Global Positioning System (GPS) Reports Database Report Set . Global Positioning System (GPS) Reports . Report Set Description .....A variety of reports referencing use of

ASRS Database Report Set

Global Positioning System (GPS) Reports

Report Set Description .........................................A variety of reports referencing use of Global Positioning System (GPS) devices.

Update Number ....................................................28.0

Date of Update .....................................................February 28, 2017

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............32

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: 1410465 (1 of 32)

Synopsis Air carrier Captain reported being issued a new arrival into MMMX at top of descent point

without being issued a descent clearance. During descent GPS jamming and a route

discontinuity were detected. A crossing restriction was overshot.

ACN: 1409526 (2 of 32)

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: 1409504 (3 of 32)

Synopsis GA pilot reported poor handling from ATC in the vicinity of UBG VOR on approach to MMV

in IMC and icing conditions.

ACN: 1409256 (4 of 32)

Synopsis A general aviation pilot reported his Garmin 530W database provided by Jeppesen did not

include several Canadian waypoints which were part of his IFR flight plan between two

domestic U.S. airports. Reporter stated some Canadian waypoints are available, but others

are not.

ACN: 1409164 (5 of 32)

Synopsis B747 Captain experienced an electrical failure that triggered multiple EICAS messages for

failed systems. The QRH and the EICAS display offered no suggestions to restore power to

what appeared to be the standby bus and the crew elected to return to the departure

airport.

ACN: 1409078 (6 of 32)

Synopsis A B737NG Captain noted [an] often reported L-GPS FAIL alert by crews on approach to

MMMX between the MAVEK and PLAZA waypoints.

ACN: 1408599 (7 of 32)

Synopsis

CL-65 Captain reported continuing the approach to a landing after receiving a windshear

warning at 1200 feet AGL.

ACN: 1407407 (8 of 32)

Synopsis PA-34 pilot reported an electrical failure during an IFR flight in VMC and continued to

destination.

ACN: 1406525 (9 of 32)

Synopsis C172 pilot experienced an alternator failure and lost comms on an IFR flight in VMC and

elected to continue to destination. During a phone call with ATC he was reminded that in

VMC he should landed at a suitable airport and not continue all the way to destination.

ACN: 1405170 (10 of 32)

Synopsis C182 pilot reported extreme weather conditions in mountainous terrain that culminated in

recovery from a stall condition and controlled flight toward terrain.

ACN: 1402304 (11 of 32)

Synopsis General Aviation pilot reported engine surging while on a sightseeing flight east of ALM,

followed shortly by GPS failure. The engine surging was tackled first and was determined

to be caused by weak batteries in the noise canceling headset. When ATC was contacted

for an IFR clearance, the reporter was advised that the GPS outage was caused by military

testing and that he was in R-5107.

ACN: 1400819 (12 of 32)

Synopsis C340 pilot reported returning to the departure airport after observing an oil leak from the

left engine.

ACN: 1400248 (13 of 32)

Synopsis M20J pilot reported having difficulty with complying with ATC headings when the workload

of a night IFR flight became more than he could comfortably handle.

ACN: 1398464 (14 of 32)

Synopsis

PA46 pilot reported loss of dual main bus power, probably because of high electrical

system demand in icing conditions.

ACN: 1396889 (15 of 32)

Synopsis C172 Pilot returned to land after noting that the airspeed indication was erroneous on

takeoff and then went to zero in the pattern. Altimeter and VSI were not affected and no

issues were apparent with the pitot tube.

ACN: 1395143 (16 of 32)

Synopsis During cruise, on an IFR flight plan, the pilot of a Piper Arrow PA28R-180 reported noticing

he was losing electrical power. The pilot continued to his destination VFR while using a

handheld radio to communicate with ATC.

ACN: 1391906 (17 of 32)

Synopsis PA28 pilot reported an alternator failure while flying at 7,000 feet above a solid overcast

and elected to divert before the battery was drained. He praised the Controller for his

assistance and the importance of modern avionics that he had recently installed.

ACN: 1388560 (18 of 32)

Synopsis Air carrier flight crew reported they experienced a GPS signal loss during a NOTAM'ed

military operation on an oceanic flight. The crew and their Dispatcher had language

difficulty explaining the navigation capability loss to the foreign ARTCC.

ACN: 1386829 (19 of 32)

Synopsis A general aviation pilot reported briefly entering Class D airspace while conducting a VFR

approach to another field.

ACN: 1386288 (20 of 32)

Synopsis Pilot reports that Localizer Performance with Vertical Guidance generated glideslopes in

many cases on start at the FAF and that the transition from level flight vectors past the

FAF to the artificial glideslope is not ideal.

ACN: 1385300 (21 of 32)

Synopsis General aviation pilot reported becoming disoriented during a night flight under smoky

conditions and landed at an unintended airport.

ACN: 1385289 (22 of 32)

Synopsis Helicopter pilot reported a verbal altercation with a TJIG Tower Controller over his position

inside or outside the Class D. The Controller then proceeded to issue a vector heading

without the benefit of Radar.

ACN: 1382727 (23 of 32)

Synopsis First Officer described the difficulties using the GPS-155XL on a cross border flight to

Mexico. The unit requires that data cards be switched prior to loading the Mexican portion

of the flight plan. Errors are made resulting in a track deviation.

ACN: 1381815 (24 of 32)

Synopsis PA28 pilot reported a ground conflict with a tailwheel aircraft after the reporter failed to

call Ground Control for clearance.

ACN: 1381209 (25 of 32)

Synopsis The Pilot of a Piper PA32-301 reported that due to not being familiar with the airport or the

new GPS that was just installed, he took off from the Taxiway.

ACN: 1381086 (26 of 32)

Synopsis EMB190 flight crew experienced an APU generator failure after being dispatched with the

number one engine generator on MEL. The crew elected to divert to a suitable airport

which was slow in switching the ILS to the runway requested resulting in reverse sensing

and an unstabilized approach to 900 feet AGL.

ACN: 1376835 (27 of 32)

Synopsis General aviation pilot on an IFR flight plan reported getting vertigo while on vectors for an

RNAV approach. While attempting to make GPS entries 500 feet of altitude is lost and the

heading drifts to the right. ATC issues instructions that do not require GPS inputs and the

approach is successfully flown.

ACN: 1375241 (28 of 32)

Synopsis An air carrier flight crew reported a GPS anomaly during arrival and departure at Manila

Airport (RPLL). The anomaly was transient and not thought to be aircraft related. Manila

station personnel indicated that this was a known issue and was being investigated.

ACN: 1374456 (29 of 32)

Synopsis The pilot of a Beechcraft Twin Engine Bonanza reported that the Left Engine failed during

cruise flight.

ACN: 1373014 (30 of 32)

Synopsis CE-560XL flight crew reported they were criticized by Departure Control about their void

time and route of flight after taking off.

ACN: 1371620 (31 of 32)

Synopsis A general aviation pilot reported ATC advised of an adjacent airspace violation after being

given a clearance to land by the Tower with no restriction cited.

ACN: 1371605 (32 of 32)

Synopsis A general aviation pilot reported that the GPS directed a missed approach course that did

not agree with the published procedure for the ILS Runway 36 at OCF.

Report Narratives

ACN: 1410465

Time / Day

Date : 201612

Local Time Of Day : 1801-2400

Place

Locale Reference.Airport : MMMX.Airport

State Reference : FO

Altitude.MSL.Single Value : 11500

Aircraft

Reference : X

ATC / Advisory.Center : MMEX

Aircraft Operator : Air Carrier

Make Model Name : Large Transport

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 121

Flight Plan : IFR

Nav In Use : GPS

Nav In Use : FMS Or FMC

Flight Phase : Initial Approach

Component

Aircraft Component : GPS & Other Satellite Navigation

Aircraft Reference : X

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Air Carrier

Function.Flight Crew : Captain

Qualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1410465

Human Factors : Confusion

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Deviation - Altitude : Overshoot

Anomaly.Deviation - Altitude : Excursion From Assigned Altitude

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Deviation - Procedural : Clearance

Detector.Person : Flight Crew

When Detected : In-flight

Result.Flight Crew : Returned To Clearance

Result.Flight Crew : Became Reoriented

Result.Air Traffic Control : Issued New Clearance

Assessments

Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings

Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure

Primary Problem : Ambiguous

Narrative: 1

During cruise, I briefed the assigned arrival and approach and verified all restrictions

associated with each. At the top of descent, we were reassigned a new arrival. We could

have been cleared to descend via this new arrival at this point but neither of us remember

that being the case. Upon inserting the new arrival and knowing we were now past our top

of descent, we inquired as to whether or not we were cleared to descend. At this point we

did receive our clearance. We were in and out of VNAV as required and even dropped the

gear to ensure crossing restrictions would be met. Even so, we failed to notice and address

the route discontinuity created by the insertion of the new arrival. Later, we knew we

needed an approach clearance and due to frequency congestion were not able to receive

one in a timely manner. Finally, we received an approach clearance and set the lower

altitude in the window. At this time we were now addressing the route discontinuity and as

we were verifying that everything looked OK, we descended below the published altitude,

but not before we received notice that our GPS was being jammed, first one side, and then

the other.

I told this story to another Captain and he told me that he had the same experience of

receiving a new arrival at top of descent. THIS MUST STOP! Mexico City is a difficult arrival

and approach and requires careful and deliberate attention to detail. We feel we did our

due diligence in this matter and all of that was negated by a different arrival being

assigned to us beyond a reasonable point in our flight.

Synopsis

Air carrier Captain reported being issued a new arrival into MMMX at top of descent point

without being issued a descent clearance. During descent GPS jamming and a route

discontinuity were detected. A crossing restriction was overshot.

ACN: 1409526

Time / Day

Date : 201610


Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US


Environment

Flight Conditions : VMC

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ

Aircraft Operator : Personal

Make Model Name : SR22



Flight Plan : IFR

Mission : Training

Nav In Use : GPS

Flight Phase : Initial Climb

Route In Use : Vectors

Airspace.Class C : ZZZ

Component



Problem : Malfunctioning

Person

Reference : 1



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

Experience.Flight Crew.Total : 1900

Experience.Flight Crew.Last 90 Days : 40

Experience.Flight Crew.Type : 300


Events


Anomaly.Deviation - Track / Heading : All Types



Detector.Person : Air Traffic Control



Assessments


Primary Problem : Human Factors

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: 1409504

Time / Day

Date : 201612


Place

Locale Reference.Airport : MMV.Airport

State Reference : OR


Environment

Flight Conditions : IMC

Weather Elements / Visibility : Icing

Weather Elements / Visibility : Cloudy

Weather Elements / Visibility : Turbulence

Weather Elements / Visibility.Visibility : 5

Light : Daylight

Ceiling.Single Value : 600

Aircraft

Reference : X

ATC / Advisory.TRACON : P80


Make Model Name : Small Aircraft, Low Wing, 2 Eng, Retractable Gear



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS


Route In Use : Direct

Airspace.Class E : P80

Person

Reference : 1




Function.Flight Crew : Single Pilot


Qualification.Flight Crew : Private

Qualification.Flight Crew : Multiengine





Human Factors : Workload


Events

Anomaly.ATC Issue : All Types

Anomaly.Inflight Event / Encounter : Weather / Turbulence



Result.Flight Crew : Requested ATC Assistance / Clarification


Assessments


Contributing Factors / Situations : Weather


Narrative: 1

There was no event. There was no conflict. The issue is bad handling by approach control,

in and around a "hot spot" near the UBG VOR. This report centers on events which

transpired during an instrument approach into MMV. This is perhaps an unusual report, as

to the best of my knowledge there were no conflicts or violations in that airspace around

that time, and certainly none involving me or my aircraft. I make this report only to flag

what I perceive to be an environment that may be unusually conducive to causing errors,

violations and conflicts. I have flown in the Northwest for decades, and MMV is my home

airport. I was returning home. The weather had been extremely bad for several days, with

snow, freezing rain, and icing in clouds, to where I was being very cautious and had

delayed my flight, and even did an overnight in ZZZ in hopes that the clearing trends

would continue, which they did.

My flight back was uneventful, VFR on top in bright sunshine, and getting colder as I

headed north. The temperature had been minus 7, but it dropped to about minus 14 as we

approached Portland. The reported weather was excellent. The AWOS at MMV said better

than 5, with broken layers at 8,000 and 6,000 with a few clouds at 600. It was several

degrees above freezing on the ground. As we passed Eugene we could see dark layers of

lower clouds in the distance. My plan was to stay as high as possible to avoid icing, and to

then drop through quickly with anti-ice on. I used this technique often in the past with

good results, despite the fact that I sometimes encountered moderate icing as I dropped

through. To this end I asked Seattle Center if I could get a clearance to the IAF for the

ILS, OZIER. They gave me that clearance, but warned me that Portland Approach might

change it. When I was switched to Portland Approach they kept that clearance for a time. I

set up the approach with OZIER as the Initial Fix. I was told to be at or below 6,000 at 16

DME from UBG. This seemed odd to me. I had been VFR on top, but was now descending

into IMC, and UBG was not part of the routing I'd been given. The response from the

controller was snappish. She repeated it, and asked me if I didn't comprehend crossing

restrictions. I said that I did, and started my descent, still planning to stay as high as

possible. She did not specify a final altitude. I assumed she intended to say 6,000, but was

reluctant to question her again. Apparently I guessed correctly. As we got closer, I was

unexpectedly told go direct UBG, with the same crossing restriction. I questioned this and

got snapped at again. By now we were in IMC. She repeated the clearance, clearly

irritated. I acknowledged, kept descending, and set to reprogramming my GPS for direct

UBG. About the time I got this done, she changed my clearance to a vector away from

UBG. Cockpit workload was getting high and I wasn't sure of her clearance or her

intentions. I asked for a repeat. She had been in intense communications with another

aircraft on the frequency. I was occupied with my own problems. What I got was harsh

words, a vector, a sharp turn, and a warning to pay attention. I replied that I was paying

attention and complied. She warned me I was getting close to my crossing restriction, so I

increased my descent rate, to over 1,200 feet per minute. I had the feeling the controller

was out of control as I leveled at 6,000.

