The following are redacted Aviation Safety Action Program (ASAP) reports from participating member companies during September 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.
Runway Excursion
We were scheduled to depart IXD for CBK and then CBK for PWK. We brought 4 pax into IXD and were taking 3 of those pax to CBK. We were going to do a quick turn. We planned on taking fuel at CBK. After landing at IXD, our company told us fuel and services would not be available at CBK. So we topped off to be able to fly to PWK without refueling. We were trying to do a quick turn at IXD, so the change of plan meant we were trying to work quickly. I ran the performance numbers with the new weights and the current weather at CBK. Approaching CBK we could see scattered areas of rain on NEXRAD (displayed on the map for situational awareness) and center also informed us of the precipitation. I received the current AWOS at 1518Z. We were concerned about convective cells, but the onboard radar did not show any hazardous cells in our path. En route we discussed the runway length and PIC briefed that he would apply maximum braking. Winds favored RWY 17 and we did the RNAV LPV RWY 17. The PIC was the Pilot Flying. I was the Pilot Monitoring. I listened to the weather a couple more times, as we were on the approach it was calling winds 120/11 with 2 ฝ miles visibility with rain. We flew through an area of heavy rain after the initial approach fix. It was a small area, and we were quickly in light rain. The rest of the events happened in light rain or drizzle. PF followed company SOPs and the approach was stable except when the PF briefly went above the glidepath. I called that we were high, and he said correcting and was able to promptly correct the glidepath.
Touchdown was normal. PIC had briefed that he would apply max braking for the wet runway. There was little deceleration at first, and I did not feel the brakes “grab”. However, it is normal for the braking to feel delayed on a contaminated runway in the Phenom. PIC said he was applying max brakes. When I realized we couldn’t stop on the remaining runway, I called to go around. Before we went off the end of the runway I yelled for the passengers to brace (the aircraft does not have a PA). When the aircraft came to a stop, we executed the emergency evacuation checklist and evacuated the passengers. There were no injuries to the passengers or crew. PIC called company operations per GOM and I called the center controller as we had been IFR.
According to Trip [trip number], the last two flights would be from KIXD to KCBK, with three passengers, and then from KCBK to KPWK, without passengers, just a repositioning flight. As soon as we landed at KCBK, I saw messages from the OCC stating that:”…Per [employee name], no one will be available at FBO today until the afternoon. Fuel will also be unavailable there until late afternoon…”, then I replied thar fuel would not be a problem because we got fuel in KIDX. From that moment, I share this messages to [name](SIC), I run a new WB at 1410UTC with 5300 lbs of fuel for take-off (topped off) and also run the new runway analysis to check if it is doable to get more fuel in KIXD, and after to fly to KPWK without refueling. So, [name]run the performance number with the current weather in KCBK at the aircraft, and I finished the paperwork at the FBO. The current weather was Marginal VFR however with no rain or any kind of storm there, only clouds (SCATERRED CLOUDS). After approximately 10 min after the takeoff, Denver Center gave us a short cut to avoid bad weather, and approaching KCBK, we noticed some scattered areas of rain on NEXRAD, and displayed thought FOREFLIGHT map in my I-pad.
During the flight, we discussed the runway length, and I focused my approaching briefing on the landing technique for a shorty runway, applying maximum breaking as soon as the nose landing gear touched the ground, with no delay. We performed the RNAV LPV RNY 17. Before the initial approach fix, ATC advised us about the convective cell with heavy rain near the final approach fix. [name] (SIC) got the weather and advised me that the wind was 120/11 gust 17 with 2 1/2 miles visibility. We flew through an area of heavy rain after the initial approach fix, but only rain without shaking the aircraft. We crossed the Final approach fix fully configured, auto pilot on, full PNAV LPV RNY 17. Around 700 to 800 ft height we got the lights inside, and quickly confirmed by [name].
