A | B | C | D | E | F | G | H | I | J | K | L | M | N | |
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1 | Time | Time | Aircraft 1 | Aircraft 1 | Aircraft 2 | Aircraft 2 | Assessments | Assessments | Events | Events | Person 1 | Place | Place | Synopsis |
2 | Date | Local Time Of Day | Flight Phase | Make Model Name | Flight Phase | Make Model Name | Contributing Factors / Situations | Primary Problem | Anomaly.Conflict | Result.Flight Crew | Human Factors | Locale Reference.Airport | Locale Reference.ATC Facility | Synopsis |
3 | 201111 | 1201-1800 | Cruise | Cessna Aircraft Undifferentiated or Other Model | Champion Citabria Undifferentiated | Human Factors | Human Factors | NMAC | Communication Breakdown, Situational Awareness | OAK.Airport | A C162 pilot experienced an NMAC inbound to PAO when he mis-identified ATC issued traffic. | |||
4 | 201111 | 0601-1200 | Taxi | B757-200 | Airport, Chart Or Publication, Procedure | Ambiguous | Requested ATC Assistance / Clarification | Confusion, Situational Awareness | SFO.Airport | A B757-200 Captain reported a discrepancy between the airport signage and the commercially provided airport page for Taxiways S at SFO. Noting, specifically, that two independent taxiway entrances to Runway 10L are identified as S. | ||||
5 | 201111 | 0601-1200 | Takeoff | B757-200 | Commercial Fixed Wing | Human Factors | Human Factors | Communication Breakdown, Situational Awareness | SFO.Airport | Air Carrier departing from SFO on an assigned 040 heading reported confusion regarding ATC's instructions involving them and and a missed approach aircraft. | ||||
6 | 201111 | 0001-0600 | Landing | B747-400 | Landing | Dassault-Breguet Undifferentiated or Other Model | Procedure | Procedure | Other / Unknown | SFO.Tower | Air Carrier landing SFO Runway 28L during side-by simultaneous approaches suggested that ATC provide more speed information on parallel traffic when issuing a "do not pass" clearance. | |||
7 | 201111 | 0601-1200 | Descent | A320 | Aircraft, Human Factors, Procedure | Human Factors | Communication Breakdown, Situational Awareness | NCT.TRACON | NCT Controller described a loss of separation event during SOIA operations when a participating aircraft entered the NTZ and failed to respond to ATC instructions to turn. | |||||
8 | 201111 | 0601-1200 | Taxi | Light Transport | Procedure | Procedure | Communication Breakdown, Situational Awareness | SFO.Airport | Air Carrier departing SFO being handled by company Ramp Control was questioned by Ground Control regarding ATC communications contact point. | |||||
9 | 201111 | 1801-2400 | Final Approach | B757-200 | Final Approach | Light Transport, Low Wing, 2 Turbojet Eng | Procedure | Procedure | Airborne Conflict | Communication Breakdown | SFO.Tower | SFO Controller voiced concern regarding alleged ambiguous visual separation procedures applied by NCT Controller during simultaneous approaches, listing aircraft passing one another as an example. | ||
10 | 201111 | 0601-1200 | Parked | A321 | Company Policy, Human Factors, Weather | Human Factors | Communication Breakdown, Situational Awareness | SFO.Airport | An A320 Captain refused a flight Release from his Dispatcher that routed them through an area of forecast and reported severe turbulence. The Dispatcher had advocated the original route because it was shorter and burned less fuel. | |||||
11 | 201111 | 1201-1800 | Final Approach | B737-800 | Human Factors, Procedure, Weather | Procedure | Communication Breakdown, Other / Unknown, Situational Awareness | SFO.Tower | SFO Tower Controller voiced concern regarding NCT's handling of a simultaneous arrivals to Runways 28L/R during rapidly changing weather conditions, suggesting NCT should have sent the second aircraft around earlier. | |||||
12 | 201111 | 1201-1800 | Climb | A320 | Climb | Gulfstream IV/G350/G450 | Human Factors, Procedure | Human Factors | SFO.Airport | Loss of separation between traffic departing Runway 1 and Runway 28 at SFO when the Runway 1 departure turned early on the OFFSH5 departure. | ||||
13 | 201111 | 1201-1800 | Final Approach | Learjet 40 | Initial Approach | Learjet 60 | ATC Equipment / Nav Facility / Buildings, Human Factors, Procedure | Ambiguous | NMAC | Took Evasive Action | Communication Breakdown | SFO.Tower | LJ40 Captain on approach to Runway 28L at SFO reports a TCAS RA with a LR60 on approach to Runway 28R. Both aircraft were in VMC and the LR60 crew had the LR40 in sight and turned away. | |
14 | 201111 | 0601-1200 | Descent | A320 | Human Factors, Weather | Weather | Took Evasive Action | SFO.Airport | A320 flight crew reports encountering turbulence, which is the subject of a SIGMET. The seatbelt sign is turned on and the flight attendants are asked to be seated prior to encountering moderate turbulence. On a subsequent leg, a Flight Attendant reports that he was injured by this turbulence. | |||||
