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ACN: 1198605

Time / Day

Date : 201408Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZZ.Airport

State Reference : FO

Altitude.AGL.Single Value : 0

Environment

Flight Conditions : VMC

Light : Daylight

AircraftReference : X

ATC / Advisory.Ramp : ZZZZAircraft Operator : Air Carrier

Make Model Name : A330

Crew Size.Number Of Crew : 3Operating Under FAR Part : Part 121Flight Plan : IFR

Mission : Passenger

Flight Phase : Parked

Person

Reference : 1Location Of Person.Aircraft : XLocation In Aircraft : Flight Deck

Reporter Organization : Air Carrier

Function.Flight Crew : CaptainFunction.Flight Crew : Pilot Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)ASRS Report Number.Accession Number : 1198605

Human Factors : Communication BreakdownHuman Factors : Distraction

Human Factors : Situational Awareness

Human Factors : Training / QualificationHuman Factors : Workload

Human Factors : ConfusionCommunication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Ground Personnel

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Ground Event / Encounter : Other / Unknown

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Detector.Person : Ground Personnel

When Detected : Taxi

Result.Flight Crew : Took Evasive ActionResult.Flight Crew : Became Reoriented

Assessments

Contributing Factors / Situations : Company PolicyContributing Factors / Situations : Human FactorsContributing Factors / Situations : Procedure

Primary Problem : Company Policy

Narrative: 1

After the pushback the parking brake was set to "Parked" and the Guideman on the

interphone was cleared to disconnect. He acknowledged, and it sounded like theinterphone was immediately unplugged. After an inordinately long period, duringwhich time we in the cockpit were preoccupied with engine starting and distracted

by multiple weight and balance uplinks, two ground crew members were observed

walking away from aircraft left. They did not turn around for a salute, but, since so

long had passed since the disconnect, it appeared that they had gotten tired ofwaiting for acknowledgment and simply walked away.

At no time during this extended wait did the Guideman re-connect the interphoneand tell us that they were experiencing difficulties. We called for taxi, and I

momentarily released the parking brake, but then did our standard clearing

procedure and observed the tug still visible below the left side cockpit window. Ireset the parking brake to "Parked", and simultaneously heard the intercom re-

connect and the Guideman inform us that they were still below. The parking brakehad only been released for a moment and the normal, manual brakes were

engaged the entire time. The aircraft did not move. I do believe that the nose

wheel steering memo had disappeared prior to parking brake release.

In summary, the pushback involved an inordinately long delay in disconnecting thetug, the failure to communicate an abnormal situation, and cockpit distractions. Our

system of multiple, layered barriers worked, however, and trapped the errorsbefore an incident occurred.

This pushback illustrates a potential threat and loss of a barrier during pushbackthat was introduced with the recent procedure change. Under legacy pushback

procedures, the tug operator remained in interphone contact with the Captain untilthe tug was disconnected and ready to drive away: "Towbar removed,

disconnecting headset, standby for hand signals." Under the recent procedurechanges, the Captain's call is "Parking brake parked, cleared to disconnect

interphone". While the intent is ambiguous, many Guideman are immediately

unplugging the interphone, and remain out of communication during the towbarremoval process. During this time, there are men and equipment under the aircraft,frequently not visible from the cockpit, and disconnected from voice

communications. This represents the loss of an important communications barrier.

I would suggest that the pushback procedure and callouts be clarified to specify

that the Guideman remain in interphone contact with the Captain until the tug is

safely disconnected and ready to drive away. Any abnormal situations or difficultiesshould immediately be communicated to the cockpit.

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Synopsis

During pushback at a foreign airport, an A330 Captain employed a new Pushback

Crew disconnect command at which time he expected the Guideman to disconnect.After a long start process, the Captain released the parking brake and found theGuideman still connected.

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ACN: 1197154

Time / Day


Place

Locale Reference.ATC Facility : ZZZ.ARTCC

State Reference : US

Altitude.MSL.Single Value : 36000

Environment

Flight Conditions : IMC

Light : Night


ATC / Advisory.Center : ZZZAircraft Operator : Air Carrier



Mission : Passenger

Flight Phase : CruiseFlight Phase : Climb

Airspace.Class A : ZZZ

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight DeckReporter Organization : Air Carrier

Function.Flight Crew : CaptainFunction.Flight Crew : Pilot Not Flying


Human Factors : Time Pressure

Human Factors : DistractionHuman Factors : Physiological - Other

Human Factors : Situational AwarenessHuman Factors : Troubleshooting

Analyst Callback : Completed

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Illness

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

Detector.Person : Flight Crew

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Detector.Person : Passenger

Detector.Person : Flight Attendant

When Detected : In-flightResult.General : Declared Emergency

Result.General : Flight Cancelled / DelayedResult.General : Maintenance Action

Result.Flight Crew : Landed in Emergency ConditionResult.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Took Evasive ActionResult.Aircraft : Equipment Problem Dissipated

Assessments

Contributing Factors / Situations : Weather

Contributing Factors / Situations : AircraftContributing Factors / Situations : Human Factors

Primary Problem : Weather

Narrative: 1

Climbing to FL370, about :50 minutes into flight, the First Officer and I noticed ahot, electrical smell. We queried the flight attendants and they also smelled it. No

smoke was visible and none reported. We had the engine anti-ice on and saw a lotof St. Elmo's fire on our windscreens. The IRO came forward from the crew-restseat as he also noticed the smell. The flight attendants and IRO walked through the

cabin to try to localize the source, especially the galleys, with no results. The First

Officer and I were on oxygen as a precaution.

We leveled off clear of clouds and static and turned off the engine anti-ice. Thesmell seemed to dissipate some. The flight attendants reported passengers

expressing concern with some complaining of minor eye irritation. As pilot

monitoring, I contacted Dispatch and Maintenance Control. Maintenance suggestedsome steps to localize the source when the Lead Flight Attendant reported that the

one Flight Attendant was feeling poorly and going on oxygen. I then told Dispatchwe were diverting and they requested we return to the departure airport. I did not

consider that it was necessary to divert to the nearest airport as there was nosmoke and the smell seemed to be diminishing. We turned toward the departure

airport and in the descent through clouds; the smell seemed to increase again so

we declared an emergency with ATC to receive priority handling and high speeddescent. The smell again seemed to decrease. I assumed pilot flying duties and

made a normal landing in VFR weather.

As requested, paramedics met us at the gate. We asked passengers to remainseated so those wanting assistance (3 flight attendants and 2 passengers) could be

seen to. Four flight attendants went with the paramedics for tests/observation. I

filled out the odor report form, made a lengthy entry in the FDML and spoke to aMaintenance Supervisor. The First Officer, IRO and I felt no ill effects other thanpossible mild eye irritation. Electrical smell from unknown source.

Callback: 1

The reporter stated that in the climb and descent when the odor was detected both

the engine anti-ice was ON and flight was in very heavy St. Elmo's fire. During the

short cruise flight period the odor dissipated but again returned as the flightdescended through the weather with engine anti-ice ON in St Elmo's conditions.

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ACN: 1193848

Time / Day


Place

Locale Reference.Airport : ZZZZ.Airport



Environment


Light : Daylight


Aircraft Operator : Air CarrierMake Model Name : A330

Crew Size.Number Of Crew : 3

Operating Under FAR Part : Part 121Flight Plan : IFRMission : Passenger


Component

Aircraft Component : Parking Brake

Aircraft Reference : XProblem : Improperly Operated

Person




Qualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1193848Human Factors : Confusion

Human Factors : Human-Machine InterfaceHuman Factors : Situational Awareness

Human Factors : Communication BreakdownCommunication Breakdown.Party1 : Ground Personnel

Communication Breakdown.Party2 : Flight Crew

Events

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Anomaly.Aircraft Equipment Problem : Critical

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Procedural : Published Material / PolicyAnomaly.Ground Event / Encounter : Loss Of Aircraft Control

Detector.Person : Flight CrewWere Passengers Involved In Event : N

When Detected : Aircraft In Service At GateResult.Flight Crew : Overcame Equipment Problem

Assessments

Contributing Factors / Situations : Human FactorsContributing Factors / Situations : Procedure

Contributing Factors / Situations : Airport

Primary Problem : Human Factors

Narrative: 1

Taxied into the [international] gate on arrival following self guidance system.

