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  1. Full List of Boeing 737 MAX Incidents Reported by Pilots
  2. From NASA ASRA Database: https://titan-server.arc.nasa.gov/ASRSPublicQueryWizard/QueryWizard_Filter.aspx
  3.  
  4.  
  5. ACN: 1604159 (1 of 20)
  6.  
  7. Time / Day
  8.  
  9. Date : 201812
  10. Local Time Of Day : 0601-1200
  11.  
  12. Place
  13.  
  14. Locale Reference.Airport : DEN.Airport
  15. State Reference : CO
  16. Altitude.MSL.Single Value : 10500
  17.  
  18. Environment
  19.  
  20. Light : Daylight
  21.  
  22. Aircraft
  23.  
  24. Reference : X
  25. ATC / Advisory.TRACON : D01
  26. Aircraft Operator : Air Carrier
  27. Make Model Name : B737-800
  28. Crew Size.Number Of Crew : 2
  29. Operating Under FAR Part : Part 121
  30. Flight Plan : IFR
  31. Mission : Passenger
  32. Nav In Use : FMS Or FMC
  33. Flight Phase : Initial Approach
  34. Airspace.Class B : DEN
  35.  
  36. Person
  37.  
  38. Reference : 1
  39. Location Of Person.Aircraft : X
  40. Location In Aircraft : Flight Deck
  41. Reporter Organization : Air Carrier
  42. Function.Flight Crew : Captain
  43. Function.Flight Crew : Pilot Flying
  44. Qualification.Flight Crew : Instrument
  45. Qualification.Flight Crew : Air Transport Pilot (ATP)
  46. Qualification.Flight Crew : Multiengine
  47. Experience.Flight Crew.Last 90 Days : 501
  48. Experience.Flight Crew.Type : 11195
  49. ASRS Report Number.Accession Number : 1604159
  50. Human Factors : Human-Machine Interface
  51. Human Factors : Situational Awareness
  52.  
  53. Events
  54.  
  55. Anomaly.Deviation - Altitude : Undershoot
  56. Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
  57. Anomaly.Deviation - Procedural : Clearance
  58. Detector.Person : Flight Crew
  59. Detector.Person : Air Traffic Control
  60. When Detected : In-flight
  61. Result.Flight Crew : Returned To Clearance
  62. Result.Flight Crew : Became Reoriented
  63. Result.Air Traffic Control : Issued Advisory / Alert
  64.  
  65. Assessments
  66.  
  67. Contributing Factors / Situations : Human Factors
  68. Primary Problem : Human Factors
  69.  
  70. Narrative: 1
  71.  
  72. We planned for the Visual to Runway 16L and talked about the possible assignment to 17R. When checking in with Approach we were advised to expect 17R. We briefed and programmed the RNP Z 17R. AS we approached the IAF I was preparing for what to do (i.e. what fix to use based on location of active waypoint) and/or the state of the IAF (i.e. active waypoint or not). To the best of my recollection, the IAF was on LSK L2, then I placed it IAF under IAF, although a review after the fact stated we "could" place in on top of it. We both complied with VVMI prior to execution. The aircraft continued on downwind with no descent. Almost simultaneously, as we noticed the wrong picture on the MAP display, the Controller asked us if we were descending. By this time I had disconnected automation and was following the purple line while both of us were monitoring altitude restrictions based on our clearance. The Pilot Monitoring reprogrammed the approach and the rest of the flight was uneventful. No further calls from ATC, altitude, or course deviations occurred. Consider calling the field in sight and requesting visual approach. We do believe that the IAF (since we were close to it) might have auto-sequenced from L2 to L1 (active), and as we know the programming in this case would have been different. Therefore, maybe a closer look at the distance remaining to the active waypoint might have helped prevent this situation.
  73.  
  74. Synopsis
  75.  
  76. B737 MAX8 Captain reported failure to descend as charted while flying the RNAV (RNP) Z approach to Runway 17R at DEN due to an FMC programming error.
  77.  
  78. ACN: 1603503 (2 of 20)
  79.  
  80. Time / Day
  81.  
  82. Date : 201812
  83.  
  84. Place
  85.  
  86. Locale Reference.Airport : ZZZ.Airport
  87. State Reference : US
  88. Altitude.AGL.Single Value : 0
  89.  
  90. Environment
  91.  
  92. Weather Elements / Visibility : Rain
  93. Light : Night
  94.  
  95. Aircraft
  96.  
  97. Reference : X
  98. Aircraft Operator : Air Carrier
  99. Make Model Name : B737-800
  100. Crew Size.Number Of Crew : 2
  101. Operating Under FAR Part : Part 121
  102. Mission : Passenger
  103. Flight Phase : Parked
  104.  
  105. Component
  106.  
  107. Aircraft Component : Aerofoil Ice System
  108. Aircraft Reference : X
  109. Problem : Malfunctioning
  110.  
  111. Person
  112.  
  113. Reference : 1
  114. Location Of Person : Company
  115. Location In Aircraft : Flight Deck
  116. Reporter Organization : Air Carrier
  117. Function.Flight Crew : Pilot Flying
  118. Function.Flight Crew : Captain
  119. Qualification.Flight Crew : Instrument
  120. Qualification.Flight Crew : Air Transport Pilot (ATP)
  121. Qualification.Flight Crew : Multiengine
  122. Experience.Flight Crew.Last 90 Days : 357
  123. ASRS Report Number.Accession Number : 1603503
  124. Human Factors : Time Pressure
  125. Human Factors : Confusion
  126. Human Factors : Distraction
  127.  
  128. Events
  129.  
  130. Anomaly.Aircraft Equipment Problem : Less Severe
  131. Anomaly.Deviation - Procedural : Published Material / Policy
  132. Anomaly.Deviation - Procedural : MEL
  133. Detector.Person : Flight Crew
  134. When Detected : In-flight
  135. Result.Flight Crew : Became Reoriented
  136.  
  137. Assessments
  138.  
  139. Contributing Factors / Situations : Chart Or Publication
  140. Contributing Factors / Situations : Equipment / Tooling
  141. Contributing Factors / Situations : Human Factors
  142. Contributing Factors / Situations : MEL
  143. Contributing Factors / Situations : Procedure
  144. Contributing Factors / Situations : Weather
  145. Primary Problem : Human Factors
  146.  
  147. Narrative: 1
  148.  
  149. ZZZ had terrible weather. We were already hours late when our aircraft arrived. The previous crew wrote up wing anti- ice not working. Outstation Maintenance arrived, and Dispatch and I determined that we could depart with a MEL (Minimum Equipment List) that allows us to fly in icing conditions. MEL was VERY complex and confusing. It required us to start a [B737] Max 8 with an air cart and start the number 2 engine first. I was concerned about the Safety of doing that in the dark and in heavy rain, so I made sure the ground crew and I were completely confident in our procedures.
  150.  
  151. A new release with MEL arrived, logbook was completed by Outstation Maintenance, and we began the process of starting the number 2 engine. During that time, we also were dealing with three different runway changes at ZZZ (XXL then XYL then XZL) which also meant three different SIDS (Standard instrument Departure) and complete re-briefing of takeoff, departure and engine out procedures. Also had to coordinate a crossbleed start. Then, our release expired and we had to get with Dispatch to reload the flight.
  152.  
  153. Amid all these distractions, we didn't realize that Maintenance never placed a sticker in the flight deck or logbook. I reviewed the logbook after Maintenance was done, but totally forgot about the stickers. I guess the major distraction was how the MEL and the MAX 8 AOM (Aircraft Operations Manual) differed with each other on this procedure, and lack of clear directions on working with this MEL. Flight was completed in ZZZ1 and we went to the hotel. I think a clearer AOM or MEL is needed on this problem.
  154.  
  155. Synopsis
  156.  
  157. B737 MAX Captain reported departing with deferred maintenance and complex MEL, but noticed MEL sticker was not properly applied.
  158.  
  159. ACN: 1597380 (3 of 20)
  160.  
  161. Time / Day
  162.  
  163. Date : 201811
  164.  
  165. Place
  166.  
  167. Locale Reference.ATC Facility : ZZZ.TRACON
  168. State Reference : US
  169. Altitude.MSL.Single Value : 2000
  170.  
  171. Environment
  172.  
  173. Weather Elements / Visibility : Rain
  174. Weather Elements / Visibility : Snow
  175.  
  176. Aircraft
  177.  
  178. Reference : X
  179. ATC / Advisory.TRACON : ZZZ
  180. Aircraft Operator : Air Carrier
  181. Make Model Name : B737-800
  182. Crew Size.Number Of Crew : 2
  183. Operating Under FAR Part : Part 121
  184. Flight Plan : IFR
  185. Mission : Passenger
  186. Nav In Use : FMS Or FMC
  187. Flight Phase : Climb
  188. Airspace.Class B : ZZZ
  189.  
  190. Component
  191.  
  192. Aircraft Component : Autoflight System
  193. Aircraft Reference : X
  194. Problem : Malfunctioning
  195.  
  196. Person
  197.  
