Inflight Weather Encounters - ASRS - Aviation Safety ... · Inflight Weather Encounters . ... A single engine pilot reported approach control vectored a military ... B737 flight crew

ASRS Database Report Set

Inflight Weather Encounters

Report Set Description .........................................A sampling of reports from both air carrier flight crews and GA pilots referencing encounters with severe or unforecast weather.

Update Number ....................................................32.0

Date of Update .....................................................December 28, 2017

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

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

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

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

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

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

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

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

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

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

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

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

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

Report Synopses

ACN: 1488242 (1 of 50)

Synopsis C525 Captain reported a track deviation during climb from SLC when they were distracted

by turbulence or a wake vortex encounter.

ACN: 1485675 (2 of 50)

Synopsis Diamond DA40 pilot reported encountering severe turbulence while traversing a mountain

pass. He and all the passengers hit their heads on the ceiling when the seat belts became

ineffective.

ACN: 1481209 (3 of 50)

Synopsis EMB-505 flight crew reported using Captain's authority to circumnavigate an area of

thunderstorms.

ACN: 1477252 (4 of 50)

Synopsis Air carrier flight crew reported descending below the MIA Runway 26R RNAV Approach

profile. The autopilot did not capture the vertical path and the crew did not detect it until

they were low causing a GPWS warning.

ACN: 1476596 (5 of 50)

Synopsis Air Carrier flight crew reported a deviation for weather in oceanic airspace, after deviating

a message was received from ATC that denied the deviation.

ACN: 1476347 (6 of 50)

Synopsis A single engine pilot reported approach control vectored a military aircraft over his aircraft

which the pilot felt was unsafe.

ACN: 1476074 (7 of 50)

Synopsis A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the

repair made by a local mechanic did not have the proper documentation.

ACN: 1476062 (8 of 50)

Synopsis A Maintenance Controller reported that he received a report that a Bombardier CRJ-700

had minor cabin damage due to turbulence, later it was found to have severe cabin

damage.

ACN: 1475960 (9 of 50)

Synopsis SF 340B Captain reported returning to the departure airport after loss of First Officer's

attitude and heading indicators.

ACN: 1475763 (10 of 50)

Synopsis SR22 pilot reported that during cruise the Multifunction Display flickered then he smelled

electrical burning/arching.

ACN: 1474961 (11 of 50)

Synopsis A319 Captain reported descending below the profile on descent to IAD when they

encountered turbulence that may have been a wake encounter.

ACN: 1474872 (12 of 50)

Synopsis Cessna pilot reported being unable to maintain altitude and airspeed due to a downdraft

on approach to COS.

ACN: 1474295 (13 of 50)

Synopsis B767-300 reported that due to weather conditions the aircraft had a hard.

ACN: 1474226 (14 of 50)

Synopsis B737 flight crew reported a rejected takeoff due to a predictive windshear warning.

ACN: 1474198 (15 of 50)

Synopsis Cessna Skymaster pilot reported inadvertently climbing VFR into Class A airspace due to

convective activity. He negotiated with the Center Controller and a Military Controller for a

new IFR clearance away from the convective activity, restricted airspace, and out of the

MOA to his destination.

ACN: 1473844 (16 of 50)

Synopsis C172 pilot reported entering an area of extreme precipitation and severe turbulence while

using NEXRAD XM weather to circumnavigate storm areas.

ACN: 1473689 (17 of 50)

Synopsis Flight crew reported windshear warnings while attempting to land at the COS airport that

resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,

and a successful landing was accomplished.

ACN: 1473122 (18 of 50)

Synopsis Learjet crew reported encountering failures of the Windshield Heat, Autopilot, and

Electronic Attitude Direction Indicator during flight. Crew continued to VMC conditions and

landed uneventfully.

ACN: 1472727 (19 of 50)

Synopsis C172 pilot reported a power loss that led to an altitude deviation that was probably related

to carburetor icing.

ACN: 1472521 (20 of 50)

Synopsis Miami Center Controller reported an aircraft that was in conflict with another and the pilot

did not want to turn away from traffic because of weather.

ACN: 1472510 (21 of 50)

Synopsis Air Traffic Controller and trainee reported a loss of separation between aircraft deviating

for weather.

ACN: 1472483 (22 of 50)

Synopsis CL350 Captain reported using his Captain's authority to avoid thunderstorms during climb.

ACN: 1471766 (23 of 50)

Synopsis

A Bombardier flight crew reported not being aware of the Precision Runway Monitor in use

because it was not advertised on ATIS.

ACN: 1471540 (24 of 50)

Synopsis LR60 Captain reported momentary loss of control after encountering a developing

thunderstorm on descent.

ACN: 1471524 (25 of 50)

Synopsis A General Aviation pilot reported canceling IFR then entering IMC weather without

obtaining a new IFR clearance in a timely manner. The reporter indicated that the delay

was due to staffing issues from ATC.

ACN: 1471374 (26 of 50)

Synopsis E-175 flight crew performed an precautionary landing after troubleshooting pressurization

door issue.

ACN: 1471341 (27 of 50)

Synopsis B737 flight crew reported on approach to DEN they had the wrong runway programmed in

the FMS which caused a deviation on the visual approach.

ACN: 1471135 (28 of 50)

Synopsis A corporate pilot reported turning away from the Mexico ADIZ airspace after being unable

to contact the Center due to frequency congestion.

ACN: 1471074 (29 of 50)

Synopsis M20 pilot reported encountering an updraft which caused him to climb into TPA Class B

airspace.

ACN: 1470687 (30 of 50)

Synopsis Air Carrier Captain reported diverting due to thunderstorms at the destination airport and

fuel concerns.

ACN: 1470661 (31 of 50)

Synopsis B737 Captain reported executing a go-around at MCO after encountering a "microburst

type event" on short final.

ACN: 1470577 (32 of 50)

Synopsis B747 flight crew reported beginning to divert due to weather and minimum fuel but ended

up going to the original destination.

ACN: 1470484 (33 of 50)

Synopsis A Center Controller reported allowing an aircraft to enter Military Operations Areas without

coordination while working special military operations and dealing with weather deviations.

ACN: 1470479 (34 of 50)

Synopsis Two Controllers and two Dispatchers reported a flight encountered severe turbulence

which resulted in injuries to flight attendants and passengers.

ACN: 1470471 (35 of 50)

Synopsis ZNY Center Controller reported the flight plan processing software did not detect that an

aircraft filed a route which reversed course at a fix and into conflict with another aircraft at

the same altitude.

ACN: 1470460 (36 of 50)

Synopsis Orlando TRACON Controller reported an airspace incursion and a loss of separation due to

another Controller being overwhelmed with traffic and weather.

ACN: 1470394 (37 of 50)

Synopsis PA32 pilot reported loss of directional control in gusty crosswind conditions that resulted in

a runway excursion.

ACN: 1469723 (38 of 50)

Synopsis

Air carrier pilot reported difficulty identifying the MUHG Runway 5 displaced threshold

because of the prevailing visibility, the runway marking width, the low contrast from the

surrounding runway surface, and no approach lights.

ACN: 1469614 (39 of 50)

Synopsis B737 flight crew reported that the First Officer experienced erroneous airspeed indications

while flying through heavy rain.

ACN: 1469590 (40 of 50)

Synopsis C90 Approach Controller reported that their sectors became overloaded and unorganized

due to numerous weather related go-arounds combined with a lack of experienced

controllers and supervision.

ACN: 1468984 (41 of 50)

Synopsis An ERJ-175 pilot reported windshear at on final which resulted in a 20 kt increase. Speed

brakes and landing gear were extended to regain a stable profile for landing.

ACN: 1468502 (42 of 50)

Synopsis ZAU Center Controller reported their session was out of control due to traffic and no flow

control from the Traffic Management Unit.

ACN: 1468179 (43 of 50)

Synopsis A flight instructor observer pilot reported not being assertive enough and allowed the pilot,

who was presumably operating under VFR, to proceed to and land at an airport that was

below VMC.

ACN: 1468164 (44 of 50)

Synopsis Atlanta Center Controller reported aircraft being cleared into known weather.

ACN: 1468132 (45 of 50)

Synopsis Turbojet flight crew reported a missed approach due to the winds at ASE. The aircraft

entered an area with a higher MSA due to a higher speed and greater turn radius.

ACN: 1468112 (46 of 50)

Synopsis B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be

expected during arrival, and did not expedite a clearance to the alternate after being

advised of the low fuel state.

ACN: 1467710 (47 of 50)

Synopsis B737 Captain reported departing DEN Runway 34L during variable windshear conditions

and recorded 192 kts at Vr, 209 kts at lift off with indicated airspeeds of 158 kts and 163

kts respectively. The maximum tire speed was exceeded.

ACN: 1467476 (48 of 50)

Synopsis ERJ175 flight crew reported receiving a stick shaker warning when intercepting the glide

slope from above with the speed brakes deployed.

ACN: 1467408 (49 of 50)

Synopsis B737 flight crew reported a weather diversion that resulted in a long delay and difficulties

deplaning the passengers due to airport rules and equipment availability.

ACN: 1467288 (50 of 50)

Synopsis IAD Tower Controller reported that a flight crew missed the taxiway turnoff, turned around

to exit, causing aircraft on final to be sent around. Instruction was too late and aircraft

landed on occupied runway.

Report Narratives

ACN: 1488242 (1 of 50)

Time / Day

Date : 201710

Local Time Of Day : 1201-1800

Place

Locale Reference.Airport : SLC.Airport

State Reference : UT

Relative Position.Angle.Radial : 220

Relative Position.Distance.Nautical Miles : 8

Altitude.MSL.Single Value : 8000

Environment

Flight Conditions : VMC

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.TRACON : S46

Aircraft Operator : Corporate

Make Model Name : Citationjet (C525/C526) - CJ I / II / III / IV

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 91

Flight Plan : IFR

Mission : Passenger

Flight Phase : Climb

Route In Use.SID : LEETZ6

Airspace.Class B : SLC

Aircraft : 2

Reference : Y

ATC / Advisory.TRACON : S46

Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer

Airspace.Class B : SLC

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Corporate

Function.Flight Crew : Captain

Qualification.Flight Crew : Air Transport Pilot (ATP)

Experience.Flight Crew.Total : 14000

Experience.Flight Crew.Last 90 Days : 85

Experience.Flight Crew.Type : 2000

ASRS Report Number.Accession Number : 1488242

Human Factors : Communication Breakdown

Human Factors : Situational Awareness

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : ATC

Events

Anomaly.Deviation - Track / Heading : All Types

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Deviation - Procedural : Clearance

Anomaly.Inflight Event / Encounter : Weather / Turbulence

Anomaly.Inflight Event / Encounter : Wake Vortex Encounter

Detector.Person : Air Traffic Control

When Detected : In-flight

Result.Flight Crew : Returned To Clearance

Result.Flight Crew : Became Reoriented

Result.Air Traffic Control : Issued Advisory / Alert

Assessments

Contributing Factors / Situations : Environment - Non Weather Related

Contributing Factors / Situations : Human Factors

Primary Problem : Human Factors

Narrative: 1

While climbing out of SLC via the LEETZ 6 departure we encountered either wake

turbulence from the aircraft ahead or severe environmental turbulence. The auto pilot

disengaged and while hand flying the aircraft trying to keep the aircraft under control we

missed the initial fix, PPIGG, by approximately 1.5 to 2 miles. SLC departure queried us

and advised we were off the departure. They issued a heading to rejoin the departure and

nothing more was said of the situation. There was no loss of separation from other

aircraft. It was a VMC day so we were never in danger of terrain contact with all of that in

full view.

In hindsight, we should have advised ATC of the encounter with turbulence and let them

know we had to deviate to get the aircraft under control. We were so preoccupied with

dealing with the situation that we never advised ATC of our actions.

Synopsis

C525 Captain reported a track deviation during climb from SLC when they were distracted

by turbulence or a wake vortex encounter.

ACN: 1485675 (2 of 50)

Time / Day

Date : 201710


Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US


Environment


Weather Elements / Visibility : Turbulence

Weather Elements / Visibility.Visibility : 50

Light : Daylight

Ceiling : CLR

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ

Aircraft Operator : Personal

Make Model Name : DA40 Diamond Star



Flight Plan : None

Mission : Personal

Flight Phase : Cruise

Route In Use : Direct

Airspace.Class E : ZZZ

Component

Aircraft Component : Seatbelt

Aircraft Reference : X

Problem : Failed

Person

Reference : 1



Reporter Organization : Personal

Function.Flight Crew : Single Pilot

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Multiengine






Analyst Callback : Completed

Events

Anomaly.Aircraft Equipment Problem : Less Severe


Detector.Person : Flight Crew


Result.General : Maintenance Action

Result.General : Physical Injury / Incapacitation

Result.Air Traffic Control : Provided Assistance

Assessments

Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Weather

Primary Problem : Aircraft

Narrative: 1

After passing northeast bound through a mountain pass, I warned my passengers to

expect turbulence. We started to experience moderate turbulence and then encountered a

sudden violent drop in altitude. All four of us hit our heads on the roof of the airplane. No

serious injuries, but possible head and spinal issues noted the next day. Two headsets

were broken. The seatbelts did not prevent head strikes and two seat belts became

unfastened. The front right possibly was not securely "clicked" in place and the right rear

came out of floor mount (looks like it was "clicked" into an inaccessible latch under back

seat) and could not be reattached during or after the flight without maintenance

assistance.

Reported the incident as "severe turbulence" to Center, telling them we had struck our

heads on roof of airplane. They were concerned and asked if we needed assistance. Each

controller that followed checked in on how we were doing.

The Diamond seat belts are particularly difficult to fasten securely. They are hard for larger

persons to reach and securely latch and they did not appear to be effective at preventing

head strike. Maybe the lap belts should have been tighter? Wind on the windward side of

the pass at this altitude was about 25-30 knots. I did not notice the wind speed at the

time of the incident on lee side of pass, but noticed it was over 40 knots (tailwind) as we

continued northeast bound toward our destination. We modified course to get farther away

from the mountains for the remainder of the flight.

Callback: 1

The reporter stated the seat belt that the passenger in the right seat was using may not

have been completely fastened because of the difficulty of accessing the buckle. The

reporter stated that in order to ensure that the front seat belts are properly fastened you

need to open the door to gain access to the buckle (especially if you're overweight). The

reporter also stated one of the seat belts for the passengers in the rear seat became

unlatched from the mount (which rendered it ineffective) and had to be reattached by

Maintenance. Reattaching the seat belt required removing the rear seat. The reporter also

stated that due to the low ceiling, the seat belts, as designed, will not prevent you from

contacting the ceiling with your head during turbulence. The reporter stated that he broke

his headset as a result of hitting his head on the ceiling.

Synopsis

Diamond DA40 pilot reported encountering severe turbulence while traversing a mountain

pass. He and all the passengers hit their heads on the ceiling when the seat belts became

ineffective.

ACN: 1481209 (3 of 50)

Time / Day

Date : 201709


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment

Flight Conditions : Mixed

Weather Elements / Visibility : Thunderstorm



Light : Daylight

Ceiling.Single Value : 37000

Aircraft

Reference : X



Make Model Name : EMB-505 / Phenom 300



Flight Plan : IFR

Mission : Training

Nav In Use : FMS Or FMC

Flight Phase : Descent

Route In Use.STAR : ZZZZZ

Airspace.Class A : ZZZ

Person : 1

Reference : 1




Function.Flight Crew : Instructor














Analyst Callback : Completed

Person : 2

Reference : 2




Function.Flight Crew : Pilot Not Flying

Function.Flight Crew : Trainee



Qualification.Flight Crew : Private









Events

Anomaly.ATC Issue : All Types






Result.Flight Crew : Took Evasive Action

Result.Flight Crew : Requested ATC Assistance / Clarification

Result.Air Traffic Control : Issued New Clearance

Assessments



Primary Problem : Weather

Narrative: 1

Instructor/Mentor Pilot was acting [as] PF. During the descent briefing the PF/IP informed

the PIT (Pilot in Training) that the weather over the arrival was deteriorating. XM Weather

and Active Weather Radar was painting numerous cells starting to top at FL400. Literally

the entire area was bubbling up with convective activity creating a dangerous situation.

