to the controller's needs to control access to the area; and I do regret adding to his workload.

GA pilot reported entering the runway to administer aid following an aircraft incident and being admonished by ATC for entering the movement area.


Situational Awareness; Workload; Confusion

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

Flight Crew Became Reoriented; Flight Crew Took Evasive Action

With both engines running and the Before Takeoff Checklist complete; we approached the hold line for Runway 9L. The Captain stopped the aircraft at the hold line and inadvertently shut down the number two engine; [intending to set] the parking brake. I did not see this happen because shortly after we stopped; the Tower cleared us for takeoff and I was busy responding to the radio call with my attention outside to clear final and verify we were turning onto Runway 9L. While applying power and slowly turning onto the active runway to line up for takeoff; the Captain stated that the number two generator had gone offline which I verified on the overhead panel. I immediately looked at the engine gages and observed zero percent N1 on the number two engine; informed the Captain the number two was not running; and radioed the Tower we needed to exit the runway at Taxiway T. We exited at Taxiway T at normal taxi speed; got back in line on Taxiway M; analyzed and discussed what had just happened; started the number two engine; did our flows; ran the Before Takeoff Checklist and departed uneventfully.

A B737 Captain stopped to hold short of the takeoff runway and meant to set the parking brake but instead shutdown number two engine just before takeoff clearance was issued.


Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy

Air Traffic Control Issued New Clearance

During the DINGO 5 arrival into TUS; after waypoint MAVVA; I continued on the charted 075 degree heading passing through the Runway 11L localizer course; not complying with the textual instruction to intercept the I-TUS localizer course. ATC gave me vectors back around to re-intercept the localizer course; and a normal landing was made.The cause of the event was a failure to cross-check the textual instructions with what is displayed on the chart. Contributing factors were as follows: 1) A 'Descend Via' clearance was not issued. ATC instructed to 'Descend and maintain 8;000 feet; and EXPECT a visual approach.' I misinterpreted that to mean he would provide vectors to the final approach course; or clear me for a visual approach passing MAVVA.  2) I found the verbiage on the chart confusing where it states 'Runway 11L EXPECT approach clearance'. I interpreted that to mean once established on the 075 heading from MAVVA; not upon intercepting the localizer; as normally you would not intercept a localizer without ATC clearance or prior to accepting a visual approach.To avoid a recurrence of this event; a thorough briefing covering all noted and textual information should be conducted and cross checked prior to every landing. While my briefing did cover all of the information on the plan-view of the arrival; I missed a crucial piece of information solely located in the textual description that was not well depicted nor defined on the plan-view. It would have been helpful if ATC had offered us a visual approach earlier; directed us to intercept the localized after MAVVA and THEN expect approach clearance; or have the instruction to Intercept I-TUS localizer clearly printed on the plan view. It is worthy to note; the ATC controller stated 'Yeah; you're not the first airliner to do this' both over the frequency and on the telephone while speaking with him after landing. This leads me to believe that this could be a common mistake that could be corrected easily with a revised; emphasized; note on the arrival chart.

Air carrier Captain reported a track heading deviation while on the DINGO 5 approach to TUS.  The reporter cited 'Descend Via' vs. 'Descend and maintain' phraseology and confusing chart verbiage contributed to event.


Medium Large Transport; Low Wing; 2 Turbojet Eng

Air Traffic Control Time Certified In Pos 1 (yrs) 1.3

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

Airspace Structure; Procedure; Human Factors

Aircraft X was crossing our airspace at 37000 feet we had to reroute the aircraft over BIKKR intersection to remain clear of the Panamint MOA which was active. I initiated a handoff to ZLA sector 16 about 70 miles from the JCF/ZLA boundary. About 20 miles from the boundary ZLA Sector 16 called instructing us to 'spin' Aircraft X. I immediately alerted the Radar Controller Sector 16's instructions and Aircraft X was issued a left turn heading 250. About 30 seconds after the turn we observed an aircraft NW of BIKKR also at 37000 feet and figured that this was why 16 spun Aircraft X as they were a tie at BIKKR. However this is not the aircraft the possible loss occurred with.Aircraft X began a slow gradual wide left turn to the 250 heading and was going to penetrate ZLA 16 airspace so I initiated a pointout with ZLA 16 and it was subsequently approved. About halfway through the turn ZLA 16 called wanting us to turn Aircraft X faster however the pilot reported that they couldn't turn any faster than what they were doing. ZLA 16 had a second aircraft also at 37000 feet. I alerted Sector 16 that Aircraft X couldn't make a harder turn and they told me the beacon code of the other aircraft and I observed it northwest of BTY and advised we would attempt to climb Aircraft X. ZLA 16 advised they were descending their traffic. The pilot advised that they could not climb as they were at their service limit and I attempted to alert ZLA 16. I observed the second aircraft begin a descent out of 37000 feet prior to lateral separation being less than 5 miles but may have not reached 36000 feet prior to reestablishing the 5 mile lateral separation. Aircraft X at the closest point appeared to be turning away from the conflicted aircraft. I believe poor planning on the part of ZLA 16 may have contributed to this event by not recognizing the situation earlier. Also the performance of Aircraft X by making such a slow wide turn exasperated the situation. The R-side did advise Aircraft X to make the turn without delay. But maybe I could have told the R-Side to use immediate or expedite to indicate to the pilot more abrupt action was needed. This was one of the those situations where I felt we had no way out given the factors above and it was all about the recovery.