  198. Reference : 1
  199. Location Of Person.Aircraft : X
  200. Location In Aircraft : Flight Deck
  201. Reporter Organization : Air Carrier
  202. Function.Flight Crew : Captain
  203. Function.Flight Crew : Pilot Flying
  204. Qualification.Flight Crew : Instrument
  205. Qualification.Flight Crew : Air Transport Pilot (ATP)
  206. Qualification.Flight Crew : Multiengine
  207. Experience.Flight Crew.Last 90 Days : 626
  208. ASRS Report Number.Accession Number : 1597380
  209. Human Factors : Human-Machine Interface
  210. Human Factors : Confusion
  211.  
  212. Events
  213.  
  214. Anomaly.Aircraft Equipment Problem : Less Severe
  215. Detector.Automation : Aircraft Other Automation
  216. Detector.Person : Flight Crew
  217. When Detected : In-flight
  218. Result.Flight Crew : FLC Overrode Automation
  219. Result.Flight Crew : Overcame Equipment Problem
  220. Result.Aircraft : Equipment Problem Dissipated
  221.  
  222. Assessments
  223.  
  224. Contributing Factors / Situations : Aircraft
  225. Contributing Factors / Situations : Human Factors
  226. Primary Problem : Aircraft
  227.  
  228. Narrative: 1
  229.  
  230. It was day three of six for me and day three with very good FO (First Officer). Well rested, great rapport and above average Crew coordination. Knew we had a MAX. It was my leg, normal Ops Brief, plus I briefed our concerns with the MAX issues, bulletin, MCAS, stab trim cutout response etc. I mentioned I would engage autopilot sooner than usual (I generally hand fly to at least above 10,000 ft.) to remove the possible MCAS threat.
  231.  
  232. Weather was about 1000 OVC drizzle, temperature dropping and an occasional snow flake. I double checked with an additional personal walkaround just prior to push; a few drops of water on the aircraft but clean aircraft, no deice required. Strong crosswind and I asked Tug Driver to push a little more tail east so as not to have slow/hung start gusts 30+.
  233.  
  234. Wind and mechanical turbulence was noted. Careful engine warm times, normal flaps 5 takeoff in strong (appeared almost direct) crosswind. Departure was normal. Takeoff and climb in light to moderate turbulence. After flaps 1 to "up" and above clean "MASI up speed" with LNAV engaged I looked at and engaged A Autopilot. As I was returning to my PFD (Primary Flight Display) PM (Pilot Monitoring) called "DESCENDING" followed by almost an immediate: "DONT SINK DONT SINK!"
  235.  
  236. I immediately disconnected AP (Autopilot) (it WAS engaged as we got full horn etc.) and resumed climb. Now, I would generally assume it was my automation error, i.e., aircraft was trying to acquire a miss-commanded speed/no autothrottles, crossing restriction etc., but frankly neither of us could find an inappropriate setup error (not to say there wasn't one).
  237.  
  238. With the concerns with the MAX 8 nose down stuff, we both thought it appropriate to bring it to your attention. We discussed issue at length over the course of the return to ZZZ. Best guess from me is airspeed fluctuation due to mechanical shear/frontal passage that overwhelmed automation temporarily or something incorrectly setup in MCP (Mode Control Panel). PM's callout on "descending" was particularly quick and welcome as I was just coming back to my display after looking away. System and procedures coupled with CRM (Resource Management) trapped and mitigated issue.
  239.  
  240. Synopsis
  241.  
  242. B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.
  243.  
  244. ACN: 1597286 (4 of 20)
  245.  
  246. Time / Day
  247.  
  248. Date : 201811
  249.  
  250. Place
  251.  
  252. Locale Reference.Airport : ZZZ.Airport
  253. State Reference : US
  254. Altitude.MSL.Single Value : 2000
  255.  
  256. Aircraft
  257.  
  258. Reference : X
  259. ATC / Advisory.Tower : ZZZ
  260. Aircraft Operator : Air Carrier
  261. Make Model Name : B737-800
  262. Crew Size.Number Of Crew : 2
  263. Operating Under FAR Part : Part 121
  264. Flight Plan : IFR
  265. Mission : Passenger
  266. Nav In Use : FMS Or FMC
  267. Flight Phase : Takeoff
  268. Airspace.Class C : ZZZ
  269.  
  270. Component
  271.  
  272. Aircraft Component : Autopilot
  273. Aircraft Reference : X
  274. Problem : Malfunctioning
  275.  
  276. Person
  277.  
  278. Reference : 1
  279. Location Of Person.Aircraft : X
  280. Location In Aircraft : Flight Deck
  281. Reporter Organization : Air Carrier
  282. Function.Flight Crew : Pilot Not Flying
  283. Function.Flight Crew : First Officer
  284. Qualification.Flight Crew : Air Transport Pilot (ATP)
  285. Qualification.Flight Crew : Instrument
  286. Qualification.Flight Crew : Multiengine
  287. Experience.Flight Crew.Last 90 Days : 511
  288. ASRS Report Number.Accession Number : 1597286
  289. Analyst Callback : Attempted
  290.  
  291. Events
  292.  
  293. Anomaly.Aircraft Equipment Problem : Critical
  294. Detector.Person : Flight Crew
  295. When Detected : In-flight
  296. Result.Flight Crew : Regained Aircraft Control
  297.  
  298. Assessments
  299.  
  300. Contributing Factors / Situations : Aircraft
  301. Primary Problem : Aircraft
  302.  
  303. Narrative: 1
  304.  
  305. Day 3 of 3 departing in a MAX 8 after a long overnight. I was well rested and had discussed the recent MAX 8 MCAS guidance with the Captain. On departure, we had strong crosswinds (gusts > 30 knots) directly off the right wing, however, no LLWS or Micro-burst activity was reported at the field. After verifying LNAV, selecting gear and flaps up, I set "UP" speed. The aircraft accelerated normally and the Captain engaged the "A" autopilot after reaching set speed. Within two to three seconds the aircraft pitched nose down bringing the VSI to approximately 1,200 to 1,500 FPM. I called "descending" just prior to the GPWS sounding "don't sink, don't sink." The Captain immediately disconnected the autopilot and pitched into a climb. The remainder of the flight was uneventful. We discussed the departure at length and I reviewed in my mind our automation setup and flight profile but can't think of any reason the aircraft would pitch nose down so aggressively.
  306.  
  307. Synopsis
  308.  
  309. B737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.
  310.  
  311. ACN: 1593701 (5 of 20)
  312.  
  313. Time / Day
  314.  
  315. Date : 201811
  316. Local Time Of Day : 1201-1800
  317.  
  318. Place
  319.  
  320. Locale Reference.Airport : ZZZ.Airport
  321. State Reference : US
  322. Altitude.MSL.Single Value : 33000
  323.  
  324. Environment
  325.  
  326. Light : Daylight
  327.  
  328. Aircraft
  329.  
  330. Reference : X
  331. ATC / Advisory.Center : ZZZ
  332. Aircraft Operator : Air Carrier
  333. Make Model Name : B737-800
  334. Crew Size.Number Of Crew : 2
  335. Operating Under FAR Part : Part 121
  336. Flight Plan : IFR
  337. Mission : Passenger
  338. Nav In Use : FMS Or FMC
  339. Flight Phase : Climb
  340. Airspace.Class A : ZZZ
  341.  
  342. Component
  343.  
  344. Aircraft Component : FMS/FMC
  345. Aircraft Reference : X
  346. Problem : Improperly Operated
  347.  
  348. Person
  349.  
  350. Reference : 1
  351. Location Of Person.Aircraft : X
  352. Location In Aircraft : Flight Deck
  353. Reporter Organization : Air Carrier
  354. Function.Flight Crew : First Officer
  355. Function.Flight Crew : Pilot Not Flying
  356. Qualification.Flight Crew : Air Transport Pilot (ATP)
  357. Qualification.Flight Crew : Multiengine
  358. Qualification.Flight Crew : Instrument
  359. Experience.Flight Crew.Last 90 Days : 454
  360. Experience.Flight Crew.Type : 454
  361. ASRS Report Number.Accession Number : 1593701
  362. Human Factors : Distraction
  363. Human Factors : Training / Qualification
  364.  
  365. Events
  366.  
  367. Anomaly.Deviation - Altitude : Undershoot
  368. Anomaly.Deviation - Procedural : Clearance
  369. Result.Flight Crew : Returned To Clearance
  370.  
  371. Assessments
  372.  
  373. Contributing Factors / Situations : Aircraft
  374. Contributing Factors / Situations : Human Factors
  375. Primary Problem : Human Factors
  376.  
  377. Narrative: 1
  378.  
  379. We were climbing from FL 330 given a clearance to FL 360. Aircraft briefly leveled at initial cruise altitude FL 340 before Aircrew intervention. [Center] queried if we received the clearance to FL 360. As a result of the brief delay [Center] issued brief off course vectors to both us and converging traffic. Causal factors were equipment: not much experience in MAX-800, as a result, still have to search for everything. Automation: Upon receipt of FL 360 clearance and after the Captain dialed the MCP Altitude 36,000 FT, I should have, but failed to, ensured the cruise altitude reflected FL 360. Engaging the ALT INTV button would have facilitated the process. The solution is to Verify/Verbalize/Monitor. Verifying the CDU cruise altitude (NAV 2/3) would have prevented the temporary level off. Monitoring would have mitigated the delay at FL 340 but could have been timelier. As a relatively new First Officer, I had not seen this issue. However, I could have done a better job with VVM (Verbalize, Verify, Monitor) to back up the Captain with his duties while flying. Had I seen the momentary level off, I might have been able to alert ATC of it, avoiding any confusion or deviation of what the expectations were.
