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|
Attributes | |
ACN | 545919 |
Time | |
Date | 200204 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl bound lower : 7000 msl bound upper : 9000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Ice Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz1.artcc artcc : zzz2.artcc |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, Low Wing, 2 Eng, Retractable Gear |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : private pilot : multi engine |
Experience | flight time last 90 days : 61 flight time total : 805 flight time type : 234 |
ASRS Report | 545919 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude inflight encounter : turbulence inflight encounter : weather inflight encounter other non adherence : clearance other anomaly other anomaly other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : provided flight assist controller : issued new clearance flight crew : became reoriented flight crew : declared emergency flight crew : diverted to another airport flight crew : exited adverse environment flight crew : regained aircraft control |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Weather ATC Human Performance Flight Crew Human Performance Environmental Factor Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Subject aircraft is certified for flight into known icing conditions with hot propellers, wing/tail boots, hot plate on windshield. Twin engine with plenty of fuel. Encountered increasing icing conditions. Requested, then demanded clearance to climb. Unable to climb successfully, experienced aircraft control problems. Finally declared emergency and diverted to ZZZ. Yesterday, I declared my first in-flight emergency. Simply put, WX and circumstances exceeded the skill and judgement of the pilot. The mission was simple. I agreed to fly the aircraft for a quick inspection and demonstration flight by a potential purchaser. The trip down and the demonstration flight were uneventful. Looking at the WX monday night and tuesday morning, I realized that the return trip would be the more challenging. I specified a departure time on the return flight plan, and was aware that my flight plan might 'time out.' I examined the radar images and textual reports on the terminal at the FBO. As forecast, rain was moving into my route of flight. For some reason, I was much more concerned about thunderstorms than icing. The destination terminal indicated rain showers, but did not seem to include any of my main worries: thunderstorms, low ceilings or low visibility. I had at least 4 hours of fuel. I did not actually speak with an FSS briefer, but his comments might have led me to give more thought/concern to icing issues. In the past, my general plan was to use the turbos and deice equipment to climb above any icing conditions and to not fly whenever freezing rain or ice pellets are forecast. Using the above rationale, I decided to launch and attempt the return flight, reasonable to at least start out and evaluate conditions as I went. I noticed that I had picked up a 'trace' of ice on my temperature probe. I asked center to obtain a tops report. He reported that clouds were layered or solid above me. It should have dawned on me that icing may be a significant issue in this flight. The ice on the temperature probe is no longer a trace but is now a 'layer.' time to turn on the hot propellers. I see a trace out on the wing boots. Pop the boots once. I get xferred to ZZZ2 center and mention that I'm picking up a little ice. The controller responds 'let me know if you need a different altitude.' this gives me an unwarranted sense of confidence. My plan to climb to a higher altitude is 'validated' by the controller. A few more mins go by. The windshield is turning opaque -- turn on the windshield plate. Now I've got some real ice building, at last 1/4 inch on the temperature probe and growing. 