JCF TRACON Controller reported an aircraft was directed to make a 360 degree turn by the adjacent facility; but the turn was not sufficient to maintain separation from the adjacent traffic.


Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport; General Maintenance Action

We were an hour and a half into our flight. I (the RFO) went back to take first rest period. I saw the FSS (Fire Suppression System) panel was continuously cycling from normal to off (blank) to a red 'FAULT argon pressure' alert. I snapped a picture of it to show the rest of the crew. We began a conversation about the DG (Dangerous Goods) we were carrying and having no back up protection available. We knew the FSS was; at best; not working. At worst; it might be leaking argon into the ship...we could not know its status. It was decided that it was best to return to SYD rather than risk the lives of the crew to proceed for another 6 hours over water with nowhere to land and with DG aboard. The DG included; not just lithium batteries; but flammable solid; liquid; gas; corrosive and more. The Captain ACAR'sed ops and Maintenance Control and also communicated by satcom. Maintenance Control reviewed the FSS history of the ship and found none. The MEL directed the crew to review the FOM. The FOM indicated that without Operational FSS on board the DG could be place in a can and the old system be reactivated or the DG could be removed from the Aircraft. We had DG on a pallet with no way to fight a fire. This was unsafe at best. The issue was this: without an operable FSS; either no DG can be carried aboard the a/c or the old system of a DG container and hoses must be in place. We had neither. The Captain elected for Safety and legality. We considered YBBN as it was closer; but elected SYD. The FO had given ATC a heads up that we likely would return to SYD. We dumped about 42;000 lbs of fuel at FL300 to reduce to below MLW. The FO flew an uneventful approach and landing to R34L SYD. (Maintenance also took photos of the malfunctioning system; as they had not seen it before either. Maintenance also confirmed that it was not safe to fly with the current DG configuration)FSS failed while carrying DG. The fault light (Argon Pressure) came on and off continuously. We had no way of knowing based on the fault light what had failed and what still worked. The Argon gas may have leaked out. The system may have been inop. There was simply no way of determining the level of the failure. This led us to believe that we may not have any ability to detect or fight any type of fire in the cargo area.

I don't think it can be prevented. Systems break. What can be changed though is a better and more thorough understanding of carrying DG. The safety of the aircraft and its crew should never be compromised to take a chance at continuing without firefighting capability. I heard statements like these while we were conferring with Maintenance Control: 'well; maintenance will just defer it and send you back out' and 'we used to not have that system'. Good grief! The folks charged with assisting us need to be better educated about the carriage of DG and how the deferral would have worked had we dispatched with it. When I contact Maintenance Control for assistance in flight; I want a full partner. I don't want to have to teach at that moment.

MD11 flight crew and the Dispatcher involved report on the decision to return to YSSY when the fire suppression system faults enroute with dangerous goods aboard.


Maintenance Airframe; Maintenance Powerplant

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

Equipment / Tooling; Procedure; Human Factors; Chart Or Publication; Aircraft

This report is being submitted in regards to Pitot Static Work Card under Maintenance Manual (M/M) 34-10-00. I complied with the Work Card Inspection Items using tooling/equipment noted on page one. I replaced pitot tubes that were found to be damaged based on the limits given in the work cards. When damage was found; additional tooling was used to verify limit exceedance. Now there is some confusion with a 'Scarf' Check and the use of a Goniometer; which was not listed on page one tooling/equipment. All other inspections on this card are done through 'Visual Inspection' process and when a defect issue was found additional tooling was used. But the work card changes direction at checking pitot scarf and Visual Inspection process now becomes a Goniometer process; even though this was not listed as a required tool. To further confuse things; there was also a note listing a Pitot Part Number (P/N) [for certain pitots]. I hope this submission can clear confusion or misunderstanding and issues resolved. If I would have found evidence of scarf damage; I would have used a Digital Protractor (which is a Goniometer) to verify damage. I believe this work card was rushed into production creating Inspection issues. This was poorly written and an incomplete list of tooling noted and inspection methods not consistent through the entire work card. Work cards should have a trial run to verify it can be accomplished before it is issued for use in production.

Reporter stated he was working an EMB-135 aircraft. The early version of the Visual Inspection Check Job Card was driven by concerns that various Line Stations and Maintenance Bases may not have been accomplishing the complete visual inspection of the pitots. That was because most locations did not have a Goniometer (Digital Protractor) available to check for scarf damage at the forward end of the pitot. That issue was clarified on later revisions of the Pitot Inspection Card.Reporter stated that # 1 and # 2 pitot tubes are the same style; but # 3 pitot; located on the lower right side of the fuselage is a different style (shape) and subject to corrosion around the static port holes on the # 3 pitot tube.

An Aircraft Inspector reports about a confusing Job Card and lack of any specific reference to Goniometer (Digital Protractor) tool required to complete a visual inspection of pitot-static tubes on their EMB-135 aircraft.