Descent/Approach briefing completed the THREATS were clearly outlined as Severe

Weather both on the arrival and the wind conditions at the field.

[While cruising] at FL450 the Controller issued a clearance to descend to FL400. PIT (Pilot

in Training) doing the radios advised the Controller to stand by. After conferring with the

IP/PF both pilots agreed it was much safer to stay at FL450. PIT reported to [ATC] that we

wished to stay at FL450 until we passed the worst of the weather. The Controller

DEMANDED a descent. Again the PIT with authorization from the PF/IP advised we were

unable to descend. The Controller then assigned us a heading of 210 and demanded a

descent. The PF/IP made the call to begin the descent and try to help the Controller out.

We accepted the 210 heading and descend to FL350. We heard the Controller ask for an

expeditious descent through FL370. Upon rolling out on the heading of 210 we were

closing in on a large cell. We asked the Controller for a 230/240 heading for weather.

When we turned to that heading, it was obvious we were going to go through the tops of

another cell.

Now unable to get on the radio due to numerous aircraft requesting VECTORS FOR

WEATHER we turned to a SAFE heading of 260 and at first break in the radio, advised the

Controller we now needed a 260 heading for weather. The Controller replied with "You are

not cleared for a 260 heading". We again advised "sir, we need the 260 heading for

weather!" again the Controller said "you are not cleared on to that heading". This left the

crew no option but to [override the Controller] for safety. We immediately took a picture

of the weather radar and view out of the window showing the imminent threat.

Pilots should keep in mind that an XM Weather image may be 20-30 [minutes] old and

that what matters most is the image out of the window and on the weather radar. The

atmosphere had clearly reached a boiling point making safe flight very much in doubt. If

we had the time we would have squawked 7700 prior to making the turn to 260 but it is

always Aviate, Navigate and then Communicate. Didn't have time in a dynamic situation. I

stand behind the decisions we took as a crew to have a safe conclusion to our flight.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

EMB-505 flight crew reported using Captain's authority to circumnavigate an area of

thunderstorms.

ACN: 1477252 (4 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : MIA.Airport

State Reference : FL


Environment


Weather Elements / Visibility : Rain


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : MIA

Aircraft Operator : Air Carrier

Make Model Name : Widebody Transport



Flight Plan : IFR

Mission : Cargo / Freight


Nav In Use : GPS

Flight Phase : Final Approach

Route In Use.Other

Airspace.Class B : MIA

Component

Aircraft Component : Autoflight System


Problem : Improperly Operated

Person : 1

Reference : 1



Reporter Organization : Air Carrier





Human Factors : Distraction


Person : 2

Reference : 2




Function.Flight Crew : First Officer




Events

Anomaly.Deviation - Altitude : Excursion From Assigned Altitude


Anomaly.Inflight Event / Encounter : CFTT / CFIT

Detector.Automation : Aircraft Terrain Warning





Assessments





Narrative: 1

Uneventful descent into Miami while avoiding thunderstorms. Vectors to intercept final

course for RNAV/GPS Rwy 26R. We kept the speed up to get on the ground before a series

of thunderstorms got to the airport and received shortened vectors to final inside the

NAYIB fix on the approach. On final and after confirming FMS speed, Nav, and profile MDA,

while consulting with each other about rain showers close to the airport, we noticed that

the airplane was descending below the profile glidepath and I disconnected the Autopilot

to arrest the descent.

We descended to 1300, below the minimum 1500 ft for that portion of the approach before

the Final Approach Fix ZARER. We immediately started a correction back to published

altitude. At that point we received a yellow GROUND PROXIMITY alert for several buildings

2 to 3 miles in front and on both sides of the approach course. After confirming we were

well clear of all obstacles and still in a safe position for landing we opted to visually

continue the approach and landing.

Distraction with weather during the approach. Clarify before the approach the duties (i.e.

who will be looking at the radar and who will be closely monitoring the instruments).

Narrative: 2


Synopsis

Air carrier flight crew reported descending below the MIA Runway 26R RNAV Approach

profile. The autopilot did not capture the vertical path and the crew did not detect it until

they were low causing a GPWS warning.

ACN: 1476596 (5 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : KZAK.ARTCC

State Reference : CA


Environment

Flight Conditions : Marginal


Aircraft

Reference : X

ATC / Advisory.Center : KZAK


Make Model Name : Widebody Transport


Flight Plan : IFR




Route In Use : Oceanic

Airspace.Class A : KZAK

Person : 1

Reference : 1









Human Factors : Time Pressure



Person : 2

Reference : 2











Events







Assessments



Narrative: 1

About 3+26 into flight at FL330, after passing N46E170, we encountered moderate to

severe turbulence with associated "pop-up" radar returns beneath the aircraft. We couldn't

see as we were at the cloud tops. As Pilot Monitoring, I sent SF Radio [ARINC] a message

requesting left deviation for weather; we had radar indications that prevented a right

deviation. SF Radio's response wasn't timely enough and we decided to deviate left off of

our Strategic Lateral Offset Procedure. We reviewed the Long Range Navigation (LRN) for

weather deviations and were aware of parameters and altitude requirements of a deviation

off course for weather. Our left deviation kept the aircraft at a safe distance away magenta

indications on the radar. SF Radio replied with "unable deviation left due to traffic." By this

time we had already deviated left. Upon receiving this message the flying pilot turned right

to return on course, while avoiding weather. SF Radio sent another message indicating

they showed us off course. We replied that we were back on course.

Intent is to communicate why we deviated for weather and that the crew was aware of off

track deviation procedures.

Narrative: 2


Synopsis

Air Carrier flight crew reported a deviation for weather in oceanic airspace, after deviating

a message was received from ATC that denied the deviation.

ACN: 1476347 (6 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : A11.TRACON

State Reference : AK


Environment

Weather Elements / Visibility : Fog


Weather Elements / Visibility : Windshear



Aircraft : 1

Reference : X

ATC / Advisory.TRACON : A11


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear



Flight Plan : None

Mission : Personal


Route In Use : VFR Route

Airspace.Class C : ANC

Aircraft : 2

Reference : Y

ATC / Advisory.TRACON : A11

Aircraft Operator : Military

Make Model Name : Military

Mission : Training

Nav In Use.Localizer/Glideslope/ILS : ILS Runway 6

Flight Phase : Initial Approach

Route In Use : Vectors

Airspace.Class C : ANC

Person

Reference : 1

















Events





Miss Distance.Horizontal : 0

Miss Distance.Vertical : 600




Assessments

Contributing Factors / Situations : Airspace Structure

Contributing Factors / Situations : Procedure

Primary Problem : Airspace Structure

Narrative: 1

I was approaching Anchorage from the north in an ADS-B in/out equipped [aircraft]. I

called Approach for radar services for routing for landing. I was given an immediate Part

93 Deviation in the PAMR segment. Weather was raining, fog, getting dark with few clouds

and 600-700, and rain obscuring visibility to 3-5 miles. Heavy wind and windshear

occurring with the traffic at ANC being routed in for the ILS for Runway 15. There was

significant traffic using Approach and I was watching the flow of the vectoring to the ILS

and handoff to the Tower. Heavy jet traffic was reporting wind shear and turbulence. I was

low at 600 feet as I had little wind and below the ground surface shear point.

Also in the mix was a [military aircraft], which was doing practice approaches and the

TRACON controller twice told traffic that the [military aircraft] was doing "Touch and go's"

and then corrected that to missed approaches. He was vectoring the [military aircraft]

around very non-standard with tight turns and low altitudes. When I was approaching the

[military aircraft] was returning to PAED on a visual. The ATC controller gave him a

weather report of heavy precipitation between the [military aircraft] and PAED in the area

which I was at the time. I am not sure if it was requested by the [military aircraft] or

suggested by the controller, but the [military aircraft] was then cleared for the ILS on

Runway 6 at PAED. The controller vectored the [military aircraft] onto the ILS INSIDE THE

FAP! His clearance also said to maintain 1600 feet until established on the ILS. The

controller then cancelled my FAR Part 93 deviation in and handed me off to my Tower with

a "caution wake turbulence" warning. I switched to Tower and now had a visual on the

[military aircraft] that was, according to my ADS-B, less than 800 feet vertical separation

and he was coming right over me. I would like to see the track but it appeared that the

[military aircraft] was below the ILS glideslope. I took evasive action by wide open throttle

and full dive to the water to try to get east of the [military aircraft] and get the largest

amount of vertical separation. I think this was way too much "cowboy" action by the

TRACON controller and put lives in danger. If the [military aircraft] wanted to go IFR and

ILS approach into PAED why the heck he was not vectored out to join at an IAP or outside

the FAP!

This did not need to happen. There was no emergency or rush to put the [military aircraft]

back into PAED that was communicated on the frequency I was on. Doing "touch and go's"

or even the missed practice approaches that they really were at ANC at a time of heavy

traffic flow and difficult conditions of wind shear, turbulence and low weather was

questionable as the ILS was stacked up with traffic. What makes the air traffic work well in

this area is that the flows of traffic at all of the airports is usually predictable, and with

ADS-B even a "little general aviation guy operation" like me can get a good sense of where

the traffic is and will be due to the normal approach/departure flows out of the airports.

This was a fly in the ointment and seemingly only the TRACON controller and the USAF

flyboys knew what was going to be coming next. I am available to discuss this, although I

am flying commercially and not contactable much of the day until I return.

Synopsis

A single engine pilot reported approach control vectored a military aircraft over his aircraft

which the pilot felt was unsafe.

ACN: 1476074 (7 of 50)

Time / Day

Date : 201708


Place



Altitude.AGL.Single Value : 0

Environment



Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ

Aircraft Operator : FBO

Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior



Flight Plan : VFR

Mission : Personal

Flight Phase : Landing

Route In Use : Visual Approach

Airspace.Class G : ZZZ

Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Stabilizer Fairing


Problem : Improperly Operated

Person

Reference : 1



Reporter Organization : FBO


Qualification.Flight Crew : Student





Human Factors : Training / Qualification


Events



Anomaly.Inflight Event / Encounter : Unstabilized Approach

Anomaly.Inflight Event / Encounter : Object

Detector.Person : Maintenance


When Detected : Routine Inspection


Result.Flight Crew : Regained Aircraft Control

Result.Flight Crew : Executed Go Around / Missed Approach

Result.Aircraft : Aircraft Damaged

Assessments





Narrative: 1

During an authorized long distance cross-country student solo flight, attempted landing at

ZZZ on runway 18. Wind was >10 knots with gusts from 260 degrees. Had 25 degrees

flaps. As the plane was about to touch down, a wind gust blew plane from right to left and

past the edge of the runway. Was unable to maintain alignment with the runway. Executed

a go-around and as power was brought in, the nose began to raise up slightly and as such

the tail lowered. The left endcap of the stabilator struck a runway light. The impact was

felt in the yoke. Remained in the pattern, and landed on runway 18. Had the plane

refueled. Inspected the plane for damage. The left plastic stabilator endcap had a hole in it

on the leading edge.

Filled out an incident report at the airport terminal to report the damage to the runway

light. An aircraft mechanic was available to effect a repair by fabricating and attaching a

sheet metal patch. The plane was inspected for additional damage, none was found. Upon

completion of the temporary repair, the plane was returned to service. The mechanic did

not provide documentation for the repair other than a description on the cash receipt. I

was ignorant of the fact that this is improper maintenance record keeping and

subsequently learned that the aircraft should not have been placed back in service without

proper documentation. The details described in this report were reported to the FBO/owner

of the aircraft upon return two days later.

The incident could have been avoided by selecting another airport prior to the flight when

it was learned from a NOTAM that [other] runways [at ZZZ] were closed. The airport was

chosen specifically because it offered multiple runways. This fact was missed because of

fixated focus on local weather for making the go/no go decision for the flight and was not

noted and added to the plan of flight. The fuel burn rate was over-estimated and there

was more than adequate fuel available to have deviated from the plan of flight to another

airport. The cross wind component was at the margin of my skill level and surpassed by

the gusts, so upon listening to AWOS another opportunity to deviate was missed. The FAR

requirements for signed documentation for returning an aircraft to service following a

repair should have been known (43.9, 91.407).

Synopsis

A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the

repair made by a local mechanic did not have the proper documentation.

ACN: 1476062 (8 of 50)

Time / Day

Date : 201708


Place




Environment


Aircraft

Reference : X


Make Model Name : Regional Jet 700 ER/LR (CRJ700)



Flight Plan : IFR

Mission : Passenger

Flight Phase : Parked

Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Cabin Furnishing


Person

Reference : 1

Location Of Person : Company


Function.Maintenance : Other / Unknown

Qualification.Maintenance : Powerplant

Qualification.Maintenance : Airframe




Communication Breakdown.Party1 : Maintenance


Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Illness



Detector.Person : Maintenance

When Detected : Routine Inspection



Assessments





Primary Problem : Procedure

Narrative: 1

Flight diverted to ZZZ for medical emergency [and] it was reported that the flight

attendant fell when turbulence was encountered. The flight attendant and 2 passengers

were transported to the hospital. The Dispatch Supervisor asked the Captain on a recorded

phone line if the turbulence was severe and the Captain said No it was not severe. I picked

up a roll over call from an open desk the Captain called and reported a broken armrest

they were going to reposition the Aircraft to ZZZ1. After talking with the supervisor it was

decided to defer the whole seat and have ZZZ1 Maintenance repair it when it arrived since

there was going to be no passengers on the flight. When the flight arrived in ZZZ1 I had

arranged for Maintenance to meet the flight and repair the armrest. The Captain called in

and talked to another Maintenance Controller and told him on a recorded phone line that

he did in fact have a severe turbulence event prior to diverting to ZZZ with the medical

emergency. It was reported to us by the Line Mechanic in ZZZ1 that in the lav there was

blue juice on the ceiling and walls also there was soda pop on the ceiling in the main cabin

area. None of this was reported to us in ZZZ by the crew. From what was reported to Line

Maintenance it sounds like the beverage cart went airborne hit the Flight Attendant and hit

[a] seat causing the damage. ZZZ1 Maintenance took some pictures showing the extent of

the damage seatback pockets were filled with soda cans and bottles of alcohol that were

picked up off the floor by passengers.

The captain flat out lied on how bad the turbulence was. I don't know if deferring the

whole seat was the right decision with it going to be a reposition flight and no passengers

it was the easiest thing to do after discussing it with the Supervisor. If the Captain would

have been honest about what happened we would have gone in a completely different

direction.

I trusted that the information that was given to me was correct and that the Captain was

being honest on what happened. I don't know if I had asked the questions again if he

would have given the same answers. I think the Crew did not want to get stuck in ZZZ.

First and foremost if the Captain would have been honest in ZZZ and told us he had

severe turbulence we could have handled the Inspection there.

It is getting tougher to work shorthanded in Maintenance Control and try to cover more

than 1 desk, if the same crew calls in more than once they can end up talking to multiple

Controllers. Even though all the questions had been asked I should have asked them

again.

Synopsis

A Maintenance Controller reported that he received a report that a Bombardier CRJ-700

had minor cabin damage due to turbulence, later it was found to have severe cabin

damage.

ACN: 1475960 (9 of 50)

Time / Day

Date : 201708


Place




Environment

Flight Conditions : IMC


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ


Make Model Name : SF 340B



Flight Plan : IFR

Mission : Passenger



Component : 1

Aircraft Component : Attitude Indicator(Gyro/Horizon/ADI)


Problem : Failed

Component : 2

Aircraft Component : Compass (HSI/ETC)


Problem : Malfunctioning

Person

Reference : 1








Events





Result.Flight Crew : Landed As Precaution

Result.Flight Crew : Returned To Departure Airport

Assessments

Contributing Factors / Situations : Equipment / Tooling




Narrative: 1

After departure, 15 minutes into flight, we leveled off at 6,000 ft, entered IMC conditions

and light to moderate rain. First Officer's Electronic Attitude Direction Indicator (EADI) and

Electronic Horizontal Situation Indicator (EHSI) screens went black. Captain's screens also

flickered on/off at the same time. The First Officer's screens did not come back on right

away. Minutes later FO HSI screen did come back on but ADI did not. Controls were

handed over to me immediately and we requested a return back to [departure airport] and

out of IMC conditions. Landed with no incident.

Synopsis

SF 340B Captain reported returning to the departure airport after loss of First Officer's

attitude and heading indicators.

