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ASRS Database Report Set
Non-Tower Airport Incidents
Report Set Description .........................................A sampling of reports involving operations at non-tower airports.
Update Number ....................................................32.0
Date of Update .....................................................December 28, 2017
Number of Records in Report Set ........................50
Number of New Records in Report Set ...............50
Type of Records in Report Set.............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.
National Aeronautics and Space Administration
Ames Research Center Moffett Field, CA 94035-1000
TH: 262-7
MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data
SUBJECT: Data Derived from ASRS Reports
The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.
ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.
Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.
After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.
The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.
Linda J. Connell, Director NASA Aviation Safety Reporting System
CAVEAT REGARDING USE OF ASRS DATA
Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.
Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.
One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.
ACN: 1483534 (1 of 50)
Synopsis RV12 pilot reported that after landing on Runway 32 at GAI, the taxiways were not
available due to construction. He was forced to taxi onto the grass due to an aircraft on
short final.
ACN: 1482595 (2 of 50)
Synopsis Helicopter pilot reported a NMAC with a UAV shortly after takeoff from a hospital.
ACN: 1481817 (3 of 50)
Synopsis Pilot reported parachute operations in the LMO vicinity put skydivers and aircraft in danger
because of the zone's proximity to V220 and V85. Reporter also stated, regular CTAF
communications may interfere with the "jumpers away" call.
ACN: 1481192 (4 of 50)
Synopsis C172 pilot reported a hard landing resulted after he encountered rotor wash from a
helicopter operating on the ground near the approach end of the runway.
ACN: 1480561 (5 of 50)
Synopsis Phenom 300 flight crew reported that a tree protrudes into the normal 3 degree glideslope
for Runway 17 at THV.
ACN: 1476706 (6 of 50)
Synopsis Business Jet flight crew reported that upon taking the runway at MTJ a GA pilot announced
that he was going around. The crew reported that this was the first transmission from the
GA Pilot.
ACN: 1476229 (7 of 50)
Synopsis Dash 8 Captain reported executing a go-around after encountering wake turbulence on
short final in trail of an E2 military aircraft.
ACN: 1476076 (8 of 50)
Synopsis An instructor reported that his student, flying a light sport aircraft, was stuck on a runway
with the brakes locked. The student injured himself in an attempt to check the brakes.
ACN: 1476074 (9 of 50)
Synopsis A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the
repair made by a local mechanic did not have the proper documentation.
ACN: 1476071 (10 of 50)
Synopsis DA20 flight instructor and student reported an NMAC with a Learjet departing JNX airport.
ACN: 1475797 (11 of 50)
Synopsis Diamond DA 20 pilot reported having a near collision with another aircraft while in the
traffic pattern at a non-towered airport.
ACN: 1475773 (12 of 50)
Synopsis Bonanza 35 pilot reported an NMAC with another light aircraft in the pattern at MLE
airport.
ACN: 1475474 (13 of 50)
Synopsis Cirrus Pilot reported going around after a bounced landing that resulted in a prop strike.
ACN: 1475444 (14 of 50)
Synopsis Pilot of a general aviation aircraft reported a near miss while landing at an uncontrolled
airport because the wrong frequency was dialed in on the radio panel.
ACN: 1475141 (15 of 50)
Synopsis C150 instructor reported engine roughness and loss of power after demonstrating a slip at
3,000 feet with a recovery at about 100 feet AGL with a climb to pattern altitude and a
successful landing. Instructor reported probable carb icing.
ACN: 1475140 (16 of 50)
Synopsis GA pilot reported a taxiway excursion while taxiing to Runway 3 at JNX.
ACN: 1474449 (17 of 50)
Synopsis GA pilot reported being cutoff on final at BID by another GA aircraft that necessitated a
go-around.
ACN: 1474439 (18 of 50)
Synopsis Turbojet pilot reported executing a go-around on the SZT Runway 02 final because a crane
protruded into the runway's visual descent path. The crane is mobile and NOTAMed, but a
danger to transient pilots and others.
ACN: 1474435 (19 of 50)
Synopsis SR20 flight instructor reported that another aircraft pulled onto the runway while they
were on short final.
ACN: 1473537 (20 of 50)
Synopsis Aeronca Pilot reported landing in an open field due to a loss of engine power.
ACN: 1473534 (21 of 50)
Synopsis Corporate jet pilot reported unknowingly flying through a military drop zone at MZJ during
final approach to AVQ.
ACN: 1473146 (22 of 50)
Synopsis Ground observer reported witnessing an NMAC between two light aircraft on short final to
DYL airport.
ACN: 1473133 (23 of 50)
Synopsis M20E pilot reported that after being unable to raise the landing gear, the gear collapsed on
the landing roll.
ACN: 1473112 (24 of 50)
Synopsis GA pilot reported taking off over emergency services that were unknowingly on the
runway.
ACN: 1472462 (25 of 50)
Synopsis C172 pilot reported an NMAC with an RV-7 on short final at O88 airport.
ACN: 1472139 (26 of 50)
Synopsis Cessna 172 pilot reported that during taxi the aircraft went off the taxiway damaging the
lower part of the rudder.
ACN: 1471858 (27 of 50)
Synopsis PA28 pilot reported engine malfunction that resulted in an emergency landing. Following
corrective maintenance and subsequent testing, a second takeoff was attempted with an
additional emergency landing.
ACN: 1471845 (28 of 50)
Synopsis Helicopter instructor pilot reported a Near Mid-Air Collision in the traffic pattern due to an
aircraft departing in the opposite direction.
ACN: 1471547 (29 of 50)
Synopsis C140 pilot reported a ground conflict occurred afterlanding when another light aircraft
touched down on the opposite direction runway. The aircraft passed each other midfield.
ACN: 1471152 (30 of 50)
Synopsis PA-28 pilot reported landing on a rural highway after experiencing an engine failure.
ACN: 1470131 (31 of 50)
Synopsis PA-28 pilot reported observing conflicting traffic and executed rapid evasive maneuver to
avoid a midair collision that was not displayed on TIS.
ACN: 1470114 (32 of 50)
Synopsis A C150 pilot reported taking evasive action to prevent airborne conflict with a no radios
aircraft entering approach pattern to an uncontrolled airport.
ACN: 1469546 (33 of 50)
Synopsis DA20 student pilot and the observing CFI reported that upon landing during a solo flight
the aircraft turned sharply and departed the runway.
ACN: 1469242 (34 of 50)
Synopsis GA pilot experienced an airborne conflict with another aircraft that had announced
entering the pattern for Runway 20, but wound up on approach to Runway 02 in conflict
with the reporter. Evasive action was taken by the reporter and the NORDO pilot departed
to the south without making radio contact.
ACN: 1469241 (35 of 50)
Synopsis C172 flight instructor reported striking a runway threshold light during landing with his
student at the controls.
ACN: 1469199 (36 of 50)
Synopsis GA pilot departing using CTAF procedures reported a NMAC with a vintage aircraft
departing on an adjacent runway without announcing on CTAF.
ACN: 1469156 (37 of 50)
Synopsis GA flight instructor reported taking evasive action from a helicopter as his student
departed SCD following a touch and go. The helicopter did not have a radio installed.
ACN: 1468447 (38 of 50)
Synopsis BE58 Baron pilot reported a landing gear motor failure and manual extension.
ACN: 1468296 (39 of 50)
Synopsis Air carrier Captain reported questioning the wisdom of using BFF as an alternate with no
tower, no gates, one frequency for CTAF and UNICOM, and no ACARS reception.
ACN: 1468195 (40 of 50)
Synopsis C172RG flight instructor reported the student pilot inadvertently grabbed the gear handle
instead of the carb heat and caused the nose gear to collapse on landing.
ACN: 1468194 (41 of 50)
Synopsis A Cessna 172 instructor pilot reported the engine failed right after takeoff.
ACN: 1468179 (42 of 50)
Synopsis A flight instructor observer pilot reported not being assertive enough and allowed the pilot,
who was presumably operating under VFR, to proceed to and land at an airport that was
below VMC.
ACN: 1467196 (43 of 50)
Synopsis General aviation flight instructor reported a near mid air collision after departure from a
CTAF airport.
ACN: 1466538 (44 of 50)
Synopsis HIO Tower Controller and pilot reported of a Class Delta airspace violation and a NMAC.
ACN: 1466524 (45 of 50)
Synopsis HCF Controller reported an airborne conflict between an IFR departure and a VFR aircraft.
ACN: 1466511 (46 of 50)
Synopsis Glasair pilot reported that during final approach prior to touchdown, a Pilatus took the
active runway.
ACN: 1466499 (47 of 50)
Synopsis Experimental aircraft pilot reported that his foot slipped off the rudder pedal on landing
resulting in a runway excursion.
ACN: 1466180 (48 of 50)
Synopsis PA34 pilot reported rejecting takeoff after observing unannounced traffic on short final
landing on the opposite direction runway.
ACN: 1466178 (49 of 50)
Synopsis Cessna pilot reported an NMAC with another light aircraft in the vicinity of JNX airport.
ACN: 1465911 (50 of 50)
Synopsis Two instructor pilots, both flying separate C172 aircraft, reported an NMAC with each
other in the pattern.
ACN: 1483534 (1 of 50)
Time / Day
Date : 201709
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : GAI.Airport
State Reference : MD
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft
Reference : X
ATC / Advisory.CTAF : GAI
Aircraft Operator : Personal
Make Model Name : RV-12
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Taxi
Route In Use : Direct
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Student
Experience.Flight Crew.Total : 48
Experience.Flight Crew.Last 90 Days : 9
Experience.Flight Crew.Type : 48
ASRS Report Number.Accession Number : 1483534
Human Factors : Situational Awareness
Events
Anomaly.Conflict : Ground Conflict, Less Severe
Anomaly.Ground Excursion : Runway
Detector.Person : Flight Crew
When Detected : Taxi
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Chart Or Publication
Primary Problem : Airport
Narrative: 1
GAI has published two NOTAMs that express the following information:
TAXIWAY F, E, D, TAXIWAY PARALLEL TAXIWAY ADJACENT RUNWAY 14/32 BETWEEN
TAXIWAY F AND TAXIWAY C CLOSED. XX SEP XA:22 2017 UNTIL YY XI:00 2017.
And:
TAXIWAY ALL BETWEEN SELF FUEL RAMP AND RUNWAY 14 THRESHOLD CLOSED. XX SEP
XB:34 2017 UNTIL YY XI:00 2017
The NOTAMs only address the taxiways. No mention of the runway exits to the taxiways.
NOTAMs lack any real actionable detail. Unfortunately, the A/FD (Airport/Facility Directory)
diagram of the airport does not show any of the taxiway designations - only shows the
actual taxiways, not the labeling. Hence, a landing pilot cannot know that all of the runway
32 taxiway exits other than the first one are closed (for which, any aircraft other than a
STOL aircraft won't be an option). These exits are closed, literally with zero asphalt.
Hence, landings on either 32 or 14 require a taxi back at landing or departure with no
ability to exit the runway at any other point than the start of 32 (which is not described in
the NOTAMs).
Here, I landed on 32 and because the taxiways were not available, I needed to taxi back.
However, another aircraft was behind me on final. While I pulled off into the grass to avoid
a possible on-runway conflict, the pilot in the twin behind me executed a go around
successfully. The core issue here is the appropriateness of how construction at this airport
is undertaken. Without any taxiway (runway exits specifically) available, the potential for a
realized conflict is much higher than it needs to be. The airport should have planned the
construction in appropriate phases to avoid the unavailability of at least one exit at each
end of the runway (regardless of the taxiway availability, minimally provide exit space to
resolve a possible conflict), reducing the real possibility of an incident or accident. Given
the very high traffic level at this airport, the approach to construction and closures was not
well thought out in respect to flight safety.
Synopsis
RV12 pilot reported that after landing on Runway 32 at GAI, the taxiways were not
available due to construction. He was forced to taxi onto the grass due to an aircraft on
short final.
ACN: 1482595 (2 of 50)
Time / Day
Date : 201709
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 100
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Air Taxi
Make Model Name : Helicopter
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 135
Mission : Ambulance
Flight Phase : Climb
Airspace.Class G : ZZZ
Aircraft : 2
Reference : Y
Make Model Name : UAV - Unpiloted Aerial Vehicle
Operating Under FAR Part.Other
Flight Phase : Cruise
Airspace.Class G : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Taxi
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Rotorcraft
ASRS Report Number.Accession Number : 1482595
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 25
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Near midair [with] a small drone flying one block east of the hospital. Our aircraft was on
initial climb out at approximately 65 knots and was climbing from helipad to 2200 MSL.
Elevation [at] time of near miss was probably 100-150 feet above helipad which is
approximately 1250 MSL. The primary departure path from this helipad is standardized
due to close noise sensitive areas and must be protected from drone activities and
intrusions due to high flight volume around the hospital. We had to look up through the
rotors to keep it in sight as it passed directly over the aircraft by about 25-50 feet. We saw
it at the last second and had no time to react.
Ground all private drones. They are going to cause a mishap with a manned aircraft, the
regulations for their operation do not provide helicopters with a margin of safety that is
acceptable to flight crews who cannot see them because they are too small. The drones
also do not have lights or markings that aid in their visual acquisition. They also do not
register on TCAS or other radar systems. Alternately, "no drone" fly zones within 1 NM of
all hospital helipads.
Synopsis
Helicopter pilot reported a NMAC with a UAV shortly after takeoff from a hospital.
ACN: 1481817 (3 of 50)
Time / Day
Date : 201709
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : LMO.Airport
State Reference : CO
Altitude.MSL.Single Value : 8500
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : LMO
Aircraft Operator : Personal
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Descent
Route In Use : Direct
Airspace.Class E : D01
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 4200
Experience.Flight Crew.Last 90 Days : 35
Experience.Flight Crew.Type : 1200
ASRS Report Number.Accession Number : 1481817
Human Factors : Workload
Human Factors : Situational Awareness
Human Factors : Distraction
Events
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
Miss Distance.Horizontal : 500
Miss Distance.Vertical : 0
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
On a frequently flown direct-route round-trip route to and from BDU from the north, three
open parachutes were encountered at or very near HYGEN intersection. There is a
parachute symbol southwest of LMO between the LMO runway depiction and the HYGEN
depiction on the sectional chart. HYGEN is also depicted on the IFR Low chart. The A/FD
(Airport/Facilities Directory) for LMO states "Parachute jumping on and invof arpt primarily
of rwy, avoid overflights mid fld." Also in the A/FD there is a "Parachute Jumping Area"
depicted as being nearly adjacent to taxiway B at LMO.
In my opinion, parachute operations southwest of LMO are extremely hazardous and
should be terminated. Parachutists drop paths vary considerably depending on winds,
altitude, and other factors, and in this encounter their paths were very near HYGEN
intersection, a crossing-point of two significant airways, V-220 and V-85. During a
common VFR practice of tracking along and over airway routes and intersections such as
HYGEN, airplanes' altitudes are often flown that are lower than IFR minimum crossing
altitudes and that fact could put aircraft in conflict with free-falling parachutists that had
exited their jump planes but had not yet descended to where they open their chutes, and
therefore would be very difficult to see and avoid in time. HYGEN is less than a mile from
the parachute depiction on the sectional chart.