Distraction; Confusion; Workload; Situational Awareness

Workload; Communication Breakdown; Distraction; Situational Awareness; Confusion

Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach

Flight Crew Became Reoriented; Flight Crew Returned To Clearance

Environment - Non Weather Related; Human Factors; Procedure

On arrival into BWI. Was cleared for the visual to 33L and to follow a B737. I turned right to intercept the final course on the localizer. Set altitude 1;500 and aimed to join at FAF. I descended to the FAF and lost [the traffic] however my first officer maintained [traffic] in sight. I searched for the runway visually and being unfamiliar with BWI I thought I had the runway in sight. I began to trust my visual and cut in tighter than required and continued descent. I began to realize I was looking at 33R. Upon recognizing my misplaced position of the runway I turned back to the localizer to gain course. I approached below the glide slope and got a 'glide slope' aural once. I finally acquired the runway and began to correct visually. I briefly noticed a 'ground proximity' icon that went away. There was no aural warning. I was fixated outside. Continued and landed. I should have never gone fully visual. I knew I was unfamiliar and should have shot the ILS. A go around was probably the best option.

We were on the ANTHM One RNAV Arrival into BWI for runway 33L. We had briefed the visual to runway 33L backed up with the ILS to 33L. At approx ROAPS intersection we were told that there was a 737 on final for 33L. We told Approach that we had the traffic in sight and were cleared to follow the traffic for a visual approach to runway 33L. When turning base to final the captain saw the lights to runway 33R; thinking he was closer then he actually was he started to descend. I pointed out 33L and we continued for the runway. At this time we were low and the captain leveled off the aircraft. As we got closer we received the 'glide slope' aural warning; and the message ground proximity on the PFD. The captain corrected and we landed on 33L. As the pilot monitoring I should have called for a go around when the criteria for a stabilized approach was not meet. Additional factors were that the ALS to 33L was out of service. I would suggest better communication between crew members to help verify that they see the correct runway.Using another source; like an ILS or GPS; as a backup for the visual approach.Paying extra attention at night when conducting a visual approach especially when some visual cues like the ALS are not available.

A Captain cleared for a night visual to BWI Runway 33L erroneously visually locked on the Runway 33R lights and prematurely descended causing the 'GLIDESLOPE' aural alert and a brief PFD GROUND PROXIMITY alert. The First Officer correctly pointed out 33L.


Flight Crew Private; Flight Crew Instrument

Flight Crew Last 90 Days 4; Flight Crew Total 720; Flight Crew Type 480

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance

Prior to a training flight from ZZZ to ZZZ1; I weather briefed and filed a flight plan with Center. At this time I clearly stated I was doing patterns at ZZZ1 and wanted to return and tried to go over exactly how that was done. The briefer indicated I would keep my code; do my patterns and call on the frequency I was last on; and get my new sqwak code for return to ZZZ.My instructor and I departed ZZZ flew to ZZZ1 and did all procedures at no time did a full stop; departed the pattern and called approach to activate in bound flight plan.Controller did not like us asking for the code and inbound flight plan in the air. He indicated we had to go to a full stop and call on the phone; not in the air. We communicated our understanding; and that this was our misunderstanding from the briefer and we would do that next time. The controller gave us the sqwak and it was an uneventful return to ZZZ. The controller said 'you are the second plane that has done this' during our indication. On the return to ZZZ the Airport manager called Center to make sure I would not be written up for a deviation. It was indicated to the Manager to tell us this would only be ok at ZZZ2 ( to call in the air) but not ZZZ1; to request in air for the return flight plan and code.

Single Pilot reported a possible deviation from the clearance and problems communicating with the controller while airborne.


Aircraft Equipment Problem Less Severe; Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter Loss Of Aircraft Control

Air Traffic Control Issued New Clearance; Flight Crew Diverted; Flight Crew Landed As Precaution; Flight Crew Regained Aircraft Control; General Maintenance Action

Cruising at FL410; the aircraft began a shallow decent followed by a cyan auto pilot A/B fail. This was followed by a sharper decent and at approx. 40;600 feet we advised ATC we unable to maintain altitude. After completing memory items QRC and QRH we were able to regain control of the aircraft and level at FL390. We diverted to ZZZ and the remainder of the flight was uneventful.

The reporter states that horizontal stabilizer trim actuators were replaced initially by maintenance; followed by stabilizer control electronics.

[Narrative contained no additional information].

A CE680 at FL410 begins a shallow descent which then causes the auto pilot to disengage. The descent steepens and the crew is initially unable to arrest the descent. Control is regained at FL390 after completing memory items and QRH procedures. Secondary trim is selected and the diversion is flown without further difficulty.


