You gotta identify them, wow....

It's not just "famous last words". There was more going on here... I read the article to say that they tried to troubleshoot and salvage the approach.

If something isn't right, declare the missed, and gain altitude.
 
Eighty-five years of aviation experience in the cockpit. Is there any hope for the rest of us? We all think we are doing what is necessary to stay safe with our actions and our decisions, "it can't happen to me because I....." it leaves me with such huge doubts.
Not to be fatalistic... I'm sure we'd be much worse off if we let our guard down and did not strive for perfection in every flight.
Our thoughts & prayers to the crew and families, friends.
 
Dave and Bill:

I agree. Man, it is easy to get in that fix. I need to imprint this lesson on my brain. If inside the FAF and troublshooting...just go missed!
 
RobertGerace said:
Dave and Bill:

I agree. Man, it is easy to get in that fix. I need to imprint this lesson on my brain. If inside the FAF and troublshooting...just go missed!
Click to expand...

Bob, you may want to think about what you'd do before the FAF. In some places, you get to the FAF and it's too late.
 
Easy to make this error on the ILS 16 to Palwaukee. A moment earlier you have OBK VOR dialed id, and they are near enough colocated that it can still make general sense. And, of course, the G/S indicator stays center pegged.

How do I know this? .....ho hum....
 
I'll likely never have anything close to the experience either of those pilots had, but in what happened during their last minutes, they speak to us from the grave and implore us to learn from their fate. And their experience becomes a little bit of mine.

That is why I always read accident reports.

God keep them.
 
If you were flying this senario ALONE, I think every pilot would imediately climb and then troubleshoot, perhaps having 2 pilots in the cockpit added to the situation, each one thinking, well maybe he knows something I dont. Perhaps thinking, "I dont want him to think Im a bad pilot by going missed and not making the approach the first time around".

I dont know, But I wonder if this ever happens in the 2 pilot cockpit. Egos.
 
I've done this a couple of times; always caught it when I identifying the dots and dashes. One can sure see how it can happen; especially single pilot when there's a lot going on and landing plans are changed. With this crew and the time they had to set the approach up, it's very surprising!!



As Spike said, their transcript will sure get the adrenal gland a working and help me continue to double and triple the settings on all approaches!!



Best,



Dave

A-36TN ADS
 
Or does 85 years of combined experience lead to complacency. Having my IR less than a year, if the GS is dead center and not moving, I'm going to start making sure everything is right, because frankly, it's hard to get it not to move! I can see that after flying ILS for years and years, the GS needle doesn't move because you get that good at it. And if they didn't notice the little GS flag, nothing is unusual for them. I always hope that as my skills improve I dont get complacent.
 
Terrible, just terrible. You can't just tune and twist, you have to put your finger on the morse displayed on the plate, and IDENT the frequency.
 
I do think there is a case of getthereitis here. You want to be on time to pickup the former President of the United States.
 
N2212R said:
I'm going to start making sure everything is right, because frankly, it's hard to get it not to move!
Click to expand...

not sure if it applies to this accident but a lot of autopilots will keep that needle dead center. I imagine if they were in apprch mode and tuned to a VOR instead of an ILS it would track well but the GS would be flagged and never capture. How they got so low is a mystery then. Handflying an imagined GS?

One take home (besides triple checking the tuning & identifying and then once more after the copilot touches it) is to continue to use altitude cross checks (we are at the marker, and should be at xxxx', yup. We are 4dme, should be around yyy', yup) Not sure if there are xing radials on this apprch but many do.
 
Let'sgoflying! said:
not sure if it applies to this accident but a lot of autopilots will keep that needle dead center. I imagine if they were in apprch mode and tuned to a VOR instead of an ILS it would track well but the GS would be flagged and never capture. How they got so low is a mystery then. Handflying an imagined GS?

One take home (besides triple checking the tuning & identifying and then once more after the copilot touches it) is to continue to use altitude cross checks (we are at the marker, and should be at xxxx', yup. We are 4dme, should be around yyy', yup) Not sure if there are xing radials on this apprch but many do.
Click to expand...

Ewwwwwww...autopilot on an approach. Not me. I want full control of the plane. An autopilot is just one more thing that can lead to complacency. At least that's what I think. Whatever that's worth.
 
Guys:

Here's a post from a friend in Houston that differs quite a bit from what is being reported in the paper. It may be the news folks don't understand the difference between the localizer and VOR. Guess we'll wait for more facts to be sure, but this sounds pretty credible.

