1. Title:Hydraulicsystem:crossedpressure lines.

Whiletroubleshootingthecauseoftwoprevious replacementsofthe hydraulicsystemreservoirpressurizationmanifold,Maintenancefoundthat"crisscrossed"pneumatic pressurelineswerepreventingthe actionoftheBluehydraulicsystem.

After discovering thatweweregoing toinstall[anA-319's] hydraulicpressure manifoldfor thethird time,Idecided tofigure outwhythefolds werenotpressurizing theBlue hydraulicreservoir to50PSI.hoursoftroubleshooting theproblem, Ifound thattheleft engine.supply lineintheleft wheel well...wasconnected toa"tee" [fittinthatsuppliesallthreehydraulicreservoirstherebybypassingthe[premanifoldcompletelyandprobably over-pressurizing thereservoirs.

TheBluesystempneumaticsupplyline(goingtothehydraulicreservoir)wasconnectedtoa"union"[fitting], whichisthemanifold supply connectionfromtheleftenginetherebynever supplyingpneumatic pressure totheBluereservoir.Sothelineswerecrisscrossed.

Both "B"nutswillfit oneitherconnectionand there isplenty ofroomfor thelinestocrossandnotchafe onanything. Itappeared thatneither linehadbeenreplaced....WhenanAirbus comesintothehangar,a low-pressure check ofeach Green,Yellow, and Blue hydraulicreservoir's head pressure isperformedusingground serviceair.AlthoughtheBluereservoir'sheadpressure wasabovethe22PSIthatsetsoffwarnings inthecockpit,itwasnotpossible toincreasetheheadpressure byapplying serviceairtoseeifthereservoirpressurizationmanifold wasfunctioning.

WhentheBlueheadpressure didnotrespond, thethoughtwasthatthemanifoldwasagainatfault.Theaircrafthadbeenflyingforsometimewiththelinescrossed, butsincetheBlueHydraulic Reservoir headpressure neverwentbelow22PSI,nodiscrepancieswerenoted.Maintenance history showed theaircraftdidhavehydraulicissues withtheGreenandYellow systemsoozing hydraulic fluid,butthosediscrepancieswereprobablycausedbyhighreservoirhead pressuresfrom thecrossedpneumatic supplylines.

QUESTION; What aretheethical implicationsofnotlookingfortherootissuesbehindrecurringmaintenanceproblems?

2. Afteranunexpected"hardbank"resultedinahardlanding,anERJ145crewdiscoveredthaticingmayhavebeenthecause.

ATC...descendedusto2,000feetandvectored usforthe approach.Wewerehavingalittleproblempicking upthelocalizer; however,wefinally gotastrongsignalbeforetheFAFanddecidedtoflytheapproach....TheCaptain called,"Visual" andIsaid,"Landing."

I triedtoturnofftheautopilotandhadahardtimegettingtheautopilotwarningoff.TheCaptaincalled, "Speed."Ihadgotten slowbyabout3-4knotsandwewereabout200feetofftheground.Isaid,"Correcting"andaddedpowerandhadnoissuefromthere.We crossedthethresholdandIstarted mycrosswindcorrectionandthat iswhentheairplanetookahardbanktotheright.

TheCaptainandIdideverything wecould togettheairplane ontheground.Thelanding washardbutwedecided thattheplane wasable to taxiin.Weaskedtoholdshortofthecenterrunwaytocollectourselves,talktotheFlightAttendant,andresume thetaxi."RudderINOP" displayed ontheEICAS duringtaxiin.Wegot to thegateanddeplanedthenstartedmaking phonecallstoreporttherudderandhardlanding.

After thatwasdone, a rampagentcameupandletusknowthatt)limitedwingdamage.We both wentoutsidetoseeanditwasthena considerableloadoficebuiltuponallleading edgesandenginean

QUESTION;Howcanpilots usethecabincrewasaItheirsensesoutside oftheflightdeck?

3. ABoeing737wasdispatchedwithoutfuelforanalternateaircraftdescendedforlandingthrough 4,000feet,onboardweatherrthunderstormcells.

