General Aviation Flight Training Incidents

ASRS Database Report Set

General Aviation Flight Training Incidents

Report Set Description .........................................A sampling of reports referencing General Aviation flight training. Update Number ....................................................28.0 Date of Update .....................................................April 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.

Report Synopses

ACN: 1418979

(1 of 50)

Synopsis PA-28R pilot reported landing gear up during a training flight with an instructor.

ACN: 1418920

(2 of 50)

Synopsis A general aviation pilot reported altimeter accuracy issues during a practice instrument approach. Pilot elected to break off approach in VMC conditions and return to base airport.

ACN: 1418434

(3 of 50)

Synopsis Military trainer pilot reported overshooting a 5,000 foot altitude constraint with traffic at 6,000 feet.

ACN: 1418180

(4 of 50)

Synopsis Instructor pilot reported a loss of separation due to confusion on where they wanted to land. Their aircraft came close to aircraft departing ONT. Pilot did not advise ATC prior to descending that they wanted to land at ONT.

ACN: 1418156

(5 of 50)

Synopsis C172 instructor pilot reported after takeoff he had trouble communicating with the student pilot. During this distracting event ATC had to repeat their clearance 3 times.

ACN: 1417915

(6 of 50)

Synopsis PA28 student pilot reported losing control during landing roll resulting in a ground loop on the runway. A subsequent landing attempt resulted in another loss of control event and a runway excursion.

ACN: 1417647

(7 of 50)

Synopsis Glider pilot reported brake failure during landing and rolled off the end of the runway and down an embankment sustaining some damage.

ACN: 1417625 Synopsis

(8 of 50)

C172 instructor pilot reported two separate near-midair collision situations during successive visual approaches for landing to CMA airport.

ACN: 1417618

(9 of 50)

Synopsis A designated examiner was giving a checkride to a CFII applicant. They were on a practice ILS approach when a Hawker approached from behind and turned left at the last minute to avoid a collision.

ACN: 1417596

(10 of 50)

Synopsis PA34 pilot reported coming upon parachute jumpers necessitating evasive action in the vicinity of 4A4 Airport.

ACN: 1417583

(11 of 50)

Synopsis A pilot conducting practice approaches to FDY Runway 36 in IMC at 2,300 FT, was issued a low altitude alert even though the GPS and glideslope appeared normal. The pilot executed a precautionary go-around, but later could find no cause for the alert.

ACN: 1417558

(12 of 50)

Synopsis Citabria pilot reported a ground conflict with a Cessna 172 at LMO airport.

ACN: 1416735

(13 of 50)

Synopsis GA CFI reported losing site of traffic they were to follow at FRG and had to make an evasive turn to avoid a collision. Instructor subsequently reported making a normal touch and go landing.

ACN: 1416207

(14 of 50)

Synopsis General aviation flight instructor reported overshooting the intended runway on base leg and landing on the wrong runway during an unplanned short approach to remain clear of inbound traffic.


(15 of 50)

C172 flight instructor reported his solo student lost control of the aircraft after landing and departed the runway and damaged the propeller.

ACN: 1415547

(16 of 50)

Synopsis BE300 Captain reported an unsafe right gear indication after two successful touch and goes. During a flyby the Tower indicated that the gear appeared to be down. While taxiing off the runway the right gear collapsed.

ACN: 1415524

(17 of 50)

Synopsis C152 student pilot became lost, penetrated restricted airspace, and did not follow proper procedures in his attempt to reorient himself.

ACN: 1415026

(18 of 50)

Synopsis Pilot of a Great Lakes biplane reported loss of directional control and a prop strike occurred when the right heel brake was inadvertently applied on the landing roll.

ACN: 1414254

(19 of 50)

Synopsis M20 Instructor Pilot reported he and his student almost landed gear up after a training flight.

ACN: 1413877

(20 of 50)

Synopsis Aerobatic pilot reported a NMAC in the pattern at SNA airport.

ACN: 1413206

(21 of 50)

Synopsis C172 pilot reported experiencing runaway nose up trim which required strong counter pressure on the yoke to maintain altitude and airspeed. A precautionary landing on a road was completed without incident.

ACN: 1412937

(22 of 50)

Synopsis A light-twin pilot reported a Class B incursion while on flight following in the SFO area.

ACN: 1412626

(23 of 50)

Synopsis A flight instructor reported misunderstooding the clearance altitude while on a San Diego Bay tour. They descended to 500 feet until ATC corrected them and they climbed to assigned crossing altitude.

ACN: 1412192

(24 of 50)

Synopsis C177RG pilot reported taking off with the tow bar still attached.

ACN: 1411473

(25 of 50)

Synopsis C172 Instructor pilot reported noting smoke coming from the master switch area and turned off the master switch. When the smoke dissipated the switch was turned back on with the same result. The training flight returned to the departure airport using lost comm procedures.

ACN: 1410886

(26 of 50)

Synopsis C150 student pilot reported that upon reaching cruise altitude the engine lost power and began to descend. After a loss of 1000 feet, power was restored and the aircraft returned for landing.

ACN: 1410161

(27 of 50)

Synopsis C172 Student pilot reported becoming confused by a Tower instruction to make a low approach while practicing touch and go landings in the pattern. The student made a flatter than normal (low) approach and touch and go, and did not acknowledge calls from the Tower until safely airborne.

ACN: 1410139

(28 of 50)

Synopsis A general aviation instructor pilot reported noticing that the CJR RNAV 22 approach could, if flown as depicted, possibly intrude on the IAD Class B airspace. Reporter recommended an adjustment to the procedure turn to preclude a possible airspace violation.

ACN: 1410118

(29 of 50)

Synopsis Reports from two light aircraft pilots involved in an NMAC in the pattern at CVH. Improper communication on CTAF frequency was reportedly a factor.

ACN: 1409526

(30 of 50)

Synopsis SR22 instructor pilot reported an issue with the Garmin Perspective system installed on Cirrus aircraft. He reported that owners of older keypads experienced difficulty with it accepting commands due to worn out buttons.

ACN: 1408989

(31 of 50)

Synopsis CFI student pilot and instructor reported an engine failure during landing practice. Post flight analysis revealed that one tank had no fuel.

ACN: 1408726

(32 of 50)

Synopsis Flight instructor reported a premature descent after assuming control of the aircraft when the instrument student pilot was unable to track the localizer.

ACN: 1408207

(33 of 50)

Synopsis Military Fighter pilot reported an airborne conflict occurred during a diversion for a low fuel situation.

ACN: 1408200

(34 of 50)

Synopsis PA-28 instructor pilot reported striking a sign with a wingtip during taxi when directional control was lost due to a malfunctioning left brake.

ACN: 1407376

(35 of 50)

Synopsis SR20 pilot reported returning to departure airport after experiencing high cylinder head temperature after takeoff.

ACN: 1406898

(36 of 50)

Synopsis A BE-95 instructor reported his student placed the landing gear lever toward the down position, but undetected by either pilot, the gear did not extend because the gear lever was actually in the neutral, off position. The aircraft landed gear up.


(37 of 50)

An instructor pilot departing RNM took aircraft control from his student then evaded an aircraft entering the pattern after ATC vectored his aircraft which resulted in the conflict.

ACN: 1406558

(38 of 50)

Synopsis A flight instructor reported being informed that a city noise abatement altitude had not been met. The pilot was not informed of the noise abatement restrictions nor were any procedures found following the notification.

ACN: 1405976

(39 of 50)

Synopsis Piper Cub instructor pilot reported a runway excursion with the aircraft flipping on its back when his student inadvertently applied right brake when attempting to apply right rudder. Soft sand and forward stick caused the aircraft to flip.

ACN: 1405955

(40 of 50)

Synopsis C172 instructor pilot reported a NMAC in the pattern at the non-towered CPT airport.

ACN: 1405735

(41 of 50)

Synopsis Flight instructor reported a NMAC at BCV while on a training flight with a student due to a combination of improper pattern entry and sun angle.

ACN: 1405721

(42 of 50)

Synopsis A PA28 flight instructor reported an off-field emergency landing due to an engine failure and smoke in the cabin.

ACN: 1405192

(43 of 50)

Synopsis DA20 instructor pilot reported a NMAC with a UAV east of ROA at 3000 feet. No evasive action was required.

ACN: 1404300

(44 of 50)

Synopsis BE-76 Instructor Pilot reported his student accidentally retracted the landing gear on a touch and go instead of the flaps, resulting in the nose gear retracting and the props striking the ground during the unsuccessful takeoff event.

ACN: 1403696

(45 of 50)

Synopsis PA-44 instructor pilot reported diverting to a nearby alternate after the right engine "exploded" in flight.

ACN: 1403416

(46 of 50)

Synopsis Helicopter instructor pilot reported a light aircraft overflew them by approximately 50 ft as they were preparing for a lift-off.

ACN: 1403333

(47 of 50)

Synopsis AA5 pilot reported diverting to an alternate after noting an electrical system anomaly.

ACN: 1403278

(48 of 50)

Synopsis C172 instructor pilot reported the student experienced a tail strike during soft field landing practice.

ACN: 1402532

(49 of 50)

Synopsis An AT-6 pilot reported performing a test flight and experiencing an airborne conflict with a Cessna Corvalis at 6000 feet after a 3 G pull up from 4000 feet. VFR flight following was in use but ATC did not report the traffic until late in the maneuver.

ACN: 1402354

(50 of 50)

Synopsis PA24 pilot reported a NMAC while practicing holds with foggles on and a safety pilot monitoring for traffic. While entering the first turn, the ADS-B announced traffic at 11 O'clock and evasive action was taken.

Report Narratives

ACN: 1418979

(1 of 50)

Time / Day Date : 201601 Local Time Of Day : 1801-2400

Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.AGL.Single Value : 0

Environment Flight Conditions : VMC Light : Night

Aircraft Reference : X Aircraft Operator : FBO Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Pilot Flying Function.Flight Crew : Trainee Qualification.Flight Crew : Instrument Qualification.Flight Crew : Private Experience.Flight Crew.Total : 290 Experience.Flight Crew.Last 90 Days : 15 Experience.Flight Crew.Type : 15 ASRS Report Number.Accession Number : 1418979 Human Factors : Situational Awareness

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Gear Up Landing Detector.Person : Flight Crew When Detected : In-flight Result.Aircraft : Aircraft Damaged

Assessments

Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 After returning from the dual night cross country my instructor told me to do several touch and go landings at ZZZ. After the first landing my instructor reached over and raised the landing gear. During the next landing the airplane landed gear up as the landing gear was not lowered during that approach. The landing gear handle was up and the automatic landing gear extension bypass lever was also found to be engaged in the up position. While I did not bypass the automatic extension feature, I failed to extend the gear and verify three green lights. My instructor also failed to verify the lights.

Synopsis PA-28R pilot reported landing gear up during a training flight with an instructor.

ACN: 1418920

(2 of 50)


Place Locale Reference.Airport : LVK.Airport State Reference : CA Altitude.MSL.Single Value : 2300

Environment Flight Conditions : IMC Weather Elements / Visibility : Fog Weather Elements / Visibility.Visibility : 7 Ceiling.Single Value : 2300

Aircraft Reference : X ATC / Advisory.Tower : LVK Aircraft Operator : FBO Make Model Name : Skyhawk 172/Cutlass 172 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Flight Phase : Final Approach Route In Use : Vectors Airspace.Class D : LVK

Component Aircraft Component : Pitot-Static System 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 Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 2000 Experience.Flight Crew.Last 90 Days : 100 Experience.Flight Crew.Type : 1800 ASRS Report Number.Accession Number : 1418920 Human Factors : Distraction Human Factors : Troubleshooting Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.ATC Issue : All Types Anomaly.Deviation - Altitude : Excursion From Assigned Altitude Anomaly.Deviation - Procedural : Clearance Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Returned To Departure Airport Result.Flight Crew : Executed Go Around / Missed Approach Result.Flight Crew : Became Reoriented Result.Air Traffic Control : Provided Assistance

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Procedure Primary Problem : Aircraft

Narrative: 1 While on the GPS 25R approach ATC alerted us that we were below altitude for the leg of the approach we were on and to stop descending. The analog altimeter was reading 300400 higher than what ATC radar was receiving from our mode C transponder. The altimeter was set correctly, and we confirmed this setting with the controller. We stopped descent and checked alternate air in the case of static port blockage, but it had no effective change in the indicated altimeter. I alerted the tower we were having "altimeter trouble" and requested that he standby as we were troubleshooting the situation. The weather was improving and the field was in sight and I was reasonably sure I could return to [home airport] for final landing, so I requested low approach only with a return to Approach frequency ASAP. The filed flight plan said training/multiple approaches in the remarks section and I was hopeful for a seamless and constant communication with Approach for the return leg. Tower ATC asked if we were canceling our IFR flight plan and continuing VFR. I said "no" and that we could maintain VFR through the low approach and climb out, but to transfer us back to Approach ASAP. ATC stated that he was in a "quandary" as to whether we were canceling IFR and going VFR. I said no, so he then told us to go missed approach, which we did, and we were transferred to Approach soon after. Approach stated that our intention to return to [home airport] threw them off guard and that they were there to help. I stated how our flight plan said training flight and multiple approaches and apologized. He vectored us back without any more incident. While researching the potential problems with the altimeter, I learned that since there had been a significant rainstorm for the previous 2-3 days with heavy winds and downpours that there was a chance water had somehow entered into the static port. I am reporting this incident because after recollecting the series of transmissions and events during the critical phase of approach flight and the controller's curt and pressing demands for answers while we were in the midst of troubleshooting, that this event could have led to this situation becoming more serious. If I wasn't being pressed for hard decisions during this time and instead supported through the tower by more informational data regarding our current received transponder altitude and comparing it to what our

analog altimeter was reading, I feel I could have made my transmission in a more concise and effective format. For instance, when he asked if we were canceling IFR and returning VFR and I said I could maintain VFR through the low approach, I should have said VMC instead of VFR, but my focus at that point was maintaining safe flight with this student and keeping the aircraft and cockpit managed. During the return leg to [home airport], I kept an eye on both the transponder's indicated altitude as well as the analog altimeter. Minor discrepancies continued, but with the weather becoming VMC, it wasn't as critical to resuming a safe flight. The aircraft was squawked upon return.

Synopsis A general aviation pilot reported altimeter accuracy issues during a practice instrument approach. Pilot elected to break off approach in VMC conditions and return to base airport.

ACN: 1418434

(3 of 50)


Place Locale Reference.Airport : NQI.Airport State Reference : TX Relative Position.Angle.Radial : 110 Relative Position.Distance.Nautical Miles : 6 Altitude.MSL.Single Value : 5000

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 4 Light : Daylight Ceiling.Single Value : 600

Aircraft Reference : X ATC / Advisory.Tower : NQI Aircraft Operator : Military Make Model Name : Military Trainer Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Flight Phase : Initial Climb Route In Use : Vectors Route In Use : Direct Airspace.Class D : NQI

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Military Function.Flight Crew : Pilot Flying Function.Flight Crew : Single Pilot Experience.Flight Crew.Total : 2900 Experience.Flight Crew.Last 90 Days : 77 Experience.Flight Crew.Type : 750 ASRS Report Number.Accession Number : 1418434 Human Factors : Communication Breakdown Human Factors : Distraction Human Factors : Workload Human Factors : Time Pressure Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.Conflict : Airborne Conflict Anomaly.Deviation - Altitude : Overshoot Anomaly.Deviation - Procedural : Clearance Detector.Person : Flight Crew Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Flight Crew : Became Reoriented Result.Air Traffic Control : Issued New Clearance

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Procedure Primary Problem : Human Factors

Narrative: 1 Upon departure from runway 13R at NQI, ATC issued Aircraft X an intermediate level off altitude of 5,000 feet MSL at a climb altitude of 2,000 feet MSL and advised of south bound Gulfstream traffic to the east of Aircraft X's position at 6,000 feet MSL. The intermediate altitude was 2,000 feet less than initial clearance of 7,000 feet MSL. While in the non-standard left hand turn to MOA entry point and scanning for the traffic Aircraft X missed level off altitude of 5,000 feet MSL by 400 ft. Aircraft X pilot made an immediate correction back to 5,000 feet MSL. Kingsville departure queried Aircraft X pilot to confirm updated level off altitude of 5,000 feet MSL. Aircraft X was visual of Gulfstream traffic during climb and left turn.

Synopsis Military trainer pilot reported overshooting a 5,000 foot altitude constraint with traffic at 6,000 feet.