The parachute symbol is only about 1/3 of a mile from the approach path for the VOR-
DME-A instrument approach for LMO, for which the approach path, based on a VOR, is
variable since it is based on the positional limitations of BJC VOR that is 15 miles distant.
The parachute symbol is similarly 1/3 of a mile from the approach path for the RNAV
(GPS)-B approach into LMO. Both of these approaches are favorites for practice by locals
in VMC, when parachutists are frequently active. The approach paths for both of these
approaches crosses exactly over the "Parachute Jumping Area" that is depicted adjacent to
taxiway B at LMO. In other words, a practice instrument approach would pass exactly
through the parachutist's landing area at the airport essentially at the missed approach
point. The AFD admonition to "avoid overflights mid fld" is in direct conflict with the
instructions to be followed when practicing these two instrument approach procedures.
The jump plane pilot routinely makes a call on the CTAF frequency when his jumpers are
away, but a pilot approaching the airport may miss that one warning if he or she is
listening to the LMO AWOS-3. Additionally, the jump plane pilot's communication could be
blocked by other voice traffic on the CTAF. The "jumpers away" call is easily missed. If an
aircraft is cruising just a thousand or two thousand feet below the jump plane when the
"jumpers away" call is made, the aircraft's pilot may not be able to see free-fallers in time,
and not have time to avoid free-falling parachutists.
I believe this situation is a disaster waiting to happen and I hope you can influence the
powers that be to take action. I do not wish to publish this recommendation at some
future time because of hearing of the death of a parachutist and possibly the occupants of
an aircraft if a parachutist goes through the windscreen of an aircraft.
Synopsis
Pilot reported parachute operations in the LMO vicinity put skydivers and aircraft in danger
because of the zone's proximity to V220 and V85. Reporter also stated, regular CTAF
communications may interfere with the "jumpers away" call.
ACN: 1481192 (4 of 50)
Time / Day
Date : 201709
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : MDQ.Airport
State Reference : AL
Altitude.AGL.Single Value : 200
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 20
Light : Daylight
Ceiling.Single Value : 2000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : MDQ
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class G : MDQ
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : MDQ
Aircraft Operator : Military
Make Model Name : Chinook (CH-47)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Mission : Ferry
Flight Phase : Taxi
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Experience.Flight Crew.Total : 750
Experience.Flight Crew.Last 90 Days : 5
Experience.Flight Crew.Type : 550
ASRS Report Number.Accession Number : 1481192
Events
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
I was on a final stabilized VFR approach to runway 18 at MDQ and just about to flare when
I encountered significant turbulence from a Chinook helicopter, both rotors turning, that
was waiting to takeoff from a spot on the grass between the touchdown zone of runway 18
and the parallel taxiway. The turbulence hit me just at about the flare and I was barely
able to salvage a very hard landing.
This is an airport that has significant helicopter activity. I believe some airport rules should
be considered to restrict this type of helicopter operation near the approach end of the
active runway as an effort to eliminate/minimize such turbulence.
Synopsis
C172 pilot reported a hard landing resulted after he encountered rotor wash from a
helicopter operating on the ground near the approach end of the runway.
ACN: 1480561 (5 of 50)
Time / Day
Date : 201709
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : THV.Airport
State Reference : PA
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : THV
Aircraft Operator : Fractional
Make Model Name : EMB-505 / Phenom 300
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class E : THV
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1480561
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1480559
Human Factors : Situational Awareness
Events
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
I was the PIC, and the Pilot Monitoring. The SIC was flying a briefed visual approach
backed up with a RNAV (GPS) Rwy 17 approach which has a 3 degree Glidepath. Inside of
a mile from the end of Runway 17, the SIC verbalized and adjusted aircraft pitch and rate
of descent because a tree appeared to be close off the right nose. There were no Terrain,
Obstacle, or Descent Rate warnings. A normal landing was made over a blast fence that
was not noted on the 10-9 page.
It was Day VFR when we flew this approach. If we had continued the approach as
depicted, the tree on short final would have been very close to the 3 degree glidepath.
This approach (THV 12-1) was dated 18 Jul 14, and it's possible this tree had grown in the
past 3 years. The PAPI is shown on the 10-9 page to be 4.5 degrees, quite a bit different
than 3.0 degrees on the RNAV (GPS) 17 approach. Flying the PAPI angle at 120 knots
would result in a descent rate of close to 1000 fpm. In addition, the blast fence was not
mentioned on NOTAMS or on the 10-9 page. The 10-9 page also does not show the tree
on short final. The 12-1 page for the RNAV (GPS) 17 does mention in note 3, that landing
on Rwy 17 at night is not authorized. I feel that this approach is also not safe in IFR
conditions.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
Phenom 300 flight crew reported that a tree protrudes into the normal 3 degree glideslope
for Runway 17 at THV.
ACN: 1476706 (6 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : MTJ.Airport
State Reference : CO
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : MTJ
Aircraft Operator : Fractional
Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Takeoff
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : MTJ
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Final Approach
Airspace.Class E : ZDV
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1476706
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Fractional
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1476707
Events
Anomaly.Conflict : Airborne Conflict
Detector.Person : Flight Crew
When Detected : In-flight
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While preparing to depart Montrose we were taxiing to runway 31 giving position reports
of the status of our intentions to take off at runway 31. No aircraft responded except for a
glider south of the field and we advised we were going north upon takeoff. Upon reaching
the runway we scan the area I cleared the left area and my PM (Pilot Monitoring) in the
right seat cleared the runway approach area. We then made another announcement that
we are taking runway 31. Upon lining up with runway 31 we had an aircraft yelling at us
[that] we had cut him off and was going around. At this time we had advanced the
throttles and I looked at the TCAS and now saw an aircraft approximately 2 miles away at
700 ft AGL. Upon landing [a company representative] called and advised me that two
witnesses and I called the company and advise them of what had taken place and gave
their version of what they saw.
[Personnel at the local FBO] saw both aircraft (they were physically at the approach end of
31 and heard the commotion on the radio they then stated that we were airborne before
the small Cessna 172 was even at the threshold going around. I have the contact
information of the two witnesses and both myself and my PM (Pilot Monitoring) did not see
any aircraft in the area nor did we hear any transmissions before we announced taking the
active runway. Again once we knew anything was happening we were already on the
takeoff roll and the other aircraft advise they were going around.
I feel we followed all SOP's and standard VFR callouts and the aircraft was just not seen or
heard before he said he was too close and commented on the price of kerosene.
Narrative: 2
Upon beginning taxi, I PM (Pilot Monitoring) began making position and intent reports on
Unicom/CTAF as we began our taxi to rwy31. A glider responded to our initial report
stating he was 5SW of the airport and were we going to conflict with him. I discussed our
routing and stated there was no conflict, which he acknowledged. I announced we were
"taking the active runway, 31, at Montrose" as we approached B-1 onto B, and there was
no response. Both crew members scanned the area and the TCAS. After we crossed the
hold short bars on B1, and about to make our turn to align on the runway, a Cessna stated
his position as "short final". I confirmed his position on TCAS as being more than short
final and his relative altitude as 800 ft and then 700 ft above us. I stated that we would be
out of his way in plenty of time. He then made a comment about kerosene costs and
stated he was "going around". As the aircraft was still behind us, we continued a rolling
take-off. When I made the "V1" call, I observed that the aircraft had yet to reach the
runway. After our landing at [the destination airport], the PIC received a call from the
company indicating that the pilot of the Cessna had contacted the company. The PIC then
contacted two witnesses and just asked them what they saw, which coincided with the
events. It appears that the Cessna pilot was angry that we had departed in front of him
and executed a go-around to prove a point. According to second hand information from
the FBO, the pilot was quite angry.
Had the Cessna made position reports, there would have been dialogue as to when we
were going to depart, and if he had felt uncomfortable, we would have delayed our
departure, just as there had been dialogue with the glider. Due to our size, we should
have been visible to the Cessna as we taxied out, thus reinforcing the need for position
reports. This entire episode could have been avoided with proper AIM position reports.
Synopsis
Business Jet flight crew reported that upon taking the runway at MTJ a GA pilot announced
that he was going around. The crew reported that this was the first transmission from the
GA Pilot.
ACN: 1476229 (7 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Environment
Light : Night
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Dash 8 Series Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Landing
Airspace.Class E : ZZZ
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Military
Make Model Name : Hawkeye (E2)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Mission : Training
Flight Phase : Climb
Airspace.Class E : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1476229
Human Factors : Situational Awareness
Analyst Callback : Attempted
Events
Anomaly.Inflight Event / Encounter : Wake Vortex Encounter
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While on a 5 mile final to Runway XX in ZZZ, we noticed previously identified traffic on a
left downwind leg starting what looked like a turn to a base leg. Unsure of his intentions,
we asked the aircraft, at which point they informed us they would be out of our way by the
time we got there. We responded by saying that would not work, and requested they do a
360 degree turn to fall in behind us. They responded by saying "ok, you're in sight." At
this point the aircraft began a turn as we expected, however we believe they shot a low
approach in the process, but it was difficult see. Once on short final, we saw them again
making a climbing left crosswind turn. Our aircraft then crossed the threshold, and
encountered wake turbulence just prior to the left main wheel touching the ground. This
caused the aircraft to lose lift suddenly, and drift left of the centerline. The FO initiated a
go-around. After the go-around we completed required checklists, I notified the flight
attendant [and] passengers, and we landed uneventfully.
Synopsis
Dash 8 Captain reported executing a go-around after encountering wake turbulence on
short final in trail of an E2 military aircraft.
ACN: 1476076 (8 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 10000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Landing
Route In Use : Visual Approach
Component
Aircraft Component : Brake System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person : Hangar / Base
Reporter Organization : FBO
Function.Flight Crew : Trainee
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 1179
Experience.Flight Crew.Last 90 Days : 87
Experience.Flight Crew.Type : 30
ASRS Report Number.Accession Number : 1476076
Human Factors : Other / Unknown
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Illness
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Other / Unknown
Detector.Person : Flight Crew
When Detected.Other
Result.General : Maintenance Action
Result.General : Physical Injury / Incapacitation
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Student was sent on his 4th solo to go to the north practice area and to do landings at
ZZZ. About an hour into my student's flight he calls me and states that he thought the
brakes were locked up after landing and he was still on the runway. He then got out of the
aircraft with the engine still running to check the brakes out to see if he could fix it. After
getting out of the aircraft he was struck by the propeller on his hand. He had been
instructed to never get near a moving propeller and to never get out of an aircraft that is
running. After being struck he then got back into the aircraft and was able to taxi the
aircraft to an FBO and walked in by himself and was able to procure assistance from the
staff inside then proceeded to the hospital.
Synopsis
An instructor reported that his student, flying a light sport aircraft, was stuck on a runway
with the brakes locked. The student injured himself in an attempt to check the brakes.
ACN: 1476074 (9 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 14000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Airspace.Class G : ZZZ
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Repair
Component
Aircraft Component : Stabilizer Fairing
Aircraft Reference : X
Problem : Improperly Operated
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Student
Experience.Flight Crew.Total : 144
Experience.Flight Crew.Last 90 Days : 19
Experience.Flight Crew.Type : 6
ASRS Report Number.Accession Number : 1476074
Human Factors : Training / Qualification
Human Factors : Situational Awareness
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Anomaly.Inflight Event / Encounter : Object
Detector.Person : Maintenance
Detector.Person : Flight Crew
When Detected : Routine Inspection
Result.General : Maintenance Action
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Weather
Primary Problem : Weather
Narrative: 1
During an authorized long distance cross-country student solo flight, attempted landing at
ZZZ on runway 18. Wind was >10 knots with gusts from 260 degrees. Had 25 degrees
flaps. As the plane was about to touch down, a wind gust blew plane from right to left and
past the edge of the runway. Was unable to maintain alignment with the runway. Executed
a go-around and as power was brought in, the nose began to raise up slightly and as such
the tail lowered. The left endcap of the stabilator struck a runway light. The impact was
felt in the yoke. Remained in the pattern, and landed on runway 18. Had the plane
refueled. Inspected the plane for damage. The left plastic stabilator endcap had a hole in it
on the leading edge.
Filled out an incident report at the airport terminal to report the damage to the runway
light. An aircraft mechanic was available to effect a repair by fabricating and attaching a
sheet metal patch. The plane was inspected for additional damage, none was found. Upon
completion of the temporary repair, the plane was returned to service. The mechanic did
not provide documentation for the repair other than a description on the cash receipt. I
was ignorant of the fact that this is improper maintenance record keeping and
subsequently learned that the aircraft should not have been placed back in service without
proper documentation. The details described in this report were reported to the FBO/owner
of the aircraft upon return two days later.
The incident could have been avoided by selecting another airport prior to the flight when
it was learned from a NOTAM that [other] runways [at ZZZ] were closed. The airport was
chosen specifically because it offered multiple runways. This fact was missed because of
fixated focus on local weather for making the go/no go decision for the flight and was not
noted and added to the plan of flight. The fuel burn rate was over-estimated and there
was more than adequate fuel available to have deviated from the plan of flight to another
airport. The cross wind component was at the margin of my skill level and surpassed by
the gusts, so upon listening to AWOS another opportunity to deviate was missed. The FAR
requirements for signed documentation for returning an aircraft to service following a
repair should have been known (43.9, 91.407).
Synopsis
A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the
repair made by a local mechanic did not have the proper documentation.
ACN: 1476071 (10 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : JNX.Airport
State Reference : NC
Altitude.AGL.Single Value : 600
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : JNX
Aircraft Operator : FBO
Make Model Name : DA20 Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Initial Climb
Airspace.Class G : JNX
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : JNX
Make Model Name : Bombardier Learjet Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Flight Plan : IFR
Flight Phase : Initial Climb
Airspace.Class G : JNX
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 320
Experience.Flight Crew.Last 90 Days : 20
Experience.Flight Crew.Type : 130
ASRS Report Number.Accession Number : 1476071
Human Factors : Situational Awareness
Person : 2
Reference : 2
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Trainee
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 800
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 7
ASRS Report Number.Accession Number : 1476109
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 500
Miss Distance.Vertical : 300
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We took off from Runway 21 at JNX. At approximately 600 ft AGL on the upwind a Learjet
that had taken off from the same runway after us passed beneath our left wing before we
had turned left crosswind. We advised the jet that they had come close to us and they
claimed that they had us in sight the entire time, however the jet had never informed the
CTAF of takeoff or any other callouts and when we spotted the jet it was uncomfortably
close.
Narrative: 2
[Report narrative contained no additional information.]
Synopsis
DA20 flight instructor and student reported an NMAC with a Learjet departing JNX airport.
ACN: 1475797 (11 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 1600
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : DA20-C1 Eclipse
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Landing
Airspace.Class E : ZZZ
Aircraft : 2
Reference : Y
Aircraft Operator : Personal
Make Model Name : Cardinal 177/177RG
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Initial Approach
Flight Phase : Landing
Route In Use.Other
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 761
Experience.Flight Crew.Last 90 Days : 50
Experience.Flight Crew.Type : 74
ASRS Report Number.Accession Number : 1475797
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 400
Miss Distance.Vertical : 0
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
I was with a first time student and performed a touch-and-go. A Cardinal called several
miles out descending through I believe 3,500 feet with no bearing from the airport. I
asked him and he responded to the SE and that the sun was in his face but he'd be
looking. I reported entering the right crosswind then called entering the right downwind.
