Communication Breakdown; Confusion; Other / Unknown

Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

Person Flight Crew; Person Air Traffic Control

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

Airport; Human Factors; Chart Or Publication

We were told to taxi to Runway 26R via B and E hold short at E5 hold short point. We turned short of E; instead turned on F; once on F we admitted making a mistake and Ground directed to Runway 26R by alternate taxi directions. All 3 pilots had out the abbreviated taxi chart for the N side complex which didn't show B on tuning to the [east] and then turning south to connect to E. Our charts were truncated. We knew LFPG Ground has the habit of abbreviating their taxi clearances and leaving out taxiways. We talked about this; upon coming to F it was assumed we needed to turn here. While we were on B I questioned the First Officer and Relief First Officer about the taxi directions and we all agreed we needed to turn on F; wrong assumption. Added to this was the First Officer's insistence we needed to turn on F. We finally turned on F and I stopped the aircraft and the First Officer urged me to continue. Needless to say there were some words in the cockpit; and I demanded taxi verification. Ground told us we turned on the wrong taxiway; but then directed us straight ahead for alternate taxi directions. Upon stopping the aircraft and getting clarification we heard the First Officer say 'my bad.' Part of the issue was the First Officer insistence he knew what was always going on; it was borderline arrogance and poor pilot not flying skills.First; get clarification from Ground Control as to what's really expected. I asked the First Officer to do this but he didn't; instead he coaxed me into continuing. It was a leadership issue. Upon turning on the wrong taxiway; I stopped the aircraft felt something was wrong; you think! and asked for clarification. Upon the First Officer urging me to continue; I raised my voice said; NO; CALL GROUND CONTROL; which he finally did and now he realized he caused some of the problems. This issue about the First Officer extended to all he does; from radio calls; to flying the aircraft. I picked up on this early on; but failed to exert my authority and stop his actions. Ultimately; it was all my fault because I didn't handle a passive aggressive First Officer.

MD11 Captain reports a taxiway incursion at LFPG due to a First Officer that claimed to know the route and using the north side taxi chart which does not show Taxiway B turning south to connect to E.


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

Flight Crew Last 90 Days 66; Flight Crew Total 10200; Flight Crew Type 500

Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

Air Traffic Control Issued New Clearance; Flight Crew Executed Go Around / Missed Approach; Flight Crew Returned To Clearance; General Maintenance Action

We were descending through 3000 feet on the ILS. After selecting flaps 20 we received a master caution TE FLAP DISAGREE EICAS message and corresponding annunciator light. I asked the PM (Pilot Monitoring) to run the TE FLAP DISAGREE checklist. While retrieving the check list; we decided a GA (Go Around) was the best course of action to work the issue. Our instructions were to fly runway heading and climb to 3000 feet. When I initiated the GA I anticipated the aircraft to level off or climb very little since we were already close to 3000 feet. It became apparent that it was not going to be close. So I disconnect the auto pilot and began a controlled level off and power reduction; aware of our potential flap issue and possible flap overspeed. We climbed to approximately 3500 feet while ATC gave us clearance to 4000 feet. We remained on ATC vectors while working the checklist and communicating with Dispatch. After completing the checklist and conversing with the company we landed flaps 20 uneventfully. On our taxi to the ramp [ground personnel] thought they detected a possible hot brake; so they followed us to our parking spot. We advised ramp control to keep the ground personnel clear until [others] could better assess the situation. Once in the blocks the brake temps were determined to be ok. Looking back my altitude deviation could have been avoided by simply selecting ALT HLD immediately after GA; then selecting V/S for the smaller adjustments. The FO (First Officer) did a great job running the checklist; talking to Dispatch; as well as staying engaged with me while I was flying the aircraft and talking to ATC. I'd like to express a thank you to our great training department and the people involved. It was brought to our attention that our 757/767 fleet experiences these types of flap/slat issues 1 to 2 times a week. If this is the case it would be beneficial to notify our crews that there is an issue with the fleet.

B757 Captain reported a trailing edge flap disagree problem.


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

ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter

Person Air Traffic Control; Person Flight Crew

Air Traffic Control Issued New Clearance; Flight Crew Returned To Clearance

Environment - Non Weather Related; Human Factors; Procedure

We were level at FL190 and given a climb to FL290. [The Captain] repeated back FL290. I started the climb and [the Captain] got up to shut the curtain and check on the passenger. Passing through FL220; the Controller asked me what altitude I was at and I replied. The Controller said I was only cleared to FL210; and to stop climb. I was climbing at approximately 2700 fpm; stopped the climb at about FL22.9 and started a descent back to FL220; which is about where I was told to stop climb. As I was descending; the aircraft made an uncommanded roll to the right; to approximately 30 degrees. The aircraft righted itself but snapped over to a left bank at a high roll rate. I disconnected the autopilot and assertively brought the aircraft back level. The aircraft started another high roll rate bank to the right and I made an aggressive input to stop the roll rate as we would have otherwise been in an unusual attitude situation. The Captain made it back to his seat and advised me we were in someone's wake. The Captain took over the radios. We got a new altitude assignment; and were asked if we had an RA. We responded; we did not; and the Captain reiterated that we had been given FL290 and responded with FL290. The Controller advised that they would look in to it. Nothing more was said; and the flight continued normally.

Original clearance was given by SDL Clearance then shortly amended due to weather on route due to 'route closure'. After takeoff; multiple altitudes were given due to other aircraft traffic. About 3-5 minutes before event; an airliner was observed directly overhead; probably 2;000 feet above our altitude on same course. At an altitude I recall was FL190; we were given climb to FL290. After completing Transition Altitude Checklist; I left cockpit to close main cabin door noise curtain. Seconds later; aircraft began to roll side to side with the equivalent of moderate turbulence. I held on to galley cabinetry for security and realized this was effect of wake turbulence from [another] aircraft. Pilot Flying took manual control of aircraft and reported to ATC. ATC reported we were assigned FL210. After returning to my seat; I inquired to ATC about my read back to climb to FL290; [Controller] said someone would look into it and determine cause of event.

