37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 350404 |
Time | |
Date | 199610 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : sgd |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 3400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | general aviation : personal |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : missed approach |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Small Transport, Low Wing, 2 Recip Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | instruction : instructor oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 60 flight time total : 900 flight time type : 4 |
ASRS Report | 350404 |
Person 2 | |
Affiliation | Other |
Function | flight crew : single pilot instruction : trainee |
Qualification | pilot : private pilot : instrument |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : far non adherence : required legal separation non adherence : clearance |
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 |
Miss Distance | horizontal : 1000 vertical : 600 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The situation includes myself as the flight instructor, acting as PIC, and a student practicing multiple instrument approachs in the local area. The student was wearing a view limiting device during the following event. Upon executing the published missed approach for the VOR 6 approach at the apc airport, we remained within 5 mi of the scaggs island VOR turned inbound as published and leveled off at our assigned altitude of 3000 ft MSL. During our track inbound we received our clearance for our next instrument approach at the sts airport. The student was confused with the clearance and asked ZOA to repeat the clearance, still confused the student turned to me for help. I read back the clearance, and we continued. As we flew over the VOR I was trying to explain to the student the procedures of our instructions, and when and what to do next. At the same time ATC advised us to turn to a new heading and intercept the outbound radial for the beginning of the ILS 32 approach at sts. During our turn we inadvertently climbed 400 ft of altitude. I pointed this out to my student and we started to correct our altitude. Shortly afterwards ATC asked if we were at 3000 ft, the student's reply was 'no, we are at 3400 ft descending.' as we turned I noted seeing a twin engine aircraft in our 1 O'clock position, approximately 1000 ft above us, crossing right to left. Shortly afterwards we were advised to call ATC from the ground and we were given a telephone number to call. On the ground ATC advised that there was a possible loss of separation between aircraft, ours at 3400 ft and an aircraft flying above us at 4000 ft and they needed to investigate further into the situation. Additional analysis of the situation provides more information as to how this event occurred. I feel that there were many little factors that all added up to cause us to unintentionally gain altitude at this critical phase of flight. These contributing factors include: 1) low experience level as both an instructor and as an instrument instructor. Instrument instructor for a short period of time (1 yr, 1 month), with less than 150 total hours given and less than 30 hours given as an instrument instructor. 2) not as familiar with this aircraft as should be. Less than 5 total hours logged in a beechcraft V35 bonanza. Similar experience flying aircraft like the cessna 182 but it is not as fast as the bonanza. 3) overestimated ability to be able to instruct instrument approachs in this fast aircraft without recently polishing instrument procedures. 4) overestimated the ability of the student to fly instrument approachs in this aircraft. 5) the student was instrument rated, but was not current. 6) the student owned this particular airplane and has over 100 hours in it, but none of it flown under instrument conditions (training or actual). 7) currently work a full time job with a minimum of 40 hours per week on swing shift, and flight instruct part time before work each day. Not providing the best eating and sleeping habits necessary to perform at peak levels for flight instruction. (Average 6 hours a night sleep and an irregular eating schedule). 8) confusion with the missed approach and clearance for the next approach by the student. 9) focus of attention, trying to explain the clearance to the student as we crossed directly over the VOR. 10) also over the VOR we received an intercept heading from ATC for an outbound course radial (adding to the high workload). 11) during execution of the turn inadvertent climb of 400 ft in altitude. Fortunately this occurrence was no more than unintentional situation that did cause serious injury or worse. Some of the corrective actions were immediate and the others will be accomplished in the near future. These include: 1) noting and promptly correcting altitude before ATC advised of our deviation. 2) as an instructor review instrument and instructing skills more often. 3) when fly different aircraft that less familiar with spend more time learning these aircraft before attempting to instruct in them. 4) reduce workload between current job and flight instruction.
Original NASA ASRS Text
Title: V35 BONANZA ON IFR INSTRUCTOR TRAINING FLT. ON A MISSED APCH FROM APC LEVELING 3000 FT, CTR ISSUED CLRNC FOR INST APCH TO STS. TRAINEE CONFUSED BY THE CLRNC RESULTING IN DEV FROM ALT 400 FT CAUSING LTSS FROM TWIN ACFT OVERFLYING AT 4000 FT.
