Missed approaches and accidents

[marcoseddi]

Seems like a lot of the accidents recently that I read about involve missed approached and on the 2nd round they crash. Not becsuse of engine failure or anything. At this point I know nothing about instrument rating and approaches I haven't started it , but curious how why this is the case in a lot of accidents with pilots with a lot of hours is there something tricky that happens on a missed approach?


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[Clip4]

Seems like a lot of the accidents recently that I read about involve missed approached and on the 2nd round they crash. Not becsuse of engine failure or anything. At this point I know nothing about instrument rating and approaches I haven't started it , but curious how why this is the case in a lot of accidents with pilots with a lot of hours is there something tricky that happens on a missed approach?


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There are basically two scenarios a pilot goes missed. He flat screws up the approach (skill issue) or weather is below minimums.

 

[MyassisDragon]

Seems like a lot of the accidents recently that I read about involve missed approached and on the 2nd round they crash. Not becsuse of engine failure or anything. At this point I know nothing about instrument rating and approaches I haven't started it , but curious how why this is the case in a lot of accidents with pilots with a lot of hours is there something tricky that happens on a missed approach?


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I dont know the actual numbers, but a few of accidents may have been from additional time in icing conditions (speculation on my part of course).

Just food for thought. I was taught if I made it to minimums and did not see the runway environment chances are I am not going to see it on the next attempt so play it safe and use my alternate.

 

[Brad Z]

There are basically two scenarios a pilot goes missed. He flat screws up the approach (skill issue) or weather is below minimums.

Or the pilot is forced to go around (no landing clearance, deer on runway, etc.)

 

[muleywannabe]

I was wondering the same thing as I am training as well.

 

[Velocity173]

Part of it is they might be announcing a MA but it reality you can bet they're still trying to peek under to see something. The second thing is that some pilots didn't prepare the aircraft for the MA segment. Now they're scrambling to get it setup, they get disoriented and crash. You want to minimize head movement and distractions from basic instrument scan during the MA.

 

[Scott@KTYR]

My friend’s brother with thousands of hours flying died after his third missed approach. The ceiling was very low and in my opinion the pilot must have been in the “GOTTA GET THERE” mode and on each approach would fly lower than the last approach. On the last missed he was to low and flew into the side of a mountain. Each approach list the safe altitude at which if you do not see the runway lights you will need to go missed. Some pilots think they can go below this altitude.

 

[poadeleted20]

I think the biggest issue is that under Part 91, pilots are free to take a look/see on an instrument approach even if the reported weather is well below minimums. When you combine that with good, old "get-there-itis", you have a lethal combination. The pilot makes one pass, doesn't make it, but sees enough to think that another try may be more successful. Then, on the second pass, s/he presses a little lower than allowed because s/he sees a little ground below and thinks that another 50 feet will be the difference, and instead it's fatal. Pressing on with low fuel so you arrive without enough to divert somewhere is another potentially fatal mistake -- lacking any other option, the pilot presses the approach below published mins because s/he has no other choice but to run out of fuel and crash, or does in fact run out while trying again and again.

A classic example of the first type is the case of the President of the Flying Physicians Association a long time back when they were having their annual convention in Montreal. As a FPA officer, he planned to arrive a day early to help set up, but the weather was horrible -- ceilings/visibility below even ILS mins. He missed the first, but feeling the need to get there, tried again, went below DH, and crashed into the approach lights. BTW, the theme of that convention was "Why do so many doctors have so many accidents?", and yes, he was flying a Bonanza.

The classic example of the second is the Avianca 052 accident, in which the crew flying a Boeing 707 pressed on to JFK despite weather at/below mins and using up all their divert fuel in a series of ATC holds, and chose not to land short to refuel at Baltimore or Philly where the weather was much better. They ran out of gas while coming back for a second approach after missing the first.

 

[roncachamp]

The classic example of the second is the Avianca 052 accident, in which the crew flying a Boeing 707 pressed on to JFK despite weather at/below mins and using up all their divert fuel in a series of ATC holds, and chose not to land short to refuel at Baltimore or Philly where the weather was much better. They ran out of gas while coming back for a second approach after missing the first.

Illustrating that it's a bad idea to miss an approach when you lack fuel to fly another one.

 

[numl0ck]

 

[peerlesscowboy]

get-there-itis I suspect in most cases. Maybe the pilot thought he saw just a hint of something on the first try and figures he'll cheat just a little. Or maybe he had ground contact for a bit at MDA a couple miles out but didn't have the runway in sight, so on he second try he determined to duck under if that happened again.

