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|
Attributes | |
ACN | 613168 |
Time | |
Date | 200404 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound upper : 8500 |
Environment | |
Flight Conditions | Marginal |
Weather Elements | Fog Turbulence Thunderstorm Rain other |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc tracon : l30.tracon tower : abe.tower |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 119 |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | arrival : on vectors departure : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude |
Route In Use | approach : traffic pattern |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : multi engine pilot : commercial pilot : cfi pilot : instrument |
Experience | flight time last 90 days : 52 flight time total : 1050 flight time type : 12 |
ASRS Report | 613168 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude altitude deviation : overshoot altitude deviation : undershoot conflict : airborne critical inflight encounter : weather non adherence : clearance non adherence : required legal separation non adherence : published procedure non adherence : far other anomaly other spatial deviation other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera other flight crewa |
Resolutory Action | flight crew : exited adverse environment flight crew : regained aircraft control flight crew : landed in emergency condition flight crew : became reoriented flight crew : declared emergency flight crew : executed go around |
Consequence | faa : reviewed incident with flight crew faa : investigated |
Miss Distance | horizontal : 200 vertical : 500 |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure |
Narrative:
Departing vgt, ground cleared us for northtown 1 departure. I advised unable to accept due no departure chart on board and no DME. On departure, aircraft performed poorly. VOR #1 indicated steady 3 dots fly right indication west/fr flag. Immediately, I turned right to intercept, assuming I flew through course on initial climb. Departure asked what we showed. I said 3 dots fly right. They said radar vectors, and we turned around. I continued climbing. I advised controller we were unable to expedite climb per their repeated requests. I had a hard time shaking the assumption that I was doing something wrong. The airplane couldn't possibly have this many problems develop all at once. We entered IMC and things really got weird. The tc wasn't reading right. The attitude indicator wasn't acting properly, later found to be a slow failure. The heading gyro was processing too fast, but it hadn't failed. Gotta be me -- maybe I'm not scanning fast enough causing a pilot induced oscillation. On the climb from past las to the valley, the controller kept telling me to turn 10 degrees left. We were in turbulence, but I couldn't pin down what was going on. The third time the controller asked me to turn 10 degrees left, I rolled into a standard rate turn on the attitude gyro, counted 3 seconds, then rolled out and struggled to maintain that heading between the GPS tk, compass froth (in turbulence), and heading gyro. The departure controller handed me off to ZLA. That controller cleared me to 10000 ft and expedite climb, then issued another heading and direct gfs VOR. I advised him I had 3 KTS between stall, climb, and descent. The controller issued another stack of instructions including another heading to track towards gfs. There was also a cargo flight coming in to the vegas area that the controller called me as traffic to him, and called him as traffic to me. Both of us were IMC and unable to spot each other. From the chatter, I estimate we were less than 500 ft apart horizontally. I asked center for the phone number that TRACON had asked me to call. I copied it, and all hell broke loose again. The vsi was jumping, altimeter was jumping, and airspeed was jumping, like encountering updrafts and downdrafts associated with convective activity. I told center I was unable to maintain altitude, then immediately encountered more turbulence. I was having a difficult time maintaining aircraft control and couldn't quite figure out what was going on. I did notice the turn coordinator as having flagged failed, so I covered it, leaving the ball available. My airspeed wound up to 80 KTS and my vsi showed a 1000 FPM positive climb rate. Maybe I'd be able to climb up to the altitude taking advantage of the updraft. I pitched the nose up and immediately the turbulence got worse, almost like the stall buffet. Airspeed increased. No stall light. Vsi increased. Felt light in my seat. The sick attitude gyro showed the nose dropping, sick heading and GPS showed a left turn. At the same time the center controller started issuing multiple clrncs at me. All I could tell the fellow was stand by. I asked for vectors to the nearest las vegas airport. The handheld GPS said I was close to jean airport, but didn't tell me how close I was to the largest set of mountains. I rolled out of the turn and the airplane went smooth, the radio silenced, and I felt a strong urge to just give up. I did not know where I was in relationship to the nearest mountain, my vsi and asi were all over the place, I wasn't bothering to look at the altimeter. I was just so tired of fighting and I couldn't figure out the current situation. I knew if I let go, the airplane would roll into a steep right turn. Then the airspeed needle stopped, about 100 