Missed Approach – CRM
On Jan 20th, I was assigned to fly as SIC with [name] as PIC. The leg was VNY-ASE-VNY. The forecasted weather into Aspen was not supposed to be VFR until 10am local. At the time of requested departure (0530L) ASE was calling VFR conditions earlier than expected. Approximately 30 minutes from landing, ASE was calling IFR conditions with 1-3/4 mile Vis. We elected to hold at DBL to formulate a plan. This current leg was Empty part 91 with only 3 crew members, as we were picking up PAX in Aspen to return to VNY. While holding at DBL, we were told by approach that the tower is calling 6 mile vis. We were asked if we wanted to try the approach. We elected to go based on that information to make an attempt at the LOC E. While on the approach we were in and out of IMC conditions and the airport was not visible at any point on the approach. After passing the MAP we were able to see the airport, we were way too high and elected to go missed. I asked the PIC to go to Rifle and land. The PIC asked for one more attempt at the approach and said if we went missed again, that we would divert to rifle.
My current thoughts on the situation were as follows.
- Weather was not going to improve enough in this short period of time to allow a safe landing and compliance with our Opp specs for ASE.
- We were consuming fuel with another wasted attempt, and going back into the hold at DBL could also be for an uncertain amount of time wasting more fuel and time.
Discussions about Rifle were underway during the previous hold at DBL and the PIC was not interested. Despite my conversations with the PIC about these concerns, the PIC was undeterred in wanting another attempt at the approach. I asked approach for another attempt. On this attempt in the second time, the PIC instructed me to not touch the altitude preselect. He set his own base altitude and then told me he was going to shoot this approach in blue needle. The PIC had already began the approach when he alerted me to his plan. While descending on the approach I asked the tower for a visibility report. They replied that it had dropped to 3-4 miles (worse than the first attempt). The PIC became very upset that I asked for a VIS report and instructed me to not do that again.
At this point I was becoming scared. The PIC was breaking SOP’s and forcing me to participate in his poor decision making. While on the approach the PIC went through several hard altitudes which caused ASE tower to issue low altitude alerts to us over the radio. Each time I told the PIC to pull up which he ignored. Once the cloud obscurement passed and the airport became visible, we were again way too high to make a safe landing. The PIC aggressively pointed the aircraft diving at the runway. I told the PIC this is not going to work. Because of the current fear of what was happening I was failing to use correct terminology but I wanted the PIC to go missed. The PIC firmly replied by saying “It’s going to work”. I observed 4 white PAPI lights through the entire approach, that never changed color. Because the approach was so forced and destabilized, the landing that followed was also unstable with significant directional control issues and panicked braking. It was lightly snowing at this time. After stopping the aircraft, the PIC was very proud of his behavior making it impossible for me to resolve any conflicts or future poor decision making. I alerted the Chief Pilot [name] immediately upon return to VNY. I did not understand at the time of the second approach that the PIC was going to do anything possible to land in Aspen. After the flight I am now aware he intended to purposefully and knowingly violate FAR,s and SOP,s to force the desired result and I was forced to participate.
KEY ERC TAKEAWAYS
- Company determined crew operated in violation of Standard Operating Procedures, with CRM identified as the main contributing factor.
- Crew has been debriefed and counseled by reviewing flights.
- Retraining was completed by management on safety issues found.
- The company requested pilot go through a performance improvement plan, but pilot elected to resign.
Course Deviation – Missing Waypoint
The flight was a repositioning flight from KFLL to KMTH with no passengers on board. I was conducting pilot training for the SIC on his first flight as a new hire.
I assessed myself as fit for duty, though I was feeling tired due to a poor night’s sleep and was emotionally affected by the recent aircraft accidents in Washington and Pennsylvania.
Flying with a new pilot on the first training flight is challenging covering all aspects of aircraft preparation, preflight, flight planning, weight and balance, performance, company SOP, checklist usage, and flows.
We were cleared via KFLL /MAYNR direct KMTH. I briefed the departure procedure and trying to stay ahead for our arrival, I also briefed the anticipated RNAV (GPS) RWY 7 approach. We loaded the approach into the FMS, expecting to receive a visual approach to the runway due to the clear weather and unlimited visibility. Since I assumed we would cancel IFR and receive a visual approach, I did not load the CARNU fix and instead selected a vector to intercept at JANKA inbound. By doing this, the procedure turn over JANKA was not displayed in the FMS. This is common on most GPS approaches, as ATC normally vectors aircraft to intercept rather than requiring a procedure turn. However, this was a procedural mistake on my part. I should not have anticipated something that may or may not happen and should have loaded the full approach procedure.
ATC cleared us to 5,000 ft. As we approached Marathon, we completed the approach and landing checklist while obtaining the ASOS and preparing for the approach. My second mistake was during the approach briefing. When the checklist called for the approach brief, I confirmed that we had previously briefed before departure and no changes were anticipated. ATC then cleared us to descend to 3,100 ft direct to JANKA and cleared us for the RNAV (GPS) RWY 7 approach. We selected direct JANKA and began our descent.
I heard another aircraft inbound receiving ATC clearance for a visual approach to RWY 7 and planned to cancel IFR to request a visual approach. KMTH is an uncontrolled airport with no tower. ATC did not inform us that their frequency coverage would be lost below approximately 4,000 ft. When we attempted to cancel IFR and request a visual approach, we could not transmit or receive ATC on frequency. This caught me by surprise and caused some confusion. I then realized we would have to continue the approach, and the intercept angle was more than 90°. Due to my earlier mistake of not loading CARNU, the procedure turn over JANKA was not displayed. The FMS, coupled with the autopilot, executed what is referred to as a smart turn intercepting the 071° course between JANKA and SEGLE (6.4 miles away) and descending on VPATH.