About the time I settled on the new vector, I was given another major heading change, a

descent to 3,000, and a new frequency. I checked in. The new controller acknowledged

and said to expect the ILS. The new controller was GOOD. My vector was now in the

opposite direction to the ILS, and close in, very tight. I kept descending and setting up for

a VTF (Vector to Final). The controller then told me he had another aircraft and he needed

me at 3,000 as soon as possible. I gave him our descent rate. I think we were within 500

feet of altitude and still at about 1,200 FPM. Whatever it was, I broadcast it to him and he

was happy. The rest the traffic handling was excellent. My 180 degree intercept angle

evolved into two precisely-called right angle turns, and I didn't even overshoot. My GPS, of

course, was overwhelmed by all this. It correctly refused to enable the approach. It was

well outside it's parameters for a VTF, but the localizer was there, VHF NAV and hand

flying worked, and, when established, I was switched to UNICOM.

The weather experienced on the approach wasn't much like the ATIS. The Northwest is like

that. We passed OZIER at 2,900 feet still in solid IMC. About LIYEV, 1,900 feet, we did

break out into good visibility except for one large cloud ahead of us on the localizer. There

was VFR traffic at MMV, a helicopter as I recall, and he asked where we were. I told him

we had just gone back into the clouds, and then gave him a report when we came out the

other side at about 600 feet. The landing was uneventful, except that I had no

communications on the ground with approach. I had to call on my cell phone from in front

of the hangar after we were down to cancel and did.

So that was the trip. Why this report? This was too much hassle, too much unnecessary

work load, and this in a situation where the official weather was good, and there was only

one or two other airplanes anywhere around. The airspace around the Newberg VOR used

to handle much more traffic, in much worse weather, and with fewer problems. It's not as

safe as it used to be. I suggest this is not a good place to assign a less-than-expert

controller without supervision, not even for the task of feeding traffic to a seasoned pro

handing the final clearances himself. Nothing bad happened this time, but this airspace is

becoming a "hot spot" known for problematic traffic handling. My concern is that

eventually there will be violations, conflicts, or incidents.

Synopsis

GA pilot reported poor handling from ATC in the vicinity of UBG VOR on approach to MMV

in IMC and icing conditions.

ACN: 1409256

Time / Day

Date : 201612


Place

Locale Reference.Airport : FRG.Airport

State Reference : NY

Altitude.AGL.Single Value : 0

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Ground : FRG





Flight Plan : IFR

Mission : Personal

Nav In Use : GPS

Flight Phase : Parked

Component

Aircraft Component : Navigation Database


Problem : Design

Person

Reference : 1




Function.Flight Crew : Pilot Flying










Human Factors : Distraction


Human Factors : Human-Machine Interface


Human Factors : Time Pressure

Events




When Detected : Aircraft In Service At Gate


Result.Flight Crew : Overcame Equipment Problem



Assessments

Contributing Factors / Situations : Equipment / Tooling

Primary Problem : Equipment / Tooling

Narrative: 1

I purchase an annual database subscription from Jeppesen that covers the Eastern and

Central U.S., but not the Canadian navigation database (more on this later). In attempting

to input my clearance into the GPS the following intersections were not found: COLTS,

BOREK, and LOPVO. I spend close to an hour on the ground with both engines running to

attempt to resolve this with ATC. We finally got a revised routing that I was able to enter.

It appears that certain Canadian fixes are included in the U.S. database and many are not.

This was quite surprising since there is no publication or notice to airman from Jeppesen to

advise the database consumer of which fixes are in or out. While this occurred on the

ground and created a process issue for me and ATC if this had been airborne it could have

been far worse.

Aircraft frequently transit Canadian airspace from the east coast U.S. to points west and

are given ATC routes that they do not have advance notice on. In my case I discovered

that certain Canadian navigational points were not in my data base but others were. This

created issues for me and ATC and expended a significant amount of fuel during the

problem resolution period. I believe that this lack of clarity in the Jeppesen provided

databases is creating uncertainty and questions about the integrity of the databases

provided by Jeppesen. This in my mind is a safety of flight issue! They need to do one of

the following:

1) In any database that does not include Canadian coverage eliminate ALL references to

any Canadian navigation points.

2) Publish a notice to airman with each database update the Canadian fixes that will be

included in the U.S. data base stipulating that no other fixes are included from Canadian

airspace.

3) Include those Canadian fixes within a 200 mile lateral northern zone into Canada to

provide consistent coverage to avoid confusion.

Synopsis

A general aviation pilot reported his Garmin 530W database provided by Jeppesen did not

include several Canadian waypoints which were part of his IFR flight plan between two

domestic U.S. airports. Reporter stated some Canadian waypoints are available, but others

are not.

ACN: 1409164

Time / Day

Date : 201612


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ


Make Model Name : B747 Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger

Flight Phase : Climb

Airspace.Class A : ZZZ

Component

Aircraft Component : Electrical Distribution Busbar


Problem : Failed

Person

Reference : 1





Function.Flight Crew : Check Pilot




Human Factors : Training / Qualification

Human Factors : Situational Awareness

Events



Detector.Automation : Aircraft Other Automation



Result.General : Maintenance Action

Result.Flight Crew : Landed As Precaution

Result.Flight Crew : Returned To Departure Airport


Assessments

Contributing Factors / Situations : Aircraft

Primary Problem : Aircraft

Narrative: 1

While conducting Capt IOE (Initial Operating Experience) on climb out, we were cleared

direct to an intersection, sometime after passing FL180 the Capt PFD displayed airspeed,

altitude, and FD (Flight Director) flags with ND (Navigational Display) map flag, loss of L

CDU and loss of upper EICAS. Lower EICAS now operated in compressed mode displaying

9 caution messages including TCAS SYSTEM, TRANSPONDER L, NO LAND 3, EFIS

CONTROL L, GND PROX SYS, ALT CALLOUTS, GPS L, STBY POWER OFF, YAW DAMPER

UPPER. I assume due to the lower EICAS operating in compressed mode there was no

display of status messages. There were 15 STATUS messages, stab auto trim, stall warn

system, VOR L, alt alert sys, MAWEA (Modular Avionics Warning Electronic Assembly) PWR

supply, rudder ratio, stdby inverter, ADC (Air Data Computer) L, ILS L, Transponder L,

IDU, Flap Control L, EFIS Control L, EIU L, EFIS Control L, elec stby power, yaw damper

upper.

I took control of the aircraft and radios while IOE Capt now referred to the QRH for the

various messages. ATC was advised while we continued to climb on course. ATC advised

loss of Mode C, R transponder was selected, ATC requested various altitude reports.

Company was contacted and advised of situation, IOE Capt spoke with maintenance

control for possible solution to restoring the stby bus. MX control requested we check CBs

which had been done, with no other suggestions as we were reaching the coast out point

concerns were that we had lost the left FMS, the left CDU, were down to one altimeter,

were not sure as to why we had lost the stby bus if there was an underlying problem with

gen bus 3 and or 1, we would have to get burns for operating below RVSM and the

deferral of the L HF radio. The decision was made that the safest course would be to

return.

ATC was advised and we were assigned a lower altitude and heading. Initially we were

planning for landing 4R as we were configuring for landing we received a flaps primary

message. We then requested 8L. After blocking in I only wrote up the loss of stby power

as all other EICAS messages were related to the loss of stby bus.

Suggestions for the use and change in the QRH. Of the ECIAS messages received not a

single QRH procedure of guidance. While the introduction states that messages may not

offer guidance as the course of action is obvious, it may not be obvious at that point in

time. I would suggest that if further action is allowed "select operable system" be added to

the procedure.

There needs to be clarification as due the crews strictly follow the QRH and if there is no

procedure written then nothing is allowed to be done or do we want crews to think and

correct issues with their system knowledge. There are crewman that have been corrected

for moving a switch that was specified in the QRH which goes against the introduction that

states we don't write a procedure for everything. Also there is no procedure or guidance

for flags on the PFD, such as selecting an operable ADC or FD computer.

Synopsis

B747 Captain experienced an electrical failure that triggered multiple EICAS messages for

failed systems. The QRH and the EICAS display offered no suggestions to restore power to

what appeared to be the standby bus and the crew elected to return to the departure

airport.

ACN: 1409078

Time / Day

Date : 201612

Place

Locale Reference.Airport : MMMX.Airport


Environment


Aircraft

Reference : X

ATC / Advisory.TRACON : MMMX





Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS

Flight Phase : Final Approach

Component



Person

Reference : 1









Analyst Callback : Attempted

Events


Anomaly.Deviation - Procedural : Other / Unknown




Assessments




Primary Problem : Equipment / Tooling

Narrative: 1

When landing in Mexico City on the transition from MAVEK to PLAZA there is an anomaly

where [an] L-GPS FAIL illuminates on the CDU. This is a momentary loss of the L-GPS

which I was told is due to a cell phone signal blocking device at a local jail (not sure if

true). I feel on the 10-7 page there should be a note to advice pilots that this anomaly

exists. I am constantly seeing write ups in the logbook for this as we have more and more

new pilots on the 737.

Synopsis

A B737NG Captain noted [an] often reported L-GPS FAIL alert by crews on approach to

MMMX between the MAVEK and PLAZA waypoints.

ACN: 1408599

Time / Day

Date : 201612


Place

Locale Reference.Airport : SAF.Airport

State Reference : NM


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : SAF


Make Model Name : Regional Jet CL65, Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Route In Use : Visual Approach

Airspace.Class D : SAF

Person

Reference : 1









Events


Anomaly.Inflight Event / Encounter : Unstabilized Approach


Anomaly.Inflight Event / Encounter : CFTT / CFIT




Result.General : None Reported / Taken

Assessments




Narrative: 1

Upon arrival into Santa Fe, all was normal. We planned the descent for 250 kts and 17,000

ft, 30 miles out. Current ATIS at our time of arrival was broadcasting visuals to RWY 20.

The winds were reported at 260/15 and gusting to 21. We called the field in sight and was

cleared visual approach for runway 20. We set up for a left downwind. Upon arrival we had

briefed the RNAV (GPS) 20 with the possibility of using the Visual 20. On the downwind I

asked the FO to load the visual approach for 20 in the FMS to replace the RNAV (GPS) 20.

The reason for this is the GPS does not align with the runway and I wanted to have the

runway centerline extended with vertical guidance from the snowflake. The FO entered

and we executed. On the downwind we began to configure flaps 8 and 20, towered cleared

us to land reporting winds at 260/16. On base we lowered gear and flaps 30, at

approximately 5 miles from the runway we turned final. Once established we configured

flaps 45 and completed the landing checklist. Established and followed the snowflake

down.

At approximately 1200 ft we received an increasing performance windshear with amber

indication. My initial reaction was to pull the nose up slightly preparing to go around. As I

did this, I realized we were on speed (top of the bucket was my target for the winds),

Aligned with runway centerline, on snowflake, and no unusual power settings (At this point

N1 was approximately 68%). I immediately believed this indication was associated with

the crosswind and gusty conditions. Skies were clear and there was no microburst or

convective type activity so I decided to continue approach. The windshear alert went

away, however, because of the immediate distraction it caused and my initial instinct was

to perform a go around I found myself slightly high on the snowflake (snowflake was just

below the horizon). We were however, lined up with runway and on speed. I increased the

rate of descent to recapture the snowflake which began to come back up and was touching

the horizon, although we were still slightly high. At 1,000 ft we were on speed, configured,

engines spooled but still slightly high. At 500 ft the FO stated "Stable", again we were on

speed, engines spooled and the snowflake touching the horizon (VASI was showing slightly

high) as we approached the runway, "Sink Rate" activated twice. We touched down in the

touchdown zone as normal, landing was normal, and exited the runway at taxiway D1

without any significant braking.

Operating in and out of Santa Fe there are numerous threats. We contend with

mountainous terrain, high concentrations of GA traffic, and varying weather conditions. On

this day, the weather was very nice, however, there were gusty winds. Additionally, the

threat was the increasing performance WINDSHEAR indication and the distraction that it

caused when activated. Further complicating the approach with the resulting higher than

normal altitude. I have thought about this approach many times since the event. I guess

we always replay our flights and when things of this nature happen we constantly replay to

make sure we made the right decision.

In reflection, there are several things I would have done differently. While we made sure

we were configured early and at the appropriate altitudes I failed to brief the possibility of

a WINDSHEAR Warning associated with the windy conditions which allowed it to become a

distraction. Furthermore, while we were configured and conditions warranted a continued

visual approach, the moment the WINDSHEAR warning activated and I allowed it to

distract me I should have continued with my original instinct to go around. Beyond that I

should have not have continued the visual approach when I was high, no matter if it was

slight or by a significant amount. In the future, for my personal briefing, whether I am

flying the approach or the First Officer into windy conditions, I am going to include a

discussion of the possibility of a WINDSHEAR warning and what our plan will be. While

there is always consideration of the terrain that Santa Fe poses, I believe on a visually

clear day and light GA traffic, a normal go around would have been no extraordinary event

and would have been the safest course of action.

