Pilot Flying narrative: …The windy conditions had been a subject of discussion and mentioned during the briefing of the arrival and approach. During the descent we had some light chop and the surface reports were easing up as we made the descent on the RNAV Approach. We were fully configured, on speed, Vref +15, the runway in sight the autopilot off.

At about 1,500 ft. AGL on final, we received a “windshear ahead” warning. Since it was a lot smoother ride than anticipated and I didn’t have any other cues about wind shear with either the airspeed or vertical speed, it took me a couple of seconds to interpret the warning which time it went away. Since we remained on speed and profile after the warning went away, I continued the approach and landed.

In debriefing the approach, we both agreed that a go around should have been initiated, but that a lack of other cues was a factor in a few moments of hesitation about whether initiating a go around was necessary. I felt like we otherwise had good monitoring, cross checking, and communication about the aircraft state throughout the arrival and approach. So often, wind shear training in the simulator is accompanied by the cues that help us identify the onset of wind shear, wind shift, airspeed vertical speed etc. I need to brief or at least tell myself to be ready to go around when directed by the predictive computer.

The reporter brings up important points. We use simulator windshear training profiles to teach the full range of indications and procedures. To get the most from our limited simulator time, airlines pack a wide range of experiences and stimuli into a single training scenario. We even instruct pilots to verbally announce when they would initiate their go around from increasing turbulence, but to delay their actual recovery maneuver until they receive the automated windshear warning (when the windshear conditions have progressed to the most challenging state). While this trains us to handle the worst possible windshear events, it unintentionally instills a mindset that windshear events start with turbulence, which intensify to flightpath deviations, and finally progress to an automated warning as we enter severe windshear conditions. In this case, the pilots got the automated warning first while experiencing “a lot smoother ride than anticipated”. While they were mentally processing this mismatch from their training, the audible warning ceased. At this point, it felt natural for the pilots to classify the warning as an anomaly or a transient condition, so they continued to land. Procedurally, a windshear warning on final approach requires an automatic, non-discretionary go around.

      Another factor is the strong incentive to land from each real-world flight versus our experience in simulator training where going around feels much more appropriate. The vast majority of daily flights end with landing, while a large percentage of simulator flights end with a go around or missed approach. Going around from a real-world flight tends to feel a bit like failure – and pilots hate failing to get their passengers to their destinations. This creates a strong incentive to rationalize landing.

In this second situation (ASRS event #1876901), a crew discovers a fuel imbalance which they quickly diagnose as a fuel leak.

Captain’s narrative: I operated Aircraft X ZZZ-ZZZ1 on DATE with a suspected fuel leak that resulted in an engine shutdown and diversion to ZZZ2. I was the Pilot Monitoring and the First Officer was the Pilot Flying on this flight. Around the ZZZ3 area the left center tank low pressure lights flickered and I turned the left center pump off with about 400 pounds remaining in the center tank. I didn’t see a fuel imbalance between the left and right tanks at this time. Several minutes later the center fuel tank was empty and I turned the right center pump switch off. In addition at this time I didn’t notice anything abnormal about the cross feed valve selector or light. At approximately 70 miles SE of ZZZ2, I heard the First Officer say we had a fuel imbalance and looked over to see the fuel IMBAL light illuminated on the right fuel tank. At this point I noted a 1,000 pound fuel imbalance and that in my experience the fuel in the right tank was decreasing at an abnormally fast rate. It had only been around 10 minutes since I turned off the center fuel tanks. At this point the First Officer and myself thought a fuel leak was plausible due to a 1,000 pound fuel imbalance occurring in around 10 minutes and observing an abnormally high rate of fuel decreasing from the right tank. I proceeded to run the fuel leak-engine QRH and contacted the flight attendants to request one of them check for a fuel leak/mist coming from the back of the right (#2) engine. While running the QRH, I felt time pressures to stop the fuel imbalance before it led to adverse control issues. At step 5, I recorded the total fuel and time (I don’t remember what I recorded) and proceeded to the condition statement in step 6. After reading the condition statements and based on the abnormally high rate of fuel decrease in the right tank I proceeded to step 7. At this point I thought I confirmed an engine fuel leak because we were now at 1,200 pounds imbalance in 10-15 minutes. Far greater than the 500 pounds in less than 30 minutes that the QRH states. By this time the FA reported not seeing any fuel leaking from behind the right (#2) engine. Knowing that we were going to shut down the #2 engine I requested priority handling and requested a lower altitude. In addition we requested vectors to ZZZ2. By the time we shut down the #2 engine we had a 1,400 pound fuel imbalance. I’d like to add that after shutting down the #2 engine the QRH calls for the cross feed selector to be opened. The cross feed valve opened normally with no abnormal indications and closed normally with no abnormal indications several minutes later when we decided to even out the imbalance by burning fuel from the left tank. .... While rereading the Fuel leak-engine QRH step 6 after the event, I realize that my decision to proceed to step 7 was based on what I read the step 6 condition statement to say of “the fuel quantity is decreasing at an abnormal rate out of the right tank”. Rather than basing it on what the condition statement actually said “or the total fuel quantity is decreasing at an abnormal rate”. This was a mistake. I can say that the fuel imbalance QRH checklist would probably have been more appropriate to call first. However this wasn’t an imbalance that took time to develop. We experienced the fuel IMBAL light and an abnormally high rate of fuel decrease from the right tank around 10 minutes after turning the center pumps off. I didn’t notice any fuel imbalance prior to turning the center tanks off. I don’t think that it was unreasonable to run the fuel leak-engine QRH in these circumstances.

First Officer’s narrative: … While looking at the fuel quantity, I noticed that quantity in the right tank was decreasing at a higher-than-normal rate, and the fuel imbalance was approximately 1,000 pounds. The Captain pulled out the QRH. I also may have verbalized “do we have a fuel leak,” or “is this a fuel leak.” This was probably confirmation bias on my part. I recently completed my annual simulator training, about 2.5 months ago. The scenario that I had on day 3 was depart ZZZ4 for ZZZ5. During that sim session we had a fuel imbalance shortly after takeoff, which was actually a fuel leak. So, the scenario we were experiencing in the airplane seemed similar to a recent training event. Since the Captain and I both thought a fuel leak was possible, he started to run the Fuel Leak checklist in the QRH. The Captain also contacted the flight attendants and asked them to check the right wing and engine for any visible fuel spray. The flight attendants reported back to us that they didn’t see anything. However, based on the fuel imbalance rapidly getting worse, exceeding the 500 pounds within 30 minutes the Captain and I confirmed a fuel leak. We requested priority handling, lower altitude requested, as well as vectors for ZZZ2. Once on a localizer intercept vector, the Captain took controls and landed the airplane. We taxied clear of the runway, and emergency personnel (crash fire and rescue) visual inspected the airplane to make sure fuel was not leaking from the aircraft. We then taxied towards the gate. Since I was the Pilot Flying, and the first person to notice the imbalance I should have asked for imbalance checklist first.

While neither pilot reveals the maintenance finding in their report, their tone implies that the cause of the fuel imbalance may have been a malfunctioning crossfeed valve that allowed fuel to transfer from the right wing fuel tank to the left resulting in the imbalance or perhaps a fuel quantity sensing probe issue. The First Officer reports that their recent simulator training event included a fuel leak scenario which biased them to interpret their imbalance as a leak. The fuel leak checklist directs an engine shutdown, while the fuel imbalance checklist does not. The FO admits that his bias may have influenced the Captain to follow the leak scenario. The crew elected to divert and land which was the safest call when single engine, but shutting down a engine may have been unnecessary.