ACN: 1475763 (10 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : SR22



Flight Plan : IFR

Mission : Personal




Component

Aircraft Component : Navigational Equipment and Processing



Person

Reference : 1













Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor




Result.Flight Crew : Diverted


Result.Flight Crew : Landed in Emergency Condition



Assessments



Narrative: 1

In cruise, having just passed over ZZZ airport. Was navigating to fly through a wide gap in

thunderstorms approximately 40 nm south of position. Noticed the Avidyne Multifunction

Display (MFD) flicker, followed immediately by the smell of electrical burning/arcing.

Elected to turn 180 deg immediately and informed ATC my intention to land at ZZZ with

priority handling. I had my copilot get the ATIS for landing information while I descended

rapidly through the OVC layer. No fire, no smoke. Display remained on during descent, but

smell continued. Due to altitude and short distance to ZZZ, I overshot airport and had to

spiral back, all in IMC. Broke out of OVC on downwind to runway, saw runway and landed

visually. Was able to taxi to the ramp and shut down without further incident. Call made to

ZZZ tower as requested.

In hindsight, I could have pulled the breaker for the MFD and relied on my GPS or iPad for

navigation to ZZZ. The display continued to function without smoke, however, and I used

it to locate the airport as I spiraled down in IMC.

Synopsis

SR22 pilot reported that during cruise the Multifunction Display flickered then he smelled

electrical burning/arching.

ACN: 1474961 (11 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : IAD.Airport

State Reference : DC


Environment

Light : Night

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZDC


Make Model Name : A319



Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Route In Use.STAR : CAVLR3

Airspace.Class A : ZDC

Aircraft : 2

Reference : Y



Make Model Name : Commercial Fixed Wing


Flight Plan : IFR



Person

Reference : 1








Analyst Callback : Attempted

Events

Anomaly.Deviation - Altitude : Overshoot


Anomaly.Inflight Event / Encounter : Wake Vortex Encounter




Assessments



Primary Problem : Ambiguous

Narrative: 1

On the CAVLR3 arrival into IAD at FL220 we were cleared to "descend via". The FO was

flying [and] he put 6000 ft in the altitude window. I went off COM1 to say goodbye to

passengers and give arrival brief. We encountered some turbulence and autopilot

disengaged. I came back to COM1 and noticed we were below profile and the FO was

correcting manually. Exact altitude loss unknown, recaptured profile. No word from ATC.

PIREP: possible mountain wave or wake turbulence.

Unknown or possible attention to aircraft trailing. Also weather could have been a factor.

Suggest offsetting further from aircraft ahead? Possibly intervene sooner.

Synopsis

A319 Captain reported descending below the profile on descent to IAD when they

encountered turbulence that may have been a wake encounter.

ACN: 1474872 (12 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : COS.Airport

State Reference : CO


Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : Cessna Single Piston Undifferentiated or Other Model



Mission : Personal


Person

Reference : 1












Events




Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control





Assessments




Narrative: 1

Flight to COS on an IFR flight plan. After crossing LUFSE at 9000 ft we turned south on

V389 after calling COS approach on 124.0, we were told to expect 'vectors for the Visual

17R' into COS. On V389, approximately 15 NM north east of COS, we received the first

vector of heading 230 for the Visual 17R. About 8 NM ahead we could see light rain shafts,

that we associated would have some downdrafts. I requested a left deviation of 20

degrees to avoid the rain shaft. During the deviation of 20 degrees we started to

experience downdrafts. The aircraft began pitching up to around 8 degrees nose up and

began decreasing in airspeed. Full power was already applied and aircraft slowed to

around 66 KIAS and was unable to hold altitude, at the same time the autopilot was

disconnected and straight and level flight was maintained. The aircraft continued to pitch

up to what was around 12 degrees. I made COS Approach on 124.0 aware that we were

descending in what occurred to be a downdraft at the altitude of 8800 ft, during which our

VSI indicated a descent at 1400 FPM. The aircraft stall warning briefly sounded. I was told

by approach to maintain 9000, and I continued to tell approach we were unable to

maintain 9000 with the current situation at hand. They understood and told us that the

minimum enroute altitude was 9000 and to turn to heading 150 for an emergency vector.

We complied with Approach's instructions and began the turn, which was about the time

the downdraft ceased, we were able to maintain level flight at 8500 and continue the climb

back to 9000. At 8500 feet we cancelled our IFR flight plan because we could maintain our

own terrain and obstacle clearance and were in VFR conditions. The rest of the flight was

continued without incident under VMC with flight following with approach to COS.

Corrective action was taken on the event during the loss of altitude due to weather.

Cancelling IFR earlier during the loss of altitude would have relieved the controller of

having to issue emergency vector due to altitude below MEA. If on an IFR flight plan,

consider flying higher than the MEA assigned for the routing to account for unknown

variables, such as weather.

Synopsis

Cessna pilot reported being unable to maintain altitude and airspeed due to a downdraft

on approach to COS.

ACN: 1474295 (13 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ


Make Model Name : B767-300 and 300 ER






Person

Reference : 1








Events

Anomaly.Ground Event / Encounter : Other / Unknown





Assessments




Narrative: 1

First Officer flying a visual approach. Winds on ATIS during descent planning was reported

17010. When cleared to land tower reported wind 170 at 14 G 22. Approach seemed

stable in the gusty conditions. At about 50 FT, the auto throttles were disconnected.

Aircraft had a hard landing and bounced. At this point Captain took aircraft and landed. No

problem stopping aircraft in remaining runway. Logbook write up was completed and was

informed by mechanics that no damage was found from the landing.

Synopsis

B767-300 reported that due to weather conditions the aircraft had a hard.

ACN: 1474226 (14 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : B737-700



Flight Plan : IFR

Mission : Passenger

Flight Phase : Takeoff

Person : 1

Reference : 1









Person : 2

Reference : 2








Events



Detector.Automation : Aircraft Other Automation



Result.General : Flight Cancelled / Delayed

Result.Flight Crew : Returned To Gate

Result.Flight Crew : Rejected Takeoff

Assessments




Narrative: 1

Just prior takeoff we received a wind shear alert of 20 knots off the end of the runway. We

declined our takeoff clearance, and ran performance weight and balance for wind shear.

While waiting for our numbers, another airline departed to the northwest without issue.

After reconfiguring for a precautionary takeoff profile with performance weight and balance

numbers and briefing the potential for wind shear, we were cleared for takeoff with a 330

heading to avoid the cell off the end of the runway. While taking the runway, Tower issued

another 20 knot wind shear alert. Seeing the cell off the end of the runway both visually

and on radar, and seeing a clear path to the northwest, we decided to depart with the

added margins afforded by the precautionary takeoff profile.

At about 90 knots, we received the PWS (Predictive Wind Shear) warning "wind shear

ahead." I announced, "Reject, I have the aircraft." Autobrake Disarm illuminated, and we

brought the aircraft to a relatively gentle stop with TRs (Thrust Reversers) and speed

brakes. We cleared the runway and briefed the FAs (Flight Attendants) and the

Passengers. We ran performance weight and balance Brake Cooling numbers, coordinated

with Dispatch, Chief Pilot on Call, Maintenance Control, and determined that after brake

cooling, we would be safe to depart with a revised fuel load to reflect the new conditions.

In hindsight, we did some things well and others we did not. Having had to reject for PWS

Warning, the red flags were certainly there to not takeoff in the first place. But, we were

wise to refuse our initial takeoff clearance so that we could acquire wind shear takeoff data

from performance weight and balance. The reject decision was assertive and decisive, and

transfer of control went well. However, the FO (First Officer) debriefed that it was difficult

to hear my reject call over the wind shear warning. Also, he mentioned that he might have

inadvertently hit the brakes when I rejected the takeoff, which could explain the autobrake

disarm (we did not get the max braking of the RTO (Rejected Takeoff).

After turning off, while we did brief the FAs immediately and then the Passengers, we

neglected to reference the QRH for the RTO. Additionally, I did not announce to "Remain

seated." I believe a contributing factor was that the reject was relatively benign due to the

RTO autobrake not taking over and being only at 90 knots. It wasn't the "screeching halt"

we've practiced many times. Once off the runway, the FO was quick to suggest releasing

the brakes, and we ran the performance weight and balance brake cooling numbers,

contacted Dispatch, and conferenced with the Chief Pilot on Call, Maintenance Control to

ensure that we did not have to return to the gate, and that we could continue for takeoff

after brake cooling with fuel onboard.

Maintenance did ask if our performance computer showed a "high energy" stop. We

informed them that we no longer use the performance computer. I tried to look up what

the performance weight and balance would say in that case, but was unable to find an

example. Also, once we had new numbers for takeoff, we found that there really isn't a

procedure for takeoff after an RTO. We ran all checklists from Before Start through Before

Takeoff as a precaution (rearming the autobrake, for example). I was happy with how we

used CRM throughout the process.

Narrative: 2


Synopsis

B737 flight crew reported a rejected takeoff due to a predictive windshear warning.

ACN: 1474198 (15 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : TWF.Airport

State Reference : ID




Environment


Weather Elements / Visibility : Haze / Smoke




Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZLC


Make Model Name : Cessna 337 Super Skymaster



Flight Plan : VFR

Mission : Personal

Nav In Use : GPS



Airspace.Class A : ZLC

Airspace.Class E : ZLC

Airspace.Special Use : JARBRIDGE MOA

Person

Reference : 1












Events

Anomaly.Airspace Violation : All Types

Anomaly.Deviation - Altitude : Overshoot

Anomaly.Deviation - Procedural : FAR



Anomaly.Inflight Event / Encounter : VFR In IMC





Result.Flight Crew : Exited Penetrated Airspace




Assessments




Narrative: 1

Was VFR enroute to BZN at 15500 feet with flight following talking to SLC Center on

134.1. I contacted SLC Center and communicated I was going to climb to 17500 feet as I

was approaching clouds ahead. As I was climbing up over the clouds my climb was

accelerating upward due to convective activity and I was contacted by SLC who saw that I

had climbed above 17500 and in fact had exceeded 18000 and was therefore in Class A

airspace. I saw that it looked like I could descend back lower heading to the west but I

decided I should request an IFR clearance to be able to fly in Class A airspace and climb

higher. Before I could call I was contacted by SLC and told that I was to contact the

military frequency for Jarbidge and was given a clearance direct to Mountain Home. I

turned to the left toward Mountain home and contacted the military facility. I believe the

frequency was 118.05. I contacted the military facility and was told that I needed to

descend to a lower altitude. I told the controller that it looked like I would be able to

descend up ahead. I failed to tell the controller about the convective activity I was

experiencing and that I was above the clouds. However due to the aggressive convective

activity of the storm building beneath me, I then asked the controller for an IFR clearance

to BZN and was told that this was not possible within the military airspace that I was now

in. I was called back by the military controller and told to contact SLC Center again and

they were going to work something out for me. I contacted SLC Center again and I was

given an IFR clearance to 21000 to BZN with vectors. I was given a heading of 070 which I

could see was to fly me to the east out of the MOA. However I replied that I was unable to

turn to the east due to a large buildup/ thunderstorm to the east on my right side. I

continued to turn east as much I was able to and soon got on a heading of 070. In the

process, the convective activity pushed me up beyond 21000 and I was contacted to get

back down to my assigned altitude. In the middle of dealing with maneuvering around the

thunderstorm to the east during the climb and the convective activity my engines were

overheating due to the decreased cooling effect of the thinner air. At the same time all of

this was going on I was managing changes to cowl flaps, mixture, power settings and

airspeed to get the engine CHT temperatures under control. In the middle of this the

convective activity was now pushing me down lower and I requested to descend to 19000.

The convective activity carried me down below 19000 and I was again contacted and had

to climb back up to the assigned altitude of 19000. I could see that I was staying south of

restricted area R3204A and B as I exited the MOA.

I realized that I should have executed a 180 degree turn when I was pushed above 17500

feet to get out of the convective area that I had flown into. Then I could have requested

an IFR clearance up to a higher altitude prior to beginning my flight. I had in fact filed an

IFR flight along the route I was flying and should have activated that flight plan when I

took off so that I could have easily requested a change in altitude when I encountered the

bad weather south of TWF. I am very thankful for the assistance of the controllers that

helped me manage this difficult weather situation that I flew into. I plan to get more

training to learn how to handle higher altitude VFR to IFR transitions. My experience with

IFR flight at high altitudes has been new learning to fly the pressurized Skymaster. I also

realize now that military controllers are not trained to handle IFR traffic for separation

since their job is to manage military aircraft that are trying to intercept one another.

Synopsis

Cessna Skymaster pilot reported inadvertently climbing VFR into Class A airspace due to

convective activity. He negotiated with the Center Controller and a Military Controller for a

new IFR clearance away from the convective activity, restricted airspace, and out of the

MOA to his destination.

ACN: 1473844 (16 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZFW.ARTCC

State Reference : TX


Environment



Weather Elements / Visibility : Hail



Weather Elements / Visibility.Visibility : 0.5

Light : Daylight


Aircraft

Reference : X

ATC / Advisory.Center : ZFW


Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : IFR

Mission : Training


Route In Use.Other

Airspace.Class E : ZFW

Component

Aircraft Component : Engine



Person

Reference : 1





Function.Flight Crew : Instructor






Events





Result.Flight Crew : Overcame Equipment Problem




Assessments




Narrative: 1

Myself and another pilot had made the flight on an IFR flight plan. On the way up to

Kansas, thunderstorms were to the west of us, but we flew east of them without any

issue. Upon arriving in Kansas, we picked up another pilot who was also instrument rated,

and he and I flew in the front seats on the way back, with the previous pilot sitting in the

backseat. We flew VFR to an airport in northern Oklahoma without issue, where we fueled

the airplane. We then filed an IFR flight plan and continued our trip back home. The initial

line of thunderstorms had passed through to the east of our route, but another line was

building over Oklahoma City. We deviated several times to avoid areas of moderate and

heavy precipitation by using ATC suggestions and XM weather (NEXRAD). After

successfully navigating the storms for some time, we were passed to Fort Worth Center.

We requested a few deviations to the right by using the XM radar in order to go around

the building storms on the back side. At this time, it had been at least 30 minutes since we

had received an advisory from ATC for moderate to heavy precipitation. We had found a

gap in the storms that was showing on our XM radar to be green and yellow areas. After

10 minutes or so in this area, the radar updated and showed us rapidly approaching a pink

area of extreme precipitation. Unable to avoid it quickly enough, we flew into the

precipitation and experienced extreme precipitation, severe turbulence, light hail (pea

sized at most), and heavy downdrafts. After flying in the extreme precipitation for 20

seconds or so, we experienced a momentary loss of power which we expect to be due to

the ingestion of water in the engine intake. We informed ATC that we were experiencing

"engine troubles" and severe turbulence, and got radar vectors out of the storm. After

exiting the precipitation, the engine power resumed and we continued the flight without

issue.

Synopsis

C172 pilot reported entering an area of extreme precipitation and severe turbulence while

using NEXRAD XM weather to circumnavigate storm areas.

ACN: 1473689 (17 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : COS.Airport



Environment





Light : Daylight

Aircraft

Reference : X


Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR


Person : 1

Reference : 1









Person : 2

Reference : 2








Events

Anomaly.Deviation - Speed : All Types



Anomaly.Inflight Event / Encounter : Fuel Issue




Assessments



Narrative: 1

The flight started normally. My First Officer (FO) and I discussed the weather surrounding

COS before and during the flight. Noticeable virga was on the approach end about 10

miles north of 17L. The airport was not reporting windshear or wind gusts on the last

ATIS. A flaps 45 landing was used on the first approach. A red wind shear appeared and

we executed a go-around. I am not sure, but we may have gone over 200 kts during the

go-around in Class C. The weather was still VFR for COS and the storms were moving

away from the airport. The weather had thunderstorm activity between COS and our filed

alternate. A quick discussion of our options resulted in another attempt to land at COS. On

the second approach, we used a flaps 22 landing. Another red windshear appeared and we

once again executed another go-around. Our best option still appeared to be another

attempt to land at COS, but on the third attempt I flew the approach. For the third time,

we got another windshear warning that quickly went away along with a soft "sink rate,

sink rate".

