37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 264250 |
Time | |
Date | 199402 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bhm |
State Reference | AL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | PA-23-250 Aztec |
Operating Under FAR Part | Part 91 |
Flight Phase | ground other : taxi |
Person 1 | |
Affiliation | government : faa |
Function | controller : ground |
Qualification | controller : non radar controller : developmental |
ASRS Report | 264250 |
Person 2 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private |
Events | |
Anomaly | non adherence : clearance other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Airport | other physical facility |
Narrative:
I was working ground control and flight data/clearance delivery combined. There was an equipment outage forcing the change of procedures and the movement and/or combination of position. While working, I was involved in notifying crash/fire/rescue vehicles of an inbound aircraft with a brake failure. I was working the small aircraft who had requested progressive instructions at the same time. I did instruct the pilot for initial directions and informed him 'progressive instructions will follow.' since I had already given the pilot progressive instructions, I intended my statement to mean additional instruction, if necessary. I checked back on the small aircraft, which by this time was 1/2 way to his destination. I became involved in other duties and the next time I checked on the small aircraft the taxiway was clear. Normal operations during night hours have the ground controller establish an unfamiliar aircraft toward this ramp which is well lit. Usually the pilot will see the ramp and continue unassisted. I can only assume the pilot saw the hangar and attempted to turn in. The pilot missed the lighted taxiway and his aircraft fell into a drainage ditch. I can list a number of things that might have prevented this. First, the airport needs to fill in the area and/or mark it better. I learned this was not the first aircraft to fall into this ditch. Second, if the pilot was unsure he should have come back and asked me. Third, I assumed the pilot found the ramp. Fourth, I will not (in the future) issue partial instructions. In my attempt to be brief and clear, I omitted the hangar's location. I am sure this would have made no difference as to the pilot's decision to turn, but now I am liable and my lesson is learned. Fifth, once again position were combined during busy traffic. Equipment reliability is to blame for combined position -- which may be to blame for my quick assumptions.
Original NASA ASRS Text
Title: PAZT TURNED OFF TXWY TOO SOON AND FELL INTO A DITCH.
Narrative: I WAS WORKING GND CTL AND FLT DATA/CLRNC DELIVERY COMBINED. THERE WAS AN EQUIP OUTAGE FORCING THE CHANGE OF PROCS AND THE MOVEMENT AND/OR COMBINATION OF POS. WHILE WORKING, I WAS INVOLVED IN NOTIFYING CRASH/FIRE/RESCUE VEHICLES OF AN INBOUND ACFT WITH A BRAKE FAILURE. I WAS WORKING THE SMA WHO HAD REQUESTED PROGRESSIVE INSTRUCTIONS AT THE SAME TIME. I DID INSTRUCT THE PLT FOR INITIAL DIRECTIONS AND INFORMED HIM 'PROGRESSIVE INSTRUCTIONS WILL FOLLOW.' SINCE I HAD ALREADY GIVEN THE PLT PROGRESSIVE INSTRUCTIONS, I INTENDED MY STATEMENT TO MEAN ADDITIONAL INSTRUCTION, IF NECESSARY. I CHKED BACK ON THE SMA, WHICH BY THIS TIME WAS 1/2 WAY TO HIS DEST. I BECAME INVOLVED IN OTHER DUTIES AND THE NEXT TIME I CHKED ON THE SMA THE TXWY WAS CLR. NORMAL OPS DURING NIGHT HRS HAVE THE GND CTLR ESTABLISH AN UNFAMILIAR ACFT TOWARD THIS RAMP WHICH IS WELL LIT. USUALLY THE PLT WILL SEE THE RAMP AND CONTINUE UNASSISTED. I CAN ONLY ASSUME THE PLT SAW THE HANGAR AND ATTEMPTED TO TURN IN. THE PLT MISSED THE LIGHTED TXWY AND HIS ACFT FELL INTO A DRAINAGE DITCH. I CAN LIST A NUMBER OF THINGS THAT MIGHT HAVE PREVENTED THIS. FIRST, THE ARPT NEEDS TO FILL IN THE AREA AND/OR MARK IT BETTER. I LEARNED THIS WAS NOT THE FIRST ACFT TO FALL INTO THIS DITCH. SECOND, IF THE PLT WAS UNSURE HE SHOULD HAVE COME BACK AND ASKED ME. THIRD, I ASSUMED THE PLT FOUND THE RAMP. FOURTH, I WILL NOT (IN THE FUTURE) ISSUE PARTIAL INSTRUCTIONS. IN MY ATTEMPT TO BE BRIEF AND CLR, I OMITTED THE HANGAR'S LOCATION. I AM SURE THIS WOULD HAVE MADE NO DIFFERENCE AS TO THE PLT'S DECISION TO TURN, BUT NOW I AM LIABLE AND MY LESSON IS LEARNED. FIFTH, ONCE AGAIN POS WERE COMBINED DURING BUSY TFC. EQUIP RELIABILITY IS TO BLAME FOR COMBINED POS -- WHICH MAY BE TO BLAME FOR MY QUICK ASSUMPTIONS.
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.