CL350 flight crew reported encountering wake turbulence departing SDL when they misunderstood a climb clearance and overshot their cleared altitude.


Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

ATC Equipment / Nav Facility / Buildings; Procedure

A B717 was cleared for take off RNAV HRSHL and he read back RNAV HRSHL and flew RNAV to RONII. He thought he was a COKEM5 Departure but he was really a RAMBLN6 Departure. The flight plan showed he was a RAMBLIN which is why I cleared him to HRSHL. He ended up less than 3 miles behind the previous departure. Visibility was 1/2 mile and ceiling was 400 OVC so I couldn't observe his turn visually; not that you can because the RACD and ASDE-X for Local Control 1 is hanging in the window blocking your view. I saw him turn towards HRSHL before I switched him to Departure but missed his turn to RONII because my RACD is slaved to Local Control 1 RACD and since that is an arrival local; the RACD is set up to see arrivals and I only can see about 5 miles of my departure airspace. Not really safe but we do the best we can. Individual RACD's for each position!

ATL Controller described a potential conflict involving an RNAV departure routing; noting that equipment limitations prevented him/her from observing the initial wrong turn and suggesting additional and/or re-location of RADAR displays in the Tower.


Flight Crew Last 90 Days 100; Flight Crew Total 18000; Flight Crew Type 8500

Communication Breakdown; Fatigue; Situational Awareness

Party1 Flight Crew; Party1 Ground Personnel; Party2 Flight Crew; Party2 Ground Personnel

Flight Crew Last 90 Days 240; Flight Crew Total 15000; Flight Crew Type 9000

Situational Awareness; Communication Breakdown; Fatigue

Conflict Ground Conflict; Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Person / Animal / Bird

17 hours on duty; divert to ZZZ1; non-standard pushback procedure. Cleared to start saw tug clear. [We were] busy with weather and cockpit duties; lost awareness of guideman; started taxi and immediately stopped; rolled 1 foot; heard guidman on interphone; he disconnected and within 3 seconds was out holding pin; clear to taxi.

During pushback I was starting engines. I heard the Captain say the tow tug had left. When I finished starting engines the Captain called for taxi clearance. I got the clearance. As soon as we started to move the Captain stopped the plane. He saw someone by the aircraft nose. He waited for them to move clear before continuing.

B747 flight crew began to taxi before receiving a salute from the guideman; still connected to the aircraft by his headset.


Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Weight And Balance; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural MEL / CDL; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter Fuel Issue

Flight Crew Returned To Departure Airport; General Declared Emergency

Maintenance advised that the fueler had requested help with a premature fuel cutoff while attempting to add fuel to the number two tank. The tank fuel gauge read approximately 3;400 LBS. Maintenance used an alternate method to check the fuel quantity in tank 2 and concluded the tank was already full. Maintenance and the fueler provided a fuel slip indicating full wing tanks and 12;000 LBS in the center tank. The number two tank gauge was placarded inoperative using MEL 28-10B and 28-06.On liftoff it was apparent that there was a fuel imbalance requiring three units of aileron trim for wings level flight. This indicated to us that the fuel load was incorrect and insufficient for the flight. Due to the excessive roll moment of the out of balance fuel load; an emergency was declared and we returned to land at [departure airport]. The aircraft was below max landing weight.Fuel measurements by alternate methods should be made with redundancy. In the future I will be personally involved in those measurements.

Air carrier Captain reported his aircraft was improperly fueled after apparent fuel quantity gauge failure; resulting in imbalance. Crew declared an emergency and returned to departure airport.


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

Automation Aircraft TA; Automation Aircraft RA; Person Flight Crew

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

After departure; we were cleared to climb and maintain FL170.  ATC control notified us there was military activity observed in the airspace [ahead].We contacted [the airspace's] Defense Radar on frequency 12 minutes before entering; and were given permission to enter at the ZZZZZ waypoint. Departure airport ATC advised us to contact [The next country`s] control on frequency. We established contact with Control prior to entering [the] FIR (Flight Information Region) at ZZZZZ. Control told us to report ZZZZZ.The Captain was still in contact with Departure Control with the left radio prior to ZZZZZ with the First Officer talking to [next ATC] on the right Radio. Just prior to ZZZZZ; Departure Control notified us of traffic 12 o'clock. We noticed the traffic on our TCAS more than 20 mile and 100 feet below our altitude.At ZZZZZ; several attempts were made to contact Control.  We could hear ATC; however ATC would not respond to us.The Traffic on TCAS turned to TA followed by a RA to Climb.  We then noticed the fighter Jet turning right to pass off our left wing less than a mile. After the RA clear of conflict; we returned to FL170 and notified [the Departure ATC] we had an RA. We attempted to contact [next ATC] to notify them of the TCAS RA; they would not respond. We broadcasted in the blind three times of our TCAS RA. Again; we could hear them; but they would not respond to us.The intercept Jet Fighter circled behind us in an aggressive manner triggering another TCAS RA to climb. We again called ATC and notified them of a TCAS RA. They responded by telling us to return to FL170. We requested climb to FL300 but was denied; they told us to maintain FL170. The Jet Fighter took position behind and to the left of us (strike position). This continued for more than 10 minutes. After several requests to climb; we were finally given a climb clearance to FL300. The Jet fighter stayed with us until we climbed. No further incident followed. Both TCAS RA resulted in a 300-feet Climb deviation; followed by a return to assigned FL170.

[Report narrative contained no additional information.]

B747 flight crew reported that ATC advised them of military activity ahead. The flight crew got a TCAS RA after a fighter jet intercepted them.