The cardinal stated that he was at 2,500 feet on the right downwind. I again stated that I
was on the right downwind and did not see the Cardinal and that I was about to enter the
base leg. I had my student turn base and stated that I was on the base leg. As I looked
toward the runway to decide when to tell my student to begin his final turn, I saw the
Cardinal, at my 2 o'clock position, co-altitude (approximately 1,600 feet MSL) and
approximately 400 feet laterally heading right toward my aircraft. My evasive action
included adding full power and initiated a climb straight ahead. I do not remember what I
said on the radio, but he told me that he saw me and turned to his left to go behind me. I
told him that I did not expect him to be coming from directly overhead the runway. I was
expecting him to be on a downwind leg. Once he was clear, I reduced the power, and
brought the aircraft onto final approach and then let my student land the plane. My
thoughts on how the near midair happened were the Cardinal flying into the sun
approaching the airport and not entering and flying a proper traffic pattern and pattern
altitude.
Synopsis
Diamond DA 20 pilot reported having a near collision with another aircraft while in the
traffic pattern at a non-towered airport.
ACN: 1475773 (12 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : MLE.Airport
State Reference : NE
Altitude.AGL.Single Value : 1000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 12
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : MLE
Aircraft Operator : Personal
Make Model Name : Bonanza 35
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Initial Approach
Route In Use : Visual Approach
Airspace.Class E : MLE
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : MLE
Make Model Name : Cessna 400
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Phase : Final Approach
Airspace.Class E : MLE
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 775
Experience.Flight Crew.Last 90 Days : 7
Experience.Flight Crew.Type : 222
ASRS Report Number.Accession Number : 1475773
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Detector.Automation : Aircraft TA
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 200
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was maneuvering near an airport to enter the pattern for Runway 30 when I had a near
miss with another aircraft also entering the pattern. I had been on VFR flight following
through a Class Charlie. ATC approved me to squawk VFR and change frequencies in an
unusual location (just after I exited the Class Charlie, about 3.5 NM final and 1,900 ft AGL;
I think they had previously kept me high to avoid wake turbulence). I circled away from
the airport while descending slowly so I could turn toward the airport about 5 NM out at
pattern altitude and be on a 45 to the downwind. I changed to CTAF and announced my
position (I think I said I was descending and 3 NM southeast) and then heard another
aircraft announce (I think he said he was descending and 5 NM south). I had been
monitoring CTAF but hadn't heard the plane make any calls, and ATC hadn't mentioned it.
The other aircraft asked me if I was straight in for 30; I said no. I thought I saw him, and
I had him on TCAS (I have mode S displayed on a GNS 530W) about 5 NM in front of me
heading directly across my path towards the airport. I assumed he would continue on that
path and enter a downwind at about 1 NM parallel to the runway, which would have given
us plenty of clearance from each other. I looked away to adjust power, etc.; when I looked
back, I had lost him, and my TCAS then said he was 2-3 NM in front of me, to my right but
on an intercept, and about 500 ft above and descending (I think this would have put him
500 ft above pattern on a downwind about 4 NM out from the runway). He then called that
he was on a downwind 4 NM out. I couldn't believe it and just stared at the screen for a
moment, then frantically started looking for him; TCAS alarmed again, and then I turned
sharply left and called, "Traffic, please climb, I'm trying to get out of your way, but you're
heading straight at me." He didn't answer and almost immediately passed over me at 200
ft above (according to TCAS; I didn't see him at this point).
I think my main mistakes were assuming the other traffic would follow a particular
pattern, and then not informing him immediately when I realized I'd lost him. I think his
main mistakes were assuming that I would provide separation just because I said I saw
him and would follow him in, and then flying a non-standard pattern. It didn't help that we
both have fast planes (Bonanza and Cessna Corvalis) and that I was not in a good place to
enter the pattern in a standard fashion. I was possibly also slower to react because I've
flown much less than usual recently, and most of that has been quiet cross country rather
than in busy airspace. Unfortunately, the other pilot landed and had left the airport while I
went around the pattern and taxied in, so I didn't have a chance to talk to him and see if
he realized what had happened. I did ask the FBO to give him my phone number so we
can talk about it.
Synopsis
ACN: 1475474 (13 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Cirrus Aircraft Undifferentiated
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Component
Aircraft Component : Propeller Blade
Aircraft Reference : X
Problem : Improperly Operated
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 1200
Experience.Flight Crew.Last 90 Days : 10
Experience.Flight Crew.Type : 1000
ASRS Report Number.Accession Number : 1475474
Human Factors : Situational Awareness
Events
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
Anomaly.Inflight Event / Encounter : Unstabilized Approach
When Detected : Routine Inspection
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Executed Go Around / Missed Approach
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While landing plane bounced several times. On third or fourth bounce I went around and
landed uneventfully. Inspection of the prop revealed a prop strike had occurred. There was
no indication that the strike had occurred.
I was concerned about the runway length. This runway had a non-landing portion before
it, so I planned to aim for this and land on or close to the numbers. When coming in I was
low and slow, so I added some power but landing just short of the actual runway, this
started the porpoise. In retrospect, I really should not have sweated the runway length
which was only 500 ft shorter than my home field, and I should have just landed as I
normally do, as I did on the go around. So the basic plan was flawed. Second when I was
low and slow, I should have gone around, and finally I was slow to recognize the porpoise,
and I initiated my go around one bounce too late.
Synopsis
Cirrus Pilot reported going around after a bounced landing that resulted in a prop strike.
ACN: 1475444 (14 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : HAF.Airport
State Reference : CA
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 1600
Aircraft
Reference : X
ATC / Advisory.CTAF : HAF
Aircraft Operator : Personal
Make Model Name : Small Transport, Low Wing, 2 Recip Eng
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Landing
Route In Use : Visual Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 200
Experience.Flight Crew.Last 90 Days : 70
ASRS Report Number.Accession Number : 1475444
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Ground Conflict, Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 75
Miss Distance.Vertical : 500
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
An aircraft was landing runway 12. We were landing runway 30. We mistakenly put 128.00
instead of 122.8 for the radio frequency. It is a keypad system. We were making radio
calls but because we were on the wrong frequency no one heard it. We landed and saw
them on final. We offset to the very right edge of the runway and they went around.
Synopsis
Pilot of a general aviation aircraft reported a near miss while landing at an uncontrolled
airport because the wrong frequency was dialed in on the radio panel.
ACN: 1475141 (15 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : Cessna 150
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Descent
Route In Use : None
Airspace.Class G : ZZZ
Component
Aircraft Component : Carburetor
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 477
Experience.Flight Crew.Last 90 Days : 72
Experience.Flight Crew.Type : 12
ASRS Report Number.Accession Number : 1475141
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
After modeling a slip for my student with the airplane in its proper configuration, we
experienced engine roughness at 3,000 feet MSL. We were on a 4 mile 45 entry for the
downwind for runway 18. I established best glide, called our position, situation and
intentions to the two aircraft in the area (which was to proceed inbound for a short
approach landing due to engine roughness) then began to troubleshoot. I confirmed that
the carb heat was full on, mixture full rich, fuel tanks on both with both being nearly full
and fuel gauges checked normal. When we departed, both tanks were full at 26 gallons
total and our flight according to the hobbs was 1.1. The mags also checked okay. Despite
full throttle, we were in a steady descent with minimal engine power and unable to climb.
Approximately 1 mile east of our downwind entry, it was evident we would not make the
runway, and with housing between us, I opted to remain to the east, and aim for a field
east of the housing. I continued my descent and prepared for a forced landing, while
continuing to attempt to regain power. The two aircraft that were in the pattern had visual
on our position. At approximately 100 feet AGL, I attempted the throttle one last time. The
engine regained full power, was smooth, and I was able to establish a climb. I continued
my climb and was able to establish an altitude to safely proceed over the housing which
would allow me the option, should it occur again, to glide to either side of the
development, at about 800 feet AGL. I was able to enter a short base and land without
incident. The engine remained normal.
Synopsis
C150 instructor reported engine roughness and loss of power after demonstrating a slip at
3,000 feet with a recovery at about 100 feet AGL with a climb to pattern altitude and a
successful landing. Instructor reported probable carb icing.
ACN: 1475140 (16 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : JNX.Airport
State Reference : NC
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Daylight
Ceiling : CLR
Aircraft
Reference : X
ATC / Advisory.CTAF : JNX
Aircraft Operator : FBO
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Taxi
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 1352
Experience.Flight Crew.Last 90 Days : 65
Experience.Flight Crew.Type : 171
ASRS Report Number.Accession Number : 1475140
Human Factors : Distraction
Events
Anomaly.Ground Excursion : Taxiway
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Anomaly.Ground Event / Encounter : Object
Detector.Person : Flight Crew
When Detected : Taxi
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While taxiing to runway 3 at JNX, I became distracted by an aircraft that seemed to be
having difficulty landing. I did not realize I had reached the end of the taxiway until I was
very near the turn towards the threshold of runway 3. I was unable to stop and ran off the
taxiway. Right rudder was applied to avoid striking the prop on a taxiway light. The left
main tire struck the taxi light. As the aircraft began to skid down sloped terrain mixture
was set to cut off, right rudder and up elevator was applied to try to prevent a prop strike.
The engine stopped before the aircraft stopped moving. The aircraft appeared undamaged.
No injury was sustained by pilot or passenger.
Synopsis
GA pilot reported a taxiway excursion while taxiing to Runway 3 at JNX.
ACN: 1474449 (17 of 50)
Time / Day
Date : 201708
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : BID.Airport
State Reference : RI
Altitude.AGL.Single Value : 500
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : BID
Aircraft Operator : Personal
Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class G : BID
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : BID
Aircraft Operator : Corporate
Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Final Approach
Airspace.Class G : BID
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 770
Experience.Flight Crew.Last 90 Days : 12
Experience.Flight Crew.Type : 770
ASRS Report Number.Accession Number : 1474449
Human Factors : Situational Awareness
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : FAR
Detector.Person : Flight Crew
Miss Distance.Horizontal : 500
Miss Distance.Vertical : 200
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While flying to Block Island State Airport (BID), reporting approximately 12 miles west of
the airport at approximately 3,000 ft MSL, I inquired for advisories at Block Island Airport
over the CTAF, 123.0 and I was advised that Runway 10 was in use. This made sense as
the prevailing winds were reported at 080 degrees and 7 knots. A few aircraft were
heading towards the airport and I communicated with at least two of the three known
aircraft flying in the vicinity. While on a 3 mile final approach to Runway 10, I announced
my position on the CTAF that I had the landing traffic ahead of me in sight and that I was
following it in. When I was approximately 2 miles from the runway, I again announced my
position and that I had a visual of the plane in front of me touching down. By this point my
airplane was on "short approach" to Runway 10. No other aircraft announced they were on
final approach. As I approached 1 mile from the threshold of Runway 10, approximately
500 ft AGL, I noticed another airplane swoop in at my 9 o'clock position (from my left) and
overtake my airplane and swoop in lower than me to beat me to the runway. Horrified, I
broke off from final approach and called a "go-around" and climbed out to pattern altitude
of 1,107 ft MSL. I commented on the CTAF to the pilot of the other aircraft, who was not
immediately identified, that he had performed an unsafe maneuver. The other pilot barked
back, "I was ahead of you!" Clearly, he was not. In fact, the other pilot appears to have
broken subsection g of "Right of Way" Rule 91.113: "(g) Landing. Aircraft, while on final
approach to land or while landing, have the right-of-way over other aircraft in flight or
operating on the surface, except that they shall not take advantage of this rule to force an
aircraft off the runway surface which has already landed and is attempting to make way
for an aircraft on final approach. When two or more aircraft are approaching an airport for
the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall
not take advantage of this rule to cut in front of another which is on final approach to land
or to overtake that aircraft."
After I re-joined the pattern and safely landed on Runway 10 about 10 minutes later, I
was led by an airport marshal to park my airplane next to the one that had cut me off. The
pilot and any person(s) who had been on the aircraft had departed the area.
I would like to see the ALB FSDO investigate the pilot who nearly caused a mid-air collision
with my airplane. He not only caused alarm to myself, but he horrified my 10-year-old
nephew on his first single engine flight over water. I am grateful for my good aeronautical
training to take evasive action to voluntarily break-off, climb, and go-around. The pilot of
the [other aircraft] appeared, at the very least oblivious to my presence and radio
transmissions, but I believe to be reckless in his actions to speed up, since, he has a faster
aircraft, and dive dangerously below my altitude to race me to the runway. This could
have ended disastrously.
Synopsis
GA pilot reported being cutoff on final at BID by another GA aircraft that necessitated a
go-around.
ACN: 1474439 (18 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : SZT.Airport
State Reference : ID
Altitude.AGL.Single Value : 300
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : SZT
Aircraft Operator : Personal
Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Passenger
Flight Phase : Final Approach
Route In Use : Visual Approach
Route In Use : Direct
Airspace.Class G : SZT
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Rotorcraft
Experience.Flight Crew.Total : 11000
Experience.Flight Crew.Last 90 Days : 35
Experience.Flight Crew.Type : 2000
ASRS Report Number.Accession Number : 1474439
Human Factors : Situational Awareness
Human Factors : Distraction
Human Factors : Confusion
Events
Anomaly.ATC Issue : All Types
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
Flying into SZT saw NOTAM and ASOS saying a crane was off the north end of RWY 02 and
90 ft off centerline. Didn't pay too much attention, but on final, flying the PAPI lights, I
had to go-around the top of the crane, which protruded some 60 ft into the PAPI glidepath.
I took a photo looking north on RWY 02 and the crane was dead center in the runway
centerline. The solution was to turn off the PAPI lights so it did not guide aircraft into the
crane, which moved east and west during the day, but often within the runway width and
extending into the PAPI glidepath. Seems that simple solution would have been to find
some other way to do work on a bridge north of SZT, but FAA decided OK, which baffles
me from a safety standpoint. Call 208-263-3074 and listen to the current ASOS, which is
better, but what if a transient pilot doesn't listen, or pay attention. Same risk on takeoff
with low-performance aircraft hitting the crane.
Synopsis
Turbojet pilot reported executing a go-around on the SZT Runway 02 final because a crane
protruded into the runway's visual descent path. The crane is mobile and NOTAMed, but a
danger to transient pilots and others.
ACN: 1474435 (19 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 100
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : SR20
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Final Approach
Airspace.Class G : ZZZ
Aircraft : 2
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Vans Aircraft Undifferentiated or Other Model
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission.Other
Flight Phase : Takeoff
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 600
Experience.Flight Crew.Last 90 Days : 300
Experience.Flight Crew.Type : 40
ASRS Report Number.Accession Number : 1474435
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Ground Conflict, Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Incursion : Runway
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 100
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
RV pulled out in front of us (knowing he was) when we were on really short final. His radio
call "RV departing RWY 34 we will be out before the cirrus". We got the pleasure of side
stepping due to us being nearly on top of him.
