non-tower airport incidents - asrs - aviation safety ...1 of 50) synopsis rv12 pilot reported that...

ASRS Database Report Set

Non-Tower Airport Incidents

Report Set Description .........................................A sampling of reports involving operations at non-tower airports.

Update Number ....................................................32.0

Date of Update .....................................................December 28, 2017

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

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

Type of Records in Report Set.............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

Report Synopses

ACN: 1483534 (1 of 50)

Synopsis RV12 pilot reported that after landing on Runway 32 at GAI, the taxiways were not

available due to construction. He was forced to taxi onto the grass due to an aircraft on

short final.

ACN: 1482595 (2 of 50)

Synopsis Helicopter pilot reported a NMAC with a UAV shortly after takeoff from a hospital.

ACN: 1481817 (3 of 50)

Synopsis Pilot reported parachute operations in the LMO vicinity put skydivers and aircraft in danger

because of the zone's proximity to V220 and V85. Reporter also stated, regular CTAF

communications may interfere with the "jumpers away" call.

ACN: 1481192 (4 of 50)

Synopsis C172 pilot reported a hard landing resulted after he encountered rotor wash from a

helicopter operating on the ground near the approach end of the runway.

ACN: 1480561 (5 of 50)

Synopsis Phenom 300 flight crew reported that a tree protrudes into the normal 3 degree glideslope

for Runway 17 at THV.

ACN: 1476706 (6 of 50)

Synopsis Business Jet flight crew reported that upon taking the runway at MTJ a GA pilot announced

that he was going around. The crew reported that this was the first transmission from the

GA Pilot.

ACN: 1476229 (7 of 50)

Synopsis Dash 8 Captain reported executing a go-around after encountering wake turbulence on

short final in trail of an E2 military aircraft.

ACN: 1476076 (8 of 50)

Synopsis An instructor reported that his student, flying a light sport aircraft, was stuck on a runway

with the brakes locked. The student injured himself in an attempt to check the brakes.

ACN: 1476074 (9 of 50)

Synopsis A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the

repair made by a local mechanic did not have the proper documentation.

ACN: 1476071 (10 of 50)

Synopsis DA20 flight instructor and student reported an NMAC with a Learjet departing JNX airport.

ACN: 1475797 (11 of 50)

Synopsis Diamond DA 20 pilot reported having a near collision with another aircraft while in the

traffic pattern at a non-towered airport.

ACN: 1475773 (12 of 50)

Synopsis Bonanza 35 pilot reported an NMAC with another light aircraft in the pattern at MLE

airport.

ACN: 1475474 (13 of 50)

Synopsis Cirrus Pilot reported going around after a bounced landing that resulted in a prop strike.

ACN: 1475444 (14 of 50)

Synopsis Pilot of a general aviation aircraft reported a near miss while landing at an uncontrolled

airport because the wrong frequency was dialed in on the radio panel.

ACN: 1475141 (15 of 50)

Synopsis C150 instructor reported engine roughness and loss of power after demonstrating a slip at

3,000 feet with a recovery at about 100 feet AGL with a climb to pattern altitude and a

successful landing. Instructor reported probable carb icing.

ACN: 1475140 (16 of 50)

Synopsis GA pilot reported a taxiway excursion while taxiing to Runway 3 at JNX.

ACN: 1474449 (17 of 50)

Synopsis GA pilot reported being cutoff on final at BID by another GA aircraft that necessitated a

go-around.

ACN: 1474439 (18 of 50)

Synopsis Turbojet pilot reported executing a go-around on the SZT Runway 02 final because a crane

protruded into the runway's visual descent path. The crane is mobile and NOTAMed, but a

danger to transient pilots and others.

ACN: 1474435 (19 of 50)

Synopsis SR20 flight instructor reported that another aircraft pulled onto the runway while they

were on short final.

ACN: 1473537 (20 of 50)

Synopsis Aeronca Pilot reported landing in an open field due to a loss of engine power.

ACN: 1473534 (21 of 50)

Synopsis Corporate jet pilot reported unknowingly flying through a military drop zone at MZJ during

final approach to AVQ.

ACN: 1473146 (22 of 50)

Synopsis Ground observer reported witnessing an NMAC between two light aircraft on short final to

DYL airport.

ACN: 1473133 (23 of 50)

Synopsis M20E pilot reported that after being unable to raise the landing gear, the gear collapsed on

the landing roll.

ACN: 1473112 (24 of 50)

Synopsis GA pilot reported taking off over emergency services that were unknowingly on the

runway.

ACN: 1472462 (25 of 50)

Synopsis C172 pilot reported an NMAC with an RV-7 on short final at O88 airport.

ACN: 1472139 (26 of 50)

Synopsis Cessna 172 pilot reported that during taxi the aircraft went off the taxiway damaging the

lower part of the rudder.

ACN: 1471858 (27 of 50)

Synopsis PA28 pilot reported engine malfunction that resulted in an emergency landing. Following

corrective maintenance and subsequent testing, a second takeoff was attempted with an

additional emergency landing.

ACN: 1471845 (28 of 50)

Synopsis Helicopter instructor pilot reported a Near Mid-Air Collision in the traffic pattern due to an

aircraft departing in the opposite direction.

ACN: 1471547 (29 of 50)

Synopsis C140 pilot reported a ground conflict occurred afterlanding when another light aircraft

touched down on the opposite direction runway. The aircraft passed each other midfield.

ACN: 1471152 (30 of 50)

Synopsis PA-28 pilot reported landing on a rural highway after experiencing an engine failure.

ACN: 1470131 (31 of 50)

Synopsis PA-28 pilot reported observing conflicting traffic and executed rapid evasive maneuver to

avoid a midair collision that was not displayed on TIS.

ACN: 1470114 (32 of 50)

Synopsis A C150 pilot reported taking evasive action to prevent airborne conflict with a no radios

aircraft entering approach pattern to an uncontrolled airport.

ACN: 1469546 (33 of 50)

Synopsis DA20 student pilot and the observing CFI reported that upon landing during a solo flight

the aircraft turned sharply and departed the runway.

ACN: 1469242 (34 of 50)

Synopsis GA pilot experienced an airborne conflict with another aircraft that had announced

entering the pattern for Runway 20, but wound up on approach to Runway 02 in conflict

with the reporter. Evasive action was taken by the reporter and the NORDO pilot departed

to the south without making radio contact.

ACN: 1469241 (35 of 50)

Synopsis C172 flight instructor reported striking a runway threshold light during landing with his

student at the controls.

ACN: 1469199 (36 of 50)

Synopsis GA pilot departing using CTAF procedures reported a NMAC with a vintage aircraft

departing on an adjacent runway without announcing on CTAF.

ACN: 1469156 (37 of 50)

Synopsis GA flight instructor reported taking evasive action from a helicopter as his student

departed SCD following a touch and go. The helicopter did not have a radio installed.

ACN: 1468447 (38 of 50)

Synopsis BE58 Baron pilot reported a landing gear motor failure and manual extension.

ACN: 1468296 (39 of 50)

Synopsis Air carrier Captain reported questioning the wisdom of using BFF as an alternate with no

tower, no gates, one frequency for CTAF and UNICOM, and no ACARS reception.

ACN: 1468195 (40 of 50)

Synopsis C172RG flight instructor reported the student pilot inadvertently grabbed the gear handle

instead of the carb heat and caused the nose gear to collapse on landing.

ACN: 1468194 (41 of 50)

Synopsis A Cessna 172 instructor pilot reported the engine failed right after takeoff.

ACN: 1468179 (42 of 50)

Synopsis A flight instructor observer pilot reported not being assertive enough and allowed the pilot,

who was presumably operating under VFR, to proceed to and land at an airport that was

below VMC.

ACN: 1467196 (43 of 50)

Synopsis General aviation flight instructor reported a near mid air collision after departure from a

CTAF airport.

ACN: 1466538 (44 of 50)

Synopsis HIO Tower Controller and pilot reported of a Class Delta airspace violation and a NMAC.

ACN: 1466524 (45 of 50)

Synopsis HCF Controller reported an airborne conflict between an IFR departure and a VFR aircraft.

ACN: 1466511 (46 of 50)

Synopsis Glasair pilot reported that during final approach prior to touchdown, a Pilatus took the

active runway.

ACN: 1466499 (47 of 50)

Synopsis Experimental aircraft pilot reported that his foot slipped off the rudder pedal on landing

resulting in a runway excursion.

ACN: 1466180 (48 of 50)

Synopsis PA34 pilot reported rejecting takeoff after observing unannounced traffic on short final

landing on the opposite direction runway.

ACN: 1466178 (49 of 50)

Synopsis Cessna pilot reported an NMAC with another light aircraft in the vicinity of JNX airport.

ACN: 1465911 (50 of 50)

Synopsis Two instructor pilots, both flying separate C172 aircraft, reported an NMAC with each

other in the pattern.

Report Narratives

ACN: 1483534 (1 of 50)

Time / Day

Date : 201709

Local Time Of Day : 1801-2400

Place

Locale Reference.Airport : GAI.Airport

State Reference : MD

Altitude.AGL.Single Value : 0

Environment

Flight Conditions : VMC

Weather Elements / Visibility.Visibility : 10

Light : Daylight

Ceiling.Single Value : 12000

Aircraft

Reference : X

ATC / Advisory.CTAF : GAI

Aircraft Operator : Personal

Make Model Name : RV-12

Crew Size.Number Of Crew : 1

Operating Under FAR Part : Part 91

Flight Plan : VFR

Mission : Training

Flight Phase : Taxi

Route In Use : Direct

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Personal

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Student

Experience.Flight Crew.Total : 48

Experience.Flight Crew.Last 90 Days : 9

Experience.Flight Crew.Type : 48

ASRS Report Number.Accession Number : 1483534

Human Factors : Situational Awareness

Events

Anomaly.Conflict : Ground Conflict, Less Severe

Anomaly.Ground Excursion : Runway

Detector.Person : Flight Crew

When Detected : Taxi

Result.Flight Crew : Took Evasive Action

Assessments

Contributing Factors / Situations : Airport

Contributing Factors / Situations : Chart Or Publication

Primary Problem : Airport

Narrative: 1

GAI has published two NOTAMs that express the following information:

TAXIWAY F, E, D, TAXIWAY PARALLEL TAXIWAY ADJACENT RUNWAY 14/32 BETWEEN

TAXIWAY F AND TAXIWAY C CLOSED. XX SEP XA:22 2017 UNTIL YY XI:00 2017.

And:

TAXIWAY ALL BETWEEN SELF FUEL RAMP AND RUNWAY 14 THRESHOLD CLOSED. XX SEP

XB:34 2017 UNTIL YY XI:00 2017

The NOTAMs only address the taxiways. No mention of the runway exits to the taxiways.

NOTAMs lack any real actionable detail. Unfortunately, the A/FD (Airport/Facility Directory)

diagram of the airport does not show any of the taxiway designations - only shows the

actual taxiways, not the labeling. Hence, a landing pilot cannot know that all of the runway

32 taxiway exits other than the first one are closed (for which, any aircraft other than a

STOL aircraft won't be an option). These exits are closed, literally with zero asphalt.

Hence, landings on either 32 or 14 require a taxi back at landing or departure with no

ability to exit the runway at any other point than the start of 32 (which is not described in

the NOTAMs).

Here, I landed on 32 and because the taxiways were not available, I needed to taxi back.

However, another aircraft was behind me on final. While I pulled off into the grass to avoid

a possible on-runway conflict, the pilot in the twin behind me executed a go around

successfully. The core issue here is the appropriateness of how construction at this airport

is undertaken. Without any taxiway (runway exits specifically) available, the potential for a

realized conflict is much higher than it needs to be. The airport should have planned the

construction in appropriate phases to avoid the unavailability of at least one exit at each

end of the runway (regardless of the taxiway availability, minimally provide exit space to

resolve a possible conflict), reducing the real possibility of an incident or accident. Given

the very high traffic level at this airport, the approach to construction and closures was not

well thought out in respect to flight safety.

Synopsis

RV12 pilot reported that after landing on Runway 32 at GAI, the taxiways were not

available due to construction. He was forced to taxi onto the grass due to an aircraft on

short final.

ACN: 1482595 (2 of 50)

Time / Day

Date : 201709


Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : ZZZ

Aircraft Operator : Air Taxi

Make Model Name : Helicopter



Mission : Ambulance

Flight Phase : Climb

Airspace.Class G : ZZZ

Aircraft : 2

Reference : Y

Make Model Name : UAV - Unpiloted Aerial Vehicle

Operating Under FAR Part.Other

Flight Phase : Cruise


Person

Reference : 1



Reporter Organization : Air Taxi

Function.Flight Crew : Single Pilot

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Rotorcraft



Events

Anomaly.Conflict : NMAC


Miss Distance.Horizontal : 0

Miss Distance.Vertical : 25

When Detected : In-flight

Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Human Factors

Primary Problem : Human Factors

Narrative: 1

Near midair [with] a small drone flying one block east of the hospital. Our aircraft was on

initial climb out at approximately 65 knots and was climbing from helipad to 2200 MSL.

Elevation [at] time of near miss was probably 100-150 feet above helipad which is

approximately 1250 MSL. The primary departure path from this helipad is standardized

due to close noise sensitive areas and must be protected from drone activities and

intrusions due to high flight volume around the hospital. We had to look up through the

rotors to keep it in sight as it passed directly over the aircraft by about 25-50 feet. We saw

it at the last second and had no time to react.

Ground all private drones. They are going to cause a mishap with a manned aircraft, the

regulations for their operation do not provide helicopters with a margin of safety that is

acceptable to flight crews who cannot see them because they are too small. The drones

also do not have lights or markings that aid in their visual acquisition. They also do not

register on TCAS or other radar systems. Alternately, "no drone" fly zones within 1 NM of

all hospital helipads.

Synopsis

Helicopter pilot reported a NMAC with a UAV shortly after takeoff from a hospital.

