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Attributes | |
ACN | 397770 |
Time | |
Date | 199803 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dvt |
State Reference | AZ |
Altitude | msl bound lower : 10700 msl bound upper : 10700 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : phx |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude cruise other other other |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 25 flight time total : 492 flight time type : 24 |
ASRS Report | 397770 |
Person 2 | |
Affiliation | Other |
Function | observation : passenger |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : less severe inflight encounter : vfr in imc inflight encounter : weather non adherence : published procedure non adherence : far other anomaly |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : regained aircraft control other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
My first mistake was letting the urgency of getting to the lake on time affect my go/no-go decision. In the past, I have always made it a point to be very stoic as to the consequences of canceling a flight for WX or any other reason. This time, 'get thereitis' combined with the beckoning patches of blue sky, and recent positive WX experiences clouded my judgement and I made the decision to fly. After considering the options, I decided that flying VFR would allow me the freedom to find a hole in the clouds and get on top in clear air instead of activating my IFR flight plan and having to follow a clearance which would force me to fly through the clouds (and possible icing conditions), even if only to get on top. With all of this in mind, we took to the sky. As we climbed toward the blue patches, it seemed harder and harder to find a hole large enough to climb through. We finally picked a hole and went for it. We weren't able to climb fast enough to get through the hole. I'll get to my second mistake later, but at this point I made my third mistake. I decided that since we were at least 20 NM from the nearest airway (we were below its MEA and squawking mode C, and at least 4000 ft above the highest surrounding terrain), and at least 30 mi from the nearest approach area, that there shouldn't be any IFR aircraft in the vicinity and since it looked like we only needed to climb about another 100 ft to clear the tops, I would plow on through. Things got worse. At first the sun poked through occasionally beckoning us on, then it started getting darker and by this time we had picked up a trace of rime ice. Then it gets exciting. Just as I was deciding that we would have to turn back, the engine started surging a little. I thought maybe carburetor ice. Carburetor heat didn't help. As I was occupied troubleshooting the engine, another aviation demon was sneaking up on us. It turned out that the pitot heat in this plane was inoperative (and so my second mistake had been not checking it on the ground before a flight into possible icing conditions). The pitot tube had frozen over, leading to the classic scenario. As we were climbing, the airspeed indicator was falsely reading a higher and higher airspeed and I was gradually compensating (unaware) to stay at vx indicated. The plane then began to porpoise indicating an imminent tall. I had not done such a gradual entry to a power-on stall in this aircraft, and so didn't recognize the situation at first. Then it struck me. Just as the stall broke (hard), the scenario came together in my mind. We banked at least 90 degrees during the stall and I pushed the yoke forward abruptly, throwing everything to the ceiling. The artificial horizon was caged and the directional gyro was spinning. I pulled the throttle back to idle as the airspeed increased rapidly, and recovered from this stall strictly 'seat-of-the-pants' in solid IMC. We lost between 500-1000 ft during this recovery. I did a 180 degree turn and headed back to dvt searching for VMC. We broke out in a few mins and landed VFR. The pitot tube didn't thaw out until we got below the freezing level, and so the airspeed indicator was indicating zero by the time we got out of the clouds. I am now convinced that the surging engine must have been due to the high pitch attitude causing the carburetor to malfunction. I think that I cured at least 2 people of flying in private aircraft that day. They stated clearly that this was more excitement than they ever wanted to experience. Conclusions: most of the lessons in this incident are obvious, and they are now written indelibly in my brain. The go/no-go decision must be based on cold hard facts, without peer or financial influence. Follow the rules. They are what they are for a reason. They are not arbitrary. What I thought would be a few seconds in the clouds turned into about 10 mins -- enough time to get into real trouble. Check the pitot heat before any flight which has the potential to be IFR. (It doesn't hurt to check it routinely anyway. It's easy to burn the element out by leaving it on while on the ground.) a lessobvious lesson (which fortunately, I was already adhering to), is in weight and balance. I had done a careful weight and balance calculation before this trip, and it quite possibly saved our lives. I had determined that we were within the prescribed envelope, but near the aft center of gravity limit, and near maximum gross weight. As such, I had prohibited any unplanned weight in the aft baggage compartment so as to keep our center of gravity within the envelope. If our center of gravity had been aft of the limit, we may not have ever recovered from the stall! This is the first time I have experienced an unintentional stall. It does happen!