15 | 201110 | 1801-2400 | B757-200 | Aircraft, Procedure | Procedure | Airborne Conflict | Other / Unknown | SFO.Tower | Air Carrier on Visual Approach to SFO Runway 28L experienced a TCAS RA after maneuvering slightly to adjust position with parallel traffic as per Tower instructions. | |||||
16 | 201110 | 1201-1800 | Initial Climb | Shorts SD-360 | Initial Climb | B737 Undifferentiated or Other Model | Human Factors, Procedure | Procedure | Situational Awareness | NCT.TRACON | NCT Controller described a conflict situation caused by SFO Tower's reported inappropriate utilization of successive departure separation criteria. | |||
17 | 201109 | 0601-1200 | Final Approach | Large Transport, Low Wing, 2 Turbojet Eng | Environment - Non Weather Related, Procedure | Ambiguous | Executed Go Around / Missed Approach, Returned To Clearance | Communication Breakdown, Confusion, Distraction, Situational Awareness, Workload | SFO.Airport | An air carrier pilot reported an unstabilized approach to SFO Runway 28L after getting high on approach, then executing a non-startard Tip Toe approach go-around. | ||||
18 | 201109 | 1801-2400 | Final Approach | B737-800 | Human Factors | Human Factors | Became Reoriented, Returned To Clearance | Confusion, Human-Machine Interface | SFO.Airport | A B737-800 flight crew reported confusion on how to properly set up the autoflight system for a visual approach (ILS out of service) to SFO at night. They improperly armed VOR/LOC mode and a track deviation resulted. | ||||
19 | 201109 | 0601-1200 | Taxi | B757-200 | Human Factors | Human Factors | Ground Conflict, Less Severe | Became Reoriented | Communication Breakdown | SFO.Airport | B757 Flight Crew reports being cleared for push back by Ramp Control, only to be countermanded by the maintenance taxi crew of the aircraft passing behind them. Non standard phraseology is used causing some confusion for the reporters. | |||
20 | 201109 | 0601-1200 | Initial Approach | Widebody, Low Wing, 4 Turbojet Eng | Climb | Small Aircraft | Airspace Structure, Human Factors, Weather | Ambiguous | Airborne Conflict | Took Evasive Action | Distraction, Situational Awareness | NCT.TRACON | Air Carrier aircraft in IMC on the SFO ILS PRM Runway 28L stopped its descent at 3,000 FT because an unknown aircraft was climbing to 2,300 FT inside the No Transgression Zone and TCAS alerted two TA's. | |
21 | 201109 | 1801-2400 | Initial Approach | Widebody, Low Wing, 2 Turbojet Eng | Weather | Weather | Regained Aircraft Control, Took Evasive Action | Physiological - Other, Situational Awareness, Workload | NCT.TRACON | A heavy jet on the SFO FMS Bridge Visual encountered severe turbulence, a 30 KT speed decrease and a 2,000 FT altitude loss passing the ARCHI waypoint at 8,000 FT. | ||||
22 | 201109 | 1801-2400 | Final Approach | B737 Undifferentiated or Other Model | Final Approach | Learjet 60 | Human Factors, Procedure | Procedure | Airborne Conflict | Communication Breakdown, Situational Awareness | OAK.Airport | OAK Tower Controller described a developing conflict between air carrier arrival traffic assigned Runway 29 and an FAA flight check operation to Runway 11, noting lack of internal coordination between positions at NCT. | ||
23 | 201108 | 1201-1800 | Initial Climb | Cessna Citation Undifferentiated or Other Model | Chart Or Publication, Human Factors, Procedure | Human Factors | Airborne Conflict | Became Reoriented | Communication Breakdown, Confusion, Human-Machine Interface | NCT.TRACON | A CE-750 flight crew failed to comply with the 2,000 MSL at 4.0 DME restriction on the SKYLINE SID off Runway 29 at OAK. Inappropriate FMS route alterations and distractions from a TA shortly after takeoff may have contributed. | |||
24 | 201108 | 0001-0600 | Final Approach | B767 Undifferentiated or Other Model | Final Approach | B757 Undifferentiated or Other Model | Human Factors | Human Factors | Situational Awareness | NCT.TRACON | NCT Controller described a loss of wake separation event on the SFO final when after issuing a go around, radar data indicated the separation was less than required prior to the go around instruction, contrary to PRM Data. | |||
25 | 201108 | 0001-0600 | Descent | A340 | Human Factors, Procedure | Procedure | Communication Breakdown | SFO.Airport | NCT Controller described a communications failure involving a visual approach clearance, the SFO landing flight crew failing to respond with their "call sign." | |||||
26 | 201108 | 1201-1800 | Final Approach | Regional Jet 200 ER/LR (CRJ200) | Final Approach | A320 | Human Factors, Procedure | Human Factors | Airborne Conflict | Situational Awareness | SFO.Airport | NCT Controller described a conflict event on the SFO final when traffic assigned a Visual Approach to Runway 28R over flew sighted traffic inbound for Runway 28L, citing pressure to establish side-by's as a causal factor. | ||