ACN: 1481817 (3 of 50)

Time / Day

Date : 201709


Place

Locale Reference.Airport : LMO.Airport

State Reference : CO

Altitude.MSL.Single Value : 8500

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : LMO


Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer



Flight Plan : None

Mission : Personal

Flight Phase : Descent


Airspace.Class E : D01

Person

Reference : 1






Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Air Transport Pilot (ATP)

Qualification.Flight Crew : Multiengine






Human Factors : Workload


Human Factors : Distraction

Events

Anomaly.ATC Issue : All Types

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Inflight Event / Encounter : Other / Unknown





Result.Flight Crew : Became Reoriented


Assessments


Contributing Factors / Situations : Airspace Structure


Contributing Factors / Situations : Procedure

Primary Problem : Procedure

Narrative: 1

On a frequently flown direct-route round-trip route to and from BDU from the north, three

open parachutes were encountered at or very near HYGEN intersection. There is a

parachute symbol southwest of LMO between the LMO runway depiction and the HYGEN

depiction on the sectional chart. HYGEN is also depicted on the IFR Low chart. The A/FD

(Airport/Facilities Directory) for LMO states "Parachute jumping on and invof arpt primarily

of rwy, avoid overflights mid fld." Also in the A/FD there is a "Parachute Jumping Area"

depicted as being nearly adjacent to taxiway B at LMO.

In my opinion, parachute operations southwest of LMO are extremely hazardous and

should be terminated. Parachutists drop paths vary considerably depending on winds,

altitude, and other factors, and in this encounter their paths were very near HYGEN

intersection, a crossing-point of two significant airways, V-220 and V-85. During a

common VFR practice of tracking along and over airway routes and intersections such as

HYGEN, airplanes' altitudes are often flown that are lower than IFR minimum crossing

altitudes and that fact could put aircraft in conflict with free-falling parachutists that had

exited their jump planes but had not yet descended to where they open their chutes, and

therefore would be very difficult to see and avoid in time. HYGEN is less than a mile from

the parachute depiction on the sectional chart.

The parachute symbol is only about 1/3 of a mile from the approach path for the VOR-

DME-A instrument approach for LMO, for which the approach path, based on a VOR, is

variable since it is based on the positional limitations of BJC VOR that is 15 miles distant.

The parachute symbol is similarly 1/3 of a mile from the approach path for the RNAV

(GPS)-B approach into LMO. Both of these approaches are favorites for practice by locals

in VMC, when parachutists are frequently active. The approach paths for both of these

approaches crosses exactly over the "Parachute Jumping Area" that is depicted adjacent to

taxiway B at LMO. In other words, a practice instrument approach would pass exactly

through the parachutist's landing area at the airport essentially at the missed approach

point. The AFD admonition to "avoid overflights mid fld" is in direct conflict with the

instructions to be followed when practicing these two instrument approach procedures.

The jump plane pilot routinely makes a call on the CTAF frequency when his jumpers are

away, but a pilot approaching the airport may miss that one warning if he or she is

listening to the LMO AWOS-3. Additionally, the jump plane pilot's communication could be

blocked by other voice traffic on the CTAF. The "jumpers away" call is easily missed. If an

aircraft is cruising just a thousand or two thousand feet below the jump plane when the

"jumpers away" call is made, the aircraft's pilot may not be able to see free-fallers in time,

and not have time to avoid free-falling parachutists.

I believe this situation is a disaster waiting to happen and I hope you can influence the

powers that be to take action. I do not wish to publish this recommendation at some

future time because of hearing of the death of a parachutist and possibly the occupants of

an aircraft if a parachutist goes through the windscreen of an aircraft.

Synopsis

Pilot reported parachute operations in the LMO vicinity put skydivers and aircraft in danger

because of the zone's proximity to V220 and V85. Reporter also stated, regular CTAF

communications may interfere with the "jumpers away" call.

ACN: 1481192 (4 of 50)

Time / Day

Date : 201709


Place

Locale Reference.Airport : MDQ.Airport

State Reference : AL


Environment



Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : MDQ


Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : None

Mission : Personal

Flight Phase : Final Approach

Route In Use : Visual Approach

Airspace.Class G : MDQ

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : MDQ

Aircraft Operator : Military

Make Model Name : Chinook (CH-47)



Mission : Ferry

Flight Phase : Taxi

Person

Reference : 1











Events

Anomaly.Inflight Event / Encounter : Weather / Turbulence

Anomaly.Inflight Event / Encounter : Unstabilized Approach




Assessments



Narrative: 1

I was on a final stabilized VFR approach to runway 18 at MDQ and just about to flare when

I encountered significant turbulence from a Chinook helicopter, both rotors turning, that

was waiting to takeoff from a spot on the grass between the touchdown zone of runway 18

and the parallel taxiway. The turbulence hit me just at about the flare and I was barely

able to salvage a very hard landing.

This is an airport that has significant helicopter activity. I believe some airport rules should

be considered to restrict this type of helicopter operation near the approach end of the

active runway as an effort to eliminate/minimize such turbulence.

Synopsis

C172 pilot reported a hard landing resulted after he encountered rotor wash from a

helicopter operating on the ground near the approach end of the runway.

ACN: 1480561 (5 of 50)

Time / Day

Date : 201709


Place

Locale Reference.Airport : THV.Airport

State Reference : PA

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : THV

Aircraft Operator : Fractional

Make Model Name : EMB-505 / Phenom 300



Flight Plan : IFR

Mission : Passenger



Airspace.Class E : THV

Person : 1

Reference : 1



Reporter Organization : Fractional

Function.Flight Crew : Captain

Function.Flight Crew : Pilot Not Flying




Person : 2

Reference : 2




Function.Flight Crew : First Officer





Events

Anomaly.Inflight Event / Encounter : CFTT / CFIT




Assessments




Primary Problem : Ambiguous

Narrative: 1

I was the PIC, and the Pilot Monitoring. The SIC was flying a briefed visual approach

backed up with a RNAV (GPS) Rwy 17 approach which has a 3 degree Glidepath. Inside of

a mile from the end of Runway 17, the SIC verbalized and adjusted aircraft pitch and rate

of descent because a tree appeared to be close off the right nose. There were no Terrain,

Obstacle, or Descent Rate warnings. A normal landing was made over a blast fence that

was not noted on the 10-9 page.

It was Day VFR when we flew this approach. If we had continued the approach as

depicted, the tree on short final would have been very close to the 3 degree glidepath.

This approach (THV 12-1) was dated 18 Jul 14, and it's possible this tree had grown in the

past 3 years. The PAPI is shown on the 10-9 page to be 4.5 degrees, quite a bit different

than 3.0 degrees on the RNAV (GPS) 17 approach. Flying the PAPI angle at 120 knots

would result in a descent rate of close to 1000 fpm. In addition, the blast fence was not

mentioned on NOTAMS or on the 10-9 page. The 10-9 page also does not show the tree

on short final. The 12-1 page for the RNAV (GPS) 17 does mention in note 3, that landing

on Rwy 17 at night is not authorized. I feel that this approach is also not safe in IFR

conditions.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

Phenom 300 flight crew reported that a tree protrudes into the normal 3 degree glideslope

for Runway 17 at THV.

ACN: 1476706 (6 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : MTJ.Airport

State Reference : CO


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : MTJ

Aircraft Operator : Fractional

Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Ferry

Flight Phase : Takeoff

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : MTJ





Flight Plan : VFR

Mission : Personal


Airspace.Class E : ZDV

Person : 1

Reference : 1








Person : 2

Reference : 2




Function.Flight Crew : First Officer




Events

Anomaly.Conflict : Airborne Conflict



Assessments



Narrative: 1

While preparing to depart Montrose we were taxiing to runway 31 giving position reports

of the status of our intentions to take off at runway 31. No aircraft responded except for a

glider south of the field and we advised we were going north upon takeoff. Upon reaching

the runway we scan the area I cleared the left area and my PM (Pilot Monitoring) in the

right seat cleared the runway approach area. We then made another announcement that

we are taking runway 31. Upon lining up with runway 31 we had an aircraft yelling at us

[that] we had cut him off and was going around. At this time we had advanced the

throttles and I looked at the TCAS and now saw an aircraft approximately 2 miles away at

700 ft AGL. Upon landing [a company representative] called and advised me that two

witnesses and I called the company and advise them of what had taken place and gave

their version of what they saw.

[Personnel at the local FBO] saw both aircraft (they were physically at the approach end of

31 and heard the commotion on the radio they then stated that we were airborne before

the small Cessna 172 was even at the threshold going around. I have the contact

information of the two witnesses and both myself and my PM (Pilot Monitoring) did not see

any aircraft in the area nor did we hear any transmissions before we announced taking the

active runway. Again once we knew anything was happening we were already on the

takeoff roll and the other aircraft advise they were going around.

I feel we followed all SOP's and standard VFR callouts and the aircraft was just not seen or

heard before he said he was too close and commented on the price of kerosene.

Narrative: 2

Upon beginning taxi, I PM (Pilot Monitoring) began making position and intent reports on

Unicom/CTAF as we began our taxi to rwy31. A glider responded to our initial report

stating he was 5SW of the airport and were we going to conflict with him. I discussed our

routing and stated there was no conflict, which he acknowledged. I announced we were

"taking the active runway, 31, at Montrose" as we approached B-1 onto B, and there was

no response. Both crew members scanned the area and the TCAS. After we crossed the

hold short bars on B1, and about to make our turn to align on the runway, a Cessna stated

his position as "short final". I confirmed his position on TCAS as being more than short

final and his relative altitude as 800 ft and then 700 ft above us. I stated that we would be

out of his way in plenty of time. He then made a comment about kerosene costs and

stated he was "going around". As the aircraft was still behind us, we continued a rolling

take-off. When I made the "V1" call, I observed that the aircraft had yet to reach the

runway. After our landing at [the destination airport], the PIC received a call from the

company indicating that the pilot of the Cessna had contacted the company. The PIC then

contacted two witnesses and just asked them what they saw, which coincided with the

events. It appears that the Cessna pilot was angry that we had departed in front of him

and executed a go-around to prove a point. According to second hand information from

the FBO, the pilot was quite angry.

Had the Cessna made position reports, there would have been dialogue as to when we

were going to depart, and if he had felt uncomfortable, we would have delayed our

departure, just as there had been dialogue with the glider. Due to our size, we should

have been visible to the Cessna as we taxied out, thus reinforcing the need for position

reports. This entire episode could have been avoided with proper AIM position reports.

Synopsis

Business Jet flight crew reported that upon taking the runway at MTJ a GA pilot announced

that he was going around. The crew reported that this was the first transmission from the

GA Pilot.

ACN: 1476229 (7 of 50)

Time / Day

Date : 201708


Place



Environment

Light : Night

Aircraft : 1

Reference : X


Aircraft Operator : Air Carrier

Make Model Name : Dash 8 Series Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger

Flight Phase : Landing

Airspace.Class E : ZZZ

Aircraft : 2

Reference : Y


Aircraft Operator : Military

Make Model Name : Hawkeye (E2)



Mission : Training



Person

Reference : 1



Reporter Organization : Air Carrier






Analyst Callback : Attempted

Events

Anomaly.Inflight Event / Encounter : Wake Vortex Encounter




Result.Flight Crew : Executed Go Around / Missed Approach

Assessments



Narrative: 1

While on a 5 mile final to Runway XX in ZZZ, we noticed previously identified traffic on a

left downwind leg starting what looked like a turn to a base leg. Unsure of his intentions,

we asked the aircraft, at which point they informed us they would be out of our way by the

time we got there. We responded by saying that would not work, and requested they do a

360 degree turn to fall in behind us. They responded by saying "ok, you're in sight." At

this point the aircraft began a turn as we expected, however we believe they shot a low

approach in the process, but it was difficult see. Once on short final, we saw them again

making a climbing left crosswind turn. Our aircraft then crossed the threshold, and

encountered wake turbulence just prior to the left main wheel touching the ground. This

caused the aircraft to lose lift suddenly, and drift left of the centerline. The FO initiated a

go-around. After the go-around we completed required checklists, I notified the flight

attendant [and] passengers, and we landed uneventfully.

Synopsis

Dash 8 Captain reported executing a go-around after encountering wake turbulence on

short final in trail of an E2 military aircraft.

ACN: 1476076 (8 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight


Aircraft

Reference : X






Flight Plan : VFR

Mission : Training



Component

Aircraft Component : Brake System

Aircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1

Location Of Person : Hangar / Base

Reporter Organization : FBO

Function.Flight Crew : Trainee









Human Factors : Other / Unknown

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Flight Deck / Cabin / Aircraft Event : Illness


Anomaly.Ground Event / Encounter : Other / Unknown


When Detected.Other

Result.General : Maintenance Action

Result.General : Physical Injury / Incapacitation

Assessments

Contributing Factors / Situations : Aircraft




Narrative: 1

Student was sent on his 4th solo to go to the north practice area and to do landings at

ZZZ. About an hour into my student's flight he calls me and states that he thought the

brakes were locked up after landing and he was still on the runway. He then got out of the

aircraft with the engine still running to check the brakes out to see if he could fix it. After

getting out of the aircraft he was struck by the propeller on his hand. He had been

instructed to never get near a moving propeller and to never get out of an aircraft that is

running. After being struck he then got back into the aircraft and was able to taxi the

aircraft to an FBO and walked in by himself and was able to procure assistance from the

staff inside then proceeded to the hospital.

Synopsis

An instructor reported that his student, flying a light sport aircraft, was stuck on a runway

with the brakes locked. The student injured himself in an attempt to check the brakes.

