37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 526453 |
Time | |
Date | 200109 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ism.airport |
State Reference | FL |
Altitude | agl single value : 300 |
Environment | |
Flight Conditions | VMC |
Weather Elements | other |
Aircraft 1 | |
Controlling Facilities | tracon : mco.tracon tower : ism.tower |
Operator | general aviation : corporate |
Make Model Name | Cessna 310/T310C |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : ism.tower |
Operator | general aviation : corporate |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Person 1 | |
Affiliation | other |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 25 flight time total : 4800 flight time type : 3800 |
ASRS Report | 526453 |
Person 2 | |
Affiliation | company : corporate |
Function | observation : company check pilot |
Events | |
Anomaly | non adherence : far non adherence : published procedure non adherence : required legal separation other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert controller : separated traffic flight crew : took evasive action |
Consequence | faa : investigated faa : reviewed incident with flight crew other |
Miss Distance | horizontal : 1000 vertical : 250 |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Passenger Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure Operational Error |
Narrative:
The aircraft involved in this incident were a twin C310, XXXX, and an aircraft the kissimmee tower referred to as 'warrior.' my mission was flying aerial photography at 2900 ft over disney world. I had filed an instrument flight plan with FSS prior to my clearance for my mission. Prior to clearance, I spoke with mr X at orl approach control. After the mission, I returned to my destination at kissimmee airport. The controller told me to contact the tower when I had the field in view and expect a VFR approach. At this time I was descending and doing my gumps and getting ready to make my visual approach. I called the tower and reported that I was inbound for a visual to runway 6 (5000 ft long), he replied with SOP, 'report 2 mi out from runway.' my environmental awareness at this time caught the next transmission, which was 'warrior, abandon the option. I have another plane to get in here.' warrior was on an instrument check ride by a designated instructor, doing an instrument approach to runway 6 for an instrument rating (see diagram a and B). I was proceeding southeast to the approach end of runway 6, in a low wing aircraft. I had not been given any instructions to square off and report a base leg, or that I was #2 to land. Warrior was now approaching the MDA and I was not advised of his location. Still being on an instrument flight plan, I was preparing to make my turn, when my cameraman, my only passenger, was alarmed at seeing a plane from his seat in the right rear, and shouted, 'do you see this plane? Do something!' at this point I was wheels down, full flaps, at blue line (110 KTS). At this very moment the tower urgently instructed warrior to break right at once. Warrior broke right. I was preparing to break left to put distance between us rapidly. Within seconds warrior had turned about 45 degrees from runway 6 and was flying southeast. At this time I estimate that I was 250 ft higher and 1000 ft from 'warrior.' I keyed my microphone and said 'thank you warrior.' then I turned to 060 degrees and continued on a short field landing. Upon turning off the active runway, I went to ground control and requested my 'taxi to YYY FBO.' this was ok'ed and the tower instructed me to call the tower on deplaning. This I did, and I was asked by the tower chief what my statement was as to what had occurred. This we discussed as described above. Contributing factors: 1) the september tragedy. Big changes occurred thereafter! 2) VFR traffic had just been released into the airspace, having been grounded for 2 weeks. 3) there are 2 large flight schools at kissimmee airport. 4) I had my instrument clearance under an IFR clearance, and did not expect a VFR plane in the approach simultaneously with my aircraft. 5) warrior's PIC was in the right seat and the check ride pilot undoubtedly in the left seat wearing a hood or foggles. 6) the warrior pilot could not see to the left, and I could not see to the right because my plane is low winged. 7) a collision was avoided by prompt tower instructions, and follow through by PIC of warrior.
Original NASA ASRS Text
Title: A SYS ERROR OCCURS WHEN ATC FAILS TO SEPARATE 2 ACFT FOR AN APCH TO THE SAME RWY AT ISM, FL.
