ILAFFT: Almost Killed my Family on an Instrument Approach

T

TruConfessions

Guest
Welp... I feel like I almost killed myself and my family of four over a stupid, stupid mistake - a simple misreading of a chart on an IFR approach.

I think the purpose of this thread is multi-parted: 1) to get this off my chest, 2) to see if anyone has recommendations on how to avoid this in the future, and 3) to understand the role of ATC in this situation. I always thought they would have been a back-stop in this scenario.

Anyway, we had very hazy conditions for a flight recently. I had expected VFR conditions throughout but our destination airport went IFR in a thick, soupy haze. No matter - I happened to be on an IFR flight plan. It was the most benign IMC conditions possible - low visibility in haze but no moisture to speak of, no icing concerns. All in all a pretty ideal little practice IMC / approach scenario.

This was a new destination to me. I had never shot this approach before or landed at the airport before. I'm PPL/IR rated, IFR current (just took and passed an IPC with "flying colors"), roughly 1,000 hours totally, fly my own plane 100+ hours a year, have a nice GTN panel with GPSS and single-axis autopilot.

I requested and was cleared for an RNAV approach. It was a pretty standard “T-shaped” approach, and I was cleared via one of the “T”’s initial approach fixes and feeder routes. I was cleared to that IAF “N1234 cleared direct IAF, cross IAF at or above 5,000, cleared RNAV Runway XX approach”.

I had already done a full briefing of the approach. Frequencies, altitudes, routes, waypoints, DAs, missed approach, terrain – the whole thing. I had had plenty of time to prepare and I don’t get the opportunity to fly that many actual approaches due to the typical weather in our area, so I was really paying attention.

I scanned the approach again and picked up the altitude for the feeder rout – 2,000’ – and after crossing the IAF, I started my descent from my “at or above 5,000’” altitude down to 2,000.

Things were fine. No visibility going forward or out the side windows. Just a touch of visibility/ground contact if I looked straight down. Autopilot’s GPSS is tracking the approach perfectly.

I descend to 4,000.

Then to 3,500.

Pretty soon, out of the haze, I start to notice some bumpy hills appearing through the mist. And they’re not that far away. I’m probably still 1,000 feet above them and offset laterally, but my mind starts thinking:

I can’t believe this approach gets that close to these hills... Doesn’t seem right…

…well, we *are* offset, so maybe it’s protected by the lateral boundaries…

…but still, this would be considered mountainous terrain – it should have 2,000’ minimum within 2+ miles either side and there’s no way I have that clearance…

…Something has to be wrong…

I go back to the chart and study it, and I suddenly realize my error. It’s not a standard T-shaped RNAV approach really… close, but not quite. There’s a stepdown fix halfway between the IAF and the holding fix and a long skinny little arrow pointing to the segment I’m on that notes “5,000 NoPT”. It’s only after the next fix, that the altitude is 2,000. And here I am descending through 3,500’.

My heart leaps and I pour on the coals.

“ABC Approach, N12345. I just realized I have mis-read the approach. I am well below the published altitude. Do you want me to stay here or climb back to the published altitude?” It was a stupid question and I was already on my way back up, but it was the best I could muster given the circumstances.

A polite and not even sort of perturbed young lady responds “N1234, you should be at the published altitude, so I would suggest a climb back to that altitude”.

And that was it. No scolding, no fanfare. The rest of the approach went perfectly, emerging from the haze directly in line with the runway at about 500 feet.

In retrospect, I am having a hard time not beating myself up about this. I remember one similar circumstance way back when I was doing my IFR training on a VOR approach where there was a slight turn in the approach on the fix just before the FAF. I missed the turn and eventually my CFII recommended I take my hood off. His recommendation was premature – I wasn’t at MDA, when he would normally make that recommendation – so I knew something had gone wrong. And it had. Missing that little bend in the approach put us off course and aiming directly at the side of the mountain. It would have been catastrophic in actual conditions. A real lesson-learner.

But apparently, I didn’t learn that lesson. Or the lesson didn’t stick. Or I’m prone to missing details. Or something. I don’t know, and I don’t know what to do about it.

And what about ATC? 1,500’ below published altitude? I know I’m the PIC and responsible for the flight – I’m not shirking that at all – but I’m still surprised. All throughout my training I assumed that if I was more than 100’ off or so, I’d get barked at. And even on this exact flight I had a moment’s inattention and got a “N1234 I need you at 9,000, altitutde inditates 9,200”. Now, it didn’t indicate 9,200 – I was only showing 100 feet over with the correct altimeter setting so I’m not sure what to make of that, but still.

