TURBOPROP TWIN PLT MAKES NUMEROUS MISTAKES DURING NIGHT INST APCH.

Date: 2006-10 · Aircraft: Small Transport; Low Wing; 2 Turboprop Eng

Anomalies: aircraft-equipment-problem-critical|deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy

Synopsis

TURBOPROP TWIN PLT MAKES NUMEROUS MISTAKES DURING NIGHT INST APCH.

Narrative

THE CHAIN OF EVENTS STARTED WHEN I LEFT ZZZ AT ABOUT XA00 LCL TIME. ONE OF OUR ACR'S RAMPERS VOLUNTEERED TO GO WITH ME TO HELP UNLOAD THE CARGO WHEN I GOT TO MY DEST (HELENA; MT); BECAUSE HE IS AN AVID AVIATION ENTHUSIAST AND STUDENT PLT. AS A CFI I FELT COMFORTABLE LETTING HIM FLY AND HAD TALKED HIM THROUGH THE ILS INTO HELENA THE NIGHT BEFORE. HE DID GREAT. IN FACT; HE DID SO WELL THAT THE NEXT NIGHT (THE NIGHT OF THE MISHAP) I DIDN'T MAINTAIN VIGILANCE IN MONITORING HIS FLYING. I WOULD LIKE TO STOP AT THIS POINT AND REVIEW THE MISTAKES THAT I HAD MADE THUS FAR. FIRST I LET SOMEONE THAT WAS NOT CHKED OUT IN THE AIRPLANE TOUCH THE CTLS OF AN ACFT FLYING UNDER 135 OPS. SECOND; I ALLOWED MYSELF TO BE COMPLACENT IN WATCHING HIM AND HIS ACTIONS. BECAUSE HE WAS FLYING I ONLY NOTICED THAT HE WAS KEEPING US MORE OR LESS ON COURSE. WHAT I DIDN'T NOTICE WAS THAT MY HDG INDICATOR WAS ABOUT 70 DEGS OFF. BEING COMPLACENT I DIDN'T DOUBLE-CHK IT BEFORE WE STARTED THE ILS TO RWY 27 INTO HELENA. IF YOU LOOK AT THAT APCH WHEN COMING OFF THE V-247 YOU WILL SEE THAT THE ARC ONLY LASTS FOR 7 DEGS BEFORE YOU HIT THE LEAD RADIAL AND IT'S TIME TO TURN AGAIN. THE OTHER TRICKY PART ABOUT THIS APCH IS THAT CTR LIKES TO KEEP YOU HIGH; NO LOWER THAN 12000 FT MSL (I ASSUME FOR RADAR COVERAGE) BEFORE YOU ARE ESTABLISHED ON THE ARC. THIS MEANS THAT THERE IS A LOT OF ALT TO LOSE IN A SHORT AMOUNT OF TIME AND NO MATTER HOW YOU WORK YOUR DRAG DEVICES AIRSPD WILL GO UP. PLANNING AHEAD ON THIS APCH IS KEY! AS I SAID I GOT COMPLACENT AND WAS INCOMPLETE WITH MY PLANNING AND DOUBLE-CHKING. HERE'S WHERE THINGS STARTED TO GET CRAZY. I DIDN'T TAKE ME LONG TO REALIZE THAT SOMETHING WAS WRONG WITH MY HDG. HOWEVER BY THE TIME I HAD TURNED OFF THE WINDSHIELD HEAT; CHKED THE MAGNETIC COMPASS; AND RESET MY DIRECTIONAL GYRO; WE HAD BLOWN THROUGH THE LOC. AT THIS POINT ONE OF OUR ACR'S OTHER PLTS CALLED ME ON CTAF AND INFORMED ME THAT CTR NOTICED I HAD PASSED THE LOC. FULL-SCALE DEFLECTION EQUALS TIME TO GO MISSED. WHAT I DIDN'T KNOW IS THAT IN THIS PARTICULAR AIRPLANE TO GET AN ACCURATE READING OFF THE MAGNETIC COMPASS; NOT ONLY DOES THE WINDSHIELD HEAT HAVE TO BE OFF; SO DOES THE BLOWER MOTOR FOR THE CABIN HEAT. BECAUSE I ONLY TURNED OFF THE WINDSHIELD HEAT WHEN I WENT MISSED I WAS STILL POINTING IN THE WRONG DIRECTION. I COULDN'T FIND THE VOR. NEEDLESS TO SAY I DID NOT DO THE MISSED AS PUBLISHED. BY THIS TIME I WAS BACK IN CONTACT WITH CTR; AND THEY INSTRUCTED ME TO CLB TO 12000 FT. I TOLD THEM THAT SOMETHING WAS WRONG WITH MY HDG INDICATOR. THE OTHER ACR PLT ASKED ME ON OUR COMPANY FREQS IF I HAD TURNED EVERYTHING OFF WHEN I GOT MY HDG OFF THE COMPASS. I TOLD HIM THAT I HAD. NOT CATCHING THAT HE SAID EVERYTHING AND NOT JUST THE WINDSHIELD HEAT. I THEN MADE ANOTHER BIG MISTAKE. I LET MYSELF START TO PANIC; NOT KEEPING IN MIND THAT I WAS WELL ABOVE THE MSA AND STILL FLYING. AS PART OF CRM TRAINING WE LEARN THAT AS EMOTION GOES UP RATIONAL GOES DOWN. THIS APPLIES NOT ONLY FOR THE CREW ENVIRONMENT BUT ALSO WHEN THINGS AREN'T GOING RIGHT. THIS IS WHY WHEN CTR SAID THAT I WAS S OF THE FIELD I STILL HAD IT IN MY MIND THAT I WAS TO THE N. CTR ASKED IF I WANTED TO TRY THE APCH AGAIN. I SAID YES; BUT BECAUSE OF MY DISORIENTATION WHEN I HIT THE ARC; I TURNED THE WRONG WAY. I COUNT CTR IN MY BLESSINGS BECAUSE IT WAS THE CTLR THAT INFORMED ME OF MY MISTAKE. REMEMBERING THAT THE CEILING WAS NOT LOW I REQUESTED THE VOR-A THINKING ALTHOUGH I COULDN'T ARC DUE TO A LOSS OF SITUATIONAL AWARENESS I COULD TRACK TO THE VOR; TRACK A RADIAL OUTBOUND; TURN AROUND; TRACK IT BACK IN AND HOPEFULLY GET LOW ENOUGH TO PICK UP THE ARPT VISUALLY. AGAIN I WAS UNABLE TO FIND THE VOR. I ASKED CTR IF IT LOOKED LIKE I WAS GOING TOWARDS THE VOR AND TOLD HIM THAT MY MAGNETIC COMPASS MUST BE INCORRECT. THE OTHER ACR PLT CAME BACK ON COMPANY AND TOLD ME TO DOUBLE-CHK THAT I TURNED OFF THE WINDSHIELD HEAT AND THE HEAT BLOWER MOTOR. THIS TIME I TURNED OFF THE BLOWER MOTOR AND ASKED THE RAMPER TO GIVE ME A READINGOFF THE COMPASS. THE HDG HE GAVE ME MESHED WITH WHAT THE VOR RECEIVER WAS TELLING ME. SHORTLY AFTER THAT I FOUND THE ARPT VISUALLY THROUGH A LARGE OPENING IN THE CLOUDS. I REQUESTED THE VISUAL AND LANDED.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.