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|
Attributes | |
ACN | 588842 |
Time | |
Date | 200307 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 4000 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : zzz.tower |
Operator | general aviation : corporate |
Make Model Name | PA-28 Cherokee Arrow IV |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 32 |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 17 flight time total : 350 flight time type : 26 |
ASRS Report | 588842 |
Person 2 | |
Function | observation : passenger |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : published procedure non adherence : clearance other anomaly other anomaly other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : became reoriented flight crew : returned to original clearance flight crew : regained aircraft control |
Supplementary | |
Problem Areas | Weather Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying 2 legs of a medical flight from ZZZ to ZZZ1 in the morning, then back from ZZZ1 to ZZZ early evening. Second leg, departed at XA30 from ZZZ1. Once out of congested class B airspace, had a fine flight at 9000 ft MSL, which put us above most late afternoon cumulus buildups. Last 100 NM, ceilings 3000-4000 ft AGL. As we approached ZZZ, we were descended to 5000 ft, then vectors for ILS runway 32, descend to 3000 ft MSL until established. I had been talking with passenger while generally staying ahead of airplane. As we descended through broken layer (bases reported 3200 ft AGL), I must have been distraction, but then sensed plane accelerating rapidly. When I looked at attitude indicator, plane was 20-30 degrees nose down and banked 45-60 degrees to right. I leveled and slowed airplane and looked at GPS and saw I was 90 degrees to localizer and through the localizer by 1/2 mi. Tower asked if I wanted vectors back for another approach. I said no and established 30 degree intercept for localizer again. We had broken out and got visual contact with airport and landed without incident. I made 2 main mistakes: 1) I violated my sterile cockpit on approach, and 2) I didn't focus on the attitude indicator when entering the clouds. I attribute these failures of cockpit discipline on a sense of complacency and, to a certain extent, fatigue. I was complacent in thinking that the flight was nearly over and we 'just' had to descend through a thin overcast layer before breaking out VFR with about a 2000 ft ceiling. Fatigue may have factored in because I had slept only a few hours the night before, planning for the initial morning flight and warning about a malfunctioning mode C transponder. By the time we made the evening return ZZZ1 to ZZZ (another 1 hour 45 min flight), it was after XA00 at destination. So fatigue may have played a factor. After these events, I resolve to do the following things: 1) I will maintain a sterile cockpit during all critical phases of flight, especially takeoff/departure and approach/landing. 2) I will fixate on primary attitude instruments when entering clouds and not let myself be distraction by secondary tasks.
Original NASA ASRS Text
Title: PA28 PLT, WITH PAX, LOSES SITUATIONAL AWARENESS ON APCH TO ITH, IS ALERTED TO COURSE AND ALTDEV, RECOGNIZING A LOSS OF COCKPIT DISCIPLINE.
Narrative: I WAS FLYING 2 LEGS OF A MEDICAL FLT FROM ZZZ TO ZZZ1 IN THE MORNING, THEN BACK FROM ZZZ1 TO ZZZ EARLY EVENING. SECOND LEG, DEPARTED AT XA30 FROM ZZZ1. ONCE OUT OF CONGESTED CLASS B AIRSPACE, HAD A FINE FLT AT 9000 FT MSL, WHICH PUT US ABOVE MOST LATE AFTERNOON CUMULUS BUILDUPS. LAST 100 NM, CEILINGS 3000-4000 FT AGL. AS WE APCHED ZZZ, WE WERE DSNDED TO 5000 FT, THEN VECTORS FOR ILS RWY 32, DSND TO 3000 FT MSL UNTIL ESTABLISHED. I HAD BEEN TALKING WITH PAX WHILE GENERALLY STAYING AHEAD OF AIRPLANE. AS WE DSNDED THROUGH BROKEN LAYER (BASES RPTED 3200 FT AGL), I MUST HAVE BEEN DISTR, BUT THEN SENSED PLANE ACCELERATING RAPIDLY. WHEN I LOOKED AT ATTITUDE INDICATOR, PLANE WAS 20-30 DEGS NOSE DOWN AND BANKED 45-60 DEGS TO R. I LEVELED AND SLOWED AIRPLANE AND LOOKED AT GPS AND SAW I WAS 90 DEGS TO LOC AND THROUGH THE LOC BY 1/2 MI. TWR ASKED IF I WANTED VECTORS BACK FOR ANOTHER APCH. I SAID NO AND ESTABLISHED 30 DEG INTERCEPT FOR LOC AGAIN. WE HAD BROKEN OUT AND GOT VISUAL CONTACT WITH ARPT AND LANDED WITHOUT INCIDENT. I MADE 2 MAIN MISTAKES: 1) I VIOLATED MY STERILE COCKPIT ON APCH, AND 2) I DIDN'T FOCUS ON THE ATTITUDE INDICATOR WHEN ENTERING THE CLOUDS. I ATTRIBUTE THESE FAILURES OF COCKPIT DISCIPLINE ON A SENSE OF COMPLACENCY AND, TO A CERTAIN EXTENT, FATIGUE. I WAS COMPLACENT IN THINKING THAT THE FLT WAS NEARLY OVER AND WE 'JUST' HAD TO DSND THROUGH A THIN OVCST LAYER BEFORE BREAKING OUT VFR WITH ABOUT A 2000 FT CEILING. FATIGUE MAY HAVE FACTORED IN BECAUSE I HAD SLEPT ONLY A FEW HRS THE NIGHT BEFORE, PLANNING FOR THE INITIAL MORNING FLT AND WARNING ABOUT A MALFUNCTIONING MODE C XPONDER. BY THE TIME WE MADE THE EVENING RETURN ZZZ1 TO ZZZ (ANOTHER 1 HR 45 MIN FLT), IT WAS AFTER XA00 AT DEST. SO FATIGUE MAY HAVE PLAYED A FACTOR. AFTER THESE EVENTS, I RESOLVE TO DO THE FOLLOWING THINGS: 1) I WILL MAINTAIN A STERILE COCKPIT DURING ALL CRITICAL PHASES OF FLT, ESPECIALLY TKOF/DEP AND APCH/LNDG. 2) I WILL FIXATE ON PRIMARY ATTITUDE INSTS WHEN ENTERING CLOUDS AND NOT LET MYSELF BE DISTR BY SECONDARY TASKS.
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.