'Center, aircraft X request 11000 ft,' and the response comes back 'on request.' my mental state has moved to one of heightened concern. I quickly don oxygen cannula and glasses, and turn on the oxygen. The ice is now building rapidly. Pop the boots again. 'Center, I need higher, now.' 'climb and maintain 9000 ft.' my mental state has moved from heightened concern to one of significant worry, and it starts to take a serious toll on my flying. I turn off the autoplt and set up the climb confign. In retrospect, what I needed here was takeoff power, not a gentle cruise climb. I was running lean-of-peak and simply added a little manifold pressure. For whatever reason, I've been reluctant (and never practiced) going from lean-of-peak to full rich for some type of emergency. I haven't had enough recent training that jamming the mixture forward was an automatic behavior. The temperature probe has at least 1/2 inch on it and is growing rapidly. I look down at the (unprotected) portion of the wing next to the fuselage and it now looks truly menacing. And worst of all, I'm barely climbing. Chunks of ice are leaving the airframe and banging into the tail. I'm popping the boots now every 20 seconds. Sometimes the vsi is going up, sometimes it's going down. Finally check the attitude indicator -- we've got a 30 degree turn going. Now the static instruments are jumping up and down. Open up the alternate static port. Darn, I'm descending again! Add more manifold pressure. Check the ice again -- truly ugly -- pop the boots. Check the attitude indicator again -- now we're in a 45 degree turn. Glance at the HSI -- we're now perpendicular to our intended course. Maybe I should engage the autoplt. I worry that the autoplt might mask aerodynamic problems. My mental state is now simply one of panic. The altimeter and vsi are bouncing all over the place. I add more manifold pressure, but the overboost warning light comes on. I'm not paying enough attention to the attitude indicator. Once again, we're in an 'unusual attitude.' I would guess that my immediate problems during this climb attempt were roughly: 25% due to lack of power (lean-of-peak), 25% due to airframe icing, and 50% due to dreadful instrument flying technique. The recognition slowly grows on me that the likely outcome of this mess is either that the ice will grow to the point that I fall out of the sky or that I will simply spiral the plane into the ground. I hadn't anticipated this and don't have a well-rehearsed escape plan. At this point, for whatever reason, the vsi goes to a 50 FPM descent. That put me over the 'edge.' 'center, this just isn't working. I need vectors to the nearest field with an instrument approach.' center asks, 'are you declaring an emergency?' lots of articles I've read stress that one should not hesitate to declare an emergency. 'Affirmative, I am declaring an emergency.' I remember the controller repeating descend and maintain 6000 ft several times. I must not have been acknowledging. The airplane seemed to handle better in the descent and I slowly began to feel that I was in control of the airplane's attitude and direction. Center asked if I would like the runway 36 approach. I'm feeling a little more comfortable -- the plane is going where I point it and the attitude indicator seems right side up. I've never done a real emergency diversion to an airport. I practiced it in my last instrument proficiency check, but that's when my mind was functioning. I pull up the GPS nearest airport page (fortunately, I'm very proficient with the GPS and zipped through this). I'm down to 5000 ft now. Each controller asks for souls on board and remaining fuel. I'd be willing to bet that at least 1 pilot has bit the dust trying to compute remaining fuel during an emergency rather than flying the airplane. The