Case review: original report beside what the AI sees

Flagged cases come first (bold in the list, gold edge), each with its question. For every case, check that it is faithful to the report, that the wording is neutral, that it reads right to a pilot with a plausible bad ending, and that nothing before the ending gives the real outcome away. Don't judge blame or polish the style. Send back the case ID and what's wrong.

S05 category C · ACN 2276020 · Human Factors · 248 words · FLAGGED

Question for you: The lowest point was about 1,000–1,100 ft above ground, right at the height where TCAS stops giving resolution advisories. The deviation began at 1,600 ft.

Original NASA report

Aircraft 1: EMB ERJ 145 ER/LR
Flight phase: Descent; Initial Approach
Reporter 1 function: Pilot Not Flying; Captain
Anomaly: Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Flight Deck / Cabin / Aircraft Event Other / Unknown; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Flying to ZZZ; we were cleared direct to final approach fix for Runway XX (ZZZZZ); descend to 3;000' and report the field in sight. After a few minutes; we identified what we believed was the airport and reported the field in sight. We were instructed to descend to 1;600 feet and cleared for the visual approach Runway XX.The pilot flying had FMS guidance (pink needles); and I as PM was monitoring the ILS (green needles). We began configuring to land and the autopilot was disconnected to start turning to a base leg and descend for landing. At this time; approach asked if we have ZZZ in sight; 12 o'clock; 10 miles. I referenced my MFD (Multi-function Display); looked at our intended turn point; then at 12 o'clock and identified the actual ZZZ airport. I advised 'now we do'. ATC instructed us to return to 1;600 feet and remain cleared for the visual Runway XX. At this point; we had descended through 1100 feet; we corrected back to 1;600 feet; continued eastbound; and completed a normal landing on Runway XX at ZZZ.The field initially reported as 'in sight' was subsequently determined to be ZZZ1.Suggestions: Being cleared for the visual approach so far from the airport (15-20 miles) may have contributed to our initial misidentification of ZZZ1 as ZZZ. I was beginning to recognize the field appeared too close to be ZZZ when approach confirmed the airport location. Because we believed we were closer to the runway than we actually were; we disconnected the autopilot; began configuring; and initiated descent earlier than intended. Descending prior to the final approach fix was not consistent with SOPs and was corrected once identified.In the future; I will place greater emphasis on confirming positive field identification prior to reporting 'field in sight'. I will also ensure that; particularly at night; we prioritize published approaches or accept vectors to final to reduce the likelihood of misidentification.

Narrative 2

While descending into ZZZ at night; Approach instructed us to descend to 1600 feet. We were still 20 miles away from the field once we leveled off. At this point they asked us if we had the field in sight to clear us for the visual for Runway XX at ZZZ. The only airport we could see was ZZZ1 which we mistook for ZZZ due to it being night time and the airport having the exact same configuration runways as ZZZ.I descended to approximately 1000 feet and lined up for a base to final for Runway XX at ZZZ1. At this point Approach gave a 'Low Altitude Alert' and we realized what was going on and our location relative to the airport. I immediately climbed back up towards 1600 feet and hand flew the aircraft to ZZZ for a successful and safe landing.Suggestions: 1600 feet is pattern altitude. 20 miles away is not considered within the traffic pattern of an airport.I understand that ZZZ1 has been mistaken for ZZZ in the past; and with that in mind my only suggestion is to advise ATC to be careful about descending aircraft to such a low altitude (especially at night) and then pestering them for the visual approach when the actual field is out of eyesight range.The airports look EXACTLY the same. Especially at night. And at 1600 feet we didn't see ZZZ until we were less than 10 miles away. At 20 miles; not a chance.

Synopsis

Air carrier pilots reported receiving an ATC altitude alert during descent to wrong airport at night.

What the AI sees

The flight. A regional jet descending towards its destination at night.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. Approach control cleared the aircraft direct to the final approach fix, to descend to 3,000 ft and report the field in sight. The only airport the crew could see was another airport with the same runway layout as the destination. The crew took it to be the destination and reported the field in sight. They were cleared down to 1,600 ft and for a visual approach; on levelling off they were still about 20 miles from the destination. The first officer followed the flight management system guidance; the captain monitored the instrument landing system. Believing they were close to the runway, the crew began configuring for landing, and the first officer disconnected the autopilot, descended before the final approach fix and lined up for a base leg to the other airport's runway. The captain was beginning to think the field looked too close to be the destination. Approach control issued a low altitude alert and asked whether the crew had the destination in sight, at 12 o'clock and 10 miles. The captain checked the navigation display and the view ahead, identified the destination, and replied "now we do". The aircraft was at about 1,000 to 1,100 ft. ATC told them to return to 1,600 ft, still cleared for the visual approach. The first officer immediately climbed back towards 1,600 ft.

Safe ending

The crew levelled at 1,600 ft, and the first officer hand-flew the aircraft to the destination, where it landed normally. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Two narratives merged (captain, pilot monitoring; first officer, pilot flying). Rule 3, removed: the captain's suggestions (confirm field identification, prefer published approaches or vectors at night) and later statement that descending before the final approach fix was not in line with SOPs; the first officer's criticism of ATC (1,600 ft is pattern altitude, 'pestering' for the visual), the remark that the other airport has been mistaken for this one before (not shown to be known at the time), and 'not a chance' at 20 miles. 'Mistook' rendered as 'took it to be'; 'earlier than intended' rendered as the plain fact 'before the final approach fix'. Rule 5, moved to the safe ending: levelling at 1,600 ft, the hand-flown arrival and the landing. Rule 6: both airports, runway and fix name removed; 'eastbound' dropped. Judgement calls: the narratives differ slightly in order (field-in-sight report vs. descent to 1,600 ft); the captain's order is used with the first officer's 20-mile figure. The captain mentions ATC's 'in sight?' question, the first officer the low altitude alert; both are kept. Lowest altitude given as 1,000-1,100 ft to cover both accounts (1,000 ft and 'through 1,100'). Conditions not coded; no 'visual conditions' stated. Bracket 'climbing': the aircraft was low near another airport and climbing back to 1,600 ft. The lowest point may be near the height below which TCAS resolution advisories are inhibited; the frozen wording is used as approved.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S07 category A · ACN 2283033 · Human Factors · 247 words · FLAGGED

Question for you: Long reports cut to fit 250 words. Some crew facts were dropped (listed in each case's notes). Does anything that matters for blame go missing?

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Final Approach
Reporter 1 function: Pilot Flying; Captain
Anomaly: ATC Issue All Types; Deviation - Speed All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Unstabilized Approach
Primary problem: Human Factors

Narrative 1

This report is to document the multiple approach changes that occurred as well as a low altitude sink rate warning on approach into Guatemala City. One hour out from landing; the winds in MGGT were variable at 4. We briefed the ILS Z Rwy 02. The briefing and descent check were completed well before top of descent. Approaching the descent point we noted the ATIS was calling the active runway 20 with winds 120/4; BKN 1800 ft with Towering Cumulus and unrestricted visibility. We completed the brief and set up for RNP Y Rwy 20 prior to top of descent. We requested and MGGT Center cleared us to GT566 (IAF). On initial contact with La Aurora Approach we were cleared direct to KATAS for the VOR Z Rwy 20. We stated we were prepared for the RNP Y and requested clearance for that; but approach said they were unable due to traffic. We briefed and loaded the VOR Z Rwy 20 and proceeded direct to KATAS. We briefed the VOR Z to 20 and were on path for the approach. Approximately 5 minutes from KATAS; we were issued holding instructions with no EFC; however it was clear we were stacked in holding with two aircraft below us at KATAS. We established a bingo for SLP of 7.5 and with 9.5 onboard; we estimated we had at least 20 minutes of holding and all should workout if the preceding aircraft were given clearances without much delay. We notified dispatch; FAs; and passengers and completed 2 turns in holding. Entering the third turn in holding; we were given vectors in a partial box pattern and eventually a greater than ninety degree turn direct to KATAS with clearance for the approach. The vectors complicated the approach unnecessarily and resulted in an overshoot of the inbound course to KATAS and a minor S turn to final.We were fully stable at 1;000 ft with checklist complete; configured with gear/30 flaps; on path and on target speed of 152 knots with the runway in sight. At approximately 500 feet we had a sustained gain in airspeed of about 15 knots. I pulled about two knob widths of power. The airspeed stayed at 160 and we were showing one red on the 3.5 degree PAPI. I attempted to lower the nose to get back to the path and we got our first sink rate warning. We were visual and I made a small correction to raise the nose but stay on a one red; three white PAPI indication to correct the sink rate. I pulled another knob width of power to reduce the airspeed and attempted to lower the nose slightly to regain a 1000 ft aim point and we again got a sink rate warning. I didn't want to reduce power any more in case we lost the added headwind. I corrected again raising the nose slightly and shifted my aim point to 1500 ft. Our speed was holding at 160. We were within stable approach criteria and I continued to landing. We touched down at about 2;500 feet and the rollout and taxi were uneventful.Per FM; for sink rate warnings at or below 500 ft the PF action is to execute a missed approach unless in visual conditions and the Captain determines that the momentary deviation is being immediately and safely corrected. We were in visual conditions the entire final approach. I did feel I was making immediate and safe corrections; and we were still in a safe position to land after the sink rate was corrected. I also knew from experience that the first part of Rwy 20 has a pronounced downslope. The unique slope of runway 20 would partially mitigate the threat of a slightly elevated vertical speed. In addition; I considered the threats of a missed approach in mountainous terrain with an approach controller who was having difficulty managing arrivals. Overall I felt it was safer to continue the approach if a safe; controlled landing could be made in the touchdown zone.

Synopsis

Air carrier Captain reported aural sink rate warnings on final approach to MGGT airport. The Captain continued the approach to landing and elected to not perform a go-around.

What the AI sees

The flight. An airliner on a passenger flight to an airport in mountainous terrain, in daylight and visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. After runway and approach changes and a hold, ATC vectored the aircraft to the approach with a turn of more than 90 degrees; it overshot the inbound course and S-turned onto final. At 1,000 ft the approach was stable: configured, on path, on the 152-knot target speed, runway in sight. At about 500 ft the airspeed rose about 15 knots. The captain reduced power; the speed stayed at 160 knots and the PAPI showed slightly high. Lowering the nose brought a "Sink rate" warning; the captain corrected, reduced power again and lowered the nose slightly, and a second warning sounded. Holding power, in case the added headwind was lost, the captain raised the nose and moved the aim point to 1,500 ft. The manual required a go-around for a sink-rate warning at or below 500 ft unless, in visual conditions, the captain judged the deviation was being corrected immediately and safely. The captain judged that it was, and that the approach was still stable. The captain knew the runway's initial downslope would partly offset the higher descent rate, and saw risk in a go-around in mountainous terrain, with a controller who seemed to be having difficulty managing arrivals. Judging it safer to continue to a controlled touchdown-zone landing, the captain continued.

Safe ending

The aircraft touched down about 2,500 ft along the runway, and the rollout and taxi were uneventful. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: "the vectors complicated the approach unnecessarily" (replaced by the observable overshoot and S-turn). Kept as reasons the captain gave for continuing: the company manual's exception for visual conditions, the captain's judgement that the corrections were immediate and safe and the approach still within stable criteria, the runway's initial downslope, the risk of a go-around in mountainous terrain, and the captain's view of the approach controller (attributed as "seemed to be"). Rule 5 moved to the safe ending: the touchdown at about 2,500 ft and the uneventful rollout and taxi. Omitted for length: the original ILS briefing for the opposite runway, the ATIS details (light wind, broken cloud at 1,800 ft, towering cumulus), the controller declining the RNP approach because of traffic, the two aircraft holding below, the holding fuel and diversion planning, notifying dispatch, cabin crew and passengers, and the partial box pattern of vectors. Judgement calls: the report gives no aircraft type, so the class is "an airliner"; the one-red PAPI is written as "showed slightly high"; the captain's "within stable approach criteria" is kept as the captain's judgement, not as a checked fact.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S08 category A · ACN 2230585 · Human Factors · 246 words · FLAGGED

Question for you: A thin pass on detail: the report gives no speeds or heights. The captain accepted a late runway change, because of a drone over the planned runway, from a high base, and landed outside the stabilised-approach criteria.

Original NASA report

Aircraft 1: B757 Undifferentiated or Other Model
Mission: Passenger
Flight phase: Final Approach
Reporter 1 function: Captain; Pilot Flying
Anomaly: Airspace Violation All Types; Deviation / Discrepancy - Procedural Unauthorized Flight Operations (UAS); Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural FAR; Inflight Event / Encounter Unstabilized Approach
Primary problem: Human Factors

Narrative 1

We were arriving from the east planning on a visual to Runway XXL backed up by the ILS. In my mind I was anchored to the XXL approach and not considering any other options. I was surprised by the approach controller when he asked us our approach preference; XYR LOC or XYR RNAV. We asked about XXL (as advertised on ATIS) and were told a drone was at 200 ft over the approach end of XXL and XYR was now the runway in use. I wanted the vertical guidance of the RNAV approach but didn't feel we could get setup in time. Our speed and altitude profile were configured for an extended right downwind arrival for XXL. I suddenly found myself on a high right base for XYR. I accepted the XYR localizer approach and that was my first mistake. I started to setup and brief the approach while doing my best to lose altitude and airspeed in anticipation for an inbound turn. I felt rushed but for some reason didn't ask for delay vectors. During my haste to; 'make it work' I failed to note the distance from the FAF to the runway threshold. This oversight negated my stabilized approach plan and caused me to be; 'behind the aircraft' for the remainder of the approach. My speed and configuration did not meet my planned approach criteria or stabilized approach criteria. It wasn't until after we completed an uneventful landing that I realized how far behind I was. We thoroughly debriefed the approach at the gate and resolved to take delay vectors or go around the next time this type of situation presents itself.

Synopsis

Air carrier pilot reported being given a last minute change to runway assignment during final approach due to a UAS flying at the approach end of the runway. The approach to the new runway became unstabilized; but the pilot continued to landing.

What the AI sees

The flight. A narrow-body airliner on a passenger flight, approaching to land in visual conditions.

The crew. The captain was the pilot flying; the other pilot was the pilot monitoring.

What happened. Arriving from the east, the crew planned a visual approach to the runway advertised on the ATIS, backed up by the ILS. The captain had planned only for that runway. The captain was surprised when approach control asked whether they preferred a localizer or RNAV approach to another runway. Asked about the planned runway, the controller said a drone was at 200 ft over its approach end and the other runway was now in use. The captain wanted the RNAV approach's vertical guidance but did not think there was time to set it up. The aircraft's speed and height suited an extended right downwind for the original runway; it was now on a high right base for the new one. The captain accepted the localizer approach and began setting up and briefing it while trying to lose height and speed before turning inbound. The captain felt rushed but did not ask for delay vectors. Trying to make the approach work, the captain did not note the distance from the final approach fix to the threshold. For the rest of the approach, speed and configuration met neither the captain's planned criteria nor the stabilised approach criteria; at the time, the captain did not realise the extent of this. The crew continued the approach and landed.

Safe ending

The landing was uneventful. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the reporter's later characterisations 'anchored' (rendered as the observable fact that the captain had planned only for that runway), 'that was my first mistake', 'for some reason', 'this oversight negated my stabilized approach plan' and 'behind the aircraft', and the gate debrief and resolution to take delay vectors or go around in future. 'I failed to note' is rendered 'did not note'. Kept as said or felt at the time: surprise at the controller's question, the wish for the RNAV vertical guidance and the belief that there was no time to set it up, feeling rushed, and the aim to 'make it work'. Kept as a fact stated afterwards, with the captain's state at the time: speed and configuration outside the planned and the stabilised approach criteria, and the captain not realising the extent until after landing (the 'after landing' is left out because it refers to the outcome). Moved under rule 5: 'uneventful landing'. Removed under rule 6: the runway identifiers (the planned runway and 'another runway'). Judgement calls: 'end', because the unstable state was speed and configuration carried from a high, fast base to landing; the standard safe-ending sentence is used because the drone was over the other runway's approach end and the report shows no conflict between this aircraft and any traffic, only the runway change, which is in the shared text. The other pilot is called 'the other pilot' because the report does not name their role.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S11 category C · ACN 2207565 · Human Factors · 122 words · FLAGGED

Question for you: Under 150 words because the reports are short (deviation D5).

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Descent
Reporter 1 function: First Officer; Pilot Flying
Anomaly: ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Going into EWR; we were assigned the Stadium Visual for 29. We had planned for 22L based of the recent ATIS. I was pilot flying. Between Hilok and Slimr I was following the FMS snowflake while getting configured. It was about this time ATC informed us that they received an altitude alert. At this point the Captain took control of aircraft and landed. I learned from this to really independently confirm the FMS altitudes and not be rushed into an amended approach.

Synopsis

Air carrier First Officer reported they descended below terrain minimums on a visual approach and received a low altitude alert from ATC.

What the AI sees

The flight. A twin-engine airliner descending towards a busy airport in visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. Based on the latest recorded airport information, the crew had planned for an approach to one runway. Air traffic control instead assigned a charted visual approach to a different runway, and the crew changed to it. Between two fixes on the visual approach, the first officer was following the vertical path guidance from the flight management system while configuring the aircraft for landing. At about this time, air traffic control told the crew that they had received a low altitude alert for the aircraft. The captain then took control of the aircraft.

Safe ending

The captain flew the rest of the approach and landed the aircraft. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

UNDER THE 150-WORD MINIMUM. The report has a single three-sentence narrative and the shared text uses every fact in it; reaching 150 words would need invented detail, so it was left short for James to decide (keep short, or replace the case). Removed under rule 3: the first officer's lesson to confirm flight management system altitudes independently and not be rushed into an amended approach. Because of that removal, the shared text does not say the approach change was late or that the flight management system altitudes were wrong; neither is stated as fact in the narrative. Moved under rule 5: the captain landing the aircraft. Removed under rule 6: the airport, runway numbers, the named visual approach and fix names. Judgement calls: (1) the aircraft type is not reported, so twin-engine airliner is used; (2) the local-time band (afternoon, in January) could include dusk, so day or night is not stated; (3) the 'FMS snowflake' is rendered as the vertical path guidance from the flight management system; (4) the synopsis says the aircraft descended below terrain minimums, but the narrative says only that air traffic control reported an altitude alert, so the shared text keeps to the narrative; (5) the coded results (air traffic control assistance, a new clearance, the crew requesting clarification) are not used because their order is unknown. Bracket: 'crossing', because the deviation was low on a visual approach near a busy airport, where the plausible conflict is lower traffic crossing the approach path. | DECISION by Claude, 1 Oct (deviation D5): kept at 122 words. The report is three sentences and padding is not allowed.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S12 category A · ACN 2301459 · Human Factors · 170 words · FLAGGED

Question for you: An unclear remark was left out: "as an FO, other captains would say no". If it was said in the flaps-3 briefing, it belongs in the text.

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Landing
Reporter 1 function: First Officer; Pilot Not Flying
Anomaly: Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach
Primary problem: Human Factors

Narrative 1

During arrival briefing capt insisted on using flaps 3. I asked about landing distance seemed adequate. Rnav y 29 was planned and flown . Last 100 feet path got flat and low. I mentioned that he cannot land on the displaced threshold. At around 30-50 ft. Capt pitch for runway threshold and may have landed on displaced theshold. I think he landed on available runway; but not positive….Cause: Capt insisted on flaps 3 on a short runway. I did the landing distance and it was approximately 300 ft more than flaps full. My rationale was that sbp runway was 300-400 ft longer than sna so it should work out. Capt for some unknown reason insisted on flaps 3. He mentioned that as an Fo; other capts would say no.

Synopsis

Air carrier pilot reported a possible touch down in the displaced threshold area on landing at SBP.

What the AI sees

The flight. An airliner arriving at night at an airport with a short runway, whose landing threshold was displaced along the runway. The report does not give the weather.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. During the arrival briefing the captain insisted on landing with flaps 3 rather than full flap. The first officer asked about the landing distance and calculated it: with flaps 3 it was about 300 ft more than with full flap, and it seemed adequate. The first officer reasoned that the runway was 300 to 400 ft longer than the runway at another airport, so it should work out. The crew planned and flew an RNAV approach. In the last 100 ft the flight path became flat and low. The first officer told the captain that they could not land on the displaced threshold. At about 30 to 50 ft the captain pitched the aircraft for the runway threshold, and the crew continued to land.

Safe ending

The aircraft landed. The first officer thought it had touched down on the usable runway but was not certain; it may have touched down on the displaced threshold. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: "for some unknown reason" (about the captain's choice of flaps 3). Rule 5 moved to the safe ending: whether the aircraft touched down on the displaced threshold or the usable runway, which the first officer could not say for certain (the synopsis says "possible touch down in the displaced threshold area"). Kept as reasoning at the time: the first officer's landing-distance check and the comparison with another airport's runway (named in the report; not named here). Judgement calls: "insisted" is kept because it is the reporter's account of what happened in the briefing, not a later characterisation; the report gives no aircraft type, so the class is "an airliner"; no weather is given and "at night" is from the 0001-0600 time block. For James: the sentence "He mentioned that as an FO, other capts would say no" was left out because it is unclear both what it means (say no to what?) and whether it was said at the time. If it means the captain had been refused flaps 3 by other captains as a first officer and said so in the briefing, it belongs in the shared text.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S23 category C · ACN 2307722 · Human Factors · 143 words · FLAGGED

Question for you: Under 150 words because the reports are short (deviation D5).

Original NASA report

Aircraft 1: EMB ERJ 145 ER/LR
Flight phase: Initial Approach
Reporter 1 function: Captain; Pilot Not Flying
Anomaly: Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

PF had good altitude set in FGP (Flight Guidance Panel) at 2100 on base VIS (Visibility) rwy XX and was slowly descending on Autopilot.He choose to TCS (Touch Control Steeing) override during the final turn and was losing altitude during turn. PM Advised correction and maintain 2100 when Aircraft at 2000. terrain warning occurred shortly thereafter and PM called GA (go around). At lowest alt circa 1900' MSL tower also issues low alt alert.Resquenced and landed; second approach to standard and stable.Suggestion: Visual approach planning skills could be improved from this PF

Synopsis

EMB-145 Captain reported receiving ATC 'low altitude' and aircraft GPWS alerts when First Officer was turning from base leg to final for landing. Captain commanded a go-around and crew landed normally on the second attempt.

What the AI sees

The flight. A regional jet on a visual approach at night, in visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. On the base leg of the visual approach, the first officer had 2,100 ft set in the flight guidance panel and was descending slowly on the autopilot. During the turn onto final, the first officer chose to fly using the touch control steering override, and the aircraft lost altitude in the turn. When the aircraft was at 2,000 ft, the captain advised a correction and told the first officer to maintain 2,100 ft. Shortly afterwards the ground proximity warning system gave a terrain warning, and the captain called a go-around. At the lowest point, about 1,900 ft above sea level, the tower also issued a low altitude alert. The crew went around.

Safe ending

ATC resequenced the aircraft. The second approach was stable and the aircraft landed normally. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (captain, pilot monitoring). Rule 3, removed: the suggestion that the first officer's visual approach planning skills could be improved. 'Had good altitude set' rendered as the plain fact '2,100 ft set'. Rule 5, moved to the safe ending: the resequencing, stable second approach and landing. Rule 6: airport and runway removed. Judgement calls: 'chose to' is kept because it is the reporter's own description of the override. The clause explaining touch control steering is a definition of the system, not from the report, added so a reader unfamiliar with the type can follow; remove it if unwanted (the text would then be 143 words). Light is not coded; 'at night' is inferred from the coded local time (18:01-24:00, November). Shared text is 154 words including the paragraph labels; the report is short and no event facts were added. Bracket 'climbing': the crew went around. | EDITED by Claude, 1 Oct (deviation D7): deleted the added definitional clause about touch control steering, which was not from the report.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S25 category A · ACN 2234485 · Human Factors · 249 words · FLAGGED

Question for you: Long reports cut to fit 250 words. Some crew facts were dropped (listed in each case's notes). Does anything that matters for blame go missing?

Original NASA report

Aircraft 1: Medium Transport; Low Wing; 2 Turbojet Eng
Flight phase: Initial Approach
Reporter 1 function: Pilot Flying; Captain
Reporter 1 experience: Flight Crew Total 21000
Anomaly: Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

We conducted a visual approach to runway 09 at DOM/TDPD. As Pilot Flying; I chose to use visual approach procedures coming from VOLAB; crossing the shoreline on a downwind (as opposed to coming from NEIDR); because this allowed me early identification of the runway and the approach environment. Weather was reported as FEW clouds at 2;200 AGL. Approaching the first waypoint; DOM R-359 D2.2; we observed the cloud deck to be at approximately 2;000 AGL; and I opted to cross the shoreline at 1200agl; fully configured at full flap; on speed 129kias. We crossed the second waypoint; DOM R310 D3.1; at 1;200 AGL. Turning to base leg proceeding to third waypoint; DOM R-271 D2.9; I turned off the autopilot; descended to 1;100 AGL and identified what I thought was the correct ridge line. It was not. Crossing this ridgeline at 1;100 AGL; I banked and started my descent into the valley. I followed the valley track for about 2 seconds when the FO called for a go around. I executed a go-around; climbed to 3;000 AGL and proceeded to VOLAB where we entered holding to decide our next course of action. FO explained that he called for a go-around when he recognized we were in the wrong valley. I turned controls over to FO while I reloaded the FMS for a second attempt.I took control of the aircraft. On this approach; while proceeding from VOLAB to the first waypoint; DOM R-359 D2.2; I identified the runway; the correct ridgeline and the valley that must be flown to arrive at runway 09. Once again; after passing the second waypoint; DOM R-310 D3.1; I turned off the autopilot and descended to 1;100 AGL. I initiated my turn into the valley early which put me into the valley high on the profile. I descended at a rate to land in the landing zone; while navigating the valley. I heard the FO call out 1;100 FPM and 1;200 FPM which I visually confirmed and acknowledged. EGPWS (Enhanced Ground Proximity Warning System) gave us a SINK RATE followed by a PULL UP warning. The FO called for a go-around. I verbally told him NO because I now had the runway in sight and was already making corrections to STABLE approach criteria. On short final; we had 900fpm and touched down in the landing zone on speed.Cause: Despite the fact that we briefed the approach very thoroughly and planned contingencies; I had only been to DOM 1 time; on my initial check with an LCA (Line Check Airman). The FO had not been to DOM many times and not for several months. Neither of us were very familiar with this approach. I prepared before the flight by reviewing the SARA (Solutions for Aircraft data Replay and Analysis) data for DOM and re-watching the video of the approach. I also reviewed my notes from my initial check ride. What caused the first missed approach and the second unstable approach was my unfamiliarity with this airport and the long interval of time between my initial check and my first time flying it on the line. This approach is unlike any other in my 35 years of flying. It is extremely challenging under the best of circumstances.Suggestions: I believe this particular approach should require an initial qualification of being flown multiple times with LCA's within a short time period; 1-2 weeks; to firmly cement in the captains experience key visual check points and help him build some muscle memory. At the very least; after flying the initial qualification; a newly qualified captain should be assigned to fly this approach several times over the next few weeks to drill into their experience all of the necessary visual checkpoints and procedures. In my opinion; it is a mistake to give a captain a qualification flight; then NOT fly the approach for months before he sees it again.

Narrative 2

Correcting an unstable approach and not going aroundCause: Coming into our first approach for runway 9 into Dominica; we setup the PBDs (Place Bearing/Distance) and altitudes into the FMS. At 1100ft prior to reaching the ridge; the captain made a hard left bank and missed the ridge and lined up onto the incorrect valley. I was unaware because of the hard bank until he leveled off and that's when I told the captain to go around. He executed the go around and we went to hold at Volab to try for another approach. On the second approach we flew to the last PBD to cross at or above 1100ft; but the captain made the turn too short and ended up high after crossing the ridge. I was noting the descent rate and it quickly started to increase past 800ftpm. When the descent rate reached 1400ftpm I called to Go Around and we received a sink rate pull up alert. The captain said no to the go around as he he was correcting. I saw the captain correcting the descent rate but I was ready to call a go around again if there was any other reason. The captain ended up with the correct speed and descent rate for a stable approach and there were no further alerts. The captain landed safe within the first 1000ft. Suggestions: Being more cautious on the turn over the ridge line to not end up high and get into an high descent rate situation. Be more situationally aware of where you are turning.

Synopsis

Air carrier crew reported receiving a GPWS warning while maneuvering for a visual approach in a valley when the crew determined the aircraft was in an incorrect position for the visual approach. The crew performed a go around; then returned from another direction; became unstable on that approach; then continued to a landing.

What the AI sees

The flight. A twin-engine airliner on a visual approach, in daylight and visual conditions, to an airport reached through a valley.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The captain had about 21,000 hours but had flown into this airport only once, on a check flight; the first officer had not been there many times, nor for several months. They had briefed the approach thoroughly.

What happened. On the first approach, flying manually at 1,100 ft, the captain crossed a ridgeline believed to be the correct one and banked hard left into a valley. It was the wrong one. When the wings levelled, the first officer recognised this and called for a go-around, which the captain flew. On the second approach the captain identified the runway, ridgeline and valley before the first waypoint. Again flying manually at 1,100 ft, the captain turned into the valley early, leaving the aircraft high on the profile, and descended to reach the landing zone. The first officer called descent rates of 1,100 and 1,200 ft per minute, which the captain acknowledged. At about 1,400 ft per minute the first officer called for a go-around, and the ground proximity warning sounded "Sink rate", then "Pull up". The captain said no: the runway was now in sight and the captain was already correcting towards stable approach criteria. The first officer saw the captain correcting and was ready to call again. The captain continued the approach and landed.

