Multi-Engine Turbojet Aircraft Upsets Incidents

Transcription

1 ASRS Database Report Set Multi-Engine Turbojet Aircraft Upsets Incidents Report Set Description...A sampling of reports concerning turbojet uncommanded control surface movement and unusual aircraft attitudes. Update Number Date of Update...March 30, 2015 Number of Records in Report Set...50 Number of New Records in Report Set...20 Type of Records in Report Set...For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

2 National Aeronautics and Space Administration Ames Research Center Moffett Field, CA TH: MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data SUBJECT: Data Derived from ASRS Reports The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points. ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System. Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event. After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited. The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials. Linda J. Connell, Director NASA Aviation Safety Reporting System

3 CAVEAT REGARDING USE OF ASRS DATA Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences. Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area A than area B simply because the airmen who operate in area A are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis. One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

4 Report Synopses

5 ACN: (1 of 50) LJ31 Captain reported encountering wake turbulence while on approach to ANC Runway 7R. Reporter was in trail of a B777 landing on 7L, which resulted in an uncommanded roll "well beyond 90 degrees". Reporter recommended ATC be more aware of the wake possibilities when using this runway configuration. ACN: (2 of 50) CRJ-200 First Officer reported encountering wake turbulence on departure from CLT in trail of an A320 that resulted in uncommanded roll and stick shaker. Reporter suggested increased separation on takeoff. ACN: (3 of 50) A B737 flight crew rejected their takeoff approaching V1 believing they had blown tires on the left side. After stopping fire crews inspected the exterior and found no visible damage. After returning to the gate passengers, ATC and other flight crews reported fireballs and booms had emanated from the left engine. ACN: (4 of 50) A CRJ-200 flight crew returned to their departure airport when aileron operation appeared severely compromised and the autopilot exhibited extreme and uncommanded elevator inputs. ACN: (5 of 50) CRJ200 Captain reports an uncommanded yaw motion during level flight at feet with the First Officer flying and the autopilot engaged. The Captain assumes control and performs the uncommanded yaw motion memory items and calls for the QRH. During this time it is determined that the rudder is trimmed full nose right and is adjusted back to center. No further rudder anomalies occur and the flight continue to destination. ACN: (6 of 50) A small transport jet flight crew reported they ran over a coyote on landing roll in TWF, no apparent damage to the aircraft. ACN: (7 of 50)

6 CRJ-200 flight crew experienced a rudder trim issue causing the aircraft to yaw to the left during the descent phase. The crew landed at their destination airport. During taxi the crew followed the wrong yellow line and ended up on the de-ice pad. ACN: (8 of 50) Upon takeoff the Captain of an EMB-175 found it necessary to maintain full down elevator deflection to prevent over rotation. The condition continued until flight attendants were able to move passengers forward. The Captain recalled noting the trim set at 4.8 units ANU during preflight and the First Officer noted 10.1 ANU during the struggle to maintain a safe attitude. ACN: (9 of 50) B flight crew reported slower than normal acceleration on takeoff roll, possibly resulting from autothrottle malfunction or error in weight and balance calculations. Captain added power at rotation to assure obstacle clearance. ACN: (10 of 50) CRJ700 flight crew reports being asked by ATC for their best rate to FL350, then being distracted by minor tasks that allow the aircraft to slow to 180 knots and sticker activation. A text book recovery is performed. ACN: (11 of 50) CRJ-200 First Officer reported wake encounter departing ATL in trail of an MD-80 that resulted in two low altitude 20-degree rolls. ACN: (12 of 50) Large Cargo aircraft flight crew experiences a sudden pitch over while being vectored for arrival and using VNAV for the descent path. The pitch over occurred just after a waypoint, with a charted holding pattern and located behind the aircraft, was removed from the legs page of the FMC. The autopilot is quickly disconnected and the aircraft returned to a reasonable descent rate and airspeed. ACN: (13 of 50)