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

Flight Crew Landed in Emergency Condition

At FL370 during cruise; approximately 10-15 minutes prior to the top of descent; the FO (First Officer)) and I noticed a brief flicker of the Master Caution light. Upon investigation; we saw the System A hydraulic quantity reading 22%. We continued to monitor the hydraulic quantity; and reviewed the QRH procedure for LOSS OF SYSTEM A. As a precaution; I notified Dispatch of a potential emergency landing; and requested they notify SJU operations to have personnel standing by to install the landing gear pins. We also notified SJU ARTCC that we had a hydraulic loss; and might need emergency handling.The FO and I considered the impact of manual gear extension. Once lowering the gear; we would be committed to landing at SJU; and would not have the fuel to make our alternate of STX. Although there was a large storm over the island of Puerto Rico; it did not significantly impact a visual landing at SJU; nor a 2-engine missed approach and second landing attempt at SJU. The airfield was CAVOK with a scattered deck at 4;800 feet.Planned aircraft weight on landing was 139;500 LBS. According to the QRH; flaps 15 landing distance with loss of system A was 5;030 feet on a dry runway at 144;000 LBS. This was sufficient landing distance for either Runway 8 or Runway 10. We elected to do a flaps 30 landing on Runway 8 with autobrakes set to 3. QRH (144K) landing distance was 4;800 feet. Upon our request; San Juan ARTCC cleared us direct to the SJU airfield; and we started a descent. The FO and I discussed a plan to allow sufficient time to configure with manual gear extension procedures. Shortly afterward; the System A quantity dropped to 21%; along with another flicker of the Master Caution light. At this point I [advised ATC]; and requested ARFF support. Dispatch had asked us to advise if we were [advising ATC]; however I do not recall if I advised them of the actual declaration. Shortly afterward the Eng1 LOW PRESSURE light illuminated steady.Since I did not know where the fluid leak was; I elected to run the LOSS OF SYSTEM A checklist. We ran the first 4 steps; and began discussing manual gear extension. We decided to lower the gear passing 10;000 feet; and were configured by 8;000 feet. We had a jumpseater onboard; who was a RJ Captain. Since the flight deck was crowded; we elected to have the jumpseater pull the manual gear extension handles. The gear extended exactly the way I remember it did in the simulator the last time I practiced the procedure. I ran the Non-Routine Landing Considerations checklist; with no HAZMAT; and no emergency evacuation planned. I gave a precautionary landing briefing to the FAs (flight attendants); and made a PA to the passengers. The Number 1 FA told me the PA was difficult to hear. Since I had spoken loudly into the pedestal handset; I didn't think a second PA would be effective. I asked the Number 1 to relay my intentions to the passengers: that we would be stopping on the runway; and we would have safety vehicles meeting us there.We flew a visual approach to Runway 8; backed up by the ILS. The approach and landing were without incident; and we stopped just prior to S6 taxiway. I made a PA for the passengers to remain seated. Maintenance asked us to shut down our engines; and requested we pass the gear pins out the cockpit window. They pinned our gear and connected a tug. While this was happening; I made a PA to further explain to the passengers what the station personnel were doing to the aircraft. We were then towed to the gate. This terminated the emergency. Post flight maintenance inspection revealed a blown seal on a right wing spoiler actuator.

B737 flight crew reported that the aircraft lost hydraulic system on descent.


Communication Breakdown; Distraction; Human-Machine Interface; Fatigue

Party1 Flight Attendant; Party2 Flight Attendant

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

After parking; the Lead Flight Attendant stated to prepare for arrival and cross checked. I proceeded to get up and disarm the slide and remove the red strap across the window. I then turned on the POS to transmit and unlocked the lavatories. I left the galley and stood by the aft lavatories and watched the deplaning process. A few passengers came back to use the restroom. Deplaning was a slow process.When there were only a few passengers left another Flight Attendant suggested we check to make sure the slides were disarmed. I was not expecting anything to be wrong. She then turned and said that my slide was still armed but my red strap was undone. I was in total disbelief! I could not believe that when I bent down to disarm the slide that I did not. I have never removed the red strap prior to disarming the door. I have always been extremely careful in following procedures. I cannot explain why the slide was not disarmed. I can see myself bending down and disarming the door. There were no emergencies or passengers asking for things or anything to disrupt my routine. However; when I proceeded back to disarm the door the second time; I did notice that the hooks that the slide sits in when disarmed were loose. The bar was more or less just sitting in the hooks rather than needing to be pressed down. So now I wonder if I put the bar in the hooks but did not make certain they were in there securely and they slipped out. My error is that I did not double and triple check the disarmed door to make sure the bar stayed in the hooks and would not fall out. Another factor may have been that I was tired and ready to get off the airplane. What I learned in this situation was to just step back and review all of the procedures each and every time I am disarming/arming a door. Maybe it has become such a habit that I need to make sure I am absolutely aware of what I am doing at all times.

A B737-900 Flight Attendant failed to properly disarm her emergency exit. An alert compatriot noted the error and the omission was promptly corrected.