Safe ending

On short final the descent rate was 900 ft per minute and the speed was correct, with no further alerts, and the aircraft touched down on speed within the first 1,000 ft of the runway. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: both "Cause" and "Suggestions" sections (the captain's view that unfamiliarity and the long gap since the check flight caused both events, "unlike any other in my 35 years" and "extremely challenging", the proposal for repeated line checks, the first officer's "be more cautious" and "more situationally aware"), and narrative 2's heading "Correcting an unstable approach and not going around". Kept from the Cause sections as facts: the captain's 21,000 hours, the single earlier visit on a check flight, the first officer's few visits and none for several months, and the thorough briefing. Rule 5 moved to the safe ending: back to 900 ft per minute and the correct speed on short final with no further alerts, and the on-speed touchdown within the first 1,000 ft. Omitted for length: the reason for the downwind entry (early sight of the runway), crossing the shoreline at 1,200 ft fully configured at 129 knots, the cloud at about 2,000 ft, the 2 seconds in the wrong valley, the hold and the FMS reload with the first officer flying, and the captain's review of flight data, video and notes before the flight. Judgement call: the narratives differ on whether the GPWS warning came before or after the first officer's go-around call (narrative 1 puts it before, narrative 2 roughly at the same time), so the text joins them with "and" without ordering them.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S26 category C · ACN 2287112 · Human Factors · 247 words · FLAGGED

Question for you: The report doesn't settle whether ATC cleared 10,000 ft or 12,000 ft. The text keeps what the crew heard and read back. If ATC really cleared 10,000 ft, the crew's action isn't central, and the case should be excluded under criterion 1.

Original NASA report

Aircraft 1: Regional Jet 200 ER/LR (CRJ200)
Mission: Passenger
Flight phase: Initial Approach
Reporter 1 function: Pilot Not Flying
Anomaly: ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Weight And Balance; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Fuel Issue
Primary problem: Human Factors

Narrative 1

CA- Pilot flying. FO- Pilot monitoring. Prior to being cleared for the RNAV XX into ZZZ from ZZZZZ crew realized current fuel load and expected burn to landing would result in touching down overweight. To alleviate this threat the crew descended early from cruise; slowed and once on the approach extended partial flaps. After crossing ZZZZZ1 the crew determined there still needed to be excess fuel burned to avoid an overweight landing so radar vectors were requested off the approach southbound and the intention of returning back to ZZZZZ1 to continue the approach was made clear and understood by ATC. A clearance of turn left heading 220 and descend and maintain 10000. FO heard and read back turn left heading 220 and descend and maintain 10000. No correction was given by ATC. CA set 10000 and began descending. ATC then informed the crew that they could stay on that heading until they advised ATC they were ready to proceed back to ZZZZZ1 and to expect a left turn. Once an acceptable fuel load was reached FO requested a left turn direct ZZZZZ1. This left turn was given by ATC. Well past heading 180 into the left turn ATC gave crew a terrain warning and instructed them to turn to a heading of 180 and seem confused why they were at 10000 and instructed the crew to climb to 12000 which was complied with immediately by the crew. This perceived confusion from ATC and the immediate climb to 12000 indicates a possible altitude deviation and is the reason for this report though crew believes they were cleared to 10000 and complied with that clearance. The crew was told to keep their own terrain clearance which was complied with. Crew queried ATC to confirm they wanted them to stop the left turn and turn back to the right to a heading of 180. ATC confirmed this and the crew complied. Once at an altitude of 12000 and heading 180 crew continued to approach and the remainder of the flight was completed without incident.Cause: The primary cause of this event was the FO potentially mishearing ATC clearance to descend to 12000 but rather heard and readback to descend to 10000. Additionally; if ATC would have corrected the possibly incorrect readback or noticed the crew descending below 12000 this would have prevented the descent to 10000 and the ATC terrain warning when cleared direct ZZZZZ1. Also; once seeing the aircraft at 10000 a right turn towards the airport and away from the terrain would seem to have been a better choice.Suggestions: In the future FO will be more careful with accurately hearing ATC instructions. Another option for the crew would have been to ask for a hold over a fix on the approach to burn fuel rather than being vectored off. Additionally; once on the vector the crew could have asked for the visual to either XX or XY given the visual contact with the airport. However; the intent of proceeding back to ZZZZZ1 to rejoin the approach was to provide an environment more conducive to a stable approach given this particular airport and it being at night. To avoid recurrences from ATC perspective it would be helpful to listen closer to verify crews are giving accurate read backs and aircraft are subsequently doing what they were instructed.

Narrative 2

Cleared for RNAV XX ZZZZZ. Noted after crossing ZZZZZ1 that fuel despite earlier efforts was still too much. Asked for and received vectors south to burn fuel with the intention of returning to the approach over ZZZZZ1. We proceeded to 10000 on 220 heading with instructions to let ATC know when we would be able to return. We were cleared initially a left turn back to ZZZZZ1. Then ATC asked if we were going to climb to 12000. We responded that we were at 10 and would climb to 12. We were established in the left turn; then told to turn right to a 180 heading. We were close to the field; asked for a visual; landed without incident.Cause: both crew believed we were cleared to 10. We were surprised that we weren't to be at 10. Somehow communication broke between clearance received; clearance read back; not challenged by ATC.Suggestions: In this case I thought we were cleared to 10. We weren't challenged by ATC until we had been level at 10; and then we called ready to return ZZZZZ1. High area of vulnerability; with changes to an approach. A lot going on; and apparently a clearance to descend was incorrectly read back and missed by all parties.

Synopsis

CRJ-200 flight crew reported a need for delay vectors to burn fuel and when cleared back to a fix for the approach they were below the MIA for the area resulting in ATC issuing a low altitude alert; climb; and vector back on course.

What the AI sees

The flight. A regional jet on a passenger flight, arriving at night in visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. Before the RNAV approach clearance, the crew realised their fuel load meant landing overweight. To avoid this, they descended early, slowed, and extended partial flaps on the approach. After crossing a fix on the approach, they judged more fuel had to be burned and asked for vectors south, off the approach, intending to return to that fix and rejoin it for a more stable approach at this airport at night, which ATC understood. The first officer heard and read back 'turn left heading 220, descend and maintain 10,000 ft'; ATC did not correct it. The captain set 10,000 ft and descended. ATC said to keep that heading until ready to return, and to expect a left turn. The airport was in sight. With enough fuel burned, the first officer requested and received a left turn direct to the fix. Well into the turn, ATC gave a terrain warning and asked if they would climb to 12,000 ft. The crew said they were at 10,000 ft and would climb. ATC, appearing surprised, instructed a climb to 12,000 ft and heading 180, and told them to keep their own terrain clearance. Both pilots believed their clearance was 10,000 ft. The crew climbed at once, confirmed ATC wanted the left turn stopped, and turned right to heading 180.

Safe ending

Level at 12,000 ft on heading 180, the crew continued towards the airport, asked for a visual approach when close to it, and landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both reporters' Cause and Suggestions sections, including their later view that the first officer may have misheard a clearance to 12,000 ft and that the readback was 'missed by all parties', their views on how ATC should check readbacks and turn the aircraft, and the alternatives they listed (holding, a visual approach). Kept from those sections because they are facts or intent at the time: the airport was in sight on the vectors, and the reason for returning to the fix (a more stable approach at this airport at night). Kept: both pilots' belief at the time that they were cleared to 10,000 ft. The report does not establish which altitude ATC actually cleared; the shared text gives what the crew heard, read back and were later told, and does not resolve it. The two narratives are merged: the exchange about climbing to 12,000 ft is from the second, the terrain warning, heading 180 and own terrain clearance from the first. 'To alleviate this threat' is rendered 'To avoid this'. Moved under rule 5: the continued approach, the visual approach and the landing without incident. Removed under rule 6: fix names and runway numbers. Judgement call: 'crossing' fits an aircraft level and turning at 10,000 ft on vectors.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S27 category B · ACN 2265970 · Human Factors · 234 words · FLAGGED

Question for you: Keeps "the centre runway" and "the left runway" (positions, no numbers), because the confusion depends on them.

Original NASA report

Aircraft 1: B777-200
Flight phase: Taxi
Reporter 1 function: First Officer; Pilot Not Flying
Anomaly: ATC Issue All Types; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Runway
Primary problem: Human Factors

Narrative 1

While taxing on 1; tower told us to line up on XXC and wait after landing traffic. I saw a plane was landing at that time. Prior to turning on [taxiway] 2 to take runway XXC I saw a plane in the distance but since there are three parallel runways I thought the closest plane was lined up with XXL. It was lined up with XXC and that was the plane we were supposed to line up behind. On 2 and the nose over the hold short we stopped to query the controller because it was evident that the plane was headed for XXC but it was too late. ATC sent the plane around. We were subsequently cleared for takeoff.Cause: Failure to understand tower's intentions.Suggestions: A hold short clearance would have alerted us that we need to stop. Tower didn't issue a hold short clearance so we assumed we could keep moving. A hold short clearance may have given us time to recognize the traffic on final was lined up for XXC before it was too late.

Narrative 2

ZZZZ [airport] - While taxiing East on TAXIWAY 1 approaching 2; TWR cleared us on to RWY XXC to line up and wait behind landing traffic". At that moment; an airplane was just landing on RWY XXC. The FO; Relief Pilot and I understood this to be the landing traffic TWR was referring to.I visually cleared RWY XXC final as I began the right turn off of TAXIWAY 1 onto TAXIWAY 2 to enter RWY XXC. There appeared to be traffic on final for the parallel RWY XXL. As we turned onto TAXIWAY 2; the approaching traffic now appeared to be lined up with our runway; RWY XXC. I stopped the jet short of RWY XXC; but just over the HOLD LINE and asked the FO to query TWR about the traffic.Before the FO had the opportunity to query TWR; TWR sent this traffic around; ensured we were stopped and clarified our instructions. We were subsequently cleared on to RWY XXC and departed.Cause: Comm; parallax - the fact that we were told to "line up and wait behind landing traffic" when there was both an aircraft just landing on our departure runway and an aircraft on a 4-5 final for what initially appeared to be the parallel runway. This led to our confusion as to which aircraft we were following.Suggestions: I am not sure. The entire crew was in agreement with the situation and our clearance until I stopped the jet and asked the FO to query tomorrow after the traffic on final appeared to be lined up for our runway as it got closer. Possibly; not utilizing 'line up after landing traffic' in such a saturated environment with close parallel runways?"

Synopsis

Air carrier flight crew reported a runway incursion and critical ground conflict resulted from misunderstanding the controller's instructions.

What the AI sees

The flight. A wide-body airliner taxiing for departure at an airport with three parallel runways, in the evening. Visual conditions, with wind.

The crew. The captain was the pilot flying and was taxiing the aircraft. The first officer was the pilot monitoring. A relief pilot was also on the flight deck.

What happened. As the aircraft approached the turn towards the centre runway, the tower controller cleared it to line up and wait on that runway behind landing traffic. At that moment an aircraft was just landing on the centre runway. All three pilots understood this to be the landing traffic the controller meant. Another aircraft was on final about four to five miles out. The first officer saw it in the distance and, with three parallel runways, took it to be lined up with the left runway. As the captain began the right turn towards the runway, the captain looked along the final approach to the centre runway, and the traffic on final appeared to be for the left runway. Believing they could keep moving, the crew continued to taxi. As the aircraft turned onto the taxiway leading to the runway, the approaching aircraft now appeared to be lined up with the centre runway. The captain stopped the aircraft short of the runway, with its nose just over the hold line, and asked the first officer to query the tower about the traffic.

Safe ending

Before the first officer could make the query, the tower controller sent the approaching aircraft around, confirmed that this aircraft had stopped and clarified the instructions. The aircraft was then cleared onto the runway and departed. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over the runway. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: the conflicting traffic was the aircraft on final to the centre runway, which ATC sent around. Bracket 'the runway': the aircraft stopped short of the runway with only its nose over the hold line, not on the runway itself. Removed under rule 3: both Cause sections ('failure to understand tower's intentions'; 'comm, parallax'), both Suggestions (a hold-short instruction would have helped; avoid 'line up behind landing traffic' at busy close-parallel airports), and the first officer's 'but it was too late'. Moved to the safe ending under rule 5: ATC sending the traffic around, confirming the aircraft had stopped, clarifying the instructions, and the later take-off. Removed under rule 6: airport, runway numbers and taxiway names. Judgement calls: B777-200 rendered as wide-body. The runway designators' left/centre positions are kept as 'the centre runway' and 'the left runway' because the confusion depends on them; no numbers are given. The four-to-five-mile range comes from the captain's Cause paragraph and is kept as a fact of what was there. 'Believing they could keep moving' is the first officer's contemporaneous assumption (stated in the Suggestions as 'we assumed we could keep moving'); the accompanying point that no hold-short was issued was not added, since the quoted clearance already shows its wording. Time band 1801-2400 rendered as 'the evening'. Crew size coded 3; the relief pilot is placed on the flight deck because all three pilots heard and understood the clearance.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S28 category C · ACN 2209353 · Human Factors · 123 words · FLAGGED

Question for you: Under 150 words because the reports are short (deviation D5).

Original NASA report

Aircraft 1: A320
Flight phase: Final Approach
Reporter 1 function: Pilot Not Flying; First Officer
Reporter 1 experience: Flight Crew Last 90 Days 152.97; Flight Crew Total 223.82; Flight Crew Type 223.82
Anomaly: Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Cleared for visual app to rwy XX at about 13000 ft; set 6700 ft for the FAF; started a slow descent and turned downwind. At about 8000 ft; a terrain warning was triggered. The PF successfully executed a terrain avoidance maneuver.

Narrative 2

Approximately 17 miles east of ZZZ we were cleared the visual to runway XX. I turned to a heading of 275 and started my descent. We got a terrain warning followed quickly by a pull up too low terrain. I executed the terrain escape maneuver and began a climb. The warning went away and we proceeded to the airport and landed uneventfully.

Synopsis

A320 flight crew reported terrain warning during approach.

What the AI sees

The flight. A narrow-body airliner arriving at an airport in visual conditions.

The crew. The captain was the pilot flying and had about 7,000 hours, all on type. The first officer was the pilot monitoring and had about 220 hours, all on type.

What happened. About 17 miles east of the airport, at about 13,000 ft, the crew were cleared for a visual approach. The crew set 6,700 ft, the final approach fix altitude, in the altitude selector. The captain turned onto a downwind heading and started a slow descent. At about 8,000 ft, the ground proximity warning system gave a terrain warning, followed quickly by "Pull up" and "Too low, terrain". The captain flew the terrain escape manoeuvre and began to climb.

Safe ending

The warning stopped, and the crew continued to the airport and landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Two narratives merged (first officer, pilot monitoring; captain, pilot flying). Both are very short and contain no reflection. 'Successfully' (of the escape manoeuvre) dropped as evaluative. Rule 5, moved to the safe ending: the warning stopping, the continued approach and the landing. Rule 6: airport, runway and the 275 heading removed. Judgement calls: shared text is 123 words, BELOW the 150-word floor, because the two narratives together give only about a dozen facts; nothing was added to reach the floor. Experience is from the coded fields (captain 6,989 h total and on type; first officer 224 h total and on type). Day or night not coded and not inferable (12:01-18:00, February), so left out. Bracket 'climbing', matching the approved pilot case 2 (terrain escape climb).

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S30 category B · ACN 2274018 · Human Factors · 177 words · FLAGGED

Question for you: "Another aircraft was on final approach" is in the shared text. It comes from the report (that traffic was sent around), so it is not invented.

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Taxi
Reporter 1 function: Pilot Not Flying; First Officer
Anomaly: Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Runway
Primary problem: Human Factors

Narrative 1

An uneventful approach and landing was conducted to rwy 26R with flaps 40 and auto brakes 2 selected. The CA decelerated at a normal pace and was at a safe taxi speed upon reaching taxiways M4 and M1. The tower controller was also controlling the ground frequency in addition to tower. During our rollout; the tower controller was giving instructions to other aircraft. No direction was given to us as to which runway exit to use. The CA had the aircraft slowed to make a comfortable turn onto taxi M1 as we were to park at the gate. After we were through the turn and crossing the runway hold short line; tower directed the aircraft on final to 'pull up and go around.' Tower then told us we made an illegal turn off. Upon further review; we did find in procedures where it states under runway 26R arrivals 'Reverse turns NOT AUTHORIZED without clearance'. We had both missed that during our descent planning.

Synopsis

Air carrier First Officer reported turning in the wrong direction after landing at CYVR; resulting in an ATC-directed go-around for an aircraft on short final.

What the AI sees

The flight. A narrow-body airliner landing at an airport in the morning. Visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. The airport's published procedures for arrivals on the landing runway stated that reverse turns off the runway were not authorised without clearance. Neither pilot noticed this note during descent planning. The approach and landing were normal, with flaps 40 and autobrake setting 2. The captain slowed the aircraft at a normal rate, and it was at a safe taxi speed on reaching two exit taxiways. One controller was working both the tower and the ground frequencies, and during the rollout was giving instructions to other aircraft. The crew were given no instruction about which exit to use. Another aircraft was on final approach. The aircraft was to park at the gate, and the captain had slowed it to make a comfortable turn onto a taxiway that involved a reverse turn off the runway. The captain made the turn, and the aircraft began to leave the runway.

Safe ending

As the aircraft completed the turn and crossed the runway hold-short line, the tower controller instructed the aircraft on final to go around. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over the runway. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: the conflicting traffic was the aircraft on final, which ATC sent around. Bracket 'the runway': the aircraft was turning off and leaving the runway, so 'this aircraft' was not assumed. Removed under rule 3: the 'upon further review' framing; the fact it uncovered (the published note, and that neither pilot noticed it during descent planning) is kept as a fact confirmed afterwards, in the same way as the flap setting in pilot case 1. Moved to the safe ending under rule 5: the aircraft's position (through the turn and crossing the hold-short line) when the go-around was ordered, and the go-around itself. Dropped: the tower's later remark that the crew had made an 'illegal turn off' - an after-the-event characterisation that would have appeared in only one ending. Removed under rule 6: the airport (named in the synopsis), runway number and taxiway names. Judgement calls: aircraft type is coded only as 'Commercial Fixed Wing'; 'narrow-body airliner' is inferred from flaps 40 and autobrake 2. The report does not say in so many words that the chosen taxiway required a reverse turn; this is inferred from the procedure note the crew found and the synopsis ('turning in the wrong direction'). 'Another aircraft was on final approach' is added to the shared text as a situational fact from the report so the bad ending has a referent; the report does not say whether the crew knew of it. 'Uneventful' approach rendered as 'normal'. Single narrative (first officer).

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S31 category C · ACN 2252551 · Human Factors · 244 words · FLAGGED

Question for you: Safe ending trimmed under deviation D6, removing the crew's response to the resolution advisory.

Original NASA report

Aircraft 1: B737 Undifferentiated or Other Model
Flight phase: Cruise
Reporter 1 function: Captain; Pilot Not Flying
Reporter 1 experience: Flight Crew Last 90 Days 59.5; Flight Crew Type 1420.42
Anomaly: Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Fuel Issue
Primary problem: Human Factors

Narrative 1

While approaching ZZZ we were assigned holding at ZZZZZ waypoint at FL370 due to thunderstorms in ZZZ. Captain and First Officer (FO) set up the holding in the FMC with the hold altitude of FL370. Two minutes prior to entering the holding; the aircraft slowed down from approximately M0.75 on VNAV to the prescribed holding speed of 229 KIAS. This was observed and discussed to be somewhat close to the yellow speed band by the Captain and FO and identified as a threat. Approaching the holding fix; ZZZ Center instructed us to descend and maintain FL360 for holding. We used a VNAV descent to FL360 and the throttles came back significantly to both continue to slow the aircraft to holding speed and descend to the commanded altitude. Upon reaching FL360; the auto throttles were very slow to increase to catch the airspeed and provide enough thrust for the aircraft to level off at FL360. It was observed by both the Captain as pilot monitoring (PM) and FO as pilot flying (PF) that the jet was beginning to sink slowly below FL360 to FL359; this also happened as the jet crossed the holding fix and began a right hand turn. FO as PF manually pushed the throttles forward and assumed a guarded position on the yoke. Despite the throttles being pushed forward the engines still slowly spooled up to their commanded setting. Captain and FO then encountered a 'TRAFFIC' TCAS call as there was an aircraft 1000' immediately below us established in holding. The TA quickly became an RA that instructed us to climb. FO as PF disconnected Autopilot and auto throttles and checked the throttles to the max position while pulling back on the yoke. In doing so; the increase in AOA; while in a turn; without commensurate thrust brought us immediately but briefly into stick shaker. Captain as PM called out 'UPSET' and the FO as PF completed the steps of the upset recovery maneuver (UPRT). FO released back yoke pressure; eased the angle of bank; and ensured the throttles were at max and we immediately stabilized. FO continued to hand fly the aircraft to straight and level flight on the outbound holding leg and reengaged Autopilot and auto throttles once level. It was observed that at no point was there a descent below FL359. While established in holding with auto flight on; Captain and FO debriefed the event. We determined that we were caught off guard by how far back the throttles had gone in the descent and how slowly they were to spool back up. We also agreed that we had been distracted by checking the holding and continually evaluating fuel state and time in holding for a possible divert. The training to immediately respond to a TCAS RA had also been ingrained in us and our reactions were commensurate with an aircraft at a lower altitude and higher airspeed. Simultaneously; we were also being commanded by the RA to maneuver the aircraft in a way that would have exacerbated the situation of converging aircraft. The roll portion of the UPRT created the best divergent vector away from the possible traffic. Captain as PM did not make a 'TCAS RA' call on Center frequency. This was also debriefed and discussed that the far greater threat was the UAS (Undesired Aircraft State) which commanded all of the crew's attention vice a radio call. Captain also determined that such a call; well after the event; would add significant confusion on a frequency that was very full of aircraft holding and diverting. A report has been submitted for the TCAS RA.

Narrative 2

Approaching top of descent for ZZZ; ATC assigned holding instructions at the ZZZZZ waypoint on the arrival at FL370 due to thunderstorms in the vicinity of ZZZ. As the pilot flying (PF); I built the hold in the FMC and the Captain verified the input prior to execution. Approaching the hold pattern; the aircraft began to slow to the calculated hold speed of 229 KIAS. The slow down was acknowledged by both Captain and First Officer (FO) as well as the proximity of the speed to the yellow band due to the altitude and identified as a threat we needed to keep an eye on. As we approached ZZZZZ; ZZZ Center directed a descent to FL360. The Captain changed the altitude on the Mode Control Panel (MCP) and the FO changed the altitude in the FMC and executed after it was verified with the Captain. With VNAV engaged; the aircraft began a descent to FL360 while still slowing to hold speed and it was observed that the throttle reduction showed RETARD initially for a short time and then FMC SPD. Upon level off at FL360; auto throttles slowly increased to catch the speed for holding. Both Captain and FO observed the slow auto throttle input and a corresponding slow descent below FL360 to FL359. The level off occurred at the hold point of ZZZZZ and the aircraft entered a right turn as directed by the FMC. As PF; I advanced the throttles to arrest the small descent and assist the auto throttles in maintaining the directed hold speed. Due to the high altitude and almost idle position when we leveled off; the engines were slow to spool up and provide the necessary thrust to maintain the directed altitude and airspeed for the turn. At this point; the TCAS system produced a 'TRAFFIC' call for the aircraft established in holding at FL350. The TA quickly switched to a Resolution Advisory and directed a climb. I as the PF disconnected Autopilot and auto throttles while advancing the throttles and pulling back on the yoke at the same time to remain in the safe area of the RA. Due to this action and the current flight envelope; the AOA increased due to the slow spool up of the engines and lack of corresponding speed increase. The stick shaker activated briefly with the Captain calling UPSET and the FO completing the necessary UPRT steps. By releasing back pressure; rolling out of the turn; and having time for the engines to spool up fully; aircraft speed increased and the aircraft stabilized immediately. I continued to hand fly the aircraft through the remainder of the turn and re-engaged the Autopilot and auto throttles after rolling out on the outbound leg of the hold pattern. The Captain and FO discussed the parameters of the what happened and highlighted that neither saw the aircraft descend below FL359. We both highlighted the large reduction in throttle position as the aircraft slowed and descended as well as the proximity of the directed speed to the stall window. And as we identified it as a threat; we both acknowledged our focus was on fuel calculations for a potential divert scenario. To mitigate any further speed problems; the MCP speed window as opened and a higher speed than was directed in the FMC was selected (I believe it was 240 KIAS). We also discussed that the Captain as the pilot monitoring (PM) did not call TCAS RA on the Center frequency as we were focused on the higher priority of the upset recovery and believed it would have caused confusion on a very busy Center frequency by the time it was made following both events. Following the debrief; we remained in holding until we were vectored to the ZZZZZ1 arrival and continued to ZZZ without further incident.

Synopsis

B737 flight crew reported receiving a cruise altitude hold using FMC recommended holding speed in knots; resulting in a stall warning and altitude deviation. The flgiht crew regained control of the aircraft then received clearance to continue the flight.

What the AI sees

The flight. A narrow-body airliner at high altitude approaching its destination, in daylight and visual conditions. Thunderstorms near the destination meant aircraft were being held.

The crew. The first officer was the pilot flying and the captain the pilot monitoring. The captain had about 1,400 hours on type, 60 in the last 90 days; the first officer about 1,800 hours on type, 104 in the last 90 days.

What happened. Air traffic control assigned holding at a waypoint at flight level 370. The first officer built the hold in the flight management computer and the captain checked it. Approaching the hold, with vertical navigation engaged, the aircraft slowed from about Mach 0.75 to the calculated holding speed of 229 knots. Both pilots noted that this was close to the low-speed band at that altitude and identified it as a threat to watch. They were also checking the hold and working out fuel and holding time for a possible diversion. Approaching the fix, the controller cleared them to descend to flight level 360. The aircraft descended in vertical navigation mode while still slowing, and the thrust levers came back almost to idle. At level-off the autothrottle increased thrust slowly, and both pilots saw the aircraft sink about 100 ft below the new level as it crossed the fix and began a right turn into the hold. The first officer pushed the thrust levers forward and guarded the control column, but the engines spooled up slowly.

Safe ending

TCAS then gave a traffic advisory, followed by a resolution advisory to climb, on an aircraft established in the hold 1,000 ft below. The crew responded, and the aircraft returned to its assigned level without coming closer to the other traffic. The aircraft continued to its destination without further incident. No one was hurt and no aircraft was damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Deviation D4 applies: the real event included a TCAS traffic advisory and a resolution advisory, so they are in the safe ending, and it ends 'No one was hurt and no aircraft was damaged.' Removed under rule 3: both pilots' debriefs (being caught off guard by the throttle reduction, 'distracted' by holding and fuel checks, RA training 'ingrained' for lower altitudes, the RA commanding a manoeuvre that would have made things worse, the roll creating the best escape path), the reason for raising the selected speed afterwards, the 'report has been submitted' line, and the synopsis wording. Kept as activity at the time, without the word 'distracted': the crew were checking the hold and working out fuel and holding time for a possible diversion. Moved under rule 5: the traffic 1,000 ft below (the crew learned of it only from the TCAS), the advisories, the crew's response, the stick shaker, the recovery and the continuation. Judgement calls for James: (1) the safe ending here contains crew actions (the response to the RA, a brief stick shaker and upset recovery) that the bad ending does not, so the two versions differ in more than the outcome. These could not go in the shared text, because they follow the advisory. James may want to trim the safe ending to the advisory and recovery, or drop the case; (2) the captain not reporting the RA on the busy frequency, and the reasons given for it in the debrief, are left out of the safe ending, because they are later decisions explained afterwards; (3) the 'yellow band' is rendered as 'the low-speed band'; the throttle indications (RETARD, then FMC SPD) are summarised as 'almost to idle'. Bracket: 'crossing', because the conflicting traffic was holding below, with this aircraft sinking and turning over it; neither climbing nor descending fits. | EDITED by Claude, 1 Oct (deviation D6): the safe ending was trimmed to the advisories and the outcome. The crew's response to the resolution advisory (the brief stick shaker and the upset recovery) was removed, because it added crew actions present in only one version.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S33 category C · ACN 2291425 · Human Factors · 163 words · FLAGGED

Question for you: Keeps the controller's later remark that other aircraft were also missing that altitude: a fact true at the time, though the crew learned it later.

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Descent
Reporter 1 function: Captain; Pilot Flying
Anomaly: Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Undershoot; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter
Primary problem: Human Factors

Narrative 1

On the CALVR6 arrival into IAD We encountered wake turbulence several times outside of KASDY and agreed to fly a bit higher to avoid the wake. We only had one operable FMS on the FO side and I the captain was PF. The descent to KASDY was only a 1.7 degree descent but then we missed crossing BARIN at 6000 as we got behind and had to lose 1000 feet in 5 miles. The ATC person asked why all the planes were missing the altitude.Suggestions: We will both be more attentive given the difference in glide path; and the distractions of wake turbulence and only 1 FMS.

Narrative 2

On the CALVR 6 arrival; at KASDY we experienced wake turbulence from aircraft ahead of us and stayed above it during descent. Resulted in being at around 6900 at BARIN which required crossing at 6000 ft. Corrected and communicated with ATC.Suggestions: More attentive to altitudes with 1 working FMS and wake turbulence.

