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|
Attributes | |
ACN | 316610 |
Time | |
Date | 199509 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mez |
State Reference | AR |
Altitude | msl bound lower : 4000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zme |
Operator | general aviation : personal |
Make Model Name | Citation I/SP |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other |
Flight Phase | descent : approach descent other |
Route In Use | enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : atp |
Experience | flight time last 90 days : 40 flight time total : 3950 flight time type : 200 |
ASRS Report | 316610 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flying single-pilot in a citation 501, from a position about 50 NM southeast of mena, ar, I was cleared down to 4000 ft, direct to the mena NDB and cleared for the NDB-a approach. This required about a 330 degree heading to the NDB, then a right turn to fly outbound on the 080 degree bearing. I was using the ADF needle for primary guidance, backed up by a GPS installed in the aircraft. I also had the DME set to the rich mountain VOR, this was the basis of the problem that followed. In this aircraft, the DME displays mileage on its face and also on the pilot's HSI, even if the GPS is coupled to the HSI. In another citation that I have been flying with similar avionics but a different GPS, DME mileage is displayed on the pilot's HSI unless the GPS is coupled, and then it displays mileage to the selected GPS waypoint. I missed the fact that in the incident aircraft, the HSI mileage was always to the VOR, never to the GPS waypoint. Inbound to the NDB, I noted the mileage on the HSI as about 30 NM. In my mind we were 30 NM from the NDB. The GPS waypoint was on the airport, where the NDB is also located. In reality, we were only about 9 NM from the NDB, but I was not looking at the mileage display on the GPS and did not catch this. Further, I somehow missed seeing the ADF needle swing as I overflew the station. At this point I was trying to figure out why the #2 needle on the RMI was not pointing to the station and believe this distracted me from the navigation situation, though it is no excuse. When the HSI mileage was down to about 12 mi it suddenly dawned on me that the ADF needle had reversed. At this point I was about 9 mi past the NDB, or northwest of it, still on a heading of about 330 degrees, and still level at 4000 ft. I started a right turn back to the station, about the time the center called to ask where we were going. The controller reclred me for the approach and asked that we cancel the IFR before landing or by phone after landing. I completed the NDB approach and landed but then, preoccupied with the procedural error, forgot to call the center and cancel. They had to call the airport to see if we had landed. I don't believe there was any loss of separation, and terrain clearance was at least adequate throughout this, but there was a loss of situational awareness on my part for at least 3 mins. I still can't believe I let this happen. It is sobering to think of what the result could have been. The problem arose from a misunderstanding of how the equipment operated. Contributing factors were the fact I have flown into this airport many times over the last 15 yrs, nearly always using the rich mountain VOR for mileage guidance, the fact that I have been flying another citation with a different mileage setup on the HSI, and the fact I was flying single-pilot. Though I am a firm believer in the safety of single-pilot citation operations with a properly trained pilot, this incident points up the value of a second pilot to catch an error like this. I will in the future pay a lot more attention to setting up the navigation equipment for an approach, and spend more time focused on the navigation situation and less time studying non- essential items that could be figured out later.
Original NASA ASRS Text
Title: PLT OF A JET CESSNA SINGLE PLT CITATION FAILED TO FOLLOW PROPOSED APCH TRACK DUE TO MISINTERP OF THE DME READOUT.
