37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 708267 |
Time | |
Date | 200608 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mvy.airport |
State Reference | MA |
Altitude | agl bound lower : 400 agl bound upper : 1500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Windshear |
Aircraft 1 | |
Controlling Facilities | tracon : k90.tracon tower : mvy.tower |
Operator | general aviation : personal |
Make Model Name | Maule Aircraft Corp Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 24 |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 25 flight time total : 300 flight time type : 200 |
ASRS Report | 708267 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Events | |
Anomaly | inflight encounter : turbulence inflight encounter : weather non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : exited adverse environment |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
I encountered IMC and traffic conditions that in combination overwhelmed my experience and abilities; and compromised the safety margins I thought I held dear. I did hand-fly the approach and land; however it was not a stabilized approach and so far from my usual centered-needle performance that my very recent experience; practice and BFR were of little help. Due to high winds (30 KTS at cruise altitudes in my briefing; and probably much higher) ATC vectored me downwind and asked me to slow down severely (well into flap territory) to which I complied; then turned me upwind and begged me to make best speed. ATC itself was very busy and customary communication ('confirm you have ATIS charlie') did not occur. I never successfully trimmed for either airspeed; and with time got further and further behind the airplane. Somehow I developed and clung to the idea I was going to have to slow the airplane down for final; rather than fly the approach at an unusually high throttle setting; no flaps; and high airspeed. By the time the tower discreetly remarked that they showed me at 20 KTS over the ground (meaning about 50 KTS of headwind) I was too preoccupied with controling the airplane for the appropriate response to come to mind. The difficulty of hand-flying in the turbulence at reduced throttle exceeded my ability to scan fast enough; and of course prolonged the approach and routinely put me below the GS. I was overcorrecting; making large horizontal and vertical 'south' excursions. Having never 'gone missed' for cause; I was now fatigued enough that in the part of my brain telling me to go missed knew that another 30 or 45 mins in this environment held its own hazards. The GPS terrain 'approach monitor' feature told me once that I was too low; this may have helped avoid terrain; but the rest of the time the GPS display was so far behind my instantaneous heading that the GPS 'advisory only' display interfered with my scan and interpretation of the other instruments. The stall light came on once; to which I reacted instantaneously. I was reminded of my failure to complete the landing checklist when the engine sputtered...fortunately I had the emergency checklist memorized and the engine recovered when I immediately flipped the fuel selector to the fuller tank without taking my eyes off the instruments...which had showed a quarter tank. I assume the less-full tank unporting later in the approach at lower altitude could have been more consequential. I exited the clouds at about 400 ft AGL at an almost-normal location and heading; saw the approach lights; and made a three-bounce landing. How the problem arose: all second-seat pilots were unavailable for the day. A string of successful prior experiences engendered confidence. I meticulously planned my arrival for after storm passage. Before entering IMC I could see the storm clouds in the distance and I had suggested slowing down to ATC but they turned down my offer while confirming the storms had passed through my destination. They and I failed to appreciate the extent to which traffic backed up from the recent thunderstorms would converge on my popular destination...leading soon-to-be overworked controllers to ask more than a hand-flown light airplane in turbulent IMC and a lone 300 hour pilot can deliver. I had never flown an approach in a near-full-throttle headwind. This pilot didn't know his limits until those limits were tested. Perceptions; judgments; decisions -- all faulty. Scan did not include ground speed. Heading information from GPS turned out to be disorienting in turbulence. Not diverting or going missed. Slightly later; not having the resolve or stamina to go missed. Based upon my scan; the ceilings; and lack of warnings from the tower; in retrospect I believe I did not go below even the localizer minimum before visualizing the runway environment. However; I should have had a much greater awareness of this in flight. Contributing factors -- the slow display update rate on GNS 530 was disorienting. This is supposedly to be remedied by waas upgrade with a faster processor; but this overdue upgrade is not yet available. Corrective actions -- I should get an autoplt or at least a heading indicator with a reference heading bug so that either I don't need to hand-fly or spend time and mental effort reading/interping the hi. I should incorporate the GPS ground speed and altitude readings (to confirm my reading/interpretation of the panel altimeter) in my scan. I should refuse ATC requests when they will adversely impact my ability to perform required tasks; or suggest a compromise compatible with the airplane; conditions; and my abilities. Pilots should be certain of what information they can expect from approach and the tower; which in the absence thereof; what implications if any can be drawn regarding the flight and flight safety. Factors affecting the quality of human performance -- while on the ground or in VMC I could have instructed my passenger to be a greater resource during the approach. I should have copied ATIS; had an energy snack and hydrated when about 30 mins out. I could divide my pre-landing checklist into two; one set that can be performed well ahead of landing; reducing the workload on or near final. By not encompassing the conditions I encountered; my training and experience led me to take actions inconsistent with the situation I was in. For instance; I always reduced the throttle on approach; and it never connected that that was not always the right thing to do. The more I practiced; the more automatic the potentially wrong action became. When the tower mentioned my airspeed; it was also not clear to me what other information they had and advice or direction they might be prepared to offer (say; if I did go too low).