Synopsis

Air carrier flight crew reported they failed to make a crossing altitude restriction on arrival into IAD when they flew a high profile to avoid wake turbulence.

What the AI sees

The flight. A twin-engine airliner descending on a standard arrival into a busy airport in the afternoon. One of the aircraft's two flight management computers was inoperative; the working one was on the first officer's side.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. Approaching a fix on the arrival, the aircraft met wake turbulence from aircraft ahead several times. The crew agreed to fly a little higher than the descent path to stay above the wake, and stayed above the path during the descent. The planned descent to that fix was shallow, about 1.7 degrees. The next fix beyond it had a crossing restriction of 6,000 ft. According to air traffic control, other aircraft on the arrival were also missing that crossing altitude. The crew then had about 1,000 ft to lose in the 5 miles to that fix. The aircraft crossed it at about 6,900 ft, some 900 ft above the restriction.

Safe ending

The crew descended to correct the altitude and spoke to air traffic control about it. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Suggestions' sections (being more attentive given the change in descent angle, the wake turbulence and the single flight management computer); the phrase 'we got behind', replaced by the observable fact (about 1,000 ft to lose in the 5 miles to the fix). The captain's 'had to lose 1000 feet in 5 miles' could mean a steeper segment after the shallow one or extra height from flying high; the wording keeps both readings open and does not link it causally to the wake avoidance. The synopsis wording 'failed to make' was not used. Moved under rule 5: the correction and the call to air traffic control. Removed under rule 6: the arrival name, fix names and airport. Judgement calls: (1) the aircraft type is not reported ('Commercial Fixed Wing'), so the most general class, twin-engine airliner, is used; (2) 'in the afternoon' comes from the coded local-time band; conditions are not coded, so none are stated; (3) the controller's question 'why all the planes were missing the altitude' was asked after the event. It is kept in the shared text as a plain fact confirmed afterwards, because it does not depend on the outcome and putting it only in the safe ending would make the two versions differ in more than the outcome. James may prefer to drop it. (4) The report is short; the shared text uses every fact in it and is just above the lower word limit (157 words without the three paragraph labels). Bracket: 'crossing', because the aircraft was about 900 ft above a crossing restriction, where the plausible conflict is traffic crossing above. The wake turbulence is part of the situation, not a traffic conflict, so the standard safe-ending sentences are used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S38 category C · ACN 2300745 · Human Factors · 141 words · FLAGGED

Question for you: Under 150 words because the reports are short (deviation D5).

Original NASA report

Aircraft 1: A320
Mission: Passenger
Flight phase: Final Approach
Reporter 1 function: Pilot Flying; Captain
Anomaly: Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Being vectored for visual approach. ILS out of service. Used RNAV RNP as a reference (did not fly the approach- just used vertical guidance for reference on the descent to runway). Unfortunately we did not go direct to an approach transition and arm the approach prior to descent. After being cleared for a visual approach we reverted to flawed habit patterns and set the FAF altitude of 2000' in MCP and initiated descent. Big threat was the FAF crossing altitude was 1000' not the normal 1500'. We failed to brief and then mitigate that and subsequently got a 'low altitude warning' from Tower controller. Lowest we saw on the RA approximately 2mi from ZZZZZ was 800'

Synopsis

A320 flight crew reported low altitude alert from ATC while on approach.

What the AI sees

The flight. A narrow-body airliner on a passenger flight, being vectored for a visual approach in visual conditions.

The crew. The captain was the pilot flying and the other pilot was the pilot monitoring.

What happened. The ILS was out of service. The crew used the RNAV (RNP) approach as a reference: they did not fly it, but used its vertical guidance for the descent to the runway. They did not go direct to an approach transition or arm the approach before the descent. After being cleared for the visual approach, the crew set the final approach fix altitude of 2,000 ft in the altitude selector and began to descend. The crossing altitude at the final approach fix was 1,000 ft, not the usual 1,500 ft. The crew had not briefed this. The tower controller then gave a low altitude warning.

Safe ending

The lowest radio altitude the crew saw was about 800 ft, about 2 miles from a fix. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: 'Unfortunately', 'we reverted to flawed habit patterns' and 'we failed to brief and then mitigate that' (rendered as the observable fact that the crew had not briefed it), and calling the lower crossing altitude the 'big threat', which was written afterwards. The report's wording '1,000 ft, not the normal 1,500 ft' is kept as written, without stating whether it is height above the runway. The report is short (one narrative of eight sentences), so the shared text is under 150 words; deviation D5 applies and nothing was added. The report does not say how the flight ended, so the safe ending says nothing about the landing. The report does not say which fix the 2 miles are measured from, so the safe ending says 'a fix'. Moved under rule 5: the lowest radio altitude (about 800 ft, about 2 miles from a fix), because it is how low the deviation ended up and, left in the shared text, it would put the aircraft below the height at which TCAS gives resolution advisories and so contradict the bad ending. Removed under rule 6: the fix name. Judgement call: 'crossing', for traffic near the airport below the expected profile.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S39 category F · ACN 2263395 · Human Factors · 247 words · FLAGGED

Question for you: ATC's traffic call is in the shared text, so the safe ending says "no further conflict".

Original NASA report

Aircraft 1: B737-800
Flight phase: Initial Climb
Reporter 1 function: Pilot Not Flying; First Officer
Anomaly: Conflict Airborne Conflict; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

This was day one (leg two) of the captain and I flying together as a flight crew. I was made aware by the captain during our introduction that he would be flying all three of our legs together; so he was PF throughout the shared portion of the trip.The captain and I were operating a flight from ZZZ1 to ZZZ. The ZZZ had ceilings of 2000-2500' throughout much of the afternoon. ATC was advertising RNAV approaches to XX and XYL.We requested the RNAVXX approach into ZZZ; as that is what we had loaded in the FMC. The captain (PF) chimed in on frequency to request vectors outside of ZZZZZ. ATC then vectored us outside of ZZZZZ and cleared us to intercept the final approach course at 3000'; with which we complied. The captain attempted to set the minimums in the MCP (Mode Control Panel) and I reminded him we had not yet been cleared for the approach. The captain then reset 3000' in the altitude window.The captain then selected at least one of; if not both; flaps 25 and 30 himself (this was not the first time he selected flaps as the PF). When he later requested flaps 40; we were 4-5 knots above the flap limitation speed. I said this and waited for the aircraft to slow before selecting flaps 40.Once cleared for the approach; the captain set minimums in the altitude window and began a shallow descent in V/S; questioning whether VNAV would capture the path. I am unsure if VNAV was eventually selected.Out of 2500' around ZZZZZ1; ATC stated there was a traffic conflict with a PC12 going to XYL and asked if we could take a vector to be resequenced. I responded in agreement and ATC assigned us heading 090 and maintain 2500'. I read back these instructions.To my surprise; the captain then hit TOGA. As far as I can recall; there was no standard 'go-around; TOGA; flaps 15' callout. The thrust levers came up and we quickly gained airspeed while initiating a slight climb. After a few seconds; the captain called for flaps 15. I complied and stated 'positive rate' and the captain called for me to raise the gear.We were still tracking approximately runway heading; so I selected heading mode and stated our need to turn. The captain then began the left turn. The aircraft was now overspeeding the flaps at flaps 15 and I noted our airspeed; to which the captain responded to raise the flaps 'on schedule.'After selecting flaps 5; I was alerted to the PFD (Primary Flight Display) by an aural 'bank angle' alert. I noticed we were in what I would estimate to be a 40-degree bank and I called 'bank angle.' The captain responded with a further leftward input of the control column. I then grabbed the yoke and help direct the aircraft in a rightward roll back to wings level.At wings level; the aircraft was still in a nose-low attitude and a high descent rate. ATC issued a low-altitude warning. The descent was arrested at approximately 2000' (1200-1300' AGL). We then climbed back to 2500-2700'. I noticed the airspeed was once again approaching an overspeed and the autothrottles were off; so I reduced the thrust slightly and offered to turn the autothrottles back on. The captain accepted. I also offered to turn the autopilot back on. The captain accepted this as well but was still making large control inputs so the autopilot wouldn't engage. Eventually; the captain reduced control inputs enough for me to re-engage the autopilot.ATC then queried us as to whether we would like XYL and we accepted. I requested the localizer approach; as per the captain's wishes. We loaded and briefed this approach and conducted a normal approach to landing.Cause: The traffic conflict was a contributing factor that led to this event. It is possible this scenario would not have occurred if we had selected the same runway that the other aircraft was using.The normalization of deviance from SOP's made it difficult to maintain effective communication and CRM. The selection of flaps and the introduction of radio calls as PF blurred the lines of our split/shared duties and eroded the foundation from which pilots operate (SOP's). I share part of the blame for not speaking up earlier in the day regarding these issues. The insistence of the captain to fly all three legs; particularly in the way it was communicated; also did not help foster good rapport.Finally; I believe the low frequency of executing soft go-arounds; and the absence of forward briefing of this maneuver; played the largest role in this situation. Had ALT HOLD and HDG been selected as opposed to TOGA; we would have had plenty of time to methodically raise the flaps and gear and our situational awareness would have been much higher. I believe encouraging forward briefing of soft go-arounds and practicing this maneuver during training would be incredibly helpful for mitigating this threat in the future.

Narrative 2

We were fully configured and on speed/ Flaps 40 for landing on the Rnav Rwy XX at ZZZ and coming up on the faf ZZZZZ. We executed a go-around at the towers request due to a single engine aircraft ahead of us landing on the same runway at a very slow speed. As we did the go-around; a heading and altitude were given by the tower. We ended up landing afterwards on XY L with no issues. Upon arriving at the gate; my FO and I discussed the event and he believes we may have oversped the flap 5 setting during cleanup. He wasn't sure by how much so; based on our pooled recollection I filled out the logbook entry as follows... Flaps 5 selection on go-around exceeded by 10kts. Request flap assembly inspection. I called dispatch and Maintenance Control. Contract maintenace was contacted to perform the inspection. The go-around was somewhat busy with heading and altitude instructions. I pressed the TOGA buttons and yes; things happen very quickly. Retrospect afterwards; the better way would have been to press " Alt Hold"...set the heading and altitude...then press Level Change and set speed to the up bug. It would have made things easier. Causal factors of the go-around in itself was a spacing issue. I'm not blaming ATC here...these things just plain happen."

Synopsis

B737 flight crew reported receiving a low altitude warning from ATC during go around. Flight crew returned to safe altitude and continued.

What the AI sees

The flight. A narrow-body airliner on approach. Daytime, with cloud ceilings of 2,000–2,500 ft.

The crew. The captain was the pilot flying and the first officer the pilot monitoring, on their first day together; the captain had chosen to fly every leg.

What happened. Earlier, the captain had made a radio call, begun setting the minimums before clearance until reminded by the first officer, selected flaps personally, and called for flaps 40 at 4–5 knots above the limit speed; the first officer waited for the speed to drop. As the aircraft left 2,500 ft near the final approach fix, ATC reported a conflict with a slower single-engine aircraft and offered a vector to resequence. The first officer accepted, reading back a heading and "maintain 2,500 ft". Treating this as a go-around, the captain pressed the take-off/go-around switches; the first officer recalled no standard callout. The aircraft accelerated quickly and climbed slightly; the captain called for flaps 15, then gear up. Still on runway heading, the first officer selected heading mode and prompted the turn; the captain began a left turn. When the first officer noted the speed was above the flaps 15 limit, the captain called for retraction on schedule. After flaps 5, the bank angle alert sounded at about 40 degrees. The first officer called "bank angle"; the captain applied more left roll, and the first officer took the control column and helped roll the aircraft back to wings level; it was nose-low and descending rapidly.

Safe ending

ATC issued a low-altitude warning. The descent was stopped at about 2,000 ft, 1,200–1,300 ft above the ground, and the aircraft climbed back to 2,500–2,700 ft. The autothrottles and autopilot were re-engaged, and the crew flew an approach to another runway and landed normally. After landing the crew recorded a flaps 5 overspeed of about 10 knots, and maintenance was called to inspect the flaps. There was no further conflict with the single-engine aircraft or other traffic. No one was hurt and no aircraft was damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the first officer's 'Cause' section (normalisation of deviance, blurred duties, sharing the blame, the captain's manner, soft go-around training) and 'To my surprise'; the captain's retrospective view that altitude hold and level change would have been better, and 'things happen very quickly'. Kept: the captain's understanding at the time that ATC wanted a go-around (captain's narrative), alongside the first officer's account of the instruction actually read back. Moved under rule 5: ATC's low-altitude warning, the height at which the descent was stopped, the climb back, re-engaging the automation, the landing on another runway, and the logbook entry and flap inspection. Removed under rule 6: airport, runway and fix names; the single-engine aircraft's type. Compressed or cut for length: the earlier approach actions (the captain's radio call requesting vectors, setting the minimums before clearance, selecting flaps 25 and 30, flaps 40 called 4–5 knots fast) are kept in one sentence; cut are the captain's shallow vertical-speed descent and doubt whether VNAV would capture the path, and the first officer's 'positive rate' call. Left out as after the outcome and differing between versions: the first officer reducing thrust as the speed again neared the limit, and the captain's large control inputs delaying autopilot engagement. Judgement calls: the narratives differ on whether the single-engine aircraft was landing on the same runway (captain) or a parallel runway (first officer); the text says only 'a slower single-engine aircraft'. Deviation D4: the report shows a traffic conflict (ATC's call), so the standard 'no conflict' line would contradict the shared text; the safe ending says there was no further conflict and ends 'no aircraft was damaged'. The report does not say whether the flap inspection found damage; the frozen 'no aircraft was damaged' is used. Bracket 'crossing': the aircraft turned off the approach path at low height near other approach traffic; 'descending' would also fit, since the reported traffic was on approach.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S45 category D · ACN 2255371 · Procedure · 247 words · FLAGGED

Question for you: The Aspen departure: borderline for the 1,000 ft rule. It keeps ATC's traffic call in the shared text, because the crew's decision was made against it.

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Climb
Reporter 1 function: First Officer; Pilot Flying
Anomaly: ATC Issue All Types; Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT
Primary problem: Procedure

Narrative 1

We were departing out of ASE with a cleared route to follow the LINDZ1 departure. We were departing runway 33. The departure states to turn at either the runway end or 1.4DME from the IPKN to a heading of 343°. This is then followed by a turn to a heading of 273° once passing 9;100MSL. During the takeoff; it was noted that there was moderate turbulence increasing the task saturation of both of us in the flight deck. Climbing through ~9;000MSL; ATC gave us an instruction to fly present heading due to conflicting traffic coming the opposite direction. The PM repeated this instruction back to ATC. I quickly asked 'are we even able to accept that?' due to the proximity of the terrain that maintaining the initial 343° heading would cause. At this point we had also initiated the turn to the 273° heading as we had climbed through 9;100MSL. Due to the task saturation of completing the after takeoff checklist while also trying to figure out if we could even accept a vector this low down on the departure; us having already initiated the turn; and our concerns that this heading would put us too close to terrain; we did not turn back to the 343° heading. ATC then said 'I see you're in your left turn now; fly heading 343° traffic 9;500 is Aircraft Y.' We responded 'Looking for the traffic; we need to turn for the terrain.' Neither of us saw the traffic due to our traffic pages being zoomed in to 2.5; but we were already at their altitude and climbing. ATC informed us that they are aware of our procedures and that next time when we accept a clearance; we need to comply with it. We responded saying we had very little time and that we needed to maintain our terrain clearance. ATC then told us to continue on the SID; with the rest of the SID and flight continuing as normal.We had task saturation of completing the after takeoff checklist while also trying to figure out if we could even accept a vector this low down on the departure; as well as dealing with moderate turbulence while we were in close proximity to terrain and complying with the departure procedure; and the late nature of the instruction. We had already initiated the turn to 273° and were unsure if we could turn back to the 343° and maintain terrain avoidance from turning back towards the terrain. There was also concern that in the event of an engine failure; if we would have been able to maintain terrain avoidance due to no longer being on the SID and no longer in a position to intercept the engine out procedure. Next time we would tell ATC we are unable to accept the heading due to terrain avoidance as we were not sure at the time. In the split second; we responded to the instruction as normal before realizing we might not have been able to accept the instruction as well as the compounded issues from above. Also having clear guidance from our company material on if we are able to accept a heading that low and early on the departure; and if we can; for how long we are able to. Currently; we have no company material stating if we are able to accept a vector or if we are not. If we had clear guidance; we would instantly know if we would have been able to accept this instruction and comply with it.

Synopsis

Air carrier pilot reported they did not comply with an ATC instruction to turn off course for traffic due to their concern for terrain avoidance.

What the AI sees

The flight. A twin-engine airliner on an airline flight, climbing out on a published departure from an airport close to high terrain. Visual conditions, daytime, with moderate turbulence.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. The departure called for heading 343 after take-off, then a left turn to 273 once passing 9,100 ft. The turbulence added to both pilots' workload. Climbing through about 9,000 ft, air traffic control told the crew to fly present heading because of opposite-direction traffic, and the pilot monitoring read it back. The first officer at once asked whether they could accept it, as holding 343 would take the aircraft close to terrain. By then the aircraft had passed 9,100 ft and the crew had begun the left turn to 273, while also completing the after take-off checklist. They were unsure whether they could accept a vector this early in the departure, and the company's manuals did not say. They were concerned that turning back would take them towards the terrain, and that after an engine failure they would be off the departure and unable to join the engine-out procedure. They did not turn back. The controller then said, "I see you're in your left turn now; fly heading 343, traffic 9,500." The crew replied, "Looking for the traffic, we need to turn for the terrain." The aircraft was already at about the traffic's altitude and climbing, and the crew continued the turn.

Safe ending

Air traffic control then told the crew to continue on the departure, and the rest of the flight was normal. Neither pilot saw the opposite-direction traffic, either outside or on the traffic display, which was set to a 2.5-mile range. No one was hurt and no aircraft was damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: 'Next time we would tell ATC we are unable', the remark that in 'the split second' the crew read back the instruction before realising they might not be able to accept it, and the recommendation for company guidance. Kept as facts at the time: the workload from turbulence and the checklist, the first officer's immediate question, the crew's uncertainty, the absence of company guidance on accepting vectors early in a departure (stated in the report as current fact), and both reasons for not turning back (terrain, and the engine-failure procedure). Kept in the shared text, as a judgement call: the controller's reason for the instruction (opposite-direction traffic) and the second call ('traffic 9,500'), because they are what the crew were told when they made their decision; removing them would remove the decision itself. Moved to the safe ending (rule 5, deviation D4): that neither pilot saw the traffic and that the traffic displays were set to 2.5 miles, since an aircraft passing half a mile away would have appeared on that display. Left out of the safe ending: the controller's remark that the crew must comply with clearances they accept, and the crew's reply that they had little time and needed terrain clearance; this is an evaluative exchange after the decision and would appear in one version only. Removed under rule 6: the departure name, the runway, the navigation aid and the airport. Judgement calls: the aircraft type is not given ('commercial fixed wing'), so 'twin-engine airliner' was used; the report names only 'the PM', taken as the captain because the first officer was pilot flying in a two-pilot crew. Bracket 'crossing' because the traffic was opposite-direction at a level the aircraft was climbing through, while the aircraft turned left across its path.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S47 category A · ACN 2293409 · Human Factors · 249 words · FLAGGED

Question for you: Long reports cut to fit 250 words. Some crew facts were dropped (listed in each case's notes). Does anything that matters for blame go missing?

Original NASA report

Aircraft 1: Regional Jet 200 ER/LR (CRJ200)
Flight phase: Landing
Reporter 1 function: First Officer; Pilot Not Flying
Anomaly: Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence
Primary problem: Human Factors

Narrative 1

Prior to departing ZZZ1 to ZZZ the Captain and I were discussing the current weather conditions at ZZZ. The weather at ZZZ was below minimums for all the runways expect the ILS to Runway XX. We looked at the winds at ZZZ and they we out of the N at 12kts Gusting 19. Knowing this we knew Runway XX would have a tail wind when we got to ZZZ and knew that it would be a possibility that we could exceed our 10kts tail wind limitation. The Captain contacted Dispatch with our concerns of possibility of not being able to complete the flight once we got there. After further discussion with Dispatch we agreed to depart and attempt the flight to ZZZ with the plan to divert back to ZZZ1 if we could not get in due to the weather. We ended up departing and once we got the current weather for ZZZ weather did not improve. We began a hold over ZZZ VOR and waited for the wind to be within limitations to land Runway XX. The Captain said he will monitor the winds while on the approach to make sure we still within the tailwind limitation. Once the winds improved we attempted the ILS XX. While over the FAF winds picked up and we commenced a miss approach. We diverted back to ZZZ1 as planned with no issues.Once we were back in ZZZ1 the company wanted us to make another attempt at making the flight to ZZZ. While looking at the new government TAF for ZZZ there was no change in the weather conditions. Both the Captain and I had the same concerns from our first attempt. Dispatch then provided us with a TAF from WSI that showed the weather improving just enough to attempt the RNAV XY into ZZZ which would allow us to land with a headwind and complete the flight. Both the Captain and I were still concerned on the the completion of the flight because we were provide two different TAFs. We did not know which one was going to be accurate. Dispatch upped our fuel reserves which would allow us multiple attempts into ZZZ and also enough fuel to divert back to ZZZ1. We departed ZZZ1 with the plan of attempting the RNAV XY first. We arrive at ZZZ and two prior planes we able to get in on the RNAV XY. We attempted the RNAV XY and made visual sight with the ground; but could not get visual on the runway. We proceeded to go missed and flew in the hold. While in the hold we discussed were going to attempt the ILS XX again if the winds were below our tailwind limitation of 10kts. We listened to the weather and verified that the winds were within our limitations. We exited the hold and began the ILS XX. Everything was standard about the approach except once we broke out of the clouds at minims. I called 'runway in sight' and the Captain said 'Landing'. After our callouts the captain communicated to me he was higher than he expected once breaking out of the clouds. To correct he increased his descent rate after that we were below glide slope and herd the EGPWS aural 'Glide Slope' followed by'Pull Up'. As Pilot monitoring I verified we were were still with in all the stable approach criteria and since we had visual contact with the runway on very short final with no obstacles I elected to allow him to complete the landing. The landing was firm and the plane touched down by the 1000ft markings. During our the debrief the Captain and I discussed what happened and both of us determined that the maneuver made seem to be erratic; but was not out of standards. After a couple of days after the event; even though it was within our company standards I was not satisfied with my actions. I should of called for a Go Around. I believe the multiple missed approaches at ZZZ made me reluctant to call for a go around once we had the runway insight.I justified the Captains actions in the moment to increase his descent rate on short final. Due to the knowledge of tailwind and wet runways to limit float and long landing.I also believe fatigue was also a contributing factor. We were coming off a minimum rest period from the night night before. Even thought at the time I felt fit tofly looking back I think fatigue affected my decision making. To avoid this in the future I will call for a go around even if the approach is stable.

Synopsis

CRJ200 First Officer reported receiving EGPWS warnings during approach. Flight crew continued to landing.

What the AI sees

The flight. A regional jet, in daylight and cloud. The destination was below minimums except for the ILS to one runway, which had a gusting tailwind.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The crew had had a minimum rest period the night before; the first officer felt fit to fly.

What happened. On a first attempt the crew went around at the final approach fix when the wind increased, and diverted back. The company asked them to try again, with extra fuel and a more favourable forecast from another provider; the crew were concerned that the forecasts differed. An RNAV approach to another runway ended in a go-around, without the runway in sight. In the hold they confirmed the tailwind was within their 10-knot limit and flew the ILS again, which was normal until they broke out of cloud at minimums. The first officer called the runway in sight and the captain called "Landing". The captain then said the aircraft was higher than expected and increased the rate of descent. The aircraft went below the glideslope, and the ground proximity warning sounded "Glide slope", then "Pull up". The first officer checked that the approach still met all the stabilised-approach criteria and, with the runway in sight on very short final and no obstacles, let the captain continue, accepting the steeper descent to limit float and a long landing on the wet runway with a tailwind. The captain continued to land.

Safe ending

The landing was firm, and the aircraft touched down by the 1,000 ft markings. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: the post-flight debrief ("erratic" but "not out of standards"), the later dissatisfaction and "I should of called for a Go Around", the reluctance attributed to the earlier missed approaches, "looking back I think fatigue affected my decision making", and "to avoid this in the future". Kept, because the reporter places them at the time: the first officer felt fit to fly, and accepted the steeper descent to limit float and a long landing with a tailwind on a wet runway ("I justified the Captain's actions in the moment"). The minimum rest the night before is kept as a fact. Rule 5 moved to the safe ending: the firm touchdown by the 1,000 ft markings. Compressed or omitted for length: the pre-departure discussion with dispatch about the tailwind limit and the plan to divert, the first hold waiting for the wind, the captain's plan to monitor the wind, the government forecast showing no change, the two aircraft that landed on the RNAV approach ahead of them, and the ground being in sight on that approach. Judgement call: the history of two earlier go-arounds is kept in brief because it is what the crew had just been through; the reporter's later view that it made the first officer reluctant to call a go-around is removed.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S01 category C · ACN 2289541 · Human Factors · 237 words

Original NASA report

Aircraft 1: A319
Flight phase: Initial Approach
Reporter 1 function: Captain
Anomaly: Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

While on left downwind for Runway XX at ZZZ; we were cleared for a visual approach. Weather was clear with great visibility. We had the RNAV XX approach loaded into the FMS to back up the visual. My plan was to turn base and intercept the final approach course at or outside of the final approach fix; 'ZZZZZ'; which has an altitude of 2900. When I looked at the approach plate to verify the altitude; I mistakenly looked at 'ZZZZZ1'; which has an altitude of 2160. I then set the altitude to 2100 and initiated a descent. At the same time I began to slow the airplane down to start the configuration process; so the descent was relatively slow. At approximately 2300 MSL; I began to realize that visually we appeared to be getting a little too low. I looked back at the approach plate to verify the altitude I had selected; and realized my mistake. At that same time; we received an altitude alert from ATC; and a L/G Gear Not Down warning from the airplane. I initiated a climb to 3000; then started the base turn; and joined the XX approach course outside of 'ZZZZZ'. The approach was stable the whole way; and we landed at ZZZ uneventfully. I will definitely be looking more carefully at altitudes on approach plates to make sure I have chosen the correct one.

Narrative 2

I was PM (pilot monitoring) Captain was PF (pilot flying). We were cleared for the visual approach XX. We had it backed up by the RNAV (GPS) Runway XX. PF requested a line off of ZZZZZ1 to sequence the flight plan. 2;100 was selected for the altitude.We were on a left downwind for Runway XX. Reaching 2;100 we got a CRC (Continuous Repetitive Chime); MASTER WARNING lights flash; and L/G GEAR NOT DOWN ECAM. As soon as that happened the PF immediately started a climb to 2;900 ft. As that was happening; ATC Tower gave us a low altitude alert. I acknowledge it. We continued the approach normally; with no further abnormality.

Synopsis

A319 flight crew reported while flying a visual approach descending early resulting in flight towards terrain. ATC issued a low altitude alert and the flight crew climbed to a safe altitude and continued the approach to the airport.

What the AI sees

The flight. A narrow-body airliner arriving at an airport for a visual approach. Clear weather with good visibility.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. On the downwind leg the crew were cleared for a visual approach, with the satellite (RNAV) approach to the same runway loaded in the flight management system as a backup. The captain planned to turn onto base and join the final approach course at or outside the final approach fix, which has a published altitude of 2,900 ft. To check that altitude, the captain looked at the approach chart and read the altitude for a different fix, 2,160 ft. At the captain's request the flight plan was sequenced to that fix. The captain set 2,100 ft in the altitude selector and began a descent on the downwind leg. At the same time the captain began slowing the aircraft to start configuring for landing, so the descent was fairly slow. Descending through about 2,300 ft, the captain saw that the aircraft appeared to be getting low, looked again at the chart, and saw that the altitude selected belonged to the other fix. At about the same time, as the aircraft neared 2,100 ft, the landing gear not down warning sounded and the tower issued a low altitude alert, which the first officer acknowledged. The captain immediately began a climb to about 3,000 ft.

