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|
Attributes | |
ACN | 250111 |
Time | |
Date | 199308 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : hgr |
State Reference | MD |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 34 flight time total : 836 flight time type : 403 |
ASRS Report | 250111 |
Person 2 | |
Affiliation | Other |
Function | observation : observer |
Qualification | other other : other |
Events | |
Anomaly | non adherence other other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I landed at hgr and taxied to the west ramp. At the ramp, I wished to check if my a&P was in his hangar. From where I was sitting, I could not clearly see if the lock was open or closed on his hangar door. I taxied to an isolated area on the ramp about 70 ft in line of sight from the hangar, closed the throttle to the lowest power, checked and ensured that the airplane would not move with that minimum power setting, and then set the hand brake. I was certain that the airplane and its surroundings were safe. I left the airplane and walked about 40 ft from the airplane to where I could better see the lock on the hangar door. At this spot I spoke for about 20 seconds to one of 2 persons standing there. By this time was feeling uncomfortable about leaving the airplane sitting empty with the engine running even though it was in my line of sight only 40 ft away. At that moment, the other person standing there commented that it was 'a dumb thing to do' to leave the airplane with the engine running. That comment cemented my uncomfortable feeling and I rapidly walked back to the airplane, belted myself in, called ground, and taxied. I was probably out of the airplane for 1 min, total. The entire sequence was totally uneventful and I departed and continued my morning trip. About 6 days have passed and I cannot shake the uncomfortable feeling in my stomach. Although I took all precautions and remain certain (from the point of view of physics and the airplane was never out of my sight, etc) that there was no way in which an accident could have happened, I have to agree that 'it was a dumb thing to do.' there are 2 contributing factors, neither of which detract from my own acceptance of my stupidity at this moment. First, for the last several months, this airplane had been having intermittent flap retraction problems. In my efforts to trouble-shoot this, I have several times on a ramp after a failure of flap retraction, set the handbrake with the engine running (at minimum RPM) and fiddled with the flaps. So that gave me a somewhat cavalier attitude about briefly leaving the airplane. Second, it was a hot morning and the engine in this airplane is a notorious for its hot-starting difficulties. These were my thoughts at the time, but I see them now as simply excuses. As I continue to mull over the event, the only two conclusions I can reach seems earth-shaking to me in their triviality. First, complacency can sneak up on me at any time, not just around those first 100 hours about which I was so often warned. That 100-200 hour time has passed some time ago and I've never thought of myself as a person who makes bad decisions in an airplane. In hindsight, however, I must consciously stay vigilant not to make bad decisions. It just seems so trite to say it out loud -- having sound judgement (at least for me) doesn't become unconscious or automatic. The second conclusion for me is that instinct and 'gut feeling' must not be ignored even though the physics and equations say 'okay.' pilot training emphasizes safety as something one does, instrument training insists that we pay attention to the to the instruments and ignore the 'seat of our pants.' obviously the 2 are talking about different things -- but I wonder if I haven't confused them. Since I got my ticket, there have been numerous articles and seminars on 'decision making theory' -- although I have read and attended several of these and they made sense at the time, I suspect that they haven't 'sunk in.'as I situation here and think and type, I cannot repeat any of these theoretical constructs, although I think that I have some of the material in my files. Nothing having to do with the conscious process of decision-making has ever been discussed in my formal flight instruction or BFR's. I think it should be.
Original NASA ASRS Text
Title: PLT JUDGEMENT AND DECISION MAKING IS MULLED OVER BY PVT PLT AFTER HE HAD SECOND THOUGHTS ABOUT THE WISDOM OF HAVING LEFT HIS SMA ON THE RAMP WITH THE ENG RUNNING WHILE HE WAS OUT OF THE COCKPIT FOR 1 MIN.
