330 Incident

ACN: 1198605
Time / Day
Date : 201408
Local 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
Aircraft
Reference : X
ATC / Advisory.Ramp : ZZZZ
Aircraft Operator : Air Carrier
Make Model Name : A330
Crew Size.Number Of Crew : 3
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Parked
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 : 1198605
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Training / Qualification
Human Factors : Workload
Human Factors : Confusion
Communication 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
Detector.Person : Ground Personnel

When Detected : Taxi
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing 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 the
interphone was immediately unplugged. After an inordinately long period, during
which 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 of
waiting for acknowledgment and simply walked away.
At no time during this extended wait did the Guideman re-connect the interphone
and 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. I
reset the parking brake to "Parked", and simultaneously heard the intercom reconnect and the Guideman inform us that they were still below. The parking brake
had 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 the
tug, the failure to communicate an abnormal situation, and cockpit distractions. Our
system of multiple, layered barriers worked, however, and trapped the errors
before an incident occurred.
This pushback illustrates a potential threat and loss of a barrier during pushback
that was introduced with the recent procedure change. Under legacy pushback
procedures, the tug operator remained in interphone contact with the Captain until
the tug was disconnected and ready to drive away: "Towbar removed,
disconnecting headset, standby for hand signals." Under the recent procedure
changes, 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 towbar
removal 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 difficulties
should immediately be communicated to the cockpit.
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 the
Guideman still connected.
ACN: 1197154
Time / Day
Date : 201408
Place
Locale Reference.ATC Facility : ZZZ.ARTCC
State Reference : US
Altitude.MSL.Single Value : 36000
Environment
Flight Conditions : IMC
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ
Flight Plan : IFR
Mission : Passenger
Flight Phase : Cruise
Flight Phase : Climb
Airspace.Class A : ZZZ
Person
Reference : 1
Function.Flight Crew : Pilot Not Flying
Human Factors : Time Pressure
Human Factors : Physiological - Other
Human 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
Detector.Person : Passenger
Detector.Person : Flight Attendant
When Detected : In-flight
Result.General : Declared Emergency
Result.General : Flight Cancelled / Delayed
Result.General : Maintenance Action
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Returned To Departure Airport
Result.Aircraft : Equipment Problem Dissipated
Assessments
Contributing Factors / Situations : Weather
Contributing Factors / Situations : Aircraft
Primary Problem : Weather
Narrative: 1
Climbing to FL370, about :50 minutes into flight, the First Officer and I noticed a
hot, 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 lot
of St. Elmo's fire on our windscreens. The IRO came forward from the crew-rest
seat 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. The
smell 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 suggested
some 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 Dispatch
we 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 no
smoke 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 speed
descent. 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 remain
seated 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 a
Maintenance Supervisor. The First Officer, IRO and I felt no ill effects other than
possible 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 flight
descended through the weather with engine anti-ice ON in St Elmo's conditions.
Maintenance did fly a test flight but found nothing. They did not fly the aircraft in
weather conditions similar to those in which the anomaly occurred. The Reporter
stated that the St Elmo's fire was the most spectacular he has experienced in his
30 plus years flying commercial aircraft.
Synopsis
An A330 in heavy St Elmo's fire with engine anti-ice on developed a strong
electrical odor which crew and passengers reacted to, so an emergency was
declared and the flight returned to the departure airport. Maintenance discovered
no anomalies and suspected a weather related phenomenon.
ACN: 1193848
Time / Day
Date : 201407
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Parking Brake
Aircraft Reference : X
Problem : Improperly Operated
Person
Reference : 1
Human Factors : Human-Machine Interface
Events
Anomaly.Aircraft Equipment Problem : Critical

Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Were Passengers Involved In Event : N
When Detected : Aircraft In Service At Gate
Result.Flight Crew : Overcame Equipment Problem
Assessments
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 up
again 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 and
continued my shutdown. I knew that the jetway was in the process of moving
backwards 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 to
set 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 pilots
regarding 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 active
runways 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 wait
for 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 my
contemporaries. 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 avoid
confusion. The aircraft needs to be chocked immediately in multiple locations. A
marshaller should be there to give the pilot a "chocks in" signal and a "set brakes"
signal.
Synopsis
After arriving in the gate an A330 Captain, holding brakes manually to preserve
extra block to block minutes prior to "setting the parking brake"--thus triggering
the flight crew's block in time--was surprised when he misinterpreted the meaning
of a self-park lighted advisory acronym to mean the nose gear had been chocked.
He then released the brakes. He was quickly alerted by his First Officer that the
aircraft was now rolling backward on the sloped ramp and then re-stopped the
airplane and set the brakes properly.
ACN: 1188333
Time / Day
Date : 201407
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Cabin Activity : Service
Function.Flight Attendant : Flight Attendant (On Duty)
Qualification.Flight Attendant : Current
Events
Were Passengers Involved In Event : Y
Result.General : Physical Injury / Incapacitation
Result.Flight Crew : Diverted
Assessments

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 the
main cabin, once I got to the back galley, I started to feel lightheaded and difficulty
breathing. I sat down on the jumpseat because I was dizzy.
Few seconds later, my hands started tingling badly and the color of both of my
hands 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. We
called 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 which
made her ill and required oxygen. The flight diverted after consulting with a
Commercial Medical Service.
ACN: 1178340
Time / Day
Date : 201406
Place
Locale Reference.ATC Facility : CZQX.ARTCC
State Reference : NF
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : CZQX
Flight Plan : IFR
Mission : Passenger
Route In Use : Oceanic
Component
Aircraft Component : FMS/FMC
Problem : Design
Person : 1
Reference : 1
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 14869
Experience.Flight Crew.Last 90 Days : 51
Experience.Flight Crew.Type : 1189
Human Factors : Fatigue

Communication Breakdown.Party2 : ATC
Person : 2
Reference : 2
Function.Flight Crew : First Officer
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Track / Heading : All Types
Anomaly.Deviation - Procedural : Clearance
Detector.Person : Air Traffic Control
Result.Flight Crew : Returned To Clearance
Result.Flight Crew : Requested ATC Assistance / Clarification
Result.Air Traffic Control : Issued New Clearance
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Primary Problem : Ambiguous
Narrative: 1
Our flight started out two hours late due to MEL 21-26-01 Avionics Equipment
Ventilation 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
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 aircraft
problems 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. On
almost 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 we
were 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 were
interrupted 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 the
FMGEC as 63N050W. Gander Controller replied negative your routing is 62N050W
63N040W 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 the
latitude 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 the
FULL 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 went
with coordinates believing our navigation numbers were correct.
After passing our coast out waypoint both of us immediately realized the
coordinates were WRONG! We selected heading. Re-enter the points then after a
short 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 a
navigation report. I acknowledged Gander's comment but we were to busy to say
anything else.
Dispatch got our reroute via ACARS then sent us a new flight plan. We deleted the
secondary flight plan in the FMGEC and uploaded the new route. The hand type
route 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." Gander
acknowledged. I told the Controller "I want all the previous ATC conversations with
the last controllers to be preserved, including this." Both First Officer's witnessed
and over heard the conversation. I also explain to the current Controller our
deviation was due to the confirmed coordinates of the previous Controller. And that
our Airbus navigation system needs the full latitude/longitude and not just the
short 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 a
fine 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
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 longitude
digits 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 and
ask 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 our
13 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 navigation
numbers 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 and
re-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 then
had a track deviation when the Controller unaccustomed to hearing the full nine
North, West and East waypoint digits incorrectly confirmed an erroneous waypoint
which the crew read exactly from the FMGC display.
ACN: 1175066
Time / Day
Date : 201405
Place
Locale Reference.Airport : ZZZ.Airport
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Airspace.Class B : ZZZ
Person
Reference : 1
Function.Flight Crew : Check Pilot
Communication Breakdown.Party1 : Flight Attendant
Events

Result.Flight Crew : Landed As Precaution
Assessments
Narrative: 1
At 500 feet after departure 2 flight attendants reported a chemical odor at doors
3L/R. In the cockpit the 3 of us smelled an odor similar to burning rubber which
soon dissipated. The flight attendants wanted medical assistance and the decision
to return to the departure airport was made. An overweight landing was made at
420,120 lbs, sink rate 200 FPM. Dispatch had also advised to make overweight
landing. 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. The
odor 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.
ACN: 1169167
Time / Day
Date : 201404
Place
Aircraft
Reference : X
Flight Plan : IFR
Person
Reference : 1
Location In Aircraft : Cabin Jumpseat
Cabin Activity : Service
Cabin Activity : Deplaning
Cabin Activity : Boarding
Events
Anomaly.Deviation - Procedural : FAR
When Detected : Pre-flight
Result.General : None Reported / Taken
Assessments

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 back
stating they would be here in a few minutes. Getting close to boarding time, still no
briefing. 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 the
Captain, 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 find
out 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 what
was 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 the
First 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, because
he 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 was
extremely winded and had to stop every so often to rest. We proceed to the bus. As
he approaches the bus he stops to smoke. When rest of crew arrives he tries to get
on 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 observe
him.
He was having extreme difficulty moving around in seat and moving left arm. I
notice his left hand is swollen and on the back of his right hand a huge black and
blue 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 is
no 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 cannot
believe he was flying this aircraft. We are making statements to First Officer; I am
not 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 was
about in the air. And it was decided then to keep us in the dark about this situation
until we landed. I am by no means happy with this decision about my life being
made for me.
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 not
flying 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 called
scheduling 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 seen
him 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 international
check-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, the
flight attendants made it clear that, in their opinion, he was not fit to fly the return
flight.
ACN: 1168184
Time / Day
Date : 201404
Place
Locale Reference.ATC Facility : ZZZZ.ARTCC
Environment
Aircraft
Reference : X
ATC / Advisory.Center : ZZZZ
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Assessments
Contributing Factors / Situations : Manuals
Narrative: 1
A company flight 30 min ahead of us at FL 390 reported descending to lower
altitude 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], checked
TCAS for traffic, turned slightly off course and descended to FL300 to avoid severe
turbulence, 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 SIGMET
had been issued). We advised Dispatch, checked fuel, and climbed back to flight
plan 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 incident
and 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: 2
I 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 the
right seat.
We contacted them for further info and found they had to descend to FL300 to get
out of the severe turbulence.
We...turned on all the external lights and began a descent.
Narrative: 3
[Report narrative contained no additional information]
Synopsis
When they received reports of severe turbulence ahead at their altitude an A330
flight crew exercised emergency authority to descend without clearance when they
were unable to obtain clearance in a timely manner from oceanic control.
ACN: 1159810
Time / Day
Date : 201403
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Exterior Pax/Crew Door
Person
Reference : 1
Cabin Activity : Boarding
Cabin Activity : Safety Related Duties
Events

Assessments
Contributing Factors / Situations :
Aircraft
Company Policy
Human Factors
Manuals
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 not
open the doors from the inside but the caterer could open it from the outside. An
Agent 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 was
going 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 door
opening. 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 thirty
minute delay and found a way to get it out via the jetway.
Our Inflight Manual, section XXXXX says, "flight attendants are NEVER to open an
aircraft 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 would
have [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 I
would 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 what
was happening on the aircraft. They both forced us into putting our own safety in
jeopardy 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 I
told her that the Ramp Agent told me that the battery was dead she said that if
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 both
supervisors 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.
Synopsis
An acrimonious exchange resulted when supervisors from passenger boarding and
Inflight 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 doing
so; 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 chair
was unable to access the door opening.
ACN: 1155343
Time / Day
Date : 201403
Place
Locale Reference.ATC Facility : LEMD.TRACON
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : LEMD
Flight Plan : IFR
Mission : Passenger
Flight Phase : Landing
Flight Phase : Final Approach
Component
Aircraft Component : Autopilot
Problem : Malfunctioning
Person : 1
Reference : 1
Function.Flight Crew : Relief Pilot
Communication Breakdown.Party2 : Other
Person : 2
Reference : 2
Events
Anomaly.Deviation - Altitude : Overshoot
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Narrative: 1
We approached the field from the northwest for landing ILS Z 18R. We were
cleared down to 8,000 FT MSL and told to intercept LOC. The winds at that altitude
were out of the north at about 60 KTS. This strong tailwind, although decreasing
slowly as we descended, made it very difficult to make our descent and capture the
glideslope. We had to ask for lower from the Controller and we were given a
frequency change to do so on final. That Controller then cleared us for the
approach. At this point we were above the glidepath and trying to descend to
capture it. At about 3,900 FT MSL (about 2,000 FT AGL) the Captain (pilot flying)
elected to go-around. Due to our altitude he elected to initially go-around using
vertical speed to climb to the 5,000 FT missed approach altitude. At some point
during the go-around I believe he selected open climb. At about this time I picked
up the PA and began to make a brief announcement. During the announcement I
heard the altitude alert warning and I discontinued the PA. It was then I observed
our climbing through about 5,500 FT and we topped out at about 5,800 FT before
returning to 5,000 FT on the missed approach. The controllers never made any
mention about our altitude.
The decision to go-around was a good one. The execution of the go-around was
somewhat out of our normal go-around TOGA routine due to our higher than
normal altitude at initiation. I believe this, along with the relative newness of the
Captain to the A330 resulted in automation inputs that somehow led to the
autopilot disconnecting. By the time the pilot flying realized the autopilot had
disconnected our pitch was such that we went through our missed approach
altitude.
As the observer seat pilot, in hindsight, I would not have been so quick to make the
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 is
usually 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 favor
during 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 I
had 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 vertical
speed 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 (2,000
FT 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. After
a 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 the
Captain 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) with
gear, Flaps 3, and full speedbrake, and we still did not get a clearance for the
approach until we were well above the glidepath. We still had the 60 KT tailwind at
8,000 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 found
themselves high and fast due to terrain and significant tail winds. When they
initiated a go-around the autopilot disconnected and they climbed through the MAP
altitude.
ACN: 1148931
Time / Day
Date : 201402
Place
Environment
Light : Dusk
Aircraft : 1
Reference : X
Flight Plan : IFR
Aircraft : 2
Reference : Y
Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model
Flight Plan : IFR
Aircraft : 3
Reference : Z
Flight Plan : IFR
Flight Phase : Taxi
Person : 1
Reference : 1
Person : 2
Reference : 2
Location Of Person.Aircraft : Y
Person : 3
Reference : 3
Location Of Person.Aircraft : Z
Person : 4
Reference : 4
Events
Anomaly.Conflict : Ground Conflict, Critical

Assessments
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 Tower
if an airplane was holding on the runway. The aircraft on the runway answered in
the 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 the
pattern and landed safely. Had visibility been more restricted, this could have been
disastrous.
Narrative: 2
Told by Tower to line up and wait on [Runway] 36C. While waiting on the runway
we 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 only
received 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 separation
between 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 , Tower
immediately 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 either
way.
Narrative: 4
...we were never issued a takeoff clearance.
Synopsis
A serious ground conflict occurred when an MD80 flight crew understanding they
were cleared only to LUAW on the active runway, remained on the runway when an
A330 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 for
takeoff.
ACN: 1147874
Time / Day
Date : 201402
Place
Aircraft
Reference : X
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations
:
:
:
:
Human Factors
Airport
Company Policy
Aircraft
Narrative: 1
Our aircraft had an MEL which affected tailwind restriction, landing distance, CAT 3
Dual Prohibited, and operating on contaminated runways. (Aircraft restriction on
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 the
return 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 put
only 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 a
runway 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 contaminated
means more than 1/8 and then goes on to describe contaminated conditions as
among 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 a
contaminated 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 I
was flying with had the same MEL weeks ago on the same airplane, which between
that 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 a
contaminated 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.
ACN: 1132342
Time / Day
Date : 201311
Place
Aircraft
Reference : X
Maintenance Status.Maintenance Deferred : N
Maintenance Status.Released For Service : Y
Maintenance Status.Maintenance Type : Scheduled Maintenance
Maintenance Status.Maintenance Items Involved : Testing
Component
Aircraft Component : Oxygen System/Pax
Manufacturer : Airbus
Person
Reference : 1
Location In Aircraft : General Seating Area
Function.Maintenance : Inspector
Qualification.Maintenance : Powerplant
Qualification.Maintenance : Airframe
Experience.Maintenance.Inspector : 30
Events
Detector.Person : Maintenance
When Detected : Routine Inspection
Assessments

:
:
:
:
Aircraft
Chart Or Publication
Manuals
Procedure
Narrative: 1
During 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 2-5-2
passenger 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 to
the 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, that
would 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 drop
check 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 to
open. The wide body aircraft has a 2-5-2 passenger seat row configuration. Each
PSU unit has either three or six masks.
ACN: 1119064
Time / Day
Date : 201309
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Nav In Use : FMS Or FMC
Flight Phase : Initial Approach
Route In Use : Visual Approach
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : Environment - Non Weather Related

Narrative: 1
Visual approach, airplane was configured for landing with full flaps, prior to
selecting the landing gear down. This is a non-standard order and not done
intentionally. 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 visual
approach with landing flaps set.
ACN: 1109749
Time / Day
Date : 201308
Place
Environment
Light : Daylight
Aircraft
Reference : X
Maintenance Status.Maintenance Deferred : Y
Maintenance Status.Records Complete : N
Maintenance Status.Released For Service : N
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Repair
Maintenance Status.Maintenance Items Involved : Work Cards
Maintenance Status.Maintenance Items Involved : Inspection
Component
Aircraft Component : Powerplant Mounting
Person
Reference : 1
Location Of Person : Hangar / Base
Function.Maintenance : Technician
Experience.Maintenance.Technician : 25
Communication Breakdown.Party1 : Maintenance

Events
Anomaly.Deviation - Procedural : Maintenance
When Detected.Other
Assessments
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 the
previously 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, the
repair was not within the Structural Repair Manual (SRM) repair limits and should
not 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 in
place 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 is
about 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 of
intense discussion between the Engineer, Inspection, Management, and the Aircraft
Manufacturer, they made the decision to fly the A330 to the [same] Repair Station
and 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 to
bring 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. We
also 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 increase
the 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 to
machine much deeper to accomplish the repair. Otherwise, with the correct cutter
and light corrosion, a 'skim' cut would have probably solved the problem. That
would have solved the problem of the radius of the spot face depth, but another
problem was also in play here. The Contract Vendor [had also] cut into the
structure wall of the engine mount. I would be surprised if the Aircraft Manufacturer
would even allow a repair after all of this. The Contract Vendor not only created a
potentially catastrophic flying situation, the total maintenance costs incurred were
absolutely staggering!!!
Our Contract Repair Station Vendor in ZZZ2 did very poor work that was totally
unacceptable and unsafe! I believe our Machine Shop should do the work,
especially in critical areas such as this. The engine mount cannot be sold
separately. It is sold as an entire assembly, pylon and all.
Callback: 1
Reporter stated he has an Airframe and Powerplant (A/P) license and has been
working as a Machinist out of his Air Carrier's Machine Shop for fifteen years. Their
Mechanics had pulled the Right Engine off of the A330 for other problems and found
corrosion on the pylon's forward mount where the engine mount bolts attach.
Company Engineering wanted to Cadmium Plate (Cad-Plate) the area, but the
corrosion removal became an issue due to the improper spot-facing of the hole
radius and additional improper machining damage that was done by the Contract
Repair Station to the wall mount structure located between the engine mount bore
holes.
Reporter stated if someone makes a straight cut, without a adequate radius cut,
then the bore area is subject to cracks that could migrate and the engine mount
failing and most likely causing an engine to separate in flight or during takeoff. He
believes the Heavy Maintenance Contract Repair Station's Quality Assurance is not
adequate and neither is his Air Carrier's oversight of the same Repair Station. He
believes his Air Carrier is asking for more trouble by sending the A330 aircraft back
to have the entire pylon removed and replaced by the same Repair Station that had
damaged and made the engine pylon not only unrepairable, but unsafe for flight.
Synopsis
A Machinist Technician describes the extent of damage he noticed that had been
caused by a Heavy Maintenance Contract Repair Station vendor's improper
machining of four forward mount bore holes on the Right Engine pylon of an A330
aircraft. The entire pylon required replacement due to the unrepairable damage and
potential for an in flight failure of the pylon engine mount.
ACN: 1107871
Time / Day
Date : 201308
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component
Aircraft Component : Engine Control
Person
Reference : 1
Location Of Person : Gate / Ramp / Line
Function.Maintenance : Inspector
Function.Maintenance : Quality Assurance / Audit
Events
Detector.Automation : Aircraft Other Automation

Assessments
:
:
:
:
:
Aircraft
Company Policy
Manuals
Procedure
Narrative: 1
The flight crew called Maintenance Control and reported that they have a Number 1
engine 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 and
only 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 1.2
EPR 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 SYS
FAULT' 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 ground
checks 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 page
associated 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 after
departing and said the Number 1 engine FMU and engine operated normally and
they are continuing on to the filed destination. Subsequently, the destination
station maintenance cleared the Verification flight deferral.
1. Even if the flight crew gives a verbal notification on their defect, the crew needs
to be accurate on their defects in the aircraft log book so the correct actions can be
taken. 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
Unit fault so the aircraft returned to the departure station. Subsequently, no test
flight was flown, but a revenue flight crew reported normal operation.
ACN: 1101128
Time / Day
Date : 201307
Place
Locale Reference.Airport : LFPG.Airport
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Ground : LFPG
Flight Phase : Taxi
Person
Reference : 1
Events
Anomaly.Ground Incursion : Taxiway
Assessments
Narrative: 1
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 were
very 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 on
ahead 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 onto
B. 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. If
you 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 an
arrow 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 to
the east runways.
Synopsis
A330 flight crew reported they were confused by poor signage on taxi out at LFPG.
ACN: 1099136
Time / Day
Date : 201306
Place
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Location Of Person.Facility : ZZZ.Tower
Reporter Organization : Government
Function.Air Traffic Control : Local
Qualification.Air Traffic Control : Fully Certified
Events
Assessments
Primary Problem : Procedure
Narrative: 1
I was working Local when told we had an A330 emergency diverting and coming in
opposite direction landing [Runway] 34R currently dumping fuel. The TRACON
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 the
stop 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 Air
Carrier 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] the
A330 was about 30 miles out. The TRACON should have coordinated with me
instead of just hitting the stop departure lights. Several aircraft had delays because
of 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, I
realized 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 the
first time we heard he needed medical assistance. I just thought that he was only a
mechanical 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 from
the TRACON.
Synopsis
Tower Controller described the complexities of handling an emergency aircraft
inbound opposite direction to the normal flow of traffic and the
coordination/communications difficulties encountered.
ACN: 1097139
Time / Day
Date : 201306
Place
Locale Reference.Airport : EDDF.Airport
Aircraft : 1
Reference : X
ATC / Advisory.Tower : EDDF
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : Runway 25L
Aircraft : 2
Reference : Y
Make Model Name : B747 Undifferentiated or Other Model
Flight Plan : IFR
Person
Reference : 1
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Assessments

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 above
glideslope 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 final
to EDDF, stating that in his opinion five miles is not enough separation.
ACN: 1094446
Time / Day
Date : 201306
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Electrical Power
Person
Reference : 1
Communication Breakdown.Party2 : Dispatch
Events
Assessments
Contributing Factors / Situations : Chart Or Publication

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 is
no way to coordinate rescue [per] FOM 4.4.1/.2 and our cell phones would be off if
we 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 in
country. 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.
ACN: 1091007
Time / Day
Date : 201305
Place
Locale Reference.ATC Facility : ZMP.ARTCC
State Reference : MN
Aircraft
Reference : X
ATC / Advisory.Center : ZMP
Flight Plan : IFR
Mission : Passenger
Route In Use.STAR : WYNDE4
Airspace.Class A : ZMP
Person
Reference : 1
Location Of Person.Facility : ZMP.ARTCC
Function.Air Traffic Control : Enroute
Events
Assessments
Narrative: 1
Aircraft X deviated from their filed flight plan of LTBA./.SSM.WYNDE4.KORD. After
SSM, they went to TVC, and flew that segment of the arrival without a clearance to
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.
ACN: 1089195
Time / Day
Date : 201305
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Turbine Engine
Problem : Failed
Person
Reference : 1
Events
Result.Flight Crew : Inflight Shutdown

Assessments
Narrative: 1
Approximately five minutes after leveling off at FL360, and prior to entering ETOPS
airspace, the Number 1 Engine EPR gauge indicator rolled back to "0" while the
commanded EPR stayed at its cruise value. The Number 1 Engine oil pressure
indication was "0", and in the red. The Number 1 N3 indicator also read "0". ECAM
alert ENG 1 FAIL occurred, Captain set thrust to MCT and called for ECAM actions to
be performed, First Officer then established contact with Center to obtain a
clearance back. Captain then declared an emergency, contacted Dispatch, informed
flight attendants and passengers of the return. Relief Officer completed fuel dump
procedure checklist while Captain and First Officer completed ENG FAIL Checklist
and Over Weight Landing Checklist. Single engine approach and landing
accomplished with a normal uneventful landing and rollout.
Synopsis
A330-200 Captain experiences an engine failure leveling at FL360. An emergency is
declared and flight returns to departure airport after dumping fuel.
ACN: 1086785
Time / Day
Date : 201305
Place
Locale Reference.ATC Facility : ZZZ.TRACON
Environment
Light : Dusk
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Hydraulic Main System
Person
Reference : 1
Events

Assessments
Narrative: 1
On takeoff was unable to raise landing gear up. Shortly after that [we] got a Green
Hydraulic pump low pressure ECAM message; both Number 1 and Number 2 Green
Engine Hydraulic pumps had faulted with the resulting Green system hydraulic low
pressure. We followed ECAM and QRH procedures and contacted Dispatch on the
SAT phone to confer with Maintenance Control. As we could not restore the Green
Hydraulic system, we informed Dispatch that we would hold to burn off fuel to
landing weight. On landing, Green Hydraulic system restored itself to normal and
we taxied to gate. Maintenance had worked on the Green system before departure
and possibly had not bleed the system before return to service, according to them.
Synopsis
A330 Captain experiences failure of the landing gear to retract after takeoff
followed quickly by failure of the Green hydraulic system. Maintenance can offer no
solution and the flight returns after burning down to landing weight. Upon
touchdown the Green hydraulic system restored itself to normal. Maintenance had
been performed on the Green system prior to departure.
ACN: 1081335
Time / Day
Date : 201304
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Phase : Taxi
Component
Aircraft Component : Electrical Power
Person
Reference : 1
Events
Assessments

Narrative: 1
Pulled into gate shut down engines and aircraft went dark. The front and back
totally due to the APU not being started. Also no dome light, no VHF #1 and APU
would not start! Only battery off light came on #1 battery when both batteries
were switched off then on! Alarm went off below in nose wheel well. The only light
was IRS on battery light. Ground power was connected in about two to three
minutes. The APU started normally and power was normal on the aircraft again.
About an hour later the Captain called Maintenance Duty Manager and asked for
tech support on the Airbus 330. They were advised of all of the above. He said
would go back to the aircraft and write it up if they thought it needed to be done.
He was put on hold and told aircraft had no history of electrical problems, no
aircraft alerts or notifications and that a write up was not necessary. He said I am
good with it if you are. He just wanted Maintenance to know if they thought it was
a valid write-up. Maybe batteries never connected back to battery bus? Check
electrical switching for faults.
Synopsis
An A330 lost all electrical power, including items that should operate on battery
power only, when the engines were shut down without APU or ground power
available. After ground power was connected and all electrical systems return to
normal.
ACN: 1075482
Time / Day
Date : 201303
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Pressurization System
Problem : Failed
Person
Reference : 1
Cabin Activity : Safety Related Duties
Events
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 were
instructed 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 instructed
a woman to use an oxygen mask for her infant, and told children not to pull on the
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 major
incidents. The flight deck crew communicated very well with the crew and kept the
passengers informed throughout. Passengers complimented the crew on their
professionalism and calm as they deplaned. I did notice upon walking through the
cabin that several passenger masks had not deployed. These passengers were not
within 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 French
speaking 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 and
informed the cabin.
ACN: 1075265
Time / Day
Date : 201303
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Pressurization System
Person
Reference : 1
Events

Result.Air Traffic Control : Provided Assistance
Assessments
Narrative: 1
While in a smooth ride at cruise, FL380, we all heard a muffled sound followed by
pressure change in the ears. We looked at cabin pressure and saw that cabin
altitude was starting to climb, slowly at first (250-500 FPM) and increasing to near
2,000 FPM. I called Center, declared an emergency and asked for an immediate
descent to 10,000 FT. Center acknowledged the emergency and cleared us to a
lower altitude. We initiated an emergency descent, followed the ECAM procedure
and followed that up with the QRH.
When we leveled at 10,000 feet we noticed that the cabin altitude had peaked at
about 14,150 feet but had partially re-pressurized to about a 7,000 foot cabin
altitude. The Second Officer advised the passengers they could take off the O2
masks and explained what had happened.
We could see no evidence of aircraft damage or system problems on ECAM, only
that the Number 2 engine HP bleed was open and Number 1 engine HP bleed was
closed. We conferred with the Dispatcher and Maintenance Control on the SAT
phone and determined, with their concurrence, we would continue to destination
as, at that time, we were about 85 NM from landing. ATC gave us priority handling
and we landed uneventfully. The flight attendants did an excellent job and got
several compliments from the passengers.
We made appropriate logbook write-ups--including that not all of the masks in the
cabin dropped, even though we had pushed the manual O2 mask pushbutton. We
split the duties among the 3 cockpit crew members, and felt we were very well
trained to do this procedure.
You will have to ask Maintenance what the cause of this incident was. They thought
it might have been a ruptured duct or bleed issue. We did check the outflow valves
and they were closed. Maintenance had checked the exterior of the aircraft before
we opened any doors and found no apparent damage.
Synopsis
An A330 flight crew heard a muffled sound, felt a pressure change and noted the
cabin altitude begin to climb rapidly. They declared an emergency, descended to a
safe altitude where stable pressurization was regained and continued the short
remaining distance to their destination.
ACN: 1069046
Time / Day
Date : 201302
Place
Locale Reference.Airport : LAX.Airport
State Reference : CA
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : SCT
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : LAX
Airspace.Class E : SCT
Component
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Assessments
Narrative: 1
[We were switched to] Tower as we were approaching the hold short line for
Runway 24L. Tower asked if we were ready to depart. I answered that we were
ready for departure. LAX Tower cleared us to RNAV to CASTA cleared to takeoff
Runway 24L. I informed the Controller that we had the GORMAN FOUR Departure
loaded. He said that since we already had that departure programmed to go ahead
and depart on the GORMAN FOUR Departure fly Heading 250 cleared for takeoff.
We completed the Before Takeoff checklist and conducted a normal takeoff from
Runway 24L.
The Captain checked in with SoCal Departure who cleared us to climb and maintain
9,000 FT and turn right heading 030 to join the departure. We complied with the
instructions and set up an intercept for the GMN 142 radial inbound to GMN. As we
began intercepting the GMN 142 Radial SoCal asked us if we were joining the
CASTA Two departure. The Captain informed him that we had been cleared for the
GORMAN FOUR Departure.
SoCal then cleared us to turn right heading 360 and that he showed us as filed for
the CASTA Two Departure and that we had strayed into another approach sector's
airspace. Apparently, the change in departure procedure by the Tower Controller

had not been conveyed to the subsequent controllers. He then had us change to a
new departure frequency.
We checked in with the new Controller on a heading of 360 and level at 9,000 FT.
The new Controller cleared us direct to GMN and climb to 15,000 FT. We were then
given clearance to climb to FL340 and [to proceed direct] AVE direct OAK. No traffic
conflicts or restricted airspace penetration occurred. There were no further
incidents during the flight.
After the initial confusion and we were climbing to FL340 between AVE and OAK the
Captain took a look at our PDC and discovered I had missed the change on the PDC
to amend the departure to the CASTA Two. On my initial contact with Clearance
delivery there was no mention of the departure change so my error went
unnoticed.
Narrative: 2
I was trying to figure out what had just happened, [and] then I checked the PDC
and realized that we had received a revised clearance and that Tower [apparently]
had not advised ATC that we were back on the original [filed] clearance. No further
incident. Always check the PDC.
Synopsis
An A330 First Officer failed to note the revised PDC clearance from the filed
GORMAN SID to the CASTA for their departure from LAX. When the error was noted
as they were about to be cleared for takeoff the Tower cleared them to fly the
GORMAN as already programmed on the FMS to avoid delay. The Controller
apparently failed to advise the TRACON and confusion and an airspace deviation
took place before the error could be resolved.
ACN: 1060870
Time / Day
Date : 201301
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Component
Problem : Failed
Person
Reference : 1
Events
Assessments
Narrative: 1
I was on my rest break and when I returned was told we had loss of Green HYD
System. Dispatch and Maintenance had been made aware of status. Said we didn't
need to divert, and decision was made to proceed to [destination.] ATC was aware
of our status upon check in. Requested equipment standing by. ATC said that they
were declaring emergency. We landed, stopped on runway, and were towed in to
gate.
Synopsis
A330-300 First Officer reported loss of Green hydraulic system enroute. Flight
declared an emergency and landed uneventfully at destination.
ACN: 1055707
Time / Day
Date : 201212
Place
Locale Reference.Airport : EGLL.Airport
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : EGLL
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Person
Reference : 1
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Flight Engineer
Events
Anomaly.Deviation - Speed : All Types

Assessments
Primary Problem : Environment - Non Weather Related
Narrative: 1
ATC assigned 160 KTS to 4 DME. The Captain (pilot flying) slowed to 155 KTS after
a wake turbulence encounter at approximately 6 DME. ATC queried our speed, we
reported 155 KTS and explanation. They chastised us and there was no problem.
Normal landing. Aircraft behind us continued normally.
Synopsis
A330-300 First Officer reported slowing below assigned speed on final at EGLL
following a wake vortex encounter.
ACN: 1042721
Time / Day
Date : 201210
Place
Environment
Light : Dusk
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZZZ
Component
Aircraft Component : Compressor Bearing
Person
Reference : 1

Events
Assessments
Narrative: 1
Flight departed and after takeoff we smelled a strange odor. After 10,000 FT the
flight attendants called and said they were experiencing a very strong odor that
was causing breathing problems and eye discomfort especially in the aft cabin. We
donned our oxygen masks and immediately the Flight Attendant called back
reported that one flight attendant had been involved in a previous situation with
the same smell. At this time I elected to return to the departure airport. We
proceeded with our checklist and returned for an overweight landing. The flight
attendants said that unless we had not returned we would have had a lot of sick
people. I asked for medical staff to meet the aircraft to check our flight attendants
and any passengers that may require assistance.
I do not know how to prevent this from reoccurring as this is an ongoing problem. I
do have some comments as to issues we had dealing with this situation. 1- We had
a lot of trouble with our oxygen masks. We all had trouble with the mask hitting
our reading glasses. I tried taking mine off but this did not work as I did need
them. My mask had smudges on the shield which made reading checklists and
seeing the PFD very hard. During landing I had to remove my mask so I could see
to land. Not good if heavy smoke had been present. 2- Communication with ATC,
Flight Attendant, [and] Dispatch was very hard. We were confused by the toggle
switch that is used for talking while using the masks. This took several minutes
before we correctly used the switch. Having to turn your head to find the switch did
not help. Boeing's switch on the yoke is better in that looking for switch is not
required. 3- When using the oxygen mask all communication comes over the
cockpit speakers. This made it very hard to hear. At times ATC was blocked by
other communications with flight attendants and Dispatch. We found the only way
to deal with this was to don our headsets over our masks. We adapted but this took
time and caused confusion. 4- I feel we need more training using the oxygen
masks. The simulator scenarios we have previously used did not simulate all the
calls from ATC, flight attendants, and Dispatch simultaneously. It is very hard to
create a scenario in the simulator with real life confusion. Communication was the
biggest problem!
Callback: 1
The Reporter stated that the oil leak was serious enough that the pilots were
feeling physical effects exhibited as a tight feeling throat. He was unable to
describe the odor except to say it was like no other odor he has experience before.
It was not the typical dirty socks smell but none the less, very distinctive. He was
told by a Mechanic several days later that the aircraft was test flown and grounded
by test pilots for the same odor which forced a maintenance examination of the
aircraft where the worn engine bearing was found.
Synopsis
An A330 returned to the departure airport after the pilots and flight attendants
detected a strange odor. Maintenance determined that oil leaking around a worn
engine bearing was entering the compressor section and then the air conditioning.
The flight crew had great difficulty with ATC and other communications because of
the oxygen masks.
ACN: 1041174
Time / Day
Date : 201210
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Galley Furnishing
Person
Reference : 1
Location In Aircraft : Crew Rest Area
Analyst Callback : Attempted
Events

Assessments
Narrative: 1
Approximately 2 hours and 30 minutes into the flight, at FL350, I was awakened
from my resting position by the Lead Flight Attendant. She informed me that Aft
Galley Oven #2 was emitting high temperature from the front, side and top of the
unit. I immediately went to the aft galley, where I was greeted by approximately
three flight attendants. As I entered the galley area, I could feel radiated heat
being emitted from the suspect unit. A Flight Attendant told me that he had notified
the cockpit that he had expended a bottle of Halon Fire Extinguishing Agent and
advised me that he was preparing to have a second bottle standing-by. He
described to me that the oven was getting hotter by the minute and explained that
it had not cooled in the same manner as the other ovens in the galley which had
been deactivated at the same time. I found the circuit breakers serving the ovens
and galley were already pulled. Additionally, the pilots in the cockpit had
deactivated the Galley Power Switch located on the cockpit upper panel. There
should not have been any electrical current serving the unit. All operational lights
and indicators on the operating panel located above the front of the oven were
extinguished. The front, top and sides of the oven were hot, allowing tactile contact
for only a second. We emptied a shelf-cupboard atop the oven which contained only
a few plastic drinking cups. I slowly opened the door of the oven with a dry cloth
towel to see if the oven contained a fire. The heat was excessive in relation to
previous experiences I've had standing in front of open galley-oven doors aboard
the A-330. There was no smoke in the galley area; however the smell of an overheated electrical kitchen appliance was present. I was able to open the oven door
enough to see that the oven was empty and clean. It was undoubtedly producing
heat. My experience with ovens convinced me that the heat pouring out of the oven
was not simply residual heat from a cooling oven. I secured the door and stepped
away from the unit for a minute or two and continued to observe the oven. I called
the cockpit to ask the pilots to start thinking about the selection of a diversionary
landing at the nearest suitable airport. I began emptying the closet area behind the
ovens which serves as a cart storage/baggage area to determine if heat was
penetrating the storage area. Although the storage space did not extend all the way
back to the suspect oven, I could feel that the inner wall closer to the oven was
warmer than the outer wall of the aircraft. I deemed this to be a normal condition
after consulting assisting flight attendants who were still present in the aft galley
area. We had no control of the oven while excessive heat was continually being
produced. I advised the flight attendants that I believe we will not be continuing
toward our destination and that it is quite probable that we will be diverting to
another airport close by. I asked them to keep me advised of the oven's status via
intercom and to keep watch over it. We agreed they would treat it as an electrical
fire should the situation escalate.
Upon returning to the cockpit, I found both pilots had already begun the
investigation of some select airports for a landing. I described the situation to
them. We displayed and examined pertinent ECAM electrical pages and found no
anomalies. We got a status call from the galley that the oven appeared to be
getting hotter. It was at this time that I decided to initiate a diversion. The two
nearest airports were both behind us. Constant communication and TEST
information was exchanged with the Aft Cabin and Lead Flight Attendant. The Relief
Pilot communicated with the company over SATCOM, the First Officer flew the
aircraft, I communicated with ATC and the Relief Pilot maintained contact with the
cabin, both via intercom and in-person. With four pilots working the situation, clear
lines of communication, responsibility and duties made the event entirely
manageable, however each of us were still very busy. We contacted ATC, declared
an emergency, and turned toward our designated en route alternate, approximately
160 miles behind us. We discussed our overweight situation (at that point, perhaps
80,000 LBS overweight) and agreed on a strategy to get a lower altitude, to slow to
gear and flap 1 extension speed, and to use 230 KTS as our new cruise speed
toward the alternate in order to exhaust as much fuel as we could to reduce the
landing weight. We agreed that if at any point the oven-overheat resulted in the
production of flames, we would expedite the arrival by cleaning-up the aircraft to
resume a higher speed. After consulting the QRH overweight landing charts it was
apparent that the 6,000 FT runway at our planned divert airport was inadequate.
The next closest airport was approximately 45 miles farther from our present track,
with an 8,000 FT runway. We set course for [the airport with the longer runway]
with complete ATC coordination and assistance. We were vectored onto the ILS and
landed without incident, taxied clear and parked at a ramp assigned to us by
Ground Control with fire trucks escorting us to the ramp. No stairs at the airport
seemed to be high enough to afford access to firefighters but somehow they
boarded and assured us that the oven, while still very hot, was no longer producing
heat. Fire crews were unsuccessful at pulling the oven out of its rack whereupon it
was agreed to keep the oven installed, but that it should be continually observed as
long as there was electrical power on the aircraft. Fire Fighters kept a log of the
oven temperatures long after they boarded. They revealed to us that temperatures
of the other three ovens were ambient. Oven number two was still hot an hour
after we landed. Despite all efforts, crew was unable to stabilize the escalating
temperature of the galley oven. All indications from galley and cockpit revealed that
the oven should have been deactivated, yet it continued to generate heat in
proportions crew deemed threatening.
Synopsis
A330 Captain is awakened from rest break by the Lead Flight Attendant and
informed of an overheating oven in the aft galley. The oven circuit breakers had all
been pulled and the galley power had been deactivated in the cockpit and all power
indicating lights were extinguished, yet the oven appeared to be getting hotter. The
Captain elects to divert to a suitable airport where the fire crew determines that the
oven is still hot but cooling and unpowered.
ACN: 1039619
Time / Day
Date : 201209
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Assessments

Narrative: 1
Our aircraft for the flight was towed from the maintenance hangar, and arrived at
the departure gate approximately two hours after scheduled departure time. We
learned after the event that Maintenance had had the aircraft "most of the day,"
and had replaced the nose landing gear actuator.
Push-back, engine start, taxi out, takeoff, climb, and initial cruise were normal.
Approximately one hour into the flight and at level cruise, the Master Caution
activated and ECAM indicated a Green Hydraulic System leak. Following our nonnormal procedures we turned off the pumps pressurizing the Green System thereby
deactivating the Green Hydraulic System. We were in ARTCC airspace at the time
and informed the Controller that we had a hydraulic problem, needed to return to
our departure airport, were not declaring an emergency at that time but would do
so when entering Approach Control airspace. The Controller issued an initial
heading, and then subsequently issued a new clearance directly to an intersection
on a STAR to the airport.
The Captain called the Lead Flight Attendant to the cockpit and briefed her on our
situation, time remaining, etc. I made the PA to the passengers that we had a
mechanical issue that required our return to our departure airport. When the Relief
Pilot returned the Captain directed him to establish SATCOM communications with
Dispatch, Maintenance Control and Airport Operations. In addition he was to
contact our departure ATC facility by VHF to let them know of our return, that we
would be an emergency, and to request CFR to be standing by.
As a result of the loss of the Green Hydraulic System, among a lengthy list of
inoperative systems, we would not have nose wheel steering or normal brakes,
slats/flaps would be slow to extend and we would have to gravity extend the
landing gear. Enroute we reviewed and briefed the QRH procedures for the gravity
gear extension including field landing length requirements and approach speed
increases; developed a plan for when and how we would configure the aircraft for
approach and landing; discussed that the gear doors would be open, and whether
they would drag on the runway. We also reviewed and briefed our STAR and
expected ILS approach. Finally, we planned to stop on the runway, shut the
engines down, and be towed to the passenger terminal.
The Captain made a PA explaining that we had a hydraulic problem, that they may
hear sounds and noises that they may not be accustom to, the landing would be
normal, airport emergency vehicles follow and surround our aircraft, and that we
would be towed back to the gate. When in communication with our destination
Center we were advised the airport had been informed, and that "they were ready."
When we switched to Approach Control we declared the emergency and received
vectors for the ILS. We extended the gear in accordance with QRH procedures so
that we were fully configured prior to glide slope intercept. The landing was
smooth, in the touch down zone and rollout was normal as we stopped in the first
three quarters of the runway. We shut down the engines, and were shortly
thereafter towed to gate. The flight was subsequently canceled.
While we were waiting for the hookup and tow I selected the Hydraulic page on the
System Display (SD). The Green System showed full and normal quantity. Once at
the gate a Mechanic came in and said that the system had been "over-serviced."
Synopsis
An A330 returned to its departure airport after receiving a Green Hydraulic System
Leak ECAM message. Maintenance later advised the system had been "over
serviced"
ACN: 1032256
Time / Day
Date : 201208
Place
Environment
Light : Dusk
Aircraft
Reference : X
Component
Aircraft Component : Pressurization Control System
Problem : Failed
Person
Reference : 1
Events
Result.Flight Crew : Rejected Takeoff
Assessments