Air Traffic Control Time Certified In Pos 1 (yrs) 7.5

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

Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Air Traffic Control Provided Assistance; Flight Crew Executed Go Around / Missed Approach; Flight Crew Requested ATC Assistance / Clarification

Airspace Structure; Chart Or Publication; Human Factors

I sat down next to the controller working SDWR (west) radar to assist them with a few coordinations. The sector wasn't busy but coordinations with approach (for handoffs) and ATCT (for opposite direction arrivals) would have added to the complexity. I noticed that an IFR Aircraft X talking to SEE ATCT was turning away from the airport and the final approach course northeast to a higher MVA. The aircrafts lowest indicated altitude was 2;400 ft. and the MVA in the area is 4;200 ft. and 3;300ft. I quickly called SEE to see if the pilot was okay. They responded that she was having issues and they were correcting her. The weather was broken at 3;300 ft. with few clouds at 2;400ft. The tower called me back asking if we could take the aircraft back. I asked if the aircraft was VFR or IFR. They stated IFR and I had them issue her a 270 heading and a climb to 6;000 ft. By the time the tower switched her back to us; the aircraft was westbound safely above the MVA.Since she needed special handling; I asked SDMR (Miramar) radar to work the aircraft back in and she landed safely. I truthfully never considered this to be a pilot deviation. And since the tower was talking to her at the low altitude; I knew they were handling the low altitude alert; getting her back on course and trying to see if she could cancel IFR. Only when the tower advised me she was IFR and needed to come back to us; did I consider her a special priority case. But also with my years of experience; I assumed she was a low hour IFR pilot that needed special handling.I didn't tell the OM immediately about the event because she was with the tower when she was at a low altitude and I knew they were handling the situation and would be filling out the appropriate paperwork on their end. Only a little bit later did I think; I should probably have the OM watch the replay and if anything; it may be declared an priority handling. The OM advised me it should have been a pilot deviation; but I still don't understand why a disoriented pilot would get a brasher. In the future; I won't assume the classification of an event; I'll ask the OM for their guidance.

A TRACON Controller reported they observed an aircraft talking to a Tower deviate from the final approach course and fly below the Minimum Vectoring Altitude but did not report it to the Operations Manager.


Troubleshooting; Distraction; Situational Awareness; Time Pressure; Workload

Aircraft Equipment Problem Dissipated; Flight Crew Landed As Precaution; Flight Crew Returned To Departure Airport; General Release Refused / Aircraft Not Accepted; General Maintenance Action

After takeoff; during climb at approximately 8;000; the Flight Attendant called to let us know that a passenger reported what appeared to be fluid streaming off of the left wing. A pass-traveling ERJ pilot also came on the interphone and told us it definitely looked unusual and excessive; also adding that it didn't appear to be condensation vapor; that it appeared 'heavier' than that. At the time of the call; we were cleared to 16;000. We told ATC we would like to level at 10;000 and stay at 250 KTS while we investigated and coordinated the situation. The venting stopped; but due to the excessiveness and duration of it and after coordinating with Maintenance via radio and Dispatch via ACARS; we elected to air-return and have it investigated. We also discussed the overweight landing with Maintenance and were advised to monitor vertical speed and firmness of touchdown. We elected to land flaps 22 to aid in controllability in the flare; to achieve a smooth touchdown and used max reverse due to the high weight. We did not declare an emergency; since the fuel venting had stopped. We had the pass rider relocated to a seat further aft so he could report to the Flight Attendant if the venting resumed. After landing; a city vehicle (not a fire truck) followed us into the gate and inspected behind the wing to ensure we were not losing fuel. After arrival at the gate; we found fuel coating the underside of the wing coming from the NACA vent. After Maintenance inspected; it was found that the flapper valve between the vent box and the tank had detached and was allowing fuel to flow freely into the vent area; resulting in the venting predominately with fuller tanks and in banks. We were tail-swapped and resumed the flight. We were conducting IOE with a new hire on day 4 with approximately 15 hours. As far as errors; I did find one point during the management of the event; the coordination of who was supposed to be doing what was becoming obscure; so I raised awareness to the event and made sure division of duties was more clearly understood. I don't so much feel that this was a result of my First Officer's inexperience; but rather my trying to make sure everything was being taken care of; causing confusion on the First Officer's part; thinking; 'OK; am I supposed to be doing this or you?' Suggestions: First off; there was no 'emergency'; since the spilling had stopped and we had time; since we were over fueled for the amount of flying we had left to do (since it was an air return). Therefore; I need to take my time a little more and clearly state plans; duties; and expectations. The act of 'micro-managing' can be interpreted as 'are you doing this or am I?' I also would have gotten on the thrust reversers earlier in the future. I should have anticipated the longer ground roll and hot breaks.

An EMB145 left wing fuel tank NACA vent flapper valve failed and allowed fuel to escape overboard through the vent so the flight returned to the departure airport where the aircraft was replaced.


Light Transport; High Wing; 2 Turboprop Eng

Air Traffic Control Time Certified In Pos 1 (yrs) 11

Communication Breakdown; Distraction; Situational Awareness; Workload

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

I was working R12 providing 25 miles in trail for EWR satellites and holding for EWR. Satellites were on alternate routing to accommodate holding aircraft. While coming out of hold; low sector presented a handoff for satellites without proper spacing for restrictions. I put them into a hold since I was too busy coming out of the hold for EWR and the high side had a long stream of satellite aircraft. Once I put the sector in hold; the CIC for that area began to scream across the aisle to get 'the crappy controller' off position and that they didn't need to provide spacing since they were a separate sector. Meanwhile; the controller I put in hold was relieved and his relief continued to call asking how much longer. Overflight traffic via RBV is normally routed via THUMP but Aircraft Y was shortcutted to ENO. I missed this and issued the normal descent clearance to the satellite aircraft. I wasn't alerted to my mistake until a conflict alert was activated. I was distracted by the unprofessional outburst of the CIC and the new controller who was holding the aircraft. TMU initiatives need to be passed back as one; the sectors in the same area; should be required to space accordingly with each other and if this isn't feasible; then hold then aircraft without disruption when told to do so. There's a mentality amongst ZDC controllers that anything happening outside their airspace is not their concern; even if that controller is not adhering to SOP; LOA; 7110.65; and TMU initiatives. There is no safety culture here at ZDC. Everything here is done in reverse order. There are no more app reqs (Approval Request) for anything. If there is an aircraft doing something you don't like; even in violation of SOP; LOA; 7110.65 it is incumbent upon the receiving controller to reach out and fix. Handoffs are presented/retracted; presented/retracted; presented/retracted; and it's up to you to figure out what has changed. Positive control is a lost art. As long as 2 aircraft don't hit; everyone here is happy. This is unacceptable.

