ILAFFT: Almost Killed my Family on an Instrument Approach

TruConfessions

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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.
 
Another item for practice is the monthly magazine “IFR”. It has many articles with items to think about and often a simulator challenge.
 
tawood said:
Have you ever mis-read an approach chart altitude or turn, while flying it? I've made some mistakes, but never one so simple, and twice no less. So what is your number? How many screw ups, on something simple yet deadly, before you either call it quits, or kill yourself and family?
Something like that would scare the dickens out of me. Though I don’t think it would make me stop flying instrument. It would make me think very seriously about what I am doing wrong and how to change. I think I would have the same attitude even if I had made a similar issue error ago during training.

If I was repeatedly making mess ups like this, say several times per year, even after trying to fix it, I would probably seek cognitive testing.

People differ in their risk tolerances. Especially in GA. Goodness knows we’ve seen some real doozies described here on PoA. I don’t view the OP as being on the extreme end of the risk taking spectrum if he continues.

GA flying has some risk. That is why a lot of people enjoy it.
 
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