37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 475391 |
Time | |
Date | 200006 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ykm.airport |
State Reference | WA |
Altitude | msl bound lower : 4700 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : psc.tracon |
Operator | general aviation : instructional |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 27 other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : multi engine pilot : atp pilot : private |
Experience | flight time last 90 days : 40 flight time total : 15000 flight time type : 200 |
ASRS Report | 475391 |
Person 2 | |
Affiliation | other |
Function | instruction : trainee |
Qualification | pilot : multi engine pilot : private pilot : instrument |
Experience | flight time total : 12000 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : became reoriented flight crew : returned to assigned altitude none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Background: this flight originated at bfi in seattle for the purpose of completing a post, annual inspection test flight and continued familiarization training for the owner/operator/PIC on newly installed, dual, garmin GNS 430 GPS navigation system. The PIC is a high time (12000+ hours) pilot with extensive cross country, IFR experience. His aircraft, (beech P58 baron) is pressurized and very well equipped. The PIC is 73 yrs of age and not computer literate, attempting to master a new state-of-the-art, GPS based area navigation system with built in commercial chart database capable of flying GPS and GPS overlays of existing approachs. Problem: chinook approach was vectoring aircraft to the final approach course, (facility) at 5000 ft and told us to 'intercept the facility and proceed inbound, at the 11 DME you are cleared for the approach.' once established on the facility at 5000 ft, the PIC confused various distance readouts, between 2 different GPS waypoints and the DME receiver and initiated descent from 5000 ft prior to reaching the 11 DME fix as depicted on the approach chart. Chinook approach noticed the altitude and requested return to 5000 ft until reaching the 11 DME fix, this altitude deviation was at approximately the 14.5 DME fix about 10 NM from the final approach fix (FAF) at donny. My belief is the PIC was thinking he was within the 10 NM as depicted on the profile view of the approach chart and was safe to descend to 4000 ft. However, and as I pointed out to the PIC afterwards, he confused the approach clearance too, meaning he was expected to remain as his last assigned altitude until such time as he arrived at the point, from which he was cleared for the approach, the 11 DME fix in this case. Performance considerations: new equipment knowledge, training and proficiency of use coupled with PIC perceptions and decisions, leading first to distractions, then to perhaps PIC not hearing or understanding the ATC clearance were factors leading to this deviation. Also, the actual approach plate is quite busy, giving this PIC, who had never flown into ykm, plenty of opportunity to develop some confusion and misunderstanding. Considerable additional training on this new equipment is scheduled to reduce the distraction factor, to the maximum extent possible to correct this and the other human factors, which lead to this error.
Original NASA ASRS Text
Title: BE58 PLT HAD ALTDEV WHILE PRACTICING OPS WITH A GPS NAV SYS.
Narrative: BACKGROUND: THIS FLT ORIGINATED AT BFI IN SEATTLE FOR THE PURPOSE OF COMPLETING A POST, ANNUAL INSPECTION TEST FLT AND CONTINUED FAMILIARIZATION TRAINING FOR THE OWNER/OPERATOR/PIC ON NEWLY INSTALLED, DUAL, GARMIN GNS 430 GPS NAV SYS. THE PIC IS A HIGH TIME (12000+ HRS) PLT WITH EXTENSIVE XCOUNTRY, IFR EXPERIENCE. HIS ACFT, (BEECH P58 BARON) IS PRESSURIZED AND VERY WELL EQUIPPED. THE PIC IS 73 YRS OF AGE AND NOT COMPUTER LITERATE, ATTEMPTING TO MASTER A NEW STATE-OF-THE-ART, GPS BASED AREA NAV SYS WITH BUILT IN COMMERCIAL CHART DATABASE CAPABLE OF FLYING GPS AND GPS OVERLAYS OF EXISTING APCHS. PROB: CHINOOK APCH WAS VECTORING ACFT TO THE FINAL APCH COURSE, (FAC) AT 5000 FT AND TOLD US TO 'INTERCEPT THE FAC AND PROCEED INBOUND, AT THE 11 DME YOU ARE CLRED FOR THE APCH.' ONCE ESTABLISHED ON THE FAC AT 5000 FT, THE PIC CONFUSED VARIOUS DISTANCE READOUTS, BTWN 2 DIFFERENT GPS WAYPOINTS AND THE DME RECEIVER AND INITIATED DSCNT FROM 5000 FT PRIOR TO REACHING THE 11 DME FIX AS DEPICTED ON THE APCH CHART. CHINOOK APPROACH NOTICED THE ALT AND REQUESTED RETURN TO 5000 FT UNTIL REACHING THE 11 DME FIX, THIS ALTDEV WAS AT APPROX THE 14.5 DME FIX ABOUT 10 NM FROM THE FINAL APCH FIX (FAF) AT DONNY. MY BELIEF IS THE PIC WAS THINKING HE WAS WITHIN THE 10 NM AS DEPICTED ON THE PROFILE VIEW OF THE APCH CHART AND WAS SAFE TO DSND TO 4000 FT. HOWEVER, AND AS I POINTED OUT TO THE PIC AFTERWARDS, HE CONFUSED THE APCH CLRNC TOO, MEANING HE WAS EXPECTED TO REMAIN AS HIS LAST ASSIGNED ALT UNTIL SUCH TIME AS HE ARRIVED AT THE POINT, FROM WHICH HE WAS CLRED FOR THE APCH, THE 11 DME FIX IN THIS CASE. PERFORMANCE CONSIDERATIONS: NEW EQUIP KNOWLEDGE, TRAINING AND PROFICIENCY OF USE COUPLED WITH PIC PERCEPTIONS AND DECISIONS, LEADING FIRST TO DISTRACTIONS, THEN TO PERHAPS PIC NOT HEARING OR UNDERSTANDING THE ATC CLRNC WERE FACTORS LEADING TO THIS DEV. ALSO, THE ACTUAL APCH PLATE IS QUITE BUSY, GIVING THIS PIC, WHO HAD NEVER FLOWN INTO YKM, PLENTY OF OPPORTUNITY TO DEVELOP SOME CONFUSION AND MISUNDERSTANDING. CONSIDERABLE ADDITIONAL TRAINING ON THIS NEW EQUIP IS SCHEDULED TO REDUCE THE DISTR FACTOR, TO THE MAX EXTENT POSSIBLE TO CORRECT THIS AND THE OTHER HUMAN FACTORS, WHICH LEAD TO THIS ERROR.
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.