ACN: 1418180

(4 of 50)


Place Locale Reference.ATC Facility : SCT.TRACON State Reference : CA Altitude.MSL.Single Value : 4000

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Light : Daylight

Aircraft : 1 Reference : X ATC / Advisory.TRACON : SCT Aircraft Operator : FBO Make Model Name : Small Aircraft, Low Wing, 2 Eng, Retractable Gear Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Descent Route In Use : Vectors Airspace.Class C : ONT

Aircraft : 2 Reference : Y ATC / Advisory.Tower : ONT Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer Flight Phase : Takeoff Airspace.Class C : ONT

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Instructor Qualification.Flight Crew : Instrument Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Commercial Experience.Flight Crew.Total : 1254 Experience.Flight Crew.Last 90 Days : 91 ASRS Report Number.Accession Number : 1418180 Human Factors : Confusion Human Factors : Distraction

Human Factors : Situational Awareness Human Factors : Training / Qualification Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.Airspace Violation : All Types Anomaly.ATC Issue : All Types Anomaly.Conflict : Airborne Conflict Anomaly.Deviation - Track / Heading : All Types Anomaly.Deviation - Procedural : Clearance Detector.Person : Flight Crew Detector.Person : Air Traffic Control Miss Distance.Horizontal : 2 Miss Distance.Vertical : 3000 When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Air Traffic Control : Issued Advisory / Alert

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Procedure Primary Problem : Procedure

Narrative: 1 I was flying long cross country to Chino via Ontario and Ramona and with touch and go landings at Ontario and Ramona. As soon as we cleared the mountains, we started our descent from 11500 feet. SoCal Approach (app) asked us what altitude we were going to descend down to. We said 4000. As Ontario Airport appeared from behind the clouds and was getting close, we started to descend to below 4000. Approach told us to fly heading 090, which we thought was going to put us to a right downwind entry for 26R. A few seconds later, app told us to fly heading 130. A few seconds later, we realized that 130 heading would take us across the departure corridor of Ontario runway 26 and we saw a jet just taking off. As soon as we saw the airplane, for safety reasons, we requested resume own navigation to avoid the traffic and we told Approach we have the airport insight. Upon approval, we turned back north away from the departure corridor to the northeast to avoid the departing traffic. That's the moment when we realized that Approach didn't know we were going to land at Ontario and that's the moment when Approach realized we were going to land at Ontario. Approach asked us what altitude we were going to descend down to. We said pattern altitude at 2000. He told us we should have informed him before descending through 4000. He told us to contact tower. We were on the right downwind at 2000. We got a possible pilot deviation warning from Ontario Tower and SOCAL Approach. We called SOCAL quality control when we landed at Ramona. SOCAL told me that we showed on the jet's TCAS. It's a case of lost separation. SOCAL was going to listen to the tape and investigate. After I got back from the flight, I talked to our chief instructor. We should have been more careful when in the unfamiliar LA area and notified the ATC for altitude changes. I should

have clarified more when there's a suspected confusion. I briefed my student and we talked about the incident. We learned from the case that we need to more cautious and listen more carefully and notify ATC of the altitude change. I also talked with other instructors so we could help prevent similar situations in the future.

Synopsis Instructor pilot reported a loss of separation due to confusion on where they wanted to land. Their aircraft came close to aircraft departing ONT. Pilot did not advise ATC prior to descending that they wanted to land at ONT.

ACN: 1418156

(5 of 50)


Place Locale Reference.Airport : GNV.Airport State Reference : FL Relative Position.Angle.Radial : 320 Relative Position.Distance.Nautical Miles : 7 Altitude.MSL.Single Value : 2500


Aircraft Reference : X ATC / Advisory.TRACON : JAX Aircraft Operator : Personal Make Model Name : Skyhawk 172/Cutlass 172 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Flight Phase : Climb Route In Use : Vectors Route In Use.Airway : V537 Airspace.Class E : ZJX

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 : Multiengine Qualification.Flight Crew : Instrument Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 2215 Experience.Flight Crew.Last 90 Days : 11 Experience.Flight Crew.Type : 1257 ASRS Report Number.Accession Number : 1418156 Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Training / Qualification

Human Factors : Troubleshooting Human Factors : Workload Human Factors : Distraction Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.ATC Issue : All Types Anomaly.Deviation - Track / Heading : All Types Anomaly.Deviation - Procedural : Clearance Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.Flight Crew : Became Reoriented Result.Flight Crew : Requested ATC Assistance / Clarification Result.Flight Crew : Returned To Clearance Result.Air Traffic Control : Issued New Clearance

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was combining a personal IFR flight with cross-country training for my student, who is a primary, pre-solo student with about 10 hours of flight time. We departed GNV and were on the initial climbout, runway heading, but my student was having some trouble establishing proper pitch attitude and holding heading. He also told me he was having a very hard time hearing me. Tower handed us to Jacksonville Departure. I told my student to continue flying while I contacted Departure. I SHOULD have told my student, "my airplane" and then contacted Departure. Departure gave me a simple vector to join the airway, but trying to get my student to turn, lower the nose so I could see traffic, and write down the frequency and airway number, I got saturated (as was my student at that point not being able to hear what I was telling him to do.) I realized I had forgotten the heading just given me and had to ask Jacksonville to say again, which he did. Because my student couldn't hear me, I pointed, trying to get him to turn, but by the time I returned to my paper to write the frequency, I had forgotten it again, and had to ask Jacksonville to say the simple clearance for the third time! From the perspective of the controller, I probably appeared to be an IFR pilot in need of remedial training, when in fact I was an instructor doing a poor job of managing the flight, not taking over when I needed to. It was a minor moment of task saturation and resulting brain freeze, which could have been avoided with prompt re-taking of the controls, when I realized we were both getting overloaded - him with flying the plane, me with troubleshooting the com problem, trying to get him to go where we needed to be pointed, and accepting the clearance.

Synopsis C172 instructor pilot reported after takeoff he had trouble communicating with the student pilot. During this distracting event ATC had to repeat their clearance 3 times.

ACN: 1417915

(6 of 50)




Aircraft Reference : X ATC / Advisory.Tower : 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 : Training Flight Phase : Landing Route In Use : Visual Approach

Component Aircraft Component : Rudder Control System 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 : Student Experience.Flight Crew.Total : 142 Experience.Flight Crew.Last 90 Days : 5 Experience.Flight Crew.Type : 87 ASRS Report Number.Accession Number : 1417915 Human Factors : Training / Qualification

Events Anomaly.Deviation - Procedural : Clearance Anomaly.Ground Excursion : Runway

Anomaly.Ground Incursion : Taxiway Anomaly.Ground Event / Encounter : Loss Of Aircraft Control Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Requested ATC Assistance / Clarification Result.Air Traffic Control : Provided Assistance

Assessments Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 This was my first time back in pilot's seat as PIC for about 6 months. Takeoff was fine and I spent about 45 minutes in the practice area. I returned to ZZZ with ATIS to practice some pattern work. I received clearance to land on runway XXL. The first approach to landing on was a "go around" due to a plane that was still on the runway. I went back into the left traffic pattern for Runway XXL. On the next approach to landing, on final, full flaps were extended, I was on the PAPI glide slope, and my approach speed was about 80 mph for a normal landing. I touched down just past the numbers and the plane abruptly pulled left of centerline by about 45 degrees. I applied right rudder and slight right brake. My focus was to try to line up with centerline. This made me swerve to the right. The plane "squirreled" left and right. I applied/fluttered between left/right rudder and brake as the plane slowed, but was still rolling. The plane made a 360 degree ground loop to the right, pointing me in the proper direction on the runway. I then notified ATC that I needed to get off the runway. I was shaken so I initially went the wrong direction and needed help from the tower to get off the runway to the southern taxiway. I took a few minutes to calm down and regroup. I went to the runup area, went through my checklist again, and pulled up to the "hold short" line for Runway XXL. My reasoning was that I messed up my landing and must have set it up improperly. I wanted to get back up and land at a slower approach speed and maybe flare more. I received clearance for left closed traffic for Runway XXL. It wasn't until I was on downwind that I realized that the ground loop may have been due to a plane issue or may have created an issue. Because of this, I made sure I was slower than my first landing, about 75 mph on final, full flaps extended, and on the glide path. Again, when I touched down, the plane abruptly pulled left and started squirrelling left and right. My focus, again, was to try to get it to centerline. Rudder and brakes were fluttered back and forth trying to correct for the swerving until, I think I overcorrected and the plane started to turn to the right, going off of the runway, into the grassy island between runways XXL/R, ending in 180 degree turn. Once I realized I was turning around again, I stopped trying to correct for it. I immediately notified the tower that I was in the grass but did not need medical help. I shut down the plane according to the checklist and switched the fuel tanks to "off" just in case. I got out of the plane and did a walk around to assess the damage and check for any leaking fluids. There were none. I called my flight school and my CFI to notify them of the ground loop. REFLECTIONS: I was told by about 4 other people that this particular plane was known to be a bit squirrelly but never to the point of a ground loop. It probably isn't a big factor, but the treads on the tires were uneven. I was told that the STOL kit on this plane adds takeoff and landing factors to account for. I was unaware of those factors. I just knew that the STOL kit was to make it difficult to stall. Overall, though, it was my inexperience with a proper reactive measures to swerving. I've logged 384 landings prior to this but did not know how to correct for it properly. I've had the plane swerve a little in the past but never

like this. Also I think I wasn't flaring enough and that my touchdown speed was too fast. Since I am prepping for my checkride, I keep setting a goal to touchdown on the runway numbers. This probably put a false sense of urgency to land it before it's at a proper speed. I was also too fixed on staying on centerline. Lastly, 100%, I should've taxied back to the flight school when the first ground loop happened. For some reason, I was completely fixed on it being my inexperience and totally blanked on how the first loop may have affected the plane. My thought was to "get back on the horse". CORRECTIVE ACTIONS: I debriefed with the owner of the flight school and some of the CFI's that helped get the plane back to the hangar. The next day I had a lesson with my CFI where we practiced directional control exercises on the runway so that I would have a better understanding on what I need to do in this situation. He put me in a swerve on the runway and taught me how the plane self-corrects. This gave me the feel for how much pressure to put on the rudders. This also taught me to not use the brakes until I am ready to stop. We also practiced more landings and I verbalized each step of the pattern work, landing checklist, and setup. Prior to another solo flight, my CFI stated that I need to redo all of my pre-solo maneuvers (to the standards) and stage check. He has invalidated my solo endorsement until this is completed. As for going back up after the first ground loop, I'm going to be more aware of ALL the possible factors with both myself AND the plane. I think I defaulted to the run-up section of the checklist as my safety net. Instead, I should've parked the plane, and started a new preflight inspection. This would've put me in the mindset of looking at the structural integrity of the plane instead of just my own personal state-of-mind.

Synopsis PA28 student pilot reported losing control during landing roll resulting in a ground loop on the runway. A subsequent landing attempt resulted in another loss of control event and a runway excursion.

ACN: 1417647

(7 of 50)




Aircraft Reference : X Aircraft Operator : Personal Make Model Name : Sail Plane Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing

Component Aircraft Component : Wheels/Tires/Brakes Aircraft Reference : X Problem : Failed

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Corporate Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Instrument Qualification.Flight Crew : Commercial Experience.Flight Crew.Total : 900 Experience.Flight Crew.Last 90 Days : 14 Experience.Flight Crew.Type : 25 ASRS Report Number.Accession Number : 1417647

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Ground Excursion : Runway Anomaly.Ground Event / Encounter : Object Detector.Person : Flight Crew

When Detected : In-flight Result.General : None Reported / Taken

Assessments Contributing Factors / Situations : Aircraft Primary Problem : Aircraft

Narrative: 1 Glider sortie occurred at an uncontrolled airport. While conducting cadet orientation ride in a glider VFR, Clear weather, wind calm, 70 degrees. Runway was clear. Pilot and [student] landed on the runway. Landed straight down middle of runway. Applied full brakes and full spoilers. Brake failed. Glider was at slower than walking speed and rolled off end of runway, down small hill. Glider struck fence that was 15 yards past end of runway threshold. Damaged nosecone of glider. A ripple in top of right wing skin close to root was noted. Glider brake was locked when attempted to ground tow. No injury to pilot or cadet.

Synopsis Glider pilot reported brake failure during landing and rolled off the end of the runway and down an embankment sustaining some damage.

ACN: 1417625

(8 of 50)


Place Locale Reference.Airport : CMA.Airport State Reference : CA Altitude.MSL.Single Value : 400


Aircraft Reference : X ATC / Advisory.Tower : CMA Aircraft Operator : FBO Make Model Name : Skyhawk 172/Cutlass 172 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Final Approach Route In Use : None Airspace.Class D : CMA

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 : Multiengine Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 1165 Experience.Flight Crew.Last 90 Days : 192 Experience.Flight Crew.Type : 1067 ASRS Report Number.Accession Number : 1417625 Human Factors : Workload Human Factors : Situational Awareness

Events Anomaly.ATC Issue : All Types Anomaly.Conflict : NMAC Detector.Person : Flight Crew

Miss Distance.Horizontal : 200 Miss Distance.Vertical : 50 When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Air Traffic Control : Issued New Clearance

Assessments Contributing Factors / Situations : Procedure Primary Problem : Procedure

Narrative: 1 I was acting as Flight Instructor and PIC during a training flight in the local area of Camarillo Airport (CMA). My student and I had completed our training flight and were returning to land. We received clearance to enter the Class D airspace approximately 5 nm SW (having been previously cleared to transition through OXR Class D by Point Mugu Approach Control). As instructed by CMA Tower, we entered left downwind for Runway 26 and were given landing clearance behind the Number 3 aircraft that was in the right downwind position. We proceeded to make our turn to base and then final normally. During this time, my student was at the controls under my supervision. While on final approach, within half a mile of the runway and descending below 500 feet AGL, Tower Control instructed me- "Turn Right and enter Right Downwind." I immediately took controls and confirmed- "Breaking off to the Right, Entering Right Downwind." I initiated a climbing right turn. At the same time, Tower then gave a landing clearance to a Cirrus. As I climbed and turned through 90 degrees, I saw the silver Cirrus fill my windscreen just as that pilot said "This is going to be close..." I made an evasive steep turn continuing to the right and was able to turn behind the Cirrus. Once established on the right downwind, at traffic pattern altitude, I reported "Established on right downwind." Tower replied, "Good work. Cleared to land, Number 2 behind aircraft to your right on the left downwind." I advised traffic in sight and turned base behind the number 1 aircraft. While on final, I heard on Tower frequency a jet announce his approach on an extended final. The jet was cleared to land "number 3 behind a Cessna on 3 mile final." I began to increase my forward speed to 95 knots anticipating the jet closing behind me. While I was less than 2 miles from the runway, the number 1 aircraft was instructed to make a "low approach only" while the jet pilot advised tower he had a Cessna in front of him in sight. I told my student I was speeding up because we had a jet behind us. He looked over his shoulder and said "Oh yeah! I can see him!" At that moment, approximately 1/2 mile from the runway and having descended below 400 feet on short final, a new Tower controller's voice said "XXX, TURN LEFT IMMEDIATELY!" I immediately broke left into a climbing turn 90 degrees from the previous final approach heading. It was clear the jet behind us was extremely close. Reaching traffic pattern altitude, I asked tower if they'd like us to join the left downwind. Tower gave the affirmative and we were then cleared to land number 2 behind a Cessna on a 4 mile final. From this point, we landed without incident. While taxiing off the runway, Tower again said, "Good work." I complied with all ATC instructions during the operations described above. It is my belief that Tower instructions resulted in two instances of my aircraft getting within dangerous proximity to other aircraft at times when I was on final approach and not in position to have prior visual contact with the other aircraft described.

Synopsis C172 instructor pilot reported two separate near-midair collision situations during successive visual approaches for landing to CMA airport.

ACN: 1417618

(9 of 50)


Place Locale Reference.Airport : BQK.Airport State Reference : GA Altitude.MSL.Single Value : 1700


Aircraft : 1 Reference : X ATC / Advisory.Center : ZJX ATC / Advisory.CTAF : BQK 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 : Training Nav In Use.Localizer/Glideslope/ILS : Runway 7 Flight Phase : Final Approach Airspace.Class E : BQK

Aircraft : 2 Reference : Y ATC / Advisory.Center : ZJX ATC / Advisory.CTAF : BQK Aircraft Operator.Other Make Model Name : Hawker Horizon (Raytheon) Flight Phase : Final Approach Airspace.Class E : BQK

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Check 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 : 20000 Experience.Flight Crew.Last 90 Days : 67

Experience.Flight Crew.Type : 4500 ASRS Report Number.Accession Number : 1417618 Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Flight Crew

Events Anomaly.Conflict : NMAC Detector.Automation : Aircraft Other Automation Detector.Person : Flight Crew Miss Distance.Horizontal : 50 Miss Distance.Vertical : 0 Were Passengers Involved In Event : N When Detected : In-flight Result.Flight Crew : Took Evasive Action

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Company Policy Primary Problem : Human Factors

Narrative: 1 The CFII applicant was flying inbound on the ILS Runway 7 at BQK under simulated instrument conditions and was crossing the FAF at YOKHO int. I reported on the CTAF, 123.0, that we were at YOKHO, 5 miles southwest of Brunswick Golden Isles inbound on the ILS 7. Immediately following this position report I observed the Hawker passing our airplane on the left side at our altitude and less than 100 ft from our aircraft. The Hawker was in a steep banked left turn to avoid a collision. I was monitoring JAX Center, but did not hear center clear the Hawker for an approach nor did I hear center approve the Hawker for a frequency change to the advisory frequency. I did not hear the Hawker make any position reports and was not aware of the Hawker's presence in the airspace overtaking our airplane until I observed the Hawker taking evasive action. When questioned about seeing our aircraft on TCAS, the response was that we were not on TCAS in the Hawker. There was much congestion on the CTAF which may have contributed to the com issue.