Stopped when indicated and waited for an "OK" indication to shutdown. Received

the "OK" then proceeded with shutdown procedures. During my flow I looked upagain to see "INBLK." I have never seen this on any other system and took it to

mean that the aircraft was chocked. I released my foot pressure off the brakes andcontinued my shutdown. I knew that the jetway was in the process of movingbackwards when the First Officer said that the aircraft was rolling backwards. I told

him it was the jetway [movement] and he assured me it was the aircraft. I

immediately applied the parking brake. The steep ramp gradient and my failure toset the parking brake prior to releasing the brakes [resulted in the aircraft rolling

backwards.]

From the pilot side of the equation I would suggest the following. I have spent

years developing a habit pattern derived from the scrutiny of my fellow pilotsregarding the [need to] capture every flight minute possible. This has included the

use of the parking brake which triggers in and out times. I have held short of activerunways straining to hold the brakes and scared to death of accidentally releasing

them. I have even had my fellow pilots remind me not to set the brakes but to waitfor a door to be opened hoping to capture another minute. I have gone ahead and

set the parking brake only to be chewed out by other pilots. So I am forced to

unlearn a bad habit, relearn a new one, and ignore the wishes of mycontemporaries. Another input on the A330 is brake temperature and the ECAM

warning hastened by the application of the parking brake.

From the other side of the equation: We should have a better system for [block]time capture. I understand that brake [cooling] fans were an option that was

turned down by the company. This airport obviously has a problem that they seem

to want to shift onto someone else. I understand we normally park at C[concourse] but instead was parked at B where the gradient may be even worse.Knowing the problem, the airport and station personnel should be more proactive in

contributing solutions. The guide in system should have "INBLK" removed to avoidconfusion. The aircraft needs to be chocked immediately in multiple locations. Amarshaller should be there to give the pilot a "chocks in" signal and a "set brakes"

signal.

Synopsis

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ACN: 1188333

Time / Day


Place




Environment

Light : Night

Aircraft

Reference : XATC / Advisory.Center : ZZZ




Flight Phase : Cruise


Person


Cabin Activity : Service

Reporter Organization : Air CarrierFunction.Flight Attendant : Flight Attendant (On Duty)

Qualification.Flight Attendant : CurrentASRS Report Number.Accession Number : 1188333

Human Factors : Physiological - Other

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / OdorDetector.Person : Flight Attendant

Were Passengers Involved In Event : YWhen Detected : In-flight

Result.General : Physical Injury / IncapacitationResult.Flight Crew : Took Evasive Action

Result.Flight Crew : Diverted

Assessments

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Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Human Factors

Primary Problem : Aircraft

Narrative: 1

A strong odor on the plane once we took off (all the way from the back to the front

of the aircraft). My eyes were burning at the beginning. After the first service in themain cabin, once I got to the back galley, I started to feel lightheaded and difficultybreathing. I sat down on the jumpseat because I was dizzy.

Few seconds later, my hands started tingling badly and the color of both of myhands turned grey/blue. Immediately, the flight attendants gave me oxygen and I

was sitting with it for almost an hour. The color came back to my hands and I felt a

little better. I was very tired and couldn't keep my eyes open. I felt fatigue. Wecalled a Commercial Medical Service since we had no Dr. onboard. My throat is

burning till now.

Hoping the company will, finally, fix this "fumes" problem. I have a hospital report.

Synopsis

An A330 Flight Attendant reported fumes after takeoff and during cruise whichmade her ill and required oxygen. The flight diverted after consulting with aCommercial Medical Service.

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Human Factors : Fatigue

Human Factors : Communication Breakdown

Human Factors : ConfusionCommunication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : ATCAnalyst Callback : Completed

Person : 2

Reference : 2



Function.Flight Crew : Pilot Flying

Function.Flight Crew : First OfficerQualification.Flight Crew : Air Transport Pilot (ATP)

Experience.Flight Crew.Total : 18500Experience.Flight Crew.Last 90 Days : 75

Experience.Flight Crew.Type : 1600

ASRS Report Number.Accession Number : 1178363Human Factors : Troubleshooting

Human Factors : Human-Machine InterfaceHuman Factors : Fatigue

Human Factors : ConfusionHuman Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight CrewCommunication Breakdown.Party2 : ATC

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.ATC Issue : All TypesAnomaly.Deviation - Track / Heading : All Types

Anomaly.Deviation - Procedural : ClearanceDetector.Person : Flight Crew

Detector.Person : Air Traffic ControlWhen Detected : In-flight

Result.Flight Crew : Took Evasive Action

Result.Flight Crew : Returned To ClearanceResult.Flight Crew : Requested ATC Assistance / Clarification

Result.Flight Crew : Became ReorientedResult.Air Traffic Control : Issued New Clearance

Result.Air Traffic Control : Issued Advisory / Alert

Assessments

Contributing Factors / Situations : Human FactorsContributing Factors / Situations : ProcedureContributing Factors / Situations : Aircraft

Primary Problem : Ambiguous

Narrative: 1

Our flight started out two hours late due to MEL 21-26-01 Avionics EquipmentVentilation Extract Fan. I was so informed by the Crew Scheduler with a new hotel

pickup time. On our departure push back and engine startup we were forced a

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return to the gate because it was loaded incorrectly and we had to return gate

because of MEL 25-51-01 Cargo Restraint Components (Includes Bulk Cargo

Netting). One of things that is never mentioned in crew fatigue are aircraftproblems such as MELs, late arrival, returns to the gate are all factors effecting

crew performance. The work load on the crew to problem solve is tremendous. Onalmost every leg of this rotation we had aircraft delay and maintenance problems.

Here at our airline it's also not improving much either. Before our departure wewere told a one of our international flights landed short of its destination because it

was short on fuel...?

After departure we were all pretty tired. We received our Oceanic Clearance from

Gander in reasonable amount time before the coast out fix out but we wereinterrupted multiple times from flight attendant requests. Also ATC was also very

busy as well. As we review the clearance and we then receive a frequency change

to Gander we were ask to report the next fix after coast out which I report off theFMGEC as 63N050W. Gander Controller replied negative your routing is 62N050W63N040W 60N030W 57N020W. I said "roger" and stand by for a read back. We

realized that the first coordinates change slightly. The First Officer was the pilot

flying then type in 62N050W which presented him with a new way point prompt for

latitude and longitude entry at about (40 NM in error). The First Officer typed thelatitude and longitude numbers in and then line selected the correct line select key

on the FMGEC. After some discussion with the First Officer I decided to VERIFY theFULL LENGTH latitude and longitude of those new numbers not just once but twice!On preflight planning we are required to circle all Class Two latitudes and

longitudes. The Gander Controller said those latitude/longitude numbers appeared

to be correct but the Controller was used hearing the short versions. So we wentwith coordinates believing our navigation numbers were correct.

After passing our coast out waypoint both of us immediately realized thecoordinates were WRONG! We selected heading. Re-enter the points then after ashort time we were back on course. This deviation off course did not sit well with

Gander and we were advised of our navigational error and Gander was going file anavigation report. I acknowledged Gander's comment but we were to busy to sayanything else.