Dave
================================================================
David,

I had lunch with tone of the head OPs guys from KHOU and the commander of the ANG at Ellington the first of this month. They both had also heard as I did that the GS was out and that this was their 2nd attempt at a localizer approach. The OPs guy said that they were lined up with the runway, just too low. The VOR is actually on the North side of the field so if they were using the DME they would have thought that they were further from the MDA then they were. Just throwing these facts out there, not implying that the report isn't accurate.

Very sad.

 
Let'sgoflying! said:
not sure if it applies to this accident but a lot of autopilots will keep that needle dead center.
Click to expand...

And not just the autopilot. I think the single greatest potential for me to screw up is with that VLOC button on the GNS530/430.

I once didn't have it sorted out until I flew through the localizer trying to intercept it (should have been on LOC). Note: I should have had the SL-30 tuned in on #2 as backup. It wasn't a tough approach and I was tired and lazy...shame on me.

I once flew a few miles off course thinking I was navigating via GPS (should have been GPS but was LOC)...which was nicely responded to by ATC with a 'Turn back on course please.'

I HATE that button. I realize why it is there, and I don't have a better idea for how to have one navigator provide both GPS and VOR/LOC guidance. I'm PIC and it's my responsibility to always have it set right.

Does anybody have a suggestion for how not to forget to set it?
 
Bob:

On my A-36 with the M-3 GPS coupled to my HSI, when a localizer frequency is tuned into com 1; as soon as the com pics up the localizer frequency, the unit automatically switches to the localizer and the annunciator panel shows a switch from GPS to VOR for Nav.

I fly a B-55 with a Garmin 430 for number 1, but a collins #2. In actual IMC conditions, I put the Garmin in the approach mode where it shows the ILS on the unit, but also tune number 2 to the localizer for cross check. Can you do something like this, or are you all glass?
I also have an IMC checklist on my knee board. I use the FATTS acronym to remember the steps.
50 miles out,
F--Fuel--quantity, proper tank-boost pump if required.
A--Altimeter set; ATIS and weather.
A--Approach reviewed: MSA, ALT, Course, FAF, MAP, DH, MDA, missed approach.
T--tune and identify navaides: this is where my check list is for frequency; course; identification; marker beakon; GPS to localizer; annunciator panel, etc.
S--Safety and special things to watch.

Best,

Dave
A-36TN (B-55 later today:))


Dave
 
Did everyone see the accident transcript posted couple days ago? It was on another board. Points out they did have the VOR tuned in; caught the error but were pretty far off the glide slope. Took over two minutes to get corrections made. If it hasn't been posted, I can put it up. It's a long transcript.

Dave
 
When you look back at an accident, you can see that anybody (including highly experienced pilots) can make a mistake. And, after-the-fact it often times looks like a silly mistake. So, none of us are immune from error -- even simple ones.
 
Troy sent it to me and I have been mulling it over. They first noticed the problem when they couldn't arm the A/P approach mode if I interpret the cvr trans correctly.

"06:12:23
HOT-1 I can't get * approach mode on my thing.
06:12:26
HOT-2 I can't get an approach mode on mine either. uuh, I wonder why?"

and it was 1&1/2 minutes later that they figured out why:

"06:13:59.3
HOT-1 oh my, what'd you do to me?
06:14:01.2
HOT-2 uuuuh.
06:14:02.2
HOT-1 ah, now I got it.
06:14:03.1
HOT-2 now you got it.
06:14:05.0
HOT-1 whoa #. what happened? did you change my frequency?
06:14:09.8
HOT-2 yeah we were down there. we had the, the VOR freq, the VOR frequency was on.'

They didn't get much time. The tape ends less than a minute later.

The biggest question I can see is what were they using for altitude guidance to get down so low, if the GS was (should have been) flagged. On an ehdi I think there should be X's through the GS displays if a VOR is tuned. There should have been no vertical guidance whatsoever if this speculation is correct.

Interestingly they did seem to tune the loc 12 mins early but presumably later flipped it to back to VOR.
Maybe hit the nav flipflop instead of comm fllipflop at one time?
Maybe wanted the vor display for positional awareness at one point and didn't switch back?

05:59:14
HOT-2 uuh, I don't know. there it is.... direct to CARCO. so that's where we're going. I'll set up our ILS, in here, one oh nine nine."

(Apologies to those who dislike accident dissection without all the data.)
 
Dave:

Lots of speculation going on with folks that fly the Gulfstream and airline pilots on another board. One suggested that an old procedure was to tune the VOR early, then switch before GPS days for situational awareness (before the localizer could be received). Another just attributes it to an error that wasn't caught soon enough. Still another says they were using DME to measure distance; which would help them know where they were on the descent.

