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Attributes | |
ACN | 582427 |
Time | |
Date | 200305 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | Bonanza 36 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : taxi ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot maintenance : technician |
Qualification | pilot : instrument pilot : private |
Experience | flight time last 90 days : 11 flight time total : 286 flight time type : 32.4 |
ASRS Report | 582427 |
Person 2 | |
Function | observation : passenger |
Events | |
Anomaly | aircraft equipment problem : less severe conflict : ground critical ground encounters other non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I arrived at the airport early in the morning, preparing to fly home after a short vacation. I had not gotten enough sleep the night before, skipped breakfast, and was rushing to takeoff. I felt confident that the flight would be easy. During preflight, I discovered that I had left the master switch on the day before, and now the battery was completely dead. I called for a jump start, and continued the preflight. Except for the electrical system, I preflted the airplane as normal, which included removing the chains and chocks. When the auxiliary power cart arrived, we began standard external power starting procedures. I had planned to jump the engine, let it run for awhile, and then shutdown and finish preparations. In hindsight, I'm not sure why I didn't completely prepare for departure at that point, as it would've been simpler than jumping, charging, shutting down, and then preparing to start things back up again. Then, I got into the airplane with my mother, planning to 'show her how to start an airplane.' I was in the right seat, and I had apparently forgotten that this particular plane had no r-side toe brakes. I forgot the engine start checklist, and in doing so, failed to remember to apply the brakes before starting. Upon starting, the throttle position was such that the plane immediately went to 2000 RPM and began moving forward quickly. Immediately I applied the brakes and throttle to idle. I was able to easily reach the l-side brakes from the right seat, but remembering to do that after instinctively trying the r-side brakes took an extra second or two. The airplane had only moved a few inches, everyone was well clear, and I thought the situation was under control at that point, so we left the airplane running and continued charging the battery. In actuality, the leading edge of the right wing had hit the auxiliary power cart and had sustained minor damage. The leading edge skin was dented, and I determined that this was not an 'accident' under the NTSB regulations. After several more mins of charging, I shutdown the engine and everyone got out of the cockpit. I assessed the damage, and then discussed the problem over the phone with an a&P. I decided that the damage would not affect the safety of flight and finished the flight home without problems. The number of errors and downright foolish decisions in the above narrative is astounding. Why didn't I take the time to get enough sleep? Why didn't I eat breakfast? Why didn't I use the checklist? Why didn't I get into the left seat? Why did I remove the chains and chocks if I had been planning on shutting down the engine after some charging time? Why was I rushing? And then, after the damage had occurred, why didn't I wait and complete the flight after I was rested? I was trained to be cautious of all of these things, and yet I wasn't. If I had used a checklist would this have happened? Maybe, but probably not. In hindsight, I believe that the biggest problem was that I failed to recognize a state of impaired judgement in myself. Whether it was caused by lack of sleep, lack of food, family distractions, rushing, or all the above, it is clear that I misjudged my abilities that morning. Sitting here now, looking back, I still cannot fathom what I was thinking at the time, or why I thought I was making good decisions. I made a series of stupid mistakes, all of which I was trained to watch out for. I no longer believe that 'it can't happen to me.' I can't excuse what happened, but in the future, I will certainly apply a much stricter set of restrs on my physical and mental state before every flight. And I will never again take the checklist for granted.
Original NASA ASRS Text
Title: MULTIPLE ERRORS IN JUDGEMENT AND PROC END IN A COLLISION WITH A GND PWR CART BY A BONANZA A36.