General Flight Cancelled / Delayed; General Maintenance Action

During C-check on Aircraft X; Job Card# 731-XXX-XX-XX was performed. This Job Card requires the removal and reinstallation of both radio altimeter transceivers. During a normal C-Check the CAT III upgrade paperwork is automatically attached to the hangar work package to cover any Cat III items disturbed during the check. This zonal inspection did not have the CAT III paperwork attached to the package and I failed to notice the missing task card. The aircraft was then turned over to day shift who were unaware of the need for an upgrade and the aircraft left without a CAT III upgrade being accomplished. While working a phase check the following night I noticed that the aircraft also did not have a CAT III upgrade task card attached which reminded me of the aircraft from the previous night and caused me to look into the issue. This is where I realized the mistake and I reported to my supervisor. Supervisor from Maintenance Control was contacted and we were told the aircraft now parked would be downgraded by the flight crew and flown to ZZZ where it could be upgraded.Preventative Measures: The majority of checks done in the C-check environment automatically have CAT III upgrade paperwork attached. Some -800 Zonal and Phase checks do not have these task cards automatically attached to the package. Due to this in the C-check environment we are accustomed to the CAT III being automatic and when it was not in this case I missed it. I believe the best option would be for this task card to be automatically issued for any aircraft in the C-check environment or anytime a c-check; phase check; or zonal check is issued in any environment.

Technician reported missing a required CAT III upgrade after maintenance actions and the aircraft departed on a scheduled flight.


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

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

Deviation / Discrepancy - Procedural Hazardous Material Violation; Deviation / Discrepancy - Procedural Published Material / Policy

Flight Crew Overcame Equipment Problem; General Maintenance Action

We were planned to take dangerous goods.  Our ACARS was inoperative; so the final text was sent via email. I thought that would suffice since we had taxied out and were not able to obtain the final copy over our printer. I was advised to file a report; so here it is. We also received our takeoff data and final weights this way.

The ACARS on our aircraft became inoperative shortly after initialization. Some of the messages that we did receive prior it becoming inoperative was the initial Dangerous Goods message. The ACARS was eventually deferred by Maintenance and we taxied without receiving a hard copy of the final Dangerous Goods message. We contacted Dispatch regarding our need for the final weights and final Dangerous Goods messages and he said that he could email those to us; which he did prior to our departure.

A-320 flight crew reported; and Load Planning verified; aircraft received departure DG final documentation via email due to inoperative ACARS.


Flight Crew Last 90 Days 5; Flight Crew Total 161; Flight Crew Type 93

Situational Awareness; Training / Qualification

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

I listened to the AWOS and noted wind at 5mph from 90 degrees with gusting to 10mph. On final approach for landing; I experienced light to moderate wind gusts that bounced the aircraft around a bit. Under those conditions; I decided to limit flaps to 20 degrees and maintain a slightly higher airspeed since the runway length was over 6;000 ft. and gusting was intermittent. Upon crossing over the runway threshold at 65kts; I reduced power to idle and flared 10 feet over the runway. The aircraft floated in the ground effect for a long distance and ultimately when the wheels made contact it bounced up into the air again and floated further in ground effect. At that moment; a wind gust pushed the tail to the left. I tried to correct with opposite rudder but the deflection did not correct the alignment before the wheels made contact with the runway. The aircraft was by then oriented at a 25-30 degree angle to the right of runway centerline. The aircraft then bolted violently to the right and rolled quickly off the runway into the grass; heading toward a rock lined; 4-ft deep drainage ditch just beyond a taxiway. As I attempted to maneuver the rolling aircraft back to the left; it began to skid and tip over to the right. I righted the aircraft to avoid driving the right wing and nose into the ground and potentially flipping the aircraft; but by then my only choice was to either roll toward the ditch or in the direction of hangars to the right. I braked but wasn't able to stop before the aircraft rolled into the ditch.The left wingtip; propeller and landing gear received damage. No injuries to myself or damage to airport property resulted. I immediately contacted the aircraft owner and airport authorities; who arrived to the scene quickly to assess the situation. The airport manager confirmed no damage to airport property. The aircraft owner and airport manager coordinated to make arrangements to remove the aircraft from the ditch.

GA pilot reported loss of directional control during a crosswind landing; which resulted in a runway excursion.


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

Flight Crew Last 90 Days 50; Flight Crew Total 850; Flight Crew Type 200

Communication Breakdown; Situational Awareness; Training / Qualification

Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Loss Of Aircraft Control; Ground Incursion Runway

Flight Crew Regained Aircraft Control; General Maintenance Action; General Flight Cancelled / Delayed

After startup with a student; we performed a brake check; both sides; with a positive exchange of controls and no issues. After receiving our taxi clearance for an intersection departure; I observed my student taxiing faster than usual; and off centerline. I told him to slow down and bring the aircraft back to centerline; and he informed me there was a problem with the right brake. I took control; was unable to slow the aircraft; and with the runway hold short line approaching notified ground of my inability to stop. I swung to the right; and used brake to perform a 180 degree turn at speed; but wasn't able to turn tight enough to avoid crossing. I notified tower of my crossing; and cleared the runway environment. I got a clearance to taxi back to parking; where we ended the attempted flight; and shut the aircraft down until maintenance could diagnose and resolve the issue.

Flight Instructor reported a runway incursion due to brake failure and loss of control of the aircraft.