ACN: 1476074 (9 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight


Aircraft

Reference : X


Aircraft Operator : FBO

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



Flight Plan : VFR

Mission : Personal




Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Stabilizer Fairing


Problem : Improperly Operated

Person

Reference : 1










Human Factors : Training / Qualification


Events




Anomaly.Inflight Event / Encounter : Object

Detector.Person : Maintenance


When Detected : Routine Inspection


Result.Flight Crew : Regained Aircraft Control


Result.Aircraft : Aircraft Damaged

Assessments



Contributing Factors / Situations : Weather

Primary Problem : Weather

Narrative: 1

During an authorized long distance cross-country student solo flight, attempted landing at

ZZZ on runway 18. Wind was >10 knots with gusts from 260 degrees. Had 25 degrees

flaps. As the plane was about to touch down, a wind gust blew plane from right to left and

past the edge of the runway. Was unable to maintain alignment with the runway. Executed

a go-around and as power was brought in, the nose began to raise up slightly and as such

the tail lowered. The left endcap of the stabilator struck a runway light. The impact was

felt in the yoke. Remained in the pattern, and landed on runway 18. Had the plane

refueled. Inspected the plane for damage. The left plastic stabilator endcap had a hole in it

on the leading edge.

Filled out an incident report at the airport terminal to report the damage to the runway

light. An aircraft mechanic was available to effect a repair by fabricating and attaching a

sheet metal patch. The plane was inspected for additional damage, none was found. Upon

completion of the temporary repair, the plane was returned to service. The mechanic did

not provide documentation for the repair other than a description on the cash receipt. I

was ignorant of the fact that this is improper maintenance record keeping and

subsequently learned that the aircraft should not have been placed back in service without

proper documentation. The details described in this report were reported to the FBO/owner

of the aircraft upon return two days later.

The incident could have been avoided by selecting another airport prior to the flight when

it was learned from a NOTAM that [other] runways [at ZZZ] were closed. The airport was

chosen specifically because it offered multiple runways. This fact was missed because of

fixated focus on local weather for making the go/no go decision for the flight and was not

noted and added to the plan of flight. The fuel burn rate was over-estimated and there

was more than adequate fuel available to have deviated from the plan of flight to another

airport. The cross wind component was at the margin of my skill level and surpassed by

the gusts, so upon listening to AWOS another opportunity to deviate was missed. The FAR

requirements for signed documentation for returning an aircraft to service following a

repair should have been known (43.9, 91.407).

Synopsis

A PA28 Student Pilot reported that after damaging the aircraft during a go-around, the

repair made by a local mechanic did not have the proper documentation.

ACN: 1476071 (10 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : JNX.Airport

State Reference : NC


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : JNX


Make Model Name : DA20 Undifferentiated



Flight Plan : None

Mission : Training

Flight Phase : Initial Climb

Airspace.Class G : JNX

Aircraft : 2

Reference : Y


Make Model Name : Bombardier Learjet Undifferentiated or Other Model


Flight Plan : IFR


Airspace.Class G : JNX

Person : 1

Reference : 1




Function.Flight Crew : Instructor










Person : 2

Reference : 2




Function.Flight Crew : Trainee










Events








Assessments



Narrative: 1

We took off from Runway 21 at JNX. At approximately 600 ft AGL on the upwind a Learjet

that had taken off from the same runway after us passed beneath our left wing before we

had turned left crosswind. We advised the jet that they had come close to us and they

claimed that they had us in sight the entire time, however the jet had never informed the

CTAF of takeoff or any other callouts and when we spotted the jet it was uncomfortably

close.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

DA20 flight instructor and student reported an NMAC with a Learjet departing JNX airport.

ACN: 1475797 (11 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight

Aircraft : 1

Reference : X



Make Model Name : DA20-C1 Eclipse


Flight Plan : None

Mission : Training



Aircraft : 2

Reference : Y


Make Model Name : Cardinal 177/177RG


Mission : Personal

Flight Phase : Initial Approach


Route In Use.Other

Person

Reference : 1













Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew


Events







Assessments





Narrative: 1

I was with a first time student and performed a touch-and-go. A Cardinal called several

miles out descending through I believe 3,500 feet with no bearing from the airport. I

asked him and he responded to the SE and that the sun was in his face but he'd be

looking. I reported entering the right crosswind then called entering the right downwind.

The cardinal stated that he was at 2,500 feet on the right downwind. I again stated that I

was on the right downwind and did not see the Cardinal and that I was about to enter the

base leg. I had my student turn base and stated that I was on the base leg. As I looked

toward the runway to decide when to tell my student to begin his final turn, I saw the

Cardinal, at my 2 o'clock position, co-altitude (approximately 1,600 feet MSL) and

approximately 400 feet laterally heading right toward my aircraft. My evasive action

included adding full power and initiated a climb straight ahead. I do not remember what I

said on the radio, but he told me that he saw me and turned to his left to go behind me. I

told him that I did not expect him to be coming from directly overhead the runway. I was

expecting him to be on a downwind leg. Once he was clear, I reduced the power, and

brought the aircraft onto final approach and then let my student land the plane. My

thoughts on how the near midair happened were the Cardinal flying into the sun

approaching the airport and not entering and flying a proper traffic pattern and pattern

altitude.

Synopsis

Diamond DA 20 pilot reported having a near collision with another aircraft while in the

traffic pattern at a non-towered airport.

ACN: 1475773 (12 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : MLE.Airport

State Reference : NE


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : MLE


Make Model Name : Bonanza 35


Flight Plan : None

Mission : Personal



Airspace.Class E : MLE

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : MLE

Make Model Name : Cessna 400




Airspace.Class E : MLE

Person

Reference : 1













Events


Detector.Automation : Aircraft TA






Assessments



Narrative: 1

I was maneuvering near an airport to enter the pattern for Runway 30 when I had a near

miss with another aircraft also entering the pattern. I had been on VFR flight following

through a Class Charlie. ATC approved me to squawk VFR and change frequencies in an

unusual location (just after I exited the Class Charlie, about 3.5 NM final and 1,900 ft AGL;

I think they had previously kept me high to avoid wake turbulence). I circled away from

the airport while descending slowly so I could turn toward the airport about 5 NM out at

pattern altitude and be on a 45 to the downwind. I changed to CTAF and announced my

position (I think I said I was descending and 3 NM southeast) and then heard another

aircraft announce (I think he said he was descending and 5 NM south). I had been

monitoring CTAF but hadn't heard the plane make any calls, and ATC hadn't mentioned it.

The other aircraft asked me if I was straight in for 30; I said no. I thought I saw him, and

I had him on TCAS (I have mode S displayed on a GNS 530W) about 5 NM in front of me

heading directly across my path towards the airport. I assumed he would continue on that

path and enter a downwind at about 1 NM parallel to the runway, which would have given

us plenty of clearance from each other. I looked away to adjust power, etc.; when I looked

back, I had lost him, and my TCAS then said he was 2-3 NM in front of me, to my right but

on an intercept, and about 500 ft above and descending (I think this would have put him

500 ft above pattern on a downwind about 4 NM out from the runway). He then called that

he was on a downwind 4 NM out. I couldn't believe it and just stared at the screen for a

moment, then frantically started looking for him; TCAS alarmed again, and then I turned

sharply left and called, "Traffic, please climb, I'm trying to get out of your way, but you're

heading straight at me." He didn't answer and almost immediately passed over me at 200

ft above (according to TCAS; I didn't see him at this point).

I think my main mistakes were assuming the other traffic would follow a particular

pattern, and then not informing him immediately when I realized I'd lost him. I think his

main mistakes were assuming that I would provide separation just because I said I saw

him and would follow him in, and then flying a non-standard pattern. It didn't help that we

both have fast planes (Bonanza and Cessna Corvalis) and that I was not in a good place to

enter the pattern in a standard fashion. I was possibly also slower to react because I've

flown much less than usual recently, and most of that has been quiet cross country rather

than in busy airspace. Unfortunately, the other pilot landed and had left the airport while I

went around the pattern and taxied in, so I didn't have a chance to talk to him and see if

he realized what had happened. I did ask the FBO to give him my phone number so we

can talk about it.

Synopsis

Bonanza 35 pilot reported an NMAC with another light aircraft in the pattern at MLE

airport.

ACN: 1475474 (13 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight


Aircraft

Reference : X



Make Model Name : Cirrus Aircraft Undifferentiated



Flight Plan : None

Mission : Personal



Component

Aircraft Component : Propeller Blade


Problem : Improperly Operated

Person

Reference : 1







Qualification.Flight Crew : Private






Events

Anomaly.Ground Event / Encounter : Ground Strike - Aircraft


When Detected : Routine Inspection




Assessments




Narrative: 1

While landing plane bounced several times. On third or fourth bounce I went around and

landed uneventfully. Inspection of the prop revealed a prop strike had occurred. There was

no indication that the strike had occurred.

I was concerned about the runway length. This runway had a non-landing portion before

it, so I planned to aim for this and land on or close to the numbers. When coming in I was

low and slow, so I added some power but landing just short of the actual runway, this

started the porpoise. In retrospect, I really should not have sweated the runway length

which was only 500 ft shorter than my home field, and I should have just landed as I

normally do, as I did on the go around. So the basic plan was flawed. Second when I was

low and slow, I should have gone around, and finally I was slow to recognize the porpoise,

and I initiated my go around one bounce too late.

Synopsis

Cirrus Pilot reported going around after a bounced landing that resulted in a prop strike.

ACN: 1475444 (14 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : HAF.Airport

State Reference : CA


Environment



Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : HAF


Make Model Name : Small Transport, Low Wing, 2 Recip Eng



Flight Plan : VFR

Mission : Training



Person

Reference : 1















Events

Anomaly.Conflict : Ground Conflict, Critical







Assessments



Narrative: 1

An aircraft was landing runway 12. We were landing runway 30. We mistakenly put 128.00

instead of 122.8 for the radio frequency. It is a keypad system. We were making radio

calls but because we were on the wrong frequency no one heard it. We landed and saw

them on final. We offset to the very right edge of the runway and they went around.

Synopsis

Pilot of a general aviation aircraft reported a near miss while landing at an uncontrolled

airport because the wrong frequency was dialed in on the radio panel.

ACN: 1475141 (15 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight

Aircraft

Reference : X






Flight Plan : None

Mission : Training


Route In Use : None


Component

Aircraft Component : Carburetor



Person

Reference : 1













Events

Anomaly.Aircraft Equipment Problem : Critical



Result.Flight Crew : Overcame Equipment Problem

Assessments


Primary Problem : Aircraft

Narrative: 1

After modeling a slip for my student with the airplane in its proper configuration, we

experienced engine roughness at 3,000 feet MSL. We were on a 4 mile 45 entry for the

downwind for runway 18. I established best glide, called our position, situation and

intentions to the two aircraft in the area (which was to proceed inbound for a short

approach landing due to engine roughness) then began to troubleshoot. I confirmed that

the carb heat was full on, mixture full rich, fuel tanks on both with both being nearly full

and fuel gauges checked normal. When we departed, both tanks were full at 26 gallons

total and our flight according to the hobbs was 1.1. The mags also checked okay. Despite

full throttle, we were in a steady descent with minimal engine power and unable to climb.

Approximately 1 mile east of our downwind entry, it was evident we would not make the

runway, and with housing between us, I opted to remain to the east, and aim for a field

east of the housing. I continued my descent and prepared for a forced landing, while

continuing to attempt to regain power. The two aircraft that were in the pattern had visual

on our position. At approximately 100 feet AGL, I attempted the throttle one last time. The

engine regained full power, was smooth, and I was able to establish a climb. I continued

my climb and was able to establish an altitude to safely proceed over the housing which

would allow me the option, should it occur again, to glide to either side of the

development, at about 800 feet AGL. I was able to enter a short base and land without

incident. The engine remained normal.

Synopsis

C150 instructor reported engine roughness and loss of power after demonstrating a slip at

3,000 feet with a recovery at about 100 feet AGL with a climb to pattern altitude and a

successful landing. Instructor reported probable carb icing.

ACN: 1475140 (16 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight

Ceiling : CLR

Aircraft

Reference : X



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



Flight Plan : None

Mission : Training

Flight Phase : Taxi

Person

Reference : 1



Reporter Organization : Corporate











Events

Anomaly.Ground Excursion : Taxiway

Anomaly.Ground Event / Encounter : Loss Of Aircraft Control

Anomaly.Ground Event / Encounter : Object



Assessments



Narrative: 1

While taxiing to runway 3 at JNX, I became distracted by an aircraft that seemed to be

having difficulty landing. I did not realize I had reached the end of the taxiway until I was

very near the turn towards the threshold of runway 3. I was unable to stop and ran off the

taxiway. Right rudder was applied to avoid striking the prop on a taxiway light. The left

main tire struck the taxi light. As the aircraft began to skid down sloped terrain mixture

was set to cut off, right rudder and up elevator was applied to try to prevent a prop strike.

The engine stopped before the aircraft stopped moving. The aircraft appeared undamaged.

No injury was sustained by pilot or passenger.

Synopsis

GA pilot reported a taxiway excursion while taxiing to Runway 3 at JNX.

ACN: 1474449 (17 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : BID.Airport

State Reference : RI


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : BID


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



Flight Plan : None

Mission : Personal



Airspace.Class G : BID

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : BID

Aircraft Operator : Corporate




Mission : Personal


Airspace.Class G : BID

Person

Reference : 1












Events


Anomaly.Deviation - Procedural : FAR







Assessments



Narrative: 1

While flying to Block Island State Airport (BID), reporting approximately 12 miles west of

the airport at approximately 3,000 ft MSL, I inquired for advisories at Block Island Airport

over the CTAF, 123.0 and I was advised that Runway 10 was in use. This made sense as

the prevailing winds were reported at 080 degrees and 7 knots. A few aircraft were

heading towards the airport and I communicated with at least two of the three known

aircraft flying in the vicinity. While on a 3 mile final approach to Runway 10, I announced

my position on the CTAF that I had the landing traffic ahead of me in sight and that I was

following it in. When I was approximately 2 miles from the runway, I again announced my

position and that I had a visual of the plane in front of me touching down. By this point my

airplane was on "short approach" to Runway 10. No other aircraft announced they were on

final approach. As I approached 1 mile from the threshold of Runway 10, approximately

500 ft AGL, I noticed another airplane swoop in at my 9 o'clock position (from my left) and

overtake my airplane and swoop in lower than me to beat me to the runway. Horrified, I

broke off from final approach and called a "go-around" and climbed out to pattern altitude

of 1,107 ft MSL. I commented on the CTAF to the pilot of the other aircraft, who was not

immediately identified, that he had performed an unsafe maneuver. The other pilot barked

back, "I was ahead of you!" Clearly, he was not. In fact, the other pilot appears to have

broken subsection g of "Right of Way" Rule 91.113: "(g) Landing. Aircraft, while on final

approach to land or while landing, have the right-of-way over other aircraft in flight or

operating on the surface, except that they shall not take advantage of this rule to force an

aircraft off the runway surface which has already landed and is attempting to make way

for an aircraft on final approach. When two or more aircraft are approaching an airport for

the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall

not take advantage of this rule to cut in front of another which is on final approach to land

or to overtake that aircraft."

