How does a highly experienced crew fly the wrong missed approach procedure? It's a mistake anyone could make...
Flying The Wrong Missed Approach Procedure
The following NASA ASRS report was filed a few years ago when a corporate jet crew flew the wrong missed approach procedure. Here's what went wrong...
After a long day of flying approaches to minimums, we were finally flying into XXX, an airport reporting IFR conditions but much better ceiling heights. The ceilings were reported at 400 feet AGL, with the minimums for our ILS taking us all the way down to 200 feet. My First Officer and I didn't think much of the 400 foot ceilings and could have done a better job reviewing NOTAMs and the missed approach procedure.
On final approach, we passed 400 feet AGL and still didn't have approach lights in sight. At minimums, to our surprise, we didn't break out of the clouds and were forced to go missed. We failed to notice that the missed approach procedure had a major change in the NOTAMs. With the XXX VOR out of service, we were supposed to fly direct to XXX and hold. This was a completely different missed approach than we briefed. After a surprise missed approach, we fumbled to figure out what was going wrong, all in IMC. Tower asked us our intentions. To make things easy, we requested runway heading for our missed approach and vectors to return. We should have reviewed the NOTAMs and done a better job briefing the approach.
Low Ceilings Can Change Rapidly
The first mistake this crew made was to assume they'd have no problem breaking out well before minimums. Rapidly changing weather conditions and various cloud decks can make accurately predicting cloud bases nearly impossible.
There was likely an area of fog or low clouds along the approach corridor that was not being reported by airport weather. Unless other airplanes are directly ahead of you in line to land on the same runway, there's very little you can do to know exactly when you'll break out.
Treat Every Approach Like A Go-Around
Every approach, visual or instrument, should be flown to a go-around until a landing is assured. Always have a solid missed approach plan in mind and never skip a full briefing. Include NOTAMs as a part of your standard brief, to keep things consistent and as a reminder to double check them.
Expectation bias played a big role here. Neither crewmember expected to go missed, so the missed approach instructions weren't top-of-mind. If the ceilings had been right at minimums, there's a good chance they might have caught their mistake and spent more time reviewing the approach.
If something goes wrong and you need an alternate missed approach, request one right away from the tower.
Always Review NOTAMs
There's a lot of NOTAMs to look through for each of your flights. Many of which don't affect you at all. But if you're flying IFR, you really should take an extra look at NOTAMs regarding your instrument approach.
FDC, or Flight Data Center NOTAMs outline changes to instrument approach procedures and airways within the U.S. The next time you're flying IFR, you should be checking them before you go. It's common to find NOTAMs for the following reasons:
- Equipment Outages
- Missed Approach Procedure Change
- New Approach Minimums
- Change For Altimeter Setting Source
What Do You Think?
What else could have been done differently in this situation? Have you found drastic changes to instrument approaches in NOTAMs before? Tell us in the comments below.
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