Safe ending

The aircraft climbed back, turned onto base and joined the final approach course outside the final approach fix. The approach was stable throughout and the aircraft landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the captain's closing resolution to check approach-chart altitudes more carefully; 'mistakenly' and 'realized my mistake', replaced by the observable facts (read the altitude for a different fix; saw that the selected altitude belonged to it). The synopsis phrase 'flight towards terrain' was not used. Moved under rule 5: joining the final course outside the final approach fix, the stable approach and the landing. Removed under rule 6: runway number, fix names and airport. Judgement calls: (1) the report does not give day or night, so none is stated; (2) the two accounts differ on the altitude at the alerts (captain about 2,300 ft, first officer reaching 2,100 ft) and on the climb target (3,000 ft vs 2,900 ft); reconciled as 'descending through about 2,300 ft' for the captain's recognition, 'neared 2,100 ft' for the warning and alert, and 'about 3,000 ft'; (3) 'requested a line off of [fix] to sequence the flight plan' is rendered as the flight plan being sequenced to that fix at the captain's request, without saying who pressed the keys; (4) the climb is kept in the shared text, as in pilot case 2. Bracket: 'crossing', because the deviation was a descent below the planned altitude on the downwind leg near the airport, where the plausible conflict is traffic passing below the pattern. No traffic interaction in the report, so the standard safe-ending sentences are used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S02 category D · ACN 2314249 · Human Factors · 164 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Climb
Reporter 1 function: Pilot Flying
Anomaly: Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy
Primary problem: Human Factors

Narrative 1

On Day 0 we were given an IFR clearance from STT to ZZZ as filed which included the standard instrument departure PALCO7.PALCO. Before taking the Runway 10 Tower assigned the new departure clearance runway heading with an initial climb of 2000ft which we complied with. After takeoff we were instructed to turn to a new heading of 360; climb to maintain 10;000; and then handed off to the departure frequency. After the frequency change we were given the instruction to proceed direct to FEKKO; but we heard and read back direct to PALCO; which was on our flight plan and on the departure procedure that we were initially cleared for. While climbing to 10;000ft and direct to PALCO our aircraft received RA guidance and audible monitor climb was announced. At that time I disconnected Autopilot and followed the RA guidance presented on my flight display. Around the same time of the RA guidance the departure controller queried our flight asking if we were proceeding direct to FEKKO to which we replied we were direct to PALCO. The controller informed our flight that the instruction was direct to FEKKO; not PALCO; and gave us the frequency change to Miami Center. At that time we proceeded direct to FEKKO and made the frequency change to Miami Center. After the frequency change we informed the new controller of the RA we encountered. The RA guidance was complied with and at no time did we see the other aircraft. Cause: I believe the causal factor that led to the RA was the naming convention of the two waypoints. The two waypoints have too similar of a pronunciation especially since they are both within one ATC boundary. Even though we heard the instruction given and read back to ATC what we heard; the error was not trapped.

Narrative 2

On departure after climbing to 7.000 on the heading 360 ATC cleared us to climb to 10.000ft and fly direct to position PALCO which was replied. Shortly after ATC inquired if we were flying direct to FEKKO and we replied that we where flying direct to PALCO to which ATC told us fly direct to FEKKO not PALCO. Approaching 10.000 ft ATC told us to call San Juan center. At this point we had a TCAS RA monitor vertical speed". We kept turning towards FEKKO and complied with the TCAS RA reaching 10.300ft approximately. We contacted San Juan center and advised them of the TCAS RA and that we were clear of conflict resuming 10.000ft.Cause: The position names should be phonetically more diverse to mitigate the possibility of mistaking FEKKO for PALCO. Also the use of CPDLC communication would vastly improve safety."

Synopsis

Air carrier flight crew reported they were cleared to FEKKO but navigated toward PALCO; a similar sounding fix which was also on the flight plan.

What the AI sees

The flight. A twin-engine airliner on an airline flight, climbing after departure from an airport.

The crew. One pilot was the pilot flying and the other the pilot monitoring.

What happened. The crew's clearance, as filed, included a published departure procedure. Before the aircraft entered the runway, the tower amended this to fly runway heading with an initial climb to 2,000 ft, and the crew complied. After take-off they were told to turn to heading 360 and climb, and were handed to the departure controller. Climbing through about 7,000 ft on that heading, they were cleared to 10,000 ft and direct to a fix. Both pilots heard the name of a different fix with a similar-sounding name, which was on their flight plan and on the departure procedure in their original clearance, and the crew read that name back. The readback was not corrected. With the autopilot engaged, the aircraft turned towards the fix the crew had heard and continued climbing towards 10,000 ft.

Safe ending

While the aircraft was climbing towards 10,000 ft, the crew received a TCAS resolution advisory to monitor vertical speed. The pilot flying disconnected the autopilot and followed it, and the aircraft reached about 10,300 ft. Neither pilot saw the other aircraft. At about the same time the departure controller asked whether they were going direct to the assigned fix; when the crew named the other fix, the controller repeated the correct one and handed them to the next controller. The crew turned towards the correct fix, reported the advisory to the next controller, and returned to 10,000 ft once clear of conflict. No one was hurt and no aircraft was damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Cause' sections (fix names too alike, CPDLC would help) and 'the error was not trapped' as a characterisation; its factual content is kept as 'The readback was not corrected'. Moved to the safe ending (rule 5, deviation D4): the TCAS resolution advisory, the autopilot disconnect and the response to it, the 10,300 ft peak, not seeing the other aircraft, the controller's query and correction, and the report to the next controller. The narratives give the advisory and the controller's query in different orders ('around the same time' in one; query first in the other), so the shared text stops before both, as the aircraft headed for the wrong fix. Removed under rule 6: the airports, the fix and departure names, the runway and the centre names. Judgement calls: the report gives no aircraft type ('commercial fixed wing'), so 'twin-engine airliner' was used; it gives roles only as pilot flying and pilot not flying, with no captain or first officer, so neither is named; no weather or light is given, so neither is stated. The two narratives differ on when the climb to 10,000 ft was given; narrative 2's version (with the direct-to clearance, at about 7,000 ft) was used. 'Similar-sounding' is how both reporters and the synopsis describe the two names. Bracket 'crossing' because the deviation was lateral, towards a fix other than the one assigned.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S03 category C · ACN 2224770 · Human Factors · 245 words

Original NASA report

Aircraft 1: A320
Flight phase: Final Approach
Reporter 1 function: First Officer; Pilot Not Flying
Reporter 1 experience: Flight Crew Last 90 Days 161.57; Flight Crew Type 161.57
Anomaly: Deviation - Altitude Excursion From Assigned Altitude; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Neither the Captain or myself have ever been into ZZZ. We were unfamiliar with the approach and airport. We referenced the company pages as well as the guide to familiarize ourselves. While on the ZZZZZ1 RNAV we were cleared to ZZZZZ 12000ft; speed assigned 230kts.We briefed and executed speed breaks 1/2 crossing ZZZZZ. We were cleaned the RNAV RNP Z rwy XX. We armed the approach and set 6500ft initially. FMA's where SPEED; FINAL APP. Brick and blue stick. Aircraft momentarily leveled at 10;600 between ZZZZZ and ZZZZZ1. Once passing ZZZZZ1 we still have 1/2 speed brakes; the aircraft began the decent for approach and accelerated to 260kts indicated. Unable to slow to gear speed; Auto pilot was disengaged by pilot flying and speed brakes full was engaged. Decent rate was decreased and speed was bled off. Reaching 230kts indicated we extended the gear. Aircraft slowed in this configuration to flaps 1; 2 speed and we configured on schedule. We crossed ZZZZZ2 6500ft; autopilot off; gear extended; flaps 2 and speed 190kts. We descended below 6500ft and received a sink Rate" alert in the flight deck. We descended to 6200ft. We received a call from ZZZ tower to check altitude. We arrested decent manually and climbed back to 6500ft. Autopilot was re- engaged. Manage speed selected and flaps 3 then full was selected on schedule. We were stabilized on approach profile at 1200ft AGL between ZZZZZ3 and ZZZZZ4 at 5700ft indicated. The remainder of the approach was uneventful and we landed successfully."

Synopsis

Air carrier First Officer reported receiving an altitude alert from ATC during approach. Flight crew returned to safe altitude and continued to landing.

What the AI sees

The flight. A narrow-body airliner on a satellite-guided (RNAV RNP) approach to an airport in the morning, in visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The first officer had about 160 hours on type, all in the last 90 days. Neither pilot had flown into the airport before; both had studied the company's airport pages and guide.

What happened. On the arrival the aircraft was cleared to a fix at 12,000 ft and 230 knots. As briefed, the crew used half speed brakes from that fix. Cleared for the approach, they armed it and set 6,500 ft in the altitude window. The flight mode annunciators showed speed and final approach modes. The aircraft levelled briefly at 10,600 ft between two fixes, then began the approach descent with half speed brakes still out and accelerated to 260 knots. Unable to slow to landing gear speed, the captain disconnected the autopilot and selected full speed brakes. The descent rate was reduced and the speed came back; at 230 knots the gear was lowered, then flaps 1 and 2 on schedule. The aircraft crossed the next fix at 6,500 ft, hand-flown, with gear down, flaps 2 and 190 knots. It then descended below 6,500 ft, a 'sink rate' alert sounded, and the aircraft reached 6,200 ft. The tower called the crew to check their altitude. The crew stopped the descent by hand and climbed back to 6,500 ft.

Safe ending

The autopilot was re-engaged, managed speed was selected, and flaps 3 and then full were set on schedule. The aircraft was stabilised on the approach profile at 1,200 ft above the ground, and the rest of the approach and the landing were uneventful. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: nothing substantive; the narrative has no cause, lesson or recommendation section. Moved under rule 5: re-engaging the autopilot, the final configuration, being stabilised at 1,200 ft above the ground, and the landing. Removed under rule 6: the airport, runway number, arrival and fix names, and the approach letter. Judgement calls: (1) the only reporter is the first officer as pilot monitoring, so the captain is taken as pilot flying ('autopilot was disengaged by pilot flying'); the captain's experience is not given; (2) the first officer's 161.57 hours on type equals the 90-day figure, written as 'about 160 hours on type, all in the last 90 days'; (3) 'in the morning' comes from the coded local-time band; (4) 'brick and blue stick' (vertical guidance symbols) is left out as jargon whose meaning is not certain; the flight mode annunciator modes are kept; (5) 'cleaned the RNAV RNP Z' is read as 'cleared'. Bracket: 'crossing', because the aircraft descended about 300 ft below the fix altitude on the approach near a Class D airport, where the plausible conflict is lower traffic crossing the approach path. No traffic interaction in the report, so the standard safe-ending sentences are used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S04 category C · ACN 2257444 · Human Factors · 230 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Flight phase: Initial Approach
Reporter 1 function: Pilot Flying; First Officer
Anomaly: ATC Issue All Types; Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Bird / Animal
Primary problem: Human Factors

Narrative 1

On approach to ZZZ late in arrival a bird strike occurred on runway XXR which we where set up for; the Captain pilot monitoring; input new approach ILS XYL we continued; we where vectored to intercept final and cleared approach XYL. As we intercepted in with nav armed and alt set to FAF alt of 1600 feet; descending and bleeding airspeed with air brakes to meet a 180 knot assigned speed. FO did not call for flaps soon enough and after being vectored off approach entered the heading assigned and did not retract speed brakes; aircraft had descended below assigned altitude and continued to descend as red line approached; captain noticed and retracted flaps but it was too late aircraft descended to 2100 feet and stick shaker activated. Captain took controls; called for; flaps1 and regained altitude to 2500 feet and airspeed into green at 180 assigned speed with flaps 1. Controls were given back to first officer who landed without further incident.Cause: Multiple quick instructions by ATC; and an aggressive decent profile along with the runway change led to first officer (pilot flying) not calling for flaps one soon enough. If that had occurred the altitude deviation issue would most likely not have occurred.Suggestions: First officer should have called for flaps one on approximate base position during intercept instead of relying on speed brakes to slow the aircraft; or used them in conjunction with speed brakes; this would have avoided the speed deviation/stick shaker. Then first officer would have been able to manage altitude without concern for airspeed deviation and altitude deviation would not have occurred.

Synopsis

EMB-175 First Officer reported a low airspeed condition which resulted in a stick shaker and an altitude deviation when being vectored off the final approach course. The Captain took the controls; recovered the airspeed and altitude; then returned the controls to the First Officer for landing.

What the AI sees

The flight. A regional jet on approach to an airport, in daylight and visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. Late in the arrival, a bird strike occurred on the runway the crew had set up for, and the approach was changed to an instrument landing system approach to a different runway. The captain entered the new approach and the crew continued. Air traffic control vectored the aircraft to intercept the final approach course and cleared it for the approach. During the intercept, with the navigation mode armed and the altitude selector set to the final approach fix altitude of 1,600 ft, the aircraft was descending, and the first officer was using the speed brakes to slow to an assigned 180 knots. The first officer had not yet called for flaps. Air traffic control then vectored the aircraft off the approach. The first officer entered the assigned heading and did not retract the speed brakes. The aircraft descended below its assigned altitude and kept descending as the speed approached the low-speed limit. The captain noticed and began to correct, but the aircraft descended to 2,100 ft and the stick shaker activated. The captain took control, called for flaps 1, and climbed back to 2,500 ft, with the speed back in the normal range at the assigned 180 knots.

Safe ending

The captain then handed control back to the first officer, who landed the aircraft without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (first officer, pilot flying). Rule 3, removed: the 'Cause' section (quick ATC instructions, 'aggressive' descent profile, runway change, late flap call) and the 'Suggestions' section (what the first officer should have done with flaps and speed brakes). 'Did not call for flaps soon enough' replaced by the observable 'had not yet called for flaps'; 'but it was too late' dropped. Rule 5, moved to the safe ending: control handed back and the landing. Rule 6: both runway identifiers removed. Judgement calls: the report says the captain 'retracted flaps', but also that flaps had not been called for and the speed brakes were still out, so the item retracted is unclear; written as 'began to correct'. 'Red line approached' read as the low-speed limit, given the stick shaker followed. The bird strike is kept as ambiguous as the report ('occurred on the runway'); whether it involved this aircraft is not stated. Bracket 'descending': the aircraft went below its assigned altitude after being taken off the approach, then climbed; other approach traffic would be descending nearby.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S06 category B · ACN 2231769 · Human Factors · 247 words

Original NASA report

Aircraft 1: B777-200
Flight phase: Takeoff / Launch
Reporter 1 function: Pilot Flying; First Officer
Anomaly: Aircraft Equipment Problem Critical; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Runway
Primary problem: Human Factors

Narrative 1

Departure runway was XXL. Taxied to 1 holding point. Landing traffic crossed runway threshold and Tower told us to line up and wait Runway XXL. We had previously completed the before takeoff checklist and runway verification process and began taking position. Tower asked the landing aircraft to vacate XXL at 2; the landing aircraft stated they missed 2 and Tower instructed them to expedite to 3 for landing traffic as well as us taxiing into position and hold.Tower then instructed us for an immediate takeoff and then restated cleared for takeoff XXL. We were still taxiing into position and in and a slight right turn to the centerline.The Captain stated that I had the aircraft and began advancing takeoff power. When he selected TOGA we received a takeoff configuration warning alarm and EICAS for MAIN GEAR CONFIG; as the main gear trucks had not locked into position from the turn onto the centerline. The Captain stated reject and that he had the aircraft. I told the Tower that we had rejected on the runway. The Tower instructed the aircraft now on short final to go around.We taxied down XXL and cleared the runway on 4. We told the Tower no assistance was required. We completed all checklists via the Electronic Checklist (ECL) at Taxiway 4. Once complete we contacted Dispatch and ZZZZ Operations to brief them on the event. After discussing with Dispatch; the Dispatcher notified the supervisor.We informed Tower we were ready for takeoff; taxied to Runway XXL; completed all required checklists; checked min fuel for departure and completed a normal takeoff.Cause: Distractions and rushing pushed us to not assure the main trucks had locked for takeoff.Suggestions: Our discussion lead us to remind ourselves that once assigned a runway; in effect we have priority of it. We all felt the need/desire to do our best to help Tower and the landing aircraft on final to vacate asap. Additionally when aligning the 777 it's critical to get the plane rolling straight to assure the main trucks are locked for takeoff prior to selecting TOGA.

Narrative 2

Cleared to taxi to holding point Runway XXL via 5 and 1. All checklists completed and all engines running for short taxi. Cleared by Tower to line up and wait Runway XXL. Took note of several aircraft on final. The approach to the Runway XXL from 1 taxiway holding point is a curved taxiway approach. While lining up; it became evident that the aircraft rolling out after landing missed expected turnoff and Tower instructed them to take the next exit. At this time Tower cleared us for an immediate takeoff as we were finishing our line up. I centered the nose on centerline while continuing to roll forward as I always do. I asked the crew if everyone was ready gave the aircraft to the First Officer (FO) and began the takeoff. Power 55%. When stable selected TOGO. Rejected TO less than 20 kts. (estimate 10 kts.) with aural warning and CONFIG GEAR STEARING. FO advised Tower of reject; cleared at 4 and stopped. Completed all checklists; referred to brake cooling chart; called Dispatcher who called supervisor; advised Ramp. Continued taxi to uneventful takeoff. I was surprised at the warning as I was confident I had completed the lineup. I want to express my praise to the FO and relief FO who were excellent team players with great input.Cause: 'Immediate takeoff' instruction by Tower was a factor however I believed I had completed a proper lineup.Suggestions: Possibly; one more second of line up.

Synopsis

B777-200 flight crew reported a rejected takeoff due to receiving a main gear configuration warning on takeoff roll.

What the AI sees

The flight. A wide-body airliner departing from an airport in the early hours of the morning. Visual conditions, with wind.

The crew. The first officer was the pilot flying for the take-off and the captain the pilot monitoring. The captain taxied and lined up the aircraft. A relief first officer was also on the flight deck.

What happened. The crew had completed the before-take-off checklist and runway verification. The captain noted several aircraft on final. The taxiway from the holding point joins the runway in a curve. As a landing aircraft crossed the threshold, the tower controller cleared this aircraft to line up and wait. The landing aircraft reported that it had passed its planned exit, and the controller told it to expedite to the next one. The controller then cleared this aircraft for an immediate take-off. It was still taxiing into position, in a slight right turn onto the centreline. The captain centred the nose on the centreline while continuing to roll forward, as usual, and believed the line-up was complete. The captain asked whether everyone was ready, handed control to the first officer, set 55 per cent thrust and, when stable, selected take-off thrust. The main gear trucks had not yet locked into position after the turn. A take-off configuration warning sounded, with a main gear steering message. At about 10 knots the captain rejected the take-off and took control. The first officer told the tower that they had rejected the take-off on the runway.

Safe ending

The tower controller instructed the aircraft now on short final to go around. The crew taxied along the runway, left it at a later exit and told the tower that no assistance was needed. They completed the checklists, checked brake cooling and minimum fuel, and later made a normal take-off. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over this aircraft. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: this aircraft was the one departing; the conflicting traffic was the aircraft on short final, which ATC sent around. Bracket 'this aircraft': after the low-speed reject the aircraft was on the runway. Removed under rule 3: both Cause sections ('distractions and rushing'; the immediate take-off instruction 'was a factor'), both Suggestions (runway priority once assigned; straightening the aircraft before TOGA; 'one more second of line up'), the captain's praise of the other two pilots, and the captain's surprise at the warning (the contemporaneous belief that the line-up was complete is kept). Moved to the safe ending under rule 5: ATC sending the short-final traffic around, the taxi clear, brake-cooling and fuel checks, and the later normal take-off. Dropped as post-event follow-up: the calls to dispatch, operations and the supervisor. Removed under rule 6: airport, runway and taxiway names. Judgement calls: the first officer's Suggestions line that the crew 'felt the need/desire' to help the tower clear the landing traffic is a motive, but it is framed as the outcome of the crew's later discussion, so it was treated as reflection and left out. The gear trucks not having locked is stated plainly as a fact established afterwards (first officer's account). Crew size is coded 2, but the captain's narrative names a relief first officer and asks 'the crew' if everyone was ready, so the relief pilot is included. Dropped for length: the restated take-off clearance, the tower's stated reason for hurrying the landing aircraft ('for landing traffic as well as us'), and 'all engines running for short taxi'. Reject speed given as 'less than 20 kts (estimate 10 kts)'; rendered as 'about 10 knots'.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S09 category C · ACN 2229930 · Human Factors · 249 words

Original NASA report

Aircraft 1: A319
Flight phase: Initial Approach
Reporter 1 function: Pilot Flying; Captain
Anomaly: Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Captain was the PF. Descending via the arrival for RWY XXR; before reaching the last fix on the arrival (ZZZZZ); ATC gave us 4;000ft; I don't recall if a Heading (HDG) was also given. As we were still descending to 4 thousand feet; ATC asked if airport was in sight. The reply was affirmative and we were cleared for the visual approach RWY XXR. CA selected direct to the FAF (ZZZZZ1) and set on the altitude window 2;000 ft (instead of the published ALT of 2;900 ft) thinking that that was the published minimum altitude for that segment. We kept descending; intending to slow and configure once at 2;000 ft. before reaching ZZZZZ1. As we are descending thru 2;900 ft; sometime after; ATC issues and altitude alert. Not aware until this moment that I had set the wrong ALT; neither my error was caught by PM; We descended below the minimum altitude (2;900) to the FAF. At 2;000 ft; reacting to the ATC ALT alert; PF disconnects Autopilot (AP); Flight Director (FD); and begins a climb back to a safe altitude. Shortly after ATC advises that the minimum altitude for our position was 2;300 ft. PF leveled off then; and continued decelerating and configuring for the final segment of the approach. Cause: The causal factor for this event; was not realizing the error PF made. As I looked to the approach plate to confirmed the ALT for the FAF while descending and flying direct to ZZZZZ1; I cannot clearly state why 2;000 ft was selected. Certainly selecting direct to the FAF also caused the distance to descent to be less leading me to rush the descent. This could have been avoided by simply staying on the arrival and join from there to the approach; this would have been the best choice as it provided more time and I could have seen the altitudes in the Multi-Function Flight Display (MFD) as well.

Narrative 2

Near ZZZZZ intersection; ATC confirmed we had the field in sight and cleared us for the visual to XXR. Captain had briefed an expected visual; and we were using navigational approach data from Jepp chart; ILS XXR. I acknowledged to ATC we were cleared for the visual to RW XXR; and turned to look at the approach plate (the specific reason I do not remember); Captain quickly and firmly addressed to me we were cleared for the visual while adjusting the aircraft course direct to ZZZZZ1--within the parameters of our clearance; though it was unexpected; causing me to take a moment to consider why he cutout the other fixes before acknowledging the change to a direct to ZZZZZ1. While descending; I recognized we were lower than expected and indicated this to the Captain. I began to review the approach plate as the sight picture was to low in altitude and to distant from the airport; this is about when ATC instructed us to check our altitude as we were lower than the appropriate altitude. I checked the altitude for ZZZZZ1; which was 2900. We were at 2000. I indicated to the Captain we were too low and stated to ATC we were beginning a climb. Captain adjusted altitude and began a gradual climb; with ATC later indicating minimum altitude for our location was 2300. We were about 2400 at that time and I indicated to ATC 'we are above that altitude' (2300). Final was intercepted and altitude eventually aligned with completing the visual to a landing.Cause: I did not immediately realize the Captain changed the altitude to 2000 when he went direct to ZZZZZ1; I was ascertaining why he decided to go direct--this is; of course; when altitude limits on the original course were erased. I do not know if I unknowingly acknowledged the 2000. My actual acknowledgment was in reference to the course change; not altitude. My primary error; as pilot monitoring; was not confirming our altitude was consistent with present position and aligned with passing ZZZZZ at 2900.

Synopsis

A319 flight crew reported during the initial approach. ATC cleared them for the visual for the runway. The captain set the altitude for 2000 feet instead of the published altitude of 2900 feet and as they were descending; they received an altitude alert from ATC.

What the AI sees

The flight. A narrow-body airliner arriving at a busy airport in the morning, in visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. The captain had briefed a visual approach, with the instrument landing system chart as reference. Before the arrival's last fix, air traffic control assigned 4,000 ft. Still descending, the crew reported the airport in sight and were cleared for the visual. The first officer acknowledged and turned to the chart. The captain said quickly and firmly that they were cleared for the visual, and set course direct to the final approach fix. This was within the clearance but unexpected, and the first officer paused to consider why before acknowledging the course change. After checking the chart, the captain set 2,000 ft, believing it was the published minimum for that segment; the published altitude at the fix was 2,900 ft. Going direct shortened the descent and removed the intermediate altitudes from the display. The first officer did not notice the altitude change. The crew kept descending, intending to slow and configure at 2,000 ft. The first officer saw that the aircraft looked too low and too far out, said so, and began checking the chart. Air traffic control then issued an altitude alert. At 2,000 ft the first officer told the captain they were too low and told air traffic control they were climbing. The captain disconnected the autopilot and flight directors and began a gradual climb.

Safe ending

Air traffic control then said the minimum altitude for the aircraft's position was 2,300 ft. The aircraft was at about 2,400 ft, and the captain levelled off. The crew continued slowing and configuring, intercepted the final approach course and landed. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Cause' sections' evaluations: the captain's 'the causal factor was not realizing the error', 'I cannot clearly state why 2,000 ft was selected', 'leading me to rush the descent' and 'could have been avoided by staying on the arrival'; the first officer's 'my primary error as pilot monitoring' and 'I do not know if I unknowingly acknowledged the 2000'. Kept from those sections, as facts of what was done or shown at the time: the captain looked at the chart before setting the altitude; going direct shortened the descent and removed the intermediate fixes and altitudes from the display; the first officer's acknowledgement was of the course change, and the first officer did not notice the altitude. 'Not aware until this moment that I had set the wrong ALT' and 'neither my error was caught' are replaced by the observable facts. Moved under rule 5: air traffic control's 2,300 ft minimum altitude for the position, the levelling at about 2,400 ft, and the landing. Removed under rule 6: runway numbers, fix names, the airport and the chart provider. Judgement calls: (1) 'in the morning' comes from the coded local-time band; 'visual conditions' is inferred from the visual approach clearance with the airport in sight; (2) the captain's account places the alert while descending through 2,900 ft and the first officer's places it during the chart check; written as following the first officer's call, without an altitude. Bracket: 'crossing', because the aircraft descended about 900 ft below the final approach fix altitude near a busy airport, where the plausible conflict is lower traffic crossing the approach path. No traffic interaction in the report, so the standard safe-ending sentences are used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S10 category D · ACN 2221505 · Procedure · 248 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Final Approach; Initial Approach
Reporter 1 function: Pilot Not Flying; First Officer
Reporter 1 experience: Flight Crew Last 90 Days 159.77; Flight Crew Type 203.42
Anomaly: ATC Issue All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT; Inflight Event / Encounter Weather / Turbulence
Primary problem: Procedure

Narrative 1

Today we flew the DSNEE 6 RNAV arrival for the ILS 20R into SNA. When verifying the points prior to descent; we noticed that the FMS would not load JWARD. We decided to query the initial Approach Controller. When we were handed off to Approach; I asked if we could expect to fly to JWARD; or if we would get vectors after DSNEE. The controller gave us the option of flying the RNAV approach from JWARD. We told him we would fly the ILS; which is what ATIS was advertising. He told us to expect radar vectors. I took that to mean expect radar vectors after DSNEE. We were later switched to our final Approach Controller. After DSNEE; we did not receive a vector and flew a 235 heading per the STAR. Before we had a chance to ask for a vector; a controller came on and informed us of a terrain alert and directed us to turn to a heading of 270 and to stop our descent. We leveled off and turned to the assigned heading. The subsequent vectors and approach were uneventful.

Narrative 2

Upon receiving the first ATIS from SNA while in cruise flight; I noticed they were using the ILS approach to 20R in lieu of the usual RNP approach; due to visibility constraints. I immediately changed the approach in the FMC to the ILS; but noticed that the last fix on the DSNEE arrival; JWARD would not load with the selection of the ILS. This was the case regardless of whether I loaded the approach with or without transitions. After multiple attempts; I conferred with the FO; we decided the best course of action was to leave the arrival as is with the ILS via SAGER transition. The plan being that we would ask the initial Approach Controller for clarification; if we were to expect final vectors from the fix DSNEE as oppose to the fix JWARD. As we checked in with the initial Approach Controller; we inquired about the issue; and he said that JWARD was the transition to the RNP; and that we would have to make that request with him. We said we wanted to do the ILS and asked if we would get radar vectors via DSNEE; he said yes. As we approached the DSNEE fix we were given a hand off; the new controller gave us a descend; but not a vector. We were experiencing moderate turbulence during this time due to fast moving weather. We continued past the DSNEE fix on a heading of 235 towards JWARD as per the arrival procedure; although not in the FMC; with the intend of staying protected and having time to ask for a vector. Before we had a chance to ask; a different controller on the same frequency said 'Aircraft X terrain alert; turn right heading 270; it looks like you're off the arrival'. I immediately disengaged the auto pilot; and made the turn. I had my ND (Navigation Display) with terrain on; and did not see any terrain closure prior to the turn. This leads me to believe that our momentary deviation from the arrival; in conjunction with our erratic descend rate due to turbulence; might have triggered the alert for the controller. We did not receive an alert on the aircraft from the EGPWS (Enhanced Ground Proximity Warning System). We continued the descend; and intercepted the ILS; and landed without further incident. I believe there was a clear misunderstanding with the initial Approach Controller on what we were asking in reference to the fix vs the arrival itself. More importantly; my concern is the fact that the fix JWARD; did not load in conjunction with the ILS to Runway 20R; no matter what transition or lack thereof we selected in the FMC.

Synopsis

Air carrier flight crew reported request to ATC was misunderstood resulted in a low altitude alert and a CFTT event during approach.

What the AI sees

The flight. A twin-engine airliner on an airline flight, descending on a published arrival. Instrument conditions with moderate turbulence, in the morning.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The captain had about 80 hours on type, the first officer about 200.

What happened. Low visibility meant the ILS approach was in use, not the usual RNP approach. When the captain selected the ILS in the flight management computer, the arrival's last fix would not load, whichever transition was chosen. The crew left the arrival as it was, planning to ask the approach controller whether vectors would start from the fix before it. The controller said the last fix began the RNP approach, and offered it. The crew chose the ILS and asked about radar vectors after the earlier fix; the controller said to expect radar vectors, which the crew took to mean after that fix. Near the fix a new controller cleared them to descend but gave no vector. They continued past the fix on the arrival's published heading of 235, intending to stay on a protected route while they asked for a vector. Before they could ask, another controller gave a terrain alert, said they seemed off the arrival, and told them to turn right to heading 270 and stop descending. The captain disconnected the autopilot and turned, and the crew levelled off. The terrain display had shown no terrain closure, and there was no ground proximity warning.