Narrative: I LANDED AT HGR AND TAXIED TO THE W RAMP. AT THE RAMP, I WISHED TO CHK IF MY A&P WAS IN HIS HANGAR. FROM WHERE I WAS SITTING, I COULD NOT CLRLY SEE IF THE LOCK WAS OPEN OR CLOSED ON HIS HANGAR DOOR. I TAXIED TO AN ISOLATED AREA ON THE RAMP ABOUT 70 FT IN LINE OF SIGHT FROM THE HANGAR, CLOSED THE THROTTLE TO THE LOWEST PWR, CHKED AND ENSURED THAT THE AIRPLANE WOULD NOT MOVE WITH THAT MINIMUM PWR SETTING, AND THEN SET THE HAND BRAKE. I WAS CERTAIN THAT THE AIRPLANE AND ITS SURROUNDINGS WERE SAFE. I LEFT THE AIRPLANE AND WALKED ABOUT 40 FT FROM THE AIRPLANE TO WHERE I COULD BETTER SEE THE LOCK ON THE HANGAR DOOR. AT THIS SPOT I SPOKE FOR ABOUT 20 SECONDS TO ONE OF 2 PERSONS STANDING THERE. BY THIS TIME WAS FEELING UNCOMFORTABLE ABOUT LEAVING THE AIRPLANE SITTING EMPTY WITH THE ENG RUNNING EVEN THOUGH IT WAS IN MY LINE OF SIGHT ONLY 40 FT AWAY. AT THAT MOMENT, THE OTHER PERSON STANDING THERE COMMENTED THAT IT WAS 'A DUMB THING TO DO' TO LEAVE THE AIRPLANE WITH THE ENG RUNNING. THAT COMMENT CEMENTED MY UNCOMFORTABLE FEELING AND I RAPIDLY WALKED BACK TO THE AIRPLANE, BELTED MYSELF IN, CALLED GND, AND TAXIED. I WAS PROBABLY OUT OF THE AIRPLANE FOR 1 MIN, TOTAL. THE ENTIRE SEQUENCE WAS TOTALLY UNEVENTFUL AND I DEPARTED AND CONTINUED MY MORNING TRIP. ABOUT 6 DAYS HAVE PASSED AND I CANNOT SHAKE THE UNCOMFORTABLE FEELING IN MY STOMACH. ALTHOUGH I TOOK ALL PRECAUTIONS AND REMAIN CERTAIN (FROM THE POINT OF VIEW OF PHYSICS AND THE AIRPLANE WAS NEVER OUT OF MY SIGHT, ETC) THAT THERE WAS NO WAY IN WHICH AN ACCIDENT COULD HAVE HAPPENED, I HAVE TO AGREE THAT 'IT WAS A DUMB THING TO DO.' THERE ARE 2 CONTRIBUTING FACTORS, NEITHER OF WHICH DETRACT FROM MY OWN ACCEPTANCE OF MY STUPIDITY AT THIS MOMENT. FIRST, FOR THE LAST SEVERAL MONTHS, THIS AIRPLANE HAD BEEN HAVING INTERMITTENT FLAP RETRACTION PROBS. IN MY EFFORTS TO TROUBLE-SHOOT THIS, I HAVE SEVERAL TIMES ON A RAMP AFTER A FAILURE OF FLAP RETRACTION, SET THE HANDBRAKE WITH THE ENG RUNNING (AT MINIMUM RPM) AND FIDDLED WITH THE FLAPS. SO THAT GAVE ME A SOMEWHAT CAVALIER ATTITUDE ABOUT BRIEFLY LEAVING THE AIRPLANE. SECOND, IT WAS A HOT MORNING AND THE ENG IN THIS AIRPLANE IS A NOTORIOUS FOR ITS HOT-STARTING DIFFICULTIES. THESE WERE MY THOUGHTS AT THE TIME, BUT I SEE THEM NOW AS SIMPLY EXCUSES. AS I CONTINUE TO MULL OVER THE EVENT, THE ONLY TWO CONCLUSIONS I CAN REACH SEEMS EARTH-SHAKING TO ME IN THEIR TRIVIALITY. FIRST, COMPLACENCY CAN SNEAK UP ON ME AT ANY TIME, NOT JUST AROUND THOSE FIRST 100 HRS ABOUT WHICH I WAS SO OFTEN WARNED. THAT 100-200 HR TIME HAS PASSED SOME TIME AGO AND I'VE NEVER THOUGHT OF MYSELF AS A PERSON WHO MAKES BAD DECISIONS IN AN AIRPLANE. IN HINDSIGHT, HOWEVER, I MUST CONSCIOUSLY STAY VIGILANT NOT TO MAKE BAD DECISIONS. IT JUST SEEMS SO TRITE TO SAY IT OUT LOUD -- HAVING SOUND JUDGEMENT (AT LEAST FOR ME) DOESN'T BECOME UNCONSCIOUS OR AUTOMATIC. THE SECOND CONCLUSION FOR ME IS THAT INSTINCT AND 'GUT FEELING' MUST NOT BE IGNORED EVEN THOUGH THE PHYSICS AND EQUATIONS SAY 'OKAY.' PLT TRAINING EMPHASIZES SAFETY AS SOMETHING ONE DOES, INST TRAINING INSISTS THAT WE PAY ATTN TO THE TO THE INSTS AND IGNORE THE 'SEAT OF OUR PANTS.' OBVIOUSLY THE 2 ARE TALKING ABOUT DIFFERENT THINGS -- BUT I WONDER IF I HAVEN'T CONFUSED THEM. SINCE I GOT MY TICKET, THERE HAVE BEEN NUMEROUS ARTICLES AND SEMINARS ON 'DECISION MAKING THEORY' -- ALTHOUGH I HAVE READ AND ATTENDED SEVERAL OF THESE AND THEY MADE SENSE AT THE TIME, I SUSPECT THAT THEY HAVEN'T 'SUNK IN.'AS I SIT HERE AND THINK AND TYPE, I CANNOT REPEAT ANY OF THESE THEORETICAL CONSTRUCTS, ALTHOUGH I THINK THAT I HAVE SOME OF THE MATERIAL IN MY FILES. NOTHING HAVING TO DO WITH THE CONSCIOUS PROCESS OF DECISION-MAKING HAS EVER BEEN DISCUSSED IN MY FORMAL FLT INSTRUCTION OR BFR'S. I THINK IT SHOULD BE.
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.