After I re-joined the pattern and safely landed on Runway 10 about 10 minutes later, I

was led by an airport marshal to park my airplane next to the one that had cut me off. The

pilot and any person(s) who had been on the aircraft had departed the area.

I would like to see the ALB FSDO investigate the pilot who nearly caused a mid-air collision

with my airplane. He not only caused alarm to myself, but he horrified my 10-year-old

nephew on his first single engine flight over water. I am grateful for my good aeronautical

training to take evasive action to voluntarily break-off, climb, and go-around. The pilot of

the [other aircraft] appeared, at the very least oblivious to my presence and radio

transmissions, but I believe to be reckless in his actions to speed up, since, he has a faster

aircraft, and dive dangerously below my altitude to race me to the runway. This could

have ended disastrously.

Synopsis

GA pilot reported being cutoff on final at BID by another GA aircraft that necessitated a

go-around.

ACN: 1474439 (18 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : SZT.Airport

State Reference : ID


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : SZT


Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger




Airspace.Class G : SZT

Person

Reference : 1









Qualification.Flight Crew : Rotorcraft







Human Factors : Confusion

Events

Anomaly.ATC Issue : All Types






Assessments

Contributing Factors / Situations : Environment - Non Weather Related




Narrative: 1

Flying into SZT saw NOTAM and ASOS saying a crane was off the north end of RWY 02 and

90 ft off centerline. Didn't pay too much attention, but on final, flying the PAPI lights, I

had to go-around the top of the crane, which protruded some 60 ft into the PAPI glidepath.

I took a photo looking north on RWY 02 and the crane was dead center in the runway

centerline. The solution was to turn off the PAPI lights so it did not guide aircraft into the

crane, which moved east and west during the day, but often within the runway width and

extending into the PAPI glidepath. Seems that simple solution would have been to find

some other way to do work on a bridge north of SZT, but FAA decided OK, which baffles

me from a safety standpoint. Call 208-263-3074 and listen to the current ASOS, which is

better, but what if a transient pilot doesn't listen, or pay attention. Same risk on takeoff

with low-performance aircraft hitting the crane.

Synopsis

Turbojet pilot reported executing a go-around on the SZT Runway 02 final because a crane

protruded into the runway's visual descent path. The crane is mobile and NOTAMed, but a

danger to transient pilots and others.

ACN: 1474435 (19 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X



Make Model Name : SR20



Flight Plan : None

Mission : Training



Aircraft : 2



Make Model Name : Vans Aircraft Undifferentiated or Other Model



Mission.Other


Person

Reference : 1

















Events



Anomaly.Ground Incursion : Runway






Assessments





Narrative: 1

RV pulled out in front of us (knowing he was) when we were on really short final. His radio

call "RV departing RWY 34 we will be out before the cirrus". We got the pleasure of side

stepping due to us being nearly on top of him.

Synopsis

SR20 flight instructor reported that another aircraft pulled onto the runway while they

were on short final.

ACN: 1473537 (20 of 50)

Time / Day

Date : 201708


Place




Environment


Weather Elements / Visibility : Haze / Smoke

Weather Elements / Visibility : Rain


Light : Daylight


Aircraft

Reference : X



Make Model Name : Aeronca Champion



Flight Plan : VFR

Mission : Training




Component

Aircraft Component : Powerplant Fuel System



Person

Reference : 1










Human Factors : Troubleshooting


Analyst Callback : Completed

Events


Anomaly.Inflight Event / Encounter : Fuel Issue



Result.Flight Crew : Diverted

Result.Flight Crew : Landed in Emergency Condition

Result.Flight Crew : Landed As Precaution

Assessments



Narrative: 1

On the way to ZZZ airport to get fuel the engine started to stutter. I immediately pulled

carb heat, verified mixture full rich, and fuel selector on, fuel gauge showing to have fuel,

oil pressure and temperature both in the green. I continually pumped the throttle, as that

seemed to be the only thing to keep the engine running partially. I looked for the private

grass strips that I know of in the area, I was too far and too low to make it to them so I

continued toward the best field options I could see when I remembered a friend of my

boss had a big field he said we could land at just north of ZZZ. I then located the field and

proceeded to circle the field while performing my final check list. I secured the engine and

preformed a textbook 3 point soft field landing. I called my boss and he promptly arrived

with an aircraft mechanic to inspect the airplane. They found absolutely no evidence of a

problem so they started the airplane and my boss flew it back to the airport where he

could have it checked tested and fixed. No one was injured, no damage to persons or

property occurred, and the airplane was in perfect flying condition. The airplane is now

grounded until the issue can be found, however, my boss could not duplicate the issue and

the engine ran perfectly smooth on the way back to the airport. The only thing they could

come up with to this point is carb ice or vapor lock. Those are just guesses seeing how the

issue cannot be duplicated. Also, I used carb heat and it only seemed to escalate the

issue, progressively losing power and never restoring fuel flow. When pumping the throttle

the engine would start back up for about a second per pump. This continued for about 2

minutes before it stopped healing and the engine stopped completely.

Callback: 1

The reporter stated that the field where he made the emergency landing was a field that

they used for practicing soft field landing. He added that maintenance has replaced the

fuel line precautionary and ensured that the carb heat was working properly. They were

unable to determine the actual cause of the engine shutting down, but suspect icing was

the probable cause since the aircraft has been operating normally since the incident.

Synopsis

Aeronca Pilot reported landing in an open field due to a loss of engine power.

ACN: 1473534 (21 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : AVQ.Airport

State Reference : AZ

Relative Position.Distance.Nautical Miles : 7


Environment



Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : AVQ


Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Ferry




Airspace.Class E : TUS

Person

Reference : 1



Reporter Organization : Corporate














Communication Breakdown.Party2 : ATC

Events

Anomaly.Airspace Violation : All Types

Anomaly.Deviation - Procedural : Clearance





Result.Flight Crew : Exited Penetrated Airspace

Assessments


Primary Problem : Airspace Structure

Narrative: 1

I was repositioning the aircraft to AVQ. Approximately 30 miles from Marana I started

monitoring CTAF in my #2 radio. There was a Cirrus on a similar route as me that I was

overtaking. I told Center that unless Tucson Approach had taken my handoff I would

cancel IFR so that I could coordinate spacing to Marana with the VFR Cirrus. Center

advised me that there was no other traffic observed between me and the Marana airport

and frequency change was approved. I slowed down and configured early to keep spacing

on final. The aircraft ahead reported over Pinal airpark shortly before I did; I then also

reported over Pinal. A voice then came onto CTAF and advised me I had flown through an

active military drop zone at Pinal. I apologized and landed normally.

I have several concerns about the jump operation at Pinal.

1. I had briefed through DUATS before departure and saw no NOTAM for parachute activity

at Pinal.

2. Center did not advise me of any jump activity over Pinal. Center and Approach typically

will advise when the jump area over Pinal and other surrounding airports is hot. Absent

this, I joined an extended final approach to 12 to allow time to slow and configure for

spacing.

3. The aircraft ahead also reported over Pinal. If the jump zone went hot in the less than 3

minutes between CTAF reports with no advisory over Marana CTAF as well as Center and

Approach not being aware, a serious conflict could develop.

4. Having a drop zone located on a 10 mile final to the calm wind runway at a busy non-

towered airport with large amounts of jet traffic does not seem like a good idea to me.

Synopsis

Corporate jet pilot reported unknowingly flying through a military drop zone at MZJ during

final approach to AVQ.

ACN: 1473146 (22 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : DYL.Airport

State Reference : PA

Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : DYL

Make Model Name : Small Aircraft


Airspace.Class G : DYL

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : DYL



Airspace.Class G : DYL

Person

Reference : 1

Location Of Person : Gate / Ramp / Line

Function.Ground Personnel : Other / Unknown



Events







Assessments



Narrative: 1

From the ground I witnessed two airplanes on final to Doylestown airport have a near miss

as they simultaneously turned to final. The lower aircraft was a high wing and the plane

immediately above it was a low wing. I had previously held a student license and

estimated they were approximately 500 ft AGL. The [high wing aircraft] took evasive

action turning west while the overhead plane continued to final. I estimated the distance

between the two aircraft to be about 40 ft.

Synopsis

Ground observer reported witnessing an NMAC between two light aircraft on short final to

DYL airport.

ACN: 1473133 (23 of 50)

Time / Day

Date : 201708


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : M-20 E Super 21



Flight Plan : None

Mission : Personal



Component

Aircraft Component : Landing Gear


Problem : Failed


Person

Reference : 1













Events




When Detected.Other


Assessments



Narrative: 1

After departing for home field, the landing gear failed to raise. When within range I called

Unicom, advised the attendant of the situation, and asked him to stay on duty to visually

verify that my gear was down. When I was adjacent to the terminal, he verified that the

gear was in fact down. I had a green gear down light and with visual confirmation I landed

the airplane. I felt the wheels on the pavement and immediately the airplane was on its

belly. I shut everything down and got out. The airport attendant had closed the runway

and met me at the airplane. He called a tow and we got the airplane back on its wheels

and towed it to the hangar.

It's worth noting that after being serviced [earlier this year], the gear had failed to raise

as I departed for home. I returned to the shop and they worked on the squat switch for

several hours before releasing it. I had not had any more issues until this incident.

Synopsis

M20E pilot reported that after being unable to raise the landing gear, the gear collapsed on

the landing roll.

ACN: 1473112 (24 of 50)

Time / Day

Date : 201708


Place




Environment




Light : Night


Aircraft

Reference : X

ATC / Advisory.UNICOM : ZZZ


Make Model Name : PA-32 Cherokee Six/Lance/Saratoga/6X



Flight Plan : VFR

Mission : Personal



Person

Reference : 1
















Communication Breakdown.Party1 : Ground Personnel


Events







Assessments



Narrative: 1

[Airport] emergency services arrived as I was running up for departure, I questioned over

Unicom whether emergency services were on the active runway and received a reply from

a pilot who departed a few moments before me stating that they were not on the active

runway. Since I was not able to directly see if they were or were not there I proceeded to

takeoff and announced my departure on Unicom. After applying power and beginning my

take off roll the emergency personnel called in over the radio stating that they were on the

runway. By that time I did not have the available distance to abort my takeoff and if I had

it may have been more dangerous than continuing the takeoff. I rotated as soon as

practical and made a sharp turn to the left to avoid overflying the cars/people on the

runway. I made all reasonable attempts to ensure the runway was clear while emergency

services made no attempt to announce their position.

Synopsis

GA pilot reported taking off over emergency services that were unknowingly on the

runway.

ACN: 1472462 (25 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : O88.Airport



Environment



Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : O88





Flight Plan : None

Mission : Personal



Airspace.Class G : O88

Aircraft : 2

Reference : Y


Make Model Name : RV-7



Mission : Personal



Airspace.Class G : O88

Person

Reference : 1











Events









Assessments



Narrative: 1

[I was] practicing touch and goes, staying in the pattern making my radio calls at every

phase of flight at traffic pattern altitude at a non-towered airport. [I] didn't hear any other

pilots making radio calls. [I] made my radio call from right base to final looking and

checking for traffic for Runway 25. I had a stabilized approach when suddenly another

airplane had come from behind and over the top of me for landing.

I side stepped and did a go around and landed. After the event I spoke with the other

pilot. He told me he was on the wrong frequency. I asked him how he entered the pattern,

he told me he was north east and entered a right base and he didn't see me. I was already

on final at 500 ft. I told him that there [are] a lot of new students training at this airport

and procedure is 45 entry to runway 25 at pattern altitude. He mentioned that he was

familiar with the airport and visits frequently. I said we're both lucky that we're standing

here and able to talk to each other to evaluate the near miss.

Synopsis

C172 pilot reported an NMAC with an RV-7 on short final at O88 airport.

ACN: 1472139 (26 of 50)

Time / Day

Date : 201705


Place




Environment



Light : Night


RVR.Single Value : 10000

Aircraft

Reference : X






Flight Plan : None

Mission : Personal

Flight Phase : Taxi

Component

Aircraft Component : Taxiing Light


Problem : Failed


Person

Reference : 1















Events

Anomaly.Ground Excursion : Taxiway








Assessments




Primary Problem : Airport

Narrative: 1

The incident occurred while taxiing from transient parking to runway XYR for takeoff. I was

taxiing from the transient parking on a taxiway to runway XYR. The incident occurred at [a

taxiway] intersection. Taxiway lighting on the segment from transient parking to [the next

taxiway] was non-existent, and the single landing light on the aircraft (it has two landing

lights and one taxi light, one landing and one taxi light were/are inoperative) was

misaligned way to the left of the path of travel and not very bright. Without sufficient

lighting, I tried following [another aircraft] on [the] taxiway and had my passenger shine

his small flashlight out his window to help with the lighting. I also tried to use the geo-

synchronizing feature of my ForeFlight software on my iPad to follow the short segment on

[the] taxiway. Unfortunately, I ran off the left edge of [the] taxiway onto the grass area. I

immediately pulled back on the yoke to offload weight from the nose-wheel and applied

power to taxi through the grass and onto [the following] taxiway making it safely onto

[the] taxiway. I then performed a series of S turns to test the integrity of the nose wheel.