Synopsis
SR20 flight instructor reported that another aircraft pulled onto the runway while they
were on short final.
ACN: 1473537 (20 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility : Rain
Weather Elements / Visibility.Visibility : 7
Light : Daylight
Ceiling.Single Value : 12000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Aeronca Champion
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Cruise
Route In Use : Visual Approach
Airspace.Class E : ZZZ
Component
Aircraft Component : Powerplant Fuel System
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
ASRS Report Number.Accession Number : 1473537
Human Factors : Troubleshooting
Human Factors : Situational Awareness
Analyst Callback : Completed
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Inflight Event / Encounter : Fuel Issue
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Landed As Precaution
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
On the way to ZZZ airport to get fuel the engine started to stutter. I immediately pulled
carb heat, verified mixture full rich, and fuel selector on, fuel gauge showing to have fuel,
oil pressure and temperature both in the green. I continually pumped the throttle, as that
seemed to be the only thing to keep the engine running partially. I looked for the private
grass strips that I know of in the area, I was too far and too low to make it to them so I
continued toward the best field options I could see when I remembered a friend of my
boss had a big field he said we could land at just north of ZZZ. I then located the field and
proceeded to circle the field while performing my final check list. I secured the engine and
preformed a textbook 3 point soft field landing. I called my boss and he promptly arrived
with an aircraft mechanic to inspect the airplane. They found absolutely no evidence of a
problem so they started the airplane and my boss flew it back to the airport where he
could have it checked tested and fixed. No one was injured, no damage to persons or
property occurred, and the airplane was in perfect flying condition. The airplane is now
grounded until the issue can be found, however, my boss could not duplicate the issue and
the engine ran perfectly smooth on the way back to the airport. The only thing they could
come up with to this point is carb ice or vapor lock. Those are just guesses seeing how the
issue cannot be duplicated. Also, I used carb heat and it only seemed to escalate the
issue, progressively losing power and never restoring fuel flow. When pumping the throttle
the engine would start back up for about a second per pump. This continued for about 2
minutes before it stopped healing and the engine stopped completely.
Callback: 1
The reporter stated that the field where he made the emergency landing was a field that
they used for practicing soft field landing. He added that maintenance has replaced the
fuel line precautionary and ensured that the carb heat was working properly. They were
unable to determine the actual cause of the engine shutting down, but suspect icing was
the probable cause since the aircraft has been operating normally since the incident.
Synopsis
Aeronca Pilot reported landing in an open field due to a loss of engine power.
ACN: 1473534 (21 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : AVQ.Airport
State Reference : AZ
Relative Position.Distance.Nautical Miles : 7
Altitude.MSL.Single Value : 4500
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 10000
Aircraft
Reference : X
ATC / Advisory.CTAF : AVQ
Aircraft Operator : Corporate
Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Ferry
Flight Phase : Initial Approach
Route In Use : Visual Approach
Route In Use : Direct
Airspace.Class E : TUS
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Corporate
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 3200
Experience.Flight Crew.Last 90 Days : 90
Experience.Flight Crew.Type : 220
ASRS Report Number.Accession Number : 1473534
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : ATC
Events
Anomaly.Airspace Violation : All Types
Anomaly.Deviation - Procedural : Clearance
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Result.Flight Crew : Exited Penetrated Airspace
Assessments
Contributing Factors / Situations : Airspace Structure
Primary Problem : Airspace Structure
Narrative: 1
I was repositioning the aircraft to AVQ. Approximately 30 miles from Marana I started
monitoring CTAF in my #2 radio. There was a Cirrus on a similar route as me that I was
overtaking. I told Center that unless Tucson Approach had taken my handoff I would
cancel IFR so that I could coordinate spacing to Marana with the VFR Cirrus. Center
advised me that there was no other traffic observed between me and the Marana airport
and frequency change was approved. I slowed down and configured early to keep spacing
on final. The aircraft ahead reported over Pinal airpark shortly before I did; I then also
reported over Pinal. A voice then came onto CTAF and advised me I had flown through an
active military drop zone at Pinal. I apologized and landed normally.
I have several concerns about the jump operation at Pinal.
1. I had briefed through DUATS before departure and saw no NOTAM for parachute activity
at Pinal.
2. Center did not advise me of any jump activity over Pinal. Center and Approach typically
will advise when the jump area over Pinal and other surrounding airports is hot. Absent
this, I joined an extended final approach to 12 to allow time to slow and configure for
spacing.
3. The aircraft ahead also reported over Pinal. If the jump zone went hot in the less than 3
minutes between CTAF reports with no advisory over Marana CTAF as well as Center and
Approach not being aware, a serious conflict could develop.
4. Having a drop zone located on a 10 mile final to the calm wind runway at a busy non-
towered airport with large amounts of jet traffic does not seem like a good idea to me.
Synopsis
Corporate jet pilot reported unknowingly flying through a military drop zone at MZJ during
final approach to AVQ.
ACN: 1473146 (22 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : DYL.Airport
State Reference : PA
Environment
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : DYL
Make Model Name : Small Aircraft
Flight Phase : Final Approach
Airspace.Class G : DYL
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : DYL
Make Model Name : Small Aircraft
Flight Phase : Final Approach
Airspace.Class G : DYL
Person
Reference : 1
Location Of Person : Gate / Ramp / Line
Function.Ground Personnel : Other / Unknown
ASRS Report Number.Accession Number : 1473146
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 40
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
From the ground I witnessed two airplanes on final to Doylestown airport have a near miss
as they simultaneously turned to final. The lower aircraft was a high wing and the plane
immediately above it was a low wing. I had previously held a student license and
estimated they were approximately 500 ft AGL. The [high wing aircraft] took evasive
action turning west while the overhead plane continued to final. I estimated the distance
between the two aircraft to be about 40 ft.
Synopsis
Ground observer reported witnessing an NMAC between two light aircraft on short final to
DYL airport.
ACN: 1473133 (23 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 6000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : M-20 E Super 21
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Component
Aircraft Component : Landing Gear
Aircraft Reference : X
Problem : Failed
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 449
Experience.Flight Crew.Last 90 Days : 18
Experience.Flight Crew.Type : 78
ASRS Report Number.Accession Number : 1473133
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
Detector.Person : Flight Crew
When Detected.Other
Result.General : Maintenance Action
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
After departing for home field, the landing gear failed to raise. When within range I called
Unicom, advised the attendant of the situation, and asked him to stay on duty to visually
verify that my gear was down. When I was adjacent to the terminal, he verified that the
gear was in fact down. I had a green gear down light and with visual confirmation I landed
the airplane. I felt the wheels on the pavement and immediately the airplane was on its
belly. I shut everything down and got out. The airport attendant had closed the runway
and met me at the airplane. He called a tow and we got the airplane back on its wheels
and towed it to the hangar.
It's worth noting that after being serviced [earlier this year], the gear had failed to raise
as I departed for home. I returned to the shop and they worked on the squat switch for
several hours before releasing it. I had not had any more issues until this incident.
Synopsis
M20E pilot reported that after being unable to raise the landing gear, the gear collapsed on
the landing roll.
ACN: 1473112 (24 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility.Visibility : 9
Light : Night
Ceiling.Single Value : 6000
Aircraft
Reference : X
ATC / Advisory.UNICOM : ZZZ
Aircraft Operator : Personal
Make Model Name : PA-32 Cherokee Six/Lance/Saratoga/6X
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Takeoff
Route In Use : Direct
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 1350
Experience.Flight Crew.Last 90 Days : 300
Experience.Flight Crew.Type : 100
ASRS Report Number.Accession Number : 1473112
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Ground Personnel
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Ground Conflict, Critical
Detector.Person : Flight Crew
Miss Distance.Horizontal : 2500
Miss Distance.Vertical : 100
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
[Airport] emergency services arrived as I was running up for departure, I questioned over
Unicom whether emergency services were on the active runway and received a reply from
a pilot who departed a few moments before me stating that they were not on the active
runway. Since I was not able to directly see if they were or were not there I proceeded to
takeoff and announced my departure on Unicom. After applying power and beginning my
take off roll the emergency personnel called in over the radio stating that they were on the
runway. By that time I did not have the available distance to abort my takeoff and if I had
it may have been more dangerous than continuing the takeoff. I rotated as soon as
practical and made a sharp turn to the left to avoid overflying the cars/people on the
runway. I made all reasonable attempts to ensure the runway was clear while emergency
services made no attempt to announce their position.
Synopsis
GA pilot reported taking off over emergency services that were unknowingly on the
runway.
ACN: 1472462 (25 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : O88.Airport
State Reference : CA
Altitude.MSL.Single Value : 500
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : O88
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class G : O88
Aircraft : 2
Reference : Y
Aircraft Operator : Personal
Make Model Name : RV-7
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class G : O88
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 268
Experience.Flight Crew.Last 90 Days : 12
Experience.Flight Crew.Type : 132
ASRS Report Number.Accession Number : 1472462
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 30
Miss Distance.Vertical : 30
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
[I was] practicing touch and goes, staying in the pattern making my radio calls at every
phase of flight at traffic pattern altitude at a non-towered airport. [I] didn't hear any other
pilots making radio calls. [I] made my radio call from right base to final looking and
checking for traffic for Runway 25. I had a stabilized approach when suddenly another
airplane had come from behind and over the top of me for landing.
I side stepped and did a go around and landed. After the event I spoke with the other
pilot. He told me he was on the wrong frequency. I asked him how he entered the pattern,
he told me he was north east and entered a right base and he didn't see me. I was already
on final at 500 ft. I told him that there [are] a lot of new students training at this airport
and procedure is 45 entry to runway 25 at pattern altitude. He mentioned that he was
familiar with the airport and visits frequently. I said we're both lucky that we're standing
here and able to talk to each other to evaluate the near miss.
Synopsis
C172 pilot reported an NMAC with an RV-7 on short final at O88 airport.
ACN: 1472139 (26 of 50)
Time / Day
Date : 201705
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Night
Ceiling.Single Value : 12000
RVR.Single Value : 10000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Taxi
Component
Aircraft Component : Taxiing Light
Aircraft Reference : X
Problem : Failed
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 670
Experience.Flight Crew.Last 90 Days : 6
Experience.Flight Crew.Type : 320
ASRS Report Number.Accession Number : 1472139
Human Factors : Confusion
Human Factors : Situational Awareness
Events
Anomaly.Ground Excursion : Taxiway
Anomaly.Ground Event / Encounter : Object
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : Taxi
Result.Flight Crew : Regained Aircraft Control
Result.Flight Crew : Became Reoriented
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Human Factors
Primary Problem : Airport
Narrative: 1
The incident occurred while taxiing from transient parking to runway XYR for takeoff. I was
taxiing from the transient parking on a taxiway to runway XYR. The incident occurred at [a
taxiway] intersection. Taxiway lighting on the segment from transient parking to [the next
taxiway] was non-existent, and the single landing light on the aircraft (it has two landing
lights and one taxi light, one landing and one taxi light were/are inoperative) was
misaligned way to the left of the path of travel and not very bright. Without sufficient
lighting, I tried following [another aircraft] on [the] taxiway and had my passenger shine
his small flashlight out his window to help with the lighting. I also tried to use the geo-
synchronizing feature of my ForeFlight software on my iPad to follow the short segment on
[the] taxiway. Unfortunately, I ran off the left edge of [the] taxiway onto the grass area. I
immediately pulled back on the yoke to offload weight from the nose-wheel and applied
power to taxi through the grass and onto [the following] taxiway making it safely onto
[the] taxiway. I then performed a series of S turns to test the integrity of the nose wheel.
I noted no problem with the nose wheel. Further, on takeoff and landing I noted no
shimmy, wobble, or other problem with the nose wheel. I [departed] with no further
incident - the plane flew as expected, easily staying in trim both vertically and laterally.
As for the damage - the trip through the grass kicked up grass into the air filter and onto
the nose wheel landing gear strut. And unbeknownst to me even after tie down,
apparently the rudder struck either the grass or edge of [the] taxiway as I was pulling
back on the yoke and powering out of the grass thus causing a bend and tear on the lower
rear portion of the rudder. I believe that there were several contributing factors to the
incident:
1) The lack of adequate lighting at ZZZ for the short segment of [the] taxiway; and
2) The owner of the aircraft I rented has deferred the repair/maintenance of the
taxi/landing lighting system of the aircraft for almost one year, and in my opinion as well
as that of my passenger and the squawk sheets on the aircraft, the taxi/landing lighting
system condition is inadequate. Not only was it misaligned, (aiming high and far to the left
of the centerline of travel) it was not providing normal amounts of light. While I verified
before flight that the airplane had at least one operable landing light, I could not tell in the
day light that the lighting was misaligned nor of inadequate illumination. Neither my
passenger, a licensed pilot, nor I could see the taxiway due to the lack of adequate
taxiway lighting and aircraft lighting. Additionally, there is a significant drop-off from the
taxiway to the adjacent grass area - FAR more than I have ever experienced at any other
airport.
Synopsis
Cessna 172 pilot reported that during taxi the aircraft went off the taxiway damaging the
lower part of the rudder.
ACN: 1471858 (27 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ2.Airport
State Reference : US
Altitude.AGL.Single Value : 175
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Takeoff
Flight Phase : Initial Climb
Flight Phase : Taxi
Route In Use : VFR Route
Airspace.Class G : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 1594
Experience.Flight Crew.Last 90 Days : 5
Experience.Flight Crew.Type : 1594
ASRS Report Number.Accession Number : 1471858
Human Factors : Training / Qualification
Human Factors : Troubleshooting
Human Factors : Workload
Human Factors : Distraction
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : FAR
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Ground Personnel
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Landed in Emergency Condition
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I picked up the aircraft from [a service center] located at ZZZ. I performed a thorough
preflight and departed ZZZ to the SW headed for ZZZ1. The flight was approximately 1
hour with maneuvering and operated flawlessly with no issues. Approximately 1 hour later
I departed ZZZ headed for ZZZ2. This flight was approximately 2 hours and as well was
flawless with absolutely no issues. I fueled at ZZZ2 self-serve Avgas pump with about 21
gallons. After performing a pre-flight inspection I departed back to ZZZ. Upon departure I
began a gradual climb at about 250 FPM on a runway heading. At about 3100 feet MSL the
engine went to what I perceived as idle or about 1000 RPMs.
I ran through the emergency checklist and hit nearest suitable airport on the GPS which
said ZZZ2 behind me. I began a gradual left turn to head back to the airport while trouble
shooting the engine issue and establishing the best glide speed of 76 knots airspeed.
When I looked at the distance to ZZZ2 it was 5.9 NM and I knew I could not make it with
the altitude I had. I looked for a suitable landing location and choose a field to my right
that I felt was my only option. Once I felt I had made the field I put in all the flaps and
performed a successful no power landing. I then inspected the plane for any damage and
began to look for the source of the problem, I manually checked the fuel in both tanks and
at the engine drain and it appeared to be clean 100 Octane Low Level with no deficiencies.