      Another interesting human factors bias is crew behavior created by the first conclusion expressed. Once the FO mentioned “fuel leak” and the crew established a fuel leak mindset, they appeared to abandon further analysis and inquiry. Granted, fuel leaks generate a high level of urgency which encourages prompt action. The Captain even mentions “time pressure” to mitigate the leak. They did take the additional analytical step of asking the cabin crew to check for fuel misting from the suspected engine. Even after the cabin crew reported no misting, they didn’t investigate further. Ideally, the crew could have compared expected fuel burn rates from their flight plan against the actual totals to see if the total fuel quantity was dropping significantly. This might have raised their curiosity to expand their inquiry and discover that the imbalance was caused by unintended fuel transfer instead of a fuel leak. Fuel imbalance procedures direct a series of steps to cure the imbalance.

      In both of these events, crews followed mindsets learned from simulator training. As an industry, we should take steps to encourage pilots to expand their mindset beyond the lessons learned in the simulator. Simulators teach procedures, but they need to also teach abnormal event processing strategies. Especially with rare events, we want crews to take enough time to examine the range of possibilities to not only select the first cause they think of. They need to take the extra step of excluding other possible causes. Had the fuel imbalance crew expanded their mindset to weigh fuel leak versus imbalance, they would have taken a closer look at their total fuel burn. Since they landed short of destination, we can assume that they had adequate fuel to take an extra minute to conduct this analysis.

      Of course, we are analyzing these events from our perfect hindsight perspective. The bottom line is that both crews landed their aircraft safely following stressful and rarely encountered conditions. I submit these events for our collective analysis to better understand the latent problems promoted by simulator versus real-world mindsets. In my book, Master Airline Pilot, I share a range of strategies for countering these biases. I encourage you to post your comments and suggestions to this forum thread.

First Officer’s report (flying a Pilot Flying-PF until the Captain takes over, then as Pilot Monitoring-PM): On departure from ZZZ CA (Captain) noticed that the RA was showing 0 ft . We were on a cruise altitude of 12,000 ft, as soon as we started to descend, the gear horn started to warn that the gear was not down. Disregarded that warning because it was due to the RA. We were cleared for the approach for visual XXL, backed up by ILS. FO (First Officer) turned into green needles 18 miles from ZZZ1 and armed APPR mode. Soon the FMA showed the green ‘GS’ mode captured. Soon Captain and FO noticed that the autopilot was not descending for us. Canceled AP (Autopilot) and GS was already 1.5 dots going down . The airspeed was 180kts with flaps 20, FO called gear down. After the gear, FO tried to put flaps 30 and therefore almost leveled off for the airspeed to reach below 180 (we were nose down to follow the GS so airspeed didn't slow down much). During this attempt, GPWS false alarm started, yelling at us “Terrain, Terrain, Pull Up”, “Too Low, Terrain”, “Glide Slope” and “Sink rate”. Captain called out disregard, it was clear that there was no terrain, but FO got distracted with the aural and started to lose cross-check. The warnings have continued all the way down to the landing, therefore distracting us from normal sequence and ATC calls. After the flaps 30 configuration was established, FO started to follow down the GS, but the lateral side was off the centerline. At some point we had PAPI showing 3~4 red lights , and Captain called out “You’re Low”. Passing ZZZZZ, at 6,800 ft FO called Flaps 45, Before Landing Checklist. FO called “One Thousand” at 6,100 ft. At this time, we were already in an unstable condition but continued. Soon after FO got even more unstable again showing 4 Red lights, Captain called “my controls”. After the Captain took control we were established again with 2 white 2 red. Around 300 AFE the aural warning said something other than usual, “Too low, Flaps”. FO noticed that the flaps were at 30 configuration, and called “Flaps 45?”. It was unstable but FO did not call “Go around”, CA put flaps 45 and landed.

Lack of hand-flying skills. Distraction management. confidence to call go around. Maybe muting the aural warnings might have helped, but also on the other hand, aural did let us know that we were in flaps 30. I think it would’ve been better if I was trained as: If “Too Low, Flaps” is heard, the next callout is “Go around”. Just like an automatic call out like “Go around thrust flaps 8” being automatic if I hear “Missed Approach”. The first thing I heard “Too Low, Flaps”, my instinct thought was “Okay, we’re low and flaps 30... so put flaps 45?”

Briefing potential warnings during approach: The crew knew after takeoff that they had a malfunctioning radio altimeter (indicating zero). Perhaps they didn’t know that this malfunction might generate spurious aural warnings during the approach. The report does not say whether they discussed these possible approach warnings or how they intended to handle them. When the spurious warnings began to happen, the report implied that the Captain immediately knew that the warnings were false since they instructed the FO to disregard them. It further implied that the FO became significantly distracted and affected their ability to fly the approach. Perhaps if the Captain had briefed this while in cruise flight, the FO might have been less vulnerable to distraction.

Getting behind on the approach parameters: The first warning they received was a landing gear warning horn as they descended out of 12,000’. The next distraction was the failure of the autopilot to capture the glideslope and descend. As the flightpath reached 1.5 dots high on glideslope, the FO disconnected the autopilot and started down. This went poorly. The FO admitted their lack of hand-flying skills. The flightpath became steep and fast. The FO called for landing gear down (to increase drag and reduce airspeed). The combination of their steep descent and high airspeed prevented them from extending the flaps to 30. They leveled until they could decelerate below flap placard speed and extend more flaps. After extending flaps to 30, the FO again increased descent rate to rejoin the glideslope. At this point, the approach appeared to be salvageable.

Escalation of warning notifications: Around 2,000’ above runway elevation, the FO was falling behind the approach profile and struggling to shed airspeed to get landing flaps extended. Addition warnings began to sound – “Terrain, Terrain, Pull Up”, “Too Low, Terrain”, “Glide Slope” and “Sink rate”. The situation became even more distracting. The FO appeared to become so tunnel focused while trying to rejoin the glideslope that they began to “lose crosscheck” resulting in a lateral deviation. Correcting for the lateral deviation, they lost glideslope alignment and flew too low. The Captain made the callout, “You’re Low”. While we don’t know this airline’s procedures, industry conventions generally require scripted callouts for approach deviations. The Captain’s callout, while accurate, probably didn’t adhere to procedures. This transition from informative callouts to procedurally-scripted callouts is an interesting topic that we can address in a later discussion (also covered in detail in my book).

Captain also becomes task saturated and tunnel focused: The FO called for flaps 45. At this point, the Captain (as PM) should have verified placard speed compliance, announced “Flaps 45”, placed the flap lever to the appropriate position, and monitored the flap gauge for desired extension. The Captain didn’t perform any of these tasks, probably because they became tunnel focused on the unstabilized flightpath as they were approaching 1000’. Understandably, the Captain probably directed their attention to the deteriorating approach parameters and on deciding whether to assume aircraft control. Somewhere below 1000’, the Captain had seen enough and assumed aircraft control.

Procedural breakdown and unstabilized approach landing: Soon after the Captain assumed aircraft control, the crew experienced an, “…aural warning said something other than the usual, ‘Too low, Flaps’”. Looking down, the FO (now serving as PM) noticed that the flaps weren’t extended to the planned 45 position. They queried the Captain, “Flaps 45?”. The FO acknowledges that they did not direct a go around. At this point, the Captain apparently reached over, set their own flaps to 45, and landed. This is considered nonstandard in most crew aircraft. First of all, they should have called for or executed a go around. Second, assuming that they were committed to land, the Captain should have called for flaps 45 to allow the FO to verify parameters, set the flaps, and confirm their extension. Third, while not stated, it is strongly indicated that they failed to complete their Before Landing Checklist.

FO’s analysis: The FO finishes their report with a brief analysis of what went wrong – “Lack of hand-flying skills. Distraction management. confidence to call go around.” They then suggested that “Maybe muting the aural warnings might have helped”. I am not sure of the systems of the CRJ200, but generally, many EGPWS (Enhanced Ground Proximity Warning System) warnings are not “mutable” until the out-of-tolerance conditions are corrected. The FO goes on to suggest that if their training was more specific, they would have felt more confident to call for a go around. While probably valid, this misses the larger point that their unstabilized approach parameters should have triggered a “Go Around” callout even without the EWGPS warnings.

