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How A Missed Checklist Item Led To An Airspace Incursion

cvtperson

Accidents and incidents start with a chain of errors nearly every time. The NASA safety report below is a perfect example of how a series of mistakes on the ground led to a problems in the air.

One Missed Checklist Item

I did a thorough preflight inspection and engine run up at U42 using a checklist. I also calculated the weight and balance of the aircraft and the aircraft was within limits but closer to the max than I usually fly. I am also typically flying out of airports at lower elevations.

After completing run up I struggled a little bit to find the taxi ways to runway 34 which the winds were favoring. I tried to find an airport diagram for U42 in advance of the flight but none was available. This struggle had me a bit flustered as this was an unfamiliar airport to me with a more complex taxi system than I am used to.

I approached the runway, checked for traffic, made a radio call and took off. The aircraft struggled more than usual to take off which I attributed to the higher altitude and higher load than I normally carry. However, after takeoff the climb was extremely slow. Normally I climb out at 88 mph (approximately Vy), but I was forced to climb out at about 80 mph (approximately Vx) in order to gain altitude. And the altitude gains were maybe 1/5th the normal rate.

I started to panic and tried to determine what was wrong. Had I grossly miscalculated the load? Was the density altitude far too high than I am used to? Were my flaps mis-configured? Did my plane have the wrong type of fuel? Had the tanks been compromised with rain water that day? Where would I make an emergency landing if my engine was failing?

I remembered my training and focused on "flying the plane." I knew I needed to keep from stalling as this would likely be deadly this close to the ground. I had to keep my airspeed above Vx and fly the plane straight and level without turning. I remembered that trying to turn back to the runway in this situation is often fatal. I had to focus on flying the plane at the expense of navigation or other concerns while determining what was wrong.

My GPS started warning that I was nearing SLC Class B airspace. I believed this was the airspace above me and focused my attention on my airspeed and trying to gain altitude. Suddenly my GPS indicated that I had entered the SLC B airspace. I knew I didn't have permission and I realized what had happened. I was so focused on flying the plane that I hadn't turned left as I had planned and runway 34 was pointed directly at the SLC class B airspace all the way to the ground.

I had gained enough altitude that I was comfortable with a careful turn to the left to get my plane out of the airspace as quickly as possible without stalling the plane.

Once clear of the B airspace, I continued to search my instruments and flight controls for the source of my engine's poor performance. Mixture was good, throttle was full, primer was in and locked. But carb heat was set to hot! I pushed the carb heat control to cold and my engine roared with new life. My airspeed and climb improved instantly and dramatically. I realized what must have happened. During my engine run up I make sure the engine would idle and turned on carb heat to prevent icing. But I had left the carb heat on by mistake and missed the check during the pre-take off checklist.

What contributed to the mistake was the lack of airport diagram for U42 and lack of familiarity with the airport which caused me to become flustered and miss a critical item on the check list. Also, I would have liked to connect with Flight Following from the ground but wasn't sure how to do this at U42. Was I supposed to call clearance? SLC Approach? SLC Center? Had I been on Flight Following a Controller might have warned me I was heading directly for [Class] B or I could have explained what was going on when I experienced engine trouble.

insEyedout

What Went Wrong

The error chain in this incident started during taxi. The pilot was unfamiliar with the airport, and the taxi to the runway had him flustered. That led the pilot to miss a critical takeoff checklist item: carb heat.

At any airport, carb heat robs your engine of power, because it introduces hot, low-density air into the carburetor. Add in the fact that this takeoff was at a 4,600' airport, and carb heat was taking away a significant percentage of takeoff climb power.

The slow climb and engine troubleshooting led the pilot to his final mistake: inadvertently entering Salt Lake's Class B airspace without a clearance.

What Went Right

Out of the things that went wrong, there was one thing that went very right: the pilot kept flying the airplane. He kept the wings level, climbed the best he could, and continued troubleshooting the engine problem.

And even though he entered Class B, he was able to find the problem, resolve it, and land safely.

Complete The Checklist, Every Time

This incident's error chain could have been broken at the runway hold-short line.

When you're feeling like thing's aren't quite "right", or you're uncomfortable, you should take extra time to make sure you're ready for takeoff.

Had that happened in this case, with the pilot running through the takeoff checklist one more time before departure, the incident most likely would have never happened.

Colin Cutler

Colin is a Boldmethod co-founder, pilot and graphic artist. He's been a flight instructor at the University of North Dakota, an airline pilot on the CRJ-200, and has directed development of numerous commercial and military training systems. You can reach him at colin@boldmethod.com.

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