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|
Attributes | |
ACN | 474443 |
Time | |
Date | 200005 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : acv.airport |
State Reference | CA |
Altitude | msl bound lower : 418 msl bound upper : 5200 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zse.artcc |
Operator | general aviation : instructional |
Make Model Name | Cessna 210 Centurion / Turbo Centurion 210C, 210D |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 32 |
Flight Phase | descent : vacating altitude |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : cfi pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 25 flight time total : 1340 flight time type : 6 |
ASRS Report | 474443 |
Person 2 | |
Affiliation | other |
Function | instruction : trainee |
Qualification | pilot : private |
Experience | flight time type : 10 |
Events | |
Anomaly | altitude deviation : undershoot altitude deviation : crossing restriction not met inflight encounter : turbulence inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : gs releiver other flight crewa |
Resolutory Action | controller : issued advisory flight crew : diverted to another airport flight crew : executed missed approach |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Weather Flight Crew Human Performance ATC Human Performance Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying as a flight instructor with my friend/student in his recently purchased turbo cessna 210. He had approximately 10 hours in the aircraft and I had approximately 4 hours in type along with 20 hours in a simulator of similar type aircraft. I was IFR current and proficient as I had flown over 10 instrument approachs within the last month and had logged over 5 hours under the hood. We took off from novato, ca, at approximately AB45 am in VFR conditions and headed north. We had received a WX briefing from FSS. The WX looked VFR in all areas except for the northern part of california extending into oregon and washington. We decided to land in arcata, ca, for fuel and lunch. The WX there was marginal IFR so I called FSS and filed a 'pop-up' clearance. This was at approximately 40 mi from arcata. I then switched to the center frequency and requested the IFR clearance. They had not received the clearance as of yet and I was still at 8500 ft MSL. I was flying from the right seat and my student had received 40-50 hours of instrument instruction from me. Center finally cleared me to 6500 ft and had received the clearance. As I was descending to 6500 ft MSL, I was within 15 mi of the arcata airport. Center asked if I would accept a clearance 'vectors direct to the localizer and still be able to descend in time?' I replied in the affirmative and proceeded inbound to the OM on a 020 degree heading per ATC instructions. I intercepted the localizer and not long thereafter, the GS. The GS had somewhat erratic indications with close to full scale up and down deflection for a second or two. We had done a VOR check earlier in the day and logged it in the aircraft records. The #1 VOR was within +/-1 degree and the #2 VOR was within +/-2 degrees. I configured the aircraft passing the OM at acata intersection and started the timer. We were, I thought, a little high but the GS was receiving and showed me on the GS. The GS did fluctuate a bit but nothing to make me alarmed. I was descending and the next thing I heard was the MM and my altitude was 5200 ft MSL. I did not see anything so I proceeded to the missed approach. However, I was much higher than the altitude stated in the missed approach procedure. The map stated a climb altitude of 3000 ft MSL and I was already at 5200 ft MSL. I was climbing through 6500 ft when I spoke with center again. They asked why I was still climbing and at that point, I stated that we wanted to make sure we avoided the mountains. I advised that we were going 'missed' and center advised to hold at the missed approach hold point of trial. At this point, I was confused as to what was happening and was not trusting my instruments. How could I be close to 4000 ft higher than I was supposed to be when I was receiving the GS? As I was holding over trial, a strange noise began to be heard in the cockpit. I asked center if we could climb to 10000 ft MSL and they accepted and also told me to hold at fortuna VOR, north, right turns. I accepted and began climbing. At 9500 ft, we broke out of the clouds and the strange noise stopped. We never figured out what the strange noise was. At this point, we proceeded to redding, ca, where the WX was VFR and we wouldn't have to complete an instrument approach. I was not trusting the instrument in the aircraft, even though all my training had said to trust the instruments. After we landed, I analyzed the situation a little more closely and came to the determination that because of my initial altitude on the approach, I had received a 'false GS.' in accepting the clearance to proceed straight in at my high altitude, I was accepting a missed approach right from the beginning. This was due to the fact that I did not recognize the false GS right away like I should have by xrefing my altitude with that of the proper altitude of the approach procedure. Due to this late recognition, I was much higher on the approach. This also contributed to my distrust of the instruments and what they were telling me. In looking back at what transpired, I should have never accepted the straight in clearance for the ILS approach at arcata. I was in a fairly new airplane for myself and was flying from the right seat in instrument conditions that I had not been in for a few months. This led to some disorientation and an unsure feeling of what was happening. I should have asked for vectors to get down to the proper intercept altitude before proceeding inbound on the approach. I also did not recognize the false GS during the approach. Thankfully, my training had ingrained in me the trust of instruments I needed in order to safely avert and possible CFIT or other possible hazard by going around at the proper point.