27 | 201108 | 0001-0600 | Climb | A320 | Climb | Regional Jet 200 ER/LR (CRJ200) | Human Factors, Procedure | Human Factors | Confusion | SFO.Tower | SFO Controller described a near conflict event when traffic departing Runway 1R started a wrong turn toward a Runway 1L aircraft, allegedly due to mis-reading the PDC clearance. | |||
28 | 201108 | 1201-1800 | Climb | PA-28 Cherokee/Archer/Dakota/Warrior | Chart Or Publication, Human Factors | Human Factors | Confusion | OAK.Tower | A PA-28 pilot cleared via the OAK NUEVO 5 Departure, mistakenly flew the "LOST COMMUNICATIONS PROCEDURE ONLY" track instead. | |||||
29 | 201108 | 1801-2400 | Landing | Skyhawk 172/Cutlass 172 | Human Factors, Procedure | Human Factors | Communication Breakdown, Confusion, Situational Awareness | OAK.Tower | OAK Controller described a near loss of separation event between an airport vehicle and a Cessna in the pattern resulting unclear communications between the Tower and the airport vehicle. | |||||
30 | 201107 | 1201-1800 | Initial Approach | A320 | Human Factors | Human Factors | Airborne Conflict | NCT.TRACON | Air Carrier being vectored by NCT was not given instructions to turn and intercept the final for Runway 28R causing a conflict with traffic intercepting the Runway 28L final, ATC acknowledged an error on their part. | |||||
31 | 201107 | 1801-2400 | Taxi | Skyhawk 172/Cutlass 172 | Airport | Airport | Other / Unknown | SJC.Tower | SJC Controller described an unauthorized Runway 29 crossing at Taxiway D, claiming additional signs are necessary to prevent similar events in the future. | |||||
32 | 201107 | 1801-2400 | Initial Climb | A320 | Initial Climb | Regional Jet 200 ER/LR (CRJ200) | Human Factors, Procedure | Human Factors | Communication Breakdown, Situational Awareness | SFO.Tower | SFO Controller described a confused departure event involving two Air Carrier aircraft on parallel tracks of Runways 1L/R, the reporter noting wrong strips were present at the position prompting the confusion. | |||
33 | 201107 | 1801-2400 | Takeoff | A320 | Takeoff | Any Unknown or Unlisted Aircraft Manufacturer | Procedure | Procedure | Airborne Conflict | Other / Unknown | SFO.Tower | Air Carrier departure from SFO voiced concern regarding the simultaneous departures from Runway 1L/R, suggesting Tower momentarily delay one of the two departing aircraft. | ||
34 | 201107 | 0601-1200 | Climb | Bonanza 33 | Chart Or Publication, Human Factors | Human Factors | Became Reoriented | Confusion, Situational Awareness | OAK.Airport | A Bonanza pilot, unfamiliar with the government published version of the NUEVO DP from OAK, misinterpreted the Lost Com procedure on the graphic depiction as the initial departure procedure and turned prior to receiving a clearance to do so. | ||||
35 | 201106 | 1801-2400 | Taxi | A380 | Takeoff | A380 | Human Factors, Procedure | Procedure | Distraction, Situational Awareness, Training / Qualification | SFO.Tower | SFO Controller reported a possible procedural violation regarding A380 operations on the airport. | |||
36 | 201106 | 0001-0600 | Descent | B757 Undifferentiated or Other Model | Descent | Heavy Transport | ATC Equipment / Nav Facility / Buildings, Human Factors, Procedure | Procedure | Situational Awareness | SFO.Airport | NCT CIC described a loss of separation behind a heavy jet, noting the difficulty of controllers trying to discern 100ths of a mile distinctions when working with the current equipment. | |||
37 | 201106 | 0601-1200 | Initial Approach | B737-700 | Airspace Structure, Chart Or Publication, Human Factors, Procedure | Procedure | Communication Breakdown, Human-Machine Interface, Training / Qualification | OAK.Airport | After being cleared for the RNAV (RNP) Z Runway 11 approach to OAK, a B737-700 flight crew was unable to comply with a subsequent clearance to cross the IF (HIRMO) at 3,000 MSL but failed to advise Approach Control. A separation issue may have ensued although ATC did not pursue the issue short of bringing it to the the attention of the flight crew. | |||||
38 | 201105 | 1801-2400 | Descent | Medium Transport, Low Wing, 2 Turbojet Eng | Climb | Small Transport, Low Wing, 2 Turboprop Eng | Environment - Non Weather Related, Procedure | Procedure | NMAC | Became Reoriented, Returned To Clearance, Took Evasive Action | Communication Breakdown, Distraction, Situational Awareness, Workload | OAK.Airport | A chartered jet on a NCT vector for OAK at 11,000 FT responded to a TCAS RA with an aircraft whose crew had reported them insight yet still passed 200 FT horizontally and 50 FT vertically. | |