  380.  
  381. Synopsis
  382.  
  383. B737 MAX8 First Officer reported an altitude deviation due to an intermediate level off by the aircraft automation.
  384.  
  385. ACN: 1593699 (6 of 20)
  386.  
  387. Time / Day
  388.  
  389. Date : 201811
  390. Local Time Of Day : 0601-1200
  391.  
  392. Place
  393.  
  394. Locale Reference.Airport : ZZZ.Airport
  395. State Reference : US
  396. Altitude.AGL.Single Value : 0
  397.  
  398. Environment
  399.  
  400. Light : Daylight
  401.  
  402. Aircraft
  403.  
  404. Reference : X
  405. Aircraft Operator : Air Carrier
  406. Make Model Name : B737-800
  407. Crew Size.Number Of Crew : 2
  408. Operating Under FAR Part : Part 121
  409. Flight Plan : IFR
  410. Mission : Passenger
  411. Flight Phase : Parked
  412.  
  413. Component
  414.  
  415. Aircraft Component : Cockpit Furnishing
  416. Manufacturer : Boeing
  417. Aircraft Reference : X
  418. Problem : Design
  419.  
  420. Person
  421.  
  422. Reference : 1
  423. Location Of Person.Aircraft : X
  424. Location In Aircraft : Flight Deck
  425. Reporter Organization : Air Carrier
  426. Function.Flight Crew : Pilot Not Flying
  427. Function.Flight Crew : Captain
  428. Qualification.Flight Crew : Air Transport Pilot (ATP)
  429. Qualification.Flight Crew : Instrument
  430. Qualification.Flight Crew : Multiengine
  431. Experience.Flight Crew.Last 90 Days : 428
  432. ASRS Report Number.Accession Number : 1593699
  433.  
  434. Events
  435.  
  436. Anomaly.Aircraft Equipment Problem : Less Severe
  437. Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
  438. Were Passengers Involved In Event : N
  439. When Detected : Pre-flight
  440.  
  441. Assessments
  442.  
  443. Contributing Factors / Situations : Equipment / Tooling
  444. Primary Problem : Equipment / Tooling
  445.  
  446. Narrative: 1
  447.  
  448. ATIS sheet fell through the slot forward of the center pedestal and the blank off plate. We had Maintenance come out to remove it. We discovered 20 other ATIS sheets mixed into the wiring. The aircraft is only six months old. Severe potential fire hazard!
  449.  
  450. Synopsis
  451.  
  452. 737MAX8 Captain reported a slot in the cockpit center pedestal allowed flight documents to slip through and collect on aircraft wire bundles.
  453.  
  454. ACN: 1593021 (7 of 20)
  455.  
  456. Time / Day
  457.  
  458. Date : 201811
  459.  
  460. Place
  461.  
  462. Altitude.AGL.Single Value : 0
  463.  
  464. Aircraft
  465.  
  466. Reference : X
  467. Aircraft Operator : Air Carrier
  468. Make Model Name : B737 Next Generation Undifferentiated
  469. Crew Size.Number Of Crew : 2
  470. Operating Under FAR Part : Part 121
  471. Flight Plan : IFR
  472. Flight Phase : Parked
  473.  
  474. Person
  475.  
  476. Reference : 1
  477. Location Of Person.Aircraft : X
  478. Location In Aircraft : Flight Deck
  479. Reporter Organization : Air Carrier
  480. Function.Flight Crew : Captain
  481. Qualification.Flight Crew : Instrument
  482. Qualification.Flight Crew : Air Transport Pilot (ATP)
  483. Qualification.Flight Crew : Multiengine
  484. Experience.Flight Crew.Total : 21200
  485. Experience.Flight Crew.Last 90 Days : 178
  486. Experience.Flight Crew.Type : 3342
  487. ASRS Report Number.Accession Number : 1593021
  488. Human Factors : Training / Qualification
  489. Human Factors : Confusion
  490.  
  491. Events
  492.  
  493. Anomaly.Deviation - Procedural : Published Material / Policy
  494. Detector.Person : Flight Crew
  495. When Detected : Pre-flight
  496. Result.General : None Reported / Taken
  497.  
  498. Assessments
  499.  
  500. Contributing Factors / Situations : Company Policy
  501. Contributing Factors / Situations : Human Factors
  502. Contributing Factors / Situations : Manuals
  503. Contributing Factors / Situations : Procedure
  504. Primary Problem : Manuals
  505.  
  506. Narrative: 1
  507.  
  508. This was the first flight on a Max for both pilots. Unfamiliarity with flight deck displays led to confusion about display annunciations and switch function. The Flight Manual does not address at least one annunciation, or the controls for the display--or if it does, neither pilot could find the explanation. I have spent literally days looking for an explanation, could not find one, and that is why I wrote this report. It shouldn't be this hard to figure out what I'm looking at.
  509.  
  510. On the First Officer side ND, on the ground only, there is a MAINT annunciation. We both saw it, couldn't find any immediate explanation for it on the ground, and didn't address it until airborne. I researched the FM (Flight Manual) for an explanation, accomplishing a word search of the term MAINT. There are only two references I could find: the overhead MAINT light (a no go item) and the CDS MAINT light (a QRH item). There is no explanation of the ND MAINT annunciation.
  511.  
  512. We spent the entire hour flight trying to find the meaning of this annunciation and came up empty handed. We determined to check it out once we landed (if the light came on again). Sure enough, after parking, the MAINT annunciation came back on the ND display. We called Maintenance to check out the light. We waited to make an ELB entry, unsure if one was required. Turned out, an ELB entry was not required.
  513.  
  514. The mechanic explained the light was part of a menu for maintenance use only on the ground.
  515.  
  516. In addition, there are two selector knobs that are under-explained (i.e., not explained) in the manual, and we were uncertain what their purpose was. One is under the Fuel Flow switch and the other under the MFD/ENG TFR display switch. These knobs don't seem to work in flight. The First Officer offered to hit the SEL function in flight, to test it out, but I thought something irreversible or undesirable might happen (not knowing what we were actually selecting), so we did not try it out in flight. The mechanic later explained SEL on the First Officer side was used on the ground by maintenance to toggle between the maintenance functions. I forgot to ask what my side did, and still don't know.
  517.  
  518. Finally, in the Captain's preflight procedure in the bulletin, it says, "Selector... C". What selector is this referring to? Is this the same selector under the Fuel Flow switch, (which is shown in the MAX panels on the L position, as if that is the normal position?) This is very poorly explained. I have no idea what switch the preflight is talking about, nor do I understand even now what this switch does.
  519.  
  520. I think this entire setup needs to be thoroughly explained to pilots. How can a Captain not know what switch is meant during a preflight setup? Poor training and even poorer documentation, that is how.
  521.  
  522. It is not reassuring when a light cannot be explained or understood by the pilots, even after referencing their flight manuals. It is especially concerning when every other MAINT annunciation means something bad. I envision some delayed departures as conscientious pilots try to resolve the meaning of the MAINT annunciation and which switches are referred to in the setup.
  523.  
  524. Synopsis
  525.  
  526. B737MAX Captain reported confusion regarding switch function and display annunciations related to "poor training and even poorer documentation".
  527.  
  528. ACN: 1593017 (8 of 20)
  529.  
  530. Time / Day
  531.  
  532. Date : 201811
  533.  
  534. Place
  535.  
  536. Altitude.AGL.Single Value : 0
  537.  
  538. Aircraft
  539.  
  540. Reference : X
  541. Aircraft Operator : Air Carrier
  542. Make Model Name : B737 Next Generation Undifferentiated
  543. Flight Phase.Other
  544.  
  545. Person
  546.  
  547. Reference : 1
  548. Location Of Person.Aircraft : X
  549. Location In Aircraft : Flight Deck
  550. Reporter Organization : Air Carrier
  551. Function.Flight Crew : Captain
  552. Qualification.Flight Crew : Air Transport Pilot (ATP)
  553. ASRS Report Number.Accession Number : 1593017
  554. Human Factors : Confusion
  555. Human Factors : Training / Qualification
  556.  
  557. Events
  558.  
  559. Anomaly.Deviation - Procedural : Published Material / Policy
  560. Detector.Person : Flight Crew
  561. When Detected : Pre-flight
  562. Result.General : None Reported / Taken
  563.  
  564. Assessments
  565.  
  566. Contributing Factors / Situations : Aircraft
  567. Contributing Factors / Situations : Manuals
  568. Primary Problem : Manuals
  569.  
  570. Narrative: 1
  571.  
  572. The recently released 737 MAX8 Emergency Airworthiness Directive directs pilots how to deal with a known issue, but it does nothing to address the systems issues with the AOA system.
  573.  
  574. MCAS (Maneuvering Characteristics Augmentation System) is implemented on the 737 MAX to enhance pitch characteristics with flaps UP and at elevated angles of attack. The MCAS function commands nose down stabilizer to enhance pitch characteristics during steep turns with elevated load factors and during flaps up flight at airspeeds approaching stall. MCAS is activated without pilot input and only operates in manual, flaps up flight. The system is designed to allow the flight crew to use column trim switch or stabilizer aisle stand cutout switches to override MCAS input. The function is commanded by the Flight Control computer using input data from sensors and other airplane systems.