7 B767 flight crew experiences an uncommanded LE slat extension climbing through FL230. As quickly as the slat extended it retracted, but the crew elected to dump fuel and return to the departure airport for an overweight landing. ACN: (14 of 50) A Captain and First Officer report about uncommanded left yaw motions similar to choppy, jerk like movements while climbing from 11,000 feet to 29,000 feet on a CRJ-200 aircraft. Yaw Damper-1 had disconnected twice while uncommanded yaw oscillations and roll motions (Dutch Roll) continued with Autopilot 'On' or 'Off'. Aircraft control became increasingly difficult, flight diverted. ACN: (15 of 50) A BE-400 R Thrust Reverser ARM and Master Warning flashed momentarily during descent accompanied by a violent 45 degree right roll and loud rumbling noise. The whole event lasted approximately 2 seconds and conditions returned to normal. The approach was continued to a normal landing. ACN: (16 of 50) First Officer reports about the cause of a Master Warning sounding due to a Rudder Configuration issue on a CRJ-700 aircraft. Second takeoff attempt aborted when similar Master Warning sounded and "Rudder Config" appeared. Pilot resets the Rudder Trim a third time and departs. Why the Rudder Trim moved out of center position uncommanded on the takeoff roll, is unknown. ACN: (17 of 50) CRJ-200 Captain reported wake turbulence encounter in trail of an MD80 on approach to DTW that resulted in a 25-degree roll and a "sudden downward push". ACN: (18 of 50) B flight crew reported wake turbulence encounter during arrival to LAX in 12-mile trail that resulted in sudden 30-degree roll. Crew paused their descent and were subsequently criticized by ATC. ACN: (19 of 50)

8 A Captain reports experiencing uncommanded yawing oscillations and rudder pedal movement in a CRJ-200 aircraft during climb to final cruise altitude. When the CRJ entered a 'Dutch Roll', the pilot disconnected the autopilot and flight director to correct the aircraft attitude. Flight diverted. During descent, oscillations continued to be felt in pedals with yaw in both directions. ACN: (20 of 50) Following the loss of the First Officer's flight instruments and the autoflight systems the flight crew of a CRJ-900 later experienced uncommanded full or near full rudder deflections to both the left and right. They descended and landed without further incident at their destination. ACN: (21 of 50) CRJ-200 Captain reported loss of control because of wake turbulence from a preceding MD-11 on approach to PHL. Reporter questioned current wake turbulence separation standards. ACN: (22 of 50) A320 Captain reported encountering wake turbulence in trail of an MD-11 on approach to DFW resulting in a 45 degree bank and 8-12 degrees nose down attitude. ACN: (23 of 50) An MD11 starting the takeoff roll was unable to center the nose gear steering and rejected the takeoff at low speed. ACN: (24 of 50) A Captain describes the violent, sharp "yank" force he felt on the Control Yoke during two takeoff rolls that included two sharp pulls to the left; resulting in two Rejected Take-Offs (RTOs) on the same EMB-145 aircraft. No EICAS messages displayed. ACN: (25 of 50) A B flight encountered severe turbulence and mountain wave at FL360 and suffered a loss of separation with an aircraft above unable to maintain altitude. One flight attendant was injured in the two to three minute exposure to the turbulence. ACN: (26 of 50)

9 A Captain describes his efforts to regain control of an EMB190 aircraft during initial climb when the aircraft suddenly pitched 'Full Down' after he had attempted to retrim Pitch 'Up', using the Manual Pitch Trim switch on his Control column. Aircraft had accelerated to 265 knots. Emergency declared. Two mechanics also report their involvement with replacement of the Captain's Pitch Trim switch that was later found installed backwards. ACN: (27 of 50) CRJ-200 flight crew reported encountering wake turbulence in trail of a B757 after takeoff at ATL that resulted in 30 degree roll and a stick shaker at low altitude. Crew cited new ATL ATC separation procedures as causal. ACN: (28 of 50) During cruise flight the crew of an MD-83 experienced autopilot and autothrottle disconnects as well as numerous annunciator warnings along with erratic flight instrument failures. The nature of the fault indications initially led the Captain to believe that an engine failure had occurred. An emergency was declared and a diversion initiated. The true nature of the problem was eventually determined to be a CSD failure, appropriate procedures were followed, and the flight continued uneventfully to the original destination airport. ACN: (29 of 50) A321 Captain experiences a failure of the landing gear to extend when needed for drag on a steep RNAV approach. After repeated attempts without success a go-around is initiated. The A321 QRH does not have a procedure and no faults were indicated. Another attempt at extending the gear is successful and a normal landing ensues. The steep descent required on the approach was also brought into question. Post flight revealed that the first extension attempt had been blocked by automatic systems due speed above 260 KTS and subsequent attempts were blocked by a two minute time delay from the initial attempt in the same system. ACN: (30 of 50) A CRJ-700 developed a STAB TRIM runaway condition and the new hire First Officer completed the immediate action and QRH procedures. The flight diverted to the nearest airport where an emergency was declared. ACN: (31 of 50) A300 Captain experiences an ADC failure at FL330 with the First Officer on a bathroom break. The autopilot pitches over, attempting to maintain Mach number which is decaying on the