Narrative: 1
On takeoff roll around 85 KTS, ECAM message "Cabin Press I and II System Fail
doors". I rejected takeoff, advised flight attendants and passengers to remain
seated, exited runway, parked at hardstand because of no available gate, called
Maintenance. After replacing the pressurization controller and waiting for brake
cooling, we were re released and taxied for an uneventful take off. All crew
members performed very well due to excellent training. Aircraft would not have
pressurized after take off. Abort saved holding for 4 hours due to landing weight
limitation.
Synopsis
A330 Captain reports rejecting the takeoff at 85 KTS for Cabin Pressure I and II
System Fail doors. Pressurization controller is replaced by maintenance and flight
departs.
ACN: 1031207
Time / Day
Date : 201208
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Wheels/Tires/Brakes
Person
Reference : 1
Function.Maintenance : Lead Technician
Experience.Maintenance.Lead Technician : 28
Events
Assessments
Contributing Factors / Situations : Staffing
Narrative: 1
The aircraft arrived with an inbound [log write-up] for a brake issue that required a
brake change. The tire in question had been written up as low pressure in flight.
Found valve core loose and serviced. No leaks noted. The Aircraft Maintenance
Manual (AMM) limits for tire pressure low were not read because all available
manpower was at the aircraft, and there was no access to them outside the shop.
AMM requires tire change and mate on axle changed when taxied with low
pressure. This is what was overlooked. The brake change required all available
manpower. The tire pressure item was lower on the priority list, as the brake was
causing a delay and taking all the attention. There were no obvious defects to the
low pressure tire other than the valve core being loose, it did not leak after being
serviced. This would be alleviated if we had more manpower, more ground time
than 1:50 to perform ETOPS checks, and portable AMM access. The brake on this
aircraft is heavy, and was very hot from landing. It could have been deferred per
MEL but the outbound weight of the aircraft precluded this option, dispatcher would
not allow.
Synopsis
The maintenance technicians did not recognize that a tire that was operated with
low pressure required a replacement along with the adjacent tire. This is due to the
loads imposed upon the tires while operated in this condition.
ACN: 1024515
Time / Day
Date : 201207
Place
Environment
Work Environment Factor : Temperature - Extreme
Light : Night
Aircraft
Reference : X
ATC / Advisory.Ramp : ZZZ
Mission : Passenger
Component : 1
Aircraft Component : Fuselage
Component : 2
Aircraft Component : Other Documentation
Person
Reference : 1
Location In Aircraft : Door Area

Events
Assessments
Primary Problem : MEL
:
:
:
:
:
:
Aircraft
Company Policy
Human Factors
MEL
Procedure
Narrative: 1
A CDL [(Configuration Deviation List)] was applied on an A330 aircraft on the 3-Left
(3L) Door Sill plate (CDL-51-021) which we did in accordance with (I/A/W) the CDL
Manual. Maintenance Control however insisted per the CDL, that the aircraft be
pressurized as part of the CDL. The CDL Manual does not require that to be done
and the aircraft took an additional 30 minute delay as a result. The aircraft was on
a gate in ZZZ, scheduled for an evening departure. Personnel involved were myself,
another Mechanic, the Lead Mechanic, and the 'A' Concourse Supervisor.
In reviewing the CDL, we saw no requirement that the aircraft be pressurized as a
result of applying this CDL and that this action be documented on an Engineering
Report as directed by Maintenance Control. It was our feeling that we were
accomplishing a special procedure that Maintenance Control had decided [needed]
to be done and not one that the CDL Manual specified.
My opinion is that the event occurred as a result of Maintenance Control adding a
Special Procedure to the application of a CDL that was not specified and not needed
to legally dispatch the aircraft. We disputed the requirement of pressurizing the
aircraft after the CDL was applied, and documented this action on a company
Engineering Report, but performed this as Maintenance Control insisted it was
required for the CDL. We were at the end of our work shift and were focused on
getting the airplane out. [Issues involve] Maintenance Control communicating
directly with the mechanics about the work to be accomplished and the
requirements of a specified CDL and no unnecessary actions being performed.
Synopsis
A Line Mechanic reports that an A330 aircraft was delayed 30 minutes while
Maintenance was required to perform an aircraft pressurization check to satisfy a
Maintenance Controller's CDL deferral of a damaged Sill plate at Cabin Door 3-Left
(3-L). Mechanic noted the CDL did not specify a pressurization check requirement
for dispatch.
ACN: 1022329
Time / Day
Date : 201207
Place
Locale Reference.Navaid : SXC.VORTAC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZLA
Flight Plan : IFR
Mission : Passenger
Nav In Use : GPS
Route In Use.SID : PEBLE3
Airspace.Class A : ZLA
Component
Problem : Design
Person
Reference : 1
Events
Anomaly.Airspace Violation : All Types

Assessments
Narrative: 1
Flight from SAN; cleared via PEBLE Three Departure, SXC, C1177. The climb out
was normal. Autopilot ON and aircraft in NAV and proceeded on course to SXC from
PEBLE. We passed SXC and noticed that the FMS made it a "FLY BY WAYPOINT"
because of the large turn it had to make to continue on C1177. This is a normal
function of the Airbus FMS. We were about FL250 or higher and at normal climb
speed of about 310 KIAS. ATC calls and tells us that we had flown into the warning
area W-291 by about 2 or so miles. He also said that he has noticed this happening
with Airbus type aircraft. We responded that the FMS does this "FLY BY WAYPOINT"
and that we have no idea that it is encroaching into the warning area. I relayed to
him that I would let the company know about this problem and that we should
make it an "OVERFLY WAYPOINT". He said he would follow up and let our company
know about the problem.
Why this event occurred in my opinion is that the FMS tries to make a smooth turn
in transition to course changes. This probably is the way that the FMS is
programmed from Airbus and Honeywell. We need to make a change to either the
FMS or make SXC an "OVERFLY WAYPOINT". Maybe the chart maker should be
notified also.
Synopsis
A330 Captain, departing on the PEBLE3 from SAN, is informed that the large radius
turn initiated approaching SXC to intercept C1177 outbound has resulted in an
incursion into W-291.
ACN: 1022017
Time / Day
Date : 201207
Place
Locale Reference.Airport : FRM.Airport
State Reference : MN
Aircraft
Reference : X
ATC / Advisory.Center : ZMP
Flight Phase : Taxi
Person
Reference : 1
Location Of Person.Facility : ZMP.ARTCC
Events
Assessments
Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
Primary Problem : ATC Equipment / Nav Facility / Buildings
Narrative: 1
I noticed that the altimeter for FRM was old, so I made a change to ERAM reporting
FRM altimeter as missing and subsequently reported this to the southeast as out of
service. This is normal and AWOS do fail at times. I noticed that the altimeter
reading for FRM was not only incorrect, it was yesterday's altimeter. It had the
same time and the altimeter reading. I verified on my AISR that I had not received
a new altimeter for the last 6 hours and I also confirmed with the ZMP weather unit
that they had not received a new altimeter for FRM for the last 24 hours. ERAM
somehow put yesterday's 1655 altimeter back in some time before today. As a
result, this will cause the controllers to issue an incorrect altimeter setting for
landing aircraft/or low flying aircraft near FRM, which is very dangerous and creates
a safety issue. Please resolve this software issue immediately. I received an error
from ERAM in the flight plan correction box on an A330. In an attempt to figure out
what was wrong with the flight plan, I re-entered the flight plan into ERAM to
generate an error message. The error message stated "invalid message type." We
have written this type of problem up with the ERAM team in the past. I believe that
the ERAM team has been diligently trying to solve this and many other ERAM
issues. However, we are not getting written direction on how to handle this problem
and the other ERAM problems. I feel that I am "flying by the seat of my pants" with
handling these ERAM messages, where in HOST we had clear written direction on
how to handle these issues. In reference to the flight plan for the A330, I suspect
that the problem is the route of flight. I have many questions. 1) Does ERAM
recognize all fixes across the globe? 2) What does ERAM do when these fixes are
duplicated? 3) Is there a way for ERAM to tell Flight Data specialist what fix it is
having an issue with? 4) If the route is the issue, why are we getting the error
message that reads "invalid message type" if in fact it is a route problem? This is
misleading There are two issues here: 1) We need written direction, even if it for
the interim, until we get ERAM figured out, on how to handle the ERAM error
messages in flight data. 2) We need new written instructions (policies, procedures,
orders) from management detailing our job responsibilities when it involves an
ERAM error message. With regards to the Altimeter issue and ERAM issue; this is
probably a software programming issue that will need correction. With regards to
the ERAM Error message issue, we need direction from ERAM software engineers
and FAA management on how to handle these ERAM issues. We need new written
policies and procedures so that we have a clear understanding of our job
responsibilities.
Synopsis
ZMP Controller described an ERAM failure to update the altimeter as required. The
reporter presented a number of questions regarding ERAM and its functionality.
ACN: 1021845
Time / Day
Date : 201207
Place
Locale Reference.ATC Facility : LPPO.ARTCC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : LPPO
Person
Reference : 1
Events
Detector.Person : Passenger
Assessments
Narrative: 1
At approximately the 5+00 hour point in cruise at FL390, a Flight Attendant advised
several passengers and a Flight Attendant could smell an odor near row 14 left.
They said it smelled "electrical". We sent an "on break" First Officer to that location
who reported he could not smell or detect any odor. To our knowledge no one else
could now smell the odor. No abnormality was witnessed or detected in the cabin.
Passenger in that area had been noticed using lap tops and Bose headset
equipment. No further odor was reported for the remainder of the flight.
About 6+30 hours into the flight I went to the cabin myself during a break. I
walked past row 14 twice plus saw and talked to numerous flight attendants. No
odors were present and everyone seemed very content. Approximately 30 minutes
later, while well into our descent, we were contacted again and told flight
attendants were experiencing headaches and nausea but no odors were present in
the cabin. I believe we were told they had been working the left side of the aisle in
coach. We selected high flow for better ventilation.
Shortly after that, one of the three flight attendants was feeling worse and felt the
need to sit down and asked for oxygen. We again asked about odors but none were
reported from any location in the cabin. We asked if the distressed flight attendant
wanted to be met by paramedics. We were told she said yes and we made the
request. We were told she was sitting up, conversing, and appeared normal but
perhaps a little pale. Remote medical assistance was not contacted directly as only
30-45 minutes of flight remained.
An emergency was not declared. We were allowed to keep speed up and ATC got us
right in and paramedics were in position awaiting us. After gate arrival I got no
updates regarding the three distressed flight attendants. Thinking someone would
come up front or call; I became involved with maintenance, paper work and
completed the cabin fume, odor, and smoke form for Maintenance. By the time my
IOE Captain and I were able to move aft everyone had already left the aircraft.
Synopsis
Faint odors detected by passengers and flight attendants aboard an A330 may have
caused nausea and headaches for three flight attendants as the flight approached
its destination.
ACN: 1018511
Time / Day
Date : 201206
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Maintenance Status.Released For Service : N
Component : 1
Aircraft Component : Fuel Quantity-Pressure Indication
Component : 2
Aircraft Component : Indicating and Warning - Fuel System
Person
Reference : 1

Events
Anomaly.Inflight Event / Encounter : Fuel Issue
Assessments
Narrative: 1
There was an MEL 28-25-03b for the Left Inner Tank high level detection system
inoperative. But no other faults for the fuel quantity or fuel system faults. I
explained to the Captain that the Fuel Quantity System (FQS) is very accurate and
if no faults were displayed that there was nothing wrong with the system. The
Magnetic Level Indicator (MLI) System [Fuel Sticks], as per the Fuel Manual for the
inner tanks are accurate to +/- 5% of their indication. If there was an error
between the Fuel Quantity Indicating System (FQIS) or the MLI System, I would
say that the MLI System would be in error with the human factor of not reading the
[fuel] charts or sticks correctly.
There were no real time Aircraft Condition Monitoring System (ACMS) faults and no
faults in the FQIS. Therefore I could apply the MEL for the MLI System. They
metered in 2,000 LBS [of fuel] supposedly into the Left Inner Tank and the three
pilots watched the indication for that Left Inner Tank and it did not increase. The
Total Fuel increased, but to their knowledge there was no indication that it went to
the Left Inner Tank or other tanks. Therefore, they were saying that their six eyes
were more believable than the aircraft's Fuel Indicating System. The MLI [fuel]
sticks for the Left Inner Tank did show an increase for the metered fuel added. The
Left Inner Tank Indication could not be MEL'd due to the pre-existing MEL for the
Left Inner Tank Detection System was inoperative. The flight was canceled. I
instructed Maintenance to transfer fuel in 1,000 LB increments to the Left Inner
Tank and to verify fuel increased in that tank only and not the other tanks.
However, before they accomplished this, they repositioned aircraft. After tow [of
aircraft], the Left Inner Tank had increased by the 2,000 LBS that was not showing
previously. After completing their fuel transfer, all indications checked normal and
no other faults could be found. No parts were replaced. Aircraft was fueled to
112,000 LBS for correct distribution.
I suspect improper sumping, not necessarily on Maintenance behalf, but rather on

extremely short turn times these aircraft experience during heavy summer flying
season/schedule. [Fuel] Tanks [were] sumped after flight canceled and aircraft was
moved to remote area. At that time, Fuel Quantity Indicating System (FQIS)
showed proper increase in fuel load. [Suggest] allowing more time on ground for
water to settle, allowing proper sumping.
Callback: 1
Reporter stated he is a Technician working the Technical Support Desk. The whole
event and flight cancellation started at the departure gate when the flight crew was
reviewing the MEL deferral for the Left Inner Tank High [Fuel] Level Detection
System. They were also watching the fuel indications and trying to determine
where 2,000 LBS of metered off fuel had gone. The Fuel Totalizer showed the
increase, but no increase in fuel levels were indicated in the other fuel tanks.
Reporter stated after the flight canceled and the aircraft was repositioned, all fuel
indications and quantities were normal, including the missing 2,000 LBS and the
'known' metered fuel in 1,000 LBS increments he requested Maintenance to
perform. The aircraft was released the next morning. He still believes water in the
fuel tanks is responsible for some of the indication failures, even though there are
no faults showing up in the Aircraft Condition Monitoring System (ACMS) data.
Their aircraft are flying constantly, with short turnarounds on the ground. Water in
the fuel just doesn't have enough time to settle down to where the Water
Extraction System can remove the water, or even manually sumping the tanks is
not adequate, because the water just hasn't settled. On one of their aircraft, ten
gallons of water had been drained (sumped) from a single fuel tank during an
Overnight Check.
Synopsis
An A330 aircraft had fuel quantity indication failures that did not show up as fuel
faults in the Aircraft Condition Monitoring System (ACMS). Only after flight
cancellation and repositioning of the aircraft did 2,000 LBS of missing fuel
reappear. Technician believes water in the fuel tanks may be a factor.
ACN: 1012505
Time / Day
Date : 201205
Place
Locale Reference.ATC Facility : EDDM.TRACON
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZZ
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Throttle/Power Level
Person
Reference : 1
Events

Assessments
Narrative: 1
Shortly after takeoff we received an ECAM advising ENG 2 Thrust Lever
Disagreement. ECAM required "Land ASAP". All engine parameters, however, were
normal.
We continued the climb and contacted Maintenance Control via SATCOM and
explained the condition, i.e. all engine parameters were normal except fluctuating
LVR CLB MCT displayed on both Captain and First officers' PFDs. MOC
recommended compliance with ECAM action to land ASAP. As a result I declared an
emergency and continued to an overweight, but uneventful landing at the nearest
suitable airport. Subsequent Maintenance inspection revealed chaffed wiring from
the EEC.
[It is of interest that our] aircraft was on MEL: "ENGINE 2 MINOR FAULT."
Immediate correction of this MEL may have revealed the underlying wiring "short"
that lead to the subsequent ENG 2 THR LEVER Disagreement.
Synopsis
An A330 flight crew delayed taking action on an ECAM thrust lever disagreement
message which directed a landing "ASAP." Upon consultation with Maintenance
Control they diverted to the nearest suitable airport.
ACN: 1005551
Time / Day
Date : 201204
Place
Aircraft
Reference : X
Flight Plan : IFR
Person
Reference : 1
Location Of Person.Facility : ZZZ.ARTCC
Events
Assessments
Narrative: 1
While working Sectors XX/YY/ZZ/WW combined, an A330 was at FL320 and
requested a climb to FL340. He was cruising at M0.81 and had an aircraft 8
minutes ahead of him at FL330 cruising at M0.79. I advised the A330 that I was
unable higher due to traffic; however, I advised the A330 that higher would be
available with a climb at M0.76 to resume M0.81 upon reaching FL340. An A330
acknowledged that advisory but did not request the advised climb. Six minutes
later, the A330 then requested to know when to expect a higher altitude. I advised
the A330 that he had traffic one thousand feet above him that is M0.03 slower than
him and at M0.76 he could climb to FL340 now; otherwise I could offer a reroute.
The A330 acknowledged the advisory. And immediately after acknowledging the
advisory sent a transmission that he was climbing to FL340. I demanded his ADS,
his altitude indicated that he was in a climb for FL340, and a trail probe went off
with the aircraft in front of him at FL330. He sent a transmission indicating he was
leveling at FL340, and I advised him that I had not sent a clearance to him and
cleared him to maintain FL340. I believe the situation could have been avoided had
I not used the words 'you can climb now' when answering his question as to when
he can expect a higher altitude. I believe the language barrier had something to do
with it. Also, the A330 should have verified if I had sent him a clearance or not, and
waited until I sent an actual clearance to FL340. I would recommend being more
clear and concise when dealing with foreign language speaking pilots.
Synopsis
Enroute Controller working non-RADAR oceanic traffic described an unauthorized
climb through occupied airspace, the reporter acknowledging using less than clear
and concise phraseology with this international flight crew.
ACN: 990183
Time / Day
Date : 201201
Place
Environment
Weather Elements / Visibility.Visibility : 3
Ceiling.Single Value : 1000
Aircraft : 1
Reference : X
Flight Plan : IFR
Flight Phase : Taxi
Route In Use : None
Aircraft : 2
Reference : Y
Flight Plan : IFR
Nav In Use.Localizer/Glideslope/ILS : Runway XXL
Aircraft : 3
Reference : Z
Make Model Name : Regional Jet CL65, Undifferentiated or Other Model
Person
Reference : 1
Events
Anomaly.Conflict : Ground Conflict, Less Severe
Assessments
Narrative: 1
The ceiling was 1,000 and the visibility was better then 3 miles, so we were VFR. A
CRJ aborted take off on Runway XXL. An A320 was on ILS XXL just inside the outer
marker. An A330 was on Taxiway "E" that crosses the far end of Runway XXL, but
does not intersect the runway. A call went out that the CRJ aborted take off by
Local Two. Local One stated after the fact that he was going to keep the A330
taxiing on Taxiway "E". I never heard the coordination about keeping the A330
rolling. I never remember giving an acknowledgement to that coordination as I was
finding out the reason for the abort. The CRJ was able to clear the runway prior to
A320 crossing the landing threshold. As I was looking at the ASDE to check the
runway I saw that the A330 had crossed the extended centerline of XXL and was
also clear. I asked Local One what was that all about and he said he had
coordinated it but I never heard anything or acknowledged anything and never
advised the A320 of the crossing traffic at the far end. Well when A320 was exiting
the runway he gave me an ear full about how his instruments were deviating so
much that he almost went around. Recommendation: get an acknowledgment
before crossing aircraft and just don't yell out and go. The other Local has to
coordinate with the aircraft.
Synopsis
Tower Controller described a probable loss of runway separation and the likely
interference with the ILS signal when an aircraft was issued a runway crossing
clearance, intra-facility coordination failures were listed as casual factors.
ACN: 984915
Time / Day
Date : 201112
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Maintenance Status.Maintenance Items Involved : Installation
Component : 1
Aircraft Component : Minimum Equipment List (MEL)
Component : 2
Aircraft Component : Fuel Trim System
Component : 3
Aircraft Component : Fuel Distribution System
Person
Reference : 1
Events
Anomaly.Deviation - Procedural : MEL
Assessments
Aircraft
Human Factors
Logbook Entry
Manuals
MEL
Procedure
Narrative: 1
I was assigned the task by my Lead to replace the Fuel Control and Monitoring
Computer (FCMC-2) on an A330 aircraft due to [discrepancy] history. The aircraft
was scheduled for Routine Over-Night (RON) maintenance and a work [paper]
package was assigned. An MEL was written against the [horizontal stabilizer] trim
tank inlet valve, but I wasn't aware that this was partly due to the FCMC. A
[previous] MEL maintenance procedure (MP) to place [install] the trim tank inlet
valve actuator locking plate was not reversed [removed] and a "dummy" plug was
not removed.
There wasn't any indication that the [MEL] maintenance procedure had been
complied with and the [FCMC] system tested OK. Another Aviation Maintenance
Technician (AMT) that was more familiar with the pre-merger paperwork for that
aircraft informed me that the item was written against an MEL. I did not see any
MEL that involved the FCMC, but he told me that the MEL that was on the aircraft
needed to be cleared since I changed out the FCMC. I cleared the MEL. I think what
caused the problem was lack of clarity on what needed to be done and why, clarity
on handling work packages, and also reading through the MEL. To prevent this
from happening again I need to review the MEL maintenance procedures more
closely. I corrected the situation by replacing the actuator and removing the locking
plate and the dummy plug.
Callback: 1
Reporter stated he has twenty-seven years experience working for two different
airlines. The "dummy" electrical connector plug was previously installed to give a
"normal" indication in the cockpit and ECAM displays; meaning no faults would
show up even with the horizontal stab trim tank fuel actuator valve being locked
and deferred in the "Open" position with the locking plate. After changing the #2
Fuel Control and Monitoring Computer (FCMC-2), he did not remove the 'dummy"
plug or fuel actuator valve locking plate from inside the tail section when he cleared
the MEL.
Reporter stated the FCMC controls all fuel functions on the aircraft including the
rate of fuel going to the center fuel tanks from the horizontal stabilizer trim tank
and the cycling of fuel back into the horizontal stab trim tank, in flight, to help
maintain aircraft trim, weight and balance. He believes the FCMC was contributing
to issues with the fuel transfer valves and the trim tank inlet valve actuator; so
both items ended up being replaced.
Synopsis
A Line Mechanic reports that after replacing the #2 Fuel Control and Monitoring
Computer (FCMC-2) on an A330 aircraft, he wasn't aware that a "Dummy"
electrical connector plug and the locking plate for the horizontal stabilizer trim tank
fuel inlet valve actuator also needed to be removed when he cleared the MEL.
ACN: 980591
Time / Day
Date : 201111
Place
Environment
Weather Elements / Visibility : Fog
Light : Dawn
RVR.Single Value : 700
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZZ
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Events
Assessments
Narrative: 1
We pushed off the gate with low visibility and fog. First Officer was in the right seat
and another First Officer was on the jump seat. The ATIS was reporting visibility of
less than 800 meters and Low Visibility Procedures in Progress. Our departure
clearance was given to us verbally because our ACARS request was rejected. We
were cleared via Runway 09. We started our engines completed our check lists and
called for taxi clearance. Ground Control cleared us to taxi to Runway 09 via
Taxiway B. Ground reported that the RVR for Runway 09 was 300 meters at all 3
positions. Before releasing the brakes we all three verified our route and how many
intersections we would pass prior to reaching the end of Runway 09, which was at
Taxiways B and N5. When we reached N5 we stopped and mentioned there were
red stop bar lights illuminated, for not entering the end of the runway. We
contacted Tower and told them we were ready for take off, to which Tower replied,
Runway 09, line up and wait. At that time the red stop bars were turned off. When
we were taxiing onto N5 to line up and wait I thought I hear Tower say [to us], new
departure clearance, CLEARED FOR TAKEOFF, FLY HEADING OF 030 DEGREES,
CLIMB TO FL60. The First Officer read back the clearance. I then briefed our
clearance as; I'm flying, fly heading 030 and climb to FL60. I then asked if we were
cleared for take off to which the First Officer said yes, clear to go. The other First
Officer did not confirm nor dispute the take off clearance. We lined up the aircraft
on the center line lights and advanced the thrust levers and took off. At 1,500 FT
Tower called and said, "Are you aware you took off without clearance? The First
Officer replied, "Negative, you cleared us for take off and I acknowledge. Tower
responded, "Negative, I did not clear you for take off, I only gave you a new
departure instructions. The First Officer responded, "Well, we are already airborne
but we apologize." All three of us instantly realized how grave of an error we just
committed! Low visibility and no take off clearance could have been disastrous! We
all agreed that we thought we had heard "CLEARED FOR TAKEOFF," but now
question what the Tower had said. I have always been very firm that anytime all
three pilots are not 100% positive on an ATC clearance we ALWAYS confirm.
Whether it is taxi instruction, take off clearance, frequency change, altitude change
or whatever, I always insist on verifying. The question is why didn't we this time?
The answer is there is no excuse. I do however believe the break down happen for
a couple of reasons. Instructions from the Tower were in accented English, and he
used the word take off. I believe that if the Controller had used the verbiage
"AFTER DEPARTURE" rather than "AFTER TAKEOFF" we would not have
misunderstood the clearance. In the future I will insist that if ALL THREE pilots are
not positive of a clearance we will verify.
Narrative: 2
Contributing: Fatigue: I got mediocre sleep prior to this take off. This was the last
day of a 6-day. It was my 9th day on the road. This trip was tougher than most.
Two legs prior I departed the airport in similar weather conditions headed to the
U.S. The leg prior I was in the U.S. for a departure during a snowstorm. We had
what seemed like a loft that took about 90 minutes to get airborne, complete with
deicing, runway closure, and almost exceeding our holdover time while dealing with
a mechanical. That leg ended with a true CAT III landing in Europe complete with a
low-vis taxi in. None of the three of us are sure of exactly what the Tower
Controller said, but we all know that we heard the word "take off", and we all
believe that this is what made us think that we were cleared for take off. Instead,
and given our position at the time, Tower could have said something more like "you
are cleared to line up and wait, but I have new departure instructions for you, after
departure turn left 030" I believe that if he had used verbiage similar to this, this
incident would not have occurred. For myself: when the Captain asked, "are we
cleared for takeoff?" I should have just keyed the mike and reconfirmed our
clearance with the Tower. We've all heard the discussion about not taking each
others' word for stuff like this inside the cockpit, and that the better solution is to
query the Controller. Why I did not do this I have no idea, but I obviously should
have. And had I, this incident would not have occurred and you would not be
reading this report right now. All three of us: Captain could have said: "confirm
with Tower that we are cleared for take off" instead of asking me if we were cleared
for takeoff. I could have asked Tower instead of just answering him, as described
above. Others could have spoken up and said "I'm not sure, let's ask" The bottom
line is that any one of us could have easily prevented this incident, but none of us
did.
Narrative: 3
[Narrative #3 has no additional information]
Synopsis
Air Carrier departure from a foreign airport initiated a take off when reportedly ATC
issued "line up and wait" followed by "after take off fly heading 030", which was
interpreted as a take off clearance.
ACN: 980467
Time / Day
Date : 201111
Place
Aircraft : 1
Reference : X
Flight Plan : IFR
Flight Phase : Initial Climb
Route In Use : None
Aircraft : 2
Reference : Y
Flight Plan : IFR
Flight Phase : Descent
Person
Reference : 1
Events
Anomaly.Conflict : Ground Conflict, Less Severe

Assessments
Narrative: 1
An A330 waiting to depart Runway XXL. I was working Local Control East and
owned Runway XXL and a crossing runway for aircraft arriving. I coordinated with
Local Control West to go in a hole between an arrival to a crossing runway and an
arrival to Runway XXL. I told the arrival on a crossing runway to plan on rolling
through Runway XXL without delay and exit at Kilo. I put an A330 in position on
Runway XXL with a B747 on a 5 mile final going 180 KTS. I prepped an A330 to be
ready for an immediate departure and went back to the B747 to start slowing a
little bit and then told him to maintain his slowest speed which he came back and
said his approach speed was 140 KTS. I was expecting him to actually slow down to
his approach speed a lot sooner than he did. He was still at 160 KTS inside a three
mile final with the arrival on a crossing runway still rolling out to clear the Runway
XXL intersection. I then went to the A330 and told him to start bringing up his
power and plan on rolling without delay and then cleared him for takeoff on
Runway XXL when the arrival on a crossing runway was clear of his intersection.
The A330 started his roll right away with the B747 inside a 2 mile final. To the
naked eye the A330 was 6,000 FT and airborne. I cleared the B747 to land on
Runway XXL. I feel that the B747 did not respond right away when given control
instructions to maintain his slowest approach speed. I do feel that if he would have
slowed to his approach speed in a timelier manner, this would never have been an
issue. However, I also understand that, since the traffic volume was so light that I
did not need to go in that hole and could have waited.
Synopsis
Tower Controller reported marginal runway separation when an arrival did not slow
as quickly as expected to allow room for the preceding departure. Traffic on a
crossing runway complicated the scenario.
ACN: 977501
Time / Day
Date : 201110
Place
Environment
Weather Elements / Visibility : Snow
Aircraft
Reference : X
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Events
Anomaly.Deviation - Procedural : Weight And Balance
Assessments
Narrative: 1
Our flight was delayed about four hours that night with maintenance, aircraft swap,
then another flight cancellation whose passengers were boarded on our flight.
There was a shift change in Dispatch. I feel the new Dispatcher was not briefed on
all of the delays nor weather that was on our planned route. I requested new
payload numbers for fuel burn since we were picking up the [canceled flight's]
passengers and luggage. He advised me to wait till final numbers were given to him
before we push off the gate to see if we needed more fuel. He advised that the new
payload was good and we could leave the gate. During taxi it occurred to me that
earlier reports that a system of severe turbulence was forecast to move north
towards our route and, since we were four hours late, we were concerned. It
sounded like he was not aware of this and said to stand by. He came back with just
a forecast of severe turbulence. As we were getting deiced, he sent us an ACARS
message of PIREP reports for severe turbulence on our route. [Later] he said we
cannot go. Thank goodness we asked about this turbulence during our taxi because
I do believe we would have departed into known severe turbulence without his
knowledge. He also advised us that he was given wrong payload numbers (heavier
by 8,000 LBS). We would still have to return to the gate for more fuel. My question
in all of this is how well are the Dispatchers briefing with each other during shift
changes. This night there was a major storm on the coast, maintenance delay on
original aircraft, aircraft swap, loading issues, and crew legalities which, because of
poor coordination and decision making, meant the flight had to be canceled due to
crew legalities.
Synopsis
An A330 Captain reported he was concerned his Dispatcher was not properly aware
of changing weather conditions when their flight was delayed.
ACN: 974676
Time / Day
Date : 201107
Place
Environment
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Cabin Lighting : High
Number Of Seats.Number : 258
Passengers On Board.Number : 0
Crew Size Flight Attendant.Number Of Crew : 9
Person
Reference : 1
Location In Aircraft : General Seating Area
Experience.Flight Attendant.Total : 19
Experience.Flight Attendant.Airline Total : 12
Experience.Flight Attendant.Number Of Acft Qualified On : 10
Experience.Flight Attendant.Type : 75
Events

Result.General : Work Refused
Assessments
Narrative: 1
Was situated in aft galley when a cabin crew member walked to the aft and
observed an odor in the aft section of the aircraft. Was unaware of the odor until I
appeared in cabin and walked forward. Detected oil odor. Dissipated near the 2L
door and forward. Reported odor to the lead purser and flight deck. Maintenance
summoned to aircraft. One member (unnamed) also detected odor. Stepped off
aircraft due to fumes. Passenger boarding had not commenced as the aircraft was
being repaired because of faulty fuel filters. Contacted the local union due to
concerns over the odor as the front end crew did not write up the odor and
Maintenance dismissed the cabin crew's concerns. During this time period the cabin
crew gathered in the front section of aircraft, and unbeknown to us, Maintenance
closed the 2L door and fired up the engines with crew onboard. This caused several
crew members to feel ill. After door was reopened, crew voluntarily asked to be
taken off the trip as we felt unsafe to fly aircraft transatlantic with the problem.
Company sent cabin crew to emergency care to be evaluated where several crew
members were treated with nebulizers and albuterol injections. I suffered from
severe headache/tingling of limbs/dizziness and an ongoing cough. Company did
not cancel flight, but replaced us with reserve crew and original flight deck crew.
Had to be seen by company physician to return to work, although company forced
us to use sick time and did not pay us for the occurrence. This in turn absolves any
wrongdoing on their part. Maintenance should have taken a more serious approach
to dealing with this problem and the flight deck should have written up this problem
instead of dismissing our concerns.
Synopsis
An A330 Flight Attendant reported detecting an oil odor in the aircraft from the 2L
door forward during preflight. Maintenance subsequently ran the engines with
closed doors for another reason after which the reporter became ill and sought
medical attention.
ACN: 973310
Time / Day
Date : 201110
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Maintenance Status.Required / Correct Doc On Board : N
Component : 1
Aircraft Component : Fuel Booster Pump
Component : 2
Aircraft Component : Circuit Breaker / Fuse / Thermocouple
Person
Reference : 1

Events
Result.Flight Crew : Returned To Gate
Assessments
Aircraft
Human Factors
Logbook Entry
MEL
Procedure
Narrative: 1
A330 aircraft experienced electrical circuit breaker (C/B) tripped, followed by fuel
left pump #2 low pressure while in flight from ZZZZ to ZZZ. While at ZZZ, I
contacted Maintenance Control for assistance to MEL this issue because, due to
insufficient ground time, aircraft would need a two day stay to be able to comply
with special FAR-88 (SFAR-88) and troubleshooting manual (TSM) 28-21-00-810.
Maintenance Control in ZZZ1 has been notified [and], as per cautionary, C/B has
been collared. This is being deferred per MEL-28-40-15A [and] entered in the back
of logbook, so I was given this MEL by Maintenance Control. I thought it was the
right MEL that applied to this issue; ETOPS was cleared, aircraft left ZZZ to ZZZZ;
it arrived there with no problem. But, leaving ZZZZ, I was [later] informed that it
had a return to block with the wrong MEL on it. So the MEL was changed to [MEL]
28-21-01, which makes it non-extended range beyond 120 minutes. So here, what
confuses me [is] how the wrong MEL was applied here in ZZZ when the outbound
crew had no problems, [but] the crew in ZZZZ didn't catch this on their preflight
and the Maintenance Controller [had] already reviewed the ETOPS and he didn't
say anything about it either. The other problem I have here is why in no place in
the MEL states to collar the tripped C/B.
Callback: 1
Reporter stated he has thirty-five years as a Mechanic with two different airlines.
Seems like there is a Catch-22 where the FAA requires compliance with SFAR-88
that also requires Maintenance Procedures be performed for deferral of a popped
wing fuel pump circuit breaker (C/B) under MEL 28-21-01 by collaring the C/B and
disconnecting the fuel pump canon plug. But, a deferral is allowed under MEL 2840-15 for the same popped fuel boost pump C/B and "No" maintenance procedure
is required to collar the pump C/B or disconnect the fuel pump canon plug. Why
should an ETOPS flight require compliance with SFAR-88 for fuel pump deferrals,
but a non-ETOPS flight does not have the same requirement for a popped fuel
pump circuit breaker?
Reporter stated he installed a collar under the #2 wing fuel boost pump C/B as a
precaution, even though the first MEL 28-40-15 they used, that ended up being
incorrect, did not require a C/B collar.
Synopsis
A Line Mechanic reports he noticed an MEL deferral maintenance procedure
discrepancy for their A330 aircraft where MEL 28-21-00 requires a popped wing
fuel boost pump circuit breaker to be collared prior to ETOPS dispatch, to comply
with SFAR-88 and troubleshooting manual (TSM) 28-21-00. However, MEL 28-4015 does not require the same popped C/B to be collared for a non-ETOPS flight.
ACN: 969119
Time / Day
Date : 201109
Place
Locale Reference.ATC Facility : ZZZZ.TRACON
Aircraft
Reference : X
Component
Problem : Failed
Person
Reference : 1
Events
Assessments
Narrative: 1
We departed after a lengthly maintenance delay to repair HYD G system. On initial

climb, when we raised the landing gear we totally lost pressure in the HYD G
system. The gear remained extended with the gear doors now open. We performed
the ECAM actions that we could and began procedures to return. We contacted
Dispatch via SATCOM and asked if they wanted us to do an overweight landing.
They replied, YES. We declared an emergency with ATC and asked to have
emergency equipment standing by for our overweight landing and that we would
not be able to clear the runway after landing due loss of NWS. We performed QRH
overweight landing checklist, then landed uneventfully. Touchdown rate of descent
was <300 FPM. With accumulator pressure we were able to clear the runway onto a
very large paved area that we could have evacuated the aircraft from. Max brake
temperature was 580. We were inspected by airport emergency personnel who
found no brake fire or anything else amiss. After releasing those emergency
personnel we were towed to parking and deplaned normally.
We were told by maintenance personnel that the most likely cause for the loss of
pressure was air trapped in the system. Perhaps a change to maintenance
procedures as HYD G system fluid was nearly depleted on the previous flight.
Synopsis
A330 Captain experiences Green Hydraulic System failure as the gear is retracted
after takeoff. The gear remains extended with the gear doors open, an emergency
is declared and the flight returns to departure airport for an overweight landing.
The G Hydraulic system had failed on the in bound flight and was repaired prior to
this flight.
ACN: 968824
Time / Day
Date : 201109
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Component
Aircraft Component : Hydraulic System Lines, Connectors, Fittings
Person
Reference : 1
Events

Assessments
Narrative: 1
About 35 minutes from landing we got a HYD G SYS low level ECAM. We did the
ECAM actions. We continued to slowly lose fluid. On the initial approach phase we
slowed, turned the pumps back on, and lowered the landing gear without incident
and then turned the pumps back off. I turned the pumps back on since we still had
fluid in the system and I wanted the gear doors shut so we would have nose wheel
steering to clear the runway, if possible. We got additional ECAMs during the
approach as the last of the fluid was lost, so I declared an emergency and informed
Tower that we would likely not be able to clear the runway due to loss of nose
wheel steering. After an uneventful landing we were able to clear the runway using
green [system] hydraulic accumulator pressure, but soon exhausted that and
needed to be towed the remaining distance to the gate.
Mechanics said it looked like a leak in the area of engine 1 green engine driven
pump. The previous crew had written up a similar fault on this aircraft on the
previous leg, which occurred during their approach/landing. [I suggest] more
thorough troubleshooting by Maintenance.
Synopsis
A330 Captain experiences a HYD G SYS low level ECAM during descent. During
approach, the green system fails and an emergency is declared. A normal landing
ensues. The previous crew had written up a similar fault on this aircraft on the
previous leg.
ACN: 968777
Time / Day
Date : 201109
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Traffic Collision Avoidance System (TCAS)
Person
Reference : 1
Events
Detector.Automation : Aircraft RA

Assessments
Narrative: 1
Inside the outer marker traffic popped up on TCAS 200 FT below us. We were told
to climb, then traffic showed at our altitude and we were told to descend. By then
we were climbing. Then traffic jumped to 6 miles away and TCAS said clear of
traffic. During go around traffic showed in our position again then jumped away.
Tower reported helicopter traffic at first and then said it was clear. The TCAS was
showing false traffic through out our go around. The traffic was always within 200
FT or at our altitude and then would jump away. We went around and made an
uneventful approach and landing and wrote up the TCAS. I chose to go around
because I did not know if there was traffic or not. I did not want to ignore the TCAS
and could not get away from the traffic.
Synopsis
An A330 TCAS issued RA warnings inside the outer marker so a go around was
executed and the crew determined the warnings were false.
ACN: 968316
Time / Day
Date : 201108
Place
Relative Position.Distance.Nautical Miles : 10
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Function.Air Traffic Control : Departure
Function.Air Traffic Control : Approach
Human Factors : Other / Unknown
Events
Assessments
Narrative: 1
I was working an A330 [that] took off and was on a 160 degree heading and
climbing to 10,000 FT. I had a crossing restriction to make at 5,000 FT at 10 miles
southeast of the airport. The A330 departed and was climbing extremely well. The
A330 was at 4,000 FT, 5 NM from the end of the runway. I knew if I turned the
A330 eastbound, based on his current climb rate, I would easily make my 5,000 FT
restriction in 5 miles since he had already climbed 4,000 FT in the previous 5 miles
and I would top the crossing traffic that was at 4,000 FT. When I turned the A330
eastbound he completely stopped climbing and leveled at 4,000 FT for
approximately 6 miles without stating he had any type of problem or letting me
know that he was going to have to stop his climb for some reason. The Controller
that was working the crossing traffic at 4,000 FT, and I, realized that the situation
was not going to work so I turned the A330 southeast-bound and told him to
expedite his climb and the adjacent Controller turned and descended his 4,000 FT
traffic to ensure we maintained separation. It was not how the situation was
planned but we adjusted to the A330 stopping his climb without giving notice and
did what we needed to do to maintain separation. I alerted the FLM immediately
after the incident. A few weeks later I was alerted that there was a QAR involving
this incident and that basically I was being blamed for the A330 stopping his climb
and us having to take evasive action to adjust for his actions. Our QA Department
is basically at war with the controller workforce at the TRACON. This is NOT an
exaggeration. The QA Manager/Office abuses their power to attack controllers and
interject opinions into OE reports, OD reports, and QARs. This was a pilot deviation,
plain and simple. You cannot just stop climbing on departure, level off, and not say
anything. If the pilot had some type of issue, all he had to do was mention it and
we would have vectored him to an area that he could level off. Yet our QA Office
continues to run rampant and target controllers and create "deficiencies" when in
reality we busted our butts to save separation in spite of the pilot deviation. We did
not CAUSE the incident; we prevented the incident from becoming a loss of
separation. Did QA contact the A330 to question him about the incident and ask
why he leveled at 4,000 FT? Did QA file a pilot deviation? No, because they think
their job is to try to find ways to pin things on controllers. Many controllers are
scared to speak up for fear of retaliation. Recommendation, first, pilots MUST let us
know if they are going to deviate from assigned control instructions so we can plan
for it and make the necessary adjustments. Second, we NEED something done
about our QA Office.
Synopsis
TRACON Controller described a loss of separation event caused by an aircraft
leveling off unexpectedly after a normal climb, the reporter voicing criticism
towards management's indictment of controller's performance.
ACN: 968299
Time / Day
Date : 201109
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use : Vectors
Component
Aircraft Component : Aircraft Auto Temperature System
Person
Reference : 1

Events
Assessments
Narrative: 1
On climb-out, aircraft was vectored off the SID and given a 350 heading and a
climb to FL350. The heading and altitude were set in the FCU and verified on the
FMA by the Captain and First Officer. This heading closely paralleled the SID. Later,
during the climb, it was noted that the air conditioning system was sending below
freezing air to the cabin. As the Captain worked the problem, and the new First
Officer helped and accomplished his other duties, the aircraft somehow reverted to
the navigation mode. This resulted in a turn to the right. The crew and ATC noticed
the turn at about 010 degrees and an immediate correction was made. This aircraft
was dispatched with two MEL's on the air conditioning system. Somehow the
combination made temperature control problematic and the distraction contributed
to the delayed recognition of the turn. While I am still not sure why the aircraft
reverted to the NAV mode, it should have been recognized sooner. I needed to
remember the cardinal rule of one pilot flying the aircraft exclusively and the other
working the problem. Secondarily, the compound MEL's led to a distraction during a
busy phase of flight. This contributed to the delayed recognition. These MEL's had
existed for three and seven days each and the aircraft had transited Maintenance
stations multiple times. Although legal, MEL's that could cause distractions should
be repaired in a timelier manner.
Synopsis
An A330 crew was distracted while dealing with an air conditioning system
malfunction. There was a track deviation after the FMGC reverted from a heading
mode to the NAV mode.
ACN: 966231
Time / Day
Date : 201108
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Component : 1
Aircraft Component : Pneumatic System - Indicating and Warning
Component : 2
Aircraft Component : Pneumatic Valve/Bleed Valve
Manufacturer : Rolls Royce Trent
Person : 1
Reference : 1