Dispatch got our reroute via ACARS then sent us a new flight plan. We deleted thesecondary flight plan in the FMGEC and uploaded the new route. The hand typeroute that the First Officer type matched perfectly! So we then upload the new

Secondary into the Primary. After some other required flying choirs were complete

I then called Gander back and said, "This is the Captain of Flight XXX." Ganderacknowledged. I told the Controller "I want all the previous ATC conversations withthe last controllers to be preserved, including this." Both First Officer's witnessed

and over heard the conversation. I also explain to the current Controller ourdeviation was due to the confirmed coordinates of the previous Controller. And that

our Airbus navigation system needs the full latitude/longitude and not just theshort version on the FMGEC coordinates. The Controller and other traffic seemed

surprise at my comments. By the way, both First Officers are excellent pilots and afine crew. They remained calm and collected through this event and I want my

statement to reflect this! Our arrival fuel was ahead our project burn, if you are off

course you are not going to beat the fuel burn.

Callback: 1

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The reporter stated that the root cause was limited FMGC memory. Normally, they

would simply enter 6350N but in this case all latitude and longitude digits were

required in order to create a waypoint so that the crew entered N6400 W05000.Even after double verifying the waypoints the crew made an error which the

Controller verified as correct, unaccustomed to the all nine latitude and longitudedigits which the crew read directly from the FMGC display.

Narrative: 2

As we were standing by for read back we realized the first coordinates changed

from 63N050W to 62N050W. I being the pilot flying entered in the MCDU the new

way point as 62N050W normal format. Once I do this a new prompt will appear andask for latitude/longitude. I am still west of my entry point and feel I have

sufficient time to build my new waypoint and verify it.

I proceed to type in LAT/LONG and discuss with the Captain that we need to verify

the full length latitude/longitude. He then request from Gander and reads them our13 digit LAT/LONG from his MCDU which he did twice to confirm. Gander Controller

said those LAT/LONG appear to be correct but admits being accustomed to the

short version with no access to 13 digits. With this done we feel our navigationnumbers are correct.

After crossing our coast out point we realize those are the wrong coordinates! I pull

heading on FCU to establish our current track. After reviewing our flight plan andre-entering a new way point and correcting the LAT/LONG we were able to confirm

and go direct to 62N050W.

Synopsis

An A330 crew reported that after a North Atlantic Track change they had difficulty

entering the coordinates in the FMGC because limited FMGC memory required the

waypoints be entered with the full nine digit latitudes and longitudes. They thenhad a track deviation when the Controller unaccustomed to hearing the full nine

North, West and East waypoint digits incorrectly confirmed an erroneous waypointwhich the crew read exactly from the FMGC display.

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ACN: 1175066

Time / Day


Place

Locale Reference.Airport : ZZZ.Airport



Environment


Light : Night


ATC / Advisory.Tower : ZZZAircraft Operator : Air Carrier



Mission : Passenger

Flight Phase : TakeoffAirspace.Class B : ZZZ

Person

Reference : 1Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Air CarrierFunction.Flight Crew : Captain

Function.Flight Crew : Check PilotQualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1175066Human Factors : Distraction


Human Factors : Time PressureHuman Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight AttendantCommunication Breakdown.Party2 : Flight Crew

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / OdorDetector.Person : Flight Crew


When Detected : In-flight

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Result.General : Maintenance Action

Result.Flight Crew : Landed As Precaution

Result.Flight Crew : Returned To Departure Airport

Assessments


Contributing Factors / Situations : Human FactorsPrimary Problem : Aircraft

Narrative: 1

At 500 feet after departure 2 flight attendants reported a chemical odor at doors3L/R. In the cockpit the 3 of us smelled an odor similar to burning rubber whichsoon dissipated. The flight attendants wanted medical assistance and the decision

to return to the departure airport was made. An overweight landing was made at420,120 lbs, sink rate 200 FPM. Dispatch had also advised to make overweightlanding. Logbook and odor forms were completed.

I suggest [we] advise Inflight Services that during sterile cockpit phases of

operation, one call to cockpit to advise us of a problem is sufficient.

Synopsis

After departure, the flight crew momentarily detected a burning rubber odor. Theodor was stronger in the cabin which caused the flight attendants to be persistent

so the Captain returned to the departure airport for a cautionary landing.

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ACN: 1169167

Time / Day


Place




Aircraft

Reference : X


Crew Size.Number Of Crew : 3Operating Under FAR Part : Part 121

Flight Plan : IFR

Person

Reference : 1Location Of Person.Aircraft : XLocation In Aircraft : Cabin Jumpseat

Cabin Activity : Service

Cabin Activity : DeplaningCabin Activity : Boarding


Function.Flight Attendant : Flight Attendant (On Duty)Qualification.Flight Attendant : Current

ASRS Report Number.Accession Number : 1169167Human Factors : Communication Breakdown

Human Factors : Situational AwarenessHuman Factors : Physiological - Other

Communication Breakdown.Party1 : Flight AttendantCommunication Breakdown.Party1 : Ground Personnel


Events

Anomaly.Flight Deck / Cabin / Aircraft Event : IllnessAnomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Deviation - Procedural : FARDetector.Person : Flight Attendant

Were Passengers Involved In Event : Y

When Detected : Pre-flightWhen Detected : In-flight

Result.General : None Reported / Taken

Assessments

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Contributing Factors / Situations : Company Policy



Narrative: 1

Flight attendants were waiting for Captain's briefing. While we were waiting for pilot

briefing we sent in the A Flight Attendant to check on front in. She came backstating they would be here in a few minutes. Getting close to boarding time, still nobriefing. First Officer and Relief Officer show up stating Captain still on phone with

Flight Planning. First officer stated, "SOP and if anything would change they would

let us know."

So at this time we proceeded to gate at this point. I have yet to see or speak to

Captain. Soon, in flight a Flight Attendant states, "Wow, you should see theCaptain, he looks really sick." I think nothing of it other then he must have a cold

or flu. Why would you come to work and expose us to his illness?

Shortly after service, a coach Flight Attendant states to me she has been called to

the flight deck and only her. Did not know why or outcome of that meeting. I findout at the hotel. She was only allowed to tell the A Flight Attendant and E Flight

Attendant. Decision was made to apparently keep rest of crew in dark about whatwas discussed.

Deplaning in ZZZZ as I am getting off jetway, I see a man sitting in a chair looking

very ill and think to myself, this person is very sick. At about this time I see theFirst Officer and Relief Pilot standing beside this person. I think to myself please

don't let this be our Captain. I did not recognize this man as an employee, becausehe had pullover wind breaker jacket of some type. Saw no stripes, crew ID or

anything that would lead me to believe he was a crew member.

At this point I hear whispers; we need to walk slowly. I'm wondering what's going

on. At this point I realize this is our Captain and he can hardly walk. He wasextremely winded and had to stop every so often to rest. We proceed to the bus. Ashe approaches the bus he stops to smoke. When rest of crew arrives he tries to geton bus. I am sitting at doorway so I have full view of him attempting to climb three

steps to get in bus. He was having a difficult time doing this. He proceeds to sit a

row in front of me on opposite side of bus so I have full view of him. So I observehim.

He was having extreme difficulty moving around in seat and moving left arm. Inotice his left hand is swollen and on the back of his right hand a huge black andblue mark, with bandage on that hand. At this point to me it is obvious to me this

person is not fit to fly. If there would be some sort of emergency in flight there isno way he could have handled it.

We arrive at hotel and Captain is one of first people to get a room. Flight

attendants are now talking amongst ourselves saying, "What the heck?" I cannotbelieve he was flying this aircraft. We are making statements to First Officer; I amnot flying back with him due to safety reasons. We had discussion what should be

done about this situation. This is when I realize this was what the meeting wasabout in the air. And it was decided then to keep us in the dark about this situationuntil we landed. I am by no means happy with this decision about my life being

made for me.

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We left the lobby to go to our rooms for the day, assuming the First Officer was

going to call scheduling about this situation because I, for one, was definitely notflying back to the States with him in charge of aircraft... I have no idea whether

First Officer called or not. I heard later in the day that a flight attendant calledscheduling to advise them of situation.