Safe ending

Air traffic control gave further vectors, and the aircraft intercepted the ILS and landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the captain's later belief that the momentary deviation and an erratic descent rate in turbulence may have triggered the alert, the view that there was 'a clear misunderstanding' with the first controller, and the concern about the navigation database. Kept as facts at the time: the fix that would not load, the crew's plan to ask, what the controller said, the first officer's reading of 'expect radar vectors', the crew's reason for holding the published heading, the clear terrain display and the absence of a ground proximity warning. Removed under rule 6: the arrival, fix and approach-transition names, the runway and the airport. Cut for length: that the turbulence came from fast-moving weather, the several attempts to load the fix, and that the last fix was not in the computer. Judgement calls: the aircraft type is not given ('commercial fixed wing'), so the generic 'twin-engine airliner' was used; the light is not given, so only 'in the morning' (local time band 0601-1200) is stated; the two accounts differ slightly on the controller's reply (first officer: 'expect radar vectors'; captain: 'yes' to vectors via the earlier fix), and the first officer's wording was used. The shared text stops after the crew turned and levelled, as the pilot case for category C did after the terrain warning. Bracket 'descending' because the aircraft was descending in the arrival flow, where other arriving traffic would also be descending; no traffic is mentioned in the report.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S13 category C · ACN 2313802 · Human Factors · 246 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Initial Approach
Reporter 1 function: First Officer; Pilot Flying
Anomaly: Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

While operating as PF on flight # to EWR; I executed a go-around after receiving a low altitude alert by ATC on the RNAV W 29. We had received numerous vectors; speed; and altitude changes from ATC which made autopilot management a bit challenging on the RNAV approach. We had just been given a clearance down to 2500ft which I descended down to using LVL CHG. After crossing fix IZEKO; the IAF; the CA immediately selected 100ft in the MCP (Mode Control Panel) window without my command and didn't realize I hadn't reselected VNAV. An added pressure was that we were closing in on traffic about 4 miles ahead of us so CA advised I start slowing down and configuring which I did. Around fix PRYRR ATC issued a low altitude alert. I looked at my altitude and saw we were 700ft below our next target altitude OF 1900 at JIMLO so I then immediately clicked off the autopilot and executed a go-around as the CA communicated with ATC. We came back around and executed the RNAV W 29 once again; landing safely with no issue.

Narrative 2

During the Williamsport Arrival we were given last minute holding at PENNS waypoint at 7000 ft due to traffic saturation in EWR. We held as published for about 10 minutes and then cleared to resume arrival and handed off to New York approach. During the routine radar vectors; with step down descent clearances; and speed reductions we were expecting a clearance direct to PATRN at 3000ft then cleared for approach -- this is what previous planes received. Instead; we got direct to IZECO descend to 2500ft cleared for RNAV W runway 29 speed -- maintain 170kts until PRYRR. I was Pilot Monitoring while the first officer was pilot flying with autopilot on; and the previous MCP (Mode Control Panel) mode prior to me perceiving his selection of VNAV was Level Change. We passed IZECO at 2500ft and I then sent altitude MCP to touchdown zone -- I thought we were in VNAV. At the same time I noticed the aircraft in front of us encroaching inside 2.5 mile lateral separation ; and I thought we couldn't keep 170 knots to PRYRR with the previous planes slower speed.Around PRYRR to JIMLO ATC told us to check altitude because we appeared lower than normal profile. We both notice being below PDI path and not in VNAV -- the FMA (Flight Mode Annunicator) was indicating Level Change. We decided to go-around; and tower gave us a heading of 220 degrees and a climb to 2000ft -- I believe our altitude was 1;400ft at go-around call. We performed go around profile; and followed ATC directed instructions. The weather was day VMC and we saw EWR well before being cleared for the approach ATC vectored us around for another RNAV W 29; but this time without the altitude of 2500ft just prior to IZECO. Instead we were given direct IZECO; maintain 3000 ft; cleared for approach. We flew the approach in normal RNAV profile using Flight Manual procedures. An uneventful landing resulted with gusty wind conditions.We debriefed at gate and decided to fill out reports to share our narrative.

Synopsis

Air carrier flight crew reported receiving a low altitude alert from ATC during approach to EWR. Crew executed a missed approach and returned for a safe landing.

What the AI sees

The flight. A twin-engine airliner arriving at a busy airport. Daylight, visual conditions, gusty winds; the airport was in sight well before the approach clearance.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. After a ten-minute hold for congestion, the aircraft was given vectors with step-down descents and speed reductions, which the first officer found made managing the autopilot difficult. The crew expected what earlier aircraft had received: direct to a fix at 3,000 ft. Instead they were sent direct to the initial approach fix at 2,500 ft and cleared for a satellite approach, at 170 knots until a later fix. The first officer descended to 2,500 ft in level change mode. Past the initial approach fix, the captain set 100 ft, about touchdown zone elevation, in the altitude window, believing vertical navigation mode had been selected. The first officer had not called for this or reselected that mode. At the same time the captain saw them closing on the aircraft ahead, 2.5 to 4 miles away, judged that 170 knots could not be kept, and had the first officer slow down and configure. Near the next fix air traffic control issued a low altitude alert. The crew saw the autopilot still in level change and the aircraft at about 1,400 ft, 700 ft below that fix's 1,900 ft target. The first officer disconnected the autopilot and began a go-around while the captain spoke to the controller.

Safe ending

The tower gave a heading and a climb to 2,000 ft, and the crew completed the go-around and followed the controller's instructions. They were vectored round for the same approach, this time cleared at 3,000 ft, and the aircraft landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the gate debrief and the decision to file reports; 'didn't realize' and 'an added pressure', replaced by the observable facts. Moved under rule 5: the tower's go-around heading and altitude, the second approach and the landing. Removed under rule 6: the airport, runway number, the arrival and holding fix names, approach fix names and the go-around heading. Judgement calls: (1) the aircraft type is not reported, so twin-engine airliner is used (the mode names indicate a Boeing-style mode control panel; not stated); (2) the first officer's 'without my command' is kept as the neutral fact that the first officer had not called for the altitude change; (3) the distance to the traffic ahead differs between the accounts (first officer about 4 miles; captain inside 2.5 miles), so both are given as a range; (4) the first officer's view that the many changes made managing the autopilot difficult is kept as workload at the time, not hindsight; (5) the closing traffic ahead is part of the situation the crew saw, with no TCAS alert or traffic call reported, so the standard safe-ending sentence 'There was no conflict with other traffic' is kept. James may want to check that it does not read as contradicting the closing traffic. Bracket: 'climbing', because the shared text ends in a go-around near a busy airport, where the plausible conflict is a departure climbing out (the same reasoning as the escape climb in pilot case 2).

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S14 category C · ACN 2210953 · Human Factors · 249 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Descent
Reporter 1 function: Pilot Not Flying; Captain
Anomaly: Deviation - Altitude Excursion From Assigned Altitude; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

We were cleared on the BOPAP 1C RNAV arrival to join the RNP runway 23. Approximately 35 miles from HMO ATC issued a heading of 130. We were cleared to track that heading until 25 DME from HMO and cleared to 4000. Upon approaching 25 DME ATC called again to issue direct to HO901. We turned to HO901 and remained at 4000. A few seconds later we were cleared for the RNP 23. Upon being cleared for the approach we armed the approach and FINAL APP was displayed on the PFD (primary flight display) with a VDEV indicator. We were approximately 20 miles from the airport to the northwest. We set 2800 in the altitude alert window then subsequently set 4000 for the missed approach as the aircraft captured the path. It was VFR and clear; yet we could not see the airport. We both knew it was beyond the mountain range we could see. As we continued the descent both of us agreed it did not look correct as we approach approximately 3100 ft and still well clear of the terrain. We agreed to climb up to 4000 ft. As we began our climb up ATC issued a climb to 3300. We requested 4000 and climbed up until we were certain of being clear of the terrain and rejoined the approach. The approach was normal from this point. Cause: There are multiple contributing factors and concerns with this arrival and approach. 1. There are no notes in the 10-7 regarding the possibility of being vectored off the arrival and a caution of the RNP approach resulting in a descent below MVA and surrounding terrain. The only note is for monitoring TERR; which we did. 2. I was not aware of the note in the RNAV setup stating Do Not accept a clearance direct to a fix unless it is outside the FAF. I thought this applied only to those with an RF leg. That should be emphasized on the 10-7 page as well as in training. Fix HO901 is the FAF. We should have gone to HO900 as that would have kept us clear and on the correct path. I would suggest making this note in the 10-7 and telling crews to not accept HO901 to ensure proper terrain clearance. 3. We did not reference the MVA chart. We should have as it would have improved SA. This was not a vector; the aircraft showed us on path which we followed. This is very; very similar to ZZZ issues we had in the past. The notes on the 10-7 should be changed immediately. We were fortunate it was VFR; we were very aware of the terrain as we briefed it and had TERR on. We did not simply follow the guidance but acted as if it was clearly not correct. I attached the MVA chart as a reference.

Synopsis

Air carrier Captain reported descending on a non-published portion of an approach below the ATC assigned altitude; resulting in proximity to mountainous terrain. The crew climbed and rejoined the approach vertical profile.

What the AI sees

The flight. An airliner arriving over mountainous terrain, in daylight and clear visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. The crew were cleared on an arrival to join an RNP approach. They had briefed the terrain and had the terrain display on. About 35 miles out, air traffic control assigned a heading until 25 miles from a beacon and cleared them to 4,000 ft. Approaching 25 miles, ATC cleared them direct to the final approach fix and, a few seconds later, for the approach. A procedures note said not to accept a clearance direct to a fix unless it was outside the final approach fix; the captain understood this to apply only to approaches with curved legs. The crew armed the approach; the flight display showed the final approach mode and a vertical deviation indicator. About 20 miles out, they set 2,800 ft in the altitude window, then 4,000 ft for the missed approach as the aircraft captured the path, and followed it down. They did not refer to the minimum vectoring altitude chart. They could not see the airport, which they knew was beyond the mountains in view. Approaching about 3,100 ft, still well clear of terrain, both pilots agreed it did not look right and decided to climb to 4,000 ft. As they began climbing, ATC issued a climb to 3,300 ft. The crew asked for 4,000 ft and climbed until sure of terrain clearance.

Safe ending

The crew then rejoined the approach, which was normal from that point. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (captain, pilot monitoring). Rule 3, removed: the 'Cause' section's chart criticism and recommendations (10-7 notes, training, telling crews not to accept the fix), 'we should have gone to' the earlier fix, 'we should have' used the MVA chart, 'we were fortunate it was VFR', and the comparison with past events elsewhere. Kept from that section as facts of the time: the terrain briefing and terrain display, the captain's understanding that the direct-to note applied only to approaches with RF (curved) legs, that the fix was the final approach fix, and that the crew did not refer to the MVA chart. Rule 5, moved to the safe ending: rejoining the approach and the normal approach from there. Rule 6: arrival name, approach and runway designator, navaid and fix names removed; 'northwest' dropped. Judgement calls: aircraft type is not reported ('Commercial Fixed Wing'), so 'an airliner'. Not stated: the captain's later view that the path from that fix led below the MVA and surrounding terrain (kept out as part of the Cause argument; the ATC climb and the crew's climb carry the fact). Bracket 'descending': the aircraft climbed back towards the arrival altitude, where other arriving traffic would be descending.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S15 category D · ACN 2263613 · Human Factors · 247 words

Original NASA report

Aircraft 1: Regional Jet 200 ER/LR (CRJ200)
Flight phase: Initial Approach
Reporter 1 function: First Officer; Pilot Flying
Anomaly: Aircraft Equipment Problem Less Severe; Deviation - Speed All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence
Primary problem: Human Factors

Narrative 1

Flight prior to event was uneventful. We were set up for the visual backed up by the ILS for Runway XX into ZZZ. After several very odd vectors we were vectored in very closely to the final approach fix. Due to this I (FO) decided to intercept in green needles in order to save me some task saturation while making that turn to final nearly over the fix. As we neared the intercept I realized that I no longer saw the green needles meaning that we wouldn't intercept. I quickly switched over to white needles as we passed through the final approach course and hit nav mode. I then immediately knew I had to also manually start the descent since this was turning into a white needles approach. I adjusted the altitude up and hit VS to manually start the descent. When I hit VS I also realized that we never intercepted the course and the airplane had switched to roll mode. It was at this time that I reached for the disconnect to manually fly it in and we momentarily had a stick shaker as my airspeed had been slowly bleeding off during this event as well as environmental factors of gusty winds. The captain stated 'SPEED' and I obtained manual control immediately correcting the speed and corrected onto course and PAPI's for an uneventful landing.Cause: The main cause of the event was a breakdown in visual scanning as I was focused on trying to correct our course issue after losing green needles. The contributing factors were the gusty winds as well as an over reliance on automation instead of manually taking control of the airplane when I realized something was going wrong. Suggestions: A proper scan of all of the instruments as well as making it a habit to always intercept in white needles would have prevented this event.

Narrative 2

On approach to Runway XX; we were cleared for the ILS XX and to maintain 170 knots until ZZZZZ. The FO (PF) elected to switch to green needles to intercept at ZZZZZ; but the localizer did not capture and he armed NAV mode. When the localizer still did not capture; he switched back to white needles for guidance. At this point; we flew past the final approach course and clicked off the autopilot to correct. I bugged our final approach speed of 143 knots; and a few seconds later we then received a stall shaker. I (PM) called SPEED and the FO corrected immediately. We were stable before the 1000 foot call and landed without further event.Cause: We were momentarily overwhelmed by our automation usage and did not pay attention to speed as we should have; neglecting it in our scan. I was also switching to Tower and calling out the before landing check; when I should have been adding speed to my scan and calling any deviations earlier. It was a typical windy afternoon in ZZZ; so that also could have contributed to our slow speed as well.Suggestions: We could have clicked off the autopilot sooner to be better prepared for any loss in speed. Since we were focused on multiple things at once (before landing check; radios; automation usage; and speed); we neglected the most important part -- fly the airplane and add speed to our scan.

Synopsis

CRJ-200 flight crew reported flying through the approach course and temporary loss of aircraft control.

What the AI sees

The flight. A regional jet on an airline flight, on approach to a large airport. Visual conditions, daytime, gusty winds.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. The crew planned a visual approach backed up by the ILS. After several vectors the crew found unusual, the aircraft was turned in very close to the final approach fix and cleared for the ILS, keeping 170 knots to the fix. Because the turn to final would be almost over the fix, the first officer decided to intercept using the flight management system's course guidance, to reduce workload. Nearing the intercept, the first officer saw that this guidance was no longer displayed and the course would not be captured. As the aircraft passed through the final approach course, the first officer switched to localiser guidance and selected navigation mode. Knowing the descent must now be started manually, the first officer reset the selected altitude and selected vertical speed. The first officer then saw that the course had not been captured and the autopilot had reverted to roll mode. The captain had set the final approach speed of 143 knots, and was changing to the tower frequency and calling the before-landing check. The speed had been slowly decreasing in the gusty wind. As the first officer reached to disconnect the autopilot, the stick shaker activated briefly. The captain called "Speed", and the first officer took manual control and increased the speed.

Safe ending

The first officer brought the aircraft back onto the final approach course and the visual approach path. The approach was stable before 1,000 ft, and the aircraft landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Cause' and 'Suggestions' sections, including 'breakdown in visual scanning', 'over reliance on automation', 'momentarily overwhelmed by our automation usage', 'did not pay attention to speed as we should have' and 'when I should have been adding speed to my scan'. Kept as facts at the time: the crew's view that the vectors were unusual, the first officer's reason for choosing the flight management system guidance (workload), the switch to localiser guidance, the manual descent set-up, the roll-mode reversion, the captain's tasks at the time (speed set, frequency change, before-landing check, taken from the captain's account with the self-criticism removed), the decaying speed in gusty wind and the brief stick shaker. Moved to the safe ending (rule 5): the correction back onto the course and approach path, stable before 1,000 ft, and the landing. Removed under rule 6: the airport, the runway and the fix name. Cut for length: 'flight prior to event was uneventful'. Plain words used for 'green needles' (flight management system course guidance) and 'white needles' (localiser guidance). Judgement calls: the narratives differ slightly on the localiser sequence (one says navigation mode was armed before switching to localiser guidance, the other after); the first officer's order was used. Bracket 'descending' because the aircraft flew through the final approach course on the approach, where other approach traffic would be descending; no traffic is mentioned in the report.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S16 category C · ACN 2223799 · Procedure · 192 words

Original NASA report

Aircraft 1: A319
Flight phase: Initial Approach
Reporter 1 function: Pilot Not Flying; First Officer
Anomaly: ATC Issue All Types; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Procedure

Narrative 1

CA was PF and I was PM. ZZZ Approach vectored us northwest of the airport on a 080 heading. Roughly abeam the FAF; we reported the airport in sight and got cleared for the Visual Approach to RWYXXR. We had planned to fly a Visual Approach backed up with the ILS. The approach clearance came at a strange angle to final; which was exacerbated by the southerly wind. The PF disconnected the autopilot and hand flew the approach starting with a base to final turn; while we slowed and configured the aircraft. At approximately 2;300 feet; the tower controller issued a Low Altitude Alert on the tower frequency. We stopped the descent and visually verified outside and inside that we were at a safe altitude. When reestablished on the glideslope; the PF continued the approach. We were stable by 1;000 feet AGL and landed. Throughout this sequence; we maintained visual contact with the airport and all surrounding terrain and obstacles.Night visual approaches present a hazard as far as terrain and obstacles are concerned. Going forward; to prevent a scenario like this; the best options would be request vectors for the published ILS approach; or request better vectors to intercept final while under radar control before accepting an approach clearance. ATC gave us a vector that was somewhere between a downwind and base pointed away from the airport. A better vector for a base or final intercept would've avoided this situation.

Synopsis

A319 pilot reported while they were conducting a Visual Approach they received a Low Altitude Alert from Tower.

What the AI sees

The flight. A narrow-body airliner on a visual approach to an airport, in visual conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. Approach control vectored the aircraft to the northwest of the airport, on a heading between a downwind and a base leg that pointed away from the airport. Roughly abeam the final approach fix, the crew reported the airport in sight and were cleared for a visual approach. They had planned to fly the visual approach backed up by the instrument landing system. The clearance came at an unusual angle to the final approach course, and the southerly wind made this worse. The captain disconnected the autopilot and hand-flew the approach, starting with a turn from base to final, while the crew slowed the aircraft and configured it for landing. At about 2,300 ft, the tower controller issued a low altitude alert on the tower frequency. The crew stopped the descent and checked, both outside and on the instruments, that the aircraft was at a safe altitude. Throughout, the crew kept the airport and the surrounding terrain and obstacles in sight.

Safe ending

When the aircraft was back on the glideslope, the captain continued the approach. The aircraft was stable by 1,000 ft above the ground and landed. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (first officer, pilot monitoring). Rule 3, removed: the reporter's view that night visual approaches are a terrain hazard; what the crew would do in future (ask for vectors to the ILS or a better intercept); and the view that a better vector would have avoided the event. Kept from that section, as a plain fact: the vector was between a downwind and a base and pointed away from the airport. 'Strange angle' rendered 'unusual angle'. Rule 5, moved to the safe ending: re-establishing on the glideslope, stable by 1,000 ft, the landing. Rule 6: airport, runway and the 080 heading removed. Judgement calls: day or night is left out because the coded local time (12:01-18:00) conflicts with the reporter's later remark about night visual approaches; 'visual conditions' is inferred from the visual approach clearance and the airport being in sight (flight conditions not coded). Bracket 'crossing': the aircraft stopped its descent at about 2,300 ft in the base-to-final turn and did not climb.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S17 category A · ACN 2304383 · Human Factors · 248 words

Original NASA report

Aircraft 1: B757 Undifferentiated or Other Model
Flight phase: Final Approach
Reporter 1 function: Captain; Pilot Flying
Anomaly: ATC Issue All Types; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Wake Vortex Encounter
Primary problem: Human Factors

Narrative 1

While on the visual approach to 26R; we were cleared with an airspeed of 170 knots to OWELL. Earlier in the approach we had been advised by ATC that we would be following a Boeing 777 and to caution wake turbulence. We had encountered their wake multiple times on the downwind with some airspeed fluctuations and turbulence.At this time currently we were on a base to final turn approximately 15 miles from the runway. I was PF and hand flying the visual approach. We intercepted the glideslope and localizer around 200 knots and 4000ft and began down on the final approach to runway. We had been fully configured at flaps 30 with the gear down just past OWELL; as briefed; and began to slow up to our Final Vapp.At this time I called for Vapp and the first officer mistakenly bugged 138 knots; which was incorrect. The actual Vref was 123 knots and with an additive of 5 knots should have been 128 knots. Passing through 1000ft we made the 1000ft callouts and were approximately 160 knots and slowing. At this time we were encountering airspeed fluctuations of plus or minus 7 knots due to wake turbulence from preceding Boeing 777. Around our 500 foot gate we were approximately 145 knots with a fluctuation of about plus or minus 5 knots due to the wake and were on a stable descent path to land. And the Captain noted he was slowing the aircraft and stable. Around the 500 foot gate the FO realized he had made a mistake and told me that he had bugged in the wrong Vapp while correcting it. I proceeded to slow the aircraft to the correct speed of 128 knots. A normal landing in the touchdown zone was made and we exited off at the first high speed exit. An uneventful taxi to the gate ended the flight.It wasn't until the roll out that we realized that there was a chance that we might have exceeded the 500 ft stabilized approach criteria of Vapp plus 15 knots. By the time the FO moved the speed bug to 128 knots. I looked at saw our speed around 140 knots and thought it was still within the limits; not taking into account our previous slightly faster speed. In hindsight having to change the speed bug at the low of an altitude; should've warranted a go-around.There were several possible causes for the error setting the wrong final approach speed occurred for several reasons. The first being confirmation bias since the FO and I both usually fly the 767. An airspeed of 138kits is a typical final approach speed so it did not appear abnormal. Second would be high workload. ATC was doing training during our approach and override the primary controllers instructions. Since I was hand flying; this increased the workload of the FO. There were multiple times where we received a clearance to turn or descend on the downwind/approach; followed by an ATC supervisor correction to the radar vectors or approach clearance. Finally; fatigue likely played a factor. It was the end of a four day trip; and we had a van time of XA:55 in ZZZ local.

Narrative 2

While on the visual approach to 26R; we were cleared with an airspeed of 170 knots to OWELL. Earlier in the approach we had been advised by ATC that we would be following a Boeing 777 and to caution wake turbulence. We had encountered their wake multiple times on the downwind with some airspeed fluctuations and turbulence.At this time we were on a base to final turn approximately 15 miles from the runway. The Captain was PF and was currently hand flying the approach. We intercepted the glideslope and localizer around 200 knots and 4000ft and began down on the final approach to runway. We had been fully configured at flaps 30 with the gear down just past OWELL; as briefed; and began to slow up to our Final Vapp.At this time the Captain called for Vapp and I bugged 138 knots; which was incorrect. The actual Vref was 123 knots and with an additive of 5 knots should have been 128 knots. Passing through 1000ft we made the 1000ft callouts and were approximately 160 knots and slowing. At this time we were encountering airspeed fluctuations of plus or minus 7 knots due to wake turbulence from preceding Boeing 777. Around our 500 foot gate we were approximately 145 knots with a fluctuation of about plus or minus 5 knots due to the wake and were on a stable descent path to land. The Captain noted he was slowing the aircraft and stable. Around the 500 foot gate I realized my mistake and told the Captain I had bugged in the wrong Vapp and corrected it. He proceeded to slow the aircraft to the correct speed of 128 knots. The Captain then landed in the touchdown zone and exited off at the first high speed exit. An uneventful taxi to the gate ended the flight.It wasn't until the roll out that I realized that there was a chance that we might have exceeded the 500 ft stabilized approach criteria of plus 15 knots of Vapp. By the time I moved the speed bug to 128 knots. I looked at saw our speed around 140 knots and thought it was still within the limits; not taking into account our previous slightly faster speed. In hindsight; having to change the speed bug at that low of an altitude should've warranted a go-around.I believe my error for setting the wrong final approach speed occurred for several reasons. The first being confirmation bias. I usually fly the 767; so an airspeed of 138 looks like a logical final approach speed. Second would be high workload. It sounded like ATC was doing training during our approach. There were multiple times where we received a clearance to turn or descend on the downwind and approach and the ATC supervisor would come on and cancel a heading or approach clearance. I was also operating the MCP (Mode Control Panel); while double checking with ATC for the correct clearance; and monitoring the flight path since the PF was hand-flying. Finally; I think fatigue played a factor. It was the end of a four day trip; and we had a van time of XA:55 in ZZZ local.

Synopsis

B757 flight crew reported that they set the wrong final approach target speed on approach to IAH; citing fatigue and workload as contributing to the error.

What the AI sees

The flight. A narrow-body airliner on a visual approach in the morning, in visual conditions.

The crew. The captain was the pilot flying, by hand. The first officer was the pilot monitoring, with about 5,100 hours, 2,068 on type. Both pilots usually flew a larger type, on which about 138 knots is a usual approach speed. It was the end of a four-day trip.

What happened. The crew were following a wide-body airliner and had met its wake several times, with airspeed changes. A supervisor corrected or cancelled several ATC clearances. The first officer was working the autopilot mode panel and checking clearances. As briefed, the crew configured fully, flaps 30, and began to slow. The captain called for the final approach speed and the first officer set the speed bug to 138 knots. The correct speed was 128 knots: reference speed 123 plus 5. Passing 1,000 ft the speed was about 160 knots and reducing, varying by about 7 knots in the wake. At the 500 ft gate it was about 145 knots, varying by about 5 knots, on a stable descent path; the company limit there was final approach speed plus 15 knots, 143 knots. The captain noted that the aircraft was slowing and stable. Around 500 ft the first officer noticed the bug was wrong, told the captain and reset it to 128 knots. Both pilots then saw about 140 knots and judged it within limits. The captain continued, slowing towards 128 knots, and landed.

Safe ending

The captain landed in the touchdown zone, the crew turned off at the first high-speed exit, and the taxi to the gate was uneventful. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: both reporters' realisation on the rollout that they might have exceeded the 500 ft criterion, "in hindsight ... should've warranted a go-around", the cause analysis (confirmation bias, high workload, fatigue "likely played a factor"), and the words "mistakenly", "incorrect" and "mistake". Kept from the cause paragraphs as facts, not explanations: both pilots usually fly a larger type on which about 138 knots is usual (a judgement call: it is offered in the report as a reason the error was not noticed); the supervisor's corrections to ATC clearances; the first officer's tasks; the end of a four-day trip (the redacted van time is omitted). Kept as a belief at the time: both pilots judged about 140 knots to be within limits. The company limit (final approach speed plus 15 knots, 143 knots) and the speeds at 1,000 ft and 500 ft are stated plainly. The reporters only say they "might have exceeded" the limit, so the text gives the numbers and does not say the limit was exceeded. Rule 5 moved to the safe ending: touchdown in the touchdown zone, the first high-speed exit, the uneventful taxi. Omitted for length: the 170-knot clearance to a named fix, the turn to final about 15 miles out, the intercept at about 200 knots and 4,000 ft, and the first officer's 98 hours in the last 90 days. The wake from the preceding wide-body is not a traffic conflict, so the standard safe-ending sentence is used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S18 category D · ACN 2257342 · Human Factors · 248 words

Original NASA report

Aircraft 1: B757-200
Flight phase: Initial Climb
Reporter 1 function: Pilot Flying; First Officer
Reporter 1 experience: Flight Crew Last 90 Days 123.7; Flight Crew Total 4700
Anomaly: Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Flight Deck / Cabin / Aircraft Event Other / Unknown; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

We arrived to the plane early and started our flows. After loading the flight plan and departure procedure during normal ground operations; we received an ATC route change via CPDLC. It was loaded; executed; and accepted together as a crew. However; due to inexperience; I did not recognize until later that this situation is when the departure procedure can be dropped from FMC flight plan. We then discussed the complex engine failure procedure at length; going over all the details for the procedure. The complex engine failure procedure included 2 fixes with 2 DME rings and radials which added more items to the nav display; so it was not apparent that the departure dropped from the FMC. Runway XXL was still on the display; and had not been dropped. The temperature was 28C with high density altitude for ground operations; which caused slower than normal engine starts; adding a bit of distraction just prior to taxi. The crew was not familiar with ZZZ and there were a few taxiway NOTAMs with closures that were discussed when planning the taxi to Runway XXL. When cleared for takeoff; winds were suddenly gusting up to 19 knots of straight crosswind of 260@15G19; which was not in the forecast; with moderate turbulence expected up to 13;000; and Aircraft Y on final that was cleared to land on Runway XXL right after we received our takeoff clearance. The Captain lined up the plane and both pilots verified the runway; and exchanged aircraft control so the FO would be pilot flying. Crew took off; checked in with ZZZ departure; and was told to climb unrestricted to FL190. Crew configured for climb on flap retraction schedule; selected VNAV; selected climb direct; and engaged the autopilot for the RNAV SID; which then followed FMC guidance directing a right turn to the next point in the FMC; which was ZZZZZ. ATC advised crew of a low altitude alert; and asked crew which SID they were assigned. Pilot monitoring responded with the ZZZZZ5; and ATC gave crew a vector of 360; which pilot flying selected. The Crew then realized the ZZZZZ5.ZZZZZ SID was dropped from the FMC prior to takeoff; and neither pilot recognized it. ATC notified crew and advised them to contact ZZZ approach. We contacted ZZZ approach after the flight; and initiated the report process.As a crew; we failed to trap the error associated with the route change clearance; as described in the AOM (attached). We discussed this error at length during the flight; realizing we had very rarely seen this situation; and the various other factors of unfamiliar airfield; weather; traffic; climb direct; and complex engine failure procedures in a high terrain environment added just enough competing factors to prevent either one of us from trapping the error. Since the runway had not been dropped from the FMC; and the addition of fixes for the complex engine failure procedure; it was not as apparent that the SID had been deleted; but neither crew member re-verified the SID constraints after the new clearance was received; only during the initial cockpit setup through the pre-flight checklist. After realizing this error; both pilots discussed adding this crosscheck to their pre-flight flow to ensure the SID is reloaded and verified after a new route clearance is received; as well as rechecking the legs page of the FMC to ensure any altitude or speed constraints associated with the SID are still programmed in the FMC immediately prior to takeoff. As the first officer; I should have reloaded the SID after the route modification; and did not recognize the situation described in the AOM. I suddenly remembered while trying to figure out how we were not on the same page as ATC. As the pilot flying; I should have recognized that the right turn to ZZZZZ directed by the FMC was too early and not at the correct altitude as the right turn to ZZZZZ in the SID. I thought it seemed off when the flight director started a right turn; but incorrectly attributed it to the climb unrestricted guidance; sincemy focus was on takeoff and aircraft configuration while flying through the wind and turbulence. As soon as we received the vector back on course; I realized my errors. I am so disappointed and embarrassed that I let a change in route clearance turn get so far off course; and not flying the SID. I should have been more familiar with the SID and not let the complex engine failure procedure overshadow normal procedures. I have reviewed the procedures with the captain; and we've discussed preventive measures and better CRM habits during high-workload environments to ensure this never happens again.

