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|
Attributes | |
ACN | 106842 |
Time | |
Date | 198903 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : vny |
State Reference | CA |
Altitude | msl bound lower : 2000 msl bound upper : 4500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : lax tower : bur |
Make Model Name | Small Aircraft, Low Wing, 1 Eng, Fixed Gear |
Flight Phase | cruise other descent : approach descent other |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private |
Experience | flight time last 90 days : 15 flight time total : 278 |
ASRS Report | 102684 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I mistook my position relative to emt. What I thought was the rotating beacon at emt was, in fact, the beacon at vny. As a consequence of this serious error, I overflew my destination by 24 NM, and in the process I definitely entered the bur arsa, and the bur and vny air traffic area's west/O call up, and therefore west/O permission. I may have entered the northeast corner of the la TCA west/O permission and west/O contact with la lax approach. I entered all or some of these areas because I misapprehended my location. The most obvious reason for landing at the wrong airport is the result of mistaking the lights of cars from the 134 and 210 freeways to be the lights of cars from the 10 and 210 freeways. Additionally, I mistook the intersection of the glendale (?) and 134 freeways to be the intersection of the 10 and 605. (In retrospect, this seems an almost impossible mistake to me, but I believe that by this point in the flight my mind was so fixated on the rotating beacon of vny that I refused to take into account indications that I was not approaching emt. I wanted that beacon to be emt!) while this is the most immediate explanation, this is also only the end result of a series of problems and mistakes that plagued the flight, that I did not perceive to be as serious as they obviously were. Before taxiing to runway 30, I did a check of the cockpit and found: the rheostat controling the overhead light was sensitive. I could turn it either way and light could be made to go off or on. It was sensitive, but with a little fiddling I seemed able to make it go on or off as I desired. The knob simply required a bit of side pressure as I turned it. (Later in flight I would find that the light would come on and go off west/O my touching the rheostat. Yet once on, it would become very difficult to intentionally shut off. It would also become balky to turn on.) the panel lights behind the attitude indicator and the dg were not functioning, but all other panel lights did work. As I proceeded wbound toward the pdz VOR, I used my flashlight with red filter to confirm my heading and to aid me as I reset the dg. But when I called up, I noticed that I was receiving no feedback through the headset. I called again and noticed that the transmit symbol, 'T,' did not illuminate when I pressed the installed yoke microphone button. I moved the button about and found that it seemed to make intermittent contact. I believe that the situation resulted from a complex of reasons: 1) lack of clear decision-making procedure re: go/no decisions. 2) lack of adequate knowledge of FSS offerings. 3) lack of adequate knowledge of ATC functions within the arsa. 4) absence of a routine for prioritizing my cockpit activities. 5) absence of a problem-solving/critical thinking process of assessing equipment problems and resolving conflicts in the information received from the environment. 6) a belief that its my responsibility to get myself out of problems that I create for myself--a belief that translates: don't export your own problems on to somebody else. 7) complacency.
Original NASA ASRS Text
Title: NIGHT FLT, ACFT EQUIPMENT PROBLEM COMBINED WITH POOR NAVIGATION. PENETRATED TCA, ARSA, ATA WITHOUT CLRNC.
