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Attributes | |
ACN | 499539 |
Time | |
Date | 200101 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bsm.airport |
State Reference | TX |
Altitude | msl single value : 2500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : aus.tracon |
Operator | general aviation : personal |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 35l-35r |
Flight Phase | descent : approach landing : go around |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 60 flight time total : 640 flight time type : 80 |
ASRS Report | 499539 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather inflight encounter other other anomaly other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance controller : provided flight assist flight crew : executed go around |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
The flight in question started well enough. I departed houston gulf in good WX conditions. My preflight WX briefing from the conroe FSS indicated that there was a stationary front in the austin area, bringing low ceilings and rain, but radar data showed nothing threatening, and the temperatures were far too warm for ice at my intended altitude of 6000 ft. The flight went smoothly until I intercepted the localizer for the ILS runway 35R approach to austin bergstrom. Things stopped going right at this stage. As I joined the localizer, the GS remained flagged. I doublechked the frequency dialed in, and idented the NAVAID again. The morse that came back was correct -- either my GS receiver had died or the GS itself had died. Somewhere in all of this, I was handed off to tower, and when I called tower, I told the controller I wasn't getting the GS. Just as I was about to call a missed approach, the controller told me to miss, and did so. The controller asked 2 other aircraft (the one in front of me and the following jet) whether they were getting the GS. The preceding jet said there were some deviations, but it was working. The following jet reported no problems at all. Tower asked if I wanted to try runway 35L, and I said 'I'd like to do that.' tower also said that the GS was monitoring just fine, too. As I followed my vectors, I was handed back to approach. In my mind I was trying to debug what was wrong with the GS, and fly the airplane, and talk to approach. I tuned the ILS for the runway 35L approach in order to try that next, as I had requested from tower. Aus approach vectored me for the approach again. '2 mi from creed, maintain 2500 ft until established, cleared ILS runway 35,' he said, which I read back without thinking about what I had just been cleared to do. I watched the ILS needles with some trepidation. The GS unflagged, and the localizer needle was in the expected place (still pegged at the left of the instrument). Then approach said 'it looks like you're intercepting the runway 35L localizer, do you have the right frequency?' whaaaa? I thought. My intention was to fly the runway 35L approach. What's going on? 'Approach, that's affirmative, I'm doing the runway 35L approach.' 'ok, 2 mi from booie, maintain 2500 ft until established, cleared for the ILS runway 35L approach.' as I intercepted the localizer (and overshot it slightly), I noticed that I had never reduced the power. I was still in 'fast jet is following' mode, so as I turned back to try and stay on the localizer, I was hurtling along at about 160 KTS or so, instead of my customary 100 KT ILS approach speed. Now that would be ok if I was expecting to fly the approach fast, but I wasn't. My mind was in 100 KT mode. To make matters worse, the GS was now coming down and I was trying to follow it too. I realized I was going to have a spot of bother slowing to gear speed. The bonanza likes to either slow down or go down, not both! I stayed a little high on the GS as I tried to get below gear speed. Finally, I could drop the wheels, but in my speed fixation, had drifted a little (about 2 dots) off the localizer. Finally, after what seemed like frantic maneuvering and ILS needles that looked a bit like a sword fight, I was back on the localizer and GS, with the wheels down and the checklists complete. Seconds later, I broke out, and saw a sight I always love -- the runway lit up like a christmas tree, right in front of me where it should be. It wasn't very long until I was in the flare and touching down. So what went wrong here? 1) fixation. First, fixation on the initial GS problem, instead of getting down to the actual flying and slowing the plane for the second attempt. 2) miscom. Notice that the approach controller cleared me for runway 35R when I wanted to do runway 35L as I had said to the tower. I should have told the approach controller of my plans when I called up. Even worse, I just read back his approach clearance for runway 35R without thinking (because I was fixated with making sure the GS came alive). It would have been totally my fault if this had led to a loss of separation. As PIC, I'm the captain, and I'm responsible, but I let that slip by not thinking about the approach clearance I had just been given. It would have been myfault and not ATC's fault is a loss of separation -- or worse, an near midair collision -- had occurred. 3) the second approach wasn't really stabilized. The fixation demon happened again, and I (successfully) attempted to salvage the approach. I should have called a miss on the second one, and tried again, this time at the right speed and no longer thinking about the errant GS. I feel about the only things I did right on that approach were to actually to remember to put the wheels down and advance the propeller control! Fortunately, the flight back home that night went perfectly. I feel the head of the chain of events was simply fixation -- something that's drummed into every instrument student as a thing not to do. It taught me that you should be on your guard at all times, and it's another reminder that single pilot IFR is something that shouldn't be taken lightly -- however current you are and however often you fly! Also, some old-timers once again admonished me to run a timer even for an ILS approach -- it would have given me an automatic backup of doing a localizer-only approach.
