Ok, now I get it. Then he made more than one mistake. You don’t brief (if he did) one approach, and fly another …
Flyer59 wrote:
You don’t brief (if he did) one approach, and fly another …
When I trained for IR, I was taught to always time the LOC MAPt when flying an ILS approach so that I could revert to LOC on the fly if the glidepath failed! I always thought that was a bad idea and have never done so after getting the rating.
As in most cases, an entire sequence of mistakes, not a single one. If a single mistake killed me, I would be long dead…
The obvious ones are
The first two are related to Neil’s point – although I would’t say the procedure is poorly designed. I would say that with a WAAS GPS unit, lateral navigation of ANY procedure should be using the FMS (i.e., procedure loaded and magenta line all the way to the final approach) and classic nav-aids up to the ILS should be consigned to the dustbin for these, only to be used by those who do not have the GPS equipment. I is atrocious that this is not the standard for both training and in practice.
Certainly the procedure (not sure if they used Jepp or AIP plates; bear in mind that normally Jepps are far more readable than the others) contains an awful lot of reading material 
Poor design of the procedure was a big contributor.
Certainly. But there are many poorly designed procedures and very few accidents. I wonder if he had an approach chart on hand, as he was “officially” flying VFR. Flying that kind of procedure on the stored data of a GNS 530 alone is a sure recipe for disaster.
What I really can’t understand: The pilot had 4000 hours, held an ATPL, had been flying a Jetstream as captain and a 737 as first officer. Standard callouts that are universal to every kind of professional operation must have been second nature to him. Like “localiser alive” or “glideslope alive”. I will call these things (silently) even when flying alone. When I don’t see a glideslope indication, as has happened quite a few times over the years, I will instinctively check two things: Did I activate the ILS frequency and is the HSI (or PFD) switched to NAV and not GPS/FMS. One of these two will bring up a glideslope indication in 99% of cases. Why did this pilot fly the approach as a non-precision approach instead? We will never know of course.
Neil wrote:
Poor design of the procedure was a big contributor.
I don’t agree. There are too many notes on the plate, but the procedure itself is completely standard. The only note that was applicable to this flight was the one about marginal ILS coverage.
Even when flying ILS approach I always check altitude against DME during whole approach. I had two occasions when I needed it (both times deep in IMC) and luckily I was prepared:
- GS receiver failure on GNS530
- LOC receiver failure on GNS530 – I had to switch to NAV2 which didn’t have GS receiver
Both times I switched to hand-flying although in the first case I could’ve kept AP in NAV mode and set descent rate.
I have wondered why somewhere on the GS receiver it doesnt display distance to threshold for any procedure regardless which mode you are in.
It seems to me this is a crucial piece of information that is always helpful to be there and after all that is the ultimate aiming point about which all the paper plates revolve.
How often have we seen pilots asked to give distance to threshold and they give distance to an AF for similiar reasons. Rightly or wrongly in the “heat of the moment” it is all to easy to be thinking the next bit of the plate and forget that ultimately it ends at the threshold.
I also commented elsewhere that there is a temptation to conclude that in some way the GPS was “wrong” whereas it was of course the wrong aiming point that created the result, and I agree with Emir for that reason it is almost impossible for the DME to be set to give the wrong aiming point.
Airborne_Again wrote:
When I trained for IR, I was taught to always time the LOC MAPt when flying an ILS approach so that I could revert to LOC on the fly if the glidepath failed! I always thought that was a bad idea and have never done so after getting the rating.
By the way, would synthetic vision have saved his life?