Lack of Captain’s report: An interesting sidenote is that this record did not include a Captain’s report. Typically, this is because the report was either not submitted or because it lacked useful information. From my experience, it was probably the former. Often, pilots who choose to deviate from procedures often choose not to highlight their noncompliance by submitting written reports. We have every indication that this Captain failed to brief for expected spurious warnings, make required deviation callouts, direct a go around when the FO’s approach became unstabilized, direct the FO to set flaps to 45, call for the Before Landing Checklist, or go around from their unstabilized approach. It would also be informative to know whether the Captain documented the radio altimeter malfunction in the logbook.

Summary: This event reflects many of the distraction-related concepts detailed in my book, Master Airline Pilot. We see how a series of escalating distractions disrupted flying, led to flightpath deviations, and inhibited the FO’s ability to restore the intended flightpath. Moreover, we see how both pilots became consumed by task saturation, plan continuation bias, and event quickening. These led them to tunnel their attention focus while trying to “save” an unstabilized approach. Granted, they landed safely. Unfortunately, landing safely has an effect of minimizing past errors. Hopefully, this crew engaged in a detailed debriefing to analyze their errors and to recommit themselves to maintaining higher standards in the future. From Discussion Topic 24-2, we have the distraction parameters of:

            - Intensity or severity: How much of our attention was diverted by the distraction?

            - Duration: How long did the distraction last?

            - Operational flow disruption: How different is our current position from where we were before the distraction?

The intensity of the distractions increasingly diverted their attention. More importantly, the severity of the distractions steadily increased. This seemed to undermine their ability to recover. The distractions demanded increasing levels of attention focus to restore their flightpath and aircraft configuration. Once the chain of distractions started, they continued. Apparently, the crew never reached a point where their distractions ceased. Finally, their operational flow remained disrupted all the way down final. When the FO failed to restore stabilized parameters, the Captain assumed aircraft control. This, in effect, became another distraction as both pilots needed to switch roles, reestablish new flight perspectives, and assume new tasks to complete. This is why most airlines encourage their pilots to go around rather than try to salvage unstabilized approaches.

I welcome your comments on this discussion.

On taxi in to the gate in BWI, I taxied past our assigned gate towards the incorrect side of the concourse and required an amended taxi clearance to reverse back to our gate.

We departed BWI from Gate YY. Now, on the return leg to BWI we were assigned Gate XX. I conducted a routine arrival briefing prior to the top of descent. At the time, I briefed that we would taxi F, T, to Gate XX. Without referencing the chart, I misidentified the location of Gate XX from “memory”. It is on the same side as YY. I believe that I had an expectation bias of the even gates being of the concourse because we had just operated out of an odd gate (YY) on the . The Pilot Monitoring (PM) did not catch my error in the briefing.

After landing on Runway 33L, we told Ground Control that we were assigned Gate XX. We were cleared to taxi F, T, to the gate. After receiving the clearance, the First Officer (PM) went off frequency to contact Operations. He was distracted receiving aircraft swap information as I taxied past Gate XX.

Another additive condition was another carrier wide body aircraft was being towed on the parallel taxiway, surrounded by emergency vehicles with lights flashing. As we taxied past the other aircraft, I wanted to make sure we had wingtip clearance as I was not sure if he was off his taxiway (it was difficult to see clearly at night with the emergency vehicle lights).

When we got to the end of the concourse and I began a turn , I first realized that the gate numbers were odd. I stopped the aircraft and advised Ground Control that I had “screwed up” our taxi and needed clearance to go back to Gate XX. The PM was just finishing communications with Operations and now realized, as I, Gate XX was. Ground Control approved us for a 180 degree turn and clearance to taxi back to Gate XX. We taxied to Gate XX without further incident and no conflicts.

The error chain started when I did not do a thorough briefing by referencing the chart. The PM had an opportunity to trap my error, but fell into the same expectation bias. After landing, I should have caught what the taxi clearance was. The bright lights of the emergency vehicles were a distraction as was the extended ground call to Operations for the PM. These were additive conditions that should have been recognized and identified. Normally, at that point I may have caught that we were taxiing past Gate XX and the even gates.

The briefing and taxi error were my fault due to complacency and lack of thoroughness. We were fortunate that there were no traffic conflicts at this time of the evening. Had the same error occurred during peak operations, it could have caused significant congestion and potential safety conflicts.

To prevent future occurrences, I need to be more thorough with my briefings. Even when I think “I know”, I need to reference and view the ramp charts just as I do the Jeppesen charts. I also should have paid closer attention to our taxi clearance and not assumed. Lastly, I need to do a better job of engaging the PM during briefings and avoid the rote regurgitation of information that leads to PM missing errors on my part.

Points to consider:

1. Operational familiarity: The report implies that the Captain was quite familiar with operating out of BWI (Baltimore/Washington International – Thurgood Marshall Airport). This was reflected by briefing their gate arrival without referencing the airport diagram. This allowed their misconception that Gate XX was on the opposite side of the terminal from previous gate, Gate YY (by assuming that all even numbered gates were on one side and all odd numbered gates were on the other). Both pilots made the same assumption. Ideally, the PM needs to capture errors like this. We don’t want PMs agreeing with the PFs, we want them verifying each facet of the game plan to detect and correct errors as early as possible. This reflects a one-sided briefing perspective (only the pilot flying dictating the game plan) instead of the interactive two-way briefing method (where both pilots work together to form the game plan). Their aligned perspectives effectively solidified their expectation bias that the gate would be where they thought it was (on the opposite side of the terminal from Gate YY) versus where it really was (adjacent to Gate XX). This kind of bias strongly influences future conceptions and choices because we treat them as “facts” that don’t require future verification or confirmation. Since they knew where their gate was, they never perceived a need to reconfirm the actual gate location or taxi routing using the ramp diagram.

2. Distraction: On their way to the gate, the crew encountered a wide-body aircraft under tow and escorting emergency vehicles. This would understandably attract most of their attention. Concerned with wingtip clearance, the Captain was highly focused on getting clear. This type of event seems to create a psychological letdown when finally clear of the hazard. It can feel like, “okay, that has ended, now we can relax and get back to normal taxi-in.” We feel a strong motivation to return to our familiar game plan. Solving a big problem creates an impression that we have solved all problems. Often, some lesser problems slip through undetected or mitigated. Having passed the wide-body aircraft under tow, we can envision this Captain breathing a sigh of relief at finally being able to taxi normally to the gate.

3. Additive Conditions: The Captain referred to additive conditions. Additive conditions reflects the language of Risk and Resource Management (RRM) – covered extensively in Master Airline Pilot: Applying Human Factors to Achieve Peak Performance and Operational Resilience. They are complicating factors that urge us to focus more attention on understanding and handling emerging problems. Conditions interact in increasingly complex ways to create competing priorities that allow unpredictable outcomes to emerge. In this case, nighttime conditions and ramp congestion required their full attention. This intensified their plan continuation bias, increased the intensity/duration of distractions/disruptions, and encouraged continuing their flawed game plan.

4. Discretionary actions: The FO had two opportunities to interdict the Captain’s misconception about the gate location. The first was during the arrival briefing while they were still in cruise flight. Had either pilot consulted their ramp diagram, they could have detected and corrected the misconception. Second, the FO engaged in time-consuming “off frequency” coordination with the station regarding an aircraft swap. While aircraft swaps are not operational concerns that we can do anything about during taxi-in, they represent major concerns with future task load. Especially if this crew routinely engaged in discretionary clean-up tasks during taxi-in, they would immediately feel behind as they now faced a much greater task load of gathering their personal items before scrambling to the swap aircraft (as compared with leaving all of their gear in place for a follow-on flight with the same aircraft). We can imagine that these concerns left the FO highly disengaged with the taxi-in process.