I noted no problem with the nose wheel. Further, on takeoff and landing I noted no

shimmy, wobble, or other problem with the nose wheel. I [departed] with no further

incident - the plane flew as expected, easily staying in trim both vertically and laterally.

As for the damage - the trip through the grass kicked up grass into the air filter and onto

the nose wheel landing gear strut. And unbeknownst to me even after tie down,

apparently the rudder struck either the grass or edge of [the] taxiway as I was pulling

back on the yoke and powering out of the grass thus causing a bend and tear on the lower

rear portion of the rudder. I believe that there were several contributing factors to the

incident:

1) The lack of adequate lighting at ZZZ for the short segment of [the] taxiway; and

2) The owner of the aircraft I rented has deferred the repair/maintenance of the

taxi/landing lighting system of the aircraft for almost one year, and in my opinion as well

as that of my passenger and the squawk sheets on the aircraft, the taxi/landing lighting

system condition is inadequate. Not only was it misaligned, (aiming high and far to the left

of the centerline of travel) it was not providing normal amounts of light. While I verified

before flight that the airplane had at least one operable landing light, I could not tell in the

day light that the lighting was misaligned nor of inadequate illumination. Neither my

passenger, a licensed pilot, nor I could see the taxiway due to the lack of adequate

taxiway lighting and aircraft lighting. Additionally, there is a significant drop-off from the

taxiway to the adjacent grass area - FAR more than I have ever experienced at any other

airport.

Synopsis

Cessna 172 pilot reported that during taxi the aircraft went off the taxiway damaging the

lower part of the rudder.

ACN: 1471858 (27 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ZZZ2.Airport



Environment



Light : Daylight


Aircraft

Reference : X






Flight Plan : None

Mission : Personal



Flight Phase : Taxi

Route In Use : VFR Route


Person

Reference : 1












Human Factors : Troubleshooting



Events




Detector.Person : Ground Personnel







Assessments



Narrative: 1

I picked up the aircraft from [a service center] located at ZZZ. I performed a thorough

preflight and departed ZZZ to the SW headed for ZZZ1. The flight was approximately 1

hour with maneuvering and operated flawlessly with no issues. Approximately 1 hour later

I departed ZZZ headed for ZZZ2. This flight was approximately 2 hours and as well was

flawless with absolutely no issues. I fueled at ZZZ2 self-serve Avgas pump with about 21

gallons. After performing a pre-flight inspection I departed back to ZZZ. Upon departure I

began a gradual climb at about 250 FPM on a runway heading. At about 3100 feet MSL the

engine went to what I perceived as idle or about 1000 RPMs.

I ran through the emergency checklist and hit nearest suitable airport on the GPS which

said ZZZ2 behind me. I began a gradual left turn to head back to the airport while trouble

shooting the engine issue and establishing the best glide speed of 76 knots airspeed.

When I looked at the distance to ZZZ2 it was 5.9 NM and I knew I could not make it with

the altitude I had. I looked for a suitable landing location and choose a field to my right

that I felt was my only option. Once I felt I had made the field I put in all the flaps and

performed a successful no power landing. I then inspected the plane for any damage and

began to look for the source of the problem, I manually checked the fuel in both tanks and

at the engine drain and it appeared to be clean 100 Octane Low Level with no deficiencies.

I then removed the cover and started the engine while holding the brakes and slowly

pushed up the throttle at about 2000 RPM the engine acted as if it was not getting fuel and

began to lose RPM almost immediately.

After calling [the service center] I found a ride home and drove back. I flew back to ZZZ2

with [someone from the service center] and we got a ride to the field where the plane was

located. We pulled the upper and lower engine covers and inspected the engine top to

bottom. After determining everything was as it should be we started the engine and as I

increased the throttle the engine began to die as if starving for fuel within a minute or so.

We then shut it down and inspected the engine again and noticed that it had a fuel leak on

the primer line that runs to 3 of the 4 cylinders. After closer inspection, we determined the

line was broken near a clamp so we repaired it with a ferrules fitting. We then started the

engine and ran it up to full rpm it maintained 2350 rpm for about 12 minutes with no

issues. We then replaced all the engine covers and began to discuss options. We did some

calculations and determined the field was more than 3000 feet long smooth low-cut grass.

We discussed that we could taxi the aircraft to the high end of the field and set it up in a

takeoff configuration and increase the throttle to full as if to take off but remain on the

ground, to further test the engine.

I taxied to the starting point and put in 1 notch of flaps then increased the throttle to full.

When the aircraft wheels departed the ground, the speed increased very quickly and

before I could set it back down I realized I may not have enough room to stop. The

aircraft lifted off the ground and at approximately 150-175 feet AGL the engine appeared

to stop or at least went to idle. I had no options for a straight ahead landing so I made a

somewhat hard left turn and attempted to keep the aircraft from stalling. I cleared several

obstacles and an electric pole/line. In an effort to avert the stall I pushed the nose down

and impacted the ground with the front nose wheel and the aircraft slid to a stop. When I

began to review my documents for the insurance claim I realized that I had inadvertently

allowed my Biennial Flight Review to expire. To avoid a situation like this in the future I

would never operate an aircraft that had a problem that could not be definitively identified

and corrected by a person with the appropriate credentials and I will also employ the use

of additional devices (such as electronic reminder) and monitor my credentials more

closely.

Synopsis

PA28 pilot reported engine malfunction that resulted in an emergency landing. Following

corrective maintenance and subsequent testing, a second takeoff was attempted with an

additional emergency landing.

ACN: 1471845 (28 of 50)

Time / Day

Date : 201708


Place





Environment




Light : Daylight


Aircraft : 1

Reference : X






Flight Plan : None

Mission : Training




Aircraft : 2

Reference : Y







Aircraft : 3

Reference : Z






Person

Reference : 1
















Human Factors : Time Pressure





Events







Assessments




Narrative: 1

On a practice approach for the RNAV into ZZZ, a pilot in Aircraft Y made a radio call he

was holding at Runway XY and said please advise if there is traffic in the area. Aircraft Z

on an 8 mile final for [Runway] XX, also on the practice approach, made immediately a

position report and we did ours right after. We reported a one mile final for Runway XX.

My Student was flying under a view limiting device and had no visual reference outside.

Visibility was 4 miles, haze and smoke so it was hard to see where that airplane was.

When I was scanning for that traffic, he appeared right in front of me, airborne, almost

same altitude heading straight toward us. I took the controls of the helicopter immediately

and did a steep right turn to avoid a midair collision. I made a radio call and said we all

would appreciate if he would make a radio call prior to take off. The pilot in Aircraft Y said

he wasn't aware of us and said we never did a radio call. However I talked with the pilot in

Aircraft Z behind us and he confirmed our radio calls and knew exactly where we were.

Synopsis

Helicopter instructor pilot reported a Near Mid-Air Collision in the traffic pattern due to an

aircraft departing in the opposite direction.

ACN: 1471547 (29 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : 50F.Airport

State Reference : TX


Environment



Light : Dusk

Ceiling : CLR

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : 50F





Mission : Personal



Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : 50F


Make Model Name : Cardinal 177/177RG



Flight Plan : None

Mission : Personal



Person

Reference : 1

















Events








Assessments



Narrative: 1

I performed a radio check with another aircraft on the ground as I was taxiing to takeoff at

Bourland Field (50F). Both of us were loud and clear on 123.0. About 30 minutes prior to

this I had observed an aircraft taking off to the north (Rwy 35), but since winds were light

from the southeast, both of us on the ground taxied to Rwy 17 for departure. The other

aircraft departed first and turned left to downwind for a touch-and-go. I departed next,

also turning left to downwind. We both continuously called pattern position in the traffic

pattern. The aircraft ahead of me performed a touch-and-go, and since I planned a full-

stop, I offered to turn off at mid-field. The other pilot said to go ahead and back-taxi and

he would just extend. The other pilot was on crosswind as I turned base. I was a bit high

and fast so I concentrated on losing altitude and speed with a sideslip. I touched down just

a bit long but on speed. At that moment I noticed an aircraft at the other end of the

runway. He was not displaying a landing light (I was). I realized he had just touched down

and that we were on a collision course. I considered leaving the runway surface to the

right, but there were taxiway lights at midfield and I was concerned about colliding with

one. So I got as far right on the runway as I could and depended on the other pilot to do

the same. There was insufficient room for me to come to a complete stop short of the

midfield taxiway. We passed near midfield with wing clearance fortunately, and I was

doing 30-40 mph. I was also calling out on the radio to the other pilot in the pattern that

we had an aircraft landing opposite direction so he would not turn final.

Afterward I taxied back, and finally the Cardinal came up on frequency 123.0 and called

out that he was back-taxiing on 35. I advised him that 17 was the active. The only other

communication from the Cardinal was when he exited the runway at the south end. My

daughter was also monitoring 123.0 and verified that the Cardinal never made any

transmissions on frequency prior to landing. The other pilot in the pattern verified this as

well when he and I talked at the gas pump after flight.

Synopsis

C140 pilot reported a ground conflict occurred afterlanding when another light aircraft

touched down on the opposite direction runway. The aircraft passed each other midfield.

ACN: 1471152 (30 of 50)

Time / Day

Date : 201708


Place




Environment


Light : Daylight


RVR.Single Value : 10

Aircraft

Reference : X

ATC / Advisory.UNICOM : ZZZ





Flight Plan : VFR

Mission : Personal



Component

Aircraft Component : Reciprocating Engine Assembly


Problem : Failed

Person

Reference : 1








Events






Result.Flight Crew : Inflight Shutdown

Assessments



Narrative: 1

I did a pre-trip inspection on the aircraft and noticed that it was a quart of oil low so I

added a quart. I got in the plane and continued to go through the checklist as always to

insure a safe flight. I listened to the unicom and decided to leave. I announced to local

traffic that I was taxiing and got to where I completed a run up of the aircraft and the

results were good so I decided to take off. I flew around the pattern once and landed to

relax me a little due to the fact that it had been a week since I had flown. Everything felt

great and it was a beautiful day so I decided to fly out towards my house. Once I got to

about 1700 ft I departed the pattern to 3000 ft to the Southwest. Upon reaching my

desired altitude I did my cruise checklist and was satisfied and entered into Slow Flight in

ordered to practice this maneuver. Once I got down to the minimum speed that I felt

comfortable I noticed a noise in the motor. I wasn't sure what it was coming from at first

but the more that I listened the more I felt like that was where it was coming from. I

departed from slow flight while looking at my instruments. I then noticed that the oil

pressure had dropped and I decided to abort and try to return to the airport for safety

reasons.

I was taught that even if you oil pressure drops that it doesn't always mean no oil that it

could be a faulty gauge so I watched the oil temp gauge and the temp was at 180 so I

turned the airplane around and felt like I was about 8 miles or so away and I decided to

get as high as I could. The knocking got louder so I slowed the power down to 2000 rpm. I

realized that I was too far away from the airport and the knocking got louder on a lower

setting and I realized that if I was going to make it that I needed to be closer. I added full

power and picked up speed but realized that even at full power that it wasn't producing full

RPM's. About 30 seconds later the plane started to shake and I heard a loud pop and the

engine stopped. Smoke had started coming out of the cowing but stopped quickly. I looked

on my checklist to see about the emergency procedures to make sure that I didn't forget

anything. I unlocked my door and opened my window. Once I realized that I was not going

to make the airport I looked around for the best place to land. There was a field to my left

but it required a sharp bank to make it and I was worried about that with no power. Ahead

of me to the right was a highway. Once I saw that I was going to have to land on the

highway I radioed in to 121.5. I tried to explain to them where I thought that I was but I

was getting too close to the ground. As I lined up with the road I accessed the traffic and

made a decision where to land. Once I touched down I had to coast to where I could be in

a safe location out of the way of everything. When I came to a complete stop I radioed

back to 121.5 to let them know that I had made it safely and that there was no damage to

me, the plane or anyone or anything else. I didn't get a response back so I called my CFI

at the airport and told him where I was in order for him to come get me. When he got

there he informed me to contact the weather briefer and let him know that everything was

ok.

Synopsis

PA-28 pilot reported landing on a rural highway after experiencing an engine failure.

ACN: 1470131 (31 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ANE.Airport

State Reference : MN



Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : 25D





Flight Plan : VFR

Mission : Personal



Airspace.Class E : M98

Aircraft : 2

Reference : Y

Make Model Name : Cessna Aircraft Undifferentiated or Other Model

Airspace.Class E : M98

Person

Reference : 1











Events








Assessments




Narrative: 1

We were about 10 mile NE of ANE under the Mode C for MSP and on the CTAF for 25D

monitoring for parachute activity in the area. I was cruising at 3300 feet MSL at a heading

of 160. I'm not sure how I missed the other traffic. The Cessna was on an approximate

heading of 270 at 3500 MSL. I do have ADS-B in and out with traffic showing on an iPad,

and the Garmin 650 in the panel. The other aircraft did not show up at all nor did a

collision avoidance activate. I took evasive action by descending quickly to 3000 feet. I'm

not sure if the other pilot was aware I was there or not. I'm also not sure why the other

pilot wasn't flying at 2500 or 4500 feet MSL on their westerly course.

Synopsis

PA-28 pilot reported observing conflicting traffic and executed rapid evasive maneuver to

avoid a midair collision that was not displayed on TIS.

ACN: 1470114 (32 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : MGJ.Airport

State Reference : NY


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : MGJ




Flight Plan : None

Mission : Personal



Airspace.Class E : MGJ

Person

Reference : 1















Communication Breakdown.Party2 : Other

Events



Anomaly.Deviation - Procedural : Other / Unknown





Assessments



Narrative: 1

During an approach for runway 03 I entered a left downwind via a 45 degree entry. I

determined the runway in use via ASOS and other aircraft in the pattern. Just after making

the self-announce transmission on CTAF, my passenger and I both observed a Beech

Bonanza opposite direction and descending to pattern altitude, approaching head on. I

applied strong forward pressure on the yoke to effect a rapid and immediate descent. We

passed under the other aircraft by approximately 50 feet. No other transmissions were

heard from the incident aircraft, however two other aircraft on the frequency in the same

pattern did answer. As I observed the Bonanza begin a wide, climbing turn to enter the

pattern behind us, and still heard no transmissions, I announced their positon for the other

aircraft. As I was taxiing to the ramp, I made my last transmission for the other aircraft as

I observed them touching down. They finally made a transmission stating, "We are on the

frequency, what is the problem?" I did not reply.

