The following are redacted Aviation Safety Action Program (ASAP) reports from participating member companies during July 2024. Each case underscores the unique challenges that test the skills and preparedness of the crew. These incidents highlight the critical importance of adhering to standard procedures and the valuable lessons learned from navigating unexpected situations.
AIRCRAFT SYSTEM/EQUIPMENT MALFUNCTION – RIGHT CARGO DOOR
Throughout my work week I flew the same aircraft. The Right cargo door would illuminate periodically during flight or before taking off or landing. I have notified maintenance, and they were aware of the issue and were working on repairing the problem. On the day of the event my SIC was in the cabin preparing it for the clients before departing KBDR. I conducted two walk arounds of the aircraft to make sure all landing gear pins were pulled, chalks were removed, and all covers, doors and latches were secured. Upon completing the second walk around I was passing the left cabin door which was open because the SIC was in there. I told him that the walk arounds were completed. He acknowledged, and I would meet him in the cockpit to get ready for departure. After the SIC was done in the cabin he went and opened the left cargo door and was securing some rags into the small aircraft bin we have in the cargo compartment. The SIC came into the cabin and we proceeded with the check list to start the aircraft. As I turned on battery power and scanned all the indications, I noticed that both cargo door open lights were now on at this time. Maintenance notified me earlier that they were adjusting the sensors and told me to report back if the lights came back on. The SIC asked me if he should hop out and check all the doors again. I said no because I told him I dealt with this issue all week and that I completed two walk arounds of the aircraft, so I was certain all doors were secured, and it was just a faulty sensor.
How the issue was found, during takeoff another company aircraft radioed me on internal company freq and notified me that the left cargo door was open. The SIC was at control and quickly landed the aircraft as I was communicating with tower that we needed to land on a taxiway to check on something. As I got out of the aircraft the left cargo door was latched in the open position. I was able to close and secure the door and latch it. We took off and continued with the first portion of our flight. Once landing at KOXC I contacted the Chief Pilot and told him what happened. He later told me to complete the flight and return to base for inspections and aircraft swap.
The SIC said that he must have just closed the left cargo door without latching it shut. I should have told him to go and check that all doors were secured for the third time. I became complacent with the warning lights because I’ve dealt with the same lights all week.
KEY ERC TAKEAWAYS:
- An internal safety report was completed on this incident, with assignment of company-wide
corrective actions. - PIC was given a PIC evaluation by the Training Officer over the course of 4 fly days
- Always walk around and check if a light is indicating something.
DIVERSION – ARRIVAL – UNPLANNED ALTERNATE
Report # 1 PIC
Global **TaIl** / **PIC** and **SIC ** along with CA ** had to change our scheduled flight from KTEB to KVNY to landing at KLAX due to the 16R runway closure at 2230 local time on June 03, 2024. While our original schedule was to arrive on 6/4, later changed to 6/3 but before the runway closure, due to the passengers showing more than 30 minutes late along with a very large amount of baggage for 9 passengers, we did not take off until 2106 local time which put us landing at 2300 local time, 30 minutes too late to land in VNY. While **SIC** tried to request a late arrival, they denied it, so we went to KLAX. While I take full responsibility for not making sure the passengers arrived on time, I wasn’t concerned knowing KLAX is much closer to the principal’s and passengers’ home/destination, and we were flying the next day to KSJC. Not to make excuses or make light of the diversion, the change was beneficial to the passengers, they didn’t mind, and the fuel is cheaper at Atlantic KLAX than home base so the principal saved money purchasing fuel for the KLAX – KSJC leg in KLAX.
Report # 2 SIC
Our flight had been scheduled to depart the night of June 3rd, then changed to the morning of the 4th, and then back to the night of the 3rd. So, we planned for an 8:30pm departure from TEB to VNY on June 3rd. 0030z, with about 5 hours flight time en route. The passengers showed up a little bit late, and we took off at 0106z, which had us arriving in VNY around 0600Z. While en route, **PIC** noticed the NOTAM for VNY that RW16R would be closed starting at 0530z, half an hour prior to our estimated time of arrival. So, as the owners lived closer to LAX, we diverted to LAX, rather than our filed alternate, BUR. **PIC** coordinated the change of destination, and the passengers were fine with it.