5. Low Operational Priority: The taxi-in and gate arrival flight phases seemed to have low operational priority with both pilots. While they went through the steps to brief the taxi-in before top-of-descent, they admitted that they didn’t give it adequate attention – briefing it completely from memory versus referencing the ramp/gate diagram. This often occurs among highly proficient pilots operating frequently through familiar airports. Familiarity with a typical flight profile allows pilots to allocate more attention toward disruptions and less toward familiar operational details. In time, these normal features become cognitively automated. Settled within our comfort zone, we relegate these repetitive tasks to habit. While this frees up mental resources to deal with unplanned or exceptional events, habits tend to weaken error detection/mitigation. We counter this by mindfully following procedures. Familiar and unfamiliar airports are treated equally, even when the process feels unnecessary or redundant.

6. Event Insignificance: In the end, this error/event proved to be fairly insignificant. It was quickly sorted out and they proceeded safely to their gate. Even so, we should not classify these kinds of errors as unimportant. In practice, many taxi-in errors remain so inconsequential that most pilots choose not to document them through event reporting. Also, they often misattribute them to conditions like adverse weather, day/night conditions, poor signage, worn taxi guidelines, etc. The importance of this topic is that it encourages us to raise our awareness level and attention focus to match high AOV aircraft movement (see Discussion Topic 24-1 and Master Airline Pilot for more on this topic). As Master Class pilots, we study ourselves to detect lapses when we allow discretionary tasks to migrate into inappropriate flight phases. Appropriate attention discipline is a Master Class skill that we continue to refine throughout our entire flying careers.

This was a flight with 3 different ATC clearance errors that were not all immediately trapped. I was Pilot Monitoring (PM) and the First Officer (FO) was Pilot Flying (PF). We were flying ZZZ1 ZZZ on the ZZZZZ arrival.

Second ATC clearance error: Then we stayed level at our last captured altitude, I think it was 12,000 ft., when I noticed that we had passed our TOD for 8,000 ft. at ZZZZZ1. I told the FO we need to descend best rate immediately, and I quickly saw we weren’t going to make the restriction. I advised, ATC, and they said “Roger”, and to just do best rate down and fly heading 360, and we complied.

Third ATC clearance error: Next we were getting set up for a visual to 28. ATC said to maintain 180 knots to the FAF. When we were still 3 to 4 miles from the fix, the FO began slowing down and asked for flaps 30. Without thinking, I glanced at the speed, and selected flaps 30. Immediately after, I realized what I had done, and told the FO to keep the speed up just under 180. The FO kept the speed mostly in the 175 to 180 range, but initially the speed had dropped almost to 160. I elected not to raise the flaps, because we were already so close we would have to immediately extend them again, and it would complicate the profile. We then finished configured at the FAF. Meanwhile tower gave a 737 instructions to do S-turns. And despite my best effort to vacate the runway quickly, had to go around.

Pilot’s Analysis: The FO was struggling to remember ATC instructions, and I was not monitoring closely enough to catch the mistakes early enough. I also need to think more before extending flaps when asked. Regarding the 250 knots at ZZZZZ I successfully identified the error and called it out.

      - Unnecessary conversation: After that the FO was talking about their previous non-flying job in law enforcement, and some of the remarkable things that he did. While technically we were above 10,000 ft. in the most critical section of an RNAV arrival is not a good time to be talking about anything of any significance. I didn’t want to egg him on, and I just nodded and said that’s interesting, but I didn’t say, “Hey let’s talk about this on the ground or on a longer flight, we gotta work on this descend via”, like I should have. Because of this, I didn’t notice that we had passed the TOD soon enough.

      - Automatic habit pattern versus appropriate attention level: Then, on the Visual Approach, I should have given it 1 more second of thought before complying with the FO’s request for flaps 30. I de-briefed the FO on all of this.

      - Inappropriate attention level: We talked about how I should have been PM more closely, that he needs to be more aware of ATC instructions, and that descending via an RNAV is not a good time to talk about heavy topics. This was a sloppy flight and we need to better. I need to PM more closely. Especially in an “easy” day in clear VMC when the airspace isn’t busy. It is when everything is easy and quiet and not a lot is going on when I get most complacent and my attention drifts. I need to do something active, like keeping a scanning loop going, checking something, or talking about the descent profile, to help keep focus. This is something I’ve been working on. I’ve been working on thinking more before extending flaps. I need to pause and verbalize the flap speed, before extending flaps to check speed and check if extending flaps makes sense in that point in time. This will help me catch a poor decision to extend flaps.

Notice how all three errors seem to stem from the decreased attention focus of both pilots. This seems to be associated with the flight environment characterized as an “easy day in clear VMC when the airspace isn’t busy”. We can envision two very comfortable pilot with expectations that this was going to be a routine, unchallenging flight that mirrored past routine, unchallenging flights. As I cover in the discussion topic (23-8), a common side effect of settling into a comfort zone is modulating attention level with perceived work level instead of with the phase of flight. Consider the following discussion questions.

1. Airline flying is often repetitive and unexceptional. It is very easy to settle into our comfort zone. How does this affect our expectations? How do our expectations change over time? How do they affect our levels of planning, briefing, SA building, and monitoring?

2. How much did the crew’s first error effect their follow-on errors? Consider an analogy of a boxer who receives a stunning blow from their opponent. They don’t immediately snap back into full readiness. They take time to get over the stun, rebuild their situational awareness, and respond. Do we see evidence of this residual effect in this crew’s subsequent errors?

3. In their analysis of the event, the Captain admits to favoring flightdeck rapport over preserving sterile flightdeck protocols compared with focusing the crew’s efforts on complying with the ATC clearances. They allude to the difference between following sterile flightdeck rules and actually satisfying the underlying objectives. The purpose of sterile flightdeck protocols is to focus the crew’s attention toward planning, monitoring, and executing flightdeck tasks during high consequence phases of flight. During this event, how did their unskillful adherence to sterile flightdeck rules affect their ability to recover from early errors and prevent follow-on errors?

(1) We tried too many approaches and our closest alternate was unsuitable at the time we decided to deviate. We then had to deviate to a further alternate knowing that we would arrive with less than 45 minute reserve and critical fuel.

(2) My Captain did not plan a suitable alternate, and may have not researched weather despite those being his company delegated pre-flight tasks. I did not receive detailed weather briefing and deviation plan from the Captain. My Captain failed to give detailed approach briefing including visibility restrictions and deviation to alternate and had a lack of personal minimums. We may have been able to land on the first and second approach attempts but my Captain's instrument approach skills were extremely poor, resulting in full scale deflection and lack of descent rate after the FAF, so despite my advisories and attempts to correct the situation we were forced to go missed.

(3) I suggested after the first two missed approaches that we hold and assess fuel, deviation plans and weather conditions, but the Captain insisted on doing the procedure turn and attempting two more approaches. I was very distracted in my radio communications because my Captain had very poor CRM, doing many Pilot Not Flying (PNF) tasks himself without notifying or requesting that I perform them because of this he was not maintaining directional control and he was also attempting to turn for missed approach instructions before the aircraft was under control resulting in very unstable missed approaches. The two additional times we attempted approaches the weather was too showery and inconsistent, and despite receiving reports from the tower that visibility was above minimums, we did not see the runway on either approach.

(4) After four consecutive approaches we finally received a long climb and turnout from Tower for our missed approach instructions and had the chance to slow down and assess our situation. I immediately asked Captain for alternate options and requested weather for our alternates from tower. The closest alternate was low IFR and the weather we were experiencing was headed toward our alternate. I asked the Captain if we had enough fuel to deviate to farthest (second) alternate which was VFR. The Captain did not know. The Captain calculated the fuel to get there and reported could but with less than 45 min reserve. He still did not make decision to stay or to deviate.