KTS, and slowly decreased to zero, then past the peg and decreased to 120 KTS. Of course, no pitot heat on the aircraft. I thought it was quite funny. I resumed command of the situation. With all of my simulator time behind failed instruments, the attitude was giving accurate nose moving up or down information, and delayed bank information. The heading indicator was showing rate of turn by how much it processed. A slow left turn was level. A faster turn in either direction was an actual turn. The ball of the turn coordinator said if I was slipping or skidding. ZLA asked me to contact las approach one more time. I directed my passenger to set the frequency as I was unable to take that distraction from scanning the flight instruments. I called, no response. No other air traffic on frequency either. Not lost communication! With my exact position unknown in relation to the terrain, I started slow right turns. I looked on my kneeboard, saw the known departure control frequency and directed the passenger to set that one in. He did and immediately the radio came to life. I tried calling the controller. He responded, 'you need to contact blah blah....' I responded 'unable.' I advised the controller I had lost all 3 gyros, navigation #1, and needed a vector to any las vegas airport. In between no gyro vectors, he cleared his scope, tried to get me into jean airport, couldn't, and advised that he was sending me into mccarran. My passenger reminded me to tell the controller that I had lost the airspeed. I did and the controller asked if I was picking up ice. No visible ice, and in heavy rain, but that doesn't mean the pitot tube had not iced over. The controller issued dscnts and gave ground speed reports. My workload decreased substantially now that someone knew where we were and was keeping us away from terrain. I was below the freezing level according to forecasts. Passing through 6500 ft, the heavens opened, I broke out between layers with a small hole revealing the ground. I aimed for the hole. I spotted I-15 and the corner of a dry lake bed. That meant I was just a few mi south of jean airport. I picked my way between clouds to jean airport. In the process, the controller advised of low altitude, and said he was vectoring me to mccarran. I kept descending. Then the controller asked if I was canceling IFR. Behold the airport, the runways, and I told the controller I was canceling. There was a helicopter on frequency, apparently conducting landing practice at the airport. I seriously considered landing opposite direction, but joined the flow of traffic, advising in the blind that I was on emergency descent into the field. I neglected the before landing checklist and tried to land too fast, too high, and without flaps. I initiated a go around. The helicopter tried to make another approach at the same time, so I was right behind him, making a mess out of things. He sidestepped to the other runway, which allowed me to make a hot, but stable approach, landing on the long runway. On final, I heard the helicopter pilot asking if I had a real or simulated emergency. On taxi into parking, I responded on frequency that there was nothing simulated about the emergency. I saw the pilot from the helicopter headed my way. I didn't stop. The helicopter pilot who had ran across the ramp to catch me, said 'I need to talk to you.' I told him to tell the TRACON that I was still alive, and then I could deal with him. I ended up talking to the TRACON. I explained the multiple equipment failures. The fellow stated he would be forwarding this to the FSDO for a possible pilot deviation. The pilot was standing in the hallway and saw the FAA embroidery on his jacket. Not a mad helicopter pilot, a mad FAA inspector. This inspector checked my pilot certificate. He asked why I had covered the turn coordinator and not the other gyros. I responded that I was still getting some useful information from them. During that inspection, we found a large pool of 100LL and fuel trail leading to the #2 cylinder. The airworthiness inspector opinioned that the intake gasket had failed and that was our loss of power. Sunday, I sat with my boss. We idented 7 really bad decisions and 26 risk factors that should have killed me. The accident chain was quite long. I ignored cues that should have sent me back to parking from the run-up area. I ignored cues during takeoff that should have had me aborting the takeoff. I ignored in-flight navigation problems with my only navigation radio, which again required a return to the airport. I tried to troubleshoot in-flight, instead of while on the ground. I didn't quit after the first gyro failure. I followed incorrect advice of my non-IFR rated passenger. I considered this flight to be similar to climbing through a thin layer, and not serious IFR in steeply rising terrain. I accepted clrncs to an altitude in the freezing levels. I didn't ask for help early.I called the TRACON again. He stated that as I had declared an emergency, there was nothing they could do, and had not filed any paperwork. However, the FSDO had called and requested information. Rule #1: do not take a sick airplane out of the traffic pattern. Rule #2: do not take a problem into the clouds, even if you suspect you are that problem. Rule #3: upon breaking rule #1 or #2 and surviving, immediately file a NASA ASRS report.
Original NASA ASRS Text
Title: PA28-140 PLT HAD INSTRUMENTATION AND ENG PROBS AFTER ENTERING IMC.