Flight attendants should never get on an aircraft without laying eyes on pilots and

having a simple conversation with them. I feel this is a must. If I would have seenhim in briefing and listened to and spoke to him I would have know something was

wrong. This man was obviously sick for some time. I believe the Chief Pilot needs

[to have] a presence in the [the pre-departure crew room] when internationalcheck-ins happen. There appears to be no accountability. We have in-flight

supervisors in the room, why not the chief pilot? I believe this to be of utmost

importance, it was quite obvious this man was extremely ill.

Synopsis

When a series of behavioral hints and suspicious events before, during and after

their transatlantic flight brought into question the Captain's fitness for flight, theflight attendants made it clear that, in their opinion, he was not fit to fly the return

flight.

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ACN: 1168184

Time / Day


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC



Environment


Aircraft

Reference : XATC / Advisory.Center : ZZZZ





Person : 1

Reference : 1

Location Of Person.Aircraft : XLocation In Aircraft : Flight DeckReporter Organization : Air Carrier

Function.Flight Crew : Captain

Function.Flight Crew : Pilot Not FlyingQualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1168184Human Factors : Situational Awareness

Human Factors : Communication BreakdownCommunication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : ATC

Person : 2



Function.Flight Crew : First OfficerFunction.Flight Crew : Pilot Not Flying


ASRS Report Number.Accession Number : 1169027

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Person : 3

Reference : 3


Function.Flight Crew : First OfficerFunction.Flight Crew : Pilot FlyingQualification.Flight Crew : Air Transport Pilot (ATP)


Events

Anomaly.ATC Issue : All Types

Anomaly.Deviation - Altitude : Excursion From Assigned Altitude

Anomaly.Deviation - Procedural : ClearanceAnomaly.Inflight Event / Encounter : Weather / Turbulence


Were Passengers Involved In Event : NWhen Detected : In-flight

Result.General : Declared Emergency

Assessments

Contributing Factors / Situations : ManualsContributing Factors / Situations : Procedure

Contributing Factors / Situations : WeatherPrimary Problem : Weather

Narrative: 1

A company flight 30 min ahead of us at FL 390 reported descending to loweraltitude on Guard Frequency due to severe turbulence and advised us to do so also.

We were unable to contact Control in a timely manner [although we were already]entering moderate turbulence, so we [advised our intentions in the blind], checkedTCAS for traffic, turned slightly off course and descended to FL300 to avoid severeturbulence, injury, and possible damage to the aircraft. We then advised Control of

our descent on CPDLC and were approved to cruise at lower altitude (no SIGMEThad been issued). We advised Dispatch, checked fuel, and climbed back to flightplan altitude later upon coast in with Control. We then continued without incident.

(Note: As Captain, I was in the cabin on scheduled rest break during above incidentand was not in cockpit to witness above events but I would have done the same

thing the relief crew did using RVSM contingency plans as far as practical to avoid

severe turbulence.)

Narrative: 2I was the Relief Pilot and pilot monitoring. I was occupying the left seat while the

Captain was on a scheduled rest break. The First Officer was the pilot flying in theright seat.

We contacted them for further info and found they had to descend to FL300 to get

out of the severe turbulence.

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We...turned on all the external lights and began a descent.

Narrative: 3

[Report narrative contained no additional information]

SynopsisWhen they received reports of severe turbulence ahead at their altitude an A330flight crew exercised emergency authority to descend without clearance when they

were unable to obtain clearance in a timely manner from oceanic control.

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ACN: 1159810

Time / Day


Place




Aircraft

Reference : X



Mission : Passenger


Component

Aircraft Component : Exterior Pax/Crew DoorAircraft Reference : X

Problem : Improperly Operated

Person

Reference : 1

Location Of Person.Aircraft : XLocation In Aircraft : Cabin JumpseatCabin Activity : Boarding

Cabin Activity : Safety Related Duties



Human Factors : Training / QualificationHuman Factors : Time Pressure


Communication Breakdown.Party1 : Flight AttendantCommunication Breakdown.Party2 : Ground Personnel

Events

Anomaly.Aircraft Equipment Problem : Less SevereAnomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Procedural : Published Material / PolicyAnomaly.Ground Event / Encounter : Other / Unknown


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When Detected : Aircraft In Service At Gate

Result.General : Flight Cancelled / Delayed

Assessments


Contributing Factors / Situations : Company Policy

Contributing Factors / Situations : Human FactorsContributing Factors / Situations : ManualsContributing Factors / Situations : Procedure


Narrative: 1

A Ramp Agent brought an electric chair to the 2R door and wanted me to open the

door so they could load it onto a catering truck. I explained to him that we do notopen the doors from the inside but the caterer could open it from the outside. AnAgent Supervisor (a woman in street clothes) came down and insisted that I open

the door and I explained again that we do not open doors from the inside. She said

that she was calling Inflight [Services].

She called me out to the jetway phone and said that when it rang again it would be

an Inflight Supervisor. When I answered the Supervisor never asked me what wasgoing on or what the problem was; simply started quoting manual chapters to me.I told her that it is hammered into us all year that we do not open the doors from

the inside. She said that I had to open the door. When I objected she said

"SWEETIE I am an Inflight Supervisor."

I then had another Flight Attendant confirm the door was disarmed and I opened it.I was forced to open a door with a large wheelchair sitting in front of the door and

leaning out a four story open door with a straight drop to concrete. After I opened

the door they discovered that the lift would not even come close to the dooropening. Now I was forced to lean out the four story drop again to close the door

that should never have been opened. So I had placed myself in danger for nothing.

They then did what they should have done in the first place before causing a thirtyminute delay and found a way to get it out via the jetway.

Our Inflight Manual, section XXXXX says, "flight attendants are NEVER to open anaircraft door from the inside...that, if there is a problem, they should contact an

agent or Maintenance". If the Inflight Supervisor had asked questions she wouldhave [learned] how dangerous her demands were. If I had bumped the wheelchair

in the opening and lost my balance or slipped while reaching outside the aircraft Iwould have dropped out of the four story opening onto the concrete below and

there would have been a dead flight attendant on the tarmac.

The Agent Supervisor would not listen to my safety concerns or to other options.The Inflight Supervisor was never interested in knowing what was going on from

our safety perspective on the aircraft and never asked any questions about whatwas happening on the aircraft. They both forced us into putting our own safety injeopardy for something that was never going to work in the first place.

After the flight the woman that owned the chair came and talked to me. When Itold her that the Ramp Agent told me that the battery was dead she said that if

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they had come and asked her she could have told them that [the battery cables]

just come loose and she could have come and reconnected it. She was very upset

about our treatment of her and her chair. All this happened because bothsupervisors were not interested in getting all the information before they made

decisions and neither gave one moment's concern for the safety of the crew.

SynopsisAn acrimonious exchange resulted when supervisors from passenger boarding andInflight Service Departments demanded that a Flight Attendant (the reporter) open

the A330's 2R cabin level passenger service door from inside the aircraft in direct

violation of the company's Flight Attendant's Operations Manual forbidding doingso; the intended reason being to remove a passenger's electric wheel chair from

the aircraft to a catering truck and thence to be boarded in cargo. After compelling

the Attendant to do so they discovered the lift vehicle intended to remove the chairwas unable to access the door opening.

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PA announcement to the cabin explaining our go-around and plans to return to the

field. This brief amount of time out of the loop kept me from being another set of

eyes that maybe could have contributed to capturing the altitude. Additionally, it isusually better to stick with the go-around TOGA routine on most go-arounds so that

our normal habit patterns kick in and the technology works more in our favorduring a missed approach.