With the fuel running low, a flight to KDEN would have put us in a min fuel status and

there was weather that would require additional vectors off course. On all three

approaches, the windshear felt minimal and I did not expect to get a windshear message

with the storms at its distance away from the field. Although we were told the storms were

moving away from the field, I did not want to risk having the storm change directions and

further limit our options. Also, the windshear message went away and I adjusted the

aircraft to not allow another sink rate aural message. After quickly reviewing our options,

we agreed to continue the approach and land in the interest of safety. The aircraft was

fully configured above 1000 AGL and no aircraft limitations were exceeded, although I was

fast on the approach.

The threats included windshear, thunderstorms in the vicinity, thunderstorms enroute to

our filed alternate, thunderstorms approaching our filed alternate, a high workload

environment, and a steadily decreasing amount of fuel.

Narrative: 2

After a normal flight with myself as pilot flying, during our arrival brief the Captain and I

briefed the possibility of a go around due to a small thunderstorm north of the COS airport

and the steps involved in go around. Our alternate was DEN with thunderstorms expected

in the vicinity. As we approached the field, still with approach control, we visually saw the

thunderstorm which was about 6 miles north of the 17L runway. Approach informed us

about the thunderstorm as well and said no aircraft had any issues with getting in and no

unusual weather alerts were given. It was my leg to fly, the Captain and I briefed the risks

and that we would need to be fully configured early to avoid an unstable approach. This

would be a flaps 45 landing. Flaps 8 was called for early and then gear down and flaps 22

was called for on our extended left base and inside outer marker. Turning final, I asked for

flaps 45 and landing check. I was a little high and corrected and was stabilized by 1000

feet, I believe about 1 to 1.5 miles from the end of runway we received a Windshear red

alert, thus we executed a go-around. We climbed out to our assigned altitude and

reconfigured, briefed what happened and I quickly asked either the tower or the approach

control, what direction the thunderstorm was moving, they said storm was basically

moving ENE away from the field. The Captain and I briefed the approach and landing

again, believing that it was safe to execute another approach and landing, but instead

using flaps 22. We executed the approach with the same result, a Windshear almost in the

same spot. We executed a go around and after a quick discussion and review of the

weather and weather at the alternate, I transferred the controls to the Captain so he could

execute the approach in the interest of safety. We briefed the weather/risks, approach and

landing, and executed a flaps 22 landing with the same results, a Windshear warning,

however, the warning was only on for a matter of maybe 2 seconds and went away then a

soft sink rate, however quickly went away. After a quick discussion we both felt the safest

option was to land the aircraft. The short final was stable, however fast (which was

briefed) and we landed with no further issue. At no time did I feel nervous or that we were

operating in a unsafe manner. I believe the Captain acted and operated in the most

professional manner. Threats included windshear, thunderstorms in the vicinity,

thunderstorms enroute to and at our alternate, a high workload environment and a always

decreasing amount of fuel. After first approach and go around we could have diverted to

our alternate, however before we even left ZZZ I checked the radar and Denver had

thunderstorms building to the west and south west and also Pueblo would normally be a

good alternate but they had storms as well. We could have diverted to the alternate with

the same results, but with landing with even lower fuel. We could have executed a hold

but, according to controllers, the storm was not moving much.

Synopsis

Flight crew reported windshear warnings while attempting to land at the COS airport that

resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,

and a successful landing was accomplished.

ACN: 1473122 (18 of 50)

Time / Day

Date : 201708


Place




Environment




Light : Daylight


Aircraft

Reference : X


Aircraft Operator : Air Taxi

Make Model Name : Learjet 36



Flight Plan : IFR




Component : 1

Aircraft Component : Window Ice/Rain System



Component : 2

Aircraft Component : Attitude Indicator(Gyro/Horizon/ADI)



Component : 3

Aircraft Component : Autopilot



Person

Reference : 1



Reporter Organization : Air Taxi


Qualification.Air Traffic Control : Fully Certified





Qualification.Flight Crew : Flight Engineer





Human Factors : Troubleshooting

Events







Assessments





Narrative: 1

Activated Windshield Heat (WSH) ten minutes prior to top of descent. Seconds later,

annunciator panel illuminated "WSH overheat" accompanied by strong odor throughout

aircraft. Deactivated WSH until Overheat (OH) light extinguished. Re-activated WSH. WSH

OH light illuminated again. Despite repeated attempts to sustain normal operation, WSH

OH light re-illuminated at even minimal settings. Descending through FL240 autopilot

disconnected. Attempts to reconnect accompanied by un-commanded right roll. With left

windshield occluded, storm clouds interspersed throughout flight path, and the AP inop,

considered switching pilot flying (PF) and pilot monitoring (PM) duties with SIC, whose

windshield was clear, possibly due to absorbed heat radiating from glare-shield (black)

after prolonged flight with sun on right side of aircraft. Prior to assigning aircraft control to

SIC, checked to confirm normal operation of right side flight instruments: noted SIC's

EADI (Electronic Attitude Direction Indicator) indicated "Fatal Failure." Aircraft type does

not provide for electronic switching to bootstrap gyro signal from opposite side to inop

side. Elected to retain aircraft control and PF duties until descended into continuous VMC.

SIC performed PM duties and provided visual guidance to avoid cumulonimbus clouds

(CBs). Slowed AC to 250 kts at 10,000 ft. At approximately 6,500 ft MSL, observed

airspeed indication had increased to 280 kts. Corrected and continued flying by instrument

reference until descending to approximately 2,500 ft (1,000 ft above pattern altitude), and

continuous VMC, in vicinity of [the airport]. Then asked SIC to take controls for landing.

Synopsis

Learjet crew reported encountering failures of the Windshield Heat, Autopilot, and

Electronic Attitude Direction Indicator during flight. Crew continued to VMC conditions and

landed uneventfully.

ACN: 1472727 (19 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZDV.ARTCC



Environment


Light : Dawn

Aircraft

Reference : X

ATC / Advisory.Center : ZDV

Make Model Name : Skyhawk 172/Cutlass 172



Airspace.Class E : ZDV

Person

Reference : 1








Events

Anomaly.Aircraft Equipment Problem : Critical






Assessments





Narrative: 1

[My aircraft] started to descend due to loss of power. I was level at 12,000 ft, at 2600

RPM, air temp was 12C and when a light drizzle of rain started, the temperature dropped

to 4C. I noticed a noise change in the engine, dropping down to 2200 RPM. This happened

right after a light drizzle of rain started. The airspeed went from 93 knots indicated, and

was dropping below 60 knots indicated. At 75 knots, I disconnected the autopilot to make

sure the aircraft wouldn't stall, then reported to ATC that we were unable to maintain

12,000 ft, and needed vectors and a lower altitude immediately. The aircraft lost

approximately 400 ft before the engine began to produce max power and was able to

maintain altitude. I noticed the power came back after I was clear of the light drizzle rain.

I would suspect induction ice was the cause of this event.

Synopsis

C172 pilot reported a power loss that led to an altitude deviation that was probably related

to carburetor icing.

ACN: 1472521 (20 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZMA.ARTCC



Environment

Light : Dusk

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZMA


Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger



Airspace.Class A : ZMA

Aircraft : 2

Reference : Y



Make Model Name : B737 Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger




Person

Reference : 1

Location Of Person.Facility : ZMA.ARTCC

Reporter Organization : Government

Function.Air Traffic Control : Instructor

Function.Air Traffic Control : Enroute


Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1







Events


Anomaly.Conflict : Airborne Conflict








Assessments





Narrative: 1

Aircraft X was deviating left from ORL and over INPIN area at FL350. INPIN is a common

arrival fix that aircraft are descending to FL270. Aircraft Y was southbound at FL350 and

the data block showed FL270. He was in the hand off flash to us. We called J86 ZEPHYR

and pointed out Aircraft X deviating left to VQQ. They did not reference traffic. As we saw,

Aircraft Y was on an intercepting heading to Aircraft X, my trainee instructed Aircraft X to

fly heading 360 for traffic. Aircraft X responded that he was unable and that it would put

him in weather. Trainee reissued the clearance and said "Unable weather deviation, fly

heading 360 for traffic." The pilot again responded that he was unable. I keyed up and told

Aircraft X, "Understand you are [exercising your emergency authority], if not, fly heading

360." He responded that he was not, and that he was in the turn. I called traffic at 11:00

and 5 miles southbound, same altitude. Aircraft X never had the traffic in site. After

clearing traffic, we re-cleared him to deviate and issued the frequency change to ZJX.

I would like to start issuing briefs to other pilots about the necessity to follow a controller's

instruction. Whether or not they want to argue it is fine, but they should be complying by

the instruction first - and then they can question it. The current attitude of, "I'm not going

to do that so issue me something else" is extremely hazardous and will eventually result in

a LoSS (Loss of Standard Separation) or worse.

This issue of assigning aircraft routes through weather goes back to my other reports, we

continually assign routes that go through weather and expect pilots to deviate when they

get close to the weather. This is also hazardous; we should not be assigning any routes

close to the weather, to alleviate this from even being a problem. By assigning these

routes, we open ourselves up to the problems such as above.

Synopsis

Miami Center Controller reported an aircraft that was in conflict with another and the pilot

did not want to turn away from traffic because of weather.

ACN: 1472510 (21 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZMA.ARTCC



Environment




Weather Elements / Visibility : Cloudy

Aircraft : 1

Reference : X



Make Model Name : Large Transport



Flight Plan : IFR

Mission : Passenger



Aircraft : 2

Reference : Y



Make Model Name : Medium Transport



Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1



Function.Air Traffic Control : Instructor



Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1.5


Human Factors : Fatigue


Human Factors : Workload


Person : 2

Reference : 2




Qualification.Air Traffic Control : Developmental





Events






Detector.Automation : Air Traffic Control



Result.Air Traffic Control : Separated Traffic


Assessments


Contributing Factors / Situations : Company Policy




Primary Problem : Company Policy

Narrative: 1

I was the Instructor at the time of this incident. We had a Handoff/Assist positon. Aircraft

X was level at 35000 feet deviating slightly left of course for weather. Aircraft Y was slow

climbing out of 33000 feet to 37000 feet. Aircraft X was indicating approximately 460

knots groundspeed with Aircraft Y indicating 375-380 knots. Aircraft Y was approximately

6 miles diagonally behind the Aircraft X. Vector lines also concurred with this, showing that

they would be 6 miles apart in 1 or 2 minutes. I assessed this situation and agreed with

what the vector lines and ground speeds were showing. Consistent to my training, Aircraft

Y should pass directly behind at 6 miles from Aircraft X. As Conflict Alert activated, my

trainee was working on another issue south of this situation which my trainee resolved.

He looked at this situation. I told him to turn the Aircraft Y 20 degrees right of course to

run behind Aircraft X. As Aircraft Y was climbing through 34100 feet the trainee asked me

if he should descend him back down to 34000 feet. I told him "no", as this instruction

would induce confusion with the pilot and would not solve the conflict possibly causing him

to speed up more by the time it's finally understood. Aircraft Y passed behind Aircraft X at

4.93 miles, resulting in a loss between the two aircraft. I take responsibility for my

actions, and admit that I misread the situation.

During this entire event, the sector had a full En route Decision Support Tool (EDST) and

the sector's Monitor Alert Parameter (MAP) number was at the original number of 18. The

actual value was borderline to this number, at 17-18 the whole time. Future 15 minute

increments were showing red. This MAP value does not change when there's weather,

which I believe is a safety issue as it lulls people into a false sense of security. Based on

that logic, we can work the same amount of planes with 100% weather as if we had 0

weather. There was a significant line of weather developing causing numerous deviations

and frequency congestion. The volume of traffic for this sector was significant even

without the weather in the north side of the sector. Routes were closed to our northeast,

and then reopened, which resulted in a significant increase of over flights to our sector.

The Q routes were closed, which resulted in aircraft going over a fix that would have

normally exited our sector significantly faster. Throughout this whole event, no Traffic

Management Issues (TMI) were applied to our sector to reduce the traffic volume, and

help alleviate our congestion. The Supervisor recognized how complex that it was, and

said "If you need help, your tracker is right behind you, just grab him." He was looking out

for the situation, whereas Traffic Management Unit (TMU) failed to help our sector from

becoming too complex.

Compounding the situation, both the trainee and I were 'assigned to duties' since XA00.

This occurred 2 hours and 17 minutes without being offered a break away from the

operational area.. We both were plugged in for approximately 30 minutes, took a 30

minute break, and went to our mandated team training. From XA00-XB00, we were in our

mandated briefing and training, and then told to report to the floor. We were plugged in at

this sector from XB00 to XC55, a 1 hour and 55 minute plugin, but being assigned to

duties for more than 2 hours and 55 minutes without a mental break or rest. Supervisors

in the area do not believe that "being assigned to training" is the same as being plugged in

at a sector, but both are mentally taxing. I believe that I was not as responsive as I would

have been within the first hour, even two hours, of working this sector. I believe that this

length of plug in negatively affected the trainee's decision making as well.

Throughout the whole summer, we are forced to push aircraft through small gaps in

extreme precipitation and convective activity. Unfortunately, this is an example of that.

Because of this, workload greatly increases exponentially in the sector as aircraft are

deviating that normally we can run parallel, and they're dangerously close to convective

weather activity. There continue to be no plans to fix this, or change this, we just continue

to run aircraft through the weather until something terrible happens.

I would require that the MAP value changes to reflect the current conditions in the sector,

as required by the Order. We currently do not do this. As such, when the sector is

borderline RED or Yellow TMU should have to advise the supervisor what actions they have

taken in order to resolve it. If the sector is already inundated with weather, the more

significant the plans should be in order to alleviate it. For example, once some of the

routes opened back up in this case, they could have offered the routes to about 10

aircraft, which would have significantly reduced the workload in this sector at the time of

the incident.

Additionally, when there is weather, especially developing lines of severe weather, as this

was, plans should be drawn up on how they will change the departures as the weather

progresses. This should be done at TMU and at the management level, so that the sector

team, who is already extremely inundated with problems, does not have to worry about

this. All they have to do is turn around and tell a Supervisor, "Hey this isn't working,

what's the next plan?" Currently, this happens, and then it's up to the sector team to

devise a new plan. If the opposite was true, then the following aircraft could already be

executing the next few plans, without sector overload.

We routinely get away from the idea of keeping aircraft away from severe weather,

instead, we run aircraft as close as 3 or 4 miles away from heavy precipitation as seen in

the situation above with BOTH Aircraft Y and Aircraft X. When weather is developing, we

need to move our traffic away from the precipitation to the recommended 20 miles.

Aircraft should not be allowed to depart on routes that take them less than that separation

(20 miles) to the weather. If they deviate that direction, that is their choice, but we are

setting ourselves up for failure by letting them depart on routes that are filed through

areas of extreme precipitation and convective activity.

I would also suggest significantly briefing supervisors on fatigue requirements, and the

mental impairment caused when controllers are on position/assigned duties for more than

2 hours. The cognitive process breaks down, and results in judgment errors that normally

wouldn't happen when the controller is fully rested.

Narrative: 2

[Report narrative contains no additional information.]

Synopsis

Air Traffic Controller and trainee reported a loss of separation between aircraft deviating

for weather.

ACN: 1472483 (22 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : ALM.Airport

State Reference : NM


Environment



Weather Elements / Visibility : Hail




Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZAB


Make Model Name : Challenger 350



Flight Plan : IFR

Mission : Passenger


Route In Use.SID : CRONA2

Airspace.Class E : ZAB

Person

Reference : 1
















Events












Assessments





Narrative: 1

We departed ALM on the CRONA2.CNX departure. After being cleared to 17000, it became

apparent that thunderstorms had moved over the departure route and that deviations

would be necessary. We were told that deviations right of course were approved. Most of

the weather was located to the right of us so we asked for deviations left and/or higher.

We were informed that we were unable to deviate left due to military airspace and unable

higher, due to military airspace. We entered a small area of what appeared on the radar to

be moderate precipitation but was in fact an area of moderate to severe turbulence and

precipitation. We repeatedly asked for higher, or deviations to the left due to weather. The

Controller denied the requests, giving us only clearance to enter into weather that

appeared more severe. We could see that the weather off to our left was clear.