No one understands why they would go below localizer minimums without the GS unless they just decided to use other guidance to come on down.

Best,

Dave
 
Dave Siciliano said:
Dave:
No one understands why they would go below localizer minimums without the GS unless they just decided to use other guidance to come on down.
Click to expand...

Twice the sic says something about their location on the glideslope and this is BEFORE they notice the VOR dialed in. I cannot come to grips with that. What was the GS saying? Where could it be getting a signal from? Doesn't add up, I can't figure what this means.
(I kind of discount the suggestions they were using other means for vertical guidance...they did not discuss it once)


HOT-2 'kay, we're high on the glide slope now.
06:13:16.3
HOT-1 'kay. okay um....
06:13:19.2
HOT [sound similar to altitude alerter]
06:13:21.1
HOT-1 uuh, * just gonna have to do it this way.
06:13:24.0
HOT-2 guess so. yeah you're on glide slope now.
 
Yes, I saw that and understand what you're saying. Some folks at Hobby understand where the VOR is actually located and that one could look at DME distance and misunderstand where it actually put you on the field.

It's a tragedy!! We may never know. All I can say it they didn't see a flag and thought needles were centered? But of course they wouldn't be. Thought they were above the GS because the needle was full up!! Can't say, but this crew should have had much better situational awareness. Never heard them identify the nav aid either dots and dashes that is. Sure make one a believer. I've shot ILSs three times this week and you better believe I'm triple checking and listening to dots and dashes!!!

Dave
 
On another site there was a brief discussion among some pro pilots and a suggestion that very few of them ID navaids anymore.

I am going to get diligent at this, plus I am going to vow never to descend past the FAF without stable, off-the-peg needles.
None of this should be new but apparently we need reminding.

We all should try to take something home from these sad events.
 
This thread seemed to have died out, but I just now got time to put my thoughts down on paper. This contains many of the elements already discussed.

This is a case where the approach is itself a potential trap for the pilot. Our point in analyzing accidents should be to learn from them, not to condemn the victims and all prior posts in this thread appear, commendably, to share this view. To my view this is more than a simple failure to identify a navaid, but rather a complex series of conditions which led to the apparent fatal failure to properly tune and identify. To understand this series of events I think we need to first understand what components an ideal ILS approach would have and understand how the lack of at least one of those components might have contributed to this accident.

But, before I go there note that the bottom line will be this - and you don't need to read any further. Always, always, always place the approach aid in the primary nav display at the time you brief the approach and don't take it out until you go missed (and even then you probably will leave it in for the next attempt).

One of my all time favorite ILS approaches is ILS 24 at Nantucket, MA because it is in my opinion a perfect ILS approach. You can find it here: http://204.108.4.16/d-tpp/0503/00659I24.PDF

Let's take a quick look at it to see why I think so highly of it. First, it is a full ILS which does not require radar to execute it. It has a Holding patterns in lieu of Procedure but that's okay its just another method of getting the job done. Second, it has a compass locator Third it has DME associated with Localizer (this is the first component on this approach that I would give up) and fourth, it has a good approach light system.

Okay, for comparison the ILS 4 at Hobby:

http://204.108.4.16/d-tpp/0503/00198I4.PDF

This is basically just a GS and a LOC to a runway, with DME on the LOC. What it is missing is any method to execute it on your own because it has no way to know where you are relative to the LOC course or along the LOC course if you don't have DME, and so RADAR and DME are required, it has an okay approach light system.

From the pilot's perspective the Hobby approach is much more complicated, it may look easier, but it is not.

Let's start by flying the ILS 24 at ACK. Setting up the approach we dial in WAIVS in the ADF and once identified we now have a reference to our lateral position relative to the OM - in other words you have situational awareness - you know when the LOC is going to come alive. It is a LOM so it is good for 15NM miles, which is quite adequate for ILS approaches. We set up our number one VHF NAV receiver to receive the LOC frequency, and that is all that is required to shoot this approach, now a prudent pilot would also set up the ACK VOR in anticipation of the missed, and technique could vary (is it in the standby for the number one or is it in the primary for the number two? There are any number of reasonable variations.) The key here is that with the LOC/DME and the LOM we always know where we are and we need NOTHING else to know this. In fact, if we just had a LOC (no DME) the LOM would give us enough information to comfortably fly this approach without looking to other navaids for valuable information. Though I would want the DME off of the ACK VOR, but that is nice to know, not need to know.

