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Pilot accepts IFR clearance with no departure procedure issued. Departs without referencing published departure procedure.
| Attributes | |
| ACN | 207668 |
| Time | |
| Date | 199204 |
| Day | Wed |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : uki |
| State Reference | CA |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : oak |
| Operator | general aviation : instructional |
| Make Model Name | Small Aircraft, Low Wing, 2 Eng, Retractable Gear |
| Flight Phase | climbout : initial climbout : takeoff ground : preflight |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : single pilot |
| Qualification | pilot : instrument pilot : commercial pilot : private |
| Experience | flight time last 90 days : 100 flight time total : 3000 flight time type : 100 |
| ASRS Report | 207668 |
| Person 2 | |
| Affiliation | government : faa |
| Function | other personnel other |
| Qualification | other |
| Events | |
| Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation other spatial deviation |
| Independent Detector | other other : unspecified cockpit |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Received relayed IFR clearance uki to pao from uki FSS. Clearance from uncontrolled airport did not include departure instructions. Clearance was 'as filed via mendocino VOR, altitude, etc.' since I normally fly from a controled airport (pao), I had the mindset that the route from the airport (uki) to the VOR was a direct climb -- since no procedure was specified. I did not rechk my IFR approach binder -- which is under published departure procedures. Anyway, after takeoff, I became very uncomfortable and maneuvered in IMC to avoid terrain. When an IFR departure procedure exists for an airport, a 'pilot advisory' after the route has been relayed should state 'a published departure procedure exists for this airport.' this notifies pilots used to receiving departure instructions to double-check their takeoff departure route. Since human error plays the dominant role in accidents, it is somewhat optimistic to assume a pilot will get a procedure right every time -- regardless of far 91.3(a). This current 'hole in the clearance situation' is directly analogous to the dec 1974 accident where air carrier collided with a va, mountain top due to misunderstanding by the pilots of their terrain/clearance/arrival procedures. ATC clrncs must be consistent no matter the departure point. Had a second pilot been on board, the double-check available would have avoided this situation. I will no longer fly single pilot IFR. In summation, the pilot is ultimately responsible for the safe conduct of a flight. ATC is responsible for traffic and terrain separation under prescribed conditions. However, the expectation or 'mental set' of a pilot, especially when operating in an unfamiliar area, promotes delegation of decision-making authority to ATC. The lack of mention of an IFR departure procedure -- especially when a pilot is used to receiving one -- can cause the wrong conclusion/decision to be reached with possible lethal consequences.
Original NASA ASRS Text
Title: PLT ACCEPTS IFR CLRNC WITH NO DEP PROC ISSUED. DEPARTS WITHOUT REFERENCING PUBLISHED DEP PROC.
Narrative: RECEIVED RELAYED IFR CLRNC UKI TO PAO FROM UKI FSS. CLRNC FROM UNCTLED ARPT DID NOT INCLUDE DEP INSTRUCTIONS. CLRNC WAS 'AS FILED VIA MENDOCINO VOR, ALT, ETC.' SINCE I NORMALLY FLY FROM A CTLED ARPT (PAO), I HAD THE MINDSET THAT THE RTE FROM THE ARPT (UKI) TO THE VOR WAS A DIRECT CLB -- SINCE NO PROC WAS SPECIFIED. I DID NOT RECHK MY IFR APCH BINDER -- WHICH IS UNDER PUBLISHED DEP PROCS. ANYWAY, AFTER TKOF, I BECAME VERY UNCOMFORTABLE AND MANEUVERED IN IMC TO AVOID TERRAIN. WHEN AN IFR DEP PROC EXISTS FOR AN ARPT, A 'PLT ADVISORY' AFTER THE RTE HAS BEEN RELAYED SHOULD STATE 'A PUBLISHED DEP PROC EXISTS FOR THIS ARPT.' THIS NOTIFIES PLTS USED TO RECEIVING DEP INSTRUCTIONS TO DOUBLE-CHK THEIR TKOF DEP RTE. SINCE HUMAN ERROR PLAYS THE DOMINANT ROLE IN ACCIDENTS, IT IS SOMEWHAT OPTIMISTIC TO ASSUME A PLT WILL GET A PROC RIGHT EVERY TIME -- REGARDLESS OF FAR 91.3(A). THIS CURRENT 'HOLE IN THE CLRNC SITUATION' IS DIRECTLY ANALOGOUS TO THE DEC 1974 ACCIDENT WHERE ACR COLLIDED WITH A VA, MOUNTAIN TOP DUE TO MISUNDERSTANDING BY THE PLTS OF THEIR TERRAIN/CLRNC/ARR PROCS. ATC CLRNCS MUST BE CONSISTENT NO MATTER THE DEP POINT. HAD A SECOND PLT BEEN ON BOARD, THE DOUBLE-CHK AVAILABLE WOULD HAVE AVOIDED THIS SITUATION. I WILL NO LONGER FLY SINGLE PLT IFR. IN SUMMATION, THE PLT IS ULTIMATELY RESPONSIBLE FOR THE SAFE CONDUCT OF A FLT. ATC IS RESPONSIBLE FOR TFC AND TERRAIN SEPARATION UNDER PRESCRIBED CONDITIONS. HOWEVER, THE EXPECTATION OR 'MENTAL SET' OF A PLT, ESPECIALLY WHEN OPERATING IN AN UNFAMILIAR AREA, PROMOTES DELEGATION OF DECISION-MAKING AUTHORITY TO ATC. THE LACK OF MENTION OF AN IFR DEP PROC -- ESPECIALLY WHEN A PLT IS USED TO RECEIVING ONE -- CAN CAUSE THE WRONG CONCLUSION/DECISION TO BE REACHED WITH POSSIBLE LETHAL CONSEQUENCES.
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.