Synopsis

CL-65 Captain reported continuing the approach to a landing after receiving a windshear

warning at 1200 feet AGL.

ACN: 1407407

Time / Day

Date : 201612


Place

Locale Reference.ATC Facility : ZME.ARTCC

State Reference : TN


Environment



Light : Daylight

Aircraft

Reference : X


Aircraft Operator : FBO

Make Model Name : PA-34-200 Seneca I



Flight Plan : IFR

Mission : Ferry

Flight Phase : Cruise


Airspace.Class E : ZZZ

Component : 1

Aircraft Component : Electrical Power



Component : 2

Aircraft Component : DC Battery


Problem : Failed

Person

Reference : 1



Reporter Organization.Other












Events





Assessments



Narrative: 1

I was the PIC and sole occupant of the Seneca which suffered an electrical failure on the

way to ZZZ. I departed at XA00 on a flight to return two Piper Seneca 3's to ZZZ. I was

preceded by a Piper Seminole, and followed by the second Seneca. The pilots of all three

aircraft were employees of our flight school but no flight training was being conducted

during the flight. All aircraft were on IFR flight plans and our first leg was to ZZZ1. While

talking to Center, I lost all D.C. Electrical power. I got no warnings prior to the failure,

everything in the cockpit just suddenly went dark. It was daylight and I was in VMC. I ran

the appropriate checklists in an attempt to restore electrical power but was unsuccessful. I

had navigation capability with an iPad with ForeFlight software and a handheld GPS. I

attempted to call flight service on my cell phone but was unable to connect to an adequate

signal.

I knew the weather at my scheduled destination was VFR, that the runways were long,

and that there were personnel there at the time (I had called the day before and they

were expecting us). I considered diverting to another airport, but elected to continue to

ZZZ1, via my cleared route, as it seemed like the most suitable airport. After arriving at

ZZZ1, I over flew the field to check for traffic and determine landing direction, then circled

east of the field to make one more attempt at the checklists. While circling (no more than

5 minutes), I saw the Seminole that left before me on the visual approach. I preformed

the emergency gear extension and followed him in. He saw me land and informed ATC that

I was safely on the ground. The supervisor of Center was on the phone with the FBO when

I arrived and they were informed that I had an electrical failure. The supervisor said that

no further information was required from me. I immediately contacted our chief flight

instructor and informed him of our situation. The second Seneca arrived a few minutes

later.

Upon inspection by an aircraft mechanic, it was determined that the battery was the

failure point in the electrical system. A new battery was located and installed (there is a

large maintenance facility at ZZZ1). After the appropriate tests by the mechanic, the

aircraft was flown to ZZZ by another pilot with no further problems. I had switched aircraft

with the pilot of the other Seneca as he was an A&P mechanic and was better qualified to

supervise repairs.

Synopsis

PA-34 pilot reported an electrical failure during an IFR flight in VMC and continued to

destination.

ACN: 1406525

Time / Day

Date : 201611


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : IFR

Mission : Personal



Component

Aircraft Component : AC Generator/Alternator



Person

Reference : 1














Events



Anomaly.Deviation - Procedural : FAR




Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

I performed a preflight inspection, and found nothing unusual. Upon attempting to start

the engine, the battery did not seem to have enough cranking power. I assumed this was

due to the cold weather, and requested a GPU Jump Start from the FBO. On the second

attempt, the engine started, and the GPU was disconnected.

I continued my after starting-engine check-list (and put my cellular phone in Airplane

Mode), and all seemed normal. I made it a special point to check the ammeter, and it

appeared to be charging slightly. I also have a "cigar lighter" USB charger/voltmeter that I

use as a secondary reference to the battery health, and I remember it being around 13

volts (which seemed normal from past experiences).

I received my IFR clearance, performed my run-up, and proceeded for normal flight. I

departed from ZZZ.

Departure began normally, I was handed off from ZZZ Tower to ZZZ Departure while

climbing to 8000. I was then handed off to [new departure frequency] had been told to

climb maintain 9000.

ZZZ Departure instructed me to climb maintain 13,000 feet. I initiated my climb and

keyed my mic to read-back my instruction. As I keyed the mic, my #1 radio (a Garmin

430W) went out. I switched my panel to my #2 radio and tuned it, I heard ZZZ Approach

repeating my climb instruction. I again keyed my mic to confirm with a read-back, and the

#2 radio (Garmin SL-30) went out. I reached for my handheld and attempted to make call

out to ZZZ Departure, but my attempted failed. I powered off the hand-held to conserve

battery when I realized that I was unable to transmit for anyone to reach me. I cycled the

power on each radio, as well as the radio master in attempts to re-establish

communications. None of my efforts worked. The Transponder (Garmin GTX-345) failed to

come back up after one of the power cycles. I then left the power off to the avionics for a

couple minutes and turned off all but the transponder with hopes that when turning back

on the transponder would have enough power to send a signal. After various attempts, the

transponder did come up, and I squawked 7600, and the transponder cut back out.

I reverted to training (that I remembered), and that was to fly my assigned clearance.

Being my last instruction was to climb and maintain 13,000, and that was my filed

altitude. I leveled off at 13,000. I turned on my Oxygen tank about 15 minutes after

crossing 12,500 feet - and maintained oxygen flow for the remainder of the flight. I

proceeded navigating with my iPad and its built-in GPS. At ZZZ VOR, I turned Direct to

ZZZ1.

As has been instilled in me, Aviate, Navigate and Communicate - I established that the

aircraft was safe to continue flight, with the noted electrical issue so I flew it. I navigated

with the iPad, and established course heading to maintain for the remainder of the flight to

ZZZ1. I then decided to attempt to communicate with my cellular phone, so I turned off

the "airplane mode."

Note, I included my cell phone number in comments of the flight plan when it was filed.

[Later] I noticed that I received a voice mail message, the message from ZZZ TRACON

stated that they saw I was on my flight plan route at 13,000, and that I was out of their

airspace, their concern was the busier airspace near ZZZ1, they asked for a call-back. I

was able to have strong enough signal at the time I read the message to make an

outgoing call. I called ZZZ Center at the number provided. Informed them that I was

following my clearance and intended to continue to ZZZ1 at 13,000. I provided a position

report and advised of the electrical issue. I also reported that the conditions were VMC. I

was told to call ZZZ TRACON upon landing. Additionally, I requested the phone number for

ZZZ1 ATC (and was provided Tower phone number).

I received a voice message from ZZZ1 Center advising that I would be entering a MOA and

to call them. As soon as I was able to get a call out, I did call them. I gave them a position

report and confirmed that I would maintain 13,000 within 100 feet.

ZZZ1 Center called and left me a few messages that they lost radar and when they picked

it up again and an additional position report request. The last of their messages requested

that I maintain 13000. They provided the call-back number. I made several attempts to

communicate with them, however the cellular signal did not allow the call to go through.

There was one point where I had brief communications and was able to get a position

report to them.

I continued my flight directly to ZZZ1. Within 10 miles of ZZZ1, I was unable to get

cellular signal to call Tower. I used my handheld to get the ATIS information L, and then

switched to Tower frequency. When within about 4 miles (at 13,000 feet) I was able to

contact Tower using the Handheld, but it was broken. I copied that I was cleared to land

Runway 1. I needed to lose 12,500 feet of altitude. I crossed midfield and started my

descent over a right-pattern for runway 1, applied a forward slip to lose more altitude

quicker. Continued a right-pattern, and crossed the runway threshold around 6000. I

made 1 more right pattern to lose the remaining altitude, and during that time, I heard

tower advise me that I was cleared to land any runway. I made a normal landing on

Runway 1, taxied off where emergency vehicles were awaiting me.

I taxied to the FBO, parked, and shut down the aircraft. I then noticed I had an additional

call from ZZZ1 Approach asking me to call. Once the aircraft was secured I called ZZZ1

Approach, and we discussed what happened. Then I called ZZZ TRACON (per request from

initial communication with ZZZ Center via phone), and they asked me why I didn't squawk

7600 immediately. I explained that I attempted to cycle the radios first.

I asked the FBO's mechanic to check the electrical system before I used the aircraft again.

I was informed that the alternator was generating 12.6 Volts, while it should be above 13.

He recharged the battery, but his belief is that over time it has been slowly discharging

because the alternator was not producing enough to support all the avionics. The

alternator was last replaced with a new one on [late] 2015.

After landing, I was reminded that the IFR Lost Communications procedure in VMC is to

land at the earliest practicable airport. I believe that turning back to the ZZZ area would

have been more dangerous without communications. I could have landed at ZZZ2, or

many other airports along the route, but I kept them in mind if I needed to deviate for a

more serious emergency. Being my mind stuck in the mantra of Aviate, Navigate,

Communicate - I was focused on safely flying the aircraft, assuring that my navigation

(with the iPad) was accurate, and attempting to communicate with ATC facilities via

phone.

I believe that I did the best that I could with the resources available to me, however I do

understand that it may have caused undue burden on ATC facilities.

Synopsis

C172 pilot experienced an alternator failure and lost comms on an IFR flight in VMC and

elected to continue to destination. During a phone call with ATC he was reminded that in

VMC he should landed at a suitable airport and not continue all the way to destination.

ACN: 1405170

Time / Day

Date : 201611


Place




Environment



Weather Elements / Visibility : Windshear

Light : Daylight

Aircraft

Reference : X



Make Model Name : Skylane 182/RG Turbo Skylane/RG


Flight Plan : None

Mission : Personal

Nav In Use : GPS



Person

Reference : 1














Events

Anomaly.Inflight Event / Encounter : CFTT / CFIT





Result.Flight Crew : Regained Aircraft Control

Result.Flight Crew : Took Evasive Action

Assessments






Narrative: 1

I took off on a 270 heading with 26016G26KT on the 1 minute weather. That should put

me just 10 degrees off RWY 27 I was using. TAF indicated there are WS (Wind Shear) at

2000 AGL 40KTS. I used short field technique on take-off and encountered light turbulence

during the initial climb out. I paid special attention for my initial climb out because of the

2000 AGL WS on TAF. The terrain at the pass was 11030 MSL, I was planning on cruising

with 12500 to clear the highest peak. Upon take off, it was obvious that my climb was not

the 500ft/min I estimated even [though] I am the only sole on board. Did not pay

attention to where I was going and focused only on choosing a heading with slowly rising

terrain, I first turn into a heading of 209 to follow the slower rising terrain and then made

the wrong turn to a heading of 135. This heading gave me the illusion of slowly rising

terrain which shortly became a fast rising terrain in merely 4 miles, directly put me on a

course to the highest peak of 12598 MSL. At this time, I hadn't looked at my track on

Foreflight once. I was navigating visually and luckily stayed on the windward side of the

mountain. About 1 minute before the event, it was obvious to me that a 180 turn was

inevitable once I can see the terrain is rising fast and a point of no return was about to

come. I was waiting for the perfect place to start the turn. I attempted first 180 left turn

about 30 sec after I decided to make the 180 turn, realizing the turn radius was much

bigger than I expected because of the higher TAS, I broke off the turn and moved as close

to the cliff on my right hand side (windward side) as I dare. 30 sec later, I made the 2nd

attempt of 180 steep left turn upon encountering a wind shear of 850ft/min drop. I did not

have much ground clearance left so I made the decision of immediately starting the left

180, I had a sink rate about 2000ft/min and 40 KTS airspeed loss, I pushed the nose way

down to keep it stalling but I had to pull it all the way up with the stall warning horn when

I was about 90 degrees into the turn to avoid trees. I barely miss the trees by probably

50-100 ft max. And I immediately pushed the nose down once I was clear the trees to

save the airplane from an imminent stall.

After reviewing the GPS track, (which is not accurate in the mountain region with a lot of

discontinuing points) I found out that I started the 180 degree turn from the windward

side of the mountain at 106 IAS and 10350 MSL with 850ft/min downwash. My power

setting was Max since I was still trying to do best-rate-climb. I reached a maximum

2400ft/min down drop shortly into the turn and reached 10080 MSL after 90 degrees and

slowed the airspeed down to stalling speed, GPS track dictates my lowest IAS was 60KTS.

I level the bank at 90 degrees and should be about 4KTS slower than my stalling speed at

the time. While the stall horn does sound almost for a good 5-6 seconds, the wing did not

drop or it was a coordinated turn. I did not pay attention to airspeed nor coordination after

hearing the stall horn but instead focused on avoiding the trees 90 degrees into the turn

by pulling on the yoke as hard as I could. The maneuver and obstacles were finished

around 10250 MSL after rolling out around 180.

After reporting the WS with the ATC, I temporarily put myself on an IFR flight plan after

climbing along the route I came to 17000 MSL and later unable to maintain that altitude

and canceled IFR and diverted instead. Before this incident, I flew twice in mountain

passes, once as my high altitude checkout, once solo. I have attended 2 mountain flying

seminars recently as part of the FAA Safety program. The dangerous situation was caused

mainly in my opinion for the following reason: Bad ADM [aeronautical decision making] for

underestimating the gusting wind and wind shear in the mountain region. Turned into a

valley without reaching a pre-determined altitude first. Did not pay attention to moving

map while flying mountain region. Sectional only offered very limited knowledge on the

mountain pass, did not use satellite image to study the pass thoroughly.