Narrative: DEPARTING VGT, GND CLRED US FOR NORTHTOWN 1 DEP. I ADVISED UNABLE TO ACCEPT DUE NO DEP CHART ON BOARD AND NO DME. ON DEP, ACFT PERFORMED POORLY. VOR #1 INDICATED STEADY 3 DOTS FLY R INDICATION W/FR FLAG. IMMEDIATELY, I TURNED R TO INTERCEPT, ASSUMING I FLEW THROUGH COURSE ON INITIAL CLB. DEP ASKED WHAT WE SHOWED. I SAID 3 DOTS FLY R. THEY SAID RADAR VECTORS, AND WE TURNED AROUND. I CONTINUED CLBING. I ADVISED CTLR WE WERE UNABLE TO EXPEDITE CLB PER THEIR REPEATED REQUESTS. I HAD A HARD TIME SHAKING THE ASSUMPTION THAT I WAS DOING SOMETHING WRONG. THE AIRPLANE COULDN'T POSSIBLY HAVE THIS MANY PROBS DEVELOP ALL AT ONCE. WE ENTERED IMC AND THINGS REALLY GOT WEIRD. THE TC WASN'T READING RIGHT. THE ATTITUDE INDICATOR WASN'T ACTING PROPERLY, LATER FOUND TO BE A SLOW FAILURE. THE HDG GYRO WAS PROCESSING TOO FAST, BUT IT HADN'T FAILED. GOTTA BE ME -- MAYBE I'M NOT SCANNING FAST ENOUGH CAUSING A PLT INDUCED OSCILLATION. ON THE CLB FROM PAST LAS TO THE VALLEY, THE CTLR KEPT TELLING ME TO TURN 10 DEGS L. WE WERE IN TURB, BUT I COULDN'T PIN DOWN WHAT WAS GOING ON. THE THIRD TIME THE CTLR ASKED ME TO TURN 10 DEGS L, I ROLLED INTO A STANDARD RATE TURN ON THE ATTITUDE GYRO, COUNTED 3 SECONDS, THEN ROLLED OUT AND STRUGGLED TO MAINTAIN THAT HDG BTWN THE GPS TK, COMPASS FROTH (IN TURB), AND HDG GYRO. THE DEP CTLR HANDED ME OFF TO ZLA. THAT CTLR CLRED ME TO 10000 FT AND EXPEDITE CLB, THEN ISSUED ANOTHER HDG AND DIRECT GFS VOR. I ADVISED HIM I HAD 3 KTS BTWN STALL, CLB, AND DSCNT. THE CTLR ISSUED ANOTHER STACK OF INSTRUCTIONS INCLUDING ANOTHER HDG TO TRACK TOWARDS GFS. THERE WAS ALSO A CARGO FLT COMING IN TO THE VEGAS AREA THAT THE CTLR CALLED ME AS TFC TO HIM, AND CALLED HIM AS TFC TO ME. BOTH OF US WERE IMC AND UNABLE TO SPOT EACH OTHER. FROM THE CHATTER, I ESTIMATE WE WERE LESS THAN 500 FT APART HORIZONTALLY. I ASKED CTR FOR THE PHONE NUMBER THAT TRACON HAD ASKED ME TO CALL. I COPIED IT, AND ALL HELL BROKE LOOSE AGAIN. THE VSI WAS JUMPING, ALTIMETER WAS JUMPING, AND AIRSPD WAS JUMPING, LIKE ENCOUNTERING UPDRAFTS AND DOWNDRAFTS ASSOCIATED WITH CONVECTIVE ACTIVITY. I TOLD CTR I WAS UNABLE TO MAINTAIN ALT, THEN IMMEDIATELY ENCOUNTERED MORE TURB. I WAS HAVING A DIFFICULT TIME MAINTAINING ACFT CTL AND COULDN'T QUITE FIGURE OUT WHAT WAS GOING ON. I DID NOTICE THE TURN COORDINATOR AS HAVING FLAGGED FAILED, SO I COVERED IT, LEAVING THE BALL AVAILABLE. MY AIRSPD WOUND UP TO 80 KTS AND MY VSI SHOWED A 1000 FPM POSITIVE CLB RATE. MAYBE I'D BE ABLE TO CLB UP TO THE ALT TAKING ADVANTAGE OF THE UPDRAFT. I PITCHED THE NOSE UP AND IMMEDIATELY THE TURB GOT WORSE, ALMOST LIKE THE STALL BUFFET. AIRSPD INCREASED. NO STALL LIGHT. VSI INCREASED. FELT LIGHT IN MY SEAT. THE SICK ATTITUDE GYRO SHOWED THE NOSE DROPPING, SICK HDG AND GPS SHOWED A L TURN. AT THE SAME TIME THE CTR CTLR STARTED ISSUING MULTIPLE