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He is not all together there

By NASA · October 19, 2023 ·

This is an excerpt from a report made to the Aviation Safety Reporting System. The narrative is written by the pilot, rather than FAA or NTSB officials. To maintain anonymity, many details, such as aircraft model or airport, are often scrubbed from the reports.

My Cardinal 177 had not been flown in over a week and I planned to stay in the pattern at ZZZ for a few touch and goes. Skies were clear, winds were light, and traffic in the pattern was light. There were a couple of other aircraft in the pattern utilizing Runway X.

During the pre-flight, I set the altimeter to that announced on ASOS and completed my radio check successfully.

Other aircraft were announcing their intentions and positions in the pattern for Runway X. I taxied and took off from Runway X and landed to a full stop. I taxied back to Runway X and departed for my second lap in the pattern. I climbed to 700 feet AGL before turning left crosswind for Runway X. I do recall the setting sun in the west as I climbed to pattern altitude of 1,666 feet MSL.

I established and announced my left downwind Runway X on CTAF. At mid downwind I ran my pre-landing procedures. All position reports were made on CTAF.

As I approached the point where I am parallel to the Runway X numbers, I glanced out toward the runway and at that point saw the other aircraft had passed under and behind me.

Vertical separation was less than 200 feet and given the plane had just passed under me I would estimate horizontal separation was less than 300 feet.

At that point I continued on the downwind, which I extended and turned left base for Runway X. I kept an eye on the aircraft, which landed on Runway XX.

Knowing the other aircraft was on the ground, I continued east of the airport at pattern altitude and rejoined the pattern for Runway X at the mid downwind point and landed on Runway X.

After landing and securing my aircraft, I tracked down the other pilot that passed under me in the pattern. I asked him if he didn’t hear the other aircraft in the pattern announcing they were using Runway X. He seemed unaware of other traffic. I asked if he even saw my plane in front of him, which he indicated “no,” at which point I expressed my concern.

The pilot did not have English as his first language based on his accent. He seemed a bit confused.

I asked the fellow at the ramp who shuttled him from his plane to the FBO if he noticed anything peculiar about the fellow. He indicated, “he is not all together there.”

How the problem arose:

  1. Pilot of second aircraft did not have a situational awareness of traffic at the airport before landing
  2. Pilot of second aircraft crossing mid field at pattern altitude despite aircraft on Runway 2 while he was landing Runway 20.
  3. As pilot landing near sunset visually looking west into the sun prevented clearly seeing aircraft.
  4. Other pilot did not give way to my aircraft which would have been approaching.

Primary Problem: Procedure

ACN: 2000403

About NASA

NASA's Aviation Safety Reporting System (ASRS) captures confidential reports, analyzes the resulting aviation safety data, and disseminates vital information to the aviation community.

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Comments

  1. Kenneth says

    October 21, 2023 at 8:55 am

    Wow… I had to re-read this entire article and comments several times. Not sure what is going on here.

    Have we lost all common sense and decency?

    Let’s take a deep breath, relax, and think about this. We are aviators, not flying detectives and police..

    First, why do we not release all this information to the public? Easy answer, the NASA report is not an official investigation… This is only one person’s perspective. We must all remember that there are three sides to this event (or story as told by the beholder, his, the other pilots, and what really happened). There is the narrative from the first pilot, but we do not have the narrative from the second pilot. We also do not have the FAA nor the NTSB official report. That is why names should never be given out.

    This is only one person’s perspective, not an officially investigated incident. Remember you could be that other offending pilot and not know you had offended or caused a situation until you find your name out in the public for creating a safety hazard, which I am sure you would then be getting an official invitation from your friends at the FAA for a nice sit-down with them.

    Wonder what that would do to your insurance rates, I don’t think they will lower them for you, or especially when the FAA and or your insurance company see’s this, “My guess: street drug impairment. Wonder who his next victim(s) will be?” (Oh an his English was not good either) Think you might have a problem with your certificate after your name was released? Or in my case, my employer would have me benched for at least six months (without pay) as they do hair and blood samples on me plus going to counselling just from the accusation.

