CALLBACK From the NASA Aviation Safety Reporting System
 Number 373   February 2011 
thought bubble of guy whispering in man's ear

 Sound Advice -
 Listen to the Little Voice

ASRS report narratives frequently contain references to a “little voice” that offers timely advice. The voice, of course, resides within the mind of the reporter and is usually the voice of experience or sometimes just the “vocalization” of a gut feeling. While it is possible to get through some situations despite what a little voice is telling us, the following reports show that the voice usually has something important to say.

“I Heard the Voice of One of My Instructors”

Good lessons from flight instructors have a way of staying in the minds of good aviators. In the case of this Piper Cherokee pilot, a little voice from the past got him refocused on the task at hand and prevented a marginal situation from getting much worse.

indication of report narrative ...I departed…eastbound for [my] destination in clear weather. Approaching the airport, a cloudbank was visible moving in from the southwest at about 2,000 feet. I flew over the clouds looking for a hole, but none was found…. Ducking under the clouds proved futile since the ceiling continued to drop as I got closer to [the airport]. At half the normal pattern altitude and without a Special VFR clearance, I decided to head back west to [the departure airport]. I made a right turn for the shortest route, but unfortunately that took us into the cloudbank. Continuing the turn would have kept us in the clouds too long and a belated left turn now would have us headed out over the Atlantic in IMC, so the only option was to climb to the cloud tops, which I knew were at about 2,000 feet. I became concerned that someone might have gotten an IFR release and that I might be on his heading and altitude, so I decided to clear the area as quickly as possible, which meant to climb.

After what seemed like an eternity, I heard the voice of one of my instructors telling me to stop looking at the white fluff outside the windscreen and to scan my instruments. I saw the airspeed indicator slicing through 60 knots and quickly began recovering from my unusual attitude. After returning the aircraft to a normal climb, we cleared the clouds and landed without incident.

Making that right turn to save a few minutes of flight time could have been disastrous, but having paid attention to good flight instructors in the past gave the little voice in my head a chance to bring me back to the job at hand.

“The Little Voice in the Back of My Head Started Getting Louder”

An Air Traffic Controller missed a potentially critical altitude error, but was set straight by a little voice that grew loud enough to get some attention.

indication of report narrative The pilot of aircraft X had requested direct to the ABCDE fix for the RNAV (GPS) RWY 31 approach with the intent of [making] two turns in the holding pattern then a touch-and-go and on to ZZZ. When I assumed the sector, the aircraft was already [proceeding] direct and descending to 8,000 feet. In the chart book for the low sector, the ILS 31 and the GPS 31 plates face each other and both use [a common fix] as part of the approach. On the ILS it is the IAF (Initial Approach Fix); on the GPS it is the point after the IAF. The MVA (Minimum Vectoring Altitude) in the sector as a whole is 3,000 feet, with some areas higher due to antennas. One such higher area is located southeast of the airport just beyond ABCDE, with an MVA of 3,600 feet. After a quick glance at the chart (where I might have viewed the ILS plan view by mistake), I cleared the flight to maintain 3,000 feet until ABCDE.

As the flight progressed toward the fix, the little voice in the back of my head started getting louder. Just how can the holding pattern at ABCDE (which is to the southeast) be at 3,000 feet when there is an antenna there? I picked up the approach plates and immediately identified my error. The aircraft was climbed to 3,600 feet with an apology and an explanation. The pilot admitted to missing the altitude error as well. The aircraft climbed in time to fly the pattern at the published altitude, but it was much closer than I would have liked.

The reporter went on to explain how fatigue and scheduling factors may have influenced this incident. These are two concerns that have been the subject of continuing study by industry and the FAA. Staying alert to the little voice in the back of our heads is one step in offsetting the effects of fatigue and work overload while more comprehensive solutions are addressed.

