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|
Attributes | |
ACN | 119145 |
Time | |
Date | 198908 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : kdk |
State Reference | AK |
Altitude | msl bound lower : 1200 msl bound upper : 1200 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zan tower : kdk |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | descent : approach landing : go around landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
ASRS Report | 119145 |
Person 2 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Events | |
Anomaly | non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Small aircraft had clearance from center for ILS DME-1 runway 25 approach to kodiak, ak. He flew the 10 DME arc transition to the localizer. When he apparently was intercepting the localizer he told me he wasn't receiving a good localizer indication, which is not uncommon for aircraft outside the final approach fix (8 DME). I told him there were no apparent discrepancies (monitors of preceding aircraft) and suggested the VOR runway 25 approach. He said he'd let me know. A few mins later he reported a good signal and 6 DME on the localizer. Because the WX was reasonable (approximately 1000' bases and unrestricted visibility) I told him to report airport in sight, which should have been imminent. In about 2 mins I asked for his DME, as he should either have been VMC or on the missed approach (DH 496 at 3.3 DME). He reported 2 DME and 'about to break out.' I told him he was apparently past the missed approach point and that he'd better miss approach if IMC due to 2500' terrain just west of the airport. He flew the missed approach and completed the VOR approach successfully. I talked later to the pilot, who said he's sure he neglected to change to the localizer DME, which would mean he was safer than I thought--but, there have been 2 accidents (3 fatalities) on this approach in the last 4 yrs and several other instances of apparent confusion worse than this instance.
Original NASA ASRS Text
Title: PLT OF SMA ON VOR APCH TO KDK MISREAD DME TO ARPT, MISSED APCH. NEXT VOR APCH SUCCESSFUL.
Narrative: SMA HAD CLRNC FROM CENTER FOR ILS DME-1 RWY 25 APCH TO KODIAK, AK. HE FLEW THE 10 DME ARC TRANSITION TO THE LOC. WHEN HE APPARENTLY WAS INTERCEPTING THE LOC HE TOLD ME HE WASN'T RECEIVING A GOOD LOC INDICATION, WHICH IS NOT UNCOMMON FOR ACFT OUTSIDE THE FINAL APCH FIX (8 DME). I TOLD HIM THERE WERE NO APPARENT DISCREPANCIES (MONITORS OF PRECEDING ACFT) AND SUGGESTED THE VOR RWY 25 APCH. HE SAID HE'D LET ME KNOW. A FEW MINS LATER HE RPTED A GOOD SIGNAL AND 6 DME ON THE LOC. BECAUSE THE WX WAS REASONABLE (APPROX 1000' BASES AND UNRESTRICTED VISIBILITY) I TOLD HIM TO RPT ARPT IN SIGHT, WHICH SHOULD HAVE BEEN IMMINENT. IN ABOUT 2 MINS I ASKED FOR HIS DME, AS HE SHOULD EITHER HAVE BEEN VMC OR ON THE MISSED APCH (DH 496 AT 3.3 DME). HE RPTED 2 DME AND 'ABOUT TO BREAK OUT.' I TOLD HIM HE WAS APPARENTLY PAST THE MISSED APCH POINT AND THAT HE'D BETTER MISS APCH IF IMC DUE TO 2500' TERRAIN JUST W OF THE ARPT. HE FLEW THE MISSED APCH AND COMPLETED THE VOR APCH SUCCESSFULLY. I TALKED LATER TO THE PLT, WHO SAID HE'S SURE HE NEGLECTED TO CHANGE TO THE LOC DME, WHICH WOULD MEAN HE WAS SAFER THAN I THOUGHT--BUT, THERE HAVE BEEN 2 ACCIDENTS (3 FATALITIES) ON THIS APCH IN THE LAST 4 YRS AND SEVERAL OTHER INSTANCES OF APPARENT CONFUSION WORSE THAN THIS INSTANCE.
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.