39 | 201105 | 1201-1800 | Final Approach | B747 Undifferentiated or Other Model | Final Approach | A319 | Human Factors, Procedure | Human Factors | Other / Unknown | SFO.Airport | SFO Controller voiced concern regarding the Local Controller and Supervisors non-action during a heavy over take situation on the final for Runway 28, adding the heavy aircraft elected to go around when ATC should have initiated the action. | |||
40 | 201105 | 1801-2400 | Climb | B737-800 | Cruise | Skyhawk 172/Cutlass 172 | Human Factors, Procedure | Procedure | Airborne Conflict | Situational Awareness | NCT.TRACON | SFO Departure Controller experienced a loss of separation event involving SFO and OAK departure traffic complicated because of SFO's refusal to allow a VFR overflight to transverse their airspace. | ||
41 | 201105 | 0001-0600 | A319 | Human Factors, Procedure | Human Factors | SFO.Airport | Air Carrier landing SFO expressed concern regarding ATC's instructions to turn off the runway, noting the clearance was unreasonable due to location and speed. | |||||||
42 | 201105 | 1201-1800 | Taxi | A320 | Airport, Chart Or Publication, Human Factors | Ambiguous | Became Reoriented, Returned To Clearance | Confusion | SFO.Airport | A320 Captain reports deviation from the taxi clearance due to confusion over the location of Taxiway F as depicted inside HS1 at SFO. | ||||
43 | 201104 | 0001-0600 | Initial Climb | EMB ERJ 190/195 ER&LR | Chart Or Publication, Human Factors, Procedure | Human Factors | Confusion | SFO.Tower | SFO Controller described a wrong turn initiated by a SFO8 departure aircraft, noting a further turn was issued to simulate the Shoreline SID given the obstruction northwest of the airport. | |||||
44 | 201104 | 0001-0600 | Descent | B767 Undifferentiated or Other Model | Descent | B757 Undifferentiated or Other Model | Procedure | Procedure | Communication Breakdown, Confusion | NCT.TRACON | NCT Controller described an ATC initiated go around event when traffic conducting side-by visual approaches to Runways 28L/R were reluctant to acknowledge visual separation directions. | |||
45 | 201104 | 1801-2400 | Climb | Bonanza 33 | Human Factors | Human Factors | Airborne Conflict | Situational Awareness | SFO.Airport | SFO Controller described a developing conflict when NCT Controller/s permitted an aircraft to fly directly toward the SFO Runway 1 departure path, noting the situation allowed only minimum time to achieve separation. | ||||
46 | 201103 | 1801-2400 | Initial Climb | B737-800 | Cruise | PA-23-250 Aztec | Procedure | Procedure | Airborne Conflict | Confusion | SFO.Airport | SFO Controller described an event when 3 VFR transition aircraft, a VFR photo mission aircraft and an Air Carrier departure presented a potential conflict. | ||
47 | 201103 | 1201-1800 | Cruise | Skyhawk 172/Cutlass 172 | Human Factors | Human Factors | Overcame Equipment Problem | OAK.Airport | A private pilot and his instructor failed to recognize inappropriate com radio settings during a training flight. As a result they transmitted numerous transmissions to unintended recipients, disrupting air traffic control and operating touch and go landings at an uncontrolled airport without position and intention reports to other traffic. | |||||
48 | 201103 | 0001-0600 | Descent | A319 | Environment - Non Weather Related, Procedure | Ambiguous | Became Reoriented, Requested ATC Assistance / Clarification, Returned To Clearance, Took Evasive Action | Communication Breakdown, Distraction, Situational Awareness | NCT.TRACON | An A319 received a TCAS TERRAIN alert at 5,000 FT on the downwind for OAK Runway 11 in the vicinity of Mount Diablo and responded by climbing above 7,000 FT where the TERRAIN alert ceased. | ||||
49 | 201103 | 1801-2400 | Descent | B737-300 | Environment - Non Weather Related, Human Factors | Human Factors | FLC complied w / Automation / Advisory, Returned To Clearance | Communication Breakdown, Confusion, Human-Machine Interface | OAK.Airport | Although questioning their altitude clearance on vectors for Runway 11 at OAK, the flight crew of a B737-300 continued their descent until receiving a GPWS terrain warning at which time they confirmed their cleared altitude as 3,100 FT not 2,100 FT as they had read back and entered in the altitude alert window. | ||||
50 | 201103 | 0001-0600 | Descent | HS 125 Series | Human Factors | Human Factors | Communication Breakdown | NCT.TRACON | NCT Controller described a MVA infraction when a SJC inbound Corporate Aircraft failed to comply with issued altitude assignments. | |||||
51 | 201103 | 0001-0600 | Landing | Small Aircraft, High Wing, 1 Eng, Fixed Gear | Airport, Human Factors | Human Factors | Confusion, Distraction, Situational Awareness | SJC.Airport | A Part 135 Cargo pilot landed on SJC Runway 30R after being cleared to land on Runway 30L. He mistook the taxiway east of 30R as Runway 30R, And because the R in 30R was faded thought he was landing on 30L. | |||||
