37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 113098 |
Time | |
Date | 198906 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : see |
State Reference | CA |
Altitude | msl bound lower : 2600 msl bound upper : 2600 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : san |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | descent : approach landing : go around |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 30 flight time total : 420 flight time type : 350 |
ASRS Report | 113098 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : undershoot non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During a localizer approach to gillespie field (see), el cajon, ca, I forgot to execute the last step-down in the descent. Thus, at the end of the timed approach I was over the airport still in IMC. I could see the runway through a break in the cloud cover, but the break was not large enough to make a descent in VFR and circle to land. The fact that I hadn't flown out of IMC during the approach, when I had every reason to expect to do so, confused me. I executed a missed approach and compounded the problem by centering the needle to fly directly to the VOR (as instructed), took my heading from the instrument, and then flew the outbnd course because I centered on from rather than to. All of this gave the controller some concern, to say the least. After inquiring as to my rating and currency (and properly so), he gave me vectors for another localizer approach, which I completed. The step-down failure occurred because I was having difficulty tracking the localizer, and I let it occupy my attention to the exclusion of other matters. Tuning the reciprocal radial and turning to the reciprocal heading was caused by my lag, mentally, in terminating the approach. Had I pre-tuned the #2 VOR for the missed approach as soon as I was finished with it for the step-downs, I would have had a tentative missed approach heading much more in mind. The published procedure does not give a heading, just direct to mzb. As it was, I let the instrument give me the heading without adequate thought as to its correctness. I plan to prevent recurrence by: 1) setting up the navigation equipment in advance for the missed approach segment, where possible, 2) verbally calling each element of the descent procedure repeatedly (airspeed, heading, descending to, etc), and 3) maintaining an adequate mental picture of the course changes required for the missed approach procedure.
Original NASA ASRS Text
Title: GA SMA MISSED HIS APCH WHEN PLT FAILED TO DESCEND TO DECISION ALT ON A LOC APCH INTO SEE. TURNED TO WRONG HEADING ON GO AROUND.
Narrative: DURING A LOC APCH TO GILLESPIE FIELD (SEE), EL CAJON, CA, I FORGOT TO EXECUTE THE LAST STEP-DOWN IN THE DSCNT. THUS, AT THE END OF THE TIMED APCH I WAS OVER THE ARPT STILL IN IMC. I COULD SEE THE RWY THROUGH A BREAK IN THE CLOUD COVER, BUT THE BREAK WAS NOT LARGE ENOUGH TO MAKE A DSCNT IN VFR AND CIRCLE TO LAND. THE FACT THAT I HADN'T FLOWN OUT OF IMC DURING THE APCH, WHEN I HAD EVERY REASON TO EXPECT TO DO SO, CONFUSED ME. I EXECUTED A MISSED APCH AND COMPOUNDED THE PROBLEM BY CENTERING THE NEEDLE TO FLY DIRECTLY TO THE VOR (AS INSTRUCTED), TOOK MY HDG FROM THE INSTRUMENT, AND THEN FLEW THE OUTBND COURSE BECAUSE I CENTERED ON FROM RATHER THAN TO. ALL OF THIS GAVE THE CTLR SOME CONCERN, TO SAY THE LEAST. AFTER INQUIRING AS TO MY RATING AND CURRENCY (AND PROPERLY SO), HE GAVE ME VECTORS FOR ANOTHER LOC APCH, WHICH I COMPLETED. THE STEP-DOWN FAILURE OCCURRED BECAUSE I WAS HAVING DIFFICULTY TRACKING THE LOC, AND I LET IT OCCUPY MY ATTN TO THE EXCLUSION OF OTHER MATTERS. TUNING THE RECIPROCAL RADIAL AND TURNING TO THE RECIPROCAL HDG WAS CAUSED BY MY LAG, MENTALLY, IN TERMINATING THE APCH. HAD I PRE-TUNED THE #2 VOR FOR THE MISSED APCH AS SOON AS I WAS FINISHED WITH IT FOR THE STEP-DOWNS, I WOULD HAVE HAD A TENTATIVE MISSED APCH HDG MUCH MORE IN MIND. THE PUBLISHED PROC DOES NOT GIVE A HDG, JUST DIRECT TO MZB. AS IT WAS, I LET THE INSTRUMENT GIVE ME THE HDG WITHOUT ADEQUATE THOUGHT AS TO ITS CORRECTNESS. I PLAN TO PREVENT RECURRENCE BY: 1) SETTING UP THE NAV EQUIPMENT IN ADVANCE FOR THE MISSED APCH SEGMENT, WHERE POSSIBLE, 2) VERBALLY CALLING EACH ELEMENT OF THE DSCNT PROC REPEATEDLY (AIRSPEED, HDG, DSNDING TO, ETC), AND 3) MAINTAINING AN ADEQUATE MENTAL PICTURE OF THE COURSE CHANGES REQUIRED FOR THE MISSED APCH PROC.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.