Poor decision making leads to loss of primary flight instruments for cpr light transport captain. Lo...

Narrative:

We were cleared for takeoff when our left-hand pitot heater failed. Our MEL states we can fly west/O the left-hand pitot heater if we stay clear clouds below +4 sat and/or known icing conditions. I was not sure we could comply with those restrictions, but I decided to go anyway. En route we checked WX at our destination and alternates. All had high ceilings (6000'), 15+ NM plus visibilities and were well above freezing (55 degrees F). We also received reports of heavy icing in clouds at 11000' MSL. Still, I elected to press on. We talked over the possible implications and possibility of losing the left-hand asi and altimeter. We discussed the procedures for having the pilot in the right seat assume flying duties if I lost my airspeed and altimeter. We were incredibly stupid. In our descent at 9000' MSL due encountered not only very heavy icing, but moderate to severe turbulence. I almost immediately lost both my asi and altimeter. The right seat pilot assumed flying duties. His asi showed a warning flag so was suspect and could not be trusted. Because of the turbulence he needed both hands to control the aircraft. I had to control the throttles, monitor his flight INS from my side, assess the situation and make decisions, and handle the radios. The PF also stated he felt he wasn't turning when he was, and vice versa, obviously he was experiencing incipient vertigo due to the turbulence and loss of INS. Even though we had good gyros the loss of other primary flight INS interrupted our normal scan and confused our normal senses. To further complicate the situation, center couldn't give us a lower altitude. I finally communicated the urgency of the situation and they gave us a lower altitude. At that point we couldn't maintain altitude because of the turbulence anyway. Once we had a clearance to a lower altitude we descended by reference to attitude only. We broke out at 5000' MSL in warmer air and almost immediately got all INS back. We made a normal approach and landing. There are many lessons to be learned here. My motivation for continuing the flight with a known deficiency was the result of pressure of a very heavy schedule with upper management aboard, and my desire not to inconvenience them. I also now realize I was getting complacent and felt I could do anything (arrogant). I am appalled by my lack of professionalism. The worst part is I know better, but I still succumbed to outside pressures. Never again. Callback conversation with reporter revealed the following: reporter reiterated self-displeasure for his actions. He said, 'I did what the company pays me not to do.' the reporter also said how shocked he was at the great speed with which the situation got out of control. One factor not initially related by the reporter is that at the time of the incident, the flight crew had been on duty 14 hours, and that fatigue probably affected judgement. The reporter is also the chief pilot for his company. After this incident, he called all company pilots to a meeting to discuss this incident, its causes and effects. He felt that his flight department could benefit from a discussion of the human factors issues.

Original NASA ASRS Text

Title: POOR DECISION MAKING LEADS TO LOSS OF PRIMARY FLT INSTRUMENTS FOR CPR LTT CAPT. LOSS OF INSTRUMENTS ALMOST LEADS TO LOSS OF CONTROL.