We were handed off to another Controller [who] upon asking, gave us a deviation to the

left. We turned left to avoid a very large storm directly in front of us. Turning to the right

would have put us into equally severe weather. Upon making the left turn, the Controller

informed us to return to the previous frequency. On calling back to the previous frequency

we were again told that there would be no left deviations and an "immediate 040 degree

heading" was ordered from the Controller. This would have put us directly back in conflict

with weather that could have damaged the aircraft or caused injury or death to the

occupants. The Controller was argumentative and insisted that we turn immediately back

towards the storm. At this time, I took the radio and informed the Controller that we were

going to turn to a heading and if I needed to declare an emergency, that I would. We

asked for a number to call to have a discussion with a ZAB supervisor.

Synopsis

CL350 Captain reported using his Captain's authority to avoid thunderstorms during climb.

ACN: 1471766 (23 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZZZ.TRACON


Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 200 ER/LR (CRJ200)



Flight Plan : IFR

Mission : Passenger


Airspace.Class B : ZZZ

Person : 1

Reference : 1










Person : 2

Reference : 2











Events










Assessments




Narrative: 1

As we began to get vectors off the arrival due to weather, approach control assigned us a

different runway than we had brief and expected. The new approach was the ILS PRM

(Precision Runway Monitor) 27L into ZZZ. Seconds after the runway change we were

assigned direct ZZZZZ and cleared for the approach. This gave us no time to brief the new

approach and due to that we forgot to put in the monitor frequency. We continued on the

approach.

During the approach the first officer had trouble switching from white needles to green

needles. This caused us to deviate from the localizer. The captain realized the mistake

shortly after and made the first officer correct before we were 1 dot off the localizer so we

continue the approach and landed safely

The cause of this was lack of briefing a possible PRM approach. We had brief both runways

but we were not aware that PRM's were in use due to the fact they were not advertised on

the ATIS. The slight deviation on the localizer was due to task saturation on the first

officer's part.

[ATC] should start advertising PRM approaches when they are actually using them. As

pilots we should recognize the threat that ZZZ sometimes is using PRM approaches even

though they are not advertised.

Narrative: 2


Synopsis

A Bombardier flight crew reported not being aware of the Precision Runway Monitor in use

because it was not advertised on ATIS.

ACN: 1471540 (24 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZDC.ARTCC

State Reference : VA


Environment




Weather Elements / Visibility : Icing


Aircraft

Reference : X


Make Model Name : Learjet 60



Flight Plan : IFR

Mission : Ferry


Route In Use.STAR : GIBZ2


Person

Reference : 1















Events


Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control




Assessments




Narrative: 1

I was Pilot in Command (PIC) and Pilot Monitoring (PM). First Officer (FO) was Pilot Flying

(PF). Forecast called for a possibility of scattered afternoon thunderstorms.

Descending on the arrival, ADS-B weather showed scattered small-but-developing

thunderstorms. Turned on aircraft weather radar and it showed the same. PIC radar was

tilted down and SIC radar was tilted up to get a full picture of the weather. Both ADS-B

and radar showed small cells left and right of our arrival route, but nothing directly along

our route. No other aircraft had reported turbulence beyond light chop.

Below us was an undercast. We turned on nacelle heat and stab/wing heat several minutes

prior to entering the cloud layer. We were indicating approximately 300 knots, slowing to

280 knots as required by the arrival. Upon entering the cloud layer, the windscreen was

instantly caked in ice and the aircraft was rolled approximately 40 degrees left and pitched

nose down. The PF disconnected the Autopilot, established a level attitude, and brought

power to idle. After 10-20 seconds the turbulence ended and the flight continued as

normal.

We made a PIREP of severe turbulence to ATC. After landing we inspected the aircraft and

found no visible damage. No injuries occurred. Maintenance was notified. Further

inspection revealed no structural damage to the aircraft.

I suspect we flew through the top of a developing thunderstorm that was embedded in the

undercast, and that had formed quickly enough that ADS-B had not yet shown the cell,

and that was below our radar as we approached it, even though my radar was tilted down.

This incident just reiterates the need to use extreme caution when flying in the vicinity of

convective activity, even if the cells appear "scattered," "small," and "weak."

Synopsis

LR60 Captain reported momentary loss of control after encountering a developing

thunderstorm on descent.

ACN: 1471524 (25 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : D10.TRACON

State Reference : TX


Environment


Weather Elements / Visibility : Haze / Smoke



Light : Night


Aircraft

Reference : X

ATC / Advisory.Center : ZFW

ATC / Advisory.TRACON : D10


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear



Flight Plan : VFR

Mission : Training


Route In Use : VFR Route

Airspace.Class E : ZFW

Person

Reference : 1












Events





Anomaly.Inflight Event / Encounter : VFR In IMC




Result.Flight Crew : Exited Penetrated Airspace



Assessments



Contributing Factors / Situations : Staffing



Narrative: 1

During a round-robin IFR cross country training flight at night, I made the decision to

cancel IFR while midway through our second leg. Center was advising us of moderate to

extreme precipitation along our route of flight. Our aircraft was equipped with a storm

scope and we were able to see the cumulus clouds ahead as the moonlight shone around

it. There were no signs of lightning visually or on the storm scope, so I made the decision

to continue underneath the weather Center was depicting.

Not wanting to get involved with even the mere possibility of embedded convective

weather, and knowing from our first leg that the cloud bases were between 2,500 and

3,000 feet I elected to cancel IFR, descend below our Minimum Enroute Altitude (MEA) to

3,000 feet and continue receiving flight following from Center. We would not have been

able to remain IFR at 3,000 feet due to the MEA and Center's Minimum IFR Altitude in this

area. We would then descend to 2,500 feet to maintain VFR cloud clearance requirements.

Center transferred us to Approach, and shortly thereafter, we had an inadvertent

encounter with IMC at 2,500 feet. I informed the Approach controller that we would need

to pick up IFR again, and he advised us to standby because he needed to call Center for

permission to make that change, as we were still not inside the Approach airspace

boundary. About 2 minutes later, we popped out of the cloud and were back in VFR

conditions. I cancelled the request to pick up IFR. The controller acknowledged that,

advising us that Center wouldn't pick up his landline call and therefore he would probably

not have been able to issue the clearance for another several miles when we entered his

boundary.

This speaks to a larger issue about staffing at Center and TRACON. It seems [in the

evening] both facilities staff with a lower-than-acceptable number of controllers. This

makes it hard to receive otherwise simple services like changing a VFR aircraft to IFR

status. We were already "in the NAS" from our previous IFR clearance, squawking our NAS

flight plan code, and yet the Approach controller couldn't get Center to pick up a simple

call to request permission to change us back to IFR. Insofar as I'm concerned, Approach

and Center should be staffed just as well at night as both seem to be staffed during the

day. In most cases I hear more traffic flying with these two facilities at night than I do

during the day. I fly at all hours of the day and night and find the most hectic hours [in

the latter half of the evening], when one controller will be combined on multiple sectors

and frequencies.

I accept responsibility for the inadvertent IMC encounter. I elected to remain in IMC rather

than descend out of the cloud thinking we would be able to switch back to an IFR

clearance without a problem. The fact that it was night time contributed to my decision to

remain at 2,500 feet rather than descend lower. Had we continued to be unable to receive

a new IFR clearance, I would have descended out of the cloud and back into VFR

conditions. We exited the cloud and were back in VFR conditions before that option

crossed my mind.

Synopsis

A General Aviation pilot reported canceling IFR then entering IMC weather without

obtaining a new IFR clearance in a timely manner. The reporter indicated that the delay

was due to staffing issues from ATC.

ACN: 1471374 (26 of 50)

Time / Day

Date : 201708

Place




Aircraft

Reference : X



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



Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1









Human Factors : Physiological - Other

Person : 2

Reference : 2





Function.Flight Crew : Check Pilot



Human Factors : Physiological - Other

Human Factors : Human-Machine Interface


Events








Assessments



Narrative: 1

Upon climbing through FL360 to FL380 we received an Engine-Indicating and Crew-

Alerting System (EICAS) warning "DOOR Passenger AFT OPEN". We [reset] warning and

called the Flight Attendant (FA) to determine status of door. They stated that it was closed

and secure yet the top right green indicator had some white area in it that was not

normal. We checked the Quick Reference Handbook (QRH) for required actions. We

continued to climb to assigned FL380. After leveling off at FL380 we were encountering

light to moderate chop turbulence. The warning message came one again. We called again

to confirm with the same answer. We requested lower as the door was still indicating

unsafe. As we descended we noticed that the differential pressure was 8.3. We referenced

the QRH for proper differential pressure for that altitude and determined that the aircraft

was indicating a high differential pressure for the altitude we were flying. At this time you

could feel the pressure on our ears and the Captain asked me if I could feel this as well. I

confirmed the discomfort. The warning was still on and had unreliable pressure readings

combined with physical discomfort from the pressure. The Captain stated "I think we need

to get lower and divert". This also was confirmed by the QRH if we lost cabin pressure. I

confirmed the need to divert. We descended to 14,000 ft. We continued to have pressure

fluctuations during the descent. Aircraft was inspected by contract maintenance and

deferred. Captain suggested we fly back at 10,000 ft to avoid issues if the pressurization

failed. We did so attempting to manage pressure manually and automatically [to ZZZ1].

The aircraft continued to have increase and decreased differential pressure for the flight

[to ZZZ1]. Unknown cause for event. The warnings and pressure issues may have been

caused by the door open indications.

Narrative: 2


Synopsis

E-175 flight crew performed an precautionary landing after troubleshooting pressurization

door issue.

ACN: 1471341 (27 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : DEN.Airport



Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : D01





Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS



Route In Use.STAR : ZPLYN3

Airspace.Class B : DEN

Person : 1

Reference : 1










Person : 2

Reference : 2









Human Factors : Confusion

Events








Assessments



Narrative: 1

Approaching Denver we had loaded and briefed the ZPLYN 3 arrival and planned on the

16L ILS as our best guess of what approach we would receive. ATIS was advertising 16L,

17R and 17L. We also briefed the Class B airspace and altitudes using the fix page to

ensure we remained above the floor of the class B if we received a visual approach

clearance. After checking in with approach control, we were told to expect the visual to

17L. At about the same time we encountered moderate turbulence in the descent and I

made the PA for the flight attendants to take their jumpseats. While we both started to set

up the necessary changes to the localizer frequency and minimums for 17L, approach

control instructed us to maintain 280 kts whereupon the FO, who was the pilot flying,

began making the changes to multiple legs of the arrival to maintain our speed while

descending in VNAV. While he was making the changes I was asked for and gave a PIREP

on the weather and ride during the descent. I believe it was these distractions that led us

to forget to change the runway in the FMC. We did a quick mini-brief on the runway

change but did not catch the fact we still had the ILS 16L loaded in the FMC. Within

minutes we were descended to 7000, given a turn off the arrival and asked if we had the

airport in sight. We both agreed and we're given a heading of 200 to join the final for 17L.

Things were happening quickly. The FO slowed the aircraft, descended and began calling

for flaps and the approach checklist which I completed. I also, distracted myself and the

FO a bit by talking about the floor of the class B and being careful not to descend below it.

I noticed that just as we were about to cross the final of 17L and asked the FO to arm the

approach mode. By the time he did so, we had crossed the final approach course of 17L

and the aircraft flew through the localizer. The FO seemed unsure what was happening so

I took the aircraft, disengaged the autopilot and turned the aircraft back toward 17L. The

turn was made between the final approach courses of 17L and 17R. At about the same

time, ATC queried us about the overshoot and I explained we were maneuvering back

towards the 17L final. At no time was there a conflict with other traffic. It was then that

the FO verbalized he had been looking at 17R (believing that he was seeing 17L) and he'd

been further convinced he was not on final yet because the final approach course line on

the MFD was actually showing 16L - much farther to the west than the 17L final. This

resulted in his delay in arming the MCP approach mode. Once established back on the 17L

final, the FO resumed flying the aircraft and configured for landing within required visual

approach criteria. We confirmed the runway again with the localizer, glideslope and our

eyeballs using the taxi chart and a normal landing was made.

Narrative: 2


Synopsis

B737 flight crew reported on approach to DEN they had the wrong runway programmed in

the FMS which caused a deviation on the visual approach.

ACN: 1471135 (28 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZLA.ARTCC

State Reference : CA


Environment




Light : Daylight


Aircraft

Reference : X

ATC / Advisory.Center : ZLA


Make Model Name : Small Transport



Flight Plan : IFR



Airspace.Class E : ZLA

Person

Reference : 1


















Events











Assessments






Narrative: 1

Another pilot and I on board experienced an incident with L.A. Center while approaching

the San Diego International Airport. The incident occurred when L.A. Center assigned our

aircraft to fly direct to the IFR fix, JONDA then direct to the San Diego International Airport

(SAN), which was our final destination. JONDA (IFR Fix) is located 55 nautical miles

southeast of the San Diego International Airport just north of the Mexican/USA border.

Our aircraft was flying on a heading direct to JONDA (IFR fix) from the north. L.A. Center

then told our aircraft to maintain present heading once we were approximately 10 nautical

miles north of JONDA (IFR Fix). Our aircraft along with multiple other aircraft approaching

the San Diego International Airport were trying to maneuver around a large wall of

thunderstorms that were located to the east of the San Diego County area.

L.A. Center had most of the aircraft approaching the San Diego International Airport fly

south close to the border of Mexico to deviate around the thunderstorm cells, then head

inbound to the San Diego International Airport. While our aircraft was quickly approaching

JONDA, maintaining our southerly heading to the Mexican border, our L.A. Center

frequency became highly saturated with radio calls. Our L.A. Center controller kept getting

stepped on while making transmissions to other aircraft. Also, two to three aircraft were

calling at one time to get a hold of our L.A. Center Controller. Our controller even stated

that two aircraft are calling at once and to say again because he did not receive the

transmissions clearly from those two other aircraft. Our aircraft was still maintaining our

present southerly heading that L.A. Center told us to fly, but we were quickly approaching

the ADIZ borderline between Mexico and the United States. My other pilot and I tried

reaching our L.A. Center Controller multiple times, but our transmissions kept getting

blocked by other aircraft and the L.A. Center Controller together.

We tried approximately 20 attempts to get a hold of our L.A. Center Controller, but were

not able to. We started calling our controller once we were about 5 nautical miles to the

North of JONDA (IFR fix) because we knew we were getting close to the ADIZ. The other

pilot and I thought that the controller became too saturated with radio calls and forgot

about our aircraft and our current position of our aircraft, which was very close to the

ADIZ. Once we passed JONDA (IFR fix) on our assigned southerly heading, we were now 5

nautical miles from the North of the ADIZ and were soon going to pass the ADIZ without

any sort of clearance or permission to cross the border of Mexico since our aircraft's final

destination was San Diego International Airport, a United States domestic destination.

Myself and other pilot kept trying and trying multiple times now, once we were quickly

approaching the ADIZ, but the L.A. Center frequency was still very saturated with

communication amongst the Controller and several other aircraft. Approximately 2-3

nautical miles north of the Mexico/United States ADIZ, myself and other pilot both decided

to deviate and make a turn to the right on a westerly heading to avoid crossing the ADIZ

from the north in VFR flight conditions. Once rolling out on the westerly heading we tried

calling L.A. Center two-three more attempts and after the third attempt we were able to

get a hold of the controller. We told the controller that we had to make a right turn to the

west to avoid crossing the ADIZ into Mexico and tried multiple times calling on the

frequency, but it was too saturated with transmissions between other aircraft and the

controller.

The L.A. Center controller then acknowledged to us that he was capable of having aircraft

cross the ADIZ due to the thunderstorms in the area, but myself and other pilot had no

knowledge of that information and were never communicated that information until after

we made the turn to the westerly heading to avoid the penetration of crossing the ADIZ.

L.A. Center then told us to fly on a heading of 255 degrees and expect radar vectors to

San Diego International from that point. Our aircraft then was assigned a different Air

Traffic Control frequency and made it safely to our destination of the San Diego

International Airport.

Synopsis

A corporate pilot reported turning away from the Mexico ADIZ airspace after being unable

to contact the Center due to frequency congestion.

