Communication: Between Pilots – Crew Resource Management
On the climb out from VNY to CNO, the captain’s FMS screen darkened, but was still functioning with data displayed on his PFD. He freaked out and missed several radio calls. The copilot (pilot flying) took over the radio calls and checklists since he couldn’t get the captain (pilot monitoring) to response for the next 8-10 minutes. The captain then spent those 8-10 minutes punching his FMS and messing with his and my radio screens, while the copilot flew, answered the radio calls, made sure he was on the right frequency, and flew headings, leveled off, and then proceeded direct POM and PDZ VORs on FMS 2, descended, spotted the destination airport, and then got his captain to chill out, stop being a hot mess of a distraction, refocus on monitoring and not creating potential safety issues.
Approximately 3 miles from Chino, I got my captain back in the game enough to answer SoCal that I had the airport in sight to do a visual with amazing conditions. I tasked him with the spoilers after that radio call, so he wouldn’t mess anything up on me or violate us as he’s historically done in similar situations. I turned downwind for runway 26L (7000′ long). He wanted me to do an ILS to the short runway 26R (less than 5000′) and proceed on the ILS 26R on autopilot. I strongly declined since:
#1. That would further distract his extreme limited capacity at this time
#2. We already briefed I would do a visual on the ground in Van Nuys, and
#3. Anything else would distract me as essentially a single pilot.
On late downwind, I turned the autopilot off since my captain was in no shape to follow any instructions concerning that. He stated he wanted the autopilot on, but I said “NO” because if he touched anything up there, I was 99% certain it led to a go around or a traffic conflict with the Cessna on 26R final. I turned base and final 26L, and did a text book approach and flare. As the mains touched down and the nose settled, the captain violently grabbed the yoke and greatly oscillated the elevator bouncing the nose wheel creating a potential safety issue. I didn’t hear him say “my controls”. He just slammed, thrashed, and pumped the controls making my correct and slight input 4-5 times worse in the opposite direction until I said “your controls” a moment later and let him pump the elevator 2/3-3/4s deflection until he calmed down and the tail couldn’t fly anymore. He taxied down to the end of the runway clearly not even half way mentally there while trying to get a hold of [name] to find out where to park instead of getting the plane off an active runway and taxiing to a safe location to make that communication, deferring it to the flight attendant, or a myriad of other safer options. I made sure he kept the jet on the runway and taxiway, while completing the checklists.
As taxiing into Threshold Aviation was fairly tight, we stopped and discussed getting marshallers out due to this, but my main concern was he still wasn’t there mentally, and I wanted a second set of eyes on his side to greatly reduce the risk of him hitting the wingtip on the other jet, a large metal box that appeared to be an electrical transformer, and several light poles. After a delay and him taking a few minutes to collect himself, we continued taxiing and shut down. I post flighted the plane, unloaded all the baggage and the 200lb windshield box with some assistance from the mechanics, and got everything squared away minus the cockpit since the captain didn’t have the mood or mental wherewithal to do a debrief more than him saying “Good Job” and me saying “Well, we survived” in a very calm, but concerned tone. He then immediately ran off to monitor the mechanics as I helped the flight attendant load the car. I tried to talk to him over the next 30 minutes in the hanger, but he avoided me by either talking with dispatch, his friends and family, or walking to the other side of the hanger when I approached him. He disappeared for 20-25 minutes as we waited for him to surface from avoiding us in the hanger. He then said he was looking for us when I was walking in front of the FBO with the car within his view most of that time or sitting in the FBO with the flight attendant less than 50′ away. I drove to the hotel, and then the same thing happened as he ran off before the rest of us checked in, which is extremely unusual for him. He said he was extremely busy with school for the next few days, and he said he’d get a hold of us if anything popped up.
As previously stated in past safety reports, I will bring my concerns up at the end of his rotation in person. Otherwise, he will become short, impulsive, and angry with the flight attendant and me. This compounds him going into this quasi-single pilot mode where he is greatly impulsive, agitated, resigned, and several other negative safety attitudes rather than him being an intricate part of the safety team and flight crew. This has continued for more than a year now. There is some improvement, but there’s a lot of relapsing when he is slightly or more fatigued if something simple like a screen darkens, a dispatcher says something to make him mad, he can’t get his particular approach, another plane didn’t taxi up to the hold short line close enough, or his hotel is a Hilton instead of a Marriott, exc….