I filed an ASRS report as soon as I got home. In the “notes” section I noted that while I briefed the approach, I did so in the air. In the future, I need to brief approaches earlier – ideally on the ground, when there are no distractions, no time pressures, no demands of flying the plane. And obviously, I need to be absolutely, 100% sure about altitudes for EVERY segment, every time. But I’m not sure what else to do.

Thanks for reading. I’d love to hear your comments or suggestions. If you’re going to be negative, fine – I can take it – but know that you can’t beat me up any harder than I am already beating myself up. Cheers.
 
I for one have nothing negative to say. I'm glad that the outcome was successful and that you learned from it. We all make mistakes, even in high-stakes situations.

I think that to add to the learning experience for all of us, telling us the airport / approach would be helpful.
 
TruConfessions said:
And what about ATC?
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Question for the controllers here: When you say "cleared for the approach" does that offload some of your monitoring duties?
TruConfessions said:
In the “notes” section I noted that while I briefed the approach, I did so in the air. In the future, I need to brief approaches earlier – ideally on the ground, when there are no distractions, no time pressures, no demands of flying the plane.
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I can see how doing it in the air increase the odds of reading something incorrectly. I very much prefer doing the prep on the ground for that very reason. However, without knowing which approach plate it's difficult to determine how easy/hard it would have been to miss the note.

But glad you had a good outcome and made it into a learning experience.
 
Kevin Holbrook said:
I think that to add to the learning experience for all of us, telling us the airport / approach would be helpful.
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Yeah... it's a fair point and request but I'd prefer not to. I'd prefer to keep this as confidential as posting about it on the internet can be!!
 
I'm not sure what to say. Your examination of what happened and where you went wrong is on target and any one of us could have done the same thing. Without knowing the specific approach you flew hard for me to suggest any procedural changes that would perhaps have prevented it. I don't think briefing the approach on deck before hand would help me at least as I tend to want to be setting stuff up in the plane as I brief it as a double check.
 
you made a mistake reading the chart. other than "everyone's ok", what else can really be said? try not to make mistakes (duh), most importantly on an approach in IMC. you said you have a gtn in the panel, that can be used as your backup for stepdown altitudes. use what you have to your advantage.
 
TruConfessions said:
Yeah... it's a fair point and request but I'd prefer not to. I'd prefer to keep this as confidential as posting about it on the internet can be!!
Click to expand...

Please reconsider this. Your are posting at least semi-anonymously, and you filed an ASRS. Honestly, if the FAA found out that you were sharing details of this experience with others, they would praise you, not punish you.
 
Kevin Holbrook said:
I for one have nothing negative to say. I'm glad that the outcome was successful and that you learned from it. We all make mistakes, even in high-stakes situations.

I think that to add to the learning experience for all of us, telling us the airport / approach would be helpful.
Click to expand...

I also have nothing negative to say.

For my own learning, I'd appreciate knowing the airport/approach.
 
asicer said:
Question for the controllers here: When you say "cleared for the approach" does that offload some of your monitoring duties?
Click to expand...
Deviation from an assigned altitude is an "additional service" and may not happen if conditions do not permit it.

The original story brought this obligatory reference to mind:
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Depending where you are ATC may not able to receive your Altitude. Even if they can, their primary function is separation of traffic. Anything else they do is on an as able basis.

A Recent discussion about Tower responsibilities makes the point that their only responsibility is to prevent and resolve conflict on the runway.

Brian
 
Once upon a time, I was riding in the jump seat as a check pilot during an instrument approach into Randolph AFB (probably the longest straight in approach in history) and ATC gave us a direct to one of the many intermediate fixes on the ILS.
The Guy flying the approach selected the assigned fix and we immediately began descending, since the flight director was coupled and the fix was at a much lower altitude.
After a few seconds of disbelief, we figured out what was happening, but by then we had lost a few hundred feet from our assigned altitude.
Automation can get you just as much as misreading a chart. Fortunately, there was only flat land below us and there was no danger of being too low, but in another location, it could have been scary...
 
What I have done in the past, and still do every now and then, is fly an approach to an unfamiliar airport on X-Plane. It's better to have your computer screen go black than to have your windscreen go black. Also, what sort of equipment were you flying with? My iPad with FF would start going yellow and red even if I wasn't on the terrain page of my 530.
 
TruConfessions said:
Welp... I feel like I almost killed myself and my family of four over a stupid, stupid mistake - a simple misreading of a chart on an IFR approach.