Narrative: 2

I noticed and advised the Captain (who was the pilot flying and had less than 100

hours on the airplane) that we were well above the glide path and additionally had

a 60 KT tailwind at 8,000 FT. Our current speed was about 200 KTS with Flaps 1.He further slowed to 190 KTS and requested Flaps 2 and I suggested gear down

and full spoilers which he commanded. By this time with the high true airspeed and

60 KT tailwind we had a full glideslope deflection below our path. Simultaneously Ihad switched frequencies and requested lower altitude from the next Controller.

After a very short delay he cleared us for the ILS Z 18R. We were in a verticalspeed mode trying to capture the glideslope from above, but due to the [still] 50

KT tailwind and high true airspeed at 6,000 FT it was becoming apparent we would

not be able to get down and be stabilized at 1,000 FT AGL. At 4,000 FT MSL (2,000FT AGL) the Captain decided to go-around.

At some point during the go-around I heard the autopilot disconnect. I thought it

disconnected due to the Captain disconnecting it and that he was hand flying. Aftera later discussion I found out that the Captain had not disconnected the autopilot

and that he had not recognized that it had disconnected.

The nose then pitched further upward and we passed through 5,000 and I told theCaptain to get the nose down and he said he was trying but the autopilot was not

following his inputs. That's when I told him that the autopilot was not on and we

both realized what the other had been thinking.

On our next approach we slowed and configured even earlier (outside MANCO) withgear, Flaps 3, and full speedbrake, and we still did not get a clearance for theapproach until we were well above the glidepath. We still had the 60 KT tailwind at8,000 FT but were able to get on the glidepath by about 2,500 FT AGL and be

stable by 1,000 AGL and make an uneventful landing.

Synopsis

An A330 flight crew being vectored to the north to land south and LEMD foundthemselves high and fast due to terrain and significant tail winds. When they

initiated a go-around the autopilot disconnected and they climbed through the MAPaltitude.

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ACN: 1148931

Time / Day


Place




Environment

Flight Conditions : IMC

Light : Dusk

Aircraft : 1Reference : X




Flight Phase : Landing

Airspace.Class B : ZZZ

Aircraft : 2

Reference : YATC / Advisory.Tower : ZZZAircraft Operator : Air Carrier

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


Flight Plan : IFRFlight Phase : Takeoff

Aircraft : 3

Reference : Z


Make Model Name : A321Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 121Flight Plan : IFR

Flight Phase : Taxi

Person : 1

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Reference : 1





Human Factors : ConfusionHuman Factors : Communication Breakdown


Communication Breakdown.Party2 : ATCCommunication Breakdown.Party2 : Flight Crew

Person : 2

Reference : 2Location Of Person.Aircraft : Y


Reporter Organization : Air CarrierFunction.Flight Crew : First Officer

Function.Flight Crew : Pilot Not FlyingASRS Report Number.Accession Number : 1149251

Person : 3

Reference : 3Location Of Person.Aircraft : Z



Function.Flight Crew : Pilot FlyingQualification.Flight Crew : Air Transport Pilot (ATP)


Person : 4

Reference : 4

Location Of Person.Aircraft : YLocation In Aircraft : Flight Deck

Reporter Organization : Air CarrierFunction.Flight Crew : Captain



Events

Anomaly.ATC Issue : All TypesAnomaly.Conflict : Ground Conflict, Critical


Detector.Person : Air Traffic ControlWere Passengers Involved In Event : N

When Detected : In-flightWhen Detected : Taxi

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Result.Flight Crew : Executed Go Around / Missed Approach

Result.Air Traffic Control : Issued New Clearance

Assessments


Contributing Factors / Situations : Weather


Narrative: 1

We broke out about 600 AGL and both the First Officer and I noticed an aircraft was

in position holding but we had been cleared to land. The First Officer queried Towerif an airplane was holding on the runway. The aircraft on the runway answered inthe affirmative and we initiated a go-around from below 500 FT as Tower issued us

go-around instructions. We executed the go-around and came back around thepattern and landed safely. Had visibility been more restricted, this could have beendisastrous.

Narrative: 2

Told by Tower to line up and wait on [Runway] 36C. While waiting on the runwaywe heard another aircraft warning that there was an aircraft on the runway (us)

and then Tower ordered a go-around of a heavy aircraft which we heard fly right

over us. Then Tower cancelled our takeoff clearance [although] we had onlyreceived a clearance to line up and wait. After wake turbulence separation we were

then cleared for takeoff.

Tower must slow down when the weather moves in and check the separationbetween landings and takeoffs.

Narrative: 3

We were number one holding short Runway 36C, looking directly at an MD-80 from

the right side lined up and waiting, ready for takeoff. I then saw an A-330 coming

out of the bottom of the clouds on approach to the same runway.

I was almost in disbelief of what I was seeing, I said to my First Officer "so how is

this going to work out?" Before he had a chance to answer, I picked up the mic and

announced "AIRCRAFT ON THE RUNWAY 36C, AIRCRAFT ON FINAL 36C , Towerimmediately said [flight number] go-around. And they did; no problem.

Shortly, Tower told the LUAW aircraft "you were cleared for takeoff." The crew

came back and said he was given only "line up and wait." I don't remember eitherway.

Narrative: 4

...we were never issued a takeoff clearance.

Synopsis

A serious ground conflict occurred when an MD80 flight crew understanding theywere cleared only to LUAW on the active runway, remained on the runway when anA330 broke out of the overcast on final about 500 AGL. An aircraft holding short

noted the conflict and alerted the conflicted aircraft and ATC. The landing aircraft

executed a go-around. ATC believed the LUAW aircraft had been cleared fortakeoff.

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ACN: 1147874

Time / Day


Place




Aircraft

Reference : X



Mission : Passenger

Flight Phase : Taxi

Person



Reporter Organization : Air CarrierFunction.Flight Crew : Pilot Flying



Human Factors : ConfusionHuman Factors : Training / Qualification

Events

Anomaly.Deviation - Procedural : Published Material / PolicyDetector.Person : Flight Crew

When Detected : Pre-flightResult.Flight Crew : Became Reoriented

Assessments


Contributing Factors / Situations : AirportContributing Factors / Situations : Company Policy

Contributing Factors / Situations : AircraftPrimary Problem : Ambiguous

Narrative: 1

Our aircraft had an MEL which affected tailwind restriction, landing distance, CAT 3Dual Prohibited, and operating on contaminated runways. (Aircraft restriction on

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release was only "no tailwind takeoff"). Dispatch did not agree that the MEL

restriction prevented us from operating on a contaminated runway. The NOTAM's

for the airport clearly indicated the departure runway had patchy thin wet snow.The TPS indicated a dry runway. The Tower confirmed for us that the runway was

dry. The Dispatcher said he would get the NOTAM changed. The NOTAM on thereturn flight remained the same. MEL 32-42-4A MEL 32-42-05A PLA CAT 3 DUAL

Prohibited.

Misunderstanding of the MEL between Dispatcher and myself. Both dispatchers putonly one of aircraft restrictions on release, and did not include increased landing

distance, no flex takeoff, and no operation on contaminated runway. NOTAM's were

not updated the entire day. Disagreement between Dispatcher and me that arunway described as patchy wet snow meant it was contaminated, whereas he

believed because it said patchy thin wet snow meant it was less than 1/8 and

therefore not contaminated. I looked at FOM and the definition of contaminatedmeans more than 1/8 and then goes on to describe contaminated conditions asamong others- wet snow.

Provide more training to pilots and dispatchers so we may agree on how to read

the restrictions on aircraft imposed by MEL's, as well as how to determine acontaminated runway. Insist on updated NOTAM's. Do not carry these MEL's in the

middle of winter where contaminated runways are likely to be an issue. The FO Iwas flying with had the same MEL weeks ago on the same airplane, which betweenthat time had been taken off and put right back on MEL to avoid the time limits.