 

[poadeleted20]

Illustrating that it's a bad idea to miss an approach when you lack fuel to fly another one.

I suppose that once you get to that point, I'd have to agree. But I would also say it illustrates that it's an even worse idea to put yourself in a situation where you have nowhere else to go.

 

[frfly172]

Most pilots fly the approach,never expecting to go missed. The airplane can get ahead of you,if your not ready for the missed. A good alternate may also be a good idea if you think you may go missed.

 

[tehmightypirate]

There is also the case of picking up ice on the approach or something goes wrong (engine out for example) and then the missed can't be flown sufficiently.

 

[bobmrg]

Most pilots fly the approach,never expecting to go missed. The airplane can get ahead of you,if your not ready for the missed. A good alternate may also be a good idea if you think you may go missed.

I taught my students, VFR and IFR, to expect every approach to end in a go-around, and that a normal landing should come as a pleasant surprise. If your mind is set for a miss rather than a landing, the decision is much easier.

Bob Gardner

 

[JeffDG]

Illustrating that it's a bad idea to miss an approach when you lack fuel to fly another one.

I always chalked that one up to poor communications from the pilot to ATC. He kept accepting holds instead of telling ATC clearly that he didn't have the gas for that...

Had he been direct and declared a fuel emergency, he would not have been put into so many holds.

 

[roncachamp]

I always chalked that one up to poor communications from the pilot to ATC. He kept accepting holds instead of telling ATC clearly that he didn't have the gas for that...

Had he been direct and declared a fuel emergency, he would not have been put into so many holds.

Yes, missing the approach was not his only error.

 

[PPC1052]

I taught my students, VFR and IFR, to expect every approach to end in a go-around, and that a normal landing should come as a pleasant surprise. If your mind is set for a miss rather than a landing, the decision is much easier.

Bob Gardner

I think that is good advice. I will try to internalize that thought process.

 

[tehmightypirate]

I think that is good advice. I will try to internalize that thought process.

Same here. Great advice for sure.

 

[poadeleted20]

I think that is good advice. I will try to internalize that thought process.

And yet, there may be times when a go-around is not an option. One example is that Avianca 052 flight -- forgetting all the errors the crew made up to the missed approach point on their first approach (something admittedly hard to do), had they just said "screw it" (or however you say that en Espanol) and followed the needles to touchdown, many or maybe all aboard might have survived. I tell my trainees much the same about a partial panel approach -- you pick the best approach and best weather you can find, and you land even if that means planting on the airport surface the plane blind because all the other options are worse. At that point, you're better off with a controlled crash on that airport surface with all the emergency gear standing by than you are crashing into a neighborhood full of buildings in Queens or losing control on the missed due to lack of instrumentation.

 

[bobmrg]

And yet, there may be times when a go-around is not an option. One example is that Avianca 052 flight -- forgetting all the errors the crew made up to the missed approach point on their first approach (something admittedly hard to do), had they just said "screw it" (or however you say that en Espanol) and followed the needles to touchdown, many or maybe all aboard might have survived. I tell my trainees much the same about a partial panel approach -- you pick the best approach and best weather you can find, and you land even if that means planting on the airport surface the plane blind because all the other options are worse. At that point, you're better off with a controlled crash on that airport surface with all the emergency gear standing by than you are crashing into a neighborhood full of buildings in Queens or losing control on the missed due to lack of instrumentation.

I totally agree with the idea of putting it on the grass, on a taxiway, wherever, in case of an emergency. I believe that in this thread we are talking about a plain-vanilla missed approach with no other complications.

Bob

 

[Velocity173]

The missed approach disorientation thing reminds me of a situation I had a few years ago in the Army.

I was conducting instrument training at night on a pilot for his progression requirements. We were doing the VOR into Hilton Head S.C. with a follow on ILS at Hunter. Our climbout instructions from SAV approach were 090 and 2,000 ft. It was a nice VMC night and for this particular approach I allowed him to take the hood off. We shot our approach to the island and then heading out into the black abyss of the Atlantic Ocean. I remember thinking that this scenario would be perfect for spatial D. Sure enough my copilot leveled off at 1,000 ft. I made him aware of the level off which he rogered and then continued a slow climb. Shortly there after he stopped his climb and then started a descending right turn. I made him aware of that. The next thing that followed was "ah, I'm disoriented, you have the controls...f#%k!"

