|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : zzz|
|Altitude||agl bound lower : 200|
agl bound upper : 200
|Controlling Facilities||tower : sdf|
|Operator||common carrier : air taxi|
|Make Model Name||Helicopter|
|Operating Under FAR Part||Part 135|
|Flight Phase||descent : approach|
|Affiliation||company : air taxi|
|Function||flight crew : single pilot|
|Qualification||pilot : cfi|
pilot : atp
|Experience||flight time last 90 days : 60|
flight time total : 8500
flight time type : 1800
|Affiliation||government : faa|
|Function||other personnel other|
|Anomaly||altitude deviation : excursion from assigned altitude|
non adherence : published procedure
non adherence : far
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : became reoriented|
flight crew : returned to intended course or assigned course
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
I was dispatched to fly to ZZZ, us, to pick up a patient for an EMS helicopter program. Having been to this location earlier in the day, I knew that the WX was marginal VFR so I received a WX report, checked NOTAMS and air filed IFR with XXX AFB to ZZZ airport. I was cleared to 4000 ft. Leveling off at 4000 ft I proceeded to set up for the approach. All the radios were set, charts were reviewed for the impending approach. The expected approach was the ILS DME, and not being authority/authorized the DME ILS, I elected to shoot the localizer approach. I set the radio altimeter to the localizer MDA plus 40 ft. Upon receiving clearance for the approach, I left YYY intersection on 185 degrees, setting the vsi to 600 FPM descent to descend to the approach altitude of 2300 ft. Upon reaching on course indication, I armed the ILS approach on the autoplt as an aid and left 4000 ft for the approach altitude. At this time I received a radio call from my dispatch asking if I were still on the radio frequency. I acknowledged that I was (first distraction). Next, I noticed that the DME was not working and tuned in the #2 DME. It was working so I went back to the #1 DME and it was also on-line and working (second distraction). I crosschecked my instruments, saw that the command bars were centered and I had 2 green lights on the heliplt controller. Incorrectly thinking that I was on the GS, I continued the approach. At this time I also called AAA center for a return IFR to be setup back to WWW (third distraction). Something on the approach just didn't feel right and I rechked the charts and the ADI and HSI and continued down. In fact, what had happened, when I had armed the vertical speed and captured the localizer, the GS had deactivated and the GS arm light had went out. The major error at this point was that I did not confirm my altitude and GS capture and flying through 3 altitude checks. Also I had not yet passed the OM. I descended until the decision ht light came on 7 mi from the airport. Knowing that this wasn't right I started a climb, broke into VMC conditions, saw the ground and trees at greater than 200 ft. The rest of the flight was uneventful. After reviewing the flight and having had time to truly go back, there were other circumstances that had a large bearing on the near disastrous flight. I had just been put on medication (prednisone) for sinus problems and was told that it might make me a little nervous. Again, after reflecting back, I became aware that I had not slept the night before. I did not feel tired at all but was apparently more under the influence than I ever imagined. I did not sleep for the next 3 nights and after contacting my medical doctor, and a psychologist for crises counseling, I was removed from the medication as rapidly and as safely possible. I had the flu the 6 days before reporting to work and had not fully recovered from those effects. I have shot that approach many times and know it well. With all the other distrs and medication I had unwittingly set myself up for what could have been a disaster. I was given a review flight the next morning and was able to fly all the approachs but was extremely nervous and distraction. I have been taken off the schedule and placed off duty until I can fully come to grips with these events and decide where I should go from here.
Original NASA ASRS Text
Title: EMS HELI FLT WAS DISTR ON APCH TO ZZZ RESULTING IN DSNDING TO 200 FT AGL PRIOR TO OM. CALLING FOR RETURN IFR CLRNC, PLUS DME, DID NOT LOCK ON IMMEDIATELY AND MISSED GS HAD DISENGAGED. WAS TAKING PREDNISONE FOR SINUS PROBS AND HAD BEEN WARNED OF SIDE EFFECTS. HAS BEEN TAKEN OFF FLYING STATUS.
