37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 667072 |
Time | |
Date | 200508 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bjc.airport |
State Reference | CO |
Altitude | msl single value : 7200 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon tower : bjc.tower |
Operator | general aviation : personal |
Make Model Name | Cheetah Tiger Traveler |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 29 |
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 : instrument pilot : private |
Experience | flight time last 90 days : 30 flight time total : 330 flight time type : 300 |
ASRS Report | 667072 |
Person 2 | |
Affiliation | government : faa |
Function | controller : flight data |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : excursion from assigned altitude inflight encounter : weather non adherence : published procedure non adherence : clearance other anomaly other anomaly other spatial deviation |
Resolutory Action | controller : issued new clearance flight crew : regained aircraft control flight crew : executed go around flight crew : became reoriented |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
I flew from billings to jeffco on an IFR flight plan with a plan to decide to stop early at my alternate (gxy) if WX forecast seemed too bad at jeffco. Enroute; I got updated WX and made a decision to proceed to jeffco. On vectors to a final approach to bjc ILS runway 29 in IFR conditions; I ended up in a confused situation resulting in poor communication protocol with controllers and tower and I disregarded ATC direction. I also experienced spatial disorientation and had poor directional and altitude control at times during approach attempts (but not during enroute). It is my own plane (grumman tiger) and I have over 300 hours in it. IFR cert about 2 years ago; but I had let currency lapse. 2 weeks earlier; I had an instrument refresher and proficiency check -- this went extremely well. I have limited experience in actual IFR conditions; some time in the clouds but no difficult apches. Flight fuel planning met reserve requirements but with no extra margin. It was a longer flight segment than I typically fly so I was very tired and needed to go to the bathroom. I was already a day and a half behind schedule due to mechanical problems. WX conditions (approximately from ny notes; but shows the trend and decision making I made): beautiful in billings and duats briefing about an hour and a half before departure showed: den (no taf for bjc): VFR at time of landing; but a temporary of 800 ft ceiling and 4 mile visibility; ending 1 hour prior to arrival. Cys: currently IFR but VFR forecast. Gxy: VFR. Airmet for IFR in the area. Preflight briefing with briefer half hour before departure showed some worsening and an extension to the forecast temporary IFR at den to envelope arrival times. Checked with flight watch about 1.5 hours out -- controller only gave me 5 mins off frequency; so it was just a quick check. Cys was at 300 ft; gxy VFR; bjc 800 ft broken. Checked cys ATIS at cys; but they had stopped updating due to rapidly changing conditions and said that controllers would provide updates. Just past cys; I got bjc ATIS (I had to pull off squelch) that showed 1300 ft broken; 800 ft scattered 10 miles visibility. Update bjc ATIS about 20 mins out showed 4 miles and 900 ft broken. This is when I made the decision to continue. Got an update from controller during vectors to second approach that showed 600 ft ceiling. This added to my mental load as I realized the WX was collapsing. Plus it was bumpy. Series of issues started happening that got me confused and behind the plane. (This is the best I can remember as to the order.) jeffco airport was busy due to bad WX plus several people were practicing. At some point; my directional gyro was not aligned to compass (about 20 degrees off) but I didn't realize it until on final for my second approach. I was told to go missed on my first approach at the missed approach point. Then I started worrying a lot about fuel and really wanted to get on the ground. I was having difficulty maintaining direction and altitude (plus 300 ft to minus 200 ft from assigned) due to disorientation and distractions from heading problem; fuel worries; etc. I had difficulty establishing on the localizer possibly due to gyro misalignment; but then I realized what was going on after crossing the localizer a couple of times and squared it up. Broke out of clouds in a good position and landed. Recommendations: require a minimum amount of actual poor WX conditions as part of certification similar to the change that required night flight and some hood time as part of the VFR certification. Another note is that all of my training was done with foggles; which allow a small amount of occasional peripheral vision that may help avoid disorientation. Next practice flight I will try a full hood to see if it does a better job of completely isolating outside views.
Original NASA ASRS Text
Title: AN IFR GRUMMAN AA5B PLT BECOMES SPATIALLY DISORIENTED; AND SITUATIONALLY CONFUSED; AND EXPERIENCES TROUBLE COMPLETING THE BJC APCH.