I chuckled a bit but it was clear that if it were not for the fact the aircraft is dual pilot, it could have ended differently. Sure scared the crap out of the crew chief in the back!

 

[poadeleted20]

That old "black hole over water after coasting out" has killed more than a few. We've had a couple of fatalities over the years with people flying left traffic to runway 32 at Ocean City MD KOXB at night ending up in the Atlantic Ocean (either CFIT or stall/spin), and pretty much everyone knows about JFK Jr's crash after coasting out on his way to Martha's Vineyard at night with no visible horizon. But I don't think that problem is connected in any meaningful way to missed approaches -- that happens when flying visually without any missed involved.

 

[Velocity173]

That old "black hole over water after coasting out" has killed more than a few. We've had a couple of fatalities over the years with people flying left traffic to runway 32 at Ocean City MD KOXB at night ending up in the Atlantic Ocean (either CFIT or stall/spin), and pretty much everyone knows about JFK Jr's crash after coasting out on his way to Martha's Vineyard at night with no visible horizon. But I don't think that problem is connected in any meaningful way to missed approaches -- that happens when flying visually without any missed involved.

Yeah i was just getting at the whole problem of going from VMC into IMC. Just so happens in this case it was on a missed. On the opposite spectrum I've seen people teach transferring the controls to the other pilot after break out during an instrument approach. Never personally had problems transitioning from IMC to VMC for landing but I guess some do.

 

[Palmpilot]

That old "black hole over water after coasting out" has killed more than a few. We've had a couple of fatalities over the years with people flying left traffic to runway 32 at Ocean City MD KOXB at night ending up in the Atlantic Ocean (either CFIT or stall/spin), and pretty much everyone knows about JFK Jr's crash after coasting out on his way to Martha's Vineyard at night with no visible horizon. But I don't think that problem is connected in any meaningful way to missed approaches -- that happens when flying visually without any missed involved.

There have been a couple of flights on which I suffered from spatial disorientation while approaching Phoenix at night in good VFR conditions. If I hadn't been instrument rated, I might be dead by now.

 

[poadeleted20]

Yeah i was just getting at the whole problem of going from VMC into IMC.

I guess my point is that it happens a lot in that black hole/overwater situation even without going into IMC (i.e., still legal VMC but actual instrument conditions due to lack of visual attitude references).

 

[Jimmy cooper]

I remember reading the navy had a special remedial course for navy pilots at pax river. They had had near disasters over the water due to vertigo and saved themselves either thru luck or last minute realization of the jam they were in. Interesting article! If this can happen to them after the stringent training they are subjected to then it can certainly happen to the average IFR pilot who, in some cases , is poorly trained and mentally unprepared.

 

[Velocity173]

I guess my point is that it happens a lot in that black hole/overwater situation even without going into IMC (i.e., still legal VMC but actual instrument conditions due to lack of visual attitude references).

Strange thing is, I've never flown with someone who got disoriented while flying IMC in the clouds. I have flown with people who were flying VMC at night with no visual references who got completely disoriented. Perhaps just not mentally prepared to be on instruments at night compared to the thought process who knowing you'll be in the soup on an IFR flight.

 

[poadeleted20]

Strange thing is, I've never flown with someone who got disoriented while flying IMC in the clouds.

I have -- it's part of the life of an instrument instructor. And if you're in the right seat when it happens, you'd better be prepared to identify that it's happening and fix the problem before it becomes unrecoverable.

 

[Velocity173]

I have -- it's part of the life of an instrument instructor. And if you're in the right seat when it happens, you'd better be prepared to identify that it's happening and fix the problem before it becomes unrecoverable.

I was reading an old Army Flight Fax years ago. It's like the equivalent to the Navy/Marine Approach mag. Anyway, these two guys where flying instruments in a Huey in Germany and one pilot got disoriented. The other guy took over and then he got disoriented and returned the controls back. They did this a few times before they got their bearings straight and were able to land. I remember thinking, crap, I hope I never get in the situation where we're both screwed up. That would be a nightmare.

 

[poadeleted20]

I was reading an old Army Flight Fax years ago. It's like the equivalent to the Navy/Marine Approach mag. Anyway, these two guys where flying instruments in a Huey in Germany and one pilot got disoriented. The other guy took over and then he got disoriented and returned the controls back. They did this a few times before they got their bearings straight and were able to land. I remember thinking, crap, I hope I never get in the situation where we're both screwed up. That would be a nightmare.