Synopsis

A330 Captain reports disagreeing with the Dispatcher over what constitutes acontaminated runway for MEL compliance. It is decided that the Dispatcher's view

that patchy thin wet snow meant it was less than 1/8 and therefore not

contaminated, is correct.

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ACN: 1132342

Time / Day

Date : 201311

Place

Locale Reference.Airport : ZZZ.AirportState Reference : US


Aircraft

Reference : XAircraft Operator : Air Carrier


Operating Under FAR Part : Part 121Flight Phase : Parked

Maintenance Status.Maintenance Deferred : N

Maintenance Status.Released For Service : YMaintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Testing

Component

Aircraft Component : Oxygen System/Pax

Manufacturer : AirbusAircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1

Location In Aircraft : General Seating Area

Reporter Organization : Air CarrierFunction.Maintenance : Inspector

Qualification.Maintenance : PowerplantQualification.Maintenance : Airframe

Experience.Maintenance.Inspector : 30ASRS Report Number.Accession Number : 1132342

Human Factors : Confusion


EventsAnomaly.Aircraft Equipment Problem : Critical

Detector.Person : MaintenanceWere Passengers Involved In Event : N

When Detected : Routine InspectionResult.General : Maintenance Action

Assessments

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Contributing Factors / Situations : Chart Or Publication

Contributing Factors / Situations : ManualsContributing Factors / Situations : Procedure


Narrative: 1During Operational Check of [passenger oxygen] 'Manual Mask Release', several(more than 50) did not drop. After replacing solenoids, accomplished test again.

Some dropped some didn't, with any rhyme or reason as to which ones dropped

and which didn't. No single [Cabin] Zone and helter skelter on which ones dropped.Fear this may be a fleet issue and wanted to report in case anybody else had

similar problems. Engineering Order (E/O) was issued.

Callback: 1

Reporter stated the A330 was held over for three days at the hangar before they

were able to fully accomplish the passenger oxygen 'Manual Mask Release' Check.

Engineering had issued an Engineering Authorization (E/A), to redo the same Test,

but that second test resulted in 38 Passenger Service Units (PSU) not dropping,that were not part of the previous 50 PSU units that did not drop during the first

'Manual Mask Release' Check. The aircraft is a wide body, twin aisle with a 2-5-2passenger seat row configuration. Each PSU unit holds three or six masks.

Reporter stated there is currently a belief that the small actuating rod that extends

and releases the PSU door panel latch is getting dusty and the electrical signal tothe actuator may not be of a high enough voltage to override and extend the dusty

actuating rod to release the PSU door latch. If that is the source of the failures, thatwould be surprising, since he has been told the same PSU actuating mechanism is

also used on the smaller Airbus A320 PSUs with very few problems. Their

Engineering and Airbus are determining whether changes to the PSU mask dropcheck needs to be revised and just what actually contributed to the failures.

Synopsis

An Aircraft Inspector reports about the failure of 50 Passenger Service Unit (PSU)oxygen masks' doors that would not open on an A330 aircraft during a 'Manual

Mask Release' Check. A second test noted that 38 different PSU doors failed toopen. The wide body aircraft has a 2-5-2 passenger seat row configuration. Each

PSU unit has either three or six masks.

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ACN: 1119064

Time / Day


Place




Environment

Light : Daylight

Aircraft

Reference : XATC / Advisory.Tower : ZZZ



Operating Under FAR Part : Part 121Flight Plan : IFRNav In Use : FMS Or FMC

Flight Phase : Initial Approach

Route In Use : Visual ApproachAirspace.Class B : ZZZ

Person



Reporter Organization : Air CarrierFunction.Flight Crew : Relief Pilot

Function.Flight Crew : First OfficerASRS Report Number.Accession Number : 1119064

Human Factors : DistractionHuman Factors : Training / Qualification

Human Factors : Fatigue

Events

Anomaly.Deviation - Procedural : Published Material / PolicyDetector.Person : Flight Crew

When Detected : In-flightResult.Flight Crew : Became Reoriented

Result.Flight Crew : Took Evasive Action

Assessments

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Contributing Factors / Situations : Environment - Non Weather Related


Contributing Factors / Situations : ProcedurePrimary Problem : Human Factors

Narrative: 1

Visual approach, airplane was configured for landing with full flaps, prior toselecting the landing gear down. This is a non-standard order and not doneintentionally. Landing gear was selected down at 900 FT MSL after recognition that

the landing gear was not down, prior to any aircraft warning but too late for a

stabilized approach.

Normally gear is selected down when selecting flaps 3 and occurs well above 1,000

FT. Contributing factors to why the event occurred were 1. A distraction on the FMS/ Flight Director showing an altitude constraint of 3,300 FT on the ILS 8L while we

were flying a hand-flown visual approach and 2. Fatigue after a long flight.

Synopsis

A fatigued and distracted A330 crew selected the gear down at 900 FT on a visualapproach with landing flaps set.

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ACN: 1109749

Time / Day


Place




Environment

Light : Daylight

Aircraft



Operating Under FAR Part : Part 121

Flight Phase : ParkedMaintenance Status.Maintenance Deferred : YMaintenance Status.Records Complete : N

Maintenance Status.Released For Service : N

Maintenance Status.Maintenance Type : Unscheduled MaintenanceMaintenance Status.Maintenance Items Involved : Repair

Maintenance Status.Maintenance Items Involved : Work Cards

Maintenance Status.Maintenance Items Involved : Inspection

Component

Aircraft Component : Powerplant Mounting

Manufacturer : AirbusAircraft Reference : X

Person

Reference : 1Location Of Person : Hangar / Base


Function.Maintenance : TechnicianQualification.Maintenance : Powerplant

Qualification.Maintenance : AirframeExperience.Maintenance.Technician : 25

ASRS Report Number.Accession Number : 1109749Human Factors : Training / Qualification

Human Factors : Communication BreakdownHuman Factors : Situational Awareness

Communication Breakdown.Party1 : Maintenance

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Communication Breakdown.Party2 : Maintenance


Events



Anomaly.Deviation - Procedural : MaintenanceAnomaly.Deviation - Procedural : FARDetector.Person : Maintenance

Were Passengers Involved In Event : N

When Detected.OtherResult.General : Maintenance Action

Assessments

Contributing Factors / Situations : Company PolicyContributing Factors / Situations : Human Factors


Narrative: 1

My name is Mechanic X and I am a Machinist in ZZZ. I went to ZZZ1 to work on an

A330 Right Engine mount problem on August 2013. The airplane was parked in the

Maintenance Hangar. The write-up addressed corrosion in and around thepreviously machined spot faced areas on the top of the [pylon where the engine's]

four forward mount bolts [would be located]. I was told that this work was done in

ZZZ2 by our Heavy Maintenance Contract Repair Station vendor. In my opinion, therepair was not within the Structural Repair Manual (SRM) repair limits and shouldnot have been flying at all. It is also my opinion that it was an accident waiting to

happen.

The original repair called out for the bottom of the spot face to be machined with

an .080" thousandths of an inch radius. The bottom of their spot face was sharp

and looked to be no more than .005" thousandths of an inch. The larger radius is inplace to prevent cracking conditions. Out of all the places on that airplane that you

do not want cracks to form, that to me is the most important area. Also, there isabout a one inch thick wall mount structure located between the bores. When they

machined the spot face they went into the sides of this wall. After three days ofintense discussion between the Engineer, Inspection, Management, and the Aircraft

Manufacturer, they made the decision to fly the A330 to the [same] Repair Stationand change the pylon. Myself and my co-worker machinists did not want to touch it

because it would have made matters much worse than they already were. I

personally would not have felt safe flying on that airplane. I am filing this report tobring to light the Contract Repair Station's shoddy maintenance practices and to

hopefully ensure this does not happen again!!!

It was quite obvious that the repair was not done correctly just by looking at it. Wealso found out that the original machined spot face depth was already below limits.