Narrative: FLYING SINGLE-PLT IN A CITATION 501, FROM A POS ABOUT 50 NM SE OF MENA, AR, I WAS CLRED DOWN TO 4000 FT, DIRECT TO THE MENA NDB AND CLRED FOR THE NDB-A APCH. THIS REQUIRED ABOUT A 330 DEG HDG TO THE NDB, THEN A R TURN TO FLY OUTBOUND ON THE 080 DEG BEARING. I WAS USING THE ADF NEEDLE FOR PRIMARY GUIDANCE, BACKED UP BY A GPS INSTALLED IN THE ACFT. I ALSO HAD THE DME SET TO THE RICH MOUNTAIN VOR, THIS WAS THE BASIS OF THE PROB THAT FOLLOWED. IN THIS ACFT, THE DME DISPLAYS MILEAGE ON ITS FACE AND ALSO ON THE PLT'S HSI, EVEN IF THE GPS IS COUPLED TO THE HSI. IN ANOTHER CITATION THAT I HAVE BEEN FLYING WITH SIMILAR AVIONICS BUT A DIFFERENT GPS, DME MILEAGE IS DISPLAYED ON THE PLT'S HSI UNLESS THE GPS IS COUPLED, AND THEN IT DISPLAYS MILEAGE TO THE SELECTED GPS WAYPOINT. I MISSED THE FACT THAT IN THE INCIDENT ACFT, THE HSI MILEAGE WAS ALWAYS TO THE VOR, NEVER TO THE GPS WAYPOINT. INBOUND TO THE NDB, I NOTED THE MILEAGE ON THE HSI AS ABOUT 30 NM. IN MY MIND WE WERE 30 NM FROM THE NDB. THE GPS WAYPOINT WAS ON THE ARPT, WHERE THE NDB IS ALSO LOCATED. IN REALITY, WE WERE ONLY ABOUT 9 NM FROM THE NDB, BUT I WAS NOT LOOKING AT THE MILEAGE DISPLAY ON THE GPS AND DID NOT CATCH THIS. FURTHER, I SOMEHOW MISSED SEEING THE ADF NEEDLE SWING AS I OVERFLEW THE STATION. AT THIS POINT I WAS TRYING TO FIGURE OUT WHY THE #2 NEEDLE ON THE RMI WAS NOT POINTING TO THE STATION AND BELIEVE THIS DISTRACTED ME FROM THE NAV SIT, THOUGH IT IS NO EXCUSE. WHEN THE HSI MILEAGE WAS DOWN TO ABOUT 12 MI IT SUDDENLY DAWNED ON ME THAT THE ADF NEEDLE HAD REVERSED. AT THIS POINT I WAS ABOUT 9 MI PAST THE NDB, OR NW OF IT, STILL ON A HDG OF ABOUT 330 DEGS, AND STILL LEVEL AT 4000 FT. I STARTED A R TURN BACK TO THE STATION, ABOUT THE TIME THE CTR CALLED TO ASK WHERE WE WERE GOING. THE CTLR RECLRED ME FOR THE APCH AND ASKED THAT WE CANCEL THE IFR BEFORE LNDG OR BY PHONE AFTER LNDG. I COMPLETED THE NDB APCH AND LANDED BUT THEN, PREOCCUPIED WITH THE PROCEDURAL ERROR, FORGOT TO CALL THE CTR AND CANCEL. THEY HAD TO CALL THE ARPT TO SEE IF WE HAD LANDED. I DON'T BELIEVE THERE WAS ANY LOSS OF SEPARATION, AND TERRAIN CLRNC WAS AT LEAST ADEQUATE THROUGHOUT THIS, BUT THERE WAS A LOSS OF SITUATIONAL AWARENESS ON MY PART FOR AT LEAST 3 MINS. I STILL CAN'T BELIEVE I LET THIS HAPPEN. IT IS SOBERING TO THINK OF WHAT THE RESULT COULD HAVE BEEN. THE PROB AROSE FROM A MISUNDERSTANDING OF HOW THE EQUIP OPERATED. CONTRIBUTING FACTORS WERE THE FACT I HAVE FLOWN INTO THIS ARPT MANY TIMES OVER THE LAST 15 YRS, NEARLY ALWAYS USING THE RICH MOUNTAIN VOR FOR MILEAGE GUIDANCE, THE FACT THAT I HAVE BEEN FLYING ANOTHER CITATION WITH A DIFFERENT MILEAGE SETUP ON THE HSI, AND THE FACT I WAS FLYING SINGLE-PLT. THOUGH I AM A FIRM BELIEVER IN THE SAFETY OF SINGLE-PLT CITATION OPS WITH A PROPERLY TRAINED PLT, THIS INCIDENT POINTS UP THE VALUE OF A SECOND PLT TO CATCH AN ERROR LIKE THIS. I WILL IN THE FUTURE PAY A LOT MORE ATTN TO SETTING UP THE NAV EQUIP FOR AN APCH, AND SPEND MORE TIME FOCUSED ON THE NAV SIT AND LESS TIME STUDYING NON- ESSENTIAL ITEMS THAT COULD BE FIGURED OUT LATER.
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.