I then removed the cover and started the engine while holding the brakes and slowly
pushed up the throttle at about 2000 RPM the engine acted as if it was not getting fuel and
began to lose RPM almost immediately.
After calling [the service center] I found a ride home and drove back. I flew back to ZZZ2
with [someone from the service center] and we got a ride to the field where the plane was
located. We pulled the upper and lower engine covers and inspected the engine top to
bottom. After determining everything was as it should be we started the engine and as I
increased the throttle the engine began to die as if starving for fuel within a minute or so.
We then shut it down and inspected the engine again and noticed that it had a fuel leak on
the primer line that runs to 3 of the 4 cylinders. After closer inspection, we determined the
line was broken near a clamp so we repaired it with a ferrules fitting. We then started the
engine and ran it up to full rpm it maintained 2350 rpm for about 12 minutes with no
issues. We then replaced all the engine covers and began to discuss options. We did some
calculations and determined the field was more than 3000 feet long smooth low-cut grass.
We discussed that we could taxi the aircraft to the high end of the field and set it up in a
takeoff configuration and increase the throttle to full as if to take off but remain on the
ground, to further test the engine.
I taxied to the starting point and put in 1 notch of flaps then increased the throttle to full.
When the aircraft wheels departed the ground, the speed increased very quickly and
before I could set it back down I realized I may not have enough room to stop. The
aircraft lifted off the ground and at approximately 150-175 feet AGL the engine appeared
to stop or at least went to idle. I had no options for a straight ahead landing so I made a
somewhat hard left turn and attempted to keep the aircraft from stalling. I cleared several
obstacles and an electric pole/line. In an effort to avert the stall I pushed the nose down
and impacted the ground with the front nose wheel and the aircraft slid to a stop. When I
began to review my documents for the insurance claim I realized that I had inadvertently
allowed my Biennial Flight Review to expire. To avoid a situation like this in the future I
would never operate an aircraft that had a problem that could not be definitively identified
and corrected by a person with the appropriate credentials and I will also employ the use
of additional devices (such as electronic reminder) and monitor my credentials more
closely.
Synopsis
PA28 pilot reported engine malfunction that resulted in an emergency landing. Following
corrective maintenance and subsequent testing, a second takeoff was attempted with an
additional emergency landing.
ACN: 1471845 (28 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Relative Position.Distance.Nautical Miles : 2
Altitude.AGL.Single Value : 400
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility.Visibility : 4
Light : Daylight
Ceiling.Single Value : 12000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Helicopter
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Final Approach
Route In Use : Direct
Airspace.Class G : ZZZ
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : ZZZ
Make Model Name : Small Aircraft
Operating Under FAR Part : Part 91
Flight Phase : Initial Climb
Flight Phase : Takeoff
Airspace.Class G : ZZZ
Aircraft : 3
Reference : Z
ATC / Advisory.CTAF : ZZZ
Make Model Name : Small Aircraft
Operating Under FAR Part : Part 91
Flight Phase : Initial Approach
Airspace.Class G : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Instructor
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Experience.Flight Crew.Total : 645
Experience.Flight Crew.Last 90 Days : 80
Experience.Flight Crew.Type : 645
ASRS Report Number.Accession Number : 1471845
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Human Factors : Confusion
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 400
Miss Distance.Vertical : 200
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
On a practice approach for the RNAV into ZZZ, a pilot in Aircraft Y made a radio call he
was holding at Runway XY and said please advise if there is traffic in the area. Aircraft Z
on an 8 mile final for [Runway] XX, also on the practice approach, made immediately a
position report and we did ours right after. We reported a one mile final for Runway XX.
My Student was flying under a view limiting device and had no visual reference outside.
Visibility was 4 miles, haze and smoke so it was hard to see where that airplane was.
When I was scanning for that traffic, he appeared right in front of me, airborne, almost
same altitude heading straight toward us. I took the controls of the helicopter immediately
and did a steep right turn to avoid a midair collision. I made a radio call and said we all
would appreciate if he would make a radio call prior to take off. The pilot in Aircraft Y said
he wasn't aware of us and said we never did a radio call. However I talked with the pilot in
Aircraft Z behind us and he confirmed our radio calls and knew exactly where we were.
Synopsis
Helicopter instructor pilot reported a Near Mid-Air Collision in the traffic pattern due to an
aircraft departing in the opposite direction.
ACN: 1471547 (29 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : 50F.Airport
State Reference : TX
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Dusk
Ceiling : CLR
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : 50F
Aircraft Operator : Personal
Make Model Name : Cessna 140
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : 50F
Aircraft Operator : Personal
Make Model Name : Cardinal 177/177RG
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 3500
Experience.Flight Crew.Last 90 Days : 15
Experience.Flight Crew.Type : 27
ASRS Report Number.Accession Number : 1471547
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Ground Conflict, Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 10
Miss Distance.Vertical : 0
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I performed a radio check with another aircraft on the ground as I was taxiing to takeoff at
Bourland Field (50F). Both of us were loud and clear on 123.0. About 30 minutes prior to
this I had observed an aircraft taking off to the north (Rwy 35), but since winds were light
from the southeast, both of us on the ground taxied to Rwy 17 for departure. The other
aircraft departed first and turned left to downwind for a touch-and-go. I departed next,
also turning left to downwind. We both continuously called pattern position in the traffic
pattern. The aircraft ahead of me performed a touch-and-go, and since I planned a full-
stop, I offered to turn off at mid-field. The other pilot said to go ahead and back-taxi and
he would just extend. The other pilot was on crosswind as I turned base. I was a bit high
and fast so I concentrated on losing altitude and speed with a sideslip. I touched down just
a bit long but on speed. At that moment I noticed an aircraft at the other end of the
runway. He was not displaying a landing light (I was). I realized he had just touched down
and that we were on a collision course. I considered leaving the runway surface to the
right, but there were taxiway lights at midfield and I was concerned about colliding with
one. So I got as far right on the runway as I could and depended on the other pilot to do
the same. There was insufficient room for me to come to a complete stop short of the
midfield taxiway. We passed near midfield with wing clearance fortunately, and I was
doing 30-40 mph. I was also calling out on the radio to the other pilot in the pattern that
we had an aircraft landing opposite direction so he would not turn final.
Afterward I taxied back, and finally the Cardinal came up on frequency 123.0 and called
out that he was back-taxiing on 35. I advised him that 17 was the active. The only other
communication from the Cardinal was when he exited the runway at the south end. My
daughter was also monitoring 123.0 and verified that the Cardinal never made any
transmissions on frequency prior to landing. The other pilot in the pattern verified this as
well when he and I talked at the gas pump after flight.
Synopsis
C140 pilot reported a ground conflict occurred afterlanding when another light aircraft
touched down on the opposite direction runway. The aircraft passed each other midfield.
ACN: 1471152 (30 of 50)
Time / Day
Date : 201708
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 3000
Environment
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
RVR.Single Value : 10
Aircraft
Reference : X
ATC / Advisory.UNICOM : ZZZ
Aircraft Operator : Personal
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Cruise
Route In Use : Visual Approach
Component
Aircraft Component : Reciprocating Engine Assembly
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
ASRS Report Number.Accession Number : 1471152
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Inflight Shutdown
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I did a pre-trip inspection on the aircraft and noticed that it was a quart of oil low so I
added a quart. I got in the plane and continued to go through the checklist as always to
insure a safe flight. I listened to the unicom and decided to leave. I announced to local
traffic that I was taxiing and got to where I completed a run up of the aircraft and the
results were good so I decided to take off. I flew around the pattern once and landed to
relax me a little due to the fact that it had been a week since I had flown. Everything felt
great and it was a beautiful day so I decided to fly out towards my house. Once I got to
about 1700 ft I departed the pattern to 3000 ft to the Southwest. Upon reaching my
desired altitude I did my cruise checklist and was satisfied and entered into Slow Flight in
ordered to practice this maneuver. Once I got down to the minimum speed that I felt
comfortable I noticed a noise in the motor. I wasn't sure what it was coming from at first
but the more that I listened the more I felt like that was where it was coming from. I
departed from slow flight while looking at my instruments. I then noticed that the oil
pressure had dropped and I decided to abort and try to return to the airport for safety
reasons.
I was taught that even if you oil pressure drops that it doesn't always mean no oil that it
could be a faulty gauge so I watched the oil temp gauge and the temp was at 180 so I
turned the airplane around and felt like I was about 8 miles or so away and I decided to
get as high as I could. The knocking got louder so I slowed the power down to 2000 rpm. I
realized that I was too far away from the airport and the knocking got louder on a lower
setting and I realized that if I was going to make it that I needed to be closer. I added full
power and picked up speed but realized that even at full power that it wasn't producing full
RPM's. About 30 seconds later the plane started to shake and I heard a loud pop and the
engine stopped. Smoke had started coming out of the cowing but stopped quickly. I looked
on my checklist to see about the emergency procedures to make sure that I didn't forget
anything. I unlocked my door and opened my window. Once I realized that I was not going
to make the airport I looked around for the best place to land. There was a field to my left
but it required a sharp bank to make it and I was worried about that with no power. Ahead
of me to the right was a highway. Once I saw that I was going to have to land on the
highway I radioed in to 121.5. I tried to explain to them where I thought that I was but I
was getting too close to the ground. As I lined up with the road I accessed the traffic and
made a decision where to land. Once I touched down I had to coast to where I could be in
a safe location out of the way of everything. When I came to a complete stop I radioed
back to 121.5 to let them know that I had made it safely and that there was no damage to
me, the plane or anyone or anything else. I didn't get a response back so I called my CFI
at the airport and told him where I was in order for him to come get me. When he got
there he informed me to contact the weather briefer and let him know that everything was
ok.
Synopsis
PA-28 pilot reported landing on a rural highway after experiencing an engine failure.
ACN: 1470131 (31 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ANE.Airport
State Reference : MN
Relative Position.Distance.Nautical Miles : 10
Altitude.MSL.Single Value : 3300
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : 25D
Aircraft Operator : Personal
Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Cruise
Route In Use : Direct
Airspace.Class E : M98
Aircraft : 2
Reference : Y
Make Model Name : Cessna Aircraft Undifferentiated or Other Model
Airspace.Class E : M98
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 250
Experience.Flight Crew.Last 90 Days : 15
Experience.Flight Crew.Type : 250
ASRS Report Number.Accession Number : 1470131
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 200
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We were about 10 mile NE of ANE under the Mode C for MSP and on the CTAF for 25D
monitoring for parachute activity in the area. I was cruising at 3300 feet MSL at a heading
of 160. I'm not sure how I missed the other traffic. The Cessna was on an approximate
heading of 270 at 3500 MSL. I do have ADS-B in and out with traffic showing on an iPad,
and the Garmin 650 in the panel. The other aircraft did not show up at all nor did a
collision avoidance activate. I took evasive action by descending quickly to 3000 feet. I'm
not sure if the other pilot was aware I was there or not. I'm also not sure why the other
pilot wasn't flying at 2500 or 4500 feet MSL on their westerly course.
Synopsis
PA-28 pilot reported observing conflicting traffic and executed rapid evasive maneuver to
avoid a midair collision that was not displayed on TIS.
ACN: 1470114 (32 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : MGJ.Airport
State Reference : NY
Altitude.AGL.Single Value : 1000
Environment
Weather Elements / Visibility.Visibility : 15
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : MGJ
Aircraft Operator : Personal
Make Model Name : Cessna 150
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Landing
Route In Use : Visual Approach
Airspace.Class E : MGJ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 4000
Experience.Flight Crew.Last 90 Days : 25
Experience.Flight Crew.Type : 800
ASRS Report Number.Accession Number : 1470114
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Other
Events
Anomaly.Conflict : NMAC
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : Other / Unknown
Detector.Person : Flight Crew
Miss Distance.Vertical : 50
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
During an approach for runway 03 I entered a left downwind via a 45 degree entry. I
determined the runway in use via ASOS and other aircraft in the pattern. Just after making
the self-announce transmission on CTAF, my passenger and I both observed a Beech
Bonanza opposite direction and descending to pattern altitude, approaching head on. I
applied strong forward pressure on the yoke to effect a rapid and immediate descent. We
passed under the other aircraft by approximately 50 feet. No other transmissions were
heard from the incident aircraft, however two other aircraft on the frequency in the same
pattern did answer. As I observed the Bonanza begin a wide, climbing turn to enter the
pattern behind us, and still heard no transmissions, I announced their positon for the other
aircraft. As I was taxiing to the ramp, I made my last transmission for the other aircraft as
I observed them touching down. They finally made a transmission stating, "We are on the
frequency, what is the problem?" I did not reply.
My guess, is that the CTAF frequency is one that is not common (122.72), and may have
not been known by the other aircraft. The other aircraft descending into the pattern did
not make for scanning for traffic easy. It was pure luck that we missed one another.
Synopsis
A C150 pilot reported taking evasive action to prevent airborne conflict with a no radios
aircraft entering approach pattern to an uncontrolled airport.
ACN: 1469546 (33 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 6500
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : DA20-C1 Eclipse
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Training
Flight Phase : Landing
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Student
Experience.Flight Crew.Total : 26
Experience.Flight Crew.Last 90 Days : 26
Experience.Flight Crew.Type : 26
ASRS Report Number.Accession Number : 1469546
Person : 2
Reference : 2
Location Of Person : Gate / Ramp / Line
Reporter Organization : FBO
Qualification.Flight Crew : Flight Instructor
Experience.Flight Crew.Total : 747
Experience.Flight Crew.Last 90 Days : 200
Experience.Flight Crew.Type : 180
ASRS Report Number.Accession Number : 1469555
Events
Anomaly.Ground Excursion : Runway
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Detector.Person : Observer
Detector.Person : Flight Crew
When Detected : In-flight
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was flying my first solo. I took off and began my pattern (crosswind, downwind, base
and final). I approached my final leg at 60 KTS with full flaps. I landed before the first
large white blocks on the runway on the center line. I landed on the main gear, then
lowered the nose. It shook (nose wheel) so I pulled up slightly, then pushed the stick
forward so shaking stopped. The plane veered to the left. I failed to pull the throttle to
idle- it was slightly above idle on landing. I attempted to slow the plane with the brakes
but I believe my feet were on the rudder and not high enough on the pedal to hit the
brakes. I left the runway into a flat, level grassy area and was headed toward the ramp. I
focused on steering the plane toward the ramp and let friction slow the plane at that point.
The propeller was cutting some of the higher grass along the way. I then entered the
paved ramp area and shut down the plane. I walked the entire route where the plane went
through the grass. There were no hard surfaces that I drove through. Most of the grass
was ankle high and some patches of grass were about a foot high. I inspected the plane
after I shut it off. There was visible green marks on the propeller and some of the leading
edge appeared to separate from the propeller. I had no injuries and there were no injuries
to others and no damage to any property.
Narrative: 2
I am a CFII. I sent my student on his first solo flight. Our Part 141 syllabus requires the
student to complete one half hour in the local traffic pattern solo. [We] had completed the
required training for the solo and he had received all endorsements, training, and pre solo
written exam. Prior to this day we had flown three days in a row that were supervised
solo's with instruction given on the ground upon our return. The student was eager and
ready to make the flight, and I had not been given any reason to doubt the safe
completion of the flight. Conditions for the day were clear skies 10 miles visibility and
winds from the south west at 5 knots. The winds were favoring Runway XX, therefor it was
in use. [The student] was instructed to do 3 full stop landings and was taxiing out to
Runway XX for departure after dropping me off at the FBO to monitor from the ground.