Synopsis A designated examiner was giving a checkride to a CFII applicant. They were on a practice ILS approach when a Hawker approached from behind and turned left at the last minute to avoid a collision.

ACN: 1417596

(10 of 50)


Place Locale Reference.Airport : 4A4.Airport State Reference : GA Relative Position.Distance.Nautical Miles : 3 Altitude.MSL.Single Value : 3500

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Light : Daylight Ceiling : CLR

Aircraft Reference : X ATC / Advisory.CTAF : 4A4 Aircraft Operator : Personal Make Model Name : PA-34-220T Turbo Seneca III Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Cruise Route In Use : Direct Airspace.Class E : A80

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Private Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 1484 Experience.Flight Crew.Last 90 Days : 11 Experience.Flight Crew.Type : 612 ASRS Report Number.Accession Number : 1417596 Human Factors : Situational Awareness Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Other

Events

Anomaly.Conflict : Airborne Conflict Anomaly.Inflight Event / Encounter : Other / Unknown Detector.Person : Flight Crew Miss Distance.Horizontal : 5000 Miss Distance.Vertical : 2000 When Detected : In-flight Result.Flight Crew : Took Evasive Action


Narrative: 1 We were doing practice approaches in VFR. We were on our way to RMG to shoot the GPS approach to RW1. I was under the hood, the safety pilot saw a parachutist we immediately deviated. We were listening to 4A4 CTAF, but did not hear info about parachute jump. In my briefing, I did not see a NOTAM about parachute jumpers in my route. While there was plenty of space to maneuver it was a concern as we did not know if there were other parachutists in the area. In retrospect I should have asked for flight following. In the future I intend to do all practice approaches under an IFR flight plan in constant communication with ATC.

Synopsis PA34 pilot reported coming upon parachute jumpers necessitating evasive action in the vicinity of 4A4 Airport.

ACN: 1417583

(11 of 50)


Place Locale Reference.Airport : FDY.Airport State Reference : OH Relative Position.Distance.Nautical Miles : 3 Altitude.MSL.Single Value : 2300

Environment Flight Conditions : IMC Weather Elements / Visibility : Rain Weather Elements / Visibility.Visibility : 10 Light : Dawn Ceiling.Single Value : 1200

Aircraft Reference : X ATC / Advisory.TRACON : TOL 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 : IFR Mission : Training Nav In Use : GPS Flight Phase : Final Approach Route In Use : Vectors Airspace.Class G : FDY

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 : 3242 Experience.Flight Crew.Last 90 Days : 35 Experience.Flight Crew.Type : 600 ASRS Report Number.Accession Number : 1417583 Human Factors : Workload Human Factors : Situational Awareness

Human Factors : Confusion Human Factors : Distraction

Events Anomaly.ATC Issue : All Types Anomaly.Deviation - Procedural : Clearance Detector.Person : Flight Crew Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Flight Crew : Executed Go Around / Missed Approach Result.Air Traffic Control : Issued Advisory / Alert

Assessments Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Contributing Factors / Situations Primary Problem : Procedure

: : : :

Airport Environment - Non Weather Related Human Factors Procedure

Narrative: 1 Flight originated from AOH for the purpose of logging IFR approaches in actual conditions and to satisfy future instrument currency requirements. Void time clearance was received by radio on ground from Indianapolis Center. After departure turned towards FDY and established airborne communication with Indy Center above 2500 feet MSL. Radar contact not possible in this area below 4000 MSL but unable to go higher than 3000 due to temperature and possible icing conditions. Center asked for position reports to determine when to hand off to Toledo approach. It seemed the handoff was late as the controller was busy with a lot of traffic. After handoff and checking in with Toledo on 120.8mhz there was a question if I was read my full clearance. I answered yes and was not given an explanation. Controller seemed unhappy. I requested as I had filed for. Direct ASPE intersection and the GPS 36 approach with course reversal at ASPE. Once established on the approach I let them know I intended to make a second RNAV 36 approach then return to AOH. The first approach was normal and I broke out below the overcast as expected, located the runway environment and made a touch and go. On climb out to 3000 feet contacted Toledo again and agreed on Radar Vectors for the second approach. The vector was excellent and I intercepted the inbound course between ASPI and FABKI still at 3000 feet. LPV was confirmed on the GPS and glide slope intercept normal. I was cleared to change to advisory frequency but had not yet. Still in IMC at about 2300 MSL I received a radio call from Toledo reporting a Low Altitude Alert. The Approach was stabilized, the needles were both crossed within the center circle (donut) and it was a mystery to me what was causing the alert. I chose to abort the approach then was cleared to return to AOH at 3000 feet without further incident. Later that evening I loaded the track log in Google earth for further review and did not see any remarkable indication of being below the glide path on the second approach. Upon speaking with another pilot who operates in Toledo airspace I am told this has happened to him more than once. I am beginning to wonder if the limits they are setting for alerts on these approaches are too narrow or restrictive. Toledo approach control has

consistently given stellar, friendly and professional handling in all types of weather conditions, training flights and passing through the area or landing. They go above and beyond for student pilots too. In no way do I wish for any of the statements above to reflect negatively.

Synopsis A pilot conducting practice approaches to FDY Runway 36 in IMC at 2,300 FT, was issued a low altitude alert even though the GPS and glideslope appeared normal. The pilot executed a precautionary go-around, but later could find no cause for the alert.

ACN: 1417558

(12 of 50)


Place Locale Reference.Airport : LMO.Airport State Reference : CO Altitude.AGL.Single Value : 0


Aircraft Reference : X Aircraft Operator : FBO Make Model Name : Champion Citabria Undifferentiated Crew Size.Number Of Crew : 1 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 : Pilot Flying Qualification.Flight Crew : Private Qualification.Flight Crew : Student Experience.Flight Crew.Total : 60 Experience.Flight Crew.Last 90 Days : 25 Experience.Flight Crew.Type : 25 ASRS Report Number.Accession Number : 1417558 Human Factors : Situational Awareness

Events Anomaly.Conflict : Ground Conflict, Critical Anomaly.Ground Excursion : Runway Detector.Person : Flight Crew Miss Distance.Horizontal : 1000 Miss Distance.Vertical : 0 When Detected : Taxi Result.Flight Crew : Took Evasive Action Result.Flight Crew : Became Reoriented


Narrative: 1 Student pilot with CFI approaching Longmont from the south 4 miles out received AWOS wind 110 at 4Kts. We entered crosswind for runway 11 making and acknowledging radio calls. Other planes in the pattern, King Air elected to land runway 29 while we were on downwind for 11. Light sport aircraft holding at 29 acknowledged King Air and us and would hold. When base to final light sport aircraft entered 29 but taxied across for Bravo taxiway and stated would be taxiing for 11. We landed on 11 during landing rollout past Alpha 3, a Cessna 172 began its takeoff on 29. We made radio calls and planned to proceed off the runway for the grass. C172 aborted takeoff and acknowledged our presence on the runway.

Synopsis Citabria pilot reported a ground conflict with a Cessna 172 at LMO airport.

ACN: 1416735

(13 of 50)


Place Locale Reference.Airport : FRG.Airport State Reference : NY Relative Position.Distance.Nautical Miles : 1 Altitude.MSL.Single Value : 1200


Aircraft : 1 Reference : X ATC / Advisory.Tower : FRG Aircraft Operator : Personal Make Model Name : Small Aircraft Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Final Approach Airspace.Class D : FRG

Aircraft : 2 Reference : Y ATC / Advisory.Tower : FRG Make Model Name : Small Aircraft Operating Under FAR Part : Part 91 Flight Phase : Final Approach Airspace.Class D : FRG

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 : Instrument Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Experience.Flight Crew.Total : 332 Experience.Flight Crew.Last 90 Days : 39

Experience.Flight Crew.Type : 33 ASRS Report Number.Accession Number : 1416735

Events Anomaly.Conflict : NMAC Detector.Person : Air Traffic Control Miss Distance.Vertical : 400 When Detected : In-flight Result.Flight Crew : Took Evasive Action


Narrative: 1 While teaching my student takeoffs and landings in the traffic pattern, Tower asked us, as we were in the right downwind for runway 19, if we could see Aircraft Y in the left downwind for runway 19, turning base over the Long Island Expressway (LIE). I saw a plane over the numbers about to land 19 and what appeared to be the traffic over the LIE and responded that we had him sight. We were then instructed to follow him and that we were number 3 cleared touch and go. I kept an eye on the traffic as I divided my attention between instructing my student and looking outside for the other traffic. When I saw what I believed was the #2 traffic we were instructed to follow abeam us on final (we were still on downwind), I waited a few seconds and then instructed my student to turn base. As we were about to turn final, Tower asked us if we still had the traffic in sight, telling us that they were 1 o'clock and just below us turning to final. I saw the traffic and took the controls from the student, stopping our descent and making an immediate left turn to avoid him. Making this turn gave us enough spacing between him and us. We rejoined final and I returned control of the aircraft to the student, and the rest of the flight proceeded as normal, we made a touch and go. I believe a big contributing factor to this was my division of attention inside and outside the aircraft. In directing my attention inside, I apparently lost contact with the conflicting traffic. I was surprised by this though because we were told by tower that we were number 3, and I saw the two other planes: the one over the numbers and the other over the LIE. Perhaps when I said I saw the traffic over the LIE, I was seeing something that actually was not the other traffic? I believe this near miss would not have occurred if I managed my division of attention better between the inside and the outside of the plane. But I am also wondering if tower misspoke and we were #4 or instead of being #3.

Synopsis GA CFI reported losing site of traffic they were to follow at FRG and had to make an evasive turn to avoid a collision. Instructor subsequently reported making a normal touch and go landing.

ACN: 1416207

(14 of 50)



Environment Flight Conditions : VMC Weather Elements / Visibility : Cloudy Weather Elements / Visibility.Visibility : 20 Light : Daylight Ceiling.Single Value : 3000

Aircraft : 1 Reference : X ATC / Advisory.Tower : 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 Airspace.Class D : ZZZ

Aircraft : 2 Reference : Y ATC / Advisory.Tower : ZZZ Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer Flight Plan : IFR Flight Phase : Initial Approach Airspace.Class D : ZZZ

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 : Multiengine Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 750 Experience.Flight Crew.Last 90 Days : 275

Experience.Flight Crew.Type : 600 ASRS Report Number.Accession Number : 1416207 Human Factors : Situational Awareness Human Factors : Communication Breakdown Human Factors : Distraction Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.Conflict : Ground Conflict, Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Anomaly.Ground Incursion : Runway Anomaly.Inflight Event / Encounter : Unstabilized Approach Detector.Person : Air Traffic Control Detector.Person : Flight Crew When Detected : In-flight Result.General : None Reported / Taken


Narrative: 1 I was conducting a private pilot training flight for check ride prep with a student at ZZZ. We had gone out to the practice area to conduct maneuvers for approximately an hour then we returned to ZZZ for pattern work. We requested full stop taxi backs and we were instructed to make left traffic for XYL. The weather was VFR with scattered clouds around 2500 feet and a broken layer approximately at 3000 feet or higher. We had to keep a much tighter pattern right away to avoid clouds that were moving towards the airport. As we were approximately abeam the numbers for XYL we we're told to make a short approach within 1/2 a mile to keep us inside traffic on the ILS for the center runway. The Left and Center runways are offset by approximately 1500 feet. The student read back the clearance incorrectly and we started the turn to base. I corrected his clearance with tower as we we're coming around the base turn and then tower came back on to explain why they wanted to make a short approach. We still had altitude to lose and we were already inside the numbers so we did a forward slip to land to remain within the first third of the runway. Without realizing it we never had sight of XYL, we were lined up for XYC. The appropriate action would've been to respond unable and execute a go-around due to the fact we were already flying an extremely tight pattern and we were having to make abnormal maneuvers for landing. Both myself and the student failed to recognize that we were lined up for the wrong runway as we rolled onto final since we were already over the numbers and we ended up landing on XYC. We exited the runway at the first available taxiway and that's when I had realized what had happened. Tower informed us of a possible pilot deviation and gave us a phone number to copy. I took control of the aircraft and requested to return to the ramp. After we shut down and secured the aircraft I contacted the tower and spoke with the supervisor to explain what had happened and provided them with all the information they required. There were no other aircraft involved and the traffic on the ILS was far enough out that we didn't cause them to have to deviate. I realize that this could've ended up way worse than it did. Going forward I fully intend to utilize this experience as a lesson learned to prevent any future occurrences for myself and my students. I failed to recognize that the given conditions were not ideal to

conduct training in the traffic pattern because we had just returned from the practice area and the clouds weren't a factor when we initially departed. I had seen other aircraft in the pattern at the same time and it appeared that the clouds were far enough away to not interfere with normal pattern operations. I firmly believe that this was the root cause of the incident and then accepting a short approach added to the already challenging conditions which ultimately led to this negative outcome. I plan to prevent this from ever happening again by being able to recognize the events that led up this and making this a personal minimum for myself when conducting training events. A practice I have adopted since this occurred is to use visual cues too in addition to the runway numbers themselves to validate I'm on the correct runway.

Synopsis General aviation flight instructor reported overshooting the intended runway on base leg and landing on the wrong runway during an unplanned short approach to remain clear of inbound traffic.

ACN: 1415884

(15 of 50)



Environment Flight Conditions : VMC Light : Daylight

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : Skyhawk 172/Cutlass 172 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing

Person Reference : 1 Location Of Person : Hangar / Base Reporter Organization : FBO Function.Flight Crew : Instructor Qualification.Flight Crew : Commercial ASRS Report Number.Accession Number : 1415884

Events Anomaly.Ground Excursion : Runway Anomaly.Ground Event / Encounter : Loss Of Aircraft Control Anomaly.Ground Event / Encounter : Ground Strike - Aircraft Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Regained Aircraft Control Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Weather Primary Problem : Human Factors

Narrative: 1

Pilot was a solo student pilot. He had a stable approach until round out in the flare. During the flare student pilot drifted to the right of centerline and stayed on the right side until touchdown. After touchdown the student pilot attempted to correct for being right of centerline by applying left rudder, but did so with too much left rudder causing the plane to veer left across the runway and into the grass. Upon entering the grass the props struck the ground. Student pilot then [advised] ATC telling them he went into the grass, and then corrected to get back on the runway and came to a stop. Remedial training on landings, crosswind landings, and rudder control upon transition from landing to taxiing. Propeller blades struck the grass/ground left side of runway and bent the tips of the blades.

Synopsis C172 flight instructor reported his solo student lost control of the aircraft after landing and departed the runway and damaged the propeller.

ACN: 1415547

(16 of 50)




Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : Government Make Model Name : Super King Air 300 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Flight Phase : Taxi

Component Aircraft Component : Gear Down Lock Aircraft Reference : X Problem : Failed

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Government Function.Flight Crew : Captain Function.Flight Crew : Instructor Qualification.Flight Crew : Flight Engineer Qualification.Flight Crew : Air Transport Pilot (ATP) Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 10200 Experience.Flight Crew.Last 90 Days : 40 Experience.Flight Crew.Type : 800 ASRS Report Number.Accession Number : 1415547

Events

Anomaly.Aircraft Equipment Problem : Critical Anomaly.Ground Event / Encounter : Other / Unknown Detector.Automation : Aircraft Other Automation Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.Flight Crew : Landed in Emergency Condition Result.Aircraft : Aircraft Damaged


Narrative: 1 Training flight for approaches with two successful gear extension and retraction sequence's with no incident. On the third visual pattern the right gear down and locked light was not illuminated. We retracted the gear with no problems, attempted to lower the gear again the same right gear light would not illuminate with gear selected down. Retracted the gear and ran the abnormal gear extension checklist then returned to ZZZ. After clearance for the approach, the gear was lowered with the right gear light not illuminated. Landing gear circuit breaker checked and gear down lights push to test checked, again all normal. Asked the tower to confirm what we saw from the cockpit the gear down in the normal position and tower confirmed that both gear appeared to be down. Briefed on a soft touchdown and to exit the runway and shutdown and wait for tow. Also, briefed if the gear collapsed the plan was perform the emergency engine shut down on the ground and egress out of the main cabin door. The gear collapsed after the rollout and the start of taxi off the runway. Performed as briefed the emergency engine shut down and evacuation.