Now let's fly the HOU ILS 4 approach. Well our first problem (assuming we do not have a moving map of some sort, which I'll assume) is how do we know where we are? There is no LOM, but there is LOC/DME. So if we dial the LOC in the number one, we know our distance from the departure end of the runway and not much else. So now we need to find another navaid to tell us where we are laterally. The HUB VOR will do, not perfect, but close enough. Should we put the HUB in the number 1 and then when we get on the LOC switch to the LOC frequency? What course do we dial in? - why the LOC course since the HUB VOR is close enough. Well that works, but now we need to know when the LOC is alive so #2 needs to be tuned to LOC. When the LOC comes alive we need to switch number one to the LOC and either leave number two on the LOC as a back up, or set it up for the missed. This is really a trap for the unwary when things get busy or you simply are distracted by the radio. You can easily miss the fact that you are still tuned the VOR as your will basically have a proper looking intercept going.

Of course we could set the number 1 to the LOC (tune and identify) and the number 2 to the HUB VOR (tune and identify) and then we have it properly set. If you fly single pilot IFR in a light aircraft this is probably the strategy you would employ. However, in two pilot transport category aircraft it is likely that the CA and FO have HSI displays for number 1 on the CA side and number 2 on the FO side, but do not have a second omni head. What they do have is an RMI on each side. So if the CA wants to maintain situational awareness without falling into the trap of having the HUB VOR displayed on the HSI, then s/he needs to tell the FO to set the HUB VOR on the number two (depriving him/her of the LOC on their HSI) and use the RMI for reference. This is the best you can do in this situation.



So this is where I end up: Always, always, always place the approach aid in the primary nav display at the time you brief the approach and don't take it out until you go missed (and even then you probably will leave it in for the next attempt).
 
Arnold said:
This thread seemed to have died out, but I just now got time to put my thoughts down on paper. This contains many of the elements already discussed.

Thank you for taking the time to write out this well throught out response.

You raise many important issues. I'd like to read through it several times before I respond in more detail. However, I shot three ILS approaches this weekend; one of which was to minimums. In addition to the approach chart sitting right in front of me throughout each approach, I double checked frequencies, flags, dots and dashes to confirm and had a cross check on each approach. I am a real redundancy fan. The approaches I made all had some manner in which I could see where they were on the approach at some point besides the GS and LOC; intersections, NDBs, LOMs, etc. In addition, on all approaches that are not GPS, I have the GPS (with moving map) tuned into the airport and can at least see the runway environment approaching as a cross check.

Best,

Dave
A-36TN ADS
Click to expand...
 
Last edited:
Dave Siciliano said:
The approaches I made all had some manner in which I could see where they were on the approach at some point besides the GS and LOC; intersections, NDBs, LOMs, etc. In addition, on all approaches that are not GPS, I have the GPS (with moving map) tuned into the airport and can at least see the runway environment approaching as a cross check.
Click to expand...

Yes, that is certainly the way to do it. The trap that the ILS4 at HOU sets is that the harder you try to maintain situational awareness the more likely you are to get into trouble, it actually penalizes the pilot who wants to do more than turn when told and fly the slide. The only way I have found to combat this is the same way I combat complacency, and that is to dogmatically follow procedures even when it looks like the short cut is okay "this time."

Fly safely
Arnold
 
grattonja said:
On one of my stage checks, the CFI flipped the VOR on standby to the front, in place of the LOC. He waited until the glideslope was centered, and I did not catch the flag. When I pulled the foggles off it was frightening how far out we were and how low!
Click to expand...

moved:
from another thread.. sorry Jim

Wow, I am going to have to try this..on someone wearing a hood. I had no idea. Maybe a study could be done or something done to raise pilot awareness - I don't recall reading about it in any of my references.
How common is it that a pilot will blindly follow a (failed&) centered GS needle?
"Of 100 pilots in which the GS had failed, only X% noticed, while YZ% continued flying an imaginary glidepath 'using' a centered, but stuck needle."
or "We flagged various instruments during brief periods in which the pilot was prevented from viewing the panel, and when allowed access again, 10% noticed the flags within 30 seconds, 30% noticed within 2 minutes, the rest did not notice for over 4 minutes"
In the accident, I think it all went to heck in just a few minutes.

Thanks for posting that JimG, I found it elucidating.
 
The flags are small, and your eye gets used to them being there on a VOR approach. It was certainly an eye opener to me when I realized what he had done. This CFI does this on the final stage check to all their IR students and, apparently, gets a lot of them.

It is not a mistake that I will lightly make again. Believe me.

Jim G
 
grattonja said:
The flags are small,
Jim G
Click to expand...

I made a note of their location and appearance today in my plane. Must do in others I fly too.

Quick, what color and where are the flags, how many in your plane?
 
You must log in or register to reply here.
Back
Top