  575.  
  576. The MCAS function becomes active when the airplane Angle of Attack exceeds a threshold based on airspeed and altitude. Stabilizer incremental commands are limited to 2.5 degrees and are provided at a rate of 0.27 degrees per second. The magnitude of the stabilizer input is lower at high Mach number and greater at low Mach numbers. The function is reset once angle of attack falls below the Angle of Attack threshold or if manual stabilizer commands are provided by the flight crew. If the original elevated AOA condition persists, the MCAS function commands another incremental stabilizer nose down command according to current aircraft Mach number at actuation.
  577.  
  578. This description is not currently in the 737 Flight Manual Part 2, nor the Boeing FCOM, though it will be added to them soon. This communication highlights that an entire system is not described in our Flight Manual. This system is now the subject of an AD.
  579.  
  580. I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models. The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone--even if the pilots aren't sure what those systems are, what redundancies are in place, and failure modes.
  581.  
  582. I am left to wonder: what else don't I know? The Flight Manual is inadequate and almost criminally insufficient. All airlines that operate the MAX must insist that Boeing incorporate ALL systems in their manuals.
  583.  
  584. Synopsis
  585.  
  586. B737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.
  587.  
  588. ACN: 1590012 (9 of 20)
  589.  
  590. Time / Day
  591.  
  592. Date : 201810
  593. Local Time Of Day : 0001-0600
  594.  
  595. Place
  596.  
  597. Locale Reference.Airport : ZZZ.Airport
  598. State Reference : US
  599. Altitude.AGL.Single Value : 1000
  600.  
  601. Environment
  602.  
  603. Light : Daylight
  604.  
  605. Aircraft
  606.  
  607. Reference : X
  608. ATC / Advisory.Tower : ZZZ
  609. Aircraft Operator : Air Carrier
  610. Make Model Name : B737-800
  611. Crew Size.Number Of Crew : 2
  612. Operating Under FAR Part : Part 121
  613. Flight Plan : IFR
  614. Mission : Passenger
  615. Flight Phase : Takeoff
  616. Airspace.Class C : ZZZ
  617.  
  618. Component
  619.  
  620. Aircraft Component : Autothrottle/Speed Control
  621. Aircraft Reference : X
  622. Problem : Improperly Operated
  623.  
  624. Person
  625.  
  626. Reference : 1
  627. Location Of Person.Aircraft : X
  628. Location In Aircraft : Flight Deck
  629. Reporter Organization : Air Carrier
  630. Function.Flight Crew : Pilot Flying
  631. Function.Flight Crew : Captain
  632. Qualification.Flight Crew : Multiengine
  633. Qualification.Flight Crew : Instrument
  634. Qualification.Flight Crew : Air Transport Pilot (ATP)
  635. Experience.Flight Crew.Last 90 Days : 419
  636. ASRS Report Number.Accession Number : 1590012
  637. Human Factors : Confusion
  638.  
  639. Events
  640.  
  641. Anomaly.Aircraft Equipment Problem : Less Severe
  642. Anomaly.Deviation - Speed : All Types
  643. Anomaly.Deviation - Procedural : Published Material / Policy
  644. Detector.Person : Flight Crew
  645. When Detected : In-flight
  646. Result.Flight Crew : Overcame Equipment Problem
  647.  
  648. Assessments
  649.  
  650. Contributing Factors / Situations : Aircraft
  651. Primary Problem : Aircraft
  652.  
  653. Narrative: 1
  654.  
  655. After 1000 feet I noticed a decrease in aircraft performance. I picked up that the autothrottles were not moving to commanded position even though they were engaged. I'm sure they were set properly for takeoff but not sure when the discrepancy took place. My scan wasn't as well developed since I've only flown the MAX once before. I manually positioned the thrust levers ASAP. This resolved the threat, we were able to increase speed to clean up and continue the climb to 3000 feet.
  656.  
  657. Shortly afterwards I heard about the (other carrier) accident and am wondering if any other crews have experienced similar incidents with the autothrottle system on the MAX? Or I may have made a possible flying mistake which is more likely. The FO (First Officer) was still on his first month and was not able to identify whether it was the aircraft or me that was in error.
  658.  
  659. Synopsis
  660.  
  661. B737-MAX8 Captain reported the autothrottles failed to move to the commanded position during takeoff and climb.
  662.  
  663. ACN: 1587343 (10 of 20)
  664.  
  665. Time / Day
  666.  
  667. Date : 201810
  668.  
  669. Place
  670.  
  671. Altitude.AGL.Single Value : 0
  672.  
  673. Aircraft
  674.  
  675. Reference : X
  676. Aircraft Operator : Air Carrier
  677. Make Model Name : B737 Next Generation Undifferentiated
  678. Crew Size.Number Of Crew : 2
  679. Operating Under FAR Part : Part 121
  680. Flight Plan : IFR
  681. Mission : Passenger
  682. Flight Phase : Taxi
  683.  
  684. Person
  685.  
  686. Reference : 1
  687. Location Of Person.Aircraft : X
  688. Location In Aircraft : General Seating Area
  689. Reporter Organization : Air Carrier
  690. Function.Flight Attendant : Off Duty
  691. Qualification.Flight Attendant : Current
  692. ASRS Report Number.Accession Number : 1587343
  693. Human Factors : Situational Awareness
  694.  
  695. Events
  696.  
  697. Anomaly.Aircraft Equipment Problem : Less Severe
  698. Anomaly.Deviation - Procedural : FAR
  699. Anomaly.Deviation - Procedural : Published Material / Policy
  700. Detector.Person : Passenger
  701. Detector.Person : Flight Attendant
  702. Were Passengers Involved In Event : Y
  703. When Detected : Taxi
  704. Result.General : None Reported / Taken
  705.  
  706. Assessments
  707.  
  708. Contributing Factors / Situations : Aircraft
  709. Primary Problem : Aircraft
  710.  
  711. Narrative: 1
  712.  
  713. I was pass riding this flight on the new 737 Max. From my seat towards the rear of the aircraft, with seats that appear to be higher, it was impossible to see the Flight Attendant perform the safety demo. It was brought to my attention when overhearing a nearby passenger comment that they could not see the demo asking if they were supposed to be able to see it.
  714.  
  715. Synopsis
  716.  
  717. Off duty Flight Attendant reported being unable to see the B737 Max cabin safety demonstration because the passenger seats are too high.
  718.  
  719. ACN: 1583127 (11 of 20)
  720.  
  721. Time / Day
  722.  
  723. Date : 201810
  724. Local Time Of Day : 1801-2400
  725.  
  726. Place
  727.  
  728. Locale Reference.Airport : DEN.Airport
  729. State Reference : CO
  730. Altitude.MSL.Single Value : 7000
  731.  
  732. Environment
  733.  
  734. Flight Conditions : VMC
  735.  
  736. Aircraft
  737.  
  738. Reference : X
  739. ATC / Advisory.Tower : DEN
  740. Aircraft Operator : Air Carrier
  741. Make Model Name : B737-800
  742. Crew Size.Number Of Crew : 2
  743. Operating Under FAR Part : Part 121
  744. Flight Plan : IFR
  745. Flight Phase : Initial Approach
  746. Airspace.Class B : DEN
  747.  
  748. Person
  749.  
  750. Reference : 1
  751. Location Of Person.Aircraft : X
  752. Location In Aircraft : Flight Deck
  753. Reporter Organization : Air Carrier
  754. Function.Flight Crew : Pilot Flying
  755. Function.Flight Crew : Captain
  756. Qualification.Flight Crew : Multiengine
  757. Qualification.Flight Crew : Instrument
  758. Qualification.Flight Crew : Air Transport Pilot (ATP)
  759. Experience.Flight Crew.Total : 18000
  760. ASRS Report Number.Accession Number : 1583127
  761. Human Factors : Situational Awareness
  762.  
  763. Events
  764.  
  765. Anomaly.Deviation - Procedural : Published Material / Policy
  766. Anomaly.Inflight Event / Encounter : Unstabilized Approach
  767. Detector.Person : Flight Crew
  768. When Detected : In-flight
  769. Result.General : None Reported / Taken
  770.  
  771. Assessments
  772.  
  773. Contributing Factors / Situations : Aircraft
  774. Contributing Factors / Situations : Human Factors
  775. Primary Problem : Human Factors
  776.  
  777. Narrative: 1
  778.  
  779. The purpose of this [report] is to explain a situation where I unintentionally used a high rate of descent to recapture a glide path landing in DEN in a 737 MAX. I have flown the MAX a few times [before] but this was the first time I've flown it in a high density altitude airport. The landing was uneventful and I felt like I was in control the entire final approach but the rate of descent was higher than I anticipated or normally use due to my hesitancy to quickly revert from reliance on technology to visual approach procedures. I understand the emphasis on visual approaches in training and safety.
  780.  