ZDC Controller reported of problems with flows into the airspace. High workload and distractions led to a conflict alert.


Air Traffic Control Time Certified In Pos 1 (yrs) 23.7

Confusion; Training / Qualification; Situational Awareness; Distraction

Training / Qualification; Distraction; Confusion; Situational Awareness

ATC Issue All Types; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Taxiway

I was conducting training on the Local 1 position. I observed the trainee enquire about what was going on with Aircraft X/BE36 who hadn't call but was in our airspace 3.5 NNE of FTW. Aircraft X checked in 2 north of the airport landing RY34. The trainee instructed Aircraft X to widen out their right downwind for RY34. Aircraft X flew through the departure corridor of RY34 and entered the left downwind at which time the trainee enquired as to what Aircraft X was doing. The only traffic involved was Aircraft Y ahead on the downwind for RY35 of Aircraft X and Aircraft Z on a 2 mile final. The trainee pointed out Aircraft Z on a 2 mile final for RY34 to follow and to continue downwind. The trainee issued touch and go clearance on RY35 to Aircraft Y and again issued sequence to Aircraft X to follow Aircraft Z now on a mile final. Aircraft X indicated they were turning base but there was traffic on a mile final. The trainee informed Aircraft X that that was Aircraft Z he was to follow. Aircraft X acknowledged sequence to follow Aircraft Z; who was doing a touch and go on RY34. A UAS pilot called indicating they were one minute from their operations and the trainee acknowledged and requested to advise when terminating operations. The trainee along with myself scanned to ensure runway spacing was adequate (which there was) with Aircraft Z doing a touch and go and Aircraft X who appeared to be on a half mile final lined up with the RY34. My trainee and I scanned RY35 to check the location of Aircraft Y which caused us to turn away from RY34. I updated my pad when my trainee; who turned to check where Aircraft X was before me; mentioned 'did that bonanza just land on taxiway alpha!' at which point I looked and observed Aircraft X rolling out on taxiway alpha north of alpha six. My trainee advised Aircraft X twice to hold position that he had just landed on taxiway alpha and of possible pilot deviation. The trainee then switched Aircraft X to ground control and informed Aircraft X they would give the phone number to call.This is not the first time a pilot has mistaken taxiway alpha for a runway. Since the construction of taxiway alpha this has occurred. The facility and the airport have tried to solve this problem from renaming 16L/34R and 16R/34L to 16/34 and 17/35; to painting 'T A X I W A Y' on taxiway alpha; to placing large ' X's ' off each end of taxiway alpha; to conducting pilot briefings; informing pilots who question which one is the runway that 'IT'S THE ONE WITH THE SQUARE END' and it still happens. In this case and I believe every other case; NOTHING was on taxiway alpha when this occurs.I'm not sure there is much else we can do to keep a pilot from landing on a taxiway that look just like a runway.

I was training on Local 1 when Aircraft X entered the Class D airspace from the northeast proceeding southwest. Aircraft X was instructed to join the right downwind for runway 34 and to widen his leg on the downwind. Aircraft X acknowledged the instructions; but continued towards a left downwind and crossed north of FTW midfield. Aircraft X was given number two in sequence for runway 34; issued traffic on Aircraft Y on base for the runway 35 and Aircraft Z two mile final; and instructed to continue on the downwind. Aircraft X advised that he did not have Aircraft Z insight; but will turn base to follow the aircraft ahead and to the left on final. Aircraft X was advised that the traffic insight was Aircraft Z that he needed to follow and was issued a landing clearance. Aircraft X was advised again that he was number two in sequence for the runway and to turn behind and follow Aircraft Z. Aircraft X acknowledged all instructions and appeared to be established on the final for runway 34. Drone [pilot] called FTW Tower with a one minute notification until launch time. I acknowledged the Drone's transmission and then advised the CIC that drone operations would be begin in one minute. I looked back out the window to see Aircraft X to appear slightly high for runway 34 as he was going to execute a long landing. Initially; I couldn't tell if he was aligned with runway 34 or taxiway Alpha. Just before Aircraft X came in contact with the surface I realized that Aircraft X was aligned with taxiway Alpha and not runway 34. I scanned taxiway Alpha to ensure no one was taxing and stated out loud that Aircraft X landed on taxiway Alpha and asked Ground Control to stop any aircraft taxing to Alpha. I instructed Aircraft X to stop/hold his position and that there had been a possible pilot deviation and asked Aircraft X if he had the number to call the tower. Aircraft X brought the plane to a stop and asked me to repeat what I said. I informed Aircraft X of a possible pilot deviation and that he had landed on taxiway Alpha. Aircraft X was instructed to call the tower upon parking and to contact Ground Control for taxi instructions to parking. Brighter; bolder markings to label Taxiway Alpha to distinguish it from Runway 16/34. A yellow letter 'A' in the run up areas or at each end of Taxiway Alpha that is big enough to see from the sky can be used to distinguish/label Taxiway Alpha.

FTW Tower Local Instructor and Developmental reported an aircraft landed on a taxiway instead of the runway.


