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|
Attributes | |
ACN | 437397 |
Time | |
Date | 199905 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : fsw.airport |
State Reference | IA |
Altitude | msl bound lower : 2300 msl bound upper : 3000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Fog Turbulence |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zau.artcc |
Operator | general aviation : personal |
Make Model Name | Skylane 182/RG Turbo Skylane/RG |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : missed approach |
Route In Use | approach : instrument non precision |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : det.tower |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : cfi pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 75 flight time total : 1100 flight time type : 500 |
ASRS Report | 437397 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : turbulence inflight encounter : weather non adherence : published procedure non adherence : clearance |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : diverted to another airport |
Supplementary | |
Problem Areas | Airport Weather Flight Crew Human Performance Environmental Factor FAA |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Airport | other physical facility |
Narrative:
Filed IFR routing was from 0v3 direct brl VOR direct fsw with an alternate of brl. The last hour of the flight was in solid IMC with constant light and occasional moderate turbulence. Flight watch reported en route that the AWOS at nearby brl had been advertising a ceiling of 800-1000 ft and 2-3 mi in light rain and mist. I reviewed both the fsw and brl approachs before starting my descent into the fsw area. I briefed myself on the approach and got fsw AWOS as we flew over the field toward the IAF. Shortly thereafter I was cleared for approach and advised to switch to CTAF. Minimums for the approach are about 500 ft and 1 mi, so I fully expected to find the field with the conditions reported by AWOS. Because of this expectation I only did a quick review of the missed approach procedure which called for a climb to 2300 ft and a turn back to brl VOR to hold. I keyed the pilot controled lighting about 10 mi out, and again at about 5 mi out from the field. My right seat passenger reported us dropping out of the overcast at about 1000 ft AGL. He said he saw lights on the ground and that he could see the airport beacon ahead. I told him to look for the runway lights while I continued to fly the airplane on the gauges. As we neared the missed approach point at just above MDA my passenger stated that he didn't see any runway lights, and that it was pretty misty down there. I again keyed the pilot controlled lighting, waited a few seconds, and took a quick glance out the windows. I saw what I thought was a rotating beacon through the mist, but no runway lights. I immediately started a missed approach. I remembered that I had to climb straight ahead, but in my mind I had remembered 3000 ft (the brl missed approach altitude) instead of 2300 ft called for out of fsw. I tried to read the approach chart during the climb, but with the turbulence, and the poor light of the cockpit at night, I couldn't tell if the small lettering on the plate read 2300 ft or 3300 ft. Neither one matched my memory of 3000 ft. I tried to both fly the airplane and get the small flashlight around my neck working so I could better read the approach plate. I switched back to ZAU to declare a missed approach climbing through 3000 ft. The controller acknowledged me and then immediately asked if the missed approach called for a climb to 3000 ft. By then I had the flashlight on could determine that the missed altitude was 2300 ft. I replied to the controller that, no, the missed called for 2300 ft and that I was now descending. He then cleared me to maintain 3000 ft, and shortly afterward asked me to climb to 4000 ft in order to get radar identify. I estimated that I had climbed to a bit over 3000 ft by the time I reversed my climb. ZAU then vectored me for an uneventful ILS approach into brl. What caused the deviation? Because flight watch and AWOS advertised conditions well above minimums, I didn't expect the missed approach, and as such, hadn't thoroughly memorized it. When the runway lights didn't come on, I wasn't fully ready to execute the missed. I remembered the climb heading, but it took about a min to sort out the altitude and by that time I had busted the 2300 ft altitude by over 700 ft. How will I avoid this situation in the future? 1) I'll do more to expect the unexpected. I'll remember that AWOS can lie, approach navaids can die, runway lights can fail, radios can be mistuned (not in this case) or quit, etc. I'll be ready to execute the missed, even when everything appears to be progressing fine. 2) I'll better brief my passenger or copilot and exercise more CRM. I thought I had done enough when I was flying the airplane, and he was watching for the runway. In the future at night I'll write down in big letters on my kneeboard the pertinent numbers for the approach. I'll make a second copy to have my passenger hold so they can confirm my recollections.
Original NASA ASRS Text
Title: A CFI CLBS ABOVE THE PUBLISHED MISSED APCH MINIMUMS AT FSW, IA.