ACN: 1471074 (29 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : TPA.Airport





Environment







Light : Daylight


Aircraft

Reference : X

ATC / Advisory.TRACON : TPA


Make Model Name : M-20 F Executive 21



Flight Plan : None

Mission : Training



Airspace.Class B : TPA

Person

Reference : 1















Events








Assessments





Narrative: 1

I had not flown for several months and was getting practice in. As I tried to get to BKV I

found myself hemmed in by building cumulonimbus, rain, and thunderstorm activity. I was

unable to make BKV and updrafts and cloud tops pushed me above the class B veil beyond

6,000 ft to 6,400 about. I had relied on my Garmin weather in cockpit, but it was not

depicting actual conditions. I will not rely on this instrument again.

Synopsis

M20 pilot reported encountering an updraft which caused him to climb into TPA Class B

airspace.

ACN: 1470687 (30 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZOB.ARTCC

State Reference : OH

Environment



Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZOB





Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZOB

Person

Reference : 1









Events




Were Passengers Involved In Event : N




Assessments



Narrative: 1

Original flight scheduled to ROC, diverted to ZZZ due to TRs at ROC. At the folder noticed

fuel was about 10.3 at ROC no alternate with lots of weather in route. I added 3k. After

takeoff ATC leveled us at 310 initially. They said this would be a final. Sent [Operations] a

msg. After a bit they gave us 330 as a final. Enroute we have to deviate for WX quite a bit.

On arrival several thunderstorms in the area. We flew over ZZZ and it looked fine. Noticed

the radar displayed strong storms east and southeast and south of ROC and closing in on

the airport. We were getting vectors for the approach and handed off to tower. We were

on a right dogleg and Tower reported winds gusting to 30 and the last jet that attempted

to land was an Airbus 319 that reported +\- 15 and a 600 ft loss on final. I could see the

strong rain down shafts and lightning almost at the field and discontinued the approach. At

this point we had about 11k on gas. I knew ZZZ was clear and I decided to go. ZZZ is a

very short flight from ROC. The FO (First Officer) was flying and I was getting our

clearance to ZZZ as well as diverting the box, loading the app, getting ATIS, working the

radar, and doing landing data. We landed and I called [Operations] then because I just flat

didn't have time to tell them in flight, very time compressed. We blocked in with 8.9 fob

(Fuel on Board). 1900 lbs above emergency fuel, glad I added 3k.

Synopsis

Air Carrier Captain reported diverting due to thunderstorms at the destination airport and

fuel concerns.

ACN: 1470661 (31 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : MCO.Airport



Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : MCO





Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 35R


Airspace.Class B : MCO

Person

Reference : 1








Events







Assessments



Narrative: 1

While conducting the ILS 35R approach into MCO, deteriorating weather conditions

mandated a missed approach. The missed approach was executed without incident. There

were storm cells around MCO but the field was VFR and normal operations/landings were

being conducted to 35R (9001 ft). Wind was approximately 45 degrees off the nose 15

gusting to 25 (approximately). Left to right crosswind. As we joined the localizer the

aircraft landing reported the first 1000 ft of runway was wet. We were cleared to land, #2.

The aircraft immediately ahead of us landed and reported that the first 4000 ft of the

runway was now wet, but no other issues. There was a storm cell approaching the field.

Approaching the final approach fix we could still see the runway (approximately 6 DME).

Fully configured, checklist complete, stable at 1000 AGL, stable at 500. Visibility rapidly

started to deteriorate after the 500 ft stable call. Heavy rain. No longer VFR, but all

approach lights and runway lights were visible. At approximately 200 ft a very strong and

sudden gust of wind left to right pushed us well right of centerline. The Captain (pilot

flying) called for and initiated a go-around. Aircrew initiated the go-around without

incident. Multiple aircraft on the localizer behind us immediately broke off their approaches

as well.

I believe the gust of wind that drove us off centerline was microburst type event. It had no

headwind component to it, only crosswind, and it was very sudden. To avoid a recurrence,

the only suggestion would to be to recognize the threat of weather earlier and discontinue

(or never start) the approach sooner.

Synopsis

B737 Captain reported executing a go-around at MCO after encountering a "microburst

type event" on short final.

ACN: 1470577 (32 of 50)

Time / Day

Date : 201708


Place




Environment





Aircraft

Reference : X







Flight Plan : IFR





Person : 1

Reference : 1














Person : 2

Reference : 2




Function.Flight Crew : Relief Pilot






Person : 3

Reference : 3










Events









Assessments




Narrative: 1

We were on the approach to ZZZ, about 18 mile final and were watching a large storm cell

over the airport. As we got closer ATC issued a micro burst alert for 50 knot wind gains

and losses on final. We elected to abandon the approach and since the cell appeared to be

moving quickly across the field, we elected to have delay vectors to evaluate the rapidly

changing weather. We had about 1+20 minutes of fuel remaining. We were sent on a

heading to ZZZZZ and switched to ZZZ1 approach. The controller there had clearly lost

the picture of his traffic situation and did not answer our initial transmissions. We

continued to have difficulty establishing communication with approach. The IRO

(International Relief Officer) was communicating with dispatch to change our alternate to

something closer to our current position than ZZZ2, but were told that none of the local

area airports were suitable. We evaluated our fuel state and determined that we needed to

divert to ZZZ2 without delay to arrive with sufficient fuel. Again, the controller seemed to

not hear our transmissions and at one point made a blind broadcast to us by our

transponder code. We finally got a heading to ZZZ2 after declaring minimum fuel. In

addition, we had to deviate around scattered cells as we headed to ZZZ2. We were

switched to ZZZ approach as we had to go by ZZZ on our way to ZZZ. The controller

informed us that Runway XYR was available for landing if we wanted it. We evaluated the

situation and saw a large gap between cells that would allow a visual approach. We were

vectored till we saw the airport and were cleared for a visual approach to XYR. I noticed

the First Officer appeared to have the wrong runway in sight and was slightly high on the

approach. He reported XYR in sight and I was providing verbal corrections to position us

for the visual approach. We had to maneuver around a rain shower between us and the

runway and I noticed we were trending to low when we got a below glide slope alert. We

immediately corrected back to course and because of our position on an angling left base,

we needed to make a turn to line up with the runway at 700 feet. My normal reaction is

not to try to salvage a bad approach, but to go around and do it again. I felt that

considering our fuel state, about 40 min remaining, and the rapidly changing weather we

needed to land rather than go around, and that we could do it safely. The approach

resembled the IGS [Instrument Guidance System] into the old Hong Kong airport. We

were lined up and on speed at 400 feet and the wind at the airport remained less than 5

knots. We landed exactly in the touchdown zone and taxied to the gate without further

incident.

Narrative: 2


Narrative: 3


Synopsis

B747 flight crew reported beginning to divert due to weather and minimum fuel but ended

up going to the original destination.

ACN: 1470484 (33 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZMP.ARTCC

State Reference : MN


Aircraft : 1

Reference : X

ATC / Advisory.Center : ZMP


Make Model Name : Medium Transport



Flight Plan : IFR

Mission : Passenger



Airspace.Class E : ZMP

Aircraft : 2

ATC / Advisory.Center : ZMP



Flight Plan : IFR



Airspace.Class E : ZMP

Person

Reference : 1

Location Of Person.Facility : ZMP.ARTCC


Function.Air Traffic Control : Approach







Events








Assessments






Narrative: 1

APN complex hot with large force exercise. Multiple airspaces, including a temporary

Military Operations Center (MOA), with bases as low as 5,000. Building weather with

deviations. First, Aircraft Y was direct to APN level at 5,000. I had moved Aircraft Y from

nonradar conditions at 4,000 to 5,000 for an unusual departure from GOV Tower, which I

had wrongly thought (as it turns out) was departing Runway 14 (he actually departed 32).

Aircraft Y then progressed into the temporary MOA (5,000 to 27,000) when APN Approach

called (upon taking their handoff), and asked whether I was going to move him down to

4,000 to avoid the airspace. I then descended Aircraft Y to 4,000. He barely entered the

lateral confines at approximately 4,500.

Sometime around the same time, APN Approach handed me Aircraft X, opposite direction,

at 5,000. I knew the airspace (Garland MOA) was active at 6,000, but simply forgot. I may

have seen the "6,000 to 23,000" associated with the MOA on the screen and used 6,000

instead of 500 to 1,000 feet below. Upon exiting APN airspace, I climbed the aircraft to

6,000, partly to avoid any potential conflict with Aircraft Y going the opposite direction.

Not that they were in conflict at the time, but I was busy and expected deviations from

both. Aircraft X was in the airspace for at least 20 to 30 miles. I realized my mistake after

the phone call about Aircraft Y from APN Approach. By this time, Aircraft X was nearly

clear, and elected to keep him there for another 5 miles until I could climb the aircraft on

course.

I was busy, and just lost the flick. There is no other excuse, it was probably my worse

session in quite some time, other than my mistake that happened here. A D-side was

provided a short while after. I should have asked for a D-side. This would have helped

immensely.

Synopsis

A Center Controller reported allowing an aircraft to enter Military Operations Areas without

coordination while working special military operations and dealing with weather deviations.

ACN: 1470479 (34 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZBW.ARTCC

State Reference : NH


Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZBW





Flight Plan : IFR

Mission : Passenger




Airspace.Class A : ZBW

Person : 1

Reference : 1

Location Of Person.Facility : ZBW.ARTCC











Person : 2

Reference : 2

Location Of Person : Company


Function.Dispatch : Dispatcher

Qualification.Dispatch : Dispatcher


Person : 3

Reference : 3



Function.Dispatch : Dispatcher

Qualification.Dispatch : Dispatcher


Person : 4

Reference : 4

Location Of Person.Facility : ZBW.ARTCC









Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Illness







Assessments





Narrative: 1

Aircraft X was on route direct to MANTA intersection and then an arrival into PHL

descending to FL280. I had plugged into Sector 31 as the radar controller a couple of

minutes prior to the aircraft checking on, and was informed by the previous controller that

there were some weather deviations, but surprisingly no bad rides.

I issued the weather to Aircraft X and received no response. No more than two minutes

later I issued a descent clearance to Aircraft X to cross 35 miles north of MANTA at FL200,

no response and I issued it one more time. The pilot read back the clearance and then

reported moderate turbulence descending from FL300-280 five miles behind. I thanked

him for the report. At this point I was relieved from position to take over as CIC

(Controller In Charge) in the area. A couple of minutes later, the new Sector 31 Controller

advised me that Aircraft X encountered moderate to severe turbulence and that there were

injuries on board the aircraft. The aircraft was switched to ZNY for more expedient routing.

Narrative: 2

Aircraft X was flight planned through a FPG (Flight Planning Guidance) that had light-

moderate-occasional Turbulence from FL280-FL340. Flight was planned to descend to

FL280 at LFV. There was an FPG in the area, if I remember it started just prior to LFV. I

had no reports of bad or good rides reported by other Flights in the area.

There were no SIGMETs or PIREPs in the area, from other flights traversing the area in

question.

Narrative: 3

The flight encountered severe turbulence resulting in injuries. Captain reported the

incident via radio and requested paramedics and ambulances meet the flight upon arrival.

The flight submitted a PIREP to ATC.

HTO UUA /OV HTO090025/TM XA44/FL280/TP [Commercial Fixed Wing] /TB MOD-SEV/RM

2 SEV BUMPS ASSOC W/ AREA OF WX, INJ PASS AND CREW CORR FOR TYPE UUA

The flight crew then requested FA supervisors meet the flight via ACARS.

VIA ops, I requested paramedics and ambulances meet the flight upon arrival due to

possible 10 passengers and 7 flight attendants injured. The crew reported that the seatbelt

sign had been on for 40 minutes before the turbulence was encountered.

Narrative: 4

I was made aware today, that on the last session of my shift yesterday, Aircraft X

encountered moderate to severe turbulence as it was leaving my sector, while already

talking to the following controller. There were numerous thunderstorms in the area and I

had been calling the weather to other aircraft in my sector. I cannot recall if the

precipitation that Aircraft X encountered was in my sector or not, and I have not seen the

radar playback to know if it did indeed fly directly through heavy/extreme precipitation. I

was told that I did not call the weather to this aircraft and for that, I am reporting myself.

I would like to see this become a training item for controllers to again remind about the

serious need to call the weather. I believe many of us get complacent because we see

aircraft all the time fly directly through what appears to us to be extreme precipitation.

This should help reinforce the need to call weather all the time.

Synopsis

Two Controllers and two Dispatchers reported a flight encountered severe turbulence

which resulted in injuries to flight attendants and passengers.

ACN: 1470471 (35 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZNY.ARTCC

State Reference : NY


Aircraft

Reference : X

ATC / Advisory.Center : ZNY

Aircraft Operator : Fractional

Make Model Name : Medium Large Transport



Flight Plan : IFR



Airspace.Class A : ZNY

Person

Reference : 1

Location Of Person.Facility : ZNY.ARTCC


Function.Air Traffic Control : Handoff / Assist







Events








Result.Flight Crew : FLC Overrode Automation

Assessments

Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings

Contributing Factors / Situations : Equipment / Tooling



Primary Problem : ATC Equipment / Nav Facility / Buildings

Narrative: 1

I was working the handoff position at the sector. There was a lot of weather deviations and

route closures. Aircraft X had a flight plan which took them backwards. The pilot did not

question the route and I did not catch the fact that the routing took them backwards.

Aircraft X was coordinated with the adjacent sector who also did not catch that the routing

would take this flight backwards. ATOP probed the flight as if he was going reverse course

at a fix. The flight did not reverse course and came together with another flight at 41000

feet.

ATOP should have a logic check when a flight reverses course like this. Also the pilot didn't

fly flight plan.

Synopsis

ZNY Center Controller reported the flight plan processing software did not detect that an

aircraft filed a route which reversed course at a fix and into conflict with another aircraft at

the same altitude.

ACN: 1470460 (36 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : F11.TRACON



Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : F11


Make Model Name : Widebody, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger



Airspace.Class B : MCO

Person

Reference : 1

Location Of Person.Facility : F11.TRACON










Events









Result.General : None Reported / Taken

Assessments







Narrative: 1

Aircraft Y was being worked by the STN controller on a 160 heading and clipped the corner

of my airspace on final (ARM sector), right where Aircraft X was descending out of 6,000

for 4,000. Aircraft Y entered my airspace without a point-out. The STN controller was busy

and had several areas of thunderstorms affecting his airspace. Aircraft Y passed less than

5 miles behind Aircraft X, a heavy with 700 feet of altitude. There was several significant

areas of precipitation affecting the entire airspace and every sector was overwhelmed

including the supervisors. There was not enough staffing to staff hand-off positions and

coordinator positions. Supervisors were having to work Coordinator positions for the MCO

departure sectors and arrivals sectors and were not able to keep an eye on other sectors

than may need attention.

I recommend adequate staffing levels to staff coordinator and hand-off positions so that

supervisors are not having to stand behind just 1 sector to coordinate for an extended

period of time and they can keep an eye on the entire operation. It is a known issue that

F11 experiences significant thunderstorms every afternoon during the summer months and

staffing was decreased instead of increased to allow for necessary positions to be staffed.

Synopsis

Orlando TRACON Controller reported an airspace incursion and a loss of separation due to

another Controller being overwhelmed with traffic and weather.

ACN: 1470394 (37 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight

Aircraft

Reference : X



Make Model Name : PA-32 Cherokee Six/Lance/Saratoga/6X


Flight Plan : VFR

Mission : Personal



Airspace.Class D : ZZZ

Person

Reference : 1












Events

Anomaly.Ground Excursion : Runway

Anomaly.Ground Event / Encounter : Loss Of Aircraft Control



When Detected.Other


Assessments




Narrative: 1

It was a warm afternoon, windy out of the northwest (after landing I approximated the

crosswind at 13 knots with winds around 350 at 20 knots). I was in a stable traffic pattern,

turned onto final and had to crab the plane to line up with the runway due to the winds. I

had a smooth landing on centerline at a higher than normal speed due to the gusting wind

conditions, then the plane quickly veered off to the right, exiting the runway, and I was

able to quickly stop it on the grass next to the runway. Tower inquired whether I needed a

tow. The engine was running normally, there were no engine warning lights or unusual

sounds so I requested and received permission to taxi back onto the runway and then exit

off at the normal taxiway.