Original NASA ASRS Text
Title: BE35 PLT HAD INST PROFICIENCY PROBS WHILE TRYING TO MAKE A LOW MINIMUMS APCH AT BSM.
Narrative: THE FLT IN QUESTION STARTED WELL ENOUGH. I DEPARTED HOUSTON GULF IN GOOD WX CONDITIONS. MY PREFLT WX BRIEFING FROM THE CONROE FSS INDICATED THAT THERE WAS A STATIONARY FRONT IN THE AUSTIN AREA, BRINGING LOW CEILINGS AND RAIN, BUT RADAR DATA SHOWED NOTHING THREATENING, AND THE TEMPS WERE FAR TOO WARM FOR ICE AT MY INTENDED ALT OF 6000 FT. THE FLT WENT SMOOTHLY UNTIL I INTERCEPTED THE LOC FOR THE ILS RWY 35R APCH TO AUSTIN BERGSTROM. THINGS STOPPED GOING RIGHT AT THIS STAGE. AS I JOINED THE LOC, THE GS REMAINED FLAGGED. I DOUBLECHKED THE FREQ DIALED IN, AND IDENTED THE NAVAID AGAIN. THE MORSE THAT CAME BACK WAS CORRECT -- EITHER MY GS RECEIVER HAD DIED OR THE GS ITSELF HAD DIED. SOMEWHERE IN ALL OF THIS, I WAS HANDED OFF TO TWR, AND WHEN I CALLED TWR, I TOLD THE CTLR I WASN'T GETTING THE GS. JUST AS I WAS ABOUT TO CALL A MISSED APCH, THE CTLR TOLD ME TO MISS, AND DID SO. THE CTLR ASKED 2 OTHER ACFT (THE ONE IN FRONT OF ME AND THE FOLLOWING JET) WHETHER THEY WERE GETTING THE GS. THE PRECEDING JET SAID THERE WERE SOME DEVS, BUT IT WAS WORKING. THE FOLLOWING JET RPTED NO PROBS AT ALL. TWR ASKED IF I WANTED TO TRY RWY 35L, AND I SAID 'I'D LIKE TO DO THAT.' TWR ALSO SAID THAT THE GS WAS MONITORING JUST FINE, TOO. AS I FOLLOWED MY VECTORS, I WAS HANDED BACK TO APCH. IN MY MIND I WAS TRYING TO DEBUG WHAT WAS WRONG WITH THE GS, AND FLY THE AIRPLANE, AND TALK TO APCH. I TUNED THE ILS FOR THE RWY 35L APCH IN ORDER TO TRY THAT NEXT, AS I HAD REQUESTED FROM TWR. AUS APCH VECTORED ME FOR THE APCH AGAIN. '2 MI FROM CREED, MAINTAIN 2500 FT UNTIL ESTABLISHED, CLRED ILS RWY 35,' HE SAID, WHICH I READ BACK WITHOUT THINKING ABOUT WHAT I HAD JUST BEEN CLRED TO DO. I WATCHED THE ILS NEEDLES WITH SOME TREPIDATION. THE GS UNFLAGGED, AND THE LOC NEEDLE WAS IN THE EXPECTED PLACE (STILL PEGGED AT THE L OF THE INST). THEN APCH SAID 'IT LOOKS LIKE YOU'RE INTERCEPTING THE RWY 35L LOC, DO YOU HAVE THE RIGHT FREQ?' WHAAAA? I THOUGHT. MY INTENTION WAS TO FLY THE RWY 35L APCH. WHAT'S GOING ON? 'APCH, THAT'S AFFIRMATIVE, I'M DOING THE RWY 35L APCH.' 'OK, 2 MI FROM BOOIE, MAINTAIN 2500 FT UNTIL ESTABLISHED, CLRED FOR THE ILS RWY 35L APCH.' AS I INTERCEPTED THE LOC (AND OVERSHOT IT SLIGHTLY), I NOTICED THAT I HAD NEVER REDUCED THE PWR. I WAS STILL IN 'FAST JET IS FOLLOWING' MODE, SO AS I TURNED BACK TO TRY AND STAY ON THE LOC, I WAS HURTLING ALONG AT ABOUT 160 KTS OR SO, INSTEAD OF MY CUSTOMARY 100 KT ILS APCH SPD. NOW THAT WOULD BE OK IF I WAS EXPECTING TO FLY THE APCH