52 | 201103 | 0001-0600 | Takeoff | B767-300 and 300 ER | Takeoff | Aircraft, Human Factors, Procedure | Procedure | Situational Awareness | SFO.Airport | SFO Controller described a possible loss of separation event when departure traffic crossing at the runway intersections may have been technically airborne bring into play additional wake separation criteria. | ||||
53 | 201103 | 1201-1800 | Final Approach | A310 | Human Factors, Procedure | Procedure | Airborne Conflict | Situational Awareness | SFO.Airport | Air Carrier flight crew described a wingtip to wingtip operations while landing at SFO that resulted in a go around by the adjacent traffic, the reporter's questioning ATC's simultaneous procedures. | ||||
54 | 201102 | 0601-1200 | Climb | B737 Undifferentiated or Other Model | Commercial Fixed Wing | Human Factors, Procedure | Human Factors | Became Reoriented, Returned To Clearance | Communication Breakdown, Confusion, Situational Awareness | SJC.Airport | Two air carrier aircraft with similar call signs confused both the flight crews and ATC when clearances intended for one were accepted and read back by the other. | |||
55 | 201102 | 1801-2400 | Climb | B737-300 | Cruise | DA40 Diamond Star | Airspace Structure, Human Factors, Procedure, Weather | Human Factors | Airborne Conflict | Communication Breakdown, Situational Awareness | OAK.Airport | Air Carrier flight crew departing Runway 11 at OAK described a TCAS RA event with unreported traffic between 600 and 1,000 FT, the reporter questioning ATC clearance for departure. | ||
56 | 201102 | 0001-0600 | Initial Climb | B747-400 | Procedure | Procedure | Other / Unknown | SFO.Airport | SFO Air Carrier departure questioned NCT's request for 300 KT speed restriction after crossing ocean shoreline. | |||||
57 | 201102 | 1201-1800 | Initial Approach | B737-700 | Initial Approach | Widebody, Low Wing, 2 Turbojet Eng | Human Factors | Human Factors | Airborne Conflict | Requested ATC Assistance / Clarification | Confusion | SFO.Airport | B737 flight crew describes a conflict with a heavy Airbus on short final during simultaneous visual approaches to Runways 28L and R. The Airbus crew either mistook or misunderstood the clearance to Runway 28L and attempted to line up on Runway 28R, before going around when the error is discovered. | |
58 | 201101 | 1801-2400 | Initial Approach | Gulfstream V/G500/G550 | Initial Approach | A319 | Human Factors, Procedure | Human Factors | Airborne Conflict | Took Evasive Action | Communication Breakdown, Distraction, Other / Unknown, Physiological - Other, Situational Awareness, Workload | SFO.Airport | The flight crew of a G-V suffered an RA while on side by side visual to Runways 28 at SFO. Poor CRM throughout the flight and the invited cockpit presence of the non-pilot passenger were contributing factors. | |
59 | 201101 | 1801-2400 | Landing | A319 | Human Factors | Human Factors | Physiological - Other | SFO.Airport | A319 First Officer reports being illuminated by a blue laser near MENLO during a night visual approach to SFO. | |||||
60 | 201101 | 0601-1200 | Initial Climb | B757 Undifferentiated or Other Model | Company Policy, Human Factors, Procedure | Human Factors | Communication Breakdown, Confusion | NCT.TRACON | A near conflict occurred when traffic departing from Runway 28 and Runway 1 at SFO turned toward one another because the clearance issued to the Runway 28 traffic was confused and/or not updated. | |||||
61 | 201101 | 0601-1200 | Final Approach | B747-400 | Procedure | Procedure | Situational Awareness | SFO.Airport | Air Carrier B747 pilot expressed concern regarding NCT's handling of parallel approach procedures into SFO, claiming NCT frequently sequences faster aircraft behind slower/smaller aircraft complicating speed adjustments. | |||||
62 | 201101 | 0601-1200 | Taxi | Commercial Fixed Wing | Chart Or Publication, Procedure | Chart Or Publication | Communication Breakdown, Confusion, Situational Awareness, Workload | SFO.Airport | An SFO Ground Controller directed a crew to taxi on Taxiway A to Taxiway Q, but the airport diagrams allegedly do not indicate a Taxiway A and Taxiway Q Intersection. | |||||
63 | 201012 | 1801-2400 | Descent | A319 | Airspace Structure, Environment - Non Weather Related, Procedure | Ambiguous | Took Evasive Action | Communication Breakdown, Distraction, Situational Awareness, Training / Qualification | OAK.Airport | An A319 crew executed an escape maneuver after the TERRAIN warning alerted while flying the OAK COMMO1 arrival to Runway 11. | ||||
64 | 201012 | 1801-2400 | Taxi | A319 | Human Factors | Human Factors | Became Reoriented, Requested ATC Assistance / Clarification | Communication Breakdown, Distraction, Situational Awareness, Workload | SFO.Airport | An A319 crew taxiing to SFO Runway 1R for takeoff advised ATC they were not ready because the cabin was not ready. ATC replied, "Advise, line up and wait 1R." The crew verified the clearance because of task saturation and the extended delay. | ||||