Person : 2
Reference : 2
Function.Maintenance : Other / Unknown
Person : 3
Reference : 3
Function.Maintenance : Other / Unknown
Person : 4
Reference : 4
Person : 5
Reference : 5
Events
Assessments
Human Factors
Manuals
Procedure
Aircraft
Narrative: 1
While troubleshooting inbound write-up, we were advised to defer item by
Maintenance Control per MEL/AMM (Aircraft Maintenance Manual) and proceeded to
"lock-out" the high pressure (HP) valve. After opening the left inboard cowl, we
then locked-out the HP valve per the maintenance manual and MEL procedures.
There were two supervisors and two mechanics, as well as myself, observing the
operation. My position while observing the procedure was from behind Mechanic Y,
who was doing the valve lock-out. The position of the valve was the most aft of the
engine. I could not see the pressure regulating valve (PRV) from my vantage point.
All of us agreed and confirmed the lockout procedure and visually checked the
valve to make sure of the proper valve position via the position indicator as well as
the correct valve was locked-out, verified by maintenance manual task 36-11-00040.
If the incorrect valve had been locked-out, there would have been no air from the
#2 engine and no bleed air indication on the ECAM air page. The aircraft would
have [had] to taxi back to the gate, as well as [had] an ECAM warning message.
A hard copy was printed of the Aircraft Condition Monitoring System (ACMS) real
time cruise performance report from the date, time, and flight after valve lockout.
The correct valve position, status, and operation was confirmed in the Description
of Parameter page in the AMM.
Maintenance Control notified that the incorrect valve had been locked-out. There is
no possible way the incorrect valve had been locked-out by ZZZ Maintenance.
There was no maintenance performed on the PRV by ZZZ station that night; only
the HP valve. [This was the] other station's troubleshooting problem.
Narrative: 2
Maintenance was deferred on #2 engine high pressure valve (HPV) due to inbound
write-up that mentioned, at engine start (idle power) and after landing (idle), the
HPV didn't open with ECAM message. I was onboard to verify the message, which
didn't show on engine warning display (EWD). Performed bleed air monitoring
computer (BMC) bite test [and] found a class-3 message. Performed #2 engine run
by flight crew and confirmed the HPV stayed closed and bleed air was supplied by
8th stage with 36 PSI [pneumatic pressure] downstream of pressure regulating
valve (PRV). Maintenance decided to defer #2 HPV after resetting FADEC and BMC
without success. Per MEL 36-11-7b maintenance procedure, needed to lock-out the
HPV per aircraft maintenance manual (AMM) 36-11-00. [The] jobs were performed
by Mechanics X, Y, and Z.
Maintenance Control informed, and computer "discrepancy histories" indicates, that
ZZZ1 Maintenance team found HPV wasn't locked-out. Instead, they found PRV was
locked-out in "closed" position with lock pin sheared. If it was true (by locking out
PRV), the bleed page in system display (S/D) shouldn't have had any pressure
downstream of the PRV indicator (neither 8th nor 14th stage). I believe the flight
crew would not accept an engine with no bleed air.
Also, there were many [flight] legs flown after the valve was locked-out. Why
[would] no one complain about not [having] air from the #2 engine? Besides, 2nd
Shift Lead Mechanic recalled Aircraft Condition Monitoring System (ACMS) #2
engine report (cruise performance report) on this flight leg and found that PRV
being indicated 1 (one) (open) with HPV being indicated 0 (zero) (close). I am
unable to explain why ZZZ1 team had found this discrepancy, but there is a
possibility that they probably used the wrong AMM that is effective on PrattWhitney PW-4160 engines, in which the PRV is at the 9 [o'clock] position; same
position that the HPV on Rolls Royce Trent 772 engines.
Narrative: 3
There is suspicion that ZZZ Maintenance locked-out the wrong the valve during a
turn in ZZZ. Aircraft arrived at ZZZ with a bleed fault. I was not physically at the
aircraft at first. I heard calls on the radio that the mechanics had reset the right
bleed system and were going to run the engine to confirm if the fault was cleared
or not. My understanding is that during the engine run, Maintenance had confirmed
that the HP valve was not opening and only intermediate air was coming out of
engine. That's when it was decided to use MEL to defer the HP valve and lock-out
the valve.
Maintenance then proceeded to open engine and lock-out valve. Maintenance had a
difficult time in opening the thrust reverser (T/R) cowling. That is when I went out
to the aircraft to see if I could assist in any way. It took us a while to open the T/R
cowling due to #4 latch sticking. Once the cowls were opened, the mechanics
locked-out the HP valve and closed the cowls. I could not confirm which valve was
locked-out, because I could not physically see it. The cowls were then closed and
the aircraft dispatched.
Later during the night, I was talking to a Maintenance Controller and he informed
me that the flight almost came back to the gate. I asked him why and he said that
just prior to takeoff, aircraft had low duct pressure on the right engine. The pilot
was asked to push-up his throttles to see if [pneumatic] pressure increased. He
confirmed that when throttles increased the duct pressure increased. By the flight
crew doing this, it confirms that the aircraft was getting pneumatic pressure from
the right engine. If the PRV was locked-out, the aircraft would not get any
pneumatic pressure from right engine. I would not think that a pilot would take an
aircraft with only one engine providing pneumatic pressure during flight.
Synopsis
Three Line Mechanics and two Line Maintenance supervisors report about the
troubleshooting, locking-out, and deferral of the High Pressure Valve (HPV) on #2
engine of an A330 aircraft. Downline Maintenance Station had reported the wrong
valve was locked-out. Questions were raised whether Downline Maintenance had
used a Pratt & Whitney manual instead of Rolls Royce Trent 770 engine manual.
ACN: 965855
Time / Day
Date : 201108
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Checklists
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
Enroute after returning from break, I found out that the Quick Reference
Handbooks were not in their normal location. We conducted a thorough search and
did not find them. We wrote up the missing QRH's in the Logbook. I will work
harder in the future to manage distractions that caused me to miss this item. I
became distracted by other preflight duties and cabin concerns. We conducted a
thorough preflight of the documents and manuals in the cockpit but missed the
QRH's. I will make sure in the future not to omit this item, and make sure it does
not happen again. Jet Librarians should remove manuals only after verifying the
new manuals are on board.
Narrative: 2
While in cruise flight midway on the North Atlantic Tracks the Captain (pilot not
flying) asked me (pilot flying) to see the Quick Reference Handbook (QRH) on my
side. I discovered it was not in its assigned slot. The Captain stated the QRH on his
side was also not in its assigned slot. We thoroughly searched the cockpit and were
unable to find the QRH's on board. This handbook is required for flight and our crew
would not have departed had we realized the ship's QRH was not on board. Both
the Captain and other First Officer did have the QRH available to them on their
laptops. Reference to the QRH was not needed on this flight. The flight continued to
an uneventful landing and we wrote up the missing QRH's in the ship's logbook.
Narrative: 3
Enroute, I noticed that the QRH was missing from my side of the cockpit. I asked
the copilot if a QRH was on his side. He said no. QRH could not be located
anywhere in the cockpit. In 27 years of flying this sort of thing has never happened
to me. I will from now on be far more diligent in my preflight process. Every other
manual was checked by all 3 pilots, up to and including airworthiness and insurance
certificates due to a recent bulletin, as we had discussion about this during
preflight, but somehow the QRH's were missed. I have never not seen the QRH's in
their storage slot, but I will be far more thorough in checking all required
documents and manuals in the future.
Synopsis
A330 flight crew reports discovering enroute that the QRH's normally stored on the
aircraft are missing. Copies of the QRH are available on personal laptop computers
but are not needed on this flight.
ACN: 965553
Time / Day
Date : 201107
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Rudder Pedal
Person
Reference : 1

Events
Result.General : Release Refused / Aircraft Not Accepted
Assessments
:
:
:
:
Aircraft
Human Factors
MEL
Procedure
Narrative: 1
During briefing with the flightcrew we discussed MEL concerning First Officer rudder
pedal adjustment. During briefing with the Dispatcher and Maintenance Control we
asked questions about the MEL and its wording/our responsibilities. We were ALL
under the impression that the rudder pedals were fixed in position, no adjustment
possible. Since all three pilots that might occupy that seat during the flight are
different in stature, we voiced our concerns. The Dispatcher told Maintenance
Control that we should have it fixed...and Maintenance Control told us how 'long'
that would delay the flight, as in...'You're refusing to take the aircraft!'...their
verbiage. When we arrived at the aircraft we quickly discovered that the rudder
pedals could be adjusted. The actuator was broken so that the rudder pedals would
not return to the zero position automatically, but had to be pulled back by inserting
your toes under the pedals and pulling after the adjustment handle was pulled out.
The Mechanic showed us that the rudder pedals in fact could be adjusted in any
position, but if you exceed an operating range for your comfort and height
adjustment; you would therefore, need to manually pull them back with your toes.
The Mechanic allowed the First Officer to sit in the seat to familiarize myself with
the "new discovery" which was not the MEL that originally discussed with the
Dispatcher during our briefing. When he pulled the release handle and pushed
forward, the rudder pedals "slammed" to the floor stop. The Mechanic made a
remark that essentially made me look like an idiot and said that there is "no
actuator" so you don't have to push like you normally does. I said..."that's the first
time that I was told there was "no actuator" since the original MEL applied did not
accurately describe the condition (IE. fixed position). The First Officer left the seat
and Mechanic took his place, wiggling the pedals and returning them to another
position. 1. Very few pilots fly with the rudder pedals full forward because of their
height. 2. The pedals were stuck full forward, requiring numerous opposite pedal
movement to correct. 3. As far as the Dispatcher and Maintenance Control
Supervisor were concerned, our MEL wasn't as expected. 4. If the pedals became
stuck again, and we had to fly the aircraft single engine from the right seat, serious
problems could arise. 5. Maintenance Control said the fix for the actuator was at
this airport but could take 4 to 5 hours. Therefore, it was requested that the "new
discovery" be fixed by replacing the actuator. It was done in 2 hours I believe,

thanks to the two mechanics that quickly got to work.
Synopsis
An A330 First Officer's fore and aft rudder pedal adjustment actuator failed and so
prior to flight had to be repaired over the objections of Maintenance Control.
ACN: 959189
Time / Day
Date : 201107
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Person
Reference : 1
Events

Assessments
Narrative: 1
We had an erroneous TCAS ECAM earlier in cruise flight (over Greenland) on ETOPS
flight. Descending on approach at 6,000, we got a TCAS TA for traffic below at -400
FT, but then noticed the target in question "jumping around" between 2 o'clock 5
miles to 10 miles, and back "under" us again and again. ATC reported no traffic
around our location. Then we got an RA, First Officer disconnected autopilot,
climbed to get descent rate out of the "red" zone per procedure. We then got "clear
of conflict" and proceeded on to land. All three of us thought that this RA was an
erroneous alert, given the earlier event in cruise and the jumping around of the
target on the TA and RA event. In any case, SOP's were followed, landed normally,
we wrote up the TCAS on arrival.
Synopsis
A330 Captain reports TCAS TA then RA during descent for approach. A previous
false alert and the current target's rapid movement suggest a malfunction. No
traffic is reported by ATC. The RA is complied with regardless by decreasing
descent rate. A "clear of conflict" is annunciated and flight continues to landing.
ACN: 958066
Time / Day
Date : 201107
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Person
Reference : 1
Events

Result.Flight Crew : FLC complied w / Automation / Advisory
Assessments
Narrative: 1
At cruise an ECAM warning was observed "HYD B Lo Level". The ECAM procedure
was completed that included turning off the left engine driven Blue hydraulic pump
and the Blue system electric hydraulic pump. It was also noted that the Blue
system quantity was at or near zero. Dispatch and Maintenance was notified and
after some time the decision was made to continue to our destination. The flight
continued and landed without further problems. On the ground, maintenance
personnel reported that the wheel well area showed signs of hydraulic fluid leaks.
Synopsis
An A330's ECAM alerted HYD B LO LEVEL so the crew complied the ECAM checklist,
secured the Blue hydraulic system and continued to their planned destination.
ACN: 957788
Time / Day
Date : 201107
Place
Environment
Weather Elements / Visibility : Turbulence
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Person
Reference : 1
Events
Assessments
Narrative: 1
At FL370 on NAT track we experienced significant wake turbulence from an aircraft
that was 1,000 FT above and 13 NM ahead on the same track headed in the same
direction. We contacted the other aircraft and asked him to offset to the right so
that we could return to centerline (we were offset 2 NM right) and get out of the
wake turbulence (winds were a quartering left tailwind and we were trying to get
upwind of him). We could not descend as there was another aircraft 1,000 FT below
us in close proximity. I suggested a left offset and after some discussion the other
First Officer agreed. We then offset 2 NM left of centerline (that put us out of the
turbulence) until we passed the higher flight and returned to centerline. We then
offset 2 NM right of course and continued to our destination. Right offset is
standard and we should have coordinated with Gander for a left 2 NM offset.
Synopsis
An A330 First Officer reported encountering wake turbulence in cruise from another
aircraft on the same NAT track routing.
ACN: 954372
Time / Day
Date : 201106
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Powerplant Lubrication System
Person
Reference : 1
Events
Assessments

Narrative: 1
Enroute engine number 1 (one) displayed low engine oil quantity. We contacted
Company Dispatcher and Maintenance Control and then made a precautionary
landing at an enroute station, under declared emergency. The landing and taxing to
the ramp was uneventful. The event occurred due to the abnormal low oil quantity
reading.
Synopsis
An A330 engine one displayed a low oil quantity so the Captain made a
precautionary landing at an enroute station for maintenance.
ACN: 952640
Time / Day
Date : 201106
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Component
Aircraft Component : Generator Drive Indicators and Warning System
Person
Reference : 1
Events
Assessments

Narrative: 1
Enroute to the NAT tracks, the number one IDG temperature increased to 212
degrees CELSIUS, even though it was disconnected by Maintenance on the ground
prior to pushback and was on MEL. This high temperature became a safety issue,
so the flight diverted. Prior to approach, I declared an emergency, then landed and
taxied to the gate without further incident.
Synopsis
An eastbound transatlantic A330 suffered elevated temperatures on the left IDG
that were incompatible with its disconnected and deferred maintenance status. The
flight crew elected to divert prior to coasting out.
ACN: 951378
Time / Day
Date : 201105
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : APU
Person
Reference : 1
Events

Assessments
Narrative: 1
When I arrived at gate, ground power was never made available. I was on the
airplane 20-25 minutes after its arrival and I passed the information onto the
mechanics who boarded after the passengers had deplaned. At some point in time,
even thought the APU was providing air, someone plugged in ground air contrary to
our limitations. Procedures and actual operations are out of alignment. Either
change the policy or provide staffing and train that staff to plug in ground power,
wait for us to turn off APU air, then turn on ground air.
Synopsis
An A330 parked at the gate after arrival with the APU providing electrical and air
also had the ground air connected contrary to aircraft limitations, because no staff
were available or trained to turn the APU OFF and ground electrical ON.
ACN: 951060
Time / Day
Date : 201105
Place
Environment
Light : Dawn
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Rudder Control System
Person
Reference : 1
Events

Assessments
Narrative: 1
Arriving at the aircraft, the incoming crew was waiting on the ramp for the bus we
arrived in. We spoke to the Captain and one of the First Officer. They told us of the
MEL (27-25-02) which was on the aircraft. They stated they had received the
warning associated with the discrepancy on final. In hindsight, this should have
been written up as the requirement of the MEL: "Condition A May be inoperative
provided before each flight, and for each inoperative caution, rudder deflection is
checked operative using only the servo control associated with each inoperative
caution." [This] cannot be complied with in such a case. Additionally, this MEL is as
setup for serious unintended consequences. We performed the required check at
the gate before leaving. I really felt uncomfortable with this MEL because of the
seriousness of the rudder jamming in flight with no recourse. Upon taxi out, we
were just going straight on the taxiway and the warning occurred. So, we
performed the check. When you turn off the Green and Yellow Hydraulic Systems to
check the B, you get a number of bells and chimes; the aircraft goes into Alternate
Law. After restoring the systems everything appeared to return to normal. Being
uncomfortable, we returned to the gate only to be told by Maintenance Control the
condition was as expect there was only a bad switch, etc. This is an unacceptable
MEL because the crew cannot comply with the "Condition A" requirement in flight
as happened to the crew of another aircraft. Also, putting the aircraft in Alternate
Law by de-powering the other two systems is, at least, a bad idea as it quite
possibly could have unintended consequences. Additionally, there is no specific
guidance on which exact switches to utilize to properly de-power the hydraulic
systems could easily have been a problem. We were fortunate to have a check
airman on the International Reserve Officer seat so that was less challenging. By
the way, this was something like the eleventh day of the MEL! So, probably twenty
something crews took it across the ocean, including us!
Synopsis
First Officer reported an A330-300 Rudder Servo was MEL'ed, but a malfunction in
flight would require turning off the Yellow and Green Hydraulic Systems which
would put the aircraft in Alternate Law with potential unintended consequences.
ACN: 950579
Time / Day
Date : 201105
Place
Aircraft
Reference : X
Component
Aircraft Component : Fuel System
Person
Reference : 1
Events
Assessments
Primary Problem : Manuals
Narrative: 1
Aircraft had MEL 28-42-01C. Our Dispatcher interpreted the MEL that the outer
tank fuel was usable due to the in flight portion of an operations bulletin which
outlined a procedure to regain outer tank fuel. I thought the information in the MEL
section F and the operation procedures 2a overrode the procedure. I believed we
could not include outer tank fuel as usable for purposes of dispatch fuel
requirements. We took off cargo and added the amount of fuel in the outer tanks
which I believed to be unusable, so that the flight would be accomplished without
need for the outer tank fuel. For our re release another Dispatcher released us with
a min fuel load which allowed for unusable fuel in the outer tanks, as though he
read the MEL as I did. The MEL's intent in explaining the procedure to regain outer
tank fuel is not clear as to the reason it is where it is and why. Make the reason for
the procedure to regain fuel clear, and unambiguous in its relationship to the
requirement that the outer tank fuel is unusable. Beyond the performance
degradation in the preflight section, make it clear there are dispatch fuel
compensations for the unusable outer tank fuel.
Synopsis
A330 Captain reports being dispatched with MEL 28-42-01 for inoperative fuel
quantity indications on the ECAM fuel page. This MEL requires outer tank fuel to be
considered unusable but the Dispatcher does not see it that way, citing a company
procedure that allows the fuel to be used. The Captain prevails.
ACN: 948597
Time / Day
Date : 201105
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Engine Pressure Ratio Indicat
Aircraft Reference : Z
Person
Reference : 1
Events

Assessments
Narrative: 1
While in Cruise FL310 just ECAM MESSAGE: AUTO FLT A/T OFF, ENG 2 EPR MODE
FAULT, N1 DEGRADED MODE, DO NOT EXCEED N1 LIMIT. MAN THRUST ADJ.
Captain assigned flying duties to First Officer and performed ECAM actions. We
contacted the Dispatcher and Maintenance Control and were advised to return to
field. We descended to 14,000 FT to burn as much fuel as possible before arrival at
our departure airport. Due to split thrust lever position and since it was day VFR we
decided to land overweight as a precautionary measure and declared an emergency
with equipment for the overweight landing. The landing was made with less than
300 FT/min sink rate and uneventful. Loss of some probes in both engines was
reported to us by Maintenance.
Synopsis
An A330 ECAM alerted AUTO FLT A/T OFF, ENG 2 EPR MODE FAULT, N1 DEGRADED
MODE, DO NOT EXCEED N1 LIMIT, MAN THRUST ADJ. The aircraft was returned to
the departure airport where EPR probes on both engines were found failed.
ACN: 944285
Time / Day
Date : 201104
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component
Aircraft Component : Nozzle
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Person : 5
Reference : 5

Events
Assessments
Aircraft
Company Policy
Environment - Non Weather Related
Human Factors
Incorrect / Not Installed / Unavailable Part
Manuals
Procedure
Narrative: 1
I, along with several other mechanics were assigned to an A330 aircraft to replace
the Common Nozzle Assembly (CNA) on the right engine. First shift started the
removal of the nozzle. We completed the removal at the beginning of our shift.
Since this was the first CNA removal here in ZZZ, most of the mechanics in the
hangar that day, a Maintenance Supervisor and a Maintenance Manager came over
to the aircraft to observe the replacement. We positioned the cradle to the CNA and
using a forklift removed the CNA. The proper lifting dolly called for in the Aircraft
Maintenance Manual (AMM) was not made available by the company.
The fork lift driver placed the removed CNA near the new one. We then installed
the lifting fixture to the removed CNA to remove it from the transport dolly. This
was done after much discussion since we had never seen or used this tooling
before. Several people not working the aircraft came over to watch/comment on
the lifting fixture operation. The lifting fixture was then placed on the new CNA to
remove it out of the container. At this time the overhead crane being used became
entangled in the safety ropes hanging from the ceiling. This diverted our attention
from the new CNA for a brief period of time until the ropes were freed.
The new CNA was then placed into the transport cradle and was positioned near the
right engine using the forklift. Using the forklift to raise the CNA cradle assembly
took much attention due to the close proximity of the forklift to the engine C-Duct.
While raising the new CNA to align the alignment pins, much input was given by all
the people watching the installation as to how best to align the nozzle. This was in
addition to the mechanics actually doing the installation. The CNA was installed
after some difficulty due to having to position the forklift/transport cradle perfectly
to align the pins and took longer than we expected. The aircraft was on a scheduled
release and was due to fly a revenue flight that evening.
Narrative: 2
Second shift. I, along with several other mechanics were tasked with an A330 right
engine CNA replacement due to damage. First Shift started the job, they pulled the
required paperwork and ordered the tooling required, and started removal. When
our [second] shift started, we attached the holding cradle, secured the holding
straps and using a forklift removed the [damaged] CNA contained in the holding
cradle. I positioned the nozzle to a staging area near the new serviceable CNA and
access to the overhead crane. Using the overhead crane and the nozzle rotating
fixture tool, we attached the [fixture] to the damaged nozzle and removed it from
the holding cradle and rotated 90-degrees and set it in temporary holding on the
hangar floor; (nozzle opening facing down).
We then removed the rotating fixture and attached it to the new serviceable nozzle
in its storage container. Also facing 90-degrees front-end down. We removed the
nozzle from the [storage] crate, inspected and installed the [serviceable nozzle]
into the empty holding cradle and secured with straps. Using the forklift to lift the
holding cradle and nozzle assembly, we installed it to the rear of number 2 engine
and torqued per AMM.
Reviewing the Remove and Replace (R/R) procedures, there was communication
about making sure that the FADEC rating was properly set to match this nozzle
assembly. Two mechanics were tasked and accomplished [FADEC rating
verification] satisfactorily. We paid a lot of attention to the unique way these tools
worked as to not cause any further damage or delay. This job was accomplished by
several mechanics and this was the first time these tools were used in ZZZ.
All discussions with all mechanics during this task did not bring up transferring the
nozzle liner. We inadvertently failed to change over the [nozzle Liner] part. After
completing this job as the senior Mechanic involved in the work and talking with my
coworkers, we were satisfied the repair was completed satisfactorily and I signedoff the discrepancy in the logbook. Overseas, four days later, [the CNA nozzle liner
was reported not installed].
Narrative: 4
This was a first time change in ZZZ. Due to 'no' tool instructions- printout, a
particular amount of time was involved with figuring out the CNA sling set-up.
Correctly installing the attach point hardware was yet another [problem] to figure
out with no reference or tool indication. We are not Engineers. With a multitude of
'chefs' involved, so were the ideas.
Much time was spent on forklift positioning and repositioning. Eight to eleven
mechanics, a Supervisor and a Shift Manager were involved out of curiosity, as this
was the only aircraft in the hangar and this job was never performed here, while no
'one' Mechanic stood out. Before complete separation of the CNA, the aircraft was
pulled forward to allow Turbine Cone clearance due to the limited side to side
forklift movement of incomplete tooling. No biggy, yet another creation of

distraction. Then more multi-ideas were spent packaging the [removed] damaged
CNA into shipping crate. I only read portions of the AMM that were directly involved
with my task. It seems now, maybe too many mechanics, 'chefs', were involved
and inadvertently the required part was not changed over as required.
Narrative: 5
An A330 aircraft was received in the hangar due to the right engine having tail pipe
damage. Removal was started by first shift and completed on second shift. I, along
with a team of mechanics, was assigned to complete this task. We removed the
CNA with the cradle and forklift. The damaged nozzle was removed from the cradle
and set aside, aft end up, with required tools and overhead crane.
At this point the tooling was switched to the new nozzle and new nozzle was
removed from the shipping container and installed in the positioning cradle and
positioned behind the engine. The cradle was picked up with the forklift and
installed on the engine. At this time we attempted to pick-up the [removed]
damaged nozzle with the overhead crane and install it in the shipping container.
While repositioning the crane, it became entangled with the safety ropes suspended
from the top of the hangar making it unusable. With the help of additional
mechanics, the damaged nozzle was picked up and placed in the shipping
container, aft end still up. At this point it should be noted that the forward surface
of the nozzle was never able to be viewed and it was our understanding the nozzle
was received in a ready for installation condition.
Synopsis
Five mechanics report about removing a damaged Common Nozzle Assembly (CNA)
from the right engine of an A330 aircraft for the first time and installing a new
serviceable CNA. Lack of a proper lifting dolly called for in the Maintenance Manual
(M/M), no tool instructions or print-outs, no training and assumptions contributed
to the primary nozzle not being transferred over to the new installed CNA nozzle
assembly.
ACN: 943863
Time / Day
Date : 201104
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Maintenance Status.Required / Correct Doc On Board : N
Component : 1
Aircraft Component : Engine Air Anti-Ice
Component : 2
Aircraft Component : Engine Starting System
Component : 3
Aircraft Component : Engine Air Pneumatic Ducting
Person
Reference : 1
Events
Assessments
Primary Problem : Chart Or Publication
Narrative: 1
April 2011, I was involved with installing the right engine on an A330 aircraft. I was
working with another Mechanic on installing parts that were on the table that
needed to be installed on the [new] engine. There was a long duct assy with a start
valve installed on it and a anti-ice valve and duct that needed to go on the engine.
So I helped installed both on the engine. The next day, the Lead [Mechanic] was
going over the paperwork and said that a shop work order was not signed-off. So I
told the Lead I was there and helped do the work and would sign it off. Then I went
out to the aircraft and did the operations and leak checks on both valves per the
Maintenance Manual (M/M), all checked "good."
Then two days later, I found out that the parts (duct assembly and start valve and
anti-ice valve) were removed from the old engine and no one had robbed
paperwork, or a Maintenance reporting form made out for the parts [removed].
Myself and the other Mechanic [were told] that the parts on the table were robbed
from the old engine. We were told at the shift turnover, that they [the previous
shift] had robbed parts needed to be installed on the engine going on.
Working on this engine change, our company, Air Carrier X, did not have any
jobcards for an engine change on the A330, so we were working from the
Maintenance Manual (M/M) only. Note: On the little Airbus [A320/319], the jobcard
for an engine change does callout for you to remove the anti-ice valve and reinstall
it on the new engine going on [the aircraft], without doing a rob paperwork
[procedure]. I believe that whoever removed the duct assembly with the start valve
and anti-ice valve and duct, may have been thinking the same for the [engine
removed from the] A330. But without any jobcard to work off of, myself and any
other Mechanic would not have known this.
I was told that the paperwork was being looked over and that someone noted that
the start valve and duct assembly and anti-ice valve may have been removed from
the old engine and did not have the paperwork. This was the first engine change.
Supervisor was able to get ahold of Maintenance Planning and have the part and
Serial Number (S/N) [assigned to] the new right engine assembly.
I believe that if the company would have had a jobcard for the engine change, that
outlines the work for the start valve and the anti-ice valve and duct to be removed
and reinstalled on the new engine, like the little Airbus engine change, there would
not have been an event.
Synopsis
A Mechanic reports involvement with a right engine change on an A330 aircraft
without an engine change jobcard being available, and paperwork not being
accomplished before the aircraft was released for service.
ACN: 942565
Time / Day
Date : 201104
Place
Environment
Light : Dusk
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Problem : Failed
Person
Reference : 1
Events

Result.Flight Crew : Inflight Shutdown
Result.Aircraft : Aircraft Damaged
Assessments
Narrative: 1
Normal takeoff from runway RNAV SID departure; we were at 8,000 and cleared to
14,000 FT 250 KTS. While starting our climb to 14,000 we were passing 9,800 we
heard a loud explosion with a yaw to the right followed by Master Warning and
Master Caution lights. I noticed the #2 engine EGT was red lined and the engine
had failed. We declared an emergency with Departure and told them we had an
engine failure and needed to return to the airport and wanted to land on the center
runway and to have equipment standing by.
We did the ECAM procedures and QRH. The Relief Pilot did a great job with the
passengers and the company and the Flight Attendant's as after the engine failed
the cabin was reported to have smoke in it and the Flight Attendant's were
concerned. We were able to clear the smoke quickly and ran all check lists and did
an over weight landing with a full stop on the runway for inspection or the tires and
for fire. The Flight Attendant's were briefed to expect a normal landing.
Synopsis
An A330 flight crew declared and emergency and returned to their departure
airport following the failure of the right engine.
ACN: 942084
Time / Day
Date : 201104
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Flight Dynamics Navigation and Safety
Problem : Failed
Person
Reference : 1
Events

Assessments
Narrative: 1
[We were] in cruise conditions at FL370, approximately 1 hour after takeoff,
discovered Integrated Standby Instrument System (ISIS) instrument blank with a
displayed message on its face: "DO NOT USE". No other malfunctions present:
electrical, ADR's (Air Data Reference) or pitot/static. Reset Breakers all OK, no
Circuit Breakers ECAM displayed open, no ECAM, memos or messages present. No
abnormal guidance was available or known to us on the flight deck to rectify this inflight loss of the ISIS. [We] could not find any applicable QRH procedure [and]
could not locate in MEL for reference information either. The ISIS was positively
operational climbing through FL180, because I observed both pilot not flying and
pilot flying perform the 18,000 FT flow requiring setting STD. I feel the ISIS had
just failed when we noticed it because all 3 flight crew members discovered it
inoperative simultaneously. The Captain established SATCOM voice with Dispatch
and Maintenance. Maintenance was at a loss for cause and indicated no receipt of
datalink messages regarding ISIS failure. There was little or no guidance from
Dispatch or Maintenance on options for dealing with this situation pertaining to
continuing operations, turn back and landing or ETOPS capability. The flight crew
felt it was required equipment since it was not in the MEL and also most likely
required in-flight for continuing operations and entering ETOPS/Long Range
Navigation conditions. Reluctant to continue long range operations with this
degraded condition, we considered the prospects of a turn back/diversion and
landing. This would most likely itself involve more than one hour of flight time
and/or hours of fuel burn-off to maximum landing weight in this degraded
condition. If we diverted/returned to field we wanted to have the ISIS back. If we
continued, we had to have the ISIS back. Flight conditions were black night, on
top, perhaps higher cirrus, no visible horizon. Due to our training, we considered an
operable ISIS fundamental in the recovery of any potential unreliable airspeed
abnormal. The only method Maintenance was aware to regain the ISIS was by an
Electronic and Equipment Compartment (EE) Circuit Breaker (C/B) reset. We
consulted and received Dispatch and Maintenance direction and authorization via
SATCOM voice and ACARS to attempt a C/B reset in the EE compartment. "PER MX
OKAY TO ATTEMPT RESET PANEL H5 742VU D64 ALSO K66 DISPATCH XA:59 END."
With the Captain's permission, I as the Relief Pilot gained access to the EE area.
The three approved C/B's were found in the "IN" position. Per Maintenance
direction I pulled all 3 C/B's and left them open for approximately 30 seconds. I
then reset all 3 in the same order to the "IN" position. Upon returning to the flight
deck, the ISIS was observed doing a self test, and then it regained full complete
operation/display. We advised Maintenance and Dispatch and maintained our
progress to the Oceanic Entry Point. We monitored the ISIS, continued normal
operation and felt it was now prudent to continue with no further problem.
Maintenance and Dispatch concurred. We experienced no further ISIS difficulty on
the flight. An early alert "Info only Item" describing the ISIS failure, C/B reset and
recovery was entered in the logbook. Engineer meeting the flight was briefed by
the Captain regarding the write up.
Synopsis
An A330 ISIS displayed the message DO NOT USE with the attitude, airspeed,
altitude, magnetic heading, and glide slope missing. The crew reset the applicable
circuit breakers in the EE compartment to successfully restore the ISIS.
ACN: 941441
Time / Day
Date : 201103
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Component : 1
Component : 2
Aircraft Component : Emergency Equipment
Person
Reference : 1

Events
Assessments
Aircraft
Company Policy
Human Factors
Procedure
Narrative: 1
An A330 aircraft came out of heavy check I believe March 2011. I accomplished a
routine check on the aircraft two days later. [Jobcard] has you check door assist
bottle pressure. To do this, I opened the door just enough to look down at the
gage. When checking it this way the firing mechanism is not exposed. [On] the
next routine check [two days later], the safety pins were found in some of the door
assist firing mechanisms. They were believed to have been installed at the heavy
check.
The event occurred because maintenance personnel from the heavy check did not
remove the pins as required. Once the [bottle] safety pins were found, the pins
were removed. Suggest [having] a sign-off for removing the pins at a heavy check,
if there isn't one already. On the routine check, put verbiage in to check the
[bottle] firing mechanism along with the [bottle] pressure.
Synopsis
A Line Mechanic reported an A330 aircraft that had come out of a heavy check with
the door emergency assist bottle safety pins still installed on some of the passenger
cabin doors. The aircraft had been flying for three days.
ACN: 939780
Time / Day
Date : 201103
Place
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Ground : ZZZ
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Events
Assessments
Procedure
Weather
Airport
Human Factors
Narrative: 1
On the flight deck at the gate Captain, First Officer, Relief Pilot present. I received
the ATIS and communicated to the crew out loud "Runway XXL in use." I DID NOT
SAY "that is the shorter runway." My concern was big, heavy airplane using the
shorter of the two runways. Off the gate and after engine start I reviewed the
weight and balance and communicated out loud to the crew "APU BLEED ON, TOGA
takeoff." I DID NOT SAY "We are using every single foot of this runway for takeoff."
My concern was big, heavy airplane using the shorter runway and to be legal we
need every LB of thrust from the engines because it is a TOGA takeoff and we are
using the APU to power pressurization and air conditioning so that we have more
engine thrust. No response from the crew. No concern expressed by the crew. We
are number 3 for takeoff. Just at that moment the Tower announces the wind as
250/11. I communicate to the crew "wind is 250/11, I DO NOT THINK WE ARE
LEGAL FOR THIS runway" I clearly and with clarity voiced a safety concern to the
crew. No response from the Relief Pilot and the Captain blew me off. The Captain
expressed no concern. The Captain had no interest in spending any time
investigating how a 10 to 11 KT tailwind affected the takeoff. The Captain said,
"Let's just go". My guts were telling me we were not legal for this takeoff. I was
completely handcuffed by a non responsive crew and a Captain that was oblivious
to the performance problem, a Captain that ignored basic CRM procedures, a
Captain that ignored the "capturing of errors model." In cruise I discussed with the
Relief Pilot the takeoff. We reviewed the weight and balance form and the TPS and
concluded that we were illegal for the takeoff. The weight and balance was
predicated on NO tailwind and it was an "IMPROVED PERFORMANCE TO" The TPS
showed that NO tailwind is allowed for a takeoff on 09L using an "IMPROVED
PERFORMANCE TO" The data was later given to the Captain.
A Captain that is unconcerned with safety. A Captain that is unconcerned with CRM.
A Relief Pilot that is not engaged as a crew member during a critical phase of flight.
A First Officer that did not stop the flight until the problem was solved to the
satisfaction of the entire crew. Load Control sent a weight and balance that did not
accurately reflect the actual wind condition. ATC did not turn the airport around
when the wind favored the west runways. Dispatch for not making the Captain
aware of the critical runway condition during the phone briefing.
[We need] further training for the Captain in areas of weight and balance, TPS,
CRM, Safety, Trapping errors, further training for the Relief Pilot in crew member
duties, weight and balance, TPS, CRM, Safety, further training for the First Officer
regarding CRM; further training for load control regarding meteorology and how
that affects safety, and further training for Dispatch regarding the interface
between ATC and meteorology and how that affects safety.
Synopsis
A330 First Officer describes a maximum performance takeoff and his inability to
convince the other crew members that they are not legal for takeoff due to
excessive tailwind.
ACN: 938196
Time / Day
Date : 201103
Place
Locale Reference.Airport : PHL.Airport
State Reference : PA
Aircraft
Reference : X
ATC / Advisory.Tower : PHL
Flight Plan : IFR
Airspace.Class B : PHL
Component
Problem : Design
Person
Reference : 1
Events
Assessments

Narrative: 1
While coupled to the ILS just inside JALTO we received a TA and looked for traffic
at the depicted one O'clock and approximately two miles position BUT saw nothing.
We received a RA a few seconds later and it depicted the target at perhaps a mile
and 400 FT below.
Autopilot and FD were disconnected and we rose above the glide slope to maintain
the RA required vertical speed. The target seemed to follow us and became amber.
No traffic was seen by us and the Tower never advised us of any traffic conflict. It
seemed to be a ghost target as it stayed with us. The only known traffic to us at
the time was an RJ landing on RWY26 in front of us initially by three and one half
miles.
Synopsis
An A330 flight crew on an ILS approach received and complied with an apparently
phantom TCAS TA and RA.
ACN: 932497
Time / Day
Date : 201102
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZZZ
Person : 1
Reference : 1
Person : 2
Reference : 2
Events

Assessments
Narrative: 1
Acrid and irritating fumes in cockpit during climb after takeoff. The operating Flight
Test Crew and Maintenance personnel declared an emergency and followed QRH
procedures.
Narrative: 2
...after takeoff while climbing through 4,000 FT strong fumes in aircraft required us
to don O2 masks, declare an emergency and return to the departure airport.
Procedures were accomplished to help remove fumes. Symptoms included eye and
throat irritations, probably Skydrol fumes.
Synopsis
An A330-300 Flight Test Crew on a post maintenance test flight declared an
emergency and returned to their departure airport when acrid fumes entered the
cockpit during initial climb.
ACN: 927728
Time / Day
Date : 201101
Place
Locale Reference.Airport : IAD.Airport
State Reference : DC
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : PCT
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : IAD
Aircraft : 2
Reference : Y
ATC / Advisory.TRACON : PCT
Make Model Name : Saab 340 Undifferentiated
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : IAD
Person
Reference : 1
Location Of Person.Facility : PCT.TRACON
Events

Assessments
Narrative: 1
I was working all three finals at Dulles combined, having just relieved another
Controller. During the briefing the Controller advised me that a SF34, approaching
the airport from the west, had been "cleared for the visual". I incorrectly assumed
he meant cleared for the visual to 01C, when in fact he had been cleared for the
visual to 01R. Had I checked the scratch pad I would've realized this, or had I
picked up on something he added at the end of the briefing, that 01C was now
open but had been closed and so I could expect several aircraft to be tagged for
01R no matter where they were approaching from. Unfortunately, I didn't realize
the problem and turned the SF34 in for 01R; believing the A330 was heading to
01C. After I had cleared the SF34 for the visual reference the airport I realized the
issue and called traffic to the SF34 in an attempt to gain visual separation. He
eventually sighted the A330, but at this point separation had diminished to below
2.5 miles lateral, I'm not sure what the vertical separation was. Additionally, the
SF34 was significantly faster than the A330 and advised that he was slowing to his
approach speed. I acknowledge his transmission and switched him to the Tower,
but lateral separation continued to diminish, eventually forcing a go-around. This
error was the result of inattention to briefing items on my part and an incomplete
briefing from the Relieved Controller. However, the responsibility must lie with me
to verify the landing runway assignment of all aircraft when assuming control of the
position.
Relieved Controllers should advise specifically of any unusual situations, such as an
aircraft cleared for, an other than, expected runway. Relieving Controllers must
verify all scratch pad data and ask for any clarification if there is doubt about a
particular aircraft's plan.
Synopsis
PCT Controller described a loss of separation event during visual approach
procedures to the Runway 01 complex, noting the failure of a proper relief briefing
and data block observance as causal factors.
ACN: 925969
Time / Day
Date : 201012
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Maintenance Status.Records Complete : Y
Maintenance Status.Required / Correct Doc On Board : Y
Component : 1
Component : 2
Aircraft Component : AC Generator/Alternator
Person
Reference : 1

Events
When Detected.Other
Assessments
Aircraft
Company Policy
Human Factors
Manuals
Procedure
Narrative: 1
Performed inspection on #1 engine IDG Quad Ring [bolt] torque. Re-safetied IDG
Quad Ring bolt. After shift, went home and slept, woke up and realized that I might
have safetied the bolt backwards. Filling out the NASA report and worrying about it
should be enough to not make mistake again.
Callback: 1
Reporter stated his employer, Air Carrier X, is currently contracted to perform oncall and overnight Maintenance for Air Carrier Y, operator of A330s and other types
of aircraft. Apparently the A330s have had problems with the engine IDG Quad
Ring locking bolt becoming loose. Mechanics have been cutting the safety wire and
re-torquing the Quad Ring bolt during overnight Checks, than re-safetying the bolt.
No Inspection of the Quad Ring and bolt safety wire is required.
Reporter stated after returning home and sleeping, he woke up and just had a
feeling he may have safety wired the Quad Ring bolt head backwards. He called the
Maintenance Controller for his carrier, who than contacted Carrier Y. The aircraft
was inspected at a downline station and the safety wire for the # 1 engine Quad
Ring locking bolt was found wired backwards and corrected.
Synopsis
An air carrier Line Maintenance Mechanic reports he had inadvertently safety wired
the #1 engine IDG Quad Ring locking bolt head backwards on an A330 after
checking bolt torque.
ACN: 924325
Time / Day
Date : 201012
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Component
Aircraft Component : Engine Fuel Filter
Person
Reference : 1
Events
Assessments
Narrative: 1
At approximately 2000ft MSL on initial climb out noticed ECAM "ENG 2 FUEL FILTER
CLOGGED". Suspect this ECAM was inhibited until 1500ft/3 min after take off. We
continued clean-up, followed by the appropriate abnormal procedures. Continuing
on our departure routing, immediate contact and coordination was established with
Dispatch and Maintenance via SAT phone. Without hesitation, Dispatch indicated
this ECAM required a return to field and Maintenance concurred. All three pilots and
an A330 qualified FAA Air Carrier Operations Safety Inspector (occupying a flight
deck jump seat) agreed this was the safest and most prudent action to take as
well. Although the abnormal was a lower priority ECAM, we felt the many unknowns
(for example, fuel contamination) and ultimate possibility of engine failure or
degraded performance made a controlled two engine overweight landing a much
safer course of action. As a precaution an emergency was declared with ATC. Our
actual landing weight was 462,560 lbs with a touchdown sink rate of 280 FPS. We
had airport fire equipment follow us to parking after landing in case hot brakes
became an issue. Brakes temps remained normal after landing and the fire
department was advised the aircraft was secure. Per Maintenance the touchdown
parameters did not require an over weight landing inspection.
After maintenance action and underway again I realized I had not put my signature
on the appropriate log white page block. I did sign the remaining pink sheet copy
however. Task saturation and many distractions had occurred. The task loading at
the gate before and after the flight was significant. Sometimes I feel it is almost
over whelming.
Synopsis
An A330 Captain experienced an "ENG 2 FUEL FILTER CLOGGED" ECAM shortly
after takeoff and returned for an overweight landing.
ACN: 921960
Time / Day
Date : 201007
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Component : 1
Aircraft Component : Escape Slide
Component : 2
Person
Reference : 1
Location In Aircraft : Door Area