answer 'I've got plenty of fuel' (4+ hours) just didn't seem to satisfy them for long. At this point they start rattling off AWOS frequencys. I'm in no condition to set up and fetch automated WX. I scribble down the frequency somewhere and moved on. Next priority is to set up the instrument approach. I set up the ILS frequency. Descend and maintain 4000 ft. Switch to another ZZZ1 center frequency. I'm finally breaking out below the clouds! It's misting/raining down here, but I can see the ground and the ice is melting off! I'm on vectors for the ILS 36 approach. Those few readers that are still with me may be thinking that I'm now 'out of the woods' and land uneventfully. Unfortunately, that is not to be the case.
Original NASA ASRS Text
Title: INFLT ENCOUNTER WITH ICING AND TEMPORARY LOSS OF ACFT CTL, DURING AN IMC FLT BY A GA ACFT, MANDATES A DECLARATION OF AN EMER AND DIVERSION TO AN ALTERNATE ARPT AT ZZZ, US.
Narrative: SUBJECT ACFT IS CERTIFIED FOR FLT INTO KNOWN ICING CONDITIONS WITH HOT PROPS, WING/TAIL BOOTS, HOT PLATE ON WINDSHIELD. TWIN ENG WITH PLENTY OF FUEL. ENCOUNTERED INCREASING ICING CONDITIONS. REQUESTED, THEN DEMANDED CLRNC TO CLB. UNABLE TO CLB SUCCESSFULLY, EXPERIENCED ACFT CTL PROBS. FINALLY DECLARED EMER AND DIVERTED TO ZZZ. YESTERDAY, I DECLARED MY FIRST INFLT EMER. SIMPLY PUT, WX AND CIRCUMSTANCES EXCEEDED THE SKILL AND JUDGEMENT OF THE PLT. THE MISSION WAS SIMPLE. I AGREED TO FLY THE ACFT FOR A QUICK INSPECTION AND DEMO FLT BY A POTENTIAL PURCHASER. THE TRIP DOWN AND THE DEMO FLT WERE UNEVENTFUL. LOOKING AT THE WX MONDAY NIGHT AND TUESDAY MORNING, I REALIZED THAT THE RETURN TRIP WOULD BE THE MORE CHALLENGING. I SPECIFIED A DEP TIME ON THE RETURN FLT PLAN, AND WAS AWARE THAT MY FLT PLAN MIGHT 'TIME OUT.' I EXAMINED THE RADAR IMAGES AND TEXTUAL RPTS ON THE TERMINAL AT THE FBO. AS FORECAST, RAIN WAS MOVING INTO MY RTE OF FLT. FOR SOME REASON, I WAS MUCH MORE CONCERNED ABOUT TSTMS THAN ICING. THE DEST TERMINAL INDICATED RAIN SHOWERS, BUT DID NOT SEEM TO INCLUDE ANY OF MY MAIN WORRIES: TSTMS, LOW CEILINGS OR LOW VISIBILITY. I HAD AT LEAST 4 HRS OF FUEL. I DID NOT ACTUALLY SPEAK WITH AN FSS BRIEFER, BUT HIS COMMENTS MIGHT HAVE LED ME TO GIVE MORE THOUGHT/CONCERN TO ICING ISSUES. IN THE PAST, MY GENERAL PLAN WAS TO USE THE TURBOS AND DEICE EQUIP TO CLB ABOVE ANY ICING CONDITIONS AND TO NOT FLY WHENEVER FREEZING RAIN OR ICE PELLETS ARE FORECAST. USING THE ABOVE RATIONALE, I DECIDED TO LAUNCH AND ATTEMPT THE RETURN FLT, REASONABLE TO AT LEAST START OUT AND EVALUATE CONDITIONS AS I WENT. I NOTICED THAT I HAD PICKED UP A 'TRACE' OF ICE ON MY TEMP PROBE. I ASKED CTR TO OBTAIN A TOPS RPT. HE RPTED THAT CLOUDS WERE LAYERED OR SOLID ABOVE ME. IT SHOULD HAVE DAWNED ON ME THAT ICING MAY BE A SIGNIFICANT ISSUE IN THIS FLT. THE ICE ON THE TEMP PROBE IS NO LONGER A TRACE BUT IS NOW A 'LAYER.' TIME TO TURN ON THE HOT PROPS. I SEE A TRACE OUT ON THE WING BOOTS. POP THE BOOTS ONCE. I GET XFERRED TO ZZZ2 CTR AND MENTION THAT I'M PICKING UP A LITTLE ICE. THE CTLR RESPONDS 'LET ME KNOW IF YOU NEED A DIFFERENT ALT.' THIS GIVES ME AN UNWARRANTED SENSE OF CONFIDENCE. MY PLAN TO CLB TO A HIGHER ALT IS 'VALIDATED' BY THE CTLR. A FEW MORE MINS GO BY. THE WINDSHIELD IS TURNING OPAQUE -- TURN ON THE WINDSHIELD PLATE. NOW I'VE GOT SOME REAL ICE BUILDING, AT LAST 1/4 INCH ON THE TEMP PROBE AND GROWING. 'CTR, ACFT X REQUEST 11000 FT,' AND THE RESPONSE COMES BACK 'ON REQUEST.' MY MENTAL STATE HAS MOVED TO ONE OF HEIGHTENED CONCERN. I QUICKLY DON OXYGEN CANNULA AND GLASSES, AND TURN ON THE OXYGEN. THE ICE IS NOW BUILDING RAPIDLY. POP THE BOOTS AGAIN. 'CTR, I NEED HIGHER, NOW.' 