|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : oth|
|Altitude||msl bound lower : 3000|
msl bound upper : 6000
|Controlling Facilities||artcc : zse|
|Operator||general aviation : instructional|
|Make Model Name||Small Aircraft, Low Wing, 1 Eng, Fixed Gear|
|Flight Phase||descent : approach|
landing : go around
|Function||instruction : instructor|
|Qualification||pilot : commercial|
pilot : instrument
pilot : cfi
|Experience||flight time last 90 days : 79|
flight time total : 7026
flight time type : 1350
|Function||instruction : trainee|
|Qualification||pilot : student|
|Anomaly||non adherence : clearance|
non adherence : published procedure
other spatial deviation
|Independent Detector||other flight crewa|
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
I was instructing instruments at roseburg finished, leaded for north bend, oregon. Could see weather was not as given (3800 scattered 10000 plus broken ceiling), so air field, decided good experience for my student to have actual IFR approach requested VOR approach. Controller cleared for approach within few miles of VOR. We were on top (VFR). Descended into clouds. Controller reported 400 and 1 1/2 miles, no I requested ILS approach. Was cleared and handed off to north bend FSS who reported 1000 scattered (and a higher ceiling I've forgotten). In haste to change approach chart to ILS I gave up my copy to my student. We had planned to do VOR approach. Student headed out from VOR on 281 degree radial. I questioned if it was 281 degree. He insisted it was. I said something is wrong. NDB should be straight ahead, so go on back course of ILS. He had problem with this. On clearance we were told middle marker was out of service. I now believed I had misheard it and must be outer marker out because ADF did not indicate NDB straight ahead. Believed something wrong, so told FSS I'd return to VOR. We were above 3000'. They handed us back to seattle center. I climbed to 6000 (VFR on top) and turned to VOR (6 miles west). Controller had someone in hold at VOR at 5000. Tried ILS approach again and again asked if student was sure if was 281 degree. He was very sure it was. (Later looked and saw he should have headed 238 degree). It all looked very wrong. Told FSS and center we would head west till on top, then cancel IFR. We did. My errors: not checking approach chart myself, but didn't in haste to change approach plates to ILS. Rushed my student. Serious 'no-no'. Should have stayed with planned VOR approach. I let controller stampede me with incorrect weather report. Or go into a hold to take more time. Did not believe ADF and NDB were correct so did not go to NDB to hold as plate calls for, and is now so obvious to me. Please notice north bend approach charts. The current one has a '281' by the arrow from the VOR. This is what my student read and believed was the direction to the NDB. Notice the last december 1987 chart. It has a different number, one not reasonable for a direction to NDB at that arrow head. I believe the location of the '281' aided in his confusion. Kept FSS fully informed, and controller as we were handed off to him. Apparently, radar had us even down to 3500 (+), for controller was aware we headed out from VOR incorrectly and told the FSS. We have mode C and it was on.
Original NASA ASRS Text
Title: GA SMA NON ADHERENCE TO CLRNC OR PUBLISHED PROC WHEN CLRNC FOR ILS APCH TO OTH OR.
Narrative: I WAS INSTRUCTING INSTRUMENTS AT ROSEBURG FINISHED, LEADED FOR NORTH BEND, OREGON. COULD SEE WEATHER WAS NOT AS GIVEN (3800 SCATTERED 10000 PLUS BROKEN CEILING), SO AIR FIELD, DECIDED GOOD EXPERIENCE FOR MY STUDENT TO HAVE ACTUAL IFR APCH REQUESTED VOR APCH. CTLR CLRED FOR APCH WITHIN FEW MILES OF VOR. WE WERE ON TOP (VFR). DESCENDED INTO CLOUDS. CTLR REPORTED 400 AND 1 1/2 MILES, NO I REQUESTED ILS APCH. WAS CLRED AND HANDED OFF TO NORTH BEND FSS WHO REPORTED 1000 SCATTERED (AND A HIGHER CEILING I'VE FORGOTTEN). IN HASTE TO CHANGE APCH CHART TO ILS I GAVE UP MY COPY TO MY STUDENT. WE HAD PLANNED TO DO VOR APCH. STUDENT HEADED OUT FROM VOR ON 281 DEG RADIAL. I QUESTIONED IF IT WAS 281 DEG. HE INSISTED IT WAS. I SAID SOMETHING IS WRONG. NDB SHOULD BE STRAIGHT AHEAD, SO GO ON BACK COURSE OF ILS. HE HAD PROBLEM WITH THIS. ON CLRNC WE WERE TOLD MIDDLE MARKER WAS OUT OF SERVICE. I NOW BELIEVED I HAD MISHEARD IT AND MUST BE OUTER MARKER OUT BECAUSE ADF DID NOT INDICATE NDB STRAIGHT AHEAD. BELIEVED SOMETHING WRONG, SO TOLD FSS I'D RETURN TO VOR. WE WERE ABOVE 3000'. THEY HANDED US BACK TO SEATTLE CENTER. I CLIMBED TO 6000 (VFR ON TOP) AND TURNED TO VOR (6 MILES WEST). CTLR HAD SOMEONE IN HOLD AT VOR AT 5000. TRIED ILS APCH AGAIN AND AGAIN ASKED IF STUDENT WAS SURE IF WAS 281 DEG. HE WAS VERY SURE IT WAS. (LATER LOOKED AND SAW HE SHOULD HAVE HEADED 238 DEG). IT ALL LOOKED VERY WRONG. TOLD FSS AND CENTER WE WOULD HEAD WEST TILL ON TOP, THEN CANCEL IFR. WE DID. MY ERRORS: NOT CHECKING APCH CHART MYSELF, BUT DIDN'T IN HASTE TO CHANGE APCH PLATES TO ILS. RUSHED MY STUDENT. SERIOUS 'NO-NO'. SHOULD HAVE STAYED WITH PLANNED VOR APCH. I LET CTLR STAMPEDE ME WITH INCORRECT WEATHER REPORT. OR GO INTO A HOLD TO TAKE MORE TIME. DID NOT BELIEVE ADF AND NDB WERE CORRECT SO DID NOT GO TO NDB TO HOLD AS PLATE CALLS FOR, AND IS NOW SO OBVIOUS TO ME. PLEASE NOTICE NORTH BEND APCH CHARTS. THE CURRENT ONE HAS A '281' BY THE ARROW FROM THE VOR. THIS IS WHAT MY STUDENT READ AND BELIEVED WAS THE DIRECTION TO THE NDB. NOTICE THE LAST DECEMBER 1987 CHART. IT HAS A DIFFERENT NUMBER, ONE NOT REASONABLE FOR A DIRECTION TO NDB AT THAT ARROW HEAD. I BELIEVE THE LOCATION OF THE '281' AIDED IN HIS CONFUSION. KEPT FSS FULLY INFORMED, AND CTLR AS WE WERE HANDED OFF TO HIM. APPARENTLY, RADAR HAD US EVEN DOWN TO 3500 (+), FOR CTLR WAS AWARE WE HEADED OUT FROM VOR INCORRECTLY AND TOLD THE FSS. WE HAVE MODE C AND IT WAS ON.
Data retrieved from NASA's ASRS site as of August 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.