My guess, is that the CTAF frequency is one that is not common (122.72), and may have

not been known by the other aircraft. The other aircraft descending into the pattern did

not make for scanning for traffic easy. It was pure luck that we missed one another.

Synopsis

A C150 pilot reported taking evasive action to prevent airborne conflict with a no radios

aircraft entering approach pattern to an uncontrolled airport.

ACN: 1469546 (33 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : DA20-C1 Eclipse



Flight Plan : VFR

Mission : Training


Person : 1

Reference : 1











Person : 2

Reference : 2

Location Of Person : Gate / Ramp / Line







Events



Detector.Person : Observer



Assessments



Narrative: 1

I was flying my first solo. I took off and began my pattern (crosswind, downwind, base

and final). I approached my final leg at 60 KTS with full flaps. I landed before the first

large white blocks on the runway on the center line. I landed on the main gear, then

lowered the nose. It shook (nose wheel) so I pulled up slightly, then pushed the stick

forward so shaking stopped. The plane veered to the left. I failed to pull the throttle to

idle- it was slightly above idle on landing. I attempted to slow the plane with the brakes

but I believe my feet were on the rudder and not high enough on the pedal to hit the

brakes. I left the runway into a flat, level grassy area and was headed toward the ramp. I

focused on steering the plane toward the ramp and let friction slow the plane at that point.

The propeller was cutting some of the higher grass along the way. I then entered the

paved ramp area and shut down the plane. I walked the entire route where the plane went

through the grass. There were no hard surfaces that I drove through. Most of the grass

was ankle high and some patches of grass were about a foot high. I inspected the plane

after I shut it off. There was visible green marks on the propeller and some of the leading

edge appeared to separate from the propeller. I had no injuries and there were no injuries

to others and no damage to any property.

Narrative: 2

I am a CFII. I sent my student on his first solo flight. Our Part 141 syllabus requires the

student to complete one half hour in the local traffic pattern solo. [We] had completed the

required training for the solo and he had received all endorsements, training, and pre solo

written exam. Prior to this day we had flown three days in a row that were supervised

solo's with instruction given on the ground upon our return. The student was eager and

ready to make the flight, and I had not been given any reason to doubt the safe

completion of the flight. Conditions for the day were clear skies 10 miles visibility and

winds from the south west at 5 knots. The winds were favoring Runway XX, therefor it was

in use. [The student] was instructed to do 3 full stop landings and was taxiing out to

Runway XX for departure after dropping me off at the FBO to monitor from the ground.

The student had a great takeoff with excellent directional control. The climb out and

pattern flown was to standards and the communications were exceptional. The approach

to landing was just as we had practiced. During his roll out to a stop [the student] took a

sudden sharp turn to the left and ran off the runway into the grass. There was no

obstruction or gusts to explain the reaction. [The student] rolled through the grass in the

runway safety area and up onto the taxi way coming to a complete stop. After assuring

the student was ok I asked what had caused him to make such a rash control input, the

student replied that he wasn't exactly sure what had happened. My best guess is the

student freaked out and had an involuntary response which he couldn't recover from. The

aircraft suffered a prop strike from the grass which he rolled through as well as a nose

wheel getting bent slightly.

Synopsis

DA20 student pilot and the observing CFI reported that upon landing during a solo flight

the aircraft turned sharply and departed the runway.

ACN: 1469242 (34 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : PWT.Airport

State Reference : WA


Environment



Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : PWT


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



Mission : Training


Airspace.Class E : PWT

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : PWT

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




Airspace.Class E : PWT

Person

Reference : 1






Qualification.Flight Crew : Flight Engineer









Events


Detector.Person : Observer





Assessments



Narrative: 1

While practicing touch and go landings, another pilot flying Aircraft Y announced his

intention to enter on a 45 degree entry to runway 20 at PWT. I continued in the pattern

announcing my position at all phases of the pattern. While on the downwind I heard [the

Aircraft Y pilot] say he was on the 45. I announced turning base and then final. I opted to

go around and heard someone warn me about an opposite direction aircraft on final. I

continued the go around. I then saw traffic directly opposite to me approaching runway

02. I avoided him while on the upwind at 300 feet AGL.

I was on my 3rd circuit with others having been in the pattern. I announced my position

and continued the go around avoiding the traffic and clearly continued to announce my

position. The pilot executed a low approach to runway 02 and continued to fly northbound

not talking on the radio.

I continued in the pattern announcing my position at every phase of flight. I tried to talk

with the pilot but no answer.

Synopsis

GA pilot experienced an airborne conflict with another aircraft that had announced

entering the pattern for Runway 20, but wound up on approach to Runway 02 in conflict

with the reporter. Evasive action was taken by the reporter and the NORDO pilot departed

to the south without making radio contact.

ACN: 1469241 (35 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Dusk

Aircraft

Reference : X






Flight Plan : None

Mission : Training


Route In Use : None


Person

Reference : 1


















Events






Assessments



Narrative: 1

I was training a student who has approximately 30 hours and who has soloed 3 times. We

were doing a training flight in the traffic pattern working on short and soft field takeoffs

and landings. For the short field landings, I was giving the scenario that a previous student

of mine had received during his private pilot checkride. Simply enough, the examiner

wanted him to land on the threshold. So that is the same scenario that my student and I

were practicing. We had performed 9 takeoffs and landings, and he was doing very well

with the spot landings and short field procedure. In the beginning I was following very

closely on the controls to ensure the proper threshold crossing height for the point which

we were landing. As the lesson progressed, I slowed eased off of the controls to allow him

to be more in control. After the 9th landing, I knew it was about time to finish up for the

evening. My student asked if we could do just one more takeoff and landing, to which I

agreed. The sun had set and we were beginning to lose some of our light. The lesson

before this was his first night flight where we did 7 full stop takeoff and landings, so I

wasn't terribly concerned with a little bit of light loss. While we were on the downwind leg,

I told my student that we would try to touchdown at the beginning of the runway, just

before the numbers one last time. As we turned onto final, the lighting system was not

turned on. I preferred it that way, but failed to vocalize to my student to keep them off.

When we approached short final I heard him keying on the lights. Before I could say

anything, the lights were coming on. He had turned them on high intensity. As we kept

coming down, I began reaching for the hand held mic to turn down the lights. We were low

enough, I thought the best decision was for me to try to get them and let him focus on the

landing. When I got the mic and got them keyed down, we were probably 20 ft above the

ground. I made a quick glance over to his airspeed indicator to verify he was at the proper

speed and to put the mic back so my hands were free. When I looked back, we were

beginning to cross the threshold and I knew we had gotten a little lower than I would have

liked and we then felt the RH (right hand) tire hit the threshold light. It didn't alter the

course of the airplane, and we were able to touchdown straight, on the main wheels, and

in the center of the runway. We didn't actually realize it was a light until we taxied back to

the beginning of the runway to make sure it wasn't a light. Sure enough, there it was. It

knocked it off its base and broke the glass. We taxied in and shutdown. We did a visual

inspection of the entire aircraft and there was no evidence of any damage. I immediately

called the airport foreman to report what had happened so he could get a hold of the

proper maintenance technician.

Looking back, there are a few things I, as the instructor, could have done differently to

prevent this situation. I should have stuck with my instinct that we had done enough

takeoffs and landings and that any more could be detrimental to the progress made. Next,

I could have made the decision to pick a point further down the runway due to the

diminishing sunlight. Third, when my student keyed the lights to high intensity, I should

have had him adjust to land farther down the runway due to the effect it was having on

our vision. I have learned a lot from this situation and will never let it happen again. I am

trying my hardest to do everything properly to fix the situation.

Synopsis

C172 flight instructor reported striking a runway threshold light during landing with his

student at the controls.

ACN: 1469199 (36 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : AMW.Airport

State Reference : IA


Environment



Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : AMW




Flight Plan : None

Mission : Personal


Route In Use : None

Airspace.Class E : AMW

Aircraft : 2

Reference : Y




Flight Plan : None

Mission : Personal


Route In Use : None

Airspace.Class E : AMW

Person

Reference : 1









Human Factors : Other / Unknown



Analyst Callback : Completed

Events





Were Passengers Involved In Event : Y



Assessments




Narrative: 1

Winds Light and variable, AMW runway 01 specified for no wind use. After runup,

announced on CTAF taking runway [01] for departure. Another person on CTAF said they

were lined up on runway 13 [which is closest to the ramp] -- said they wanted immediate

departure. I said I would stay lined up on 01 and they could depart.

I watched, lined up on 01, as the plane took off and watched it climb to about 500' and

they announced turning crosswind to stay in the pattern. I said, I was rolling on 01. At

about 10' AGL someone [unknown] said there are two planes taking off! I started looking

toward runway 13/31 and couldn't see, my passenger pointed and the vintage aircraft was

rapidly approaching the intersection of 13/31 [on Runway 13] and 01/19 at the same

altitude as me. He was less than 100' away horizontally as I immediately pitched down

(about 50' AGL at this time) and he flow over the top of me. I had to recover and pitch

back up about 10' AGL and continue takeoff as I was hitting 100 kts and was not stabilized

nor had enough runway to land on back on 01.

I can only assume the pilot was NORDO or just not listening and assumed there was only

1 active runway. I listened and heard no reports on the radio from that plane.

Factors in play were the NORDO pilot, or not using CTAF if he was equipped. The fact that

some pilots use the closest runway in no-wind conditions when 01 is spelled out as the no-

wind desired runway. Also beneficial was the one pilot who saw both planes departing and

called out on the radio -- if this hadn't happened I don't know if I would have avoided the

other plane. Also a factor is you can't really see the departure [approach?] end of 13 from

01 and vice-versa.

Callback: 1

The reporter confirmed that the vintage aircraft was departing from Runway 13.

Synopsis

GA pilot departing using CTAF procedures reported a NMAC with a vintage aircraft

departing on an adjacent runway without announcing on CTAF.

ACN: 1469156 (37 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : SCD.Airport

State Reference : AL


Environment




Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : SCD





Flight Plan : None

Mission : Training



Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : SCD





Flight Plan : None

Mission : Agriculture


Airspace.Class G : ZTL

Person

Reference : 1





















Events









Assessments






Narrative: 1

On short final RWY 27 into SCD to perform a touch and go landing for a commercial pilot

training flight, I noticed a clear object rise above the tree line just off the far western end

of the runway. Moments prior to touchdown I determined the object I saw was a small

bubble canopy helicopter. I had my student continue the landing as the helicopter

appeared to be heading westbound, away from us. After touchdown, my student

reconfigured the aircraft, applied full power, and initiated a takeoff. At rotation, the

helicopter turned from the west to the east, and headed straight down the opposite end of

the runway towards us. I briefly considered aborting the takeoff, but was worried that a

high speed ground collision between our two aircraft might occur. After rotation, I took the

flight controls and continued to climb out at the best rate of climb speed, and sidestepped

north, away from the helicopter and runway environment. To my knowledge and from

what I saw, the helicopter took no evasive action, and I'm not certain if they even made

visual contact with us. Our landing light, taxi light, anti-collision lights, and flashing beacon

were all on, and we had been making radio calls on CTAF from at least 10 nm from the

airport. The helicopter in question was a small agricultural helicopter, and it had not been

making radio calls on SCD CTAF 122.8. Upon arrival back to my home airport, I spoke with

the assistant chief flight instructor (and Safety Officer) about the event, and also filed a

company safety report. I also called SCD to inquire as to the nature of the helicopter

operating on the field without making radio calls. They were operating in the area spraying

herbicide on power lines, and also on tree tracts and that their helicopters are not

equipped with radios. I believe this event was caused by the pilot of the aforementioned

helicopter failing to exercise proper collision avoidance and scanning techniques, and

assuming that a normally quiet airport with low amounts of traffic would automatically be

free of any landing traffic. The winds at the time of the event were favoring RWY 27.

In the future, publishing a NOTAM to alert transient aircraft of this non-routine (to SCD)

traffic operating in the area could help aid in situational awareness for other pilots

operating in the vicinity of the airport. And although not legally required, it would be

beneficial for those helicopters to be equipped with radios, so they can more safely

coordinate with traffic, and also build a better situational awareness picture for themselves

with regards to other aircraft in the area.

Synopsis

GA flight instructor reported taking evasive action from a helicopter as his student

departed SCD following a touch and go. The helicopter did not have a radio installed.

ACN: 1468447 (38 of 50)

Time / Day

Date : 201707


Place





Environment



Light : Daylight


Aircraft

Reference : X


ATC / Advisory.TRACON : ZZZ


Make Model Name : Baron 58/58TC



Flight Plan : None

Mission : Personal



Component

Aircraft Component : Gear Extend/Retract Mechanism


Problem : Failed

Person

Reference : 1













Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor






Assessments



Narrative: 1

I was approaching ZZZ airport from the west for landing. I had been making radio calls

over the CTAF from 15 miles west of the airport all the way into the downwind for runway

30. No other aircraft seemed to be in the vicinity or at least nobody made any radio calls

that they were in that vicinity.

When I moved the gear selector to the down position I heard the gear move but did not

receive three green lights. I confirmed the lights with the light annunciator button and

verified the lights were in working condition. I then cycled the gear back up and after a

period of waiting put the selector back into the down position. At this time I began to smell

a slight burning odor and noticed a small amount of smoke coming from under the

pilot/co-pilot seat. I reached over to pull the gear motor circuit breaker, but realized it had

already tripped. At this point I called Approach to notify them of my situation and

explained to them I just wanted to make contact with them in case I needed some help,

but for the time being I would be performing a manual extension.