Original NASA ASRS Text
Title: A PA28 PLT FLEW INTO IMC CONDITIONS, INCLUDING ICING, WHILE ON A VFR FLT PLAN WITH NO PITOT HEAT. HE ACQUIRED ICE ON THE AIRFRAME AND THE PITOT STATIC SYS AND STALLED THE ACFT.
Narrative: MY FIRST MISTAKE WAS LETTING THE URGENCY OF GETTING TO THE LAKE ON TIME AFFECT MY GO/NO-GO DECISION. IN THE PAST, I HAVE ALWAYS MADE IT A POINT TO BE VERY STOIC AS TO THE CONSEQUENCES OF CANCELING A FLT FOR WX OR ANY OTHER REASON. THIS TIME, 'GET THEREITIS' COMBINED WITH THE BECKONING PATCHES OF BLUE SKY, AND RECENT POSITIVE WX EXPERIENCES CLOUDED MY JUDGEMENT AND I MADE THE DECISION TO FLY. AFTER CONSIDERING THE OPTIONS, I DECIDED THAT FLYING VFR WOULD ALLOW ME THE FREEDOM TO FIND A HOLE IN THE CLOUDS AND GET ON TOP IN CLR AIR INSTEAD OF ACTIVATING MY IFR FLT PLAN AND HAVING TO FOLLOW A CLRNC WHICH WOULD FORCE ME TO FLY THROUGH THE CLOUDS (AND POSSIBLE ICING CONDITIONS), EVEN IF ONLY TO GET ON TOP. WITH ALL OF THIS IN MIND, WE TOOK TO THE SKY. AS WE CLBED TOWARD THE BLUE PATCHES, IT SEEMED HARDER AND HARDER TO FIND A HOLE LARGE ENOUGH TO CLB THROUGH. WE FINALLY PICKED A HOLE AND WENT FOR IT. WE WEREN'T ABLE TO CLB FAST ENOUGH TO GET THROUGH THE HOLE. I'LL GET TO MY SECOND MISTAKE LATER, BUT AT THIS POINT I MADE MY THIRD MISTAKE. I DECIDED THAT SINCE WE WERE AT LEAST 20 NM FROM THE NEAREST AIRWAY (WE WERE BELOW ITS MEA AND SQUAWKING MODE C, AND AT LEAST 4000 FT ABOVE THE HIGHEST SURROUNDING TERRAIN), AND AT LEAST 30 MI FROM THE NEAREST APCH AREA, THAT THERE SHOULDN'T BE ANY IFR ACFT IN THE VICINITY AND SINCE IT LOOKED LIKE WE ONLY NEEDED TO CLB ABOUT ANOTHER 100 FT TO CLR THE TOPS, I WOULD PLOW ON THROUGH. THINGS GOT WORSE. AT FIRST THE SUN POKED THROUGH OCCASIONALLY BECKONING US ON, THEN IT STARTED GETTING DARKER AND BY THIS TIME WE HAD PICKED UP A TRACE OF RIME ICE. THEN IT GETS EXCITING. JUST AS I WAS DECIDING THAT WE WOULD HAVE TO TURN BACK, THE ENG STARTED SURGING A LITTLE. I THOUGHT MAYBE CARB ICE. CARB HEAT DIDN'T HELP. AS I WAS OCCUPIED TROUBLESHOOTING THE ENG, ANOTHER AVIATION DEMON WAS SNEAKING UP ON US. IT TURNED OUT THAT THE PITOT HEAT IN THIS PLANE WAS INOP (AND SO MY SECOND MISTAKE HAD BEEN NOT CHKING IT ON THE GND BEFORE A FLT INTO POSSIBLE ICING CONDITIONS). THE PITOT TUBE HAD FROZEN OVER, LEADING TO THE CLASSIC SCENARIO. AS WE WERE CLBING, THE AIRSPD INDICATOR WAS FALSELY READING A HIGHER AND HIGHER AIRSPD AND I WAS GRADUALLY COMPENSATING (UNAWARE) TO STAY AT VX