Original NASA ASRS Text
Title: A CFI AND HIS STUDENT IN A TURBO C210 MAKES AN ATTEMPT AT AN ILS INTO ARCADIA BUT PERFORM A MISSED APCH WHEN OVER THE MM SOME 5000 FT ABOVE THE PUBLISHED XING ALT, 1 MI SE OF ACV, CA.
Narrative: I WAS FLYING AS A FLT INSTRUCTOR WITH MY FRIEND/STUDENT IN HIS RECENTLY PURCHASED TURBO CESSNA 210. HE HAD APPROX 10 HRS IN THE ACFT AND I HAD APPROX 4 HRS IN TYPE ALONG WITH 20 HRS IN A SIMULATOR OF SIMILAR TYPE ACFT. I WAS IFR CURRENT AND PROFICIENT AS I HAD FLOWN OVER 10 INST APCHS WITHIN THE LAST MONTH AND HAD LOGGED OVER 5 HRS UNDER THE HOOD. WE TOOK OFF FROM NOVATO, CA, AT APPROX AB45 AM IN VFR CONDITIONS AND HEADED N. WE HAD RECEIVED A WX BRIEFING FROM FSS. THE WX LOOKED VFR IN ALL AREAS EXCEPT FOR THE NORTHERN PART OF CALIFORNIA EXTENDING INTO OREGON AND WASHINGTON. WE DECIDED TO LAND IN ARCATA, CA, FOR FUEL AND LUNCH. THE WX THERE WAS MARGINAL IFR SO I CALLED FSS AND FILED A 'POP-UP' CLRNC. THIS WAS AT APPROX 40 MI FROM ARCATA. I THEN SWITCHED TO THE CTR FREQ AND REQUESTED THE IFR CLRNC. THEY HAD NOT RECEIVED THE CLRNC AS OF YET AND I WAS STILL AT 8500 FT MSL. I WAS FLYING FROM THE R SEAT AND MY STUDENT HAD RECEIVED 40-50 HRS OF INST INSTRUCTION FROM ME. CTR FINALLY CLRED ME TO 6500 FT AND HAD RECEIVED THE CLRNC. AS I WAS DSNDING TO 6500 FT MSL, I WAS WITHIN 15 MI OF THE ARCATA ARPT. CTR ASKED IF I WOULD ACCEPT A CLRNC 'VECTORS DIRECT TO THE LOC AND STILL BE ABLE TO DSND IN TIME?' I REPLIED IN THE AFFIRMATIVE AND PROCEEDED INBOUND TO THE OM ON A 020 DEG HDG PER ATC INSTRUCTIONS. I INTERCEPTED THE LOC AND NOT LONG THEREAFTER, THE GS. THE GS HAD SOMEWHAT ERRATIC INDICATIONS WITH CLOSE TO FULL SCALE UP AND DOWN DEFLECTION FOR A SECOND OR TWO. WE HAD DONE A VOR CHK EARLIER IN THE DAY AND LOGGED IT IN THE ACFT RECORDS. THE #1 VOR WAS WITHIN +/-1 DEG AND THE #2 VOR WAS WITHIN +/-2 DEGS. I CONFIGURED THE ACFT PASSING THE OM AT ACATA INTXN AND STARTED THE TIMER. WE WERE, I THOUGHT, A LITTLE HIGH BUT THE GS WAS RECEIVING AND SHOWED ME ON THE GS. THE GS DID FLUCTUATE A BIT BUT NOTHING TO MAKE ME ALARMED. I WAS DSNDING AND THE NEXT THING I HEARD WAS THE MM AND MY ALT WAS 5200 FT MSL. I DID NOT SEE ANYTHING SO I PROCEEDED TO THE MISSED APCH. HOWEVER, I WAS MUCH HIGHER THAN THE ALT STATED IN THE MISSED APCH PROC. THE MAP STATED A CLB ALT OF 3000 FT MSL AND I WAS ALREADY