(5) With weather still below minimums at current airport and 4 approach attempts failed and an inactive Captain, I demanded an immediate deviation to the farther (second alternate). I did not feel experienced enough or prepared to make the decision but felt at that point I had no other choice .... It was risky but at that point everything was. The Captain agreed to deviate. I requested immediate deviation from the tower and the Captain reported fuel critical and requesting priority handling. The Captain gained altitude for better fuel burn.

(6) Enroute we received a fuel low warning and the Captain did not call for QRH, so I suggested and followed QRH procedures (turning on the standby pumps). The Captain agreed. I brought up and discussed the possible scenario of engine failure due to fuel loss on approach with the Captain. The Captain decided to continue with both engines running. We briefed and discussed descent and approach in detail. My Captain decided not declare emergency for fear of reprimand/paperwork. We landed with both engines running but without enough fuel to conduct a go around or missed approach. The deviation took over and hour and we had 25 minutes or less fuel for normal cruise when we touched down.

(7) I requested a post flight briefing with the Captain. I reported the details of the flight to Chief Pilot and Director of Operations (DO). I have confirmed plans to meet with the Chief Pilot and DO to discuss the details. The DO and chief pilot said they would speak with the Captain. I requested Chief Pilot give me and additional training session on actual planned alternates, fuel planning and applicable weather trends. I suggested planning materials be made more available to First Officers (FO) and that FOs should be encouraged to share that duty with the Captains.

(8) I resolved to practice a 2-approach personal minimum and only a second attempt if there are significant weather changes and if fuel generously allows. I resolved to memorize each route alternate choices and the minimum fuel for each so I know exactly when the last opportunity is to deviate, even if the captain does not, and lastly to take a much stronger stance on my responsibility to also route, fuel and weather plan and exercise full discipline in questioning the Captain when they are vague or omit details of planning and or weather.

(9) We received distracting and tempting weather updates from Tower that the visibility was increasing to "2 miles" again and "this was our only chance" just as crossing the final approach fix outboard (perfect timing for procedure turn and not for hold) which made the temptation of trying again hard to suppress. This helped contribute to the momentum of the situation resulting in four continuous approach attempts in the minimum amount of time. We failed to realize each visibility report from the tower was not accurate or if it was, they were, conditions were changing so rapidly we did not have time complete our approaches.

(10) This was the first time I was ever forced to go missed on a non-training flight, exercise personal approach minimums or deviate in flying career so though I had the right instincts I had a lack of insight on the overall situation and the experience not just to suggest, but to demand to hold and deviate earlier. The Captain had an attitude like he had to begrudgingly use the QRH I called for it after the fuel warning. He also harbored an attitude that everything was someone else's fault - it was the plane, or the weather or my fault as a new FO.

(11) My company has showed the attitude and specifically said in training multiple times that FOs are not responsible and do not need to be trained on routes, alternates, and fuel planning which are considered captains duties. This creates a poor attitude and culture for FOs. Captains briefing FOs on above topics was suggested but nowhere and no time stressed. Materials for actual routes flown, alternates used and fuel plans are either nonexistent or not readily available for FOs. Additionally, the Company has a reputation of protecting Captains who have received multiple serious complaints.

Discussion questions:

• Identify the abnormal indication
• Reference the applicable procedure in our abnormal/non-normal procedures manual
• Perform the corrective actions
• Modify our gameplan to accommodate any residual effects from degraded systems
• Choose to continue or land

Occasionally, we encounter anomalous situations that:

• Generate indications and symptoms that are unfamiliar
• Emerge from unknown causes
• Are not covered in our manuals
• Significantly increase situational complexity and event novelty

Following is a situation from a EMB-175 crew (minor changes were made to the following text to improve readability and to clarify the sequence of events – NASA ASRS report 1714483).

We departed normally, climbed to cruising altitude and leveled off. Approximately 6-7 minutes into cruise, a sudden humming noise was heard from an unknown location. It grew gradually into a loud whistling sound with vibration. We were unable to determine source of sound. The Lead Flight Attendant called shortly after inquiring about the noise and informed us that the noise was coming from L1 boarding door. We cross-checked status pages and pressurization. All indications were green and normal. No EICAS MSGs were presented and crew communication was established.

We requested descent from ATC to lower altitude. Center assigned 10,000 feet. The Captain called for the donning of cockpit oxygen masks. Pilot Flying duties were assigned to the First Officer. The Captain attempted to communicate with cabin crew to investigate the noise. The sound was too loud for FA (Flight Attendant) to hear the pilots. We asked ATC about the nearest airport, ZZZ1, at 45 miles. Weather there was ¾ mile visibility and a ceiling of 900 broken. We determined that ZZZ was the most suitable airport and proceeded there. We requested and were given direct to the destination, ZZZ. Center provided priority handling for us. We notified Dispatcher of priority handling and intentions. Our Dispatcher concurred with our decision. We removed oxygen masks at 10,000 feet and proceeded to destination. No limitations were exceeded. No FARs were violated. We requested CFR (Crash Fire Rescue) equipment to be standing by. We taxied off the runway and rescue vehicles were told to stand down.

Surprise, startle and early problem diagnosis: The first effect that the flight crew might have experienced in this situation was surprise or startle. Imagine these two pilots on a routine climbout on a familiar flight. Suddenly, there is a “sudden humming noise was heard from an unknown location” that “grew gradually into a loud whistling sound with vibration”. The startle effect typically degrades our higher-level thinking. We need some time to restore our situational awareness. As we recover, we prioritize our assessment of critical parameters and systems, then work down to lesser parameters and systems. We can imagine this crew quickly glancing at their critical systems (like engines) to see if they had a serious problem. While neither pilot reports their early problem diagnosis steps, whatever they were doing was quickly interrupted by the Lead Flight Attendant calling up to report that the sound was coming from the L1 cabin entry door.

Focused problem diagnosis: The Flight Attendant’s information focused their attention on pressurization concerns. They checked systems and noted, “all indications were green and normal”, and “no EICAS MSGs were presented”. While this may have eased their concerns about critical systems, it may not have decreased their “fear of the unknown”.

Probable cause and early precautionary steps: Those of us with experience flying older airline aircraft recognize this as a faulty door seal event – something that occurred fairly often with older aircraft designs. Typically, the noise started when the pressurization differential between the cabin and the outside air reached a particular threshold. The damaged or misaligned seal began to whistle and vibrate. One other possibility was an unsecured door strap that got caught partially outside the aircraft. At the right speed, it would begin to whip around and beat against the side of the aircraft. In either case, the aircraft typically maintains cabin pressure. The plug door design ensures that it will not blow out or create further hazard. In fairness to this crew, the NASA ASRS report doesn’t record the maintenance diagnosis or remedy – so we don’t know the cause of this event.

      Newer aircraft with better-engineered door seals have produced a prevailing environment where most pilots never experience door seal events like this. We can theorize that neither pilot had since the Captain elected to don oxygen masks against a possible rapid depressurization if the door blew out. This was probably unnecessary and perhaps added to the follow-on communications difficulties with the Flight Attendants. Still, in the heat of the moment, it probably felt like a prudent precaution.

Forming a gameplan: The crew elected to make an expeditious recovery and landing. This was the most prudent gameplan to minimize the time exposed to the very loud and unnerving vibration and whistle. There were two landing options. The closest option (ZZZ1) had unfavorable weather. The further option (ZZZ) was apparently better. The Captain divided crew duties by assigning flying duties to the FO while they tried to communicate with the FAs (unsuccessful because of the noise), coordinated priority handling with ATC, informed their Dispatcher, and coordinated with local ATC. They completed their descent to 10,000 feet, removed their oxygen masks, and flew an approach to ZZZ.

Crash Fire Rescue (CFR) response: The Captain requested a CFR response for their landing. Across our industry, there is a pervasive culture of reluctance to “roll the trucks” except for the most obvious or dire emergency situations. Many would judge this Captain’s choice as unnecessary. Given the Captain’s likely mindset, I disagree. Each of this crew’s actions reflected a mindset of guarding against the unknown. Given this, it is both reasonable and prudent to mobilize all assets to favor desirable outcomes. After landing, CFR can provide immediate and detailed information about the security of the L1 door. They can’t do this from the inside of the firehouse, so roll the trucks. Reassured that the door was intact, the Captain chose to release CFR crews.