Synopsis BE300 Captain reported an unsafe right gear indication after two successful touch and goes. During a flyby the Tower indicated that the gear appeared to be down. While taxiing off the runway the right gear collapsed.

ACN: 1415524

(17 of 50)


Place Locale Reference.Airport : OMN.Airport State Reference : FL Altitude.MSL.Single Value : 1800


Aircraft Reference : X ATC / Advisory.TRACON : JAX Aircraft Operator : FBO Make Model Name : Cessna 152 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Cruise Route In Use : Direct Airspace.Class E : JAX

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Single Pilot Qualification.Flight Crew : Student Experience.Flight Crew.Total : 70 ASRS Report Number.Accession Number : 1415524 Human Factors : Distraction Human Factors : Situational Awareness Human Factors : Training / Qualification Human Factors : Confusion

Events Anomaly.Airspace Violation : All Types Anomaly.Deviation - Track / Heading : All Types 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 Result.Flight Crew : Requested ATC Assistance / Clarification Result.Air Traffic Control : Provided Assistance

Assessments Contributing Factors / Situations : Chart Or Publication Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I had been scheduled for a solo-cross country flight and to return back to OMN. On the way back after I departed from my destination I got lost on the way back to OMN and I didn't figure it out until I reached a city where I couldn't figure out where I was so I called the Jacksonville Approach and requested to confirm my location because I am lost. All I heard was squawk a number and I did as requested flew near the ocean to try to figure out where I was on a low altitude 1000 feet. Then I decided to call the emergency frequency but ended up calling the wrong frequency. I dialed in 120.5 and requested help because I didn't recognize where I was and they kindly helped to set me up back on my route and they gave me a number to let my instructor call them when I reach OMN and land safely. On my way back I figured that I had low fuel and informed the Approach and he asked me to either land on FIN or continue to OMN so I choose to continue. I could see Tamoka Basin from my location. Mistakes I made during the flight are the following, I flew on a wrong heading which ended me up in the wrong place. I didn't figure out that I was lost earlier. I didn't have flight following on my way back. I did not follow the lost procedure correctly. I made a very poor decision to continue flying while I am low on fuel. I ended up entering some restricted or military areas without even recognizing it.

Synopsis C152 student pilot became lost, penetrated restricted airspace, and did not follow proper procedures in his attempt to reorient himself.

ACN: 1415026

(18 of 50)



Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10

Aircraft Reference : X Aircraft Operator : Personal Make Model Name : Aerobatic Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing

Component Aircraft Component : Normal Brake System Aircraft Reference : X Problem : Improperly Operated

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Government Function.Flight Crew : Pilot Flying Function.Flight Crew : Single Pilot Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Air Transport Pilot (ATP) Experience.Flight Crew.Total : 5011 Experience.Flight Crew.Last 90 Days : 23 Experience.Flight Crew.Type : 4 ASRS Report Number.Accession Number : 1415026 Human Factors : Situational Awareness Human Factors : Training / Qualification

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Loss Of Aircraft Control Anomaly.Ground Event / Encounter : Ground Strike - Aircraft

Detector.Person : Flight Crew When Detected : In-flight Result.Aircraft : Aircraft Damaged


Narrative: 1 A Great Lakes model 2T-1A-2 had a nose-over/propeller strike during landing rollout while performing the first landing of the flight. It appeared the PIC inadvertently pressed the right heel-brake while pressing the right rudder. The aircraft yawed right, the right tire locked and an immediate nose-over and prop strike occurred. There were two souls on board. No injuries occurred. Damage appeared to be confined to the propeller, engine and wheel fairings. There was approximately 10 knots of right crosswind (210 16G21). The PIC executed a stable approach and the aircraft touched down within the first 1,000 ft in a forward slip (wing-down, top rudder), on centerline, on speed. During rollout, at approximately 20 mph ground speed, the PIC noticed a left drift trend and right rudder was applied with the heel positioned over/near the right brake causing unintentional brake application. The brake was not released in time to prevent the propeller striking the runway. The incorporation of heel brakes requires unconventional placement of heels relative to the rudder pedals. Once the heels are placed on/over the heel brakes, rudder inputs cannot effectively be made without rotating the heels away from the brakes. The PIC's limited experience with heel brakes was a contributing factor.

Synopsis Pilot of a Great Lakes biplane reported loss of directional control and a prop strike occurred when the right heel brake was inadvertently applied on the landing roll.

ACN: 1414254

(19 of 50)


Place Locale Reference.Airport : ZZZ.Airport State Reference : US Relative Position.Distance.Nautical Miles : 5 Altitude.MSL.Single Value : 3000


Aircraft Reference : X ATC / Advisory.CTAF : ZZZ Aircraft Operator : Personal Make Model Name : M-20 B/C Ranger 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 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 : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 2000 Experience.Flight Crew.Last 90 Days : 5 Experience.Flight Crew.Type : 30 ASRS Report Number.Accession Number : 1414254 Human Factors : Distraction Human Factors : Situational Awareness

Events Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Inflight Event / Encounter : Unstabilized Approach

Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Executed Go Around / Missed Approach Result.Flight Crew : Became Reoriented


Narrative: 1 During FAA biannual flight review, we performed slow flight and stalls in the client's (pilot flying) airplane. Stalls and slow flight were performed with gear down and full flaps in the landing configuration approximately 3000-3500 feet in proximity to the airport. As an important side note, the aircraft used employs the manual "Johnson bar" landing gear handle/system for extension and retraction. When the slow flight/stalls were complete, the pilot flying cleaned up the aircraft to cruise configuration. I was at that point looking for self-announced traffic in the area and I failed to notice the pilot only raised the flaps but left the gear extended. We then set up for practice hood work, but then I called for simulated low to zero oil pressure, followed by simulated engine out for the pilot to practice engine out scenario to an airfield. We began spiraling down to set up for a landing to [the airport]. As we passed 1000 feet AGL I could tell the pilot was going to be short of the field. Passing 700-800 feet AGL I advised for him to add power if needed and gear when needed. At approximately 500 feet AGL the pilot reached down and operated the landing gear Johnson bar and announced "gear down and locked". The pilot then added a small amount of power since we would be short of the runway and performed a normal flare to [the] runway. We began a lower than normal settle to the runway and with the sight picture not looking right I called for "power" and "go around". The pilot then performed a successful go-around. On climb out the pilot realized the gear was actually retracted and that on short final he had actually raised the landing gear [from] the down and locked position. A successful normal landing was [subsequently] performed.

Synopsis M20 Instructor Pilot reported he and his student almost landed gear up after a training flight.

ACN: 1413877

(20 of 50)

Time / Day Date : 201612

Place Locale Reference.Airport : SNA.Airport State Reference : CA Relative Position.Distance.Nautical Miles : 1 Altitude.AGL.Single Value : 1000

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Ceiling.Single Value : 10000

Aircraft : 1 Reference : X ATC / Advisory.Tower : SNA Aircraft Operator : Personal Make Model Name : Aerobatic Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Final Approach Route In Use : Visual Approach Airspace.Class C : SNA

Aircraft : 2 Reference : Y ATC / Advisory.Tower : SNA Make Model Name : Cessna Aircraft Undifferentiated or Other Model Operating Under FAR Part : Part 91 Flight Phase : Final Approach Airspace.Class C : SNA

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 : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Experience.Flight Crew.Total : 5000 Experience.Flight Crew.Last 90 Days : 16 Experience.Flight Crew.Type : 1500 ASRS Report Number.Accession Number : 1413877 Human Factors : Situational Awareness

Events Anomaly.Conflict : NMAC Detector.Person : Flight Crew Miss Distance.Vertical : 500 When Detected : In-flight Result.General : None Reported / Taken


Narrative: 1 I was practicing landings in a moderately busy pattern. At the time of the incident I was [planned] to land #2 behind a high wing Cessna. As he was preparing to turn base, I was instructed by the tower to "Change to runway 20R" and was cleared for the option. At that time I turned from downwind to base entry for 20R. The #1 airplane for 20L was in his base turn in a descent. I felt it safe and appropriate to overfly on an extended base to 20R. Vertical separation was very adequate in my estimation. I had the traffic in sight at the time. Apparently from his vantage point I was too close. I [admit] no guilt but acknowledge in retrospect I should have extended my downwind a bit before commencing left turn. As he was in a high wing airplane, his view was probably limited whereas my view from above [allowed me] to safely avoid as necessary.

Synopsis Aerobatic pilot reported a NMAC in the pattern at SNA airport.

ACN: 1413206

(21 of 50)


Place Locale Reference.ATC Facility : ZZZ.ARTCC State Reference : US Altitude.MSL.Single Value : 9500


Aircraft Reference : X ATC / Advisory.Center : 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 : Training Flight Phase : Cruise Route In Use : Direct Airspace.Class E : ZZZ

Component : 1 Aircraft Component : Elevator Trim System Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Autopilot 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 Function.Flight Crew : Single Pilot Qualification.Flight Crew : Private Experience.Flight Crew.Total : 270 Experience.Flight Crew.Last 90 Days : 75 Experience.Flight Crew.Type : 65

ASRS Report Number.Accession Number : 1413206 Human Factors : Training / Qualification

Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew Were Passengers Involved In Event : N When Detected : In-flight Result.Flight Crew : Landed in Emergency Condition

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Procedure Primary Problem : Aircraft

Narrative: 1 Commercial rating cross country flight. Trim wheel began spinning to a nose high attitude on its own. I corrected it to maintain correct altitude. It started spinning to a nose high attitude again, only this time it was stuck. I was forced to apply intense strong pressure on yoke to maintain airspeed and altitude. At this point I concluded that there must be a flight control malfunction with the trim system. As this issue began getting worse, further flight under these conditions [would] not be in my best interest for safety. I was also concerned that another flight control system may malfunction or fail. I spotted a wide gravel road where I could safely land. I notified Center of the issues; reported Mayday. Upon safely landing I contacted an airliner who forwarded my coordinates to Center who then contacted the [local] Sheriff's Office. I believe the autopilot system malfunctioned. If I were in this situation again I would have tried turning OFF the autopilot system, reset the avionics switch and or pull the autopilot circuit breaker and see if those actions solved the problem.

Synopsis C172 pilot reported experiencing runaway nose up trim which required strong counter pressure on the yoke to maintain altitude and airspeed. A precautionary landing on a road was completed without incident.

ACN: 1412937

(22 of 50)


Place Locale Reference.Airport : HWD.Airport State Reference : CA Altitude.MSL.Single Value : 2300


Aircraft Reference : X ATC / Advisory.Center : ZOA ATC / Advisory.TRACON : NCT Aircraft Operator : FBO Make Model Name : Small Aircraft, Low Wing, 2 Eng, Retractable Gear Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Climb Airspace.Class B : SFO

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 : 1200 Experience.Flight Crew.Last 90 Days : 45 Experience.Flight Crew.Type : 200 ASRS Report Number.Accession Number : 1412937 Human Factors : Situational Awareness

Events Anomaly.Airspace Violation : All Types Anomaly.ATC Issue : All Types Detector.Person : Flight Crew Detector.Person : Air Traffic Control

When Detected : In-flight Result.Flight Crew : Took Evasive Action

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Procedure Primary Problem : Ambiguous

Narrative: 1 Today I departed from HWD on a cross country training flight. Since HWD is right under SFO Class B airspace, to avoid hard time I requested radar flight following from the ground itself. I took off the runway with a southeast departure right in between San Jose Class C and SFO Class B for avoiding most of the complex airspaces. As I took off and started my climb out Tower transferred me to the Norcal Departure. I had two way radio communication with Norcal and Norcal instructed me to maintain VFR for the flight. When I was climbing out of 1500 MSL Norcal vectored me towards San Mateo Bridge for traffic separation. When I reached San Mateo Bridge, Norcal told me to stay at or below 2500 feet and stay out of Class B Airspace. By this time I was already at 2300 feet and super close to the floor of Class B airspace which starts at 1500 feet. I had to descend 800 feet in less than 1 NM and turn almost 90 degrees to avoid Class B airspace. But the problem descending below 1500 feet MSL is the obstacles and high terrain surrounding the Bay Area. If I descend to 1500 feet MSL to avoid entering Class B I would be very close to the obstacles on the ground and cannot maintain 1000 feet above the highest obstacle according to the Part 91 rule. If I do not descend I will annoy the Center. I determined avoiding obstacle was more important than following ATC command. I stopped my descent and turned 90 degrees to avoid obstacles. I used my Aviate Navigate and Communicate principle to avoid bad consequences in this situation. But in the end Center was not happy with me and transferred me to another frequency for the rest of the flight. Out of my 1200 hour experience I never had a problem like this and this is the [first] time I am filing a report. What I think would avoid this kind of situation again is if Center gave a vectoring heading and altitude instead [of] simply instructing me to avoid Class B when I have very [little] reaction time and close to the airspace.

Synopsis A light-twin pilot reported a Class B incursion while on flight following in the SFO area.

ACN: 1412626

(23 of 50)


Place Locale Reference.Airport : SAN.Airport State Reference : CA Altitude.MSL.Single Value : 1200


Aircraft Reference : X ATC / Advisory.Tower : SAN Aircraft Operator : FBO Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Climb Route In Use : VFR Route Airspace.Class B : SAN

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Instructor Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 575 Experience.Flight Crew.Last 90 Days : 30 Experience.Flight Crew.Type : 40 ASRS Report Number.Accession Number : 1412626 Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Confusion Communication Breakdown.Party1 : ATC Communication Breakdown.Party2 : Flight Crew

Events Anomaly.Deviation - Altitude : Excursion From Assigned Altitude Anomaly.Deviation - Procedural : FAR Anomaly.Deviation - Procedural : Clearance Detector.Person : Air Traffic Control When Detected : In-flight

Result.Flight Crew : Returned To Clearance Result.Air Traffic Control : Provided Assistance


Narrative: 1 I was doing the San Diego Bay tour at 800 ft MSL. After reporting my 180 degree turn over the Coronado Bridge during the bay tour with a student, I was cleared for the SAN Delta transition at 1500 ft MSL to travel northbound to MYF. I misunderstood the clearance to be 500 ft MSL. I started a descent to 500 ft MSL when Lindbergh Tower instructed me to climb immediately. I crossed SAN at 1200 ft MSL and was instructed to continue to the Mission Bay VOR. I am a new flight instructor and new to San Diego. I had practiced the bay transition earlier in the morning with another instructor with no problems and I understand my mistake. After conversing with the Director of Operations at my flight school, we have agreed that I will receive more training on the transition and the San Diego airspace, and I will give a safety briefing at the next pilot meeting about the event.

Synopsis A flight instructor reported misunderstooding the clearance altitude while on a San Diego Bay tour. They descended to 500 feet until ATC corrected them and they climbed to assigned crossing altitude.

ACN: 1412192

(24 of 50)




Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : Personal Make Model Name : Cardinal 177/177RG Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Takeoff 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 : 866 Experience.Flight Crew.Last 90 Days : 3 Experience.Flight Crew.Type : 866 ASRS Report Number.Accession Number : 1412192 Human Factors : Situational Awareness

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Other / Unknown Detector.Person : Flight Crew When Detected : Taxi When Detected : In-flight

Result.Flight Crew : Became Reoriented Result.Flight Crew : Landed As Precaution Result.Flight Crew : Requested ATC Assistance / Clarification Result.Air Traffic Control : Issued Advisory / Alert


Narrative: 1 Took off in VMC conditions on a flight with a safety pilot to practice instrument approaches VFR. While taxiing we noted a very brief, slight shudder in what we thought was the nose wheel. We decided we might have ran over a rough spot. We noted it seriously. We did the run up and taxied and started the takeoff roll. There was the same shudder just before liftoff. I considered aborting but we lifted off too quickly. After retracting the gear, I decided to ask the Tower for a low pass to see if my nose wheel had retracted properly. They informed me there was a tow bar hanging out. We decided to fly over the field and lower the gear and see if it would fall off. It did not. The tow bar had passed under the tire and was trailing the tire. Everything appear OK otherwise. We did a slow nose high landing. We exited to the taxi way and removed the tow bar. Why was the tow bar left on? This was a case where two pilots both thought the other had removed it. We have two planes in our hangar and they have to be exchanged front to back. This requires moving the front one out and pulling the rear one out and putting the front one back. This day was especially difficult due to ice and packed snow in front of the hangar. We used a gas powered hand tug for the plane we were not flying this day. I placed the tow bar for it where we would normally place the tow bar for the one we were flying. When I asked if we had removed the tow bar on the first check list item on the startup checklist. The safety pilot replied the tow bar was in the hangar. He thought I put it there and I thought he did. It was the tow bar from the other plane. How to improve the procedure so it does not happen again? I have always tried to take the tow bar off immediately after towing the plane to starting position in front of the hangar. I helped pull the plane in place but did not handle the tow bar this time. I am considering putting the tow bar in plane when I remove it from the nose wheel so I can see it in the plane when I do the check list.