Narrative 2

While completing normal ground operations and the block out checklist procedures. The crew received a route change via CPDLC from ATC. The crew reviewed; loaded; verified; and accepted the clearance. The crew did not trap the error of the ZZZZZ5 departure dropping out of the FMC Flight plan. During the CRM/Safety Briefing; the crew discussed in detail the following threats presented with the flight. Such as; high terrain; high DA; moderate turbulence forecast up to 13;000 (not engaging the A/P at 200 AGL) to include the complex engine failure procedure departing on Rwy XXL which included 2 fixes with 2 DME rings and radials. This additional information on the Nav display may have contributed to the error not being trapped. FO/PF did an excellent job with the PF briefing. The crew discussed the threats presented.An additional distraction was during engine start; due to the high DA (Density Altitude) and temperature of 28 degrees C. The engines started very slowly. The other threats considered prior to taxi was the taxiway closures and the unfamiliar airport for the crew. The crew taxied to Rwy XXL. As the crew was cleared for T/O; the winds started gusting reported 26015G19. Also; aircraft Y was on final and cleared to land on Rwy XXL.Once lined up and Rwy verified; the crew exchanged aircraft controls and began T/O Roll with TO1 takeoff. As previously briefed; LNAV was engaged and VNAV at 1000AGL. The A/P was engaged after VNAV. On departure; PM contacted ZZZ Departure and crew was immediately directed to climb unrestricted to FL190. All occurring while; retracting flaps and getting the aircraft cleaned up on schedule. Once the A/P was engaged; the aircraft began a right turn too early; but in the same direction as the SID. This also; added a threat.ATC advised the crew of the low altitude alert and queried the crew as to which SID was assigned. Crew responded ZZZZZ5 Departure. ATC directed the crew to heading of 360 degrees. Crew immediately followed ATC instructions. Crew was notified by ATC and advised to contact ZZZ departure. Upon completion of flight; crew contacted ZZZ [Departure] as instructed and provided them with the requested information.Once at cruise altitude; crew thoroughly discussed/debriefed how the threat developed and how to mitigate the error in the future. Crew determined the error occurred with the route change during ground operations which led to the departure procedure being deleted from FMC flight plan. Unfortunately; the crew did not re-verify the SID constraints. Crew discussed ensuring to cross check; verify the SID; and any other new route clearances received.

Synopsis

B757-200 pilots reported a navigation deviation and low altitude alert from ATC after a programming error in the FMC.

What the AI sees

The flight. A narrow-body airliner on an airline flight, departing an airport in high terrain in the evening. Hot, with a high density altitude and moderate turbulence forecast.

The crew. The first officer, with about 4,700 hours, was the pilot flying; the captain, with about 4,430, the pilot monitoring. Neither pilot was familiar with the airport.

What happened. Before departure the crew received a route change by datalink, which they loaded, executed and accepted together. This removed the departure procedure from the flight plan, though the runway stayed on the display; the operating manual describes this effect. Neither pilot noticed; they had checked the departure during the initial set-up and did not check it again. A complex engine-failure procedure, briefed at length, added fixes, distance rings and radials to the navigation display. Slow engine starts in the heat added distraction. At take-off an unforecast crosswind gusted to 19 knots, and another aircraft was cleared to land behind them. After take-off they were cleared to climb unrestricted to flight level 190. During flap retraction the first officer selected vertical navigation and direct climb and engaged the autopilot. The aircraft turned right towards the next fix in the computer, earlier than the departure's right turn. The first officer thought this seemed odd but put it down to the unrestricted climb. The controller then gave a low altitude alert and asked which departure they were assigned. The captain named it; the controller gave heading 360, and the first officer selected it.

Safe ending

The aircraft turned onto the assigned heading, and the flight continued to its cruising altitude. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both reporters' debriefs, 'due to inexperience', 'we failed to trap the error', 'I should have reloaded the SID', 'I should have recognized', 'incorrectly attributed', 'I am so disappointed and embarrassed', the agreed preventive measures and 'better CRM habits', and the praise of the first officer's briefing. Kept as facts at the time or confirmed afterwards: the route change dropping the departure (confirmed afterwards), that the runway stayed displayed, that the operating manual describes this effect, that the departure was checked at initial set-up but not after the route change (stated by both reporters), the engine-failure procedure's added display items, the slow starts, the unforecast gusting crosswind, the landing traffic, the early right turn (narrative 2: 'too early, but in the same direction as the SID') and the first officer's thought at the time that it seemed odd. Moved to the safe ending (rule 5): the turn onto the assigned heading and the continued flight. Left out of the safe ending: the controller's request that the crew contact the approach facility, which they did after the flight; it would appear in one version only. Removed under rule 6: the departure and fix names, the runway and the airport. Cut for length: arriving early, taxiway closures, the exact wind, turbulence forecast up to 13,000 ft, the take-off thrust setting and the control handover after line-up. Judgement calls: time of day given only as the local band 1801-2400, so 'in the evening'; one narrative ties the early turn to the flight director and the other to engaging the autopilot, so the text says only that the aircraft turned. Bracket 'crossing' because the deviation was an early lateral turn off the departure track.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S19 category D · ACN 2272363 · Human Factors · 249 words

Original NASA report

Aircraft 1: B737 MAX 8
Flight phase: Initial Approach
Reporter 1 function: Captain; Pilot Flying
Anomaly: ATC Issue All Types; Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

On downwind leg tracking 079 for Runway XX approach of the ZZZZZ arrival past ZZZZZ1 we are given instructions to descend to 4000 and turn to heading 170. I entered the altitude and heading on the Mode Control Panel (MCP) but was late to select HDG and start a turn; Approximately 35 seconds late to select HDG. My unintentional error. Weather: CAVU - DaylightWe were in the turn to 170 when the controller issued an additional turn to 180. For the next 2 minutes the controller did a poor job of managing the situation. We followed every subsequent instruction the controller issued.What ensued next largely increased our workload and introduced unnecessary stress to the event by the controller. Throughout this event we were issued non-standard phraseology instructions; asked if we needed assistance; were given a low altitude alert at 4600' with an MVA of 4200' never told to stop our descent; just told to Turn your plane now" while we were fully established in a standard turn then given a traffic alert of a converging aircraft 2 miles; 11 O'clock and 1000' below us while in the right turn away from traffic. A very confusing set of instructions in a short period while being vectored to the airport environment was less than ideal.My First Officer (FO) stayed calm and professional throughout the whole event. He kept this situation from getting any worse. I take full responsibility for the late turn. What happened after the late turn should have been handled better by the controller. We never received any terrain alerts or traffic alerts from our instruments throughout the arrival. Only non-standard calls and instructions from the controller. Apparently the MVA altitude the controller was primarily focused on was a main factor in what escalated this event.At no point was the flight ever in an unsafe condition. I was not going to let the fact the controller issued non-standard phraseology in a stressed tone put me; my crew or my aircraft in an unsafe situation. The controller may have thought they were helping the situation but in reality made it worse. We were vectored back to an intercept heading to Runway XX and landed uneventfully.Cause: Mitigating factors on this event would include the company strategy. Failed to verify the turn."

Narrative 2

We were on radar downwind for Runway XX from the ZZZZZ RNAV STAR. ATC gave us instructions to turn to heading 170 and descend and maintain 4000 feet. I read the clearance back and ensured the correct numbers were dialed in to the heading and altitude on the Mode Control Panel (MCP) and confirmed them. I then divided my scan between looking out to the right to scan for traffic that we would be following on the visual approach to XX and cross-checked the Class B airspace diagram to ensure we would be operating at a safe altitude of 4000 feet for when we were cleared the visual approach. The controller issued us a further turn to heading 180 for the approach; and I confirmed 180 heading on the MCP; and realized that the HDG button had not initially engaged. I made an accidental mistake by not verifying that the HDG mode had engaged in the Flight Mode Annunciator; only that the number was correct in the MCP window. After starting the turn; the controller subsequently told us to continue our turn to 210. The controller then asked us if we required any assistance; which confused me; then the controller attempted to issue a Low Altitude Alert for an MVA of 4;200 and acknowledged we were at 4;600. The controller's instructions did not include the 7110.65W standard phraseology Check Your Altitude Immediately"; which did not lead me to think that we were in fact going to descend below any MVA; only that the MVA for the area ahead was soon going to be 4;200 but we would be OK because we were at 4;600; turning; and still cleared to 4;000. The controller did not tell us to stop our descent or modify the altitude part of our clearance. Per the class B diagram; 4000 is a safe altitude out to the 15 DME ring from ZZZ; which I was tracking we were in; and we have no ability in the flight deck to know where all the minimum vectoring altitudes are. Shortly after that; we were issued an alert for traffic at 11 o'clock; which further distracted my attention searching for the traffic and monitoring the right turn. The next instruction that the controller issued to us included the non-standard phraseology "Turn Your Plane Now"; which was further confusing to me as we were already in a right-hand turn. We could not safely achieve any additional bank angle in the turn without creating an unusual attitude; and the Captain did a good job of maintaining safe aircraft control and not over banking the aircraft despite the controller's non-standard instructions and heightened tone of voice. We had no alerts of anything abnormal such as a TCAS TA; or a GPWS alert throughout the pattern. We were then vectored off the approach and re-vectored back in for another intercept for Runway XX. We had no idea that there was a concern with our altitude and the MVA until the ATC said that the flight might have gotten close to the MVA. It was my accidental error as the pilot monitoring that I did not ensure that the HDG mode button press had engaged the first time to start the turn.Cause: Automation Management/Monitoring- A causal factor would have been that I verified the correct heading and altitude in the Mode Control Panel window; however I accidentally did not verify that it actually engaged. In the future; I can also point to the Flight Mode Annunciator on my Primary Flight Display to double check that the correct roll mode engages.Communication-ATC- Another causal factor would be that the ATC controller did not directly address the concern that they had in standard phraseology or even in plain english. The controller asked us if we required any assistance; which was a confusing question when everything seemed normal to us. A more straightforward way to address a developing concern might have been to say 'I don't observe a turn yet on radar; stop descent at 4;200 for Minimum Vectoring Altitude.' This could have alleviated the controller from having to issue a Low Altitude Alert.Airport Conditions- Another causal factor is the amount of traffic inboundfor landing on Runway XX. During the early phases of our descent; another aircraft asked if they could get Runway XX instead of Runway XYL; and the controller replied that there is a 5:1 ratio of aircraft inbound for Runway XX versus runway XYL; and that a runway change was not possible for them. I suspect this could have also led to controller saturation; and led to the downwind leg for XX getting 'stretched out' for the aircraft in the pattern; which potentially put aircraft further to the east during the pattern; closer to potential terrain. We were already slowed to 190 per the controller's instructions; potentially slowing the downwind aircraft to 170 could have allowed more time to react in the event that altitude and terrain became an issue.Unpublished Restrictions- Minimum Vectoring Altitude information is not readily available to pilots. According to an article about MVAs; stakeholders and other pilot unions and groups have asked the FAA to release the MVA information to pilots for situational awareness. This would be an incredibly useful tool on the flight deck; leading to an increased ability to identify and trap errors. Even if it is not feasible to incorporate this into an FMS; a chart on Jepp Flight Deck Pro app; in the reference tab; or company charts; in conjunction with the aircraft moving map symbol would be a huge increase in pilot situational awareness. Yet; since the advent of the electronic flight bag; we still have no meaningful tools on the flight deck with respect to minimum vectoring altitudes. Terrain clearance is a shared responsibility with ATC; however we have no tools to assist with this besides our Ground Proximity Warning System; which does not prevent a situation from developing such as this one. In an age where air traffic is at an all-time high and visual approaches are preferred by ATC to increase traffic volume; we have no meaningful tools to choose altitudes for visual approaches besides using altitudes on IFR approaches; which do not take into account obstacle clearance areas not on the straight-in obstacle clearance surface on a charted Instrument Approach Procedure. I think having some charts for busy terminal areas (especially those with terrain concerns) would be a very valuable tool for pilot descent planning and provide an added margin of safety to mitigate the risks of controlled flight into terrain."

Synopsis

Air carrier pilots reported receiving a low altitude alert from ATC during approach.

What the AI sees

The flight. A narrow-body airliner on an airline flight, on radar vectors for a visual approach to a large airport. Clear visual conditions, daytime.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. On the downwind leg, air traffic control told the crew to descend to 4,000 ft and turn right to heading 170. The captain set both on the mode control panel; the first officer read back and confirmed the numbers. Heading mode did not engage at first, and the turn began about 35 seconds late. Meanwhile the first officer was looking out for traffic and checking the airspace chart, which showed 4,000 ft as safe there. In the turn, the controller gave further turns to 180 and 210 and asked if the crew needed assistance, which confused the first officer, as everything seemed normal. The controller then gave a low altitude alert for a minimum vectoring altitude of 4,200 ft, noting the aircraft was at 4,600 ft, but did not say to stop the descent. The first officer understood that the minimum ahead was 4,200 ft and that the aircraft, above it, turning and cleared to 4,000 ft, was fine. The crew had no means of seeing minimum vectoring altitudes. The controller then said, in a raised voice, "Turn your plane now." The aircraft was already in an established turn; the crew judged more bank would risk an unusual attitude. The captain held the bank and continued the turn.

Safe ending

Air traffic control vectored the aircraft off the approach and back round for another intercept, and it landed without further incident. During the turn, air traffic control had given traffic information on a converging aircraft about 2 miles away, at 11 o'clock and 1,000 ft below, while this aircraft was turning right, away from it. There were no TCAS or ground proximity alerts. No one was hurt and no aircraft was damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Cause' sections; the captain's 'my unintentional error', 'I take full responsibility', 'at no point was the flight ever in an unsafe condition' and praise of the first officer; the captain's characterisations of the controller ('did a poor job', 'stressed tone', 'made it worse'); the first officer's 'accidental mistake' and the later discussion of controller workload, unpublished minimum vectoring altitudes and recommendations. Kept as facts at the time: the late turn, the first officer's check of the numbers in the windows, the first officer's reading of the low altitude alert and the reason for it (no instruction to stop the descent or change the clearance), the lack of minimum vectoring altitude information on the flight deck, and the crew's reason for not increasing bank. Moved to the safe ending (rule 5, deviation D4): the ATC traffic information on the converging aircraft, and the absence of TCAS and ground proximity alerts. Left out: ATC's remark after the event that the flight might have come close to the minimum vectoring altitude (an assessment, not an event). Removed under rule 6: arrival and fix names, the runway and the airport. Judgement calls: the captain says heading mode was selected late and the first officer says it did not engage at first, so the text says it 'did not engage at first'; the two accounts give the 'Turn your plane now' call and the traffic call in different orders, so no order is stated. The aircraft's speed (190 knots, as assigned) was left out for length. Bracket 'crossing' because the traffic reported was converging from the left while this aircraft turned and descended.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S20 category B · ACN 2233329 · Procedure · 201 words

Original NASA report

Aircraft 1: A300
Flight phase: Landing
Reporter 1 function: Pilot Not Flying; Captain
Anomaly: ATC Issue All Types; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Clearance; Ground Incursion Runway
Primary problem: Procedure

Narrative 1

During rollout; Tower asked us to get off at [Taxiway] 1. We were too fast to get off at that taxiway and we missed it and coordinated with Tower to get off at 2. The airplane behind us had to go around and ZZZ Tower asked us to call them to explain why we couldn't get off at 1. I told him we were to fast and didn't have time to safely make it. Cause: Late instructions from ZZZ TOWER.

Narrative 2

Upon landing during IOE I was pilot flying; we had briefed that in this reduced flap landing; I would let the auto brakes slow the aircraft to below 30 kts. before transfer of controls to the Captain. As we were rolling out and monitoring the deceleration; Tower asked us to turn onto [Taxiway] 1. We were just prior to that taxiway and the deceleration was not complete to allow for control transfer to execute the turn off. I looked up and realized that we were passing 1. We radioed Tower that we were unable to make the 1 turn. He said to hurry down to the next exit as there was traffic on short final. We tried to be expeditious but the traffic behind us had to go around.Cause: Perhaps we could have been more expeditious in our exit; but in a training environment where configurations are dictated by trading needs; with the given spacing; I am not sure that this was avoidable. (At least by our part).Suggestions: Spacing by ATC is surely optimized for maximum arrival rate but that may not always be the solution that works for all situations. When training is involved; our performance may not be what is expected by ATC. Perhaps there is a way to alert them ahead of time to make their expectations equal our capabilities.

Synopsis

A300 flight crew reported ATC late instructions to clear runway resulted ground conflict and an aircraft having to go-around.

What the AI sees

The flight. A wide-body airliner landing at an airport in the early hours of the morning.

The crew. The first officer was the pilot flying and was in line training (initial operating experience) on the aircraft. The captain was the pilot monitoring.

What happened. The crew had briefed a reduced-flap landing. Under their plan, the first officer would let the autobrakes slow the aircraft to below 30 knots and then hand control to the captain, who would make the turn off the runway. During the rollout, while the crew were monitoring the deceleration, the tower controller told them to turn off at a taxiway. The aircraft was just short of that taxiway, and it had not yet slowed enough for control to be handed over and the turn made. The crew judged that the aircraft was too fast to make that turn safely. The first officer looked up and saw that they were passing the taxiway. The crew told the tower that they were unable to make the turn. The controller told them to hurry to the next exit, because there was traffic on short final. The crew tried to be quick and continued along the runway towards the next exit.

Safe ending

The traffic on short final behind them went around, and the aircraft left the runway at the next exit. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over this aircraft. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: the conflicting traffic was the aircraft on short final behind, which went around. Bracket 'this aircraft': the aircraft was still on the runway heading for the next exit. Removed under rule 3: the captain's Cause ('late instructions' from the tower); the first officer's Cause and Suggestions (whether it was avoidable, ATC spacing optimised for arrival rate, alerting ATC to training flights). Moved to the safe ending under rule 5: the go-around of the following traffic and the exit at the next taxiway. Dropped as post-event follow-up: the tower asking the captain to telephone afterwards to explain. Removed under rule 6: airport and taxiway names. Judgement calls: aircraft class from A300 (wide-body). No weather or light condition is coded; the 0001-0600 time band is rendered as 'the early hours of the morning'. 'Too fast to make that turn safely' is the captain's account (also what the captain told ATC afterwards), stated as the crew's judgement. 'Initial operating experience' (IOE) kept as the training context; the report's link between training needs and the flap configuration sits in the Cause section and was not used. The safe ending does not say the go-around was 'in good time' because the report does not say so (D4 applied).

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S21 category B · ACN 2237239 · Human Factors · 246 words

Original NASA report

Aircraft 1: A220-300
Flight phase: Taxi
Reporter 1 function: Pilot Flying
Anomaly: ATC Issue All Types; Conflict Ground Conflict; Critical; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Incursion Runway; Ground Incursion Taxiway
Primary problem: Human Factors

Narrative 1

Upon taxi we were given [taxiway] 1; 2; 3 hold short of [runway] XXL. The first officer read back the instructions including the hold short. As we approached XXL; ATC told us to follow Aircraft Y or Aircraft Z (can't remember) from the right; monitor tower. We cleared the runway before making the turn on 3; turned the lights on to cross. We checked for traffic which we did not see; anyone on final; and began to cross. Upon reaching the middle of the runway I checked right again and noticed a landing light for XXL. At that point I noticed that there was not enough room to clear the runway due to the lineup of aircraft waiting to takeoff from runway XY. We asked ATC if the aircraft in front of us can move up so we can clear; which they did; however at that point ATC told the aircraft on XXL to go around.

Narrative 2

At ZZZ; we were cleared to taxi via 1; 2; 3 and to hold short of [Runway] XXL. I copied the instructions on a piece of paper and then read back the instructions; including the hold short detail. After the taxi instructions were read back; we proceeded to taxi along that route; and while under way; we completed the taxi/flight control checks along with the Taxi Checklist. I was performing my duties of monitoring Ground Control while running our checklists. I completed the checklist prior to entering the area of the designated hot spot between Runway XXL and Taxiway 3. We were both heads-up. Around the time of completing the checklist and going heads-up; Ground Control instructed us to follow Aircraft Y ahead and from the right and to monitor Tower. I read those instructions back. Approaching XXL on Taxiway 3; we each cleared the runway; including the final approach path in accordance with our policies and procedures. When I looked to clear the final; I did not see any aircraft. When we reached the middle of the runway we both realized that we couldn't clear it because of the traffic ahead associated with Runway XY. It was at that point that I had a feeling we were not in the correct position and that perhaps we were not in fact cleared to cross XXL. As I queried the Tower to see if they could move the plane up ahead of us; the Captain noticed a small landing light coming from Aircraft Z approaching XXL. Aircraft Z was then instructed to go around. Traffic moved ahead and we proceeded off the runway.

Synopsis

A220 flight crew reported while taxing for departure entering a runway and could not exit the runway due to aircraft on the other side of the runway resulting in ATC sending an aircraft around to avoid a collision with their aircraft.

What the AI sees

The flight. A narrow-body airliner taxiing for departure at an airport in the afternoon.

The crew. The captain was the pilot flying and was taxiing the aircraft. The first officer was the pilot monitoring.

What happened. The crew were cleared to taxi via three taxiways and hold short of a runway. The first officer wrote the instructions down and read them back, including the hold short. While taxiing, the crew completed their checks and the taxi checklist, with the first officer monitoring the ground frequency. The first officer finished the checklist before reaching a designated hot spot where the taxiway met the runway, and both pilots were then looking outside. At about that time the ground controller told them to follow another aircraft ahead, from the right, and to monitor tower. The first officer read this back. Approaching the runway, both pilots checked it and its final approach path, as their procedures required, and saw no traffic. The captain turned the lights on, and the aircraft began to cross. In the middle of the runway, both pilots realised they could not clear it, because aircraft queuing to take off from another runway blocked the way ahead. The first officer began to feel that perhaps they had not been cleared to cross. The first officer asked the tower whether the aircraft ahead could move up. At about the same time, the captain looked right again and saw a small landing light from an aircraft approaching the runway.

Safe ending

The tower controller instructed the approaching aircraft to go around. The aircraft ahead moved up, and this aircraft taxied off the runway. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over this aircraft. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: the conflicting traffic was the aircraft approaching to land, which ATC sent around. Bracket 'this aircraft': the aircraft was stopped in the middle of the runway. No Cause or Suggestions sections in this report; nothing removed under rule 3 except the captain's aside that the aircraft to follow could not be remembered. Moved to the safe ending under rule 5: the go-around, the queue moving up, and the aircraft taxiing clear. Removed under rule 6: airport, runway and taxiway names; the hot spot is described, not named. Judgement calls: A220-300 rendered as narrow-body airliner. The two accounts order the landing-light sighting differently (the captain saw it on reaching mid-runway; the first officer says it was seen while the query was being made), so the text says 'at about the same time'. The first officer's feeling that they might not have been cleared to cross is kept because it was felt at the time. The ground controller's later instruction is given as reported, with no statement added about whether it amounted to a crossing clearance. Checks condensed to 'their checks and the taxi checklist' for length. No weather is coded; the 1201-1800 time band is rendered as 'the afternoon'.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S22 category F · ACN 2304318 · Human Factors · 247 words

Original NASA report

Aircraft 1: A321
Flight phase: Descent
Reporter 1 function: Captain; Pilot Not Flying
Reporter 1 experience: Flight Crew Last 90 Days 210; Flight Crew Total 17400; Flight Crew Type 4000
Anomaly: Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

Descending on the ZZZZZX into ZZZ. At 15000' and 250kts; was given cross ZZZZZ1 at 10000' then 250kts. The FO tried to make the restriction while slowing to 250kts. I rebugged his speed to 300Kts explaining that the speed will help him get down and we don't need the 250kts yet as the instructions were 10000'; then 250. Being high; I asked ATC for relief of 10000' and it was granted. However the FO had selected VS at -5000fpm and the speed quickly accelerated past 300Kts even with the speed brakes deployed . As the trend arrow approached over speed and speed approached 320kts; the FO disconnected the autopilot and began to pitch up to arrest the speed. In doing so I noticed the G meter activate. I commented to reduce his maneuvers and saw the meter read 1.4G and then 1.6G. My attention then went back to the PFD (Primary Flight Display) and noted the pitch at 10° nose up. This was corrected almost as soon as I saw it and I noticed the G meter extinguish out of my peripheral vision. We continued to 10000' at a normal descent and then slowed to 250kts. The rest of the flight proceeded normally.

Synopsis

Air carrier Captain reported the First Officer pilot flying caused an overspeed and temporary loss of control while attempting to comply with a STAR crossing restriction.

What the AI sees

The flight. A narrow-body airliner descending on a standard arrival route towards an airport. Visual conditions, at dawn.

The crew. The first officer was the pilot flying and the captain the pilot monitoring. The captain had about 17,400 hours, 4,000 on type.

What happened. At 15,000 ft, ATC cleared the aircraft to cross a fix at 10,000 ft and then to fly at 250 knots. The first officer began trying to meet the crossing altitude while slowing to 250 knots. The captain reset the selected speed to 300 knots, explaining that the higher speed would help the descent and that 250 knots was not needed until after the 10,000 ft crossing. As the aircraft was high, the captain asked ATC for relief from the 10,000 ft crossing, and ATC granted it. The first officer had selected vertical speed mode at 5,000 ft per minute down. The speed quickly increased past 300 knots, even with the speed brakes extended. As the speed trend arrow approached the overspeed limit and the speed approached 320 knots, the first officer disconnected the autopilot and pitched up to stop the speed increasing. The captain saw the g-load indication appear and told the first officer to make smaller control inputs. The captain then saw the g-load read 1.4 g and then 1.6 g. Looking back at the flight display, the captain saw the pitch attitude at 10 degrees nose up. The pitch was corrected almost at once, and the g-load indication went out.

Safe ending

The aircraft continued down to 10,000 ft at a normal rate of descent and then slowed to 250 knots. The rest of the flight was normal. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: nothing in the narrative is later reflection; NASA's synopsis wording ('caused an overspeed and temporary loss of control') is not used. Kept: the captain's reasons at the time for resetting the speed and for asking for relief; the first officer's reason for pitching up (to stop the speed increase), as the captain reported it. Moved under rule 5: the continued descent to 10,000 ft, slowing to 250 knots and the rest of the flight. Removed under rule 6: arrival, fix and airport names. Cut for length: the captain's 210 hours in the previous 90 days. Judgement calls: the report does not say what replaced the 10,000 ft crossing once relief was granted, so nothing is added. The report's 'G meter' is written as the g-load indication. Bracket 'descending': the aircraft was descending on an arrival, where other arrival traffic is also descending; 'crossing' would also fit the abrupt pitch-up.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S24 category C · ACN 2282853 · Human Factors · 248 words

Original NASA report

Aircraft 1: A319
Flight phase: Descent
Reporter 1 function: Pilot Flying; Captain
Anomaly: Deviation - Altitude Overshoot; Deviation - Altitude Crossing Restriction Not Met; Deviation / Discrepancy - Procedural FAR; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

On approach into ZZZ; I was pilot flying on the flight into ZZZ. Initially the metar was calling for the northerly runway but then upon listening to atis and center telling us there was significant weather on the RNAV XX final; we switched to the southerly runway. We had to change the runway and rebrief; the mountain guide was referenced while deviating from weather. Center cleared us for the approach and descend and maintain 15000. I queried the instruction from the first officer; he confirmed cleared the approach so we set the bottom altitude and armed the approach to follow the vertical guidance on the approach which had 11000 the 9400 then 8100. Since the FMS was showing us very high; I pulled speed breaks and initiated a rapid descent down. Center called us at 11000 ft to say we needed to climb back to 15000 as the MSA in the area was 14000 and called a low altitude alert. We initiated a climb to 15000 until we were given another altitude and requested vectors because we would have been very high. ATC gave the vectors. The approach and landing was continued successfully.