I think the purpose of this thread is multi-parted: 1) to get this off my chest, 2) to see if anyone has recommendations on how to avoid this in the future, and 3) to understand the role of ATC in this situation. I always thought they would have been a back-stop in this scenario.

Anyway, we had very hazy conditions for a flight recently. I had expected VFR conditions throughout but our destination airport went IFR in a thick, soupy haze. No matter - I happened to be on an IFR flight plan. It was the most benign IMC conditions possible - low visibility in haze but no moisture to speak of, no icing concerns. All in all a pretty ideal little practice IMC / approach scenario.

This was a new destination to me. I had never shot this approach before or landed at the airport before. I'm PPL/IR rated, IFR current (just took and passed an IPC with "flying colors"), roughly 1,000 hours totally, fly my own plane 100+ hours a year, have a nice GTN panel with GPSS and single-axis autopilot.

I requested and was cleared for an RNAV approach. It was a pretty standard “T-shaped” approach, and I was cleared via one of the “T”’s initial approach fixes and feeder routes. I was cleared to that IAF “N1234 cleared direct IAF, cross IAF at or above 5,000, cleared RNAV Runway XX approach”.

I had already done a full briefing of the approach. Frequencies, altitudes, routes, waypoints, DAs, missed approach, terrain – the whole thing. I had had plenty of time to prepare and I don’t get the opportunity to fly that many actual approaches due to the typical weather in our area, so I was really paying attention.

I scanned the approach again and picked up the altitude for the feeder rout – 2,000’ – and after crossing the IAF, I started my descent from my “at or above 5,000’” altitude down to 2,000.

Things were fine. No visibility going forward or out the side windows. Just a touch of visibility/ground contact if I looked straight down. Autopilot’s GPSS is tracking the approach perfectly.

I descend to 4,000.

Then to 3,500.

Pretty soon, out of the haze, I start to notice some bumpy hills appearing through the mist. And they’re not that far away. I’m probably still 1,000 feet above them and offset laterally, but my mind starts thinking:

I can’t believe this approach gets that close to these hills... Doesn’t seem right…

…well, we *are* offset, so maybe it’s protected by the lateral boundaries…

…but still, this would be considered mountainous terrain – it should have 2,000’ minimum within 2+ miles either side and there’s no way I have that clearance…

…Something has to be wrong…

I go back to the chart and study it, and I suddenly realize my error. It’s not a standard T-shaped RNAV approach really… close, but not quite. There’s a stepdown fix halfway between the IAF and the holding fix and a long skinny little arrow pointing to the segment I’m on that notes “5,000 NoPT”. It’s only after the next fix, that the altitude is 2,000. And here I am descending through 3,500’.

My heart leaps and I pour on the coals.

“ABC Approach, N12345. I just realized I have mis-read the approach. I am well below the published altitude. Do you want me to stay here or climb back to the published altitude?” It was a stupid question and I was already on my way back up, but it was the best I could muster given the circumstances.

A polite and not even sort of perturbed young lady responds “N1234, you should be at the published altitude, so I would suggest a climb back to that altitude”.

And that was it. No scolding, no fanfare. The rest of the approach went perfectly, emerging from the haze directly in line with the runway at about 500 feet.

In retrospect, I am having a hard time not beating myself up about this. I remember one similar circumstance way back when I was doing my IFR training on a VOR approach where there was a slight turn in the approach on the fix just before the FAF. I missed the turn and eventually my CFII recommended I take my hood off. His recommendation was premature – I wasn’t at MDA, when he would normally make that recommendation – so I knew something had gone wrong. And it had. Missing that little bend in the approach put us off course and aiming directly at the side of the mountain. It would have been catastrophic in actual conditions. A real lesson-learner.

But apparently, I didn’t learn that lesson. Or the lesson didn’t stick. Or I’m prone to missing details. Or something. I don’t know, and I don’t know what to do about it.

And what about ATC? 1,500’ below published altitude? I know I’m the PIC and responsible for the flight – I’m not shirking that at all – but I’m still surprised. All throughout my training I assumed that if I was more than 100’ off or so, I’d get barked at. And even on this exact flight I had a moment’s inattention and got a “N1234 I need you at 9,000, altitutde inditates 9,200”. Now, it didn’t indicate 9,200 – I was only showing 100 feet over with the correct altimeter setting so I’m not sure what to make of that, but still.

I filed an ASRS report as soon as I got home. In the “notes” section I noted that while I briefed the approach, I did so in the air. In the future, I need to brief approaches earlier – ideally on the ground, when there are no distractions, no time pressures, no demands of flying the plane. And obviously, I need to be absolutely, 100% sure about altitudes for EVERY segment, every time. But I’m not sure what else to do.

