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|
Attributes | |
ACN | 516852 |
Time | |
Date | 200106 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : 79j.airport |
State Reference | AL |
Altitude | agl bound lower : 200 agl bound upper : 300 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ozr.tower |
Operator | general aviation : personal |
Make Model Name | M-20 J (201) |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach landing : go around |
Route In Use | arrival : on vectors |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : private |
Experience | flight time last 90 days : 20 flight time total : 690 flight time type : 105 |
ASRS Report | 516852 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : executed missed approach flight crew : exited adverse environment flight crew : took evasive action flight crew : became reoriented flight crew : took precautionary avoidance action |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
What was to be a simple, short VFR flight turned out to be a perilous approach to low ceilings, during which I endangered myself and my passenger. I had spent a couple of days on vacation near montgomery, al. The WX had been good throughout the week except for the typical sporadic afternoon and evening thunderstorms. I looked at the WX on the WX channel, but didn't get a preflight WX briefing prior to departing willow point (AL71) approximately XA15 in beautiful clear WX. I had intended to drop off a passenger at my home field of andalusia-opp (79J) and continue to destin, fl (dts). Everything was fine approximately 30 mi north of 79J when I saw a layer of clouds in the andalusia direction below our level of 2500 ft. I had received flight following from mgm and he had just canceled radar service. I contacted cairnes approach (the facility covering andalusia) and requested an IFR descent expecting a thin layer of clouds. He issued a squawk code and told me to expect radar vectors for the NDB approach. Since I had IFR certified GPS on board, I asked for the GPS approach, but he was apparently busy with other traffic and didn't hear me. I decided to take the NDB approach using the GPS since I was familiar with the approach at my home field (or at least I thought I was). I checked the ASOS and was surprised to hear ceiling of 300 ft and 1 mi visibility in fog. At this point, I began a series of errors and poor decisions which could have led to a tragic outcome. When the controller turned me onto final and cleared me for the approach, I don't remember setting the altimeter or checking it. For some reason, I had in my mind that the minimums for the approach were 800 ft (actually, it is 800 ft AGL, or 1150 ft). I descended on the approach to 800 ft, but never saw the runway. As I also was surprised the tower at 79J wasn't open, since it usually is on wkdays. On the missed approach, I called cairnes and requested the GPS approach. In my experience, the ASOS can be quite unreliable concerning ceilings and I thought it was worth another try. The controller assigned an altitude and cleared me to the FAF for the GPS to runway 29. I turned onto the final approach course outside the fix just after the controller cleared me for the approach. I remember at that time checking the ASOS again and adjusting my altimeter setting. I then descended to the minimum which was 860 ft MSL. I flew a distance at that altitude then the fog thinned and I saw the tree tops. I realized I was too low and should have gone missed approach at that time, but expected to see the runway any second and continued. The fog thickened again and I lost sight of the ground and executed the missed approach procedure. I contacted approach and requested an IFR clearance directly to destin. I checked the ASOS again and discovered I had set the altimeter incorrectly, enough to make a 200-300 ft altimeter error. I knew I was fortunate to escape that approach. In summary, I feel that by not getting a preflight WX briefing, I didn't prepare adequately for the flight I undertook. I had made the same flight scores of time and had never encountered the situation previously. I let my guard down concerning WX and it led to a tense situation. When I encountered the unexpected low IFR conditions at my destination, I just didn't handle it well. I was well rested and healthy, but for some reason made technical errors, procedural errors and poor judgements. I relied on my memory instead of reviewing the approach plate on the first approach, I set the altimeter incorrectly, I failed to execute a missed approach when I discovered I was too low and didn't have the runway in sight, and overall just blew the whole thing. Like so many accidents I read about, this near disaster would have been averted if any of several things had been different. If I had gotten WX prior to the flight, I would have made different plans. If I had looked at the plate on the first approach or set the altimeter properly on the second, I would have been safely above danger. If the tower had been open, they could have told me what the actual conditions were and I wouldn't have tried the approach. I do know that I have learned a lesson from this episode, several in fact. Idoubt I will ever take the WX for granted. I know I will never fail to be sure the altimeter is properly set. I know I will immediately execute a missed approach if anything is amiss and will never rely on memory only for details of an approach, even one at my home field. I know I will diligently attempt to practice instrument procedures more regularly, with my instructor or IFR certified check pilot.