Events
Assessments
Aircraft
Company Policy
Human Factors
Procedure
Narrative: 1
Worked a scheduled slide change per the Jobcard XXXX; to the best of my
knowledge the job was completed in accordance with this card. The Door Assist
Arm/Disarm lever was found to be safetied in the disarm position. I don't know if
any maintenance had been done to this door since then. The configuration error
was corrected after ZZZ Inspection found it.
Callback: 1
Reporter stated he was working the night shift at an international gate. Door 4-Left
was the location where the Door Emergency Assist Bottle was found safety wired in
the disarm position. Another Mechanic worked with him on the door slide change
and one of their inspectors performed the (Required Inspection Item) RII for the
slide installation. The same Inspector also verified the position of the striker lever
and safety wiring of the knurled screw. He finds it hard to believe that all three of
them would have missed noticing that the position of the Striker lever was
incorrect. The Maintenance Manual is fairly detailed and not an issue.
Reporter stated his carrier did a fleet wide system check and found four other
Airbus aircraft with the Door Emergency Assist Bottle safety wired in the disarm
position.
Synopsis
A Mechanic reports that after he had replaced a door slide on an A330 aircraft, the
Door Assist Arm/Disarm lever was found safetied in the Disarm position by an
Inspector at a downline Maintenance Station.
ACN: 921536
Time / Day
Date : 201011
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Assessments
Narrative: 1
Approximately an hour and a half into the flight we were notified that a gentleman
seated in First Class was having difficulty breathing, showing some signs of
discomfort, and was being attended to by two physicians traveling on the flight.
Blood pressures and vital sign were taken. His BP was 140/90 which, according to
his wife, was normal for him. His pulse, according to the physicians was weak and
they requested he be placed on oxygen which he refused. His wife informed us that
he had a 40 to 50 percent blockage going to one side of his heart, that he was
allergic to penicillin, and that he had nitroglycerin with him. The Doctors on board
had him take the nitro and continued recommending that he use the bottled
oxygen. A call to Medlink was made from the cockpit through our Dispatcher.
Medlink recommended that the gentleman be placed on oxygen for 30 minutes, be
given an aspirin with something sweet to drink, and to continued using
nitroglycerin. Upon my request the gentleman begin using oxygen.
Medlink requested that we report back with them in 30 minutes. After complying
with Medlink, the two physicians and nurse continued their monitoring of patient
who at first appeared to be resting comfortably. Approximately 15 to 20 minutes
after being placed on Oxygen, the Purser notified me that the gentleman appeared
to be breathing very shallowly, was sweating, and had a grayish skin color. The on
board doctors once again sprang into action and recognized the individuals
condition was turning worse. BP was dropping and no pulse could be found. The
AED was used, and cardiac massage immediately commenced. The on board
doctors were recommending an immediate divert. Medlink was once again
contacted and given the updated condition of our passenger. Medlink was told that
the AED unit was used twice and that cardiac massage was be implemented.
Medlink recommended that epinephrine be immediately started and a medical
divert to landing take place. The doctors attempted to start an IV with the
medication recommended by Medlink. It is my understanding that difficulties,
because BP was low and pulse non existent, manifested themselves. Other
procedures were required and used. I was told that our on board physicians felt
that the gentleman had died, but they continued in their resuscitation attempts,
each taking turns. This procedure continued throughout our approach and landing.
As the two physicians, nurse, continued working on the gentleman our flight
attendants continued working at comforting the gentleman's wife and our other
passengers in the immediate area as well as the other cabin areas.
I along with the other pilots as well Dispatch began working on the medical divert
only 160 NMs away. The FMS's were reprogrammed for a flight, descent, and
approach to our divert airport. An overweight landing was going to be made.
Landing distance was determined using full flaps, and overweight landing
procedures as spelled out in the QRH were followed. Medlink, notified the airport of
our medical emergency and had the paramedics and well and medical equipment
standing by. Because our landing was going to be significantly overweight,
emergency fire crews were also called upon to be standing by. The flight attendants
prepared the cabin for quick approach as well as normal landing. Medical attention
continued throughout the approach and landing and up until airport medical crews
arrived. It is my understanding that the airport medical crews continued the
medical resuscitation for 10 to 15 minutes and then determined or confirmed that
our passenger had died. Because the airport physician, who arrived with the
Paramedics, marked our passengers death as unnatural, the airport police as well
as the investigative police became involved. Tensions within the cabin of our
aircraft rose quickly. I explained to a female investigating officer that the doctors,
nurse, as well as any other that attended to the medical care of our passenger did
so under the instructions of Medlink. The medical procedures that were carried out
were those that Medlink had recommended and that no one on my aircraft did
anything outside the parameters of those instructions. If fault was to be found they
would have to contact Medlink.
After approximately 2 hours I was informed by the airport police officer in charge
that everything was OK and our passengers were allowed to deplane. The female
investigating officer politely explained to me that when a passenger dies in flight
that it will normally be reported by their doctor as unnatural. I guess I am to
assume that dying in flight is not natural. She apologized for the inconvenience and
than asked to see the cockpit to which I complied. My crew, both pilots and flight
attendants, performed in an exemplary manner. My First Officer and Relief Pilots
shared the planning work load. They began doing what was needed immediately.
QRH procedures for an overweight landing, clearances, as well as cabin to cockpit
communication were equally shared like a fine precision watch runs. Our
Dispatcher, worked the weather problems on his end making my decisions and
divert easier. My flight attendants kept our passengers content and comfortable
filling on board requests as they were made. All of my crew members acted
compassionately and professionally for which I would like to extend my
thankfulness.
Synopsis
Captain describes the events surrounding a passenger illness and death resulting in
a diversion during an international flight.
ACN: 916744
Time / Day
Date : 201010
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events

Assessments
Narrative: 1
On this flight and several in the past, when operating long oceanic flights the crew
receives significant pressure from the Dispatcher, to take the maximum payload to
the determent of arriving back at the final destination with a safe fuel load. This
flight was no exception. Captain agreed to a fuel load of 178,752 LBS with cargo
already being offloaded as the headwinds were significant that evening with a flilght
time scheduled for over thirteen hours and this particular flight being 44 minutes
over scheduled block time. Typically, the burn is based on an oceanic flight level of
a cruise altitude that is close OR over the maximum allowable for the aircraft based
on the weight at coast out. But, typically, the problem remains: if you DON'T push
the limits on requesting a higher altitude, then because of all the eastbound
oceanic traffic, you get assigned a flight level in the very low thirties (FL310 or
FL320). This possibility and reality on many flights, obviously burns gas at a level
that is significantly higher than what is planned on the flightplan, but also, puts you
into the domestic destination with an uncomfortably low fuel on board (FOB). The
other alternative in this situation is to simply divert to an alternate, but obviously
that isn't in the Company's best interest. History revels that when we first took
delivery of the Airbus' the flight planning program showed the aircraft starting a
descent VERY late in the flightplan, NOT AT ALL reflective of the correct altitudes
assigned by ATC with airspace restrictions. This was reportedly "fixed" a little over
a year ago. Well, apparently someone in Dispatch changed our flightplan, on this
particular flight to reflect FL400 at an initial SID point and FL220 at the next
significant point. The typical altitudes assigned by ATC are FL200 and 14,000
respectively for the same two fixes. Somehow these got changed to REFLECT a
lower burn overall and a higher FOB arrival into the domestic destination. For the
last two hours of the flight, the Dispatcher was insisting that data transmitted to
Dispatch from the aircraft was showing a landing with approximately 14K, when the
FMC was showing (until the last 1,000 FT) a landing with around 12K. Remarkably,
the FMC updated itself in the last 1,000 FT and showed a landing with about 14K.
So, as I see it we have three problems here: 1) Being pressured to accept a fuel
load at our foreign departure airport that unless a flight level for the oceanic
crossing is FL390 or FL400, a divert is certain if you get stuck at an altitude in the
low flight levels. 2) The flight plan (at least in this case) were altered to show an
unrealistic top of descent point (TOD) that, of course, shows a lower overall burn
and is NOT reflective of realistic altitudes assigned by ATC for the restrictive
airspace on the east coast. Lastly, 3) apparently the data uploaded to Dispatch's
computers does NOT agree with the information displayed to the crew on the FMC.
I have no explanation for this phenomena. Very simple explanation: too much
emphasis on taking maximum payload and not enough on uploading enough fuel
that accounts and allows for most contingencies. Consider revisiting the three
points that are raised in this report.
Callback: 1
The Reporter stated that the Captain was fairly new and had not flown this long leg
before and so had been reluctant to take the reporter's recommendations over the
fuel given on the release. The reporter felt that accepting a destination arrival fuel
of 14K was too low given the possibility of a low enroute altitude restriction and
possible destination traffic delays which were typical during bank arrivals at the
destination. This particular flight enters the Atlantic Oceanic Track system very
early in the morning and is head on to the the early morning European Oceanic
arrivals. If the aircraft is not capable of attaining an altitude of FL390 or above then
they will have to remain at an altitude which is not fuel efficient. The reporter did
say that at this point the Air Carrier's Chief Pilot's are not admonishing flight crews
for requesting additional fuel but it appears the dispatchers are the pressure point.
Synopsis
An A330 pilot reported that Dispatch is pressuring pilots to accept an unreasonably
low fuel departure fuel on a very long flight into headwinds, with the potential for a
low Oceanic enroute altitude.
ACN: 907368
Time / Day
Date : 201009
Place
Locale Reference.ATC Facility : ZOB.ARTCC
State Reference : OH
Aircraft
Reference : X
ATC / Advisory.Center : ZOB
Flight Plan : IFR
Mission : Passenger
Route In Use : None
Airspace.Class A : ZOB
Person
Reference : 1
Location Of Person.Facility : ZOB.ARTCC
Events
Assessments
Narrative: 1
Aircraft departed DTW, their route according to the flight plan, was
DTW..DUNKS.J70.GEP..AXN. The requested flight plan was
..DUNKS.J70.ALPHE.J34.BAE.J70.GEP..AXN. The aircraft made an unexpected turn
at ALPLE Intersection to the north on J34 rather than stay on J70. I asked the pilot
if he was making a turn to J34 and he said yes so I told him to go direct PMM and
join J70 to GEP. Recommendation, this has happened many times and could be
dangerous as the planes make a north turn into traffic that they would normally be
clear of. I think that Clearance Delivery at DTW fails to issue the right routing and
just says "as filed" to the pilot. The route part that is incorrect is in blue brackets
on the URET flight plan in the departure proposal but disappears once the flight
departs. The strange thing is the flight plan read out on the RADAR display still
shows this route part where the URET does not, further leading to the confusion. I
would suggest possibly informing the airlines to stop filing this routing to help
things out, and also to stress to Clearance Delivery at DTW to make sure the routes
are right.
Synopsis
ZOB Controller voiced concern regarding unexpected routings resulting from
clearances issued by DTW, noting more attention needs to be given to filed vs.
cleared routings.
ACN: 903847
Time / Day
Date : 201008
Place
Locale Reference.ATC Facility : ZBW.ARTCC
State Reference : NH
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZBW
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZBW
Aircraft : 2
Reference : Y
ATC / Advisory.Center : ZBW
Aircraft Operator : Corporate
Make Model Name : Challenger CL604
Flight Plan : IFR
Route In Use : Direct
Airspace.Class A : ZBW
Person
Reference : 1
Location Of Person.Facility : ZBW.ARTCC
Events

Anomaly.Conflict : Airborne Conflict
Miss Distance.Horizontal : 25519
Miss Distance.Vertical : 700
Assessments
Narrative: 1
A330 was on a vector towards the holding pattern at RKA at FL260 at 250K due to
ZNY not taking any more PHL arrivals. ZNY called to say send PHL traffic on course
they will hold him. A330 cleared to resume normal speed. A330 replied where do
you want me to go. A330 cleared direct DNY speed your discretion expect to hold
with the next controller. A330 was cleared to FL190. A Corporate Jet was
eastbound deviating south of DNY cleared to FL230 direct PETER when able. A330
was told to maintain at least 1,500 FT per minute; A330 read back 600 FT per
minute. Nobody at the sector heard the erroneous read back. As the aircraft were
getting closer, A330 was told to maintain 2,000 FT per minute. Corporate Jet
responded to a TCAS-RA and climbed and was then cleared to FL240. A330 later
said he received a TCAS-RA as well. Recommendation: issue crossing restriction/s
instead of descent rate.
Synopsis
ZBW Controller described a conflict event when an A330 descent rate instruction
was read back incorrectly, but not noted by the reporter, setting the stage for the
loss of separation.
ACN: 901719
Time / Day
Date : 201007
Place
Environment
Work Environment Factor : Temperature - Extreme
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Component : 1
Aircraft Component : Hydraulic System Lines, Connectors, Fittings
Component : 2
Aircraft Component : Gear Extend/Retract Mechanism
Person
Reference : 1
Experience.Maintenance.Avionics : 25
Events
Assessments
Narrative: 1
Hydraulic leak observed by flight crew on preflight walk around. Found leak in right
wheel well on landing gear valve and manifold assembly, leaking o-ring. Replaced
O-ring in Green hydraulic system fitting. Leak checks OK.
Wrenches may have been left on platform in wheel well. There is a large work
platform in the A330 wheel well under the manifold assembly. Wrenches used to
repair problem may have been left on that platform. Aircraft departed before
wrenches were found to be missing.
Synopsis
After repairing an A330 hydraulic leak a Mechanic realized, after the aircraft
departed, that he may have left tools in the wheel well on the aircraft work
platform.
ACN: 898825
Time / Day
Date : 201007
Place
Locale Reference.Airport : LAX.Airport
Aircraft : 1
Reference : Y
Flight Plan : IFR
Aircraft : 2
Reference : X
Make Model Name : Challenger CL600
Flight Plan : IFR
Person
Reference : 1
Location Of Person.Facility : SCT.TRACON
Events
Result.Air Traffic Control : Separated Traffic
Assessments

Narrative: 1
I was working Malibu Departure Sector. Aircraft X was run down by LAX Tower for
departure from SMO. In my rundown list for departure from the LAX North Complex
was Aircraft Y Heavy. Normally LAX sequences SMO departures with the LAX North
Complex departures. In this case both aircraft tagged up within seconds of each
other and separation was lost almost immediately. I recognized the problem and
promptly turned Aircraft X twenty degrees to the right to establish divergence.
Separation was established and both aircraft proceeded without further issue.
Neither aircraft mentioned an issue. Recommendation, further training for LAX
Local controllers. I also believe that a new, safer departure procedure should be
established for SMO.
Synopsis
SCT Controller described a loss of separation event when LAX Tower failed to
provide adequate separation between a SMO and LAX departure.
ACN: 898667
Time / Day
Date : 201007
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Problem : Design
Person
Reference : 1
Events
Result.Aircraft : Automation Overrode Flight Crew
Assessments
Narrative: 1
On take-off roll with "TOGA" (takeoff/go around) thrust selected, take-off reference
speeds did not appear on either PFD. "V" speed callouts were made by the nonflying pilot with reference to the weight/balance printout. Following lift-off and
normal autopilot engagement recognized that commanded pitch and thrust
indications were not normal. Autopilot caused aircraft to pitch up to a point that I
believe would have maintained Vls speed, thrust lever movement to climb appeared
to have to no corresponding immediate thrust reduction. [We] disengaged autopilot
to hand fly proper pitch [and] disconnected autothrust to regain proper thrust for
continued climb to initial level-off altitude, 8,000'. At initial level-off, prior to
achieving proper reduced thrust value, experienced momentary "clean" airspeed
overspeed (250 KTS below 10,000'). ATC asked us to confirm our airspeed; First
Officer responded that it was "250 KTS". After new cruise altitude was selected,
reengaged autopilot and autothrust; all remaining operations completely normal
using fully "managed" and automated configuration. Please note that this situation
occurred following a change of runway assignment. In re-reading A-330 Handbook
bulletin it would appear that this situation should be expected following every
runway change which occurs after original "PERF Takeoff" entries have been made.
In this situation, the "Confirm TO DATA" entry action was not done. Rather, the
First Officer manually entered "V" speeds as if this was an entirely new take-off
iteration. Those re-entered "V" speeds and FLEX thrust values were properly
displayed and confirmed during the subsequent "TAXI" checklist. The First Officer
confirmed that no further entries or changes to the FMC were made after the
"TAXI" checklist was completed. In reading the aforementioned handbook bulletin
in the most verbatim fashion, it would appear that "V" speed information may
continue to be displayed on both PFD's following a runway change but will
disappear "after FLEX or TOGA is selected"...in fact, further guidance on how to
continue the takeoff without the expected "SRS" display is contained in the same
bulletin. I would suggest that trying to remember the contents and corrective
actions contained in a two-year old bulletin while trying to wrestle with a near gross
takeoff weight A-330 at 500' AGL would tend to be nearing the "red" side of most
pilot's comfort and safety levels. Perhaps we should consider demonstrating this
degradation anomaly during future simulator sessions.
Synopsis
An A330 Captain reported that after a runway change prior to departure, the FMS
was not updated although the V Speeds were changed. During takeoff the SRS did
not engage and after liftoff autothrottle and autopilot pitch commands were
erroneous.
ACN: 898267
Time / Day
Date : 201007
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Nacelle/Pylon
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : Logbook Entry

Contributing Factors / Situations : MEL
Narrative: 1
When looking at the Aircraft Maintenance Log (AML) at altitude, I noticed a writeup for holes in the left engine [cowling]. My Relief Pilot confirmed that he had seen
the holes on his walk around and they had yellow paint. I could not find the
paperwork within the logbook on these holes. The logbook page indicated they
would be fixed within 50 hours of flying. On this date it was clear from the log book
pages the aircraft had flown over 50 hours. I had a similar write up in June with the
same 50 hours mentioned. There was paperwork about the damage again
mentioning the 50 hours. This time there was a mechanic nearby and when I asked
about the 50 hours, he left and returned with new paperwork saying it would be
fixed the next "extended ground time".
If we see the yellow paint, we are not required to check the damage list in the AML.
There is something incongruent about the 50 hours for repair, which can be
changed to "extended ground time" when challenged, rewritten up again as a repair
in 50 hours, not included in the damage list, and flying the airplane well over 50
hours again. Whatever the procedure is for damage to the engines and repair time,
the process is not transparent or consistent. This makes any kind of error trapping
by pilots virtually impossible.
Synopsis
An A330 Captain expressed concern that holes in the engine cowls had been
written up requiring repair within 50 flight hours but when that time was exceeded
the restriction was altered to require maintenance at the "next extended ground
time".
ACN: 898259
Time / Day
Date : 201007
Place
Environment
Aircraft
Reference : X
Flight Plan : IFR
Component
Aircraft Component : Hydraulic System
Problem : Failed
Person
Reference : 1
Events
Assessments

Narrative: 1
At FL380 60 miles before the NAT Track we got ECAM of green system low level
followed a few minutes later by ECAM green hydraulics low pressure. We preformed
all ECAM procedures and after a short consult with Maintenance Control and ATC
decided to divert to a foreign airport. Burned fuel down to below Maximum Landing
Weight of 401.2, landed and were towed off the runway to parking stand. Repairs
were made by the next day.
Synopsis
An A330 about to enter the NAT Tracks westbound suffered the loss of the Green
Hydraulic system. After consulting with maintenance the flight crew diverted
successfully to a nearby airport for repairs.
ACN: 892394
Time / Day
Date : 201006
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Component
Aircraft Component : Cockpit Window
Person
Reference : 1
Events

Assessments
Narrative: 1
We were climbing through FL270 when First Officer's forward windshield cracked
and shattered. We advised ATC of the problem slowed and descended to a lower
altitude. We also advised ATC that we would be returning to our departure airport
and declaring an emergency. An overweight landing was made and we taxied to the
gate without further incident.
Synopsis
An A330 flight crew descended and returned to their departure airport when the
First Officer's windshield cracked and then shattered during the climbout.
ACN: 890905
Time / Day
Date : 201005
Place
Locale Reference.ATC Facility : ZNY.ARTCC
State Reference : NY
Environment
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZNY
Airspace.Class A : ZNY
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
Primary Problem : ATC Equipment / Nav Facility / Buildings
Narrative: 1
We heard NY Center giving holding instructions to several aircraft as we

approached our oceanic entry point. We had requested NAT X FL370, M.82 for the
crossing. We offered FL390 as MAX. We were told by NY Center the Oceanic
Clearance System had crashed and no clearances were ready. We were then
cleared to FL390 maintain M.82, and to continue on our filed track, when the
oceanic clearance was ready we would be SEL called and received the clearance by
CPDLC. We proceeded as instructed. We called NY 2 times in attempt to get a
clearance. We received our oceanic clearance as requested. I believe the NY Center
did an excellent job of managing the situation.
Synopsis
A oceanic air carrier arrival described a ZNY Oceanic Clearance System failure
resulting in holding for inbounds, the reporter praised ZNY Controllers for doing an
excellent job given the conditions.
ACN: 885339
Time / Day
Date : 201004
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
Flight Plan : IFR
Mission : Passenger
Route In Use.Airway : WOOLY..BROSS.J42
Airspace.Class A : ZDC
Person
Reference : 1
Location Of Person.Facility : ZDC.ARTCC
Experience.Air Traffic Control.Radar : 8
Experience.Air Traffic Control.Military : 4
Events
Assessments

Narrative: 1
An A330 departure out of IAD over WOOLY direct BROSS.J42./. - overseas through
the SWANN Sector (17) at Washington Center, took an Airbus turn at BROSS that
commenced more than 16 miles prior to the fix. The turn did not get close to
BROSS and encroached upon the DuPont Sector (18) in transition to the
Woodstown Sector (19). I was working Sector 19 and had to point this aircraft out
to Sector 18 as the aircraft began its early turn toward their airspace. The Sector
18 controller had a TEB arrival at FL240 overhead, which, by letter of agreement, is
required to cross the JAIKE intersection approximately 38 miles away at 130 before
exiting their airspace. This normally requires Sector 18 controllers to issue a decent
clearance as soon as the aircraft enters the lateral confines of their sector, or
shortly thereafter. In this case, the Sector 18 Controller was not able to do so, and
their aircraft had to be vectored off course in order to comply with the crossing
restriction. Sector 17 departures and Sector 18 arrivals, particularly TEB arrivals,
are procedurally separated by airspace boundaries. When aircraft violate those
boundaries, evasive action may be required and controller workload is greatly
increased. This situation is becoming all too common for international departures
Eastbound out of IAD through Sector 17 and highlights the need for corrective
action. There were two Air Traffic Bulletins released by the FAA on this issue in
2000 and 2003 respectively. The 2000 bulletin (00-1) addressed High Altitude Turn
Anticipation in response to reports of certain aircraft beginning to turn a significant
distance from a fix. The bulletin addressed a known issue of Airbus aircraft;
specifically, the A319/320/321, making turns greater than 70 degrees above
FL180. The A330 was identified with this issue as well. It was found that these
aircraft have been designed, for reasons of passenger comfort and aerodynamics,
to make what we would consider shallow turns at altitude. This particular turn,
from a direct course, WOOLY to BROSS, onto J42, is not a 70 degree or greater
turn. The 2003 bulletin (03-5 SPECIAL) went further in depth by explaining aircraft
behavior while performing advanced RNAV procedures. One of the benefits of RNAV
described to the air traffic workforce was increased flight path predictability and
repeatability. This came with the caveat, however, that RNAV databases and
equipment are not fully standardized, and there is no firm guidance on how the
information is processed by aircraft systems. Further, these track differences
should not be significant enough to appear as deviations from the published
procedure. This guidance is open to too much interpretation for application within
the rigid East Coast airspace structure of the United States. I can say,
unequivocally, these flight paths are not predictable, and the track differences are
significant enough to be considered as deviations from published procedures.
System errors have occurred due to this issue, and will continue to occur if it is not
addressed. In the ten years since the FAA issued its first Air Traffic Bulletin covering
this topic, these procedures are still not covered in FAA Order 7110.65T.
Synopsis
ZDC Controller described a potential adjacent airspace entry event that involved an
Airbus aircraft, noting Airbus aircraft execute shallow turns that can easily infringe
on closely space airspace boundaries.
ACN: 883229
Time / Day
Date : 201004
Place
Locale Reference.ATC Facility : ZDC.ARTCC
State Reference : VA
Aircraft
Reference : X
ATC / Advisory.Center : ZDC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZDC
Person
Reference : 1
Events
Assessments
Narrative: 1
A330 departed out of IAD over WOOLY direct BROSS.J42./. Overseas through the
SWANN Sector (17) at Washington Center, took an Airbus turn at BROSS that
commenced nearly 15 miles prior to the fix. The turn did not get close to BROSS
and encroached upon the DuPont Sector (18) in transition to the Woodstown Sector
(19). The Sector 17 Controller had to point the aircraft out to the Sector 18
Controller, which created unnecessary added workload during a busy departure
push out of the Washington Metro area. This situation is becoming all too common
for international departures eastbound out of IAD through Sector 17 and highlights
the need for corrective action. There were two Air Traffic Bulletins released by the
FAA on this issue in 2000 and 2003 respectively. The 2000 bulletin (00-1)
addressed High Altitude Turn Anticipation? In response to reports of certain aircraft
beginning to turn a significant distance from a fix? The bulletin addressed a known
issue of Airbus aircraft; specifically, the A319/320/321, making turns greater than
70 degrees above FL180.? The A330 was identified with this issue as well. It was
found that these aircraft have been designed, for reasons of passenger comfort and
aerodynamics, to make what we would consider shallow turns at altitude? This
particular turn, from a direct course, WOOLY to BROSS onto J42, is not a 70 degree
or greater turn. The 2003 bulletin (03-5 SPECIAL) went further in depth by
explaining aircraft behavior while performing advanced RNAV procedures. One of
the benefits of RNAV described to the air traffic workforce was increased flight path
predictability and repeatability? This came with the caveat, however, that RNAV
databases and equipment are not fully standardized, and there is no firm guidance
on how the information is processed by aircraft systems. Further, these track
differences should not be significant enough to appear as deviations from the
published procedure. This guidance is open to too much interpretation for
application within the rigid East Coast airspace structure of the United States. I can
say, unequivocally, these flight paths are not predictable, and the track differences
are significant enough to be considered as deviations from published procedures as
in this case. System errors have occurred due to this issue, and will continue to
occur if it is not addressed. In the ten years since the FAA issued its first Air Traffic
Bulletin covering this topic, these procedures are still not covered in FAA Order
7110.65T, AIR TRAFFIC CONTROL for controllers throughout the NAS).
Synopsis
ZDC Controller described near airspace entry event, the reporter claiming the turns
used by Airbus aircraft are extremely shallow and take up too much space in the
cramped Eastern airspace, noting procedure expectations are not adequately
covered in FAA directives.
ACN: 881970
Time / Day
Date : 201003
Place
Environment
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Problem : Failed
Person
Reference : 1
Location Of Person : Company
Function.Ground Personnel : Other / Unknown
Events
Assessments
Narrative: 1
During cruise phase, "HYD G SYS LO PR" and "HYD G RSVR LO LVL" warnings
showed up on ECAM. Landing gears were extended in alternate mode and the
aircraft landed safely. It was necessary to tow the aircraft from the runway due to
nose wheel steering inoperative. There were no injuries.
Synopsis
An air carrier Flight Safety representative reported hydraulic failure on one of their
aircraft.
ACN: 879060
Time / Day
Date : 201003
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Assessments
Narrative: 1
In receiving our weight and balance, it was for the arrival Runway 9R. When we
requested the departure runway, we received weight and balance numbers we
intuitively knew were wrong, but could not immediately find the mistake. We asked
to have the numbers run again and got the same result. Since we could not find the
error, and we knew something was wrong, we chose to depart on Runway 9R for
which the weight and balance matched our experiences with weight and balance.
Later without time pressure, the error was found to be in the MTOW [Maximum
Take-off Weight]. The wrong number was used.
I am not sure why the MTOW was imputed incorrectly by load control. Since it is a
number that does not change we in the cockpit were not looking for that kind of
error.
It is unknown how the MTOW was a variable in load planning. There was a Captain
acting as an relief pilot. I am sure a regularly assigned relief pilot, whose duties are
to regularly evaluate the weight and balance, would have found this error much
more quickly.
Synopsis
An A330 Flight Crew received inaccurate weight and balance information for takeoff
calculations.
ACN: 877143
Time / Day
Date : 201003
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Pilot Seat
Person
Reference : 1
Events
Assessments
Narrative: 1
During pre-flight checks I noticed the First Officer seat was not the same as the
other cockpit seats on our A330 fleet. It had no head restraint or a place for one. I
had previously stated my concerns for the crash worthiness of this seat and the fact
that it didn't look like it belonged on the flight deck. Previously, someone from the
Flight Safety Department left a voice message on my cell thanking me for reporting
about this seat. They said that the Fleet Captain had been involved and found out
that Maintenance Control had the wrong seat numbers in their manual and that the
seat was not an approved seat for the aircraft. Imagine my surprise to find the seat
still installed and Maintenance signing off my logbook stating that the seat was
approved. Dispatch said they talked with an A330 Check Airman who said the seat
had been on the aircraft for a year so it must be legal. This aircraft had just come
back from maintenance work and I wondered if the unapproved seat had been
installed there. This seat should be removed from the aircraft. It has no head
restraint to prevent severe neck injuries during an otherwise survivable crash.
Synopsis
An A330 Captain reported discovering a First Officer's seat with no head restraint
and no place to install one.
ACN: 875010
Time / Day
Date : 201002
Place
Locale Reference.Airport : LFPG.Airport
Environment
Aircraft
Reference : X
ATC / Advisory.Ground : LFPG
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Events
Anomaly.Ground Incursion : Taxiway
Assessments
Primary Problem : Airport
Narrative: 1
After landing runway 27R and clearing 27L, we were instructed by Ground Control
to taxi via D, MD3, A, taxi gate 16 to our parking gate. As I taxied east on D
looking for MD3 I came upon a taxiway that looked like it should be MD3 (it took a
90 degree right turn Southbound), however when I looked down that taxiway it
was clearly marked as taxiway A. I proceeded ahead looking for MD3. Almost as
soon as I continued past that intersection the Ground Controller told us that we had
missed our turn and gave us an alternate taxi route which we used and taxied to
our gate uneventfully. Upon reaching the gate I closely examined the airport charts
and could clearly see that the charts and airport markings did not match. I called
Ground Control and mentioned that fact to him and he just gave us a difficult to
understand reply that basically dismissed my comment. Interestingly, another
inbound flight, which had been assigned the same taxi route as us, heard my
comments and piped in and agreed with me that the taxi charts and taxiway
markings did not match with regard to MD3. Also, to the best of my recollection,
there was not a sign in advance of the intersection in question that told what the
upcoming intersecting taxiway was, nor was it painted on the pavement as they do
in other instances. While some of LFPG's taxiways are clearly marked, there are
instances such as the above, and others, which need to be addressed.
Callback: 1
The reporter clarified that they had taxied beyond MD3 on D because the only sign
at MD3 was down the taxiway where MD3 changes to A, the outer circular taxiway
around the terminal.
Synopsis
An air carrier flight inbound to the gate at LFPG missed the turn from D to MD3,
claimed to be due to the lack of an identifying sign.
ACN: 872380
Time / Day
Date : 201001
Place
Environment
Light : Night
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : APU Pneumatic System & Ducting
Person
Reference : 1
Events
Assessments
Contributing Factors / Situations : Equipment / Tooling
Narrative: 1
I was assigned to work an Airbus Aircraft with a few other mechanics at the Hangar
January 2010, on the second shift. I was to work the current APU MEL, 49-11-01.
The aircraft was currently on MEL 49-11-01A for APU Bleed Air Inoperative. Before
the aircraft arrived at the hangar that night, I found two AMM references that
indicated that the reason the APU was on MEL was normal under certain conditions.
I discussed my findings with Maintenance Controller Mr. "X" and we decided that
the MEL could be cleared with no further Maintenance action taken. I signed off the
item on the Maintenance computer's work package for the Log page and made my
MEL compliance statement on the Logbook page. I did not replace any part on the
aircraft for this MEL. At the completion of my shift that day I began my weekend.
Returning to work three days later, I reviewed some of my previous Maintenance
actions to see if my "fixes stayed fixed". Reviewing the same Airbus and its APU
history, I discovered a Rotable Part removal and installation was added to my
closed Logbook page sign off. As I wrote earlier, I did not replace any part on that
aircraft. In fact, examining the Serialized part history for the Part Number, showed
I removed the part the day before I was even assigned to the aircraft.
Another anomaly that caught my attention was the fact the part Removed and
Replaced is an engine part and in no way related to the APU. Further review of ATA
Chapters 75 and 36 showed no history of engine bleed work being accomplished on
this aircraft during this time frame. The part removal information on Logbook page
does not include a tracking number and no information is included as to the part
being replaced per any accepted data. Noticing these discrepancies, I contacted the
Maintenance Controller Manager on duty at that time, to take a look at the history
with me. I do not know the cause of this problem at this time. I have insufficient
information and everyone I have approached with this problem has helped to
determine the cause but also have been unable.
After notifying Duty Manager of the problems with my original sign off, he said he
would make a call to "a Maintenance computer system "guru" to see if there could
be a problem with the system and a plausible reason for the discrepancies. Later
that day the Duty Manager informed me that the person he called could not explain
the situation and that person called a third person in IT who also could not explain
the problem. The Manager then told me to "give it a few days" to see if an answer
could be found.
After not hearing anything "for a few days", I called Maintenance Control and spoke
with Maintenance Controller Mr. "Y" who was working the Airbus desk. I explained
why I was calling and he remembered an issue with the same aircraft the previous
week. He told me that prior to departure from ZZZ a week earlier, the Flight Crew
heard an air leak from an engine that was later determined to be a bleed leak
coming from the engine Precooler Heat Exchanger. The aircraft was placed on an
estimated time for repairs, the part was ordered, replaced and it corrected the
bleed leak. This was the same part that showed on my sign off. However, the APU
bleed valve showed what was thought to be erroneous information and the aircraft
was placed on MEL 49-11-01A.
The aircraft departed on a ZZZ - ZZZZ - ZZZ round trip returning to ZZZ [the same
day] when I was assigned to the aircraft. Mr.Y informed me that Maintenance
Control records did not show anyone there reopening the Logbook and he could not
explain the parts information entry, nor could he find any history of Maintenance
work being accomplished in ATA chapters 36, 49 or 75 during this time frame,
except the issuance of the APU MEL and my sign-off of that item. I then took this
new information to my Supervisor. I explained the situation to him and he could
not determine a reason for the discrepancies. He later talked with a third shift
Supervisor, Mr.Z, who was on duty on the day [prior to my being assigned to the
aircraft], since it was the third shift that supposedly replaced the part. Mr Z did not
provide any information since the Lead Mechanic on duty [that day earlier], was on
his days off. At this time I felt it necessary to submit this report for several
reasons.
First: if there is a problem with the data entry system and closed entries can be
modified without any identifying tags or markers of who, when, or why the
modification was made, this is a major flaw in our record keeping process.
Second: it appears that undocumented Maintenance may have occurred which is a
serious problem.
Third: a satisfactory explanation has not been given to me regarding this situation
and there does not seem to be a priority in finding one.
Finally, and most importantly, the appearance of undocumented Maintenance has
only my name attached to it and I did not, I repeat, did not remove, replace or do
any other Maintenance to the aircraft except to clear an APU MEL using two AMM
references.
Without knowing the exact cause, I am unable at this time to offer any substantial
suggestions as to preventing this situation in the future. For all Maintenance
computer entries, only a portion of my employee file number is used.
Callback: 1
Reporter stated if someone has a Part Number and aircraft Tail Number, then you
can see who installed the part, including the Date when part(s) were changed.
Although Swing shift started work on the Airbus, Midnight (Mids) took over the
work. But Mechanics and their Lead thought each other would fill out the Logbook,
the Maintenance reporting paper form and enter the data into their Maintenance
computer system; because usually whoever fills out the Maintenance form also
enters the same data into their computer system. The parts that were changed are
Rotables and they must have hard paper plus a computer entry of the Part Number.
Reporter stated there have been many fixes to their Maintenance computer system
program. But even today, an employee can go back into the computer system and
post date any information that may have happened five weeks earlier. Many times
Mechanics would fill out the Maintenance reporting paper form, but not get the MEL
Corrective Action data information signed-off in the Logbook and not loaded into
their Maintenance computer system prior to the aircraft being Released. So Pilots
think an item is still on an MEL deferral, but in actuality, the item has already been
repaired and later shows cleared in their Maintenance computer system, but not in
the Logbook. Flight Crews do not have access to their hard paper Maintenance
reporting forms.
Reporter stated again the appearance of undocumented Maintenance with his name
and employee file number next to the item is a serious issue.
Synopsis
A Mechanic reports reviewing some of his previous Maintenance actions and
discovering a Rotable part had been Removed and Replaced (R/R) and added to his
already closed Logbook page sign-off.
ACN: 870309
Time / Day
Date : 201001
Place
Locale Reference.ATC Facility : ZJX.ARTCC
State Reference : FL
Environment
Weather Elements / Visibility : Rain
Weather Elements / Visibility : Thunderstorm
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZJX
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZJX
Person
Reference : 1
Experience.Air Traffic Control.Radar : 12.5
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 3
Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 6
Events
Assessments

Narrative: 1
While working ZJX ultra high sector 87, aircraft were forced through the weather
instead of being routed around. There was light turbulence at FL350-FL370 and
moderate turbulence at FL390. FL410 had reports of continuous light turbulence.
ZJX management and TMU didn't try to reroute aircraft around the weather or
ground stop the departures to the north from TPA and MCO. It is my opinion that
ZJX management and TMU refuses to reroute aircraft because they don't want any
delays assigned to ZJX. This is totally unsatisfactory and unsafe. Before I knew it,
the heavy Airbus was in severe turbulence at FL410 over TAY VOR. Earlier 2 aircraft
declared emergencies due to the turbulence. One aircraft flamed out and had to
restart and the other received an indicator light. It has been an unsafe work day at
ZJX.
Synopsis
ZJX Controller expressed concern regarding the continued routing of aircraft
through known weather and turbulence, indicating traffic management was
reluctant to re-route traffic because of facility traffic delay numbers.
ACN: 864867
Time / Day
Date : 200912
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Rudder
Person
Reference : 1
Qualification.Other
Events
Assessments
Narrative: 1
During climb phase at about 5000 feet and 250 knots, flight crew observed that the
aicraft rudder trim had moved to the left side and then was positioned in neutral
manually. The flight proceeded without further events and landed safely. There
were no injuries.
Synopsis
An A330's rudder trim moved left after takeoff without crew input. The rudder was
centered and the flight continued normally to its destination.
ACN: 863229
Time / Day
Date : 200911
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Flight Phase : Taxi
Person : 1
Reference : 1
Qualification.Flight Crew : Sea
Qualification.Flight Crew : Commercial
Person : 2
Reference : 2
Qualification.Flight Crew : Sea
Qualification.Flight Crew : Glider

Person : 3
Reference : 3
Events
Detector.Person : Other Person
Assessments
Narrative: 1
Departed at maximum takeoff weight. About a half hour later received an ACARS
message from Operations/Load Control that an additional 2,028 LBS was loaded on
aircraft and not included in the weight and balance (into bin #3). Dispatcher spoke
with Load Planner who was distracted when additional cargo was added at the last
minute. Though we exceeded max taxi and takeoff weights, neither taxi nor flying
qualities were degraded. We exceeded takeoff weight by 1,828 LBS.
Narrative: 2
After reaching FL360 Operations/Load Control sent ACARS message stating that an
extra 2,028 LBS of cargo was loaded in POSN #3, but not entered on load
manifest. This led to over max weight for both taxi and takeoff. With an over 8
hour flight plan landing weight was below max limit. Load Controller stated he was
distracted and cargo department added extra weight without him knowing about it.
That error equaled approximately 1/10 of 1% over gross.
Synopsis
A330 flight crew is informed after takeoff that an extra 2,000 LBS of cargo was
added at the last minute and not included in the weight and balance. This exceeded
maximum taxi and takeoff weights by 1,800 LBS.
ACN: 861053
Time / Day
Date : 200911
Place
Environment
Light : Daylight
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Aircraft : 2
Reference : Y
Make Model Name : BAe 146 Undifferentiated or Other Model
Airspace.Class B : EDDF
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Anomaly.Ground Incursion : Runway
Assessments
Narrative: 1
Holding short for T/O. Tower clears position and hold. I went to taxi into position
while saying position and hold. Looked to left and saw traffic out a ways but could
be going to parallel runway. As we entered runway it became apparent to me that
traffic was landing on our runway (25R) I stopped as tower said "Flight number....
traffic (I forget the call sign of landing traffic) go around." They commenced go
around (BAe-146) about a mile out. Apparently the clearance was position and hold
after traffic 5 miles out (according to F/O). I did not hear the 5 miles out part. F/O
was then heads down for checklist. Relief Officer realized our situation at same time
as I did.
I intend to repeat any clearances to enter any runway (crossing AND entering for
takeoff) so as to verify that both or all pilots in cockpit hear my understanding of
the clearance. Frankfurt is a little different (don't go there often) I don't think a
clearance to position and hold after traffic 5 miles out is the best way to directly
control access to the active runway.
Narrative: 2
Holding short for T/O on RWY 25R at FRA. Tower issued clearance "behind landing
traffic 5 miles final, line up RWY 25R and wait". As I was heads down
reading/accomplishing "below line" part of checklist, Captain began to slowly taxi
aircraft forward. As I looked up, I noticed we were moving and the Captain began
to stop, and ask if the aircraft on final was "coming to our runway". Tower called
our call sign, then changed call sign to the aircraft on final, and told it to go around.
Clearance was to taxi in position AFTER the aircraft on final landed. I believe the
Captain misunderstood the clearance, and was thinking of taxiing into "position and
hold". Also, the fact that the approaching aircraft was five miles out contributed, as
the Captain stated that before he began to taxi forward he cleared the final
approach view, and could not see the approaching aircraft.
Narrative: 3
Apparently, our clearance was to line up behind aircraft on 5 mile final, not into
position and hold. Somehow, three pilots did not catch this, as we rolled forward
before the aircraft on final went by. Captain's experience at this airport was limited.
First officer was reading line items after receiving clearance.
This type of clearance is not uncommon, but the aircraft was on an unusually long
final that we were to go into position after. Also, none of us remembered hearing
the aircraft type that was on final, another detail that is usually given. In any case,
we all must be vigilant of these types of clearances and of aircraft on final. It is
difficult to tell, however if an aircraft is lined up for your runway or the parallel until
it is fairly close. After clearance is read back to ATC, pilots could repeat it in the
cockpit to each other to prevent misunderstanding.
Synopsis
A330 Flight Crew is issued a "line up and wait behind landing traffic" but the
Captain fails to hear the "behind landing traffic" part and the First Officer is head
down finishing the checklist. A runway incursion occurs with the landing traffic
going around.
ACN: 860386
Time / Day
Date : 200911
Place
Locale Reference.ATC Facility : EGGX.ARTCC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : EGGX
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Location In Aircraft : Crew Rest Area
Events

Assessments
Narrative: 1
I was actually in a crew bunk just beginning my crew rest (first break) during the
timeframe of the event. When I returned from first break the Captain and later the
other First Officer related similar versions of the following: During this rotation
there was some personal conflict between the Captain and the other First Officer.
During this specific event the Captain asked the other First Officer to update the
MCDU with a newly received EEP and ETP's. The First Officer stated that she was
the pilot flying and he should be doing the update. The Captain then took over the
PF duties and told the F/O to do the update. The F/O began the update and the
Captain then stated he was going to make a top of climb PA and that he was off of
the radios. The F/O missed a frequency change issued by Scottish ATC. I believe
this occurred because she was off headset and had her speakers turned down/off.
The Captain completed his PA and began PF duties and verified the updated EEP
and ETP's. At some point appx 5-7 minutes later either the CA or F/O noticed the
lack of radio communication. I believe the CA may have been slow to come back
"on" the radios after making the PA and assumed the F/O was monitoring the
radios. At this time radio communication was reestablished with ATC and ATC
informed the Crew that they had been out of radio contact for 60 km and a
violation may have to be filed.
Ultimately better interpersonal communication between the CA and FO is needed. A
strong factor in this loss of radio communication with ATC was a high level of
animosity between the CA and FO. Throughout this rotation the FO was consistently
hesitant/slow to perform her duties and when she did so she was often "inaccurate"
and defensive. On this final leg of a multi-day day trip, this less than professional
performance by the FO began to wear on the Captain. There was minimum
communication between the two by this point and when the FO was not willing to
update the FMS as the CA requested the CA became very frustrated.
Synopsis
A330 relief pilot is informed after the fact and relates that a conflict developed
between between the Captain and First Officer resulting in lost comm departing
Scottish airspace.
ACN: 860344
Time / Day
Date : 200911
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Inflight Event / Encounter : Other / Unknown
Assessments
Narrative: 1
Our flight, was in a group of transatlantic flights all with similar sounding call signs.
Inattention to correcting similar flight numbers regardless of airline. In addition to
changing within airline, flight numbers that are so close as to be confusing, the
same care should be applied to similar flight numbers across airlines.
Synopsis
A330 Captain laments that not only does his company create many similar flight
numbers, but other carriers in this instance had flight numbers ending in the same
two digits causing confusion.
ACN: 860343
Time / Day
Date : 200911
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Phase : Taxi
Person
Reference : 1
Events
Anomaly.Ground Event / Encounter : Aircraft
Detector.Person : Ground Personnel
Assessments