Reasons that probably saved me were, flying on the windward side (albeit unintentionally).

Flying as close to the cliff as possible, so that 180 became a feasible option. Knowing the

lower terrain is behind me, so even a descending 180 degree turn might save me.

Reasons that could probably ended up in a fatal accident were underestimating the

TAS/turn radius and a possible stall or spin (which did not happen fortunately).

Synopsis

C182 pilot reported extreme weather conditions in mountainous terrain that culminated in

recovery from a stall condition and controlled flight toward terrain.

ACN: 1402304

Time / Day

Date : 201611


Place

Locale Reference.Airport : ALM.Airport

State Reference : NM


Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZAB


Make Model Name : Small Aircraft, High Wing, 1 Eng, Retractable Gear



Flight Plan : None

Mission : Personal

Nav In Use : GPS


Airspace.Class E : ZAB

Airspace.Special Use : R-5107

Component : 1

Aircraft Component : Headset



Component : 2




Person

Reference : 1














Events


Anomaly.Airspace Violation : All Types




Anomaly.Deviation - Procedural : FAR



Result.Flight Crew : Exited Penetrated Airspace




Assessments





Narrative: 1

The plan was to fly VFR to sightsee the valley east of Alamogordo (ALM), NM. Then after

reaching ALM, file IFR to Nogales, AZ (OLS) the destination. VFR flight following with ABQ

center was used for the first phase of flight into ALM. I requested an IFR to OLS from ABQ

center and they declined and advised to contact Flight Services (FSS). I switched to FS

frequency ABQ radio but it was weak. Request the IFR flight plan and provided the

information but lost contact before being able to confirm. I continued westward and

switched [back] to ABQ center, but did not immediately regain contact.

I encounter a major distraction at this time, the engine began to surge. I could not

determine the issue but the sound was clearly changing. All gauges were good. I'm also an

A&P and continued to try and diagnose the problem and determine whether a

precautionary landing was needed. It turned out that the batteries in my ANR headset

were dying and causing what sounded like an engine surge with the ANR feature fading in

and out. Went back to ABQ center and re-established comm with them to get the IFR, but

about that time both GPS devices became erratic and unreliable. Had never experienced

this before. ATC advised they could not give me the IFR until I cleared the R-5107

airspace to the west. They also gave me phone numbers to call. Later I learned that the

Military was testing their GPS blocking system. It works well. After clearing to the west, I

picked up the IFR to OLS and the rest of the flight was fortunately uneventful. I have

spoken with ABQ center and have left multiple messages for the White Sands Missile

Range air space manager.

Synopsis

General Aviation pilot reported engine surging while on a sightseeing flight east of ALM,

followed shortly by GPS failure. The engine surging was tackled first and was determined

to be caused by weak batteries in the noise canceling headset. When ATC was contacted

for an IFR clearance, the reporter was advised that the GPS outage was caused by military

testing and that he was in R-5107.

ACN: 1400819

Time / Day

Date : 201611


Place




Environment



Light : Daylight

Aircraft

Reference : X



Make Model Name : Cessna 340/340A



Flight Plan : None

Mission : Personal

Nav In Use : GPS




Component

Aircraft Component : Engine



Person

Reference : 1













Events

Anomaly.Aircraft Equipment Problem : Critical





Result.Flight Crew : Landed in Emergency Condition

Result.Flight Crew : Returned To Departure Airport


Assessments



Narrative: 1

Climbing VFR with climb power above a scattered layer monitoring ADSB traffic on Garmin

430 and iPad using ForeFlight at approximately 6500 ft MSL, I noticed an extreme oil leak

on the left engine. I observed no traffic conflicts visually or on the ADSB displays. I

immediately turned back towards [departure airport], reduced power, and started a

descent while simultaneously [advising] ATC and requesting an IFR clearance back to

[departure airport]. ATC asked the nature of the event, I replied, extreme oil leak on left

engine. ATC issued IFR clearance to [departure airport] and assigned a heading of 270. I

responded "Unable, request direct." ATC gave me a direct clearance and clearance to

descend at pilot's discretion to 2000. I acknowledged clearance. At some point I was

descending through the clouds, I asked for vectors because I had not yet had time to

reprogram my GPS. ATC gave me a vector and offered an alternative landing site. I

proceeded to [departure airport], did a visual approach and canceled my IFR clearance in

the air. ATC requested that I call them after landing to ensure that I landed safely. I

announced my position and landing intentions on CTAF. Someone responded asking if I

needed assistance. I replied negative. I landed without incident, taxied toward my hangar

and had my aircraft towed to the maintenance shop. I called Approach as requested and

provided more details on the event, my name, and pilot certificate number. The FAA

visited the shop 2 days later to inspect my plane. I commend ATC on their professionalism

and assistance.

Upon reviewing the incident, I do not believe that I violated any clearances or FARs.

1. I was receiving flight following so I did not need to locate a frequency and contact ATC.

2. I acted decisively (within seconds) to [advise ATC], request an IFR clearance, establish

a descent and turn towards the most suitable airport.

3. I asserted my Pilot in Command authority and declined a heading clearance that took

me farther from the most direct route to [departure airport].

3. I utilized ATC as a resource for a vector because it was quicker than reprogramming the

GPS at that moment. My 25 years of flying experience and annual recurrent training gave

me the knowledge and experience to execute the items above.

4. While descending and turning in the clouds, I found that I was descending at 2,000 feet

per minute and I was in a bank in excess of 45 degrees. I reduced the bank to 30 degrees

and the descent to 1000 feet per minute. This was unintended and could have resulted in

a more serious unusual attitude if I had not corrected in a short period of time. I believe

that this was caused by the stress of the situation and my failure to properly monitor the

attitude indicator in the turn. I was preoccupied with turning to the most direct heading

and was acting in a rushed manner when I should have remained calmer.

Reviewing my performance and completing this form as it relates to my event was a

valuable training experience and has made to a safer and more experienced pilot.

Synopsis

C340 pilot reported returning to the departure airport after observing an oil leak from the

left engine.

ACN: 1400248

Time / Day

Date : 201610


Place

Locale Reference.Airport : BWI.Airport

State Reference : MD

Relative Position.Distance.Nautical Miles : 10


Environment




Light : Night


Aircraft

Reference : X

ATC / Advisory.TRACON : PCT


Make Model Name : M-20 J (201) / Allegro



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS


Airspace.Class B : BWI

Person

Reference : 1















Analyst Callback : Attempted

Events




Anomaly.Inflight Event / Encounter : Wake Vortex Encounter



Result.Flight Crew : Diverted

Assessments




Narrative: 1

On approach to BWI at night while on an IFR flight plan, but in VFR conditions, I had

difficulty following ATC requested headings and I missed the intercept for the ILS. At the

time my new GPS (Garmin 650) self-dimmed to such a low level that it could not be seen.

I could not figure out how make it brighter and readable. At the same time the airspeed

indicator and directional gyro were also poorly lighted despite the fact that that I had the

panel lighting turned up to maximum. I used a flashlight to light those two instruments

while I was flying the plane. The original plan was to land at Carroll County Airport (DMW),

but due to very bad weather there, at the last moment, I made a choice to land at BWI. I

was also experiencing at times severe wake turbulence.

Next time I should make sure that these instruments and the GPS are well lighted. Also, I

waited in the decision to divert, and once I did so I was immediately exposed to an

extremely busy ATC environment with no time to prepare or find the approach in my back-

up paper approach plates. I was way too busy, and overwhelmed. Next time the decision

to divert will be made further out and I will prepare for the approach way ahead of time. I

will practice my instrument approaches more and practice landing at busy airports. Also it

probably would have been much better to divert to a much less busy major GA airport

such as Martin State Airport (MTN).

Synopsis

M20J pilot reported having difficulty with complying with ATC headings when the workload

of a night IFR flight became more than he could comfortably handle.

ACN: 1398464

Time / Day

Date : 201610


Place




Environment


Weather Elements / Visibility : Icing

Light : Dusk

Aircraft

Reference : X



Make Model Name : PA-46 Malibu/Malibu Mirage/Malibu Matrix



Flight Plan : IFR

Mission : Personal



Component

Aircraft Component : Electrical Power


Problem : Failed

Person

Reference : 1















Events







Assessments





Narrative: 1

Climbing to cruising altitude at dusk (climbing back into the sunset, but IMC in clouds), the

aircraft was passing through FL230 on the way to FL260, the aircraft suffered a dual main

bus breaker failure. The plane was climbing through layers of IMC clouds, light ice,

accordingly the electrical anti-ice/de-ice systems were on including windshield heat

(always on above FL180), pitot heat (always on for all flights), stall warning heat, prop

heat, and cabin electrical auxiliary heat for windshield defog. Systems on for much of the

climb, but at some point either transient voltage greater than the dual 80 amp breakers

could handle, or resistance on one breaker increased. Regardless of the cause, the result

was a failure of numerous systems tied to the main bus including: Pilot's PFD/MFD

(Garmin G500), Copilot Sandel EHSI failed, copilot electric Attitude Indicator (AI) probably

spooled down (unclear and didn't check), all cabin illumination, wing to header tank fuel

pumps, header tank to PT6A electrical boost pump, annunciator panel, all engine

instruments (torque/temperature, fuel flow/pressure/quantity, oil temperature/pressure,

vacuum pressure), all of the above mentioned anti/de-ice electrical systems, de-ice boot

activation switch, p3 heat, and a bunch more that is not relevant to the situation. Dual

GPS Nav/Comms (Avidyne IFD 540/440 with large map displays), radar, XM weather,

traffic, transponder, and generator/battery volts/amp indicator continued to work worked.

(Since the Nav/Comm and transponders were working, ATC communication was

maintained and until I noted the issue to them, they were unaware of any problems.) The

autopilot control head was illuminated, but without the AHRS from the G500, it wasn't

functional.

The pilot's backup instruments (airspeed, vacuum driven AI, and altimeter) were all

functioning. Using the backup instruments, I maintained positive control of the aircraft

while splitting my time to troubleshoot the problem. I advised ATC that I might need

vectors to the nearest best weather, however, I did not want to immediately descend back

into the much worse weather lower down (rain/snow/winds, low visibility). There was

some wandering of heading and altitude during this period as I was forced to split focus

between the instruments and checking breakers/etc using a flashlight. Shortly after the

failure, I emerged out of the tops of the clouds in that area and in VMC conditions, and

had no immediate icing concerns. With the loss of the wing fuel pumps to the header tank,

I knew that although siphoning would continue to pull fuel to the header tank, it would be

at a slower rate and fuel to the engine might eventually become an issue.

The breakers would not initially reset since the electrical systems were all still on.

However, after load-shedding some of the icing equipment via their individual circuit

breakers --since the "dead" control panel contains lighted push buttons (green dot light

when on) without physical indication of whether they are on or off-- and waiting for a brief

period, I was able to restore power to both main bus breakers. I was able to maintain an

amp load below 70 amps for all electrical use (below the level of a single main breaker) in

the plane with pitot and windshield heat on. I was actually enroute to the maintenance

facility (for annual inspection), and much better weather was ahead at my destination than

what was below. I elected to continue the trip and there were no further issues.

In retrospect, this failure would not have happened had I not engaged the "aux heat"

which is an electric heater that warms the air coming out of the vent defog blower fan.

That heater draws considerable amperage and I rarely have it on in active icing conditions.

Generally that heater is on in high altitude cruise when it is too cold for icing, so only the

pitot and windshield heaters are on when that is switched on. In those conditions the load

is well below the 160 amp limit. It was the confluence of all the electrical systems engaged

together with what may perhaps have been degraded breakers. I will recommend that the

POH advise of high electrical loads in icing conditions. (Placing the PFD on main bus and

avionics bus with fail over would improve redundancy too. Or having that Aux heat on the

"non-essential" bus would have eliminated the risk too. 90 amp breakers might be nice

too.)

My perception of time during the troubleshooting was very off. I thought the event lasted

quite a while, 20 minutes or more. However, when I looked at Flight Aware, I was shocked

to discover that the total elapsed time from failure to restoration of one of the breakers

was 6-7 minutes or less. I am glad in that dilation of time, I didn't elect to make a rash

decision such as deviating and descending as I believe that would have made matters

worse. Taking time to troubleshoot resulted in a favorable resolution.

The incident also reinforced knowing the electrical systems (and all systems in general)

well enough so as to conduct proper troubleshooting and to understand the knock-on

implications of the loss of a particular bus (e.g.the potential for eventual engine power loss

from inadequate fuel flow from the wing to the header tank due to loss of pumps). There is

no "bus failure" process in the abnormal procedures for the aircraft. So I, while I don't

think it was difficult to figure out how to correct the issue (load shed is pretty obvious), I

didn't have a written guide.

I had been in a climb to FL260, so some amount of altitude was blocked by ATC, but while

troubleshooting, my altitude peaked at FL25 before I returned to FL240 and maintained

that altitude. ATC did not advise me of any issues with these altitude deviations, just

requested I maintain my current heading, and were very cooperative and helpful during

my troubleshooting.

Synopsis

PA46 pilot reported loss of dual main bus power, probably because of high electrical

system demand in icing conditions.