Thanks for reading. I’d love to hear your comments or suggestions. If you’re going to be negative, fine – I can take it – but know that you can’t beat me up any harder than I am already beating myself up. Cheers.
Click to expand...
We’re you in Radar Contact when this happened?
 
asicer said:
Question for the controllers here: When you say "cleared for the approach" does that offload some of your monitoring duties?……
Click to expand...
No. That being said, often by the time the Approach Clearance is given, traffic conflictions have been resolved. If there are other things going on elsewhere that require attention to avoid conflictions, the just cleared plane may not spend a whole lot of time in the Controllers scan. Kinda like flying. At any given time, some instruments are more important than some of the others.
 
Do you expect the approach controller to be instrument rated, have an instrument approach chart out or displayed on his radar, and monitor your flying the approach all while continuing to provide radar service to the other aircraft in his sector? What if his/her sector has multiple airfields with multiple approaches and multiple aircraft flying said approaches? The controller is required to provide IFR traffic, separation from other IFR traffic, not act as copilot and monitor your flying of an approach. I maintain it would be shear luck for a controller to notice someone screwing up an approach unless it results in a loss of separation or the aircraft is grossly off course.
 
luvflyin said:
We’re you in Radar Contact when this happened?
Click to expand...

Yes, at least, I hadn't gotten any "radar contact lost" and really don't think there's any chance there wouldn't be radar coverage in that area.

eman1200 said:
Depending where you are ATC may not able to receive your Altitude. Even if they can, their primary function is separation of traffic. Anything else they do is on an as able basis.

A Recent discussion about Tower responsibilities makes the point that their only responsibility is to prevent and resolve conflict on the runway.

Brian
Click to expand...

FWIW, this was with the approach controller still and while I'll never know, I can't imagine I was either out of radar contact or in an area where they couldn't get my altitude.
 
Glad you caught the mistake and corrected. I do review the approaches prior to a flight and note any terrain that may be an issue. I also like to dial in my altitude for each step down in my Aspen for altitude awareness and set the missed/decision height.

Procedures get adjusted each flight if need be and we all learn from mistakes we make. Thanks for sharing your experience.
 
Witmo said:
Do you expect the approach controller to be instrument rated, have an instrument approach chart out or displayed on his radar, and monitor your flying the approach all while continuing to provide radar service to the other aircraft in his sector? What if his/her sector has multiple airfields with multiple approaches and multiple aircraft flying said approaches? The controller is required to provide IFR traffic, separation from other IFR traffic, not act as copilot and monitor your flying of an approach. I maintain it would be shear luck for a controller to notice someone screwing up an approach unless it results in a loss of separation or the aircraft is grossly off course.
Click to expand...

See:

TruConfessions said:
I know I’m the PIC and responsible for the flight – I’m not shirking that at all – but I’m still surprised.
Click to expand...

So, two thoughts. On one hand, I'd say 1,500' off the published altitude constitutes grossly off course but I see why being off course vertically might not be as obvious as being off course horizontally. My second thought is that while I totally agree that the PIC remains responsible for the flight, I would sure hope to get a "hey, you look like you're going to crash into a mountain" if I was, in fact, about to crash into a mountain. Not as a first line of defense, but as a last line of defense.
 
Witmo said:
Do you expect the approach controller to be instrument rated, have an instrument approach chart out or displayed on his radar, and monitor your flying the approach all while continuing to provide radar service to the other aircraft in his sector? What if his/her sector has multiple airfields with multiple approaches and multiple aircraft flying said approaches? The controller is required to provide IFR traffic, separation from other IFR traffic, not act as copilot and monitor your flying of an approach. I maintain it would be shear luck for a controller to notice someone screwing up an approach unless it results in a loss of separation or the aircraft is grossly off course.
Click to expand...
No, but more than once I received low altitude alerts from towers during instrument approaches before I replaced my encoder (I was at the proper altitude, but they thought I was lower than I really was.) There is automation which knows the altitudes and slopes even if the controllers don't. I don't know if this is for the FAS only, though.
 
Glad you caught your mistake in time to correct it. I'm sure its a lesson that will stick.

Honestly, you're human, and humans make mistakes. We've all done it. Some of us live to tell the story, others well...