Creditmustnowbegiven totheFAAfor whatisthebestjob byhaveseenin19yearsofmilitary andcivilianflying. Thecontrollerbaconcise stream of descriptive communications topaint apictureof location, intensity,reportedmicroburstactivity,winds,andrunwaya

Hethenwentontodescribevariousoptionsavailabletous.Att.flightconditionswereVFR,butweweremaneuveringtoavoidthereturnsonourradar.Tofacilitateoursituationalawareness,theconthelightsonRunway08totheirhighest setting....Ourfuelwasn1,andRunway8appearedclearlyinfrontandtoourright....toucheddownoncenterlineapproximately 1,100feet from thethreshold

Iknewinstinctivelythattimewasnotonmysideandeverymmaneuveringat2,000 feet withthefuelIhadwasquickly takingaandnoneofthemwereverygood.Thisaircraft madeitsafelyondeoutstandingwork oftheFAAandtheskillsoftheflight crew.

QUESTION;Whatroledoesaflight dispatcherplayvaluechain?

4. Acommunicationsbreakdownbetweenthecockpitandatugdrivinglocation ledtoapushbackwithnooneinpositive controlofthetosomesoulsearching afterwardbytheinvolvedflight crew.

Thepushback beganinanormalfashion.Engine startwasunevenafterstartflows wereaccomplished.Atthatpointweexperience,theleftbleedairvalve....The MELshowedthisasareturnAtthispoint, Itoldthemechanicweneededtobetugged backin..soundedlikehewasaskingustoreleasetheparkingbrake;however

wequiteunderstoodwhathehadsaidaboutthebrakes. Iaskedhimifhewasaskingustorelease theparkingbrake,towhichheresponded,"Releaseparkingbrake."Ireleased theparking brakeandthetugoperation commenced.

Withthetugoperation underway,Iturnedmyattention tothelogbook,thinkingabouthowIwasgoingtowriteupthisproblem. TheFirstOfficerputawaytheQRHandthenwaslookingovertheMEL,whichlistedrestrictionsaboutflyinginicingconditions.Whattomeseemedlikeafewsecondsafterwebegantobetugged,theFirstOfficerrhetoricallyasked,"Whereisthisguytakingus?"AsIlookedupIsawtheendof thepavedrampapproachingrapidlyandheard theFirstOfficer saysomethingaboutstoppingtheaircraft.

At thatpointwewerebothsimultaneouslyonthebrakes.... Afterleavingabout20feetofskidmarksontheramp,theaircraftcametoastopwiththenosewheelapproximately8feetfromtheendofthepavedsurface...andwithoutthetugconnected!!Afterstoppingtheaircraft andshuttingdowntheenginesandtryingtocomprehendwhathadjusthappened,mynextconcernwasthelocation ofthemechanic andifhewas okay. Hewasokay.

AlthoughthismechanicspeaksfairlygoodEnglish, Iwastruly surprisedatthelevelofcommunicationbreakdown thathadjustoccurred....HetoldmehethoughtIwastelling himIwasreleasingtheparkingbrake.Oncewestartedrollinghedidnottellustostop,butinstead simplyunpluggedhisheadsetandgotoutoftheway.

Whatlessonscanbelearnedorrelearnedfrom all of this? Firstofall,thisisareminder ofsomething we all know, that being tugged isan operationthatrequiressomeone tobemonitoring theaircraft. Second,neverassumeanything.Sinceweneversawthetugpullaway(itpulledawaywhilewewerein thebooks},andweweretoldtoreleasetheparking brake,wethoughtwewereundertow....Also,nexttimeIhavedeterminedIneedtodoareturntothe gate,Iwillshutdowntheenginessooner...Weweresodistracted bywhatwasgoingonthatneitherofusthoughtofshuttingdowntheengines, nordiditseemcritical atthemomentsince wethought wewereunder tow....Thank goodness noonewashurt,nometalwasbent,andnocareerswereputinjeopardy,butwesurecamedarnclose.

QUESTION: Whatspecificactionscouldtheflightcrewhavetakento preventsuchasituation?

5. Title:Distractioninthe Cockpit.

AsIwasapproachingthe gate. I shutdownthe#2engine(per our OpsManual).Iwasmomentarilydistractedinsidethecockpit. Therewasenoughroomtomakeaturn...tothe gate.Iaddedpower tothe#1engine.Duringtheleftturn,thejetblastfromthe#1engine blewamechanicoffamaintenancestand.Italsoblewpartofanenginecowling offthestand.Infuturesituations,Iwill...shutdownanduseatugtorepositionif thereisanydoubtaboutthe jet blast.

QUESTION; Speculate onwhatothertypesofhuman

performanceissuesmayhavealsocontributedtothiseventbutarenotmentioned inthenarrative.