ACN: 1396889

Time / Day

Date : 201610


Place




Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ


Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : None

Mission : Personal

Flight Phase : Takeoff

Route In Use : None

Component

Aircraft Component : Airspeed Indicator


Problem : Failed

Person

Reference : 1












Events


Anomaly.Deviation - Speed : All Types




Assessments



Narrative: 1

During the takeoff roll on a normal takeoff, the airspeed indicator started to come alive as

speed increased but did not fully reach takeoff speed though the aircraft felt as though it

had. The aircraft rotated and took off normally but the airspeed indicator eventually

settled to 0 just below pattern altitude. Using normal power and attitude setting and

referencing the GPS groundspeed during relatively calm wind conditions, the aircraft was

landed safely after a circuit in the pattern. The altimeter and VSI were not affected and

alternate air did not resolve the problem, leaving me to believe the pitot system was the

issue. Inspection on the ground of the pitot tube did not indicate any issues.

What should have been done is the takeoff should have been aborted after noticing that

airspeed was not continuing to increase past a certain point or that the airspeed indicator

was not fully functional.

Synopsis

C172 Pilot returned to land after noting that the airspeed indication was erroneous on

takeoff and then went to zero in the pattern. Altimeter and VSI were not affected and no

issues were apparent with the pitot tube.

ACN: 1395143

Time / Day

Date : 201610


Place




Environment



Light : Daylight

Aircraft

Reference : X




Make Model Name : PA-28R Cherokee Arrow All Series



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS



Component

Aircraft Component : DC Generation


Problem : Failed

Person

Reference : 1












Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : ATC

Events






Result.Air Traffic Control : Provided Assistance

Assessments



Narrative: 1

Enroute on an IFR plan at 9000 feet in VMC I noticed the ammeter was reading zero. I

turned off all unnecessary equipment to include autopilot, 2nd COM/NAV radio. I also

lowered the screen brightness on GPS to minimum level. I recycled master and waited 30

seconds. Attempted this twice. I then noticed the volt meter begin to drop. I contacted

ATC and informed them I was losing electrical and would like to cancel IFR and proceed

VFR to my destination. I asked for a VFR altitude and was given and climbed to 9500 feet.

I changed my squawk to VFR. I recycled my electrical and was briefly able to reach ATC

and was given a unique squawk code by ATC. After I lost my aircraft radios completely and

realized my handheld was not working, I began to squawk 7600, just in case the

transponder had sufficient electrical to function

Though ATC did not object to me proceeding VFR to my destination, I thought it prudent

to attempt contact to confirm there were no issues with my plan to continue the flight. I

was unable to reestablish contact. Therefore, I continued as discussed with the last

controller with whom I could communicate. I continued at 9500 feet and then began a vfr

descent to 5500 which would place me 500 feet above Class C airspace. Upon reaching

this altitude, I attempted to contact approach via my handheld and was successful. The

controller was aware of my situation and directed me to not descend below 5500 feet. I

told him I planned to proceed to ZZZ he advised he would prefer I go to ZZZ as [the main]

airport was very busy. As I was proceeding to my destination, I was warned by Foreflight

that I was about to enter a TFR. I changed course to avoid the TFR, not having sufficient

time to determine if the TFR was active. I attempted to contact approach to inform him of

this course change (though he had not told me to hold a heading). I finally did reach him

as I was turning back to the east as I circled around the TFR. He advised me TFR not yet

active and to maintain my current heading. I proceeded at the current heading, though I

may have deviated somewhat as I had only noted the direction on my iPad and not the

actual heading on the DG. If I did deviate, ATC did not inform me. After a while approach

advised me to turn direct to ZZZ and to inform him when I began my descent. I proceeded

to turn and hold altitude, and quickly realized I had lost 200 ft. which I quickly regained. I

then advised ATC that I was ready to begin my descent. I proceeded to ZZZ while

beginning my descent as directed and informed approach when I had ZZZ in site. I landed

without incident, using manual override to lower landing gear. I had been asked by

approach to call them to advise safe landing, but upon landing was informed by airport

staff that ATC had called them and were informed I had landed safely. I proceeded to

secure my aircraft and did call approach to thank them for their help.

I decided to continue to ZZZ rather than land immediately for several reasons. Of primary

importance, the aircraft was running perfectly and there were no indications of a failure

that would compromise safety. I knew electrical was not necessary for the engine to

continue to run. Having briefed the weather and with independent battery powered ADSB

weather and navigation coupled with my iPad onboard, I knew I could reach the airport

VFR. I also had a handheld radio and even though I had not been able to reach center at

9500 ft. I felt I would be able to reach approach and the traffic advisory frequency at ZZZ

when at a lower altitude. I did not want to land at an unknown airport for which I had no

accommodations or knowledge as to maintenance personnel to repair the aircraft. This

was especially important given the purpose of the trip was to take my son, a cancer

patient who was in between chemotherapy treatments for a few days to enjoy the

mountains. If I landed elsewhere, it may have been difficult to have the aircraft repaired

or to find accommodations and a rental car to return back home. I had been to ZZZ before

and knew they had a large general aviation community and I expected it would be easy to

find a qualified mechanic. Further, we already had a place to stay and a vehicle.

Continuing VFR to our destination was the best choice.

Thoughts about the flight:

1) The decision to cancel IFR and proceed VFR to my destination did not compromise

safety. I maintained VFR taking care to not invade airspace where radio communication

was required. When near class C airspace, I successfully established communication with

ATC using my handheld and followed their directions.

2) I probably should not have changed my squawk code to VFR without direction from

ATC.

3) I should purchase headset attachment as I believe any deviations which may have

occurred during this flight were due to having to remove my headset in order to speak on

a handheld in a noisy aircraft.

Synopsis

During cruise, on an IFR flight plan, the pilot of a Piper Arrow PA28R-180 reported noticing

he was losing electrical power. The pilot continued to his destination VFR while using a

handheld radio to communicate with ATC.

ACN: 1391906

Time / Day

Date : 201610


Place




Environment

Flight Conditions : Mixed

Weather Elements / Visibility : Cloudy


Light : Daylight


Aircraft

Reference : X



Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS




Component



Problem : Failed

Person

Reference : 1









Experience.Flight Crew.Last 90 Days : 20.3




Events









Assessments



Narrative: 1

While in good visual conditions above a solid overcast, the alternator went offline.

Attempts to reset the alternator would work for a minute or two, then the alternator would

go offline again. Decided to divert to ZZZ to preclude potential loss of navigation and

communications upon battery exhaustion. Approach controller offered ZZZ1, as it was

directly ahead, but the ceiling was lower (OVC009 vs MVFR) and a high descent rate would

be required. The controller greatly assisted by providing information such as airport

conditions and runway availability that I could have obtained myself but at the cost of time

and increased workload.

I recently equipped this aircraft with a GTN-750 GPS and Aspen EFD-1000 Pro. I also fly

with a tablet that runs Garmin Pilot. These enabled me to easily determine my position

relative to nearby airports and rapidly prepare the ILS approach. While the controller

provided radar vectors, the large GPS display showed clearly how I was approaching the

localizer course. The tablet allowed me view the approach plate without fumbling for books

of plates in my flight bag; I had not anticipated a landing in [this state], and would not

have had the NE-4 book at the ready. During the approach, presentation of the Aspen

minimized the workload associated with integrating the attitude indicator, airspeed,

altimeter, and LOC/GS indications by displaying it all in one instrument. Further, I recently

installed an EDM-900 primary engine monitor. It provided very timely alerts to the low bus

voltage situation that signaled the alternator failure (the factory "ALT" failure light on the

Piper panel is rather dim and not always in the primary scan). Although I initially

considered the device a bit of a "splurge", I now feel it greatly helps monitor an aircraft's

systems and likely alerted me to this condition much earlier than I might have otherwise

noted. I doubt many private pilots have given much thought to how long their avionics will

run after an alternator failure. Given that my ammeter generally shows about 28 amps

and 12 volts, and the battery is rated at 28-30 Amp-Hours, that's at most an hour.

Probably less given a delay in recognizing the problem and attempts at restoring alternator

function. Reviewing the flight track on FlightAware I was surprised to discover that it took

me about 20 minutes from the time I decided there was a problem to having wheels on

the ground. I think this is an area that should be emphasized during instrument training

and instrument proficiency training.

Synopsis

PA28 pilot reported an alternator failure while flying at 7,000 feet above a solid overcast

and elected to divert before the battery was drained. He praised the Controller for his

assistance and the importance of modern avionics that he had recently installed.

ACN: 1388560

Time / Day

Date : 201609


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC



Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ





Flight Plan : IFR

Mission : Passenger

Nav In Use : FMS Or FMC

Nav In Use : GPS


Route In Use : Oceanic

Component




Person : 1

Reference : 1













Person : 2

Reference : 2




Function.Flight Crew : First Officer









Events






Result.Flight Crew : FLC complied w / Automation / Advisory


Assessments



Primary Problem : ATC Equipment / Nav Facility / Buildings

Narrative: 1

Enroute while in Oceanic airspace we got a message on the navigation display "UNABLE

REQD NAV PERF RNP". The Values on the FMC were 4.0/4.15 approximately.

Prior to starting the flight there was a NOTAM for military GPS jamming activity that could

affect us up to approximately 400 nm of ZZZ. After departure approximately 5 minutes

both GPS signals were lost and aircraft operated normally with no messages. We expected

this. We continued on with no issues and followed procedure verifying our position and

coast out check required with no GPS. After entering Oceanic airspace as noted on chart

and flight plan approximately 10 minutes later we received the "UNABLE REQD NAV PERF

RNP". We ran checklist and began plotting our positions on the chart per procedures while

we evaluated. Everything was fine and on course. We then began the process of advising

Dispatch and consulting with Operations. We all concur and we continued normally with

alternate plotting procedures. We then contacted ARTCC to advise of our degraded RNP

above the RNP 4.0. They said fine and told us we had space for 100nm. We asked them to

pass along to the foreign ARTCC our condition and that was it...

When we checked in with the foreign ARTCC (HF) we reported normally and tried to relay

our degrade RNP to them. There was a language barrier and we knew they did not

understand. So we messaged dispatch to have them call the foreign controllers and tell

them via land line. They did and also noted to us that they thought the foreign controllers

did not understand. A short while after that the foreign ARTCC called us on HF and asked

us if we can comply RNP 10. We had a hard time understanding what he really meant but

we eventually decided he was asking if we could comply with RNP 10 even though we were

degraded from RNP 4.0. WE replied and reported able to comply RNP 10. This was the end

of all communication regarding our navigation issue. The rest of the flight proceeded

normally via calls and plotting etc. and resulted in no navigational errors... We reported

via VHF and received a code and were radar identified. Position based on radar fix was

within 2nm of what we showed. Flight continued without incident to our destination

airport.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

Air carrier flight crew reported they experienced a GPS signal loss during a NOTAM'ed

military operation on an oceanic flight. The crew and their Dispatcher had language

difficulty explaining the navigation capability loss to the foreign ARTCC.

ACN: 1386829

Time / Day

Date : 201609


Place

Locale Reference.Airport : EIK.Airport

State Reference : CO


Environment


Light : Daylight

Ceiling : CLR

Aircraft

Reference : X

ATC / Advisory.CTAF : EIK

ATC / Advisory.Tower : BJC


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear



Flight Plan : None

Mission : Personal


Route In Use : Visual Approach

Airspace.Class E : EIK

Person

Reference : 1















Events






Assessments


Contributing Factors / Situations : Manuals


Narrative: 1

[Flying] northbound to EIK, which is only 1.5nm outside of the BJC Airport Traffic

Area/Class D airspace. While flying on an approved northerly heading, I was given

frequency change by BJC tower. As I approached EIK I realized that I was already too far

north to enter the downwind leg of the EIK right traffic pattern for runway 15 on the

recommended 45-degree angle, and decided to make a 270-degree left turn to put me in a

better position for a 45-degree entry. During this maneuver my flight path took me back

into the edge of the Class D airspace by approximately 1/2 mile for a short time without

being in communication with BJC tower. I realized my error just after I entered into the

Class D airspace by looking at the GPS display for my aircraft on my iPad, which was

displaying the VFR sectional chart for the area using the Foreflight app. I continued my

approach to EIK, entered the downwind leg on a 45-degree angle, and landed safely.

There are two factors that caused the error. (1) Primarily, I had previously flown into EIK

numerous times, I had never before approached EIK from the south. I was therefore

unfamiliar with the area in the context of how close to the BJC Class D airspace I was

maneuvering, and where the actual edge of the Class D airspace is located in relation to

recognizable landmarks. (2) I had enlarged (zoomed in) the image of the VFR sectional

chart displayed on my iPad to such a high magnification that the screen only showed the

very northernmost portion of the blue segmented circle designating the BJC Airport Traffic

Area. Without seeing more of the blue segmented circle along with the airport inside it, it

did not register in my mind as being what it was, the edge of the Airport Traffic Area, until

after I had crossed it. In other words, when I zoomed the screen to a point where the blue

segmented line appeared out of context, it temporarily suppressed the BJC Airport Traffic

Area from my consideration as an important navigation factor that I was in close proximity

to and which I must avoid. It is important to note that I was not flying by constant

reference to my iPad. I was flying by visual reference to the ground and checking my

position on the iPad from time to time. Nonetheless, by altering the display such that the

Airport Traffic Area as such was not visible, it had an effect on my mental picture and

contributed to my error. Out of sight, out of mind.

After landing, I called the BJC tower and spoke with the controller who I had worked with,

notifying him of and apologizing for my encroachment into his Class D airspace without

communication and discussing what had happened. His reaction was positive, and he

commended me both for apologizing and for being aware of what had happened. He said

that he had been unaware of the encroachment.