10 Captain's instruments. The First Officer returns to find the airspeed 20 knots into the barber pole on his side. The airspeed is stabilized at 280, an emergency is declared and the flight diverts to a suitable airport. ACN: (32 of 50) A MD-83 Digital Flight Guidance System (DFGS) circuit breaker opened after takeoff, IMC near convective weather. With all DFGS system indications frozen and contending with uncommanded yaw oscillations, the crew declared an emergency and diverted to a nearby VMC airport where an emergency landing was completed after a go-around for unsafe gear. ACN: (33 of 50) MD83 First Officer experiences autopilot and autothrottle failures during climb along with most DFGS functions. The crew elects to divert to a suitable airport due to weather at the departure airport. The landing gear fails to extend normally when selected down and a go-around ensues. Emergency gear extension procedures are successful followed by a normal landing. ACN: (34 of 50) Just as they were about to intercept the localizer in IMC the flight crew of an MD-83 suffered the loss of first the Captain's PFD, ND, autothrottles and MCP panel and, after passing control to the First Officer, his PFD and ND failed as well. A go-around was initiated on standby instruments during which they encountered a windshear alert warning accompanied by associated significant performance degradation. An ATC assisted diversion to another airport for a fuel mandated downwind emergency landing was nearly an anticlimactic conclusion. ACN: (35 of 50) Pilot reports he has experienced seven incidents of rudder stiffness on landing and prior to departure taxi-out, followed by an EICAS Rudder 1-2 Inop, Manual Reversion message and Master Caution annunciation on EMB-145 aircraft. Concerns raised that slowness in rudder response in Manual Reversion could affect controllability with an engine loss or uncommanded nose steering excursion on landing. ACN: (36 of 50) CRJ-200 First Officer describes a near loss of control incident shortly after takeoff with the Captain flying in moderate turbulence. A rudder anomaly was thought to be the issue and a large amount of left rudder trim was required to bring the aircraft back to stable flight.

11 ACN: (37 of 50) A Falcon 20 autopilot amplifier malfunctioned at FL340 which resulted in a rapid roll to 60 degrees, and a 1,000 FT altitude loss. The flight descended out of RVSM airspace for the remainder of the flight. ACN: (38 of 50) B First Officer reported encountering wake turbulence from preceding B777 on departure from LAX. ACN: (39 of 50) An A319 developed an uncommanded rudder movement during descent through FL240 at 320 knots significant enough to be heard in the cockpit and cause an aft galley flight attendant imbalance. No ECAM alerts coincident with the event. ACN: (40 of 50) CRJ-900 Captain reports an underspeed condition at FL370 resulting in autopilot disconnect and loss of 1,200 FT before the flying First Officer can add thrust and recover. The Captain was occupied with weather and planning a possible reroute. ACN: (41 of 50) A Cessna 560 First Officer reported the PFD displayed an Amber "A" followed shortly by a Red Boxed "A", and then it entered an uncommanded turn. With autopilot OFF as per the QRH, significant forces were required to control the aircraft so an emergency was declared and the flight diverted. Technician reporter suspects the grease used to lubricate the aileron trim actuator retains water and freezes. The same grease is used on elevator trim actuators that have a history of freezing in flight. ACN: (42 of 50) A319 flight crew experiences an out of trim situation during initial climb and when the First Officer applies slight rudder pressure the aircraft yaws dramatically. Trim is used to center the brick and the autopilot engaged, resulting in about three units of nose right rudder trim. Another sharp yaw event is produced with the autopilot engaged and the crew elects to return to the departure airport.

12 ACN: (43 of 50) A B757 crew reported uncommanded left and right yaw motions during climb with no EICAS or other malfunction indications so as a precaution, the crew returned to the departure airport ACN: (44 of 50) CRJ200 Captain experiences a large rudder deflection during climb requiring a great deal of rudder trim to neutralize. Shortly after a YD 1 Status message appeared. After consulting the QRH the YD is reengaged and the rudder trim is no longer required. Flight continues to destination. ACN: (45 of 50) CRJ-200 flight crew experiences a jammed stabilizer on takeoff, indicated by STAB TRIM/MACH TRIM caution messages, and elects to return to the departure airport. The crew had written the aircraft up the previous evening for STAB TRIM/MACH TRIM caution messages, which were signed off by Maintenance as ops check OK. ACN: (46 of 50) EMB145 First Officer experiences runaway aileron trim at FL360 with the Captain in the lavatory. The Captain quickly enters the cockpit and the decision is made to divert to the nearest suitable airport. During the descent a second attempt is made to center the aileron trim which is successful. ACN: (47 of 50) A B engine failed during climb so after running the QRH, an emergency was declared and the flight returned to the departure airport for an uneventful landing. ACN: (48 of 50) B737 First Officer reported a wake vortex encounter in trail of an A330 on approach to CYVR that resulted in a roll and speed deviation. ACN: (49 of 50)