I performed a thorough inspection of the aircraft afterwards and there was no damage to

the aircraft or obvious wear changes to the tires. A mechanic examined the plane the next

day and no obvious damage was noted. No damage to the airport environment was noted.

The runway excursion was the result of a high crosswind and my delay in correcting for it.

I was reminded of the importance and difficulty in maintaining crosswind correction during

all phases of aircraft movement and was too slow to respond given the very windy

conditions at the airport. I am unfamiliar with this airport and need more experience with

this airport environment and its windy conditions. I plan on working with a local CFI to

improve on these skills.

Synopsis

PA32 pilot reported loss of directional control in gusty crosswind conditions that resulted in

a runway excursion.

ACN: 1469723 (38 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : MUHG.Airport

State Reference : FO

Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : MUHG


Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS

Nav In Use.Localizer/Glideslope/ILS : Runway 5


Person

Reference : 1











Events






Assessments



Contributing Factors / Situations : Airport

Primary Problem : Airport

Narrative: 1

We stayed offshore to avoid thunderstorms on the arrival. About 20 miles out from the

airport we proceeded to DME 8.5 on the approach course to avoid thunderstorms over

BEMUV. We shot the LOC Runway 5 approach because the glideslope was not available

due to the DTHR for Runway 5. We were not able to acquire the displaced runway

threshold (DTHR) marking until 2.5 miles out on the approach. The runway marking isn't

wide enough and has almost no contrast to the surrounding runway surface. The marking

for the DTHR is about 200 ft northeast of Taxiway B. My local knowledge of where the

DTHR was made the difference in continuing the approach. We departed at dusk with the

runway lights on and the DTHR was clearly marked. The lack of approach lighting and an

almost invisible DTHR would result in a missed approach in IFR weather conditions.

Synopsis

Air carrier pilot reported difficulty identifying the MUHG Runway 5 displaced threshold

because of the prevailing visibility, the runway marking width, the low contrast from the

surrounding runway surface, and no approach lights.

ACN: 1469614 (39 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Pitot-Static System



Person : 1

Reference : 1










Person : 2

Reference : 2









Events








Result.Flight Crew : FLC Overrode Automation


Assessments




Narrative: 1

As Pilot Flying, we were navigating around moderate to heavy precipitation using heading

select and climbing to FL330 using VNAV. During the climb, I realized I had bad air data,

as the airspeed suddenly displayed in the 130 knot range along with other erroneous

readouts. At the same time I was trying to diagnose the situation, the Captain noticed the

autopilot had commanded a descent. Realizing my computer was receiving bad data,

controls were quickly transferred to the Captain, who turned off the automation and began

to hand fly.

In regaining positive aircraft control, our flight altitude reached 33,100 ft, but

simultaneously we were also given a new heading and altitude clearance of FL390. The

autopilot was commanded back on and the flight continued a normal climb using the

Captain-side air data. During the climb, we discussed the situation and determined the

First Officer static port had iced over and caused my computer to display wrong

information. The system returned to normal once clear of the precipitation, and the aircraft

control was later returned to the First Officer side after verifying read outs on both sides

corresponded with each other.

Narrative: 2


Synopsis

B737 flight crew reported that the First Officer experienced erroneous airspeed indications

while flying through heavy rain.

ACN: 1469590 (40 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : C90.TRACON

State Reference : IL

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : C90

Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer






Airspace.Class B : ORD

Person

Reference : 1

Location Of Person.Facility : C90.TRACON










Events













Assessments







Narrative: 1

I was vectoring when level 5 weather popped up near the west side of the airport. We

were on west flow. I asked if we should really keep going into 3 full runways with weather

like this. The response was "the tower says it doesn't look that bad out the window".

Everyone started to go around. We had nowhere to go with all these planes with weather

and so many in the airspace. No preemptive strike to help the situation. I believe part of

the problem is that there were younger people, while all very skilled, were not sure what

to do with the situation without getting in trouble or feeling they might. There were only

CICs being utilized rather than a supervisor being in charge of the front line.

There was an OM on duty, although, one, I'm not sure if he was in the room, and two, he

has really no idea what's going on. There were so many go arounds and no instructions as

to what to do with all of them, i.e. another runway, divert, etc. Many were minimum fuel.

It was very frustrating and stressful. It seemed like survival of the fittest rather than any

coordination or instruction being given. Also, monitors were never called for with extreme

weather, even after everyone started going around.

A supervisor should be in charge of the front line when there is only one in the room.

Coordination should be done to lessen the arrivals with extreme weather in the area. CICs

should be made aware that they can do what they need to for the safety of the aircraft

coming rather than the "who am I going to be in trouble with" rather than slowing fixes

and holding or coming off a runway, or two for that matter, with extreme weather. CICs

are put in a bad position because they are unsure of what they can and can't do. Same as

unsupervised mid shifts.

Synopsis

C90 Approach Controller reported that their sectors became overloaded and unorganized

due to numerous weather related go-arounds combined with a lack of experienced

controllers and supervision.

ACN: 1468984 (41 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : ZZZ.Tower



Environment




Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Person

Reference : 1









Events










Assessments




Narrative: 1

Over the 10 DME fix on the ILS, we had a strong rain shaft at an 8 DME from the runway

that we had to fly through which looked like it was stable but had very strong 20Kts+

windshear gain. Before we entered the PF (Pilot Flying) determined to try to get configured

partially for the approach which is also SOP and I had no objections we selected Flaps 1 at

210kts and after they were set we entered the rain. As we descended I called out rising

airspeed, at that time the PF already had Spoilers deployed and thrust levers at IDLE, he

called for the gear after we couldn't stabilize the airspeed and reached around 237 kts

before the gear was able to assist in slowing the aircraft. The flaps continued to work for

the rest of the approach and had no issues getting on the ground. The weather was due to

the developing Nor-Easter in the area and we were the first aircraft to report the 20kt+

gain on final.

We could've called for the gear sooner when I noticed the speed increase but not sure if

that would have even stopped the gain it jumped quickly and suddenly from 210 to 228 to

238.

Synopsis

An ERJ-175 pilot reported windshear at on final which resulted in a 20 kt increase. Speed

brakes and landing gear were extended to regain a stable profile for landing.

ACN: 1468502 (42 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ZAU.Airport

State Reference : IL

Aircraft

Reference : X

Make Model Name : No Aircraft

Person

Reference : 1

Location Of Person.Facility : ZAU.ARTCC








Events






Assessments




Primary Problem : Staffing

Narrative: 1

I returned from a break and looked at the "numbers" for BAE sector and showed a yellow

26 or 28, I can't remember. I saw there was no one on break and was assigned BAE sector

to let that controller go home. I asked the Supervisor about the lack of staffing and the

high traffic count coming up at BAE. [The Supervisor] said hold-overtime was not

approved. I plugged in at BAE and was getting busy. I had asked for a D-side. It was

getting much worse and needed help right away. I asked at least 5 times for a D-side. It

took maybe 15 minutes or so before I got one. The sector was near out of control. We had

[a nearby sector] traffic from the low side. It was humid and aircraft were not climbing.

Swap north was getting out of hand and departures opposite direction was a problem too.

Most aircraft were complaining about chop/turbulence and was tying up the freq. I stopped

taking hand-offs here and there from the low side and he couldn't take my hand-offs as a

result.

Where is flow in all this! How about hold-overtime! We had plenty of people that went

home. I never complain about working busy periods, I enjoy it. And I understand we need

to move aircraft but this was a totally unsafe situation. I ended up 2.5 hours on the

position. I completely lost track of time so times are approximate. Please really look into

this.

Better flow! Better management with traffic volume forecast!

Synopsis

ZAU Center Controller reported their session was out of control due to traffic and no flow

control from the Traffic Management Unit.

ACN: 1468179 (43 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : FOD.Airport

State Reference : IA




Environment


Weather Elements / Visibility : Cloudy


Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : FOD


Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear



Flight Plan : VFR

Mission : Personal



Airspace.Class E : FOD

Person

Reference : 1




Function.Flight Crew : Other / Unknown










Communication Breakdown.Party1 : Other


Events



Detector.Person : Passenger




Assessments





Narrative: 1

Flying as an "extra set of eyes" for a pilot friend while enroute to Oshkosh, we

inadvertently flew into a class E surface airport with weather below VFR minimums. When

approximately 10-15 miles west of FOD, we picked up the AWOS weather and observed

the field was barely above VFR minimums: 1000 ft Broken, 10 SM visibility. I pointed out

to the pilot that there was an airport 10 miles northwest of our position that was reporting

VFR, in case FOD went below minimums. The pilot elected to continue to FOD to take a

look. After descending, we picked up the AWOS again and observed the clouds were now

at 800 ft broken. Already being below the clouds and 2 miles from the airport, the pilot

elected to continue and land at FOD. Looking back, this was probably the safer option at

that point, already being under the cloud deck, but we never should have gotten to that in

the first place. The landing was uneventful and we waited on the ground until the weather

raised back to VFR minimums, and departed for the rest of our trip.

Lessons learned: I should have been more forceful with the pilot on the suggestion of

going to the alternate airport that was VFR. The pilot may not have understood that FOD

was class E and the weather minimums associated with class E. It was ignorant to proceed

into deteriorating weather, when a viable alternate was so close.

Synopsis

A flight instructor observer pilot reported not being assertive enough and allowed the pilot,

who was presumably operating under VFR, to proceed to and land at an airport that was

below VMC.

ACN: 1468164 (44 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : ZTL.ARTCC

State Reference : GA


Environment




Aircraft

Reference : X




Mission : Tactical


Route In Use.STAR : Raggz1

Person

Reference : 1

Location Of Person.Facility : ZTL.ARTCC




Experience.Air Traffic Control.Radar : 23


Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 7



Events








Assessments





Narrative: 1

Weather that was depicting heavy to extreme precipitation impacted the Tiroe sector ZTL.

The area of convective activity covered a 90 mile radius in the sector. There was no "clean

air" we had aircraft inbound to ATL deviate to avoid the heavy thunderstorms. They

deviated into the south departure sector and also the west departure sector. It was not

possible for them to join the arrival from the south west. We coordinated headings with

ATL approach A80.

Our Traffic Management Unit (TMU) was informed by our Controller in Charge (CIC) that

aircraft were requesting different arrival fixes. The other 3 arrival fixes and sectors in ZTL

airspace had no weather at all. 2 Air carriers demanded a new arrival for safety. Our TMU

responded by saying the air carriers could deviate. So we vectored aircraft to deviate

north and rejoin the arrival when able. When the aircraft reached the Transfer Control

Point (TCP) however the controllers at A80 said they had no knowledge of this plan and

did not agree to it. Lack of communication between our TMU and A80 put the flying public

safety at risk.

Our TMU said that they put out a re-route to put the arrivals on other arrivals. However

the aircraft were still purposely being routed into known convective activity on the arrival

into ATL. No proactive measures were taken by our TMU to off-load arrivals to safe arrivals

with no convective activity. The flying public was put at risk by this lack of action and

planning. In the future when an arrival sector is covered in convective activity the aircraft

should be re-routed to other arrivals.

This was another example of how our management and TMU do NOT work to help the

controllers of ZTL.

Synopsis

Atlanta Center Controller reported aircraft being cleared into known weather.

ACN: 1468132 (45 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ASE.Airport



Environment


Light : Dusk

Aircraft

Reference : X

ATC / Advisory.TRACON : ASE



Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 15


Airspace.Class E : ASE

Person : 1

Reference : 1







Person : 2

Reference : 2







Events

Anomaly.Deviation - Procedural : Weight And Balance







Assessments




Narrative: 1

Enroute to ASE we sent for landing data for Rwy 15 on a wet runway and the winds were

roughly 270/12G19. The data came back and said we didn't have the required runway

length necessary. We immediately asked dispatch to run the numbers as well and then

referenced the flight release. Dispatch came back initially and said we should be good but

they were going to check with their boss. The flight release said that we had more than

enough runway. We decided to continue the approach. Somewhere around XTREM or

TIKET we received a message from dispatch that said,"not legal to land, sorry." We

executed the missed approach and started our climb to 14200 feet. Because of our speed

and altitude I called for VfTO (Final Takeoff Speed) because we didn't have too far to climb

and I didn't want to blow through our missed approach altitude. As we leveled we noticed

the FMS didn't sequence. We verified on the FMA we were in GA mode but it wasn't

sequencing. At that point we identified RIKOC and realized we were already passed it and

turned immediately to a heading of 300. Because we exceeded 190 knots we had a wider

turning radius and exceeded the 13.5 DME arc from DBL when we were intercepting the

303 course outbound. Because of the wide turn tower told us the MSA was 16000 feet and

cleared us to maintain 16000 ft. We complied immediately. We only had 4100 lbs of fuel

onboard and decided to divert to ZZZ. We requested direct to the airport and asked

dispatch for the fuel burn and informed them of our intentions. They responded that ZZZ

isn't a legal alternate because the tower is closed and we need to go to DEN. We started

the turn towards DEN and then received word that ZZZ tower was open and we were good

to go. We proceeded to ZZZ and landed without incident.

I think that an 11 hour duty day is too much. There are too many factors that can get you

behind and make it impossible to catch up without rushing. I think it would also be

beneficial to do more training on the missed approach procedure for the LOC Rwy 15 from

earlier on in the approach. It changes things quite a bit. We need to refine the new data

because it is spitting out data that seems completely and utterly inaccurate and will

completely tie our hands and create situations like this. That being said there was certainly

mistakes made on my part that I haven't made before on this missed approach procedure.

We had already briefed it three times that day but could have been more thorough. Many

of the small but important details that were missed I think were due mostly to a long duty

day with many distractions that took a toll on us mentally. We did identify our long day as

a threat in the WANT briefing but didn't realize how big of a threat it was.

Narrative: 2


Synopsis

Turbojet flight crew reported a missed approach due to the winds at ASE. The aircraft

entered an area with a higher MSA due to a higher speed and greater turn radius.

ACN: 1468112 (46 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ZSPD.Airport

State Reference : FO

Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZSHA


Make Model Name : B787 Dreamliner Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1




Function.Flight Crew : Relief Pilot






Events









Assessments




Narrative: 1

I was the [relief pilot] on this flight. Just before the landing, the crew returned from break

we updated weather and everything looked normal for arrival and landing into ZSPD. Once

the landing crew got in their seats, PVG approach started to give us a speed reduction and

then eventually a delay turn to the north. Approach was very vague on the reason other

than traffic. We flew north for some time and queried why. Eventually they turned us back

towards arrival and we were told number 2 for landing and the reason was weather. Our

weather radar wasn't painting anything that caused us concern. Our fuel by this time was

getting close to bingo however we were assured that they will get us right in as we told

approach fuel was critical. Once on the arrival the controller said 35 minute delay. This

was not going to work for us so we told controller we will fly direct to our alternate of

ZZZZ. He gave us a vector that was not direct and held us at a lower altitude. We then

[advised ATC] and flew direct ZZZZ and continued our climb.

This was caused by a communication problem with the controller. It was late into the

arrival before we realized it was a weather delay. The controller did not understand our

fuel situation and continued to lead us on. Even after we [advised them of the severity of

the situation] he tried to vector us and keep us down low. Unacceptable considering our

fuel state. Controllers in Shanghai need to understand how to communicate with English

carriers. The need to be very clear on the reasons for delays and real time expected

delays. Dispatchers can help by being more proactive with information on flow into

Shanghai and expected delays. As we pass the South Korean Peninsula it would be nice to

know how things are looking on the arrival. It's easier to stop in Incheon for fuel than

ZZZZ.

Synopsis

B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be

expected during arrival, and did not expedite a clearance to the alternate after being

advised of the low fuel state.

ACN: 1467710 (47 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : DEN.Airport



Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : DEN





Flight Plan : IFR

Mission : Passenger


Flight Phase : Takeoff

Person

Reference : 1













Events


Anomaly.Deviation - Procedural : Weight And Balance






Assessments


Contributing Factors / Situations : Chart Or Publication






Narrative: 1

Dispatch remarks field on SABRE flight plan for Flight DEN-ZZZ said, "planned bleeds off

takeoff at 37 degrees off longer runway for best ATOG (Allowable Takeoff Gross Weight)".