Training / Qualification; Situational Awareness

Flight Crew Overcame Equipment Problem; Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory; General Maintenance Action

We received the inbound aircraft shortly after noon at an out station. The inbound flight crew was leaving the aircraft heading for the hotel van and said 'good aircraft'. We proceeded to board the aircraft and perform preflight duties. Approximately 5 minutes later the First Officer advised me that there was something 'like' speed tape that was covering the static ports on the First Officer side of the aircraft. I exited the aircraft and followed the First Officer to the right side of the aircraft and saw what appeared to be silver 'speed tape' covering the static ports. I called the Chief Pilot's office for advice and was told that she was the only person there at the time. I then contacted SOC and explained what was going on; so they patched me through to Maintenance Control. I spoke a Controller and explained that we discovered tape covering the static ports on the First Officer side of the aircraft and I asked if there was any reason why it should be there. He advised that there should NOT be anything covering the static ports. We both began putting the pieces of the puzzle together. The aircraft apparently came out of maintenance that morning; but he couldn't immediately say why that the static ports would have been covered up with tape. Later he said that they were possibly doing a check of the CATII system and might have needed to test the Pitot/Static system. I told the Maintenance Controller that; obviously; we were not going to fly the aircraft with tape covering the ports. I asked him if it was safe for us to remove the tape to fly our flight to our next destination; a Maintenance base. He advised us 'yes' it was OK to remove the tape; and we did not see any damage or tape residue in the RVSM area. I asked him if he would notify the overnight Maintenance about the possible error on their part and he said that he would. The rest of the preflight was uneventful and all systems were indicating normal.Apparently; Maintenance forgot to remove the tape. The preflight crew that morning apparently missed the tape covering the static ports; and subsequent post flights. We; however; have no proof where the tape originated. We simply found it on our preflight.

During a turnaround preflight; an EMB-145 crew discovered silver colored speed tape covering the First Officer static ports after the aircraft had flown a series of flights since being released following overnight maintenance.


ATC Issue All Types; Conflict Ground Conflict; Less Severe

Air Traffic Control Issued New Clearance; Flight Crew Rejected Takeoff

[We were] cleared for takeoff Runway 31 at LGA. Landing traffic for Runway 22 was reported at 2.3 miles. After brake release we received a blocked radio call that was unreadable. A second radio call from Tower cancelled our takeoff clearance. At the same time I noticed a private jet approaching the over run [for Runway 22]. Takeoff was rejected somewhere between 60 KTS and 80 KTS. Reverser and manual braking were used and we exited the runway at Taxiway S prior to Runway 22. Flight attendants reported modest deceleration with no passenger complaints. We returned to Runway 31 for a normal takeoff. I think the aircraft on final was closer than 2.3 miles; but since it was a small private jet it appeared to be further away than it actually was. Takeoff spacing was too tight even if Tower had told us to be ready for an immediate takeoff. I think this was primarily a spacing problem but if we had received the first cancel takeoff clearance we would have had a rejected takeoff right after brake release.

B737 pilot reports being cleared for takeoff on Runway 31 at LGA then having the takeoff clearance canceled at 60 KTS due to traffic landing on Runway 22. The clearance may have been canceled earlier but the transmission from the Tower was blocked.


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

Human-Machine Interface; Situational Awareness; Troubleshooting

Aircraft Equipment Problem Less Severe; Flight Deck / Cabin / Aircraft Event Illness / Injury

Flight Crew Became Reoriented; Flight Crew Landed in Emergency Condition; General Physical Injury / Incapacitation

After a 1R door slide replacement by Maintenance; the number 1 Flight Attendant had trouble arming the 1R door at the gate. Maintenance was called. Maintenance found a broken piece of dish under the arming lever. After the piece was removed; the door was able to be armed; but the arming lever was more difficult than usual to move. Maintenance signed off the 1R door arming lever as operational and we departed. After takeoff; at about 500 feet the number 1 Flight Attendant called the flight deck and told us that he had a flashing cabin pressurization warning light. He was told to standby while the flight crew continued to fly and identify the problem. The 1R door armed light was found to be extinguished. The aircraft was leveled at 10;000 feet for analysis. After determining there was no issue with the aircraft pressurization system and that the problem was likely associated with the arming issue experienced at the gate; we elected to continue the flight as planned.The flight attendants were notified along with an explanation as to what was occurring. Approximately 10 minutes after leveling at cruise at 36000 feet; the number 1 Flight Attendant called to inform us that the other two flight attendants were experiencing symptoms of hypoxia. The cabin altitude at 36000 feet was approximately 7100 feet and holding stable with no adverse pressurization indications. A lower altitude of 24000 feet was immediately requested and obtained. After leveling at 24000 feet; the Captain checked on the flight attendants. The Captain was informed that their symptoms were worsening. We immediately [advised ATC].  The portable O2 bottles were used by each affected flight attendant; an onboard doctor began monitoring the situation; and the paramedics were requested to meet us at the gate. Upon arrival at the gate; their symptoms had subsided and the flight attendants reported fit for duty for their next leg. This event occurred due to an equipment failure in flight. If the door arming lever would not have changed status to 'disarmed' after takeoff; this event would not have occurred.I recommend informing both Maintenance and flight attendants that if a door arming lever is difficult to move after a slide replacement; even if the door is able to be armed; do not take the aircraft. The aircraft should be removed from service until the arming lever not only arms; but also moves with the normal amount of force application.