Narrative: I FLEW FROM BILLINGS TO JEFFCO ON AN IFR FLT PLAN WITH A PLAN TO DECIDE TO STOP EARLY AT MY ALTERNATE (GXY) IF WX FORECAST SEEMED TOO BAD AT JEFFCO. ENROUTE; I GOT UPDATED WX AND MADE A DECISION TO PROCEED TO JEFFCO. ON VECTORS TO A FINAL APCH TO BJC ILS RWY 29 IN IFR CONDITIONS; I ENDED UP IN A CONFUSED SIT RESULTING IN POOR COMMUNICATION PROTOCOL WITH CTLRS AND TWR AND I DISREGARDED ATC DIRECTION. I ALSO EXPERIENCED SPATIAL DISORIENTATION AND HAD POOR DIRECTIONAL AND ALT CTL AT TIMES DURING APCH ATTEMPTS (BUT NOT DURING ENROUTE). IT IS MY OWN PLANE (GRUMMAN TIGER) AND I HAVE OVER 300 HRS IN IT. IFR CERT ABOUT 2 YEARS AGO; BUT I HAD LET CURRENCY LAPSE. 2 WEEKS EARLIER; I HAD AN INSTRUMENT REFRESHER AND PROFICIENCY CHK -- THIS WENT EXTREMELY WELL. I HAVE LIMITED EXPERIENCE IN ACTUAL IFR CONDITIONS; SOME TIME IN THE CLOUDS BUT NO DIFFICULT APCHES. FLT FUEL PLANNING MET RESERVE REQUIREMENTS BUT WITH NO EXTRA MARGIN. IT WAS A LONGER FLT SEGMENT THAN I TYPICALLY FLY SO I WAS VERY TIRED AND NEEDED TO GO TO THE BATHROOM. I WAS ALREADY A DAY AND A HALF BEHIND SCHEDULE DUE TO MECHANICAL PROBS. WX CONDITIONS (APPROX FROM NY NOTES; BUT SHOWS THE TREND AND DECISION MAKING I MADE): BEAUTIFUL IN BILLINGS AND DUATS BRIEFING ABOUT AN HOUR AND A HALF BEFORE DEP SHOWED: DEN (NO TAF FOR BJC): VFR AT TIME OF LNDG; BUT A TEMPORARY OF 800 FT CEILING AND 4 MILE VISIBILITY; ENDING 1 HOUR PRIOR TO ARR. CYS: CURRENTLY IFR BUT VFR FORECAST. GXY: VFR. AIRMET FOR IFR IN THE AREA. PREFLT BRIEFING WITH BRIEFER HALF HOUR BEFORE DEP SHOWED SOME WORSENING AND AN EXTENSION TO THE FORECAST TEMPORARY IFR AT DEN TO ENVELOPE ARR TIMES. CHKED WITH FLT WATCH ABOUT 1.5 HOURS OUT -- CTLR ONLY GAVE ME 5 MINS OFF FREQ; SO IT WAS JUST A QUICK CHK. CYS WAS AT 300 FT; GXY VFR; BJC 800 FT BKN. CHKED CYS ATIS AT CYS; BUT THEY HAD STOPPED UPDATING DUE TO RAPIDLY CHANGING CONDITIONS AND SAID THAT CTLRS WOULD PROVIDE UPDATES. JUST PAST CYS; I GOT BJC ATIS (I HAD TO PULL OFF SQUELCH) THAT SHOWED 1300 FT BKN; 800 FT SCATTERED 10 MILES VISIBILITY. UPDATE BJC ATIS ABOUT 20 MINS OUT SHOWED 4 MILES AND 900 FT BKN. THIS IS WHEN I MADE THE DECISION TO CONTINUE. GOT AN UPDATE FROM CTLR DURING VECTORS TO SECOND APCH THAT SHOWED 600 FT CEILING. THIS ADDED TO MY MENTAL LOAD AS I REALIZED THE WX WAS COLLAPSING. PLUS IT WAS BUMPY. SERIES OF ISSUES STARTED HAPPENING THAT GOT ME CONFUSED AND BEHIND THE PLANE. (THIS IS THE BEST I CAN REMEMBER AS TO THE ORDER.) JEFFCO ARPT WAS BUSY DUE TO BAD WX PLUS SEVERAL PEOPLE WERE PRACTICING. AT SOME POINT; MY DIRECTIONAL GYRO WAS NOT ALIGNED TO COMPASS (ABOUT 20 DEGS OFF) BUT I DIDN'T REALIZE IT UNTIL ON FINAL FOR MY SECOND APCH. I WAS TOLD TO GO MISSED ON MY FIRST APCH AT THE MISSED APCH POINT. THEN I STARTED WORRYING A LOT ABOUT FUEL AND REALLY WANTED TO GET ON THE GND. I WAS HAVING DIFFICULTY MAINTAINING DIRECTION AND ALT (PLUS 300 FT TO MINUS 200 FT FROM ASSIGNED) DUE TO DISORIENTATION AND DISTRACTIONS FROM HDG PROB; FUEL WORRIES; ETC. I HAD DIFFICULTY ESTABLISHING ON THE LOCALIZER POSSIBLY DUE TO GYRO MISALIGNMENT; BUT THEN I REALIZED WHAT WAS GOING ON AFTER CROSSING THE LOCALIZER A COUPLE OF TIMES AND SQUARED IT UP. BROKE OUT OF CLOUDS IN A GOOD POSITION AND LANDED. RECOMMENDATIONS: REQUIRE A MINIMUM AMOUNT OF ACTUAL POOR WX CONDITIONS AS PART OF CERTIFICATION SIMILAR TO THE CHANGE THAT REQUIRED NIGHT FLT AND SOME HOOD TIME AS PART OF THE VFR CERTIFICATION. ANOTHER NOTE IS THAT ALL OF MY TRAINING WAS DONE WITH FOGGLES; WHICH ALLOW A SMALL AMOUNT OF OCCASIONAL PERIPHERAL VISION THAT MAY HELP AVOID DISORIENTATION. NEXT PRACTICE FLT I WILL TRY A FULL HOOD TO SEE IF IT DOES A BETTER JOB OF COMPLETELY ISOLATING OUTSIDE VIEWS.
Data retrieved from NASA's ASRS site as of January 2009 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.