Synopsis C177RG pilot reported taking off with the tow bar still attached.

ACN: 1411473

(25 of 50)


Place Locale Reference.Airport : ZZZ.Airport State Reference : US Altitude.MSL.Single Value : 1500

Environment Flight Conditions : VMC

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : Skyhawk 172/Cutlass 172 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Mission : Training Flight Phase : Cruise Airspace.Class C : ZZZ

Component Aircraft Component : Electrical Wiring & Connectors Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Pilot Flying Function.Flight Crew : Instructor Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor ASRS Report Number.Accession Number : 1411473 Human Factors : Situational Awareness

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.Flight Crew : Landed As Precaution

Assessments

Contributing Factors / Situations : Aircraft Primary Problem : Aircraft

Narrative: 1 In the practice area, I noticed my radio coming in and out. Trouble shooting the issue I noticed that smoke was coming from the master switch area. I turned the master switch off. The cockpit did have a lot of smoke so I ventilated the aircraft. After ensuring all switches were turned off and checking the circuit breakers, I tried engaging the master switch. Immediately smoke was generating again, so I turned the master switch off again. Communication with ATC was not possible with the com radio and transponder. I proceeded northbound on the published Arrival and was looking for light gun signals from the tower. After arriving at the downwind for 27L, I still did not see any signal. I assumed they saw me and checked vigorously for traffic before descending from 1500 to Traffic Pattern Altitude. After landing, it came to me that I had a cell phone and possibly could have found reception at a lower altitude, but I was more focused on the airplane and the best navigation possible for ATC and Traffic. After landing I called Tower as I still could not see any light gun signals. I got in touch with ground control via my cell, and received progressive taxi on the ground. The student in the back seat did say that he saw a flashing white light from tower while I was calling, but I did not see that signal. I forgot that I had ATC programmed on my cell phone. Perhaps I could have checked for cell reception before beginning my approach.

Synopsis C172 Instructor pilot reported noting smoke coming from the master switch area and turned off the master switch. When the smoke dissipated the switch was turned back on with the same result. The training flight returned to the departure airport using lost comm procedures.

ACN: 1410886

(26 of 50)




Aircraft Reference : X ATC / Advisory.TRACON : ZZZ Aircraft Operator : Personal Make Model Name : Cessna 150 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Cruise Airspace.Class B : 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 : Personal Function.Flight Crew : Trainee Qualification.Flight Crew : Student Experience.Flight Crew.Total : 74 Experience.Flight Crew.Last 90 Days : 0 Experience.Flight Crew.Type : 74 ASRS Report Number.Accession Number : 1410886

Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Returned To Departure Airport Result.Flight Crew : Requested ATC Assistance / Clarification

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Weather Primary Problem : Aircraft

Narrative: 1 Ceiling unlimited. Winds 4 kts out of the south. Visibility unlimited. Prior days were substantially below freezing with high moisture. At the time of the flight it was 42 degrees Fahrenheit. We were heading out towards the training area northwest of ZZZ. The instructor contacted Approach to request clearance to enter class B airspace. We were granted clearance with the request that we ascend to 3000 MSL. When reaching 3000 MSL, we lost engine efficiency and began to descend. After losing 500 feet of altitude, the instructor [advised ATC]. Reaching roughly 2000 AGL, we regained engine efficiency. We then successfully made our way back to ZZZ with routine check-ins from Approach. The recovery at ZZZ was uneventful.

Synopsis C150 student pilot reported that upon reaching cruise altitude the engine lost power and began to descend. After a loss of 1000 feet, power was restored and the aircraft returned for landing.

ACN: 1410161

(27 of 50)




Aircraft Reference : X ATC / Advisory.Tower : 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 : Training Flight Phase : Landing Route In Use : Visual Approach

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 : 95 Experience.Flight Crew.Last 90 Days : 24 Experience.Flight Crew.Type : 95 ASRS Report Number.Accession Number : 1410161 Human Factors : Communication Breakdown Human Factors : Situational Awareness Human Factors : Training / Qualification Human Factors : Confusion Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Person : 2 Reference : 2 Location Of Person : Gate / Ramp / Line

Reporter Organization : FBO Function.Flight Crew : Instructor Qualification.Flight Crew : Commercial Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 621 Experience.Flight Crew.Last 90 Days : 171 Experience.Flight Crew.Type : 388 ASRS Report Number.Accession Number : 1412242

Events Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Executed Go Around / Missed Approach Result.Flight Crew : Became Reoriented Result.Air Traffic Control : Issued Advisory / Alert


Narrative: 1 Student Pilot Solo Traffic Pattern, practicing landings and touch and go's. Wind was runway direction of 070~080 with moderate strong of 10+/- knots. I was able to climb with good performance, then I was told to make right downwind for Runway 6R traffic pattern. Each touch and go's happened quickly, each 6~ 8 minutes and it was shorter than usual 10 minutes, if weather was calm. Once I was doing left 360 on right downwind to keep space from other landing traffic. And also, there was an airliner Boeing doing traffic pattern on runway 6L. Unlike other ATC official, he was giving me chance to practice touch and go's on Runway 6R, as long as safety is not compromised. (By setting enough time and distance apart) Starting on 4th, and 5th landing, there was cloud level as low as 1400 feet and I was intentionally turning other lights and flying at 1100~1200 (8~900 AGL) MSL so I can keep distance from cloud and have this plane visible. I did 6 touch and go's then full stop. The last touch I was instructed to do "low approach" and 2nd to touch and go's on runway 6R, following other Cessna. For 6th, passing mid-field, I requested touch and go. He instructed me as 2nd, and runway 6 right following Cessna on final approach. I was already at 1100 Feet MSL. [I] extended downwind, until I passed him over the window (parallel, he's on final, I'm downwind). When I was on downwind, I thought he had given me clear to touch and go on 6R, after the landing Cessna. But I could be wrong. I remember he confirmed with me, as I turn into base. There was 2 way communication about "low approach" I read back, Aircraft X

low approach to 6R. Here problem was that I had wrong understanding of low approach. I thought as short approach was immediate (or expedited approach to runway for touch and go's), I assume low approach was coming to land/touch and go, with lower than usual altitude. I was in hurry to end this session of flying because more cloud with possibly lower ceiling and precipitation was coming. Then, in final 1 mile. I was coming lower than 3 degree approach angle. Once I was passing number mark 6R, I only had capacity to fly and land the Cessna for touch and go. Which was result of wrong conception. Because I was coming low, I was doing slow flight and slow descend as 100 feet per minute by the time passing the displaced threshold. ATC tower called me several time, prior to or after I did the touch and go's. I was overloaded with uncertainty that I might be doing wrong procedures. Then, I could not reply back to tower until 10 seconds. I could not stop on the runway. After regaining climbing attitude I reached tower "Aircraft X" It was unauthorized landing. I was notified I failed to follow the ATC direction and it was deviation. After I came back to land and talk to CFI, I understand low approach was "not landing" and simulating landing procedures. There were 2 major mistakes. First, I did not clarify the instruction which I am not familiar with "low approach." Secondly, I failed to keep 2 way radio communication and follow ATC direction at airport facility. I am sorry and acknowledge that those 2 [mistakes] and any similar case, such action can lead to major incident, endangering people's life and property. I will clarify and have correct procedure for each part of flight and develop clear understanding of aviation guidelines and regulations. I am sorry for mishap I caused and do my best not to repeat in future.

Narrative: 2 My student was solo doing in pattern touch and goes. Student performed 5 touch and goes without incident. He was on the right downwind and requested a touch and go, he was told he was number 2 following a Cessna 172 on final cleared for low approach. My student, even though he repeated back low approach mistook the meaning to be short approach. On short final he was called several times by tower who later said that they were trying to contact him to give him an amended clearance to permit a touch and go. My student ended up low and slow and was busy with trying to return the plane to a normal approach condition and did not immediately answer tower. He then proceeded to touch down and take off, then answer tower at which time tower informed him that his actions were a deviation from instructions, to land and call the tower. He landed and called the tower. I was on the phone with him to tower so I could hear what they said. I have since given him additional training ground and flight and again gone over the meanings of low approach, short approach, "the option", full stop, cleared to land etc. I have also instructed him in the importance of maintaining communication with the ATC facility and what to do if he is uncertain of the instructions given the ATC facility.

Synopsis C172 Student pilot reported becoming confused by a Tower instruction to make a low approach while practicing touch and go landings in the pattern. The student made a flatter than normal (low) approach and touch and go, and did not acknowledge calls from the Tower until safely airborne.

ACN: 1410139

(28 of 50)


Place Locale Reference.Airport : CJR.Airport State Reference : VA Altitude.MSL.Single Value : 3000


Aircraft Reference : X ATC / Advisory.TRACON : PCT Aircraft Operator : Personal Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Nav In Use : GPS Flight Phase : Initial Approach Route In Use.Other Airspace.Class E : PCT

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 : Air Transport Pilot (ATP) Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 10000 Experience.Flight Crew.Last 90 Days : 50 Experience.Flight Crew.Type : 3000 ASRS Report Number.Accession Number : 1410139 Human Factors : Situational Awareness Human Factors : Distraction Human Factors : Confusion

Events

Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : FAR Detector.Person : Flight Crew When Detected : In-flight

Assessments Contributing Factors / Situations : Airport Contributing Factors / Situations : Airspace Structure Contributing Factors / Situations : Procedure Primary Problem : Airspace Structure

Narrative: 1 During a practice instrument approach (RNAV 22) at Culpepper Airport (CJR) in VFR conditions, I noted that the depicted course reversal at the DOYAT IAF at the published initial approach altitude (3000 ft MSL) would appear to result in an incursion into the class B airspace 2500 altitude floor if one complied with the 4 NM course reversal required by the published approach procedure. While the DOYAT intersection lies below the 4500 foot class B floor, the required course reversal appears to result in an incursion into the 2500 foot ring. Upon noting the upcoming incursion, I believe that I was able to avoid the incursion by flying a 3 mile course reversal pattern rather than the depicted 4 mile pattern but it was certainly close to the 2500 foot boundary. I recommend that the depicted course reversal leg be shortened or the approach procedure amended to require obtaining a class B clearance prior to executing this procedure to avoid a possible class B infraction. Most students are more focused on executing the published procedure than figuring out that the depicted procedure could result in a class B infraction. While I do not think that an incursion occurred, the resolution of the onboard avionics display cannot with absolute certainty guarantee this especially if the 4 mile reversal is flown.

Synopsis A general aviation instructor pilot reported noticing that the CJR RNAV 22 approach could, if flown as depicted, possibly intrude on the IAD Class B airspace. Reporter recommended an adjustment to the procedure turn to preclude a possible airspace violation.

ACN: 1410118

(29 of 50)


Place Locale Reference.Airport : CVH.Airport State Reference : CA Altitude.AGL.Single Value : 500


Aircraft : 1 Reference : X ATC / Advisory.CTAF : CVH Aircraft Operator : Personal Make Model Name : Bonanza 36 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Final Approach Route In Use : Visual Approach Airspace.Class G : CVH

Aircraft : 2 Reference : Y ATC / Advisory.CTAF : CVH Aircraft Operator : Personal Make Model Name : Bonanza 36 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Final Approach Route In Use : Visual Approach Airspace.Class G : CVH

Person : 1 Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Private Experience.Flight Crew.Total : 160 Experience.Flight Crew.Last 90 Days : 20

Experience.Flight Crew.Type : 15 ASRS Report Number.Accession Number : 1410118 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 : Personal Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 475 Experience.Flight Crew.Last 90 Days : 30 Experience.Flight Crew.Type : 200 ASRS Report Number.Accession Number : 1412616 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 : 20 Miss Distance.Vertical : 30 When Detected : In-flight Result.Flight Crew : Took Evasive Action


Narrative: 1 I was PIC flying an A36 Bonanza to Hollister with [another pilot] sitting in the right seat. [He] is a certified pilot. We were approaching Hollister Airport (CVH) from the north and entered on a left downwind for Runway 31 and announced our position on CTAF. The only other planes on frequency were a helicopter doing pipeline work west of the field at 300 feet and [another aircraft] getting ready to takeoff. As we entered the downwind, [right seat pilot] and I noted an aircraft departing Runway 31. It did not make any radio announcements on CTAF. I announced my position throughout the pattern. There were no communications from other airplanes in the pattern. We set up for a normal approach. We turned final and the [other aircraft] was holding short of runway 31. As we were on final at approximately 500 feet AGL, the pilot of the [other aircraft] announced that there were two planes on final. I looked up and observed another Bonanza

right above us on approach for the same runway approximately twenty to thirty feet above us and slightly in front of us. I immediately began a turn to the right and initiated a go around, parallel and east of the runway. As I was in my upwind, I remained east of the runway, and observed the other Bonanza climbing off Runway 31 parallel to us. No communication from the other Bonanza was made throughout the incident. He proceeded to fly straight out parallel to us. The helicopter made a radio call saying that there were two airplanes flying parallel to each other on upwind, and I responded that the other airplane was not on frequency, but I had them in sight. I proceeded to turn crosswind behind the Bonanza and re-entered the pattern. We did not see him again.

Narrative: 2 I was carrying out a commercial training with my CFI. As part of these procedures we obtained the weather at Hollister and communicated our intentions on CTAF (123.0) and carried out 3 touch-and-gos while constantly communicating on CTAF. We did not observe any other aircraft in the pattern but we continued to communicate. Two days later we got a report from a near-miss from another aircraft on final. They additionally raised the concern of not hearing us on the CTAF. On post-mortem of the event we remember the following: - We obtained AWOS on the same radio. So it was clearly working - We tuned to CTAF but did not hear anyone on it. The only conclusions we could come to is we tuned the frequency incorrectly. Lesson learned is when tuning a radio to CTAF/UNICOM you need to triple-check it since there is no confirmation response you will receive unlike all other frequencies.

Synopsis Reports from two light aircraft pilots involved in an NMAC in the pattern at CVH. Improper communication on CTAF frequency was reportedly a factor.

ACN: 1409526

(30 of 50)




Aircraft Reference : X ATC / Advisory.TRACON : ZZZ Aircraft Operator : Personal Make Model Name : SR22 Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Nav In Use : GPS Flight Phase : Initial Climb Route In Use : Vectors Airspace.Class C : ZZZ

Component Aircraft Component : GPS & Other Satellite Navigation Aircraft Reference : X Problem : Malfunctioning

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 : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 1900 Experience.Flight Crew.Last 90 Days : 40 Experience.Flight Crew.Type : 300 ASRS Report Number.Accession Number : 1409526

Events

Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Track / Heading : All Types Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Returned To Clearance


Narrative: 1 I recently learned about an event that occurred while I was instructing. He is a retired 121 Captain and bought into a partnership of a SR22 based at ZZZ. It was our 3rd training session together and the purpose of the flight was an IFR procedure flight and getting him more familiar with the Garmin Perspective system and autopilot automation. We were given the departure from Runway XXR and I had him load that in the FMS and our first enroute fix. We used the flight director in TOGA mode then at 500 feet engaged the autopilot in HDG and IAS. In the Perspective system there is a Manual Sequencing at 835 feet in the Flight Plan and the Navigator goes into Suspend. We were then given a left turn to 330 I believe and turned the heading bug to that heading and the plane turned left accordingly. Next we were given direct ZZZZZ intersection and I watched him follow my instruction which was to select Direct To/Enter/Enter/Nav button on the AP. At that point the planed turned right and I thought ZZZZZ intersection might be to the left. I believe somewhere between 15-20 seconds expired while we sorted that out and then ATC asked us if we were direct ZZZZZ intersection. I quickly looked at the HSI and saw it was in Suspend mode. The buttons I watched him push were correct and the HSI should have been in GPS mode. We reprocessed the buttonology and the plane headed to ZZZZZ intersection. ATC was very nice about it and aside from being confused on why it happened I did not see that there was an issue. Later that evening I reviewed the 752 page Garmin Perspective manual and there was only once sentence in there about manual sequencing. With manual sequencing the navigator remains suspended in HDG mode on a vector and only unsuspends when a fix is selected which we did. I tried flying the scenario in the simulator but never could get the plane to turn right as it did on the flight. The pilot informed me last week of a letter he received from the FAA and I presented the scenario to several other instructors and we used the simulator and could not recreate the flight path. After it was mentioned to me that this was one of the earlier Perspective models and that there have been mechanical issues with the FMS keypad, I had a thought and tried it on the simulator. The discovery was, and confirmed by the aircraft owners, that the keypad has some wear and they have experienced difficulty with it accepting commands at times. The enter button of course is the one most used. So while I watched the pilot physically push the correct buttons, the 2nd Enter push was not accepted. When the NAV button was pressed the plane turned to 050 which is odd in itself because the heading bug was on a 330 heading, but it turned back to the programed departure leg which was in suspend. Not back to Runway XXR just 050 so that is why the radar will show that track. The takeaway is that they are having their plane serviced. On the pilot side we should have recognized that while ZZZZZ intersection had been selected and was showing

on the MFD and Flight plan the track and direct were different. It's on days like this I miss VORs and needles.