ERC Acceptance & Closing Notes:
- CRM issues identified as root cause.
- Crew debriefed and counseled.
- No issues between pilots since.
Navigational Fix Confusion
On February 17, 2025, at approximately 0400Z (February 18, 2025) we were on the CAVLR6 Arrival into KIAD and the approach controller gave us instructions to fly direct to the fix ESPNN (IAF for ILS Rwy 1R), intercept the localizer and descend and maintain 3000ft. My Co Captain responded direct ESPNN and then clarified the fix with the controller. The controller confirmed the fix was ESPNN and my Co Captain and myself distinctly heard the “NN” at the end of the fix name. We proceeded direct to ESPNN and I noticed it was listed on the approach plate at or above 7000ft. I then noticed a fix called ESTYN further down on the localizer which had a crossing altitude of at or above 3000ft, the same altitude we were instructed to descend to; both fixes sounded similar. At this point the controller cleared a “Copa” call sign to fly direct to the fix ELLLA. ELLLA is the fix after ESPNN. I immediately instructed my Co Captain to verify the fix we were to fly direct to. The controller came back with, descend and maintain 4000ft. My Co Captain replied with the new altitude and said again that we were flying direct to the fix ESPNN, he even spelled it out. During this time the controller seemed overloaded and at one point told everyone to standby and stop talking on frequency. We then heard the “Copa” flight on the radio and it turns out they were behind us yet were told to fly direct to the fix ELLLA, one fix in front of ours thus adding more to our confusion. The controller then asked if we had the field in sight and when we responded we did, he cleared us for a visual approach to Rwy 1R and were later handed off to tower. At no time were we told we did anything wrong and were never given a phone number to call.
Suggestions:
Given the initial altitude clearance of 3000ft (the altitude at ESTYN), and the “Copa” aircraft behind us being sent to the fix in front of ours, I do believe the controller meant to send us to the fix ESTYN and mistakenly sent us to ESPNN. We verified it two if not three times with him. I feel this was a controller error that was created by the controller being overwhelmed as exhibited when he told everyone to stop talking.
ERC Acceptance & Closing Notes:
- Crew debriefed.
- FAA explored for any waypoint confusion.
Multiple Consecutive TCAS Resolution Advisories
While on an IFR flight plan, enroute from KMLB-KVRB, VMC conditions, daylight hours. We were level at 4000 ft and cleared direct to KVRB, we were told to contact Palm Beach Approach on 123.62. Upon tuning the radio for Palm Beach Approach we could tell right away that the frequency was extremely busy and the controller seemed somewhat overwhelmed. It took three radio check-in calls before the controller acknowledged us, with approximately 1.5-2.0 minutes of lapse time between initial check-in and ATC acknowledgement. There was a lot of radio congestion and tail numbers/call signs being blocked. We saw on TCAS, at very close proximity, about 3 what appeared to be VFR targets.
The closest target was about -300 feet below us, we received an RA to “climb, climb” as the PF initially started the procedure to comply and climb, we simultaneously received a Traffic Alert for a target slightly above our altitude and we received a TCAS warning to “monitor vertical speed”, which the PF did. We also had a third target in the TCAS window within this cluster of aircraft as well.
While all this was taking place, the controller did advise us to turn 280 heading, but in this first transmission, the tail number for this assigned heading was blocked and we were already dealing with the multiple TCAS alerts, from multiple locations and altitudes and the PF maneuvered slightly in a manner to keep us in a, best safe condition altitude/heading. We were unable, due to the safety of flight in that current situation, to turn to that 280 heading at that particular time. After passing the multiple TCAS targets, the ATC controller advised us to maintain current heading and altitude and then eventually brought us pass the airport and took us south then north to enter and set up for a visual approach to runway 12R. This all happened in just a few short minutes. The crew had to deal with this situation and focus on the top priority of flying safely and avoiding a potential collision and thus missed calling the RA alerts to the ATC controller. Given the sound in her voice, I strongly believe that she was well aware of the situation and our need to prioritize the hazard.
Suggestions:
We currently have multiple SOPs in place for operating in/out of KVRB, given the very high volume of air traffic, particularly training/VFR aircraft. We can continue to look at avenues to find more ways to mitigate these safety situations.
ERC Acceptance & Closing Notes:
- Sole source.
- ERC spoke with pilots – ATC communication, training environment and task saturation were contributing factors.
- Company plans to send a notice to pilot group – emphasis to follow up with controller after an incident like this.