They may have had authorization to machine to this depth. In order for us to

accomplish the .080" thousandths of an inch radius, we would have had to increasethe depth by at least .080" thousandths to achieve the correct radius. The Aircraft

Manufacturer did not want to do that, since the Contract Vendor did not machine

the correct radius in the first place; this is why our repair would have required us tomachine much deeper to accomplish the repair. Otherwise, with the correct cutter

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ACN: 1107871

Time / Day


Place




Environment

Light : Daylight

Aircraft


Make Model Name : A330Operating Under FAR Part : Part 121


Component

Aircraft Component : Engine Control

Aircraft Reference : X


Person

Reference : 1Location Of Person : Gate / Ramp / LineReporter Organization : Air Carrier

Function.Maintenance : Inspector

Function.Maintenance : Quality Assurance / AuditQualification.Maintenance : AirframeQualification.Maintenance : Powerplant


Human Factors : ConfusionHuman Factors : Troubleshooting

Human Factors : Workload

Human Factors : Communication BreakdownCommunication Breakdown.Party1 : Maintenance


Events


Anomaly.Deviation - Procedural : FARAnomaly.Deviation - Procedural : Published Material / Policy

Detector.Automation : Aircraft Other AutomationDetector.Person : Flight Crew

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When Detected : In-flight

Result.General : Maintenance Action

Result.Flight Crew : Landed As PrecautionResult.Flight Crew : Returned To Departure Airport

Assessments

Contributing Factors / Situations : AircraftContributing Factors / Situations : Chart Or PublicationContributing Factors / Situations : Company Policy

Contributing Factors / Situations : Manuals

Contributing Factors / Situations : ProcedurePrimary Problem : Ambiguous

Narrative: 1

The flight crew called Maintenance Control and reported that they have a Number 1engine that is slow to respond with associated ECAM message. At that time that I

was conversing with the crew I was looking at the computer for the associated

faults. The computer showed an 'ENG 1 CTL SYS FAULT.' I asked the crew if they

also see this fault on ECAM. The crew responded that they do not see this fault andonly have 'ENG1 slow to respond.' Crew also relayed that there are no ECAM

actions with this fault. Crew also reported that they cannot achieve more then 1.2EPR with autothrottles ON or OFF.

At that time it was decided to have the aircraft return to the departure airport.

Aircraft returned safely. According to the message associated with 'ENG 1 CTL SYSFAULT' it refers to the Fuel Metering Unit (FMU) as the faulty component and that

the FMU needs to be replaced. Maintenance replaced the FMU and did the groundchecks per the AMM and the FMU operated normally. Subsequently a Verification

flight deferral was issued for the FMU replacement in accordance with Company

A330 manual.

According to our A330 documents after an in-flight engine shutdown, throttle back,un-commanded power change or surge or an inability to control an engine or obtain

desired power PAX NOT AUTHORIZED for Verification flight. Looking at the log pageassociated with this event it states: 'ATB: ENG 1 CTL SYS FAULT' in Cruise [This is

Not the fault that was relayed to me during the phone patch]. No where does it

state that the crew did not obtain desired power from the number 1 engine.Verification flight for Number 1 engine FMU replacement was accomplished by the

crew on a flight. The crew reported back to Maintenance Control 1 hour afterdeparting and said the Number 1 engine FMU and engine operated normally and

they are continuing on to the filed destination. Subsequently, the destinationstation maintenance cleared the Verification flight deferral.

1. Even if the flight crew gives a verbal notification on their defect, the crew needsto be accurate on their defects in the aircraft log book so the correct actions can betaken. 2. Before issuing any Verification flight. All personnel needs to review the

Company A330 documents to ensure all guide lines are followed.

Synopsis

An A330 ECAM alerted ENG 1 SLOW TO RESPOND in flight, but the Maintenance

Control Computer displayed ENG 1 CTL SYS FAULT which indicated a Fuel Metering

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Unit fault so the aircraft returned to the departure station. Subsequently, no test

flight was flown, but a revenue flight crew reported normal operation.

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ACN: 1101128

Time / Day


Place

Locale Reference.Airport : LFPG.Airport



Environment


Light : Daylight


ATC / Advisory.Ground : LFPGAircraft Operator : Air Carrier


Crew Size.Number Of Crew : 2Operating Under FAR Part : Part 121Flight Phase : Taxi

Person

Reference : 1


Location In Aircraft : Flight DeckReporter Organization : Air CarrierFunction.Flight Crew : Captain




Events

Anomaly.Deviation - Procedural : Clearance

Anomaly.Ground Incursion : Taxiway

Detector.Person : Air Traffic ControlWhen Detected : Taxi

Result.Flight Crew : Became Reoriented

Assessments

Contributing Factors / Situations : Airport

Contributing Factors / Situations : Human FactorsContributing Factors / Situations : Procedure


Narrative: 1

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Taxiing out of LFPG our instructions were cleared via A to N turn onto B Then BD14

D to Y3 holding point Runway 09R. The First Officer and I had briefed the route we

thought we would use, and then talked about the clearance we received. They werevery similar except we would use D instead of B to get to Y3. As we taxied up N we

received our weight and balance about that time an A340 under tow pulled onahead of us, this created a little confusion because we had not heard him receive

clearance to enter the taxiway. As we came up to Taxiway B we turned on left ontoB. As we did I realized that BD14 was basically straight ahead and no turn was

needed onto B taxiway.

As I stopped the aircraft and was about to call Ground Control they advised us to

hold our position. At that intersection of B and BD14 there is no signage at all. Ifyou come from the other direction on the upper end of that taxiway there [are]

painted numbers on the ground, but not from the direction we were coming from.

It is very poorly marked!

Major cause of this is the poor signage along with a very non-standard taxi

clearance. The signage at the intersection of B where it meets with N is good but

the lack of signage of BD14 and where it is from that direction is not there, leading

to great confusion. Have Paris put signage out or paint on the taxiway with anarrow of where BD14 is. Coming off the runway to the gates it is painted on the

north side showing BD14 on Taxiway D. It is not when coming from the south tothe east runways.

Synopsis

A330 flight crew reported they were confused by poor signage on taxi out at LFPG.

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ACN: 1099136

Time / Day


Place



Aircraft

Reference : XATC / Advisory.Tower : ZZZ

ATC / Advisory.TRACON : ZZZAircraft Operator : Air Carrier



Flight Plan : IFRMission : Passenger

Flight Phase : LandingAirspace.Class B : ZZZ

Person

Reference : 1Location Of Person.Facility : ZZZ.Tower

Reporter Organization : Government

Function.Air Traffic Control : LocalQualification.Air Traffic Control : Fully Certified


Human Factors : Situational AwarenessCommunication Breakdown.Party1 : ATC

Communication Breakdown.Party2 : ATC

Events

Anomaly.ATC Issue : All Types


Detector.Person : Air Traffic ControlResult.General : None Reported / Taken

Assessments

Contributing Factors / Situations : ProcedurePrimary Problem : Procedure

Narrative: 1

I was working Local when told we had an A330 emergency diverting and coming inopposite direction landing [Runway] 34R currently dumping fuel. The TRACON

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advised they would let me know when to stop departures. I was very busy on Local

had about ten departures for [Runway] 16L and was launching them as fast as

possible. I had just put another Air Carrier in position when the TRACON hit thestop departure lights. I called Departure and let them know about the aircraft in

front of the other Air Carrier that was already departing, then since the other AirCarrier hadn't lined up yet taxied him across [Runway] 16L to hold short of the

center to get him off the runway. I think they stopped departures too soon [as] theA330 was about 30 miles out. The TRACON should have coordinated with me

instead of just hitting the stop departure lights. Several aircraft had delays becauseof the departure(s) cut off. The A330 was too high and had to do a 360 on final, all

done on final frequency no coordination was done with me. I think a little heads up

would have been nice, further delaying departures. As the A330 was landing, Irealized I should have made sure Intersection E was no longer blocked. I did not

think he would land that long with calm winds and coming in slow. Long story short

he rolled down to E, then requested a doctor meet him at the gate. That was thefirst time we heard he needed medical assistance. I just thought that he was only amechanical emergency. Better communication, making sure the intersection wasn't

blocked, enough people to have local assist open would have helped but that late at

night it was impossible, CIC being busy with a lot of phone calls and working

clearance delivery at the same time so he was distracted, better coordination fromthe TRACON.