    I have investigated probably over 50 people for DOT drug and alcohol violations in over fifteen years while in my profession and would never make a comment like that without full tests and drug screens. We need to step back and look in the mirror an see how we look to others, we do not walk on the surface of water.

    Are we really going to call the local FSDO to report a fellow pilot because his “English is not so good”. How is your English? I would probably have acted the same way if I was attacked by another pilot. How would you act if you were getting ready to leave the airport and someone come up to you and is belligerent to you? Calling your piloting skills into question? Accusing you with being on street drugs? Do you think the FSDO will not look at you? Is this the way you would have wanted to be treated? Lets treat other pilots the way we would want to be treated.

    Let’s just go through his analysis:

    How the problem arose: (His version, notice as you read this he has no culpability in this, his flying is perfect, in altitude, heading, and procedures.

    Pilot of second aircraft did not have a situational awareness of traffic at the airport before landing. (How does he know this? Is he an FAA Safety Inspector? Don’t think so or he would not have done a NASA report to protect himself. From what he wrote he never did get to sit down with the other pilot and get his prospective, just that the other pilot did not see him and was using street drugs and did not speak good English.

    Pilot of second aircraft crossing mid field at pattern altitude despite aircraft on Runway 2 while he was landing Runway 20.

    The following is from the FAA’s, Airplane Flying Handbook (FAA-H-8083-3C)
    Chapter 8: Airport Traffic Patterns page 8-4, here is the link for those that are interested:
    https://www.faa.gov/sites/faa.gov/files/regulations_policies/handbooks_manuals/aviation/airplane_handbook/09_afh_ch8.pdf

    Non-Towered Airports
    Non-towered airports traffic patterns are always entered at pattern altitude. How a pilot enters the pattern depends upon the direction of arrival. The preferred method for entering from the downwind leg side of the pattern is to approach the pattern on a course 45° to
    the downwind leg and join the pattern at midfield.

    As pilot landing near sunset visually looking west into the sun prevented clearly seeing aircraft. Other pilot did not give way to my aircraft which would have been approaching.

    This is what made him mad. He should not have had to alter his coarse.

    Certain times of the day create quite imposing situations that require very good pilotage. We must all stay very vigilant. We must balance out heads on a swivel looking out, left to right, up and down, while keeping our airspeed, and heading, and getting our plane into the landing configuration. We are the ULTIMATE authority to our aircraft. See 91.3a and 91.3b below:

    § 91.3 Responsibility and authority of the pilot in command.
    (a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.

    (b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.

    If you are that close you need to break off, that is why we teach go arounds, always be ready to go around, pull up, dive, whatever it takes to avoid and keep from a collision.

    Primary Problem: Procedure
    Do not understand this. Who’s procedure? Primary problem as I read it is not following see and avoid, I see “Air Rage”. We chase down another pilot to confront him? Because he did not alter his course? Is this what we consider good Pilot Etiquette? Then because his English is not what you deem appropriate, we say he is using street drugs? I see a pilot that was scared after he saw an aircraft too close to him, for his comfort. His estimated footage, I bet, in reality is very far off. All he did to avoid the situation was extend his downwind… not, I made a hard diving 45 to avoid hitting him….

    We need to get back to basics of Flying, We need to re-learn we are responsible for our pilotage, we need to look and avoid. We put way too much dependance on, I called on the CTAF…. That is not a magic bubble around us. Our iPads are not our total encompassing “there is no traffic out there”.

    Electronics fail and no not everyone carries a radio and remember Murphy’s law. Things go wrong. We are the ones that are taught to take Lemons and make Lemonade. The most mundane “around the pattern” flight has killed several of my friends, and their passengers. I am sure you have your list too.

