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|
Attributes | |
ACN | 391767 |
Time | |
Date | 199801 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : pao |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | Bonanza 36 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground other : taxi |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 38 flight time total : 440 flight time type : 64 |
ASRS Report | 391767 |
Person 2 | |
Affiliation | government : faa |
Function | controller : ground |
Qualification | controller : non radar |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : clearance other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : insufficient time other |
Consequence | other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After a normal preflight and runup, I departed the pao airport to the west, PIC and sole person on board. WX VMC, clear sky, visibility perhaps 15-20 mi. After about 8 mins, I reached my initial cruising altitude and configured the aircraft for cruise. Checking the engine instruments shortly after, I saw the digital readout of the turbine inlet temperature for the turbocharger was abnormally high. All cht's and egt's on the graphic engine monitor were normal. I looked across at the analog (master) turbine inlet temperature in time to see the gauge pass through red line and peg itself against the right end stop in perhaps 1-2 seconds. The mixture was full rich so I pulled the throttle to idle and started a 180 degree turn back to the airport, some 8 mi or so away (still the nearest). The turbine inlet temperature fell with the idle throttle as I began to descend. I cautiously and slowly applied power to maintain altitude while monitoring the engine instruments. I was at a loss as to what was happening. While the engine continued to run, I anticipated the worst and decided that getting back on the ground in the shortest possible time was the #1 priority. I called pao and explained I had a high and fluctuating turbine inlet temperature and requested an expedited clearance back into the class D airspace for landing. This was quickly approved as I continued back to the airport. During the descent, the turbine inlet temperature made 1 or 2 brief excursions from normal but returned to normal. I stayed high throughout the approach to landing until I had the runway made. The landing was smooth and I let the aircraft run to the end of the runway and then turned off. I think I can safely say that I have never been so glad to get back on the ground. I paused for a min or so reflecting on the flight. I was shaken, but thankfully in 1 piece. I cleaned up the aircraft and then checked the checklist - - this was not a time to trust to memory. Verified ok and began to taxi. It was only as I approached the tower that I realized I had failed to switch to ground control and was still on the tower frequency. I switched over to ground control in time to hear the controller ask if I was on frequency. I had commenced taxi without clearance! After apologizing to the ground controller, I received permission to taxi. Fortunately there had been no conflicting ground traffic. Human performance: it was only after the landing that I felt shaken. During the time of the flight from the turbine inlet temperature excursion to the landing, I was afraid but in control -- clearly the first priority was getting on the ground. Landing was a huge relief. At that point I was distraction by the events of the flight and failed to comply with the tower controller's instruction to contact ground control. I had deliberately used the postlndg checklist because I felt the level of distraction. I cannot explain why I didn't contact ground control, I was still distraction and didn't remember. Preventing recurrence: I am amending my checklist to add 'contact ground control' as the final item on the after landing checklist. Hopefully this will serve as a final reminder for the next time something causes such levels of distraction.
Original NASA ASRS Text
Title: PLT OF A BEECH BE36TC FAILED TO SWITCH TO GND CTL FREQ AFTER LNDG DUE TO AN EMER RETURN TO THE ARPT, WHEREIN THE TURBINE INLET TEMP EXCEEDED RED LINE. BECAUSE OF THIS, THE PLT WAS DISTR FROM HIS NORMAL FLYING TASKS AFTER SUCCESSFULLY LNDG AND FORGOT TO CONTACT GND CTL.