Narrative: 1
At night, raining, and windy received pushback clearance for nose west from Ramp
Control. As we started pushback, there was an abrupt stop. The man on the
headset said we had just missed by 10 feet hitting an aircraft passing by. When we
contacted Ramp Control to ask why we had not been advised of traffic, the reply
was "that's what wing-walkers are for." The man on the headset said he had lost
sight of the wing walkers when they got behind the engine. He said his supervisor
was pushing for on time.
It seems Ramp Control chooses not to take responsibility to advice on pushback of
crossing, conflicting traffic, and believes that responsibility lies with wing walkers.
It seems the pushback crew does not understand if they lose sight of their wing
walkers to stop the push until line of sight can be re-established. It seems their
priority was simply pleasing their supervisor with on time performance. Provide
ground crew with higher level of safety training. Clearly delineate the responsibility
of Ramp Control in terms of pushback clearances.
Synopsis
A330 Captain reports conflict with a taxiing aircraft during pushback, requiring an
abrupt stop by the pushback crew. The tug driver had lost sight of the wing walkers
and ramp control did not advise of the conflict.
ACN: 859734
Time / Day
Date : 200911
Place
Environment
Light : Dawn
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZZZZ
Component
Aircraft Component : Fuel System
Person
Reference : 1
Events

Assessments
Narrative: 1
Soon after climbing to altitude it was observed that the actual fuel burn was in
excess of the fuel burn provided in the dispatch release. The takeoff fuel quantity at
the gate and prior to takeoff were in excess of the minimum requirement. As the
flight progressed this increased burn continued to worsen. Dispatch was contacted
and advised of the situation and asked to provide a modified re-release fuel as we
were estimating below re-release fuel. A modification to re-release fuel was
provided and the flight was re-released. As the fuel situation continued to worsen
the Dispatcher was asked to provide a closer alternate in order to free up more
fuel. However a closer suitable alternate could not be provided due to poor weather
at all closer airports. Destination weather was also reporting marginal. By the time
we left the track structure we were 3500 pounds above the burn and calculated
that we did not have the fuel required to fly to our destination with adequate fuel to
alternate and a 45 minute reserve. Dispatch provided us with weather at two close
enroute preferential stations as there was Company support there. Prior to passing
that station we decided to divert, for fuel, into it. No emergency was declared as
the fuel to that destination was satisfactory. An uneventful landing was performed,
the aircraft was refueled and de-iced and a subsequent flight to our original
destination ensued. We have yet to determine if the aircraft or the fuel plan
provided in the dispatch release was at fault. All techniques for minimizing fuel
burn were employed to no avail. The continued poor weather at destination coupled
with the unavailability of nearer alternates removed any option of continuing to
destination and a divert for fuel was the safest course of action. Normally the fuel
burns experienced are below that in the flight plan and in many cases the aircraft
arrives with more than planned FOB at destination. This was an unusual event and
I do not believe that there was any indication at the outset that the fuel plan was in
error. The flight plan provided for approximately 30 minutes of holding fuel in
excess of the minimum reserve and alternate fuel which would normally be
sufficient. I recommend that the historical fuel burns of the particular aircraft be
examined to see if it consistently exceeds a normal fuel burn rate and if so it should
be corrected or the flight plans should provide extra fuel for this excessive fuel
burn.
Synopsis
An A330 diverted to an unscheduled enroute station after the flight crew
determined that an excessive fuel burn did not provide the aircraft with enough fuel
to proceed to its alternate and have the required 45 minute reserve.
ACN: 852153
Time / Day
Date : 200909
Place
Environment
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZZ
Flight Plan : IFR
Mission : Passenger
Component
Person
Reference : 1
Events

Assessments
Narrative: 1
We were flying the VOR DME approach. When we flew over the 4 DME fix the
aircraft made a right turn with a bank of at least 10 degrees with a heading change
of about 15 degrees before the First Officer disconnected the autopilot. We had just
broken out of the clouds so we corrected the heading and flew in visual conditions
to a normal landing. After review and talking to others I'm sure it was a database
problem. Check all new approaches in the simulator before flying.
Synopsis
An A330 pilot reported his aircraft turned off course on a VOR DME approach
presumably because of a database error.
ACN: 851847
Time / Day
Date : 200909
Place
Environment
Weather Elements / Visibility.Visibility : +20
Light : Daylight
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : SFO
Aircraft : 2
Mission : Passenger
Person
Reference : 1
Events
Assessments
Aircraft
Airspace Structure
Human Factors
Procedure
Narrative: 1
ATC Advised us (Aircraft X) of traffic over the bay for the right runway. Aircraft X
acknowledged the traffic and was cleared "to maintain visual separation" and
cleared visual approach to 28L. Aircraft Y was cleared visual to 28R and advised to
keep up speed. Aircraft X intercepted final to 28L utilizing the localizer and slowed
to final approach speed. (below 150 KTS). Aircraft Y appeared to intercept final for
28R by continuing to close in on our position (we were already established on LOC)
from the right, and was exactly abeam our position as he came closer to his
extended final. As we were already slowed by approach control and now
configured, we could not slow any further to create any longitudinal separation with
the Aircraft Y, and we could not increase our speed as that would have put us
ahead of the smaller aircraft (Aircraft Y) and caused a wake turbulence issue.
Although the final positioning of the 2 aircraft was not apparent during the initial
vectoring due to the opposing entry points and relative position further out, with
hindsight I can conclude that at no time was my aircraft going to be behind Aircraft
Y and ATC was struggling to keep us from being ahead of Aircraft Y and settled on
us being abeam each others position. We flew the initial part of the final approach
exactly wingtip to wingtip with the Aircraft Y in VFR conditions but having (an
assumed) higher final approach speed, which caused us difficulty in not passing
Aircraft Y's position abeam us on final. We were not advised of Aircraft Y's final
approach speed. After contacting SFO Tower, we were cleared to land on 28L.
Aircraft Y announced to us, on the Frequency, something to the effect that they
were advised to fall back from the abeam position. I took that to mean that Aircraft
Y was assuming and accepting responsibility for his wake turbulence avoidance,
and I did not need to avoid passing forward of his position. Aircraft Y began to slow
and fall behind by several plane lengths prior to touchdown. At no time were we aft
of the Aircraft Y's position and were forward of his position only when he slowed
and fell aft of us. Although we were the aircraft assigned "maintain visual
separation" and we were the Heavy that had to keep from passing the Large
aircraft to our right, Aircraft Y had the only tool to accomplish any separation and
that was to maintain a high speed and when he needed to slow, he had to assume
wake turbulence responsibility even though he really had no way to know if there
would be a wake problem. I recommend that in the future, all heavy aircraft be
excluded from the simultaneous visual approach situation that includes (and is the
specific goal of approach control) to place 2 aircraft wingtip to wingtip on final. I
suspect that they are doing this to facilitate departures on the perpendicular
runway complex of 1R and 1L. If a Heavy is included in the simultaneous visuals,
then it should only be the aircraft joining from the east (over the bay) and be
positioned by vectors, well aft of the left-side aircraft, which will always be
established on extended final earlier then the right-side aircraft. The runway center
lines of 28R and 28L are only 750' apart which leaves a heavy aircraft as close as
500' wingtip separation, if both aircraft are exactly on center line, closer if either or
both aircraft are even slightly to the inside of their course. The Heavy aircraft
generally have higher approach speeds than others and are further encumbered by
the wake turbulence considerations. In this case, each aircraft landed without
further incident.
Synopsis
A330 Captain reports being cleared for the visual 28L and instructed to maintain
visual separation with traffic for 28R. The A320 traffic joins wingtip to wingtip and
the faster A330 eventually pulled ahead and was unable to maintain visual
separation.
ACN: 851232
Time / Day
Date : 200909
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component
Problem : Failed
Person
Reference : 1
Events
Assessments

Narrative: 1
ECAM Message: Yellow System Low Level followed by Yellow Hydraulic System
Failure. SOP's/Company Policies/Procedures and checklists followed. Continued to
destination. Flight terminated with a normal landing and taxi in. No emergency was
declared by pilots. Company requested emergency equipment standing by upon
arrival as a precaution.
Synopsis
An A330 suffered the loss of the yellow hydraulic system.
ACN: 851208
Time / Day
Date : 200909
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Flight Phase : Taxi
Component
Aircraft Component : Brake System
Person
Reference : 1
Events
Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
When Detected.Other
Result.Flight Crew : Regained Aircraft Control
Assessments
Narrative: 1
We arrived at the gate a few minutes early. I followed the parking system, applied
the brakes when indicated to do so and shut the engines down. I watched the
Marshaller holding the cross wands and continued to hold the brakes while waiting
for the chocks in signal. During this time, out the corner of my eye, I noticed
movement of the jetway and thought that was normal since we had just parked.
Shortly thereafter, I realized that it was the aircraft that had begun to roll
backwards and not the jetway. I thought I was applying adequate/constant
pressure to the brakes to hold the aircraft, but obviously it started to roll and I
hadn't realized it until we had rolled about 6 or 8 FT. I then aggressively applied
the brakes and the aircraft stopped. I would like to blame this incident on the fact
that it was a trying day in that the weather was lousy, the day was long, etc., but
this happened because I failed to hold adequate pressure on the brakes while
waiting for the signal. Most of my flights during the past summer, I arrived at the
gate with fairly hot brakes. Knowing that the parking brake should be released after
the chocks are in so that the brakes can cool, I usually held the brakes (rather than
setting the parking brake on) until the chocks in signal. In the future, I fully intend
to set the parking brake and wait for the chocks signal before releasing the brakes.
Synopsis
An A330 Captain's personal preference to hold the brakes vice set the parking
brake when given the stop signal by the marshaller results in the aircraft rolling
backward when insufficient pressure was kept on the brake pedals.
ACN: 846468
Time / Day
Date : 200908
Environment
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Cabin Entertainment
Person
Reference : 1
Events
Assessments
Narrative: 1
IFE system was not functioning. We did a complete shut down and restart. ECAM
message came up "System is shutting down due to bulk avionics smoke." I called
Maintenance Control and we all agreed to attempt another restart. Second attempt
failed and we got the same message. I elected to not continue since I was unsure
of the status of the IFE problem with smoke.
Synopsis
ECAM smoke messages in response to attempts to restart the A330 IFE system
results in a refusal of the aircraft.
ACN: 841560
Time / Day
Date : 200906
Place
Locale Reference.Airport : ZZZZ
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Engine Air Indications
Person
Reference : 1
Events

Assessments
Narrative: 1
After takeoff ECAM warning indicated that we had a wing bleed duct leak. After
discussion with maintenance we were advised that we may still have a bleed leak
and it was agreed that we should return to our departure airport. Due to the
possibility of a continued bleed duct leak and the possibility of icing conditions and
thunderstorms in the area we determined that is was safer to do an overweight
landing than to delay the landing. We returned and landed without incident.
Callback: 1
The reporter stated that this aircraft has dual wing bleed overheat sensors. In this
case a relatively minor bleed leak was blowing directly on one of the sensors
causing the overheat warning. This same event occurred several days earlier on
this aircraft and had been assumed corrected. After the reporter talked with
maintenance, he was told that several other ECAM messages were sent to
maintenance that were not displayed in the aircraft. The reporter stated he was
unable to recall the specific messages but the aircraft may have been able to safely
complete the trip if the crew had had more knowledge about the malfunction.
Reporter also mentioned a reset procedure was available which if it cleared the
fault would have allowed the aircraft to continue.
Synopsis
An A330 returned to land after an ECAM warning indicated a wing bleed duct leak
detected during climb out.
ACN: 837999
Time / Day
Date : 200906
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Window Ice/Rain System
Problem : Failed
Person
Reference : 1
Events

Assessments
Narrative: 1
At cruise right windshield anti-ice and right windshield heat ECAMs came on. We
notified Maintenance and Dispatch. Dispatcher told us to return. We returned to our
departure airport and did an overweight landing with no problems. Windshield antiice and heaters failed.
Synopsis
A330 Captain reports right windshield heat failure at FL330. After conferring with
dispatch, flight returned to departure airport for overweight landing.
ACN: 837992
Time / Day
Date : 200906
Place
Aircraft
Reference : X
ATC / Advisory.Ground : ZZZ
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Events
Anomaly.Ground Event / Encounter : Object
Narrative: 1
We departed gate for departure, as we were enroute for departure we were notified
by ramp that airport vehicles saw something wrong with one of our tires and to
stop so they could inspect it. Maintenance came out and determined that a large
clump of tar and asphalt was stuck to the tire and it needed to be changed. We
returned to a gate where the tire was changed. This resulted in a 1:31 delay
causing several of our passengers to miss connections. This could have caused a
real safety issue if the attached asphalt was not noticed and it was flung off at high
speed during departure. The city had apparently patched a hole in the concrete at
our gate just under our right main gear and the tire sank into the asphalt. This was
not apparent during either the maintenance or Relief Pilot walkaround, but when
the aircraft was pushed off the gate the asphalt attached itself to the tire. Holes in
the concrete should never be patched with this type of material, but need to be
patched with concrete or a metal plate until a permanent repair can be made. I
believe who ever authorized this type of repair should be responsible for our air
carrier's expenses.
Synopsis
An Airbus flight crew was alerted by ground control of a concern with a main tire.
Airport employees noticed a large clump of tar had adhered to the tire and
maintenance determined the tire needed to be changed.
ACN: 837690
Time / Day
Date : 200905
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Assessments
Narrative: 1
Once again, we received a flight plan that is not flyable: the cruise speed was filed
and fuel planned for .795 mach. This is an unacceptable situation for a dispatcher
to flight plan using performance specifics that we cannot comply with. This flight
plan had minimum fuel for arrival of 14,400, which was at or very close to FAR
minimums. Therefore, there was no actual, reasonable expectation of complying
with the FAR fuel requirements if this flight plan had been accepted without
additional fuel. This is unacceptable and a deliberate violation of FARs as there is
no reasonable expectation of success. This is not a new problem. On the same
flight earlier in the month, the Captain spent about 30 minutes on the phone with
the Dispatcher getting him to change the speeds to ones we could actually select. It
can be done therefore not doing it is an intentional violation, which is not
acceptable. I believe it is because of dispatchers who are unfamiliar with the
performance capabilities of the aircraft and of normal operating procedures. A cost
index of 100 is a predictable set of speeds, which is what normal procedures lead
us to expect and operate with. This is a serious legal and safety issue. I don't
appreciate having to, in essence, do the job of the dispatcher. The continuation of
these intentional acts is unacceptable and professionally disappointing.
Synopsis
A330 First Officer reports receiving release with cruise speed and fuel burn that is
not compatible with the way his air carrier normally expects the aircraft to be
operated or with enroute ATC clearances.
ACN: 837533
Time / Day
Date : 200905
Place
Locale Reference.Navaid : ZZZ.VOR
Environment
Light : Dusk
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Location Of Person.Aircraft : x
Events
Anomaly.Deviation - Procedural : Other / Unknown
Result.Flight Crew : Requested ATC Assistance / Clarification
Assessments

Narrative: 1
Flight departed expecting to land with 14,100 LBS of fuel. However, throughout
flight, fuel consumption was higher than planned, despite many efforts by crew,
enroute, to change cost index, fly at max altitudes available, reduce cabin air flow
to low flow, change alternate airport, communicate the problem to the company
and invite feedback, as well as other steps outlined in manuals. In addition, an
ACARS message was sent to our Dispatcher asking for our ATC Desk to contact the
TRACON Supervisor to advise that our flight could be declaring "Minimum Fuel"
when checking in with Approach Control. Unfortunately, Center required us to
descend from FL400 to FL280. This resulted in our estimated fuel on board at
landing to be reduced to 11,200 LBS of fuel which was calculated to be 49-55
minutes of fuel projected at landing. Minimum fuel was declared at that time with
Center rather than waiting to reach TRACON. This declaration benefited us because
we were allowed to fly at FL340 for an extended period of time and allowed us
direct routing with three Centers. After changing to Approach Control, an idle thrust
profile descent was provided from 6000 FT to 1500 FT, resulting in minimum fuel
burn. We landed with 13,100 LBS of fuel and reached the gate with approximately
12,400 LBS. Since departing with full knowledge that we were dispatching with no
holding fuel, no tanker fuel, and just 1000 LBS of extra fuel, the crew kept
exceptional fuel records not only over the Atlantic Ocean as required, but at fixes
en route for the entire flight. Both the Master and second Flight Releases were
completed by different pilots so that results and conclusions could be contrasted
and compared even prior to leaving the European Continent. We knew less than
half way across the ocean that a problem was developing and began
communications with the company at that time by requesting the change of
alternate airports and requesting that we all focus added attention to the re-release
fuel requirements (since it was projected to be acceptable by just 300 LBS which is
less than 90 seconds for the A-330 aircraft). We were legal to continue and were
re-released at SEAER Intersection. We also consulted the FOM and PH to review
policy and procedural barriers. The team worked together extremely well and we
were able to reach unanimous agreements with adjustments necessary to reduce
fuel burn throughout the flight. We also reviewed at each crew break interval how
the problem was developing and what steps were warranted as the flight
progressed. Although dispatch had conducted excellent fuel planning in advance of
our flight, winds were not as favorable as planned, resulting in a need to change
plans and use all available resources. All parties reached unanimous agreement to
dispatch with this fuel load even though it is lower than we normally receive. This
was in accordance with the company's desire to reduce fuel burn en route by
operating with minimum dispatched fuel loads. Weather was excellent en route and
at the destination and alternates. Therefore, we believed we could complete this
flight safely from the preflight until landing and possibly delete alternate airports
altogether if it became necessary. Unfortunately, the winds were not as forecast
and the flight planning considerations proved not to be totally correct. I have no
suggestions since I believe we did the best job we could under the circumstances,
and so did the Dispatchers.
Synopsis
Dispatched across the Atlantic Ocean with planned minimum fuel reserves at their
destination, an A330 flight crew struggled to adapt to higher fuel burn and less
favorable winds than forecast.
ACN: 819119
Time / Day
Date : 200812
Place
Aircraft
Reference : X
Component
Aircraft Component : Mininum Equipment List (MEL)
Person
Reference : 1
Function.Dispatch : Dispatcher
Qualification.Dispatch : Dispatcher
Events
Assessments
Narrative: 1
During flight planning, Dispatch Computer System showed 1 MEL item on Aircraft X
for flight ZZZ-ZZZ1 which was 25-22-03B 'inflight entertainment.' I opened
computer system to see what component of that system was inoperative so I could
put the information in the remarks section of the release. I found not only MEL item
25-22 but also 38-10. I called Maintenance Control to see if 38-10 was active or
not. Maintenance Control confirmed 38-10 was an active MEL on Aircraft X. I
notified the training department of the discrepancy. I also wrote out the MEL 38-10
in the remarks section of the release, since it did not appear in computer system. I
am unclear as to why there was/is a discrepancy between Maintenance Computer
System and Dispatch Computer System at this time on this aircraft. Must ensure
Maintenance Computer System and Dispatch Computer System share correctly the
information concerning MEL's in order to safely plan and dispatch our
aircraft/flights. Callback conversation with Reporter revealed the following
information: Reporter stated their aircraft releases are generated under their
Dispatch Computer System. But their Maintenance System Computer program does
not automatically show all maintenance MEL's, or flight logs information in their
Dispatch System. So the Dispatcher has to try and access their Maintenance
Computer System to make sure all the MEL procedures are complied with prior to
issuing a dispatch release.
Synopsis
During flight planning the Dispatcher's Computer System showed only one MEL
item 25-22-03, for an in-flight entertainment system. But the Maintenance System
also showed another MEL deferred under Chapter 38-10 for the A330 aircraft.
ACN: 808615
Time / Day
Date : 200810
Place
Environment
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZ.Tower
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person
Reference : 1
Function.Air Traffic Control : Ground
Function.Ground Personnel : Ramp
Events
Assessments
Narrative: 1
AIRBUS A330, CALLED FOR PUSHBACK FROM THE TERMINAL TO GATE, BUT
FAILED TO CALL FOR PERMISSION TO TAXI. THIS IS A SAFETY CONCERN HAVING
ONE TFC LANE. AIRLINE STATION MGR WAS NOTIFIED AND HAS ADVISED IT WILL
BE ADDRESSED WITH THE FLT CREW.
Synopsis
RAMP CONTROLLER DESCRIBED EVENT WHEN ACR CREW FAILED TO CALL BEFORE
TAXIING AFTER PUSHBACK CONTRARY TO RAMP OPERATIONAL PROCEDURES.
ACN: 805358
Time / Day
Date : 200809
Place
Locale Reference.Navaid : CCC.VOR
Relative Position.Angle.Radial : 180
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZNY.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZNY.E
Aircraft : 2
Reference : Y
Make Model Name : B767-300 and 300 ER
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZNY.A
Person
Reference : 1
Location Of Person.Facility : ZNY.ARTCC

Events
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Detector.Automation : Air Traffic Control
Assessments
Narrative: 1
HOLDING FOR JFK ARRS AT CCC. FIRST ACFT (A330) WAS ASSIGNED TO CROSS
CCC AT 14000 FT UPON HOLD ENTRY. SECOND ACFT (B763) WAS ASSIGNED TO
CROSS CCC AT 15000 FT UPON HOLD ENTRY. FIRST ACFT DID NOT COMPLY WITH
THE 14000 FT RESTR AND WAS STILL DSNDING OUT OF APPROX 14600 FT ON THE
OUTBOUND LEG OF THE HOLDING PATTERN RESULTING IN THE LOSS OF MINIMUM
SEPARATION WITH THE SECOND ACFT WHO WAS LEVEL AT 15000 FT ON THE
INBOUND LEG OF THE HOLDING PATTERN.
Synopsis
ZBW CTLR DESCRIBED LOSS OF SEPARATION EVENT WHEN ACR FAILED TO
MEETING CROSSING RESTRICTION AT 14000 DURING HOLDING PROCS.
ACN: 804282
Time / Day
Date : 200810
Place
Environment
Light : Night
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ.TRACON
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZZZ.E
Component
Aircraft Component : AHRS/ND
Problem : Failed
Person
Reference : 1
Events
Assessments
Narrative: 1
SHORTLY AFTER TKOF IN THE TURN, FO, PF, LOST ALL NAV DATA ON HIS LOWER
DISPLAY. QRH CONSULTED. ACFT SPD HELD TO 250 KTS NO PROC LOCATED AND
BOTH THE FO AND RELIEF PLT, LONG TIME AIRBUS PLTS, OPINED THAT NEITHER
OF THEM HAD SEEN THESE CONDITIONS. WHILE THEY WERE TROUBLESHOOTING
COMMUNICATING WITH CO AND MAINT I ELECTED TO RETURN TO ZZZ. ACFT
LANDED ON LONGEST RWY AND I REQUESTED EMER EQUIP BE DISPATCHED AS I
HAD NEVER LANDED AN A330 THAT HVY. AUTO BRAKE MED WAS
SELECTED.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING
INFO: THE RPTR STATED THAT THE ICONS ON THE FO'S ND DISAPPEARED. THE
ATTITUDE WAS FUNCTIONIUNG NORMALLY. THE FO AND RELIEF PILOT WERE
EXTREMELY EXPERIENCED AND WHEN A CAUSE OF THE FAILURE COULD NOT BE
FOUND, THE DECISION WAS MADE TO REMAIN VFR AND RETURN TO LAND. THE
RPTR BELIEVED THAT THE FAILED COMPONENT WAS SOME SORT OF NAVIGATION
UPLINK AND INTERFACE COMPONENT.
Synopsis
AN A330 FO'S NAV DATA FAILED AFTER TKOF. AN IMMEDIATE RETURN TO LAND
FOR AN OVERWT LNDG. EMER EQUIP WAS STANDING BY BECAUSE OF THE ACFT'S
WT.
ACN: 798470
Time / Day
Date : 200808
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Other
Assessments
Narrative: 1
RELEASE SHOWED FLT ARRIVING WITH 15000 LBS OF FUEL. I TOLD DISPATCH I
WAS UNCOMFORTABLE ARRIVING WITH SO LITTLE FUEL. I ASKED WHAT ARR WX
WOULD BE. HE SAID CLR AND 87 DEGS. I MADE A COMMENT ABOUT THE
FORECAST FOR ZZZ1 SHOWING SOME CLOUD COVER. DISPATCH DID NOT
CHANGE HIS FORECAST. THE FORECAST IN OUR PAPERWORK DID NOT START
UNTIL WELL PAST OUR SCHEDULED ARR TIME. I ASKED FOR 1000 LBS
ADDITIONAL FUEL. WX ON ATIS AT OUR ARR WAS 'FEW 065, SCATTERED 150,
BROKEN 220.' RELEASE PREDICTED THAT WE WOULD BURN 1200 LBS OF FUEL
BTWN ZZZZZ AND TOUCHDOWN USING THE ARR RTE. APCH ACTUALLY TURNED
US N WELL SHORT OF THE VOR (MAYBE 10 NM SHORT). WE WERE GIVEN SOME
VECTORS BUT WE ESSENTIALLY WERE ON A BASE LEG AND TURNED FINAL INSIDE
10 NM. THIS WAS BY FAR THE SHORTEST APCH I HAVE HAD INTO ZZZ SINCE IT
WAS MADE A HUB. WE BURNED 2000 LBS OF FUEL BTWN ZZZZZ AND
TOUCHDOWN. RELEASE SHOWED ZZZ1 AS OUR ALTERNATE AND DIVERTING
WOULD TAKE 2756 LBS OF FUEL AND 15 MINS. IT ALSO SHOWED THAT WE
WOULD CLB TO FL180. AND WE WOULD DO ALL THIS IN THE 40 NM BTWN ZZZ
AND ZZZ1. I LOOKED AT THE RELEASE AND SAW SOME FIGURES THAT I
QUESTIONED AND VERIFIED THE INACCURACY OF THE FIGURES DURING THE FLT.
I MUST ADMIT THAT I DID NOT NOTICE THE PLANNED CLB TO FL180 FOR THE FLT
TO THE ALTERNATE UNTIL WE WERE ENRTE. I BELIEVE THAT THERE IS SO MUCH
EMPHASIS ON SAVING FUEL THAT PERSONNEL ARE NOT CHKING QUESTIONABLE
FUEL BURNS. PLTS AND DISPATCHERS SHOULD TAKE A CLOSER LOOK AT
QUESTIONABLE FUEL BURNS IN THE FLT RELEASE.
Synopsis
A330 CAPTAIN PROVIDES EXAMPLE OF WHY HE FEELS HIS AIRLINE HAS
OVEREMPHASIZED FUEL SAVINGS AT THE EXPENSE OF CONSERVATIVE FLT
PLANNING.
ACN: 797548
Time / Day
Date : 200807
Place
Environment
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : ZZZ.B
Person
Reference : 1
Events
Assessments
Narrative: 1
DUE TO FORECAST POSSIBILITY OF TSTMS IN THE AREA AROUND OUR ARR TIME I
ELECTED TO ADD 1296 LBS AFTER CONFERRING WITH DISPATCH. ONCE IN
CONTACT WITH CTR, THEY HAD US START OUR DSCNT PRIOR TO THE FLT PLAN
TOD. WHEN WE WERE TURNED OVER TO THE NEXT CTR, THEY STARTED
VECTORING US FOR TFC IN THE ZZZ AREA. OUR ORIGINAL PLANNED ARR FUEL
ACCORDING TO THE FLT PLAN WAS 15400 LBS. WE ARRIVED WITH 14020 LBS.
THE RESULT WAS THAT HAD WE NOT ADDED THE ADDITIONAL FUEL, OUR ARR
FUEL WOULD HAVE BEEN 12724 LBS. WITH TSTMS IN THE FORECAST, THE FUEL
LOAD WOULD HAVE BEEN INSUFFICIENT IF I WOULD HAVE ACCEPTED THE
ORIGINAL FUEL LOAD.
Synopsis
AN A330 CAPT ADDED ADDITIONAL FUEL BECAUSE OF FORECAST WX AT THE
DEST. EVEN AFTER ADDING FUEL THE ACFT LANDED WITH LESS THAN PLANNED
BECAUSE OF AN EARLY DSCNT AND VECTORS.
ACN: 795678
Time / Day
Date : 200807
Place
Environment
Light : Dawn
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Other
Assessments
Narrative: 1
ORIGINAL FLT RELEASE FUEL/BURN WAS INACCURATE. UPON ARR AT THE GATE
AT ZZZ2, I CHKED THE FLT RELEASE. I CALLED THE DISPATCHER AS I NORMALLY
DO, LISTENED TO THE BRIEF, AND THEN DISCUSSED THE FACT THAT I WAS
RELATIVELY NEW ON THE ACFT AND NOT VERY COMFORTABLE LNDG WITH A FUEL
LOAD OF 14000 LBS. AS IT IS, I'M NOT YET COMFORTABLE WITH ANY LESS THAN
17K, BUT I ASKED TO PLAN FOR 17K ARR FUEL. THE DISPATCHER WAS NOT THE
ONE WHO CREATED THE RELEASE AND IT WAS MUTUALLY AGREED THAT THE FUEL
BE CHANGED FROM 121305 LBS TO 125000 LBS. THE ORIGINAL RELEASE CALLED
FOR TAXI FUEL OF 1595 LBS. WE PUSHED WITH 125000 LBS AND TOOK THE RWY
WITH 123200 LBS (1800 LBS ACTUAL BURNED/TAXI FUEL). OBVIOUSLY, ALL THE
FUEL CHKS LOOKED TO BE 3000-4000 LBS ON THE PLUS SIDE UNTIL ARR IN THE
ZZZ AREA. APCHING ABC1, WE WERE VECTORED 25 MI FURTHER S AND CROSSED
THE SHORE WELL S OF ABC2. AT ABC3, WE WERE GIVEN A VECTOR OF 270 DEGS
AND A SPD OF 210 KTS. WE WERE TURNED BACK TO THE E, EXECUTED A LONG,
SLOW DOWNWIND TO A 20 MI FINAL TO RWY XXR AT ZZZ. WE ARRIVED AT THE
GATE WITH 13600 LBS. WX WAS SCATTERED CLOUDS AND GREAT VISIBILITY.
ZZZ WAS OVERLOADED WITH ARRIVING TFC. HAD I ACCEPTED THE ORIGINAL
FUEL LOAD, WE WOULD HAVE HAD TO RETURN TO THE GATE AT ZZZ2 AND IF WE
HAD GOTTEN AIRBORNE WITH THE ORIGINAL FUEL, WE WOULD HAVE LANDED
WITH ABOUT 10000 LBS. IF WE HAD TO DO A GAR DUE TO CONFLICTING TFC
LNDG ON RWY XY (AS WAS ALMOST THE CASE), THEN WE WOULD HAVE BEEN IN
AN EMERSITUATION. I UNDERSTAND THE NEED TO CONSERVE, BUT UNTIL ZZZ
CAN BE MORE PREDICTABLE ON ITS HANDLING OF TFC IN VFR WX, I HAVE TO
CONSIDER PAST EXPERIENCE WITH ZZZ WHEN I ACCEPT A FUEL LOAD.
OBVIOUSLY, THIS IS CAUSING A LOT OF ATTN. WHEN I WAS GOING THROUGH
TRAINING ON THE ACFT, ONE OF MY MANY QUESTIONS WAS -- WHAT ARR FUEL
WAS COMFORTABLE FOR OTHER A330 PLTS? I REMEMBER AN INSTRUCTOR
SAYING HE WAS COMFORTABLE WITH 17K - 18K BECAUSE TOO MANY TIMES
ARRIVING AT INTL DESTS, THERE ARE CONSIDERABLE DELAYS AND 1 GAR CAN
CONSUME A CONSIDERABLE AMOUNT. FOR A NEW CAPT ON THE AIRPLANE, HE
INDICATED THAT ASKING FOR 20K WOULD BE A GOOD AMOUNT UNTIL I FELT
MORE COMFORTABLE WITH A LESSER AMOUNT. TODAY'S RELEASE WAS PLANNED
WITH THE BARE MINIMUM OF FUEL. IT DID NOT CONSIDER GND DELAYS AT ZZZ2
(WHICH WE HAD), IT DID NOT CONSIDER OFF-COURSE VECTORS FROM ZZZ2 TO
THE TRACKS (WHICH WE HAD) AND IT DID NOT ACCOUNT FOR EXCESSIVE
VECTORS AT ZZZ. THE LOW FUEL EVENT DID NOT OCCUR BECAUSE THE
DISPATCHER AND I AGREED TO INCREASE THE FUEL. AN EVENT WOULD HAVE
OCCURRED HAD WE LEFT WITH THE ORIGINAL PLANNED FUEL.
Synopsis
NEW A330 CAPTAIN BELIEVES MORE PLANNED FUEL ON INTERNATIONAL
ARRIVALS IS NECESSARY TO ACCOUNT FOR OPERATIONAL PROBLEMS.
ACN: 794940
Time / Day
Date : 200807
Place
Environment
Light : Dawn
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Trailing Edge Flap
Problem : Failed
Person
Reference : 1
Events
Result.Flight Crew : Landed In Emergency Condition
Assessments

Narrative: 1
WHILE CONFIGURING FOR APCH, ECAM FOR FLAPS JAMMED APPEARED, ALONG
WITH THE ASSOCIATED AMBER FLAP INDICATION. WE DISCONTINUED THE APCH,
WENT TO A HOLDING PATTERN, DECLARED AN EMER, AND COMPLETED THE QRH
PROCS. EXECUTED A ZERO FLAP APCH, SLATS AT 2 DEG POS. APCH SPD WAS 163
KTS, WT 393000 LBS, AND LNDG WAS UNEVENTFUL. PROCS AND CRM WORKED
EXACTLY LIKE TRAINING. VERY SMOOTH APPLICATION OF OUR TRAINING.
Synopsis
A330 CAPT REPORTS JAMMED FLAPS DURING APPROACH, RESULTING IN ZERO
FLAPS LANDING WITH SLATS AT 2.
ACN: 794914
Time / Day
Date : 200806
Place
Environment
Aircraft
Reference : X
ATC / Advisory.Center : ZZZZ.ARTCC
Component
Problem : Failed
Person
Reference : 1
Events
Assessments
Narrative: 1
THE FO'S FORWARD WINDSHIELD BEGAN ARCING. SHORTLY THEREAFTER IT

CRACKED IN SEVERAL PLACES. WE FOLLOWED ECAM, QRH AND FOM PROCS,
DSNDED TO FL230 AND ULTIMATELY LANDED IN ZZZ2. ALL PARTIES WERE
INFORMED. WE SAW IT AND HEARD IT. REQUESTED A DEV FROM ATC. DECLARED
AN EMER. LEFT THE TRACK. CONFERRED WITH DISPATCH. APPARENTLY THE
WINDSHIELD CTLR CAUSED THE ARCING AND SUBSEQUENTLY THE CRACKING OF
THE WINDSHIELD.
Synopsis
AN A330 FO'S FORWARD WINDOW CRACKED AT FL370. AN EMER WAS DECLARED
WITH A DIVERSION TO A NEARBY ARPT.
ACN: 794886
Time / Day
Date : 200806
Place
Environment
Ceiling : CLR
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Pneumatic Ducting
Person
Reference : 1
Events
Assessments

Narrative: 1
RECEIVED ECAM WARNING AT APPROX 1 HR INTO FLT. CONTACTED DISPATCH
AND MAINT CTL VIA SAT. WAS DECIDED UNABLE TO PROCEED WITH BLEED LOSS
AS OUR APU BLEED WAS ON MEL AND WOULD LEAVE US ONLY 1 BLEED SYS.
DISPATCH REQUESTED WE LAND AT ZZZZ FOR REPAIRS. PROCEEDED TO ZZZZ,
BRIEFED CREW AND CONTACTED OPS AT ZZZZ, MADE VISUAL APCH WITH
OVERWT LNDG, RWY 26L. ENTERED BLEED LEAK AND OVERWT LNDG IN
LOGBOOK. MAINT REPAIRED ACFT AND WE CONTINUED ONTO ZZZ. I BELIEVED IT
WOULD BE SAFER TO LAND OVERWT SINCE I DID NOT KNOW THE EXTENT OF THE
R WING BLEED LEAK.
Synopsis
AN A330 DEVELOPED A WING BLEED AIR LEAK IN FLT. THE CREW RETURNED FOR
AN OVER WT LANDING BECAUSE THE EXTENT OF BLEED LEAK WAS UNKNOWN.
ACN: 788753
Time / Day
Date : 200805
Place
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZZ.Tower
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Engine Pressure Ratio Indicat
Problem : Failed
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Events
Assessments
Narrative: 1
DURING TKOF ROLL, RECEIVED ECAM ENG THRUST LEVERS NOT SET. POSITIONED
THRUST TO TOGA THRUST. NEAR 80 KTS, RECEIVED ECAM ENG #1 EPR MODE
FAULT AND AUTO FLT A/THRUST OFF. THE ECAM ENG AND WARNING DISPLAY ENG
#1 EPR INDICATION WAS ABSENT, AND THE ECAM SHOWED SEVERAL FAULTS IN
A ROW. BECAUSE OF NUMEROUS ECAM ALERTS AND INABILITY TO DETERMINE
ENG THRUST AND ENG THRUST LIMIT, I INITIATED A REJECTED TKOF AT 100-110
KTS. THE REJECTED TKOF RESULTED IN A NORMAL TURNOFF OFF RWY 23L. THE
RTE BACK TO THE GATE INVOLVED A BACK TAXI ON RWY 23L AND XING RWY 23R.
DURING TAXI BACK TO THE GATE WE NOTICED THE BRAKE TEMP RISE,
ESPECIALLY ON #1 BRAKE. WE ASKED THE TWR IF THEY HAD HAD A HOT BRAKE
AREA, AND IT DIRECTED US TO A SPOT NEAR THE ARPT CFR. AS WE NEARED THE
ASSIGNED AREA, THE #1 TIRE FUSE PLUG MELTED AND THE TIRE DEFLATED. WE
STOPPED AND CALLED FOR CFR TO INSPECT THE TIRE AND BRAKES. THEY
ARRIVED VERY QUICKLY AND ADVISED US TO HOLD OUR POS, AND THAT #1 TIRE
HAD INDEED DEFLATED. WE THEN RECEIVED ECAM GREEN SYS HYD QUANTITY
UNDERFILLED, FOLLOWED BY GREEN HYD PRESSURE LOSS. PAX WERE DEPLANED
IN AN ORDERLY MANNER VIA AIRSTAIRS FROM DOOR 1R. ONCE THE EVENT WAS
IDENTED, PUBLISHED PROCS WERE FOLLOWED TO PROVIDE FOR A SAFE
CONCLUSION. THE EVENT BEGAN BECAUSE #1 EPR INDICATION FAILURE DURING
TKOF ROLL. THIS THEN LED TO THE TIRE, BRAKE, AND GREEN SYS HYD FAILURES
DUE TO EQUIP FAILURE DURING THE REJECTED TKOF. THIS SITUATION CAN
HAPPEN AT ANY TIME AND PROCS TO DEAL WITH IT SHOULD CONTINUE TO BE
REINFORCED DURING QUALIFICATION AND CONTINUING QUALIFICATION
TRAINING. SUPPLEMENTAL INFO FROM ACN 788754: LOGBOOK ENTRY
INCOMPLETE. DUE TO CREW TASK LOADING, CREW COORD, TAKING CARE OF
ACFT AND PAX PLUS REQUIREMENT TO LEAVE THE ACFT BY LCL AUTHS, FLT CREW
SIMPLY FORGOT SEVERAL MAINT LOG WRITE-UPS. 'BRAKE 5 RELEASED' ECAM AS
WELL AS DEFLATED TIRE #1 AND GREEN HYD QTY LOSS. THESE ITEMS WERE
CLEARLY VISIBLE AND KNOWN BY ENGINEERS TENDING TO THE ACFT, HOWEVER
WE FORGOT TO ENTER INTO THE MAINT LOG. ADDITIONAL INFO: SUGGEST 'ENG
EPR MODE FAULT' ECAM ON TKOF BE INTRODUCED INTO INITIAL AND RECURRENT
A330 TRAINING SCENARIOS. ADDITIONAL EMPHASIS ON EPR MODE VERSUS N1
MODE SYS AND ASSOCIATED DYNAMICS WOULD ALSO BE HELPFUL AS WELL. MY
SENSE IS WE HAVE PUT THESE 2 ITEMS ON THE BACK BURNER THE LAST
SEVERAL YRS IN THE A330 TRAINING ARENA. SUPPLEMENTAL INFO FROM ACN
788752: DURING TKOF ROLL RECEIVED ECAM ENG THRUST LEVERS NOT SET.
PLACED THRUST LEVERS FROM FLEX TO TOGA. THEN RECEIVED ECAM ENG #1 EPR
MODE FAULT AND AUTO FLT A/THRUST OFF. THE #1 EPR INDICATION
DISAPPEARED FROM EFIS. UNABLE TO READILY DETERMINE ENG THRUST STATUS,
THEREFORE REJECTED TKOF AT 100-110 KTS.
Synopsis
AN A330 TKOF WAS REJECTED FOLLOWING ECAM MSGS: ENG TFR LEVERS NOT
SET, #1 EPR MODE FAULT, AUTO FLT A/TFR OFF. DURING TAXI BACK A TIRE
DEFLATED AND THE GREEN HYD SYSTEM LOST FLUID. THE ACFT WAS DEPLANED
USING STAIRS.
ACN: 784902
Time / Day
Date : 200805
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZZZ.A
Component
Aircraft Component : Exhaust Gas Temperature Indicat
Problem : Failed
Person
Reference : 1
Events
Assessments

Narrative: 1
FLT DEPARTED ZZZ FOR LFPG AFTER A 3 HR MAINT DELAY REPAIRING A #1 ENG
EGT INDICATOR FAILURE. WE WERE RELEASED ON A CONDITIONAL RELEASE. THE
SYS FAILED AGAIN PRIOR TO ENTERING OCEANIC AIRSPACE, AND WE WERE
DIRECTED BY DISPATCH TO RETURN TO ZZZ. WE DISCUSSED VIA ACARS
WHETHER TO LAND OVERWT OR NOT AND WERE URGED TO LAND ASAP BY THE
DISPATCHER. FLT RETURNED TO ZZZ FOR AN UNEVENTFUL OVERWT LNDG,
WEIGHING 431800 LBS, AND AT A VERT SPD OF 300-400 FPM. THE CREW
WORKED VERY WELL TOGETHER, APPLYING THE THREAT AND ERROR MGMNT
PRINCIPLES.
Synopsis
AN AIRBUS A330 CAPTAIN EXPERIENCED A #1 EGT FAILURE SHORTLY AFTER DEP
ON A TRANSOCEANIC FLT AND RETURNED TO DEP ARPT.
ACN: 780578
Time / Day
Date : 200802
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Hydraulic System
Person : 1
Reference : 1
Person : 2
Reference : 2
Events

Assessments
Narrative: 1
MESSAGE WAS RECEIVED VIA ACARS THAT ECAM HYD 'G' SYS LEAK. REQUEST
WAS MADE OF PRESSURE AND QUANTITY. 2950 WAS PRESSURE SENT, NEVER
RECEIVED QUANTITY ANSWER. WITH PRESSURE BARELY IN AMBER RANGE AND
HEARING NO ANSWER ABOUT QUANTITY, I DIDN'T ASK IF CREW WANTED EQUIP
CALLED. AFTER ARR IN ZZZ, I NOTICED A LENGTHY TAXI-IN TIME. UPON CALLING
ZZZ, I WAS TOLD OF HYD FAILURE WHICH FORCED ACFT TO BE TOWED TO THE
GATE. I RECEIVED NO PHONE CALL FROM THE CREW ABOUT THIS INCIDENT.
Synopsis
FLT CREW OF A330 FAILS TO KEEP DISPATCH INFORMED OF PROGRESSION OF G
SYSTEM HYDRAULIC PROBLEM.
ACN: 778856
Time / Day
Date : 200803
Place
Environment
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Nosewheel Steering
Problem : Failed
Person
Reference : 1
Events