Narrative 2

It was leg 2 of 4 for the day. ZZZ1-ZZZ. We were descending into ZZZ and were planning on the RNAV XX approach. We loaded and briefed the descent and approach in some detail. There was weather near the field and center told us there was heavy/extreme precipitation on the final approach course. After a brief discussion; the captain and I decided to change to the ILS XY. The winds were mainly crosswinds. So we loaded the approach and briefed. Shortly after; ATC gave us a descent to 15;000 at ZZZZZ. Then he cleared us for the approach. Conditions at the time were VFR day. We were well above our descent path so the captain asked me to set 8100'; the FAF altitude on the approach. I did and they pulled open descent and extended the speed brakes. We began descending rapidly although the captain verified on the MCDU (Multipurpose Display Control Unit) that we would meet the constraints at each fix on the approach. We descended through 15;000 and ATC informed us we were below the MSA; which was 14;400 and reminded us that we should be at 15;000 at ZZZZZ. We then proceeded to climb back to 15;000. The lowest we got before we began climbing was about 11;500. We got to 15;000 just past ZZZZZ but by then we were too high for a stable approach; so we took vectors from center told us descend; and landed without further incident.

Synopsis

A319 flight crew reported a low altitude alert and CFTT event after descending below the MSA for an ILS approach. Crew climbed back and requested vectors for a second approach and landing.

What the AI sees

The flight. A narrow-body airliner descending towards an airport in mountainous terrain. Daylight, visual conditions, with storms near the airport.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. It was the second of four flights that day.

What happened. The crew had briefed a satellite approach. Air traffic control reported heavy to extreme precipitation on its final approach course, so after a brief discussion the crew changed to the instrument landing system approach to a different runway, with mainly crosswinds. They briefed it, and referred to the company's mountain guide while deviating around weather. Air traffic control cleared the aircraft down to 15,000 ft at a fix, then cleared it for the approach. The captain asked the first officer to confirm this, and the first officer confirmed they were cleared for the approach. The flight management system showed the aircraft well above its descent path, so the captain had the first officer set 8,100 ft, the final approach fix altitude. The captain selected open descent, extended the speed brakes and checked on the flight management display that the aircraft would meet each altitude constraint on the approach. The aircraft descended rapidly through 15,000 ft. Air traffic control issued a low altitude alert, gave the area's minimum safe altitude as about 14,000 ft, and reminded the crew to be at 15,000 ft at the fix. The crew climbed back towards 15,000 ft from a lowest altitude of about 11,000 to 11,500 ft.

Safe ending

The aircraft reached 15,000 ft just past the fix, by then too high for a stable approach. The crew asked for vectors, were vectored round and descended, and the aircraft landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: nothing substantive; neither narrative contains a cause, lesson or recommendation section. The synopsis term 'CFTT' was not used. Moved under rule 5: reaching 15,000 ft past the fix, being too high for a stable approach, the vectors and the landing. Removed under rule 6: the airport, runway numbers, fix names and the published approach names (rendered as 'a satellite approach' and 'the instrument landing system approach to a different runway'). Judgement calls: (1) the two accounts differ on the minimum safe altitude (14,000 ft vs 14,400 ft), on when air traffic control called (captain: at 11,000 ft; first officer: passing 15,000 ft) and on the lowest altitude (11,000 ft vs 11,500 ft); reconciled as 'about 14,000 ft' and 'about 11,000 to 11,500 ft', with the call placed after the aircraft passed 15,000 ft and no altitude given for it; (2) the captain's account gives the approach step altitudes (11,000, 9,400 and 8,100 ft); these are left out to stay within the word limit, and the captain's check of the constraints is kept; (3) the climb back is kept in the shared text, as in pilot case 2. Bracket: 'crossing', because the aircraft descended rapidly some 3,500 ft below its cleared altitude, where the plausible conflict is traffic crossing at a lower level. No traffic interaction in the report, so the standard safe-ending sentences are used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S29 category F · ACN 2280940 · Human Factors · 211 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Flight phase: Climb; Initial Climb; Takeoff / Launch
Reporter 1 function: Captain; Pilot Flying
Reporter 1 experience: Flight Crew Total 5810
Anomaly: Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Wake Vortex Encounter
Primary problem: Human Factors

Narrative 1

We took off from Runway 25R on the FYRBD1 Departure. We had some wake turbulence during climb-out. At 1;000 feet AGL I called for VNAV and noticed the aircraft wasn't accelerating like expected. ATC called for max forward speed then turned us off course. We discussed possible problems then my FO noticed the speed selector was in manual mode when it should have been in FMS mode. We normally rely on automation to maintain speed on departure. Once we selected FMS speed the aircraft accelerated to 210 KIAS. We expected automation to position the Flight Director (FD) to maintain the correct speed but neglected to select FMS speeds. We accidentally took off with the switch in the wrong position. I will be more careful next time.

Narrative 2

I was pilot monitoring for this flight. I completed all my flows normally and entirely. Checklist done as usual and without time pressure. We departed Runway 25R on Firebird1 Departure (not listed in procedures). 80; V1; R; V2 callouts made as usual with normal speeds. We experienced wake turbulence; NAV and VNAV callout was made; frequency change to Departure in brief amount of time. Soon after change to Departure we noticed we were not speeding up. We discussed this out loud then I realized speeds were set to manual not FMS. We switched to FMS and began to speed up as normal. Due to the slow speed; Phoenix gave us a heading off the departure then we resumed departure shortly after.Upon landing; most pilots immediately switch speeds from manual to FMS. Also; when I brief as pilot flying; I brief departing in FMS speeds;" physically touching to make sure switch in proper position; rarely finding it out of position. I was pilot monitoring for this flight and did not catch the switch being in the wrong position. In the air; distraction with radio calls and wake turbulence impacted my own response time to noticing the speed and improper switch placement.I will make sure that I add checking the FMS speed switch regardless of if I am flying or not. Complacency and lack of experience never having experienced this issue before impacted my ability to notice the issue but are easy to address for the future. I will be certain this mistake does not occur again."

Synopsis

EMB-175 flight crew reported distraction with radio calls and wake turbulence from a preceding aircraft led to the aircraft's slow acceleration during the climb; which were caused by the aircraft speeds being set to manual instead of FMS.

What the AI sees

The flight. A regional jet taking off from a large airport and climbing out on a published departure procedure. Visual conditions, daytime.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The captain had about 5,800 hours.

What happened. Before departure the first officer completed the flows in full, and the checklists were done as usual, without time pressure. The take-off was normal, with the usual speed callouts. During the climb-out the aircraft encountered wake turbulence. At 1,000 ft above the ground the captain called for the navigation modes, and soon afterwards the crew changed to the departure frequency. The crew normally relied on the automation to manage speed on departure, and expected the flight director to command the correct speed. Soon after the frequency change, the crew noticed that the aircraft was not accelerating as expected. ATC asked for maximum forward speed, and then gave a heading off the departure route because of the slow speed. The crew discussed possible causes aloud. The first officer then saw that the speed selector was in manual mode instead of the FMS mode used for departure. It had been in manual mode since before take-off. The crew selected FMS speed, and the aircraft accelerated to 210 knots.

Safe ending

Shortly afterwards the aircraft resumed the departure route. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the captain's 'neglected to select', 'accidentally' and 'I will be more careful next time'; the first officer's later reflections that radio calls and wake turbulence slowed their response, 'complacency and lack of experience', 'this mistake', future self-checks, the first officer's own briefing habit as pilot flying, and the general remark that most pilots switch to FMS speed after landing and the switch is rarely out of position (afterwards commentary; the crew's expectation at the time, that the automation would manage speed, is kept). Kept: the first officer's statement that flows and checklists were done as usual without time pressure; the wake turbulence, radio frequency change and ATC's speed request and heading, all received before the cause was found. The switch position since take-off is stated as a fact confirmed afterwards. Moved under rule 5: resuming the departure route. Removed under rule 6: airport, runway and departure procedure names. Judgement calls: the two narratives differ slightly in order; the captain's order (ATC request and heading before the discussion) is followed. Standard safe-ending line used: the wake encounter and ATC's heading are not reported as a traffic conflict. Bracket 'climbing': the event is in the departure climb, where the natural conflict is another departing aircraft.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S32 category D · ACN 2220139 · Human Factors · 158 words

Original NASA report

Aircraft 1: B737 Undifferentiated or Other Model
Flight phase: Final Approach
Reporter 1 function: Captain
Reporter 1 experience: Flight Crew Last 90 Days 106.12; Flight Crew Type 106.12
Anomaly: Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence
Primary problem: Human Factors

Narrative 1

On approach to ZZZ we were cleared the visual approach. With the autopilot on; leave overshot final due to tailwinds. I advised the Fo; who disconnected the auto pilot to correct but he banked past 30 degrees by accident in getting back to corse. I advised him of his bank as the bank angle call came over the speaker. And he corrected back immediately. A normal landing occurred. Estimated 38-40 degrees of bank.

Synopsis

B737 pilot reported overbanking during approach resulted in a bank angle warning.

What the AI sees

The flight. A narrow-body airliner on an airline flight, on a visual approach to an airport in controlled airspace. Visual conditions, with tailwinds on the approach.

The crew. The first officer was the pilot flying and the captain the pilot monitoring. The captain had about 106 hours on type, all of them in the previous 90 days.

What happened. Air traffic control cleared the aircraft for a visual approach. The autopilot was engaged and was flying the turn onto final. Because of the tailwinds, the aircraft overshot the final approach course. The captain told the first officer, who disconnected the autopilot to correct back towards the course. In the turn back, the bank went past 30 degrees, to an estimated 38 to 40 degrees; the first officer had not intended this. As the captain told the first officer about the bank, the "bank angle" aural alert sounded. The first officer corrected the bank immediately, and the approach continued.

Safe ending

The aircraft landed normally. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

The source narrative is only about 80 words; the shared text reaches the range by stating each reported fact in full, with nothing added. Nothing to remove under rule 3: the report has no reflection section. 'By accident' was rendered as 'which the first officer had not intended'. Moved to the safe ending (rule 5): 'A normal landing occurred'. Removed under rule 6: the airport. Judgement calls: the reporter is coded only as captain, not as pilot flying or monitoring; the first officer is taken as pilot flying because the first officer disconnected the autopilot and flew the correction; 'about 106 hours on type, all in the previous 90 days' follows from the coded type and 90-day hours being the same (106.12); time of day is not given, so it is not stated. Bracket 'descending' because the aircraft overshot the final approach course, beyond which other approach traffic would be descending; no traffic is mentioned in the report.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S34 category F · ACN 2279951 · Human Factors · 248 words

Original NASA report

Aircraft 1: B737 Undifferentiated or Other Model
Flight phase: Initial Approach
Reporter 1 function: Pilot Flying; Captain
Anomaly: Aircraft Equipment Problem Less Severe; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control; Inflight Event / Encounter Weather / Turbulence
Primary problem: Human Factors

Narrative 1

I was the Captain and pilot flying on flight # from ZZZ1 to ZZZ. During pre-departure review; the First Officer (FO) and I noted that convective weather was forecasted at the time of our arrival in ZZZ. We discussed the associated weather threats and continued to monitor field conditions while enroute.During the flight we encountered numerous areas of moderate turbulence requiring us to change altitudes multiple times in attempt to find a more comfortable ride. Our final cruising altitude was FL240 with continuous light turbulence much of the flight. ATC advised us of holding into ZZZ. The decision was made to slow our speed and holding was lifted prior to our arrival.An hour prior to landing I set-up and briefed the ZZZZZ 2 arrival and ILS to Runway XXL; which was later assigned to us. There were two convective cells near the airport; one to the west and another to the east. Weather to the north and south was generally clear. Due to weather near the airport; ATC gave us vectors and step-down altitudes to the final approach course; which required the use of speed brakes and flaps to meet speed and altitude restrictions. We remained clear of the weather at that point; which was depicted on the radar as heavy to extreme precipitation and areas of significant turbulence. Approximately 20 miles from the airport ATC advised us that there was FOD from another aircraft on Runway XXL and changed us to Runway XXR. The FO switched the FMC programming and we both reviewed the approach differences. Approximately 5 miles prior to intercepting the final approach course and starting to level at 3000 feet with flaps 5 and speed brakes extended; ATC advised us that the winds had shifted 180 degrees and were gusty. We were asked if we wanted the ILS to Runway XYL. I made to decision to switch runways out of concern for tailwind limitations and associated issues in the event of a go-around. ATC then instructed us to turn left to an assigned heading and climb to 6000 feet. The FO input 6000 in the MCP (Mode Control Panel) and selected vertical speed +700 while I adjusted the heading. As we made the turn I observed stationary weather to the east of the airport; while also observing that the weather west of the airport was moving closer with light rain and light turbulence starting to develop. Both of us immediately recognized we weren't climbing so I disconnected the autopilot; applied power and pulled back into the Flight Director. The speed was increasing so we retracted the flaps to 1. There was still barely a positive rate of climb at which point the FO recognized the speed brakes were still extended. The speedbrakes and flaps were subsequently retracted. ATC instructed us to level at 4000 feet. I leveled the aircraft at 4000 feet and we re-cruised the FMC to 4000 at a speed below 250 knots; then reengaged the autopilot and VNAV. It took a couple attempts to reengage the autopilot as I worked to trim the aircraft. The FO then began reprogramming the FMC for ILS Runway XYL. As we came around to the south we lost sight of the airport by a wall of clouds. I could see ZZZ2; which I initially thought was ZZZ after making the turn; before realizing ZZZ was completely obscured. We requested weather conditions at the field after observing various convective radar returns in the area. While I don't recall the verbatim response; light rain was reported by the last arrival on the opposite runaway; but we were told we were the first to land from the south. ATC then gave us vectors to the final approach course. Once intercepting the final approach course the latest radar return indicated a convective cell was directly over the field. I made the decision to go-around at that point as we could not see the airport and were not receiving realtime field conditions. As I executed the go-around we entered IMC and the ride conditions deteriorated rapidly. I observed lightening to the left and front of the aircraft.By that time we were in heavy rain and moderate turbulence conditions. I immediately initiated a right turn away from the weather while simultaneously instructing the FO to advise ATC we required an immediate right turn. ATC gave us latitude to turn at our discretion and assisted with a heading away from the weather. We were in a gear-up; flaps 10 configuration at that time. While in the right turn a gust of wind lifted the left wing causing a bank angle of approximately 35 degrees; which gave us a brief bank angle alert. I corrected the bank angle without issue. As we retracted the flaps to 5 and then 1; the speed increased quickly and over-sped the flaps by approximately 15 knots. The airspeed was stabilized and we leveled off at 3000 feet as instructed on an assigned heading. Upon exiting the weather; ATC asked our intentions. We requested a hold south of the field. ATC instructed us to hold as published at ZZZZZ1; which is the Runway XYL IAF. The autopilot was reengaged; the FO reprogrammed the FMC for the hold; we established ourselves in the hold and then took a couple moments to regroup. After two turns in the hold; the weather began to clear the area. Winds were reported to be calm and we could see the airport. We then successfully completed a second approach and landing to runway XYL. Upon landing we documented the flap overspeed and contacted maintenance for a required inspection prior to our return flight. No abnormalities were noted. In debriefing this event it was clear to me that I became task saturated with pilot flying duties and command decision making responsibilities. Trying to maintain a big picture without tunnel vision in a dynamic environment while facing deteriorating weather and ride conditions became challenging. Automation management became increasingly difficult as we were monitoring the weather situation; complying with ATC instructions and continuously reprogramming the FMC. Ultimately we had four approach set-ups to three different runaways; a discontinued approach; a go-around and a hold. I credit teamwork; communication and the FO's stellar pilot monitoring skills to maintaining safety during this event. A factor that negatively contributed to this event was fatigue. While we were fit for duty; this was the second leg on day 4 of 4 of the trip. The day prior was a long duty day extended by a maintenance delay and followed by minimum rest. There was also fatigue associated with the poor ride conditions and increased workload the entire way down from ZZZ1. The combination of factors certainly contributed to delayed mental processing while executing procedures not routinely conducted. During the debrief we discussed that using LVL CHG with an appropriate speed rather than VS would have been a better option. Ensuring and verifying the speed brakes were fully retracted prior to discontinuing the first approach would have also been prudent. Also; being more deliberate on the go-around procedure; including speed management would have mitigated the risk of a flap overspeed. Finally; we discussed that if we had it to do all over again; following the first approach attempt we would have requested a hold and given ourselves more time to evaluate the most current weather conditions rather than feel pressured to beat the weather. We felt like the decision to discontinue both approaches was appropriate and noted the positive application of CRM/TEM (Threat and Error Management) in successfully completing the flight.

Synopsis

B737 Captain reported a momentary loss of aircraft control and flap overspeed after abandoning approach in convective weather. Crew landed normally after convective weather passed.

What the AI sees

The flight. A narrow-body airliner arriving at an airport with thunderstorms nearby. Daytime, instrument conditions.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. On the last day of a four-day trip, after minimum rest, both were fit for duty but reported fatigue.

What happened. The crew had briefed the forecast storms. Levelling at 3,000 ft, with flaps 5 and speed brakes out for ATC's step-down restrictions, the crew learned the wind had reversed and was gusty. Concerned about tailwind limits, the captain accepted the opposite-direction approach; ATC gave a turn and climb to 6,000 ft. The first officer set a 700 ft per minute climb in vertical speed mode, but both pilots saw at once it was not climbing. The captain disconnected the autopilot, added thrust and pitched up, and the flaps went to 1. With barely a positive climb, the first officer saw the speed brakes still extended, and they were retracted. ATC then assigned 4,000 ft. On final approach, with the airport hidden by cloud, no current field conditions and a storm cell over it on radar, the captain went around. In cloud, heavy rain, moderate turbulence and lightning, the captain turned right at once, away from the weather; ATC approved. A gust rolled the aircraft to about 35 degrees of bank; the captain corrected it. As the flaps came up from 10 to 5 and 1, the speed rose quickly, exceeding the flap limit by about 15 knots.

Safe ending

The airspeed was stabilised, and the aircraft levelled at 3,000 ft on a heading from ATC. After leaving the weather the crew held south of the airport; after two turns the weather cleared, and they landed after a second approach. Maintenance inspected the flaps for the overspeed and found no abnormalities. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the whole debrief paragraph (task saturation, tunnel vision, 'delayed mental processing', the view that level change mode would have been better than vertical speed, that the speed brakes should have been checked, that the go-around should have been more deliberate, that a hold should have been requested, and the credit to teamwork and CRM). The fatigue facts (last day of a four-day trip, minimum rest, fit for duty, reported fatigue) are kept as the crew's state at the time. Moved under rule 5: stabilising the airspeed, levelling at 3,000 ft, the hold, the second approach and landing, and the flap inspection result. Removed under rule 6: airport names, runway numbers and fix names. Cut for length (at-the-time facts; the report is long): the previous day's maintenance delay, the en-route turbulence and altitude changes, holding advised then lifted, the vectors between cells to the east and west, an earlier runway change because of debris, the FMC reprogramming after each runway change, the increasing speed as the reason for flaps 1, re-engaging the autopilot and VNAV at 4,000 ft (a couple of attempts while trimming), losing sight of the airport and the captain briefly mistaking a nearby airport for it, the last arrival reporting light rain and the crew being the first to land from the south, the first officer telling ATC an immediate turn was needed, gear up in the go-around, and the brief bank angle alert. Judgement calls: the report has two deviation episodes (not climbing to the assigned 6,000 ft with speed brakes extended, and the flap overspeed in the go-around); both are kept and the text stops at the overspeed. Bracket 'crossing': the aircraft made an unplanned right turn off the go-around path in weather, where other aircraft could be crossing.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S35 category C · ACN 2316309 · Procedure · 249 words

Original NASA report

Aircraft 1: B737-800
Flight phase: Initial Approach
Reporter 1 function: Captain; Pilot Not Flying
Anomaly: ATC Issue All Types; Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Procedure

Narrative 1

On approach to runway XX ZZZ. FO told them that he was transferring to ZZZ and has not had a lot of experience in ZZZ and asked to fly the flight. I agreed as I was based here and flown this approach many times and would help him with it. But had not been up in ZZZ for a few years and not flown the River Visual XX in a long time. Before Top of Descent we briefed the arrival and approach in a lot of detail and helped him with the visual clues and locations on the approach; Bridges; ZZZ1 and where to turn final. Approach left us high and fast on downwind; and tuned us close to the start of the visual approach on the highway bridge over the River. We were getting behind the plane and I told FO to hand fly the approach so I could set up the V-Nav and not have the V-Nav/Autopilot level us off. FO called for 'Gear down; flaps 45' and I just selected the gear down and flaps; without looking at the speed and that's when the FO thought we deployed the flaps 5 knots fast. I did not see the speed and when I did we were already below the flap speed. We did not get a flap 'clacker'. We were descending and finishing the configuration; as I looked out the window and felt that we were low. The flight director was showing us on path. At the same time we got the '1;000 feet' GPWS call out and I saw we were 1;000' low over the fix we were over. FO stopped the descent; and leveled off. All happening at the same time; ZZZ Tower told us he had a low altitude alert and I called the go-around; as trying to 'save the approach' was not a good idea. We went around and the FO and I agreed that it be best for me to fly the approach. We came around for 4th second approach and successfully landed. We were task saturated; and I was trying to mentor/teach the FO the River Visual XX; which added to my task load. I thought having the FO fly would make it easier; but actually me flying and telling the FO what I am doing verse the FO flying and telling them what to do was not a good idea.Try to not get behind the plane; and ask ATC for lower altitude sooner or start slowing instead of being 250kts abeam the airport and descending. I was not expecting to be number 1 to the airport; as I thought I saw on TCAS a plane to the north and we were to follow that plane and be number 2 for the approach. Also for selecting flaps; I need to make sure that I look at the speed before moving the flap handle.

Narrative 2

During approach on the River Visual to Runway XX; we broke 1000 feet AFL while in the descent over the river. We began well before the arrival thoroughly briefing the arrival and approach. The CA had slightly more experience with ZZZ and I as the FO had very little and had never done the River Visual Rwy XX. The set up and arrival were uneventful and we had briefed that I should follow the altitude guidance on the PFD (Primary Flight Display) as we should be in VNAV Path. As we began the approach we set the altitude to 900 feet for guidance. After crossing ZZZZZ; we noticed we were much lower and still descending. I announced I was confused as to why we were so low as we were descending through 1100 feet. At 1000 feet; the CA and I both were feeling task saturation and the CA immediately told me to arrest the descent and that we were too low. I arrested the descent and ATC informed us we were too low at the same time we immediately called for and executed a Go-Around. We informed ATC we were going around and they gave us vectors to the west in order to set up for another approach. We both then realized we were not in VNAV Path and believe that is why the altitude guidance was telling us to keep descending.Task saturation and lack of understanding of altitudes on the River Visual XX to ZZZ. Even though we thoroughly briefed the arrival and approach; we still became task saturated and confused as to why we were descending. We should definitely set hard altitudes in the FMC for each point in order to assist with altitude guidance. Also; I as PF should have been more outside in my scan and recognized that I was too low.

Synopsis

A flight crew descended below the charted altitude on a Charted Visual Approach and received a Low Altitude Alert from ATC.

What the AI sees

The flight. A narrow-body airliner on a charted visual approach to a large airport.

The crew. The first officer, new to this base and to this approach, asked to fly and was the pilot flying. The captain, the pilot monitoring, was based there and had often flown the approach, but not for some years.

What happened. In a detailed briefing, the crew agreed the first officer would follow the altitude guidance on the flight display, in the vertical navigation path mode. The captain expected to be second to land, behind traffic seen on TCAS. Air traffic control left the aircraft high and fast on the downwind and turned it in close to the start of the approach. Feeling they were getting behind, the captain had the first officer hand-fly while the captain set up the vertical navigation, so the autopilot would not level off. The altitude selector was set to 900 ft. On the first officer's call, the captain selected gear and flap without checking the speed. Past a fix, the crew saw they were much lower and still descending, though the flight director showed them on path. The vertical navigation path mode was not engaged. Both pilots felt task-saturated. At the "1,000" callout, about 1,000 ft low, the captain told the first officer to level off, and the first officer did. The tower issued a low altitude alert at that moment. The captain called a go-around rather than try to save the approach, and the crew went around.

Safe ending

ATC gave the aircraft vectors for another approach. The crew agreed that the captain would fly it, and the aircraft landed from the second approach. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Two narratives merged (captain, pilot monitoring; first officer, pilot flying). Rule 3, removed: both reporters' lessons (don't get behind the aircraft, ask for lower sooner, check speed before moving the flap handle, set hard altitudes in the FMC, scan outside more), the captain's view that having the first officer fly while mentoring was 'not a good idea', and the first officer's 'lack of understanding of altitudes'. Kept, as said at the time: 'getting behind the plane' (the captain's stated reason for having the first officer hand-fly), the task saturation both felt, and the go-around reason ('save the approach'). The VNAV PATH mode not being engaged was realised afterwards and is stated as a plain fact. Rule 5, moved to the safe ending: vectors, the agreement that the captain would fly, the landing. Rule 6: airport, runway, the named charted visual, the river, bridges and the nearby airport used as landmarks, and the fix name removed (the river and bridges would identify the approach). Judgement calls: 'flaps 45' does not exist on this type, so the setting is left out ('gear and flap'). Dropped to stay within 250 words: '250 kts abeam the airport', 'no flap clacker', the first officer's view that the flaps went out about 5 knots fast (the captain says the speed was already below the limit when checked), and the briefed landmarks. The first officer's 'set up and arrival were uneventful' (which differs from the captain's 'high and fast') is left out as a characterisation. 'Broke 1,000 ft AFL' and '1,000 ft low over the fix' merged. Day or night not coded and not inferable (12:01-18:00, December), so left out. Bracket 'climbing': the crew went around. The captain's sighting of traffic on TCAS was not a conflict, so the standard safe-ending sentence is used.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S36 category C · ACN 2207575 · Human Factors · 186 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Final Approach
Reporter 1 function: First Officer; Pilot Flying
Anomaly: Deviation - Altitude Overshoot; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

I was pilot flying on flight ABCD to IAD for approach into 1C. Approach had us at 3000ft and gave us an intercept heading of 080 for 1C; before shortly after clearing us for the visual 1C. We were backing up the approach with the ILS 1C and upon localizer capture with the Autopilot; the airplane looked to not be turning toward the approach path. At that point; the CA and pilot monitoring told me I'd have to hand fly it as it looked to be a false capture. Slightly fixated on ensuring we don't overshoot final; and being on the segment of the approach that displays 2000ft; I went to about 1700 ft before the pilot monitoring indicated the altitude deviation and I promptly began correcting. Immediately we received one aural Enhanced Ground Proximity Warning System (EGPWS) 'Pull Up' as I was correcting. After the correction; I guided the aircraft to a stable approach and landing on 1C.

Synopsis

Air carrier First Officer reported the aircraft failed to intercept the localizer while descending and they received a ground proximity warning.

What the AI sees

The flight. An airliner on final approach to an airport before dawn, cleared for a visual approach.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. Approach control had the aircraft at 3,000 ft, gave it a heading to intercept the final approach course, and shortly afterwards cleared it for a visual approach. The crew were backing up the visual approach with the instrument landing system approach to the same runway. When the autopilot captured the localiser, the aircraft did not appear to be turning towards the approach path. The captain said that it looked like a false capture and that the first officer would have to hand-fly the approach. The first officer concentrated on not overshooting the final approach course. The aircraft was on the segment of the approach that is shown at 2,000 ft. The first officer descended to about 1,700 ft before the captain pointed out the altitude deviation, and the first officer promptly began to correct. As the first officer was correcting, the enhanced ground proximity warning system gave one aural "Pull up" warning.

Safe ending

After the correction, the first officer flew the aircraft to a stable approach and landed. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (first officer, pilot flying); the report has no reflection section. Rule 3: 'slightly fixated on ensuring we don't overshoot final' replaced by the stated intent, 'concentrated on not overshooting the final approach course'. The synopsis wording 'failed to intercept' is not used. Rule 5, moved to the safe ending: the stable approach and landing. Rule 6: airport, runway, flight number and the 080 heading removed. Judgement calls: aircraft type is not reported ('Commercial Fixed Wing'), so 'an airliner' rather than one of the brief's classes. Light is not coded; 'before dawn' is inferred from the coded local time (00:01-06:00, January). Bracket 'descending': the aircraft was near the final approach course, where other arriving traffic would be descending.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S37 category A · ACN 2247962 · Human Factors · 194 words

Original NASA report

Aircraft 1: B737-800
Flight phase: Initial Approach
Reporter 1 function: Pilot Flying
Anomaly: Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

On the approach via Location A visual; due to both weather west of the field; and gusty tail winds at altitude; we found ourselves slightly high on the final segment of the approach. To reestablish landing aim point; I did push the nose over more than normal for my experiences into ZZZ as a ZZZ based pilot. This resulted in a 3 alert GPWS sink rate call out when the aircraft was sinking at 1800 ft./min. through 500 feet AGL. This was corrected prior to 300 feet but exceeds are normal SOP. Cause: While the tail winds and the weather west of the field created compression and get their -itis; and a little bit of last leg syndrome; in the future; I will go around due to the improper application of delayed descent.

Synopsis

B737-800 pilot reported a GPWS Alert on approach. The pilot corrected rate of descent and landed uneventfully.