13 B757 flight crew experiences violent yawing at FL400 with no EICAS messages present. The autopilot is turned off and a descent to FL300 requested. During the descent the yawing stops. While communicating with the company the yawing returns and the crew declares an emergency and diverts. At 800 feet AGL during the visual approach, an L YAW DAMPER message appeared on EICAS and the left yaw damper is turned off, stopping the oscillations. ACN: (50 of 50) An EMB-145 flight crew was flummoxed by inappropriate EGPWS call-outs while at high flight levels and a tendency for the aircraft to initiate uncommanded turns to the right. Upon landing nearly full left aileron was required to maintain wings level on approach, despite a crosswind from the right.

14 Report Narratives

15 ACN: (1 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : ANC.Airport State Reference : AK Altitude.AGL.Single Value : 1000 Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Light : Daylight Aircraft Reference : X ATC / Advisory.Tower : ANC Aircraft Operator : Air Taxi Make Model Name : Learjet 31 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 135 Flight Plan : IFR Mission : Passenger Flight Phase : Final Approach Route In Use : Visual Approach Airspace.Class C : ANC Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Taxi Function.Flight Crew : Captain Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Instrument Qualification.Flight Crew : Air Transport Pilot (ATP) Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Experience.Flight Crew.Total : 6265 Experience.Flight Crew.Last 90 Days : 35 Experience.Flight Crew.Type : 955 ASRS Report Number.Accession Number : Events Anomaly.Inflight Event / Encounter : Wake Vortex Encounter Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control

16 Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Flight Crew : Regained Aircraft Control Result.Flight Crew : Executed Go Around / Missed Approach Result.Air Traffic Control : Issued New Clearance Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Environment - Non Weather Related Contributing Factors / Situations : Airport Primary Problem : Procedure Narrative: 1 We were descending while being vectored on a right downwind for runway 7R. Approach control pointed out traffic, a 777 on final for 7L, which I reported in sight. As we passed the 777, approach control turned us to a heading of 040 and cleared us for a visual approach to 7R with instructions not to overtake the 777 and to plan to land long. We intercepted final just west of Fire Island, approximately 6 NM from the threshold of 7R. We were level with the 777 at that point. We had the 7R ILS tuned for backup guidance, so I instructed the first officer to stay at least one dot high on the ILS glideslope. I checked the wind vector on the HSI, which showed a 19 knot wind from the right, and the last time I looked at the glideslope pointer, it was showing almost full deflection high. When we were fully configured for landing and slowed to final approach speed, the 777 was faster and was moving away. As I watched the 777 moving away from us, I became aware of how far the parallel runways are staggered. The threshold for 7L is well beyond the threshold for 7R, and I became concerned that we might not be staying high enough to avoid the wake turbulence. I considered that it might be a good idea to tune the ILS for 7L to ensure we were remaining above that glideslope, and checked the wind vector again, which was now showing a 9 knot wind from the left. It was very shortly after that that we encountered the wake turbulence. It rolled us first rapidly to the left. Although I'm sure the first officer reacted, I immediately took the controls, applying full right aileron and maximum thrust. The roll to the left stopped and was followed by a rapid roll back to the right, which continued well beyond 90 degrees despite full left aileron deflection. The roll stopped and we returned to wings level, climbing. I retracted the flaps to 20 degrees and reported to the tower that we were going around. They instructed us to climb to 2500 and turn right to 200 and asked the reason for our go-around. I continued cleaning up our configuration, retracting the landing gear and flaps, then asked the first officer how he was feeling. He said he could take the controls, so I returned control to him, then signaled to our passengers that the situation was under control. We were sent back to approach control, who gave us a turn to downwind and a descent, then cleared us for a visual approach. We landed without further incident. As I reviewed this incident later and looked at the airport diagram for the Anchorage airport, I came to the conclusion that it is not possible to follow a heavy aircraft in this situation with anything less than standard radar separation. Because of the way the runways are staggered, effectively applying normal visual wake turbulence avoidance procedures produces a highly abnormal and potentially hazardous situation even if the wake turbulence is successfully avoided. Runway 7R is 12,400 feet long. The threshold for runway 7L, just estimating from the airport diagram, is roughly 6,000 feet beyond the threshold for 7R. If the heavy aircraft