Synopsis SR22 instructor pilot reported an issue with the Garmin Perspective system installed on Cirrus aircraft. He reported that owners of older keypads experienced difficulty with it accepting commands due to worn out buttons.

ACN: 1408989

(31 of 50)



Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Ceiling.Single Value : 3400

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : Cessna 210 Centurion / Turbo Centurion 210C, 210D Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Initial Climb Airspace.Class C : ZZZ

Component Aircraft Component : Engine Aircraft Reference : X Problem : Failed

Person : 1 Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Pilot Not Flying Function.Flight Crew : Trainee Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Commercial Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 3500 Experience.Flight Crew.Last 90 Days : 20 Experience.Flight Crew.Type : 7 ASRS Report Number.Accession Number : 1408989

Person : 2

Reference : 2 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Instructor Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Commercial Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 1610 Experience.Flight Crew.Last 90 Days : 132 Experience.Flight Crew.Type : 95 ASRS Report Number.Accession Number : 1408196

Events Anomaly.Aircraft Equipment Problem : Critical Anomaly.Ground Event / Encounter : Object Anomaly.Inflight Event / Encounter : Fuel Issue Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Landed in Emergency Condition


Narrative: 1 My CFI and I were flying the Cessna T210L. We took off for an ILS approach on Runway XY, then cancelled IFR to conduct traffic pattern work. I am in training for my CFI, therefore occupying the right seat, pretending to be the instructor conducting demonstration-performance for the traffic pattern VFR approach procedure. I did 3 landings with no issues, and after that we did positive change of controls, so he could play the role of the student flying and I would be the instructor, talking him through. It was a touch and go, and he did the landing, and subsequent takeoff roll with no issues. During the initial climb, at about 200 feet AGL the engine quit running. He was already flying so he did the landing straight ahead. I offered flaps, so we landed with flaps. The landing was made within the runway pavement. One runway light was broken. The main landing gear tires went bald due to the heavy braking. There were no other damages, nor injuries. Emergency personnel came to the site and assisted with removing the airplane out of the runway and checking on me and [my CFI]. We had no injuries. At the time we weren't positive on what caused the engine to fail. As soon as the airplane was brought back to the hangar, one of the mechanics started the engine and it ran. The mechanic then told us he would drain the tanks on the next [week]. So, I received a text message from [my CFI] saying the mechanic drained the tanks and found no fuel on the left tank. On a phone call with the mechanic, I learned that the last person who flew the airplane did not refuel it because the FBO which does the refueling was closed. There were no notes or communication regarding that. As per club policy, every pilot must get the airplane refueled after each flight and annotate the amount of fuel in the airplane logbook. The reason [my CFI] and I didn't have any information that the

airplane wasn't refueled was because the annotation was on the last line of the sheet which was detached from the logbook, as they are every calendar month for accounting purposes. [My CFI] and I started our flight on a brand new log sheet with no previous information about the airplane. I conducted my preflight inspection as I do every time with the C210, specifically the fuel check. There is a small ladder to climb, not tall enough to enable me to see the fuel tank opening from above (a visual inspection looking to the fuel tank opening from above is the ideal way to visually check for fuel quantity inside the tanks. There was no plastic tank fuel gauge stick available). I used my tactical sense (I put my finger inside the tank to feel the fuel), and I double checked with the fuel gauges, which were indicating full. With that I had no doubt we had fuel in the airplane. [My CFI] was not present at the time I did my preflight, but I told him how I did my preflight and my findings, to include fuel check. He accepted it, and we went flying. [My CFI] and I did not brief ourselves in who would be the PIC, as I had the assumption he was the PIC, since he was the CFI and the one allowed to fly the C T210L as per flying club policies, (I am not allowed to schedule the C T210L myself as I have not met all the training requirements yet), and he thought I was the PIC because I have more flight hours than he does. This event was an extremely sobering experience for me. I have always been a safety oriented pilot, but this experience has driven home to me the significance of visual, accurate and positive fuel inspection on preflight.

Narrative: 2 [Report narrative contained no additional information.]

Synopsis CFI student pilot and instructor reported an engine failure during landing practice. Post flight analysis revealed that one tank had no fuel.

ACN: 1408726

(32 of 50)



Environment Flight Conditions : IMC Weather Elements / Visibility.Visibility : 3 Light : Daylight Ceiling.Single Value : 1100

Aircraft Reference : X ATC / Advisory.TRACON : 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 : IFR Mission : Training Flight Phase : Initial Approach Airspace.Class E : ZZZ

Component : 1 Aircraft Component : Altimeter Aircraft Reference : X Problem : Malfunctioning

Component : 2 Aircraft Component : Vertical Speed System Aircraft Reference : X Problem : Malfunctioning

Component : 3 Aircraft Component : GPS & Other Satellite Navigation 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 : Flight Instructor Qualification.Flight Crew : Commercial Qualification.Flight Crew : Multiengine Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 1190 Experience.Flight Crew.Last 90 Days : 150 Experience.Flight Crew.Type : 110 ASRS Report Number.Accession Number : 1408726 Human Factors : Situational Awareness Human Factors : Distraction

Events Anomaly.Deviation - Altitude : Excursion From Assigned Altitude Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Anomaly.Inflight Event / Encounter : CFTT / CFIT Detector.Person : Flight Crew Detector.Person : Air Traffic Control Miss Distance.Vertical : 1300 When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Flight Crew : Became Reoriented Result.Air Traffic Control : Issued Advisory / Alert

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors Primary Problem : Human Factors

Narrative: 1 I was providing instrument instruction but my student wasn't doing a good job tracking the localizer. We wanted to discontinue but the controller gave us a heading to reintercept instead. Since the situation was not improving I decided to take the controls from the student but got confused on how far were we in the localizer and started my descent as if I were already past the FAF. Just when I noticed how far in reality I was and about 1,300 feet AGL the controller called us to climb immediately back to 1,800 feet (the prescribed altitude for that segment of the approach) which we immediately complied with. The approach was finished uneventfully after that and landed safely at our destination. I lost situational awareness momentarily due to the fact that so many things were going on at the same time plus the fact that I started doubting my instruments because the GPS installed in the airplane was giving a different information of our position in relation to the localizer. I know that I should rely on my instruments at all times but the altimeter and VSI had been acting weird jumping up and down a couple of hundred feet for very brief and sporadic periods of time. The solution I'm going to implement to prevent this from ever happening again is to not start a descent until I verbally manifest my position on the approach and challenging myself or whoever I'm flying with that we can do so and not just assume it. Also I will

discontinue an approach if I don't feel confident on it regardless of suggested headings from the controller to re-intercept.

Synopsis Flight instructor reported a premature descent after assuming control of the aircraft when the instrument student pilot was unable to track the localizer.

ACN: 1408207

(33 of 50)


Place Locale Reference.Airport : NTU.Airport State Reference : VA Relative Position.Angle.Radial : 359 Relative Position.Distance.Nautical Miles : 20 Altitude.MSL.Single Value : 26000

Environment Flight Conditions : Mixed Weather Elements / Visibility.Visibility : 1.5 Light : Daylight Ceiling.Single Value : 400

Aircraft : 1 Reference : X ATC / Advisory.Center : ZDC Aircraft Operator : Military Make Model Name : Fighter Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Climb Route In Use : Direct Airspace.Class A : ZDC

Aircraft : 2 Reference : Y ATC / Advisory.Center : ZDC 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 Nav In Use : FMS Or FMC Flight Phase : Cruise Airspace.Class A : ZDC

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Military Function.Flight Crew : Single Pilot

Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 780 Experience.Flight Crew.Last 90 Days : 22 Experience.Flight Crew.Type : 550 ASRS Report Number.Accession Number : 1408207 Human Factors : Communication Breakdown Human Factors : Situational Awareness Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : ATC

Events Anomaly.ATC Issue : All Types Anomaly.Conflict : Airborne Conflict Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Deviation - Procedural : Clearance Anomaly.Inflight Event / Encounter : Fuel Issue Detector.Automation : Aircraft RA Detector.Person : Flight Crew Miss Distance.Horizontal : 24000 Miss Distance.Vertical : 6000 When Detected : In-flight Result.Flight Crew : Returned To Clearance Result.Flight Crew : Diverted Result.Flight Crew : Became Reoriented Result.Flight Crew : Took Evasive Action Result.Air Traffic Control : Issued New Clearance


Narrative: 1 [I] diverted from NTU to ZZZ on a low fuel profile after NTU's single runway was fouled on a day with ceilings down around 400 ft and 3/4-1.5nm visibility. On the climb profile [I] was passed a different squawk code. Upon switch to Center frequency it was apparent that Center was unaware of the situation in progress. Additionally, [I] was on the wrong frequency, the frequency that was passed from Approach. [I] communicated [my] situation and intentions. On the climb with the rate of ascent and proximity to a commuter airliner TCAS was set off. [I] arrested [my] ascent and descended to the Center requested altitude of FL260 and remained there for the duration of the transit contrary to the aircraft's max conserve bingo fuel profile. In conclusion the lessons to take away are a function of communication and intentions. Aircraft and controllers need to clearly and quickly establishing an understanding of the situation in progress and what is needed to cope with the situation so that all parties, controllers, aircraft, and any potential conflicts in the airspace may sooner rather than later take the appropriate and timely action. Additionally, perhaps changing an aircraft's squawk code may not have been the best answer with traffic in the vicinity and an aggressive climb for fuel requested. Lastly, just because you are a priority aircraft does not necessarily mean you "own the road", successful conclusion to situations are often a team effort. However, clearing your flight path with onboard RADAR, an aggressive visual

look out, while communicating the situation will continue to be required until all parties have total situational awareness.

Synopsis Military Fighter pilot reported an airborne conflict occurred during a diversion for a low fuel situation.

ACN: 1408200

(34 of 50)




Aircraft Reference : X ATC / Advisory.Ground : 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 : None Mission : Training Flight Phase : Taxi

Component Aircraft Component : Brake 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 Function.Flight Crew : Instructor Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Qualification.Flight Crew : Multiengine Experience.Flight Crew.Total : 294 ASRS Report Number.Accession Number : 1408200

Events Anomaly.Aircraft Anomaly.Ground Anomaly.Ground Anomaly.Ground

Equipment Problem : Less Severe Excursion : Taxiway Event / Encounter : Object Event / Encounter : Loss Of Aircraft Control

Detector.Person : Flight Crew When Detected : Taxi Result.Flight Crew : Took Evasive Action Result.Aircraft : Aircraft Damaged


Narrative: 1 I was taxiing [a] Piper Archer to the run-up area. The flight was being conducted as an introductory flight for a brand new customer. The pre-flight, startup, and taxi, up until the run-up pad, were normal. A brake test was accomplished during the first part of the taxi and both brakes were used gently during the taxi. Upon reaching the run-up pad, a right turn was made to enter it, followed by a gentle left turn (I did not use any braking for this left turn). As the aircraft reached the desired run-up spot on the southeast side of the pad, I applied pressure to both brakes. The aircraft veered sharply to the right heading off of the pad to the south. I immediately released the right brake and applied full left nose wheel steering as well as continued left brake in order to straighten the aircraft. The left brake did not react and the aircraft proceeded to make a gentle left turn. Because the left brake did not actuate, the aircraft continued off the pad into the grass. I did not want to use the right brake for fear of striking the sign with the propeller, rather than the right wing. The fiberglass right wingtip impacted the sign off of the southeast side of the pad, knocking it over. Damage to the aircraft appears to be a cosmetic paint scrape. I immediately shut down the engine and contacted the ground frequency in order to inform them of what happened. Post shut down inspection revealed that the left brake pedal had gone "soft" with no pressure. There were no injuries and damage to aircraft and property was minimal.

Synopsis PA-28 instructor pilot reported striking a sign with a wingtip during taxi when directional control was lost due to a malfunctioning left brake.

ACN: 1407376

(35 of 50)


Place Locale Reference.Airport : ZZZ.Airport State Reference : US


Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : SR20 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Mission : Training Flight Phase : Climb

Component Aircraft Component : Cylinder Head Temperature Aircraft Reference : X Problem : Malfunctioning

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Air Carrier Function.Flight Crew : Single Pilot Function.Flight Crew : Pilot Flying Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Commercial ASRS Report Number.Accession Number : 1407376

Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Returned To Departure Airport Result.Flight Crew : Landed As Precaution


Narrative: 1 Upon takeoff, CHT #5 rapidly climbed into the yellow and kept climbing. I kept the mixture full forward, the fuel pump on boost, and lowered the nose to try to cool the engine, however it stayed hot. I immediately contacted Approach and told them that I needed to return to the airport and my engine was reading hot.

Synopsis SR20 pilot reported returning to departure airport after experiencing high cylinder head temperature after takeoff.

ACN: 1406898

(36 of 50)




Aircraft : 1 Reference : X ATC / Advisory.CTAF : ZZZ Aircraft Operator : Personal Make Model Name : Travelair 95 Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing Route In Use : Visual Approach

Aircraft : 2 Reference : Y Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer Mission : Training Flight Phase : Final Approach Route In Use : Visual Approach Airspace.Class G : ZZZ

Component Aircraft Component : Landing Gear Aircraft Reference : X Problem : Design Problem : Improperly Operated

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Personal Function.Flight Crew : Instructor Qualification.Flight Crew : Multiengine

Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Air Transport Pilot (ATP) Qualification.Flight Crew : Commercial Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 10000 Experience.Flight Crew.Last 90 Days : 40 Experience.Flight Crew.Type : 3500 ASRS Report Number.Accession Number : 1406898 Human Factors : Confusion Human Factors : Distraction Human Factors : Human-Machine Interface Human Factors : Workload Human Factors : Communication Breakdown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Flight Crew

Events Anomaly.Aircraft Equipment Problem : Less Severe Anomaly.Deviation - Procedural : Published Material / Policy Anomaly.Ground Event / Encounter : Gear Up Landing Detector.Person : Flight Crew When Detected : In-flight Result.General : Maintenance Action Result.Aircraft : Aircraft Damaged

Assessments Contributing Factors / Situations : Human Factors Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Procedure Primary Problem : Aircraft

Narrative: 1 I was the CFIME for a multi-engine training flight. We were practicing a simulated single engine approach to a landing. This is a complex, nonstandard simulated emergency procedure where the power from only one engine is used to fly and land the aircraft. This is a challenging exercise that was further complicated by conflicting aircraft traffic. In the stress and rush of the landing I observed my student, who was flying the aircraft, reached across the instrument panel and put his hand on the landing gear control lever. I believed the plane was configured to land. We did land, but with gear up. My student's first words were, "I was sure the gear was down." At that point I checked the gear control handle. It wasn't in the up locked position. It wasn't in the down locked position. It was in a central or neutral position. We both failed to confirm that the gear was actually down. Very expensive, indelible lesson learned, the hard way. Shouldn't the gear position selector have only 2 possible positions (settings) up or down? My student thought he had moved the selector from up to down, when in fact he had only moved it out of the up latched position. The center/neutral/off position seems to have no purpose other than to cause expensive problems.

Synopsis

A BE-95 instructor reported his student placed the landing gear lever toward the down position, but undetected by either pilot, the gear did not extend because the gear lever was actually in the neutral, off position. The aircraft landed gear up.