To my knowledge this is the first time that I have ever unintentionally encroached on any

airspace that has requirements for entry, and it shocked me as soon as I realized that I

had done so. I have reviewed my actions, and closely examined the area of the event to

determine precisely where the edge of the Class D airspace is located and how to

recognize it from the air using landmarks. I have also resolved to be more careful in

planning my flight path when approaching an airport from an unfamiliar direction, and to

be more careful when maneuvering in congested airspace. Finally, I am now aware that,

when using an Electronic Flight Bag, I should avoid enlarging the image of my VFR

sectional chart (or any other chart) to a point where chart designations can lose their

context and significance.

Synopsis

A general aviation pilot reported briefly entering Class D airspace while conducting a VFR

approach to another field.

ACN: 1386288

Time / Day

Date : 201609

Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : RV-9



Flight Plan : None

Mission : Training

Nav In Use : GPS



Airspace.Class C : ZZZ

Component

Aircraft Component : Approach Coupler


Problem : Design

Person

Reference : 1













Events





Assessments



Primary Problem : Ambiguous

Narrative: 1

My airplane has a Garmin G3X touch system fed by a GTN650. I've emailed Garmin on this

topic before, but they may need additional motivation. With the current design, it is almost

impossible to fly a stable, legal vectors to final LPV (Localizer Performance with Vertical

guidance) approach.

From this morning's email to them:

Back to vectors to final on an LPV approach. With the glide path coming alive only as the

airplane passes the final approach fix, this pretty much guarantees an unstable approach.

Here are several bad things that can happen:

(1) Suppose the airplane is at the FAF glide path crossing altitude with power to fly level, a

perfect approach. Once the glide path comes alive at the FAF, the plane will overshoot the

glide path because the velocity vector is still level, and neither an abrupt power reduction

nor an abrupt pitch over (both destabilizing) will track the glide path as well as an

intercept from below.

(2) The airplane is slightly above the FAF glide path crossing altitude, either hand-flown or

due to barometric altimetry or charting errors. In this case, the G3X will not capture the

glide path, will not annunciate the failure to capture, and again, the pilot will have to

capture the glide path from above, a destabilizing maneuver.

(3) If the pilot anticipates glide path intercept by reducing power as the FAF gets close,

this means that the pilot is flying an energy profile contrary to the vertical guidance,

slowing in anticipation of intercept and then regaining speed on the glide path. That's

pretty radical.

(4) The only solution I see to having the automation be guaranteed to capture the LPV

glidepath on vectors to final is to intercept the glide path below the intercept angle, such

as by descending 100 feet below the intercept altitude. I've not looked at the GPS

equivalent of the TERPS for guaranteed obstacle clearance, but deliberately flying one leg

of the approach low is a tacky way to make up for the automation's shortcomings. I feel

that this is a safety of flight issue -- that the automation will not let you fly a stable

approach -- and will file an ASRS report on this.

Synopsis

Pilot reports that Localizer Performance with Vertical Guidance generated glideslopes in

many cases on start at the FAF and that the transition from level flight vectors past the

FAF to the artificial glideslope is not ideal.

ACN: 1385300

Time / Day

Date : 201608


Place




Environment


Weather Elements / Visibility : Haze / Smoke


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ


Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear



Flight Plan : VFR

Mission : Personal

Flight Phase : Landing

Airspace.Class D : ZZZ

Person

Reference : 1












Events



Anomaly.Deviation - Procedural : Landing Without Clearance








Assessments

Contributing Factors / Situations : Environment - Non Weather Related




Narrative: 1

I was planning to go to PLU (Thun Field, Washington) for dinner. This field is uncontrolled.

I filed a flight plan to PLU, and departed from an airport to the south. I opened my flight

plan after departing. I planned on flying direct. While enroute my GPS was not working

properly, so I switched to navigation via a ForeFlight standby device. I used VOR and

dead-reckoning skills to pinpoint and track my progress along the route. I planned my

descents to avoid nearby Bravo airspace shelves. About 12 miles south of my intended

destination, I encountered heavy smoke due to a nearby fire. At the same time I accessed

weather at my intended destination via ASOS. At about 8 miles from my intended

destination, I started making traffic calls to on the CTAF to announce my position and

intention of landing.

I saw a tower light flash and I turned my plane towards the light while making position

reports on CTAF. I announced my position on final and subsequently landed. After I

landed, I noticed that I was not at the airport that I intended to land at, but instead, at a

nearby controlled airport. I immediately contacted the Control Tower and followed the

controller's instructions. After advising airport personnel that I intended to land at a

nearby airport, I was given clearance to depart.

The cause of the problem was my misidentification of the airport that I intended to land at.

I discovered this problem upon landing. Contributing factors were the nighttime conditions

as well as the smoke in the air. In the future I could more readily familiarize myself with

ForeFlight on my standby electronic device, as well as refresh my VOR, dead reckoning,

and nighttime airport identification skills.

Synopsis

General aviation pilot reported becoming disoriented during a night flight under smoky

conditions and landed at an unintended airport.

ACN: 1385289

Time / Day

Date : 201609


Place

Locale Reference.Airport : TJIG.Airport

State Reference : PR


Environment



Light : Daylight


Aircraft

Reference : X

Make Model Name : Helicopter



Flight Plan : None



Person

Reference : 1



Reporter Organization : Government


Qualification.Flight Crew : Rotorcraft









Human Factors : Other / Unknown



Events






Assessments

Contributing Factors / Situations : Airport




Narrative: 1

Eight miles from TJIG, I retrieved current ATIS information. I tuned to the Isla Grande

airport tower frequency (135.875) and made a call. My call was as follows " Isla Grande

Tower, helicopter abc Water Tower with ATIS, Landing. At this point I was still several

miles from the tower (it's a BIG tower), and approximately 6 to 7 miles from the Isla

Grande Airport. The controller immediately responded with "possible pilot deviation....you

need to report from outside the delta" with which I replied "I am outside the delta" and he

responded "no you are not!". I immediately pushed the Ident button to hopefully mark my

location at that point in time (well outside the delta airspace) I asked for the controller's

initials and a phone number to contact the tower and told him to "mark the tape". He

refused to give me his initials and a phone number and did not reply until I said again

"mark the tape, I need your initials and a phone number". All of this time I was still

outside the delta airspace. My observer took a picture of the GPS and I was still

approximately one mile from the delta airspace. I started doing 360's outside the delta

airspace until the controller asked me what my intentions were. I told him "I'm trying to

land at TJIG if you'd give me some help". At which point he told me to fly South to a

landmark I wasn't familiar with. I replied that I was not familiar with that landmark, so he

gave me a vector of 140 to which I complied. He then cleared me to TJIG and told me to

remain South of the runway and report landing assured, which I did. Upon landing, I called

the tower and that controller refused to give me his initials. He told me to call another

number. I spoke with an individual who refused to identify himself who also refused to

give me the controller initials and said he would look into it and call me back.

Approximately 20 minutes later the individual called me back and very aggressively told

me that he had reviewed the tapes and that he heard me report "overtop the water tower"

to which I replied "I did not say that" I simply said "water tower" He informed me that

they base all their information on the pilots position report. When I asked him if he had

radar and that I wanted to review the tapes, he told me they did not have radar. I then

asked him, well if you don't have radar; 1. What is your controller doing giving me

vectors, and 2. How can you emphatically state a "possible pilot deviation"?? I asked him

where I could retrieve radar data and he gave me the number in San Juan which I called. I

spoke with a very helpful gentleman. He said he would try and get the radar tape. He

called me back and informed me that it would be [a few days] before his supervisor would

be able to review the tapes. I asked him if I could view the tapes and he responded, he

didn't know but his supervisor would. I asked him how long the tapes would be held in

memory and he said 45 days. He was very helpful and polite just like every other

controller/ATC person I have dealt with in 30+ years of flying. He asked me (can't

remember the verbage) if the controller had violated me....if he had asked me to call the

tower. I told him no, I was the one who asked for the controllers initials and for him to

mark the tape. (again, I was assuming he had a radar feed)

This is the very first time I have ever encountered an unsafe controller. When that

controller vectored me to 140, he vectored me directly into the final approach path for San

Juan airport runway 09 (although I was at only 500 feet), I can only imagine the TCAS of

an airliner alerting due to my proximity! I had been briefed upon arriving on the island of

Puerto Rico that the Isla Grande tower had a radar feed from San Juan control. Apparently

this is not the case! Had I known this, I would not have accepted his vector, after all,

without radar how does he know where he is vectoring me! Incredibly, that same

controller said the exact same thing to me yesterday while I was reporting to land at Isla

Grande. He stated "Possible pilot deviation....report outside the delta next time" to which I

replied "I am outside the delta" and he said "no you are not!" But yesterday I replied "well

my GPS must be wrong" and he replied "yes it is!" in his typical unpleasant tone...and I

just complied with his instructions and landed. It might be noted that he yelled at a

National Guard helicopter this same day after my incident "possible pilot deviation" and

then a week or two ago, I heard him riding a first time solo student pilot (who announced

"student pilot first solo") with "possible pilot deviation" when he failed to turn to base at a

checkpoint he was unfamiliar with. He told the student pilot (who was in landing

configuration) "turn 270" which the student "complied" and turned to a heading of 270,

but the controller stated "That's not what I told you!" He wanted the student to make a

270 degree turn to line back up with the runway. Luckily, the student pilot was sharp

enough to transition back to cruise mode (flaps up,power,etc) I feel this controller is

dangerous, unsafe and is NOT an asset to the thousands of fine men and women in air

traffic control. I plan on filing a formal complaint with the FAA but was told it won't do any

good because this is a civilian "contract" tower (whatever that means). This individual

should be fired in my opinion or at least be given extensive retraining.

Synopsis

Helicopter pilot reported a verbal altercation with a TJIG Tower Controller over his position

inside or outside the Class D. The Controller then proceeded to issue a vector heading

without the benefit of Radar.

ACN: 1382727

Time / Day

Date : 201608


Place

Locale Reference.ATC Facility : ZFW.ARTCC

State Reference : TX


Environment


Light : Night

Aircraft

Reference : X


Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR


Route In Use.SID : JPOOL8


Component



Problem : Design

Problem : Improperly Operated

Person

Reference : 1








Experience.Flight Crew.Last 90 Days : 67.5





Events












Assessments




Narrative: 1

Prior to departure, I loaded the flight plan into the GPS, a GPS-155XL. This model GPS

requires the data cards to be changed when crossing the border between the US and

Mexico.

After crossing NELYN intersection, the captain instructed me to finish inputting the flight

plan into the GPS. I tuned the ACT VOR into both NAV radios, and the 357 radial (inbound)

was selected. After swapping the data cards, I input the remainder of our flight plan and

selected direct to ACT from the flight plan page. I selected the CDI selector back to GPS. I

put the USA card back into the GPS and the captain tried to review what I had input.

Because the cards were swapped, all of the waypoints in Mexico showed as "locked." I

swapped the cards again so the captain could see what input was.

We incorrectly assumed that the GPS would sequence to HOARY intersection as it was

listed as the next fix in the GPS flight plan. Because the MEX data card was still installed it

did not, and as a result, the aircraft continued on a 177 track for approximately 5 minutes

rather than the 193 course depicted on the SID. At that time, I noted that we had passed

ACT, and we realized the GPS failed to sequence to HOARY intersection, instead showing a

from indication and the ACT VOR as the active waypoint. We began a right turn in an

attempt to rejoin the departure as Fort Worth Center called to advise us that we were

approximately 8 miles left of course. As I tried to correct the issue with the GPS by

switching the data cards, we were cleared direct [to our destination].

One factor affecting our performance during this incident is a lack of recent experience

with this GPS. In our fleet [majority] are equipped with a GNS430 GPS, and this aircraft is

equipped with a GPS-155XL. While the operation is similar in many ways, they also differ

in several ways, notably the need to switch the data card when traveling across the

border. In retrospect, we should have waited until getting closer to Mexico to switch the

cards and load the remainder of the flight plan.

Additionally, though the pilot was receiving navigation information from the GPS, my CDI

was receiving information from the NAV radio. And, as such, I failed to effectively monitor

our position relative to ACT, and did not note station passage.

Synopsis

First Officer described the difficulties using the GPS-155XL on a cross border flight to

Mexico. The unit requires that data cards be switched prior to loading the Mexican portion

of the flight plan. Errors are made resulting in a track deviation.

ACN: 1381815

Time / Day

Date : 201608


Place

Locale Reference.Airport : UAO.Airport

State Reference : OR


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Ground : UAO


Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior



Flight Plan : None

Mission : Personal

Flight Phase : Taxi

Aircraft : 2

Reference : Y

ATC / Advisory.Ground : UAO


Make Model Name : Pitts Undifferentiated or Other Model



Mission : Personal

Flight Phase : Taxi

Person

Reference : 1
















Events

Anomaly.Conflict : Ground Conflict, Critical



Anomaly.Ground Incursion : Taxiway


Miss Distance.Horizontal : 20

Miss Distance.Vertical : 0

When Detected : Taxi



Assessments



Narrative: 1

There are several issues involved in this incident. First is my failure to contact Aurora

Ground Control for a clearance to taxi, and when I realized I had not done so my aircraft

had partially entered an active taxiway. Second, the Aurora Ground Controller issued an

inappropriate taxi clearance following my radio call without first checking the area to which

my aircraft had been cleared to taxi, there being another aircraft heading toward my

aircraft on the same taxiway. Third is the failure of the Pitts pilot to taxi at a safe and

prudent pace, and to maintain adequate forward visibility to be able to see and avoid

obstacles in the path of his aircraft. [After engine start] I neglected to stop at the end of

our hangar row and contact Aurora Ground Control for a taxi clearance. Instead I

continued to the ramp, then partially entered taxiway Alpha at the north exit from the

ramp. At this point I realized I had not contacted Ground Control and stopped. I then

contacted Ground Control, explained that I had forgotten to call for a taxi clearance, and

reported my position. The Aurora Ground Controller immediately issued a clearance to me

to taxi on Alpha to Runway 35. I repeated the clearance. Before I set the aircraft in motion

I looked south down taxiway Alpha, the direction in which I had been cleared to taxi.