17 lands 1000 feet beyond the threshold for 7L, and we plan to land 1,000 feet beyond that, it leaves something slightly more than 4,000 feet of runway on which to stop. While that is well within the capability of the Lear 31, landing on the last third of a runway is not something we would ever plan to do in any normal circumstance, and is well beyond what anyone would normally consider a long landing, as we were instructed by ATC to plan for. In future similar situations where normal visual wake turbulence avoidance is not practical, I think it would be advisable to request standard radar separation before accepting a visual approach in order to ensure there is sufficient time for the wake turbulence to dissipate. It seems to me that ATC should really be aware of this situation as well in order to avoid placing lighter aircraft in a position where following a heavy aircraft is practically not possible. LJ31 Captain reported encountering wake turbulence while on approach to ANC Runway 7R. Reporter was in trail of a B777 landing on 7L, which resulted in an uncommanded roll "well beyond 90 degrees". Reporter recommended ATC be more aware of the wake possibilities when using this runway configuration.

18 ACN: (2 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : CLT.Airport State Reference : NC Altitude.AGL.Single Value : 1000 Environment Flight Conditions : Marginal Light : Daylight Aircraft : 1 Reference : X ATC / Advisory.Tower : CLT Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Initial Climb Airspace.Class B : CLT Aircraft : 2 Reference : Y Aircraft Operator : Air Carrier Make Model Name : A320 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Initial Climb Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Pilot Flying Function.Flight Crew : First Officer Qualification.Flight Crew : Air Transport Pilot (ATP) Qualification.Flight Crew : Instrument Qualification.Flight Crew : Multiengine ASRS Report Number.Accession Number : Events

19 Anomaly.Inflight Event / Encounter : Wake Vortex Encounter Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Took Evasive Action Assessments Contributing Factors / Situations : Procedure Contributing Factors / Situations : Environment - Non Weather Related Primary Problem : Procedure Narrative: 1 Departing out of CLT were cleared for takeoff behind an A320. I anticipated that ATC would keep us adequately separated from any potential wake turbulence. As we began our climb and acceleration through 1,000 feet AGL I could see the probability of flying through that aircraft's wake. I called for continuous ignition then just before we were about to retract the flaps we got into it pretty hard. Counter control required full aileron deflection and some additional rudder. The stick shaker activated as well. The stick shaker activation was due to the turbulent air deflecting the AOA vanes and not due to an excessive angle of attack. Airspeed throughout the maneuver was approximately 190KIAS. To avoid this in the future I think Charlotte tower should give the following aircraft an upwind vector, or turn the leading aircraft downwind and earlier, or hold the following aircraft until separation is sufficient. Based on the CRJ's long takeoff roll it is inevitable that following a larger aircraft will cause the climbing flight path to intersect with the flight path of the leading aircraft. The most likely cause was ATC clearing us for takeoff before there was adequate separation. CRJ-200 First Officer reported encountering wake turbulence on departure from CLT in trail of an A320 that resulted in uncommanded roll and stick shaker. Reporter suggested increased separation on takeoff.

20 ACN: (3 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0 Environment Flight Conditions : Mixed Weather Elements / Visibility.Visibility : 3 Light : Night Ceiling.Single Value : 800 Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : Air Carrier Make Model Name : B737 Undifferentiated or Other Model Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Takeoff Component Aircraft Component : Turbine Engine Aircraft Reference : X Problem : Malfunctioning Person : 1 Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Air Transport Pilot (ATP) Experience.Flight Crew.Last 90 Days : 158 Experience.Flight Crew.Type : 7500 ASRS Report Number.Accession Number : Person : 2 Reference : 2 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier

21 Function.Flight Crew : First Officer Function.Flight Crew : Pilot Not Flying Experience.Flight Crew.Last 90 Days : 90 Experience.Flight Crew.Type : 700 ASRS Report Number.Accession Number : Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor Detector.Person : Other Person Detector.Person : Passenger Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.General : Maintenance Action Result.Flight Crew : Rejected Takeoff Result.Flight Crew : Returned To Gate Assessments Contributing Factors / Situations : Aircraft Primary Problem : Aircraft Narrative: 1 Takeoff roll was normal until about kts when we felt a jolt and a slight veer to the left. The aircraft began to suddenly and violently shake and got worse as we accelerated. At this point I did not think the aircraft was capable of flight and decided to reject the takeoff. The procedure was initiated at about 110 kts. V1 was about 130 kts. The aircraft came to a stop and I announced to the passengers to "remain seated". The First Officer contacted the tower and noted the reject speed. We asked tower to send fire trucks to look for damage or fire. We both assumed we had blown one or more tires as we reviewed the RTO procedure and notes. There were no abnormal engine indications. Once on single frequency with the fire Marshall we shut down the engines and he inspected the aircraft. He found no damage and requested that we start the engines and taxi to the gate. Since I had no idea why the aircraft shook so violently we decided to have the aircraft towed to the gate with the engines off. There were no injuries. At the gate we heard from the Tower that they saw a fireball and a passenger saw 2 fireballs from under the left wing when the event happened. Narrative: 2 The weather was rainy, temperature 8 degrees, dewpoint 7 degrees, and it was fully dark at the time. The captain was the pilot flying and the first officer was the pilot monitoring. At approximately 95 knots, both pilots heard the aircraft make a loud bang, the aircraft shuddered, and the nose of the aircraft took an un-commanded and definite jolt to the left. The captain immediately stated "REJECT" and applied the brakes smoothly and expeditiously to bring the aircraft to a complete stop. Tower stated that for safety purposes they were deploying the fire trucks to confirm that there was no fire on the aircraft. The fire department inspected the aircraft and told us over the radio that there indeed appeared to be a blown tire. However, a couple of minutes later they called back to inform