Original NASA ASRS Text
Title: MAULE M5 PLT ENCOUNTERS IMC AND TFC CONDITIONS THAT OVERWHELMED HIS ABILITIES.
Narrative: I ENCOUNTERED IMC AND TFC CONDITIONS THAT IN COMBINATION OVERWHELMED MY EXPERIENCE AND ABILITIES; AND COMPROMISED THE SAFETY MARGINS I THOUGHT I HELD DEAR. I DID HAND-FLY THE APCH AND LAND; HOWEVER IT WAS NOT A STABILIZED APCH AND SO FAR FROM MY USUAL CTRED-NEEDLE PERFORMANCE THAT MY VERY RECENT EXPERIENCE; PRACTICE AND BFR WERE OF LITTLE HELP. DUE TO HIGH WINDS (30 KTS AT CRUISE ALTS IN MY BRIEFING; AND PROBABLY MUCH HIGHER) ATC VECTORED ME DOWNWIND AND ASKED ME TO SLOW DOWN SEVERELY (WELL INTO FLAP TERRITORY) TO WHICH I COMPLIED; THEN TURNED ME UPWIND AND BEGGED ME TO MAKE BEST SPD. ATC ITSELF WAS VERY BUSY AND CUSTOMARY COM ('CONFIRM YOU HAVE ATIS CHARLIE') DID NOT OCCUR. I NEVER SUCCESSFULLY TRIMMED FOR EITHER AIRSPD; AND WITH TIME GOT FURTHER AND FURTHER BEHIND THE AIRPLANE. SOMEHOW I DEVELOPED AND CLUNG TO THE IDEA I WAS GOING TO HAVE TO SLOW THE AIRPLANE DOWN FOR FINAL; RATHER THAN FLY THE APCH AT AN UNUSUALLY HIGH THROTTLE SETTING; NO FLAPS; AND HIGH AIRSPD. BY THE TIME THE TWR DISCREETLY REMARKED THAT THEY SHOWED ME AT 20 KTS OVER THE GND (MEANING ABOUT 50 KTS OF HEADWIND) I WAS TOO PREOCCUPIED WITH CTLING THE AIRPLANE FOR THE APPROPRIATE RESPONSE TO COME TO MIND. THE DIFFICULTY OF HAND-FLYING IN THE TURB AT REDUCED THROTTLE EXCEEDED MY ABILITY TO SCAN FAST ENOUGH; AND OF COURSE PROLONGED THE APCH AND ROUTINELY PUT ME BELOW THE GS. I WAS OVERCORRECTING; MAKING LARGE HORIZ AND VERT 'S' EXCURSIONS. HAVING NEVER 'GONE MISSED' FOR CAUSE; I WAS NOW FATIGUED ENOUGH THAT IN THE PART OF MY BRAIN TELLING ME TO GO MISSED KNEW THAT ANOTHER 30 OR 45 MINS IN THIS ENVIRONMENT HELD ITS OWN HAZARDS. THE GPS TERRAIN 'APCH MONITOR' FEATURE TOLD ME ONCE THAT I WAS TOO LOW; THIS MAY HAVE HELPED AVOID TERRAIN; BUT THE REST OF THE TIME THE GPS DISPLAY WAS SO FAR BEHIND MY INSTANTANEOUS HDG THAT THE GPS 'ADVISORY ONLY' DISPLAY INTERFERED WITH MY SCAN AND INTERP OF THE OTHER INSTS. THE STALL LIGHT CAME ON ONCE; TO WHICH I REACTED INSTANTANEOUSLY. I WAS REMINDED OF MY FAILURE TO COMPLETE THE LNDG CHKLIST WHEN THE ENG SPUTTERED...FORTUNATELY I HAD THE EMER CHKLIST MEMORIZED AND THE ENG RECOVERED WHEN I IMMEDIATELY FLIPPED THE FUEL SELECTOR TO THE FULLER TANK WITHOUT TAKING MY EYES OFF THE INSTS...WHICH HAD SHOWED A QUARTER TANK. I ASSUME THE LESS-FULL TANK UNPORTING LATER IN THE APCH AT LOWER ALT COULD HAVE BEEN MORE CONSEQUENTIAL. I EXITED THE CLOUDS AT ABOUT 400 FT AGL AT AN ALMOST-NORMAL LOCATION AND HDG; SAW THE APCH LIGHTS; AND MADE A THREE-BOUNCE LNDG. HOW THE PROB AROSE: ALL SECOND-SEAT PLTS WERE UNAVAILABLE FOR THE DAY. A STRING OF SUCCESSFUL PRIOR EXPERIENCES ENGENDERED CONFIDENCE. I METICULOUSLY PLANNED MY ARR FOR AFTER STORM PASSAGE. BEFORE ENTERING IMC I COULD