  781. After an uneventful flight to DEN we were given a left downwind turn to base for DEN runway 16L outside of LEETS at 7000 feet. It was a clear night so I accepted the visual when offered and slowed appropriately for the final decent. To increase my familiarity of the MAX, prior to top of descent, I briefed and intended to engage ARM III below 5000 feet AGL and set up the HUD to do so. As we neared LEETS I pushed the Approach ARM button (with 7000 feet in the MCP) but my attention was outside and on the flight display system when I made a rookie mistake. I didn't notice that the Approach mode did not arm.
  782.  
  783. I have flown the 737 MAX a few times and was familiar with, what I believe to be, slightly different descent characteristics. Also, I armed the speed brakes but apparently when I did so the handle was slightly past the detent. I don't know if the ARM switch wouldn't engage as a result of this or not? Also I don't know if the Landing Attitude Modifier behaves differently due to the speed brake handle not precisely set in detent? Of course since I had 7000 feet in the MCP as we flew past LEETS I lost vertical path display and in the moment(s) it took to evaluate what was happening, I got high on path.
  784.  
  785. The vertical guidance displays were now unusable so I abandoned the idea of the CAT III practice and adjusted to a high rate of descent to visually get on the PAPI. Since DEN is 5434 feet I rationalized that a higher descent rate was appropriate due to the high density altitude and called "stable" at 1000 feet with a 1200 feet rate of descent but correcting. When I adjusted the throttles, the speed brake green light went to amber and the FO (First Officer) quickly and correctly armed the speed brake. I didn't get enough power in soon enough and ended up getting three reds on the PAPI and a "Glide Slope" announcement to which I adjusted up to regain path. I continued to an uneventful landing.
  786.  
  787. As a result of this situation which happened very quickly, I will 1) recommit to confirming buttons arm when pushed, 2) recommit to confirming the speed brake handle is fully in the arm detent (in addition to the green arm light) 3) react more swiftly to visual methods (or go around) when appropriate when displays don't appear as expected and 4) continue to ensure stabilized approaches or go around as necessary.
  788.  
  789. Synopsis
  790.  
  791. B737 MAX Captain reported an unstabilized approach into DEN due to human factors and aircraft familiarization.
  792.  
  793. ACN: 1583028 (12 of 20)
  794.  
  795. Time / Day
  796.  
  797. Date : 201809
  798.  
  799. Environment
  800.  
  801. Light : Daylight
  802.  
  803. Aircraft
  804.  
  805. Reference : X
  806. Aircraft Operator : Air Carrier
  807. Make Model Name : B737 Next Generation Undifferentiated
  808. Crew Size.Number Of Crew : 2
  809. Operating Under FAR Part : Part 121
  810. Flight Plan : IFR
  811. Mission : Passenger
  812. Nav In Use : FMS Or FMC
  813. Nav In Use : GPS
  814. Flight Phase : Cruise
  815.  
  816. Component
  817.  
  818. Aircraft Component : Powerplant Fuel System
  819. Aircraft Reference : X
  820. Problem : Malfunctioning
  821.  
  822. Person
  823.  
  824. Reference : 1
  825. Location Of Person.Aircraft : X
  826. Location In Aircraft : Flight Deck
  827. Reporter Organization : Air Carrier
  828. Function.Flight Crew : Captain
  829. Function.Flight Crew : Pilot Flying
  830. Qualification.Flight Crew : Instrument
  831. Qualification.Flight Crew : Air Transport Pilot (ATP)
  832. Qualification.Flight Crew : Multiengine
  833. Experience.Flight Crew.Last 90 Days : 420
  834. Experience.Flight Crew.Type : 9000
  835. ASRS Report Number.Accession Number : 1583028
  836. Human Factors : Troubleshooting
  837.  
  838. Events
  839.  
  840. Anomaly.Deviation - Procedural : Weight And Balance
  841. Anomaly.Deviation - Procedural : Published Material / Policy
  842. Anomaly.Inflight Event / Encounter : Fuel Issue
  843. Detector.Person : Flight Crew
  844. When Detected : In-flight
  845. Result.General : None Reported / Taken
  846.  
  847. Assessments
  848.  
  849. Contributing Factors / Situations : Aircraft
  850. Primary Problem : Aircraft
  851.  
  852. Narrative: 1
  853.  
  854. My concern is that some MAX 8 aircraft are burning significantly more fuel than what is calculated on the Dispatch release. Perhaps the fuel bias on these aircraft needs to be re-evaluated. On this particular flight, the burn rate was so high that the Pilots referred to the MAX AOM (Aircraft Operator Manual) to look up what constitutes a fuel leak. Our flight plan fuel was for a burn of 21,600 pounds from push to touchdown. Our actual burn was 22,900 pounds (actual fuel load of 28,100 at push minus our 5,200 pounds at touchdown. We pulled into the gate with 5,000 pounds). This was 1,300 pounds more fuel burned than planned.
  855.  
  856. Other than a direct to ZZZ shortly after departing ZZZ1, we flew the flight planned altitude and routing. I also slowed to .76 Mach a couple of times for pockets of turbulence. Winds were close to flight plan and there was minimal off-course maneuvering to avoid a couple of buildups. Based on another long MAX 8 flights where we burned more than flight plan, I kept a detailed fuel log this flight. We pushed with 700 pounds fuel more than flight plan. Fifty minutes into the flight we were plus 500 pounds of fuel over flight plan.
  857.  
  858. At 1+20 into the flight, we were plus 300 pounds. At 1+49 we were at the calculated flight plan fuel. Eleven minutes later we were at -300 pounds from flight planned fuel. Around that point we contacted Dispatch through ACARS to let them know our fuel was not trending well. We got into the books and ran the Fuel Leak QRH just in case. The flight attendants scanned the engines and the wings. Everything checked out ok with respect to the QRH, except we had an unusual fuel burn. Dispatch, the FO (First Officer), and I came up with a plan to update our status over ZZZ and also over ZZZ2. At 2+11, we were -500 pounds for fuel. The fuel trend stayed constant at -500 pounds from flight plan for the duration of the flight from that point onward.
  859.  
  860. The weather was VFR at ZZZ3 so we elected to continue over ZZZ and also ZZZ2. I was concerned as my calculations had us landing with less than 5,000 pounds. Dispatch said his calculations had us landing with 6,300 pounds. Dispatch was very helpful throughout the majority of the flight providing updates on weather and asking our fuel status. Dispatch also asked that I call him after landing. We landed uneventfully other than fuel being 900 pounds lower than the Dispatch Release after flying the flight plan. After landing, I walked around the aircraft and went into the main gear well. My concern was a potential fuel leak. I noted none nor any abnormal fuel smells.
  861.  
  862. After that, I called Dispatch and we had a conference call with Maintenance. The Maintenance Controller said they were noting that several MAX 8 aircraft are not fuel efficient. He said they think the Boeing-recommended engine cleaning cycle is not frequent enough. I was told during this call that when the LEAP engines are dirty they lose all of their efficiency. If this is the case, shouldn't the fuel bias on these aircraft be adjusted accordingly? From now on, I am going to plan on an extra 400 pounds per hour of fuel on each MAX 8 I fly on a leg longer than two and a half hours.
  863.  
  864. Synopsis
  865.  
  866. B737 MAX-8 Captain reported the engine fuel burn was higher than expected.
  867.  
  868. ACN: 1572630 (13 of 20)
  869.  
  870. Time / Day
  871.  
  872. Date : 201808
  873. Local Time Of Day : 1201-1800
  874.  
  875. Place
  876.  
  877. Locale Reference.Airport : ZZZ.Airport
  878. State Reference : US
  879. Altitude.AGL.Single Value : 0
  880.  
  881. Environment
  882.  
  883. Light : Daylight
  884.  
  885. Aircraft
  886.  
  887. Reference : X
  888. Aircraft Operator : Air Carrier
  889. Make Model Name : B737-800
  890. Crew Size.Number Of Crew : 2
  891. Operating Under FAR Part : Part 121
  892. Flight Plan : IFR
  893. Mission : Passenger
  894. Flight Phase : Taxi
  895.  
  896. Component
  897.  
  898. Aircraft Component : Engine Starting System
  899. Aircraft Reference : X
  900. Problem : Improperly Operated
  901.  
  902. Person : 1
  903.  
  904. Reference : 1
  905. Location Of Person.Aircraft : X
  906. Location In Aircraft : Flight Deck
  907. Reporter Organization : Air Carrier
  908. Function.Flight Crew : Pilot Flying
  909. Function.Flight Crew : Captain
  910. Qualification.Flight Crew : Air Transport Pilot (ATP)
  911. Qualification.Flight Crew : Instrument
  912. Qualification.Flight Crew : Multiengine
  913. Experience.Flight Crew.Last 90 Days : 354
  914. ASRS Report Number.Accession Number : 1572630
  915. Human Factors : Other / Unknown
  916.  
  917. Person : 2
  918.  
  919. Reference : 2
  920. Location Of Person.Aircraft : X
  921. Location In Aircraft : Flight Deck
  922. Reporter Organization : Air Carrier
  923. Function.Flight Crew : Pilot Not Flying
  924. Function.Flight Crew : First Officer
  925. Qualification.Flight Crew : Air Transport Pilot (ATP)
  926. Qualification.Flight Crew : Multiengine
  927. Qualification.Flight Crew : Instrument
  928. ASRS Report Number.Accession Number : 1573224
  929. Human Factors : Other / Unknown
  930.  