22 us that they were mistaken, there appeared to be no discernible damage to the aircraft whatsoever. However, as we were about to depart the aircraft, we learned of several eye witness reports (from both passengers and other aircraft) of flames coming from the left engine as well as approximately six loud bangs. Tower confirmed this report when I called them directly to tell them that there was no visible damage to the engine. A B737 flight crew rejected their takeoff approaching V1 believing they had blown tires on the left side. After stopping fire crews inspected the exterior and found no visible damage. After returning to the gate passengers, ATC and other flight crews reported fireballs and booms had emanated from the left engine.

23 ACN: (4 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : ZZZ.Airport State Reference : US Environment Flight Conditions : VMC Light : Dusk Aircraft Reference : X ATC / Advisory.TRACON : ZZZ Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Climb Component : 1 Aircraft Component : Aeroplane Flight Control Aircraft Reference : X Problem : Malfunctioning Component : 2 Aircraft Component : Autopilot Aircraft Reference : X Problem : Malfunctioning Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Air Transport Pilot (ATP) ASRS Report Number.Accession Number : Human Factors : Human-Machine Interface Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew Were Passengers Involved In Event : N

24 When Detected : In-flight Result.General : Maintenance Action Result.General : Declared Emergency Result.Flight Crew : Returned To Departure Airport Assessments Contributing Factors / Situations : Aircraft Primary Problem : Aircraft Narrative: 1 During Climbout, I felt that the control wheel forces were not normal. I had to trim "RWD" [Right Wing Down] almost full trim deflection in order to get the aircraft to stay trimmed. I also noticed that there was about 3" of play in the control wheel travel before any aileron movement occurred. Mach Trim/Stab Trim disconnected twice during this flight. I had turned the autopilot on at one point, and after a few seconds, the yoke had slammed rearward towards my seat very abruptly and instantly returned to neutral. At that time I turned the autopilot off and hand flew the aircraft back to our departure airport. I advised ATC of situation, described the aircraft condition to the ATC controller, and informed ATC that I wanted to return to the airport. We sent Dispatcher a text via ACARS as to what was happening and what our intentions were. I called dispatch once we were on the ground. Maintenance was notified next. No QRH procedure was followed because there is no QRH procedure for this incident as I recognized it. There was no "Runaway" condition... Just severe play in the control wheel in the roll axis. I would like to know what maintenance found when they inspected the aircraft. The threat was the possibility of an aircraft upset scenario. Threat of a total loss of roll control. I am sure there were some errors performed by myself or the F/O, but I really can't remember them. We worked well as a team to land the aircraft safely. A CRJ-200 flight crew returned to their departure airport when aileron operation appeared severely compromised and the autopilot exhibited extreme and uncommanded elevator inputs.

25 ACN: (5 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.ATC Facility : ZDC.ARTCC State Reference : VA Altitude.MSL.Single Value : Environment Flight Conditions : VMC Light : Daylight Aircraft Reference : X ATC / Advisory.Center : ZDC Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Crew Size.Number Of Crew : 2 Flight Plan : IFR Mission : Passenger Flight Phase : Climb Route In Use : Direct Airspace.Class E : ZDC Component Aircraft Component : Rudder Trim System Aircraft Reference : X Problem : Malfunctioning Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Air Transport Pilot (ATP) ASRS Report Number.Accession Number : Human Factors : Human-Machine Interface Human Factors : Confusion Analyst Callback : Completed Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action