Could be worse. When I was in VA-128, the west coast A-6 training squadron, we had a rookie pilot on his first night high-loft maneuver (essentially a half-Cuban-8 with the bomb coming off at about 70 degrees of pitch and the maneuver completed to exit the same way you came in). Unfortunately, the INS which drives the primary attitude display indicator tumbled just past 90 degrees of pitch, sending the ADI into a tizzy. Unable to transition to the back-up peanut gyro, the young pilot reverted to his Training Command habits, let go of the stick, and said, "I'm disoriented -- you've got it".

Unfortunately, the B/N in an A-6 had only a radar slew stick on his side of the cockpit.



The experienced instructor B/N said something I can't repeat here, reached across between the pilot's legs, grabbed the control stick, and recovered the plane. If you've ever been in an A-6, you'll know that was quite some feat of both aeronautical skill and suppleness. At least the airplane was going up, not down, which gave the IB/N time to try it before punching out.

And that was that young pilot's last flight in the Navy. Not so much for losing the bubble originally, but for forgetting that the B/N has no flight control stick and that "you've got it" simply isn't considered a viable option. The B/N, on the other hand, got a commendation.

 

[Fearless Tower]

Strange thing is, I've never flown with someone who got disoriented while flying IMC in the clouds. I have flown with people who were flying VMC at night with no visual references who got completely disoriented.

Every Navy helo pilot I know, including my current CO, has gotten spatial D in night IMC at least once on their careers.

I have heard stories of guys passing the controls back and forth several time in the course of a single approach to the boat because they were both disoriented.

 

[Velocity173]

Could be worse. When I was in VA-128, the west coast A-6 training squadron, we had a rookie pilot on his first night high-loft maneuver (essentially a half-Cuban-8 with the bomb coming off at about 70 degrees of pitch and the maneuver completed to exit the same way you came in). Unfortunately, the INS which drives the primary attitude display indicator tumbled just past 90 degrees of pitch, sending the ADI into a tizzy. Unable to transition to the back-up peanut gyro, the young pilot reverted to his Training Command habits, let go of the stick, and said, "I'm disoriented -- you've got it".

Unfortunately, the B/N in an A-6 had only a radar slew stick on his side of the cockpit.



The experienced instructor B/N said something I can't repeat here, reached across between the pilot's legs, grabbed the control stick, and recovered the plane. If you've ever been in an A-6, you'll know that was quite some feat of both aeronautical skill and suppleness. At least the airplane was going up, not down, which gave the IB/N time to try it before punching out.

And that was that young pilot's last flight in the Navy. Not so much for losing the bubble originally, but for forgetting that the B/N has no flight control stick and that "you've got it" simply isn't considered a viable option. The B/N, on the other hand, got a commendation.

Lol! No way I could do the BN, WSO, RIO thing with no controls. I'd get airsick with someone else flying that kind of maneuvering.

VA-128 was at El Centro when I was a kid. Got to get a personal tour of the aircraft. I wanna say they have one sitting on the flightline down from the Blues even today.

 

[gismo]

I think the biggest issue is that under Part 91, pilots are free to take a look/see on an instrument approach even if the reported weather is well below minimums. When you combine that with good, old "get-there-itis", you have a lethal combination. The pilot makes one pass, doesn't make it, but sees enough to think that another try may be more successful. Then, on the second pass, s/he presses a little lower than allowed because s/he sees a little ground below and thinks that another 50 feet will be the difference, and instead it's fatal. Pressing on with low fuel so you arrive without enough to divert somewhere is another potentially fatal mistake -- lacking any other option, the pilot presses the approach below published mins because s/he has no other choice but to run out of fuel and crash, or does in fact run out while trying again and again.

A classic example of the first type is the case of the President of the Flying Physicians Association a long time back when they were having their annual convention in Montreal. As a FPA officer, he planned to arrive a day early to help set up, but the weather was horrible -- ceilings/visibility below even ILS mins. He missed the first, but feeling the need to get there, tried again, went below DH, and crashed into the approach lights. BTW, the theme of that convention was "Why do so many doctors have so many accidents?", and yes, he was flying a Bonanza.

The classic example of the second is the Avianca 052 accident, in which the crew flying a Boeing 707 pressed on to JFK despite weather at/below mins and using up all their divert fuel in a series of ATC holds, and chose not to land short to refuel at Baltimore or Philly where the weather was much better. They ran out of gas while coming back for a second approach after missing the first.