The student had a great takeoff with excellent directional control. The climb out and
pattern flown was to standards and the communications were exceptional. The approach
to landing was just as we had practiced. During his roll out to a stop [the student] took a
sudden sharp turn to the left and ran off the runway into the grass. There was no
obstruction or gusts to explain the reaction. [The student] rolled through the grass in the
runway safety area and up onto the taxi way coming to a complete stop. After assuring
the student was ok I asked what had caused him to make such a rash control input, the
student replied that he wasn't exactly sure what had happened. My best guess is the
student freaked out and had an involuntary response which he couldn't recover from. The
aircraft suffered a prop strike from the grass which he rolled through as well as a nose
wheel getting bent slightly.
Synopsis
DA20 student pilot and the observing CFI reported that upon landing during a solo flight
the aircraft turned sharply and departed the runway.
ACN: 1469242 (34 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : PWT.Airport
State Reference : WA
Altitude.AGL.Single Value : 500
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 20000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : PWT
Aircraft Operator : Personal
Make Model Name : Small Aircraft, High Wing, 1 Eng, Retractable Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Training
Flight Phase : Takeoff
Airspace.Class E : PWT
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : PWT
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Flight Phase : Landing
Route In Use : Visual Approach
Airspace.Class E : PWT
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Captain
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Flight Engineer
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
ASRS Report Number.Accession Number : 1469242
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Airborne Conflict
Detector.Person : Observer
Detector.Person : Flight Crew
Miss Distance.Horizontal : 200
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While practicing touch and go landings, another pilot flying Aircraft Y announced his
intention to enter on a 45 degree entry to runway 20 at PWT. I continued in the pattern
announcing my position at all phases of the pattern. While on the downwind I heard [the
Aircraft Y pilot] say he was on the 45. I announced turning base and then final. I opted to
go around and heard someone warn me about an opposite direction aircraft on final. I
continued the go around. I then saw traffic directly opposite to me approaching runway
02. I avoided him while on the upwind at 300 feet AGL.
I was on my 3rd circuit with others having been in the pattern. I announced my position
and continued the go around avoiding the traffic and clearly continued to announce my
position. The pilot executed a low approach to runway 02 and continued to fly northbound
not talking on the radio.
I continued in the pattern announcing my position at every phase of flight. I tried to talk
with the pilot but no answer.
Synopsis
GA pilot experienced an airborne conflict with another aircraft that had announced
entering the pattern for Runway 20, but wound up on approach to Runway 02 in conflict
with the reporter. Evasive action was taken by the reporter and the NORDO pilot departed
to the south without making radio contact.
ACN: 1469241 (35 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 2
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Landing
Route In Use : None
Airspace.Class E : ZZZ
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 1450
Experience.Flight Crew.Last 90 Days : 130
Experience.Flight Crew.Type : 550
ASRS Report Number.Accession Number : 1469241
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Ground Event / Encounter : Object
Anomaly.Inflight Event / Encounter : Unstabilized Approach
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I was training a student who has approximately 30 hours and who has soloed 3 times. We
were doing a training flight in the traffic pattern working on short and soft field takeoffs
and landings. For the short field landings, I was giving the scenario that a previous student
of mine had received during his private pilot checkride. Simply enough, the examiner
wanted him to land on the threshold. So that is the same scenario that my student and I
were practicing. We had performed 9 takeoffs and landings, and he was doing very well
with the spot landings and short field procedure. In the beginning I was following very
closely on the controls to ensure the proper threshold crossing height for the point which
we were landing. As the lesson progressed, I slowed eased off of the controls to allow him
to be more in control. After the 9th landing, I knew it was about time to finish up for the
evening. My student asked if we could do just one more takeoff and landing, to which I
agreed. The sun had set and we were beginning to lose some of our light. The lesson
before this was his first night flight where we did 7 full stop takeoff and landings, so I
wasn't terribly concerned with a little bit of light loss. While we were on the downwind leg,
I told my student that we would try to touchdown at the beginning of the runway, just
before the numbers one last time. As we turned onto final, the lighting system was not
turned on. I preferred it that way, but failed to vocalize to my student to keep them off.
When we approached short final I heard him keying on the lights. Before I could say
anything, the lights were coming on. He had turned them on high intensity. As we kept
coming down, I began reaching for the hand held mic to turn down the lights. We were low
enough, I thought the best decision was for me to try to get them and let him focus on the
landing. When I got the mic and got them keyed down, we were probably 20 ft above the
ground. I made a quick glance over to his airspeed indicator to verify he was at the proper
speed and to put the mic back so my hands were free. When I looked back, we were
beginning to cross the threshold and I knew we had gotten a little lower than I would have
liked and we then felt the RH (right hand) tire hit the threshold light. It didn't alter the
course of the airplane, and we were able to touchdown straight, on the main wheels, and
in the center of the runway. We didn't actually realize it was a light until we taxied back to
the beginning of the runway to make sure it wasn't a light. Sure enough, there it was. It
knocked it off its base and broke the glass. We taxied in and shutdown. We did a visual
inspection of the entire aircraft and there was no evidence of any damage. I immediately
called the airport foreman to report what had happened so he could get a hold of the
proper maintenance technician.
Looking back, there are a few things I, as the instructor, could have done differently to
prevent this situation. I should have stuck with my instinct that we had done enough
takeoffs and landings and that any more could be detrimental to the progress made. Next,
I could have made the decision to pick a point further down the runway due to the
diminishing sunlight. Third, when my student keyed the lights to high intensity, I should
have had him adjust to land farther down the runway due to the effect it was having on
our vision. I have learned a lot from this situation and will never let it happen again. I am
trying my hardest to do everything properly to fix the situation.
Synopsis
C172 flight instructor reported striking a runway threshold light during landing with his
student at the controls.
ACN: 1469199 (36 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : AMW.Airport
State Reference : IA
Altitude.AGL.Single Value : 50
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 12000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : AMW
Aircraft Operator : Personal
Make Model Name : Small Aircraft
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Takeoff
Route In Use : None
Airspace.Class E : AMW
Aircraft : 2
Reference : Y
Aircraft Operator : Personal
Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Takeoff
Route In Use : None
Airspace.Class E : AMW
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
ASRS Report Number.Accession Number : 1469199
Human Factors : Communication Breakdown
Human Factors : Other / Unknown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Analyst Callback : Completed
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 0
Miss Distance.Vertical : 15
Were Passengers Involved In Event : Y
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airport
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Winds Light and variable, AMW runway 01 specified for no wind use. After runup,
announced on CTAF taking runway [01] for departure. Another person on CTAF said they
were lined up on runway 13 [which is closest to the ramp] -- said they wanted immediate
departure. I said I would stay lined up on 01 and they could depart.
I watched, lined up on 01, as the plane took off and watched it climb to about 500' and
they announced turning crosswind to stay in the pattern. I said, I was rolling on 01. At
about 10' AGL someone [unknown] said there are two planes taking off! I started looking
toward runway 13/31 and couldn't see, my passenger pointed and the vintage aircraft was
rapidly approaching the intersection of 13/31 [on Runway 13] and 01/19 at the same
altitude as me. He was less than 100' away horizontally as I immediately pitched down
(about 50' AGL at this time) and he flow over the top of me. I had to recover and pitch
back up about 10' AGL and continue takeoff as I was hitting 100 kts and was not stabilized
nor had enough runway to land on back on 01.
I can only assume the pilot was NORDO or just not listening and assumed there was only
1 active runway. I listened and heard no reports on the radio from that plane.
Factors in play were the NORDO pilot, or not using CTAF if he was equipped. The fact that
some pilots use the closest runway in no-wind conditions when 01 is spelled out as the no-
wind desired runway. Also beneficial was the one pilot who saw both planes departing and
called out on the radio -- if this hadn't happened I don't know if I would have avoided the
other plane. Also a factor is you can't really see the departure [approach?] end of 13 from
01 and vice-versa.
Callback: 1
The reporter confirmed that the vintage aircraft was departing from Runway 13.
Synopsis
GA pilot departing using CTAF procedures reported a NMAC with a vintage aircraft
departing on an adjacent runway without announcing on CTAF.
ACN: 1469156 (37 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : SCD.Airport
State Reference : AL
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Haze / Smoke
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 2700
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : SCD
Aircraft Operator : FBO
Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Takeoff
Route In Use : Visual Approach
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : SCD
Aircraft Operator : Corporate
Make Model Name : Helicopter
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 137
Flight Plan : None
Mission : Agriculture
Flight Phase : Cruise
Airspace.Class G : ZTL
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : Instructor
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Experience.Flight Crew.Total : 560
Experience.Flight Crew.Last 90 Days : 104
Experience.Flight Crew.Type : 520
ASRS Report Number.Accession Number : 1469156
Human Factors : Communication Breakdown
Human Factors : Distraction
Human Factors : Situational Awareness
Human Factors : Time Pressure
Human Factors : Workload
Human Factors : Confusion
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 200
Miss Distance.Vertical : 500
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Chart Or Publication
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
On short final RWY 27 into SCD to perform a touch and go landing for a commercial pilot
training flight, I noticed a clear object rise above the tree line just off the far western end
of the runway. Moments prior to touchdown I determined the object I saw was a small
bubble canopy helicopter. I had my student continue the landing as the helicopter
appeared to be heading westbound, away from us. After touchdown, my student
reconfigured the aircraft, applied full power, and initiated a takeoff. At rotation, the
helicopter turned from the west to the east, and headed straight down the opposite end of
the runway towards us. I briefly considered aborting the takeoff, but was worried that a
high speed ground collision between our two aircraft might occur. After rotation, I took the
flight controls and continued to climb out at the best rate of climb speed, and sidestepped
north, away from the helicopter and runway environment. To my knowledge and from
what I saw, the helicopter took no evasive action, and I'm not certain if they even made
visual contact with us. Our landing light, taxi light, anti-collision lights, and flashing beacon
were all on, and we had been making radio calls on CTAF from at least 10 nm from the
airport. The helicopter in question was a small agricultural helicopter, and it had not been
making radio calls on SCD CTAF 122.8. Upon arrival back to my home airport, I spoke with
the assistant chief flight instructor (and Safety Officer) about the event, and also filed a
company safety report. I also called SCD to inquire as to the nature of the helicopter
operating on the field without making radio calls. They were operating in the area spraying
herbicide on power lines, and also on tree tracts and that their helicopters are not
equipped with radios. I believe this event was caused by the pilot of the aforementioned
helicopter failing to exercise proper collision avoidance and scanning techniques, and
assuming that a normally quiet airport with low amounts of traffic would automatically be
free of any landing traffic. The winds at the time of the event were favoring RWY 27.
In the future, publishing a NOTAM to alert transient aircraft of this non-routine (to SCD)
traffic operating in the area could help aid in situational awareness for other pilots
operating in the vicinity of the airport. And although not legally required, it would be
beneficial for those helicopters to be equipped with radios, so they can more safely
coordinate with traffic, and also build a better situational awareness picture for themselves
with regards to other aircraft in the area.
Synopsis
GA flight instructor reported taking evasive action from a helicopter as his student
departed SCD following a touch and go. The helicopter did not have a radio installed.
ACN: 1468447 (38 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Relative Position.Distance.Nautical Miles : 1
Altitude.MSL.Single Value : 1400
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 30
Light : Daylight
Ceiling.Single Value : 20000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Personal
Make Model Name : Baron 58/58TC
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Initial Approach
Airspace.Class E : ZZZ
Component
Aircraft Component : Gear Extend/Retract Mechanism
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 791
Experience.Flight Crew.Last 90 Days : 69
Experience.Flight Crew.Type : 163
ASRS Report Number.Accession Number : 1468447
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Landed in Emergency Condition
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
I was approaching ZZZ airport from the west for landing. I had been making radio calls
over the CTAF from 15 miles west of the airport all the way into the downwind for runway
30. No other aircraft seemed to be in the vicinity or at least nobody made any radio calls
that they were in that vicinity.
When I moved the gear selector to the down position I heard the gear move but did not
receive three green lights. I confirmed the lights with the light annunciator button and
verified the lights were in working condition. I then cycled the gear back up and after a
period of waiting put the selector back into the down position. At this time I began to smell
a slight burning odor and noticed a small amount of smoke coming from under the
pilot/co-pilot seat. I reached over to pull the gear motor circuit breaker, but realized it had
already tripped. At this point I called Approach to notify them of my situation and
explained to them I just wanted to make contact with them in case I needed some help,
but for the time being I would be performing a manual extension.
I departed the airport pattern to the north-west and used the auto pilot in heading and
altitude hold modes while I pulled out the POH and referred to the gear manual extension
section. I explained to my passenger to help me scan for traffic while I was multi-tasking.
Upon execution of the POH instructions I was unsuccessful in producing three green lights.
I decided to call [a relative] via cell phone and have him drive to the airport so I could
perform a low approach and he could attempt a visual look at the landing gear. Upon his
arrival another very experienced commercial pilot who was at the field helped him to look
at the landing gear while I flew the low approach. They were both confident all three gears
were down and locked. I then decided to attempt and turn the manual extension handle
more, but could still not get three green lights. With plenty of time I then did a second low
approach to confirm again all three gears looked down and locked. They confirmed once
again that the gear looked down and locked.
I referred to the POH on a gear-up landing and had the plane configured and/or ready for
a possible gear collapse upon landing. I made a normal approach to landing and was very
careful to set the plane onto the runway softly. After touch down the airplane reacted
normal and we were able to exit the runway without incident.
All worked out well in this situation, but we were prepared for the worse.
Synopsis
BE58 Baron pilot reported a landing gear motor failure and manual extension.
ACN: 1468296 (39 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : BFF.Airport
State Reference : WY
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.CTAF : BFF
Aircraft Operator : Air Carrier
Make Model Name : Commercial Fixed Wing
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Parked
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Type : 1736
ASRS Report Number.Accession Number : 1468296
Events
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : Aircraft In Service At Gate
Result.General : None Reported / Taken
Assessments
Contributing Factors / Situations : Company Policy
Primary Problem : Company Policy
Narrative: 1
Due to weather we diverted to BFF which was the alternate as listed on our flight plan. We
had several problems with BFF. We were the 6th aircraft on the ground to divert there at
the time. BFF is an uncontrolled airport. This is the biggest problem for aircraft diverting.
The aircraft on approach cannot land until the aircraft on the ground call in. This causes
big delays in the air and for diverting aircraft with low fuel that's not good. BFF has no
gates. And there was no option to allow passengers to get off the plane for delays. It took
2 hrs to get gas. It could have taken a lot longer. Unicom was the only source of
communications. There was only one person answering the radio which was not very
often. Very bad communications there. ACARS has no reception at BFF. This adds another
layer of problems and delays to get information, get a flight plan, weights, etc. With no
ACARS and since no door opened, VNAV did not work properly on descent to ZZZ1. And
we kept getting error messages while airborne asking us to open a door to reset the
system. I do not believe BFF should be used as a regular alternate airport. If anything else
this can cause large fines due to ground delays without egress options. When we finally
got to destination we arrived at gate and waited 53 minutes with the parking brake set.