CLRNCS AT ME. ALL I COULD TELL THE FELLOW WAS STAND BY. I ASKED FOR VECTORS TO THE NEAREST LAS VEGAS ARPT. THE HANDHELD GPS SAID I WAS CLOSE TO JEAN ARPT, BUT DIDN'T TELL ME HOW CLOSE I WAS TO THE LARGEST SET OF MOUNTAINS. I ROLLED OUT OF THE TURN AND THE AIRPLANE WENT SMOOTH, THE RADIO SILENCED, AND I FELT A STRONG URGE TO JUST GIVE UP. I DID NOT KNOW WHERE I WAS IN RELATIONSHIP TO THE NEAREST MOUNTAIN, MY VSI AND ASI WERE ALL OVER THE PLACE, I WASN'T BOTHERING TO LOOK AT THE ALTIMETER. I WAS JUST SO TIRED OF FIGHTING AND I COULDN'T FIGURE OUT THE CURRENT SIT. I KNEW IF I LET GO, THE AIRPLANE WOULD ROLL INTO A STEEP R TURN. THEN THE AIRSPD NEEDLE STOPPED, ABOUT 100 KTS, AND SLOWLY DECREASED TO ZERO, THEN PAST THE PEG AND DECREASED TO 120 KTS. OF COURSE, NO PITOT HEAT ON THE ACFT. I THOUGHT IT WAS QUITE FUNNY. I RESUMED COMMAND OF THE SIT. WITH ALL OF MY SIMULATOR TIME BEHIND FAILED INSTS, THE ATTITUDE WAS GIVING ACCURATE NOSE MOVING UP OR DOWN INFO, AND DELAYED BANK INFO. THE HDG INDICATOR WAS SHOWING RATE OF TURN BY HOW MUCH IT PROCESSED. A SLOW L TURN WAS LEVEL. A FASTER TURN IN EITHER DIRECTION WAS AN ACTUAL TURN. THE BALL OF THE TURN COORDINATOR SAID IF I WAS SLIPPING OR SKIDDING. ZLA ASKED ME TO CONTACT LAS APCH ONE MORE TIME. I DIRECTED MY PAX TO SET THE FREQ AS I WAS UNABLE TO TAKE THAT DISTR FROM SCANNING THE FLT INSTS. I CALLED, NO RESPONSE. NO OTHER AIR TFC ON FREQ EITHER. NOT LOST COM! WITH MY EXACT POS UNKNOWN IN RELATION TO THE TERRAIN, I STARTED SLOW R TURNS. I LOOKED ON MY KNEEBOARD, SAW THE KNOWN DEP CTL FREQ AND DIRECTED THE PAX TO SET THAT ONE IN. HE DID AND IMMEDIATELY THE RADIO CAME TO LIFE. I TRIED CALLING THE CTLR. HE RESPONDED, 'YOU NEED TO CONTACT BLAH BLAH....' I RESPONDED 'UNABLE.' I ADVISED THE CTLR I HAD LOST ALL 3 GYROS, NAV #1, AND NEEDED A VECTOR TO ANY LAS VEGAS ARPT. IN BTWN NO GYRO VECTORS, HE CLRED HIS SCOPE, TRIED TO GET ME INTO JEAN ARPT, COULDN'T, AND ADVISED THAT HE WAS SENDING ME INTO MCCARRAN. MY PAX REMINDED ME TO TELL THE CTLR THAT I HAD LOST THE AIRSPD. I DID AND THE CTLR ASKED IF I WAS PICKING UP ICE. NO VISIBLE ICE, AND IN HVY RAIN, BUT THAT DOESN'T MEAN THE PITOT TUBE HAD NOT ICED OVER. THE CTLR ISSUED DSCNTS AND GAVE GND SPD RPTS. MY WORKLOAD DECREASED SUBSTANTIALLY NOW THAT SOMEONE KNEW WHERE WE WERE AND WAS KEEPING US AWAY FROM TERRAIN. I WAS BELOW THE FREEZING LEVEL ACCORDING TO FORECASTS. PASSING THROUGH 6500 FT, THE HEAVENS OPENED, I BROKE OUT BTWN LAYERS WITH A SMALL HOLE REVEALING THE GND. I AIMED FOR THE HOLE. I SPOTTED I-15 AND THE CORNER OF A DRY LAKE BED. THAT MEANT I WAS JUST A FEW MI S OF JEAN ARPT. I PICKED MY WAY BTWN CLOUDS TO JEAN ARPT. IN THE PROCESS, THE CTLR ADVISED OF LOW ALT, AND SAID HE WAS VECTORING ME TO MCCARRAN. I KEPT DSNDING. THEN THE CTLR ASKED IF I WAS CANCELING IFR. BEHOLD THE ARPT, THE