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|
Attributes | |
ACN | 170480 |
Time | |
Date | 199102 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : oth |
State Reference | OR |
Altitude | msl bound lower : 3500 msl bound upper : 3500 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | climbout : intermediate altitude cruise other other |
Route In Use | enroute airway : zse |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 50 flight time total : 1023 |
ASRS Report | 170480 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : clearance other anomaly other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented other other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The aircraft had been thoroughly preflted, full fuel, full oil, all INS fully functional. The aircraft was 15 hours from its last annual inspection completed 2 weeks previously at troutdale. The aircraft has all equipment required for IFR flight, although limited due to its age and lack of supporting equipment. The gyros are mid-1960's vintage, the single VOR head is a tube radio, the LORAN is not IFR certified, there is no G/south or ADF equipment on board. An in-person WX briefing was obtained from the WX station at ast. A briefing for NOTAMS and operational ability of navaids was obtained by phone from mc minnville FSS. A flight plan was filed, opened and closed for the flight from ast to oth. The eventual destination was eureka, ca. Strong headwinds (average gndspd of 65 KTS), need for fueling, need for restroom facs, update on WX, approaching darkness and the filed for destination of oth led to an uneventful landing at oth in P.M. Because it was not dark and there are few ground lights along the coastline to the south for navigation by pilotage, I elected to depart IFR. WX conditions indicated that it would be safer to fly at higher altitudes along arwys than to rely on pilotage following dark featureless terrain along the coastline. The time of departure was :10Z. Mmv FSS acknowledged and I departed on runway 13. In accordance with the published departure procedure I turned right on takeoff and climbed out on the 250 degree right, then reversed course and proceeded to cross the VORTAC at 3000'. I encountered VMC at approximately 2000' in the climb. At approximately 3200', just prior to crossing the VORTAC, I heard the stall horn due to an excessive high pitch in the climb. I immediately reduced the pitch attitude and returned to straight and level flight. The excessive pitch and recovery caused a change in heading. The close proximity to the VORTAC made identify of the current radial difficult to identify. The stress of the moment led to anxiousness. Recognizing the limitations of the aircraft, the lack of actual IMC experience and currency on my part, the stress and spatial disorientation of the moment, I immediately informed ZSE of my circumstances. In the interest of safety of specifically declared an emergency. The controller asked about the problem. I informed him of my navigation difficulties and disorientation. He asked what my intentions were. I requested return to oth. He cleared me back to the VORTAC for the VOR approach to oth. My attempts were unsuccessful due to my inability to maintain a specific heading for any necessary period of time. He suggested I proceed south to my planned destination where WX was more favorable. I declined due to the long distance and thus long period of flight. He later suggested vectors to eugene, which I acknowledged as the safest option and accepted his directions. Precession of the gyros, combined with the reverse displays of the older instruments (on the attitude indicator the bank needle shows a right deflection when in a left bank; the dg progresses to the displayed headings on the right side of the INS when making a turn to the left) made flight changes confusing. Approximately 1 hour after departure from oth, and a handoff from ZSE to eug approach to eug tower, a safe landing was made in VMC at eug. Probable cause of incident: lack of IMC experience by the pilot and absence of required IFR currency requirements by the pilot. Contributing factors: antiquated instrumentation. Pilot fatigue from previous flying leg. Reverse displays on critical INS (attitude indicator and heading indicator). Lack of supporting instrumentation. Suggestion for corrective actions/improvements: pilot maintain currency and obtain experience in IMC. Equipment aircraft beyond minimum requirements of the regulations if used for IFR flight. Equipment aircraft with direct display instrumentation.
Original NASA ASRS Text
Title: A NON CURRENT INS RATED SMA PLT SUFFERS FROM SPATIAL DISORIENTATION ON A NIGHT OPERATION IFR FILED FLT PLAN.