[Report narrative contained no additional information.]

Air carrier flight crew reported a cabin pressure issue and flight attendants experiencing hypoxia.


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

Party1 Flight Crew; Party2 ATC; Party2 Flight Crew

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

Automation Aircraft TA; Automation Aircraft RA; Person Flight Crew

Flight Crew Took Evasive Action; Flight Crew FLC complied w / Automation / Advisory; Flight Crew Requested ATC Assistance / Clarification

Procedure; Human Factors; Environment - Non Weather Related

We were cleared to join the transition to the TEJAS4 STAR into IAH; and issued a clearance to climb from 11;000 ft to 17;000 ft. The Autopilot was on. I heard [Houston] Center give a traffic report to a [military] trainer; an '[Aircraft] out of 11 for 17' which I assumed was us. Center did not advise us of the traffic; but I was looking for it and I saw the traffic on the TCAS; descending and converging. Just before 12;000 ft. we had a TCAS TA then RA; at one point commanding vertical speed in excess of 3;000 fpm. The TCAS indicator was a red square; well inside the 3 mile ring on the TCAS screen and converging to our location. It appeared the [military trainer] was descending right on top of us; much like the TCAS avoidance exercise in recurrent training. I immediately disconnected the autopilot and pushed the nose down; taking evasive action as the TCAS commanded a high rate of descent to avoid collision. We announced our TCAS descent to Houston Center. After the event was over; we continued our climb to 17;000 ft. I queried the controller regarding the event. The [military trainer] pilot stated he had visual with us the entire time which I find dubious as we were far too close. At one point the TCAS indicated 300 ft. vertical separation.  We did not have a visual with the [military trainer]; largely due to the fact that he was approaching from our right side and was obscured by the rising sun. The Flight Attendant confirmed no injuries to passengers or herself and everyone was seated. I am unsure if the [military trainer] is equipped with TCAS; as the aircraft made no observable attempt to climb as would be expected when both aircraft are equipped with TCAS.Both ATC and the other pilot made critical errors in separation. ATC cleared the [military trainer] to descend too close to us and through our altitude; and the [military trainer] pilot made no discernible effort to alter flight path despite maintaining visual with us.

Air carrier Captain reported an NMAC during departure from IAH.


Flight Crew Last 90 Days 219; Flight Crew Total 16624; Flight Crew Type 13060

Human Factors; Environment - Non Weather Related; Aircraft; ATC Equipment / Nav Facility / Buildings

'GPS invalid' appeared on initial climbout. GPSs returned at 17;000 ft.

B737 Captain reported getting a 'GPS invalid' message on departure.  The GPS systems returned to normal at 17;000 feet.


Human-Machine Interface; Situational Awareness

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

Human Factors; Aircraft; Chart Or Publication

Flying the KAROO Arrival into RDU; I asked the First Officer to select the lowest altitude on the arrival which was 6;000 MSL. I pulled up the direct/intercept screen and looked at the VSI rates required to meet all the restrictions and I selected a VSI rate of 900 FPM which I thought would meet all the restrictions. I must have not thought it out correctly because we descended below the floor of one of the restrictions by 500 FT. I immediately noticed and entered a climb back up to the appropriate altitude. ATC said nothing to us and we continued the flight without further incident.This happened because I set an incorrect descent rate to meet all the restrictions. Also; I have learned my lesson that I should always set the individual floors of the arrivals one by one instead of just asking for the lowest altitude of the arrival to be set. If I had asked the First Officer to set the first floor; then the second; then the third and so forth this problem would never have happened. In the future I will do it that way.

We went 500 FT below the charted altitude crossing ARGAL...The altitude deviation occurred because the Captain put in a rate of descent that would allow us to cross the last fix [as required] versus the intermediate fixes.

The flight crew of a CRJ-700 failed to comply with the crossing restriction at ARGAL on the KAROO RNAV STAR to RDU.


Flight Crew Executed Go Around / Missed Approach

On a visual approach we were configuring the aircraft for landing. Slats were already extended to Slats 15. Captain called for Flaps 15. The slat/flap handle would not move out of the Slat 15 detent to extend the flaps to the 15 position. The slat/flap handle was cycled; but it would not extend past the Slat 15 position. A go-around was initiated and we complied with the Tower and Departure Control instructions. Departure Control was advised we needed to stay in the area to run some checklists. We ran and complied with the QRH and recalculated our airspeed and landing distance for a no flap landing. We advised Approach Control of the situation. We requested the longer runway and were told to expect [another runway] to accommodate the higher approach speed and longer landing distance. We advised Operations of the situation as well to give Maintenance a heads up. We were vectored back and landed without incident and taxied to the ramp.  We consulted with Maintenance about the problem after arrival to the gate. I followed up online to see the maintenance history of the aircraft as of today. Maintenance could not get the slat/flap handle to operate normally as well. The slat/flap handle unit was replaced according to the history and the aircraft was returned to service.

A300 First Officer reported flap handle would not move beyond the 'Slat 15' position. Flight crew ran the procedure and landed with zero flaps.