I admit, I missed seeing the NOTAM of the runway closure. I looked at the weather for VNY but skipped over the NOTAMs. I will need to double check them myself, not just rely on **PIC**. That is part of why we have two crew members, so if one misses something, the other will catch it, and I missed it. Thankfully, **PIC** did catch it while en route, with plenty of time to re-arrange the transportation for the passengers, rather than descending in to land at VNY, and being surprised that the runway was closed and asked about our intentions. So, it all worked out well in the end, but I learned a good lesson, to always double check NOTAMs and not just rely on the other pilot.
KEY ERC TAKEAWAYS:
- Always check NOTAMs prior to the flight and verify. Do not always rely on the other pilot.
DOCUMENTATION EVENT – MEL CHECK
Report #1 PIC
Prior to departure the aircraft had a MEL 21-51-01-03. Prior to departure we failed to review the MEL (o) procedure but we were aware of the altitude limitation which was discussed. We also discussed in the event of a dual PACK failure options we could take. On Departure we received a HI PRESS indication. We arrested the climb after notifying ATC. We followed the QRH Procedures in an attempt to reset the operable PACK. After power reduction, we reset the PACK until the power was applied to climb power. The HI PRESS indication came on again. The decision was made to return to PBI and a visual approach was completed.
Report #2 Pilot Flying
The aircraft had an MEL 21-51-01-02 for a left PACK inoperative. Since the MEL was entered during the night previous to the flight, the first opportunity to review the MEL remarks was during our preflight preparation. During our preflight preparation we did not review the MEL remarks. While we were aware of the altitude limitation, we did not review the remarks for operating with one PACK inoperative on page 21-19 of the MEL. During our climb out, the PM attempted to transfer the right PACK to the right engine bleed air. The right PACK immediately experienced an overpressure, indicated by the R PACK HI PRESS CAS message. After returning the PACK to APU bleed air, we requested and received a level off at 10k’ for troubleshooting. The PM and Pilot Observer (PO) completed the QRH procedure for this malfunction. They were unable to transfer the PACK to engine bleed air using this procedure. During subsequent troubleshooting, they were able to complete the transfer; they tried other configurations of the bleed air valves. However, advancing the right thrust lever above approximately 75% resulted in another overpressure in the PACK. After 1 additional attempt, with the same results, I made the decision to return to PBI. We coordinated our return to PBI and recovered via a visual approach without further incident.
Report #3 Pilot Monitoring/Observer
Prior to departure the aircraft had an MEL 21-51-01-03. Prior to departure we failed to review the MEL (o) procedure but we were aware of the altitude limitation. We discussed in the event of a dual PACK failure options we could take. On Departure we received a HI PRESS indication. We arrested the climb after notifying ATC. We followed the QRH Procedures in attempt to reset the operable PACK. After power reduction, we were able to reset the PACK until the power was applied to climb power. The HI PRESS indication came on again. The decision was made to return to PBI and a visual approach was completed.
KEY ERC TAKEAWAYS:
- MEL Guidance has been sent out.
- Sole source event.
- Self-diagnosed from all 3 pilots and Director of Operations.
- Review all MEL remarks especially after returning from maintenance.
CUSTOMS ISSUE – AIRCRAFT REGISTRATION
Report #1 PIC
As a [company name] crew member assigned to part 91 manage aircraft, [tail number]. I was informed that there is a problem with the aircraft registration for [tail number] that was discovered by Universal who was working a schedule trip to Mexico. “[Company name] is shown as a Non-Citizen or Foreign Owned Corporation therefore twice a year they are required to complete AC Form 8050-117 aka Flight Hours for Not U.S. Citizens. Their failure to do so has caused their registration certificate to become “Ineffective/Invalid.”
It appears, [company name] has operational control and has not complied with CFR 47.9, the biannually filing of completed AC Form 8050-117. Hence, I have been unknowingly flying an improperly registered aircraft since 7/11/2018. As a crew member on [flight number], I do check the required documentation is on board and up to date regularly. The displayed paper registration has an expiration date of 01/31/2024 and the Texas address, see attached. Looking at the registration, I have no indication that it is invalid.