Assessments
Narrative: 1
NOSEWHEEL STEERING FAILED WITH ASSOCIATED ECAM AT GEAR DOWN ON THE
APCH. EXECUTED A GAR AND ACCOMPLISHED ALL PROCS. CONTACTED DISPATCH
VIA SATCOM AND THEY COULD NOT HELP. BRIEFED FLT ATTENDANTS AND PAX.
DECLARED AN EMER WITH APCH. LANDED ON RWY XXL IN ZZZ WITH NO OTHER
PROBS. HYD SELECTOR VALVE IN NOSEWHEEL STEERING SYS FAILED.
Synopsis
A330 ECAM INDICATED NOSEWHEEL STEERING FAILURE. FLT CREW DECLARED AN
EMER AND LANDED SAFELY.
ACN: 777274
Time / Day
Date : 200711
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Fan Reverser
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Assessments
Narrative: 1
FOUND SEAL BLOCK AND 2 RIVETS MISSING ON #1 ENG INBOARD THRUST
REVERSER UPPER FAIRING ON ETOPS CHK. INSTALLED SEAL BLOCK WITH
CORRECT BOLTS AND NUTS AND SECURED FAIRING WITH 2 SCREWS AND CLIP
NUTS. THE UPPER FAIRING WAS PROGRAMMED FOR REPLACEMENT MAINT
ROUTINE OVERNIGHT WITH NO REINSPECTION OR TERMINATING ACTION DATE.
DUE TO THIS ITEM HAVING NO TERMINATING DATE ASSIGNED IT WAS
DETERMINED THAT TRACKING WAS NOT REQUIRED. THE NOTIFICATION BY MY
LEAD MECH FROM THE SUPVR THAT THE PROPER PAPERWORK AND PROCS WERE
NOT COMPLIED WITH AND DOCUMENTED CORRECTLY. THE 2 SCREWS AND CLIP
NUTS WERE REMOVED AND REPLACED WITH BLIND RIVETS PER AMM TO BE REINSPECTED EVERY 2500 CYCLES AND REPLACED WITH SOLID RIVETS NO LATER
THAN 20000 CYCLES. THE FAILURE TO PROPERLY RESEARCH AND DOCUMENT THE
PAPERWORK AND COMPUTER ENTRIES NECESSARY FOR A FINAL TERMINATING
ACTION LED TO THIS EVENT. THROUGH CORRECT RESEARCH, DOCUMENTATION
AND COMPUTER ENTRIES THIS WOULD HELP ELIMINATE AND AVOID EVENTS LIKE
THIS.
Synopsis
AN AIRBUS A330 #1 ENG INBOARD THRUST REVERSER UPPER FAIRING WAS
FOUND WITH SEAL BLOCK AND TWO RIVETS MISSING. AFTER REPAIRS, NO REINSPECTION OR TERMINATING ACTION DATE RECORDED OR TRACKING
PROCEDURE ESTABLISHED.
ACN: 757094
Time / Day
Date : 200710
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Other
Assessments
Narrative: 1
WAS GIVEN HOLDING OF APPROX 45 MINS. DETERMINED WE DID NOT HAVE THAT
MUCH FUEL AND ADVISED ATC THAT WE WOULD NOT BE ABLE TO HOLD. ATC
ASKED IF WE WERE DECLARING MINIMUM FUEL AND I ELECTED TO DECLARE

MINIMUM FUEL AT THAT TIME. WAS ABLE TO GET SLOT FOR NO DELAY ARR. WX
WAS CLR AND VISIBILITY UNLIMITED. LANDED NORMAL WITH FLT PLANNED FUEL
ON BOARD. AN EARLY DSCNT BY CTR TO 4000 FT BELOW FLT PLAN RESULTED IN
A FUEL BURN THAT LEFT US WITH NO HOLDING FUEL. WX WAS CLR AND NO HOLD
ANTICIPATED. HOLD WAS GIVEN DUE TO SLOT SATURATION. WHEN ATC WAS
ADVISED WE WERE MINIMUM FUEL THEY CANCELLED HOLD AND WE CONTINUED
IN TO ZZZ. I HAD ASKED DISPATCH TO HAVE ATC DESK WORK SOMETHING OUT
SO WE WOULD NOT HAVE TO PROCEED TO ALTERNATE AND THEY DID. THE SYS
WORKED AS PLANNED AND WE LANDED WITH THE ORIGINAL FLT PLANNED ARR
FUEL. GOOD JOB BY EVERYONE. DISPATCH COULD KEEP A CLOSER LOOK AT THE
ARR SLOT SATURATION AND IF IT IS GETTING CLOSE TRY TO GET PRIORITY FOR
INTL ARRS THAT ARE APCHING MINIMUM FUEL.
Synopsis
A330 CAPT REPORTS DECLARING MINIMUM FUEL AFTER BEING ISSUED HOLDING
INSTRUCTIONS, AND RECEIVING CLEARANCE TO THE HEAD OF THE LINE.
ACN: 748486
Time / Day
Date : 200708
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Cockpit Canopy Window
Person
Reference : 1
Events
Assessments
Narrative: 1
CARGO DOOR ECAM, UNKNOWN CAUSE. AFT CARGO DOOR ECAM. ECAM AND
NOISE IN BACK. RETURN TO DEP FIRST FOR UNUSUAL NOISE IN BACK, AND THEN
SECOND TIME PLANE WOULD NOT PRESSURIZE AND THIRD TIME BECAUSE THE
GOOD SENSOR INDICATED OPEN. CALLBACK CONVERSATION WITH RPTR
REVEALED THE FOLLOWING INFO: THE REPORTER STATED THAT THIS SAME
EVENT OCCURRED ON THIS ACFT THE PREVIOUS DAY. THAT CREW RETURNED TO
THE DEP ARPT AND THE NEXT DAY WERE CALLED IN BY CHIEF PILOT FOR
INCORRECTLY RESPONDING TO THE ECAM PROCEDURE. THE DAY OF THIS EVENT,
THE ACFT PRESSURIZED NORMALLY DURING CLB BUT AT FL280 A DOOR ECAM
ILLUMINATED. THE CREW WAS UNABLE TO DETERMINE THE DOOR'S POSITION
AND THE FLT ATTENDANTS REPORTED A NOISE IN THE ACFT CABIN. THE CREW
ELECTED TO RETURN AND WERE MET BY THE CHIEF PILOT WHO CHASTISED THEM
FOR AN UNNECESSARY RETURN WHEN THEY SHOULD HAVE CONTINUED SINCE
THE PRESSURIZATION WAS NORMAL. HOWEVER, THE CREW CITED ABNORMAL
SOUNDS AND THE ECAM AS REASONS FOR THE RETURN. A MECHANIC WAS PUT
IN THE FLT STATION AND AFTER DEPARTING THE GATE, THE ECAM RETURNED
AND THE ACFT WOULD NOT PRESSURIZE. UPON RETURN TO THE GATE, A CARGO
DOOR SWITCH WAS MEL'ED AND THE FLT DEPARTED ONLY TO HAVE THE ECAM
AGAIN ALERT AT FL280 ON DEP. THE CREW ELECTED TO RETURN AGAIN AND THE
FLT WAS CANCELED. EACH TIME THE CREW RETURNED, MAINTENANCE ATTESTED
THAT THE DOOR WAS CLOSED BUT WERE UNABLE TO EXPLAIN THE DOOR ECAM'S
CONTINUED ALERTING. THIS REPORTER WAS CONCERNED BECAUSE THIS ACFT'S
CARGO DOOR IS NOT A PLUG TYPE DOOR AND THE POSSIBILITY OF IT OPENING
IF SOMETHING WAS WRONG WITH THE DOOR LOCKS OR STRUCTURE. THE
REPORTER STATED THAT BY THIS TIME THE 290 PASSENGERS HAD BEEN ON ACFT
8 HOURS AND HAD NOT BEEN ALLOWED BY THE PASSENGER SERVICE AGENTS TO
EXIT THE ACFT EVEN THOUGH THE CAPT HAD AUTHORIZED IT.
Synopsis
AN A330 PILOT REPORTS THREE AFT CARGO DOOR ECAM EVENTS ON THE SAME
ACFT AND TRIP WITH ONE FAILURE TO PRESSURIZE ON THE GND.
ACN: 748471
Time / Day
Date : 200707
Place
Aircraft
Reference : X
Component
Aircraft Component : Integrated Audio System
Person : 1
Reference : 1
Person : 2
Reference : 2
Events
Assessments
Contributing Factors / Situations : Airspace Structure

Narrative: 1
INCORRECT IDENT OF JOB PRIORITIES ON THE PAPERWORK PACKAGE. ROUTINE
OVERNIGHT CHK AT THE HANGAR IN ZZZ WITH 2 AUDIO CTL PANELS IN FLT DECK
ON MEL. THE INTL RELIEF OFFICER AUDIO CTL PANEL WITH A LOOSE PUSH-TOTALK SWITCH LOG PAGE PRIORITY 2 ON THE WORK RPT AND THE ADDITIONAL
OBSERVER'S SEAT AUDIO CTL PANEL PUSH-TO-TALK SWITCH BROKEN. LOG PAGE
XXXXXX PRIORITY 1 ON THE WORK RPT. WE ONLY HAD 1 AUDIO CTL PANEL IN
STOCK AT ZZZ. I WAS THEN INFORMED BY MY SUPVR TO FIX THE ADDITIONAL
OBSERVER'S SEAT AUDIO CTL PANEL DUE TO IT BEING A DROP DEAD MEL,
PRIORITY 1 LOG PAGE. I THEN REMOVED AND REPLACED THE ADDITIONAL
OBSERVER'S SEAT AUDIO CTL PANEL AS INSTRUMENTAL AND REMOVED THE MEL
FROM THE ACFT AND INFORMED MAINT CTL BY PHONE. LATER I WAS INFORMED
THAT THE PRIORITY CODES HAD BEEN INCORRECTLY STATED ON THE WORK CTL
CONTENTS RPT AND THAT THE INTL RELIEF OFFICER AUDIO CTL PANEL SHOULD
HAVE BEEN REPLACED. DISCREPANCY WAS IDENTED IN COMPUTER MAINT
PROGRAM. WHEN THE DISCREPANCY WAS IDENTED, THE IFO, AUDIO CTL PANEL
WAS REPLACED AT THE GATE. DROP DEAD ITEMS FOR MEL'S AND INSPECTIONS,
ETC, SHOULD BE INDICATED ON THE WORK CONTENTS RPT, IE, TIME REMAINING,
DAYS, CYCLES, HRS, ETC, OR INDICATED ON THE TALLY SHEETS.
Synopsis
AN AIRBUS A330 ACFT MECHANIC REPORTS INCORRECT IDENTIFICATION OF JOB
PRIORITIES ON THE PAPERWORK PACKAGE CAUSING INCORRECT MEL
REQUIREMENTS.
ACN: 748106
Time / Day
Date : 200707
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Door Warning System
Person : 1
Reference : 1

Person : 2
Reference : 2
Events
Assessments
Narrative: 1
CLBING THROUGH FL270, ECAM MESSAGE 'REAR CARGO DOOR.' ACFT LEVELED
OFF AT FL275. COMPLIED WITH ECAM (WE THOUGHT). ECAM SHOULD HAVE SAID
'IF ABN CAB V/S MAX FL-100 MEA.' STATUS PAGE SAID, 'MAX FL-100/MEA.' WE
SAW THE STATUS PAGE, BUT DID NOT SEE THE 'IF ABN CAB V/S' INFO. WE DID
APPEAR TO HAVE NORMAL CABIN PRESSURE, HOWEVER FO HAD PULLED OUT
OXYGEN MASK. HE THOUGHT THERE WAS A PRESSURE BUMP, BUT DID NOT PUT
ON MASK. CONSIDERING 3+ HR FLT OVERWATER, WE DECIDED TO RETURN TO
ZZZ. ESTIMATED LNDG WT OF 430000 LBS, MAX LNDG WT 412200 LBS. REFED
OVERWT LNDG CHKLIST. CHKLIST NOTE 'PERFORM AN OVERWT LNDG WHEN A
CONDITION CAUSES IT TO BE SAFER TO LAND OVERWT THAN THE CONTINUE FLT
UNTIL AT OR BELOW MAX CERTIFICATED LNDG WT.' PLANNED LNDG ZZZ, RWY
10506 FT, QRH INDICATED 5940 FT REQUIRED. BY SATCOM, I DISCUSSED
ALTERNATIVES WITH DISPATCH AND MAINT CTL. WE ALL AGREED TO LAND
OVERWT AND NOT HOLD FOR 1 1/2-2 HRS TO BURN DOWN TO MAX LNDG WT.
RETURNED TO ZZZ. AFTER BRAKES COOLED, RETURNED TO GATE. MAX BRAKE
TEMP 580 DEGS. OUR PLT HANDBOOK HAS A CHAPTER WHICH IS A DETAILED
VERSION OF THE ECAM FOR NON-NORMAL PROCS. IT IS 210 PAGES LONG AND
STATES, 'AFTER PERFORMING THE ECAM ACTIONS AND REVIEWING ECAM
STATUS, REFER TO THE PLT'S HANDBOOK PROC FOR SUPPLEMENTAL INFO IF TIME
PERMITS.' ON THIS PAGE FOR THE CARGO DOOR OPEN, A NOTE SAYS, 'INFLT -NO CREW ACTION REQUIRED AS LONG AS CABIN PRESSURE IS NORMAL.' THIS IS
NOT ANNOTATED ON ECAM. WE WERE ATTEMPTING TO COMPLY WITH ECAM
STATUS PAGE, DSNDING TO FL100, BEFORE EVER GETTING TO THIS CHAPTER.
CHIEF PLT REQUESTED A MEETING WITH THE FLT CREW TO DISCUSS FLT, WITH
UNION REPRESENTATIVES THE NEXT DAY. HE DID NOT AGREE WITH OUR RETURN
TO ZZZ AND OUR DECISION TO LAND OVERWT. WE WERE GIVEN TRAINING IN
ECAM USAGE AT THIS TIME BY A CHK AIRMAN. MY CONCERNS ARE: 1) DOES IT
MAKE ANY SENSE TO CONTINUE A FLT WITH AN UNKNOWN CARGO DOOR PROB
ON AN ETOPS FLT JUST BECAUSE AIRBUS SAYS IT'S OK, ESPECIALLY WHEN YOU
ARE ONLY 25 MINS INTO THE FLT? 2) CRM IS STRESSED EXTENSIVELY IN OUR
TRAINING AND THAT INCLUDES WITH DISPATCH AND MAINT CTL. ALL 3 AGREED
ON THE OVERWT LNDG. THEN WE WERE ALL BEING SECOND GUESSED BY THE
CHIEF PLT. NOTE: AS MEETING CONCLUDED, CHIEF PLT WAS NOTIFIED THE SAME
ACFT, SAME FLT NUMBER, WITH THE SAME CARGO DOOR INDICATION, HAD JUST
LANDED IN ZZZ AND MADE AN OVERWT LNDG. MAINT COMPLIED WITH CARGO
DOOR MEL, WHICH INHIBITS THE DOOR WARNING. SAME ACFT DEPARTED ONCE
MORE, SAME FLT NUMBER. EVEN THOUGH THE DOOR WARNING HAD PRESUMABLY
BEEN DISABLED, THE WARNING CAME ON ONCE AGAIN! ACFT ONCE AGAIN
RETURNED TO ZZZ WITH AN OVERWT LNDG.
Synopsis
A330 ECAM INDICATED 'REAR CARGO DOOR' WARNING DURING CLIMBOUT. FLT
CREW RETURNED TO DEP ARPT AND LANDED OVERWEIGHT.
ACN: 745134
Time / Day
Date : 200707
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Other
Assessments
Narrative: 1
I WAS SURPRISED TO LEARN ATC HAD DECLARED AN EMERGENCY FOR US. THERE
WAS NO TCAS INVOLVEMENT. ATC DECLARED AN EMERGENCY WITHOUT OUR
INPUT. WE WERE GIVEN HOLDING INBOUND TO ZZZ. CENTER SAID ZZZ HAD
LOST A RWY AND THE HOLD WAS INDEFINITE. WE DETERMINED OUR FILED
ALTERNATE WAS NO LONGER FEASIBLE DUE TO THUNDERSTORMS. I CALLED
DISPATCH ON THE SAT PHONE AND WE CHANGED ALTERNATE. WE THEN
DETERMINED WE HAD FUEL FOR ONLY 3 TURNS IN THE PATTERN AND ADVISED
ATC AND THE DISPATCHER THAT WE WERE DECLARING MINIMUM FUEL AND THAT
IF WE DID NOT START INBOUND FOR ZZZ WE WOULD HAVE TO PROCEED TO OUR
ALTERNATE. THE DISPATCHER ACARS'ED THAT HE AGREED. WE WERE THEN
GIVEN A HEADING TOWARDS ZZZ AND HANDED OFF TO ANOTHER CENTER. TO
CLARIFY, I ASKED CENTER IF HE WAS AWARE OF OUR MIN FUEL DECLARATION,
AND THAT WE COULD NOT ACCEPT FURTHER HOLDS INTO ZZZ. HE STATED THAT
THE CENTER HAD DECLARED AN EMERGENCY FOR US. I STATED THAT WE WERE
NOT IN AN EMERGENCY CONDITION AND THAT OUR SITUATION WAS THAT IF
THEY TRIED TO GIVE US A HOLDING CLEARANCE THAT WE WOULD HAVE TO
PROCEED IMMEDIATELY TO OUR ALTERNATE ZZZ1. HE SAID THEY UNDERSTOOD
AND THAT THEY HAD STILL DECLARED AN EMERGENCY FOR US. WE CONTINUED
TO ZZZ WITH MINOR DEVIATIONS FOR THUNDERSTORMS AND MADE A NORMAL
LANDING IN ZZZ. COMPANY POLICY IS TO CARRY MINIMUM AMOUNT OF FUEL AND
ACCEPT DIVERSIONS TO ALTERNATE. TO AVOID THIS WE SHOULD BE CARRYING
MORE CONTINGENCY FUEL. ATC SHOULD INFORM ACFT THAT AN EMERGENCY HAS
BEEN DECLARED FOR THEM.
Synopsis
AN A330 WITH A MIN FUEL, NO DELAY REQUEST WAS INFORMED THAT ATC
DECLARED AN EMERGENCY FOR THEM BECAUSE OF MINIMUM FUEL.
ACN: 733137
Time / Day
Date : 200703
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Function.Flight Crew : Other / Unknown
Events
Assessments
Narrative: 1
THE FLIGHT WAS GIVEN THE OKAY TO PUSH BY GND CTL. LOAD PLANNING
CALLED DISPATCH TO ADVISE THE CHILD COUNT TO BE 50. I CONTACTED THE
FLIGHT TO CONFIRM. THE CREW THEN ADVISED THE NUMBER OF CHILDREN ON
BOARD TO BE 16. THE FLIGHT RETURNED TO THE GATE FOR REMOVAL OF A
PALLET TO BALANCE THE AIRCRAFT. I CONTACTED THE CREW VIA ACARS TO
CHECK ON THE CHILD COUNT AFTER BEING ALERTED BY LOAD PLANNING. THIS IS
HOW IT CAME TO MY ATTENTION. ONCE THE EVENT WAS IDENTIFIED THE
AIRCRAFT RETURNED TO THE GATE TO HAVE THE NECESSARY WEIGHT REMOVED
FOR WEIGHT AND BALANCE PURPOSES. MUST HAVE ACCURATE PASSENGER
COUNT.
Synopsis
A330 MUST RETURN TO HAVE CARGO REMOVED WHEN IT IS LEARNED THAT AN
EXCESSIVE NUMBER OF CHILD WTS HAVE BEEN UTILIZED FOR THEIR TKOF
PERFORMANCE DATA.
ACN: 724468
Time / Day
Date : 200701
Place
Environment
Weather Elements / Visibility : Windshear
Weather Elements / Visibility.Visibility : 1.5
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : ZZZZ.Tower
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : 26L
Route In Use.Other
Component
Aircraft Component : Autothrottle/Speed Control
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
ILS APCH, RWY 26L, ZZZZ, JAN 2007. VERY WINDY (230/20G35). TOPS 5000 FT
MSL. IMC CONDITIONS THROUGHOUT VECTORS, APCH AND GO AROUND.
MODERATE TO SEVERE TURB THROUGHOUT. AT ABOUT 1000 FT AGL RECEIVED
PWS (PREDICTIVE WINDSHEAR) WARNING. EXECUTED REQUIRED GO AROUND.
STILL IMC. FOLLOWED MAP PROC, PROCEEDED STRAIGHT AHEAD, LEVELED OFF
AT 3000 FT MSL. CAPT (PF) CALLED, 'FLAPS 3, POSITIVE RATE, GEAR UP,' AT
START OF GO AROUND BUT FO DID NOT COMPLY DUE TO CONFUSION OVER
WHETHER THIS WAS A WINDSHEAR PROC (GEAR AND FLAPS TO REMAIN AS THEY
WERE) OR A STANDARD GO AROUND (GEAR/FLAPS UP). HOWEVER, ACFT
PERFORMANCE UPON GO AROUND INITIATION WAS VERY POSITIVE AND
IMMEDIATE. DURING END OF VERY RAPID CLB FROM 1000 FT MSL TO 3000 FT
MSL, FLAPS BEGAN TO OVERSPD. RELIEF CAPT IN EXTRA CREW SEAT REITERATED
CALL FOR FLAP RETRACTION AND FO RESPONDED WITH RAPID SUCCESSION FLAP
RETRACTION TO FULL UP. APCHING LEVEL OFF AT 3000 FT MSL PF REDUCED
THRUST AND GOT NO RESPONSE. ENGS WERE AT MAX TOGA THRUST. PF'S
ATTENTION BEGAN TO BE FOCUSED EXCLUSIVELY BETWEEN FLYING AIRPLANE,
LEVELING OFF, RAPIDLY INCREASING AIRSPD AND LACK OF ENG RESPONSE TO
THRUST LEVER POSITIONS TO REDUCE THRUST. DURING THIS TIME ATC CALLED
FOR LEFT TURN -- FO VERBALLY RESPONDED BUT PF DID NOT DUE TO TASK
SATURATION CAUSED BY ENG THRUST PROB AND RAPIDLY BUILDING AIRSPD.
SECOND ATC CALL FOR LEFT TURN NOT RESPONDED TO FOR SAME REASON.
THIRD CALL BY ATC FOR LEFT TURN RESPONDED TO AND COMPLIED WITH. BY
THIS TIME, ACFT SPD HAD BUILT UP TO THE POINT OF 'AUTO SYSTEM SPD
PROTECTION FEATURE ACTIVATION' CAUSING ACFT TO CLB ON ITS OWN
(AGAINST PLT INPUTS TO REMAIN LEVEL) IN ATTEMPT TO PREVENT ACFT
OVERSPD. BY 3700 FT MSL, ENGS BEGAN TO RESPOND -- CLB STOPPED AT 4000
FT MSL. ATC OBSERVED THE CLB AND RECLEARED US TO MAINTAIN CURRENT ALT
OF 4000 FT MSL. PF TRIED MULTIPLE TIMES TO REGAIN THRUST CTL THROUGH
THROTTLE REDUCTIONS AS FAR BACK AS IDLE AND MULTIPLE USE OF AUTOTHRUST DISCONNECT BUTTONS TO NO AVAIL. UPON ANNOUNCING THRUST PROB
TO THE OTHER PLTS, RELIEF CAPT ALSO TRIED SAME THINGS MULTIPLE TIMES.
FINALLY, ENG RESPONSE RETURNED. QUALITY OF HUMAN PERFORMANCE
AFFECTED BY A) FATIGUE INDUCED BY OVERNIGHT FLT FROM ZZZ TO ZZZ1 (8
HOURS FLT). B) MODERATE TO SEVERE TURB THROUGH APCH, GO AROUND AND
POST GO AROUND INCIDENT. C) CONFUSION ON PART OF FO REGARDING
COMMANDS FOR CONFIGURATION CHANGE AFTER WINDSHEAR-INSTIGATED GO
AROUND.
SUPPLEMENTAL INFO FROM ACN 724464: OBSERVED WINDS OF 245/70 AT 4000
FT, 245/65 AT 3000 FT, 245/45 AT 1500 FT. MODERATE TURB BELOW 5000 FT.
MOMENTARY AIRSPD FLUCTUATIONS OF +/- 10 KTS OBSERVED, ONCE WE WERE
DSNDING ON THE GLIDESCOPE. NO WINDSHEAR WAS RPTED ON ZZZZ TWR
FREQ. SHORTLY AFTER PASSING 4.0 DME ON FINAL, A PREDICTIVE WINDSHEAR
WARNING WAS RECEIVED, WITH AN AREA (STRIPED ICON) OF WINDSHEAR
AHEAD ON FINAL APCH DISPLAYED ON THE ND'S. THE PF (CAPT) IMMEDIATELY
ANNOUNCED HIS DECISION TO INITIATE A GO AROUND, ADVANCED THRUST
LEVERS TO TOGA POSITION AND CALLED FOR 'FLAPS 3,' FOLLOWED SHORTLY
THEREAFTER BY 'GEAR UP.' I MOMENTARILY THOUGHT THAT THE PRESENT
CONFIGURATION (GEAR DOWN, FLAPS FULL) SHOULD BE MAINTAINED AS IN A
WINDSHEAR RECOVERY MANEUVER, HOWEVER A CHK OF THE FO'S FLT
INSTRUMENT SHOWED THAT THE ACFT WAS ACCELERATING AND CLBING. THE FO
DID NOT SELECT FLAPS 3 OR THE RETRACT THE LNDG GEAR, IN RESPONSE TO
THE CAPT'S COMMANDS TO DO SO. I STATED THAT THE FLAPS WERE STILL IN
THE FULL POSITION. THE FLAP LOAD SYSTEM RELIEF WAS ACTIVATED, AND THE
FLAPS WERE RETRACTED AUTOMATICALLY FROM THE FULL POSITION. I STATED
AGAIN THAT WE NEEDED TO RETRACT THE FLAPS, AND EVENTUALLY THE FO
MOVED THE FLAP HANDLE TO THE FLAPS 3 POSITION. I THEN STATED THAT WE
NEEDED TO CLEAN THE ACFT UP, AND THAT THE FLAPS AND GEAR WERE
EXTENDED, AND THAT THE FLAPS WERE BEING OVERSPEEDED. THE ACFT WAS
RAPIDLY ACCELERATING AS IT CLBED, AND THE FLAP LOAD RELIEF SYSTEM KEPT
RETRACTING THE FLAPS FROM THE SELECTED POSITIONS OF THE FLAP HANDLE.
EVENTUALLY, THE FLAP HANDLE WAS MOVED TO THE CLEAN POSITION, HOWEVER
T
Synopsis
AN A330 EXPERIENCED AN UNCANCELABLE TOGA LOCK THRUST CONDITION
FOLLOWING A PREDICTIVE WINDSHEAR GO AROUND.
ACN: 719893
Time / Day
Date : 200612
Place
Locale Reference.Navaid : JHW.VOR
Environment
Light : Night
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZOB.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZOB.A
Aircraft : 2
Reference : Y
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
CLB RATE OF HVY AIRBUS WAS INCONSISTENT. ONCE CLB RATE DROPPED, ACFT
CAME INTO CONFLICT WITH ENRTE TFC. ALSO PLT OF AIRBUS TFC MADE EARLY
TURN ON JET RTE FROM PRESCRIBED ROUTING. ACFT IN CONFLICT HAD RA
WHICH ADVISED TO DSND, WHICH SECOND ACFT DID.
Synopsis
ZOB CTLR EXPERIENCED OPERROR AT FL320 WHEN CLBING AIRBUS CONFLICTED
WITH ENRTE TFC.
ACN: 713857
Time / Day
Date : 200610
Place
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component : 1
Aircraft Component : Fuel Control Computer
Component : 2
Aircraft Component : AC Generator/Alternator
Component : 3
Aircraft Component : Electrical Wiring & Connectors
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
ACFT AIRBUS A330, SERIAL NUMBER X, OPERATED BY ACR FROM ZZZ ARPT TO
ZZZZ, RETURNED TO ZZZ AFTER 50 MINS OF FLT DUE TO ENG #2 N1, N2 AND
EGT OSCILLATION AND ENG PWR REDUCTION BY FLT CREW. CORRECTIVE
ACTIONS: ENG #2 (MODEL CF6-80E1A3), ELECTRONIC CTL UNIT, PERMANENT
MAGNET ALTERNATOR AND WIRING (REF 4258KS, 4256KS AND 4261KS) WERE
REPLACED ACCORDING TO AIRBUS AMM (ACFT MAINT MANUAL). ENG RUN UP
TEST PERFORMED OK AND ACFT RELEASED FOR SVC.
Synopsis
AN A330-200 IN CRUISE RETURNED TO THE DEP ARPT DUE TO #2 ENG N1, N2,
AND EXHAUST GAS TEMP OSCILLATION AND PWR REDUCTION BY CREW.
ACN: 711329
Time / Day
Date : 200609
Place
Locale Reference.Airport : CYYT.Airport
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.Center : CZQX.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : CZQX.A
Component
Person : 1
Reference : 1

Person : 2
Reference : 2
Events
Result.Flight Crew : Overrode Automation
Assessments
Narrative: 1
DURING THIS POTION OF CRUISE FLT, THE ACFT EXPERIENCED MODERATE TURB.
WE REDUCED THE SPD TO THAT APPROPRIATE TO TURBULENT AIR PENETRATION
AND SWITCHED TO CONTINUOUS IGNITION. THE CAPT WAS ON HIS SCHEDULED
BREAK AND I WAS THE ACTING PIC. SHORTLY WE ENCOUNTERED (OR THE TURB
LED THE AUTOPLT TO ARTIFICIALLY CREATE) WAVE ACTION. IT BEGAN A LIGHT,
BUT ABOUT THE SIXTH 'PARABOLA' HAD BECOME MODERATE OR GREATER. OUR
IVSI MODULATED BTWN AN 1800 FPM CLB AND 1800 FPM DSCNT. OUR IAS, BTWN
10 KTS BELOW VMO/MMO AND ABOUT 10 KTS BELOW GREEN DOT, A SPREAD OF
CLOSE TO 40 KTS. IT WAS THEN THAT I DISCONNECTED BOTH AUTOPLT AND
AUTOTHRUST AND BROUGHT THE ACFT BACK TO STRAIGHT AND LEVEL. I THEN
RECONNECTED BOTH AUTOPLT AND AUTOTHRUST. LIGHT TO MODERATE TURB
CONTINUED, BUT THE WAVE ACTION HAD CEASED. THIS IS WHY I BELIEVE THAT
THE ACFT HAD CREATED OR SIGNIFICANTLY CONTRIBUTED TO ITS OWN WAVE
EFFECT. THE FLT CONTINUED WITHOUT FURTHER INCIDENT, BUT OUR
EXCEEDANCE RPT WAS GENERATED BY THE PRINTER. OBSERVATION AND
OPINION: 1) THE AIRBUS SOFTWARE PACKAGE SHOULD INCLUDE A PROGRAM TO
DAMPEN SELF-INDUCED WAVE ACTION. 2) WE SHOULD RECEIVE TRAINING ON
PROPER RECOVER TECHNIQUES. 3) I HAD REACTED, IN PART, TO THRUST INPUTS
WHICH MODULATED FROM FLT IDLE TO THE TLA (THRUST LEVER ANGLE), BUT
THERE IS NO INDICATION, THAT WE HAD A THRUST MGMNT PROB. AT LEAST
INITIALLY I SHOULD HAVE LEFT THE AUTOTHRUST ENGAGED AND DISCONNECTED
ONLY THE AUTOPLT. MY MISTAKE. IT CREATED MORE WORK IN AN ALREADY
DIFFICULT SITUATION. 4) I SHOULD HAVE TURNED UP THE EFIS BACKGROUND
LIGHTS AT THE START OF THE EVENT. SCREENS THAT ARE EASY TO READ IN
SMOOTH, STRAIGHT AND LEVEL FLT BECOME VERY DIFFICULT TO OBSERVE IN
MODERATE TURB AND WAVE ACTION. ADJUSTING THE SCREENS WHILE HAND
FLYING IS, OF COURSE, IMPOSSIBLE. CALLBACK CONVERSATION WITH RPTR
REVEALED THE FOLLOWING INFO: RPTR STATED THAT HE STILL BELIEVES THE
ACFT CONTINUED IN SELF INDUCED OSCILLATIONS BECAUSE OF HOW RAPIDLY
THE OSCILLATIONS CEASED AFTER THE AUTOPLT AND AUTOTHRUST WERE
REMOVED. HE STATED THE TURB DID NOT END BUT THE ACFT'S APPARENT WAVE
MOTION DID CEASE FOLLOWING HIS ACTIONS. DURING A DISCUSSION ABOUT
POSSIBLE RVSM TCAS WARNINGS, THE RPTR STATED THAT A TCAS WARNING
WAS NOT A CONCERN AT THEIR PARTICULAR LOCATION. HOWEVER THE RPTR
STATED THAT HE TALKED WITH A CAPT WHO HAD EXPERIENCED A SIMILAR
EVENT AND A TCAS REACTION WAS REQUIRED.
Synopsis
AN A330 PLT DESCRIBES A WAVE ACTION EVENT WITH MODERATE TURB AND AN
AIRSPD EXCEEDANCE.
ACN: 700638
Time / Day
Date : 200606
Place
Aircraft
Reference : X
Mission : Passenger
Component
Aircraft Component : Oil Filler Cap
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3

Events
Assessments

Aircraft
Logbook Entry
Human Factors
Narrative: 1
ON JUN/SAT/06, ACFT LANDED IN ZZZ FROM ZZZZ1. PER OUR COMPANY POLICY,
A PREDEP CHK (WORK CARD) WAS ACCOMPLISHED. PER CHK REQUIRED OIL CHK
AFTER 45 MINS TO WITHIN 2 HRS. OIL CHK ON #2 ENG WAS ACCOMPLISHED AND
CHKED FULL. REMOVED OIL CAP AND PUSHED IN SCUPPER SEAL TO VERIFY FULL.
REINSTALLED OIL CAP. SECURED CLOSED AND PULLED ON CHAIN TO VERIFY
SECURED. CLOSED OIL SVC DOOR, OIL QUANTITY VERIFIED 22.4 QUARTS, MADE
LOGBOOK ENTRY. #2 ENG WAS ON OIL WATCH. LOG ENTRY WAS MADE DURING
CRUISE ON JUN/SAT/06. I FIND THIS INCIDENT IS INCONCEIVABLY WRONG. AS I
FOLLOW THE SAME PROCESS FOR THE LAST 15 YRS, I WILL ALWAYS INSTALL OIL
CAP AND MAKE SURE IT SECURED BY PULLING ON THE CHAIN WITH
CONSIDERABLE FORCE TO MAKE SURE IT DOES NOT COME OFF. THEN I WILL DO
A VISUAL CHK PRIOR TO CLOSING OIL SVCING DOOR. AS FOR MAKING SURE THIS
WILL NEVER HAPPEN A SECOND TIME, I WILL FOLLOW THE SAME ACTION I HAVE
PRACTICED FOR THE LAST SEVERAL YRS ALONG WITH ASKING A CO-WORKER TO
HAVE A SECOND LOOK TO VERIFY CAP IS ON AND SECURED.
Synopsis
AN A320 IN CRUISE RPTED LOSS OF #2 ENG OIL. ON GND DISCOVERED OIL CAP
NOT SECURED.
ACN: 692074
Time / Day
Date : 200603
Place
Locale Reference.ATC Facility : EISN.ARTCC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : EISN.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : EISN.A
Component
Aircraft Component : Transponder
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : EISN.ARTCC
Person : 5
Reference : 5
Location Of Person.Facility : LFRR.ARTCC
Events
Assessments
Narrative: 1
ESTABLISHED LEVEL NORTH ATLANTIC YANKEE. AS FO LEAVING TO TAKE THE
SECOND REST BREAK, XPONDER DIGITAL SCREEN DISPLAY WENT BLANK. UPON
RETURN NO CHANGE TO XPONDER ALONG WITH TCAS FAIL ON ECAM. BEFORE
TAKING LAST REST BREAK CAPT ADVISED HE SPOKE WITH DISPATCH AND MAINT.
ALSO MENTIONED GANDER 'SAW' US ON CODE XXXX. CONTACTED SHANNON CTR
AT SOMAX INTXN. ADVISED SHANNON UNABLE TO CHANGE SQUAWK. SHANNON
REPLIED WE WERE IN RADAR CONTACT WITH CORRECT ALT READOUT ON CODE
XXXX. SENT MESSAGE TO DISPATCH TO ADVISE FRENCH AND ITALIAN ATC OF
SITUATION. UPON XFER TO BREST CTL WE WERE ASSIGNED SQUAWK CODE.
ADVISED UNABLE. BREST REPLIED WE COULD NOT CONTINUE IF UNABLE TO
SQUAWK CODE ASSIGNED. SENT MESSAGE TO DISPATCH AND RECALLED CAPT
FROM BREAK. UPON RETURN, CAPT ASKED CTL TO AGAIN CHK ON CODE XXXX.
CTLR THEN CLRED US TO CONTINUE. SUBSEQUENT CTLRS CLRED US ON RTE AND
TO FL270 BELOW RVSM AIRSPACE LEADING ME TO QUESTION WHETHER WE
WERE IN FACT IN RADAR CONTACT WITH ALT READOUT. CONTINUED TO
UNEVENTFUL LNDG LIRF. FATIGUE AND LANGUAGE BARRIERS ARE FACTORS IN
OUR ASSESSMENT AND PERCEPTION OF SITUATION. NOT SURE IF IT WAS THE
CAPT ASKING ATC TO CHK AGAIN CODE XXXX OR DISPATCH COORDINATING
WITH THEM THAT ALLOWED US TO CONTINUE. AS SHANNON DID SAY RADAR

CONTACT CODE XXXX MY ASSUMPTION WAS FRANCE AND ITALY WOULD AS WELL.
NOT SURE THEY FULLY UNDERSTOOD OR WERE CAPABLE WITH THEIR EQUIP.
THIS ACFT E&E COMPARTMENT IS PRESSURIZED AND ACCESSIBLE FROM THE
COCKPIT. WITHOUT PROVISIONS FOR OXYGEN CAPT ELECTED NOT TO PROCEED
WITH MAINT SUGGESTION TO RESET XPONDER CIRCUIT BREAKER. ON ARR,
MAINT REATTACHED 2 CANNON PLUGS AND RECOVERED OP OF XPONDER AND
TCAS.
Synopsis
A320 EXPERIENCES LOSS OF ABILITY TO TUNE XPONDER WHILE ESTABLISHED AT
AN RVSM FLT LEVEL ON A NAT. ATC AGREES TO ACCEPT THEM BASED ON CODE
OF XXXX WITH ALT READOUT.
ACN: 689518
Time / Day
Date : 200603
Place
Locale Reference.Navaid : OMN.VORTAC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZJX.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZJX.A
Person : 1
Reference : 1
Location Of Person.Facility : ZJX.ARTCC
Person : 2
Reference : 2
Events
Anomaly.Airspace Violation : All Types

Assessments
Narrative: 1
I WAS WORKING R57 ST JOHNS SECTOR AT ZJX ARTCC. THE PLKA MOA'S WERE
HOT FROM SURFACE TO FL240. THE ORCA ALTRV WAS HOT BLOCK ALT FL190FL230. THIS IS USED TO TRANSIT MIL ACFT FROM W158A TO THE PLKA MOA. I
HAD CLBED ACR X TO FL180 TO TRANSIT UNDER THE ALTRV. THE CTLR (NEXT TO
ME R58 SGJ) A '4000' CODE (BEACON FOR MIL) ACFT TRANSITING UNDER THE
ALTRV AT FL180. I IMMEDIATELY DSNDED ACR X TO 17000 FT TO AVOID TFC. THE
PLT QUESTIONED ME AS HE WANTED TO CLB TO CRUISE. I REITERATED 17000 FT.
AFTER PASSING THE 4000 CODE INTRUDER (SHOULD HAVE BEEN IN THE ALTRV
BTWN FL190-FL230), I CLBED ACR X BACK TO FL180. SHORTLY AFTERWARDS, I
NOTICE 4000 CODES SPILLING OUT OF THE PLK MOA ON THE N3 SIDE, THEY
WERE AROUND FL188. I CALLED THE SUPVR OVER AND TOLD HIM I WAS VERY
UNCOMFORTABLE CLBING MCO DEPS TO FL180 WITH ALL THE SPILLOUTS GOING
ON. SHORTLY AFTER THIS I HAD ACR Y AN MCO DEP. I ONLY CLBED HIM TO 17000
FT. GOOD THING BECAUSE AS HE APCHED THE MOA AND ALTRV MORE 4000
CODES WERE SPILLING OUT OF THE SE SIDE OF THE MOA AT FL186-FL188. I
CALLED THE TFC TO ACR Y AND HE GOT A VISUAL ON THEM. THIS SIT REQUIRED
EXTREME VIGILANCE WHICH DETRACTED FROM MY ABILITY TO MANAGE THE
SECTOR. I WAS PRETTY BUSY AT THE TIME. WITH THE MOA'S HOT AND THE
ALTRV HOT, OUR USABLE AIRSPACE IS SEVERALLY LIMITED. ALL DEPS (WHEN
MCO IS N A N OP) MUST E HELD DOWN AT FL180 FOR 40-50 MI TO TRANSIT
UNDER THE ALTRV. TO COMPOUND THIS THE LATERAL BOUNDARIES ESSENTIALLY
SHRINK TO 11 MI, TO BOTH CLB DEPS AND DSND ARRS. 2 STREAMS IN AN 11 MI
WIDE CORRIDOR? PLUS TRYING TO MISS THE MOA. I USED VISUAL SEPARATION
TO CLB ANOTHER FLT THROUGH A JAX LANDER. HE OFFSET TO THE W TOWARDS
THE MOA. ALSO AT THIS TIME ORL APCH WAS TRYING TO HAND OFF AN ACFT
THAT HAD NO FLT PLAN IN THE SYS. I AGAIN CALLED FOR THE SUPVR AND ASKED
FOR A D-SIDE (RADAR ASSOCIATE). BECAUSE WE WERE SHORT STAFFED, ONE
WAS NOT AVAILABLE. ULTIMATELY HE BROKE TRAINING TO SEND SOMEONE OVER
TO HELP. ORL ASKED WHAT TO DO WITH THE ACFT, IF HE SHOULD HOLD HIM, I
SAID YES. HE MISUNDERSTOOD AND HELD ALL OF HIS DEPS. I BELIEVE HE SPUN
4 ACFT. THESE TYPE OF EVENTS SEEM TO BE A DAILY OCCURRENCE AT THIS
SECTOR WITH THE ORCA ALTRV HOT. I BELIEVE MARCH TO THE WRONG TIME TO
EXECUTE MAJOR MIL EXERCISES IN THIS PARTICULAR AREA. MARCH IS PROBABLY
OUR BUSIEST MONTH AT ZJX ARTCC WITH SPRING BREAK TFC, ETC. ALSO WITH
THESE MOA'S AND ALTRV HOT JUST N OF ORL APCH BOUNDARY, OUR ABILITY TO
MOVE THIS TFC IS SEVERELY HAMPERED. IT CERTAINLY PUTS UNDO STRESS ON
THE ENTIRE SYS. IT'S ONLY MADE WORSE WHEN THE MIL ACFT DO NOT REMAIN
CONTAINED WITHIN THE DESIGNATED AIRSPACE (AS IN THIS CASE). IT WOULD
APPEAR THAT SCHEDULING THE EXERCISES DURING A SLOWER TFC SEASON
WOULD BENEFIT ALL THE USERS.
Synopsis
ZJX CTLR DESCRIBED POTENTIAL CONFLICTS WHEN VECTORING DEPS FROM MCO
AND PROVIDING CLRNC FROM SEVERAL MIL ACFT THAT WERE SPILLOUTS FROM
RESTR AIRSPACE.
ACN: 679927
Time / Day
Date : 200511
Place
Aircraft
Reference : X
Component
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events

