Single pilot of C525 citation flying an IFR pleasure flight in icing conditions encounters multiple ...

Narrative:

The flight, an IFR trip from sdf to hef, contained a series of stress increasing incidents leading up to the specific deviation from ATC direction. About half way through the flight, a momentary increase in air or blower noise in the cockpit was accompanied by an illumination of the master caution light, but no cause would be found and the noise subsided. I was however on edge that there was a mechanical problem in process. As the let down on the jasen 3 arrival progressed, crossing puttz at FL240 and doccs at 11000 ft, ice had been accumulating. Prior to leveling off at 11000 ft, I was directed to go directly to destination, hef. Then, shortly later I was directed to go to esl and hold and I read this instruction back. This controller was noticeably busier than the previous ones. In 1 or 2 mins the controller came back and questioned why I was going northeast instead of southeast and I replied that I had been directed to esl to hold. He corrected me saying that I was to go to csn to hold. Apparently I had misheard the original instruction, but I had not been corrected in my readback. So, I programmed the FMS to go to csn and hold as instructed, which was south on the 180 degree radial, right turns, 10 mi legs. With the confusion on the holding point, checking to see if the ice protection was removing the ice collected in the descent, wondering if I had a pressurization problem, and the general tension of a busy sector, I misprogrammed the FMS so that it began to hold north on the 360 degree radial. This occurred because entering holding instructions on the FMS requires entering the inbound leg and I entered the holding radial of 180 degrees instead of the inbound leg of 360 degrees. After a partial turn in the holding pattern, the controller then gave me a vector of 190 degrees to begin what was ultimately a visual approach to the destination. He admonished me by saying that I was told to hold south of cns, not north. The rest of the flight progressed routinely. I was immediately aware of my mistake, even before the controller called with the vector, but the chain of confusion resulting from accumulating stressors had set in which resulted in difficulty with spatial awareness, and what should have been a simple error to correct was not immediately dealt with. Luckily, no conflict resulted. Contributing factors were the mysterious mechanical event, ice accumulation, the busy voice traffic on sector, the surprise hold, and very infrequent use of the FMS for holding operations. The entire mistake would probably not have occurred if I had used the old fashioned way of holding with HSI and VOR as I have practiced for so many yrs. Modern avionics still require basic monitoring. Also, single pilot operations require planning and anticipation more than crew sits. It requires a very special attention to break the error chain before disaster results. My specific response to the mistake has been to spend more time on the FMS simulator so that it becomes more routine and allow me more attention to oversee its results.

Original NASA ASRS Text

Title: SINGLE PLT OF C525 CITATION FLYING AN IFR PLEASURE FLT IN ICING CONDITIONS ENCOUNTERS MULTIPLE PROBS CULMINATING IN ONE MISSED CLRNC AND A MISPROGRAMMED HOLDING PATTERN.