65 | 201012 | 1801-2400 | Takeoff | Large Transport, Low Wing, 2 Turbojet Eng | Airport, Environment - Non Weather Related | Environment - Non Weather Related | Landed As Precaution, Returned To Departure Airport | Situational Awareness, Training / Qualification, Troubleshooting, Workload | SFO.Airport | An Air Carrier aircraft departed SFO Runway 1R and struck a flock of birds at about 700 FT damaging the left engine. The crew returned to land and found 6-8 blades with significant damage. | ||||
66 | 201012 | 1801-2400 | Taxi | Regional Jet 700 ER/LR (CRJ700) | Taxi | Medium Large Transport, Low Wing, 2 Turbojet Eng | Human Factors, Procedure | Human Factors | Ground Conflict, Less Severe | Situational Awareness | SJC.Tower | SJC Controller described a taxi conflict event resulting in an abrupt stop by one of the aircraft, the reporter acknowledging more positive sequencing instructions should have been issued prior to the aircraft taxiing. | ||
67 | 201011 | 1801-2400 | Taxi | Skyhawk 172/Cutlass 172 | Airport, Chart Or Publication, Human Factors | Human Factors | Became Reoriented, Returned To Clearance | Confusion, Situational Awareness, Training / Qualification | OAK.Airport | C172 pilot experiences confusion while taxiing to Runway 27R at OAK via C Taxiway during night time conditions. Alpha Taxiway is inadvertently entered which has no connection to Runway 27R. | ||||
68 | 201012 | 1201-1800 | Descent | B737-800 | ATC Equipment / Nav Facility / Buildings, Human Factors | Human Factors | Confusion, Distraction, Situational Awareness | SFO.Airport | NCT Controller described a possible MVA infraction during SOIA procedures when distracted by a sudden PRM failure requiring an immediate change to conventional approach procedures. | |||||
69 | 201011 | 1801-2400 | Descent | Commercial Fixed Wing | Aircraft, Company Policy, Human Factors, Procedure, Weather | Weather | Communication Breakdown, Confusion | SFO.Airport | An Air Carrier arrival into SFO received confused holding instructions issued by ATC followed by an unexpected routing and runway change. The absence of automated ATIS updating reportedly added to the confusion experienced. | |||||
70 | 201011 | 0001-0600 | Initial Approach | Global Express (BD700) | Final Approach | Commercial Fixed Wing | Human Factors, Procedure, Weather | Human Factors | Communication Breakdown, Situational Awareness | SJC.Airport | SJC Controller described a go around event caused by a strong tail wind, the reporter noting NCT's reluctance to change runway configurations. | |||
71 | 201011 | 0601-1200 | Descent | B757-200 | Airspace Structure, Human Factors, Procedure | Procedure | Communication Breakdown, Situational Awareness | SFO.Airport | Air carrier landing at SFO and kept high on the landing profile voiced concern regarding the handling by NCT as compared to other ATC facilities. | |||||
72 | 201011 | 0001-0600 | Final Approach | B757-200 | Human Factors, Procedure | Human Factors | Situational Awareness | SFO.Airport | Air Carrier landing SFO was issued a go around by ATC because traffic and speed assignments could not be achieved, the reporter voicing concern regarding the NCT Controller's technique and speed/visual separation requests. | |||||
73 | 201011 | 1801-2400 | Landing | B757-200 | Human Factors | Human Factors | Distraction, Other / Unknown | SJC.Airport | B757 First Officer reports another Green Laser incident approaching SJC from the south. Local police show up to take a statement and report that one perpetrator has already been arrested during a previous incident. | |||||
74 | 201011 | 1201-1800 | Final Approach | Commercial Fixed Wing | Human Factors, Procedure | Human Factors | Became Reoriented, Regained Aircraft Control | Communication Breakdown, Confusion, Human-Machine Interface, Situational Awareness, Training / Qualification, Workload | SFO.Airport | An air carrier First Officer described her first experience with an unstabilized approach flown by the other pilot and the mental gymnastics involved with interpreting, reacting, and safely resolving the events that followed. | ||||
75 | 201011 | 0001-0600 | Initial Approach | Large Transport, Low Wing, 2 Turbojet Eng | Environment - Non Weather Related | Environment - Non Weather Related | Distraction, Physiological - Other | SJC.Airport | An Air Carrier Captain reported that while over West Santa Clara Valley on the SJC Runway 30 Fairgrounds Visual he and the First Officer were hit by an intense green laser which originated somewhere west of the airport. Both pilots reported visual impairment requiring medical attention. | |||||