One bone headed mistake I made IFR was during my training for my instrument. For some reason I was misreading the altimeter 1,000 foot low. Don't ask me to explain why, my brain just wasn't seeing the 1,000 foot needle in relation to the big number on the dial. We were in actual, with my CFII, and coming down the approach. My instructor saw the situation, but decided to allow me to proceed down to learn. I couldn't figure out why we hadn't broke out of the clouds on this non-precision dive and drive type approach. Still had a few miles to the airport, but was already at MDA and in the clouds, despite the AWOS report. Finally we reach the airport still in the clouds and I was as confused as could be.

Finally my instructor asked me what was wrong and the light bulb went off, I had leveled off 1,000 above the MDA, still in the clouds. Safer than the opposite I guess, but I couldn't believe how I could misread something as simple as the altimeter.
 
midwestpa24 said:
Glad you caught your mistake in time to correct it. I'm sure its a lesson that will stick.

Honestly, you're human, and humans make mistakes. We've all done it. Some of us live to tell the story, others well...

One bone headed mistake I made IFR was during my training for my instrument. For some reason I was misreading the altimeter 1,000 foot low. Don't ask me to explain why, my brain just wasn't seeing the 1,000 foot needle in relation to the big number on the dial. We were in actual, with my CFII, and coming down the approach. My instructor saw the situation, but decided to allow me to proceed down to learn. I couldn't figure out why we hadn't broke out of the clouds on this non-precision dive and drive type approach. Still had a few miles to the airport, but was already at MDA and in the clouds, despite the AWOS report. Finally we reach the airport still in the clouds and I was as confused as could be.

Finally my instructor asked me what was wrong and the light bulb went off, I had leveled off 1,000 above the MDA, still in the clouds. Safer than the opposite I guess, but I couldn't believe how I could misread something as simple as the altimeter.
Click to expand...
I often find myself cross-checking the steam gauge altimeter with the tape on the G5 to avoid the same thing.
 
TruConfessions said:
Welp... I feel like I almost killed myself and my family of four over a stupid, stupid mistake - a simple misreading of a chart on an IFR approach.

I think the purpose of this thread is multi-parted: 1) to get this off my chest, 2) to see if anyone has recommendations on how to avoid this in the future, and 3) to understand the role of ATC in this situation. I always thought they would have been a back-stop in this scenario.

Anyway, we had very hazy conditions for a flight recently. I had expected VFR conditions throughout but our destination airport went IFR in a thick, soupy haze. No matter - I happened to be on an IFR flight plan. It was the most benign IMC conditions possible - low visibility in haze but no moisture to speak of, no icing concerns. All in all a pretty ideal little practice IMC / approach scenario.

This was a new destination to me. I had never shot this approach before or landed at the airport before. I'm PPL/IR rated, IFR current (just took and passed an IPC with "flying colors"), roughly 1,000 hours totally, fly my own plane 100+ hours a year, have a nice GTN panel with GPSS and single-axis autopilot.

I requested and was cleared for an RNAV approach. It was a pretty standard “T-shaped” approach, and I was cleared via one of the “T”’s initial approach fixes and feeder routes. I was cleared to that IAF “N1234 cleared direct IAF, cross IAF at or above 5,000, cleared RNAV Runway XX approach”.

I had already done a full briefing of the approach. Frequencies, altitudes, routes, waypoints, DAs, missed approach, terrain – the whole thing. I had had plenty of time to prepare and I don’t get the opportunity to fly that many actual approaches due to the typical weather in our area, so I was really paying attention.

I scanned the approach again and picked up the altitude for the feeder rout – 2,000’ – and after crossing the IAF, I started my descent from my “at or above 5,000’” altitude down to 2,000.

Things were fine. No visibility going forward or out the side windows. Just a touch of visibility/ground contact if I looked straight down. Autopilot’s GPSS is tracking the approach perfectly.

I descend to 4,000.

Then to 3,500.

Pretty soon, out of the haze, I start to notice some bumpy hills appearing through the mist. And they’re not that far away. I’m probably still 1,000 feet above them and offset laterally, but my mind starts thinking:

I can’t believe this approach gets that close to these hills... Doesn’t seem right…

…well, we *are* offset, so maybe it’s protected by the lateral boundaries…

…but still, this would be considered mountainous terrain – it should have 2,000’ minimum within 2+ miles either side and there’s no way I have that clearance…

…Something has to be wrong…

I go back to the chart and study it, and I suddenly realize my error. It’s not a standard T-shaped RNAV approach really… close, but not quite. There’s a stepdown fix halfway between the IAF and the holding fix and a long skinny little arrow pointing to the segment I’m on that notes “5,000 NoPT”. It’s only after the next fix, that the altitude is 2,000. And here I am descending through 3,500’.

