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|
Attributes | |
ACN | 1143993 |
Time | |
Date | 201401 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Flight Phase | Final Approach |
Route In Use | None |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Flying Single Pilot |
Qualification | Flight Crew Multiengine Flight Crew Private Flight Crew Instrument |
Experience | Flight Crew Last 90 Days 30 Flight Crew Total 630 Flight Crew Type 143 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy Flight Deck / Cabin / Aircraft Event Other / Unknown Inflight Event / Encounter CFTT / CFIT Inflight Event / Encounter Unstabilized Approach Inflight Event / Encounter Weather / Turbulence |
Narrative:
While practicing the ILS approach; single pilot; the autopilot lost capture of the glideslope and localizer prior to the missed approach point. As I unsuccessfully tried to reengage the autopilot; something dropped from the ceiling of the cockpit; momentarily distracting me. Turning my attention back to the panel; I discovered both needles had gone full deflection and my heading was showing 157 degrees instead of 143. I was now 14 degrees off course in IMC at 200 ft AGL. I was confused because ATIS called for 300 foot ceilings and I was already at 200 ft with neither visual of the runway nor ground. I had lost my point of reference and was unsure about my position relative to the runway and airport. My next concern was my proximity to the control tower; the only vertically-prominent building on the airport property; situated mid field; just west of the runway. Because of the 157 heading that I had been flying following the disengagement of the autopilot; I feared the plane was now headed toward it; or perhaps near it. I knew the missed approach procedure calls for making a climbing right turn to the west of the airport to the VORTAC; however; without knowing where I was; at 200 ft AGL in IMC; flying at 120 KTS; and having lost my point of reference; I justified a potential hazard and erred on the side of caution. This decision resulted in pilot deviation to the east; away from the perceived hazard. I immediately banked away in a climbing left turn until I was in VFR conditions on top at 1;800 ft MSL where I continued my climb to the VORTAC; albeit from the east side of the airport. Upon emerging from the cloud layer; I immediately reported my position to the tower. After being handed off to approach; I briefly explained my disorientation and set up for another ILS approach. Following the second approach to an uneventful landing; I turned off the runway and was taxiing in zero-zero visibility. The ceiling had deteriorated such that at that end of the runway; I could not see the tower and had to alert them to my field position as I taxied back to the hangar. At the hangar; I finally discovered the 'mystery object' that had perpetrated the distraction. It was a vent nozzle above me that had become loose from the headliner and had fallen. Over the years; I have learned that many accidents happen as a result of a series of events that ultimately lead to disastrous and sometimes fatal consequences; rather than just a single event. The combination of losing autopilot capture of both the localizer and glideslope at a critical time; the distraction of the fallen 'mystery object;' and flying 14 degrees off course at 120 KTS that close to the ground in IMC; coupled with disorientation; I recognized the situation as a recipe for disaster. I chose the only course of action which I felt was safe: climb away from the perceived hazard. Although the whole ordeal lasted only seconds it left me quite shaken.
Original NASA ASRS Text
Title: BE58 pilot experiences autopilot disengagement at low altitude on an ILS approach in IMC. An object falls from the ceiling causing further distraction and a missed approach is initiated with fully deflected needles and 14 degrees off runway heading.
Narrative: While practicing the ILS approach; single pilot; the autopilot lost capture of the glideslope and localizer prior to the missed approach point. As I unsuccessfully tried to reengage the autopilot; something dropped from the ceiling of the cockpit; momentarily distracting me. Turning my attention back to the panel; I discovered both needles had gone full deflection and my heading was showing 157 degrees instead of 143. I was now 14 degrees off course in IMC at 200 FT AGL. I was confused because ATIS called for 300 foot ceilings and I was already at 200 FT with neither visual of the runway nor ground. I had lost my point of reference and was unsure about my position relative to the runway and airport. My next concern was my proximity to the Control Tower; the only vertically-prominent building on the airport property; situated mid field; just west of the runway. Because of the 157 heading that I had been flying following the disengagement of the autopilot; I feared the plane was now headed toward it; or perhaps near it. I knew the missed approach procedure calls for making a climbing right turn to the west of the Airport to the VORTAC; However; without knowing where I was; at 200 FT AGL in IMC; flying at 120 KTS; and having lost my point of reference; I justified a potential hazard and erred on the side of caution. This decision resulted in pilot deviation to the east; away from the perceived hazard. I immediately banked away in a climbing left turn until I was in VFR conditions on top at 1;800 FT MSL where I continued my climb to the VORTAC; albeit from the east side of the airport. Upon emerging from the cloud layer; I immediately reported my position to the Tower. After being handed off to Approach; I briefly explained my disorientation and set up for another ILS approach. Following the second approach to an uneventful landing; I turned off the runway and was taxiing in zero-zero visibility. The ceiling had deteriorated such that at that end of the runway; I could not see the Tower and had to alert them to my field position as I taxied back to the hangar. At the hangar; I finally discovered the 'mystery object' that had perpetrated the distraction. It was a vent nozzle above me that had become loose from the headliner and had fallen. Over the years; I have learned that many accidents happen as a result of a series of events that ultimately lead to disastrous and sometimes fatal consequences; rather than just a single event. The combination of losing autopilot capture of both the localizer and glideslope at a critical time; the distraction of the fallen 'mystery object;' and flying 14 degrees off course at 120 KTS that close to the ground in IMC; coupled with disorientation; I recognized the situation as a recipe for disaster. I chose the only course of action which I felt was safe: climb away from the perceived hazard. Although the whole ordeal lasted only seconds it left me quite shaken.
Data retrieved from NASA's ASRS site 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.