Situational Awareness; Training / Qualification; Confusion; Communication Breakdown

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

FL 350; profile; autopilot 1 engaged; .78 Mach; ground speed approximately 480. Optimum alt 350; max 370. Autopilot 2 deferred. FILPZ one arrival to CLT; Line Check Airmen (LCA) Captain giving IOE to FO. Captain was Pilot Monitoring (PM); First Officer (FO) was Pilot Flying. Clearance to cross SKYWA intersection at 330. FO put 330 in FCP; I added a constraint to FMS to cross SKYWA at FL 330. I had unspoken concerns that the FMS computed descent point was too close to assigned constraint. ATC gave frequency change; prior to checking in I directed FO to select immediate descent at approximately 11 miles from SKYWA. I  Checked in with center leaving 350 with clearance to cross SKYWA at 330. They acknowledged. Descent was proceeding normally at 1;000 fpm; shortly after going thru FL 340; FMS picked up its computed profile and increased its descent rate to honor constraint. I recognized at 33;200 feet that the autopilot was not going to capture FL 330. Descent rate was approximately 2;000 fpm and not decreasing. I directed FO to disengage the autopilot and manually level the aircraft. While the autopilot disconnect warning was going off I decided to take control of the airplane. In normal conversational tone I announced I had the aircraft; and I punched off the autopilot warning and began level off.  As I put in back pressure to level off I was surprised that the aircraft entered a buffet. I released back pressure; the buffet stopped; aircraft altitude was now about 32;850. I added a small amount of back pressure back in to climb back to our assigned altitude and the buffet reoccurred. I released back pressure; allowed the aircraft to stabilize 150 below our assigned altitude for about 10 seconds and then manually climbed back up to FL330. During that time I confirmed the speed brake was retracted. I directed the FO to reengage autopilot 1 and to select alt hold.  He completed the descent from altitude with autopilot 1 engaged using level change without further issue. I wrote the incident up in the logbook in detail and also gave CLT maintenance a thorough verbal debriefing. Neither the FO or I felt we induced enough G on the aircraft to induce the buffet; control inputs seemed smooth to both of us with little noticeable G force. During post flight conversation I discovered the FO did not hear me take control of the airplane due to the blaring autopilot disconnect warning and he also did not realize I was putting inputs to the controls. I too did not notice his inputs or ever felt they were contrary to mine. He stated he was also putting inputs in; and from what both of us could tell; his inputs mirrored mine and vice versa. Neither one of us felt at any time that the aircraft response was anything other than what we expected considering the inputs we were applying. The initial manual level off that resulted in the first airframe buffet did not seem aggressive or abrupt to either of us nor did the first attempt to climb back to our assigned altitude which resulted in the second airframe buffet. Stick shaker did not occur at any time. We both completed a visual walk around inspection of the aircraft after landing and noticed nothing unusual. I informed the FO I was submitting [a safety] report and advised him to do the same so causes and errors could be identified and others could gain awareness and knowledge. Maintenance action post flight revealed no system anomalies; ACARS showed lateral g of .15; inspection showed no aircraft damage.

Enroute to CLT we were cruising at FL350 and cleared to cross SKYWA at FL330. I selected 330 in the FCP; the captain edited the FMS to put the crossing restriction in the FMS and I pulled the altitude selector to arm the descent via profile mode. Approximately 11 miles prior to the fix the captain asked me to begin an immediate descent. I selected IMM DESC on the FMS and began a 1;000 foot per minute descent. Passing approximately FL 340 and 4 miles prior to SKYWA the profile mode recaptured the descent and increased the rate of descent to approximately 2;000 feet per minute. At 33;200 with a 2;000 feet per minute descent and the throttles back and no attempt by the autopilot to begin a level off; I realized the autopilot was not going to capture the altitude. At the same time I heard the captain say 'it's not going to capture.' I disconnected the autopilot and began to pull the nose back to the horizon at .78M and 275kts. Almost immediately; I felt a buffet on the aircraft and released back pressure. The altitude decreased to approximately 32;800 feet. After stopping the descent; I attempted to increase altitude by bringing the nose above the horizon. Once again I felt an immediate buffet and released back pressure. The captain put the autopilot back on and I selected alt hold at 32;900 feet. I subsequently selected VS up to bring the aircraft back to FL330 and reselected alt hold. I did not use profile the remainder of the flight. ATC did not mention any altitude deviations. During debrief the captain told me he also disconnected the autopilot at the same time I did and initiated a pull back to the horizon. Due to the loud autopilot disconnect alert; I did not hear him say 'I've got the airplane.' We were both pulling back on the control column same time. After landing the captain wrote up the aircraft for maintenance to investigate both the profile failure to capture and the airframe buffet. Additionally; the number 2 autopilot was MEL and I was using autopilot number 1. The FMS showed the optimum cruise altitude at FL350 with a max of FL370.

While enroute to CLT and beginning descent; the autopilot failed to capture an intermediate altitude. Both crewmembers disconnected the autopilot and corrected back to altitude at the same time which may have resulted in a slight overcorrection and associated airframe buffet.