Narrative: THE ACFT INVOLVED IN THIS INCIDENT WERE A TWIN C310, XXXX, AND AN ACFT THE KISSIMMEE TWR REFERRED TO AS 'WARRIOR.' MY MISSION WAS FLYING AERIAL PHOTOGRAPHY AT 2900 FT OVER DISNEY WORLD. I HAD FILED AN INST FLT PLAN WITH FSS PRIOR TO MY CLRNC FOR MY MISSION. PRIOR TO CLRNC, I SPOKE WITH MR X AT ORL APCH CTL. AFTER THE MISSION, I RETURNED TO MY DEST AT KISSIMMEE ARPT. THE CTLR TOLD ME TO CONTACT THE TWR WHEN I HAD THE FIELD IN VIEW AND EXPECT A VFR APCH. AT THIS TIME I WAS DSNDING AND DOING MY GUMPS AND GETTING READY TO MAKE MY VISUAL APCH. I CALLED THE TWR AND RPTED THAT I WAS INBOUND FOR A VISUAL TO RWY 6 (5000 FT LONG), HE REPLIED WITH SOP, 'RPT 2 MI OUT FROM RWY.' MY ENVIRONMENTAL AWARENESS AT THIS TIME CAUGHT THE NEXT XMISSION, WHICH WAS 'WARRIOR, ABANDON THE OPTION. I HAVE ANOTHER PLANE TO GET IN HERE.' WARRIOR WAS ON AN INST CHK RIDE BY A DESIGNATED INSTRUCTOR, DOING AN INST APCH TO RWY 6 FOR AN INST RATING (SEE DIAGRAM A AND B). I WAS PROCEEDING SE TO THE APCH END OF RWY 6, IN A LOW WING ACFT. I HAD NOT BEEN GIVEN ANY INSTRUCTIONS TO SQUARE OFF AND RPT A BASE LEG, OR THAT I WAS #2 TO LAND. WARRIOR WAS NOW APCHING THE MDA AND I WAS NOT ADVISED OF HIS LOCATION. STILL BEING ON AN INST FLT PLAN, I WAS PREPARING TO MAKE MY TURN, WHEN MY CAMERAMAN, MY ONLY PAX, WAS ALARMED AT SEEING A PLANE FROM HIS SEAT IN THE R REAR, AND SHOUTED, 'DO YOU SEE THIS PLANE? DO SOMETHING!' AT THIS POINT I WAS WHEELS DOWN, FULL FLAPS, AT BLUE LINE (110 KTS). AT THIS VERY MOMENT THE TWR URGENTLY INSTRUCTED WARRIOR TO BREAK R AT ONCE. WARRIOR BROKE R. I WAS PREPARING TO BREAK L TO PUT DISTANCE BTWN US RAPIDLY. WITHIN SECONDS WARRIOR HAD TURNED ABOUT 45 DEGS FROM RWY 6 AND WAS FLYING SE. AT THIS TIME I ESTIMATE THAT I WAS 250 FT HIGHER AND 1000 FT FROM 'WARRIOR.' I KEYED MY MIKE AND SAID 'THANK YOU WARRIOR.' THEN I TURNED TO 060 DEGS AND CONTINUED ON A SHORT FIELD LNDG. UPON TURNING OFF THE ACTIVE RWY, I WENT TO GND CTL AND REQUESTED MY 'TAXI TO YYY FBO.' THIS WAS OK'ED AND THE TWR INSTRUCTED ME TO CALL THE TWR ON DEPLANING. THIS I DID, AND I WAS ASKED BY THE TWR CHIEF WHAT MY STATEMENT WAS AS TO WHAT HAD OCCURRED. THIS WE DISCUSSED AS DESCRIBED ABOVE. CONTRIBUTING FACTORS: 1) THE SEPTEMBER TRAGEDY. BIG CHANGES OCCURRED THEREAFTER! 2) VFR TFC HAD JUST BEEN RELEASED INTO THE AIRSPACE, HAVING BEEN GNDED FOR 2 WKS. 3) THERE ARE 2 LARGE FLT SCHOOLS AT KISSIMMEE ARPT. 4) I HAD MY INST CLRNC UNDER AN IFR CLRNC, AND DID NOT EXPECT A VFR PLANE IN THE APCH SIMULTANEOUSLY WITH MY ACFT. 5) WARRIOR'S PIC WAS IN THE R SEAT AND THE CHK RIDE PLT UNDOUBTEDLY IN THE L SEAT WEARING A HOOD OR FOGGLES. 6) THE WARRIOR PLT COULD NOT SEE TO THE L, AND I COULD NOT SEE TO THE R BECAUSE MY PLANE IS LOW WINGED. 7) A COLLISION WAS AVOIDED BY PROMPT TWR INSTRUCTIONS, AND FOLLOW THROUGH BY PIC OF WARRIOR.
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.