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Attributes | |
ACN | 587493 |
Time | |
Date | 200307 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : cle.airport |
State Reference | OH |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog Rain Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : cle.tracon |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude cruise : level |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : cle.tracon |
Operator | general aviation : personal |
Make Model Name | Cessna 210 Centurion / Turbo Centurion 210C, 210D |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude climbout : initial cruise : level |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : instrument |
Experience | flight time last 90 days : 25 flight time total : 2500 flight time type : 500 |
ASRS Report | 587493 |
Person 2 | |
Function | flight crew : single pilot |
Events | |
Anomaly | other anomaly other |
Independent Detector | atc equipment other atc equipment : radar other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Weather |
Primary Problem | Ambiguous |
Narrative:
This safety issue is a disoriented IFR pilot not receiving help from a controller. Rather, he was pressured and further burdened. He was in trouble with pitch, directional, and communication control. I was not personally involved, just witnessing. I was not able to take notes, I was hand flying IFR in WX that changed direction and altitude due to turbulence in 2 dimensional motion, and was plenty busy myself. I was 5000 ft IFR east of cleveland, oh, IFR conditions. Cessna 210 was departing a field east of cleveland and reported airborne to cle approach. Cleveland instructed cessna 210 to turn south. Pilot response was 'roger.' following exchanges were: aircraft Y say altitude. Pilot: no response, repeated a few times. Pilot: cleveland, I switched radios, how do you hear? Aircraft Y. Cleveland: I haven't any problem hearing you. Aircraft Y, you have missed several calls, how do you hear. Turn south. Aircraft Y: that's better, roger, aircraft Y. Cleveland: aircraft Y I show you heading east sir, please turn south. Aircraft Y: (garbled). Cleveland: (same). Aircraft Y: roger. Cleveland: aircraft Y say your heading. I show you east, I need you to turn south. Aircraft Y: roger. Then a similar exchange, all poor communication went around altitude, at 4700 ft, 5200 ft, 5500 ft, and finally the correct altitude. Also, as the flight moved southwest. Cleveland: cessna aircraft Y, say heading. Aircraft Y: roger 210 degrees. Cleveland: cessna aircraft Y, you were told to turn south, who gave you 210 degrees? Aircraft Y: roger 210 degrees. This was repeated a few times, followed by, cleveland: cessna aircraft Y contact akron approach. Aircraft Y: roger, akron. My concern was, and is: the pilot was in very rough WX. I know, I was flying too. The pilot was having communication trouble. The pilot was disoriented, may have lost confidence in his directional gyro, and tried to reset to compass setting while in a climbing turn. (Not going to work.) the pilot was 1 voice, probably single pilot IFR (heavy workload, few 210's can climb with autopilot, requires a lot of hand flying). The pilot is confused. He has apparently confused cessna 210 and heading 210 degrees to be his correct orientation. It wasn't correct. He was confused and off course. He was now being aggressively and repeatedly challenged by controller. He was clearly intimidated and now fearful. This is based on classic fear responses. He had narrowed his perspective, then stopped talking (fixate and freeze scenario, very unsafe). He needed help, bad, and didn't get any. He got intimidation and increased workload. It was ugly to listen to. The pilot flew out of it, in control, thank god. Callback conversation with reporter revealed the following information: reporter stated he and another instrument rated pilot were en route to up state new york in a PA28 and could understand the C210 pilot's dilemma. He said the WX was very rough with turbulence and moderate to heavy rain. He said the controller's phraseology was large part of the problem and thought it really flustered the C210 pilot. The reporter said after they landed, he and the other pilot noted what had happened and sent in the ASRS report.
Original NASA ASRS Text
Title: C210 PLT OFF A NEARBY ARPT ON AN IFR FLT PLAN IN SEVERE IFR CONDITIONS REPORTEDLY DISORIENTED AND RECEIVING POOR ATC SVC.