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

Flight Crew Last 90 Days 15; Flight Crew Total 1520; Flight Crew Type 140

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

After an initial low approach to survey the runway; and while on a subsequent short final into a turf 1200 feet runway in hilly terrain; a sudden; powerful downdraft caused the aircraft to lose altitude and impact a utility line just prior to the approach end of [the] runway. All actions to mitigate the drop in altitude (adding full power; pitching up for maximum climb); proved unsuccessful in arresting the sink rate. The sink resulted in the propeller cutting a utility line approximately 200 feet before the runway threshold; resulting in minor damage to the propeller. A normal landing and rollout was accomplished after the impact with the utility line.

Light Sport Airport pilot reported cutting a power line with his propeller when a downdraft forced an altitude loss.


Workload; Distraction; Communication Breakdown

ATC Issue All Types; Conflict Airborne Conflict

Flight Crew Requested ATC Assistance / Clarification

ATC had us on the KEPEC3 RNAV arrival. We were cleared to 8;000 ft just passing NIPZO. We acquired traffic circling to our south. We received no notice from ATC as to the traffic. The traffic turned toward us and we received an RA. I was the pilot flying and immediately turned off the auto pilot and responded to the RA commands. My FO acted appropriately and turned on the lights and queried ATC as to the traffic and that we were responding to the RA. They replied 'Yea there is traffic circling off your 9 O'clock. The traffic was within 500 ft and directly under our position. They told us to slow to 170 and descend to 6;000 ft. As well as turn left to 330. We stated again that we were complying to an RA. Once clear of traffic we began our decent to 6;000. Our speed was reducing to 170. ATC asked our speed. We stated a speed greater than 170. They told us to slow then continue descent. We complied. We were then given vectors to RNAV 19R and a turn to intercept the final approach course. We stated that we were high and don't know if we could make it at this point. They told us a turn to the left was approved but not the right because of helicopter traffic. We made an attempt to the runway but they had left us too high and turned us in too early. I initiated a Go-around at 1500 AGL. They asked what the reason for the go-around was. We did not respond; requested vectors and an altitude. We received both back to 19R and landed without further incident. I was completely appalled as to the control received from ATC. We received no communication as to the Traffic and Poor vectors and altitude instructions.

Pilot reports of not being advised of traffic that ATC knew about and that the pilot received an RA on. Controller kept aircraft too high and eventually the pilot had to make a go around.


Maintenance Powerplant; Maintenance Airframe

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

General Release Refused / Aircraft Not Accepted; General Maintenance Action

Chart Or Publication; Logbook Entry; Procedure; Aircraft

AMM task 25-61-00-710-801A was unclear and not performed correctly. During Short Term Storage Aircraft Return to Service work card. Unfamiliar and unclear task. Misinterpreted Task. Have the TASK easier to follow. Have a GSE number for tools/equipment and add it to beginning as a required tool/equipment.

[This report narrative contains no additional information.]

Technicians reported tasks on work cards were unclear and technicians performed the task incorrectly.


Dassault-Breguet Undifferentiated or Other Model

Flight Crew Last 90 Days 150; Flight Crew Total 10300; Flight Crew Type 2800

Inbound to ZELEN IAF; New York Approach cleared us for RNAV Runway 5 approach to MMU. After crossing ZELEN at 3;000 FT; Approach handed us off to MMU Tower. While on the approach segment from ZELEN to KWITE at 3;000 FT; TCAS alerted us to traffic at our altitude. There was no warning other than the RA command to climb; which we immediately initiated; climbing to approximately 3;400 FT. We saw a single engine aircraft pass directly beneath us. I notified MMU tower of our RA. As we leveled at 3;400 FT and started a return to 3;000 FT; a Falcon crossed our path at 4;000 FT. We resumed the approach to MMU Runway 05. I contacted TRACON after parking. TRACON indicated that the conflict traffic was a VFR aircraft; not under their control. Our aircraft lighting was configured to be seen. We had position lights; beacon; strobes and pulse lights all operating.

A BD700 Captain reported a NMAC with a light aircraft that was not in contact with ATC on approach to MMU.


Time Pressure; Situational Awareness; Distraction; Confusion; Communication Breakdown; Training / Qualification

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

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

ATIS was advertising LDA-R and we were set up for it. Being vectored for the approach I was still not receiving either LOC/GS. We were cleared for the LDA-DME 19 and the First Officer read it back before I could say anything. I questioned Tower and they told us they were using the LDA-DME and showed green. We were well outside the marker and I knew the approaches were very similar. I changed the LOC frequency and minimums and re-briefed the First Officer. After Bessie (1;600 FT) I continued down to our adjusted minimums of 800 FT. I inadvertently went below 1;000 FT prior to 4 DME and received a low altitude alert from the Tower. I was using FLCH. Normally I would have used FPA from the FAF but we had been left high. Remainder of approach and landing was normal. They still had not updated the ATIS after we had landed and I advised ground. If we had requested to be resequenced for the approach it may have helped by giving us additional time.

DCA ATIS reported the LDA-R approach active but because no LOC/GS signal was received an air carrier crew tuned the LOC; re-briefed the approach and continued to land after a low altitude alert prior to 4 DME.