Any Unknown or Unlisted Aircraft Manufacturer

Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter VFR In IMC; Inflight Event / Encounter Weather / Turbulence

Automation Aircraft RA; Person Flight Crew

Flight Crew Requested ATC Assistance / Clarification; Flight Crew Took Evasive Action

Airspace Structure; Procedure; Human Factors

We were on frequency with Boston Center just a minute or so north of the LEMOR intersection at 6;000 when we experienced two RAs of different severities. The first; Center asked if we had traffic to our right in sight; and we did briefly until going into the clouds. He suggested 20 degrees right for traffic; which I queried; as that would send us directly into the traffic. He confirmed; so we turned; thinking he had the bigger picture and had positive control over the other aircraft. This gave us a descend RA; which we complied with; until it was clear of conflict. We informed ATC and then returned to our original altitude. At 6;000 feet; just past LEMOR; we saw a rapidly climbing target on our TCAS from below on a direct course with our aircraft. We asked ATC about it and he was busy and said 'he just popped up.' At the time; we were IMC in the clouds and has negative contact on that aircraft. When the target was 300 feet below us; a mile or less directly in front of us; the RA directed us to descend. Immediately followed it; then realized that would send us into the offending traffic and then evasively banked to the right and initiated a climb. As soon as I initiated this maneuver; the TCAS (while zoomed into 6 miles as well) indicates the target as same altitude and same location. His target was spot on the middle of the TCAS. This was all done in the clouds with a VFR target. We once again informed ATC and continued on our way after recovering safely. I requested a number from Approach and called them after the flight. I spoke to a very nice gentleman who explained to me that it's a known issue. The offending airplane was a [skydive service aircraft]. This aircraft has 900hp and a 4 bladed prop; so it climbs like a rocket through the clouds and the airways. He let me know that unfortunately nothing can be done about it; and recommended I talk to [the] Quality Control Supervisor. We had a constructive conversation regarding the incidents and both agreed that; unfortunately; the only regulation broken was the VFR Caravan flying into the clouds. That however; would be my word vs the skydive pilot and that would go nowhere. [I was provided] with the radar tracks and the closest separation is as follows:6;000 feet; 1.39 miles horizontal; 100 feet vertical; then 1.04 and 100; then 'less than a mile' 100 vertical. Fortunately TCAS saved us on the first one and a solid flight crew and good CRM saved 47 lives on the Dash and a dozen on the skydive plane.Skydive planes shouldn't be allowed to climb through clouds; through airways; and drop skydivers through them. It's extremely dangerous and will eventually cause an accident.

A Dash 8 Captain reported an airborne conflict with a skydive service aircraft that was climbing VFR through clouds.


Training / Qualification; Communication Breakdown; Confusion

Party1 Flight Crew; Party2 Ground Personnel

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

Flight Crew FLC complied w / Automation / Advisory; Flight Crew Took Evasive Action

Manuals; Environment - Non Weather Related; Procedure

We were on a military charter with 4 dangerous goods (DG) pallets. Aircraft was loaded when pilots arrived at the aircraft. DG was presented by load master (LM). On DG inspection; noted discrepancies with our FOM guidance; especially with aisle way requirements; number of pallets; placement on aircraft; etc. Was told by LM that 'it's OK; it's a military charter and the DG is accessible.' Briefed Captain and First Officer. First Officer went back to check DG and concurred with my assessment. We know there are many exceptions while operating a military charter so we asked the question if 18 inch aisle ways on left and aft sides of ADG pallets were waived on military charters? Answer back was that they knew of nothing that waived the FOM guidance. Briefed LM; who got on his cell phone and coordinated with DO; his boss; safety; etc. to get a waiver. Waiver was provided and attached to paperwork; and flight proceeded normally.DG and aircraft loading is a frequent discrepancy area between our FOM guidance and what in reality takes place. I have done several military charters and have observed this first hand. There are many requirements in FOM Chapter 10 that are routinely 'violated' during military charter operations as the pallets are built up outside of our control; the load plan and orientation of pallets; etc are controlled by this 'special' military user. Suggest a team be formed of the Load masters; Safety; Charters; DG Specialists; pilots; etc to work out a method of providing waivers; permanent or otherwise; of FOM requirements for DG loading when warranted. By operating on a daily basis with only 'it's OK' from the load master; 'we don't have to follow that FOM paragraph because it's impractical'; we promote a culture of the normalization of deviance and increase the possibility of an aircraft incident. We need to decide if these issues (and there will likely be more that a team brainstorms) can be waived for our military charter operations: carriage of lithium batteries on an ADG pallet with other ADG; ADG pallets not on left side of aircraft; missing 18 inch aisle ways on ADG pallets and/or normal pallets that separate ADG pallets; aisle ways not on left/aft sides; but they still provide adequate access to the ADG cargo; wrapping ADG pallets in clear plastic (some military buildups are in hard cases and not normally covered in plastic); requiring netting on ADG pallets (some military buildups; such as ammo cases are strapped to the pallet and not netted); normal max of 3 ADG pallets on wide bodies; 10.43 MD-11 Position Configuration Chart; etc. We routinely operate with all of the above and to remove the normalization of deviance by winking at the restrictions in the FOM; why don't we formally waive them after examine the safety aspects; or provide the LM with the authority and training on military charters to certify the acceptability of the load and DG even with conflicts with the FOM; with the Captain's concurrence. We need to re-establish the FOM as a source document for the aircrew which we can rely on for charter operations; while at the same time; meeting the unique needs of our military customer.

[Narrative 2 contains no additional information.]

A MD-11 flight crew on a Military cargo flight noted that the dangerous goods were not loaded in accordance with the FOM; but discovered after examination that exceptions are made for military dangerous goods flight loaded by non-company specialists.


Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Fuel Issue

Air Traffic Control Provided Assistance; Flight Crew Diverted; Flight Crew Landed in Emergency Condition

We did an originator out of ZZZ and had a maintenance delay while going back and forth with MX control; dispatch and gate agent trying to get off the gate in a timely manner. I signed the release and forgot to check my alt/msap fuel. We got airborne and during the climb I grabbed the release to calculate my minimum fuel and that is when I noticed that we had 0 fuel dispatched for alt/msap even though we had an alternate and the weather was overcast at 1200. I sent an ACARS to dispatch about the situation and asked for them to send me the alt/msap fuel to see if I could use my tanker fuel. The number came back at 1500lbs and added with reserve fuel we needed 3800lbs. We were showing landing about 500lbs short. We declared min fuel; climbed an additional 2000 ft; got short cuts and pulled back power but was only able to save 100lbs. After talking with dispatch about our options we [advised ATC] and diverted. Once we were cleared and our new FOB went up we landed then re-dispatched with an alternate and plenty of fuel and continued to the original destination.Dispatch failed to catch the 0 fuel in the alt/msap when an alt was filed; and the captain did not catch it before signing the release and taking off.