Around 500 ft I disconnected the Auto pilot and handled flight following the PAPI lights. Due to the gust wind, I flew VREF +5 (120-123 kt), and around 300ft I got three white lights momentarily and quickly correct to the right path, reducing the speed to a little bit below the VREF. The landing was pretty normal on the center line and touch down zone, I prompt placed the nose landing gear on the ground and applied maximum brake, however the main brakes did not respond at all. Normally, even with a wet runway, there is a delay in breaking time but in this case, there was no reaction. [name] asked me to go around but the speed was below 70kt, however for safety reasons (I used to go around after the landing when I flew the Embraer 145 and 135, I knew the aircraft reaction but I had never performed this maneuver on the Phenom 300, then I decided to continue trying to brake, by the way I did not pump the brakes, I only keep my foot on the breaks, full pedal. Before 100 meters from the end of the runway, around 50 kt, I applied the emergency brake, but the aircraft started to slide to the left and then I released the emergency parking brake. It was the first time that I felt the brake reaction during this landing.
Before we went off the end of the runway, [name] asked to the passengers to brace. We went off with approximately 25-30kt. When the aircraft came to a stop, we executed the emergency evacuation checklist and evacuated the passengers. There were no injuries to the passengers or crew, and the aircraft at the first glance there seemed to be no damage. We went off around 80 meters onto the grass. After that, I called OCC per GOM, [name 2], [name 3], and [name 4] as [name] advised ATC to cancel IFR plan.
Suggestions:
I would recommend these spoofed airfields be considered DAY VFR for crews who have not operated there before and further training on operations in these contested spaces (at the sim or ACA training modules). These advanced aircraft systems are significantly impacted by GPS interference. Normalization of deviation is not a good thing for the aviation industry, but it is critically necessary to operating safely in these spaces until better understanding and systems improvements have been made to mitigate the impacts.
Note: The GPS system is somehow bleeding into TERRAIN feature (Synthetic Vision) of the PFD, so whenever the GPS was spoofed to another location the PFD would either appear to helicopter down to the runway in Beirut or start to go backwards in the air. This can be very disorienting if you are in the weather or at night.
KEY ERC TAKEAWAYS:
- Crew debriefed
- Reports no brake response when applied. Emergency braking activated.
- No aircraft damage or injuries.
- Comprehensive maintenance inspection conducted in accordance with manufacturer guidance.
- Company policies are being changed regarding landing in wet conditions.
- Sole source event as of 8/28.
Communication Between Pilots & MX
FLT ID 880 – First Officer – Pilot Flying
On July 2nd the captain reported a low RH main tire. My knowledge of the occurrence is that maintenance said they would take a look at it momentarily but did not specify when or where. Captain [name] asked if there was a preferred maintenance in KPLN, where we were flying to, air up the tire of if mx wanted us to wait. There was no response to that communication. When we arrived at KPLN there was little to no cell service and without the captain’s knowledge an unknown mx person apparently had came by the airplane and aired up the right tire. Our passengers were early, so I was trying to flight prep and get baggage loaded while the captain had to go back and forth to the FBO Wi-Fi service. Neither the captain nor I were informed that any mx was going to be done in KPLN and we were not contacted about the aircraft being grounded. captain [name] I see check for emails before and after every flight and with the cell service being poor, we didn’t have anything saying the above situation. it wasn’t until landing in KHLB that [name] and I got an email saying that [tail number] was grounded. We had no way of knowing and there should have been confirmation. If either of us didn’t respond it should have been assumed, we didn’t get informed and a call to FBO or someone to get ahold of the crew should have been initiated to prevent a “grounded” airplane from departing.
FLT ID 879 – Captain – Pilot
PIC (reporter) notified MX of low tire pressure during pre-flight before first sector. (KMEM-KPLN).
Asked if MX could arrange engineer in KPLN. The only response received before departure was to ask for photos and deny MX at the point of departure. Aircraft was still mobile so it was repositioned to KPLN. (NIL PAX). KPLN ramp had zero mobile coverage, (APPs wouldn’t work on ramp etc.) Went to FBO to make EFF / iPreflight work on Wi-Fi etc. No comms from company whilst on KPLN. Upon taking PAX to aircraft discovered unknown engineer (no ID or vest etc) had pumped up the tire. He departed without formalities. I noted tire now looked OK and departed for KHLB.