I departed the airport pattern to the north-west and used the auto pilot in heading and

altitude hold modes while I pulled out the POH and referred to the gear manual extension

section. I explained to my passenger to help me scan for traffic while I was multi-tasking.

Upon execution of the POH instructions I was unsuccessful in producing three green lights.

I decided to call [a relative] via cell phone and have him drive to the airport so I could

perform a low approach and he could attempt a visual look at the landing gear. Upon his

arrival another very experienced commercial pilot who was at the field helped him to look

at the landing gear while I flew the low approach. They were both confident all three gears

were down and locked. I then decided to attempt and turn the manual extension handle

more, but could still not get three green lights. With plenty of time I then did a second low

approach to confirm again all three gears looked down and locked. They confirmed once

again that the gear looked down and locked.

I referred to the POH on a gear-up landing and had the plane configured and/or ready for

a possible gear collapse upon landing. I made a normal approach to landing and was very

careful to set the plane onto the runway softly. After touch down the airplane reacted

normal and we were able to exit the runway without incident.

All worked out well in this situation, but we were prepared for the worse.

Synopsis

BE58 Baron pilot reported a landing gear motor failure and manual extension.

ACN: 1468296 (39 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : BFF.Airport

State Reference : WY


Environment


Light : Dusk

Aircraft

Reference : X

ATC / Advisory.CTAF : BFF


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Passenger

Flight Phase : Parked

Person

Reference : 1



Reporter Organization : Air Carrier





Events



When Detected : Aircraft In Service At Gate


Assessments

Contributing Factors / Situations : Company Policy

Primary Problem : Company Policy

Narrative: 1

Due to weather we diverted to BFF which was the alternate as listed on our flight plan. We

had several problems with BFF. We were the 6th aircraft on the ground to divert there at

the time. BFF is an uncontrolled airport. This is the biggest problem for aircraft diverting.

The aircraft on approach cannot land until the aircraft on the ground call in. This causes

big delays in the air and for diverting aircraft with low fuel that's not good. BFF has no

gates. And there was no option to allow passengers to get off the plane for delays. It took

2 hrs to get gas. It could have taken a lot longer. Unicom was the only source of

communications. There was only one person answering the radio which was not very

often. Very bad communications there. ACARS has no reception at BFF. This adds another

layer of problems and delays to get information, get a flight plan, weights, etc. With no

ACARS and since no door opened, VNAV did not work properly on descent to ZZZ1. And

we kept getting error messages while airborne asking us to open a door to reset the

system. I do not believe BFF should be used as a regular alternate airport. If anything else

this can cause large fines due to ground delays without egress options. When we finally

got to destination we arrived at gate and waited 53 minutes with the parking brake set.

Here are the times of this flight:

ZZZ-BFF

OUT XA:01

OFF XA:20

ON XD:41

IN XE:01 (parked at remote spot)

FUEL 7300 lbs

BFF-ZZZ1

OUT XG:12

OFF XG:22

ON XH:02

IN XI:14

FOB 11000 lbs (Estimated)

Also, do the math. The passengers were on the plane for well over 7 hrs when we arrived

at the gate. They then had to wait another 53 min to get off. I called Operations several

times. This is embarrassing.

Synopsis

Air carrier Captain reported questioning the wisdom of using BFF as an alternate with no

tower, no gates, one frequency for CTAF and UNICOM, and no ACARS reception.

ACN: 1468195 (40 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight

Aircraft

Reference : X






Flight Plan : None

Mission : Training



Person

Reference : 1














Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown






Assessments



Narrative: 1

C172RG nose wheel collapsed during the end of a landing roll out. The student

inadvertently reached for the Carb-heat. Instead he grabbed the gear handle. I (CFI) saw

the student reaching and tried to intercept/block the action. I was too slow and could not

stop my student's hand. The gear handle moved only half-travel before my hand returned

the gear lever to "down." The nose wheel gave way despite the squat switch. I am

reporting this here because as a CFI I did my best to prevent the mistake but wasn't fast

enough. My student was able to move from the throttle to the gear handle faster than I

could block it.

Synopsis

C172RG flight instructor reported the student pilot inadvertently grabbed the gear handle

instead of the carb heat and caused the nose gear to collapse on landing.

ACN: 1468194 (41 of 50)

Time / Day

Date : 201707


Place




Environment


Light : Daylight

Aircraft

Reference : X





Flight Plan : None

Mission : Training



Component

Aircraft Component : Cylinder


Problem : Failed

Person

Reference : 1












Events








Result.Flight Crew : Returned To Departure Airport



Assessments



Narrative: 1

Landed in a field on airport property as a result of Power loss due to a cracked cylinder

#4.

I was on a training flight with a Student Pilot getting check ride ready, which was to take

part two days later. Before takeoff I did my usual check with the student, oil was at 6qts

and fuel was topped off (53 Gal) as a safety precaution.

The flight was a typical training flight, took off from [home airport], did some ground

reference maneuvers in the area, followed by landings in ZZZ airport, an uncontrolled

field. After two landings in the pattern, I told the student to prepare for a short field

takeoff and since he was getting ready for check ride everything was by the book, from

checklists to airspeed and Oil temperature and pressure call outs. On this one, I said,

"ENGINE FAILED", student took appropriate action and stopped the aircraft, pulled throttle

and said in real life he would pull the mixture and the appropriate checklist. I was satisfied

and we further discussed eventualities if the engine did fail on takeoff roll, below 1000 feet

and after that.

After this simulated abort takeoff, [we decided to return to home airport]. On this final

departure, again everything by the book, proper non-towered radio calls, checklists and

use of runway space. On takeoff roll, on the Vx climb, I was satisfied and continued with a

clear of obstacle call, the student then pitched for Vy. About 3 seconds after, I heard a

BANG! I immediately looked at the tires to see if they popped, the oil pressure and

temperature, they were green. Simultaneously the aircraft began to shake and vibrate

violently. I looked at the VSI and saw the climb go from +800 FPM down to barely +50

FPM.

My student looked at me and said, "I've lost the engine...", I took over controls and added

full power, Idle, then power again. Nothing changed and clearly there was a problem. At

this point, I'm still maintaining heading, airspeed began to decrease and I said, "confirm

engine loss....", student said, "confirm!". I had no choice, I had to put it down. Told the

student, "seatbelt on tight, door open now, I have this". Immediately, I knew from

experience that I could not land this plane straight given the speed and rate of drop and

ground roll. I banked about 15-20 Degrees left and slipped the plane down to the corner of

a field and put the plane diagonally off the runway numbers, an approximate 305 heading.

On touchdown, I had flaps full and hit the ground right as the stall horn went off,

touchdown was rough but I held the back pressure in and did a basic soft field landing.

Since I had never done a real grass landing before I did not apply brakes and knew the

plane will stop eventually.

When the plane came to a full stop, I told the student, "after landing checklist now!" He

ran it pulled full emergency cutoff, fuel selected off and ran the checklist. I had my left

hand on the fire extinguisher and my right hand had the checklist in hand ready for a fire,

explosion, oil spewing, whatever come may.

To our luck, nothing came after, so when we got out, I said "fuel check", we had 42Gal

total and Oil was still around 6quarts.

Post incident:

On my inspection, no oil leaked, no sign of outside damage. I called the owner/flight

school and did a post check of the exterior, no damage to the propeller, wheel pants, tires,

or fuselage. Luckily we found a crack in cylinder #4 next to the spark plug which caused

the Partial Power Loss and vibration issue with the aircraft. 65 feet remained between the

aircraft and a fence, luckily an airport tenant saw and heard the incident so he

immediately sprang in to help and get a tow to get our plane out.

Since my student and I were in the check ride prep mode, I believe that this led to the

great outcome of our flight. The issue could not be prevented since it was a maintenance

problem, so my job as an instructor was done and had I made any calls differently, surely

the result would have been bad. My student remained calm and collected and I think I

acted appropriately given the situation I had.

I know this is not standard, but I do train my SEL students for private at a higher standard

and although not a required procedure except for MEL, I train my students to react if an

engine loss occurs 800 feet to return to the field in the opposite direction. My student said

that me practicing this with him helped in alleviating the fear if the plane lost power and

said attributed to the issue.

Synopsis

A Cessna 172 instructor pilot reported the engine failed right after takeoff.

ACN: 1468179 (42 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : FOD.Airport

State Reference : IA

Relative Position.Angle.Radial : 010



Environment

Flight Conditions : IMC

Weather Elements / Visibility : Cloudy


Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : FOD





Flight Plan : VFR

Mission : Personal



Airspace.Class E : FOD

Person

Reference : 1




Function.Flight Crew : Other / Unknown










Communication Breakdown.Party1 : Other


Events



Detector.Person : Passenger


Result.Flight Crew : Landed As Precaution


Assessments



Contributing Factors / Situations : Weather


Narrative: 1

Flying as an "extra set of eyes" for a pilot friend while enroute to Oshkosh, we

inadvertently flew into a class E surface airport with weather below VFR minimums. When

approximately 10-15 miles west of FOD, we picked up the AWOS weather and observed

the field was barely above VFR minimums: 1000 ft Broken, 10 SM visibility. I pointed out

to the pilot that there was an airport 10 miles northwest of our position that was reporting

VFR, in case FOD went below minimums. The pilot elected to continue to FOD to take a

look. After descending, we picked up the AWOS again and observed the clouds were now

at 800 ft broken. Already being below the clouds and 2 miles from the airport, the pilot

elected to continue and land at FOD. Looking back, this was probably the safer option at

that point, already being under the cloud deck, but we never should have gotten to that in

the first place. The landing was uneventful and we waited on the ground until the weather

raised back to VFR minimums, and departed for the rest of our trip.

Lessons learned: I should have been more forceful with the pilot on the suggestion of

going to the alternate airport that was VFR. The pilot may not have understood that FOD

was class E and the weather minimums associated with class E. It was ignorant to proceed

into deteriorating weather, when a viable alternate was so close.

Synopsis

A flight instructor observer pilot reported not being assertive enough and allowed the pilot,

who was presumably operating under VFR, to proceed to and land at an airport that was

below VMC.

ACN: 1467196 (43 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : OKB.Airport



Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : OKB





Flight Plan : VFR

Mission : Personal


Airspace.Class G : SCT

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : OKB






Airspace.Class G : SCT

Person

Reference : 1













Events








Assessments




Narrative: 1

This was the return leg of a personal pleasure flight to Oceanside, CA (OKB). I was the PIC

pilot flying for the first leg and had swapped seats and was not flying on the return flight.

Not being PIC for this leg, and despite being the more experienced aviator, I was relaxing

and mentally disengaged with more of a passenger mindset, given I was with a properly

rated, current and qualified pilot in the left seat of a single-pilot aircraft. We briefed the

takeoff procedures after the run-up, and the PIC had verbally noted the "fly friendly" noise

abatement sign at the departure end of the runway, and I reiterated the sign text: follow

the river to the shoreline. A C172 departed in front of us for closed traffic, and when the

PIC began taxiing towards the runway immediately after they began takeoff roll, I

recommended we hold for separation given our dissimilar aircraft. After the 172 had

gotten airborne, we taxiied onto Runway 24 and departed. This was sooner than I

personally would have departed, but I did not verbalize this and felt it would be a non-

issue since they were remaining in the pattern and we were a west departure. In the

moments after takeoff leading up to the event, I was enjoying the view out my side of the

aircraft while casually glancing over to keep an eye on the traffic that departed in front of

us. I noticed our courses diverging and made a call-out that the traffic was now at 11

o'clock, which was acknowledged. There was a scattered layer above us, which

momentarily caused a level off. On my next glance I noticed the 172 had turned

northbound and our courses were nearly perpendicular and we were co-altitude, so I again

called out that the 172 was 11 o'clock, northbound, same altitude, which was again

acknowledged, but no action was taken. As we continued westbound I saw the situation

developing, and I issued another verbal warning to the PIC, which was acknowledged, but

again no corrective action was taken and the aircraft continued to converge. I immediately

looked inside and saw the PIC with his head down at the iPad and at that point I assumed

the controls and initiated a pitch up and climbed the aircraft through a break in the clouds.

Aircraft 2 passed below and behind at an estimated range of 400 feet diagonally. While I

do not believe the situation was unsafe, the separation was not comfortable nor expected

by either aircraft. I should have taken action sooner, and believe I would have had I been

participating in the flight more actively. It is worth noting that I often fly into [an airport

with parallel runways], so I am frequently exposed to aircraft being closer than normal

during arrival and departure, which may bias my opinion of whether or not a collision

hazard existed. In those situations, however, the aircraft are typically on parallel or

divergent courses, which was not the case here, and had I not taken action, a collision

hazard would have certainly existed regardless of any subjectivity.

As with most abnormal events in aviation, there were numerous links in the chain of

events, and there were missed opportunities to break that chain sooner. This was a case

involving both poor communication and poor CRM. During the debrief of the event, the PIC

stated he was just flying straight out to the shoreline as he was used to when flying out of

many southern California airports, and did not notice or follow the river, which turns

slightly south, as the 172 did. I wish the PIC would have verbalized to me that he was

overwhelmed, confused or unsure of the departure routing, and I would have been able to

assume the role of a proactive crew member and help the PIC stay mentally ahead of the

aircraft instead of just sight-seeing. If I had better situational awareness of my pilot's

workload, I could have stepped in earlier in the flight to assist. While unable to see the

river from the right side of the aircraft, I am still guilty of not querying the PIC when I

initially noticed our departure courses diverging. We should have been following behind

the preceding traffic which would have averted the need for corrective action. Additionally,

had I pushed for additional separation between our aircraft on departure that would have

given additional time to maneuver behind the preceding 172 when they began the

crosswind turn over the shoreline, building additional lateral separation. The PIC, a VFR

private pilot, mentioned during the debrief of the event that he was distracted by the

clouds. This fixation likely contributed to the PIC's inaction and loss of situational

awareness. The weather was reporting CLR at the field, had it been reporting clouds or

had I personally looked at weather and seen the marine layer approaching, I would have

filed for an IFR departure, we would have been able to climb above the traffic in front of

us, and ATC would've been there acting as a third set of eyes for safe separation.