Narrative: WE WERE CLRED FOR TKOF WHEN OUR LEFT-HAND PITOT HEATER FAILED. OUR MEL STATES WE CAN FLY W/O THE LEFT-HAND PITOT HEATER IF WE STAY CLR CLOUDS BELOW +4 SAT AND/OR KNOWN ICING CONDITIONS. I WAS NOT SURE WE COULD COMPLY WITH THOSE RESTRICTIONS, BUT I DECIDED TO GO ANYWAY. ENRTE WE CHKED WX AT OUR DEST AND ALTERNATES. ALL HAD HIGH CEILINGS (6000'), 15+ NM PLUS VISIBILITIES AND WERE WELL ABOVE FREEZING (55 DEGS F). WE ALSO RECEIVED RPTS OF HEAVY ICING IN CLOUDS AT 11000' MSL. STILL, I ELECTED TO PRESS ON. WE TALKED OVER THE POSSIBLE IMPLICATIONS AND POSSIBILITY OF LOSING THE LEFT-HAND ASI AND ALTIMETER. WE DISCUSSED THE PROCS FOR HAVING THE PLT IN THE RIGHT SEAT ASSUME FLYING DUTIES IF I LOST MY AIRSPD AND ALTIMETER. WE WERE INCREDIBLY STUPID. IN OUR DSCNT AT 9000' MSL DUE ENCOUNTERED NOT ONLY VERY HEAVY ICING, BUT MODERATE TO SEVERE TURB. I ALMOST IMMEDIATELY LOST BOTH MY ASI AND ALTIMETER. THE RIGHT SEAT PLT ASSUMED FLYING DUTIES. HIS ASI SHOWED A WARNING FLAG SO WAS SUSPECT AND COULD NOT BE TRUSTED. BECAUSE OF THE TURB HE NEEDED BOTH HANDS TO CONTROL THE ACFT. I HAD TO CONTROL THE THROTTLES, MONITOR HIS FLT INS FROM MY SIDE, ASSESS THE SITUATION AND MAKE DECISIONS, AND HANDLE THE RADIOS. THE PF ALSO STATED HE FELT HE WASN'T TURNING WHEN HE WAS, AND VICE VERSA, OBVIOUSLY HE WAS EXPERIENCING INCIPIENT VERTIGO DUE TO THE TURB AND LOSS OF INS. EVEN THOUGH WE HAD GOOD GYROS THE LOSS OF OTHER PRIMARY FLT INS INTERRUPTED OUR NORMAL SCAN AND CONFUSED OUR NORMAL SENSES. TO FURTHER COMPLICATE THE SITUATION, CENTER COULDN'T GIVE US A LOWER ALT. I FINALLY COMMUNICATED THE URGENCY OF THE SITUATION AND THEY GAVE US A LOWER ALT. AT THAT POINT WE COULDN'T MAINTAIN ALT BECAUSE OF THE TURB ANYWAY. ONCE WE HAD A CLRNC TO A LOWER ALT WE DSNDED BY REF TO ATTITUDE ONLY. WE BROKE OUT AT 5000' MSL IN WARMER AIR AND ALMOST IMMEDIATELY GOT ALL INS BACK. WE MADE A NORMAL APCH AND LNDG. THERE ARE MANY LESSONS TO BE LEARNED HERE. MY MOTIVATION FOR CONTINUING THE FLT WITH A KNOWN DEFICIENCY WAS THE RESULT OF PRESSURE OF A VERY HEAVY SCHEDULE WITH UPPER MGMNT ABOARD, AND MY DESIRE NOT TO INCONVENIENCE THEM. I ALSO NOW REALIZE I WAS GETTING COMPLACENT AND FELT I COULD DO ANYTHING (ARROGANT). I AM APPALLED BY MY LACK OF PROFESSIONALISM. THE WORST PART IS I KNOW BETTER, BUT I STILL SUCCUMBED TO OUTSIDE PRESSURES. NEVER AGAIN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR REITERATED SELF-DISPLEASURE FOR HIS ACTIONS. HE SAID, 'I DID WHAT THE COMPANY PAYS ME NOT TO DO.' THE REPORTER ALSO SAID HOW SHOCKED HE WAS AT THE GREAT SPD WITH WHICH THE SITUATION GOT OUT OF CONTROL. ONE FACTOR NOT INITIALLY RELATED BY THE RPTR IS THAT AT THE TIME OF THE INCIDENT, THE FLT CREW HAD BEEN ON DUTY 14 HRS, AND THAT FATIGUE PROBABLY AFFECTED JUDGEMENT. THE RPTR IS ALSO THE CHIEF PLT FOR HIS COMPANY. AFTER THIS INCIDENT, HE CALLED ALL COMPANY PLTS TO A MEETING TO DISCUSS THIS INCIDENT, ITS CAUSES AND EFFECTS. HE FELT THAT HIS FLT DEPT COULD BENEFIT FROM A DISCUSSION OF THE HUMAN FACTORS ISSUES.

Data retrieved from NASA's ASRS site as of July 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.

Attributes
ACN	139971
Time
Date	199003
Day	Mon
Local Time Of Day	1801 To 2400
Place
Locale Reference	atc facility : etx
State Reference	PA
Altitude	msl bound lower : 7000 msl bound upper : 7000
Environment
Flight Conditions	IMC
Light	Night
Aircraft 1
Controlling Facilities	artcc : zny
Operator	general aviation : corporate
Make Model Name	Light Transport, Low Wing, 2 Turbojet Eng
Navigation In Use	Other
Flight Phase	descent other
Flight Plan	IFR
Person 1
Affiliation	Other
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 100 flight time total : 12000 flight time type : 5000
ASRS Report	139971
Person 2
Affiliation	Other
Function	flight crew : first officer
Qualification	pilot : atp
Experience	flight time last 90 days : 100 flight time total : 3000 flight time type : 500
Events
Anomaly	aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : far other anomaly other
Independent Detector	other flight crewa
Resolutory Action	controller : issued new clearance flight crew : exited adverse environment flight crew : overcame equipment problem
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Poor decision making leads to loss of primary flight instruments for cpr light transport captain. Loss of instruments almost leads to loss of control.