[Company name] doesn’t share any information on contractual obligations with aircraft owners or regulation complaints with the pilots. So, I have no knowledge of [tail number]’s registration validity, constraints or the status of compliance, except the displayed paper registration. If I would’ve known about the registration issues, I would’ve not flown the aircraft.
Report #2 Pilot Monitoring
Operations notified the crew that they were unable to obtain a permit to fly into Mexico due a problem with [tail number] not having an active registration. The physical registration and only document that the crew has access to has an issuance date of January 11, 2018, and an expectation date of January 31, 2024. The issuance of this document is to a U.S. addressed company. Due to the unknown fact the registration holder is held by a foreign entity, Per FAR 47.9 a report must be submitted every 6 months to comply with conditions that keep the registration valid. 6 months after, no person from our employer’s office completed this form and the aircraft was no longer registered because of this condition.
KEY ERC TAKEAWAYS:
- Company filled out VDRP for compliance.
- Crew acknowledged the mistake in the foreign registration compliance and responded appropriately.
ATC ADVISED WRONG ALTITUDE
Report #1 PIC
Departing VIDP (Delhi, India) from runway 29L on the AKRIB5C SID there is no assigned altitude on the SID, nor was there an assigned altitude on the DCL/PDC in the format that we would expect, i.e. “MAINTAIN 2600”. Crew had agreed that the altitude restriction on the SID of FL070 or below would be the limit initially. After takeoff departure control was contacted passing approximately 3000′. They assigned a level off of 4000′ then asked why we did not maintain 2600′.
Background: The AKRIB5C SID (10-3L) is an RNAV SID that falls under the RNAV SID Designation chart (10-3). There is a separate SID Designation Index (103A) for non-RNAV SIDS. It references a single chart titled Initial Climb Procedures (10-3X1). That chart is the only SID chart that specifies an initial climb altitude but is not applicable to the RNAV SIDS as it is a completely separate procedure.
The crew (myself as PM) double checked the SID chart and the PDC for an initial altitude assignment while still parked on the ramp. We agreed that it must be FL070. I had a thought that tower might assign an initial altitude as is sometimes common at other airports we have operated to. I was actively listening for that when the takeoff clearance was given, but there were no instructions beyond being
cleared for takeoff.
Report #2 SIC
I was the PF / SIC for our leg from VIDP (New Delhi, India) to VOHS(Hyderabad, India). When doing our preflight and reviewing the attached Data Link Clearance the PM / PIC and I looked for an assigned initial altitude. As a crew, the PM and I each looked closely at the AKRIB5C SID and the printed clearance for our initial altitude. We discussed it amongst the two of us and in accordance with the note on the SID and the lack of any other specified limit, identified our first limit as FL070 at VEMEV. We then put FL070 in the guidance panel altitude selector and completed the rest of our setup and briefings. With our passengers on board, we advised receipt of our DCL, confirmed the POB and security checks complete and requested pushback and start clearance. After start, we requested and were cleared to taxi via the anticipated route to runway 29L.
While monitoring tower frequency, we were issued a lineup clearance and as we were complying with that we were issued takeoff clearance. As we were climbing on the SID on our way to our first altitude of FL070, we were switched to departure frequency. When the PM / PIC checked in with departure at approximately 3000′ MSL the controller issued us an altitude of 4000′ and asked us what altitude we were climbing to. The PM responded that we were climbing to FL070 as per the SID. She replied that 2600′ was the initial altitude limit. The PM responded that we were not aware of that limit as we complied with the assigned 4000′ altitude assignment. The controller did not notify us of any traffic conflicts. We did not receive a TA or RA from TCAS. The controller then cleared us to a higher altitude and shortly after handed us off to the next sector. The remainder of the flight was uneventful.
KEY ERC TAKEAWAYS:
- Crew asked ERC investigators how they would have flown this clearance. Screenshots of clearance were shown in the meeting. ERC determined the same actions as the crew.
- FAA recommends including clearance variations in training.
- FAA and Company investigated how this information can get back to international entities.
- Company included this airport in their SMS risk assessment.
