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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 754248 |
Time | |
Date | 200707 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 1000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower tower : pbi.tower |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Navigation In Use | other vortac |
Flight Phase | descent : approach |
Route In Use | approach : instrument non precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | instruction : trainee |
Qualification | pilot : private |
Experience | flight time last 90 days : 60 flight time total : 150 flight time type : 145 |
ASRS Report | 754248 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Events | |
Anomaly | airspace violation : entry non adherence : far non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On an IFR flight planned instrument training flight to ZZZ1. A decision was made by my flight instructor to divert to ZZZ for a practice VOR-a approach. While talking to approach controllers en route; we were cleared to the abc VOR; the initial approach fix; and then told to 'contact tower.' the apparatus that initially sparked this hazardous situation was the organization of the kneeboard holding my approach plates. The manner in which the plate page protectors opened up like a book; from left to right; presented a situation where I was looking at 2 different approach plates to 2 different airports; one right next to the other - ZZZ on the left; and ZZZ1 on the right. When told to 'contact tower;' I must have looked down quickly at the wrong plate without verifying it and plugged in the wrong tower frequency; which was picked up by ZZZ1 tower. The second hazardous situation that helped feed into this event was the fact that ZZZ1 tower actually responded and acknowledged me when I called them by 'ZZZ tower.' I do not remember specifically hearing either 'ZZZ' or 'ZZZ1 tower' in the response; but just hearing that I needed to report the final approach course inbound. I executed the full published VOR-a approach into ZZZ airport; and when my instructor told me to go missed; I called what I thought was ZZZ tower and told them I was going missed; only to hear 'warrior xyz are you at ZZZ? Because you're talking to ZZZ1!' I then quickly verified the actual tower frequency at ZZZ on the correct approach plate and switched over. The controllers seemed very concerned; and told us that they had light guns signaling out the tower for us. My instructor apologized for the inconvenience and ATC cleared us out of the airspace and instructed us to contact approach to continue the flight. As of yet; there is no further information on this matter. The 3 contributing factors in this incident; in my opinion; were the disorganization of the approach plates; my instructor's failure to catch my error of plugging in the wrong frequency; and ZZZ1 tower's acknowledgement and response. To prevent this situation from happening again in the future; I have invested in purchasing chart organizers in which you are only looking at 1 chart or plate at a time; and not having 2 different ones which could easily be confused right next to each other. Even then; I also plan on including a frequency check in my pre-landing checklist from now on as well.
Original NASA ASRS Text
Title: A PA28 PILOT AND HIS CFI CONDUCTED A PRACTICE VOR APCH TO ONE ARPT AFTER CONTACTING AND BEING ACKNOWLEDGED BY A NEARBY TOWER.
Narrative: ON AN IFR FLT PLANNED INST TRAINING FLT TO ZZZ1. A DECISION WAS MADE BY MY FLT INSTRUCTOR TO DIVERT TO ZZZ FOR A PRACTICE VOR-A APCH. WHILE TALKING TO APCH CTLRS ENRTE; WE WERE CLRED TO THE ABC VOR; THE INITIAL APCH FIX; AND THEN TOLD TO 'CONTACT TWR.' THE APPARATUS THAT INITIALLY SPARKED THIS HAZARDOUS SITUATION WAS THE ORGANIZATION OF THE KNEEBOARD HOLDING MY APCH PLATES. THE MANNER IN WHICH THE PLATE PAGE PROTECTORS OPENED UP LIKE A BOOK; FROM L TO R; PRESENTED A SITUATION WHERE I WAS LOOKING AT 2 DIFFERENT APCH PLATES TO 2 DIFFERENT ARPTS; ONE RIGHT NEXT TO THE OTHER - ZZZ ON THE L; AND ZZZ1 ON THE R. WHEN TOLD TO 'CONTACT TWR;' I MUST HAVE LOOKED DOWN QUICKLY AT THE WRONG PLATE WITHOUT VERIFYING IT AND PLUGGED IN THE WRONG TWR FREQ; WHICH WAS PICKED UP BY ZZZ1 TWR. THE SECOND HAZARDOUS SITUATION THAT HELPED FEED INTO THIS EVENT WAS THE FACT THAT ZZZ1 TWR ACTUALLY RESPONDED AND ACKNOWLEDGED ME WHEN I CALLED THEM BY 'ZZZ TWR.' I DO NOT REMEMBER SPECIFICALLY HEARING EITHER 'ZZZ' OR 'ZZZ1 TWR' IN THE RESPONSE; BUT JUST HEARING THAT I NEEDED TO RPT THE FINAL APCH COURSE INBOUND. I EXECUTED THE FULL PUBLISHED VOR-A APCH INTO ZZZ ARPT; AND WHEN MY INSTRUCTOR TOLD ME TO GO MISSED; I CALLED WHAT I THOUGHT WAS ZZZ TWR AND TOLD THEM I WAS GOING MISSED; ONLY TO HEAR 'WARRIOR XYZ ARE YOU AT ZZZ? BECAUSE YOU'RE TALKING TO ZZZ1!' I THEN QUICKLY VERIFIED THE ACTUAL TWR FREQ AT ZZZ ON THE CORRECT APCH PLATE AND SWITCHED OVER. THE CTLRS SEEMED VERY CONCERNED; AND TOLD US THAT THEY HAD LIGHT GUNS SIGNALING OUT THE TWR FOR US. MY INSTRUCTOR APOLOGIZED FOR THE INCONVENIENCE AND ATC CLRED US OUT OF THE AIRSPACE AND INSTRUCTED US TO CONTACT APCH TO CONTINUE THE FLT. AS OF YET; THERE IS NO FURTHER INFO ON THIS MATTER. THE 3 CONTRIBUTING FACTORS IN THIS INCIDENT; IN MY OPINION; WERE THE DISORGANIZATION OF THE APCH PLATES; MY INSTRUCTOR'S FAILURE TO CATCH MY ERROR OF PLUGGING IN THE WRONG FREQ; AND ZZZ1 TWR'S ACKNOWLEDGEMENT AND RESPONSE. TO PREVENT THIS SITUATION FROM HAPPENING AGAIN IN THE FUTURE; I HAVE INVESTED IN PURCHASING CHART ORGANIZERS IN WHICH YOU ARE ONLY LOOKING AT 1 CHART OR PLATE AT A TIME; AND NOT HAVING 2 DIFFERENT ONES WHICH COULD EASILY BE CONFUSED RIGHT NEXT TO EACH OTHER. EVEN THEN; I ALSO PLAN ON INCLUDING A FREQ CHK IN MY PRE-LNDG CHKLIST FROM NOW ON AS WELL.
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.