Original NASA ASRS Text
Title: M20P PLT IS VECTORED TO 79J ARPT IN IMC, MAKES 2 INCORRECT APCHS BEFORE DIVERTING TO ANOTHER ARPT AND THEN DETERMINES AN ALTIMETER SETTING ERROR.
Narrative: WHAT WAS TO BE A SIMPLE, SHORT VFR FLT TURNED OUT TO BE A PERILOUS APCH TO LOW CEILINGS, DURING WHICH I ENDANGERED MYSELF AND MY PAX. I HAD SPENT A COUPLE OF DAYS ON VACATION NEAR MONTGOMERY, AL. THE WX HAD BEEN GOOD THROUGHOUT THE WK EXCEPT FOR THE TYPICAL SPORADIC AFTERNOON AND EVENING TSTMS. I LOOKED AT THE WX ON THE WX CHANNEL, BUT DIDN'T GET A PREFLT WX BRIEFING PRIOR TO DEPARTING WILLOW POINT (AL71) APPROX XA15 IN BEAUTIFUL CLR WX. I HAD INTENDED TO DROP OFF A PAX AT MY HOME FIELD OF ANDALUSIA-OPP (79J) AND CONTINUE TO DESTIN, FL (DTS). EVERYTHING WAS FINE APPROX 30 MI N OF 79J WHEN I SAW A LAYER OF CLOUDS IN THE ANDALUSIA DIRECTION BELOW OUR LEVEL OF 2500 FT. I HAD RECEIVED FLT FOLLOWING FROM MGM AND HE HAD JUST CANCELED RADAR SVC. I CONTACTED CAIRNES APCH (THE FACILITY COVERING ANDALUSIA) AND REQUESTED AN IFR DSCNT EXPECTING A THIN LAYER OF CLOUDS. HE ISSUED A SQUAWK CODE AND TOLD ME TO EXPECT RADAR VECTORS FOR THE NDB APCH. SINCE I HAD IFR CERTIFIED GPS ON BOARD, I ASKED FOR THE GPS APCH, BUT HE WAS APPARENTLY BUSY WITH OTHER TFC AND DIDN'T HEAR ME. I DECIDED TO TAKE THE NDB APCH USING THE GPS SINCE I WAS FAMILIAR WITH THE APCH AT MY HOME FIELD (OR AT LEAST I THOUGHT I WAS). I CHKED THE ASOS AND WAS SURPRISED TO HEAR CEILING OF 300 FT AND 1 MI VISIBILITY IN FOG. AT THIS POINT, I BEGAN A SERIES OF ERRORS AND POOR DECISIONS WHICH COULD HAVE LED TO A TRAGIC OUTCOME. WHEN THE CTLR TURNED ME ONTO FINAL AND CLRED ME FOR THE APCH, I DON'T REMEMBER SETTING THE ALTIMETER OR CHKING IT. FOR SOME REASON, I HAD IN MY MIND THAT THE MINIMUMS FOR THE APCH WERE 800 FT (ACTUALLY, IT IS 800 FT AGL, OR 1150 FT). I DSNDED ON THE APCH TO 800 FT, BUT NEVER SAW THE RWY. AS I ALSO WAS SURPRISED THE TWR AT 79J WASN'T OPEN, SINCE IT USUALLY IS ON WKDAYS. ON THE MISSED APCH, I CALLED CAIRNES AND REQUESTED THE GPS APCH. IN MY EXPERIENCE, THE ASOS CAN BE QUITE UNRELIABLE CONCERNING CEILINGS AND I THOUGHT IT WAS WORTH ANOTHER TRY. THE CTLR ASSIGNED AN ALT AND CLRED ME TO THE FAF FOR THE GPS TO RWY 29. I TURNED ONTO THE FINAL APCH COURSE OUTSIDE THE FIX JUST AFTER THE CTLR CLRED ME FOR THE APCH. I REMEMBER AT