    Our EYE’s and our skills are our final and last defense in keeping us safe. Flying a real plane is not a video game. It is real and we can get killed in thirty seconds or less. (Yes your life does pass before your eyes as it happens). There are no reboots, resets, or do overs. This is why we do flight reviews, and I just enjoy going out with another instructor and learning something new.

    Further reading on mid-air collisions from Page 8-6 of the Airplane Flying Handbook (FAA-H-8083-3C):

    ⦁ Mid-air collisions generally occur during daylight hours—56 percent occur in the afternoon, 32 percent occur in the morning, and 2 percent occur at night, dusk, or dawn.

    ⦁ Most mid-air collisions occur under good visibility.

    ⦁ A mid-air collision is most likely to occur between two aircraft going in the same direction.

    ⦁ The majority of pilots involved in mid-air collisions are not on a flight plan.

    ⦁ Nearly all accidents occur at or near uncontrolled airports and at altitudes below 1,000 feet.

    ⦁ Pilots of all experience levels can be involved in mid-air collisions.

    Figure 8-4. Location distribution of mid-air collisions in the airport traffic pattern. (look this up, very interesting)

    The following are some important procedures that all pilots should follow when flying in a traffic pattern or in the vicinity of an
    airport.

    1. Tune and verify radio frequencies before entering the airport traffic area.
    2. Monitor the correct Common Traffic Advisory Frequency (CTAF).
    3. Report position 10 miles out and listen for reports from other inbound traffic.
    4. At a non-towered airport, report entering downwind, turning downwind to base, and base to final.
    5. Descend to traffic pattern altitude before entering the pattern.
    6. Maintain a constant visual scan for other aircraft.
    7. Be aware that there may be aircraft in the pattern without radios.
    8. Use exterior lights to improve the chances of being seen.

    NASA reports are a wonderful thing, they give us a “Get out of Jail Card, FREE”, and they are a great learning tool for us to sit down and go over. We just need to be abstract and take the data and apply to any airport or situation see what we can learn…

    Go out, have fun, be safe, and enjoy the freedom of flying!

  2. Scott Patterson says

    October 20, 2023 at 11:11 am

    Trying to upend procedures based on one person’s opinion tend to produce undesired results. Perhaps like disallowing landing to full stop and back taxi on an active runway.

  3. Sideckey says

    October 20, 2023 at 7:05 am

    Let’s leave the NASA report the way it is. However I don’t see a problem at all to call the FSDo and report mr pilot. I’m sure a ramp check on his airplane will not only improve his English, verify his plane is ‘legal’ but maybe put a little review of his piloting privileges under an appropriate light. Of course I could be wrong.

  4. James Brian Potter says

    October 20, 2023 at 6:47 am

    Why sanitize the reports at all? These reports document grave life-and-death issues of public safety, and no privacy consideration should interfere with straight-forward reporting. We the general public have a right to know identities of key persons involved in incidents. News reports of motor vehicle accidents generally include make-and-mode data on the vehicles involved and eventually the names of persons injured or killed. Why not in the aviation industry? After the dust settles in Washington DC I suggest a write-in campaign to our respective Congress Critters to demand relaxation of that NASA rule.

    That offending pilot should be ‘outed’ as to his name and tail number and interrogated by the authorities with possible license suspension and fine. But for the Grace of God there were no crashes and fatalities. My guess: street drug impairment. Wonder who his next victim(s) will be?

    Regards/J

  5. Flying B says

    October 20, 2023 at 6:20 am

    It is the so called NASA report where the original report is redacted to take out the airport names and IDs, along with runway numbers. For report like this one it makes it really hard to read. Not a General Aviation News issue as they don’t have the info either. I do think the NASA redaction rules should change some so we can see some more detail.

  6. Some pilot says

    October 20, 2023 at 4:55 am

    Why teveal the TPA of 1666’ and use directions like “east,” etc., if you’re trying to sanitize the report with ZZZ, Runway X, etc.? Why not use pattern altitude “1234,” and etc. all in the spirit of sanitization and making the report really hard to read. Over.

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