76 | 201010 | 0601-1200 | Landing | B747-400 | Human Factors, Procedure | Human Factors | Other / Unknown | NCT.TRACON | Air Carrier inbound to SFO Runway 28L failed to comply with go around instructions issued by the PRM Monitor Controller because the crew believed they were issued a standard ILS procedure and changed to the Tower frequency. | |||||
77 | 201010 | 1801-2400 | Taxi | HS 125 Series | Procedure | Procedure | Communication Breakdown | SFO.Tower | SFO Controller described a confused "Line Up And Wait" event noting the new phraseology is flawed because it is limited to one action, when other ATC instructions/advisories involve entering/holding on the runway. | |||||
78 | 201010 | 1801-2400 | Climb | A320 | Human Factors, Procedure | Human Factors | Situational Awareness | SFO.Airport | NCT Controller witnessed an unauthorized airspace entry event where the Controller in question had a poor understanding of point outs and airspace restrictions. | |||||
79 | 201010 | 1201-1800 | Descent | Commercial Fixed Wing | Human Factors, Procedure | Human Factors | Communication Breakdown | SFO.Airport | B777 on final for SFO Runway 28L described a go around event involving a B757 on final for Runway 28R claiming the instructions from the Approach Controller were reversed by the Tower Controller causing the event. | |||||
80 | 201010 | 1201-1800 | Descent | Falcon 2000 | Any Unknown or Unlisted Aircraft Manufacturer | Human Factors | Human Factors | Airborne Conflict | Took Evasive Action | Situational Awareness, Time Pressure | NCT.TRACON | DA2000 First Officer reports declining a descent clearance from ATC at the Captains request, due to traffic on the TCAS display. This results in a TCAS TA then RA to climb, to which the crew responds. | ||
81 | 201009 | 1201-1800 | Descent | B757-200 | Human Factors | Human Factors | Airborne Conflict | Took Evasive Action | Other / Unknown | NCT.TRACON | Air Carrier descending on the FMS Bridge arrival into SFO was issued conflicting VFR traffic by ATC and issued an avoidance turn, TCAS TA/RA was received, the reporter noting ATC should have issued a level off altitude. | |||
82 | 201009 | 1201-1800 | Landing | B737 Undifferentiated or Other Model | Human Factors | Human Factors | Airborne Conflict | Executed Go Around / Missed Approach | Communication Breakdown | SFO.Airport | SFO Controller described a conflict event involving an Runway 28R go-around and a Runway 1R departure, the Controller alleged landing traffic did not advise ATC, and appeared to be using the IFR published missed approach. | |||
83 | 201009 | 0001-0600 | Climb | B737-800 | Cruise | Cessna Aircraft Undifferentiated or Other Model | Human Factors, Procedure | Human Factors | Airborne Conflict | Took Evasive Action | Situational Awareness | SFO.Airport | Air Carrier departure from SFO described a TCAS RA event shortly after take off on the SHOR1 SID, noting ATC had re-assigned an interim altitude (3000 FT) just prior to the event. | |
84 | 201009 | 1201-1800 | Final Approach | B737 Undifferentiated or Other Model | Cruise | Skyhawk 172/Cutlass 172 | Human Factors | Human Factors | Airborne Conflict | Situational Awareness | SJC.Airport | SJC Controller described a TCAS RA event when an Air Carrier on final for Runway 30R conflicted with a traffic watch aircraft on the Tower frequency, the reporter indicating the traffic watch aircraft should have been transferred to the Approach Control. | ||
85 | 201009 | 1201-1800 | Final Approach | B737 Undifferentiated or Other Model | Landing | B757 Undifferentiated or Other Model | ATC Equipment / Nav Facility / Buildings, Human Factors, Procedure | Human Factors | NCT.TRACON | NCT Controller described a loss of B757 separation event on final to SFO when he/she failed to note the "BAT", (an electronic RADAR display separation device), was set at 3 miles instead of the required 4 miles in this instance. | ||||
86 | 201009 | 1201-1800 | Taxi | Medium Transport, High Wing, 2 Turboprop Eng | Airport | Airport | Distraction, Situational Awareness | OAK.Airport | An air carrier Captain reported the designated parking location for an in ground fueling cart was too close for comfort when being marshalled into the gate. | |||||
87 | 201009 | 0001-0600 | Initial Approach | B757-200 | ATC Equipment / Nav Facility / Buildings, Human Factors, Procedure | ATC Equipment / Nav Facility / Buildings | Human-Machine Interface, Other / Unknown | SFO.Airport | SFO Controller described an overtake event on short final during parallel operations to Runways 28L/R, the reporter noting available RADAR equipment makes it difficult for controllers to identify overtake events. | |||||