Some fifty (50) [yards]away, and getting closer quickly at a faster-than-a-walk pace, was

a dark [colored] Pitts biplane making very shallow "S" turns, apparently oblivious to my

aircraft's position. I was about to say something into my microphone when the Ground

Controller commanded the Pitts to stop immediately, which he did approximately twenty

(20) feet from my aircraft. The controller then told me to hold my position, which I had

been doing without his instruction. At this point the Pitts pilot became very vocal when he

realized he had not seen my aircraft at all and had been totally dependent on the Ground

Controller to advise him of any obstacles in the path of his aircraft. He even admitted that

he could not see forward in his aircraft. The controller asked the Pitts pilot if he could

"make it past the Cherokee". The Pitts pilot replied sarcastically that he would move

completely out of the way, which he did by performing a 180 degree turn and moving onto

taxiway Alpha 2. The Ground Controller used the phrase "possible pilot deviation" at some

point during this time frame.

After the Pitts moved onto taxiway Alpha 2 the Ground Controller cleared me to taxi to

Runway 35 via Alpha. Soon the controller told me to call Aurora Tower and provided the

phone number. I taxied south on Alpha, then moved off to an open ramp area in front of a

hangar under construction, informing Ground Control of my intention. I then shut down

the engine and called Aurora Tower at the phone number provided. The Ground Controller

answered, asked for my name and phone number, and then told me to expect a call

shortly. [After a conversation with Tower personnel] I then started my aircraft, called

Ground Control, received a taxi clearance to Runway 35, where a run-up was performed

[and I departed].

I have flown from the Aurora State Airport, until recently an uncontrolled field, for over

thirty (30) years. Only within the past ten (10) months has there been an operating

control tower at this airport. I have less than six months of experience with this tower. My

flight was to take place on a beautiful summer day, to an aviation destination. My wife and

I did what we had always done - arrived at our hangar in plenty of time to obtain fuel,

check the tire pressure, and perform a thorough pre-flight inspection. Following the fuel

truck's departure I noticed that we had plenty of time before we needed to begin our

flight, but my wife and I agreed to get on our way early. This was perhaps the first link in

the chain of events. When it came time to start the aircraft's engine it seemed to be

another summer day with a flight at an uncontrolled field I had known for many, many

years. This was perhaps the second link. My wife was busy programming a GPS unit and

doing other tasks. We usually act as a team, but this time she did not notice that I had not

called Aurora Ground Control at the end of our hangar row to obtain a taxi clearance. This

was the third link in our chain of events. I do not know what made me realize I was no

longer operating from an uncontrolled field and that I had not called Aurora Ground

Control. I know that beginning to move onto taxiway Alpha is when I realized my error. I

stopped immediately, but with the nose of the aircraft, and perhaps the nose gear,

impinging on the taxiway surface area, but certainly not very far. My actions to this point

had been inappropriate for my level of experience.

Ground Controllers actions:

When I contacted Aurora Ground Control at the north exit of the ramp the controller

seemed "new" and inexperienced. He did not have the polished, self-confident speech of

an experienced controller. Link four? His immediate issuance of an ill-advised taxi

clearance to me appeared to me to show a lack situational awareness, since I assume he

had cleared the Pitts to taxi north on taxiway Alpha. He did recognize his error fairly

quickly, which was fortunate since the Pitts pilot showed no signs of stopping on his own.

Links five and six? As the Pitts pilot became more vocal, expressing disbelief that the

controller had not kept him informed about the possible obstacle in his way, that this was

the very reason he depended on controllers since he was unable to see forward in his

plane, his voice indignant, the controller uttered the phrase "possible pilot deviation." The

controller seemed to recover his composure quickly, continuing with his activities in

communicating with both pilots in a civil manner.

Pitts pilot's actions:

From our vantage point both my wife and I considered the Pitts' taxi speed to be

excessive. We were taught to taxi no faster than a person can walk. Also, the "S" turns

made by the Pitts were very shallow, seemingly only token movements, solely to keep the

plane aligned with the center of the taxiway. More pronounced (and at a slower pace) "S"

turns would have allowed the pilot to look out the side of his cockpit to actually see what

was in front of his aircraft, not simply the edge of the taxiway. By the pilot's tone of voice

and his choice of aircraft he appeared to be a "Type A" personality, perhaps with an ego.

The color of the Pitts was dark. It was not instantly visible on the taxiway. If this situation

had presented itself with a light color aircraft, I would have noticed it simply by peripheral

vision. Being dark it was not as noticeable. I believe the Pitts pilot's very vocal, indignant,

and sarcastic comments contributed to the escalation of this incident to a "possible pilot

deviation." He has lessons to learn from this scenario, as does the controller, I, and my

wife.

Synopsis

PA28 pilot reported a ground conflict with a tailwheel aircraft after the reporter failed to

call Ground Control for clearance.

ACN: 1381209

Time / Day

Date : 201608


Place




Environment



Light : Daylight


Aircraft

Reference : X


Make Model Name : PA-32 Cherokee Six/Lance/Saratoga/6X


Flight Plan : IFR

Mission : Personal

Flight Phase : Takeoff


Person

Reference : 1


















Events



Anomaly.Ground Incursion : Taxiway

Anomaly.Ground Incursion : Runway




Assessments




Narrative: 1

Low ceiling in the morning, didn't want to do an approach when I didn't know the new

GPS. I had just gotten the bill when they pushed the plane out and it was more than the

quote, Mr. X wasn't there to discuss it. I didn't know how to use the new system,

[someone] was going to show me but then he wasn't there. I had taken my airport

diagram books out of the plane before I dropped it off, I knew I needed to able to find the

safe taxi page.

The new motor is still in the break in phase. Lycoming recommends three minutes from

start up to take off until break in is complete. I used most of that trying to figure out the

GPS. I was having trouble loading the way point then trying to find the safe taxi page. I

gave up and called the tower. I told him I was ready to taxi but needed a progressive

because I had just gotten a new panel and I wasn't familiar with how to use it.

The tower told me to take A. Then talked to maintenance truck I think I then asked if I

was on the right path, it seemed like extra talking in the back ground, I was having

trouble hearing him. I went past the hold short which I thought I was supposed to do. He

gave me a 180 degree and then another 180 degree and to stop at the hold short. He

cleared me for takeoff. I guess I got confused at that point thinking I was lined up on the

runway. I did my run up and immediately took off. I was given vectors twice.

I was told to take a note down to call when I landed. I asked why and he said I had taken

off on the taxiway.

When I called, he asked me if I heard him tell me to stop and I said no. He said there was

a plane about to enter the taxi from the other end. He asked me if I saw it. I said no. He

said it seemed like I was taxing faster than normal, I told him I didn't think I was. Then I

told him about the new motor.

I realized while in the air the battery was dead on my headset. I have worked in the

construction business running loud equipment all my life. My hearing is not what it used to

be and the ANR headsets greatly assist my ability to hear and comprehend radio

communications in the otherwise loud aircraft environment. I do not often operate from

tower controlled airports and I was unfamiliar with the newly installed aircraft avionics

(Garmin 750). All of these factors contributed to my difficulty in finding my way on the

ground. In retrospect, I should have printed a copy of the airport diagram and reviewed it

before taxiing, and I should have had the avionics shop show me how to pull up the safe

taxi diagram (which was one of the reasons I upgraded the panel) so that I would know

how to use it on the first flight.

Synopsis

The Pilot of a Piper PA32-301 reported that due to not being familiar with the airport or

the new GPS that was just installed, he took off from the Taxiway.

ACN: 1381086

Time / Day

Date : 201608


Place




Environment


Light : Dusk

Aircraft

Reference : X



Make Model Name : EMB ERJ 190/195 ER/LR



Flight Plan : IFR

Mission : Passenger



Component



Problem : Failed

Person : 1

Reference : 1








Person : 2

Reference : 2









Events










Assessments




Narrative: 1

Aircraft had MEL 24-4, #1 IDG (Integrated Drive Generator) inop. We complied with the

MEL and had the APU running. During the initial climb out through 3,000 ft, APU GEN OFF

BUS CAUTION MESSAGE annunciated. The captain ran the QRH and the APU returned to

normal. Around 17,000 ft the message returned. We then elected to advise ATC and divert

to ZZZ. During the approach we noticed reverse sensing on the ILS so I disconnected the

autopilot. I continued to monitor our DME using GPS and PAPI. The glide slope and PAPI

are not coincident. Around 1500 ft on final tower switched to the correct ILS where we

noticed we were 1 dot high. I corrected back using electronic means but caused us to

descend at 1100 FPM through 1000 ft. We decided due to the nature of the situation it was

imperative to continue the approach and land. We were stabilized by 900 AGL. The

unstable approach was caused by the lack of electronic guidance until just prior to 1000

AGL.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

EMB190 flight crew experienced an APU generator failure after being dispatched with the

number one engine generator on MEL. The crew elected to divert to a suitable airport

which was slow in switching the ILS to the runway requested resulting in reverse sensing

and an unstabilized approach to 900 feet AGL.

ACN: 1376835

Time / Day

Date : 201607


Place

Locale Reference.Airport : DBQ.Airport

State Reference : IA


Environment



Light : Daylight


Aircraft

Reference : X

ATC / Advisory.Center : ZAU


Make Model Name : Small Aircraft



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS



Airspace.Class D : DBQ

Airspace.Class E : ZAU

Person

Reference : 1












Human Factors : Physiological - Other

Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Altitude : Excursion From Assigned Altitude










Assessments





Narrative: 1

Inbound to DBQ on an instrument flight plan, we were at 8,500 msl ready to begin our

descent for a visual approach to the airport. Chicago Center advised that the ATIS had

changed and I should listen to it again. The new ATIS revealed that the airport had just

gone IFR and they were now using the RNAV 18 approach. When I reported that I had the

updated ATIS, Center assigned a heading around 010 or 020, a descent to maintain 3,000

and said to expect vectors to the RNAV 18 approach. I took that to mean vectors to final

on the RNAV 18 and activated vectors to final RNAV 18 on our Garmin 430. I turned to the

assigned heading and began the descent.

We entered the cloud layer at about 4,000 feet. I was hand flying the aircraft and almost

immediately upon cloud entry began feeling disoriented with a distinct lean to the right.

Trusting the instruments I held the aircraft wings level and leveled off at 3,000. We were

in and out of the base of the cloud layer at this point.

Still struggling with the disorientation but stable according to instruments we flew on

expecting a turn to the right to vector to the final for RNAV 18. Instead the controller

asked me for direct WITOK, an initial approach fix that was still further north of my

position. Unfortunately, my GPS was already set for vectors to final (ZUGNI), and didn't

offer WITOK.

Now a little stressed and still fighting the disorientation, I tried to reset the GPS to show

the WITOK waypoint but as I was working with the GPS, the aircraft began an actual turn

to the right and a descent of about 500', allowing a view of the ground. I recovered,

stabilized and began climbing back to the assigned altitude but was already on a heading

toward the final approach fix inside of WITOK. I decided that manipulating the GPS was a

bad idea and asked the controller for a vector to ZUGNI. Instead of a vector he questioned

why I couldn't get to WITOK.

Before I could answer, he warned me that my altitude was 500' low asked if I could see

the ground. I said I could and that we were inbound to ZUGNI. He replied continue to

ZUGNI and contact tower. From there the rest of the approach was uneventful, we landed

without incident and taxied to the ramp.

I had used Garmin 430s frequently in other aircraft and felt familiar with their operation.

The feeling of disorientation was a surprise and a great distraction. Coupled with the

unexpected instructions, I was overwhelmed. I continued to fly the aircraft and we got

safely to landing but the experience was not ideal.

Going forward, I will fly more actual IMC approaches with an instructor in this aircraft to

become solidly proficient. I also need to re-familiarize myself with editing GPS flight plans

in the avionics. But, most importantly, I will now specify the initial approach fix I will use

on an approach and ask the controller for that fix. In the case of the DBQ RNAV 18

approach, there were four possible initial fixes I could have used, any of which, when

planned for in the GPS would have prevented the confusing instructions at a time when my

workload was heightened due to the disorientation.

Synopsis

General aviation pilot on an IFR flight plan reported getting vertigo while on vectors for an

RNAV approach. While attempting to make GPS entries 500 feet of altitude is lost and the

heading drifts to the right. ATC issues instructions that do not require GPS inputs and the

approach is successfully flown.