AT 5200 FT MSL. I WAS CLBING THROUGH 6500 FT WHEN I SPOKE WITH CTR AGAIN. THEY ASKED WHY I WAS STILL CLBING AND AT THAT POINT, I STATED THAT WE WANTED TO MAKE SURE WE AVOIDED THE MOUNTAINS. I ADVISED THAT WE WERE GOING 'MISSED' AND CTR ADVISED TO HOLD AT THE MISSED APCH HOLD POINT OF TRIAL. AT THIS POINT, I WAS CONFUSED AS TO WHAT WAS HAPPENING AND WAS NOT TRUSTING MY INSTS. HOW COULD I BE CLOSE TO 4000 FT HIGHER THAN I WAS SUPPOSED TO BE WHEN I WAS RECEIVING THE GS? AS I WAS HOLDING OVER TRIAL, A STRANGE NOISE BEGAN TO BE HEARD IN THE COCKPIT. I ASKED CTR IF WE COULD CLB TO 10000 FT MSL AND THEY ACCEPTED AND ALSO TOLD ME TO HOLD AT FORTUNA VOR, N, R TURNS. I ACCEPTED AND BEGAN CLBING. AT 9500 FT, WE BROKE OUT OF THE CLOUDS AND THE STRANGE NOISE STOPPED. WE NEVER FIGURED OUT WHAT THE STRANGE NOISE WAS. AT THIS POINT, WE PROCEEDED TO REDDING, CA, WHERE THE WX WAS VFR AND WE WOULDN'T HAVE TO COMPLETE AN INST APCH. I WAS NOT TRUSTING THE INST IN THE ACFT, EVEN THOUGH ALL MY TRAINING HAD SAID TO TRUST THE INSTS. AFTER WE LANDED, I ANALYZED THE SIT A LITTLE MORE CLOSELY AND CAME TO THE DETERMINATION THAT BECAUSE OF MY INITIAL ALT ON THE APCH, I HAD RECEIVED A 'FALSE GS.' IN ACCEPTING THE CLRNC TO PROCEED STRAIGHT IN AT MY HIGH ALT, I WAS ACCEPTING A MISSED APCH RIGHT FROM THE BEGINNING. THIS WAS DUE TO THE FACT THAT I DID NOT RECOGNIZE THE FALSE GS RIGHT AWAY LIKE I SHOULD HAVE BY XREFING MY ALT WITH THAT OF THE PROPER ALT OF THE APCH PROC. DUE TO THIS LATE RECOGNITION, I WAS MUCH HIGHER ON THE APCH. THIS ALSO CONTRIBUTED TO MY DISTRUST OF THE INSTS AND WHAT THEY WERE TELLING ME. IN LOOKING BACK AT WHAT TRANSPIRED, I SHOULD HAVE NEVER ACCEPTED THE STRAIGHT IN CLRNC FOR THE ILS APCH AT ARCATA. I WAS IN A FAIRLY NEW AIRPLANE FOR MYSELF AND WAS FLYING FROM THE R SEAT IN INST CONDITIONS THAT I HAD NOT BEEN IN FOR A FEW MONTHS. THIS LED TO SOME DISORIENTATION AND AN UNSURE FEELING OF WHAT WAS HAPPENING. I SHOULD HAVE ASKED FOR VECTORS TO GET DOWN TO THE PROPER INTERCEPT ALT BEFORE PROCEEDING INBOUND ON THE APCH. I ALSO DID NOT RECOGNIZE THE FALSE GS DURING THE APCH. THANKFULLY, MY TRAINING HAD INGRAINED IN ME THE TRUST OF INSTS I NEEDED IN ORDER TO SAFELY AVERT AND POSSIBLE CFIT OR OTHER POSSIBLE HAZARD BY GOING AROUND AT THE PROPER POINT.
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.