26 Result.Flight Crew : Became Reoriented Result.Aircraft : Equipment Problem Dissipated Assessments Contributing Factors / Situations : Manuals Contributing Factors / Situations : Aircraft Primary Problem : Aircraft Narrative: 1 In level flight at 17,000 feet we were given direct to our first fix which was approximately 60 degrees to our right. The First Officer was flying and the Autopilot was on. The autopilot had initiated a right turn towards the fix when we received a rather violent movement further to the right as though someone had slammed on the right rudder. Upon realizing that it was from neither I nor the First Officer's input I called for and assumed control of the aircraft. I performed the memory items for an uncommanded yaw motion and called for the appropriate checklist followed by the appropriate QRH. In looking at ED 1 and 2 I realized that the rudder trim was full deflection Nose Right. We were able to bring the trim back to neutral but were unable to decipher if it was the only reason for the yaw motion or in combination with a uncommanded yaw motion from the yaw damper. At the time of the yaw motion there had been no previous trimming of the aircraft rudder trim nor aileron trim. We elected to leave the yaw damper disconnected, as a result leaving the autopilot disconnected for the duration of flight and continued to destination. After confering with dispatch we informed the Flight Attendant of the situation and made a brief announcement to the passengers for the erratic movements and that a normal landing was to be expected. During the incident we did ask ATC to remain at our current altitude and heading to troubleshoot the problem. Upon completion of the QRH and concurrence of dispatch we informed ATC that the problem had been alleviated and that we would be continuing as filed. There was no injury to passengers or crew during the incident and a normal landing was conducted. After conducting the safety conference call debrief about an hour after landing I was asked if we as a crew were able to continue. I said for the time being I believed we could continue. After getting off the phone and speaking with my First Officer and Flight Attendant we decided that regardless of when the aircraft was signed off that it would be best to not continue with the rest of our day. After having more time to go through the QRH and to think logically about what had occured I believe this was actually a rudder trim runaway. Neither I nor the First Officer had touched the trim and I believe the right turn by the autopilot in conjuction with the sudden and continuous right yaw motion led us down the path of thinking it was an uncommanded yaw motion event and subsequently performed the memory items, checklist, and QRH as such. After examining the QRH and what occured the runaway rudder trim makes the most sense but after performing the uncommanded yaw motion QRH there was no further instruction as to troubleshooting if it had been caused by a rudder trim runaway. My suggestion would be to clarify in the QRH after performing the uncommanded yaw motion checklist that the first line should read something like, "Has the uncommanded yaw motion been caused by a rudder out of trim situation or rudder trim runaway?" If so proceed to section 10 for Rudder or Aileron Trim Runaway. I think this could have at least led us down the right path for the proper QRH given the circumstances and enabled us to re-engage the yaw damper and autopilot to continue. Given the violent yaw movement I do believe we were correct in initially suspecting an uncommanded yaw motion and performing the applicable memory items and procedures. In hindsight the rudder trim runaway was most likely the proper procedure to follow but if the uncommanded yaw motion is called for first there is nothing in the QRH to lead you

27 towards the proper QRH, unless you ignore what was initially called for. Both QRH procedures lead to a normal landing at the destination but clarification on this would lead to a more accurate QRH being run as well as a much more clear write up when arriving at the destination. Callback: 1 The reporter again stated that he believes that this was a runaway rudder trim situation and that the rudder trim switch was not in use by the First Officer at the time of the runaway. No further runaways occurred during the flight and the crew was not informed by Maintenance of the actions required to return the aircraft to service. CRJ200 Captain reports an uncommanded yaw motion during level flight at feet with the First Officer flying and the autopilot engaged. The Captain assumes control and performs the uncommanded yaw motion memory items and calls for the QRH. During this time it is determined that the rudder is trimmed full nose right and is adjusted back to center. No further rudder anomalies occur and the flight continue to destination.

28 ACN: (6 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : TWF.Airport State Reference : ID Altitude.AGL.Single Value : 0 Environment Light : Dusk Aircraft Reference : X ATC / Advisory.Tower : TWF Make Model Name : Light Transport, Low Wing, 2 Turbojet Eng Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Phase : Landing Person : 1 Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Function.Flight Crew : First Officer Function.Flight Crew : Pilot Not Flying ASRS Report Number.Accession Number : Person : 2 Reference : 2 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Function.Flight Crew : Captain Function.Flight Crew : Pilot Flying ASRS Report Number.Accession Number : Events Anomaly.Ground Event / Encounter : Person / Animal / Bird Detector.Person : Flight Crew When Detected : In-flight Result.General : None Reported / Taken Assessments Contributing Factors / Situations : Airport Primary Problem : Airport Narrative: 1

29 Immediately after touching down to land, two animals ran perpendicular to the runway in Twins Falls. A fox caught our eye which was then followed by a coyote. We felt a sudden but slight swerve to the right and heard a "thud." The Captain was pilot flying and continued the roll out without incident. Thrust reversers were deployed at or shortly after the time of impact with the animal. No damage to the gear was perceptible but we informed tower as soon as possible and a fresh animal carcass was found by airport authority. Narrative: 2 [Report narrative contained no additional information] A small transport jet flight crew reported they ran over a coyote on landing roll in TWF, no apparent damage to the aircraft.