Narrative: THE SIT INCLUDES MYSELF AS THE FLT INSTRUCTOR, ACTING AS PIC, AND A STUDENT PRACTICING MULTIPLE INST APCHS IN THE LCL AREA. THE STUDENT WAS WEARING A VIEW LIMITING DEVICE DURING THE FOLLOWING EVENT. UPON EXECUTING THE PUBLISHED MISSED APCH FOR THE VOR 6 APCH AT THE APC ARPT, WE REMAINED WITHIN 5 MI OF THE SCAGGS ISLAND VOR TURNED INBOUND AS PUBLISHED AND LEVELED OFF AT OUR ASSIGNED ALT OF 3000 FT MSL. DURING OUR TRACK INBOUND WE RECEIVED OUR CLRNC FOR OUR NEXT INST APCH AT THE STS ARPT. THE STUDENT WAS CONFUSED WITH THE CLRNC AND ASKED ZOA TO REPEAT THE CLRNC, STILL CONFUSED THE STUDENT TURNED TO ME FOR HELP. I READ BACK THE CLRNC, AND WE CONTINUED. AS WE FLEW OVER THE VOR I WAS TRYING TO EXPLAIN TO THE STUDENT THE PROCS OF OUR INSTRUCTIONS, AND WHEN AND WHAT TO DO NEXT. AT THE SAME TIME ATC ADVISED US TO TURN TO A NEW HDG AND INTERCEPT THE OUTBOUND RADIAL FOR THE BEGINNING OF THE ILS 32 APCH AT STS. DURING OUR TURN WE INADVERTENTLY CLBED 400 FT OF ALT. I POINTED THIS OUT TO MY STUDENT AND WE STARTED TO CORRECT OUR ALT. SHORTLY AFTERWARDS ATC ASKED IF WE WERE AT 3000 FT, THE STUDENT'S REPLY WAS 'NO, WE ARE AT 3400 FT DSNDING.' AS WE TURNED I NOTED SEEING A TWIN ENG ACFT IN OUR 1 O'CLOCK POS, APPROX 1000 FT ABOVE US, XING R TO L. SHORTLY AFTERWARDS WE WERE ADVISED TO CALL ATC FROM THE GND AND WE WERE GIVEN A TELEPHONE NUMBER TO CALL. ON THE GND ATC ADVISED THAT THERE WAS A POSSIBLE LOSS OF SEPARATION BTWN ACFT, OURS AT 3400 FT AND AN ACFT FLYING ABOVE US AT 4000 FT AND THEY NEEDED TO INVESTIGATE FURTHER INTO THE SIT. ADDITIONAL ANALYSIS OF THE SIT PROVIDES MORE INFO AS TO HOW THIS EVENT OCCURRED. I FEEL THAT THERE WERE MANY LITTLE FACTORS THAT ALL ADDED UP TO CAUSE US TO UNINTENTIONALLY GAIN ALT AT THIS CRITICAL PHASE OF FLT. THESE CONTRIBUTING FACTORS INCLUDE: 1) LOW EXPERIENCE LEVEL AS BOTH AN INSTRUCTOR AND AS AN INST INSTRUCTOR. INST INSTRUCTOR FOR A SHORT PERIOD OF TIME (1 YR, 1 MONTH), WITH LESS THAN 150 TOTAL HRS GIVEN AND LESS THAN 30 HRS GIVEN AS AN INST INSTRUCTOR. 2) NOT AS FAMILIAR WITH THIS ACFT AS SHOULD BE. LESS THAN 5 TOTAL HRS LOGGED IN A BEECHCRAFT V35 BONANZA. SIMILAR EXPERIENCE FLYING ACFT LIKE THE CESSNA 182 BUT IT IS NOT AS FAST AS THE BONANZA. 3) OVERESTIMATED ABILITY TO BE ABLE TO INSTRUCT INST APCHS IN THIS FAST ACFT WITHOUT RECENTLY POLISHING INST PROCS. 4) OVERESTIMATED THE ABILITY OF THE STUDENT TO FLY INST APCHS IN THIS ACFT. 5) THE STUDENT WAS INST RATED, BUT WAS NOT CURRENT. 6) THE STUDENT OWNED THIS PARTICULAR AIRPLANE AND HAS OVER 100 HRS IN IT, BUT NONE OF IT FLOWN UNDER INST CONDITIONS (TRAINING OR ACTUAL). 7) CURRENTLY WORK A FULL TIME JOB WITH A MINIMUM OF 40 HRS PER WK ON SWING SHIFT, AND FLT INSTRUCT PART TIME BEFORE WORK EACH DAY. NOT PROVIDING THE BEST EATING AND SLEEPING HABITS NECESSARY TO PERFORM AT PEAK LEVELS FOR FLT INSTRUCTION. (AVERAGE 6 HRS A NIGHT SLEEP AND AN IRREGULAR EATING SCHEDULE). 8) CONFUSION WITH THE MISSED APCH AND CLRNC FOR THE NEXT APCH BY THE STUDENT. 9) FOCUS OF ATTN, TRYING TO EXPLAIN THE CLRNC TO THE STUDENT AS WE CROSSED DIRECTLY OVER THE VOR. 10) ALSO OVER THE VOR WE RECEIVED AN INTERCEPT HDG FROM ATC FOR AN OUTBOUND COURSE RADIAL (ADDING TO THE HIGH WORKLOAD). 11) DURING EXECUTION OF THE TURN INADVERTENT CLB OF 400 FT IN ALT. FORTUNATELY THIS OCCURRENCE WAS NO MORE THAN UNINTENTIONAL SIT THAT DID CAUSE SERIOUS INJURY OR WORSE. SOME OF THE CORRECTIVE ACTIONS WERE IMMEDIATE AND THE OTHERS WILL BE ACCOMPLISHED IN THE NEAR FUTURE. THESE INCLUDE: 1) NOTING AND PROMPTLY CORRECTING ALT BEFORE ATC ADVISED OF OUR DEV. 2) AS AN INSTRUCTOR REVIEW INST AND INSTRUCTING SKILLS MORE OFTEN. 3) WHEN FLY DIFFERENT ACFT THAT LESS FAMILIAR WITH SPEND MORE TIME LEARNING THESE ACFT BEFORE ATTEMPTING TO INSTRUCT IN THEM. 4) REDUCE WORKLOAD BTWN CURRENT JOB AND FLT INSTRUCTION.
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.