My heart leaps and I pour on the coals.

“ABC Approach, N12345. I just realized I have mis-read the approach. I am well below the published altitude. Do you want me to stay here or climb back to the published altitude?” It was a stupid question and I was already on my way back up, but it was the best I could muster given the circumstances.

A polite and not even sort of perturbed young lady responds “N1234, you should be at the published altitude, so I would suggest a climb back to that altitude”.

And that was it. No scolding, no fanfare. The rest of the approach went perfectly, emerging from the haze directly in line with the runway at about 500 feet.

In retrospect, I am having a hard time not beating myself up about this. I remember one similar circumstance way back when I was doing my IFR training on a VOR approach where there was a slight turn in the approach on the fix just before the FAF. I missed the turn and eventually my CFII recommended I take my hood off. His recommendation was premature – I wasn’t at MDA, when he would normally make that recommendation – so I knew something had gone wrong. And it had. Missing that little bend in the approach put us off course and aiming directly at the side of the mountain. It would have been catastrophic in actual conditions. A real lesson-learner.

But apparently, I didn’t learn that lesson. Or the lesson didn’t stick. Or I’m prone to missing details. Or something. I don’t know, and I don’t know what to do about it.

And what about ATC? 1,500’ below published altitude? I know I’m the PIC and responsible for the flight – I’m not shirking that at all – but I’m still surprised. All throughout my training I assumed that if I was more than 100’ off or so, I’d get barked at. And even on this exact flight I had a moment’s inattention and got a “N1234 I need you at 9,000, altitutde inditates 9,200”. Now, it didn’t indicate 9,200 – I was only showing 100 feet over with the correct altimeter setting so I’m not sure what to make of that, but still.

I filed an ASRS report as soon as I got home. In the “notes” section I noted that while I briefed the approach, I did so in the air. In the future, I need to brief approaches earlier – ideally on the ground, when there are no distractions, no time pressures, no demands of flying the plane. And obviously, I need to be absolutely, 100% sure about altitudes for EVERY segment, every time. But I’m not sure what else to do.

Thanks for reading. I’d love to hear your comments or suggestions. If you’re going to be negative, fine – I can take it – but know that you can’t beat me up any harder than I am already beating myself up. Cheers.
Click to expand...
Thanks for sharing. We all learn from each other. You caught the error, made the right calls, and saved it. It's a learning experience. No value in beating yourself up over it, just take the lessons and learned and apply it for next time
 
Witmo said:
Do you expect the approach controller to be instrument rated, have an instrument approach chart out or displayed on his radar, and monitor your flying the approach all while continuing to provide radar service to the other aircraft in his sector? What if his/her sector has multiple airfields with multiple approaches and multiple aircraft flying said approaches? The controller is required to provide IFR traffic, separation from other IFR traffic, not act as copilot and monitor your flying of an approach. I maintain it would be shear luck for a controller to notice someone screwing up an approach unless it results in a loss of separation or the aircraft is grossly off course.
Click to expand...

While I do not disagreement with your assessment I think the language is a bit harsh -- but to each their own. That said, there are times when approach will get a low altitude alert and I've heard them issue such alerts to pilots. "Air Carrier 101 low altitude alert, altimeter 29.88 check altitude. This may have been the fall out from the TWA (IIRC) crash in VA way back when.
 
Witmo said:
Do you expect the approach controller to be instrument rated, have an instrument approach chart out or displayed on his radar, and monitor your flying the approach all while continuing to provide radar service to the other aircraft in his sector?
Click to expand...
FWIW - and not just around here, but places in the middle of the country too, approach seems to be very sensitive to deviations from the approach path. Heck, landing at SEE you will get a near guaranteed alert from the tower for terrain while being perfectly set up on the approach

Not something to be expected, but I'd be surprised if I was PIC too and I was that far off the path as the OP and to not have received anything from the controller. We're PIC for sure, and not an expectation, but these guys do a great job of keeping pilots out of trouble.
 
TruConfessions said:
Welp... I feel like I almost killed myself and my family of four over a stupid, stupid mistake - a simple misreading of a chart on an IFR approach.

I think the purpose of this thread is multi-parted: 1) to get this off my chest, 2) to see if anyone has recommendations on how to avoid this in the future, and 3) to understand the role of ATC in this situation. I always thought they would have been a back-stop in this scenario.

Anyway, we had very hazy conditions for a flight recently. I had expected VFR conditions throughout but our destination airport went IFR in a thick, soupy haze. No matter - I happened to be on an IFR flight plan. It was the most benign IMC conditions possible - low visibility in haze but no moisture to speak of, no icing concerns. All in all a pretty ideal little practice IMC / approach scenario.