Narrative: THE FLT, AN IFR TRIP FROM SDF TO HEF, CONTAINED A SERIES OF STRESS INCREASING INCIDENTS LEADING UP TO THE SPECIFIC DEV FROM ATC DIRECTION. ABOUT HALF WAY THROUGH THE FLT, A MOMENTARY INCREASE IN AIR OR BLOWER NOISE IN THE COCKPIT WAS ACCOMPANIED BY AN ILLUMINATION OF THE MASTER CAUTION LIGHT, BUT NO CAUSE WOULD BE FOUND AND THE NOISE SUBSIDED. I WAS HOWEVER ON EDGE THAT THERE WAS A MECHANICAL PROB IN PROCESS. AS THE LET DOWN ON THE JASEN 3 ARR PROGRESSED, XING PUTTZ AT FL240 AND DOCCS AT 11000 FT, ICE HAD BEEN ACCUMULATING. PRIOR TO LEVELING OFF AT 11000 FT, I WAS DIRECTED TO GO DIRECTLY TO DEST, HEF. THEN, SHORTLY LATER I WAS DIRECTED TO GO TO ESL AND HOLD AND I READ THIS INSTRUCTION BACK. THIS CTLR WAS NOTICEABLY BUSIER THAN THE PREVIOUS ONES. IN 1 OR 2 MINS THE CTLR CAME BACK AND QUESTIONED WHY I WAS GOING NE INSTEAD OF SE AND I REPLIED THAT I HAD BEEN DIRECTED TO ESL TO HOLD. HE CORRECTED ME SAYING THAT I WAS TO GO TO CSN TO HOLD. APPARENTLY I HAD MISHEARD THE ORIGINAL INSTRUCTION, BUT I HAD NOT BEEN CORRECTED IN MY READBACK. SO, I PROGRAMMED THE FMS TO GO TO CSN AND HOLD AS INSTRUCTED, WHICH WAS S ON THE 180 DEG RADIAL, R TURNS, 10 MI LEGS. WITH THE CONFUSION ON THE HOLDING POINT, CHKING TO SEE IF THE ICE PROTECTION WAS REMOVING THE ICE COLLECTED IN THE DSCNT, WONDERING IF I HAD A PRESSURIZATION PROB, AND THE GENERAL TENSION OF A BUSY SECTOR, I MISPROGRAMMED THE FMS SO THAT IT BEGAN TO HOLD N ON THE 360 DEG RADIAL. THIS OCCURRED BECAUSE ENTERING HOLDING INSTRUCTIONS ON THE FMS REQUIRES ENTERING THE INBOUND LEG AND I ENTERED THE HOLDING RADIAL OF 180 DEGS INSTEAD OF THE INBOUND LEG OF 360 DEGS. AFTER A PARTIAL TURN IN THE HOLDING PATTERN, THE CTLR THEN GAVE ME A VECTOR OF 190 DEGS TO BEGIN WHAT WAS ULTIMATELY A VISUAL APCH TO THE DEST. HE ADMONISHED ME BY SAYING THAT I WAS TOLD TO HOLD S OF CNS, NOT N. THE REST OF THE FLT PROGRESSED ROUTINELY. I WAS IMMEDIATELY AWARE OF MY MISTAKE, EVEN BEFORE THE CTLR CALLED WITH THE VECTOR, BUT THE CHAIN OF CONFUSION RESULTING FROM ACCUMULATING STRESSORS HAD SET IN WHICH RESULTED IN DIFFICULTY WITH SPATIAL AWARENESS, AND WHAT SHOULD HAVE BEEN A SIMPLE ERROR TO CORRECT WAS NOT IMMEDIATELY DEALT WITH. LUCKILY, NO CONFLICT RESULTED. CONTRIBUTING FACTORS WERE THE MYSTERIOUS MECHANICAL EVENT, ICE ACCUMULATION, THE BUSY VOICE TFC ON SECTOR, THE SURPRISE HOLD, AND VERY INFREQUENT USE OF THE FMS FOR HOLDING OPS. THE ENTIRE MISTAKE WOULD PROBABLY NOT HAVE OCCURRED IF I HAD USED THE OLD FASHIONED WAY OF HOLDING WITH HSI AND VOR AS I HAVE PRACTICED FOR SO MANY YRS. MODERN AVIONICS STILL REQUIRE BASIC MONITORING. ALSO, SINGLE PLT OPS REQUIRE PLANNING AND ANTICIPATION MORE THAN CREW SITS. IT REQUIRES A VERY SPECIAL ATTN TO BREAK THE ERROR CHAIN BEFORE DISASTER RESULTS. MY SPECIFIC RESPONSE TO THE MISTAKE HAS BEEN TO SPEND MORE TIME ON THE FMS SIMULATOR SO THAT IT BECOMES MORE ROUTINE AND ALLOW ME MORE ATTN TO OVERSEE ITS RESULTS.

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.

Attributes
ACN	620033
Time
Date	200406
Day	Sun
Local Time Of Day	1201 To 1800
Place
Locale Reference	navaid : csn.vortac
State Reference	VA
Altitude	msl single value : 5000
Environment
Flight Conditions	IMC
Weather Elements	Ice Rain
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : pct.tracon
Operator	general aviation : personal
Make Model Name	Citationjet, C525/C526
Operating Under FAR Part	Part 91
Navigation In Use	other other vortac
Flight Phase	descent : holding
Route In Use	approach : visual arrival : on vectors arrival star : jasen
Flight Plan	IFR
Person 1
Affiliation	other
Function	flight crew : single pilot
Qualification	pilot : atp
Experience	flight time last 90 days : 60 flight time total : 3450 flight time type : 287
ASRS Report	620033
Person 2
Affiliation	government : faa
Function	controller : approach
Events
Anomaly	aircraft equipment problem : critical non adherence : clearance non adherence : published procedure other spatial deviation
Independent Detector	other controllera
Resolutory Action	controller : issued new clearance controller : issued advisory
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	ATC Human Performance Weather Flight Crew Human Performance Aircraft
Primary Problem	Flight Crew Human Performance

Single pilot of C525 citation flying an IFR pleasure flight in icing conditions encounters multiple problems culminating in one missed clearance and a misprogrammed holding pattern.