Narrative: I WAS DISPATCHED TO FLY TO ZZZ, US, TO PICK UP A PATIENT FOR AN EMS HELI PROGRAM. HAVING BEEN TO THIS LOCATION EARLIER IN THE DAY, I KNEW THAT THE WX WAS MARGINAL VFR SO I RECEIVED A WX RPT, CHKED NOTAMS AND AIR FILED IFR WITH XXX AFB TO ZZZ ARPT. I WAS CLRED TO 4000 FT. LEVELING OFF AT 4000 FT I PROCEEDED TO SET UP FOR THE APCH. ALL THE RADIOS WERE SET, CHARTS WERE REVIEWED FOR THE IMPENDING APCH. THE EXPECTED APCH WAS THE ILS DME, AND NOT BEING AUTH THE DME ILS, I ELECTED TO SHOOT THE LOC APCH. I SET THE RADIO ALTIMETER TO THE LOC MDA PLUS 40 FT. UPON RECEIVING CLRNC FOR THE APCH, I LEFT YYY INTXN ON 185 DEGS, SETTING THE VSI TO 600 FPM DSCNT TO DSND TO THE APCH ALT OF 2300 FT. UPON REACHING ON COURSE INDICATION, I ARMED THE ILS APCH ON THE AUTOPLT AS AN AID AND LEFT 4000 FT FOR THE APCH ALT. AT THIS TIME I RECEIVED A RADIO CALL FROM MY DISPATCH ASKING IF I WERE STILL ON THE RADIO FREQ. I ACKNOWLEDGED THAT I WAS (FIRST DISTR). NEXT, I NOTICED THAT THE DME WAS NOT WORKING AND TUNED IN THE #2 DME. IT WAS WORKING SO I WENT BACK TO THE #1 DME AND IT WAS ALSO ON-LINE AND WORKING (SECOND DISTR). I XCHKED MY INSTS, SAW THAT THE COMMAND BARS WERE CTRED AND I HAD 2 GREEN LIGHTS ON THE HELIPLT CTLR. INCORRECTLY THINKING THAT I WAS ON THE GS, I CONTINUED THE APCH. AT THIS TIME I ALSO CALLED AAA CTR FOR A RETURN IFR TO BE SETUP BACK TO WWW (THIRD DISTR). SOMETHING ON THE APCH JUST DIDN'T FEEL RIGHT AND I RECHKED THE CHARTS AND THE ADI AND HSI AND CONTINUED DOWN. IN FACT, WHAT HAD HAPPENED, WHEN I HAD ARMED THE VERT SPD AND CAPTURED THE LOC, THE GS HAD DEACTIVATED AND THE GS ARM LIGHT HAD WENT OUT. THE MAJOR ERROR AT THIS POINT WAS THAT I DID NOT CONFIRM MY ALT AND GS CAPTURE AND FLYING THROUGH 3 ALT CHKS. ALSO I HAD NOT YET PASSED THE OM. I DSNDED UNTIL THE DECISION HT LIGHT CAME ON 7 MI FROM THE ARPT. KNOWING THAT THIS WASN'T RIGHT I STARTED A CLB, BROKE INTO VMC CONDITIONS, SAW THE GND AND TREES AT GREATER THAN 200 FT. THE REST OF THE FLT WAS UNEVENTFUL. AFTER REVIEWING THE FLT AND HAVING HAD TIME TO TRULY GO BACK, THERE WERE OTHER CIRCUMSTANCES THAT HAD A LARGE BEARING ON THE NEAR DISASTROUS FLT. I HAD JUST BEEN PUT ON MEDICATION (PREDNISONE) FOR SINUS PROBS AND WAS TOLD THAT IT MIGHT MAKE ME A LITTLE NERVOUS. AGAIN, AFTER REFLECTING BACK, I BECAME AWARE THAT I HAD NOT SLEPT THE NIGHT BEFORE. I DID NOT FEEL TIRED AT ALL BUT WAS APPARENTLY MORE UNDER THE INFLUENCE THAN I EVER IMAGINED. I DID NOT SLEEP FOR THE NEXT 3 NIGHTS AND AFTER CONTACTING MY MEDICAL DOCTOR, AND A PSYCHOLOGIST FOR CRISES COUNSELING, I WAS REMOVED FROM THE MEDICATION AS RAPIDLY AND AS SAFELY POSSIBLE. I HAD THE FLU THE 6 DAYS BEFORE RPTING TO WORK AND HAD NOT FULLY RECOVERED FROM THOSE EFFECTS. I HAVE SHOT THAT APCH MANY TIMES AND KNOW IT WELL. WITH ALL THE OTHER DISTRS AND MEDICATION I HAD UNWITTINGLY SET MYSELF UP FOR WHAT COULD HAVE BEEN A DISASTER. I WAS GIVEN A REVIEW FLT THE NEXT MORNING AND WAS ABLE TO FLY ALL THE APCHS BUT WAS EXTREMELY NERVOUS AND DISTR. I HAVE BEEN TAKEN OFF THE SCHEDULE AND PLACED OFF DUTY UNTIL I CAN FULLY COME TO GRIPS WITH THESE EVENTS AND DECIDE WHERE I SHOULD GO FROM HERE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.