What the AI sees

The flight. A narrow-body airliner on a visual approach in the evening, arriving at the airport where the pilot flying was based. There was weather to the west of the airfield, and the winds at altitude were gusty tailwinds.

The crew. The report comes from the pilot flying, who had experience of approaches to this airport as a pilot based there. It does not say whether the pilot flying was the captain or the first officer, and gives no flying hours.

What happened. The crew flew a published visual approach procedure. Because of the weather west of the field and the gusty tailwinds at altitude, the aircraft was slightly high on the final segment. To get back to the landing aim point, the pilot flying pushed the nose down further than the pilot flying normally did on approaches to this airport. Passing 500 ft above the ground the aircraft was descending at 1,800 ft per minute, which was outside the company's normal standard operating procedures, and the ground proximity warning system gave three "Sink rate" alerts. The pilot flying corrected the rate of descent before 300 ft. The crew continued the approach and landed.

Safe ending

The aircraft landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: the whole "Cause" section ("compression", "get-there-itis", "last leg syndrome", "in the future I will go around", "improper application of delayed descent"). "Last leg" was not used as a fact because it appears only inside that label. Rule 5 moved to the safe ending: the uneventful landing (from the synopsis). Judgement calls: "a 3 alert GPWS sink rate call out" is read as three "Sink rate" alerts; the report does not say whether the reporter (the pilot flying) was the captain or the first officer, and the crew paragraph says so; no light or weather conditions are coded, so "in the evening" is from the 1801-2400 time block and the approach is described as visual, as the report does; the SOP exceedance is the reporter's own statement and is given as a fact. A short report: the shared text is within range with nothing added.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S40 category F · ACN 2219049 · Human Factors · 175 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Flight phase: Climb
Reporter 1 function: Pilot Flying; First Officer
Anomaly: Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

Upon takeoff at ZZZ; we departed via the ZZZZZX departure off of Runway XXL. At 400 feet when turning via the SID to a heading of 190; we experienced moderate turbulence while in a bank and climbing with the flaps extended; leaving a narrow margin of airspeed to work with to keep the aircraft within limits. I (First Officer) while flying the SID and Turing to a heading of 220 while leveling off noticed a possible over speed of the flaps and instinctively disconnected the Autopilot via the TCS switch and pitched up to avoid a flap over speed. Given the flap setting; slow speed; and moderate turbulence fluctuating the barber poles; this induced a momentary stick shaker at which time the corrective action was taken and the Captain took over flying duties. After the event the Captain maintained flight duties to give me (First officer) an opportunity to discuss the event. During the discussion we elected to maintain flying duties as Captain pilot flying (PF) and First Officer pilot monitoring (PM) for the rest if the flight to ZZZ1. The flight continued to ZZZ1 without event.Suggestions: After reflecting on tonight's events me and the Captain discussed the importance of maintaining vigilance to airspeed not only on the high side during a rough air penetration but the slow side as well especially with fluctuations in altitude. The complexity of the departure; moderate turbulence; multiple aircraft above and below; plus a tight turn to maintain the SID all contributed to the event.

Narrative 2

Upon takeoff at ZZZ; we departed via the ZZZZZX departure from Runway XXL. At 400 feet when turning via the SID on a heading of 190; we experienced moderate turbulence while in a bank and climbing with flaps extended; leaving a narrow margin of airspeed to work with to keep aircraft within limits. The First Officer while trying to fly the SID and turn to the 220 heading while leveling off noticed a possible over speed of the flaps and instinctively pitched up to prevent said over speed. Given the flap setting and slow speed with the turbulence fluctuating the barber poles; this induced a momentary stick-shaker at which time; the corrective action was taken; and I took control of the flying duties. After said event; I maintained flying duties to give the First Officer an opportunity for us to discuss the event once at cruise. After discussion; we elected to continue duties as Captain pilot flying (PF); and First Officer; pilot monitoring (PM). The rest of said flight was uneventful and normal. Suggestions: After the said event; the First Officer and I discussed the importance of maintaining vigilance to airspeed not only on the high side while during rough air penetration; but the slow side as well; especially with fluctuations in altitude. The complexity of the departure; multiple aircraft above and below and a tight turn to maintain the SID all contributed to the said event with the moderate turbulence.

Synopsis

EMB-170 flight crew reported on departure experiencing moderate turbulence resulting in temporary loss of control of the aircraft. The flight crew regained control of the aircraft and proceeded to their destination.

What the AI sees

The flight. A regional jet climbing out from a large airport on a published departure procedure. Night, with turbulence and icing conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. The departure procedure required a tight turn soon after take-off and a level-off, and there were other aircraft above and below. At 400 ft, turning onto the procedure's first heading while climbing with the flaps extended, the aircraft met moderate turbulence in the bank. This left a narrow airspeed margin within the aircraft's limits, and the turbulence was making the high- and low-speed limit indications on the speed tape fluctuate. While turning onto the next heading and levelling off, the first officer saw a possible flap overspeed. The first officer at once overrode the autopilot with the touch control steering switch and pitched up to avoid the overspeed. With the flaps extended, the low speed and the fluctuating limits, the stick shaker activated briefly. The crew took corrective action, and the captain took over the flying.

Safe ending

The captain flew the rest of the flight. After discussing the event at cruise, the crew kept those roles, and the flight continued to its destination without further event. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: both 'Suggestions' sections (vigilance to airspeed on the slow side as well as the high side) and the list of contributing factors. 'Instinctively' (both reporters) is replaced by the observable 'at once'. Kept: the tight turn, the level-off and the other aircraft above and below, which appear in the contributing-factors list but are facts the crew knew at the time; the first officer's reason for pitching up (to avoid a flap overspeed). Moved under rule 5: the captain flying the rest of the flight, the discussion at cruise and the uneventful continuation. Removed under rule 6: airport, departure and runway names; the two assigned headings are not given. Judgement calls: only the first officer mentions overriding the autopilot (touch control steering); the captain's narrative does not, and the first officer's account is used. The level-off altitude is not given. Standard safe-ending line used: other aircraft were present but no conflict is reported. Bracket 'descending': the pitch-up came during the level-off with traffic above, which near a departure is typically arriving traffic descending; 'crossing' would also fit.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S41 category C · ACN 2282213 · Human Factors · 152 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Mission: Passenger
Flight phase: Initial Approach
Reporter 1 function: Instructor; Pilot Not Flying; Captain
Anomaly: Deviation - Altitude Crossing Restriction Not Met; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

While flying inbound on the ILS XXC into ZZZ; ATC instructed us to maintain 5000ft to ZZZZZ and cleared for the approach. The VNAV Path was set at 2.0 degrees; so it showed the VNAV Path below our altitude of 5000 feet. prior to ZZZZZ; FPA (Flight Path Angle) was selected to 'chase' the path and I stated we are supposed to maintain altitude until the ZZZZZ fix. Once the aircraft started to descend below the assigned 5000ft we were queried about our altitude by ATC. ATC instructed us to climb back to 5000ft and maintain 5000ft until ZZZZZ; and cleared for the ILS XXC approach. We climbed to 5000ft; maintained 5000ft until ZZZZZ; then executed the approach with no further issues. ZZZ ILS XXC Low Altitude Alert.

Synopsis

ERJ-170 Captain reported they descended below a crossing restriction on approach and received a low altitude alert from ATC.

What the AI sees

The flight. A regional jet on a passenger flight, flying an ILS approach by day.

The crew. The captain was the pilot monitoring and was also acting as an instructor. The other pilot was the pilot flying.

What happened. Inbound on the ILS approach, ATC instructed the crew to maintain 5,000 ft to a fix on the approach and cleared them for the approach. The vertical navigation path was set at 2.0 degrees, so it showed the path below their altitude of 5,000 ft. Before the fix, flight path angle mode was selected to 'chase' the path. The captain stated that they were supposed to maintain altitude until the fix. The aircraft started to descend below the assigned 5,000 ft. ATC queried their altitude, instructed them to climb back to 5,000 ft and maintain it until the fix, and cleared them again for the approach. The crew climbed back to 5,000 ft.

Safe ending

The aircraft maintained 5,000 ft until the fix, and the approach was flown with no further issues. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was climbing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Nothing to remove under rule 3: the report has no Cause or Suggestions section. The report is short (one narrative of seven sentences), so the shared text is under 150 words; deviation D5 applies and nothing was added. The report does not say who selected flight path angle mode, so the passive is kept; the pilot flying is called 'the other pilot' because the report gives no other role for them. Kept as said at the time: the captain's statement that they were to maintain altitude until the fix. 'By day' is from the coded local time, 1201-1800. Moved under rule 5: maintaining 5,000 ft to the fix and flying the approach with no further issues. Removed under rule 6: the fix name, the runway and the airport. Judgement call: 'climbing', for traffic below the assigned altitude such as a departure.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S42 category F · ACN 2240035 · Human Factors · 208 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Flight phase: Descent
Reporter 1 function: Pilot Flying; Captain
Anomaly: Deviation - Speed All Types; Inflight Event / Encounter Weather / Turbulence; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

While on descent on the ZZZZZ [arrival]; ATC instructed us to maintain 310 kts or better. The ride was mostly smooth but then we started to get into a little it of light chop. I was PF and keeping a close eye on the airspeed while in the descent. I was overriding the throttles to keep them at idle and as the chop began to increase; the airspeed began to fluctuate and slowly increase; turning amber. Upon seeing the airspeed slowly continue increasing; I deployed full speed brakes to assist in slowing down; to no avail with the light chop we were in. With throttles at idle; full speed brakes deployed; I engaged TCS (Touch Control Steering) and firmly pulled the control wheel back; resulting in the airspeed quickly deteriorating and the stick shaker briefly activating for approximately 2 seconds. This was due to the perhaps aggressive nature I used to prevent the airspeed from reaching the barber pole. But I was trying to avoid an overspeed event and instead activated the stick shaker. I quickly stowed the speed brakes; relieved pressure on the control wheel and airspeed returned to our 310 kts. I further reduced airspeed to less than the 300 kts and instructed my FO to advise ATC we could it do 310 kts in the descent. We continued and landed normally.

Synopsis

EMB-170 Captain reported the stick shaker activated briefly during descent due to the Captain pulling the control wheel back and resultant airspeed loss.

What the AI sees

The flight. A regional jet descending on a standard arrival route. Daytime, with light turbulence.

The crew. The captain was the pilot flying and the first officer the pilot monitoring.

What happened. ATC instructed the crew to maintain 310 knots or more in the descent. The ride was mostly smooth, then the aircraft entered light chop. The captain was watching the airspeed closely and holding the thrust levers at idle, overriding the autothrottle. As the chop increased, the airspeed began to fluctuate and slowly increase, and the speed indication turned amber. As the airspeed kept increasing, the captain extended the speed brakes fully, but the speed did not come down. With the thrust at idle and full speed brakes, the captain pressed the touch control steering switch to override the autopilot and pulled the control wheel firmly back, intending to keep the speed from reaching the maximum speed limit. The airspeed fell quickly, and the stick shaker activated for about two seconds. The captain retracted the speed brakes and eased the back pressure, and the airspeed returned to 310 knots. The captain then reduced the speed below 300 knots and asked the first officer to tell ATC that the aircraft could not maintain 310 knots in the descent.

Safe ending

The flight continued and landed normally. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was descending nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the captain's later characterisation 'the perhaps aggressive nature I used'. Kept: the captain's intent at the time (to keep the speed from reaching the maximum speed limit and avoid an overspeed), and the speed reduction below 300 knots with the request to tell ATC, which is the deviation from the 310-knot instruction and a crew action. Moved under rule 5: the normal continuation and landing. Removed under rule 6: the arrival name. Judgement calls: the report's 'we could it do 310 kts' is read as 'could not', since the captain had just slowed below 300 knots. The report does not say how ATC responded, so nothing is added. 'Turning amber' is written as the speed indication turning amber. Bracket 'descending': the aircraft slowed below an assigned descent speed on an arrival, where the natural conflict is other arrival traffic descending behind or nearby.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S43 category A · ACN 2280891 · Human Factors · 166 words

Original NASA report

Aircraft 1: EMB ERJ 170/175 ER/LR
Flight phase: Final Approach; Landing
Reporter 1 function: Pilot Flying; First Officer
Anomaly: Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Unstabilized Approach; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

I was pilot flying landing in ZZZ. The approach was stable on visual glide path into runway XX. I rotated for landing and the aircraft floated more than I had expected. Causes where potentially me starting the rotation high and the aircraft being lighter due to less passengers. I was fixating on landing and correcting what I saw developing by holding pitch or even lowering it. I touched down on the main wheels at or just beyond the last touchdown zone stripe. I began to pull the triggers and pull back to engage thrust reversers for the landing when the Captain called the go around. I hesitated to initiate it and then looked over to see if my reversers had engaged and the Captain took control of the aircraft to complete the landing.

Synopsis

ERJ 170 First Officer reported an unstable approach and long landing resulted in the Captain taking controls.

What the AI sees

The flight. A regional jet on a passenger flight, landing in the evening after a visual approach. The aircraft was lighter because there were fewer passengers. The report does not give the weather.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. The approach was stable on the visual glide path to the runway. The first officer began the landing flare, and the aircraft floated further than the first officer expected. To correct this and land, the first officer held the pitch attitude or even lowered it. The main wheels touched down at or just beyond the last touchdown zone marking. The first officer began to pull the reverse thrust triggers and levers to deploy the thrust reversers. At that moment the captain called for a go-around. The first officer did not start the go-around at once, and looked to see whether the reversers had deployed. The captain then took control of the aircraft to complete the landing.

Safe ending

The captain completed the landing, and the aircraft stopped on the runway without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (A-excursion)

The aircraft could not be stopped on the remaining runway. It left the end of the runway at about 30 knots and came to rest on the grass. The passengers were evacuated, and two received minor injuries during the evacuation. The aircraft was slightly damaged.

What was cut, moved or changed (condenser's notes)

Rule 3 removed: "fixating on landing" (replaced by the observable actions: holding or lowering the pitch to correct the float and land), "I hesitated" (replaced by "did not start the go-around at once"), and the hedged cause "potentially me starting the rotation high". Kept from the cause sentence as a fact: the aircraft was lighter because there were fewer passengers. Judgement call: the touchdown at or just beyond the last touchdown-zone marking is kept in the shared text. Where they touched down is normally safe-ending material, but here the crew's later actions (selecting reverse, the captain's go-around call, the change of control) follow from it, and it does not contradict the bad ending. Safe ending: the report stops at the captain taking control "to complete the landing"; that the aircraft then stopped on the runway without further incident is inferred from the absence of any excursion or damage in the coded fields. No weather or light is coded; "in the evening" is from the 1801-2400 time block. The coded anomaly "loss of aircraft control" is not described in the narrative and was not added.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S44 category B · ACN 2222332 · Procedure · 238 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Landing
Reporter 1 function: Captain; Pilot Not Flying
Reporter 1 experience: Flight Crew Last 90 Days 225; Flight Crew Total 7750; Flight Crew Type 1600
Anomaly: ATC Issue All Types; Conflict Ground Conflict; Critical; Ground Incursion Runway; Ground Incursion Taxiway
Primary problem: Procedure

Narrative 1

Performing the flight ZZZ1 - FLL. On the approach and landing for Runway 28L we were light weighted for landing (approximately 57.5 tons) with a Vapp speed of about 122 kt. plus a headwind of about 15 kt.; factors that made us land very short; making us between intersection J8 and J7 be at taxi speed. As there was traffic behind us we thought the best course of action would be to vacate the runway at J7 instead of continuing down the runway at taxi speed and vacate on J5 or J4.Already turning on J7 the Tower advised us to continue down and vacate the next right; but the turn was already made and it was not possible to turn back to the runway. We were instructed to hold short on the runway before Taxiway J; because there were aircraft taxiing to Runway 28L on Taxiway J. As we were still on the runway; Aircraft Z landing behind us was instructed for a go-around.Contributing factors: Low approach speed making us land very short; fatigued; low experience operating at the airport; lack of information on the chart alerting the crews that Taxiway J7 is a hotspot when operating Runway 28L for takeoff; as vacating on this taxiway conflicts with traffic taxiing to Runway 28 for takeoff on Taxiway J.Suggestions: Implementing a hotspot on Taxiway J7 alerting the risk of vacating on J7 when landing on Runway 28L and 28L being used for takeoff as there will be traffic taxiing in the opposite direction on Taxiway J.An internal safety report was made.

Synopsis

Air carrier Captain reported landing at FLL and exiting the runway at an earlier taxiway than normal that then led to an active runway. Reporter suggested a hotspot designation.

What the AI sees

The flight. A narrow-body airliner landing at an airport at night. Visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring. The captain had 7,750 hours, 1,600 of them on type, and 225 hours in the previous 90 days. The crew were tired and had little experience of operating at the airport.

What happened. The runway was in use for both landings and departures. The aircraft was light, at about 57.5 tonnes, with an approach speed of about 122 knots and a headwind of about 15 knots. The landing roll was very short, and the aircraft was at taxi speed between two exits early in the roll. There was traffic behind, and the crew judged it best to leave the runway at the next exit rather than continue at taxi speed to an exit further down the runway. The airport chart did not mark this exit as a hot spot. As the aircraft was already turning onto the exit, the tower controller told the crew to continue down the runway and leave at the next exit on the right. The turn had already been made, and it was not possible to turn back onto the runway. The controller then told the crew to hold short of a parallel taxiway, because aircraft were taxiing along it towards the runway for departure. The crew stopped the aircraft as instructed, still on the runway.

Safe ending

The tower controller instructed the aircraft landing behind to go around. No one was hurt and no aircraft was damaged.

Bad ending (B-landing)

The landing aircraft's crew saw the conflict late and went around from about 50 feet, passing low over this aircraft. A flight attendant on the landing aircraft was thrown off balance by the abrupt go-around and received a minor injury.

What was cut, moved or changed (condenser's notes)

Variant B-landing: the conflicting traffic was the aircraft landing behind, which ATC sent around; the departing aircraft on the taxiway were taxiing, not taking off. Bracket 'this aircraft': the aircraft was stopped still on the runway. Removed under rule 3: the Suggestions (designate a hot spot at that exit) and the note that an internal safety report was made. From the Contributing factors list, kept only the facts and states: tiredness, little experience at the airport, the low approach speed and short landing roll, and that the chart did not mark the exit as a hot spot; the list's causal framing was dropped. Moved to the safe ending under rule 5: the go-around of the following aircraft. Removed under rule 6: airport (named in the narrative, synopsis and airspace field), runway number, taxiway names and the departure point. Judgement calls: aircraft type coded only as 'Commercial Fixed Wing'; 'narrow-body airliner' inferred from the 57.5-tonne landing weight and 'Vapp'. The pilot flying is not named; the captain was pilot not flying, so the first officer is given as pilot flying. 'Fatigued' is unattributed in the report and rendered as 'the crew were tired'. Light coded as Night with a 0601-1200 time band; given as 'at night'. 'Land very short' is read as a very short landing roll (the aircraft was at taxi speed early), not a touchdown short of the runway.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S46 category D · ACN 2201642 · Human Factors · 247 words

Original NASA report

Aircraft 1: Commercial Fixed Wing
Flight phase: Climb
Reporter 1 function: Pilot Flying; Captain
Reporter 1 experience: Flight Crew Last 90 Days 64.27; Flight Crew Type 161.12
Anomaly: ATC Issue All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Loss Of Aircraft Control
Primary problem: Human Factors

Narrative 1

(The following incident occurred over approximately 1 minute and 30 seconds after departure from Newark).We were cleared for the Newark5 Departure to 2500 and to expect vectors on course. Departures at that time were from runway 22R intersection M. The FO and I reviewed the plate and discussed the threats because neither of us regularly operate out of Newark. We talked about the notes about avoiding LNAV on the company pages. Then I briefed the departure and explained that it would be hand flown using Heading Mode; we built the box accordingly with the appropriate frequency and distance ring. Performance data gave flaps 5 and due to the gusty winds we elected to conduct the max thrust takeoff procedure. Everything between the gate; taxi and takeoff was normal.We were cleared for takeoff at approximately XA:36Z. At 400' I began the left turn to 190 and we were handed off to Newark Departure (119.200). We checked in and the instructions we received were to 'turn left heading three-zero-zero; climb and maintain one-zero-thousand'. FO readback the instructions; spun the heading bug left to 300 and set the correct altitude. I verified each. At the same time we were beginning the cleanup phase but I noted to the FO that although I wasn't certain this instruction seemed non -standard so I intended to temporarily keep the flaps at 1 and the speed at 210 to help keep the turn radius tight and the climb steep. My thought was that perhaps they were planning to have us cross over the field at 10;000 similar to how LAX occasionally handles vectored departures; but I don't operate out of Newark often so I wasn't certain about this. Either way I didn't want the turn radius to be wide. This will be very relevant later.It took about 30 seconds for Newark Departure to come back on the radio and ask us why we were going left and to command an immediate right turn to heading 270 (no longer to 300; although later we would be asked to 'please keep turning' as if we just stopped out of non-compliance). This was a major startle for us in the flight deck; we were in a steep climb to the left and being told to immediately bank right. My FO spun the heading bug and I executed the turn. My gut sank out; adrenaline spiked and I became very nervous that we somehow deviated from ATC's instructions. I didn't realize it in the moment but my FO caught it and called out for me to watch my bank which was then around 45 degrees to the right. I believe the startle combined with the spike in stress of a possible deviation; loss of traffic separation or airspace excursion contributed to my over reaction. The aircraft gave the 'bank angle' call two different times during this period; as it rightly should have. A second controller (possibly a supervisor) then came over the radio and commanded us to stop our climb 'now!' and I leveled off; rolled wings level and asked the FO to set 3000' in the altitude window and hit level change. For a moment we tried to re-cage our flight deck and collect ourselves from the startle that just occurred. We had started to accelerate towards 250 knots when I noticed the speed tape and realized the flaps were still at 1 and called for 'flaps up after takeoff checklist'. I have no reason to believe we exceeded a flap speed; the speed bug never went past 250 from what either of us saw and we never heard an aural alert indicating an overspeed. It was just something that had been lost from our attention in the commotion but we finally got back to it before it became a problem.Between the two controllers we were eventually vectored back to 300 and out of their airspace. I believe the departure controllers realized they had perhaps given the wrong initial instruction and therefore never followed up with us on the issue. Either way it became very troubling for us in the flight deck because we spent the next 4 hours debriefing ourselves about our mistakes: Did we go the wrong way?What had we heard or thought we had heard?What willwe do in the future?Why did I over control the aircraft?What are the passengers thinking?How about the flight attendants?It was very embarrassing. I spoke with the flight attendants a little while later in the flight; explained what had occurred and asked if there were any injuries or concerned passengers and they said it was a little exciting for about thirty seconds but no; there were no injuries and no passengers seemed to really be concerned.

Synopsis

Air carrier Captain reported an excessive bank angle when correcting a turn from a heading deviation while climbing on a departure procedure. The pilot recovered the bank angle and followed ATC instructions and continued the flight.

What the AI sees

The flight. A twin-engine airliner on an airline flight, departing a large airport neither pilot used regularly. Visual conditions, gusty winds.

The crew. The captain was the pilot flying and the first officer the pilot monitoring. The captain had about 160 hours on type.

What happened. Cleared for the published departure to 2,500 ft, the crew briefed a hand-flown departure in heading mode. At 400 ft the captain began the published left turn to heading 190. The instruction the crew received from the departure controller was to turn left to heading 300 and climb to 10,000 ft. The first officer read it back and set it; the captain checked. The captain said that, though not certain, it seemed non-standard, perhaps to take them over the airport, so they would keep flaps 1 and 210 knots for a tight turn and steep climb. About 30 seconds later the controller asked why they were turning left and ordered an immediate right turn to heading 270. Startled, and anxious that they had deviated, the captain rolled right. The first officer called out the bank, which reached about 45 degrees, and the "bank angle" alert sounded twice. A second controller ordered them to stop the climb immediately; the captain levelled off and had 3,000 ft set. As the speed rose towards 250 knots, the captain saw the flaps were still at 1 and called for flaps up. Neither pilot saw the speed pass 250 knots, and there was no overspeed warning.

Safe ending

Air traffic control then vectored the aircraft back to heading 300 and out of the departure airspace, and the flight continued. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Removed under rule 3: the captain's later belief that the controllers had given the wrong initial instruction and so never followed it up; the captain's view that startle and stress 'contributed to my over reaction' and the question 'Why did I over control the aircraft?'; the four hours of self-debriefing, 'our mistakes' and 'very embarrassing'; the aside that the flap point 'will be very relevant later'; the captain's reading of 'please keep turning' as implying non-compliance. Kept as facts at the time: the crew's unfamiliarity with the airport, the hand-flown heading-mode briefing, the instruction as the crew received it and its readback, the captain's doubt about it and reason for keeping flaps 1 and 210 knots, the startle and the captain's anxiety (a state reported at the time), the bank of about 45 degrees and the two bank angle alerts, the stop-climb order and level-off, and the late flap retraction with no observed flap overspeed. Moved to the safe ending (rule 5): the vectors back to heading 300 and out of the airspace. The flight attendants' later report of no injuries is covered by the fixed ending line. Removed under rule 6: the airport, departure name, runway, intersection and frequency. Judgement calls: the report does not show whether the controller actually said 'left heading 300', so the text says only that this was the instruction the crew received; the type is not given ('commercial fixed wing'), so 'twin-engine airliner' was used; the light is not given (local time band 1201-1800, January), so day or night is not stated; cut for length: the chart and threat review (including company notes on avoiding lateral navigation mode), 'expect vectors', the maximum-thrust take-off, the first officer setting the new heading, the level-change mode, the after take-off checklist call, and a controller's request to 'please keep turning' (its timing in the sequence is unclear); the shared text runs to the flap retraction, which came after the stop-climb order, because it is a crew action in the same sequence and leaving it out of one version only would make the versions differ. The report shows no traffic, so the standard safe-ending line is used. Bracket 'crossing' because the deviation was a turn the opposite way from the one controllers expected, across other airspace, followed by an order to stop climbing.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?

S48 category C · ACN 2203905 · Human Factors · 153 words

Original NASA report

Aircraft 1: Regional Jet 700 ER/LR (CRJ700)
Flight phase: Initial Approach
Reporter 1 function: First Officer; Pilot Flying
Anomaly: Aircraft Equipment Problem Less Severe; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Primary problem: Human Factors

Narrative 1

Person A was pilot flying (PF) and Person B was pilot monitoring (PM).On the arrival into ZZZ we were being vectored for the visual to Runway XX. We were given a left turn from the downwind to a pseudo left base leg and given clearance for the visual approach XX. Upon receiving this clearance I selected 1900 feet in the altitude selector as we were outside of ZZZZZ for the next point on the approach. We were simultaneously slowing and configuring the aircraft at the time and did not notice the aircraft had descended to 1600. We received a caution obstacle" alert off of the GPWS from the Tower in line with the LOC of Runway XX. Visual contact was kept at all times and we continued the left turn to the approach course and landed safely.The primary reason behind this issue was the compression of time due to the late configuration.From my perspective; this issue began on the downwind leg. In retrospect; I would have preferred to start slowing down and configuring much earlier to prevent us from becoming overwhelmed with tasks."

Synopsis

CRJ-700 First Officer reported altitude overshoot resulted in GPWS alert and a CFTT event.

What the AI sees

The flight. A regional jet on a visual approach to an airport, in visual conditions.

The crew. The first officer was the pilot flying and the captain the pilot monitoring.

What happened. On the arrival, air traffic control was vectoring the aircraft for a visual approach. The aircraft was turned from the downwind leg onto something close to a base leg and cleared for the visual approach. On receiving the clearance, the first officer selected 1,900 ft in the altitude selector, because the aircraft was still outside the next fix on the approach. The crew were slowing the aircraft and configuring it for landing at the same time, and did not notice that the aircraft had descended to 1,600 ft. The ground proximity warning system then gave a "Caution, obstacle" alert, for a tower in line with the localiser. The crew kept visual contact throughout and continued the turn towards the approach course.

Safe ending

The aircraft joined the approach course and landed without further incident. There was no conflict with other traffic. No one was hurt and the aircraft was not damaged.

Bad ending (LOS)

Another aircraft was crossing nearby. Both crews received TCAS resolution advisories and followed them, and the aircraft passed about 300 feet vertically and half a mile apart. A flight attendant on this aircraft was thrown against a galley cart during the manoeuvre and received a minor injury.

What was cut, moved or changed (condenser's notes)

Single narrative (first officer, pilot flying). Rule 3, removed: the stated primary reason (time compression from late configuration), the 'in retrospect' preference to slow and configure earlier, and 'overwhelmed'. Rule 5, moved to the safe ending: joining the approach course and the landing. Rule 6: airport, runway and fix name removed. Judgement calls: the report's 'caution obstacle alert off of the GPWS from the Tower in line with the LOC' is read as a GPWS obstacle alert caused by a tower (structure) on the localiser line; no ATC alert is coded in the result fields, which supports that reading, but it is an interpretation. 'Pseudo left base' rendered 'something close to a base leg'. The report does not say whether or how the crew climbed back; nothing was added. Day or night not coded and not inferable (12:01-18:00, January), so left out. Shared text is 153 words including the paragraph labels (147 without); the report is short and nothing was added. Bracket 'crossing': the aircraft went below its selected altitude in a turn and did not climb.

Faithful? · Neutral wording? · Reads right to a pilot (and bad ending plausible)? · Nothing before the ending gives the real outcome away?