30 ACN: (7 of 50) Time / Day Date : Local Time Of Day : Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.MSL.Single Value : Environment Flight Conditions : VMC Light : Night Aircraft Reference : X ATC / Advisory.Center : ZZZ Aircraft Operator : Air Carrier Make Model Name : Regional Jet 200 ER/LR (CRJ200) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 121 Flight Plan : IFR Mission : Passenger Flight Phase : Descent Airspace.Class E : ZZZ Component Aircraft Component : Rudder Trim System Aircraft Reference : X Problem : Malfunctioning Person : 1 Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : First Officer Function.Flight Crew : Pilot Not Flying ASRS Report Number.Accession Number : Human Factors : Situational Awareness Person : 2 Reference : 2 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Captain Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Air Transport Pilot (ATP)

31 ASRS Report Number.Accession Number : Human Factors : Human-Machine Interface Human Factors : Training / Qualification Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Anomaly.Ground Incursion : Taxiway Detector.Person : Flight Crew When Detected : In-flight Result.General : Declared Emergency Result.Flight Crew : Landed in Emergency Condition Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Primary Problem : Aircraft Narrative: 1 We were descending into ZZZ and I was making my arrival PA to the passengers. As I was looking down to switch back to COMM 1, I felt a violent yaw motion in the aircraft. As I was looking up, I saw the rudder trim was full nose left and the Captain (CA) had his hand on the rudder trim. I immediately asked him what happened and he said that the rudder trim had not stopped while he was trying to trim up the aircraft. He then continued to try to re-trim the aircraft, and there were a few more very noticeable yaw moments, but not as bad as the first one. I stated that this is an uncommanded yaw moment, and asked if we should disconnect the yaw dampers as per the memory items, and the CA said not to worry about it. He then said we should write it up, and called the FA to make sure she was OK with everyone in the back. When he got off the call, he then said he was seriously thinking of declaring an emergency. I told him, as far as I know this is an uncommanded yaw moment and is a flight control failure. He said he needed a second to think about it, and then, after about 30 seconds, said he was going to tell ATC what was going on and ask for priority. I told him this is a flight control failure again, and an emergency needed to be declared and he agreed. As we continued, the brick continued to bounce back and forth between a half scale deflection on either side, and was uncontrollable. We declared an emergency and were already set up for XXL, which was the closest to us, so decided it was best to continue for that runway. I, again, asked him if we should disconnect the yaw dampers as per the memory items, and he, again, said no and said he was not aware of the memory item for the uncommanded yaw motion. We were on approach at this time, and had to configure the aircraft, so had no more time to discuss this. We never did run the QRH due to time constraints. We landed and taxied to the gate. During the taxi, as a result of all the chaos, we missed a turn and ended up in the deice pad. Ground asked us to ask iceman for permission to continue to "K", which we got, and continued to the gate. The CA had me write the write up, as he was calling Flight Control. He told me to put his number down, as required, and told me what to write. I wrote what he said, and placed the AFDL on the pedestal against the throttle quadrant. He read the write up, and asked me if there was a QRH procedure. I said I believe so, as I know for sure there were memory items which I was questioning him about, looked in the QRH to verify there is a procedure, and told him there was. He then told me to add in to the write up that the had ran and complied with the QRH, which we did not. I added it at his request, as he was on the phone with flight control.

32 Narrative: 2 While I was descending into ZZZ somewhere between 14,000 to 18,000 feet I adjusted the rudder trim slightly to the left. After taking my hand off the trim the rudder continued full left. I overrode the malfunction and then ran the QRH. The rudder "brick" continued vacillating right and left after I had centered the "brick". I advised ATC and landed in ZZZ. We landed without an event. After clearing the runway we taxied to the gate. While taxing I followed the wrong yellow line onto the de-ice pad. I stopped the aircraft on the pad and notified ground of my mistake. Ground had us contact the Ice-man for taxi instructions. After approaching the end of the de-ice pad we contacted ground for taxing instructions to the gate. We were about 100 yards away from the actual de-icing that was going on. CRJ-200 flight crew experienced a rudder trim issue causing the aircraft to yaw to the left during the descent phase. The crew landed at their destination airport. During taxi the crew followed the wrong yellow line and ended up on the de-ice pad.