Here are the times of this flight:
ZZZ-BFF
OUT XA:01
OFF XA:20
ON XD:41
IN XE:01 (parked at remote spot)
FUEL 7300 lbs
BFF-ZZZ1
OUT XG:12
OFF XG:22
ON XH:02
IN XI:14
FOB 11000 lbs (Estimated)
Also, do the math. The passengers were on the plane for well over 7 hrs when we arrived
at the gate. They then had to wait another 53 min to get off. I called Operations several
times. This is embarrassing.
Synopsis
Air carrier Captain reported questioning the wisdom of using BFF as an alternate with no
tower, no gates, one frequency for CTAF and UNICOM, and no ACARS reception.
ACN: 1468195 (40 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Landing
Route In Use : Visual Approach
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 1718
Experience.Flight Crew.Last 90 Days : 153
ASRS Report Number.Accession Number : 1468195
Human Factors : Situational Awareness
Events
Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
Detector.Person : Flight Crew
When Detected : In-flight
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
C172RG nose wheel collapsed during the end of a landing roll out. The student
inadvertently reached for the Carb-heat. Instead he grabbed the gear handle. I (CFI) saw
the student reaching and tried to intercept/block the action. I was too slow and could not
stop my student's hand. The gear handle moved only half-travel before my hand returned
the gear lever to "down." The nose wheel gave way despite the squat switch. I am
reporting this here because as a CFI I did my best to prevent the mistake but wasn't fast
enough. My student was able to move from the throttle to the gear handle faster than I
could block it.
Synopsis
C172RG flight instructor reported the student pilot inadvertently grabbed the gear handle
instead of the carb heat and caused the nose gear to collapse on landing.
ACN: 1468194 (41 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : CA
Altitude.AGL.Single Value : 150
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Skyhawk 172/Cutlass 172
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Takeoff
Airspace.Class G : ZZZ
Component
Aircraft Component : Cylinder
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Experience.Flight Crew.Total : 630
Experience.Flight Crew.Last 90 Days : 56
Experience.Flight Crew.Type : 510
ASRS Report Number.Accession Number : 1468194
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Ground Excursion : Runway
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Diverted
Result.Flight Crew : Landed in Emergency Condition
Result.Flight Crew : Overcame Equipment Problem
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Regained Aircraft Control
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft
Narrative: 1
Landed in a field on airport property as a result of Power loss due to a cracked cylinder
#4.
I was on a training flight with a Student Pilot getting check ride ready, which was to take
part two days later. Before takeoff I did my usual check with the student, oil was at 6qts
and fuel was topped off (53 Gal) as a safety precaution.
The flight was a typical training flight, took off from [home airport], did some ground
reference maneuvers in the area, followed by landings in ZZZ airport, an uncontrolled
field. After two landings in the pattern, I told the student to prepare for a short field
takeoff and since he was getting ready for check ride everything was by the book, from
checklists to airspeed and Oil temperature and pressure call outs. On this one, I said,
"ENGINE FAILED", student took appropriate action and stopped the aircraft, pulled throttle
and said in real life he would pull the mixture and the appropriate checklist. I was satisfied
and we further discussed eventualities if the engine did fail on takeoff roll, below 1000 feet
and after that.
After this simulated abort takeoff, [we decided to return to home airport]. On this final
departure, again everything by the book, proper non-towered radio calls, checklists and
use of runway space. On takeoff roll, on the Vx climb, I was satisfied and continued with a
clear of obstacle call, the student then pitched for Vy. About 3 seconds after, I heard a
BANG! I immediately looked at the tires to see if they popped, the oil pressure and
temperature, they were green. Simultaneously the aircraft began to shake and vibrate
violently. I looked at the VSI and saw the climb go from +800 FPM down to barely +50
FPM.
My student looked at me and said, "I've lost the engine...", I took over controls and added
full power, Idle, then power again. Nothing changed and clearly there was a problem. At
this point, I'm still maintaining heading, airspeed began to decrease and I said, "confirm
engine loss....", student said, "confirm!". I had no choice, I had to put it down. Told the
student, "seatbelt on tight, door open now, I have this". Immediately, I knew from
experience that I could not land this plane straight given the speed and rate of drop and
ground roll. I banked about 15-20 Degrees left and slipped the plane down to the corner of
a field and put the plane diagonally off the runway numbers, an approximate 305 heading.
On touchdown, I had flaps full and hit the ground right as the stall horn went off,
touchdown was rough but I held the back pressure in and did a basic soft field landing.
Since I had never done a real grass landing before I did not apply brakes and knew the
plane will stop eventually.
When the plane came to a full stop, I told the student, "after landing checklist now!" He
ran it pulled full emergency cutoff, fuel selected off and ran the checklist. I had my left
hand on the fire extinguisher and my right hand had the checklist in hand ready for a fire,
explosion, oil spewing, whatever come may.
To our luck, nothing came after, so when we got out, I said "fuel check", we had 42Gal
total and Oil was still around 6quarts.
Post incident:
On my inspection, no oil leaked, no sign of outside damage. I called the owner/flight
school and did a post check of the exterior, no damage to the propeller, wheel pants, tires,
or fuselage. Luckily we found a crack in cylinder #4 next to the spark plug which caused
the Partial Power Loss and vibration issue with the aircraft. 65 feet remained between the
aircraft and a fence, luckily an airport tenant saw and heard the incident so he
immediately sprang in to help and get a tow to get our plane out.
Since my student and I were in the check ride prep mode, I believe that this led to the
great outcome of our flight. The issue could not be prevented since it was a maintenance
problem, so my job as an instructor was done and had I made any calls differently, surely
the result would have been bad. My student remained calm and collected and I think I
acted appropriately given the situation I had.
I know this is not standard, but I do train my SEL students for private at a higher standard
and although not a required procedure except for MEL, I train my students to react if an
engine loss occurs 800 feet to return to the field in the opposite direction. My student said
that me practicing this with him helped in alleviating the fear if the plane lost power and
said attributed to the issue.
Synopsis
A Cessna 172 instructor pilot reported the engine failed right after takeoff.
ACN: 1468179 (42 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : FOD.Airport
State Reference : IA
Relative Position.Angle.Radial : 010
Relative Position.Distance.Nautical Miles : 2
Altitude.MSL.Single Value : 800
Environment
Flight Conditions : IMC
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 800
Aircraft
Reference : X
ATC / Advisory.CTAF : FOD
Aircraft Operator : Personal
Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Descent
Route In Use : Direct
Airspace.Class E : FOD
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Other / Unknown
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 800
Experience.Flight Crew.Last 90 Days : 20
Experience.Flight Crew.Type : 40
ASRS Report Number.Accession Number : 1468179
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Other
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Deviation - Procedural : FAR
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Passenger
When Detected : In-flight
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Became Reoriented
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Weather
Primary Problem : Human Factors
Narrative: 1
Flying as an "extra set of eyes" for a pilot friend while enroute to Oshkosh, we
inadvertently flew into a class E surface airport with weather below VFR minimums. When
approximately 10-15 miles west of FOD, we picked up the AWOS weather and observed
the field was barely above VFR minimums: 1000 ft Broken, 10 SM visibility. I pointed out
to the pilot that there was an airport 10 miles northwest of our position that was reporting
VFR, in case FOD went below minimums. The pilot elected to continue to FOD to take a
look. After descending, we picked up the AWOS again and observed the clouds were now
at 800 ft broken. Already being below the clouds and 2 miles from the airport, the pilot
elected to continue and land at FOD. Looking back, this was probably the safer option at
that point, already being under the cloud deck, but we never should have gotten to that in
the first place. The landing was uneventful and we waited on the ground until the weather
raised back to VFR minimums, and departed for the rest of our trip.
Lessons learned: I should have been more forceful with the pilot on the suggestion of
going to the alternate airport that was VFR. The pilot may not have understood that FOD
was class E and the weather minimums associated with class E. It was ignorant to proceed
into deteriorating weather, when a viable alternate was so close.
Synopsis
A flight instructor observer pilot reported not being assertive enough and allowed the pilot,
who was presumably operating under VFR, to proceed to and land at an airport that was
below VMC.
ACN: 1467196 (43 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : OKB.Airport
State Reference : CA
Altitude.MSL.Single Value : 1200
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 9
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : OKB
Aircraft Operator : Personal
Make Model Name : Small Aircraft
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : VFR
Mission : Personal
Flight Phase : Initial Climb
Airspace.Class G : SCT
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : OKB
Make Model Name : Small Aircraft
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Phase : Initial Climb
Flight Phase : Initial Approach
Airspace.Class G : SCT
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 900
Experience.Flight Crew.Last 90 Days : 8
Experience.Flight Crew.Type : 47
ASRS Report Number.Accession Number : 1467196
Events
Anomaly.Conflict : NMAC
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
Miss Distance.Horizontal : 375
Miss Distance.Vertical : 150
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Airspace Structure
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
This was the return leg of a personal pleasure flight to Oceanside, CA (OKB). I was the PIC
pilot flying for the first leg and had swapped seats and was not flying on the return flight.
Not being PIC for this leg, and despite being the more experienced aviator, I was relaxing
and mentally disengaged with more of a passenger mindset, given I was with a properly
rated, current and qualified pilot in the left seat of a single-pilot aircraft. We briefed the
takeoff procedures after the run-up, and the PIC had verbally noted the "fly friendly" noise
abatement sign at the departure end of the runway, and I reiterated the sign text: follow
the river to the shoreline. A C172 departed in front of us for closed traffic, and when the
PIC began taxiing towards the runway immediately after they began takeoff roll, I
recommended we hold for separation given our dissimilar aircraft. After the 172 had
gotten airborne, we taxiied onto Runway 24 and departed. This was sooner than I
personally would have departed, but I did not verbalize this and felt it would be a non-
issue since they were remaining in the pattern and we were a west departure. In the
moments after takeoff leading up to the event, I was enjoying the view out my side of the
aircraft while casually glancing over to keep an eye on the traffic that departed in front of
us. I noticed our courses diverging and made a call-out that the traffic was now at 11
o'clock, which was acknowledged. There was a scattered layer above us, which
momentarily caused a level off. On my next glance I noticed the 172 had turned
northbound and our courses were nearly perpendicular and we were co-altitude, so I again
called out that the 172 was 11 o'clock, northbound, same altitude, which was again
acknowledged, but no action was taken. As we continued westbound I saw the situation
developing, and I issued another verbal warning to the PIC, which was acknowledged, but
again no corrective action was taken and the aircraft continued to converge. I immediately
looked inside and saw the PIC with his head down at the iPad and at that point I assumed
the controls and initiated a pitch up and climbed the aircraft through a break in the clouds.
Aircraft 2 passed below and behind at an estimated range of 400 feet diagonally. While I
do not believe the situation was unsafe, the separation was not comfortable nor expected
by either aircraft. I should have taken action sooner, and believe I would have had I been
participating in the flight more actively. It is worth noting that I often fly into [an airport
with parallel runways], so I am frequently exposed to aircraft being closer than normal
during arrival and departure, which may bias my opinion of whether or not a collision
hazard existed. In those situations, however, the aircraft are typically on parallel or
divergent courses, which was not the case here, and had I not taken action, a collision
hazard would have certainly existed regardless of any subjectivity.
As with most abnormal events in aviation, there were numerous links in the chain of
events, and there were missed opportunities to break that chain sooner. This was a case
involving both poor communication and poor CRM. During the debrief of the event, the PIC
stated he was just flying straight out to the shoreline as he was used to when flying out of
many southern California airports, and did not notice or follow the river, which turns
slightly south, as the 172 did. I wish the PIC would have verbalized to me that he was
overwhelmed, confused or unsure of the departure routing, and I would have been able to
assume the role of a proactive crew member and help the PIC stay mentally ahead of the
aircraft instead of just sight-seeing. If I had better situational awareness of my pilot's
workload, I could have stepped in earlier in the flight to assist. While unable to see the
river from the right side of the aircraft, I am still guilty of not querying the PIC when I
initially noticed our departure courses diverging. We should have been following behind
the preceding traffic which would have averted the need for corrective action. Additionally,
had I pushed for additional separation between our aircraft on departure that would have
given additional time to maneuver behind the preceding 172 when they began the
crosswind turn over the shoreline, building additional lateral separation. The PIC, a VFR
private pilot, mentioned during the debrief of the event that he was distracted by the
clouds. This fixation likely contributed to the PIC's inaction and loss of situational
awareness. The weather was reporting CLR at the field, had it been reporting clouds or
had I personally looked at weather and seen the marine layer approaching, I would have
filed for an IFR departure, we would have been able to climb above the traffic in front of
us, and ATC would've been there acting as a third set of eyes for safe separation.
While often mentioned, it is worth reiterating that cockpit technology serves to aid in our
situational awareness, and is no substitute for true situational awareness of what's
happening both in and out of the cockpit. This should continue to be stressed to pilots in
training, and to experienced pilots who use this technology. The FAA is already in the
process of realigning training to focus on decision making, task priority, and situational
awareness in lieu of purely maneuver-based evaluation. Instructors also need training in
these subject areas so students are properly educated. I support this shift and believe it
could prevent future occurrences of events such as this. In addition to teaching standard
traffic patterns, pilot training also needs to highlight the existence of numerous non-
standard procedures that pilots will encounter, particularly at uncontrolled fields, and the
importance of proper pre-flight planning to review and understand these procedures prior
to stepping into the cockpit. I believe flight planning applications can sometimes be
detrimental to the formation of good habits for proper pre-flight planning, because they
can tempt pilots into a feeling of security with having all the information available on-
demand at your fingertips. Instructors need to stress the importance of thorough pre-flight
planning even more so with the advent of this technology.
It should be general good practice that whenever occupying a crewmember seat that a
rated pilot always stay engaged in the flight's progression and be ready to offer assistance
regardless of who is pilot in command. I had made the trip to relax and get away for an
afternoon, and my decision to disengage from the planning and execution of the return
flight proved detrimental, and was a missed opportunity to act as a mentor to a fellow
aviator.
Synopsis
General aviation flight instructor reported a near mid air collision after departure from a
CTAF airport.