Summary: In hindsight, we can categorize this as a fairly benign “emergency” event. What made it concerning was the extremely loud and scary noise emanating from an unknown cause. Unknown causes should cue us to select conservative gameplan options – as this flight crew did. The event followed the typical progression:

• Surprise/Startle from an anomalous event
• Initial recovery and critical system assessment
• Crew coordination and problem diagnosis
• Gameplan selection and contingency preparation
• Execution of the gameplan
• Resolution of the event to reach a safe conclusion

Consider other similar scenarios with strong “unknown factors”. In Master Airline Pilot, I present a particularly scary event (Box 22.4: Loud Bang Begins an Unknown Cause Emergency Event – pages 454-455.) In that event, “large sections of air plumbing in the belly of airplane, fed by the Ram Air Inlet, had exploded into pieces.” The highly anomalous event generated particularly worrisome symptoms heard and felt throughout the aircraft and from the flight controls.

Dealing with events with unknown causes and lack of procedural guidance compel us to revert to basic emergency event guidance like MATM:

• Maintain aircraft control.
• Analyze the problem.
• Take appropriate action.
• Maintain situational awareness.

We need to diagnose the problem and form a gameplan concurrently. This usually means that we need to repeat early assessment and later planning steps to continuously validate and update our gameplan. (See Master Airline Pilot, the Risk and Resource Management model (RRM) in chapter 10).

Please feel free to respond with your ideas and impressions.

While working this leg in cruise at FL300 about an hour out from our scheduled landing, me and the Captain could clearly hear a scuffle going on in the cabin. We looked at each other and were going to call back to the flight attendant but just before we could she called up to us and informed us that she had a medical emergency with a passenger having a seizure in row 5. The Captain (PF) said we will get the plane on the ground and hung up the phone and we got working on an alternate. Captain advised a landing in ZZZ as that was only about 40 miles ahead at 12 o’clock. I gave a quick thought as to whether that would be a suitable alternate and being that we have scheduled service into there and it was nearest practical I agreed and immediately informed ATC, they then immediately issued a descent. On the way down we were very saturated with calls from ATC and from the cabin passing back and forth information regarding the sick passenger and services required upon landing on top of the instructions given to us by ATC in regards to just flying the aircraft. The Captain was able to complete a diversion report and I was able to get enough time off frequency to get the ATIS, runway landing, landing speeds, determine that we would be underweight, and attempted to contact operations. In all of this scuffle we had been in a steep descent into ZZZ with the Captain unnecessarily taking his attention away from flying the aircraft. This led to us being very fast descending through 10,000 feet which triggered the high speed master warning multiple times. I gave a stern call for correction once and then again I said more abruptly that he needs to slow the plane down again of which he made a less than sufficient correction but we eventually were able to get down to a correct airspeed by about 8,500 feet.

It was about this time we had a break and I could read and complete the in-range checklist. We were all caught up by about this time although still in a steep descent we did a 360 to help get down with the help of ATC. But calls from the cabin started to come back again from both the flight attendant and a physician who was tending to the passenger when we were entering a very critical phase of flight and also with the sterile light illuminated. Again despite my best attempts to help alleviate workload for the Captain, he was task saturating himself and taking his attention away from flying the aircraft. I could sense his manic pace that he was attempting to use to get the aircraft on the ground and tried to alert him to slow down and relax but it did not seem to have effect. As we soon approached ZZZ airport I and the Captain lost situational awareness due to task saturation and unfortunately marginal conditions at the airport. Which were reported as very VMC but due to a large amount of glare from landing into the sun made it difficult to see the field of which we were attempting a visual approach backed up with and ILS NAVAID as had been briefed. The approach checklist had been completed but due to us loosing situational awareness we were a lot closer to the airport than we thought and despite the captains attempts at some steep S-turns there was just no way to make that approach happen and we did get a sink rate aural warning on approach. So we broke off to the right and the Captain asked me to request a visual approach to Runway XX, of which I obliged and the tower advised that it was closed. So I said how about left traffic for runway 9, tower said that’s just fine and cleared us to maneuver as necessary and cleared to land runway 9. I checked the winds to make sure the tailwinds were not excessive (which it was a 6 knot tailwind component) and made sure the Captain was comfortable with making that maneuver which he said he was.

From this point we made a left visual traffic pattern for runway 9 at about 1,000 AGL. I quickly gave the Captain a the ILS course and frequency for backup and hoped the approach would work out better for us. Unfortunately, the Captain again overcome by his emotion to get the aircraft on the ground tried to rush too quickly and cut the turn to base way to short. We rolled final at about 400 feet and received and aural sink rate and bank angle warning on short final. We touched down relatively on speed and in the touchdown zone but the approach was far from stable. We turned off the runway and were met by paramedics who pushed stairs up to the aircraft and tended to the stricken passenger. Both the Captain and myself were visibly shaken by the event. The passenger was taken off along with another passenger who had a slight injury while helping the man suffering from the seizure but he was able to get fixed right up and boarded the plane again. We did what we could to try to block out what happened and concentrate for our next leg to continue on to destination which happened without incident. The Captain told me later on that he had never had a medical emergency on one of his flights before.

There were a lot of threats on this flight but as I see it the overwhelming factor that led to the undesired aircraft state was just the Captain’s inability to slow down and take his time. I tried to explain to him at one point that risking 50 lives is not beneficial to helping one life but it did not seem to take effect. Also the basic division of attention which allowed himself to get far too task saturated and stop flying the aircraft of which I was guilty of as well. Other threats were that: the Captain had never had a medical emergency before, the multiple and unnecessary calls coming from the cabin in a critical phase of flight, Marginal weather at our airport of intended landing, and lack of leadership in the cockpit. There were a couple undesired aircraft states that occurred during this emergency diversion due to factors listed above but the most prominent undesired aircraft state that I observed was the airplane landing from a very unstable approach. The go-around was on the tip of my tongue during that whole approach, but being the fashion the aircraft had been operated up to that point I feel it was probably safer that we were on the ground, but landing from an approach like that is something I hope to never do again and I think the Captain would agree with me we were both very disappointed in ourselves in how we handled this emergency.

In the future I will be much more vocal and assertive in taking our time and making sure there is one level of safety in an event like this to prevent undesired aircraft states like this one. I have had a few of these types of emergencies before and frankly have gotten mixed assessments from pilots in prominent positions in this company some saying to do everything you can to get that aircraft on the ground quickly and some saying the opposite. This may just be a position that is just left up to people and their opinions but after this event I realize just how bad things can go if you do not take your time and lose focus on the bigger picture.

There is quite a bit to unpack here. Let’s examine some of the main points:

Division of tasks during high task loading:  Immediately after learning about the medical emergency, the Captain selected a divert airport that was very close. They had some 30,000 feet to lose within 40 miles. They also had a large number of tasks to complete before landing. The FO’s report indicates that they divided the task load to accomplish everything before landing. They don’t report on how they communicated dividing those tasks. When we don’t coordinate division of tasks, we default to dividing them quickly and spontaneously. Perhaps the Captain assigned some tasks to the FO while he chose to complete others himself. This is a commonly used technique among proficient airline crews. Each pilot completes their tasks independently and then the crew realigns their efforts as the workload eases. While this is a useful process for handling task overload, it relies on each pilot’s accuracy and thoroughness. A resilient practice is to verify each other’s task accomplishment after workload subsides. Often this doesn’t happen because the crew never reaches a low-workload phase. Most crews rely on checklists to capture the major items and hope that everything else was handled accurately, that missed items will prove inconsequential, or that anything missed will be discovered before it becomes consequential.

