37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 793111 |
Time | |
Date | 200807 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : hto.vortac |
State Reference | NY |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : personal |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : go around |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar controller : approach |
Qualification | controller : radar |
Experience | controller radar : 18 |
ASRS Report | 793111 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : required legal separation non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated |
Miss Distance | horizontal : 6000 vertical : 200 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
BE58 executing the GPS 28 at hto; C182 eastbound toward hto VOR to depart hto on the GPS 6 approach course at mtp; level at 3000 ft. BE58 declares missed approach. I instructed him to maintain 2000 ft (missed approach published altitude 1800 ft) via the published missed approach procedure (direct goodi waypoint). I instruct BE58 to 'identify and say altitude leaving.' next thing I know; the BE58 is climbing out of 2500 ft and turning towards hto VOR (still not officially radar idented); converging on C182. I ask BE58 to maintain 2000 ft; verify altitude and identify again. Pilot responds with some mumbles about 'descending to 2000 ft.' I call traffic for the C182 who responds 'IMC.' at this point the C182 is approximately 2 mi west of hto VOR; eastbound level at 3000 ft; and BE58 is approximately 2 mi north of hto VOR; sbound; altitude indicates 2400 ft. I again repeat instructions for BE58 to maintain 2000 ft immediately; to identify; and if he shows himself established on the published missed approach procedure (he's nowhere near it by now). Next thing I know; the BE58 is turning wbound; converging on the C182; and altitude indicates 2800 ft. Separation was lost. BE58 pilot was behaving as if he were under the influence. He had no rational response to questions; would not or could not seem to follow instructions even when they were repeated up to 6 times in a row (separate xmissions). The hto WX was reported by previous arrival to be right at minimums; but appeared to be improving (hto was VMC within 20 mins of this event). No storms or convective activity; and winds at hto were less than 10 KTS out of the west. This is not the first time that I have had an IFR aircraft execute a 'made up' missed approach procedure. I must have reiterated to the BE58 pilot at least 5 times that I needed him to proceed to goodi and enter the hold 'as published on the GPS 28 missed approach.' the pilot seemed confused and yet would respond in the affirmative; only to then wander around in the airspace at random altitudes.
Original NASA ASRS Text
Title: N90 CTLR DESCRIBED PLTDEV; SEPARATION LOSS AT 3000 FT WHEN ACFT ON GPS 28 APCH TO HTO FAILED TO ADHERE TO MISSED APCH PROCS; CONFLICTING WITH IFR TFC.
Narrative: BE58 EXECUTING THE GPS 28 AT HTO; C182 EBOUND TOWARD HTO VOR TO DEPART HTO ON THE GPS 6 APCH COURSE AT MTP; LEVEL AT 3000 FT. BE58 DECLARES MISSED APCH. I INSTRUCTED HIM TO MAINTAIN 2000 FT (MISSED APCH PUBLISHED ALT 1800 FT) VIA THE PUBLISHED MISSED APCH PROC (DIRECT GOODI WAYPOINT). I INSTRUCT BE58 TO 'IDENT AND SAY ALT LEAVING.' NEXT THING I KNOW; THE BE58 IS CLBING OUT OF 2500 FT AND TURNING TOWARDS HTO VOR (STILL NOT OFFICIALLY RADAR IDENTED); CONVERGING ON C182. I ASK BE58 TO MAINTAIN 2000 FT; VERIFY ALT AND IDENT AGAIN. PLT RESPONDS WITH SOME MUMBLES ABOUT 'DSNDING TO 2000 FT.' I CALL TFC FOR THE C182 WHO RESPONDS 'IMC.' AT THIS POINT THE C182 IS APPROX 2 MI W OF HTO VOR; EBOUND LEVEL AT 3000 FT; AND BE58 IS APPROX 2 MI N OF HTO VOR; SBOUND; ALT INDICATES 2400 FT. I AGAIN REPEAT INSTRUCTIONS FOR BE58 TO MAINTAIN 2000 FT IMMEDIATELY; TO IDENT; AND IF HE SHOWS HIMSELF ESTABLISHED ON THE PUBLISHED MISSED APCH PROC (HE'S NOWHERE NEAR IT BY NOW). NEXT THING I KNOW; THE BE58 IS TURNING WBOUND; CONVERGING ON THE C182; AND ALT INDICATES 2800 FT. SEPARATION WAS LOST. BE58 PLT WAS BEHAVING AS IF HE WERE UNDER THE INFLUENCE. HE HAD NO RATIONAL RESPONSE TO QUESTIONS; WOULD NOT OR COULD NOT SEEM TO FOLLOW INSTRUCTIONS EVEN WHEN THEY WERE REPEATED UP TO 6 TIMES IN A ROW (SEPARATE XMISSIONS). THE HTO WX WAS RPTED BY PREVIOUS ARR TO BE RIGHT AT MINIMUMS; BUT APPEARED TO BE IMPROVING (HTO WAS VMC WITHIN 20 MINS OF THIS EVENT). NO STORMS OR CONVECTIVE ACTIVITY; AND WINDS AT HTO WERE LESS THAN 10 KTS OUT OF THE W. THIS IS NOT THE FIRST TIME THAT I HAVE HAD AN IFR ACFT EXECUTE A 'MADE UP' MISSED APCH PROC. I MUST HAVE REITERATED TO THE BE58 PLT AT LEAST 5 TIMES THAT I NEEDED HIM TO PROCEED TO GOODI AND ENTER THE HOLD 'AS PUBLISHED ON THE GPS 28 MISSED APCH.' THE PLT SEEMED CONFUSED AND YET WOULD RESPOND IN THE AFFIRMATIVE; ONLY TO THEN WANDER AROUND IN THE AIRSPACE AT RANDOM ALTS.
Data retrieved from NASA's ASRS site as of May 2009 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.