Narrative: THIS SAFETY ISSUE IS A DISORIENTED IFR PLT NOT RECEIVING HELP FROM A CTLR. RATHER, HE WAS PRESSURED AND FURTHER BURDENED. HE WAS IN TROUBLE WITH PITCH, DIRECTIONAL, AND COM CTL. I WAS NOT PERSONALLY INVOLVED, JUST WITNESSING. I WAS NOT ABLE TO TAKE NOTES, I WAS HAND FLYING IFR IN WX THAT CHANGED DIRECTION AND ALT DUE TO TURB IN 2 DIMENSIONAL MOTION, AND WAS PLENTY BUSY MYSELF. I WAS 5000 FT IFR E OF CLEVELAND, OH, IFR CONDITIONS. CESSNA 210 WAS DEPARTING A FIELD E OF CLEVELAND AND RPTED AIRBORNE TO CLE APCH. CLEVELAND INSTRUCTED CESSNA 210 TO TURN S. PLT RESPONSE WAS 'ROGER.' FOLLOWING EXCHANGES WERE: ACFT Y SAY ALT. PLT: NO RESPONSE, REPEATED A FEW TIMES. PLT: CLEVELAND, I SWITCHED RADIOS, HOW DO YOU HEAR? ACFT Y. CLEVELAND: I HAVEN'T ANY PROB HEARING YOU. ACFT Y, YOU HAVE MISSED SEVERAL CALLS, HOW DO YOU HEAR. TURN S. ACFT Y: THAT'S BETTER, ROGER, ACFT Y. CLEVELAND: ACFT Y I SHOW YOU HDG E SIR, PLEASE TURN S. ACFT Y: (GARBLED). CLEVELAND: (SAME). ACFT Y: ROGER. CLEVELAND: ACFT Y SAY YOUR HDG. I SHOW YOU E, I NEED YOU TO TURN S. ACFT Y: ROGER. THEN A SIMILAR EXCHANGE, ALL POOR COM WENT AROUND ALT, AT 4700 FT, 5200 FT, 5500 FT, AND FINALLY THE CORRECT ALT. ALSO, AS THE FLT MOVED SW. CLEVELAND: CESSNA ACFT Y, SAY HDG. ACFT Y: ROGER 210 DEGS. CLEVELAND: CESSNA ACFT Y, YOU WERE TOLD TO TURN S, WHO GAVE YOU 210 DEGS? ACFT Y: ROGER 210 DEGS. THIS WAS REPEATED A FEW TIMES, FOLLOWED BY, CLEVELAND: CESSNA ACFT Y CONTACT AKRON APCH. ACFT Y: ROGER, AKRON. MY CONCERN WAS, AND IS: THE PLT WAS IN VERY ROUGH WX. I KNOW, I WAS FLYING TOO. THE PLT WAS HAVING COM TROUBLE. THE PLT WAS DISORIENTED, MAY HAVE LOST CONFIDENCE IN HIS DIRECTIONAL GYRO, AND TRIED TO RESET TO COMPASS SETTING WHILE IN A CLBING TURN. (NOT GOING TO WORK.) THE PLT WAS 1 VOICE, PROBABLY SINGLE PLT IFR (HVY WORKLOAD, FEW 210'S CAN CLB WITH AUTOPILOT, REQUIRES A LOT OF HAND FLYING). THE PLT IS CONFUSED. HE HAS APPARENTLY CONFUSED CESSNA 210 AND HDG 210 DEGS TO BE HIS CORRECT ORIENTATION. IT WASN'T CORRECT. HE WAS CONFUSED AND OFF COURSE. HE WAS NOW BEING AGGRESSIVELY AND REPEATEDLY CHALLENGED BY CTLR. HE WAS CLEARLY INTIMIDATED AND NOW FEARFUL. THIS IS BASED ON CLASSIC FEAR RESPONSES. HE HAD NARROWED HIS PERSPECTIVE, THEN STOPPED TALKING (FIXATE AND FREEZE SCENARIO, VERY UNSAFE). HE NEEDED HELP, BAD, AND DIDN'T GET ANY. HE GOT INTIMIDATION AND INCREASED WORKLOAD. IT WAS UGLY TO LISTEN TO. THE PLT FLEW OUT OF IT, IN CTL, THANK GOD. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED HE AND ANOTHER INST RATED PLT WERE ENRTE TO UP STATE NEW YORK IN A PA28 AND COULD UNDERSTAND THE C210 PLT'S DILEMMA. HE SAID THE WX WAS VERY ROUGH WITH TURB AND MODERATE TO HVY RAIN. HE SAID THE CTLR'S PHRASEOLOGY WAS LARGE PART OF THE PROB AND THOUGHT IT REALLY FLUSTERED THE C210 PLT. THE RPTR SAID AFTER THEY LANDED, HE AND THE OTHER PLT NOTED WHAT HAD HAPPENED AND SENT IN THE ASRS RPT.
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.