Narrative: I ARRIVED AT THE ARPT EARLY IN THE MORNING, PREPARING TO FLY HOME AFTER A SHORT VACATION. I HAD NOT GOTTEN ENOUGH SLEEP THE NIGHT BEFORE, SKIPPED BREAKFAST, AND WAS RUSHING TO TKOF. I FELT CONFIDENT THAT THE FLT WOULD BE EASY. DURING PREFLT, I DISCOVERED THAT I HAD LEFT THE MASTER SWITCH ON THE DAY BEFORE, AND NOW THE BATTERY WAS COMPLETELY DEAD. I CALLED FOR A JUMP START, AND CONTINUED THE PREFLT. EXCEPT FOR THE ELECTRICAL SYS, I PREFLTED THE AIRPLANE AS NORMAL, WHICH INCLUDED REMOVING THE CHAINS AND CHOCKS. WHEN THE AUX PWR CART ARRIVED, WE BEGAN STANDARD EXTERNAL PWR STARTING PROCS. I HAD PLANNED TO JUMP THE ENG, LET IT RUN FOR AWHILE, AND THEN SHUTDOWN AND FINISH PREPARATIONS. IN HINDSIGHT, I'M NOT SURE WHY I DIDN'T COMPLETELY PREPARE FOR DEP AT THAT POINT, AS IT WOULD'VE BEEN SIMPLER THAN JUMPING, CHARGING, SHUTTING DOWN, AND THEN PREPARING TO START THINGS BACK UP AGAIN. THEN, I GOT INTO THE AIRPLANE WITH MY MOTHER, PLANNING TO 'SHOW HER HOW TO START AN AIRPLANE.' I WAS IN THE R SEAT, AND I HAD APPARENTLY FORGOTTEN THAT THIS PARTICULAR PLANE HAD NO R-SIDE TOE BRAKES. I FORGOT THE ENG START CHKLIST, AND IN DOING SO, FAILED TO REMEMBER TO APPLY THE BRAKES BEFORE STARTING. UPON STARTING, THE THROTTLE POS WAS SUCH THAT THE PLANE IMMEDIATELY WENT TO 2000 RPM AND BEGAN MOVING FORWARD QUICKLY. IMMEDIATELY I APPLIED THE BRAKES AND THROTTLE TO IDLE. I WAS ABLE TO EASILY REACH THE L-SIDE BRAKES FROM THE R SEAT, BUT REMEMBERING TO DO THAT AFTER INSTINCTIVELY TRYING THE R-SIDE BRAKES TOOK AN EXTRA SECOND OR TWO. THE AIRPLANE HAD ONLY MOVED A FEW INCHES, EVERYONE WAS WELL CLR, AND I THOUGHT THE SIT WAS UNDER CTL AT THAT POINT, SO WE LEFT THE AIRPLANE RUNNING AND CONTINUED CHARGING THE BATTERY. IN ACTUALITY, THE LEADING EDGE OF THE R WING HAD HIT THE AUX PWR CART AND HAD SUSTAINED MINOR DAMAGE. THE LEADING EDGE SKIN WAS DENTED, AND I DETERMINED THAT THIS WAS NOT AN 'ACCIDENT' UNDER THE NTSB REGS. AFTER SEVERAL MORE MINS OF CHARGING, I SHUTDOWN THE ENG AND EVERYONE GOT OUT OF THE COCKPIT. I ASSESSED THE DAMAGE, AND THEN DISCUSSED THE PROB OVER THE PHONE WITH AN A&P. I DECIDED THAT THE DAMAGE WOULD NOT AFFECT THE SAFETY OF FLT AND FINISHED THE FLT HOME WITHOUT PROBS. THE NUMBER OF ERRORS AND DOWNRIGHT FOOLISH DECISIONS IN THE ABOVE NARRATIVE IS ASTOUNDING. WHY DIDN'T I TAKE THE TIME TO GET ENOUGH SLEEP? WHY DIDN'T I EAT BREAKFAST? WHY DIDN'T I USE THE CHKLIST? WHY DIDN'T I GET INTO THE L SEAT? WHY DID I REMOVE THE CHAINS AND CHOCKS IF I HAD BEEN PLANNING ON SHUTTING DOWN THE ENG AFTER SOME CHARGING TIME? WHY WAS I RUSHING? AND THEN, AFTER THE DAMAGE HAD OCCURRED, WHY DIDN'T I WAIT AND COMPLETE THE FLT AFTER I WAS RESTED? I WAS TRAINED TO BE CAUTIOUS OF ALL OF THESE THINGS, AND YET I WASN'T. IF I HAD USED A CHKLIST WOULD THIS HAVE HAPPENED? MAYBE, BUT PROBABLY NOT. IN HINDSIGHT, I BELIEVE THAT THE BIGGEST PROB WAS THAT I FAILED TO RECOGNIZE A STATE OF IMPAIRED JUDGEMENT IN MYSELF. WHETHER IT WAS CAUSED BY LACK OF SLEEP, LACK OF FOOD, FAMILY DISTRACTIONS, RUSHING, OR ALL THE ABOVE, IT IS CLR THAT I MISJUDGED MY ABILITIES THAT MORNING. SITTING HERE NOW, LOOKING BACK, I STILL CANNOT FATHOM WHAT I WAS THINKING AT THE TIME, OR WHY I THOUGHT I WAS MAKING GOOD DECISIONS. I MADE A SERIES OF STUPID MISTAKES, ALL OF WHICH I WAS TRAINED TO WATCH OUT FOR. I NO LONGER BELIEVE THAT 'IT CAN'T HAPPEN TO ME.' I CAN'T EXCUSE WHAT HAPPENED, BUT IN THE FUTURE, I WILL CERTAINLY APPLY A MUCH STRICTER SET OF RESTRS ON MY PHYSICAL AND MENTAL STATE BEFORE EVERY FLT. AND I WILL NEVER AGAIN TAKE THE CHKLIST FOR GRANTED.
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.