37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 576552 |
Time | |
Date | 200303 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : bal.vortac |
State Reference | MD |
Altitude | msl single value : 9000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Ice Snow other |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : pct.tracon |
Operator | general aviation : personal |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 15r |
Flight Phase | descent : approach |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot oversight : pic |
Qualification | pilot : multi engine pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 30 flight time total : 1300 flight time type : 400 |
ASRS Report | 576552 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Events | |
Anomaly | inflight encounter : weather non adherence : clearance other spatial deviation |
Independent Detector | other controllerb |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I had been cleared by approach to descend from 9000 ft and intercept the runway 15 localizer at bwi. I flew through the localizer and missed 2 calls from approach. This resulted in approach having to rerte 2 other aircraft. The WX in the dc/bwi area was deteriorating, with ceilings lowering rapidly, visibility dropping below 2 mi, and snow. I had picked up light/moderate ice during the initial descent from 13000 ft and observed that the left alternator was not indicating that it picked up any load. The 'alternator out' warning light was not flashing. In the process of analyzing the electrical issue, and picking up the ATIS, I lost track of how far past the westminster fix I was. As a result, when approach cleared me to 3500 ft, and to intercept the runway 15 localizer, and asked me to pick up the just posted new ATIS, I did not establish a rate of descent necessary to comply. Further, in listening to new ATIS, loading the approach for runway 15 in the GPS, and continuing to monitor parts of the electrical system, I missed the 2 calls from approach. (I had turned the volume up on the second communication to better hear the ATIS.) when I punched the #2 communication off, I heard the call from approach advising me that I had been off the air and missed his calls. I was surprised, as communication #1 had been active the entire time, but at that point, I also realized that I had flown through the localizer. Then I knew I had been so preoccupied with the ATIS (greatly deteriorating conditions to 400 ft, 1 mi and snow), and watching the electrical loads, that I had not realized how close I had been to the extended line of runway 15 when instructed to descend from 9000 ft to 3500 ft. The approach terminated in a landing on runway 15. While taxiing to the FBO, the left alternator indicated that it was picking up the appropriate share of load. On the return trip to bna, the left alternator again showed that it was not carrying load. However, during ground tests on the next day by the FBO, both alternators tested as carrying load. I had flown very little, about 30 hours, in the past 90 days, although this included recurrent training in late january. The 4 trips had been long haul cross country, and flown under IFR flight plans. It had been 32 days since my previous flight. I had never flown into bwi before and, therefore, was not familiar with how the increased security measures might affect operations. I knew I was a little rusty, as my recent flying had all been 3- and 4-HR legs to places I had been many times and in good WX. Under the stress of a potential electrical problem, in class B airspace, and next to the dc air defense zones, while attempting to listen to 2 radios, program the GPS, descend, and intercept a localizer, while flying in IMC with ice, I fell into the trap of becoming overly focused on parts of the task, and lost situational awareness. All of this should have been manageable, as evidenced by the ultimate outcome of a stable approach and landing. However, what was missing was the ability to properly prioritize, and stay focused on just flying the approach. The icing was not a critical problem below 9000 ft, and the right alternator was definitely working. I should have told approach that I would not be able to get the updated ATIS in time, given the very short distance to the localizer and single pilot operations, rather than risk missing communications. Being a little rusty just added to my inefficiency, such as not dialing in the localizer on the #2 navigation soon enough or switching the GPS to vloc as soon as the procedure was entered. Prevention: a mental checklist when working on a non routine flight issue, something along the lines of: 1) fly the plane. 2) what's most important right now? 3) relax. 4) repeat steps #1-#3 above.
Original NASA ASRS Text
Title: BE58 PLT LOSES SITUATIONAL AWARENESS DURING APCH TO BWI.