This was a new destination to me. I had never shot this approach before or landed at the airport before. I'm PPL/IR rated, IFR current (just took and passed an IPC with "flying colors"), roughly 1,000 hours totally, fly my own plane 100+ hours a year, have a nice GTN panel with GPSS and single-axis autopilot.

I requested and was cleared for an RNAV approach. It was a pretty standard “T-shaped” approach, and I was cleared via one of the “T”’s initial approach fixes and feeder routes. I was cleared to that IAF “N1234 cleared direct IAF, cross IAF at or above 5,000, cleared RNAV Runway XX approach”.

I had already done a full briefing of the approach. Frequencies, altitudes, routes, waypoints, DAs, missed approach, terrain – the whole thing. I had had plenty of time to prepare and I don’t get the opportunity to fly that many actual approaches due to the typical weather in our area, so I was really paying attention.

I scanned the approach again and picked up the altitude for the feeder rout – 2,000’ – and after crossing the IAF, I started my descent from my “at or above 5,000’” altitude down to 2,000.

Things were fine. No visibility going forward or out the side windows. Just a touch of visibility/ground contact if I looked straight down. Autopilot’s GPSS is tracking the approach perfectly.

I descend to 4,000.

Then to 3,500.

Pretty soon, out of the haze, I start to notice some bumpy hills appearing through the mist. And they’re not that far away. I’m probably still 1,000 feet above them and offset laterally, but my mind starts thinking:

I can’t believe this approach gets that close to these hills... Doesn’t seem right…

…well, we *are* offset, so maybe it’s protected by the lateral boundaries…

…but still, this would be considered mountainous terrain – it should have 2,000’ minimum within 2+ miles either side and there’s no way I have that clearance…

…Something has to be wrong…

I go back to the chart and study it, and I suddenly realize my error. It’s not a standard T-shaped RNAV approach really… close, but not quite. There’s a stepdown fix halfway between the IAF and the holding fix and a long skinny little arrow pointing to the segment I’m on that notes “5,000 NoPT”. It’s only after the next fix, that the altitude is 2,000. And here I am descending through 3,500’.

My heart leaps and I pour on the coals.

“ABC Approach, N12345. I just realized I have mis-read the approach. I am well below the published altitude. Do you want me to stay here or climb back to the published altitude?” It was a stupid question and I was already on my way back up, but it was the best I could muster given the circumstances.

A polite and not even sort of perturbed young lady responds “N1234, you should be at the published altitude, so I would suggest a climb back to that altitude”.

And that was it. No scolding, no fanfare. The rest of the approach went perfectly, emerging from the haze directly in line with the runway at about 500 feet.

In retrospect, I am having a hard time not beating myself up about this. I remember one similar circumstance way back when I was doing my IFR training on a VOR approach where there was a slight turn in the approach on the fix just before the FAF. I missed the turn and eventually my CFII recommended I take my hood off. His recommendation was premature – I wasn’t at MDA, when he would normally make that recommendation – so I knew something had gone wrong. And it had. Missing that little bend in the approach put us off course and aiming directly at the side of the mountain. It would have been catastrophic in actual conditions. A real lesson-learner.

But apparently, I didn’t learn that lesson. Or the lesson didn’t stick. Or I’m prone to missing details. Or something. I don’t know, and I don’t know what to do about it.

And what about ATC? 1,500’ below published altitude? I know I’m the PIC and responsible for the flight – I’m not shirking that at all – but I’m still surprised. All throughout my training I assumed that if I was more than 100’ off or so, I’d get barked at. And even on this exact flight I had a moment’s inattention and got a “N1234 I need you at 9,000, altitutde inditates 9,200”. Now, it didn’t indicate 9,200 – I was only showing 100 feet over with the correct altimeter setting so I’m not sure what to make of that, but still.

I filed an ASRS report as soon as I got home. In the “notes” section I noted that while I briefed the approach, I did so in the air. In the future, I need to brief approaches earlier – ideally on the ground, when there are no distractions, no time pressures, no demands of flying the plane. And obviously, I need to be absolutely, 100% sure about altitudes for EVERY segment, every time. But I’m not sure what else to do.

Thanks for reading. I’d love to hear your comments or suggestions. If you’re going to be negative, fine – I can take it – but know that you can’t beat me up any harder than I am already beating myself up. Cheers.
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They probably queried your 9200' because of traffic separation. When flying an approach no one is going to be below you, so you are not likely to get a warning unless they happen to be watching your altitude. Some controllers have minimum safe altitude warning (MSAW), but it looks like there wasn't one in this case.

