 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
BE76 pilot, distracted by fatigue, begins inadvertent descent while still assigned radar vectors with altitude assignment. Pilot returns to assigned altitude when alerted by military controller.
| Attributes | |
| ACN | 410819 |
| Time | |
| Date | 199808 |
| Day | Fri |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | atc facility : anx |
| State Reference | MO |
| Altitude | msl bound lower : 2000 msl bound upper : 2600 |
| Environment | |
| Flight Conditions | Marginal |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | military facility : szl |
| Operator | general aviation : personal |
| Make Model Name | Duchess 76 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | descent : approach descent other |
| Route In Use | arrival other enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : single pilot instruction : instructor |
| Qualification | pilot : cfi pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 100 flight time total : 1470 flight time type : 235 |
| ASRS Report | 410819 |
| Person 2 | |
| Affiliation | Other |
| Function | instruction : trainee |
| Qualification | pilot : private |
| Events | |
| Anomaly | non adherence : clearance other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | flight crew : returned to intended course or assigned course other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Problem arose by the PF starting a descent when directly over the final approach fix inbound, as if on the VOR-DME/a approach for 9k4 (skyhaven). Contributing factors was pilot fatigue, awake for 20 hours with 7.8 hours of straight flying. Error was discovered when the approach controller wanted to verify altitude. Immediate action was taken to begin a best rate climb to maintain 2600 ft MSL. Since on an IFR flight plan, and originally still maintaining course for the instrument approach, the PF began a descent at the final approach fix inbound, still thinking I was on an instrument approach, while the controller thought we were on a visual with vectors, even though I do not recall a vector being given. Inaction on the part of the PF and PNF's to query ATC about which approach and minimum altitude we could descend to. Fatigue was a major factor in this event, and lack of communication between the PF and PNF.
Original NASA ASRS Text
Title: BE76 PLT, DISTRACTED BY FATIGUE, BEGINS INADVERTENT DSCNT WHILE STILL ASSIGNED RADAR VECTORS WITH ALT ASSIGNMENT. PLT RETURNS TO ASSIGNED ALT WHEN ALERTED BY MIL CTLR.
Narrative: PROB AROSE BY THE PF STARTING A DSCNT WHEN DIRECTLY OVER THE FINAL APCH FIX INBOUND, AS IF ON THE VOR-DME/A APCH FOR 9K4 (SKYHAVEN). CONTRIBUTING FACTORS WAS PLT FATIGUE, AWAKE FOR 20 HRS WITH 7.8 HRS OF STRAIGHT FLYING. ERROR WAS DISCOVERED WHEN THE APCH CTLR WANTED TO VERIFY ALT. IMMEDIATE ACTION WAS TAKEN TO BEGIN A BEST RATE CLB TO MAINTAIN 2600 FT MSL. SINCE ON AN IFR FLT PLAN, AND ORIGINALLY STILL MAINTAINING COURSE FOR THE INST APCH, THE PF BEGAN A DSCNT AT THE FINAL APCH FIX INBOUND, STILL THINKING I WAS ON AN INST APCH, WHILE THE CTLR THOUGHT WE WERE ON A VISUAL WITH VECTORS, EVEN THOUGH I DO NOT RECALL A VECTOR BEING GIVEN. INACTION ON THE PART OF THE PF AND PNF'S TO QUERY ATC ABOUT WHICH APCH AND MINIMUM ALT WE COULD DSND TO. FATIGUE WAS A MAJOR FACTOR IN THIS EVENT, AND LACK OF COM BTWN THE PF AND PNF.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.