“…Then That Little Voice… Started Shouting”

Poor visibility and unfamiliarity with the GPS navigation equipment contributed to a Piper Cherokee pilot’s approach to the wrong airport. It took the emphatic interruption of a little voice to get the reporter to climb, confess and communicate.

indication of report narrative I skipped getting a weather briefing. [The flight] should have taken no more than 30 minutes. Smoke and haze filled the sky and the visibility was probably made worse by a nearby forest fire. I flew…to the coast, then eastward. When ready to call Tower to request landing clearance, I checked the GPS to get the distance. The GPS was displaying the satellite page…. I flipped through the GPS pages looking in vain for navigation information and returned to the satellite page. I backtracked and dialed in the VOR…then called for landing clearance. The VOR needle wandered and I told Tower that I was having problems with my navigation equipment, but I declined the offer of additional assistance. I couldn’t think of anything to ask for. Descending to pattern altitude, I peered into the [partially obscured] sky, keeping the beachfront to my left, looking for the smoke stack and runways at the water’s edge. It seemed to take forever. The GPS did not give me ground speed or any navigation information. Since I thought that the GPS automatically switches from the satellite page to a navigation page on startup, I decided that the signal quality was not good enough to switch….

Finally, two crossing runways appeared to my left, but it didn’t look quite right. I told Tower that the runways were in sight and asked whether he could see me just off shore. I was cleared for Runway 24 and started looking for the numbers. Tower asked me for a position report, leading me to believe that he didn’t see me. I was looking straight at the Tower and he should have been able to see me. When a runway numbered “2” became visible, I starting to figure out how to get to Runway 24. Then that little voice that lives somewhere in the back of my brain started shouting, “There should not be a Runway 2 at this airport.” At the same time, Tower was again asking me for a position report. I was looking down the departure end of a runway at an unknown field at pattern altitude. I could imagine an aircraft on takeoff roll coming straight toward me. My response was an immediate right turn to get away from there. In a 45-degree bank and losing altitude, unusual attitude training kicked in and I got the plane straight and level. Then the 5 “C’s” came to mind: Confess that I’m lost; Climb above the Minimum Safe Altitude; Communicate with the appropriate controlling agency; Conserve fuel; Comply with the Controller’s instructions. I told Tower, “I’m declaring an emergency. I don’t know where I am. I’m lost.” I climbed back up to 2,800 feet while the Tower contacted Approach Control and got me a [transponder] code. A very professional Controller vectored me to the correct airport.

I have spoken to an instrument instructor and arranged for additional training…. I will be sure to learn more about using the GPS. I did not know that it would not automatically return to a navigation page after acquiring satellites…. I will not skip a weather briefing even for a short flight.

“I Dismissed the Little Voice as Paranoia”

A pilot flying solo on a FAR Part 135 cargo flight ignored a warning from “that little voice” and descended below an assigned altitude.

indication of report narrative I was beginning my descent from cruise altitude on the first of six legs on a [FAR] Part 135 cargo run. Approach Control cleared me out of 6,000 feet to descend and maintain 5,000 feet. As I was descending through 4,600 feet, ATC told me they were showing me 400 feet low on the [transponder] Mode C. They gave me the current altimeter setting and restated that I was to maintain 5,000 feet. I acknowledged my mistake, apologized and promptly climbed back to 5,000 feet. Nothing further was said. In my mind I was thinking that I was cleared to 3,000 feet instead of 5,000 feet. In fact, I even set 3,000 feet in my altitude alerter.

There was one moment during the descent that a little voice in the back of my mind questioned the assigned altitude. I very nearly asked ATC to confirm my altitude limit, but decided not to. I dismissed the little voice as paranoia. Had ATC not made the comment that I was 400 feet below my cleared altitude, I would have descended to 3,000 feet.

Why I was thinking 3,000 feet instead of 5,000 feet is still not clear to me. Maybe I was looking at my approach plate and noted the 3,000 foot Initial Approach Altitude on the ILS profile. One thing is clear. There was a moment when that little voice in my head spoke out and I ignored it. In the future I will not hesitate to ask questions and resolve any doubts I have when a similar situation occurs.

 
ASRS Alerts Issued in December 2010
Subject of Alert
No. of Alerts
Aircraft or aircraft equipment
6
ATC equipment or procedure
2
Airport facility or procedure
6
TOTAL
14
 
December 2010 Report Intake
 Air Carrier/Air Taxi Pilots
2,519
 General Aviation Pilots
695
 Controllers
672
 Cabin/Mechanics/Military/Other
472
 TOTAL
4,358

A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189  |  Moffett Field, CA  |  94035-0189
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