Suggestions:
At KHLB received multiple emails from MX stating we hade left with an open MX item on iCamp. We had no messages either by email or phone notifying us of this. We had no connectivity on iCamp either. In the past I have never seen a defect opened for simply adding air/N2 to a tire. As this is line maintenance, MX could have called the FBO at PLN to ensure we were notified both of an engineer’s attendance at the aircraft AND that an MX item had been opened and the aircraft was AOG. They did not. They assumed we had received the emails.
KEY ERC TAKEAWAYS:
- A policy change implemented with pilots having to receive confirmation/clearance from MOC before proceeding with departure.
- VDRP has been submitted.
Engine Fail and Shutdown
While conducting flight [flight number] KLIT-KPBI, the aircraft was leveling to cross MOLIE at FL350. After level-off and altitude capture, the crew continued preparation for the VUUDU1 Arrival and was anticipating a continued descent or “Descend-Via” clearance. During level cruise flight at FL350 the crew felt a very sudden vibration, likened to the extension of AB1, in their seats. The PM quickly recognized an Amber ITT value on the PFD and was beginning to see Engine Rollback as evidenced by the decreasing N1. The PM immediately alerted the PF and instructed him to reduce power on Engine 2.
The singular passenger quickly entered the cockpit area from the aft cabin and informed the crew that there was a loud noise coming from the back of the aircraft. The pax was promptly advised that the crew confirmed the abnormality from the engine instruments and the situation was under control. The pax retreated to the aft lavatory.
At this time ZMA issued the crew a clearance to “Descend-Via” the VUUDU1 arrival. The PM declined the clearance, informing the controller there was an engine issue, and that further info and requests would be soon to come. The PM then announced, “engine 2 failure” and received confirmation from the PF. The PM initiated the high ITT checklist as driven by the ECL and commenced an engine shutdown and securement. Prior to securing the Engine 2 Fuel switch with the power lever to idle, the ITT still continued to rapidly increase into a Red ITT value exceeding 1,000 degrees. N1 was spooling below 30%. After securing the engine and completing the checklist, the ITT value quickly decreased into an acceptable range, understood to mean the failure was contained and no fire was present. N1 still showed indications above 0.0 and N2 also showed rotation. After securing the engine and containing the failure, the crew elected to continue to PBI due to the short distance and considering the high altitude the aircraft was currently at. The crew reviewed intermediate airports available for diversion, if necessary. The PM had by this point already advised ZMA that they were declaring an emergency for an Engine 2 Failure and requested priority handling into PBI.
The crew continued to assess the situation and review all available indications as well as abnormal procedures during the descent. The crew prepared for potential cascading failures or challenges which could arise from the loss of engine 2, including but not limited to hydraulic system performance Et al. The PF and PM briefed the plan of action as well as escape procedures / alternatives in the event of further failures. The crew elected to continue to PBI and planned to land normally, vacate the runway, and immediately thereafter stop on the taxiway for an inspection from airport crash / fire rescue services. Pending the acceptable outcome of the visual inspection, the crew would taxi to the ramp and shutdown the aircraft. ZMA and PBI TRACON were kept updated with pertinent information and made aware of the crew’s after-landing plan of action.
During the descent and preparation for landing, the crew continued to monitor the location of the pax. The passengers did not vacate the lavatory and re-enter the cabin until minutes before landing, at which point the PM entered the cabin. The PM briefed the passengers on the current status of the aircraft as well as the intended plan of action for landing. The pax was made aware that the aircraft would sit for a few minutes on the taxiway prior to arrival at the ramp, and that airport emergency vehicles would be noticed around the outside through the cabin windows. The passenger was asked to remain seated with a seatbelt fastened and utilize the call button if they required immediate assistance. After landing, the crew left the aircraft configuration as-is and coordinated with airport C/FR for the inspection. After the ground team advised the crew that no further danger appeared present, the PF instructed the PM to complete the after-landing flow / checklist. The crew agreed that the APU should not be started until a more thorough inspection could be completed, and maintenance was consulted. The crew taxied the aircraft to the ramp and shut down the remaining engines. The PF exited the aircraft and coordinated with airport authorities while the PM entered the cabin to address and assist the pax. An after-shutdown inspection was completed around the exterior of the aircraft by the crew and no further abnormalities were found.