While often mentioned, it is worth reiterating that cockpit technology serves to aid in our

situational awareness, and is no substitute for true situational awareness of what's

happening both in and out of the cockpit. This should continue to be stressed to pilots in

training, and to experienced pilots who use this technology. The FAA is already in the

process of realigning training to focus on decision making, task priority, and situational

awareness in lieu of purely maneuver-based evaluation. Instructors also need training in

these subject areas so students are properly educated. I support this shift and believe it

could prevent future occurrences of events such as this. In addition to teaching standard

traffic patterns, pilot training also needs to highlight the existence of numerous non-

standard procedures that pilots will encounter, particularly at uncontrolled fields, and the

importance of proper pre-flight planning to review and understand these procedures prior

to stepping into the cockpit. I believe flight planning applications can sometimes be

detrimental to the formation of good habits for proper pre-flight planning, because they

can tempt pilots into a feeling of security with having all the information available on-

demand at your fingertips. Instructors need to stress the importance of thorough pre-flight

planning even more so with the advent of this technology.

It should be general good practice that whenever occupying a crewmember seat that a

rated pilot always stay engaged in the flight's progression and be ready to offer assistance

regardless of who is pilot in command. I had made the trip to relax and get away for an

afternoon, and my decision to disengage from the planning and execution of the return

flight proved detrimental, and was a missed opportunity to act as a mentor to a fellow

aviator.

Synopsis

General aviation flight instructor reported a near mid air collision after departure from a

CTAF airport.

ACN: 1466538 (44 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : HIO.Tower

State Reference : OR


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : HIO


Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger



Airspace.Class D : HIO

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : 7S3


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



Flight Plan : None

Mission : Personal

Nav In Use : GPS


Route In Use : None

Airspace.Class D : HIO

Person : 1

Reference : 1

Location Of Person.Facility : HIO.Tower

Reporter Organization : Government

Function.Air Traffic Control : Local

Qualification.Air Traffic Control : Fully Certified

Experience.Air Traffic Control.Time Certified In Pos 1 (mon) : 10


Human Factors : Human-Machine Interface



Person : 2

Reference : 2

Location Of Person.Aircraft : Y












Events

Anomaly.Airspace Violation : All Types



Detector.Person : Air Traffic Control


Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

I was working Local 1. There were two GA aircraft on final for Runway 31L that were

cleared to land. I had one GA aircraft extended on right downwind to follow the two

aircraft on final, but then I received an inbound point-out from P80, the overlying

TRACON, on Aircraft X from the southeast. I asked P80 to slow Aircraft X and direct him to

fly over the fix INTLL. I told the GA aircraft extended in the right downwind that I was

unable to accommodate his full stop on Runway 31L because of the faster Aircraft X traffic.

I instructed the GA aircraft to extend right downwind and contact the Local 2 controller on

132.8 for a full stop landing on Runway 31R. Aircraft X checked on frequency and I cleared

him to land number two behind the GA aircraft on short final. Additionally, I told Aircraft X

that there would be traffic ahead and to his right on extended final for the north parallel.

When Aircraft X was on about a five mile final, I observed an aircraft on what appeared to

be a right base about four miles from the airport. I told Aircraft X to stop his descent and

that it appeared that the aircraft for the north runway was overshooting final underneath

Aircraft X at 1000 MSL. At that point Aircraft X indicated 1600 MSL. Aircraft X said that he

saw the aircraft and was responding to a TCAS RA, but it didn't look like one of the high

wing GA aircraft. Local 2 immediately advised that that was not his aircraft, and we

determined that the southwest-bound aircraft was an airspace violator. I passed this

information along to Aircraft X and asked if he would like to continue the approach.

Aircraft X said he could, and I cleared him to land again on Runway 31L. I did not observe

Aircraft X take any evasive maneuver to avoid the aircraft. I had both aircraft in sight the

entire time, and Aircraft X appeared to cross over the violator between 400-600 feet. After

Aircraft X landed the pilot called the tower and advised that the violator in question,

Aircraft Y, landed at 7S3 shortly after. The pilot of Aircraft X also advised that they were

reporting this incident as a near mid-air collision.

On the FALCON replay, Aircraft Y could be seen violating the airspace from the northeast

and then exiting the Delta airspace and skirt the edge of the airspace south bound. Aircraft

Y re-entered the airspace from the southeast and made a turn southwest bound. This put

him directly under final at about 1000 MSL. Had I noticed this violator earlier, I could have

prepped Aircraft X sooner. But I am confident that my timely actions to stop Aircraft X's

descent prevented this from becoming a collision.

Narrative: 2

After departing [north of SPB] to 7S3 and just setting cruise after climb out I realized that

I was very close to HIO Class D. I immediately turned east toward PDX and flew between

their airspace until clear to the south of HIO. I then continued on to 7S3 and landed there

for fuel. After fueling I was told that I had entered the Class D airspace and that I would

be hearing from ATC. I was not given a number to call, but was told that since I had

installed ADSB they already had my information. I believe that a contributing factor was

that in approaching from the north the Class D line is missing or obscured due to all of the

printing. As soon as I realized how close I was I watched for other aircraft and diverted to

an area I knew to be outside. Another factor was my inexperience with the area and the

short duration of the flight. Had I prepared more I might have had their frequency dialed

in but I had just set the radio to 7S3 frequency and changing to HIO freq. would have

required more time than simply exiting.

Synopsis

HIO Tower Controller and pilot reported of a Class Delta airspace violation and a NMAC.

ACN: 1466524 (45 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : HCF.TRACON

State Reference : HI


Environment


Weather Elements / Visibility : Cloudy


Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.TRACON : HCF


Make Model Name : Small Transport


Flight Plan : IFR


Airspace.Class E : HCF

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : JHM


Make Model Name : Small Transport


Flight Plan : VFR


Route In Use : None

Airspace.Class E : HCF

Person

Reference : 1

Location Of Person.Facility : HCF.TRACON

Reporter Organization : Government

Function.Air Traffic Control : Approach

Qualification.Air Traffic Control : Fully Certified

Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 2.75




Events




Anomaly.Inflight Event / Encounter : CFTT / CFIT

Detector.Person : Air Traffic Control


Result.Flight Crew : Returned To Clearance

Result.Air Traffic Control : Issued New Clearance

Assessments





Narrative: 1

Aircraft X was on the instrument approach into JHM. The Aircraft before him reported

BKN048 10 NW of the airport. Aircraft X was 15 NW of JHM descending when a VFR

aircraft on a 1200 squawk departed JHM head on. I issued traffic advisories to Aircraft X

but had no idea who the other aircraft was. Traffic advisories became traffic alerts 5 miles

between the two aircraft at 4800 (same ALT). Then at two miles at 4800 the Captain says

"I'm going right". A right turn would have put the Aircraft X even closer and the targets

would have merged. I told the Aircraft X to make a left 360 before proceeding back on

course, they were below the MVA at the time but over water. I noticed Aircraft X had

climbed to 5000 and asked if they had an RA. The pilot replied in the affirmative and I

reported it to my Supervisor. Later we found out the other aircraft was Aircraft Y when

they requested flight following from the adjacent sector.

Recommendations:

1. Request flight following in and out of JHM.

2. JHM issues a VFR code on the ground and has them contact HCF on departure.

3. Development of a VFR procedure where aircraft remain clear of the final approach

course.

Synopsis

HCF Controller reported an airborne conflict between an IFR departure and a VFR aircraft.

ACN: 1466511 (46 of 50)

Time / Day

Date : 201707


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X



Make Model Name : Amateur/Home Built/Experimental



Mission : Personal


Route In Use : VFR Route

Aircraft : 2

Reference : Y


Make Model Name : PC-12



Person

Reference : 1














Events









Assessments



Narrative: 1

We were over the threshold doing 95 knots when a Pilatus began to take the active

runway. My lovely passenger and I reported that we were on a very short final!! The pilot

then shot on the runway and said: "Go around!" We thought we were goners!! I nearly

dug in a wing tip missing the Pilatus by only a few feet and passed by him and flew

alongside the plane during its takeoff roll.

Synopsis

Glasair pilot reported that during final approach prior to touchdown, a Pilatus took the

active runway.

ACN: 1466499 (47 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Amateur/Home Built/Experimental



Flight Plan : None

Mission : Personal


Route In Use : None

Component

Aircraft Component : Nose Gear


Problem : Failed

Person

Reference : 1















Events






Assessments



Narrative: 1

On roll out after a series of landings, pilot's foot slipped off the rudder/brake and aircraft

veered onto the shoulder and the nose gear collapsed.

Synopsis

Experimental aircraft pilot reported that his foot slipped off the rudder pedal on landing

resulting in a runway excursion.

ACN: 1466180 (48 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : JYO.Airport

State Reference : VA


Environment



Light : Daylight


Aircraft : 1

Reference : X

ATC / Advisory.CTAF : JYO


Make Model Name : PA-34-200T Turbo Seneca II



Flight Plan : IFR

Mission : Personal


Route In Use : Vectors

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : JYO


Make Model Name : Cirrus Aircraft Undifferentiated



Mission : Personal


Airspace.Class G : PCT

Person

Reference : 1

















Events

Anomaly.Conflict : Ground Conflict, Less Severe


Anomaly.Ground Incursion : Runway






Result.Flight Crew : Rejected Takeoff

Assessments



Narrative: 1

Departing JYO. Part time Tower closes in the afternoon. Called Ground for clearance. Was

informed Tower was closing, Runway 35 was in use and to get clearance from Potomac

Approach. Announced taxi to Runway 35 on Unicom and taxied to run-up area. Switched

frequencies and got IFR clearance. Was told there was inbound IFR traffic and that we

were cleared to go as soon as they arrived. Traffic was on base for 35. They landed and

we announced our departure for 35 on Unicom and taxied out. As landing traffic cleared

runway we started our takeoff roll. As we rolled I spotted landing lights on short final for

Runway 17. I aborted takeoff and stopped the plane well to the side of the runway. The

approaching airplane, a Cirrus, landed and taxied off the runway. We then departed on

Runway 35. I do not believe the Cirrus ever saw us. We did not hear him call position or

intentions on Unicom. The wind favored Runway 35 and that was the direction all traffic

had been landing according to the Tower before it closed. The runway is long and neither

airplane was in jeopardy as the Cirrus stopped in a short distance and exited the runway.

But had I not seen them in the distance it could have been much closer.

Synopsis

PA34 pilot reported rejecting takeoff after observing unannounced traffic on short final

landing on the opposite direction runway.

ACN: 1466178 (49 of 50)

Time / Day

Date : 201707


Place




Environment

Flight Conditions : Marginal


Light : Daylight


Aircraft : 1

Reference : X


Make Model Name : Cessna Single Piston Undifferentiated or Other Model



Flight Plan : IFR

Nav In Use : GPS


Route In Use.Other

Airspace.Class E : RDU

Aircraft : 2

Reference : Y


Make Model Name : Cessna Aircraft Undifferentiated or Other Model


Airspace.Class E : RDU

Person

Reference : 1















Events







Assessments



Narrative: 1

At the time of the incident I had been cleared for the RNAV 21 approach. I entered VMC

after passing the IAF and contacted Raleigh approach to cancel my IFR flight plan. Raleigh

confirmed my cancellation and approved me to change to the CTAF frequency. Ceiling was

around 2,500 feet MSL. I announced on the CTAF frequency that I was 8 miles out on the

GPS approach for Runway 21 at JNX. I made an announcement that I was 5 miles out on

the GPS approach for Runway 21 at JNX. At this time another pilot made announcement

that he was overflying the tank farm 4 miles away and would be passing the approach end

of Runway 21. I made an announcement that I was 3 miles out on the GPS approach for

Runway 21 at JNX. The other pilot announced that he had me in sight and would maintain

visual separation. I had just passed CUMUT. It was after this when I saw a Cessna

disappear underneath my nose. I immediately executed a steep climbing turn to the left to

avoid the airplane and announced my intentions on the CTAF. I completed a 360 degree

turn and landed on Runway 21 without further incident.

Synopsis

Cessna pilot reported an NMAC with another light aircraft in the vicinity of JNX airport.

ACN: 1465911 (50 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft : 1

Reference : X






Flight Plan : None

Mission : Training



Aircraft : 2

Reference : Y






Mission : Training



Person : 1

Reference : 1

















Person : 2

Reference : 2

Location Of Person.Aircraft : Y
















Events







Assessments



Narrative: 1

While on downwind during a training flight in the traffic pattern during a time of very

heavy activity, as I began to turn base there was another aircraft slightly above and

behind me. I immediately took evasive action by descending and turning away from the

other aircraft. We had both been announcing our positions on CTAF but were not aware of

how close we were to each other.

Narrative: 2

I was on downwind with a student and we were just about to call our base turn when

another airplane called turning base. I started to look for it and had just pushed the push

to talk button when I saw it low and to our right, so instead of "where are you" in surprise

I said "Oh [expletive]" and then saw that he had seen us too and was starting to dive left

so I took the controls from the student and climbed right. There was no further conflict.

Prior to this happening we had approached the airport on the upwind, then crosswind,

then downwind. While we were turning crosswind a plane on the runway called their

departure so I was looking for them to make sure there was no conflict with them. The

other plane in the pattern had made a radio call that he was inbound to the downwind, but

due to distraction with the plane on the runway I never heard him say he was entering

downwind and I assumed he was far ahead of us. We had made radio calls at each turn. I

did not see him on downwind until we were ready to turn base. I do not think entering a

pattern from upwind is a good idea, we should only enter to the downwind.

Synopsis

Two instructor pilots, both flying separate C172 aircraft, reported an NMAC with each

other in the pattern.

non-tower airport incidents - asrs - aviation safety ...1 of 50) synopsis rv12 pilot reported that...

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