  931. Events
  932.  
  933. Anomaly.Aircraft Equipment Problem : Less Severe
  934. Anomaly.Deviation - Procedural : Published Material / Policy
  935. Detector.Automation : Aircraft Other Automation
  936. When Detected : Taxi
  937. Result.Flight Crew : Overcame Equipment Problem
  938.  
  939. Assessments
  940.  
  941. Contributing Factors / Situations : Aircraft
  942. Contributing Factors / Situations : Human Factors
  943. Contributing Factors / Situations : Manuals
  944. Primary Problem : Human Factors
  945.  
  946. Narrative: 1
  947.  
  948. We were pushing back from the gate in a MAX 8 and were starting the number 2 engine. The FO (First Officer) configured the air conditioning panel before the tick on the EGT was gone, causing the EEC (Electronic Engine Controller) to abort the engine start. Once we saw the white box flashing, we aborted the engine start, reviewed the QRC, and followed the QRH guidance. After confirming with Maintenance (and a review of the [operation manual]) a second successful start was made.
  949.  
  950. We conducted a briefing about the MAX engine start and the items that we were going to see, and time limits associated during our normal preflight briefings. I was very surprised when the aborted start happened due to the fact that we had reviewed the start process. I will continue to brief the engine start procedures with a bigger emphasis on the EGT roll back.
  951.  
  952. Narrative: 2
  953.  
  954. [Report narrative contained no additional information.]
  955.  
  956. Synopsis
  957.  
  958. B737 MAX-8 crew reported failing to follow the engine start procedure resulting in an aborted engine start.
  959.  
  960. ACN: 1568887 (14 of 20)
  961.  
  962. Time / Day
  963.  
  964. Date : 201808
  965. Local Time Of Day : 1801-2400
  966.  
  967. Place
  968.  
  969. Locale Reference.Airport : ZZZ.Airport
  970. State Reference : US
  971. Altitude.AGL.Single Value : 0
  972.  
  973. Environment
  974.  
  975. Flight Conditions : VMC
  976. Light : Night
  977.  
  978. Aircraft
  979.  
  980. Reference : X
  981. ATC / Advisory.Ramp : ZZZ
  982. Aircraft Operator : Air Carrier
  983. Make Model Name : B737-800
  984. Crew Size.Number Of Crew : 2
  985. Operating Under FAR Part : Part 121
  986. Flight Plan : IFR
  987. Mission : Passenger
  988. Flight Phase : Taxi
  989.  
  990. Person
  991.  
  992. Reference : 1
  993. Location Of Person.Aircraft : X
  994. Location In Aircraft : Flight Deck
  995. Reporter Organization : Air Carrier
  996. Function.Flight Crew : Pilot Flying
  997. Function.Flight Crew : Captain
  998. Qualification.Flight Crew : Air Transport Pilot (ATP)
  999. Experience.Flight Crew.Total : 11000
  1000. ASRS Report Number.Accession Number : 1568887
  1001. Human Factors : Situational Awareness
  1002.  
  1003. Events
  1004.  
  1005. Anomaly.Conflict : Ground Conflict, Critical
  1006. Detector.Person : Flight Crew
  1007. When Detected : Taxi
  1008. Result.Flight Crew : Took Evasive Action
  1009.  
  1010. Assessments
  1011.  
  1012. Contributing Factors / Situations : Human Factors
  1013. Primary Problem : Human Factors
  1014.  
  1015. Narrative: 1
  1016.  
  1017. Upon taxi into gate, [guidance system] was active, both pilots cleared ramp area. Approximately 20 ft remaining FO yells for me to stop. I immediately stopped aircraft and FO [advised] fueler was backing up into our safety zone. We were in a B737 MAX with the split winglets and thus the clearance provided below the wingtip was considerably less. After speaking with ramp [personnel] who reviewed the ramp video, I believe the monitoring and quick response of the FO averted possible damage or impact to aircraft. Ramp fueler personnel inattentive to position on ramp. [Not] all ramp personnel may be accustomed to the 737 MAX winglet design and the increased clearance required. Training for this may be beneficial.
  1018.  
  1019. Synopsis
  1020.  
  1021. B737-800 Captain reported making a sudden stop to avoid a collision with a fuel truck on the ramp.
  1022.  
  1023. ACN: 1565207 (15 of 20)
  1024.  
  1025. Time / Day
  1026.  
  1027. Date : 201808
  1028.  
  1029. Place
  1030.  
  1031. Altitude.MSL.Single Value : 33000
  1032.  
  1033. Environment
  1034.  
  1035. Flight Conditions : VMC
  1036.  
  1037. Aircraft
  1038.  
  1039. Reference : X
  1040. Aircraft Operator : Air Carrier
  1041. Make Model Name : B737 Next Generation Undifferentiated
  1042. Crew Size.Number Of Crew : 2
  1043. Operating Under FAR Part : Part 121
  1044. Flight Plan : IFR
  1045. Mission : Passenger
  1046. Flight Phase : Cruise
  1047.  
  1048. Component : 1
  1049.  
  1050. Aircraft Component : Data Transmission and Automatic Calling
  1051. Aircraft Reference : X
  1052. Problem : Malfunctioning
  1053.  
  1054. Component : 2
  1055.  
  1056. Aircraft Component : Other Documentation
  1057. Aircraft Reference : X
  1058.  
  1059. Person
  1060.  
  1061. Reference : 1
  1062. Location Of Person.Aircraft : X
  1063. Location In Aircraft : Flight Deck
  1064. Reporter Organization : Air Carrier
  1065. Function.Flight Crew : Pilot Flying
  1066. Function.Flight Crew : Captain
  1067. Qualification.Flight Crew : Instrument
  1068. Qualification.Flight Crew : Multiengine
  1069. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1070. Experience.Flight Crew.Last 90 Days : 50
  1071. Experience.Flight Crew.Type : 2978
  1072. ASRS Report Number.Accession Number : 1565207
  1073.  
  1074. Events
  1075.  
  1076. Anomaly.Aircraft Equipment Problem : Less Severe
  1077. Detector.Person : Flight Crew
  1078. When Detected : In-flight
  1079. Result.Flight Crew : Overcame Equipment Problem
  1080.  
  1081. Assessments
  1082.  
  1083. Contributing Factors / Situations : Aircraft
  1084. Primary Problem : Aircraft
  1085.  
  1086. Narrative: 1
  1087.  
  1088. At cruise flight, our Wi-Fi stopped working. I then saw that I was unable to access the Pilot Mobile app. Since I do not routinely copy the flight plan to iBook or acrobat (we are not required to do this), I was unable to access the flight plan. I've lost Wi-Fi before but not had this problem. Maybe it's a 737max thing. My First Officer had a copy on iBook and airdropped it to me. Later we were able to restore the Wi-Fi and I could login to pilot mobile but the [flight plan] was not there anymore.
  1089.  
  1090. Synopsis
  1091.  
  1092. B737NG Captain reported the aircraft Wi-Fi was not working in cruise, which affected the ability to access the flight plan on the iPad.
  1093.  
  1094. ACN: 1560763 (16 of 20)
  1095.  
  1096. Time / Day
  1097.  
  1098. Date : 201807
  1099. Local Time Of Day : 0601-1200
  1100.  
  1101. Place
  1102.  
  1103. Locale Reference.Airport : BWI.Airport
  1104. State Reference : MD
  1105. Altitude.MSL.Single Value : 17000
  1106.  
  1107. Environment
  1108.  
  1109. Light : Daylight
  1110.  
  1111. Aircraft
  1112.  
  1113. Reference : X
  1114. ATC / Advisory.TRACON : PCT
  1115. Aircraft Operator : Air Carrier
  1116. Make Model Name : B737-800
  1117. Crew Size.Number Of Crew : 2
  1118. Operating Under FAR Part : Part 121
  1119. Flight Plan : IFR
  1120. Mission : Passenger
  1121. Nav In Use : FMS Or FMC
  1122. Nav In Use : GPS
  1123. Flight Phase : Climb
  1124. Route In Use.SID : TERPZ 6
  1125. Airspace.Class E : PCT
  1126.  
  1127. Person
  1128.  
  1129. Reference : 1
  1130. Location Of Person.Aircraft : X
  1131. Location In Aircraft : Flight Deck
  1132. Reporter Organization : Air Carrier
  1133. Function.Flight Crew : Pilot Not Flying
  1134. Function.Flight Crew : First Officer
  1135. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1136. Qualification.Flight Crew : Multiengine
  1137. Qualification.Flight Crew : Instrument
  1138. Experience.Flight Crew.Last 90 Days : 230
  1139. Experience.Flight Crew.Type : 1600
  1140. ASRS Report Number.Accession Number : 1560763
  1141.  
  1142. Events
  1143.  
  1144. Anomaly.Deviation - Altitude : Crossing Restriction Not Met
  1145. Anomaly.Deviation - Procedural : Published Material / Policy
  1146. Detector.Person : Flight Crew
  1147. When Detected : In-flight
  1148. Result.General : None Reported / Taken
  1149.  
  1150. Assessments
  1151.  
  1152. Contributing Factors / Situations : Airspace Structure
  1153. Contributing Factors / Situations : Aircraft
  1154. Primary Problem : Airspace Structure
  1155.  