Assessments
Aircraft
Airspace Structure
Human Factors
Narrative: 1
ON NOV/FRI/05 I WAS ASSIGNED TO INSTALL THE SLIDE COVERS PER 'A' CHK
JOB CARD. I INSTALLED THE SLIDE COVERS ON L1, R1, R2, L2 AND R3. THE
OTHER DOORS HAD THE SLIDE COVERS ON ALREADY, MAINT WAS BEING DONE
ON THE L4 AND R4 DOORS AT THE TIME AND OTHER DOORS EARLIER. THE ACFT
DEPARTED ZZZ AND ON ARR TO ITS DEST (I'M GUESSING ON A DAILY CHK) SLIDE
PINS WERE FOUND ON DOOR OR DOORS. I DON'T KNOW WHICH. I ACCEPTED
FULL RESPONSIBILITY FOR NOT CHKING THE DOORS THAT HAD THE SLIDE
COVERS ON. THIS COULD HAVE BEEN PREVENTED BY HAVING INDIVIDUAL
BLOCKS FOR EACH DOOR SLIDE COVER INSTALLATION.
Synopsis
AN A330 WAS DISPATCHED OUT OF AN 'A' CHK WITH DOOR ESCAPE SLIDE
SAFETY PINS STILL INSTALLED. DISCOVERED ON ROUTINE OVERNIGHT CHK.
ACN: 679881
Time / Day
Date : 200512
Place
Locale Reference.Airport : BUF.Airport
Environment
Light : Night
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Make Model Name : B757-200
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Assessments
Narrative: 1
I CLBED ACR X NEBOUND FROM FL330 CLB TO FL370. WHEN I NOTICED THE
SLOW CLB, I TURNED ACR Y NWBOUND 15 DEGS L FOR DIRECT ECK. AFTER 30
SECONDS, I OBSERVED NO TURN (I BELIEVE THAT HAD THE ACR Y INITIATED THE
TURN, THAT THE ERROR WOULD HAVE BEEN AVOIDED). I TURNED THE DAL
FURTHER AND I ALSO TURNED THE ACR X, BUT SEPARATION WAS LOST.
Synopsis
ZOB CTLR EXPERIENCED OPERROR AT FL340 WHEN ACR WAS LATE TO REACT TO
CTL INSTRUCTIONS.
ACN: 677023
Time / Day
Date : 200510
Place
Locale Reference.ATC Facility : ZOA.ARTCC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : ZOA.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZOA.A
Person : 1
Reference : 1
Location Of Person.Facility : ZOA.ARTCC
Experience.Air Traffic Control.Non Radar : 5
Person : 2
Reference : 2
Events
Assessments
Narrative: 1
I HAD AN OPERROR WHILE WORKING SECTOR OC-5 AT ZOA. I XFERRED ACFT X
AT DOHRT AND STATED HE WAS AT FL390 WHEN HE WAS ACTUALLY AT FL370. I
WAS WORKING ON A NEW SYS (ATOPS) FOR LESS THAN 2 WKS WHEN THE ERROR
OCCURRED. THE ERROR SHOULD BE COVERED UNDER AN IMMUNITY AGREEMENT
COVERED IN A NATIONAL MOU.
Synopsis
ZOA CTLR DESCRIBED POSSIBLE ERROR WHEN RELAYING WRONG ALT INFO TO
ADJACENT CTLR.
ACN: 667308
Time / Day
Date : 200508
Place
Locale Reference.Navaid : ILM.VORTAC
State Reference : NC
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZDC.ARTCC
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZDC.A
Person : 1
Reference : 1
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1.75

Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Assessments
Narrative: 1
I WAS WORKING THE RADAR POS R-48 GEORGETOWN AT ZJX. I RECEIVED THE
HDOF ON A330 (ACFT #1) FROM ZDC R-09 AND THEY CHKED ON THE FREQ AT
FL400 WHILE STILL IN ZDC AIRSPACE (ABOUT 20 MI FROM MY BOUNDARY). I HAD
SWITCHED B737 (ACFT #2) AT FL390 TO ZDC R-09 A FEW MINS BEFORE, AND
AFTER B737 CROSSED THE CTR BOUNDARY INTO ZDC AIRSPACE, I NOTICED THAT
HIS ALT WAS SHOWING FL393. THIS CAN BE A COMMON OCCURRENCE AS WE
SOMETIMES GET BAD RADAR HITS AND THE NEXT UPDATE WILL SHOW THEM
LEVEL. THE NEXT UPDATE, HOWEVER, SHOWED THE ALT AS FL395. I CALLED
SECTOR 09 ON THE LANDLINE ASKING WHAT WAS THE B737 DOING SINCE HE
HAD TFC HEAD-ON AT FL400 AND 8 MI. I RECEIVED NO RESPONSE FROM THE
SECTOR. I HUNG UP THE LANDLINE AND TOLD A330 TO TURN R HDG 270 DEGS
AS I OBSERVED THAT B737 WAS NOW SHOWING LEVEL AT FL400. HE RESPONDED
THAT HE HAD A TCAS ALERT AND WAS DSNDING. I CALLED TO SECTOR 09 TO
TELL THEM THAT A330 WAS NOW DSNDING DUE TO TCAS. AGAIN, I RECEIVED NO
RESPONSE. AS THE ACFT PASSED, I SHOWED THAT B737 WAS NOW BACK LEVEL
AT FL390. I DON'T KNOW IF SEPARATION WAS LOST OR HOW CLOSE THE ACFT
WERE, BUT THE TARGETS DID PASS WITHIN 1 MI OF EACH OTHER. I NEVER DID
GET ANY RESPONSES FROM THE ZDC SECTOR 09, SO I DO NOT KNOW WHAT
HAPPENED WITH THE B737 -- WHETHER HE HAD ANY TCAS ALERTS OR IF THE
CTLR HAD CLBED OR DSNDED HIM. I CALLED A330 AFTER THE INCIDENT AND
APOLOGIZED, SAYING THAT I WASN'T TALKING TO THE OTHER PLT SO I DON'T
KNOW WHAT HE WAS DOING. HE RESPONDED THAT HE WANTED THE CALL SIGN
OF THE OTHER ACFT BECAUSE HE NEEDED TO FILE A TCAS RPT. I TOLD HIM IT
WAS B737 THAT WAS ON ZDC FREQ. I DON'T KNOW WHAT THE CAUSE OF THIS
INCIDENT WAS WHETHER IT WAS CTLR OR PLT ERROR OR BOTH SINCE I NEVER
COULD TALK TO THE CTLR VIA THE LANDLINE. WHEN I LATER CALLED THE
SECTOR, A DIFFERENT CTLR ANSWERED AND DIDN'T KNOW WHAT HAD
HAPPENED. POSSIBLE CONTRIBUTING FACTORS COULD BE THAT THERE WAS
LOTS OF WX IN THE AREA. MOST ACFT WERE DEVIATING AROUND STORMS AND
BUILDUPS IN THE AREA NEAR THE INCIDENT. I WAS VERY BUSY AT THE TIME AS
I'M SURE THE ZDC CTLR WAS AS WELL DUE TO ALL THE TX DEVIATIONS. ONCE A
PLT SAYS THEY ARE RESPONDING TO THEIR TCAS, THE CTLR CAN'T DO ANYTHING
BUT WATCH AS THE TCAS IS SUPPOSED TO SEPARATE THE ACFT AND YOU MAY
GIVE INSTRUCTIONS CONTRARY TO TCAS ON ONE OF THE ACFT AND THINGS
COULD BE EVEN WORSE. THEREFORE, I DON'T KNOW THAT THERE WAS
ANYTHING I COULD HAVE DONE DIFFERENTLY AS I TRIED TO TURN THE A330 AS
SOON AS I SAW THAT THE ACFT WERE COMING CLOSER TO EACH OTHER.
SUPPLEMENTAL INFO FROM ACN 667537: B737 CHKED ON TO THE FREQ AT FL390
REQUESTING FL410. B737 REQUEST FOR AN ALT CHANGE WAS ACKNOWLEDGED.
UPON ENTERING ZDC'S AIRSPACE, B737 WAS ISSUED A CLB CLRNC TO FL410.
THE CONFLICT ALERT ACTIVATED AS B737 WAS OBSERVED AT FL399 CLBING TO
FL410. I ISSUED AN IMMEDIATE DSCNT TO FL380, THEN I CALLED JACKSONVILLE
CTR TO ADVISE THEM THAT B737 WAS DESCENDING. A330 WAS OBSERVED
CLBING TO FL405. SUBSEQUENTLY B737 REPORTED LEAVING FL390 FOR FL380.
Synopsis
BOTH ZJX AND ZDC CTLRS CHRONICLE EVENTS LEADING UP TO OPERROR AT
FL400 IN CLOSE PROX OF COMMON AIRSPACE BOUNDARY.
ACN: 665822
Time / Day
Date : 200507
Place
Locale Reference.Airport : PDX.Airport
State Reference : OR
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : P80.TRACON
Flight Plan : IFR
Mission : Passenger
Airspace.Class C : PDX.C
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Location Of Person.Facility : P80.TRACON
Events
Detector.Automation : Aircraft TA
Assessments
Narrative: 1
THE PDX ATIS ADVISED THAT VISUAL APCHS TO RWY 28L&R WERE IN PROGRESS.
WHEN WE CONTACTED PDX APCH, WE WERE ADVISED TO EXPECT THE 'MILL
VISUAL APCH' TO RWY 28L. WE WERE VECTORED ON A HIGH R DOWNWIND N OF
THE ARPT. WE WERE THEN VECTORED SBOUND OVERHEAD THE 'PAPER MILL' (PDX
079 DEG RADIAL, 9 DME FIX) AND THEN CLRED FOR THE MILL VISUAL APCH. WE
WERE GIVEN A DSCNT CLRNC TO 3000 FT SHORTLY BEFORE ARRIVING OVERHEAD
THE PAPER MILL. THE MILL VISUAL APCH CHART INDICATES THAT AN ALT OF 3000
FT OR ABOVE IS RECOMMENDED OVER THE PAPER MILL. THE 240 DEG HDG WAS
FLOWN TO INTERCEPT THE RWY 28L FINAL APCH COURSE, BUT WE WERE UNABLE
TO LAND, DUE TO BEING TOO HIGH AS WE APCHED THE RWY THRESHOLD. OUR
COMPANY PROCS REQUIRE A GAR IF THE ACFT IS NOT ON THE GS AND AT FINAL
APCH SPD AT 1000 FT AGL. WE PERFORMED A GAR. WHEN ASKED BY ATC WHY WE
WENT AROUND, I TOLD THEM THAT THE MILL VISUAL PROC DID NOT WORK WELL
WITH THE AIRBUS 330. WE WERE THEN VECTORED FOR ANOTHER APCH WITH A
TURN ON THE LOC 10 MI OUT. THIS APCH WAS SUCCESSFUL. SUBSEQUENTLY, I
WAS ABLE TO DETERMINE THAT XING THE PAPER MILL AT 3000 FT MSL, AND
FLYING THE CHARTED 240 DEG HDG UNTIL INTERCEPTING THE RWY 28L LOC,
PLACES THE ACFT 3000 FT ABOVE THE ARPT WITH 8.5 FLYING MI TO THE RWY
THRESHOLD. THIS IS 550 FT ABOVE A 3 DEG GS, 8.5 MI FROM THE ARPT. THE
AIRBUS 330 HAS A HIGH ASPECT RATIO WING THAT MAKES DSCNTS IN THE
TERMINAL AREA CHALLENGING. THE AIRPLANE DOES NOT DSND RAPIDLY AT
APCH SPDS. ANY CHARTED PROC THAT POSITIONS AN AIRBUS 330 ABOVE THE GS
LESS THAN 10 FLYING MI FROM RWY IS PROBLEMATICAL. PDX APCH DID NOT
SEEM TO BE AWARE OF THE DSCNT CHARACTERISTICS OF THIS ACFT. THIS WAS
THE FIRST TIME THAT I HAD THE MILL VISUAL APCH ASSIGNED WHILE FLYING
THE AIRBUS 330. I HAD FLOWN THE APCH MANY TIMES IN THE B757, AND IT WAS
A CHALLENGE TO DSND THAT ACFT IN SUCH A MANNER THAT THE APCH WAS
STABILIZED AT 1000 FT AGL. IN THE AIRBUS 330, IT IS EVEN MORE OF A
CHALLENGE.
Synopsis
A330 CAPT EXPRESSED CONCERN REGARDING CHARTED VISUAL APCH TO PDX
THAT CONTAINS ALT RESTRS DIFFICULT TO ACHIEVE IN AN A330.
ACN: 664483
Time / Day
Date : 200506
Place
Aircraft
Reference : X
Component
Aircraft Component : Toilet Furnishing
Person : 1
Reference : 1
Qualification.Maintenance : Avionics
Person : 2
Reference : 2
Person : 3
Reference : 3
Events

Assessments
Aircraft
Logbook Entry
Human Factors
Narrative: 1
2 LOG PAGE WRITE-UPS ON SAME LAVATORY: 1) WASTE CONTAINER ACCESS
DOOR, AND 2) WASTE CONTAINER FLAP. FIRST WRITE-UP WAS MAINT CTLR
DEFERRED BUT SHOULD HAVE BEEN ON MEL. SECOND WRITE-UP WAS CLRED.
THERE WAS A PLACARD IN THE BOOK FOR AN MEL, BUT NO MEL ON LOG PAGE. I
PULLED THE PLACARD AND CLRED THE BINS AND WASTE CONTAINER FLAP
WRITE-UP REF ON A NEW LOG PAGE ENTRY AFTER CHKING THAT CONTAINER FLAP
WAS REPAIRED. THE ACCESS DOOR WAS STILL AN OPENED ITEM BUT I CLOSED
IT ON THE NEW LOG PAGE THINKING THEY WERE DUPLICATE WRITE-UPS. THE
CONFUSION OCCURRED WHEN THE MAINT CTLR DEFERRAL ON ACCESS DOOR
SHOULD HAVE BEEN ON MEL AND THE PLACARD I REMOVED SHOULD HAVE BEEN
COMPLETED WITH THE EMPLOYEE NAME AND NUMBER. NO NAME OR NUMBER
WAS ON THE PLACARD. JUST THE ACFT NUMBER, DISCREPANCY, AND MEL 38-2204 AND LOG PAGE NUMBER THAT WAS DESIGNATED AS MAINT CTLR DEFERRAL.
ACFT DEPARTED AND MY LEAD INFORMED ME THAT THE LOG PAGE IN QUESTION
WAS STILL OPEN AND WAS IMPROPERLY DEFERRED SO HE NOTIFIED MAINT CTL
TO HAVE THEM CREW DEFER THE WASTE ACCESS DOOR AND CLOSE THE
LAVATORY.
Synopsis
AN A320 LAVATORY TRASH BIN WAS DEFERRED IMPROPERLY BY A TECHNICIAN.
TRASH BINS NEEDED MAINT CTLR APPROVAL. LAVATORY CLOSED AND LOCKED.
ACN: 660763
Time / Day
Date : 200506
Place
Locale Reference.Airport : BGR.Airport
State Reference : ME
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : CZQX.ARTCC
Person : 5
Reference : 5
Events
Assessments
Narrative: 1
WHILE ON CLRNC DIRECT TO 46N 50W ISSUED BY GANDER CTR, CTR ASKED IF
WE WERE FOLLOWING THE DIRECT TO 46N 50W. I LOOKED AT MY NAV DISPLAY
AND OBSERVED THE ACFT ON DIRECT COURSE TO 46N 50W, AND ANSWERED
YES. GANDER CTR REPLIED HE SHOWED OUR COURSE MISSING 46N 50W. I WENT
TO BASIC HDG MODE, CHKED MY NAV DISPLAY WITH COMPASS HDGS THEN REENTERED DIRECT 46N 50W. CTR INFORMED US WE WERE STILL OFF COURSE,
AND OUR ACFT WOULD NOT BE ALLOWED TO ENTER THE NAT SYS. AFTER COM
WITH COMPANY DISPATCH, WE RETURNED TO ZZZ1. CALLBACK CONVERSATION
WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE FMGC
DISPLAYED THE TRACK FROM THE ACFT'S PRESENT POS TO THE SELECTED FIX
(46N 50W) BUT IN REALITY IT WAS TRACKING TO NEXT FIX (46N 40W) AND SO
WAS GOING TO MISS THE FIX TO WHICH THEY WERE CLRED. GANDER OCEANIC
GAVE THE CREW THE OPPORTUNITY TO MAKE A 360 DEG TURN BACK ON TRACK
TO FIGURE OUT WHAT WAS WRONG, BUT IF THEY DID THE DELAY TURN, THEY
WOULDN'T HAVE LEGAL FUEL TO CONTINUE THE TRIP. IN THE END, 2 WKS AFTER
THIS INCIDENT, THE CONTENTS OF THE FMGC WERE LOADED INTO A TRAINING
SIMULATOR, IT WAS DISCOVERED THAT THE RTE WAS CORRECT, BUT AN

ANOMALY EXISTED THAT CAUSED THE ACFT TO BYPASS THE FIRST FIX AND
DISPLAY THE FIRST FIX AS THE DESIRED TRACK. AIRBUS INDUSTRIES KNOWS
ABOUT THE ANOMALY.
Synopsis
AN A330-300 WITH A NAV HDG DISCREPANCY WAS NOT PERMITTED ON AN
OCEANIC TRACK AND RETURNED TO ITS DEP POINT.
ACN: 639183
Time / Day
Date : 200311
Place
Environment
Light : Night
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Main Gear Tire
Problem : Failed
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3

Events
Anomaly.Ground Event / Encounter : FOD
Assessments
Primary Problem : Airport
Narrative: 1
FLT ZZZ-SBGR WAS DISPATCHED NORMALLY. DURING A TKOF ROLL ON RWY 12
OUT OF ZZZ INTL ARPT, JUST RIGHT BEFORE V1 AND XING TXWY V, THE #2 TIRE
BLEW OUT. THE CAPT INFORMED THE TWR OF THE OCCURRENCE AND ASKED TO
VERIFY IF THERE WAS DEBRIS OF TIRES ON THE RWY. AS A PRECAUTION, THEY
LEFT THE GEAR IN THE 'DOWN' POS UNTIL CONFIRMING POSSIBLE FAILURES,
THOUGHT TO BE ECAM. THE DEP CTL INFORMED THEM THAT THEY ONLY FOUND A
PIECE OF TIRE ON THE RWY 12. THEY FLEW TO SBGR WHERE THEY LANDED
NORMALLY AND DURING TAXIING TO THE GATE, THE #1 TIRE BLEW OUT, CAUSED
BY THE OVERLOAD ON TURN TO GATE. THE TECHNICAL STAFF DID THE DUE
INSPECTION FOR SUCH EVENT AND DAMAGED ON THE L-HAND FLAP AND REAR LHAND WING WERE FOUND, CAUSED BY SPREAD OUT DEBRIS FROM THE BLOWN
TIRE. WE CONTACTED TIRE MANUFACTURER TO HELP US OUT WITH THE
INVESTIGATION AND THEY SUSPECT THAT THIS WAS CAUSED BY FOD ON THE
RWY DUE TO EVIDENCE THAT THIS TIRE HAD AN IMPACT BREAK. ALSO A SIMILAR
EVENT IN OCT/04, FLT ZZZ-SBGR, DURING TKOF ROLL, THE TREAD FROM #2 TIRE
CAME OUT OF IT AND THE POSSIBLE CAUSE WAS NOT DETECTED. THE TREAD
HAD NOT BEEN FOUND.
Synopsis
AN A330-200 ON TKOF HAD #2 FORWARD TIRE BLOW OUT, BELIEVED TO BE
CAUSED BY FOD. AFTER LNDG, #1 MAINT TIRE BLEW OUT ON TURN TO GATE.
ACN: 629207
Time / Day
Date : 200408
Place
Environment
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZZZ1.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZZZ1.A
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3

Person : 4
Reference : 4
Function.Other
Events
Assessments
Narrative: 1
ASTHMATIC PAX FELT ILL. FLT ATTENDANT ADMINISTERED OXYGEN AND
REQUESTED PARAMEDICS MEET THE FLT UPON ARR IN ZZZ. DECLARED MEDICAL
EMER. NO FURTHER PROBS.
Synopsis
AN A330 CAPT RPTED THAT AN ILL PAX CAUSED HIM TO DECLARE A MEDICAL
EMER WITH ZDC BEFORE LNDG AT THE PLANNED DEST OF PHL.
ACN: 620159
Time / Day
Date : 200406
Place
Locale Reference.Navaid : IGN.VOR
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Center : ZBW.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZBW.A
Aircraft : 2
Reference : Y
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1

Person : 2
Reference : 2
Function.Air Traffic Control : Handoff / Assist
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Assessments
Narrative: 1
I HAD ASSIGNED A 285 DEG HDG TO ACR X AT FL350 TO COMPLY WITH THE 30 MI
IN-TRAIL RESTR TO DULLES (IAD). I ACCEPTED A HDOF ON ACR Y AT FL370
PROCEEDING DIRECT ALBANY (ALB), LNDG MANCHESTER (MHT). I CLRED ACR X
DIRECT SPARTA (SAX) WHEN THE REQUIRED IN-TRAIL SPACING WAS ACHIEVED.
OTHER IAD TFC WAS BEING VECTORED TO COMPLY WITH THE IN-TRAIL RESTR.
THE SUPVR INFORMED US THAT ACR Z WAS EXEMPT FROM THE IN-TRAIL RESTR,
BUT WE WERE REQUESTED TO GIVE AS MANY MI IN-TRAIL AS POSSIBLE. THE DSIDE WAS VERY BUSY SEEING WHERE THIS ACFT WOULD FIT IN WITH OTHER IAD
TFC. THE SECTOR WAS VERY BUSY AND I HAD OTHER ACFT ON VECTORS. THE DSIDE WAS HAVING DIFFICULTY CONTACTING ZNY TO COORDINATE PARALLEL
HDGS ON 2 OTHER ACFT. THEY WANTED 1 ACFT ASSIGNED A DIFFERENT ALT AND
I COMPLIED WITH THAT. I THEN CLRED ACR Y TO DSND TO FL330 TO COMPLY
WITH THE RESTR ON ACFT LNDG MHT. I RECOGNIZED THAT ACR Y'S DSCNT WAS
GOING TO BE CLOSE TO ACR X. I ASSIGNED ACR X A L TURN, INSTRUCTED ACR Y
TO STOP DSNDING, AND ALSO ASSIGNED ACR Y A L TURN. A CONTRIBUTING
FACTOR WAS THE 30 MI IN-TRAIL RESTR. THIS TFC MUST BE TAKEN OFF THEIR
RTE AND VECTORED WHICH CAN CAUSE CONFLICT WITH OTHER ACFT. THIS
INCREASES GREATLY THE WORKLOAD.
Synopsis
ZBW CTLR EXPERIENCED OPERROR AT FL350 DURING VECTORS FOR IN-TRAIL
SPACING REQUIREMENT.
ACN: 619395
Time / Day
Date : 200405
Place
Locale Reference.Navaid : ORL.VORTAC
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use.Airway : A300.Airway
Component
Aircraft Component : Oil Distribution
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : ZNY.COMRDO
Reporter Organization : Contracted Service
Person : 5
Reference : 5
Events
Assessments
Narrative: 1
AT FL390 ON AIRWAY A-300 ENRTE TO SJU FROM PHL, THE R ENG OIL QUANTITY
WENT FROM 19 QUARTS TO 7 QUARTS. DISPATCH AND I DECIDED TO DIVERT TO
MCO INSTEAD OF GOING TO SJU. WE GOT OFF A-300, DSNDED TO FL385 TO CLR
TFC, THEN RECEIVED CLRNC FROM NEW YORK COMRDO TO PROCEED DIRECT TO
MCO AT FL380. LANDED MCO.
Synopsis
AN A330 NOTES AN OIL LOSS OF 12 QUARTS FROM THE R ENG ON AIRWAY A-300
DURING AN OVERWATER OP AND DIVERTS TO MCO, FL.
ACN: 616031
Time / Day
Date : 200404
Place
Locale Reference.Airport : SJU.Airport
State Reference : PR
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : SJU.Tower
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Component : 1
Aircraft Component : Door Warning System
Component : 2
Aircraft Component : Normal Brake System
Component : 3
Aircraft Component : Parking Brake
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Function.Ground Personnel : Vehicle Driver
Person : 4
Reference : 4
Events
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Assessments
Narrative: 1
ON PUSHBACK, A CARGO DOOR LIGHT ANNUNCIATED DURING PUSHBACK AND
ENG START. I INSTRUCTED THE GND PUSH CREW TO STAY CONNECTED BECAUSE
THEY WOULD HAVE TO TOW US BACK IN TO THE GATE. I RELEASED THE PARKING
BRAKE AFTER I SAID I WAS RELEASING IT AND DIRECTED THEM TO TOW US BACK
TO THE GATE. SOON I RECEIVED A VISUAL INDICATION FROM THE GND CREW TO
STOP. I DID. I THEN REALIZED THAT WE WEREN'T BEING PULLED BY THE TUG,
BUT INSTEAD ROLLING UNDER OUR OWN PWR. NO DAMAGE OR INJURIES
RESULTED. I BELIEVE THE INCIDENT WAS PRIMARILY CAUSED BY THE INABILITY
OF THE GND CREW TO UNDERSTAND MY ENGLISH. THE CONTRIBUTING FACTORS
WERE CREW DISTR AND WORKLOAD MGMNT. WE WERE BUSY DEALING WITH
CHKLISTS AND ABNORMAL PROCS. THE COCKPIT AND CABIN WERE ALSO VERY
HOT BECAUSE THE PACKS DO NOT OPERATE WHEN THE ENGS ARE RUNNING AND
THE CARGO DOOR INDICATES OPEN. SUPPLEMENTAL INFO FROM ACN 616897: AT
THE CONCLUSION OF THE START PROC, WE RECEIVED AN ECAM WARNING THAT
THE FORWARD CARGO DOOR WAS OPEN AND THE PACKS WERE INOP. (THIS WAS
A RECURRING PROB WITH THIS ACFT. WE HAVE NO REASON TO BELIEVE THAT
THE DOOR WAS ACTUALLY OPEN ON INDICATION PROB ONLY.) THE CAPT
INFORMED THE GND CREW (THROUGH THE INTERPHONE) 'CONFIRM TOW BAR
CONNECTED.' THE GND COORDINATOR STATED 'OK.' THE CAPT STATED HE WAS
RELEASING BRAKES AND THEN DID SO. WE STARTED TO MOVE. WHEN I LOOKED
UP, WE WERE PASSING OUR GATE AND INCREASING SPD. WE THEN NOTICED THE
WING WALKER GIVING US THE STOP SIGNAL. I SAID, 'I DON'T THINK WE'RE
CONNECTED.' THE CAPT AND I WERE RELUCTANT TO APPLY THE BRAKES FOR
FEAR OF SNAPPING AND DAMAGING THE NOSE GEAR. SOON, THE CAPT DECIDED
THAT WE HAD TRAVELED FAR ENOUGH. HE APPLIED THE BRAKES. WE THEN
RETURNED TO THE GATE UNDER OUR OWN PWR, HAVING REALIZED THAT THE
TOW BAR HAD BEEN DISCONNECTED. OBSERVATION: BETTER TO HAVE FORCED
THE AGENT TO RPT WHAT WE TOLD HIM.
Synopsis
A330 CAPT RELEASED THE BRAKES TO BE TOWED BACK TO THE GATE. THE CREW
DISCOVERED THEY WERE ROLLING WITH NO TUG ATTACHED.
ACN: 607468
Time / Day
Date : 200312
Place
Aircraft
Reference : X
Component
Aircraft Component : Lifevest/Jacket
Person
Reference : 1
Events
Assessments

Narrative: 1
DURING THE PAST YR, I HAVE BEEN ASSIGNED MOSTLY TO THE AFTERNOON
HANGAR CREW. NUMEROUS CHKS HAVE COME THROUGH DURING THIS TIME.
THIS SPECIFIC ACFT I'M NOT SURE OF THE EXACT CIRCUMSTANCES, BUT DURING
THE CHK I'VE FOUND THE UPPER NOTE TO CAUSE CONFUSION TO THE SPECIFIC
TASK NUMBER. I WOULD ALSO LIKE TO SAY THAT DURING THE 'A' CHK, I
WORKED WITH OTHER PEOPLE ON THE SPECIFIC AREA CORDS, INTERIOR, ENGS,
ETC. IT'S VERY POSSIBLE I DIDN'T DO THAT PART OF THE INTERIOR CHK IN
QUESTION. I FOUND OTHER DISCREPANCIES AND FIXED THESE ITEMS WHICH I
HOPE SHOWS THAT I WOULDN'T INTENTIONALLY NOT REPAIR OR PROGRAM
ITEMS FOR REPAIR THAT WERE FOUND.
Synopsis
THE TECHNICIAN WORKING ON AN AIRBUS 330, DURING A MAINT CHK, FOUND
LATER THAT THE UNDER SEAT LIFE VESTS WERE NOT INSPECTED FOR TIME AND
SVCABILITY DUE TO HIS CONFUSION WITH THE INSPECTION JOB CARD.
ACN: 606322
Time / Day
Date : 200401
Place
Environment
Weather Elements / Visibility : Snow
Weather Elements / Visibility : Icing
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Events
Assessments
Narrative: 1
ON TAXI-IN (USING VISUAL PARKING SYS, GATE X), GATE ENTRY AND TAXI-LINES
WERE COVERED WITH ICE/SNOW. OUT OF SIGHT OF FLT DECK, TOWBAR
CONTACTED NOSE GEAR/TIRE. CONTACT WAS ENTERED IN MAINT LOGBOOK.
Synopsis
A330-300 CREW HIT A TOWBAR WITH A NOSEWHEEL WHEN USING THE VISUAL
PARKING SYS AT THE GATE.
ACN: 593944
Time / Day
Date : 200309
Place
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Assessments
Narrative: 1
MY CREW AND I WERE TASKED TO REPLACE AN IDG OIL FILTER AND A FUEL
FILTER ON #2 ENG. WE OPENED THE COWLS AND STARTED TO LOCK OUT THE
THRUST REVERSERS PRIOR TO OUR FILTER CHANGES. I STARTED TO PIN THE
LOCKING ACTUATORS AND WAS ADVISED THAT THE PAPERWORK SAID WE ONLY
NEEDED TO PIN THE DIRECTIONAL CTL VALVE SO I STOPPED. WE COMPLETED
OUR ASSIGNED TASK AND THE ACFT LEFT FOR ZZZ1 THAT EVENING. I WAS
INFORMED THE NEXT DAY THE THRUST REVERSERS DID NOT DEPLOY IN ZZZ1
DUE TO THE INADVERTENT PIN LEFT IN THE LOCKING ACTUATOR. I BELIEVE THAT
IF THE THRUST REVERSER IS DEACTIVATED OR THE SYS IS WORKED ON IN ANY
WAY, THERE SHOULD BE AN OPERATIONAL CHK OF THE THRUST REVERSER AND A
CORRESPONDING LOGBOOK ENTRY. THIS INCIDENT WOULD HAVE BEEN
PREVENTED HAD THESE STEPS BEEN IN PLACE.
Synopsis
#2 THRUST REVERSER ON A330 FAILED TO DEPLOY ON LNDG DUE TO FAILURE OF
MAINT CREW TO REMOVE A DIRECTIONAL CTL VALVE LOCKING PIN INSTALLED
DURING ROUTINE SVCING OF THE ENG.
ACN: 586198
Time / Day
Date : 200306
Place
Environment
Light : Dusk
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Nav In Use : INS
Nav In Use : GPS
Component : 1
Problem : Failed
Component : 2
Aircraft Component : Indicating and Warning - Hydraulics
Problem : Design
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Anomaly.Other
Assessments
Narrative: 1
AT APPROX XA15 ON 6/SUN/03, OUR ANNUNCIATOR PANEL (ECAM) INDICATED A
POSSIBLE LEAK IN THE 'GREEN' HYDRAULIC SYSTEM. WE STARTED TO MONITOR
THE SYSTEM OVER THE NEXT 10 MINUTES. AT THE END OF THAT TIME, PRIOR TO
EXITING ZZZZ AIRSPACE, WE DETERMINED THAT THERE EXISTED A HIGH
PROBABILITY OF A LEAK. SHUT DOWN THE GREEN SYSTEM, AND REQUESTED
PRIORITY LNDG TO OUR DEST, ZZZ, ABOUT 1.5 HR AWAY. (THE 'GREEN' SYSTEM
IS PRIMARY ONLY FOR LNDG GEAR AND STEERING, AND NOT CRITICAL TO THE
PHASE OF FLT WE WERE IN.) THE FLT CONTINUED NORMALLY UNTIL APCH INTO
ZZZ. THERE, THE CAPT ASKED FOR THE 'GREEN' SYSTEM TO BE SWITCHED BACK
ON. I DID SO AND WE LOWERED THE LNDG GEAR. THIS EXHAUSTED THE
REMAINDER OF OUR AVAILABLE 'GREEN' SYSTEM FLUID, ANNUNCIATING A LOSS.
THE CAPT DECLARED AN EMER, AND WE LANDED WITHOUT FURTHER INCIDENT.
DIFFERENTIAL BRAKING ALLOWED US TO CLR THE RWY, ALTHOUGH WE HAD TO
BE TOWED TO THE GATE. PROBLEM: THE A330 GAGES COVERING HYDRAULIC
FLUID ARE NEARLY IMPOSSIBLE TO READ VIS, DETECTING THE RAPIDITY OF A

LEAK. BETTER GAGES SHOWING RATE WOULD THE HELPFUL. CALLBACK
CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED
THE ECAM WARNING ON THE POSSIBLE LEAK IN THE GREEN HYDRAULIC SYSTEM
ALERTED THEM TO TURN OFF THE SYSTEM AND SAVE THE REMAINING FLUID FOR
GEAR EXTENSION. THE RPTR STATED THERE IS NO WAY TO DETERMINE THE RATE
OF LOSS OF FLUID DUE TO THE HYDRAULIC QUANTITY INDICATORS HAVE NO
INDICES. THE MAIN CAUSE OF THE HYDRAULIC LOSS IS UNKNOWN AS MAINT HAS
MADE NO RPT TO THE CREW.
Synopsis
AN AIRBUS 330 IN CRUISE AT FL400 DECLARED AN EMER DUE TO LOSS OF GREEN
HYDRAULIC SYSTEM QUANTITY AND PRESSURE. CAUSE UNKNOWN. CREW NOTES
DIFFICULTY CALCULATING RATE OF LOSS AS QUANTITY INDICATORS HAVE NO
INDICES.
ACN: 586193
Time / Day
Date : 200306
Place
Environment
Flight Conditions : Mixed
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Tower : PHL.Tower
ATC / Advisory.TRACON : PHL.TRACON
Flight Plan : IFR
Mission : Passenger
Airspace.Class B : PHL.B
Component
Problem : Failed
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Location Of Person.Facility : PHL.TRACON
Person : 4
Reference : 4
Location Of Person.Facility : PHL.Tower
Events
Assessments
Narrative: 1
GREEN HYD SYS FAILURE ON APCH AFTER SWW LEAK IN CRUISE AND DSCNT.
EMER DECLARED AFTER GEAR EXTENSION WHEN FLUID DEPLETED. LANDED ON
LONGEST RWY 27L AT PHL. TURNED OFF RWY AT HIGH SPD S-9 WITH
DIFFERENTIAL BRAKING. SHUTDOWN ACFT -- TOWED TO GATE. NO INJURIES. NO
DAMAGE TO ACFT.
Synopsis
A330 CREW LOST GREEN SYS HYD FLUID AND PRESSURE IN PHL CLASS B.
ACN: 583093
Time / Day
Date : 200305
Place
Locale Reference.Airport : ACY.Airport
State Reference : NJ
Environment
Light : Daylight
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZDC.E
Aircraft : 2
Reference : Y
Flight Plan : IFR
Mission : Passenger
Airspace.Class E : ZDC.E
Person : 1
Reference : 1
Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 11

Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
ACFT #1 ORIGINALLY CLRED TO 8000 FT. THEN GIVEN HOLDING INSTRUCTIONS,
ALT CHANGED TO 9000 FT AND READ BACK CORRECTLY. ACFT #2 SUBSEQUENTLY
CLBED TO 8000 FT. TFC CALLED AND SAW EACH OTHER. ACFT #1 DSNDED
THROUGH ASSIGNED ALT, RECEIVED TCASII ALERT AND CLBED BACK UP.
Synopsis
ZDC CTLR EXPERIENCED LOSS OF SEPARATION IN HOLDING PATTERN.
ACN: 580479
Time / Day
Date : 200304
Place
Locale Reference.Airport : PIT.Airport
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : PIT.Tower
Flight Plan : IFR
Mission : Ferry
Flight Phase : Taxi
Aircraft : 2
Reference : Y
Aircraft Operator : Corporate
Make Model Name : Commercial Fixed Wing
Airspace.Class B : PIT.B
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Reporter Organization : Corporate
Person : 4
Reference : 4
Location Of Person.Facility : PIT.Tower
Events
Anomaly.Other
Assessments
Narrative: 1
WE WERE CLRED INTO POS AND HOLD RWY 28R BY TWR. AS WE STARTED THE L
TURN FROM TXWY B, FO NOTICED AN ACFT ON FINAL APCH 1 1/2 TO 2 MI OUT. I
STOPPED ACFT IMMEDIATELY BEFORE ENTERING RWY. WE WERE WELL CLR OF
RWY BUT NOSE OF OUR ACFT WAS OVER HOLD LINE. THE CPR ACFT THEN CHKED
IN WITH TWR AND TWR TOLD HIM TO GO AROUND. THERE WAS NO CONFLICT
AND WE DEPARTED AFTER THE CPR JET WENT AROUND. I DID NOT SEE THE ACFT
INITIALLY BECAUSE I WAS TAXIING THE ACFT AND MY ATTN WAS WITH THE HARD
L TURN DUE TO THE LENGTH OF THE ACFT.
Synopsis
AN A330 FLT CREW WAS ISSUED A TIPH WITH A CPR ACFT ON FINAL RESULTING
IN A GAR.
ACN: 579966
Time / Day
Date : 200304
Place
Locale Reference.ATC Facility : EISN.ARTCC
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.Center : EISN.ARTCC
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : EISN.A
Component
Aircraft Component : AC Generation
Problem : Failed
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : EISN.ARTCC
Events
Assessments
Narrative: 1
AT APPROX XA17Z GENERATOR 1 FAULTED. RESET UNSUCCESSFUL, APU START
UNSUCCESSFUL. REQUESTED LOWER ALT IN HOPES OF APU START -- NOT
AVAILABLE. I DECLARED AN EMER, TURNED OFF TRACK, AND MADE COURSE FOR
LONDON-GATWICK. ONCE OFF TRACK, I DSNDED TO FL270. APU START WAS
THEN SUCCESSFUL. IT ASSUMED ITS ELECTRICAL LOAD. WE INFORMED OCC AND
ATC AND CANCELED OUR EMER STATUS. WE LANDED AT LGW WITHOUT FURTHER
INCIDENT.
Synopsis
A330 FLT CREW HAS GENERATOR FAILURE DURING ETOPS TRANSATLANTIC FLT.
ACN: 577770
Time / Day
Date : 200303
Place
Environment
Light : Daylight
Aircraft
Reference : X
Mission : Passenger
Component
Problem : Failed
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Anomaly.Other
Assessments
Narrative: 1
EMER ESCAPE SLIDE FAILED TO DEPLOY DURING SHOP FUNCTIONAL TEST. THE
SLIDE BOTTLE LANYARD WAS PULLED AND THE REGULATOR BFG P/N 4A3857-1
FAILED TO FIRE AND INFLATE THE SLIDE. THIS IS THE THIRD TIME THIS
REGULATOR HAS FAILED TO OPERATE. THE FIRST TIME WAS IN THE FALL OF 2002
AND THE REGULATOR WAS SENT TO BFG FOR EXAMINATION. NO DEFECTS WERE
NOTED. ON THUR/MAR/03 S/N X FAILED TO FIRE AND ON MON/MAR SN Y FAILED
TO FIRE. ACR X SVC RPT. MANY MISFIRINGS HAVE BEEN RECORDED DURING THE
TESTING OF THE ABOVE REGULATOR IN THE ZZZ OXYGEN SHOP WHERE I WORK.
INTERNAL EXAMINATION HAS FOUND DEFECTS AND METAL PARTICLES IN THE
REGULATING SECTION OF THE VALVE. IT IS UNKNOWN TO THIS DATE WHAT HAS
CAUSED THE NO FIRE EVENTS WE HAVE HAD. MGMNT HAS REQUESTED THAT WE
RETURN THE VALVES BACK TO BFG FOR EVALUATION. WE HAVE TALKED TO THE
BFGOODRICH ENGINEERING DEPT SEVERAL TIMES. I FEEL THAT THE DESIGN OF
THIS REGULATOR IS DEFICIENT IN THAT THERE IS NO POSITIVE MECHANICAL
MEANS TO ENSURE THAT THE REGULATOR VALVE WILL OPEN AND DISCHARGE
THE BOTTLE WHEN THE LANYARD IS PULLED. THE BELLEVILLE WASHERS IN THE
PRESSURE REGULATING SECTION OF THE VALVE ARE ALSO DEFICIENT
EVIDENCED BY THE FACT THAT 50 PERCENT OF THE REGULATORS TESTED ON
OUR PRESSURE TEST BENCH FAIL. THE WASHERS HAVE BEEN FOUND TO BE
CHAFFING AND RUBBING ON THE CYLINDER BORE AND REGULATOR ADJUSTING
SCREW INTRODUCING METAL PARTICLES TO THE REGULATOR. A COMPLETE
INDEPENDENT REVIEW OF THE DESIGN AND OPERATION OF THIS SERIES
REGULATOR IS IN ORDER. FIRING ROD MUST MOVE UPWARD IN ORDER FOR
VALVE TO FIRE. NO POSITIVE MECHANICAL LINKAGE TO LANYARD TO ENSURE
THAT ROD MOVES UP INVESTIGATION NEEDS TO BE MADE TO FIND OUT WHAT
HAS CAUSED ROD TO STICK WHICH RESULTS IN A 'NO FIRE' SIT 'NO FIRE'
VALVES FOUND AT ACR X ARE CURRENTLY AT BFG AWAITING EVALUATION. BFG
RPTED TO ACR X THAT THEY HAVE RECORDED 15 'NO FIRE' RPTS FROM A330 AND
A340 OPERATORS. 7 WERE ON ACFT AND THE REMAINDER IN SHOP CHECKS THEY
FORGOT TO COUNT THE FIRST VALVE WE SENT TO THEM AND DID NOT EVALUATE
IT FOR THE 'NO FIRE' EVENT. CALLBACK CONVERSATION WITH RPTR REVEALED
THE FOLLOWING INFO: THE RPTR STATES THE ESCAPE SLIDE PROBLEM IS
LIMITED TO THE AIRBUS 330 AND 340 WHICH USE THE SAME ESCAPE SLIDE
PRESSURE REGULATOR. THE RPTR STATED THAT THREE OF THE SHOP ESCAPE
SLIDE DEPLOYMENTS THAT FAILED WERE TRACED TO FAILED PRESSURE
REGULATORS THAT DID NOT OPEN. THE RPTR SAID ON DISASSEMBLY METAL
PARTICLES ARE FOUND THROUGHOUT THE REGULATOR AND ARE COMING FROM
THE BELLEVILLE SPRING WASHERS WHICH ARE CHAFFING ON EACH OTHER, THE
ADJUSTER AND THE VALVE BODY WHICH CONTAINS THE SPRING. THE RPTR
STATED THE CARRIER FORBIDS THE SHOP TECHNICIANS FROM REPAIRING THIS
REGULATOR AND REQUIRES THE UNIT TO BE SENT TO THE MANUFACTURER FOR
REPAIR. THE RPTR SAID THE MANUFACTURER HAS RPTED TO THE CARRIER THAT
THEY HAVE RECORDED 15 FAILURES OF THIS REGULATOR FROM A330 AND 340
OPERATORS. THE RPTR STATES THAT DUE TO THE SERIOUS NATURE OF THE
CONSEQUENCES THIS REGULATOR CAN CAUSE A MAJOR REDESIGN SHOULD BE
MADE.
Synopsis
AN ESCAPE SLIDE SHOP TECHNICIAN RPTS A PATTERN OF ESCAPE SLIDES
FAILING TO DEPLOY DURING SHOP TESTS. PROB TRACED TO PRESSURE
REGULATOR.
ACN: 564670
Time / Day
Date : 200210
Place
Locale Reference.Airport : JFK.Airport
Environment
Light : Night
Aircraft : 1
Reference : X
ATC / Advisory.Tower : JFK.Tower
Flight Plan : IFR
Mission : Passenger
Flight Phase : Taxi
Aircraft : 2
Reference : Y
ATC / Advisory.Tower : JFK.Tower
Flight Plan : IFR
Mission : Passenger
Person : 1
Reference : 1
Location Of Person.Facility : JFK.Tower
Function.Air Traffic Control : Ground
Person : 2
Reference : 2
Location Of Person.Facility : JFK.Tower
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 14.5
Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Result.Air Traffic Control : Separated Traffic
Assessments
Narrative: 1
ACR X, AN A330, WAS TAXIING TO RWY 31L. AS HE APCHED TXWY J ON TXWY A,
HE WAS INSTRUCTED TO CROSS RWY 4L ON TXWY J AND HOLD SHORT OF TXWY
Z. INSTEAD OF TURNING L ONTO TXWY J, HE CONTINUED STRAIGHT AHEAD AND
WOULD HAVE CROSSED RWY 31L AT TXWY K-A. THE GND CTLR SAW THIS ERROR,
INSTRUCTED ACR X TO HOLD HIS POS AND POINTED THE SIT OUT TO THE LCL
CTLR. ACR Y, A B767, HAD BEEN CLRED FOR TKOF. BECAUSE IT COULD NOT
IMMEDIATELY BE DETERMINED IF ACR X WAS BEYOND THE HOLD LINE, ACR Y