Based on your description, reading altitudes or headings on an approach chart seems to be a weak link for you. There's nothing wrong with that - everyone has their weak points. You could make a briefing checklist with special emphasis on headings and altitudes. My philosphy has been that checklists should be specific to each individual, taking into account their personal weaknesses.
 
TruConfessions said:
…but still, this would be considered mountainous terrain – it should have 2,000’ minimum within 2+ miles either side and there’s no way I have that clearance…
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Without seeing the actual approach chart to be sure*, you seem to be saying you were inside one of the IAFs and on the initial segment leading to the IF. If that's the case, then there is only a minimum of 1000 feet of obstacle clearance, mountainous or non-mountainous, on an approach.

*(which I and others really wish you would post, as it would be very beneficial and educational)
 
You're right about needing to make a change in your SOP. Insanity is doing the same thing expecting another result. I once (hopefully it remains "once") didn't see the step-down on a localizer approach and had in mind descending to MDA. Someone else pointed it out to me, but it shook me to the core, like you. Since then I changed my ways and don't look so far down the road ahead. When I hear "Cleared for the approach,' I think "You're on your own, pal." Then I verify the next fix and minimum safe altitude until crossing it. No need to be thinking about DA/MDA until past the last fix.
 
I told my husband if he makes a boneheaded mistake and crashes and kills the whole family, I will haunt him for all eternity and make his afterlife a complete hell even if we go in the upward direction. How’s that for extra pressure? :) His response was, “How would that be different from now?” :D

Seriously, you’re doing great. You’re analyzing what went wrong, what you can learn from it and resolving to figure out what you can do to prevent something like that from happening again. It’s called “experience”. It’s what you get just after when you need it. Sometimes you’re lucky and fate saves you anyway. It’s happened to all of us.

Beating yourself up over it just shows you’re not some psycho who thinks he can do no wrong and doesn’t care. You obviously care very much and the bad feelings are nature’s way of motivating you to put the work into doing better in the future. That’s a fantastic ingredient to making you a better pilot.

So is writing out your story here. Writing about it helps you process it, and it helps everyone here learn from your mistake. So thank you for that. We all screw up. Sometimes we are lucky and it doesn’t end badly. Take that as a gift: Experience.
 
Good post describing the situation that you found yourself in and the fact that you had suspicions that something wasn't right. Not ignoring that may have saved your bacon. So, what could you have done differently? It appeared you were very thorough so hard to say, but one thing stuck out to me. That was "missing that detail" about what the chart was really saying. But, you've already figured that out. If I were in your shoes, I'd simply make it a routine each week to pick out a new IAP at an unfamiliar airport and study it, learn exactly what its telling you and playing scenarios of entries to that approach from various directions. Keep doing that over and over, make it a game until (and if) you get stumped. Not sure how well the IAP procedure is written for the one you did. Perhaps it was an mistake that may have happened to others? Sometimes there is expectation bias. You are about to do something and expect that it will occur a certain way and you proceed to perform a task as if that's the case. Avoid that trap.
 
This is why I like my plate up and in my scan, and not on my lap or the yoke. Also have my EFB (iFly) set up to display every altitude I am supposed to be that and cross reference with the chart during my scan.

No terrain alerts? I have those set up as well, and would have been seeing that in the scan as well.
 
Re-reading the OP's post. I'm curious if the approach, and the airplane's equipment, had LPV or LNAV/VNAV available for that particular RNAV approach.
 
Good point what others are making about your navigation equipment. What do you navigate with and are there features you aren't using?
 
ATC is worried about an altitude deviation that results in loss of separation with another aircraft or obstruction. No, 100 ft won’t matter. That’s actually still within (less 300 ft) their criteria for mode C validation. In your case, after you’ve been cleared for the approach and cross the fix that had the altitude restriction, they don’t have time to monitor your progress. Probably don’t even know what altitudes you should be at other than at the IAF and MDA.

Now, during the approach, if they receive an MSAW alert they will let you know. “Cessna 345, low altitude alert, check your altitude immediately, the published (MDA / MVA) in your area is XXX.” You either weren’t low enough to set off the alert or that particular controller had it inhibited.
 
I used to fly IFR sims all the time (not rated) but that was a program long gone. Are there any available now that have actual approaches you can fly before you do it IRL? I think Mark used to do that, I’ll have to ask him when he gets home.
 
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