THAT TIME CHKING THE ASOS AGAIN AND ADJUSTING MY ALTIMETER SETTING. I THEN DSNDED TO THE MINIMUM WHICH WAS 860 FT MSL. I FLEW A DISTANCE AT THAT ALT THEN THE FOG THINNED AND I SAW THE TREE TOPS. I REALIZED I WAS TOO LOW AND SHOULD HAVE GONE MISSED APCH AT THAT TIME, BUT EXPECTED TO SEE THE RWY ANY SECOND AND CONTINUED. THE FOG THICKENED AGAIN AND I LOST SIGHT OF THE GND AND EXECUTED THE MISSED APCH PROC. I CONTACTED APCH AND REQUESTED AN IFR CLRNC DIRECTLY TO DESTIN. I CHKED THE ASOS AGAIN AND DISCOVERED I HAD SET THE ALTIMETER INCORRECTLY, ENOUGH TO MAKE A 200-300 FT ALTIMETER ERROR. I KNEW I WAS FORTUNATE TO ESCAPE THAT APCH. IN SUMMARY, I FEEL THAT BY NOT GETTING A PREFLT WX BRIEFING, I DIDN'T PREPARE ADEQUATELY FOR THE FLT I UNDERTOOK. I HAD MADE THE SAME FLT SCORES OF TIME AND HAD NEVER ENCOUNTERED THE SIT PREVIOUSLY. I LET MY GUARD DOWN CONCERNING WX AND IT LED TO A TENSE SIT. WHEN I ENCOUNTERED THE UNEXPECTED LOW IFR CONDITIONS AT MY DEST, I JUST DIDN'T HANDLE IT WELL. I WAS WELL RESTED AND HEALTHY, BUT FOR SOME REASON MADE TECHNICAL ERRORS, PROCEDURAL ERRORS AND POOR JUDGEMENTS. I RELIED ON MY MEMORY INSTEAD OF REVIEWING THE APCH PLATE ON THE FIRST APCH, I SET THE ALTIMETER INCORRECTLY, I FAILED TO EXECUTE A MISSED APCH WHEN I DISCOVERED I WAS TOO LOW AND DIDN'T HAVE THE RWY IN SIGHT, AND OVERALL JUST BLEW THE WHOLE THING. LIKE SO MANY ACCIDENTS I READ ABOUT, THIS NEAR DISASTER WOULD HAVE BEEN AVERTED IF ANY OF SEVERAL THINGS HAD BEEN DIFFERENT. IF I HAD GOTTEN WX PRIOR TO THE FLT, I WOULD HAVE MADE DIFFERENT PLANS. IF I HAD LOOKED AT THE PLATE ON THE FIRST APCH OR SET THE ALTIMETER PROPERLY ON THE SECOND, I WOULD HAVE BEEN SAFELY ABOVE DANGER. IF THE TWR HAD BEEN OPEN, THEY COULD HAVE TOLD ME WHAT THE ACTUAL CONDITIONS WERE AND I WOULDN'T HAVE TRIED THE APCH. I DO KNOW THAT I HAVE LEARNED A LESSON FROM THIS EPISODE, SEVERAL IN FACT. IDOUBT I WILL EVER TAKE THE WX FOR GRANTED. I KNOW I WILL NEVER FAIL TO BE SURE THE ALTIMETER IS PROPERLY SET. I KNOW I WILL IMMEDIATELY EXECUTE A MISSED APCH IF ANYTHING IS AMISS AND WILL NEVER RELY ON MEMORY ONLY FOR DETAILS OF AN APCH, EVEN ONE AT MY HOME FIELD. I KNOW I WILL DILIGENTLY ATTEMPT TO PRACTICE INST PROCS MORE REGULARLY, WITH MY INSTRUCTOR OR IFR CERTIFIED CHK PLT.
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.