37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 530285 |
Time | |
Date | 200111 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ykm.airport |
State Reference | WA |
Altitude | msl single value : 4500 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Rain |
Light | Night |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach descent : intermediate altitude |
Route In Use | approach : instrument non precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : instrument pilot : cfi pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 190 flight time total : 1300 flight time type : 500 |
ASRS Report | 530285 |
Person 2 | |
Affiliation | other |
Function | instruction : trainee |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude inflight encounter : weather non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Weather Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was on my last flight of the day, an IFR training flight. The flight was an IFR cross country in night, VMC with intermittent moderate precipitation. We were shooting our 3RD instrument approach when I looked up at the altimeter and realized my student had begun a descent which put us 500 ft below the minimum published altitude for that portion of the approach. I immediately took the controls and began a climb back to our minimum altitude. In hindsight, there were several factors that contributed to this error. Upon completion of our approach, we both discussed what had led to the error. Although neither of us had mentioned it at the time, we both felt fatigued prior to the flight and had considered calling the flight off. Unfortunately, neither of us had mentioned it or applied the 'I'm safe' checklist to ourselves. We both agreed the complexities of night flight had added to our fatigue and workload. In addition, a lack of CRM procedures (altitude callout that we were leaving an altitude) prevented communication and early detection of the error. On future flts, I will definitely put more emphasis on the 'I'm safe' checklist for both myself and students as well as more emphasis on CRM procedures.
Original NASA ASRS Text
Title: A PA28 FLT INSTRUCTOR AND STUDENT, WHILE ON A GPS APCH, DSNDED PREMATURELY BELOW THE MINIMUM PUBLISHED ALT.
Narrative: I WAS ON MY LAST FLT OF THE DAY, AN IFR TRAINING FLT. THE FLT WAS AN IFR XCOUNTRY IN NIGHT, VMC WITH INTERMITTENT MODERATE PRECIPITATION. WE WERE SHOOTING OUR 3RD INST APCH WHEN I LOOKED UP AT THE ALTIMETER AND REALIZED MY STUDENT HAD BEGUN A DSCNT WHICH PUT US 500 FT BELOW THE MINIMUM PUBLISHED ALT FOR THAT PORTION OF THE APCH. I IMMEDIATELY TOOK THE CTLS AND BEGAN A CLB BACK TO OUR MINIMUM ALT. IN HINDSIGHT, THERE WERE SEVERAL FACTORS THAT CONTRIBUTED TO THIS ERROR. UPON COMPLETION OF OUR APCH, WE BOTH DISCUSSED WHAT HAD LED TO THE ERROR. ALTHOUGH NEITHER OF US HAD MENTIONED IT AT THE TIME, WE BOTH FELT FATIGUED PRIOR TO THE FLT AND HAD CONSIDERED CALLING THE FLT OFF. UNFORTUNATELY, NEITHER OF US HAD MENTIONED IT OR APPLIED THE 'I'M SAFE' CHKLIST TO OURSELVES. WE BOTH AGREED THE COMPLEXITIES OF NIGHT FLT HAD ADDED TO OUR FATIGUE AND WORKLOAD. IN ADDITION, A LACK OF CRM PROCS (ALT CALLOUT THAT WE WERE LEAVING AN ALT) PREVENTED COM AND EARLY DETECTION OF THE ERROR. ON FUTURE FLTS, I WILL DEFINITELY PUT MORE EMPHASIS ON THE 'I'M SAFE' CHKLIST FOR BOTH MYSELF AND STUDENTS AS WELL AS MORE EMPHASIS ON CRM PROCS.
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.