Synopsis

Tower Controller described the complexities of handling an emergency aircraft

inbound opposite direction to the normal flow of traffic and thecoordination/communications difficulties encountered.

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ACN: 1097139

Time / Day


Place

Locale Reference.Airport : EDDF.Airport



Aircraft : 1

Reference : X

ATC / Advisory.Tower : EDDFAircraft Operator : Air Carrier



Flight Plan : IFRMission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 25LFlight Phase : Initial Approach

Aircraft : 2

Reference : YATC / Advisory.Tower : EDDF

Aircraft Operator : Air Carrier

Make Model Name : B747 Undifferentiated or Other ModelFlight Plan : IFR

Flight Phase : Initial Approach

Person

Reference : 1

Location Of Person.Aircraft : XLocation In Aircraft : Flight Deck

Reporter Organization : Air CarrierFunction.Flight Crew : First Officer



Events

Anomaly.Inflight Event / Encounter : Wake Vortex EncounterDetector.Person : Flight Crew

When Detected : In-flightResult.Flight Crew : Took Evasive Action

Assessments

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Contributing Factors / Situations : Environment - Non Weather Related

Contributing Factors / Situations : Procedure


Narrative: 1

At 4,000 FT MSL [we] encountered wake turbulence from a 747 five miles ahead on

final approach Runway 25L EDDF. Climbed to 4,400 FT MSL and stayed aboveglideslope for a normal landing. Five miles is not enough space for 747.

Synopsis

A330 First Officer reported encountering wake turbulence in trail of a B747 on finalto EDDF, stating that in his opinion five miles is not enough separation.

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ACN: 1094446

Time / Day

Date : 201306

Place

Locale Reference.Airport : ZZZ.AirportState Reference : US


Aircraft



Operating Under FAR Part : Part 121Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Electrical PowerAircraft Reference : X


Person

Reference : 1




Communication Breakdown.Party1 : Flight CrewCommunication Breakdown.Party2 : Dispatch

Communication Breakdown.Party2 : Ground PersonnelCommunication Breakdown.Party2 : ATC

Events


Detector.Person : Flight CrewWhen Detected : Aircraft In Service At Gate

Result.General : None Reported / Taken

Assessments


Contributing Factors / Situations : Chart Or PublicationContributing Factors / Situations : Company Policy

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Contributing Factors / Situations : Procedure


Narrative: 1

Since I now know of three incidences in which an A330 found itself relying on

battery power only on the ground, and did not have VHF 1. We need an FOM policy

for lost communications on the ground as well as in flight. Without 1 VHF there isno way to coordinate rescue [per] FOM 4.4.1/.2 and our cell phones would be off ifwe were blessed enough to have one and be in a country in which it had service. I

would not want to explain to relatives their loved one perished while my phone

powered up to call Dispatch to call rescue, or worse yet, no one's phone worked incountry. We could never explain why we didn't make contingencies for documented

failures of battery only VHF 1 on ground. Failures are occurring that prevent

evacuation checklist to be accomplished.

Synopsis

An A330 Captain reported losing electrical power on the ground and VHF 1 did not

operate, so the crew had no means of contacting first responders or Dispatch

unless their personal phones worked on foreign communications systems.

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do so. ELIMINATE THE TVC TRANSITION OF THE WYNDE4 ARRIVAL!!!!! It has

routinely happened for 2 years, and it needs to be fixed.

Synopsis

ZMP Controller suggested the elimination of the TVC Transition on the WYNDE4

STAR, noting frequent route confusion when this procedure is issued.

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ACN: 1089195

Time / Day


Place




Environment


Light : Daylight


ATC / Advisory.Center : ZZZAircraft Operator : Air Carrier


Crew Size.Number Of Crew : 3Operating Under FAR Part : Part 121Mission : Passenger



Component

Aircraft Component : Turbine EngineAircraft Reference : XProblem : Failed

Person



Reporter Organization : Air CarrierFunction.Flight Crew : Pilot Flying



Events



When Detected : In-flightResult.General : Declared Emergency

Result.Flight Crew : Inflight Shutdown

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ACN: 1086785

Time / Day


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment


Light : Dusk


ATC / Advisory.TRACON : ZZZAircraft Operator : Air Carrier



Mission : Passenger

Flight Phase : TakeoffAirspace.Class B : ZZZ

Component

Aircraft Component : Hydraulic Main SystemAircraft Reference : X


Person

Reference : 1




Function.Flight Crew : Pilot FlyingQualification.Flight Crew : Air Transport Pilot (ATP)


Events



When Detected : In-flightResult.General : Maintenance Action

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ACN: 1081335

Time / Day


Place




Environment

Light : Daylight

Aircraft




Flight Phase : Taxi

Component

Aircraft Component : Electrical Power

Aircraft Reference : XProblem : Improperly Operated

PersonReference : 1Location Of Person.Aircraft : X


Reporter Organization : Air CarrierFunction.Flight Crew : First OfficerFunction.Flight Crew : Pilot Not Flying


ASRS Report Number.Accession Number : 1081335Human Factors : Human-Machine Interface

Events

Anomaly.Aircraft Equipment Problem : Less SevereAnomaly.Deviation - Procedural : Published Material / Policy


When Detected : Aircraft In Service At GateResult.General : None Reported / Taken

Assessments

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ACN: 1075482

Time / Day

Date : 201303

Aircraft




Mission : PassengerFlight Phase : Cruise

Component

Aircraft Component : Pressurization SystemAircraft Reference : X

Problem : Failed

Person

Reference : 1Location Of Person.Aircraft : XLocation In Aircraft : Cabin Jumpseat

Cabin Activity : Safety Related Duties


Qualification.Flight Attendant : Current


Communication Breakdown.Party1 : Flight CrewCommunication Breakdown.Party2 : Other

Events

Anomaly.Aircraft Equipment Problem : CriticalDetector.Person : Flight Crew

When Detected : In-flightResult.General : None Reported / Taken

Assessments



Narrative: 1

Captain instructed crew to prepare cabin for a normal arrival, as we were about to

experience a decompression. As oxygen masks were deployed, passengers wereinstructed to "Don Oxygen Masks and Fasten Seat Belts." I sat at my assigned 3L

door, donned my oxygen mask, and assisted passengers sitting nearby. I instructeda woman to use an oxygen mask for her infant, and told children not to pull on the

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masks, etc. Once Captain advised us that it was safe to walk around, flight

attendants walked through the cabin assisting passengers. A young woman was

hyperventilating, other passengers were shaken, but overall there were no majorincidents. The flight deck crew communicated very well with the crew and kept the

passengers informed throughout. Passengers complimented the crew on theirprofessionalism and calm as they deplaned. I did notice upon walking through the

cabin that several passenger masks had not deployed. These passengers were notwithin view of the flight attendants, so they remained without oxygen. Also, we did

not have a French translator on the flight; therefore communication with the Frenchspeaking passengers was compromised.

Synopsis

A330 Flight Attendant describes a loss of cabin pressure during during descent. The

cockpit crew was apparently aware that the masks were about to drop andinformed the cabin.

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Result.General : Declared Emergency

Result.Air Traffic Control : Issued New Clearance

Result.Air Traffic Control : Provided Assistance

Assessments



Narrative: 1

While in a smooth ride at

Documents

330 Incident