RWYS, AND I TOLD THE CTLR I WAS CANCELING. THERE WAS A HELI ON FREQ, APPARENTLY CONDUCTING LNDG PRACTICE AT THE ARPT. I SERIOUSLY CONSIDERED LNDG OPPOSITE DIRECTION, BUT JOINED THE FLOW OF TFC, ADVISING IN THE BLIND THAT I WAS ON EMER DSCNT INTO THE FIELD. I NEGLECTED THE BEFORE LNDG CHKLIST AND TRIED TO LAND TOO FAST, TOO HIGH, AND WITHOUT FLAPS. I INITIATED A GAR. THE HELI TRIED TO MAKE ANOTHER APCH AT THE SAME TIME, SO I WAS RIGHT BEHIND HIM, MAKING A MESS OUT OF THINGS. HE SIDESTEPPED TO THE OTHER RWY, WHICH ALLOWED ME TO MAKE A HOT, BUT STABLE APCH, LNDG ON THE LONG RWY. ON FINAL, I HEARD THE HELI PLT ASKING IF I HAD A REAL OR SIMULATED EMER. ON TAXI INTO PARKING, I RESPONDED ON FREQ THAT THERE WAS NOTHING SIMULATED ABOUT THE EMER. I SAW THE PLT FROM THE HELI HEADED MY WAY. I DIDN'T STOP. THE HELI PLT WHO HAD RAN ACROSS THE RAMP TO CATCH ME, SAID 'I NEED TO TALK TO YOU.' I TOLD HIM TO TELL THE TRACON THAT I WAS STILL ALIVE, AND THEN I COULD DEAL WITH HIM. I ENDED UP TALKING TO THE TRACON. I EXPLAINED THE MULTIPLE EQUIP FAILURES. THE FELLOW STATED HE WOULD BE FORWARDING THIS TO THE FSDO FOR A POSSIBLE PLTDEV. THE PLT WAS STANDING IN THE HALLWAY AND SAW THE FAA EMBROIDERY ON HIS JACKET. NOT A MAD HELI PLT, A MAD FAA INSPECTOR. THIS INSPECTOR CHKED MY PLT CERTIFICATE. HE ASKED WHY I HAD COVERED THE TURN COORDINATOR AND NOT THE OTHER GYROS. I RESPONDED THAT I WAS STILL GETTING SOME USEFUL INFO FROM THEM. DURING THAT INSPECTION, WE FOUND A LARGE POOL OF 100LL AND FUEL TRAIL LEADING TO THE #2 CYLINDER. THE AIRWORTHINESS INSPECTOR OPINIONED THAT THE INTAKE GASKET HAD FAILED AND THAT WAS OUR LOSS OF PWR. SUNDAY, I SAT WITH MY BOSS. WE IDENTED 7 REALLY BAD DECISIONS AND 26 RISK FACTORS THAT SHOULD HAVE KILLED ME. THE ACCIDENT CHAIN WAS QUITE LONG. I IGNORED CUES THAT SHOULD HAVE SENT ME BACK TO PARKING FROM THE RUN-UP AREA. I IGNORED CUES DURING TKOF THAT SHOULD HAVE HAD ME ABORTING THE TKOF. I IGNORED INFLT NAV PROBS WITH MY ONLY NAV RADIO, WHICH AGAIN REQUIRED A RETURN TO THE ARPT. I TRIED TO TROUBLESHOOT INFLT, INSTEAD OF WHILE ON THE GND. I DIDN'T QUIT AFTER THE FIRST GYRO FAILURE. I FOLLOWED INCORRECT ADVICE OF MY NON-IFR RATED PAX. I CONSIDERED THIS FLT TO BE SIMILAR TO CLBING THROUGH A THIN LAYER, AND NOT SERIOUS IFR IN STEEPLY RISING TERRAIN. I ACCEPTED CLRNCS TO AN ALT IN THE FREEZING LEVELS. I DIDN'T ASK FOR HELP EARLY.I CALLED THE TRACON AGAIN. HE STATED THAT AS I HAD DECLARED AN EMER, THERE WAS NOTHING THEY COULD DO, AND HAD NOT FILED ANY PAPERWORK. HOWEVER, THE FSDO HAD CALLED AND REQUESTED INFO. RULE #1: DO NOT TAKE A SICK AIRPLANE OUT OF THE TFC PATTERN. RULE #2: DO NOT TAKE A PROB INTO THE CLOUDS, EVEN IF YOU SUSPECT YOU ARE THAT PROB. RULE #3: UPON BREAKING RULE #1 OR #2 AND SURVIVING, IMMEDIATELY FILE A NASA 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.