'CLB AND MAINTAIN 9000 FT.' MY MENTAL STATE HAS MOVED FROM HEIGHTENED CONCERN TO ONE OF SIGNIFICANT WORRY, AND IT STARTS TO TAKE A SERIOUS TOLL ON MY FLYING. I TURN OFF THE AUTOPLT AND SET UP THE CLB CONFIGN. IN RETROSPECT, WHAT I NEEDED HERE WAS TKOF PWR, NOT A GENTLE CRUISE CLB. I WAS RUNNING LEAN-OF-PEAK AND SIMPLY ADDED A LITTLE MANIFOLD PRESSURE. FOR WHATEVER REASON, I'VE BEEN RELUCTANT (AND NEVER PRACTICED) GOING FROM LEAN-OF-PEAK TO FULL RICH FOR SOME TYPE OF EMER. I HAVEN'T HAD ENOUGH RECENT TRAINING THAT JAMMING THE MIXTURE FORWARD WAS AN AUTOMATIC BEHAVIOR. THE TEMP PROBE HAS AT LEAST 1/2 INCH ON IT AND IS GROWING RAPIDLY. I LOOK DOWN AT THE (UNPROTECTED) PORTION OF THE WING NEXT TO THE FUSELAGE AND IT NOW LOOKS TRULY MENACING. AND WORST OF ALL, I'M BARELY CLBING. CHUNKS OF ICE ARE LEAVING THE AIRFRAME AND BANGING INTO THE TAIL. I'M POPPING THE BOOTS NOW EVERY 20 SECONDS. SOMETIMES THE VSI IS GOING UP, SOMETIMES IT'S GOING DOWN. FINALLY CHK THE ATTITUDE INDICATOR -- WE'VE GOT A 30 DEG TURN GOING. NOW THE STATIC INSTS ARE JUMPING UP AND DOWN. OPEN UP THE ALTERNATE STATIC PORT. DARN, I'M DSNDING AGAIN! ADD MORE MANIFOLD PRESSURE. CHK THE ICE AGAIN -- TRULY UGLY -- POP THE BOOTS. CHK THE ATTITUDE INDICATOR AGAIN -- NOW WE'RE IN A 45 DEG TURN. GLANCE AT THE HSI -- WE'RE NOW PERPENDICULAR TO OUR INTENDED COURSE. MAYBE I SHOULD ENGAGE THE AUTOPLT. I WORRY THAT THE AUTOPLT MIGHT MASK AERODYNAMIC PROBS. MY MENTAL STATE IS NOW SIMPLY ONE OF PANIC. THE ALTIMETER AND VSI ARE BOUNCING ALL OVER THE PLACE. I ADD MORE MANIFOLD PRESSURE, BUT THE OVERBOOST WARNING LIGHT COMES ON. I'M NOT PAYING ENOUGH ATTN TO THE ATTITUDE INDICATOR. ONCE AGAIN, WE'RE IN AN 'UNUSUAL ATTITUDE.' I WOULD GUESS THAT MY IMMEDIATE PROBS DURING THIS CLB ATTEMPT WERE ROUGHLY: 25% DUE TO LACK OF PWR (LEAN-OF-PEAK), 25% DUE TO AIRFRAME ICING, AND 50% DUE TO DREADFUL INST FLYING TECHNIQUE. THE RECOGNITION SLOWLY GROWS ON ME THAT THE LIKELY OUTCOME OF THIS MESS IS EITHER THAT THE ICE WILL GROW TO THE POINT THAT I FALL OUT OF THE SKY OR THAT I WILL SIMPLY SPIRAL THE PLANE INTO THE GND. I HADN'T ANTICIPATED THIS AND DON'T HAVE A WELL-REHEARSED ESCAPE PLAN. AT THIS POINT, FOR WHATEVER REASON, THE VSI GOES TO A 50 FPM DSCNT. THAT PUT ME OVER THE 'EDGE.' 'CTR, THIS JUST ISN'T WORKING. I NEED VECTORS TO THE NEAREST FIELD WITH AN INST APCH.' CTR ASKS, 'ARE YOU DECLARING AN EMER?' LOTS OF ARTICLES I'VE READ STRESS THAT ONE SHOULD NOT HESITATE TO DECLARE AN EMER. 'AFFIRMATIVE, I AM DECLARING AN EMER.' I REMEMBER THE CTLR REPEATING DESCEND AND MAINTAIN 6000 FT SEVERAL TIMES. I MUST NOT HAVE BEEN ACKNOWLEDGING. THE AIRPLANE SEEMED TO HANDLE BETTER IN THE DSCNT AND I SLOWLY BEGAN TO FEEL THAT I WAS IN CTL OF THE AIRPLANE'S ATTITUDE AND DIRECTION. CTR ASKED IF I WOULD LIKE THE RWY 36 APCH. I'M FEELING A LITTLE MORE COMFORTABLE -- THE PLANE IS GOING WHERE I POINT IT AND THE ATTITUDE INDICATOR SEEMS RIGHT SIDE UP. I'VE NEVER DONE A REAL EMER DIVERSION TO AN ARPT. I PRACTICED IT IN MY LAST INSTRUMENT PROFICIENCY CHECK, BUT THAT'S WHEN MY MIND WAS FUNCTIONING. I PULL UP THE GPS NEAREST ARPT PAGE (FORTUNATELY, I'M VERY PROFICIENT WITH THE GPS AND ZIPPED THROUGH THIS). I'M DOWN TO 5000 FT NOW. EACH CTLR ASKS FOR SOULS ON BOARD AND REMAINING FUEL. I'D BE WILLING TO BET THAT AT LEAST 1 PLT HAS BIT THE DUST TRYING TO COMPUTE REMAINING FUEL DURING AN EMER RATHER THAN FLYING THE AIRPLANE. THE ANSWER 'I'VE GOT PLENTY OF FUEL' (4+ HRS) JUST DIDN'T SEEM TO SATISFY THEM FOR LONG. AT THIS POINT THEY START RATTLING OFF AWOS FREQS. I'M IN NO CONDITION TO SET UP AND FETCH AUTOMATED WX. I SCRIBBLE DOWN THE FREQ SOMEWHERE AND MOVED ON. NEXT PRIORITY IS TO SET UP THE INST APCH. I SET UP THE ILS FREQ. DSND AND MAINTAIN 4000 FT. SWITCH TO ANOTHER ZZZ1 CTR FREQ. I'M FINALLY BREAKING OUT BELOW THE CLOUDS! IT'S MISTING/RAINING DOWN HERE, BUT I CAN SEE THE GND AND THE ICE IS MELTING OFF! I'M ON VECTORS FOR THE ILS 36 APCH. THOSE FEW READERS THAT ARE STILL WITH ME MAY BE THINKING THAT I'M NOW 'OUT OF THE WOODS' AND LAND UNEVENTFULLY. UNFORTUNATELY, THAT IS NOT TO BE THE CASE.
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.