KEY ERC TAKEAWAYS:
- Sole source.
- ERC has had debriefed with crew.
- ERC feels a discussion with pilot group and chief pilot on lesson learned.
Aircraft Collision
Captain’s Report
After landing Falcon [tail number] on runway 18 at KTVL, while taxiing into the ramp via taxiway “G” we were contacted by the Mt West FBO linemen via radio that they wanted to park us on the ramp between Gulfstream [tail number] and Gulfstream [tail number]. This would require us to “nose in” between the aircraft and make a 180 degree turn. They stated they had wing walkers to assist. As I approached, I felt there was enough space to perform the maneuver. There were 4 wing walkers on the right side of our airplane to watch the clearance from Gulfstream [tail number], which was parked on that side of our airplane. I proceeded into the parking area watching the signals of the linemen and verbal instructions from the F.O. [name]. We came to a point where I felt we should be turning left and was given the “X” stop command from the wing walker that was standing at the end of the right wing of Gulfstream [tail number]. He was the only reference that I could see at that point. I stopped and waited for instructions. I got the move signal and turned the tiller hard left moved a short distance and got the stop signal again. This happened one more time, move signal, plane moved slightly and stop signal. When given the OK signal to move again I continued turning left and lost sight of the lineman/wing walker. The F.O. could still see the lineman and yelled stop, stop when she saw the signal. I stopped as quickly as I could react, but our right winglet contacted the right wing of Gulfstream [tail number]. We then set the parking brake, followed the engine shut down checklist. After shutdown, we deplaned our five passengers and unloaded the baggage.
Ground Crew’s Report
Aircraft [tail number] was taxiing that day .I was by the nose of [tail number] when i noticed as it was making a turn if was coming to close to the Mountain West golf cart the right hand Wing tip. Mountain West ground crew stopped [tail number] and Cleared the golf cart out the way.
As for safety and precaution I decide to assist the line crew,i came to the wing of [tail number], When the Aircraft began to moved again I sign to stop and order to get better view, once the aircraft was stop this where i use my Hand as a distance gauge to show room remaining.Once the aircraft start moving again immediately signal to stop.
First Officer’s Report
Arrived at TVL at 0021z. Weather was SKC, visibility 10 SM, wind 180@8, baro 30.24. Upon reaching the mountain west ramp via G, which the ramp staff directed, the line man radioed and asked us to park between [tail number] and [tail number]. It was mentioned by the line staff that the plan was to have us turn in and 180 degrees between the aircraft and wing walkers would be provided. We, as the crew, discussed and determined this would be within airplane capability and that we saw enough wing walkers attending. The PF was following cues from the lead line guy to guide parking and I kept my attention on the right wing. When we started getting cues to turn left we followed. One line guy was on the right wing toward the wing tip and leading edge. He signaled to stop. We stopped. Another line guy arrived and said to continue the left turn upon inspecting the distance. The original line guy gave no signals and then said to stop again. We again stopped the left turn. Two more men approached the wing leading edges to inspect the distance available. We were given the signal to turn left and one guys arms were raised separately and wide to cue ample clearing distance. Given the signal to turn left again, we started a left turn. I saw one of the guys cross their arms to stop. I yelled ”stop, stop,stop” and the PF stopped. This is when the wingtip of [tail number] contacted the leading edge of [tail number]. We stopped all aircraft motion, set the parking brake, and followed shut down checklists. There was 3 crew on board, PF, PM, and the flight attendant, and 5 passengers on board. No injuries. No people were on board [tail number].
KEY ERC TAKEAWAYS:
- Both aircraft involved were from CEOC
- Both back in service
- Sole source event
- Case not deemed accident, minor incident by FAA Inspector
- Event discussed during pilot safety meeting.