FAST, BUT I WASN'T. MY MIND WAS IN 100 KT MODE. TO MAKE MATTERS WORSE, THE GS WAS NOW COMING DOWN AND I WAS TRYING TO FOLLOW IT TOO. I REALIZED I WAS GOING TO HAVE A SPOT OF BOTHER SLOWING TO GEAR SPD. THE BONANZA LIKES TO EITHER SLOW DOWN OR GO DOWN, NOT BOTH! I STAYED A LITTLE HIGH ON THE GS AS I TRIED TO GET BELOW GEAR SPD. FINALLY, I COULD DROP THE WHEELS, BUT IN MY SPD FIXATION, HAD DRIFTED A LITTLE (ABOUT 2 DOTS) OFF THE LOC. FINALLY, AFTER WHAT SEEMED LIKE FRANTIC MANEUVERING AND ILS NEEDLES THAT LOOKED A BIT LIKE A SWORD FIGHT, I WAS BACK ON THE LOC AND GS, WITH THE WHEELS DOWN AND THE CHKLISTS COMPLETE. SECONDS LATER, I BROKE OUT, AND SAW A SIGHT I ALWAYS LOVE -- THE RWY LIT UP LIKE A CHRISTMAS TREE, RIGHT IN FRONT OF ME WHERE IT SHOULD BE. IT WASN'T VERY LONG UNTIL I WAS IN THE FLARE AND TOUCHING DOWN. SO WHAT WENT WRONG HERE? 1) FIXATION. FIRST, FIXATION ON THE INITIAL GS PROB, INSTEAD OF GETTING DOWN TO THE ACTUAL FLYING AND SLOWING THE PLANE FOR THE SECOND ATTEMPT. 2) MISCOM. NOTICE THAT THE APCH CTLR CLRED ME FOR RWY 35R WHEN I WANTED TO DO RWY 35L AS I HAD SAID TO THE TWR. I SHOULD HAVE TOLD THE APCH CTLR OF MY PLANS WHEN I CALLED UP. EVEN WORSE, I JUST READ BACK HIS APCH CLRNC FOR RWY 35R WITHOUT THINKING (BECAUSE I WAS FIXATED WITH MAKING SURE THE GS CAME ALIVE). IT WOULD HAVE BEEN TOTALLY MY FAULT IF THIS HAD LED TO A LOSS OF SEPARATION. AS PIC, I'M THE CAPT, AND I'M RESPONSIBLE, BUT I LET THAT SLIP BY NOT THINKING ABOUT THE APCH CLRNC I HAD JUST BEEN GIVEN. IT WOULD HAVE BEEN MYFAULT AND NOT ATC'S FAULT IS A LOSS OF SEPARATION -- OR WORSE, AN NMAC -- HAD OCCURRED. 3) THE SECOND APCH WASN'T REALLY STABILIZED. THE FIXATION DEMON HAPPENED AGAIN, AND I (SUCCESSFULLY) ATTEMPTED TO SALVAGE THE APCH. I SHOULD HAVE CALLED A MISS ON THE SECOND ONE, AND TRIED AGAIN, THIS TIME AT THE RIGHT SPD AND NO LONGER THINKING ABOUT THE ERRANT GS. I FEEL ABOUT THE ONLY THINGS I DID RIGHT ON THAT APCH WERE TO ACTUALLY TO REMEMBER TO PUT THE WHEELS DOWN AND ADVANCE THE PROP CTL! FORTUNATELY, THE FLT BACK HOME THAT NIGHT WENT PERFECTLY. I FEEL THE HEAD OF THE CHAIN OF EVENTS WAS SIMPLY FIXATION -- SOMETHING THAT'S DRUMMED INTO EVERY INST STUDENT AS A THING NOT TO DO. IT TAUGHT ME THAT YOU SHOULD BE ON YOUR GUARD AT ALL TIMES, AND IT'S ANOTHER REMINDER THAT SINGLE PLT IFR IS SOMETHING THAT SHOULDN'T BE TAKEN LIGHTLY -- HOWEVER CURRENT YOU ARE AND HOWEVER OFTEN YOU FLY! ALSO, SOME OLD-TIMERS ONCE AGAIN ADMONISHED ME TO RUN A TIMER EVEN FOR AN ILS APCH -- IT WOULD HAVE GIVEN ME AN AUTOMATIC BACKUP OF DOING A LOC-ONLY APCH.
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.