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A cpr pilot in a PA31 descended to decision ht too soon on an ILS approach to runway 11 at pwm. The low altitude system was, coincidentally, discovered to be OTS after the incident.
| Attributes | |
| ACN | 377238 |
| Time | |
| Date | 199708 |
| Day | Wed |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : pwm |
| State Reference | ME |
| Altitude | agl bound lower : 200 agl bound upper : 200 |
| Environment | |
| Flight Conditions | IMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | tower : pwm tower : bwi |
| Operator | general aviation : corporate |
| Make Model Name | PA-31T Cheyenne II |
| Operating Under FAR Part | Part 91 |
| Flight Phase | descent : approach landing : missed approach |
| Route In Use | enroute other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : single pilot |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 120 flight time total : 4000 flight time type : 1000 |
| ASRS Report | 377238 |
| Person 2 | |
| Affiliation | government : faa |
| Function | controller : local |
| Qualification | controller : non radar |
| Events | |
| Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : far non adherence : published procedure other anomaly other other spatial deviation |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : became reoriented flight crew : took evasive action other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
| Situations | |
| ATC Facility | other physical facility |
Narrative:
Failure to scan instruments during ILS approach allowed the aircraft to descend to decision ht prematurely. When GS signal was lost the flight director assumed the last pitch attitude which was flown down to 200 ft AGL. The aircraft operated approximately 20 seconds/1 mi without obstacle clearance. Missed approach initiated, notified tower. They were not aware of the situation - - found out later that the 'low altitude alert' warning system was inoperative, but that the portland tower wasn't aware that it was inoperative. After missed approach a normal landing was performed - - pilot's poor scan and failure to notice the GS resulted in this happening. (Pilot fixated on flight director.)
Original NASA ASRS Text
Title: A CPR PLT IN A PA31 DSNDED TO DECISION HT TOO SOON ON AN ILS APCH TO RWY 11 AT PWM. THE LOW ALT SYS WAS, COINCIDENTALLY, DISCOVERED TO BE OTS AFTER THE INCIDENT.
Narrative: FAILURE TO SCAN INSTS DURING ILS APCH ALLOWED THE ACFT TO DSND TO DECISION HT PREMATURELY. WHEN GS SIGNAL WAS LOST THE FLT DIRECTOR ASSUMED THE LAST PITCH ATTITUDE WHICH WAS FLOWN DOWN TO 200 FT AGL. THE ACFT OPERATED APPROX 20 SECONDS/1 MI WITHOUT OBSTACLE CLRNC. MISSED APCH INITIATED, NOTIFIED TWR. THEY WERE NOT AWARE OF THE SIT - - FOUND OUT LATER THAT THE 'LOW ALT ALERT' WARNING SYS WAS INOP, BUT THAT THE PORTLAND TWR WASN'T AWARE THAT IT WAS INOP. AFTER MISSED APCH A NORMAL LNDG WAS PERFORMED - - PLT'S POOR SCAN AND FAILURE TO NOTICE THE GS RESULTED IN THIS HAPPENING. (PLT FIXATED ON FLT DIRECTOR.)
Data retrieved from NASA's ASRS site as of July 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.