Continuous interruptions from the cabin: The FO expressed frustration with continued “multiple and unnecessary calls coming from the cabin.” This highlights the conflict between cabin procedures and flightdeck workload. The Flight Attendants don’t know how busy we are or how much their calls disrupt our workflow. They only know that their procedures direct them to keep the pilots informed. In the end, the pilots turned on the sterile environment indicator to stop the cabin interruptions.

Captain’s rushing: The FO expresses frustration with being unable to get the Captain to ease his sense of urgency and fly a safer profile. They made “stern” callouts to get the Captain to comply with safe aircraft operation. This problem persisted through landing. The FO vows to “be much more vocal and assertive” in the future. While this is important, every PM needs to prepare which responses they will use across the full range from simple callouts through interventions including assuming aircraft control. This FO’s indecision set the stage for the next point.

FO’s acceptance of the unstabilized approach and landing: The FO made a conscious decision to allow the second (unstabilized) approach to continue. This is a common feature of events like this. PMs make a “safety” determination when they judge that a profile can be guided to a safe conclusion even though it violates procedures. We don’t talk about this flightdeck dynamic enough – the gap between procedural compliance and “safe operation”. (See my book for an in depth discussion of the types of safety margins.) As pilots, we perceive that we have discretionary space to manage this gap. With most crews, we only apply this in exceptional situations (like this one). With other crews, these excursions into the discretionary gap safety margin becomes common, even routine, depending on the pilot personalities and company’s line culture. Notice how the FO reported, “The go-around was on the tip of my tongue during that whole approach…”

Practice and rehearsal: Notice how the Captain attributed their choices to the situation’s novelty (first time they had ever experienced a medical emergency). This is a defining aspect of the Master Class path. Master Class pilots study, imagine, and practice situations like this regularly. This improves the accuracy and speed of their actions and choices during the event and reduces the adrenaline factor (startle and surprise). In line flying, we have a lot of quiet time in cruise flight. Imagine if these pilots had imagined this kind of scenario and discussed the sequence of actions, the defining conditions, the division of roles, and the descent and landing process. This practice and rehearsal would have reduced the sense of urgency and guided a more appropriate response.

The big picture: A passenger seizure is a serious medical event, but it is rarely deadly – especially when the patient is attended by a qualified physician and Flight Attendants. There was every reason to make an expeditious descent and landing, but not one that warranted extreme measures. While I acknowledge that I make this assessment in hindsight, we generally know what constitutes the need for extreme speed – heart failure or severe bleeding. Baring these factors with a medical emergency, we should declare the emergency, gain priority handing, and make reasonable efforts to get the aircraft on the ground at an airport with capable medical facilities.

Please follow this post with your comments on the event and my analysis.

a slow speed event in which the autopilot disconnected at approximately 170 knots. The aircraft did not enter a stall as both the Captain and I were able to correct and maintain the airspeed above stall margins.

During enroute transit ATIS and gate information was unavailable through the FMS due to NO ACARS COMM status message that remained until approximately 9 mins prior to arrival. At this time the Captain and I had already made the decision to use ILS XXR approach and had briefed and set up the cockpit as such. At this time the weather was OVC 600 2SM/MIST. While on the Initial Approach to ILS XXR, Approach informed us of the ATIS and runway change to the Visual YYL or RNAV/LOC YYL. At this time the updated weather reported was OVC 900 just above the airport but with visibility 10SM. We then decided to accept the RNAV YYL approach and entered a hold for traffic separation and to program the FMS for continued descent via vectors.

Prior to reaching Intermediate Approach Fix I was unable to program the FMS to show either the hold at Intermediate Fix or the runway on the FMS. Neither myself nor the Captain had ever had any issue with loading an approach into FMS and not having the correct waypoints show. The Captain and I both verified with Approach the correct waypoint at IAF and again could not get the FMS to show the approach and runway. It was at this time that the autopilot kicked off while in the hold due to speed loss and the Captain immediately took corrective action to prevent a stall. No altitude was lost in the hold and the Captain decided to keep the autopilot off and hand fly the remainder of the approach. We then accepted the Visual YYL and proceeded to continue via the Initial Approach via the Visual for Runway YYL.

After review and analysis of the situation from my perspective, as the PM (Pilot Monitoring) I should have been more attentive to ALL of the instruments/indications in the cockpit and should have told the Captain to maintain flying while I troubleshoot the FMS when he tried to assist in programming the FMS which caused temporary loss of situational awareness while on Initial Approach. Had I done so, I would’ve noticed the speed reduction well in advance of the autopilot kicking off. Also, although we were on the Initial Approach prior to turning base, it would’ve been more prudent to just accept the Visual for XXL and hand fly the approach rather than to continue trying to program the FMS.

This event is rather instructive when paired with Topic 23-4: The Importance of Staying Out-of-Synch. Here was a situation where the FO/PM encountered difficulty reprogramming the FMS during a last-minute approach/runway change. Clearly, both pilots became deeply concerned with the problem and devoted most of their attention toward solving it. The CA/PF diverted their attention from flying the aircraft to assisting the FO/PM with solving the FMC problem. Soon, they encountered a slow-speed event that automatically disconnected the autopilot. The Captain reacted quickly to add thrust and restore airspeed.

Some questions to consider:

1. It is interesting that the FO filed a report, but the Captain didn’t. What are some reasons why this commonly happens?

2. Most airlines direct the PM to attend to complex FMC reprogramming while the PF retains operational control of the aircraft and flightpath. We rarely see problems when the FO is the PF and the Captain is the PM. Why do we see more problems when the roles are reversed?

3. This event seems to describe an environment where crews favor full FMS automation for STAR and approach guidance (and, frankly, who doesn’t). Unfortunately, we can’t freeze the aircraft in midair. It keeps moving forward. This often promotes a rising sense of urgency to resolve the programming problem as quickly as possible. Should the crew have reverted to a lower level of automation to keep moving toward their Intermediate Approach Fix – then to work on the following approach routing while the aircraft is enroute? Is this a skill that is practiced or supported by your airline?

4. The FO states that, “I should have been more attentive to ALL of the instruments/indications in the cockpit…” As an assigned role, the PF is responsible for remaining attentive to the flightpath. Generally, we assume that the PM is only responsible for monitoring the quality of the PF’s flightpath management – not the fine details. The FO’s statement implies that they should have split their attention between solving their difficult FMC problem and monitoring the PF’s performance. Is this reasonable? What are some strategies for dividing workload with situations like this?

5. The FO states that they, “…should have told the Captain to maintain flying while I troubleshoot the FMS when he tried to assist in programming the FMS…” Let’s dig deeper into this thought. It implies that the PM, regardless of their workload, needs to monitor the quality of the PF’s flying. We don’t know whether the FO detected the Captain’s distraction into the FMS issue or whether they drew this conclusion via hindsight. What measures could the FO have employed to ensure that the crew maintained effective role discipline?

During takeoff roll, after 80 knots, Master Caution illuminated briefly. FO (First Officer) didn’t say anything at first. Then he said “over temp”. I looked at the speed and it was 125 knots. I looked down at the engine instruments and the #2 engine N1 numerical presentation was displayed in red with a red box around it. I looked back at the speed and it was 131 kts. V₁ was 134 kts. I immediately applied the Phase One and rejected. FO did not call Tower to advise our reject. After taxiing clear, I noticed a Level One ENG 2 EXCEEDANCE. Ran appropriate checklists and taxied back to the gate. This was the second time in the same day that this aircraft rejected for the same thing. Maintenance ended up replacing the engine fan speed sensor.

Poor analysis, troubleshooting and resolution of the same issue earlier that morning.