CRJ-900 flight crew reported being dispatched without alternate fuel.


Traffic Collision Avoidance System (TCAS)

ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance

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

PHX takeoff Runway 25R flaps 5. CLEARANCE: MAXXO 2. CNX. [We were] cleared to 8;000 FT. Visual avoidance instructions with Airbus which took off ahead of us. [We had a] normal takeoff; handoff to Departure. We turned to heading 240 at 1;550 FT per the departure and were cleared to FL210 at around 4;500 FT by ATC. Airbus was in sight by First Officer; ahead and to our right after the turn to 240. We climbed at 200 KTS for a fast climb due to clearance to FL210 and no restriction. At 7;500 ATC changed altitude back to 8;000 FT. As we leveled and continued heading 240 as per the departure; ATC asked if we had the airbus in sight. First Officer had traffic but I had lost sight due to left turn to 240 and my position in the left seat. We had just reached the turn point (9 miles) to turn left to 140. First Officer heard ATC issue a turn to 120 for the Airbus. First Officer noticed the Airbus turning into us and we were surprised. We noticed a rapid closure and climbed over 8;000 to 8;300 and stopped making the turn to 140 to avoid. The Airbus reported us in sight to ATC and that we cleared at around 100 FT (exaggeration) vertical separation. The Airbus passed beneath us about 400 FT below. We returned to 8;000 FT after passing the Airbus. ATC never gave any additional instructions to either us or the Airbus. Why did the Airbus continue to turn into us after he reported us in sight? First Officer said the Airbus stopped his turn for a moment and then started again. [I] asked by ATC to call upon arrival. Spoke to ATC and he said it looked like we had started to turn to 140 heading prior to 9 DME fix per the departure. I assured him that we didn't initiate turn to 140 prior to the 9 DME fix. It may have looked like we started prior to that point as we maneuvered to avoid the Airbus but returned to our heading of 240 until 9 DME. He advised that we had cleared the Airbus by 0.6 miles and 400 FT and as he had complied with an RA he was required to submit the event for review. The Airbus climbed slower and at a faster speed which put him further away at 1;550 FT from departure end of runway before turn to 240. That put him to our right side when he turned left to 240. Our left turn to 240 at the same altitude (1;550 FT) was much closer to the departure end of the runway due to our climb rate at 200 KTS. ATC had us depart too soon after the Airbus to have the same departure routing and such different aircraft climb performance. Also; the new company procedure of turning the transponder to 'ATC ALT' on taxi out and then adding ANOTHER runway item of switching it to TA/RA is a task overload. The CE750 will not give an RA on the ground and the transponder may be selected to TA/RA and left that way during taxi. We had missed the switch to TA/RA upon entering the runway and didn't get a traffic alert once airborne.

There was an Airbus that departed before us and we were cleared for takeoff [Runway] 25R and maintain visual avoidance. The MAXXO 2 departure instructions were 258 heading to 1;550 FT; then left turn to 240 to the 9 DME off PXR; then a 140 heading for vectors; climb to 8;000 FT. As soon as we took the runway all the take off numbers dropped out; the Captain quickly got the number back; but that was a distraction for me as I did the runway items and I left the transponder in ATC ALT. We had a normal takeoff; at 1;550 we turned to 240 and were climbing at 200 KTS I lost sight of the Airbus in the turn to 240. ATC cleared us to FL210; while we were on the 240 heading. [I] then amended our altitude to go back to 8;000; as we went through 7;500 FT. We hit the 9 DME and started our turn to 140. The Captain started the turn a little early; but quickly corrected back no more than 10 degrees off heading. While in our turn ATC came on and asked; 'Are you in your turn;' I responded that we were in our turn to 140. While in our turn to 140 ATC came on and reported airbus traffic at 2 o'clock. I spotted the Airbus traffic at 2 o'clock; in a left turn and about 2 miles. I delayed about 5 seconds as the right wing lowered and confirmed that the Captain had the traffic in sight and reported airbus in sight to ATC. We were instructed to maintain visual separation. We had a parallel course with the airbus for a few seconds then the airbus started a left turn into us. A heading change assigned by ATC. In the turn the airbus crew reported us in sight; but continued their left turn into us. The Captain had to climb to 8;300 and the airbus passed 500 FT under us. Airbus crew reported that we passed 100 FT over them. A few seconds after the conflict; ATC asked if the Airbus had responded to the RA. He stated yes. Before being handed over to a next controller we were requested to copy down and number which we did.With the takeoff numbers dropping out we should have taxied off the runway and then reloaded them. We would not have been rushed and would not have missed the transponder on the checklist. It would help if the color was different between ATC ALT and TA/RA. Standby is in green which is easier to pick up when it is on. What I feel caused the conflict with the airbus was that we turned inside of the airbus on the departure do to our greater performance and when in that situation ATC should be given a heads up. More traffic vigilance should be given when turning inside of another aircraft on the same departure and transition. It would be a good idea to confirm with ATC what departure and transition the aircraft is on that takes off before you; so you can anticipate sooner if there is going to be a conflict. As soon as the Airbus turned into us we should have contacted ATC and start maneuvers to avoid the conflict.

CE750 flight crew departing PHX Runway 25R on the MAXXO 2 departure report a conflict with an Airbus departing the same runway on the same departure just before the CE750 departure. The very different performance characteristics of the two aircraft resulted in a conflict at 9 DME during the turn to 140 degrees.