TKOF CLRNC WAS CANCELED AS A PRECAUTION. AFTER THE TKOF CLRNC WAS
CANCELED, AND AS ACR Y WAS SLOWING DOWN TO EXIT THE RWY, AN AMASS
WARNING WAS RECEIVED. SUPPLEMENTAL INFO FROM ACN 564054: ACR Y WAS
CLRED FOR TKOF (ON RWY 31L) AND HAD STARTED TO ROLL WHEN THE GND
CTLR SHOUTED 'CANCEL HIS TKOF' BECAUSE HE WAS AFRAID THAT ACR X MIGHT
BE TAXIING ONTO RWY 31L. I CANCELED ACR Y'S TKOF CLRNC AND HE EXITED
RWY 31L PRIOR TO ACR X'S LOCATION.
Synopsis
FOREIGN ACR A330 ALMOST TAXIED IN FRONT OF A B767 ON TKOF ROLL AT JFK.
ACN: 562836
Time / Day
Date : 200210
Place
Locale Reference.Intersection : ZAIKO
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use.Other
Route In Use.Other
Airspace.Class B : PIT.B
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Location Of Person.Facility : PIT.Tower
Events
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Assessments
Narrative: 1
CLRED FOR RNAV APCH. FO (ME) MISTAKENLY PROGRAMMED AUTOPLT TO DSND
TO DECISION ALT VICE INITIAL APCH ALT. AFTER LOW ALT ALERT FROM TWR,
AUTOPLT WAS SELECTED OFF AND ACFT FLOWN UP TO INTERCEPT GLIDE PATH.
UNEVENTFUL LNDG.
Synopsis
A330 FLC DSNDS BELOW MINIMUM ALT PRIOR TO INTERCEPTING GS OF A NON
PRECISION APCH. TWR ISSUES A LOW ALT WARNING.
ACN: 560346
Time / Day
Date : 200209
Place
Locale Reference.Intersection : MANTA
State Reference : NJ
Environment
Light : Daylight
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Aircraft : 2
Reference : Y
Aircraft Operator : Military
Make Model Name : Dassault-Breguet Undifferentiated or Other Model
Component
Aircraft Reference : Y
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Person : 4
Reference : 4
Reporter Organization : Military
Person : 5
Reference : 5
Events
Anomaly.Other
Assessments
Contributing Factors / Situations : Incorrect / Not Installed / Unavailable Part

Narrative: 1
ZNY (128.3) CLRED US (ACFT #1) TO 16000 FT, AFTER XING 35 NM NE OF
'MANTA' INTXN AT FL200, ON A DIRECT COURSE TO 'MANTA.' (ACFT #2), A
FALCON JET, WAS GIVEN OUR ACFT #1 AS TFC AND RECEIVED A CLB CLRNC FROM
(128.3 NYC) THROUGH OUR ALT. AFTER RESPONDING HE (ACFT #2) HAD OUR
ACFT (#1) IN SIGHT. WE BEGAN SEARCHING TCASII AND VISUALLY ACQUIRING
TCASII TARGET RAPIDLY APCHING OUR ACFT (#1) FROM 12 O'CLOCK POS,
WITHIN 10 NM. TCASII TARGET RAPIDLY CHANGED TO 'AMBER' AS HE LEVELED
OFF SLIGHTLY AT OUR ASSIGNED ALT OF 16000 FT. TCASII 'AMBER' TARGET
RAPIDLY CHANGED TO 'RED,' WITH AN 'RA,' CALLING FOR 'CLB, CLB.' AS AUTOPLT
WAS DISCONNECTED AND NOSE RAISED TO RESPOND TO TCASII RA, OTHER
COCKPIT CREW VISUALLY ACQUIRED MIL FALCON JET (ACFT #2) AT OUR ALT AT
1-2 O'CLOCK POS, AS HE BANKED SHARPLY TO HIS L, ABOUT 30-45 DEG BANK.
HE PASSED US TO R SIDE, ABOUT 16200 FT, WITHIN 2 NM, OR LESS. ZNY KEPT
ASKING MIL FALCON JET (ACFT #2) IF HE HAD US VISUALLY. PAX IN BACK, R
SIDE, COMMUNICATED TO FO, 'THAT MIL FALCON PASSED PRETTY CLOSE!' OUR
ALTDEV WAS NOT MORE THAN 200 FT.
Synopsis
POTENTIAL CONFLICT BTWN A DSNDING A330-300B CARGO FLT AND A MIL
FALCON JET ON A VISUAL SEPARATION CLB THROUGH OCCUPIED ALT AT 16000
FT, 35 MI NE OF MANTA INTXN, NJ.
ACN: 552247
Time / Day
Date : 200206
Place
Environment
Light : Daylight
Aircraft
Reference : X
Component
Aircraft Component : Indicating and Warning - Flight & Navigation Systems
Person : 1
Reference : 1
Qualification.Maintenance : Repairman
Person : 2
Reference : 2
Person : 3
Reference : 3
Events

Assessments
Narrative: 1
JOB CARD 2602 ISSUED BY PLANNING. DROPPED DEAD IN 4 HRS. CALLS FOR
BRIGHTNESS MEASUREMENT OF DISPLAY UNITS USING A LUMINANCE METER, LS100, TOOL #T650001. HAVING NEVER PERFORMED THIS TASK, IT TOOK A WHILE
TO READ, RETRIEVE TOOL, AND UNDERSTAND WHAT WAS WHAT. NEITHER
MYSELF NOR ANYONE IN THE SHOP HAVE HAD TRAINING ON TOOL #T650001.
HAVING BEEN ISSUED JOB CARD AND READING, THERE WASN'T A FIGURE 1. HAD
TO CALL MAINT CTL AND HAVE FIGURE 1 FAXED. FIGURE 1 GIVES VALUES
ACCEPTABLE. AFTER READING AND TRYING TO UNDERSTAND WHAT WAS
REQUIRED, IT WAS DETERMINED THAT TOOL T650001 WAS UNACCEPTABLE. THE
LUMINANCE METER AS TO HAVE A CORRECTION FACTOR WITH UNIT TO MAKE
CALCULATION. INFORMED MAINT CTL THAT METER COULDN'T BE USED WITHOUT
CORRECTION FACTOR. MAINT CTL TRIED TO DEFER CHK, BUT PLANNING WOULD
NOT DEFER. HAD TO HAVE TOOL #T650001 FLOWN IN FROM ZZZ. THIS TOOL HAD
THE CORRECTION FACTOR LISTED WITH TOOL. PERFORMED JOB CARD PER JOB
CARD, BUT TILL PAPER IS CONFUSING AND BY NOT HAVING BEEN TRAINED ON
TEST EQUIP, IT TOOK TIME TO EVALUATE THE ANALYSIS REQUIRED. ALL UNITS
CHKED WITHIN TOLERANCE THAT I DETERMINED TO BE ACCURATE. ACR X NEEDS
TO PROVIDE MORE TRAINING ON TEST EQUIP AND PROCS.
Synopsis
AN AIRBUS 330 REQUIRED A BRIGHTNESS CHK OF COCKPIT DISPLAY UNITS WITH
A SPECIAL INST LACKING A CALIBRATION CHART AND NO TECHNICIAN TRAINING.
ACN: 547154
Time / Day
Date : 200205
Place
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : LIRF.TRACON
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : 16R
Route In Use.Other
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : LIRF.TRACON
Events
Anomaly.Other
Assessments
Narrative: 1
THIS WAS A TRANSATLANTIC FLT FROM ZZZ, US, TO FCO (ROME, ITALY) IN AN
AIRBUS A330-300 ACFT. THE EVENT/SIT TOOK PLACE UPON ARRIVING INTO APCH
CTL AIRSPACE IN FCO. I WAS FLYING THIS LEG, WE WERE ON AUTOPLT WITH FMC
ENGAGED. WE WERE TOLD TO PROCEED DIRECT VALMA DIRECT TAQ (TARQUINA),
TAQ BEING A VOR APPROX 32 NM NNE OF FCO. 'NORMALLY' THE APCH CTL WILL
TELL YOU EITHER TO HOLD AT TAQ OR GIVE A HDG. ALTHOUGH A HOLDING
PATTERN IS DEPICTED ON THE AREA CHART AT TAQ, IT IS NOT NOTED AS A
CLRNC LIMIT FIX. NO FURTHER CLRNC WAS RECEIVED AND THE ACFT, NOW AT
6000 FT, 230 KTS, TURNED R INBOUND TOWARDS FCO. THE ATC CTLR TOLD US
HE HAD NOT ISSUED US A CLRNC TO TURN AND NOW ISSUED A HDG L TO 30
DEGS. NEXT, WE RECEIVED THE FOLLOWING: 'TURN R TO 130 DEGS ILS 16R.' I
COMPLIED AND ENGAGED LOC CAPTURE/INTERCEPT SWITCH. WHEN ACFT
STARTED TO CAPTURE THE LOC THE CAPT ASKED IF WE HAD RECEIVED CLRNC
FOR THE ILS RWY 16R. HE TOLD ME TO GO BACK TO HDG MODE WHILE HE
CONFIRMED CLRNC WITH APCH CTLR. THE ACFT ROLLED OUT AND STARTED TO
TURN BACK TO 130 DEGS. APCH CTL TOLD US, YES WE WERE CLRED FOR APCH
RWY 16R AND TO TURN R TO INTERCEPT, AS WE WERE HDG FOR RWY 16C. I
DISCONNECTED AUTOPLT, TURNED ACFT TO NEW HEADING AND MANUALLY FLEW
THE ILS RWY 16R VISUALLY AND LANDED WITHOUT FURTHER INCIDENT. AFTER
DISCUSSING THE EVENT(S) ON THE GND, WE CONCLUDED THAT WE CANNOT
ASSUME ANYTHING IN EUROPE -- ESPECIALLY IN FCO, AND THAT LANGUAGE
BARRIER AND UNCLR, NON STANDARD TO US, CLRNCS GIVEN LED US INTO THIS
SIT. THE WX WAS VFR SUNNY, NO CONFLICT WITH OTHER ACFT OCCURRED.
SUPPLEMENTAL INFO FROM ACN 547217: ON ARR TO ROME/FUIMICHINO WE HAD
DIFFICULTY FOLLOWING CLRNC LIMIT DIRECTIONS. WE UNDERSTOOD WE WERE
OKAY TO PROCEED IN TO INTERCEPT RWY 16R LOC, AND APCH SAID OUR CLRNC
LIMIT HAD BEEN TAQ VOR. THE ACCENT/LANGUAGE IS DIFFICULT TO
UNDERSTAND. CLRNC LIMITS SHOULD BE MADE MORE EXPLICITLY.
Synopsis
A330 CREW HAD LANGUAGE BARRIER AND CLRNC INTERP PROBS ON ARR AT LIRF.
ACN: 546982
Time / Day
Date : 200205
Place
Aircraft
Reference : X
Component
Aircraft Component : Waste Water Disposal System
Person : 1
Reference : 1
Experience.Maintenance.Avionics : 7
Person : 2
Reference : 2
Events

Assessments
Logbook Entry
Aircraft
Human Factors
Narrative: 1
I WAS WORKING ACFT X ETOPS SVC CHK ON A THROUGH FLT. I WAS ALSO TO
REPLACE LAVATORY L54 TOILET. THE TOILET WAS ON MEL. I FINISHED THE
ETOPS CHK AT XA00. THE PLANE WAS SET TO DEP AT XC40. I WAS SUPPOSED TO
BE FINISHED WITH THE TOILET BY XB30, SO CREWS COULD BOARD PAX. AS I
WAS RESEARCHING REQUIRED PAPERWORK I TOLD THE LEAD 'THIS IS A BIG
JOB,' INDICATING I WOULD NEED MORE TIME, HELP AND TOOLING. THE LEAD
GOT MAD AND VERY DEFENSIVE, RAISING HIS VOICE HE SAID 'IT'S ONLY A
TOILET, JUST CHANGE IT OUT.' WELL I DID. ALL I DID WAS JUST CHANGE IT OUT,
REMOVE AND REPLACE WITH A WATER LEAK CHK AND OPS CHK (WHICH WENT
FINE). THE MAINT MANUAL CALLS OUT FOR ADDITIONAL STEPS PRE AND POST
INSTALLATION. I FELT TAKEN ADVANTAGE OF. THE UPGRADE LEAD MECH SHOULD
HAVE GOT INVOLVED TO HELP, AND TO SEE WHAT EXACTLY THE MAINT MANUAL
CALLED OUT.
Synopsis
AN A330-200 WAS DISPATCHED IN NON-COMPLIANCE WITH A LAVATORY TOILET
REPLACED WITH ALL REQUIRED MAINT MANUAL CHKS NOT ACCOMPLISHED.
ACN: 545495
Time / Day
Date : 200204
Place
Locale Reference.Navaid : LVZ.VORTAC
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use.STAR : MAZIE 1
Airspace.Class E : ZNY.E
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Person : 4
Reference : 4
Events
Anomaly.Other
Assessments
Narrative: 1
ON ARR TO PHL, ON MAZIE 1 ARR, WERE CLRED TO CROSS D15 DNY INTXN AT
FL190. WE EXPECTED TO CROSS CORLE AT 12000 FT. WE WERE THEN GIVEN
WHAT I THOUGHT TO BE 10 MI N OF LVZ AT 10000 FT. I CONFIRMED THE 10000
FT PER COMPANY FOM WITH CAPT AND THEN BUILT NEW ONE IN FMC WITH 10000
FT RESTR, DELETING CORLE AT 12000 FT. AT ABOUT 11000 FT, ZNY ASKED IF WE
WERE GOING TO LEVEL AT 12000 FT. CAPT REPLIED WE WERE DSNDING TO
10000 FT. ZNY SAID WE WERE ONLY CLRED TO 12000 FT. I STOPPED THE DSCNT
AND CLBED BACK TO 12000 FT. AFTER RECEIVING THIS DSCNT CLRNC, WE WERE
GIVEN A SHORT VECTOR TO THE W, THEN CLRED TO LVZ. BEFORE THE VECTOR,
WE WERE FLYING THE MAZIE 1 ARR AND PLANNED TO CROSS CORIE AT 12000 FT.
THE CLRNC GIVEN BY ZNY HAD US XING CLOSE TO CORIE (2 MI) AT 12000 FT
WHICH ADDED WORKLOAD AND CONFUSION. DURING THIS DSCNT AND CLRNC,
WE HAD A MEDICAL EMER IN THE CABIN OF THE ACFT AND HAD NUMEROUS
CALLS FROM THE FLT ATTENDANT ON THE COCKPIT SPEAKER WHICH ADDED
DISTR DURING A CRITICAL PHASE OF FLT. I BELIEVE THE MEDICAL EMER DISTR
HAD A LOT TO DO WITH THE DEV AND ALSO THE CTLR'S CHANGES ADDED TO THE
WORKLOAD AND CONFUSION. LESS COM WITH CABIN CREWS DURING CRITICAL
PHASES OF FLT MIGHT HELP PREVENT THESE SITS.
Synopsis
A330 AIRBUS FLC OVERSHOT INTERMEDIATE ARR FIX DUE TO MISINTERP OF
THEIR CLRNC DURING A MEDICAL PAX EMER.
ACN: 541951
Time / Day
Date : 200203
Place
Environment
Light : Night
Aircraft
Reference : X
Component
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events

Assessments
Narrative: 1
WORKED PART OF ENGINEERING ORDER XXX -- INSTALL IMPROVED SLIDING
WINDOW SHADE. STEPS HAVE YOU REMOVE WINDOW SHROUD TO CHANGE
SHADES. SHROUD REMOVAL NOT REQUIRED -- PLENTY OF ACCESS. WAS ADVISED
BY THE FORMAN TO 'N/A' STEPS [NOT APPLICABLE]. FOUND OUT LATER THAT WE
NEEDED AN 'OK' ON ANY CHANGE. ENGINEERING WAS NOTIFIED FOR THIS AND
NEXT ACFT TO CHANGE ANY STEPS. ALSO, THE ENGINEERING ORDER THAT WAS
WORKED.
Synopsis
AN AIRBUS 330 DURING A COCKPIT WINDOW SHADE MODIFICATION, THE
ENGINEERING ORDER HAD UNNECESSARY STEPS FOR THE SHADE INSTALLATION
NOT ACCOMPLISHED.
ACN: 540070
Time / Day
Date : 200202
Place
Environment
Weather Elements / Visibility.Other
Light : Night
Aircraft
Reference : X
Component
Aircraft Component : Gear Extend/Retract Mechanism
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Aircraft
Logbook Entry
Human Factors
Narrative: 1
DURING WALKAROUND OF AN A330 A HYD LEAK WAS FOUND COMING FROM THE
GEAR DOOR/LNDG GEAR MANIFOLD IN THE TOP OF THE WHEELWELL. I NOTIFIED
MAINT CTL TO ORDER A NEW MANIFOLD. ACR Y LOANED THE PART, FLOWN AOG
TO ZZZZ. I FITTED THE MANIFOLD WITH TECHNICIAN X. I COMPLETED THE
INSTALLATION AS PER THE MAINT MANUAL BUT REFED THE INCORRECT TANK IN
THE LOGBOOK AND MISSED THE REQUIREMENT FOR A GEAR SWING. MAINT CTL
ALSO DID NOT NOTIFY ME OF THIS REQUIREMENT.
Synopsis
AN AIRBUS 330 WAS DISPATCHED IN NON COMPLIANCE AFTER A LNDG GEAR
SELECTOR VALVE HYD MANIFOLD WAS REPLACED BUT THE REQUIRED LNDG GEAR
REACTION TEST NOT ACCOMPLISHED.
ACN: 538112
Time / Day
Date : 200202
Place
Locale Reference.Airport : DCA.Airport
State Reference : DC
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Airspace.Class A : ZDC.A
Component
Aircraft Component : Toilet Smoke, Overheat, Fire Detectors & Warning
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Anomaly.Other
Assessments
Narrative: 1
WE RECEIVED AN ECAM ADVISORY OF SMOKE LAVATORY AND CARGO DETECTION
FAULT, WHICH MEANS WE HAD NO DETECTION OF SMOKE OR FIRE IN ANY
LAVATORY OR CARGO COMPARTMENT. COMPANY POLICY STATES THAT WE ARE
NOT TO RESET BREAKERS TO RESTORE SYS FUNCTION INFLT, UNLESS WE USE
'CAPT'S EMER AUTH' TO DO SO. WE WERE OVER LNDG WT, AND I CONFERRED
WITH MAINT, AND DECIDED TO RESET BREAKERS AS A SAFER COURSE OF
ACTION TO RESTORE SYS FUNCTION, THAN TO FLY WITH NO SMOKE DETECTION.
THIS HAPPENED 14 MINS OUT OF DCA. BECAUSE OF SECURITY REASONS, AND
BEING OVERWT (LNDG WT), IT SEEMED PRUDENT TO TRY TO RESTORE SYS
FUNCTION, WHICH WE DID. ALL OPS NORMAL FOR REST OF FLT.
Synopsis
AN AIRBUS 320 IN CRUISE AT FL350 HAS ECAM WARNING OF NO SMOKE OR FIRE
DETECTION IN ANY LAVATORY AND CARGO COMPARTMENT. RESET CIRCUIT
BREAKER AND RESTORED SYS.
ACN: 532213
Time / Day
Date : 200112
Place
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Nav In Use.Localizer/Glideslope/ILS : NS
Airspace.Class B : PHL.B
Component
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Location Of Person.Facility : PHL.TRACON
Events
Assessments
Narrative: 1
DURING OUR DSCNT/APCH INTO PHL, WITH THE CAPT SERVING AS THE PF, HE
TURNED THE ACFT ONTO FINAL INSIDE THE OM, THEREBY NEVER CAPTURING THE
LOC AND GS. HE THEN DISCONNECTED THE AUTOPLT AND BEGAN A SAFE, ABOUT
1 DOT LOW, INITIAL DSCNT. THE AUTOTHRUST SYS HAS AN UTTERLY
RIDICULOUS COMPONENT WHICH THEN MATCHED THRUST WITH THE FLT
DIRECTOR COMMAND, NOT CONSIDERING WHAT THE ACFT WAS ACTUALLY
DOING. THUS, THRUST SURGED TO 4000 PPH FUEL FLOW AND 180 KTS EVEN
THOUGH WE WERE TRYING TO FLY A COMMANDED 135 KTS AND DSCNT. I THEN
SWITCHED OFF BOTH FLT DIRECTORS AS PER OUR COMPANY PROC AND THE SPD
STARTED DECREASING (IDLE PWR). THE CAPT INSTRUCTED ME TO SWITCH THE
FLT DIRECTORS BACK ON. I DID AND THE PWR INCREASED TO 4000 PPH FUEL
FLOW AND SPD RETURNED TO 180 KTS. I AGAIN SWITCHED THE FLT DIRECTORS
OFF. (I HAD SET IN AN MCP ALT OF 3000 FT, OUR MISSED APCH LEVEL.) THE
THRUST DECREASED, AS DID THE SPD. THE CAPT THEN INSTRUCTED ME TO TURN
THE FLT DIRECTORS BACK ON. I COMPLIED AND THRUST RETURNED TO THAT
NEEDED TO HOLD 180 KT FLT DIRECTOR ALT. AT 500 FT AGL, I SUGGESTED A
GAR. THE CAPT DEMURRED. I SUGGESTED THIS AT LEAST 1 MORE TIME AS WE
CONTINUED. THE CAPT AGAIN REFUSED, BUT RETARDED THE THRUST LEVERS TO
IDLE (AT ABOUT 300 FT AGL). THE ACFT CROSSED THE RWY THRESHOLD AT
ABOUT 165 KTS -- 30 KTS FASTER THAN APPROPRIATE. WE LANDED SLIGHTLY
LONG. OBSERVATION: I COULD HAVE ASSISTED THE CAPT MORE BY SELECTING
VERT SPD -1000 EARLY IN THE APCH. HE COULD HAVE HELPED HIMSELF BY
LISTENING TO ME.
Synopsis
AN A330 CREW, ON FINAL TO PHL, EXCEEDED NORMAL APCH SPD, LNDG LONG.
ACN: 523520
Time / Day
Date : 200108
Place
Environment
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.TRACON : EDFF.TRACON
Flight Plan : IFR
Mission : Passenger
Person
Reference : 1
Events
Anomaly.Deviation - Altitude : Crossing Restriction Not Met
Assessments
Narrative: 1
WE BRIEFED THE DEP AS THIS IS WHAT WE EXPECTED. WE NOTED, AND

PREVIOUS EXPERIENCE DICTATED, THIS DEP DUE TO UNABLE TO MAKE CLB
RESTR IN LATER PART OF DEP (ABOVE FL250). WHEN CLRNC WAS RECEIVED, THE
CLRNC WAS FOR DEP PROC. WE ALSO BRIEFED THAT IF GIVEN A DIFFERENT DEP
PROC, WE WOULD REQUEST THE ORIGINAL DEP PROC AS WAS NOTED ON SID
PAGE FOR UNABLE CLB RESTR. AFTER CLRNC WAS RECEIVED, WE FAILED TO
REQUEST DEP PROC EVEN THOUGH ALL IN COCKPIT HEARD CLRNC READBACK. TO
PREVENT RECURRENCE, BRIEF DEP OFF OF AND XREF NOTES MADE WHILE
COPYING CLRNC. DEP CTL REMARKED OF OUR INCORRECT RTE.
Synopsis
AN A320 FLT CREW FAILED TO READ THE NOTE ON THE SID AND DIDN'T MEET A
XING RESTR.
ACN: 508242
Time / Day
Date : 200104
Place
Locale Reference.Intersection : NANCE
Environment
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use.Airway : R763.Airway
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Reporter Organization : Contracted Service
Qualification.Other
Events
Assessments
Narrative: 1
WHEN I RETURNED TO COCKPIT AFTER USING FORWARD LAVATORY, THE SELCAL
STARTED TO BUZZ JUST AS I WAS STRAPPING IN. COMMERCIAL RADIO WANTED
US TO CONFIRM OUR ALT. I ACKNOWLEDGED THAT WE WERE AT FL390. JUST
PRIOR TO MY RETURN, THE CAPT (PF), INDICATED HE HAD MADE A POS RPT OVER
NANCE INTXN. HE ALSO INDICATED HE HAD STATED OUR ALT WAS FL370, WHEN
IN FACT IT WAS FL390 -- OUR ASSIGNED ALT. HUMAN FACTORS.
Synopsis
NEW YORK COMMERCIAL RADIO CHALLENGES ACR FLC POS RPT.
ACN: 507220
Time / Day
Date : 200104
Place
Environment
Light : Night
Aircraft
Reference : X
Person
Reference : 1
Events
Assessments
Narrative: 1
I COMPLIED WITH AN ETOPS CHK FOR AN AIRBUS 330, FOR TRANS-ATLANTIC
SVC. UPON SIGNING OFF 2 PAGES OF LOGBOOK ITEMS AND THE AIRWORTHINESS
BLOCK, I NEGLECTED TO MAKE AN ENTRY FOR MAINT ACCOMPLISHMENT OF
ETOPS CHK AND THE APPROPRIATE ACTION TAKEN AND REQUIRED SIGNOFF AS
PER ETOPS CHK CARD. NOTE: THE LOGBOOK WRITE-UPS AND ETOPS CHK WERE
ADDRESSED/COMPLIED WITH. ACFT WAS DISPATCHED UNDER NOMINAL
CONDITIONS SAVE FOR THE OMITTED WRITTEN ETOPS
COMPLIED/ENTRY/SIGNOFF IN THE LOGBOOK. THIS OMISSION WAS NOT
DISCOVERED UNTIL AFTER THE ACFT WAS DISPATCHED AND ENRTE FOR EUROPE,
PERHAPS 1/2 HR AFTER DISPATCH. FOR WHATEVER AN EXCUSE, I NEGLECTED

THIS REQUIREMENT AND CAN SEE ANY FUTURE TIMES PERTAINING TO THIS LIKE
SIT TO BE ENSCONCED IN MEMORY AND NOT FAIL IN ADMINISTERING THIS
REQUIREMENT.
Synopsis
AN ETOPS CHK WAS COMPLETED BUT THE PROPER LOG SIGNOFF WAS NOT
ACCOMPLISHED ON AN AIRBUS 330.
ACN: 500385
Time / Day
Date : 200102
Place
Environment
Weather Elements / Visibility.Other
Light : Daylight
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Route In Use.Other
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Person : 4
Reference : 4
Location Of Person.Facility : CZQX.ARTCC
Events
Anomaly.Other
Assessments
Narrative: 1
FLT WAS TRANSITING A SIGMET AREA OF RPTED MODERATE TO SEVERE TURB IN
THE VICINITY OF 54N 50W. FOR APPROX 30-40 MINS WE ENCOUNTERED TURB
THAT I WOULD CHARACTERIZE AS BEING IN THE UPPER END OF A RANGE THAT
WOULD BE CONSIDERED MODERATE. A COUPLE OF TIMES FOR A FEW SECONDS
THE TURB INCREASED TO A LEVEL I CONSIDERED TO BE AT THE LOWER END OF
THE SEVERE RANGE. I RECALL MY FO STATING THAT HE WAS NOT SURE WE HAD
CROSSED THE LINE FROM MODERATE TO SEVERE. THERE WERE A NUMBER OF
OTHER ACFT IN THE AREA THAT WERE GIVING TURB RPTS, WHICH INCLUDED
INTENSITY OF TURB, POS AND ALT. THESE RPTS HELP EVERYONE IN THE AREA
DETERMINE WHEN, WHERE AND AT WHAT ALT THEY MIGHT ENCOUNTER SUCH
TURB. MOST OF THE RPTS INDICATED CONTINUOUS MODERATE TURB, HOWEVER,
ONE ACFT RPTED AS I DID THAT THE TURB WAS MODERATE AND VERY
OCCASIONALLY SEVERE. ANOTHER ACFT CALLED IT APCHING SEVERE. I DID NOT
THINK THE TURB WE ENCOUNTERED WAS SEVERE ENOUGH TO DAMAGE THE ACFT
OR WARRANT AFTER FLT LOG ENTRY OR INSPECTION. THE LINE BTWN TURB
INTENSITIES, ALTHOUGH DEFINED IS STILL A SUBJECTIVE JUDGEMENT BY
INDIVIDUAL PLTS. THE RPT I MADE WAS INTENDED TO MORE ACCURATELY IDENT
FOR THE PLTS IN THE AREA, THE INTENSITY OF THE TURB WE WERE
EXPERIENCING AS BEING AT THE UPPER END OF MODERATE AND PERHAPS
OCCASIONALLY XING INTO THE LOWER END OF SEVERE. I DID NOT KNOW OR
RECALL THAT USING THE WORD SEVERE IN ANY CONTEXT WOULD REQUIRE A
LOG ENTRY AND ACFT INSPECTION. I WAS INFORMED OF THIS REQUIREMENT BY

TELEPHONE OF FEB/XA/01.
Synopsis
A330 ENCOUNTERED SEVERE TURB IN CZQX OCEANIC.
ACN: 497373
Time / Day
Date : 200101
Place
Locale Reference.Navaid : HTO.VORTAC
Environment
Light : Dusk
Aircraft : 1
Reference : X
Flight Plan : IFR
Mission : Passenger
Nav In Use.VOR / VORTAC : HTO.VORTAC
Aircraft : 2
Reference : Y
Flight Plan : IFR
Mission : Passenger
Nav In Use.VOR / VORTAC : HTO.VORTAC
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Events
Assessments
Narrative: 1
ACFT #2 WAS CLRED VIA NAVAID RADIAL TO INTERCEPT AIRWAY S OF COURSE.
DSNDING ACFT #1 ON COURSE TO PARALLEL ACFT #2 TO ACCOMMODATE DSCNT.
ACFT #1 WAS GIVEN DSCNT CLRNC FROM FL370 TO FL310. ACFT #2 WAS
OBSERVED NOT ON RADIAL VECTOR AND CONVERGING WITH ACFT #1. ACFT #2
WAS TURNED 30 DEGS L OF COURSE TO MAINTAIN SEPARATION. ACFT #1 WAS
MISTAKENLY TURNED 30 DEGS L IN ERROR -- SHOULD HAVE BEEN 30 DEGS R TO
MAINTAIN SEPARATION.
Synopsis
ARTCC CTLR MISTAKENLY TURNED 1 OF 2 DSNDING ACFT THE WRONG WAY FOR
SEPARATION RESULTING IN LOSS OF LEGAL SEPARATION.
ACN: 491713
Time / Day
Date : 200011
Place
Locale Reference.Airport : EGKK.Airport
Environment
Flight Conditions :
Weather Elements
Weather Elements
Weather Elements
Light : Daylight
Mixed
/ Visibility : Rain
/ Visibility : Fog
/ Visibility.Visibility : 10
Aircraft
Reference : X
ATC / Advisory.Center : EGTT.ARTCC
ATC / Advisory.TRACON : EGKK.TRACON
Flight Plan : IFR
Mission : Passenger
Route In Use.STAR : WILLO
Component
Aircraft Component : Data Processing
Problem : Design
Person : 1
Reference : 1

Person : 2
Reference : 2
Person : 3
Reference : 3
Function.Other
Person : 4
Reference : 4
Person : 5
Reference : 5
Location Of Person.Facility : EGKK.TRACON
Events
Anomaly.Other
Assessments

:
:
:
:
Aircraft
Airspace Structure
Company Policy
Human Factors
Narrative: 1
NEARING THE END OF A 7 HR FLT FROM PHL TO LGW, UNITED KINGDOM, THE
GATWICK/LONDON DIRECTOR ATC AREA, WE WERE ADVISED TO ENTER HOLDING
AT THE HOLLY/WILLO ARR CIRCUIT DUE TO TFC CONGESTION. THE HOLLY/WILLO
ARR IS HARD PROGRAMMED INTO OUR SOFTWARE. UPON THE SECOND CIRCUIT
(SECOND L TURN IN HOLDING PATTERN) AFTER JUST PASSING WILLO INTXN, WE
WERE GIVEN AN APPROX HDG OF 044 DEGS TO HEAD US TOWARD MAYFIELD
(MAY) INTXN ON THE RNAV RWY 26L ARR. UPON PULLING AND DRAGGING THE
HDG TRACK SELECTOR KNOB TO THE L, THE ACFT WAS VIRTUALLY NON
RESPONSIVE. THE CTLR, THINKING THAT WE HAD MISSED HIS INSTRUCTION,
ASKED US IF WE WERE IN A L TURN, AT WHICH TIME WE WERE SLOWLY
TURNING. THE CTLR THEN ASKED US TO TURN TO THE R OVER 180 DEGS
TOWARD MAYFIELD (ON ASSIGNED HDG NOT DIRECT). THE PLANE AGAIN WAS
VIRTUALLY UNRESPONSIVE (VERY SLOW TO TURN). IT SHOULD BE POINTED OUT
THAT WE HAD A CHK AIRMAN WHO WAS IN THE COCKPIT TO CERTIFY THE RNAV
CAPABILITIES OF THE AIRBUS 330 OVERSEAS AT GATWICK. OVER THE 14 YRS
THAT I'VE BEEN FLYING TO GATWICK WITH THIS CARRIER, THIS (WILLO/HOLLY)
ARR HAS ALWAYS BEEN A PROB AREA OF UNDERSTANDING. THE LONDON CTLRS
ARE EXCELLENT AND HAVE ALWAYS BEEN IN THIS AREA. AT THE PRESENT TIME
WE ARE EXPERIENCING NAV/HDG PROBS IN SEQUENCING OVER THE NORTH
ATLANTIC. APPARENTLY SOFTWARE UPGRADES/CHANGES ARE BEING MADE.
LONDON CTLRS SHOULD BE ADVISED OF THIS PROB AND SHOULD AVOID GIVING
US 180 DEG TURNS IMMEDIATELY (A TURN WITH 45 DEGS SHOULD BE INITIALLY
GIVEN TO GET ACFT TURNING IN CORRECT DIRECTION AND THEN FOLLOWED BY
FINAL DESIRED TURN). THIS WAS CAPT'S SECOND TRIP TO EUROPE ON THIS
ACFT. 4 HIGHLY QUALIFIED PLTS IN COCKPIT (91 YRS OF EXPERIENCE).
CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE FO
STATED THAT THIS PROB WITH THE SLOW TURN RATE WAS PROBABLY
ASSOCIATED WITH THE DESIGN OF THE SOFTWARE WITHIN THE FMS/IRS SYS OF
THE A330-300. THIS SOFTWARE PROB WAS ALSO INVOLVED IN AT LEAST 2
KNOWN 'FAILURES TO SEQUENCE THE NAT' (WHEN OVER 1 WAYPOINT THE FMS
FAILED TO SHIFT TO THE NEXT WAYPOINT). NAT TRACK DEVS EXPERIENCED BY 2
SEPARATE OTHER AIRLINE CHK AIRMEN ON THIS EQUIP. IT WAS ALLEGED THAT
THESE 2 TRACK DEVS WERE ASSOCIATED WITH SOFTWARE INTERFACE
MALFUNCTIONS AND THAT THE MANUFACTURER OF THE SOFTWARE DID NOT
COORD WITH RPTR'S AIRLINE. RPTR STATED THAT 'A MAJOR SOFTWARE CHANGE
IS FORTHCOMING TO CORRECT THIS PROB.' IN THIS EVENT, DURING ONE OF
MANY REQUIRED RNAV EQUIP CERTIFICATION FLTS, THE FLYING FO DID NOT
DISENGAGE THE AUTOPLT TO MAKE A MANUAL HDG CHANGE. HE ADMITS THAT
HE SHOULD HAVE. HE CITED AN OLD INBRED TRAINING ISSUE OF NOT
DISCONNECTING THE AUTOMATED SYS. HE ALSO SAID TO 'FORGET ALL THE OLD
XYZ ACFT STUFF.' FO FEELS THAT THE AUTOPLT/FMS THOUGHT THE ACFT WAS
STILL IN THE HOLDING PATTERN DURING THE ATTEMPTED TURN. THE FO
(TERMED A 'WHIZ ON THE COMPUTERS') AND THE CHK AIRMAN WERE JUMP
SEATING AND COULD NOT MAKE OUT WHY THE ACFT WAS NOT RESPONDING AS
IT SHOULD HAVE. EVERYONE IS 'NEW' TO THIS ACFT, THE CAPT HAVING ABOUT
60 HRS TOTAL IN TYPE. SO FAR AS THE RPTR KNOWS, THE ONLY FEEDBACK TO
ACFT MANUFACTURER ON THESE EVENTS IS THE METHODOLOGY USED IN

SELECTING THE NEW HDG. ACFT MANUFACTURER SAYS TO 'SELECT HDG FIRST,
THEN PULL THE HDG/TRACK SELECTOR KNOB.' THE COMPANY IS MONITORING
THE SIT BUT IS 'HAMPERED BY THE FACT THAT AN ALL NEW AIRLINE SAFETY
BOARD IS IN PLACE.' A COPY OF THIS RPT WAS ALSO SENT TO THE UNION
SAFETY OFFICE.
Synopsis
AN A330-300 FO RPT ON THE INABILITY OF THE CREW TO TURN THEIR ACFT IN
ACCORDANCE WITH RADAR VECTORS IN THE LONDON AREA OF GATWICK, EGKK,
FO.
ACN: 489770
Time / Day
Date : 200010
Place
Environment
Light : Dusk
Aircraft
Reference : X
Mission : Passenger
Flight Phase : Taxi
Component
Aircraft Component : Emergency Equipment
Person : 1
Reference : 1
Person : 2
Reference : 2
Person : 3
Reference : 3
Function.Flight Crew : Flight Engineer / Second Officer
Person : 4
Reference : 4
Location Of Person.Facility : ZZZ.TRACON
Person : 5
Reference : 5
Person : 6
Reference : 6
Person : 7
Reference : 7
Events
Anomaly.Other
Assessments
Narrative: 1
ARRIVED AT ACFT 50 MINS PRIOR TO DEP AND COMPLETED PREFLT. CREW
CONSISTED OF CAPT, FO AND SO. DURING PREFLT PREPARATIONS I WAS CALLED
TO CABIN TO HELP FLT ATTENDANTS WITH A MINOR PROB. UPON MY RETURN I
OBSERVED DATA LINK MESSAGE BEING PRINTED. I BELIEVED IT WAS OUR ATC
CLRNC. MY INTENTION WAS TO READ THE PRINTED CLRNC, BUT I WAS
DISTRACTED BY THE ARR OF THE ACFT'S MAINT LOGBOOK, AGENTS COMING TO
COCKPIT FOR VERIFICATION OF PAX COUNT, ETC. AS IT WAS DEP TIME AND WE
WERE IN CONTACT WITH PUSHBACK CREW WE COMPLETED BEFORE START
CHKLIST AND CONTACTED RAMP CTL AND WERE CLRED FOR PUSHBACK. WE
STARTED ENGS, COMPLETED CHKLISTS, CALLED FOR TAXI AND WERE CLRED FOR
TAXI TO RWY 28L. DURING TAXI TWO FURTHER DISTRACTIONS OCCURRED. ONE
WAS AN INADVERTENT PUSHING OF THE EVAC COMMAND BUTTON BY ONE OF THE
FLT ATTENDANTS CAUSING AN AURAL WARNING AND RED LIGHT IN COCKPIT.
AND AFTER THAT WAS CLRED UP, A PAX RPTED TO A FLT ATTENDANT THAT THERE
WERE STRANGE NOISES COMING FROM BELLY OF ACFT. I STOPPED THE ACFT
SHORT OF RWY AND SENT SO TO CHK ON NOISES. WE DETERMINED THE NOISES
WERE THE HYD BRAKE NOISES. COMPLETED BEFORE TKOF CHKLIST AND CALLED
TWR READY TO GO. RECEIVED TKOF CLRNC WITH A TURN TO 350 DEGS. WHEN
WE WERE SWITCHED TO DEP CTL WE WERE TOLD TO SQUAWK ANOTHER CODE. I
THEN ASKED IF FO HAD IN FACT GOTTEN OUR ENRTE CLRNC. HE REPLIED NO. SO
THEN SENT REQUEST FOR CLRNC BY DATA LINK AND WE RECEIVED IT. TOTAL
TIME FROM TKOF TO CLRNC WAS 2 MINS. AT NO TIME WAS THE ACFT IN ANY
DANGER.
Synopsis
AN ACR CREW DEPARTS WITHOUT RECEIVING ENRTE CLRNC.
ACN: 480690
Time / Day
Date : 200007
Place
Locale Reference.Airport : PIT.Airport
Environment
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
Flight Plan : IFR
Mission : Passenger
Component
Aircraft Component : Brake System
Person : 1
Reference : 1
Person : 2
Reference : 2

Person : 3
Reference : 3
Location Of Person.Facility : DTW.Tower
Person : 4
Reference : 4
Events
Assessments
Narrative: 1
ON VISUAL APCH TO RWY 28R (ASKED FOR RWY 28L) BRIEFED BOTH APCHS.
CLRED FOR VISUAL TO RWY 28L. ENDED UP A LITTLE HIGH FOR RWY 28L SINCE IT
WAS CLOSER. NO PROB SINCE IT IS 11500 FT LONG. DECIDED TO USE 'LO' ON
AUTOBRAKE. TOUCHED DOWN AND DID NOT USE BRAKES UNTIL TURNOFF AT
END. AFTER PARKING, BRAKE TEMP STARTED TO RISE AND I LEFT THE PARKING
BRAKE OFF AS CHOCKS WERE IN. AFTER DOING PARKING AND SECURITY
CHKLISTS AND HDG FOR HOME, I WAS TOLD BY A MECH THAT THERE WAS A
BRAKE FIRE. WE CHKED THE BOOK TOGETHER AND DECIDED THAT THE
PARAMETERS WERE NOT EXCEEDED TO CAUSE A WRITE-UP IN THE LOG.
SUPPLEMENTAL INFO FROM ACN 480695: I CHKED THE MANUAL. BRAKES GOT TO
620 DEGS AND MANUAL SAID WRITE-UP WAS REQUIRED IF BRAKES GOT TO 900
DEGS.
Synopsis
AFTER A LNDG 20 KTS ABOVE REF SPD USING 'LO' AUTOBRAKE SETTING, MAINT
RPTED A BRAKE FIRE EVEN THOUGH BRAKE TEMP INDICATED 280 DEGS BELOW
THE REQUIRED WRITE-UP TEMP.

330 Incident

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330 Incident

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ACN: 1198605

Detector.Person : Ground Personnel

Anomaly.Aircraft Equipment Problem : Critical

Contributing Factors / Situations : Aircraft

Human Factors : Fatigue

Result.General : Maintenance Action

Contributing Factors / Situations : Company Policy

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

When Detected : Aircraft In Service At Gate

Result.Flight Crew : Executed Go Around / Missed Approach

Contributing Factors / Situations

Contributing Factors / Situations : Environment - Non Weather Related

Communication Breakdown.Party2 : Maintenance

When Detected : In-flight

Contributing Factors / Situations : Environment - Non Weather Related

Contributing Factors / Situations : Procedure

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

Result.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Landed As Precaution

Contributing Factors / Situations : Aircraft

Result.General : Declared Emergency

airspace. Apparently, the change in departure procedure by the Tower Controller

Anomaly.Deviation - Speed : All Types

Communication Breakdown.Party2 : Dispatch

Result.General : Declared Emergency

Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Aircraft

ASRS Report Number.Accession Number : 1024515

Anomaly.Airspace Violation : All Types

Human Factors : Confusion

I suspect improper sumping, not necessarily on Maintenance behalf, but rather on

Result.General : Declared Emergency

Location In Aircraft : Flight Deck

Detector.Person : Air Traffic Control

Detector.Person : Flight Attendant

Human Factors : Confusion

We departed after a lengthly maintenance delay to repair HYD G system. On initial

Result.General : Maintenance Action

When Detected : In-flight

Human Factors : Workload

Human Factors : Troubleshooting

Communication Breakdown.Party2 : Dispatch

discovery" be fixed by replacing the actuator. It was done in 2 hours I believe,

When Detected : In-flight

Result.General : Maintenance Action

Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Aircraft

When Detected : Aircraft In Service At Gate

Anomaly.Aircraft Equipment Problem : Critical

Detector.Person : Flight Crew

Human Factors : Time Pressure

forklift movement of incomplete tooling. No biggy, yet another creation of

Result.General : Declared Emergency

Result.General : Maintenance Action

Human Factors : Situational Awareness

Contributing Factors / Situations : Aircraft

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

Anomaly.ATC Issue : All Types

Human Factors : Situational Awareness

Human Factors : Training / Qualification

When Detected : Pre-flight

Anomaly.ATC Issue : All Types

Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Logbook Entry