Narrative: I MISTOOK MY POS RELATIVE TO EMT. WHAT I THOUGHT WAS THE ROTATING BEACON AT EMT WAS, IN FACT, THE BEACON AT VNY. AS A CONSEQUENCE OF THIS SERIOUS ERROR, I OVERFLEW MY DEST BY 24 NM, AND IN THE PROCESS I DEFINITELY ENTERED THE BUR ARSA, AND THE BUR AND VNY ATA'S W/O CALL UP, AND THEREFORE W/O PERMISSION. I MAY HAVE ENTERED THE NE CORNER OF THE LA TCA W/O PERMISSION AND W/O CONTACT WITH LA LAX APCH. I ENTERED ALL OR SOME OF THESE AREAS BECAUSE I MISAPPREHENDED MY LOCATION. THE MOST OBVIOUS REASON FOR LNDG AT THE WRONG ARPT IS THE RESULT OF MISTAKING THE LIGHTS OF CARS FROM THE 134 AND 210 FREEWAYS TO BE THE LIGHTS OF CARS FROM THE 10 AND 210 FREEWAYS. ADDITIONALLY, I MISTOOK THE INTXN OF THE GLENDALE (?) AND 134 FREEWAYS TO BE THE INTXN OF THE 10 AND 605. (IN RETROSPECT, THIS SEEMS AN ALMOST IMPOSSIBLE MISTAKE TO ME, BUT I BELIEVE THAT BY THIS POINT IN THE FLT MY MIND WAS SO FIXATED ON THE ROTATING BEACON OF VNY THAT I REFUSED TO TAKE INTO ACCOUNT INDICATIONS THAT I WAS NOT APCHING EMT. I WANTED THAT BEACON TO BE EMT!) WHILE THIS IS THE MOST IMMEDIATE EXPLANATION, THIS IS ALSO ONLY THE END RESULT OF A SERIES OF PROBS AND MISTAKES THAT PLAGUED THE FLT, THAT I DID NOT PERCEIVE TO BE AS SERIOUS AS THEY OBVIOUSLY WERE. BEFORE TAXIING TO RWY 30, I DID A CHK OF THE COCKPIT AND FOUND: THE RHEOSTAT CTLING THE OVERHEAD LIGHT WAS SENSITIVE. I COULD TURN IT EITHER WAY AND LIGHT COULD BE MADE TO GO OFF OR ON. IT WAS SENSITIVE, BUT WITH A LITTLE FIDDLING I SEEMED ABLE TO MAKE IT GO ON OR OFF AS I DESIRED. THE KNOB SIMPLY REQUIRED A BIT OF SIDE PRESSURE AS I TURNED IT. (LATER IN FLT I WOULD FIND THAT THE LIGHT WOULD COME ON AND GO OFF W/O MY TOUCHING THE RHEOSTAT. YET ONCE ON, IT WOULD BECOME VERY DIFFICULT TO INTENTIONALLY SHUT OFF. IT WOULD ALSO BECOME BALKY TO TURN ON.) THE PANEL LIGHTS BEHIND THE ATTITUDE INDICATOR AND THE DG WERE NOT FUNCTIONING, BUT ALL OTHER PANEL LIGHTS DID WORK. AS I PROCEEDED WBOUND TOWARD THE PDZ VOR, I USED MY FLASHLIGHT WITH RED FILTER TO CONFIRM MY HDG AND TO AID ME AS I RESET THE DG. BUT WHEN I CALLED UP, I NOTICED THAT I WAS RECEIVING NO FEEDBACK THROUGH THE HEADSET. I CALLED AGAIN AND NOTICED THAT THE XMIT SYMBOL, 'T,' DID NOT ILLUMINATE WHEN I PRESSED THE INSTALLED YOKE MIC BUTTON. I MOVED THE BUTTON ABOUT AND FOUND THAT IT SEEMED TO MAKE INTERMITTENT CONTACT. I BELIEVE THAT THE SITUATION RESULTED FROM A COMPLEX OF REASONS: 1) LACK OF CLEAR DECISION-MAKING PROC RE: GO/NO DECISIONS. 2) LACK OF ADEQUATE KNOWLEDGE OF FSS OFFERINGS. 3) LACK OF ADEQUATE KNOWLEDGE OF ATC FUNCTIONS WITHIN THE ARSA. 4) ABSENCE OF A ROUTINE FOR PRIORITIZING MY COCKPIT ACTIVITIES. 5) ABSENCE OF A PROBLEM-SOLVING/CRITICAL THINKING PROCESS OF ASSESSING EQUIP PROBS AND RESOLVING CONFLICTS IN THE INFO RECEIVED FROM THE ENVIRONMENT. 6) A BELIEF THAT ITS MY RESPONSIBILITY TO GET MYSELF OUT OF PROBS THAT I CREATE FOR MYSELF--A BELIEF THAT TRANSLATES: DON'T EXPORT YOUR OWN PROBS ON TO SOMEBODY ELSE. 7) COMPLACENCY.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.