37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1198716 |
Time | |
Date | 201408 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | IMC |
Light | Dusk |
Aircraft 1 | |
Make Model Name | PA-28 Cherokee/Archer/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | Final Approach |
Route In Use | Direct |
Flight Plan | IFR |
Person 1 | |
Function | Single Pilot Pilot Flying |
Qualification | Flight Crew Multiengine Flight Crew Commercial Flight Crew Instrument |
Experience | Flight Crew Last 90 Days 30 Flight Crew Total 5600 Flight Crew Type 5000 |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Inflight Event / Encounter Unstabilized Approach Inflight Event / Encounter CFTT / CFIT Inflight Event / Encounter Weather / Turbulence |
Narrative:
I have many hours and many approaches to minimums as a single pilot operator over 30 years of flying; mostly part 91. Very few missed approaches in that time span. Based upon current weather at time of approach; I expected to breakout well above the 250 ft da. [Decision altitude] the aircraft did not have an autopilot and my hand-flown approach was rock solid right down to da. I looked up fully expecting to see the runway in sight for continuation and landing. I was flying the ILS as it had lower minimum than the RNAV/GPS approach. Looking up; I saw nothing of the runway environment as I tried to discern the nature and meaning of glowing globes through the fog (which I later concluded were lights on the ground diffused by the fog at dusk). I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had several times in past years. The only conscious control input that I can recall is leveling at the MDA while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at nor interpreting the flight instruments as I began what in retrospect was an uncontrolled; unconscious 90 degree turn to the left - still looking for the runway environment. Through a break in the clouds and fog - (don't know how low I was) I saw a clear picture of the runway lights (which I had clicked on 5 times at approach top of descent) showing the intersection of the two runways. I just happened to be on a (very) low right base to the cross runway and reacted by chopping power; setting full flaps (which probably saved me) and executed a steep right-hand turn at low altitude to uneventfully land and consider it a blessing to be writing this to you. I was tired when I began my flight; having circumvented convective activity with center help on a previous flight earlier that day. I did file an alternate based on the weather (taf) but really just wanted to get home; and really never seriously considered that I would have to make a missed approach. I was flabbergasted when I looked up and could not see the runway; and my behavior was all downhill from there. My perceptions; judgments and decisions from that point were automatic; faulty and flawed. The discipline to call a missed approached had totally evaded me as I wandered in the fog trying to see the runway. I will never again launch on an approach to low minimums without respectfully considering the real necessity of having to call a go-around and be much more than casually aware of the implications of making that decision. The taf forecast visibility and ceiling was for better conditions than I encountered. At time of approach the ASOS was reporting visibility and ceilings better than I experienced. I'm also working up a personal minimum for low approaches to the effect that even though I do and always have enjoyed making approaches to low minimums; I will bring a different mindset to the game in the future. I'm still refining my personal minimum rule but something along the line of: if the approach da is 250 ft (as in the case of this ILS) then double this figure to 500 ft. If the taf is lower than that number; then there must be a total expectation and commitment to either not take the flight if one is tired (as I was) or be totally and irrevocably committed to a missed approach and alternate airport landing. I was not; but lived to relate this story to you. I would also treat the taf visibility in a similar fashion but haven't as yet reflected on that component as a personal minimum.
Original NASA ASRS Text
Title: A commercial and instrument rated pilot flying a single engine aircraft describes his near fatal loss of situational awarness when intentionally descending below minimums on an instrument approach.
Narrative: I have many hours and many approaches to minimums as a single pilot operator over 30 years of flying; mostly Part 91. Very few missed approaches in that time span. Based upon current weather at time of approach; I expected to breakout well above the 250 FT DA. [Decision Altitude] The aircraft did not have an autopilot and my hand-flown approach was rock solid right down to DA. I looked up fully expecting to see the runway in sight for continuation and landing. I was flying the ILS as it had lower minimum than the RNAV/GPS approach. Looking up; I saw nothing of the runway environment as I tried to discern the nature and meaning of glowing globes through the fog (which I later concluded were lights on the ground diffused by the fog at dusk). I had made no mental accommodation to do a missed approach as I just KNEW that my skills would allow me to land as they had several times in past years. The only conscious control input that I can recall is leveling at the MDA while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at nor interpreting the flight instruments as I began what in retrospect was an uncontrolled; unconscious 90 degree turn to the left - still looking for the runway environment. Through a break in the clouds and fog - (don't know how low I was) I saw a clear picture of the runway lights (which I had clicked on 5 times at approach top of descent) showing the intersection of the two runways. I just happened to be on a (very) low right base to the cross runway and reacted by chopping power; setting full flaps (which probably saved me) and executed a steep right-hand turn at low altitude to uneventfully land and consider it a blessing to be writing this to you. I was tired when I began my flight; having circumvented convective activity with Center help on a previous flight earlier that day. I did file an alternate based on the weather (TAF) but really just wanted to get home; and really never seriously considered that I would have to make a missed approach. I was flabbergasted when I looked up and could not see the runway; and my behavior was all downhill from there. My perceptions; judgments and decisions from that point were automatic; faulty and flawed. The discipline to call a missed approached had totally evaded me as I wandered in the fog trying to see the runway. I will never again launch on an approach to low minimums without respectfully considering the real necessity of having to call a go-around and be much more than casually aware of the implications of making that decision. The TAF forecast visibility and ceiling was for better conditions than I encountered. At time of approach the ASOS was reporting visibility and ceilings better than I experienced. I'm also working up a personal minimum for low approaches to the effect that even though I do and always have enjoyed making approaches to low minimums; I will bring a different mindset to the game in the future. I'm still refining my personal minimum rule but something along the line of: If the approach DA is 250 FT (as in the case of this ILS) then double this figure to 500 FT. If the TAF is lower than that number; then there must be a total expectation and commitment to either not take the flight if one is tired (as I was) or be totally and irrevocably committed to a missed approach and alternate airport landing. I was not; but lived to relate this story to you. I would also treat the TAF visibility in a similar fashion but haven't as yet reflected on that component as a personal minimum.
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.