Narrative: FILED IFR ROUTING WAS FROM 0V3 DIRECT BRL VOR DIRECT FSW WITH AN ALTERNATE OF BRL. THE LAST HR OF THE FLT WAS IN SOLID IMC WITH CONSTANT LIGHT AND OCCASIONAL MODERATE TURB. FLT WATCH RPTED ENRTE THAT THE AWOS AT NEARBY BRL HAD BEEN ADVERTISING A CEILING OF 800-1000 FT AND 2-3 MI IN LIGHT RAIN AND MIST. I REVIEWED BOTH THE FSW AND BRL APCHS BEFORE STARTING MY DSCNT INTO THE FSW AREA. I BRIEFED MYSELF ON THE APCH AND GOT FSW AWOS AS WE FLEW OVER THE FIELD TOWARD THE IAF. SHORTLY THEREAFTER I WAS CLRED FOR APCH AND ADVISED TO SWITCH TO CTAF. MINIMUMS FOR THE APCH ARE ABOUT 500 FT AND 1 MI, SO I FULLY EXPECTED TO FIND THE FIELD WITH THE CONDITIONS RPTED BY AWOS. BECAUSE OF THIS EXPECTATION I ONLY DID A QUICK REVIEW OF THE MISSED APCH PROC WHICH CALLED FOR A CLB TO 2300 FT AND A TURN BACK TO BRL VOR TO HOLD. I KEYED THE PLT CTLED LIGHTING ABOUT 10 MI OUT, AND AGAIN AT ABOUT 5 MI OUT FROM THE FIELD. MY R SEAT PAX RPTED US DROPPING OUT OF THE OVCST AT ABOUT 1000 FT AGL. HE SAID HE SAW LIGHTS ON THE GND AND THAT HE COULD SEE THE ARPT BEACON AHEAD. I TOLD HIM TO LOOK FOR THE RWY LIGHTS WHILE I CONTINUED TO FLY THE AIRPLANE ON THE GAUGES. AS WE NEARED THE MISSED APCH POINT AT JUST ABOVE MDA MY PAX STATED THAT HE DIDN'T SEE ANY RWY LIGHTS, AND THAT IT WAS PRETTY MISTY DOWN THERE. I AGAIN KEYED THE PCL, WAITED A FEW SECONDS, AND TOOK A QUICK GLANCE OUT THE WINDOWS. I SAW WHAT I THOUGHT WAS A ROTATING BEACON THROUGH THE MIST, BUT NO RWY LIGHTS. I IMMEDIATELY STARTED A MISSED APCH. I REMEMBERED THAT I HAD TO CLB STRAIGHT AHEAD, BUT IN MY MIND I HAD REMEMBERED 3000 FT (THE BRL MISSED APCH ALT) INSTEAD OF 2300 FT CALLED FOR OUT OF FSW. I TRIED TO READ THE APCH CHART DURING THE CLB, BUT WITH THE TURB, AND THE POOR LIGHT OF THE COCKPIT AT NIGHT, I COULDN'T TELL IF THE SMALL LETTERING ON THE PLATE READ 2300 FT OR 3300 FT. NEITHER ONE MATCHED MY MEMORY OF 3000 FT. I TRIED TO BOTH FLY THE AIRPLANE AND GET THE SMALL FLASHLIGHT AROUND MY NECK WORKING SO I COULD BETTER READ THE APCH PLATE. I SWITCHED BACK TO ZAU TO DECLARE A MISSED APCH CLBING THROUGH 3000 FT. THE CTLR ACKNOWLEDGED ME AND THEN IMMEDIATELY ASKED IF THE MISSED APCH CALLED FOR A CLB TO 3000 FT. BY THEN I HAD THE FLASHLIGHT ON COULD DETERMINE THAT THE MISSED ALT WAS 2300 FT. I REPLIED TO THE CTLR THAT, NO, THE MISSED CALLED FOR 2300 FT AND THAT I WAS NOW DSNDING. HE THEN CLRED ME TO MAINTAIN 3000 FT, AND SHORTLY AFTERWARD ASKED ME TO CLB TO 4000 FT IN ORDER TO GET RADAR IDENT. I ESTIMATED THAT I HAD CLBED TO A BIT OVER 3000 FT BY THE TIME I REVERSED MY CLB. ZAU THEN VECTORED ME FOR AN UNEVENTFUL ILS APCH INTO BRL. WHAT CAUSED THE DEV? BECAUSE FLT WATCH AND AWOS ADVERTISED CONDITIONS WELL ABOVE MINIMUMS, I DIDN'T EXPECT THE MISSED APCH, AND AS SUCH, HADN'T THOROUGHLY MEMORIZED IT. WHEN THE RWY LIGHTS DIDN'T COME ON, I WASN'T FULLY READY TO EXECUTE THE MISSED. I REMEMBERED THE CLB HEADING, BUT IT TOOK ABOUT A MIN TO SORT OUT THE ALT AND BY THAT TIME I HAD BUSTED THE 2300 FT ALT BY OVER 700 FT. HOW WILL I AVOID THIS SIT IN THE FUTURE? 1) I'LL DO MORE TO EXPECT THE UNEXPECTED. I'LL REMEMBER THAT AWOS CAN LIE, APCH NAVAIDS CAN DIE, RWY LIGHTS CAN FAIL, RADIOS CAN BE MISTUNED (NOT IN THIS CASE) OR QUIT, ETC. I'LL BE READY TO EXECUTE THE MISSED, EVEN WHEN EVERYTHING APPEARS TO BE PROGRESSING FINE. 2) I'LL BETTER BRIEF MY PAX OR COPLT AND EXERCISE MORE CRM. I THOUGHT I HAD DONE ENOUGH WHEN I WAS FLYING THE AIRPLANE, AND HE WAS WATCHING FOR THE RWY. IN THE FUTURE AT NIGHT I'LL WRITE DOWN IN BIG LETTERS ON MY KNEEBOARD THE PERTINENT NUMBERS FOR THE APCH. I'LL MAKE A SECOND COPY TO HAVE MY PAX HOLD SO THEY CAN CONFIRM MY RECOLLECTIONS.
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.