ACN: 1406875

(37 of 50)


Place Locale Reference.Airport : RNM.Airport State Reference : CA Altitude.MSL.Single Value : 2200


Aircraft Reference : X ATC / Advisory.Tower : RNM 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 : Training Flight Phase : Climb Route In Use : Direct Airspace.Class D : RNM

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 : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 2700 ASRS Report Number.Accession Number : 1406875 Human Factors : Communication Breakdown Human Factors : Confusion Human Factors : Distraction Human Factors : Situational Awareness Human Factors : Workload Communication Breakdown.Party1 : ATC Communication Breakdown.Party2 : Flight Crew

Events

Anomaly.ATC Issue : All Types Anomaly.Conflict : Airborne Conflict Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Miss Distance.Horizontal : 1000 Miss Distance.Vertical : 50 When Detected : In-flight Result.Flight Crew : Became Reoriented Result.Flight Crew : Took Evasive Action Result.Air Traffic Control : Issued New Clearance

Assessments Contributing Factors / Situations : Airport Contributing Factors / Situations : Procedure Primary Problem : Procedure

Narrative: 1 This was an instructional flight with a student pilot. We were cleared for takeoff on Runway 27 with a right turnout. The takeoff proceeded normally with the student flying and we climbed straight ahead to 1900' MSL in accordance with noise abatement procedures. Just prior to reaching 1900' tower requested that we start our turn and we complied. On crosswind, tower issued a traffic advisory (10 O'clock?). As we were a high wing we had difficulty seeing the traffic which was joining directly on the downwind for Runway 27. When I finally saw the traffic, we appeared to be on a collision course. I took control and performed a diving turn to the right. Tower then requested that we maintain 2500' MSL which we did until the edge of the Class D at which point we resumed normal navigation. It appeared that the tower had tried to turn us early with the expectation that we would pass in front of the aircraft joining downwind.

Synopsis An instructor pilot departing RNM took aircraft control from his student then evaded an aircraft entering the pattern after ATC vectored his aircraft which resulted in the conflict.

ACN: 1406558

(38 of 50)


Place Locale Reference.Airport : SBA.Airport State Reference : CA Altitude.MSL.Single Value : 1300

Environment Flight Conditions : VMC Weather Elements / Visibility : Rain Weather Elements / Visibility : Thunderstorm Weather Elements / Visibility.Visibility : 10 Light : Daylight Ceiling.Single Value : 1800

Aircraft Reference : X ATC / Advisory.TRACON : SBA 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 : IFR Mission : Training Flight Phase : Initial Approach Route In Use : VFR Route Airspace.Class C : SBA

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 : Air Transport Pilot (ATP) Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Multiengine Experience.Flight Crew.Total : 2000 Experience.Flight Crew.Last 90 Days : 36 Experience.Flight Crew.Type : 300 ASRS Report Number.Accession Number : 1406558 Human Factors : Situational Awareness Human Factors : Confusion Analyst Callback : Completed

Events Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Other Person When Detected : In-flight Result.General : None Reported / Taken

Assessments Contributing Factors / Situations : Manuals Contributing Factors / Situations : Chart Or Publication Contributing Factors / Situations : Procedure Primary Problem : Chart Or Publication

Narrative: 1 I was a flight instructor planning an IFR flight with a client who has a Private Pilot rating. Plan was to file and conduct an IFR training flight for the Private Pilot. I have a CFII rating also. IFR flight plan was to Santa Barbara Muni (SBA), CA. The IFR flight plan was filed and weather and NOTAMS for SBA and route of flight were checked. I was in the right seat as an instructor while the Private Pilot flew left seat. ATIS from SBA was received airborne and Information was current with wind 110 at 9 knots, visibility 10 miles, ceiling 3500 BKN and altimeter 29.92. At approximately 22NM from SBA and heading about 280 degrees at 4000ft, I checked in with Santa Barbara Approach control and requested the GPS Runway 25 Approach, enter at KWANG intersection, to circle to land on runway 15 because of the prevailing wind from 110 at 9 knots. Approach controller informed me that it would be a 30 minute delay. I could see the city from 20NM with what appeared to be an overcast layer at 2000ft. Field elevation is 10ft. I decided to cancel IFR and proceed VFR. ATC gave me instructions to "remain VFR and follow the freeway". The freeway is Highway 101 that runs east to west, along the California coast, through the city of Santa Barbara and bypasses to the north of SBA. We flew as directed and as we approached nearer to SBA, about 10-12 NM from the east, the ceiling appeared lower, about 1500-1800 ft. MSL, and we descended to approximately 1300 ft MSL to adhere to VFR cloud clearance requirements. The flight path took us over the city and we subsequently descended to enter a left base to land on Runway 15 VFR. After being on deck at SBA for 20 minutes we picked up our IFR flight plan back [home airport]. [A few weeks later] I was informed by my Chief Flight Instructor that the owner of [aircraft], who we lease the aircraft from for flight training, received a letter saying that his plane had descended below the Santa Barbara city ordinance of no lower than 1500 ft over the city. Reported altitude was 1300 ft and the ordinance is in place due to noise abatement. I admitted to being in that aircraft and described to him the facts previously stated. I asked my Chief Flight Instructor if I was being flight violated and he said no. We just deviated from a Santa Barbara city ordinance by being 200 ft lower than we should have been. I informed him that I checked NOTAMS before flight and inflight Approach control and SBA Tower never informed us of the no lower than 1500ft altitude limit. So how is a pilot supposed to know? Recently I called the phone number given in the FAA Southwest Flight Information Publication. This number is listed to call for noise abatement procedures. Outside of normal working hours you get a voicemail from the airport manager but it does not give a recording for noise abatement procedures. I also checked online on the AIRNAV website, looked up SBA, and NOTAMS on the Defense Internet NOTAM Service website. Again, nowhere on these sites does it specify in detail what the noise abatement procedures are for SBA and the no lower than 1500ft altitude limit. As stated, I [had] checked with FSS and also the AIRNAV and NOTAM websites for SBA procedures and did not see anything specific to noise abatement. These procedures need

to be published or at least recorded on the SBA phone number, when calling after hours, so pilots are aware so they can avoid future complaints from the city of Santa Barbara.

Callback: 1 Phone calls were made to the phone number listed for noise abatement information and procedures. The person on the phone stated their were no altitude restrictions and to abide by Tower instructions. Tower did not issue any altitude restrictions. The ATC Facility Manager is not aware of the altitude restriction of the noise abatement procedure.

Synopsis A flight instructor reported being informed that a city noise abatement altitude had not been met. The pilot was not informed of the noise abatement restrictions nor were any procedures found following the notification.

ACN: 1405976

(39 of 50)




Aircraft Reference : X ATC / Advisory.CTAF : ZZZ Aircraft Operator : Personal Make Model Name : J3 Cub Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Mission : Training Flight Phase : Landing

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 : Flight Instructor Qualification.Flight Crew : Commercial Experience.Flight Crew.Total : 5825 Experience.Flight Crew.Last 90 Days : 75 Experience.Flight Crew.Type : 1200 ASRS Report Number.Accession Number : 1405976 Human Factors : Communication Breakdown Human Factors : Other / Unknown Communication Breakdown.Party1 : Flight Crew Communication Breakdown.Party2 : Flight Crew

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 Contributing Factors / Situations : Aircraft Primary Problem : Human Factors

Narrative: 1 The instructor and pilot were returning to the home airport after flying around the area performing landings at 6 various airports. On return, the pilot set up for final to runway XX and made a perfect wheel-landing on the grass runway. Upon landing and roll-out the aircraft started to veer slightly to the left. The pilot was told by instructor to give the aircraft slight right rudder to compensate. The pilot accidently pressed the right brake which sent the right wheel into the soft sandy grass. At this time the pilot also pushed the stick forward which sent the aircraft over. I, the instructor, had no option to recover the aircraft after the pilot accidentally pressed the right brake. I crawled out of the starboard side of the aircraft and turned off the master, starter, and fuel control. I then assisted the pilot out of the aircraft on the starboard side. Even though the front cockpit pilot is a very competent commercial pilot he reacted incorrectly and opposite of the instructors' guidance direction which resulted in an incident that the instructor could not recover from. Once the brakes are applied while the aircraft still has momentum on roll-out the pilot (instructor or otherwise) no longer has control. My recommendation as a pilot and instructor in tail-wheel aircraft is that all people in tailwheel aircraft be instructed to only use the brakes in times of an emergency when there is an obstacle on the ground and the tail wheel is firmly on the ground. The pilot was instructed in this way but it is pertinent that all pilots be taught in this procedure. Incidents can happen (as witnessed from this document) with this training; however, the training will lessen the frequency of such incidents occurring in the future.

Synopsis Piper Cub instructor pilot reported a runway excursion with the aircraft flipping on its back when his student inadvertently applied right brake when attempting to apply right rudder. Soft sand and forward stick caused the aircraft to flip.

ACN: 1405955

(40 of 50)


Place Locale Reference.Airport : CPT.Airport State Reference : TX Altitude.MSL.Single Value : 1800


Aircraft : 1 Reference : X ATC / Advisory.CTAF : CPT 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 : Climb Route In Use.Other Airspace.Class E : CPT

Aircraft : 2 Reference : Y ATC / Advisory.CTAF : CPT Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear Operating Under FAR Part : Part 91 Flight Phase : Initial Approach Airspace.Class E : CPT

Aircraft : 3 Reference : Z ATC / Advisory.CTAF : CPT Make Model Name : PA-44 Seminole/Turbo Seminole Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Phase : Takeoff Airspace.Class E : CPT

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 : 700 Experience.Flight Crew.Last 90 Days : 100 Experience.Flight Crew.Type : 300 ASRS Report Number.Accession Number : 1405955 Human Factors : Situational Awareness

Events Anomaly.Conflict : NMAC Anomaly.Deviation - Procedural : Published Material / Policy Detector.Person : Flight Crew Miss Distance.Horizontal : 200 Miss Distance.Vertical : 200 When Detected : In-flight Result.Flight Crew : Took Evasive Action


Narrative: 1 While in the pattern at CPT on my third touch and go I called myself on final for runway 15 with my intentions of [doing] another touch and go. On climb out I heard another airplane call 2 miles southwest of CPT. I then called out [my call sign] turning right crosswind for runway 15 followed by a Seminole announcing takeoff and following myself in the pattern. Upon following my turn to downwind I saw my shadow, and a low wing airplane descending near us. I once again called my position and what was this low wing doing descending into a pattern from above the traffic pattern altitude. The Seminole that had been following me diverted its pattern in order to make room for this person who thought he could just make room for them and see everyone else make room. I then descended to make sure that this person who clearly didn't observe the traffic pattern was clear of me.

Synopsis C172 instructor pilot reported a NMAC in the pattern at the non-towered CPT airport.

ACN: 1405735

(41 of 50)


Place Locale Reference.Airport : BCV.Airport State Reference : AK Altitude.MSL.Single Value : 1500

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 50 Weather Elements / Visibility.Other Light : Dawn Ceiling.Single Value : 12000

Aircraft : 1 Reference : X ATC / Advisory.CTAF : BCV Make Model Name : Small Aircraft, High Wing, 1 Eng, Retractable Gear Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Descent

Aircraft : 2 ATC / Advisory.CTAF : BCV Make Model Name : Small Aircraft Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Phase : Climb

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck 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 : 750 Experience.Flight Crew.Last 90 Days : 90 Experience.Flight Crew.Type : 100 ASRS Report Number.Accession Number : 1405735

Events

Anomaly.Conflict : Airborne Conflict Detector.Person : Flight Crew Miss Distance.Horizontal : 500 Miss Distance.Vertical : 100 When Detected : In-flight Result.Flight Crew : Took Evasive Action


Narrative: 1 I was on a training flight with a commercial student who was transitioning to a new complex airplane. It was a mid-morning flight in Alaska, and the sun had just peaked over the eastern Chugach Mountains. We headed to Birchwood airport, an uncontrolled airport northeast of Anchorage for some landing practice. We had thoroughly briefed the flight, but my student quickly began to get behind the aircraft. Eventually, we got the weather information at Birchwood and got onto the CTAF frequency. As we made the approach to Birchwood from the west, my student made a radio call that we were 5 miles to the west at 3,000 feet and would be entering the traffic pattern on the 45 for Runway 20R, right traffic (the traffic pattern for the southern facing runway is on the same side that we were approaching from). The sun was just up over the mountains, and we were looking directly into it as we approached the airport. My student stated that he was having trouble seeing the runway. He started his descent to the airport too late, and we were going to end up fast and high in the pattern. While he was wrestling with the airplane I was scanning the pattern. I could see the downwind leg, base and final were clear, but the sun was directly in line with the crosswind leg coming off the runway, and the little bit of snow on the runway was creating a bad glare. However, I wasn't too concerned, we hadn't heard anyone on the CTAF. About two and half miles away from the airport I told my student he needed to make another radio call. My instruction went unnoticed as he was still trying to make his descent into the pattern work. Seeing that, I switched gears and gave him some options that would help make his descent into the pattern work out, including dropping the gear, S-turns, or a 360 degree turn. Another option I mentioned was to turn right slightly to gain a little space, then turn left back to our 45 entry. This is the option that my student took. He turned just barely to the right and we were still pointed pretty much at the airport. By this time we were about 2 miles away, still 1,000 feet too high, and about 30 knots too fast for the pattern. Due to the slight right turn, our 45 degree entry to the runway was really about a 30 degree entry, and was going to take us through the crosswind leg of the pattern. A quick note about Birchwood: there is a restricted area less than a mile off the departure end of Runway 20R, so most people turn their crosswind a little early to avoid the restricted area. We were just west of the tip of the restricted area, still a little high and a little fast, on a 30 degree entry to the downwind, about to cut through the crosswind leg that we couldn't see. I told my student he needed to announce our position on the radio. Just as he keyed the mike, I saw a shape at our 1 o'clock, same altitude. As my eyes focused, I saw it was a plane, headed directly at us. We must have seen each other at the same time. He broke up and left. I took the controls and broke down and left. It was a little difficult to discern the distance, but we were probably 500 to 700 feet from one

another when we both took evasive action. For some reason, my first thought was, "he must not have had a radio" since we hadn't heard anything on the CTAF, and I had confirmed we were on the correct frequency. Suddenly, I heard the pilot from the other plane announce, "near miss, Birchwood!" I confirmed that they were okay over the radio and if they were departing the pattern or staying. They left the pattern, and my student and I continued our training with no further incident. Back on the ground, it was clear to me that they had taken off, and turned crosswind just as we were on a "modified" 45 entry that made our flight paths intersect. Of course, that was the place that we couldn't see into the pattern. My student and I had a full debrief. We talked about proper descent planning, flying appropriate patterns, making radio calls, but most importantly we discussed that every PIC should ensure that they have a full understanding of what is happening visually in the traffic pattern before entering, nonradio airplanes can, and do, operate at uncontrolled airports. I think both my student and I have a greater appreciation of sun angles and how they can be a huge detriment to visibility. We discussed ways to maneuver the airplane to see all of the pattern before entering during those bad sun angle times. For my part as an instructor, I learned a couple things out of this experience. First, complacency sneaks up on you. I hadn't heard anything on the radio, therefore there were no other airplanes in the area. This time, there happened to be one. Secondly, I need to be more assertive in telling a student to abort if he or she puts us in a situation I don't like. I was uncomfortable being that close to the airport while still descending at a high rate when we should have been on a 45 entry at the proper altitude and airspeed. We could have descended onto another plane. In this situation, it would have been an easy answer for me to take the controls and let the student catch back up if there was a large amount of traffic in the area or some other immediate safety factor when task saturation can turn deadly. Today, I got complacent with allowing the student to put us in a bad situation without my intervention because I didn't think anything was going to happen. In the future, I'll be able to not only use this story as a case scenario, but to recognize that when I'm uncomfortable because we could end up in a bad situation, I need to take more assertive action.

Synopsis Flight instructor reported a NMAC at BCV while on a training flight with a student due to a combination of improper pattern entry and sun angle.

ACN: 1405721

(42 of 50)

Time / Day Date : 201611


Environment Flight Conditions : VMC Light : Dusk

Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Airspace.Class E : ZZZ


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 : 350 Experience.Flight Crew.Last 90 Days : 80 Experience.Flight Crew.Type : 300 ASRS Report Number.Accession Number : 1405721

Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew

When Detected : In-flight Result.Flight Crew : Landed in Emergency Condition Result.Air Traffic Control : Provided Assistance


Narrative: 1 We departed ZZZ airport to the southwest practice area to do a review flight with my student. We were passing over military airspace heading to [a local] lake. After passing [the] lake we started performing slow flight (3500 feet; 240 heading). Then, I asked the student to perform the maneuver (about 3300 feet; 210 heading) and upon recovery the student added full power and then started to remove the flaps. After removing the first notch, the engine started knocking "severe engine roughness." After that I took control to recover. Moments after, we had smoke in the cockpit. We were around 2800 feet so I reported to ZZZ Tower our aircraft call sign and position. Then maintained glide speed 73 KTS. Picked out a field and started heading towards the field. After losing altitude we reported again to ZZZ Tower that we are making an emergency landing in a field 3 to 4 nautical miles south of [the] lake, that we have smoke in the cockpit, and engine failure with two people on board. Then they asked us if we had fuel, I replied, "almost full fuel." Then started doing engine restart procedures. While doing this the tower tried to direct us to ZZZ, then they got confused and thought we [were] "northwest of ZZZ Airport." They tried to give us heading to ZZZ1 "northwest of our position." We were around 1400 MSL. Tower asked us to make a 180 degree turn if possible go to ZZZ1. So I declined the request and continued gliding towards the field, did securing procedures and concentrated on making a safe landing. Squawked 7700 and kept going to the field. Made a safe "soft field landing" and evacuated the aircraft. Aircraft was not damaged at all.