Narrative: THE ACFT HAD BEEN THOROUGHLY PREFLTED, FULL FUEL, FULL OIL, ALL INS FULLY FUNCTIONAL. THE ACFT WAS 15 HRS FROM ITS LAST ANNUAL INSPECTION COMPLETED 2 WKS PREVIOUSLY AT TROUTDALE. THE ACFT HAS ALL EQUIP REQUIRED FOR IFR FLT, ALTHOUGH LIMITED DUE TO ITS AGE AND LACK OF SUPPORTING EQUIP. THE GYROS ARE MID-1960'S VINTAGE, THE SINGLE VOR HEAD IS A TUBE RADIO, THE LORAN IS NOT IFR CERTIFIED, THERE IS NO G/S OR ADF EQUIP ON BOARD. AN IN-PERSON WX BRIEFING WAS OBTAINED FROM THE WX STATION AT AST. A BRIEFING FOR NOTAMS AND OPERATIONAL ABILITY OF NAVAIDS WAS OBTAINED BY PHONE FROM MC MINNVILLE FSS. A FLT PLAN WAS FILED, OPENED AND CLOSED FOR THE FLT FROM AST TO OTH. THE EVENTUAL DEST WAS EUREKA, CA. STRONG HEADWINDS (AVERAGE GNDSPD OF 65 KTS), NEED FOR FUELING, NEED FOR RESTROOM FACS, UPDATE ON WX, APCHING DARKNESS AND THE FILED FOR DEST OF OTH LED TO AN UNEVENTFUL LNDG AT OTH IN P.M. BECAUSE IT WAS NOT DARK AND THERE ARE FEW GND LIGHTS ALONG THE COASTLINE TO THE S FOR NAV BY PILOTAGE, I ELECTED TO DEPART IFR. WX CONDITIONS INDICATED THAT IT WOULD BE SAFER TO FLY AT HIGHER ALTS ALONG ARWYS THAN TO RELY ON PILOTAGE FOLLOWING DARK FEATURELESS TERRAIN ALONG THE COASTLINE. THE TIME OF DEP WAS :10Z. MMV FSS ACKNOWLEDGED AND I DEPARTED ON RWY 13. IN ACCORDANCE WITH THE PUBLISHED DEP PROC I TURNED RIGHT ON TKOF AND CLBED OUT ON THE 250 DEG R, THEN REVERSED COURSE AND PROCEEDED TO CROSS THE VORTAC AT 3000'. I ENCOUNTERED VMC AT APPROX 2000' IN THE CLB. AT APPROX 3200', JUST PRIOR TO XING THE VORTAC, I HEARD THE STALL HORN DUE TO AN EXCESSIVE HIGH PITCH IN THE CLB. I IMMEDIATELY REDUCED THE PITCH ATTITUDE AND RETURNED TO STRAIGHT AND LEVEL FLT. THE EXCESSIVE PITCH AND RECOVERY CAUSED A CHANGE IN HDG. THE CLOSE PROX TO THE VORTAC MADE IDENT OF THE CURRENT RADIAL DIFFICULT TO IDENT. THE STRESS OF THE MOMENT LED TO ANXIOUSNESS. RECOGNIZING THE LIMITATIONS OF THE ACFT, THE LACK OF ACTUAL IMC EXPERIENCE AND CURRENCY ON MY PART, THE STRESS AND SPATIAL DISORIENTATION OF THE MOMENT, I IMMEDIATELY INFORMED ZSE OF MY CIRCUMSTANCES. IN THE INTEREST OF SAFETY OF SPECIFICALLY DECLARED AN EMER. THE CTLR ASKED ABOUT THE PROB. I INFORMED HIM OF MY NAV DIFFICULTIES AND DISORIENTATION. HE ASKED WHAT MY INTENTIONS WERE. I REQUESTED RETURN TO OTH. HE CLRED ME BACK TO THE VORTAC FOR THE VOR APCH TO OTH. MY ATTEMPTS WERE UNSUCCESSFUL DUE TO MY INABILITY TO MAINTAIN A SPECIFIC HDG FOR ANY NECESSARY PERIOD OF TIME. HE SUGGESTED I PROCEED S TO MY PLANNED DEST WHERE WX WAS MORE FAVORABLE. I DECLINED DUE TO THE LONG DISTANCE AND THUS LONG PERIOD OF FLT. HE LATER SUGGESTED VECTORS TO EUGENE, WHICH I ACKNOWLEDGED AS THE SAFEST OPTION AND ACCEPTED HIS DIRECTIONS. PRECESSION OF THE GYROS, COMBINED WITH THE REVERSE DISPLAYS OF THE OLDER INSTRUMENTS (ON THE ATTITUDE INDICATOR THE BANK NEEDLE SHOWS A RIGHT DEFLECTION WHEN IN A LEFT BANK; THE DG PROGRESSES TO THE DISPLAYED HDGS ON THE RIGHT SIDE OF THE INS WHEN MAKING A TURN TO THE LEFT) MADE FLT CHANGES CONFUSING. APPROX 1 HR AFTER DEP FROM OTH, AND A HDOF FROM ZSE TO EUG APCH TO EUG TWR, A SAFE LNDG WAS MADE IN VMC AT EUG. PROBABLE CAUSE OF INCIDENT: LACK OF IMC EXPERIENCE BY THE PLT AND ABSENCE OF REQUIRED IFR CURRENCY REQUIREMENTS BY THE PLT. CONTRIBUTING FACTORS: ANTIQUATED INSTRUMENTATION. PLT FATIGUE FROM PREVIOUS FLYING LEG. REVERSE DISPLAYS ON CRITICAL INS (ATTITUDE INDICATOR AND HDG INDICATOR). LACK OF SUPPORTING INSTRUMENTATION. SUGGESTION FOR CORRECTIVE ACTIONS/IMPROVEMENTS: PLT MAINTAIN CURRENCY AND OBTAIN EXPERIENCE IN IMC. EQUIP ACFT BEYOND MINIMUM REQUIREMENTS OF THE REGS IF USED FOR IFR FLT. EQUIP ACFT WITH DIRECT DISPLAY INSTRUMENTATION.
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.