Situational Awareness; Training / Qualification

Deviation / Discrepancy - Procedural Published Material / Policy

Environment - Non Weather Related; Company Policy; Human Factors

I was scheduled to complete the one day training event for the X type aircraft as a result of downgrade due to planned furloughs.  I was previously an X type aircraft Captain. However; between my last flight as an X type aircraft Captain and being assigned this training; I completed the Y and Z type aircraft Qualification Course as I was awarded a bid to Y and Z type aircraft Captain prior to the planned downsizing. I was bumped from that position prior to IOE but after the completion of the course (I was home awaiting an IOE trip). My final position was X type aircraft FO after the bump bids. I asked multiple different sources and all seemed to agree that my situation would dictate at least a multi-day re-qualification course. I was surprised when I was scheduled for the 1 day class; landings event. Yes; I have XXXX hours in the FO seat of the aircraft but my last experience was X years ago. Yes; I was a Captain on it for a year but again; I last flew the aircraft 6 months ago and had an entire course on a different airframe in the interim.  When I asked about this I was told 'If you need more training just ask for it.' Fortunately the simulator broke and we were unable to complete the enhanced items so I will need to go back for another sim period. I'm going to be blunt and tell you there is no way I should have had one period; let alone one period where I get 2 hours to relearn everything and have to share it with another student.  In my particular case I should have had the entire X hour period to myself or been scheduled for a multi-day day re-qualification event. Had I gone on a different aircraft IOE and activated that bid would I have been scheduled differently? If the answer is yes; then brake release on IOE needs to be re-evaluated as the line.  If the answer is no then the entire thought process behind this needs some serious examination. The course would have been fine if I had been coming directly and untainted from the left seat.

Air carrier First Officer reported that re-qualification training was inadequate.


ATC Issue All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance

Air Traffic Control Issued New Clearance; Flight Crew Requested ATC Assistance / Clarification; Flight Crew Returned To Clearance

Airspace Structure; Chart Or Publication; Procedure; Manuals; Human Factors

We departed Runway 36C in MEM via the GOETZ TWO departure (we believe this to be pronounced 'GOATS' which lead to confusion.) Shortly after contacting Departure; I believe between JAAXX and AYERR; we were cleared 'direct 'GATTS' and resume the departure.' With this clearance we selected GHATS from the legs page and executed. Our [original] Legs page showed GOETZ-BNA-SWAPP-GHATS. Being on Autopilot in FMS mode; the aircraft made a slight left turn and proceeded to GHATS which was just past BNA on J42. In the moments after this occurred something didn't sit well with me. I mentioned to the Captain; 'how can we 'resume the departure' from a fix that is past the last fix on the departure?' I queried the Controller by asking if he had cleared us to 'G.H.A.T.S.' to which he said 'no; it's G.O.E.T.Z' and we pronounce it as 'Gats' here.' We said that we interpreted that as 'Goats'; not 'Gats' but would proceed there now anyway. He didn't seem to mind and then we got the hand off to Memphis Center and the flight continued normally. I believe that GOETZ is sounded out as 'Goats'. The Controller told us to go to 'Gats' (like Bats or Hats only with a G). I am not sure he knew that just past BNA we had an intersection called GHATS; also sounded out as 'Gats.' This seems wrong to us but either way having two intersections close to each other on our flight (GOETZ and GHATS) caused confusion and caused us to proceed to a fix that the controller didn't intend for us to proceed to. We noticed this before ATC said anything and we queried the Controller who seemed to not have noticed what we were doing just yet (The two courses didn't deviate from each other much.)

On initial climb out via the GOETZ RNAV SID from MEM; the flight crew of a CRJ-700 was cleared direct to GOETZ (pronounced 'gats' by the Controller) and to resume the departure. The flight crew (believing GOETZ should be pronounced 'goats') instead selected direct to GHATZ; a downline waypoint on their cleared route. Only the reporter's recollection of the controller's phrase '...resume the departure' alerted them to the error.


Air Conditioning and Pressurization Pack

Communication Breakdown; Training / Qualification; Time Pressure

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

General Flight Cancelled / Delayed; General Maintenance Action

Incorrect / Not Installed / Unavailable Part; Human Factors; Aircraft; Logbook Entry; Procedure; MEL

Walking to the aircraft; the inbound crew informed me the cabin was warm during ground operations and while operating at low altitudes but would cool down in cruise. The logbook had a maintenance deferral for the hot air valve which I noted. I was the Pilot Monitoring for this leg; and did my best to keep the cabin cool while taxiing and during initial climb; but the cabin would not cool below 82 degrees F.After examining the Bleed and Pressure systems pages; it was evident the Pack 1 flow control valve was closed despite the pushbutton being in the Auto position. The indication was supported by a cool compressor outlet temperature and a warm pack outlet temperature on the Bleed system page. We wrote up the discrepancy and were met by local Maintenance; who opened a belly panel and found the Pack 1 flow control valve secured in the closed position without a maintenance deferral. Upon further examination of the aircraft logbook; a deferral was cleared the previous night in ZZZ1 for the Pack 1 Inlet Door which requires the flow control valve to be secured closed by maintenance. The mechanic re-activated the valve; but it would not operate normally; so a deferral for the Pack 1 flow control valve and pack were applied.After discussing this event with another Captain; he stated that in his previous discussions with ZZZ1 Maintenance that the station is not qualified to work on the flow control valve; including securing the valve in the closed position or re-activating it. It appears that in this situation; the aircraft should have been grounded until a qualified mechanic could re-activate the flow control valve; but it was instead pushed back into service in unairworthy condition. This causes considerable doubt in the quality of maintenance on our aircraft as well as the question of what trap will be laid for another flight crew to deal with in the future. Less importantly; the process of troubleshooting the flow control valve in caused a three-hour delay.

A319 Captain reported an incorrect MEL action by an unqualified Maintenance Personnel; resulting in a loss of cabin cooling during the flight.