  1156. Narrative: 1
  1157.  
  1158. I have flown out of BWI on the TERPZ 6 to either OTTTO or RAMAY the last three weeks. Each time I have flown a 737-800 or MAX8. The first two times in the 737-800 we had to adjust our climb out speed below the ECON Schedule (which was around 300) to make the 17,000ft., or above restriction at FOXHL (FMC warnings were received "unable next altitude"). In the 737 MAX8, it was less. So by starting early to adjust our profile we were able to meet the restriction. It appears like a trend that heavy 737-800 aircraft in summertime will have a hard time meeting the climb restriction, and if you do not catch it soon enough you may not make the FOXHL restriction.
  1159.  
  1160. [Suggestion].In the Departure Section of the SID add a note. If departing the TERPZ 6 to OTTTO or RAMAY be aware that high gross weights and hot temperatures may not allow you to climb via the FMC ECON Speed and meet the 17,000ft., or above restriction at FOXHL.
  1161.  
  1162. Synopsis
  1163.  
  1164. B737-800 First Officer reported that departing out of BWI, the aircraft is unable to make the 17000ft. restriction at FOXHL on TERPZ 6 departure.
  1165.  
  1166. ACN: 1555013 (17 of 20)
  1167.  
  1168. Time / Day
  1169.  
  1170. Date : 201806
  1171.  
  1172. Place
  1173.  
  1174. Locale Reference.Airport : ZZZ.Airport
  1175. State Reference : US
  1176. Altitude.AGL.Single Value : 0
  1177.  
  1178. Aircraft
  1179.  
  1180. Reference : X
  1181. Aircraft Operator : Air Carrier
  1182. Make Model Name : B737 Undifferentiated or Other Model
  1183. Crew Size.Number Of Crew : 2
  1184. Operating Under FAR Part : Part 121
  1185. Flight Plan : IFR
  1186. Mission : Passenger
  1187. Nav In Use : FMS Or FMC
  1188. Flight Phase : Parked
  1189.  
  1190. Person
  1191.  
  1192. Reference : 1
  1193. Location Of Person.Aircraft : X
  1194. Location In Aircraft : Flight Deck
  1195. Reporter Organization : Air Carrier
  1196. Function.Flight Crew : First Officer
  1197. Function.Flight Crew : Pilot Not Flying
  1198. Qualification.Flight Crew : Instrument
  1199. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1200. Qualification.Flight Crew : Multiengine
  1201. Experience.Flight Crew.Total : 10861
  1202. Experience.Flight Crew.Type : 1660
  1203. ASRS Report Number.Accession Number : 1555013
  1204. Human Factors : Human-Machine Interface
  1205. Human Factors : Training / Qualification
  1206.  
  1207. Events
  1208.  
  1209. Anomaly.Deviation - Procedural : Published Material / Policy
  1210. Anomaly.Inflight Event / Encounter : Weather / Turbulence
  1211. Detector.Person : Flight Crew
  1212. When Detected : Pre-flight
  1213. Result.General : None Reported / Taken
  1214.  
  1215. Assessments
  1216.  
  1217. Contributing Factors / Situations : Company Policy
  1218. Contributing Factors / Situations : Human Factors
  1219. Contributing Factors / Situations : Manuals
  1220. Contributing Factors / Situations : Procedure
  1221. Primary Problem : Company Policy
  1222.  
  1223. Narrative: 1
  1224.  
  1225. I had my first flight on the Max [to] ZZZ1. We found out we were scheduled to fly the aircraft on the way to the airport in the limo. We had a little time [to] review the essentials in the car. Otherwise we would have walked onto the plane cold.
  1226.  
  1227. My post flight evaluation is that we lacked the knowledge to operate the aircraft in all weather and aircraft states safely. The instrumentation is completely different - My scan was degraded, slow and labored having had no experience w/ the new ND (Navigation Display) and ADI (Attitude Director Indicator) presentations/format or functions (manipulation between the screens and systems pages were not provided in training materials. If they were, I had no recollection of that material).
  1228.  
  1229. We were unable to navigate to systems pages and lacked the knowledge of what systems information was available to us in the different phases of flight. Our weather radar competency was inadequate to safely navigate significant weather on that dark and stormy night. These are just a few issues that were not addressed in our training.
  1230.  
  1231. I recommend the following to help crews w/ their introductory flight on the Max:
  1232. Email notification the day before the flight (the email should include: Links - Training Video, PSOB and QRG and all relevant updates/FAQ's)
  1233. SME (Subject Matter Expert) Observer - the role of the SME is to introduce systems navigation, display management, answer general questions and provide standardized best practices to the next generation aircraft.
  1234.  
  1235. Additionally, the SME will collect de-identified data to provide to the training department for analysis and dissemination to the line pilots regarding FAQs and know systems differences as well best practices in fly the new model aircraft.
  1236.  
  1237. Synopsis
  1238.  
  1239. B737 MAX First Officer reported feeling unprepared for first flight in the MAX, citing inadequate training.
  1240.  
  1241. ACN: 1550073 (18 of 20)
  1242.  
  1243. Time / Day
  1244.  
  1245. Date : 201806
  1246.  
  1247. Aircraft
  1248.  
  1249. Reference : X
  1250. Aircraft Operator : Air Carrier
  1251. Make Model Name : B737 Next Generation Undifferentiated
  1252. Crew Size.Number Of Crew : 2
  1253. Operating Under FAR Part : Part 121
  1254. Flight Plan : IFR
  1255. Mission : Passenger
  1256. Nav In Use : FMS Or FMC
  1257. Flight Phase : Cruise
  1258.  
  1259. Component
  1260.  
  1261. Aircraft Component : Air/Ground Communication
  1262. Aircraft Reference : X
  1263. Problem : Design
  1264.  
  1265. Person
  1266.  
  1267. Reference : 1
  1268. Location Of Person : Company
  1269. Reporter Organization : Air Carrier
  1270. Function.Maintenance : Other / Unknown
  1271. ASRS Report Number.Accession Number : 1550073
  1272. Human Factors : Communication Breakdown
  1273. Communication Breakdown.Party1 : Maintenance
  1274. Communication Breakdown.Party2 : Flight Crew
  1275.  
  1276. Events
  1277.  
  1278. Anomaly.Aircraft Equipment Problem : Less Severe
  1279. Anomaly.Deviation - Procedural : Published Material / Policy
  1280. Detector.Person : Maintenance
  1281. When Detected : In-flight
  1282. Result.General : None Reported / Taken
  1283.  
  1284. Assessments
  1285.  
  1286. Contributing Factors / Situations : Aircraft
  1287. Contributing Factors / Situations : Equipment / Tooling
  1288. Primary Problem : Ambiguous
  1289.  
  1290. Narrative: 1
  1291.  
  1292. Ever since the 737MAX, it seems most 737 controllers are not getting ACARS messages or Electronic Logbook write-ups the crew sends. The messages are not coming through on Maintenance Control ACARS/ELB page or through the Maintenance Control's alert manager application.
  1293.  
  1294. Yesterday on a flight, I received a call from dispatch asking if I could answer the crew. Since I had not received any messages and no other controllers had either we were in the dark. Dispatcher gave me the info I proceeded to reply to Captain's inquiry, also telling him to message both dispatch and Maintenance Control, as we were not receiving the messages from him. We never got a response, but dispatch called and said Captain received our message and problem was resolved.
  1295.  
  1296. After this situation, I decided to try and test it out on another aircraft, which had just arrived in our base. I sent a test log page. Again, we did not receive any pop up on Maintenance Control [page] or Maintenance Control's alert manager informing us of the write-up.
  1297.  
  1298. Synopsis
  1299.  
  1300. Maintenance personnel reported that on Boeing 737MAX, Maintenance Control is not receiving ACARS or Electronic Logbook write-ups the flight crew sends.
  1301.  
  1302. ACN: 1538699 (19 of 20)
  1303.  
  1304. Time / Day
  1305.  
  1306. Date : 201804
  1307.  
  1308. Place
  1309.  
  1310. Locale Reference.ATC Facility : ZZZ.TRACON
  1311. State Reference : US
  1312. Relative Position.Distance.Nautical Miles : 15
  1313. Altitude.MSL.Single Value : 3000
  1314.  
  1315. Environment
  1316.  
  1317. Flight Conditions : VMC
  1318.  
  1319. Aircraft
  1320.  
  1321. Reference : X
  1322. ATC / Advisory.TRACON : ZZZ
  1323. Aircraft Operator : Air Carrier
  1324. Make Model Name : B737 Undifferentiated or Other Model
  1325. Crew Size.Number Of Crew : 2
  1326. Operating Under FAR Part : Part 121
  1327. Flight Plan : IFR
  1328. Mission : Passenger
  1329. Flight Phase : Initial Approach
  1330. Airspace.Class B : ZZZ
  1331.  
  1332. Person : 1
  1333.  
  1334. Reference : 1
  1335. Location Of Person.Aircraft : X
  1336. Location In Aircraft : Flight Deck
  1337. Reporter Organization : Air Carrier
  1338. Function.Flight Crew : First Officer
  1339. Function.Flight Crew : Pilot Not Flying
  1340. Qualification.Flight Crew : Instrument
  1341. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1342. Qualification.Flight Crew : Multiengine
  1343. Experience.Flight Crew.Last 90 Days : 496
  1344. Experience.Flight Crew.Type : 2200
  1345. ASRS Report Number.Accession Number : 1538699
  1346. Human Factors : Situational Awareness
  1347. Human Factors : Human-Machine Interface
  1348. Human Factors : Training / Qualification
  1349. Human Factors : Distraction
  1350.  