ACN: 1375241

Time / Day

Date : 201607


Place

Locale Reference.ATC Facility : RPHI.ARTCC



Environment


Aircraft

Reference : X

ATC / Advisory.Center : RPHI


Make Model Name : Boeing Company Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS


Component




Person

Reference : 1










Human Factors : Troubleshooting

Events


Anomaly.Inflight Event / Encounter : Other / Unknown




Result.Aircraft : Equipment Problem Dissipated

Assessments

Contributing Factors / Situations : Environment - Non Weather Related

Primary Problem : Environment - Non Weather Related

Narrative: 1

On arrival into RPLL, we experienced a dual GPS failure. Both GPS indicated invalid on the

CDU. This occurred on final approach to runway 24 around 20 miles from landing. We

were able to continue and land visually uneventfully and the AC discrepancy was added to

the logbook. We were informed by the local station maintenance that this is a known issue

that has happened repeatedly and is being investigated. Both GPS systems were

confirmed normal operation and the discrepancy was cleared on the ground before

departure. On departure on Runway 06, once again both GPS signals were lost soon after

departure. At 30 miles to the east of RPLL while proceeding toward JOM VOR, both GPS

systems were operating normally. They both seemed to come back to normal reception

simultaneously. There were no further anomalies during the remainder of the flight.

Synopsis

An air carrier flight crew reported a GPS anomaly during arrival and departure at Manila

Airport (RPLL). The anomaly was transient and not thought to be aircraft related. Manila

station personnel indicated that this was a known issue and was being investigated.

ACN: 1374456

Time / Day

Date : 201607


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Twin Bonanza 50



Flight Plan : VFR

Mission : Personal

Nav In Use : GPS




Component

Aircraft Component : Engine

Manufacturer : Lycoming


Problem : Failed

Person

Reference : 1







Qualification.Flight Crew : Flight Engineer



Events





Result.Flight Crew : Took Evasive Action




Result.Flight Crew : Inflight Shutdown


Result.Aircraft : Aircraft Damaged

Assessments



Narrative: 1

During last portion of cruise phase at 6,500 feet MSL weather was Clear Air Visibility Okay

(CAVU). Had just changed back to main tanks and a few min latter the left engine began

to "Rumble and miss" like it may have some issue with the fuel supply from left main tank.

I was just looking at engine gauges when there was a loud bang and I saw the oil service

port cover fly open and oil spewing out all over the cowling.

As I retarded the throttle I noticed damage to the cowling and lots of oil spewing out when

throttle was moved anywhere forward of idle. I advance the right engine to Maximum

Expected Takeoff Power (METO) power and I then elected to shut down the left engine.

After feathering the left engine and insuring there was no other issue requiring my

attention I called the ATC facility that had been providing flight following to declare an

emergency and help with selection of the nearest suitable field. The Twin Bonanza flies

very well on one engine after the malfunctioning engine is feathered. I was able to hold

6,500 feet at METO power and began a slow turn toward the nearest suitable airport (30-

35 nm distant) . The best wind runway is 8,000 feet long and 150 feet wide with fire

equipment. That field was far superior to the nearest airport (25 NM north with a 4,000

foot runway and required a low level course reversal to land into the 15 to 20 knot winds)

and no dedicated fire department.

This aircraft has a Garmin 480 WAAS GPS. Among the many features is the Nearest p.b.

Using that feature I was able to review several airports before choosing [my diversion

airport]. After reprograming the Garmin 480 for the new destination I proceeded direct to

the RNAV/GPS FAF. My power was reduced to adjust the descent to cross the FAF a few

hundred feet high and the flaps and gear were configured to approach flaps during the

initial crossing and as I approached 1,200 feet AGL I extended the gear. Final flaps were

extended at approximately 300 AGL. With the gear down ad full flaps this aircraft requires

almost METO power to maintain the glide path in a 20 knot headwind. The landing was

normal and after clearing the runway I had the fire trucks follow me to the ramp in case

the shutdown generated some kind of abnormal issue. After completing the shutdown

checklist and securing the aircraft I cancelled the emergency. Many thanks to the firemen

and ATC for a superb job in all my requests. Hard to be hotter than Hades on the ramp as

the ambient temp was near 100 degrees F.

Post flight inspection revealed a connecting rod bolt had failed, and the rod end impacted

the crankcase and destroyed the impacted area and drove the camshaft thru the top of the

engine case. This generated numerous pieces of shrapnel and considerable secondary

damage. The newly overhauled propeller had all 3 blades damaged with shrapnel and the

engine cowling was punctured with a few small holes in several places.

Engine history. When I purchased this used engine (Lycoming GO 480) it did not have oil

filters as part of it's original equipment. The engine had been on an oil analysis program

and all parameters were "Nominal". Before entry into service on this airframe I installed

some aftermarket STC'ed oil filter mounts and the first few oil changes generated quite a

bit of metal. We surmised the metal was part of what had been left behind during

operations without an oil filter. The metal particles were mostly fine particles. After a

couple oil filter changes and exams at 10 hour intervals the particles diminished to

"normal". At the time of this failure the engine was approx. 150 hours past TBO. I had

planned to overhaul it after the summer flying season was completed. The engine was

equipped with an oil filter and had just completed an annual inspection with no metal

found in the filter material. Additionally the engine was running as "Smooth as a top"

when it failed with no warning. Photos from the inside of the engine revealed the

crankshaft journal had not suffered from lack of lubrication. The connecting rod is barely

visible and it appears that one rod bolt was bent in its respective location but the second

bolt could not be seen. I surmise that the missing rod bolt failed for reasons that are not

clear at this time. The shuddering and missing during the initial part of the engine failure

was probably the engine balance being disturbed as each successive revolution of the

crankshaft bent the remaining bolt and when it failed the connecting road detached and

the crankshaft drove the rod end thru the top of the engine case. This impact on the

camshaft forced it thru the top of the crankcase generating the shrapnel that impacted the

three propeller blades and engine cowling.

Glad I had two engines and the training necessary to use the capacity of the aircraft. NO

more flying past TBO. I have heard lots of stories about folks flying well past TBO with just

a top overhaul or minor maintenance. In my case this engine had never suffered any

damage with the exception of exhaust valve failure that did not require an inflight

shutdown and did not puncture the piston or generate metal debris in the engine. A new

cylinder was installed and all parameters were normal. The oil pressure (60psi at normal

operating temps) was the same as it had been when the engine was originally installed.

There was absolutely NO indication this engine was in trouble before it failed.

The other engine is already being scheduled for overhaul and whatever engine I put on

this aircraft to ferry home will be overhauled before regular flying resumes.

Synopsis

The pilot of a Beechcraft Twin Engine Bonanza reported that the Left Engine failed during

cruise flight.

ACN: 1373014

Time / Day

Date : 201607


Place




Environment



Light : Daylight


Aircraft

Reference : X


Aircraft Operator : Corporate

Make Model Name : Citation Excel (C560XL)



Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1



Reporter Organization : Corporate
















Person : 2

Reference : 2



Reporter Organization : Corporate




Qualification.Flight Crew : Flight Engineer







Human Factors : Time Pressure


Human Factors : Physiological - Other







Events












Assessments


Contributing Factors / Situations : Company Policy



Narrative: 1

We stopped in ZZZ to drop off one passenger with a quick turn out. I was SIC on this leg.

The PIC is a contract pilot whom I have never flown with until this trip. I walked the

passenger inside the FBO and paid the landing fee while the Captain stayed in the plane

and got the IFR clearance for our departure. I came back to the plane, shut the door, and

asked for a briefing on our clearance. He gave me a briefing that included a runway,

heading, altitude, route, frequency, and squawk code. I asked him which way to turn after

departure because it was just about a 180 degree turn, he said that he couldn't remember

and to just ask as soon as we check on with departure. This was red flag #1 that I did pick

up on.

We depart and I switch to Departure and immediately ask which way he wanted us to turn

and the controller said to make a right turn to 090 deg. The controller immediately comes

back and says you do realize that you had a void time of XA:50 and right now it's XA:52. I

looked over at the Captain in confusion and because I wasn't aware of this void time. So I

apologize to the controller. A few minutes later the controller asked us to go direct to

some fix that wasn't loaded in our GPS or on the route the Captain briefed me on. I told

the controller that the fix wasn't on our flight plan and he said yea it should be! I read him

off a few of our next waypoints and he said that it was wrong and we were cleared XYZ.

So I loaded the correct route in our GPS and again apologize to the controller for the

confusion.

What I feel really caused the issue was the lack of correctly copying down the clearance

and briefing the SIC on every aspect of the clearance including the void time.

Unfortunately, I was inside with the passenger when the Captain was copying this down,

so I didn't have any way of backing him up on copying down the clearance. The Captain I

think is 70 and we had two early mornings of flying. So maybe age and fatigue could have

been a human performance limitation. Afterwards, I talked to our Chief Pilot and Safety

Director about this, specifically the void time issue. They are going to be limiting the use

of this contract pilot.

Narrative: 2

Aircraft clock showed XA:50 on take off and XA:51 when contacted. Do not believe there is

a problem, but submitting in case there is a question.

Synopsis

CE-560XL flight crew reported they were criticized by Departure Control about their void

time and route of flight after taking off.

ACN: 1371620

Time / Day

Date : 201607


Place

Locale Reference.ATC Facility : HCF.TRACON

State Reference : HI


Environment



Light : Daylight


RVR.Single Value : 2400

Aircraft

Reference : X

ATC / Advisory.Tower : HNL


Make Model Name : PA-31 Navajo/Chieftan/Mojave/T1040



Flight Plan : VFR

Mission : Personal



Airspace.Class B : HNL

Person

Reference : 1













Events






Assessments

Contributing Factors / Situations : Airport

Contributing Factors / Situations : Airspace Structure

Contributing Factors / Situations : Chart Or Publication



Primary Problem : Airspace Structure

Narrative: 1

Flying back from Honolulu I was authorized to enter the Class Bravo airspace at Honolulu

and I requested vectors to [the] Runway. Given vectors and an altitude of 2,000 feet until

5 DME I was then handed off to tower and given clearance to land. No other restrictions

were given. Upon being cleared to land, I DID. And I went from where I was to where the

runway was by the safest and most expeditious manner.

ATC failed to give further restrictions and further failed to inform me of the airspace they

vectored me into, I noticed on my GPS that I was going to cut the outer edge of Kalaeloa

airport's airspace, as it has a ceiling of 2,000 feet. But given a new clearance, one to land

and not given any other restrictions, I began my descent and landed uneventfully.

While taxing to park I was given a phone number to call. It was the Honolulu Tracon

telling me I had violated Kalaeloa's airspace by descending after I was cleared to land. I

was aware of the airspace but as I stated, when switched to tower I was cleared to land

with no further instructions to maintain 2,000 feet. I therefore entered the landing phase

of the flight thinking I had complied with each controllers instructions.

Synopsis

A general aviation pilot reported ATC advised of an adjacent airspace violation after being

given a clearance to land by the Tower with no restriction cited.

ACN: 1371605

Time / Day

Date : 201607


Place

Locale Reference.Airport : OCF.Airport

State Reference : FL


Environment


Light : Daylight

Ceiling : CLR

Aircraft

Reference : X

ATC / Advisory.Tower : OCF





Flight Plan : None

Mission : Personal

Nav In Use : GPS

Nav In Use.Localizer/Glideslope/ILS : Runway 36

Nav In Use.VOR / VORTAC : OCF


Airspace.Class D : OCF

Component




Person

Reference : 1












Events








Assessments



Narrative: 1

I was flying multiple ILS 36 practice approaches at OCF under the hood (with a safety

pilot). My Nav 1 is a Garmin 430W. After the second approach I planned on flying the

published missed for a hold. On the missed, the procedure calls for flying the OCF VORTAC

R-355 to the holding fix. On missed, I engaged the autopilot which initiated a standard

turn to the right to intercept what I then noticed to be the magenta course line which was

well to the right of the heading called for in the procedure. The heading taken by the

autopilot to the magenta line turned us approximately 35 degrees to the right of the

published missed course, away from the runway, and in the general direction of the

control tower. It was confusing at the time at a critical stage of my flight (climb-out on

missed in simulated instrument conditions). However, there was no conflicting traffic, the

tower controllers didn't mention it, and my safety pilot didn't comment on it.

I became alarmed after the flight when I viewed my ground track on Foreflight and saw

that my heading on that botched missed approach took me generally towards the control

tower. I simulated the approach on the 430W trainer at home to try to understand what

happened. What I discovered, and since believe I have confirmed with other pilots, is that

my Garmin 430W navigation data base (which is current) erroneously renders the starting

point of the missed approach course to the NE side of the runway (the OCF VORTAC is

located on the NW side of the runway). The autopilot was attempting to intercept the

erroneous missed approach course.

The problem arose because the navigation data is incorrect and I spent time trying to

figure out why things were happening like they were. I should have been flying the

airplane where the approach plate directed me regardless of the GPS magenta line.

Contributing to the problem was my bias towards believing my automation over myself,

my concern that deviating from its guidance would endanger the flight, and the fact that

the problem developed during a critical stage of the flight (climb-out in a high

performance, complex airplane in simulated instrument conditions on missed approach).

I'll definitely stick to the approach plates over my automation/GPS in the future (this

situation has reformed my bias). Also, I'll ask my safety pilot (who is instrument rated) to

follow along the approach procedures on these practice approaches more closely for

deviations; we've evidently lapsed into a mere "see and avoid" role for him.

Synopsis

A general aviation pilot reported that the GPS directed a missed approach course that did

not agree with the published procedure for the ILS Runway 36 at OCF.

Documents

Global Positioning System (GPS) Reports Database Report Set . Global Positioning System (GPS) Reports . Report Set Description .....A variety of reports referencing use of