Communication: Pilots and Flight Attendant
At the beginning of the trip rotation with the FA, I asked the FA if she felt comfortable providing the pax emergency briefings since this is the company’s norm to have the FA provide the briefings. She acknowledged yes. During the previous day of this flight, we repositioned the plane to PU pax. Due to weather, I had to verbally request the FA to take her seat during the approach phase of flight although I attempted to notify her via the fasten seat belt sign illumination. We were below 10,000’. She finally took her seat and about 2500’ above the ground and in position to land, I looked back to make sure she was seated when I noticed she had the table fully out in the first club seat sorting candy or something with her plastic food bins. I asked her to stow the table because we were landing. She complied. We picked up our lead pax. I briefed the pax about the weather in vicinity and then told him that the FA would be assisting him in the back, and she would provide him with an emergency briefing. The FA then came up and told me cabin is secure. The next day we were to PU the same lead pax along with an additional pax. There was weather once again. I briefed both pax of the weather. The lead went to restroom and then I noticed the FA did not provide the pax with emergency briefing. I asked her if she had already, and she replied no because she asked the pax the day before if he was familiar and he said yes to her. As a crew, we have never flown either of these two pax prior to this trip. I asked the FA to please provide a pasenger brief because it’s required per the 135 regs and if she felt uncomfortable then I could do the briefing. She seemed disgruntled that I was asking her to do this, but she said she could provide the briefing. She later came up and said the cabin was safe.
KEY ERC TAKEAWAYS:
- Memo has been sent out to FAs as reminder to conduct emergency briefing and properly secure the cabin prior to take off/landing.
- Event discussed during CRM meeting.
Possible Altitude Deviation – Similar Call Sign
Pilot Flying
Houston ATC seemingly called “[call sign], descend and maintain flight level 360.” I was the non-flying pilot handling the radios and returned/repeated the call, “[call sign] out of flight level 370, descending flight level 360” and set the altitude preselect to 36,000. The pilot flying likewise acknowledged the descent. Nothing was said by Houston ATC at that time. Upon arriving at flight level 360, Houston ATC said, “[call sign], that was for ‘[another call sign], climb and maintain flight level 370,” which we did immediately. Upon reaching flight level 370 again, I called Houston ATC, stating there seemed to be some uncorrected confusion as to which aircraft with call signs ATC was talking to that as used us to descend 1,000 feet below our assigned cruising altitude and specifically asked “did that cause a violation?” Houston ATC replied that it did not, seemed to acknowledge the confusion over similar call signs and said something to the affect, “no need to worry about it.” Typically, the limit for an altitude deviation before ATC might ask pilots what’s going on is 300’. No such query from Houston ATC was made. This event occurred at 2210Z.
Non-Flying Pilot
Roughly 70NM west of the SAT VOR I was pilot flying and my captain was pilot monitoring. We received a call from Center to descend to FL360. My captain acknowledged the instruction and we descended 1000’. As we were leveling we received the call “[call sign] say altitude” to which we responded “leveling 360”. Center responded “[call sign] that was for [similar call sign], climb/maintain FL370”. We acknowledged and returned to FL370. On returning to FL370 my captain confirmed with center that there was not a deviation which center told us it was not an issue.
Suggestions
CA: This event is the 4th callsign confusion reported in 2024. Wing expects to see increased reporting of this event as it was covered in a previous Pilot Safety Action Group Meeting. Pilots were advised to file an ASAP report for any callsign confusion that may reduce the margins of safety in all aspects of flight operations. This event and statistics of similar occurrences will be shared at the May 9, 2024 pilot safety meeting. Pilots will be reminded to remain vigilant for this increasing error and to use CRM skills for effective communication.
KEY ERC TAKEAWAYS:
- Sole source event.
- Two reports filed for this one event.
- BowtieXP: Hazard 7 Mid Aid Collision- No correlating barrier for ATC miscommunication. All other barriers effective.
- RCA: Callsign confusion- Effective communication needs improvement.
- RA: 2C High
- TEM: Environmental Threat: ATC leading to Communications Error: Callsign confusion, resulting in Aircraft Handling Error and Undesired Aircraft State: Aircraft Handling.