Narrative: I HAD BEEN CLRED BY APCH TO DSND FROM 9000 FT AND INTERCEPT THE RWY 15 LOC AT BWI. I FLEW THROUGH THE LOC AND MISSED 2 CALLS FROM APCH. THIS RESULTED IN APCH HAVING TO RERTE 2 OTHER ACFT. THE WX IN THE DC/BWI AREA WAS DETERIORATING, WITH CEILINGS LOWERING RAPIDLY, VISIBILITY DROPPING BELOW 2 MI, AND SNOW. I HAD PICKED UP LIGHT/MODERATE ICE DURING THE INITIAL DSCNT FROM 13000 FT AND OBSERVED THAT THE L ALTERNATOR WAS NOT INDICATING THAT IT PICKED UP ANY LOAD. THE 'ALTERNATOR OUT' WARNING LIGHT WAS NOT FLASHING. IN THE PROCESS OF ANALYZING THE ELECTRICAL ISSUE, AND PICKING UP THE ATIS, I LOST TRACK OF HOW FAR PAST THE WESTMINSTER FIX I WAS. AS A RESULT, WHEN APCH CLRED ME TO 3500 FT, AND TO INTERCEPT THE RWY 15 LOC, AND ASKED ME TO PICK UP THE JUST POSTED NEW ATIS, I DID NOT ESTABLISH A RATE OF DSCNT NECESSARY TO COMPLY. FURTHER, IN LISTENING TO NEW ATIS, LOADING THE APCH FOR RWY 15 IN THE GPS, AND CONTINUING TO MONITOR PARTS OF THE ELECTRICAL SYS, I MISSED THE 2 CALLS FROM APCH. (I HAD TURNED THE VOLUME UP ON THE SECOND COM TO BETTER HEAR THE ATIS.) WHEN I PUNCHED THE #2 COM OFF, I HEARD THE CALL FROM APCH ADVISING ME THAT I HAD BEEN OFF THE AIR AND MISSED HIS CALLS. I WAS SURPRISED, AS COM #1 HAD BEEN ACTIVE THE ENTIRE TIME, BUT AT THAT POINT, I ALSO REALIZED THAT I HAD FLOWN THROUGH THE LOC. THEN I KNEW I HAD BEEN SO PREOCCUPIED WITH THE ATIS (GREATLY DETERIORATING CONDITIONS TO 400 FT, 1 MI AND SNOW), AND WATCHING THE ELECTRICAL LOADS, THAT I HAD NOT REALIZED HOW CLOSE I HAD BEEN TO THE EXTENDED LINE OF RWY 15 WHEN INSTRUCTED TO DSND FROM 9000 FT TO 3500 FT. THE APCH TERMINATED IN A LNDG ON RWY 15. WHILE TAXIING TO THE FBO, THE L ALTERNATOR INDICATED THAT IT WAS PICKING UP THE APPROPRIATE SHARE OF LOAD. ON THE RETURN TRIP TO BNA, THE L ALTERNATOR AGAIN SHOWED THAT IT WAS NOT CARRYING LOAD. HOWEVER, DURING GND TESTS ON THE NEXT DAY BY THE FBO, BOTH ALTERNATORS TESTED AS CARRYING LOAD. I HAD FLOWN VERY LITTLE, ABOUT 30 HRS, IN THE PAST 90 DAYS, ALTHOUGH THIS INCLUDED RECURRENT TRAINING IN LATE JANUARY. THE 4 TRIPS HAD BEEN LONG HAUL XCOUNTRY, AND FLOWN UNDER IFR FLT PLANS. IT HAD BEEN 32 DAYS SINCE MY PREVIOUS FLT. I HAD NEVER FLOWN INTO BWI BEFORE AND, THEREFORE, WAS NOT FAMILIAR WITH HOW THE INCREASED SECURITY MEASURES MIGHT AFFECT OPS. I KNEW I WAS A LITTLE RUSTY, AS MY RECENT FLYING HAD ALL BEEN 3- AND 4-HR LEGS TO PLACES I HAD BEEN MANY TIMES AND IN GOOD WX. UNDER THE STRESS OF A POTENTIAL ELECTRICAL PROB, IN CLASS B AIRSPACE, AND NEXT TO THE DC AIR DEFENSE ZONES, WHILE ATTEMPTING TO LISTEN TO 2 RADIOS, PROGRAM THE GPS, DSND, AND INTERCEPT A LOC, WHILE FLYING IN IMC WITH ICE, I FELL INTO THE TRAP OF BECOMING OVERLY FOCUSED ON PARTS OF THE TASK, AND LOST SITUATIONAL AWARENESS. ALL OF THIS SHOULD HAVE BEEN MANAGEABLE, AS EVIDENCED BY THE ULTIMATE OUTCOME OF A STABLE APCH AND LNDG. HOWEVER, WHAT WAS MISSING WAS THE ABILITY TO PROPERLY PRIORITIZE, AND STAY FOCUSED ON JUST FLYING THE APCH. THE ICING WAS NOT A CRITICAL PROB BELOW 9000 FT, AND THE R ALTERNATOR WAS DEFINITELY WORKING. I SHOULD HAVE TOLD APCH THAT I WOULD NOT BE ABLE TO GET THE UPDATED ATIS IN TIME, GIVEN THE VERY SHORT DISTANCE TO THE LOC AND SINGLE PLT OPS, RATHER THAN RISK MISSING COMS. BEING A LITTLE RUSTY JUST ADDED TO MY INEFFICIENCY, SUCH AS NOT DIALING IN THE LOC ON THE #2 NAV SOON ENOUGH OR SWITCHING THE GPS TO VLOC AS SOON AS THE PROC WAS ENTERED. PREVENTION: A MENTAL CHKLIST WHEN WORKING ON A NON ROUTINE FLT ISSUE, SOMETHING ALONG THE LINES OF: 1) FLY THE PLANE. 2) WHAT'S MOST IMPORTANT RIGHT NOW? 3) RELAX. 4) REPEAT STEPS #1-#3 ABOVE.
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.