Narrative: AFTER A NORMAL PREFLT AND RUNUP, I DEPARTED THE PAO ARPT TO THE W, PIC AND SOLE PERSON ON BOARD. WX VMC, CLR SKY, VISIBILITY PERHAPS 15-20 MI. AFTER ABOUT 8 MINS, I REACHED MY INITIAL CRUISING ALT AND CONFIGURED THE ACFT FOR CRUISE. CHKING THE ENG INSTS SHORTLY AFTER, I SAW THE DIGITAL READOUT OF THE TURBINE INLET TEMP FOR THE TURBOCHARGER WAS ABNORMALLY HIGH. ALL CHT'S AND EGT'S ON THE GRAPHIC ENG MONITOR WERE NORMAL. I LOOKED ACROSS AT THE ANALOG (MASTER) TURBINE INLET TEMP IN TIME TO SEE THE GAUGE PASS THROUGH RED LINE AND PEG ITSELF AGAINST THE R END STOP IN PERHAPS 1-2 SECONDS. THE MIXTURE WAS FULL RICH SO I PULLED THE THROTTLE TO IDLE AND STARTED A 180 DEG TURN BACK TO THE ARPT, SOME 8 MI OR SO AWAY (STILL THE NEAREST). THE TURBINE INLET TEMP FELL WITH THE IDLE THROTTLE AS I BEGAN TO DSND. I CAUTIOUSLY AND SLOWLY APPLIED PWR TO MAINTAIN ALT WHILE MONITORING THE ENG INSTS. I WAS AT A LOSS AS TO WHAT WAS HAPPENING. WHILE THE ENG CONTINUED TO RUN, I ANTICIPATED THE WORST AND DECIDED THAT GETTING BACK ON THE GND IN THE SHORTEST POSSIBLE TIME WAS THE #1 PRIORITY. I CALLED PAO AND EXPLAINED I HAD A HIGH AND FLUCTUATING TURBINE INLET TEMP AND REQUESTED AN EXPEDITED CLRNC BACK INTO THE CLASS D AIRSPACE FOR LNDG. THIS WAS QUICKLY APPROVED AS I CONTINUED BACK TO THE ARPT. DURING THE DSCNT, THE TURBINE INLET TEMP MADE 1 OR 2 BRIEF EXCURSIONS FROM NORMAL BUT RETURNED TO NORMAL. I STAYED HIGH THROUGHOUT THE APCH TO LNDG UNTIL I HAD THE RWY MADE. THE LNDG WAS SMOOTH AND I LET THE ACFT RUN TO THE END OF THE RWY AND THEN TURNED OFF. I THINK I CAN SAFELY SAY THAT I HAVE NEVER BEEN SO GLAD TO GET BACK ON THE GND. I PAUSED FOR A MIN OR SO REFLECTING ON THE FLT. I WAS SHAKEN, BUT THANKFULLY IN 1 PIECE. I CLEANED UP THE ACFT AND THEN CHKED THE CHKLIST - - THIS WAS NOT A TIME TO TRUST TO MEMORY. VERIFIED OK AND BEGAN TO TAXI. IT WAS ONLY AS I APCHED THE TWR THAT I REALIZED I HAD FAILED TO SWITCH TO GND CTL AND WAS STILL ON THE TWR FREQ. I SWITCHED OVER TO GND CTL IN TIME TO HEAR THE CTLR ASK IF I WAS ON FREQ. I HAD COMMENCED TAXI WITHOUT CLRNC! AFTER APOLOGIZING TO THE GND CTLR, I RECEIVED PERMISSION TO TAXI. FORTUNATELY THERE HAD BEEN NO CONFLICTING GND TFC. HUMAN PERFORMANCE: IT WAS ONLY AFTER THE LNDG THAT I FELT SHAKEN. DURING THE TIME OF THE FLT FROM THE TURBINE INLET TEMP EXCURSION TO THE LNDG, I WAS AFRAID BUT IN CTL -- CLRLY THE FIRST PRIORITY WAS GETTING ON THE GND. LNDG WAS A HUGE RELIEF. AT THAT POINT I WAS DISTR BY THE EVENTS OF THE FLT AND FAILED TO COMPLY WITH THE TWR CTLR'S INSTRUCTION TO CONTACT GND CTL. I HAD DELIBERATELY USED THE POSTLNDG CHKLIST BECAUSE I FELT THE LEVEL OF DISTR. I CANNOT EXPLAIN WHY I DIDN'T CONTACT GND CTL, I WAS STILL DISTR AND DIDN'T REMEMBER. PREVENTING RECURRENCE: I AM AMENDING MY CHKLIST TO ADD 'CONTACT GND CTL' AS THE FINAL ITEM ON THE AFTER LNDG CHKLIST. HOPEFULLY THIS WILL SERVE AS A FINAL REMINDER FOR THE NEXT TIME SOMETHING CAUSES SUCH LEVELS OF DISTR.
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.