The Planned Weight/Maximum Allowable weights on the flight plan were 160446/166777

lbs. Release 2 was issued due to ZFW increase of 1800 pounds. The takeoff data requested

at the gate was for runway 34L, bleeds off, planned TOW 161,300 lbs. SABRE returned a

flaps 1 setting with max EPR (Engine Pressure Ratio) V1, Vr and V2 of 145, 158, 163. We

had a discussion about the fact that the takeoff data message showed a reduced EPR line

as a legal option. We decided using reduced EPR with bleeds off seemed ill-advised. Had

we used this option, our v-speeds would have been higher at 152, 162, 166.

On taxi out, we requested final takeoff data for runway 34L TOW 161,000 lbs. Again

SABRE sent us flaps 1 with a reduced EPR option. We elected to use max EPR with its

enhanced performance and lower v-speeds. I mentioned to the FO that in the previous

three weeks out of Denver, we had been unable to extract anything other than flaps 1

bleeds off on runway 34L. An error was all we got, bleeds off, if other flap settings were

requested. I also mentioned that I thought we had been very close to exceeding tire speed

each time.

In line for takeoff, ATC reported windshear and shifting winds on our runway. An aircraft

gave a PIREP after takeoff that tailwinds were 16 kts until liftoff, when then shifted to a

four kt headwind. The windsock was initially hidden by an aircraft body, but as we

approached the number two position in line for takeoff, we saw very clearly that the sock

showed a variable tailwind of 5-15 kts. We called up data for 34L with winds at 160/10.

SABRE offered us flaps 5 bleeds off, with 10 kt tailwind. V-speeds were 134, 152, 157. We

reset takeoff data and re-ran the checklists. The company aircraft ahead of us refused

takeoff until more favorable winds developed. Tower seemed miffed at their reluctance to

go, saying, "I said 25 kt GAIN on runway." In fact, as we waited in line, ATC was

consistently reporting "wind shear alert, 25 kt gain on the runway." Sometimes the

verbiage was "...25 kt gain over the numbers" for the landing runway 35R. At any rate,

the aircraft in front was eventually satisfied the winds were acceptable. Tower cleared

them for takeoff, reporting 34L winds as 360/9. Interestingly, the windsock clearly showed

a tailwind. We were cleared for takeoff, with winds reported at 070/4. The windsock

showed a slight tailwind. I had asked the FO to note our ground speed on liftoff. I was

watching them also. At the Vr call, groundspeed was 192. At liftoff, groundspeed was 209.

Rotation rate was normal, and the pitch at takeoff was 4.8. We wrote a logbook entry for

the tire over speed.

Clearly, the allowable TOW on both the SABRE flight plan and takeoff data messages do

not take tire speeds into account. Had we carried the max allowable weight of 166,777 lbs

(per flight plan), or 167,900 per takeoff data message, our tire speeds would've exceeded

tire speeds even more. We mitigated our v-speeds as best we could (most of the time, out

of Denver, only flaps 1 will work, but today we got lucky, I guess). Also, had we use

reduced EPR (an option given us, but not appropriate considering the windshear), our v-

speeds would've been higher. I don't see how B737s can takeoff during summertime out

of Denver (or any high altitude airport) at these "allowable" weights without grossly

exceeding tire speed. In fact, I am sure tire overspeeds are routine.

Synopsis

B737 Captain reported departing DEN Runway 34L during variable windshear conditions

and recorded 192 kts at Vr, 209 kts at lift off with indicated airspeeds of 158 kts and 163

kts respectively. The maximum tire speed was exceeded.

ACN: 1467476 (48 of 50)

Time / Day

Date : 201707


Place



Environment




Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1









Person : 2

Reference : 2











Events







Assessments




Narrative: 1

Descending through the ZZZZZ fix on the ILS approach, the First Officer (FO) was

maintaining a speed of 210 Knots using Full Boards. We hit turbulence while descending

through the clouds and the load factor increased and quickly the speed dropped and the

stick shaker came on. I quickly called for the command of the controls and the FO quickly

removed his hands from the controls. I then added power and lowered the nose and

removed the boards to close and thus regain full control authority. I then re-intercepted

the Glide Slope and then gave the controls back to the FO. I then continued with the gear

and flap settings and by the 1000 feet call all was configured and by 500 was stable and

the landing was spot on.

I believe that I have been noticing a trend where the FOs do not really understand the use

of flight boards, especially when inputting full amount. They seem to fixate on the descent

and omit the visual indications such as the yellow band and incremental Pitch Limit

Indicator (PLI). For some reason, these visual indications are either omitted or not used as

an impending warning to probable events such as a stall. I notice that in almost every

flight I have to discuss the use of Boards or in some cases I have had to assist in closing

boards because the yellow band turned RED.

In some cases FOs have taken the assist personally and have increased tension in the

cockpit because in their perception the assist was taken as intrusion. I further believe that

CRM has been taken out of context and has made FOs the premier Flying pilot that "is the

sole manipulator of controls." For example, I had an FO, recently, who thought that having

an EMB 190 type certificate made him loggable PIC when flying.

They seem to look at themselves as PIC rather than first officers who are still flying and

assisting the Captain. I believe this false sense of understanding, hierarchy, has misguided

FOs and thus relied on a false sense of a pilot who never has the need to ask questions.

I think that during training or Initial Operating Experience (IOE), the FO needs to be

reminded of the need to keep learning and that just because they passed IOE is by no

means an excuse to overlook the Captains experience. CRM should be shared information

that allows for Safety but in some cases new FOs are relying less on sharing and more on

acting as individuals in command authority when the sole manipulator of controls.

Narrative: 2


Synopsis

ERJ175 flight crew reported receiving a stick shaker warning when intercepting the glide

slope from above with the speed brakes deployed.

ACN: 1467408 (49 of 50)

Time / Day

Date : 201707


Place




Environment


Light : Night

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger

Flight Phase : Parked

Person : 1

Reference : 1









Person : 2

Reference : 2








Events

Anomaly.Deviation - Procedural : Other / Unknown



Were Passengers Involved In Event : Y

When Detected : Aircraft In Service At Gate


Assessments





Primary Problem : Ambiguous

Narrative: 1

EDCT (Expected Departure Clearance Time) already in place for PHL. We discussed current

weather/fuel state. Ops affirmed EDCT time and need for the gate. Dispatcher affirmed

weather forecast and lack of alternate required (we were prior to forecast storms even

with our delay) but we had contingency fuel to hold/divert if contingency arose. Enough

for deviations but not likely a lengthy hold. Pushed and held in pad for approximately 25

minutes. Takeoff and flight through Western PA uneventful with some deviations for

weather. Fuel burn matching Dispatch and continued flight deck efforts to fly efficiently

while monitoring PHL. Saw cells via radar on arrival corridor but not on the field.

Started hearing about arrivals 2-3 aircraft ahead of us going into hold and reviewed

options for hold/divert if needed. IAD, BWI and others eliminated for obvious

weather/saturation issues. PIT, ZZZ, EWR all discussed and weather obtained. No NOTAMS

onboard for any of these due to not being an alternate. Asked dispatcher about those

fields as well as supportability for 737-900 in ZZZ (most specifically the ability to takeoff

with fuel/pax load). I have not been to ZZZ but looked adequate as I reviewed with the

Captain. Dispatcher recommended ZZZ or EWR. Queried ATC about EWR or ZZZ being ok

for flow and weather. Was told EWR would not be good for flow but ZZZ was ok. Found

ZZZ in JeppFD-Pro and looked at Weather flow we had seen/expected. Of note, no 10-7

page but manual lists as category R for 737. ZZZ was north of the problematic weather

and close enough to quickly get into PHL or deplane passengers if needed. No known

issues as we could see it with any supportability. Landed at ZZZ without incident and went

to the ramp area. ZZZ ATC asked of our intentions--we stated a refuel and go if

weather/ATC allowed but we weren't sure if/when that would happen. We were marshaled

by contract maintenance support to the southern tip of the ramp. Shut down,

accomplished appropriate checklists, door opened with air stairs. Safe divert arrival and

times passed to company.

We were parked in the corner of the ramp, between 500 and 600 feet from gate where we

would ultimately deplane. Some passengers immediately expressed an interest to deplane

given proximity to PHL. Refuelers and air stairs were prompt. We were initially told

approximately an hour until a bus available but the local personnel were working on it

while we looked into legality/security from the Company standpoint. We had some

concerns/questions about checked bags continuing without their associated passengers in

the aircraft and wanted to consult with Operations and our publications. Stipulation would

be no checked bags removed and those that deplaned would not get back on. We were to

ask about how many wanted off and provide a number for accountability and load

planning. The Captain passed this to the passengers and continued to make calls toward

that effort.

Simultaneously worked with dispatch to obtain new flight plan and determine refuel

amount. Gas provided but receipt was not on standard sheet. Provided that printout and

fueler went with air stairs and paperwork to another flight that had also diverted. No

frequencies or phone numbers for operations but eventually obtained them from a

dispatcher who happened to be onboard our aircraft. Took at least 20 minutes to hear

from anyone. The other flight appeared a priority. Ops/ramp Member hooked back up. We

passed 55 people wanted off. Also learned from security/police that no one could walk

across the ramp, that transportation was required. Local operations also given official

on/in times for planning purposes.

We were still under the impression productive efforts were being made to obtain

transportation. We made it clear to multiple ZZZ personnel that any options were fine--

multiple trips via minivan vs one size fits all bus if it would enable deplaning sooner than

later. The next time the stair came up some 30 minutes later we were told by Contract

lead no one could deplane due to lack of a tail stand per her supervisor who was not yet

present but allegedly coming into work. We asked about deplaning from back to front, or

even using the aft doors, as this was beginning to take on a sense of urgency. The lead

stated that her supervisor would not allow it until at the 3 hour point when we had to per

DOT (Department of Transportation) guidelines. This seemed to drive a reduction in

timeline management by local operations who felt they had more time to devise a viable

solution, but didn't seem to think how long it would take to execute a plan for 55-181

souls depending on the situation. Security officer reinforced that under NO circumstances

were people walking across the ramp despite the fact that he personally understood our

plight. We received no completed fuel sheet so I approximated using fuel levels in our

tanks and total gallons (provided on the original sheet so we could insert into ACARS).

Completed the walk around and continued to make any available pre-flight preparations if

there was a break in the weather. However efforts continued to accommodate passengers

wishing to deplane, particularly between Captain and Operations.

PHL continues on a ground stop and storms continue from the east. Also told that ATC is

not taking flights above 10K over ZZZ. Our assessment remained that a second divert was

very likely given the weather and it was not fair to passengers to do that. CA made

numerous calls to dispatch and Operations relaying situation. Local ops was non

responsive about deplaning or transportation updates, making it nearly impossible to

make PA announcements to the passengers but the Captain did his best. No information

provided by dispatch or ATC about whether anyone was able to land in PHL so we had to

go with our judgment as pilots looking at the radar and the forecast coupled with ground

stop information. We were told of an extended PHL ground stop until at least 45 minutes

from now so we turned our primary attention to deplaning passengers. Captain passed this

plan to Operations as best as I can recall.

Throughout tarmac delay, the passengers had appropriate temperatures, food, water, and

lav access at all times. Flight attendants did a great job accommodating while informing us

of questions/concerns. While on a lav break, I personally and publicly inquired about

temps and engaged with a couple customers up in first class area. The only thing they

could not do was deplane, which was increasingly frustrating to them and us. We provided

updates every 10-15 minutes but those often were that we were waiting back for answers.

Near the end of our delay we were informed one passenger was suffering a panic attack,

but that apparently subsided with interaction from the flight attendant and the security

official who happened to be on the aircraft at the time (second/final air stair usage in

remote parking). No Medlink or other efforts seemed warranted other than expediting the

stalled deplaning process. We also anticipated there would be a crew duty day limitation

about the time the weather could break and discussed those ramifications as well. That

information was passed to Operations and scheduling. Just prior to timeout and as we

were approaching the 3 hour point, We received word that ATC approved us to go quickly

to PHL but there was a 40K cell 5-10 miles west of their field, making successful arrival to

PHL unlikely. We focused our efforts on deplaning passengers discussing the need to

deplane if departure was doubtful at 2+15.

Due to inaction from ZZZ ops/security, Captain directed that we would move the aircraft

to gate. Despite ops understanding this final decision, and no other activity on the ramp, it

took 15 minutes to get the airstairs removed so we could safely start engines. We

accomplished checklists, sat passengers, started both engines and taxied to the gate.

Then, jet bridge broke and would not extend to the aircraft front door. We had to reseat

everyone again and push back the aircraft 3-5 feet to use the same air stairs walking

across the same ramp, some 175 yards closer. In total, it took 45 minutes from decision

to move the aircraft to deplaning passengers.

Narrative: 2


Synopsis

B737 flight crew reported a weather diversion that resulted in a long delay and difficulties

deplaning the passengers due to airport rules and equipment availability.

ACN: 1467288 (50 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : IAD.Tower

State Reference : DC


Environment



Light : Night

Aircraft : 1

Reference : X

ATC / Advisory.Tower : IAD


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger


Flight Phase : Taxi

Aircraft : 2

Reference : Y

ATC / Advisory.Tower : IAD


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger



Airspace.Class B : IAD

Person

Reference : 1

Location Of Person.Facility : IAD.Tower


Function.Air Traffic Control : Local






Human Factors : Fatigue







Events


Anomaly.Conflict : Ground Conflict, Less Severe



Anomaly.Ground Incursion : Runway




When Detected : Taxi



Assessments






Narrative: 1

I was working LC1 [Local1], LC2, and LC3 combined at the time of the event. The position

was combined at LC3 which faces the west side of the airport. This configuration makes

working the east side of the airport (RWY1R/19L) difficult. I also had planes on 2 separate

frequencies 120.1 which is LC1 frequency and 134.42 which is LC3 frequency. This also

creates confusion and potential for transmissions being stepped on.

There was weather in the area with a thunderstorm over the airport. This added

complexity and extra focus necessary to issue weather updates, wind shear alerts, and

RVR [Runway Visual Range] readings. I have received many briefings in the last year

stressing how important weather dissemination is. This was my major focus during this

event which could have lead me to get tunnel vision.

I had Aircraft X number 1 for RWY 1R and Aircraft Y number 2 for RWY 1R. Both planes

were cleared to land and given weather advisories. I was working a departure in position

on RWY 30 that was given weather information and was holding in position looking at the

weather and deciding if they were able to depart. My attention was on the weather and

trying to give accurate information and watching the TDWR [Terminal Doppler Weather

Radar] for new wind shear readings because it was continuously changing. Aircraft X had

safely landed and missed the last high speed exit (K2) so I instructed them to turn left J1.

At this time Aircraft Y was on a 1.5 mile final and with the speed of Aircraft X continuing

down the runway I did not think timing would be a factor. The visibility was drastically

reduced and the end of the runway was not visible from the tower. I was relying now on

the ASDE-X [Airport Surface Detection Equipment] to insure that Aircraft X had cleared the

runway. I saw what I believed to be Aircraft X committed to the K1 exit while Aircraft Y

was short final and I allowed them to continue. The Controller in Charge saw Aircraft X's

target still on the ASDE-X now at J1 and instructed me to send Aircraft Y around.

I issued go around to Aircraft Y and it was too late he had already crossed the landing

threshold and responded that they "had already touched down". I then realized my

mistake of issuing Aircraft X to turn off the runway at J1 instead of K1 which caused

confusion to the pilot because J1 is 500 feet farther down the runway. I believe Aircraft X

was exiting the runway at K1 and realized he made the wrong turn and then turned back

to comply with my exiting instructions of J1.

This event happened because of an incorrect runway exiting instruction, weather at the

airport, the position being combined due to lack of staffing and not recognizing a

developing situation due to fatigue.

I recommend that when weather is a factor and adds complexity to workload that LC1 be

separate from LC2 and LC3 and worked from the proper position in the tower. The tower

was improperly staffed and I believe with holdover overtime this event could have been

prevented.

Synopsis

IAD Tower Controller reported that a flight crew missed the taxiway turnoff, turned around

to exit, causing aircraft on final to be sent around. Instruction was too late and aircraft

landed on occupied runway.

Documents

Inflight Weather Encounters - ASRS - Aviation Safety ... · Inflight Weather Encounters . ... A single engine pilot reported approach control vectored a military ... B737 flight crew