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An ATP single jet pilot has problems with his missed approach procedure when losing his ADI and having to fly 'partial panel' during the missed approach. Radar advisories provided by ZJX, fl.
| Attributes | |
| ACN | 441055 |
| Time | |
| Date | 199906 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | navaid : ssi.vor |
| State Reference | GA |
| Altitude | msl single value : 700 |
| Environment | |
| Flight Conditions | IMC |
| Weather Elements | Windshear Turbulence Thunderstorm Rain |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zjx.artcc |
| Operator | general aviation : personal |
| Make Model Name | Small Transport, Low Wing, 2 Turbojet Eng |
| Operating Under FAR Part | Part 91 |
| Navigation In Use | other other vortac |
| Flight Phase | descent : approach |
| Route In Use | approach : instrument non precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government other |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 25 flight time total : 4200 flight time type : 400 |
| ASRS Report | 441055 |
| Person 2 | |
| Affiliation | government : faa |
| Function | controller : radar |
| Qualification | controller : radar |
| Events | |
| Anomaly | aircraft equipment problem : critical inflight encounter : weather inflight encounter : turbulence non adherence : published procedure other anomaly other spatial deviation |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : exited adverse environment flight crew : regained aircraft control |
| Supplementary | |
| Problem Areas | Weather Flight Crew Human Performance Environmental Factor Aircraft |
| Primary Problem | Aircraft |
Narrative:
Localized area of moderate/heavy rain near and over destination airport. Center controller reported 'it's only heavy rain, there's nothing in it.' this was consistent with the pattern of the previous day or 2. Carried out normal VOR approach using autoplt/flight director. At missed approach, began a climb on autoplt. Encountered very heavy rain, moderate turbulence. At approximately 700 ft MSL 9250 ft above minimums) ADI failed with loss of all autoplt/flight director functions. Pilot had difficulty maintaining precise control over aircraft using backup instruments due to turbulence and loss of position and altitude guidance. Contributing factors: 1) backup instruments not set up for missed approach. 2) pilot did not study and prepare adequately for missed approach. 3) lack of situational awareness when talking with controller due to lack of familiarity with nearby landmarks, fixes and waypoints. Corrective actions: training should include setting up backup navigation indicators for approach/missed approach in anticipation of primary ADI/HSI failure. Pilots need to thoroughly memorize and set up missed approach because an emergency or equipment failure does not leave time to read it while executing. Poor software design of KLN90B GPS contributes to difficulties with situational awareness.
Original NASA ASRS Text
Title: AN ATP SINGLE JET PLT HAS PROBS WITH HIS MISSED APCH PROC WHEN LOSING HIS ADI AND HAVING TO FLY 'PARTIAL PANEL' DURING THE MISSED APCH. RADAR ADVISORIES PROVIDED BY ZJX, FL.
Narrative: LOCALIZED AREA OF MODERATE/HVY RAIN NEAR AND OVER DEST ARPT. CTR CTLR RPTED 'IT'S ONLY HVY RAIN, THERE'S NOTHING IN IT.' THIS WAS CONSISTENT WITH THE PATTERN OF THE PREVIOUS DAY OR 2. CARRIED OUT NORMAL VOR APCH USING AUTOPLT/FLT DIRECTOR. AT MISSED APCH, BEGAN A CLB ON AUTOPLT. ENCOUNTERED VERY HVY RAIN, MODERATE TURB. AT APPROX 700 FT MSL 9250 FT ABOVE MINIMUMS) ADI FAILED WITH LOSS OF ALL AUTOPLT/FLT DIRECTOR FUNCTIONS. PLT HAD DIFFICULTY MAINTAINING PRECISE CTL OVER ACFT USING BACKUP INSTS DUE TO TURB AND LOSS OF POS AND ALT GUIDANCE. CONTRIBUTING FACTORS: 1) BACKUP INSTS NOT SET UP FOR MISSED APCH. 2) PLT DID NOT STUDY AND PREPARE ADEQUATELY FOR MISSED APCH. 3) LACK OF SITUATIONAL AWARENESS WHEN TALKING WITH CTLR DUE TO LACK OF FAMILIARITY WITH NEARBY LANDMARKS, FIXES AND WAYPOINTS. CORRECTIVE ACTIONS: TRAINING SHOULD INCLUDE SETTING UP BACKUP NAV INDICATORS FOR APCH/MISSED APCH IN ANTICIPATION OF PRIMARY ADI/HSI FAILURE. PLTS NEED TO THOROUGHLY MEMORIZE AND SET UP MISSED APCH BECAUSE AN EMER OR EQUIP FAILURE DOES NOT LEAVE TIME TO READ IT WHILE EXECUTING. POOR SOFTWARE DESIGN OF KLN90B GPS CONTRIBUTES TO DIFFICULTIES WITH SITUATIONAL AWARENESS.
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.