37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 804133 |
Time | |
Date | 200809 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sdl.airport |
State Reference | AZ |
Altitude | agl single value : 400 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : sfo.tower |
Operator | general aviation : instructional |
Make Model Name | Small Aircraft Low Wing 1 Eng Fixed Gear |
Operating Under FAR Part | Part 91 |
Navigation In Use | other vortac |
Flight Phase | descent : approach |
Route In Use | approach : traffic pattern |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : commercial pilot : instrument pilot : multi engine pilot : cfi |
Experience | flight time last 90 days : 150 flight time total : 1100 flight time type : 339 |
ASRS Report | 804133 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On the night before this flight; I had worked till about XA00 and had to be back at work early the next morning. Considering the time it takes me to drive to and from work; I was only able to sleep about 4.5 hours before I had to get ready for work the next day. On the day in question; I was scheduled to work a very long day from XA00-XP00 with only a 1.5 hour lunch. Due to this I was fairly tired and fatigued. At the flight school I work for it can sometimes we somewhat of a hassle to cancel flts so I decided to just push through my fatigue. On my last flight of the day we went on a flight to do some practice VFR instrument approachs. The student I was with was a very confident and capable pilot. Throughout the flight lesson my student had done very well on all of his approachs. On the last approach of the night at about XO00; we contacted ATC and requested a VOR C practice approach into sdl. The controller told us to intercept the 313 degree radial; maintain 3000 ft until established; procedure turn not authority/authorized; remain VFR and that no separation services were provided. At the time we were fairly close to sdl so I; as the PNF; was scrambling to set the approach set-up; the student climbed past 3000 ft by about 400 ft. Part of the reason he climbed past 3000 ft was that when we received our instructions we were already climbing through this altitude. As soon as I realized our altitude we immediately returned to 3000 ft. Once we were established on the approach; ATC told us to squawk VFR and to contact the CTAF at sdl. When we contacted the CTAF it was made apparent that there was another aircraft that was in the traffic pattern that might be an issue so considering that my student was under the hood I was the one looking for it. After crossing the FAF; my student began his descent down to the published MDA. At this time I noticed that the GPS had failed to activate the final approach course. Instead it was trying to do the procedure turn. Noticing this; I tried to activate the final approach course at the same time I was still looking for the other traffic and talking to the other traffic to assure separation. After gaining visual contact with the other traffic; I noticed that my student had descended past the published MDA by about 450 ft which put us about 400 ft AGL. As soon as I noticed this I took the controls and immediately started a climb back to the published MDA at which time we were at the missed approach point and went missed. Factors that I think contributed to this was first of all fatigue. Having just been at work for almost 14 hours I was tired and my judgement had suffered due to this. Also I fell into complacency with my student. Because he had done so well on approachs in the past; I focused more on scanning for traffic than watching what he was doing. Also; the GPS not activating the final approach course and the fact that I was in the process of talking to the other aircraft so as to maintain separation diverted my attention from watching. All of this led to a high workload and distraction my attention from monitoring my student's actions. After talking to my student about what happened; he mentioned that he was fixated on the VOR and was not aware of his altitude. Also; the controller had us at an altitude that was 1000 ft lower than what was published on the approach plate crossing the FAF. This led to my student not realizing how close we were to the MDA upon crossing the FAF which gave him a false sense of time meaning he thought he had more time before reaching the MDA. This situation could have been prevented had I not been complacent with my student and focused more on what he was doing as opposed to trying to fix the GPS problem. Although it was important that I scan for the other traffic that was in front of us I should have diverted my attention more wisely to include scanning my students' instruments more often. Another factor that contributed was my level of fatigue. Knowing I was tired I should have just canceled the flight. Luckily; no incident came of this. In the future; I will watch myself more closely so as not to fall into complacency and I won't hesitate to cancel a flight if I am fatigued.
Original NASA ASRS Text
Title: AN INSTRUCTOR WITH A STUDENT DESCENDED ON A PRACTICE NIGHT APPROACH BELOW THE PROCEDURE ALT TO 400 FT AGL. THE REPORTER CITED FATIGUE AS A FACTOR.