INDICATED. THE PLANE THEN BEGAN TO PORPOISE INDICATING AN IMMINENT TALL. I HAD NOT DONE SUCH A GRADUAL ENTRY TO A PWR-ON STALL IN THIS ACFT, AND SO DIDN'T RECOGNIZE THE SIT AT FIRST. THEN IT STRUCK ME. JUST AS THE STALL BROKE (HARD), THE SCENARIO CAME TOGETHER IN MY MIND. WE BANKED AT LEAST 90 DEGS DURING THE STALL AND I PUSHED THE YOKE FORWARD ABRUPTLY, THROWING EVERYTHING TO THE CEILING. THE ARTIFICIAL HORIZON WAS CAGED AND THE DIRECTIONAL GYRO WAS SPINNING. I PULLED THE THROTTLE BACK TO IDLE AS THE AIRSPD INCREASED RAPIDLY, AND RECOVERED FROM THIS STALL STRICTLY 'SEAT-OF-THE-PANTS' IN SOLID IMC. WE LOST BTWN 500-1000 FT DURING THIS RECOVERY. I DID A 180 DEG TURN AND HEADED BACK TO DVT SEARCHING FOR VMC. WE BROKE OUT IN A FEW MINS AND LANDED VFR. THE PITOT TUBE DIDN'T THAW OUT UNTIL WE GOT BELOW THE FREEZING LEVEL, AND SO THE AIRSPD INDICATOR WAS INDICATING ZERO BY THE TIME WE GOT OUT OF THE CLOUDS. I AM NOW CONVINCED THAT THE SURGING ENG MUST HAVE BEEN DUE TO THE HIGH PITCH ATTITUDE CAUSING THE CARB TO MALFUNCTION. I THINK THAT I CURED AT LEAST 2 PEOPLE OF FLYING IN PVT ACFT THAT DAY. THEY STATED CLRLY THAT THIS WAS MORE EXCITEMENT THAN THEY EVER WANTED TO EXPERIENCE. CONCLUSIONS: MOST OF THE LESSONS IN THIS INCIDENT ARE OBVIOUS, AND THEY ARE NOW WRITTEN INDELIBLY IN MY BRAIN. THE GO/NO-GO DECISION MUST BE BASED ON COLD HARD FACTS, WITHOUT PEER OR FINANCIAL INFLUENCE. FOLLOW THE RULES. THEY ARE WHAT THEY ARE FOR A REASON. THEY ARE NOT ARBITRARY. WHAT I THOUGHT WOULD BE A FEW SECONDS IN THE CLOUDS TURNED INTO ABOUT 10 MINS -- ENOUGH TIME TO GET INTO REAL TROUBLE. CHK THE PITOT HEAT BEFORE ANY FLT WHICH HAS THE POTENTIAL TO BE IFR. (IT DOESN'T HURT TO CHK IT ROUTINELY ANYWAY. IT'S EASY TO BURN THE ELEMENT OUT BY LEAVING IT ON WHILE ON THE GND.) A LESSOBVIOUS LESSON (WHICH FORTUNATELY, I WAS ALREADY ADHERING TO), IS IN WT AND BAL. I HAD DONE A CAREFUL WT AND BAL CALCULATION BEFORE THIS TRIP, AND IT QUITE POSSIBLY SAVED OUR LIVES. I HAD DETERMINED THAT WE WERE WITHIN THE PRESCRIBED ENVELOPE, BUT NEAR THE AFT CTR OF GRAVITY LIMIT, AND NEAR MAX GROSS WT. AS SUCH, I HAD PROHIBITED ANY UNPLANNED WT IN THE AFT BAGGAGE COMPARTMENT SO AS TO KEEP OUR CTR OF GRAVITY WITHIN THE ENVELOPE. IF OUR CTR OF GRAVITY HAD BEEN AFT OF THE LIMIT, WE MAY NOT HAVE EVER RECOVERED FROM THE STALL! THIS IS THE FIRST TIME I HAVE EXPERIENCED AN UNINTENTIONAL STALL. IT DOES HAPPEN!
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.