Synopsis A PA28 flight instructor reported an off-field emergency landing due to an engine failure and smoke in the cabin.

ACN: 1405192

(43 of 50)


Place Locale Reference.Airport : ROA.Airport State Reference : VA Relative Position.Angle.Radial : 090 Relative Position.Distance.Nautical Miles : 4.8 Altitude.MSL.Single Value : 3000

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10 Light : Dusk Ceiling.Single Value : 5000

Aircraft : 1 Reference : X ATC / Advisory.Tower : ROA Aircraft Operator : FBO Make Model Name : DA20 Undifferentiated Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : VFR Mission : Training Flight Phase : Cruise Route In Use : None Airspace.Class C : ROA

Aircraft : 2 Reference : Y Make Model Name : UAV - Unpiloted Aerial Vehicle Flight Phase : Cruise Airspace.Class C : ROA

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Pilot Not Flying Function.Flight Crew : Instructor Qualification.Flight Crew : Instrument Qualification.Flight Crew : Commercial Qualification.Flight Crew : Flight Instructor Experience.Flight Crew.Total : 4600 Experience.Flight Crew.Last 90 Days : 130

Experience.Flight Crew.Type : 150 ASRS Report Number.Accession Number : 1405192

Events Anomaly.Conflict : NMAC Detector.Person : Flight Crew Miss Distance.Horizontal : 200 Miss Distance.Vertical : 100 When Detected : In-flight Result.General : None Reported / Taken


Narrative: 1 Flight departed Runway 06 at ROA. Initial heading was 070 with a climb to our requested VFR altitude. A few minutes later, ROA Tower cleared us on course (south). After leveling at 3000 feet MSL, we observed what appeared to be a small unmanned aircraft of moderate size (3 feet or less), possibly a quadcopter approximately 100 feet above and 200 feet to our left (east). It appeared to be maneuvering but not converging with us. We continued on our heading and altitude and informed Tower of the sighting.

Synopsis DA20 instructor pilot reported a NMAC with a UAV east of ROA at 3000 feet. No evasive action was required.

ACN: 1404300

(44 of 50)




Aircraft Reference : X ATC / Advisory.Tower : ZZZ Aircraft Operator : FBO Make Model Name : Duchess 76 Operating Under FAR Part : Part 91 Mission : Training Flight Phase : Takeoff Airspace.Class D : ZZZ

Component Aircraft Component : Landing Gear 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 : 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 : 1777 Experience.Flight Crew.Last 90 Days : 190 Experience.Flight Crew.Type : 334 ASRS Report Number.Accession Number : 1404300 Human Factors : Training / Qualification Human Factors : Situational Awareness

Events

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


Narrative: 1 During an initial multi-engine training flight with a student he retracted the gear instead of the flaps on a touch and go. The aircraft system is based on airspeed to retract the gear. During the ground roll after the landing and cleaning the flaps up the student stated flaps up and pulled the gear switch up then the aircraft nose started to retract. A quick second later the nose was on the ground and both props struck the runway and we continued to slide approximately 400 feet until aircraft came to rest.

Synopsis BE-76 Instructor Pilot reported his student accidentally retracted the landing gear on a touch and go instead of the flaps, resulting in the nose gear retracting and the props striking the ground during the unsuccessful takeoff event.

ACN: 1403696

(45 of 50)


Place Locale Reference.ATC Facility : ZZZ.ARTCC State Reference : US Altitude.MSL.Single Value : 9000


Aircraft Reference : X ATC / Advisory.Center : ZZZ Aircraft Operator : FBO Make Model Name : PA-44 Seminole/Turbo Seminole Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Mission : Training Flight Phase : Cruise Airspace.Class E : ZZZ


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 ASRS Report Number.Accession Number : 1403696

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 [We were] at cruise altitude 9000 ft when crew became aware of massive sudden engine vibration. IP (Instructor Pilot) (PIC) immediately turned fuel pumps on, mixture full rich on both engines. Immediately after, right engine exploded without noticeable fire. IP took controls from PUI (Pilot Under Instruction) (student pilot) to maintain aircraft control, and to attempt to feather right prop and secure engine. Right prop did not feather and was wind milling and wobbling. IP called Center and [advised ATC] of engine failure and unable to feather prop. Squawked 7700. IP asked for nearest airport notification. IP chose [a nearby alternate] as we were 20nm SW of airfield and on "left base" for RWY 01. ATC concurred and facilitated emergency vehicles on field for emergency arrival. IP flew aircraft in degraded un-feathered conditions for safe landing. Aircraft was able to exit RWY, but unable to make left turn to clear hold short marking of RWY exit. Airport OPS met aircraft.

Synopsis PA-44 instructor pilot reported diverting to a nearby alternate after the right engine "exploded" in flight.

ACN: 1403416

(46 of 50)


Place Locale Reference.Airport : MPO.Airport State Reference : PA Altitude.MSL.Single Value : 1915

Environment Flight Conditions : VMC Weather Elements / Visibility.Visibility : 10

Aircraft Reference : X ATC / Advisory.CTAF : MPO Aircraft Operator : FBO Make Model Name : Helicopter Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Landing Airspace.Class G : MPO

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 : Commercial Qualification.Flight Crew : Flight Instructor Qualification.Flight Crew : Instrument Experience.Flight Crew.Total : 640 Experience.Flight Crew.Last 90 Days : 150 Experience.Flight Crew.Type : 470 ASRS Report Number.Accession Number : 1403416 Human Factors : Situational Awareness Human Factors : Training / Qualification

Events Anomaly.Conflict : Ground Conflict, Critical Detector.Person : Flight Crew Miss Distance.Horizontal : 0 Miss Distance.Vertical : 50 When Detected : Taxi Result.General : None Reported / Taken


Narrative: 1 During pattern training with solo student my student and I performed a right pattern for runway 31, while another aircraft performing [fixed wing] training performed a left pattern for the same runway. Communication and visual contact between us and the [fixed wing] operating on a left pattern was maintained for the whole pattern. Upon coming around for landing the [fixed wing] landed first, and the helicopter came in second. This was communicated between us and the [fixed wing], and every other leg of the pattern was announced. As the [fixed wing] cleared the runway he called clear and announced back taxi on crossing runway. Helicopter called short final and landed on the runway, close to the threshold/numbers. Student brought the helicopter to a hover and attempts a set-down, then picked helicopter back up. As the first set-down was somewhat abrupt another setdown was performed. While preparing to pick back up and departing for another pattern an airplane was observed 30-50 ft above the helicopter. The airplane proceeds to land past us on runway 31, showing no signs of evasive action. The airplane was promptly called on the radio and responded insisting that calls had been made throughout approach and confirming that he had heard all communication between us and the airplane landing ahead of us. The airplane also stated that he had heard someone clearing the runway and assumed from that that the runway was clear. I later had found the pilot and talked with him about what happened. He was very cooperative and apologetic. According to him he had heard all communication and knew that both an airplane and helicopter were landing in front of him. He also said that he never saw the helicopter until the last minute and then "floated" past it and proceeded to land. His choice of performing a very long straight in approach was also discussed. Contact information was also exchanged between pilots. The pilot of the aircraft landing over the helicopter also discussed the situation with a highly experience senior pilot working out of the field to identify what could be done to avoid similar situations in the future.

Synopsis Helicopter instructor pilot reported a light aircraft overflew them by approximately 50 ft as they were preparing for a lift-off.

ACN: 1403333

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Environment Flight Conditions : VMC Weather Elements / Visibility.Other Light : Daylight

Aircraft Reference : X ATC / Advisory.TRACON : ZZZ Aircraft Operator : Personal Make Model Name : Cheetah, Tiger, Traveler AA5 Series Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Flight Plan : IFR Mission : Training Flight Phase : Cruise Route In Use : Vectors Airspace.Class E : ZZZ

Component Aircraft Component : Electrical Power 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 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 : 3928 Experience.Flight Crew.Last 90 Days : 13 Experience.Flight Crew.Type : 14 ASRS Report Number.Accession Number : 1403333

Events Anomaly.Aircraft Equipment Problem : Critical Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Landed As Precaution Result.Flight Crew : Diverted


Narrative: 1 While under radar vectors for intercept of ILS, ALT warn light came on and system began to show an electrical discharge rather than a charge. To avoid any chance of serious electrical issues and to preserve battery power for landing (radio and flaps), we cancelled IFR with approach, turned to a heading of about 320 degrees, descended to 4500 MSL, turned off all electrical, and proceeded to [an alternate airport] (a location with maintenance facilities for aircraft type). Landed without further incident. Investigation on ground found a "shorting" connecting wire on the alternator which, if system had not been shut down, could have led to an inflight fire. Day VMC enabled us to make the early choice for shut down of electrical systems. An on board iPad with ForeFlight provided current VFR charts and confirmed navigation to [alternate]. Mission was for IFR refresher training, with pilot under hood and Instructor/safety pilot. Following electrical system shut down, pilot removed hood to enable both pilots to clear for conflicts.

Synopsis AA5 pilot reported diverting to an alternate after noting an electrical system anomaly.

ACN: 1403278

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Environment Light : Daylight

Aircraft Reference : X ATC / Advisory.Tower : 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 : VFR Mission : Training Flight Phase : Landing

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : FBO Function.Flight Crew : Pilot Not Flying Function.Flight Crew : Instructor ASRS Report Number.Accession Number : 1403278 Human Factors : Situational Awareness Human Factors : Training / Qualification

Events Anomaly.Ground Event / Encounter : Ground Strike - Aircraft Detector.Person : Flight Crew When Detected : In-flight Result.Flight Crew : Took Evasive Action Result.Aircraft : Aircraft Damaged


Narrative: 1 Student was performing a soft field landing with minimal help from the instructor. The instructor informed the student that he was 5 knots slow and that he should correct for it.

Student reacted by pulling power to idle at 40 feet and flaring. The plane got extremely slow and started to descend fast. The instructor at that point tried to correct the student by applying power and initiating a go around. The plane at that point was about to touch the ground. The student pulled the yoke back causing the plane to smack into the ground [with] the tail hitting first. The bottom portion of the tail was scraped a bit. A go-around should have been initiated when there wasn't a stabilized approach.

Synopsis C172 instructor pilot reported the student experienced a tail strike during soft field landing practice.

ACN: 1402532

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Place Locale Reference.ATC Facility : ZZZ.TRACON State Reference : US Altitude.MSL.Single Value : 4000


Aircraft Reference : X ATC / Advisory.TRACON : ZZZ Aircraft Operator : Corporate Make Model Name : T6A Texan II / Harvard II (Raytheon) Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Cruise Airspace.Class E : ZZZ

Person Reference : 1 Location Of Person.Aircraft : X Location In Aircraft : Flight Deck Reporter Organization : Corporate Function.Flight Crew : Captain Function.Flight Crew : Pilot Not Flying Qualification.Flight Crew : Air Transport Pilot (ATP) ASRS Report Number.Accession Number : 1402532 Human Factors : Situational Awareness

Events Anomaly.ATC Issue : All Types Anomaly.Conflict : Airborne Conflict Detector.Person : Flight Crew Detector.Person : Air Traffic Control When Detected : In-flight Result.Flight Crew : Became Reoriented Result.Air Traffic Control : Issued Advisory / Alert

Assessments Contributing Factors / Situations : Aircraft Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure Primary Problem : Ambiguous

Narrative: 1 During a recent VFR (with flight following) test sortie in an AT-6, we were conducting a test maneuver to capture 3.0 G's from a 20 degree dive. Maneuver began at 4,000 ft MSL on heading 015, and was terminated at 5,900 ft MSL shortly thereafter. We received a traffic call from ATC indicating that we had traffic directly above us, and the altitude mentioned by the controller was unreadable to us, due to intra-flight communications. We completed the maneuver at the same time of that radio call and started looking above our canopy for the traffic, and then noticed a Cessna Corvalis pass approximately 500 ft off of our right wing, co-altitude, westbound. I queried the controller if I had missed a previous traffic call from him, and he said that he had not personally made a traffic call to us until he advised that the VFR traffic was directly above us. This caused me to think that perhaps a controller change had just occurred and caused us to not be notified of this VFR traffic. I again asked the controller why we had not been notified of this traffic, and he gave me a phone number to call to file a near mid-air collision report with ATC. AT-6's do not have TCAS installed. Recommend further communication with ATC of T-6/AT-6 dynamic maneuvering during test flights to notify flight crews of nearby traffic that could be potential threats.

Synopsis An AT-6 pilot reported performing a test flight and experiencing an airborne conflict with a Cessna Corvalis at 6000 feet after a 3 G pull up from 4000 feet. VFR flight following was in use but ATC did not report the traffic until late in the maneuver.

ACN: 1402354

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Place Locale Reference.Airport : JWY.Airport State Reference : TX Altitude.MSL.Single Value : 2500


Aircraft : 1 Reference : X Aircraft Operator : Personal Make Model Name : PA-24 Turbo Comanche Crew Size.Number Of Crew : 2 Operating Under FAR Part : Part 91 Flight Plan : None Mission : Training Flight Phase : Climb Route In Use : Direct Airspace.Class E : D10

Aircraft : 2 Reference : Y Aircraft Operator : Personal Make Model Name : Cessna Single Piston Undifferentiated or Other Model Crew Size.Number Of Crew : 1 Operating Under FAR Part : Part 91 Mission : Passenger Flight Phase : Cruise Airspace.Class E : D10

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 Experience.Flight Crew.Total : 505 Experience.Flight Crew.Last 90 Days : 60 Experience.Flight Crew.Type : 125

ASRS Report Number.Accession Number : 1402354 Human Factors : Other / Unknown

Events Anomaly.Conflict : NMAC Detector.Automation : Aircraft TA Detector.Person : Flight Crew Miss Distance.Horizontal : 200 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 Primary Problem : Human Factors

Narrative: 1 I was flying for instrument currency with a safety pilot. The plan [was] to do one hold after an initial departure from JWY, then to depart to the south for more approaches at other airports. We departed runway 36 at JWY and elected to fly the missed approach upon departure and proceeded to CHMPZ (the missed approach RNAV 36 holding fix). The entire missed approach would keep us clear of the Dallas Class B. 30 seconds before reaching the fix, I put on the view limiting device, and called to my safety pilot, "you're outside the plane," and he responded with "I'm outside the plane" Upon reaching the holding fix, CHMPZ, and rolling into the first holding turn, as my aircraft is ADS-B in/out equipped, we had a traffic alert traffic, 'less than a mile, 11 o'clock, same altitude.' I immediately took off the foggles, and began scanning. I was able to spot the aircraft, a grey Cessna taildragger, facing us head on. I immediately rolled hard right and watched the Cessna pass behind me and under my left wing as I turned. I was able to see other aircraft flying almost in a staggered formation in the same direction. The Cessna never flinched, turned, or changed altitude. We climbed as far as we could without infringing upon the Class B airspace above us, turned south, kept the Cessna in sight and departed the area without further incident. The next day on social media, a friend had posted event photos. He'd posted a photo of the flight plan for the pilots to follow as a part of their pre-flight brief I'd assume. Their route practically intersected CHMPZ. We'd flown right through the path of a train of maybe a dozen aircraft. My hypothesis was confirmed when someone else posted a video on social media of the mass of aircraft taxiing out and I recognized the grey taildragger we almost collided with on the video. I did not recall seeing anything in the NOTAMs for JWY. I went back and double checked the NOTAM archives and did not see anything noted for JWY or the airport [the event] was occurring that day. Didn't see anything regarding the volume and route of aircraft. The ADS-B alert broke the accident chain and prompted us to get 2 sets of eyes scanning the horizon before taking evasive action. Had I known I was flying into their route of flight, I'd never have contemplated flying the missed approach or anywhere near their flight path. It seems like this volume of traffic occurring all day long at an otherwise relatively slow airport should be something that could warrant the issuance of a NOTAM. Only other thing I could have done was to call approach control and let them know what I was up to. I'm not afraid of approach and practically learned how to fly at ADS, so Class B

and radio work is something I'm really pretty good at. I didn't call them up because it was a busy day and I was going to be departing the area almost immediately anyway. The irony is, that in hindsight, my reasoning for not calling up approach was exactly why I should have called approach. Near misses will happen on their own, but when there's this kind of volume coming in and out of an airport, I think if a NOTAM can be issued, it should be issued.

Synopsis PA24 pilot reported a NMAC while practicing holds with foggles on and a safety pilot monitoring for traffic. While entering the first turn, the ADS-B announced traffic at 11 O'clock and evasive action was taken.