Narrative: ON THE NIGHT BEFORE THIS FLT; I HAD WORKED TILL ABOUT XA00 AND HAD TO BE BACK AT WORK EARLY THE NEXT MORNING. CONSIDERING THE TIME IT TAKES ME TO DRIVE TO AND FROM WORK; I WAS ONLY ABLE TO SLEEP ABOUT 4.5 HRS BEFORE I HAD TO GET READY FOR WORK THE NEXT DAY. ON THE DAY IN QUESTION; I WAS SCHEDULED TO WORK A VERY LONG DAY FROM XA00-XP00 WITH ONLY A 1.5 HR LUNCH. DUE TO THIS I WAS FAIRLY TIRED AND FATIGUED. AT THE FLT SCHOOL I WORK FOR IT CAN SOMETIMES WE SOMEWHAT OF A HASSLE TO CANCEL FLTS SO I DECIDED TO JUST PUSH THROUGH MY FATIGUE. ON MY LAST FLT OF THE DAY WE WENT ON A FLT TO DO SOME PRACTICE VFR INST APCHS. THE STUDENT I WAS WITH WAS A VERY CONFIDENT AND CAPABLE PLT. THROUGHOUT THE FLT LESSON MY STUDENT HAD DONE VERY WELL ON ALL OF HIS APCHS. ON THE LAST APCH OF THE NIGHT AT ABOUT XO00; WE CONTACTED ATC AND REQUESTED A VOR C PRACTICE APCH INTO SDL. THE CTLR TOLD US TO INTERCEPT THE 313 DEG RADIAL; MAINTAIN 3000 FT UNTIL ESTABLISHED; PROC TURN NOT AUTH; REMAIN VFR AND THAT NO SEPARATION SVCS WERE PROVIDED. AT THE TIME WE WERE FAIRLY CLOSE TO SDL SO I; AS THE PNF; WAS SCRAMBLING TO SET THE APCH SET-UP; THE STUDENT CLBED PAST 3000 FT BY ABOUT 400 FT. PART OF THE REASON HE CLBED PAST 3000 FT WAS THAT WHEN WE RECEIVED OUR INSTRUCTIONS WE WERE ALREADY CLBING THROUGH THIS ALT. AS SOON AS I REALIZED OUR ALT WE IMMEDIATELY RETURNED TO 3000 FT. ONCE WE WERE ESTABLISHED ON THE APCH; ATC TOLD US TO SQUAWK VFR AND TO CONTACT THE CTAF AT SDL. WHEN WE CONTACTED THE CTAF IT WAS MADE APPARENT THAT THERE WAS ANOTHER ACFT THAT WAS IN THE TFC PATTERN THAT MIGHT BE AN ISSUE SO CONSIDERING THAT MY STUDENT WAS UNDER THE HOOD I WAS THE ONE LOOKING FOR IT. AFTER XING THE FAF; MY STUDENT BEGAN HIS DSCNT DOWN TO THE PUBLISHED MDA. AT THIS TIME I NOTICED THAT THE GPS HAD FAILED TO ACTIVATE THE FINAL APCH COURSE. INSTEAD IT WAS TRYING TO DO THE PROC TURN. NOTICING THIS; I TRIED TO ACTIVATE THE FINAL APCH COURSE AT THE SAME TIME I WAS STILL LOOKING FOR THE OTHER TFC AND TALKING TO THE OTHER TFC TO ASSURE SEPARATION. AFTER GAINING VISUAL CONTACT WITH THE OTHER TFC; I NOTICED THAT MY STUDENT HAD DSNDED PAST THE PUBLISHED MDA BY ABOUT 450 FT WHICH PUT US ABOUT 400 FT AGL. AS SOON AS I NOTICED THIS I TOOK THE CTLS AND IMMEDIATELY STARTED A CLB BACK TO THE PUBLISHED MDA AT WHICH TIME WE WERE AT THE MISSED APCH POINT AND WENT MISSED. FACTORS THAT I THINK CONTRIBUTED TO THIS WAS FIRST OF ALL FATIGUE. HAVING JUST BEEN AT WORK FOR ALMOST 14 HRS I WAS TIRED AND MY JUDGEMENT HAD SUFFERED DUE TO THIS. ALSO I FELL INTO COMPLACENCY WITH MY STUDENT. BECAUSE HE HAD DONE SO WELL ON APCHS IN THE PAST; I FOCUSED MORE ON SCANNING FOR TFC THAN WATCHING WHAT HE WAS DOING. ALSO; THE GPS NOT ACTIVATING THE FINAL APCH COURSE AND THE FACT THAT I WAS IN THE PROCESS OF TALKING TO THE OTHER ACFT SO AS TO MAINTAIN SEPARATION DIVERTED MY ATTN FROM WATCHING. ALL OF THIS LED TO A HIGH WORKLOAD AND DISTR MY ATTN FROM MONITORING MY STUDENT'S ACTIONS. AFTER TALKING TO MY STUDENT ABOUT WHAT HAPPENED; HE MENTIONED THAT HE WAS FIXATED ON THE VOR AND WAS NOT AWARE OF HIS ALT. ALSO; THE CTLR HAD US AT AN ALT THAT WAS 1000 FT LOWER THAN WHAT WAS PUBLISHED ON THE APCH PLATE XING THE FAF. THIS LED TO MY STUDENT NOT REALIZING HOW CLOSE WE WERE TO THE MDA UPON XING THE FAF WHICH GAVE HIM A FALSE SENSE OF TIME MEANING HE THOUGHT HE HAD MORE TIME BEFORE REACHING THE MDA. THIS SIT COULD HAVE BEEN PREVENTED HAD I NOT BEEN COMPLACENT WITH MY STUDENT AND FOCUSED MORE ON WHAT HE WAS DOING AS OPPOSED TO TRYING TO FIX THE GPS PROB. ALTHOUGH IT WAS IMPORTANT THAT I SCAN FOR THE OTHER TFC THAT WAS IN FRONT OF US I SHOULD HAVE DIVERTED MY ATTN MORE WISELY TO INCLUDE SCANNING MY STUDENTS' INSTS MORE OFTEN. ANOTHER FACTOR THAT CONTRIBUTED WAS MY LEVEL OF FATIGUE. KNOWING I WAS TIRED I SHOULD HAVE JUST CANCELED THE FLT. LUCKILY; NO INCIDENT CAME OF THIS. IN THE FUTURE; I WILL WATCH MYSELF MORE CLOSELY SO AS NOT TO FALL INTO COMPLACENCY AND I WON'T HESITATE TO CANCEL A FLT IF I AM FATIGUED.
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.