SEE THE STORM CLOUDS IN THE DISTANCE AND I HAD SUGGESTED SLOWING DOWN TO ATC BUT THEY TURNED DOWN MY OFFER WHILE CONFIRMING THE STORMS HAD PASSED THROUGH MY DEST. THEY AND I FAILED TO APPRECIATE THE EXTENT TO WHICH TFC BACKED UP FROM THE RECENT TSTMS WOULD CONVERGE ON MY POPULAR DEST...LEADING SOON-TO-BE OVERWORKED CTLRS TO ASK MORE THAN A HAND-FLOWN LIGHT AIRPLANE IN TURBULENT IMC AND A LONE 300 HR PLT CAN DELIVER. I HAD NEVER FLOWN AN APCH IN A NEAR-FULL-THROTTLE HEADWIND. THIS PLT DIDN'T KNOW HIS LIMITS UNTIL THOSE LIMITS WERE TESTED. PERCEPTIONS; JUDGMENTS; DECISIONS -- ALL FAULTY. SCAN DID NOT INCLUDE GND SPD. HDG INFO FROM GPS TURNED OUT TO BE DISORIENTING IN TURB. NOT DIVERTING OR GOING MISSED. SLIGHTLY LATER; NOT HAVING THE RESOLVE OR STAMINA TO GO MISSED. BASED UPON MY SCAN; THE CEILINGS; AND LACK OF WARNINGS FROM THE TWR; IN RETROSPECT I BELIEVE I DID NOT GO BELOW EVEN THE LOC MINIMUM BEFORE VISUALIZING THE RWY ENVIRONMENT. HOWEVER; I SHOULD HAVE HAD A MUCH GREATER AWARENESS OF THIS IN FLT. CONTRIBUTING FACTORS -- THE SLOW DISPLAY UPDATE RATE ON GNS 530 WAS DISORIENTING. THIS IS SUPPOSEDLY TO BE REMEDIED BY WAAS UPGRADE WITH A FASTER PROCESSOR; BUT THIS OVERDUE UPGRADE IS NOT YET AVAILABLE. CORRECTIVE ACTIONS -- I SHOULD GET AN AUTOPLT OR AT LEAST A HDG INDICATOR WITH A REF HDG BUG SO THAT EITHER I DON'T NEED TO HAND-FLY OR SPEND TIME AND MENTAL EFFORT READING/INTERPING THE HI. I SHOULD INCORPORATE THE GPS GND SPD AND ALT READINGS (TO CONFIRM MY READING/INTERP OF THE PANEL ALTIMETER) IN MY SCAN. I SHOULD REFUSE ATC REQUESTS WHEN THEY WILL ADVERSELY IMPACT MY ABILITY TO PERFORM REQUIRED TASKS; OR SUGGEST A COMPROMISE COMPATIBLE WITH THE AIRPLANE; CONDITIONS; AND MY ABILITIES. PLTS SHOULD BE CERTAIN OF WHAT INFO THEY CAN EXPECT FROM APCH AND THE TWR; WHICH IN THE ABSENCE THEREOF; WHAT IMPLICATIONS IF ANY CAN BE DRAWN REGARDING THE FLT AND FLT SAFETY. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE -- WHILE ON THE GND OR IN VMC I COULD HAVE INSTRUCTED MY PAX TO BE A GREATER RESOURCE DURING THE APCH. I SHOULD HAVE COPIED ATIS; HAD AN ENERGY SNACK AND HYDRATED WHEN ABOUT 30 MINS OUT. I COULD DIVIDE MY PRE-LNDG CHKLIST INTO TWO; ONE SET THAT CAN BE PERFORMED WELL AHEAD OF LNDG; REDUCING THE WORKLOAD ON OR NEAR FINAL. BY NOT ENCOMPASSING THE CONDITIONS I ENCOUNTERED; MY TRAINING AND EXPERIENCE LED ME TO TAKE ACTIONS INCONSISTENT WITH THE SIT I WAS IN. FOR INSTANCE; I ALWAYS REDUCED THE THROTTLE ON APCH; AND IT NEVER CONNECTED THAT THAT WAS NOT ALWAYS THE RIGHT THING TO DO. THE MORE I PRACTICED; THE MORE AUTOMATIC THE POTENTIALLY WRONG ACTION BECAME. WHEN THE TWR MENTIONED MY AIRSPD; IT WAS ALSO NOT CLR TO ME WHAT OTHER INFO THEY HAD AND ADVICE OR DIRECTION THEY MIGHT BE PREPARED TO OFFER (SAY; IF I DID GO TOO LOW).
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.