88 | 201009 | 0601-1200 | Takeoff | Commercial Fixed Wing | Environment - Non Weather Related, Procedure | Procedure | Ground Conflict, Less Severe | Rejected Takeoff, Took Evasive Action | Communication Breakdown, Situational Awareness | SFO.Airport | An air carrier Captain reported rejecting a SFO Runway 1L takeoff after ATC alerted the takeoff clearance cancellation. Traffic was on short final for Runway 28 but the crew could not see the aircraft in the sun over the bay. | |||
89 | 201009 | 0601-1200 | Final Approach | Commercial Fixed Wing | Final Approach | Commercial Fixed Wing | Airport, Airspace Structure, Procedure | Ambiguous | Returned To Clearance, Took Evasive Action | Distraction, Human-Machine Interface, Situational Awareness, Training / Qualification | SFO.Airport | An air carrier crew reported a TCAS RA warning on short final to SFO Runway 28R behind a B767 on final for Runway 28L. The crew adjusted the profile slightly to increase clearance with the traffic in sight, and feeling in control continued the approach normally. | ||
90 | 201008 | 0601-1200 | Taxi | A318 | Environment - Non Weather Related, Procedure | Procedure | Took Evasive Action | Communication Breakdown, Distraction | SFO.Airport | Airbus flight crew preparing for taxi had to abruptly stop when a tug approached the front of their aircraft to inquire about an on board passenger. | ||||
91 | 201008 | 1201-1800 | Taxi | Small Transport, Low Wing, 2 Turbojet Eng | Human Factors, Procedure | Human Factors | Communication Breakdown, Confusion, Situational Awareness | SFO.Airport | Small turbojet First Officer reports crossing runways 1L and 1R inadvertently after being cleared to taxi via Taxiway A to Runway 1R behind a B757. The B757 had been cleared to Runway 28L. | |||||
92 | 201008 | 0601-1200 | Final Approach | B777-200 | Final Approach | Cessna Citation Undifferentiated or Other Model | Human Factors, Procedure | Procedure | Airborne Conflict | Other / Unknown | SFO.Airport | B777 at 800 FT and assigned Runway 28R SFO described a conflict event with a light jet when ATC initiated a last minute runway change resulting in the light jet directly overhead, the reporter noting this was becoming standard at SFO. | ||
93 | 201008 | 1201-1800 | Descent | Commercial Fixed Wing | Airport, Human Factors, Procedure | Human Factors | Became Reoriented | Communication Breakdown, Confusion, Situational Awareness, Workload | NCT.TRACON | A320 flight crew cleared for the visual to Runway 28R at SFO from a right base reports conflict with another aircraft landing Runway 28L. After switching to Tower it was discovered that both aircraft were trying to land on Runway 28R. | ||||
94 | 201008 | 0601-1200 | Initial Climb | Learjet 60 | Chart Or Publication, Human Factors | Human Factors | Took Evasive Action | Confusion, Training / Qualification | OAK.Airport | LJ60 Captain departing OAK reports mistaking the lost comm procedure for the normal departure procedure. Reporter turned to 200 degree heading at 3000 FT much to the chagrin of an NCT Controller. | ||||
95 | 201008 | 0001-0600 | Final Approach, Initial Approach | A319 | ATC Equipment / Nav Facility / Buildings, Human Factors | Human Factors | Executed Go Around / Missed Approach | Situational Awareness | SFO.Airport | NCT Controller working the final position for SFO described a loss of wake turbulence separation. | ||||
96 | 201008 | 1801-2400 | Initial Approach | P180 Avanti | Initial Approach | Skylane 182/RG Turbo Skylane/RG | Human Factors | Human Factors | Airborne Conflict | Situational Awareness | OAK.Airport | OAK Local Controller described a conflict between a VFR arrival to HWD and an aircraft inbound to OAK Runway 27R on a visual approach, the reporter listing several actions which would have prevented the event. | ||
97 | 201007 | 1201-1800 | Taxi | Heavy Transport | Airport, Chart Or Publication, Procedure | Procedure | Returned To Clearance | Communication Breakdown, Confusion | SFO.Airport | A clearance from Spot 10 at SFO was incompatible with Ground Control's clearance to taxi via taxiway B and F to the departure runway. | ||||
98 | 201007 | 1801-2400 | Landing | Commercial Fixed Wing | Human Factors | Human Factors | Distraction, Physiological - Other | OAK.Airport | Air Carrier Captain reports being illuminated by a green laser on a four mile final to Runway 29 at OAK. | |||||
99 | 201007 | 0001-0600 | Initial Climb | Commercial Fixed Wing | Human Factors | Human Factors | Became Reoriented | Confusion, Situational Awareness | SJC.Airport | An air carrier Captain reported exceeding FAR speed limit below Class B on the SJC Loupe 1 SID. | ||||
100 | 201007 | 0001-0600 | Takeoff | B757-300 | Company Policy, Environment - Non Weather Related, Human Factors | Human Factors | Confusion, Human-Machine Interface, Time Pressure, Training / Qualification, Workload | SFO.Airport | B757-300 flight crew mistakenly departed with derated power after misreading their company provided performance information. |