  1351. Person : 2
  1352.  
  1353. Reference : 2
  1354. Location Of Person.Aircraft : X
  1355. Location In Aircraft : Flight Deck
  1356. Reporter Organization : Air Carrier
  1357. Function.Flight Crew : Captain
  1358. Function.Flight Crew : Pilot Flying
  1359. Qualification.Flight Crew : Multiengine
  1360. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1361. Qualification.Flight Crew : Instrument
  1362. Experience.Flight Crew.Last 90 Days : 327
  1363. ASRS Report Number.Accession Number : 1538699
  1364. Human Factors : Troubleshooting
  1365. Human Factors : Confusion
  1366. Human Factors : Human-Machine Interface
  1367.  
  1368. Events
  1369.  
  1370. Anomaly.Deviation - Altitude : Overshoot
  1371. Anomaly.Deviation - Track / Heading : All Types
  1372. Anomaly.Deviation - Procedural : Clearance
  1373. Detector.Automation : Aircraft Other Automation
  1374. Detector.Person : Flight Crew
  1375. When Detected : In-flight
  1376. Result.Flight Crew : FLC Overrode Automation
  1377. Result.Flight Crew : Became Reoriented
  1378. Result.Air Traffic Control : Provided Assistance
  1379.  
  1380. Assessments
  1381.  
  1382. Contributing Factors / Situations : Aircraft
  1383. Contributing Factors / Situations : Company Policy
  1384. Contributing Factors / Situations : Human Factors
  1385. Primary Problem : Aircraft
  1386.  
  1387. Narrative: 1
  1388.  
  1389. While on a 300 degree intercept heading, at an assigned altitude of 3000 feet, autopilot engaged, we received clearance "Maintain 3000 ft until established, cleared for the ILS Approach", and were handed over to the Tower. The pilot flying "armed" VOR/LOC, which was verified on the FMA (Flight Mode Annunciator). Approaching the extended centerline of the runway, the pilot flying determined that VOR/LOC had failed to "capture" and was overshooting the final. The pilot flying then made immediate correction back toward centerline via manual input with the control yoke, which disengaged the autopilot in all axes. The pilot flying noted there was no ILS "raw data" presented on his EADI (Electronic Attitude Direction Indicator). Pilot not flying noted he did have CDI (Coursed Deviation Indicator) and glideslope pointers, but did not have VOR/LOC capture yet. Both pilot flying and pilot not flying verified that proper frequencies and inbound courses were set correctly.
  1390.  
  1391. The pilot flying had the runway in sight visually at that point and continued hand flying toward the runway. The pilot not flying's FMA then "captured" VOR/LOC, while pilot flying's remained in "arm". At that time we were outside of the Final Approach Fix. We then received instruction from Final Monitor to climb back to 3000 feet. The pilot flying immediately returned to altitude, while maintaining centerline track to the runway visually. In the distraction, we had inadvertently descended to approximately 2450 feet. Inside of the Final Approach Fix, pilot flying set and descended to 2700 feet. Pilot not flying's FMA remained in VOR/LOC with glideslope pointer descending the scale toward the "centered" position, while pilot flying's "raw data" indications remained blank, with VOR/LOC "armed" on his FMA. At, or just prior to, ZZZZZ at 2700 feet, LOC and glideslope indications suddenly appeared, and VOR/LOC captured on the pilot flying's FMA. Pilot flying selected APP mode on the MCP (Mode Control Panel). Glideslope immediately "captured" on the pilot flying's FMA, and indications remained normal without further anomaly. Approach and landing were made on without incident.
  1392.  
  1393. Contributing factors were this was the first flight of a morning trip. Also both pilots first flight in MAX aircraft so there was a lot of looking around for information that has become instinctual in the NG. The weather was ragged SCT-BKN layer between 3000-3200 feet. More time in the MAX aircraft would be helpful. Time spent looking for information on redesigned display layout was definitely a distraction. I have never seen such a disparity between Captain and First Officer instrumentation like we experienced, where one side has good data and the other has none (assuming both are tuned/setup identically, which ours were). I'm not sure if this issue is MAX specific. As the pilot monitoring, I should have done a better job monitoring our altitude, especially after the autopilot was disconnected. I became too distracted by the problem and trying to quickly correct it. I should have recognized and called out the altitude deviance.
  1394.  
  1395. Narrative: 2
  1396.  
  1397. [Report narrative contained no additional information.]
  1398.  
  1399. Synopsis
  1400.  
  1401. B737 MAX pilots reported flying through the final approach course and descending below published altitudes due to confusion with the new style instrument displays.
  1402.  
  1403. ACN: 1517486 (20 of 20)
  1404.  
  1405. Time / Day
  1406.  
  1407. Date : 201802
  1408. Local Time Of Day : 1201-1800
  1409.  
  1410. Place
  1411.  
  1412. Locale Reference.Airport : ZZZ.Airport
  1413. State Reference : US
  1414. Altitude.AGL.Single Value : 0
  1415.  
  1416. Environment
  1417.  
  1418. Light : Daylight
  1419.  
  1420. Aircraft
  1421.  
  1422. Reference : X
  1423. Aircraft Operator : Air Carrier
  1424. Make Model Name : B737 Undifferentiated or Other Model
  1425. Crew Size.Number Of Crew : 2
  1426. Operating Under FAR Part : Part 121
  1427. Flight Plan : IFR
  1428. Mission : Passenger
  1429. Flight Phase : Taxi
  1430.  
  1431. Person
  1432.  
  1433. Reference : 1
  1434. Location Of Person.Aircraft : X
  1435. Location In Aircraft : Flight Deck
  1436. Reporter Organization : Air Carrier
  1437. Function.Flight Crew : Pilot Flying
  1438. Function.Flight Crew : Captain
  1439. Qualification.Flight Crew : Air Transport Pilot (ATP)
  1440. ASRS Report Number.Accession Number : 1517486
  1441. Human Factors : Communication Breakdown
  1442. Human Factors : Training / Qualification
  1443.  
  1444. Events
  1445.  
  1446. Anomaly.Deviation - Procedural : Published Material / Policy
  1447. Anomaly.Ground Event / Encounter : Other / Unknown
  1448. Detector.Person : Flight Crew
  1449. When Detected : Aircraft In Service At Gate
  1450. When Detected : Taxi
  1451.  
  1452. Assessments
  1453.  
  1454. Contributing Factors / Situations : Company Policy
  1455. Contributing Factors / Situations : Airport
  1456. Contributing Factors / Situations : Procedure
  1457. Contributing Factors / Situations : Human Factors
  1458. Primary Problem : Procedure
  1459.  
  1460. Narrative: 1
  1461.  
  1462. As we contacted the Pushback Driver for the required exchange of call outs, we finished running the Before Pushback Checklist. The First Officer and I, and Company Dispatcher doing his annual qualification on the jumpseat, were all listening on the Flight interphone to the exchange between the Pushback Driver and me. All call outs were normal up to the pushback call for "Brakes Set". Once the return reply "Brakes Set" was said by me, at that second the communication plugs were pulled and the communications ended. All three of us in the cockpit heard the headset connection plugs pulled out along with the door shut. I also watched the Ramp Agent walk away with the box in hand.
  1463.  
  1464. This was very disturbing because we were starting the new 737 MAX engines, and number 2 was not stable and running yet. I was hoping for them to stay until we cleared them off, as per procedure. They all started to walk off without even any hand signals. I opened my window, and with number 1 still shut down, I got the attention of the nearby Wing Walker, and asked him to tell the pushback to "hook back up". After enduring their looks as if I had asked them to do something insane, they hooked back up. At this point all three of us in the cockpit listened to what I could only call a cover up for their poor and improper adherence to our procedures.
  1465.  
  1466. We didn't have any communication problems during this push; it was crystal clear, all up to this re-plug in. It was still very clear; however, every time I made a call or statement on the interphone, it was followed by the pushback saying "can you hear me". I changed the pace of my calls, different intervals, and was never interrupted, just the reply, "can you hear me" after each of my responses. You could tell they were making a joke out of this. I stated on the intercom that this entire pushback is so wrong, and their attitudes showed they don't care. "I will write this up, and this activity will stop".
  1467.  
  1468. After my comments, he responded in a manner that showed he heard me just fine. All three of us in the cockpit listened and observed this low moment in communications intended for Safety. The other two Crew Members are willing to verify this report. This type of unsafe, anti-procedure behavior cannot be tolerated. This is becoming a nation-wide trend, with this being one of the worst examples. I'm sure excuses will be made concerning poor communications involving equipment. I will not buy that excuse in this example. The attitudes on the Ramp came through loud and clear on this day that they do not buy into our Company procedures.
  1469.  
  1470. Synopsis
  1471.  
  1472. A pilot reported a tug driver and ramp crew did not follow proper procedures during pushback.
  1473.  
  1474.  
  1475.  
  1476.  
  1477. v2.9
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