Maybe they should change the rules so part 91 pilots can start an approach with below min reported wx but only once on a given flight (sans emergency).

 

[RotorAndWing]

Maybe they should change the rules so part 91 pilots can start an approach with below min reported wx but only once on a given flight (sans emergency).

A Part 91 flight (except Subpart K) can start an approach with weather below mins anytime they want.

GA has a higher accident rate on this (missed approaches) because of lack of training and recurrency. Once someone gets his instrument rating that ends any additional training or standardized recurrency.

 

[poadeleted20]

GA has a higher accident rate on this (missed approaches) because of lack of training and recurrency. Once someone gets his instrument rating that ends any additional training or standardized recurrency.

It may end the requirement, but it doesn't necessarily end the training. We have a lot of clients who have us come in for a couple of days of refresher training every year or two. Sure, it's not as good as a Part 121 air carrier pilot getting such training every six months, but it's still something. Yes, I know that our clientele is only a small fraction of the GA pilot population, but let's not tar everyone with that brush.

 

[gismo]

A Part 91 flight (except Subpart K) can start an approach with weather below mins anytime they want.

True but your good friend Ron suggested that it's the third attempt that tempts part 91 pilots to "sniff a bit deeper" with too often unpleasant results. I was suggesting that limiting us "non-professionals" to two cracks at an approach would eliminate a substantial portion of the risk without removing all the flexibility we have.

GA has a higher accident rate on this (missed approaches) because of lack of training and recurrency.

How do you know that a combination of "get there itis", poor decisions, and the less complete approach and runway lighting aren't bigger factors than a lack of training and recurrency?

Once someone gets his instrument rating that ends any additional training or standardized recurrency.

That may be common but it's certainly not universally true. I know plenty of GA pilots who employ regular recurrent training to stay sharper.

 

[poadeleted20]

True but your good friend Ron suggested that it's the third attempt that tempts part 91 pilots to "sniff a bit deeper" with too often unpleasant results.

That wasn't this Ron who made that comment.

I was suggesting that limiting us "non-professionals" to two cracks at an approach would eliminate a substantial portion of the risk without removing all the flexibility we have.

I don't see the FAA doing that. They do give Part 91 flyers a good bit more freedom because they are willing to accept a lower level of safety in noncommercial flying, and in the long run, I don't think I'd like to give that up. If nothing else how would you differentiate between flying more approaches trying to get in versus multiple approaches for training? I've flown the same ILS as many as seven times in a row when someone's learning how to do it.

 

[RotorAndWing]

How do you know that a combination of "get there itis", poor decisions, and the less complete approach and runway lighting aren't bigger factors than a lack of training and recurrency?

Many factors come into play which have their root in poor training and lack of currency.

That may be common but it's certainly not universally true. I know plenty of GA pilots who employ regular recurrent training to stay sharper.

And I can point out a larger number that do not. Once your average PP has his rating (IR) that's it. There are no regs to have him complete a true recurrent or further his training. His "proficiency" is left up to him.

Introduce tougher recurrent requirements and listen to the wailing from the GA community of "how unfair" it is.

 

[poadeleted20]

Many factors come into play which have their root in poor training and lack of currency.

I'll buy that in a heartbeat. I see it all the time when I do a refresher with someone who's not done much instrument flying since the last training session or who have gone a very long time since then.

And I can point out a larger number that do not. Once your average PP has his rating (IR) that's it. There are no regs to have him complete a true recurrent or further his training. His "proficiency" is left up to him.

Agreed again -- the percentage of nonprofessional pilots who obtain recurrent training is abysmally low. Most of those who do, do so as a requirement of their insurer because of the size/complexity of the aircraft they fly (e.g., cabin-class twins). Many of those who do, do so out of genuine desire to maintain proficiency. But the vast majority of nonprofessional pilots do only the absolute minimum required by law -- two hours with a cooperative CFI every 24 months, and instrument work is not required as part of that flight review even if they are instrument rated and fly IFR regularly.

Introduce tougher recurrent requirements and listen to the wailing from the GA community of "how unfair" it is.

Sad but true. For those who don't remember, the original proposal for the flight review was an annual event, and the GA world went nuts. The second proposal was an annual review for PP's with under 400 hours and biennial for everyone else, and that still didn't stand up to the protests. And if you search a bit here, you'll see the moaning and groaning about a CFI who wouldn't sign a flight review with only the minimum two hours of training and/or wanted to cover more things than the wailer felt were necessary.