37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 300950 |
Time | |
Date | 199504 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : vny |
State Reference | CA |
Altitude | msl bound lower : 2000 msl bound upper : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : vny |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid enroute airway : vny |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 8000 flight time type : 6 |
ASRS Report | 300950 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe conflict : airborne less severe non adherence : required legal separation other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : took evasive action other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 6000 vertical : 600 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On apr/wed/95 at approximately XA00 I departed vny airport in an a- 36 bonanza on an IFR SID-glendale 7 departure. The glendale 7 departure calls for maintaining runway heading until 1.5 DME at or below 1700 ft, and then a left turn to a 110 degree heading for vectors to the vny R-095. After takeoff and passing 1.5 DME and approximately 1200 ft, I started my turn to a 110 degree heading. The controller called radar contact and I acknowledged his call. I then looked into the cockpit and saw that one VOR was reading to and the other was reading from the station. I attempted to center the HSI VOR needle and also the obs. I then began to wonder if I had an HSI failure or just a VOR failure. During this time I had allowed my heading to drift to the left to approximately 097 degrees. I looked out to the left and saw a large commercial aircraft, 757/767 probably on an approach into the bur airport, approximately 1 NM horizontal and 500- 700 ft vertical altitude separation. As I started to make a turn away to the right. The controller called me for an immediate right turn to a heading of 160 degrees. I immediately complied with the turn to 160 degree heading. After the next called turn to on course, I asked the controller to verify my course so I could determine if the #2 VOR was operating properly. It was determined that it was operating properly and the remainder of the flight was completed without incident. Postflt investigation revealed that the GPS/VOR push-tile was in the GPS position causing the #1 VOR to give erroneous indications. Due to the sitting ht of the pilot, the under the glare shield location of the GPS/VOR push-tile, and the GPS/VOR enunciator light being dim, the pilot did not notice the light/selection, which was the cause of the VOR false failure, and the ultimate cause of the incident. Recommendations: 1) the pilot be more attentive in ensuring proper set up and identify of navaids, and monitoring headings while trouble-shooting cockpit discrepancies. 2) since both aircraft were in close radar contact, any time there is any deviation in heading in high density areas, the controller immediately correct those deviations.
Original NASA ASRS Text
Title: SWITCH POS LEADS TO TRACK DEV LEADS TO LTSS.
Narrative: ON APR/WED/95 AT APPROX XA00 I DEPARTED VNY ARPT IN AN A- 36 BONANZA ON AN IFR SID-GLENDALE 7 DEP. THE GLENDALE 7 DEP CALLS FOR MAINTAINING RWY HDG UNTIL 1.5 DME AT OR BELOW 1700 FT, AND THEN A L TURN TO A 110 DEG HDG FOR VECTORS TO THE VNY R-095. AFTER TKOF AND PASSING 1.5 DME AND APPROX 1200 FT, I STARTED MY TURN TO A 110 DEG HDG. THE CTLR CALLED RADAR CONTACT AND I ACKNOWLEDGED HIS CALL. I THEN LOOKED INTO THE COCKPIT AND SAW THAT ONE VOR WAS READING TO AND THE OTHER WAS READING FROM THE STATION. I ATTEMPTED TO CTR THE HSI VOR NEEDLE AND ALSO THE OBS. I THEN BEGAN TO WONDER IF I HAD AN HSI FAILURE OR JUST A VOR FAILURE. DURING THIS TIME I HAD ALLOWED MY HDG TO DRIFT TO THE L TO APPROX 097 DEGS. I LOOKED OUT TO THE L AND SAW A LARGE COMMERCIAL ACFT, 757/767 PROBABLY ON AN APCH INTO THE BUR ARPT, APPROX 1 NM HORIZ AND 500- 700 FT VERT ALT SEPARATION. AS I STARTED TO MAKE A TURN AWAY TO THE R. THE CTLR CALLED ME FOR AN IMMEDIATE R TURN TO A HDG OF 160 DEGS. I IMMEDIATELY COMPLIED WITH THE TURN TO 160 DEG HDG. AFTER THE NEXT CALLED TURN TO ON COURSE, I ASKED THE CTLR TO VERIFY MY COURSE SO I COULD DETERMINE IF THE #2 VOR WAS OPERATING PROPERLY. IT WAS DETERMINED THAT IT WAS OPERATING PROPERLY AND THE REMAINDER OF THE FLT WAS COMPLETED WITHOUT INCIDENT. POSTFLT INVESTIGATION REVEALED THAT THE GPS/VOR PUSH-TILE WAS IN THE GPS POS CAUSING THE #1 VOR TO GIVE ERRONEOUS INDICATIONS. DUE TO THE SITTING HT OF THE PLT, THE UNDER THE GLARE SHIELD LOCATION OF THE GPS/VOR PUSH-TILE, AND THE GPS/VOR ENUNCIATOR LIGHT BEING DIM, THE PLT DID NOT NOTICE THE LIGHT/SELECTION, WHICH WAS THE CAUSE OF THE VOR FALSE FAILURE, AND THE ULTIMATE CAUSE OF THE INCIDENT. RECOMMENDATIONS: 1) THE PLT BE MORE ATTENTIVE IN ENSURING PROPER SET UP AND IDENT OF NAVAIDS, AND MONITORING HDGS WHILE TROUBLE-SHOOTING COCKPIT DISCREPANCIES. 2) SINCE BOTH ACFT WERE IN CLOSE RADAR CONTACT, ANY TIME THERE IS ANY DEV IN HDG IN HIGH DENSITY AREAS, THE CTLR IMMEDIATELY CORRECT THOSE DEVS.
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.