The maintenance sign off of the morning’s reject before I got the airplane was a joke. Both rejects in this aircraft that day are extremely serious in nature and the first of the two wasn’t treated as such. … It’s an understatement to say rejecting 3 knots before V₁ is highly dangerous. Further, I would have rejected at a much lower speed had my FO been doing his job correctly. I don’t think he was looking at the engine instruments during the takeoff roll as he should have been. When the Master Caution came on, I doubt he wasn’t looking where he should have been to notice the alert. And when he finally did notice the alert, he said the wrong problem. He said “over temp”. There was no over temp it was pretty clearly spelled out in amber “ENG 2 EXCEEDANCE” Is this the result of him not bringing his A-Game to work that day? Is this the result of poor training? Is this the result of hiring low hour pilots directly to the right seat of a heavy? Whatever the case, I was on my own during this one.

Questions for analysis:

1. The Captain voices clear frustration with maintenance clearing the previous rejected takeoff event and the FO not making appropriate callouts. The Captain doesn’t share what they briefed prior to takeoff. Given prior knowledge of the previous rejected takeoff event, what briefing points would be appropriate to cover during the Captain’s briefing?

2. The FO failed to advise Tower of the rejected takeoff. What does this imply about the FO’s mindset during the RTO?

3. What evidence implies startle and surprise behaviors in the FO’s performance?

4. The FO made the incorrect callout during the event. How did this affect the Captain’s reject decision?

5. The Captain reported that the maintenance sign-off from the earlier event “was a joke”. Does this imply hindsight bias? If the Captain thought it was an invalid sign-off, what steps should the Captain have taken before accepting the aircraft?

6. The Captain reports several assumptions about where the FO wasn’t looking and should have been looking during takeoff. This implies that the crew didn’t effectively debrief the event. What debrief topics should have been covered?

Captain’s Narrative: Taking off on Runway XXR at ZZZ, I was pilot flying. Approaching V₁ we noticed a large bird with an estimated wing span of ten feet appear out of nowhere on the right side of center just in front of the aircraft. I was hoping the blue heron would climb out and not hit us for if it did, it would hit either the right cockpit window, the right side of the fuselage and the First Officer's sensors, or the right engine. I was concentrating on the runway center line trying not to be distracted when the impact occurred. WHAM somewhere on the right side. I did not know if it hit the engine or the right side of the fuselage, I knew it hit and there was a serious chance of impending damage and possible injuries. I still had my hands on the throttles, we were still on the ground just a few kts. from rotation when I rejected the takeoff. I pulled the throttles to idle as my First Officer announced V₁ but I was committed. I went into full reverse, felt the auto-brakes kick in and we rapidly decelerated. Approaching a safe taxi speed I de-selected the auto-brakes, heard my First Officer state "Remain Seated, Remain Seated!" to the passengers. I taxied off the runway and when I knew we had sufficient clearance from the runway I set the parking brake. My First Officer had the QRC out and we made sure we performed all the pertinent items on the checklist. Then we secured the right engine to minimize any possible damage.

We did not know the extent of the damage, if any, to the aircraft. I checked with the flight attendants to ensure the cabin was undamaged and the passengers were safe and secure. I made a quick announcement over the PA to assure the passengers of what happened then went back to my duties. We initially stated to Ground Control no assistance was needed but a very short attempt to taxi revealed we had problems. We quickly noticed the aircraft was listing one or two degrees and we knew the tires were deflating. The brake temperature indicators were all over 900 degrees. We called Ground Control and asked for assistance. Shortly the ZZZ fire department arrived and hosed the tires and main landing gear area with plain water. The fire department informed us the tires were smoking and small flames were on the wheels. They extinguished all and checked for damage which they did not find.

We checked with the Operations, informed them of the situation and made other phone calls to ensure proper agencies and corporate entities were informed. We also kept the flight attendants and passengers involved. Later the boarding steps and buses arrived and we de-planed the passengers with their carry-on luggage into the waiting buses.

No passengers were injured, no damage was done to the aircraft except the deflated tires.

FO’s Narrative: The event occurred while taking off on Runway XXR at ZZZ on an A319. The aircraft had a final takeoff weight of 139.3 and calculated V₁-145 kts., V_R-145 kts. and V₂-150 kts. for a Flaps 1 reduced thrust takeoff. I was the Pilot Monitoring during the takeoff. The aircraft was operating normally through the takeoff roll and as we were approaching the " V₁" callout (V₁-5) we noticed a very large bird (I estimate a 10-12ft wingspan) appear in front of and slightly to the right of center at cockpit height above the runway. The bird appeared out of nowhere and I was fully expecting it to impact my First Officer side front window as it was not moving to avoid the aircraft. I used a composite crosscheck to ensure the V₁ callout at the correct time and also try and gauge the relative movement of the bird to the aircraft. Before I opened my mouth to announce " V₁" (at V₁-5 kts., 140 kts. in this case) the bird impacted the aircraft just below my front window on the nose and I saw a very large black mass move past my lower right peripheral. It's trajectory past the nose and down the right side of the fuselage led me to believe that it was going to take out right side fuselage sensors and most likely be ingested into Engine #2 causing further damage.

Based on the strong impact and very loud bang happening just before I got the V₁ call announced I saw the Captain had already initiated the reject when I called V₁. I then monitored the CDUs and PFD for proper speed brake deployment, full thrust reverser deployment, deceleration and potential damage to Engine #2. The auto brakes engaged and we rapidly decelerated. I called "80 kts." as we slowed below that speed and then announced "Remain Seated, Remain Seated" over the PA. I also notified Tower of our reject on Runway XXR and told them to stand by for further coordination after we cleared the runway. The auto brakes were deselected upon reaching a safe taxi speed and I pulled up the rejected takeoff QRC to run once we were clear of the runway. We taxied off the runway and set the parking brake in order to run the QRC and Rejected Takeoff non-normal checklist. We also secured Engine #2 in order to minimize any potential damage.

The Captain was coordinating with the cabin crew to check on the state of the cabin and the passengers while I was giving ZZZ Operations an initial notification of the event. We then called for further taxi away from the runway onto a taxiway and to standby for any further assistance requests. After a very short taxi I informed the Captain that I felt that the aircraft listing to the right a few degrees and he agreed. We immediately stopped for suspected tire deflation. We cross checked the brake temperature indicators and they were increasing above 900 degrees with a peak of 980 degrees.

We called ZZZ Ground Control to dispatch fire department trucks to assist in helping determine the state of the aircraft. Upon arrival at the aircraft the fire department stated that they observed smoke and some small flames on the wheel assembly. They then proceeded to spray the tires and main landing gear at regular intervals to extinguish the flames and cool the brakes. We regularly communicated with the fire chief over the radio relaying brake temperatures until they went down to 50 degrees across all main brakes. They conducted multiple inspections during the process and did not find any damage to aircraft except the deflated tires.

During this period we also coordinated with Operations, Maintenance via ACARS, Dispatch and other appropriate entities to make sure all were informed. We requested boarding steps and buses for the passengers be readied so that we could deplane them and take them back to the terminal once it was safe to do so. The cabin crew also reported no injuries to anyone on board the aircraft.

After all passengers were off the aircraft we ran the parking checklist, absent setting the parking brake for previous events, before turning the aircraft over to Maintenance and deplaned the aircraft ourselves. We inspected the bird strike areas with the fire department and maintenance personnel and found initial strikes on the Engine #2 cowling and inboard leading edge of the right wing.

Synopsis: A319 flight crew reported that a large bird strike just prior to V₁ resulted in a rejected takeoff and a minor wheel fire.

Discussion: This is a fairly classic birdstrike-during-takeoff event. The rejected takeoff decision was fairly straightforward. Since they were below V₁, The Captain didn’t take time to analyze the engines. They knew that it was a large bird and that that they had just hit it. Some discussion questions:

1. How does our attention level affect how well we recover from startle/surprise?

2. How much (or what kind of) “decision making” was involved with the Captain’s decision to reject this takeoff?

3. What CRM factors were reported by the pilots? While we don’t know much about flightdeck dialog, what useful dialog should have been used?

4. How did their event evolve in complexity and novelty? What resources could they have employed to improve their response?