ACN: 1466538 (44 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : HIO.Tower
State Reference : OR
Altitude.MSL.Single Value : 1600
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.Tower : HIO
Aircraft Operator : Air Carrier
Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Final Approach
Route In Use : Visual Approach
Airspace.Class D : HIO
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : 7S3
Aircraft Operator : Personal
Make Model Name : Small Aircraft, Low Wing, 1 Eng, Retractable Gear
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Nav In Use : GPS
Flight Phase : Cruise
Route In Use : None
Airspace.Class D : HIO
Person : 1
Reference : 1
Location Of Person.Facility : HIO.Tower
Reporter Organization : Government
Function.Air Traffic Control : Local
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 10
ASRS Report Number.Accession Number : 1466538
Human Factors : Human-Machine Interface
Human Factors : Situational Awareness
Human Factors : Distraction
Person : 2
Reference : 2
Location Of Person.Aircraft : Y
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Private
Experience.Flight Crew.Total : 1200
Experience.Flight Crew.Last 90 Days : 45
Experience.Flight Crew.Type : 445
ASRS Report Number.Accession Number : 1467150
Human Factors : Distraction
Human Factors : Time Pressure
Human Factors : Confusion
Events
Anomaly.Airspace Violation : All Types
Anomaly.Conflict : NMAC
Anomaly.Deviation - Procedural : FAR
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Air Traffic Control : Issued Advisory / Alert
Assessments
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Procedure
Narrative: 1
I was working Local 1. There were two GA aircraft on final for Runway 31L that were
cleared to land. I had one GA aircraft extended on right downwind to follow the two
aircraft on final, but then I received an inbound point-out from P80, the overlying
TRACON, on Aircraft X from the southeast. I asked P80 to slow Aircraft X and direct him to
fly over the fix INTLL. I told the GA aircraft extended in the right downwind that I was
unable to accommodate his full stop on Runway 31L because of the faster Aircraft X traffic.
I instructed the GA aircraft to extend right downwind and contact the Local 2 controller on
132.8 for a full stop landing on Runway 31R. Aircraft X checked on frequency and I cleared
him to land number two behind the GA aircraft on short final. Additionally, I told Aircraft X
that there would be traffic ahead and to his right on extended final for the north parallel.
When Aircraft X was on about a five mile final, I observed an aircraft on what appeared to
be a right base about four miles from the airport. I told Aircraft X to stop his descent and
that it appeared that the aircraft for the north runway was overshooting final underneath
Aircraft X at 1000 MSL. At that point Aircraft X indicated 1600 MSL. Aircraft X said that he
saw the aircraft and was responding to a TCAS RA, but it didn't look like one of the high
wing GA aircraft. Local 2 immediately advised that that was not his aircraft, and we
determined that the southwest-bound aircraft was an airspace violator. I passed this
information along to Aircraft X and asked if he would like to continue the approach.
Aircraft X said he could, and I cleared him to land again on Runway 31L. I did not observe
Aircraft X take any evasive maneuver to avoid the aircraft. I had both aircraft in sight the
entire time, and Aircraft X appeared to cross over the violator between 400-600 feet. After
Aircraft X landed the pilot called the tower and advised that the violator in question,
Aircraft Y, landed at 7S3 shortly after. The pilot of Aircraft X also advised that they were
reporting this incident as a near mid-air collision.
On the FALCON replay, Aircraft Y could be seen violating the airspace from the northeast
and then exiting the Delta airspace and skirt the edge of the airspace south bound. Aircraft
Y re-entered the airspace from the southeast and made a turn southwest bound. This put
him directly under final at about 1000 MSL. Had I noticed this violator earlier, I could have
prepped Aircraft X sooner. But I am confident that my timely actions to stop Aircraft X's
descent prevented this from becoming a collision.
Narrative: 2
After departing [north of SPB] to 7S3 and just setting cruise after climb out I realized that
I was very close to HIO Class D. I immediately turned east toward PDX and flew between
their airspace until clear to the south of HIO. I then continued on to 7S3 and landed there
for fuel. After fueling I was told that I had entered the Class D airspace and that I would
be hearing from ATC. I was not given a number to call, but was told that since I had
installed ADSB they already had my information. I believe that a contributing factor was
that in approaching from the north the Class D line is missing or obscured due to all of the
printing. As soon as I realized how close I was I watched for other aircraft and diverted to
an area I knew to be outside. Another factor was my inexperience with the area and the
short duration of the flight. Had I prepared more I might have had their frequency dialed
in but I had just set the radio to 7S3 frequency and changing to HIO freq. would have
required more time than simply exiting.
Synopsis
HIO Tower Controller and pilot reported of a Class Delta airspace violation and a NMAC.
ACN: 1466524 (45 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.ATC Facility : HCF.TRACON
State Reference : HI
Altitude.MSL.Single Value : 4800
Environment
Flight Conditions : VMC
Weather Elements / Visibility : Cloudy
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 4800
Aircraft : 1
Reference : X
ATC / Advisory.TRACON : HCF
Aircraft Operator : Air Taxi
Make Model Name : Small Transport
Operating Under FAR Part : Part 135
Flight Plan : IFR
Flight Phase : Initial Approach
Airspace.Class E : HCF
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : JHM
Aircraft Operator : Air Taxi
Make Model Name : Small Transport
Operating Under FAR Part : Part 135
Flight Plan : VFR
Flight Phase : Climb
Route In Use : None
Airspace.Class E : HCF
Person
Reference : 1
Location Of Person.Facility : HCF.TRACON
Reporter Organization : Government
Function.Air Traffic Control : Approach
Qualification.Air Traffic Control : Fully Certified
Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 2.75
ASRS Report Number.Accession Number : 1466524
Human Factors : Time Pressure
Human Factors : Situational Awareness
Events
Anomaly.Conflict : Airborne Conflict
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Clearance
Anomaly.Inflight Event / Encounter : CFTT / CFIT
Detector.Person : Air Traffic Control
When Detected : In-flight
Result.Flight Crew : Returned To Clearance
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Environment - Non Weather Related
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Human Factors
Narrative: 1
Aircraft X was on the instrument approach into JHM. The Aircraft before him reported
BKN048 10 NW of the airport. Aircraft X was 15 NW of JHM descending when a VFR
aircraft on a 1200 squawk departed JHM head on. I issued traffic advisories to Aircraft X
but had no idea who the other aircraft was. Traffic advisories became traffic alerts 5 miles
between the two aircraft at 4800 (same ALT). Then at two miles at 4800 the Captain says
"I'm going right". A right turn would have put the Aircraft X even closer and the targets
would have merged. I told the Aircraft X to make a left 360 before proceeding back on
course, they were below the MVA at the time but over water. I noticed Aircraft X had
climbed to 5000 and asked if they had an RA. The pilot replied in the affirmative and I
reported it to my Supervisor. Later we found out the other aircraft was Aircraft Y when
they requested flight following from the adjacent sector.
Recommendations:
1. Request flight following in and out of JHM.
2. JHM issues a VFR code on the ground and has them contact HCF on departure.
3. Development of a VFR procedure where aircraft remain clear of the final approach
course.
Synopsis
HCF Controller reported an airborne conflict between an IFR departure and a VFR aircraft.
ACN: 1466511 (46 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 5
Environment
Flight Conditions : VMC
Light : Daylight
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Amateur/Home Built/Experimental
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Final Approach
Route In Use : VFR Route
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : ZZZ
Make Model Name : PC-12
Crew Size.Number Of Crew : 1
Flight Phase : Takeoff
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Commercial
Experience.Flight Crew.Total : 2000
Experience.Flight Crew.Last 90 Days : 9
Experience.Flight Crew.Type : 1200
ASRS Report Number.Accession Number : 1466511
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : NMAC
Anomaly.Conflict : Ground Conflict, Critical
Detector.Person : Flight Crew
Miss Distance.Horizontal : 100
Miss Distance.Vertical : 20
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Executed Go Around / Missed Approach
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
We were over the threshold doing 95 knots when a Pilatus began to take the active
runway. My lovely passenger and I reported that we were on a very short final!! The pilot
then shot on the runway and said: "Go around!" We thought we were goners!! I nearly
dug in a wing tip missing the Pilatus by only a few feet and passed by him and flew
alongside the plane during its takeoff roll.
Synopsis
Glasair pilot reported that during final approach prior to touchdown, a Pilatus took the
active runway.
ACN: 1466499 (47 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 10000
Aircraft
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : Personal
Make Model Name : Amateur/Home Built/Experimental
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Personal
Flight Phase : Landing
Route In Use : None
Component
Aircraft Component : Nose Gear
Aircraft Reference : X
Problem : Failed
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 20000
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 200
ASRS Report Number.Accession Number : 1466499
Human Factors : Training / Qualification
Events
Anomaly.Ground Excursion : Runway
Anomaly.Ground Event / Encounter : Loss Of Aircraft Control
Detector.Person : Flight Crew
When Detected : In-flight
Result.Aircraft : Aircraft Damaged
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
On roll out after a series of landings, pilot's foot slipped off the rudder/brake and aircraft
veered onto the shoulder and the nose gear collapsed.
Synopsis
Experimental aircraft pilot reported that his foot slipped off the rudder pedal on landing
resulting in a runway excursion.
ACN: 1466180 (48 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : JYO.Airport
State Reference : VA
Altitude.AGL.Single Value : 0
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 5000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : JYO
Aircraft Operator : Personal
Make Model Name : PA-34-200T Turbo Seneca II
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Takeoff
Route In Use : Vectors
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : JYO
Aircraft Operator : Personal
Make Model Name : Cirrus Aircraft Undifferentiated
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Mission : Personal
Flight Phase : Final Approach
Airspace.Class G : PCT
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 4000
Experience.Flight Crew.Last 90 Days : 25
Experience.Flight Crew.Type : 1200
ASRS Report Number.Accession Number : 1466180
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : Ground Conflict, Less Severe
Anomaly.Deviation - Procedural : Clearance
Anomaly.Ground Incursion : Runway
Detector.Person : Flight Crew
Miss Distance.Horizontal : 3000
Miss Distance.Vertical : 0
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
Departing JYO. Part time Tower closes in the afternoon. Called Ground for clearance. Was
informed Tower was closing, Runway 35 was in use and to get clearance from Potomac
Approach. Announced taxi to Runway 35 on Unicom and taxied to run-up area. Switched
frequencies and got IFR clearance. Was told there was inbound IFR traffic and that we
were cleared to go as soon as they arrived. Traffic was on base for 35. They landed and
we announced our departure for 35 on Unicom and taxied out. As landing traffic cleared
runway we started our takeoff roll. As we rolled I spotted landing lights on short final for
Runway 17. I aborted takeoff and stopped the plane well to the side of the runway. The
approaching airplane, a Cirrus, landed and taxied off the runway. We then departed on
Runway 35. I do not believe the Cirrus ever saw us. We did not hear him call position or
intentions on Unicom. The wind favored Runway 35 and that was the direction all traffic
had been landing according to the Tower before it closed. The runway is long and neither
airplane was in jeopardy as the Cirrus stopped in a short distance and exited the runway.
But had I not seen them in the distance it could have been much closer.
Synopsis
PA34 pilot reported rejecting takeoff after observing unannounced traffic on short final
landing on the opposite direction runway.
ACN: 1466178 (49 of 50)
Time / Day
Date : 201707
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : JNX.Airport
State Reference : NC
Altitude.MSL.Single Value : 800
Environment
Flight Conditions : Marginal
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 2000
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : JNX
Make Model Name : Cessna Single Piston Undifferentiated or Other Model
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Nav In Use : GPS
Flight Phase : Final Approach
Route In Use.Other
Airspace.Class E : RDU
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : JNX
Make Model Name : Cessna Aircraft Undifferentiated or Other Model
Crew Size.Number Of Crew : 1
Airspace.Class E : RDU
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 791
Experience.Flight Crew.Last 90 Days : 150
Experience.Flight Crew.Type : 85
ASRS Report Number.Accession Number : 1466178
Human Factors : Situational Awareness
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 500
Miss Distance.Vertical : 100
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
At the time of the incident I had been cleared for the RNAV 21 approach. I entered VMC
after passing the IAF and contacted Raleigh approach to cancel my IFR flight plan. Raleigh
confirmed my cancellation and approved me to change to the CTAF frequency. Ceiling was
around 2,500 feet MSL. I announced on the CTAF frequency that I was 8 miles out on the
GPS approach for Runway 21 at JNX. I made an announcement that I was 5 miles out on
the GPS approach for Runway 21 at JNX. At this time another pilot made announcement
that he was overflying the tank farm 4 miles away and would be passing the approach end
of Runway 21. I made an announcement that I was 3 miles out on the GPS approach for
Runway 21 at JNX. The other pilot announced that he had me in sight and would maintain
visual separation. I had just passed CUMUT. It was after this when I saw a Cessna
disappear underneath my nose. I immediately executed a steep climbing turn to the left to
avoid the airplane and announced my intentions on the CTAF. I completed a 360 degree
turn and landed on Runway 21 without further incident.
Synopsis
Cessna pilot reported an NMAC with another light aircraft in the vicinity of JNX airport.
ACN: 1465911 (50 of 50)
Time / Day
Date : 201707
Local Time Of Day : 1201-1800
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 2000
Environment
Flight Conditions : VMC
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 3500
Aircraft : 1
Reference : X
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Flight Plan : None
Mission : Training
Flight Phase : Initial Approach
Airspace.Class E : ZZZ
Aircraft : 2
Reference : Y
ATC / Advisory.CTAF : ZZZ
Aircraft Operator : FBO
Make Model Name : Skyhawk 172/Cutlass 172
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 91
Mission : Training
Flight Phase : Initial Approach
Airspace.Class E : ZZZ
Person : 1
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 2115
Experience.Flight Crew.Last 90 Days : 65
Experience.Flight Crew.Type : 850
ASRS Report Number.Accession Number : 1465911
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Person : 2
Reference : 2
Location Of Person.Aircraft : Y
Location In Aircraft : Flight Deck
Reporter Organization : FBO
Function.Flight Crew : Instructor
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Flight Instructor
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 3200
Experience.Flight Crew.Last 90 Days : 100
Experience.Flight Crew.Type : 3200
ASRS Report Number.Accession Number : 1465931
Human Factors : Communication Breakdown
Human Factors : Situational Awareness
Communication Breakdown.Party1 : Flight Crew
Communication Breakdown.Party2 : Flight Crew
Events
Anomaly.Conflict : NMAC
Detector.Person : Flight Crew
Miss Distance.Horizontal : 400
Miss Distance.Vertical : 100
When Detected : In-flight
Result.Flight Crew : Took Evasive Action
Assessments
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
While on downwind during a training flight in the traffic pattern during a time of very
heavy activity, as I began to turn base there was another aircraft slightly above and
behind me. I immediately took evasive action by descending and turning away from the
other aircraft. We had both been announcing our positions on CTAF but were not aware of
how close we were to each other.
Narrative: 2
I was on downwind with a student and we were just about to call our base turn when
another airplane called turning base. I started to look for it and had just pushed the push
to talk button when I saw it low and to our right, so instead of "where are you" in surprise
I said "Oh [expletive]" and then saw that he had seen us too and was starting to dive left
so I took the controls from the student and climbed right. There was no further conflict.
Prior to this happening we had approached the airport on the upwind, then crosswind,
then downwind. While we were turning crosswind a plane on the runway called their
departure so I was looking for them to make sure there was no conflict with them. The
other plane in the pattern had made a radio call that he was inbound to the downwind, but
due to distraction with the plane on the runway I never heard him say he was entering
downwind and I assumed he was far ahead of us. We had made radio calls at each turn. I
did not see him on downwind until we were ready to turn base. I do not think entering a
pattern from upwind is a good idea, we should only enter to the downwind.
Synopsis
Two instructor pilots, both flying separate C172 aircraft, reported an NMAC with each
other in the pattern.