We switched to CTAF 122.97 traffic advisories, began reporting our position and intensions, and listened for other traffic. Before starting the approach, we were unaware of any other aircraft also inbound, as we had lost Miami approach coverage and lacked a full picture of other traffic. After passing SEGLE inbound, we heard a twin-engine aircraft announce its position 2.5 miles final for RWY 7. We identified the aircraft on the TCAS display ahead of us and announced our position. I realized the aircraft was flying at approximately 80 knots, while we were at 160 knots and would overtake it. We visually acquired the aircraft and immediately broke off the approach, executing a left 360° turn before rejoining the approach to RWY 7 to allow for separation. Landing was normal.
Contributing Factors
- Physically and mentally not feeling 100%.
- High work load environment conducting OE with a new-hire pilot on our first flight together.
- Briefing the approach before departure and assuming we would receive a visual approach on arrival.
- Not loading the approach with the CARNU fix, which caused the procedure turn over JANKA to be omitted.
- ATC not informing us that we would lose communication below 4,000 ft.
- Trying to cover to many training topics for the SIC on a short flight, causing distraction and missed details in the FMS approach display.
Actions Taken
- We quickly established two-way radio communication with CTAF and announced our position and intensions for landing on RWY 7.
- Identified a potential conflict with another aircraft ahead on the approach.
- Visually acquired the aircraft and recognized the overtake risk.
- Immediately broke off the approach, announcing a left 360° turn for separation.
- After landing, we conducted a thorough debrief of the flight, which included a conversation with an FAA representative by telephone.
Recommendations for Improvement
- Ensure fit-for-duty assessments include mental, physical, and emotional factors. Do not fly if stressors may impact performance.
- Better understand the high workload environment involved in flight training and checking.
- Thoroughly re-brief the approach procedure after receiving approach clearance and ensure it is correctly loaded in the FMS.
Closing Statement
As a crew, we recognize our mistakes and the importance of following SOPs and maintaining clear communication.
As a check airman, it is my responsibility to ensure safe practices and procedures are communicated, understood and implemented. This event provided valuable lessons that I will use to improve my own performance and help our pilot group maintain the highest safety standards in our flight operations.
ERC Acceptance & Closing Notes:
- Non sole source event, Pilot Deviation has been reported by ATC.
- Event to be studied and discussed during pilot safety meeting.
Course Deviation – FMS Programming
While preparing for our departure from TEB to CMA, I was the PF and conducting the cockpit preflight. This included programming the FMS. I recalled our filed flight plan through datalink and verified the uplink with the flight plan. All checked good, however, the flight plan filed and uplinked did not include a SID for TEB. I proceeded to complete the PERF portion of the FMS load and selected RWY 24 for departure as indicated in the ATIS. For some reason I also selected the TEB4 SID as a place holder for our departure since I wasn’t yet able to retrieve the clearance. I don’t know why I did this. This is not something I normally do for this exact reason.
When the First Officer returned to the cockpit after completing the exterior preflight duties, we completed the cockpit checks and the before starting engines checklist. At this point we had received clearance via CPDLC and the FO/PM read back our squawk and ATIS (as requested in TEB) to the TEB clearance delivery controller. We were cleared via the WENTZ1 departure, NOT the TEB4 as I had previously entered into the FMS. We briefed the correct departure procedure (WENTZ1) and referenced the correct chart when doing so.
Unfortunately, I failed to go back into the FMS and change the departure procedure from the TEB4 to the correct and cleared procedure, WENTZ1. We also failed to confirm together that the FMS indicated the correct procedure and fixes. We referenced and briefed the correct chart and procedure, but the LNAV guidance on departure guided us on the TEB4 instead of the WENTZ1. The departures are similar but not the same, nonetheless. Fortunately, we had the correct initial altitude set of 1500 feet, which we flew.
Shortly after leveling off at 1500 feet, Newark Departure Control instructed us to turn right HDG 290 and we complied. A moment later he queried us as to the departure we were flying. We advised WENTZ1. He then stated something to the effect of, “then why aren’t you where everyone else is who’s flying/flown that departure?” Shortly after we were cleared direct to our first fix and issued a climb. There was no further inquiry or discussion with ATC about this event. We were directed as normal and continued the flight.
There are many lessons to be learned here. Firstly, I should’ve never entered in a “place holder” departure procedure into the FMS prior to receiving the clearance. Second, I should’ve advised the FO/PM that I had done that. Third, when completing the checklist, we both should have reviewed the inputted FMS data and compared it to the clearance. This is usually automatic for us so I don’t know why we failed to do so in this case; especially when completing the checklist.
ERC Acceptance & Closing Notes.
- Crew has been debriefed, counseled, and underwent retraining.
- Complacency identified as a main contributing factor.
- A company safety video has been made and distributed to the pilot group.
Communication: Pilots and ATC – Descent Clearance
17,000 feet – top of descent, Fresh Creek Landing
First Officer contacts 126.37 assigned Miami frequency
No response after 4 to 5 attempts. No communication on the radio was heard.
First officer goes to another known frequency Miami 125.7
Two or three attempts and no answer.
Captain suggested to first officer contact 121.0 Nassau to coordinate with Miami
121.0 Nassau normally coordinates with Miami on every departure out of Fresh Creek
First officer, contacts 121.0 Nassau stating that we are at 17,000 feet looking for lower for Fresh Creek. No response was heard on the assigned frequency for Miami.
Short delay, controller 121.0 Nassau replies, CSI 300 decent pilot discretion 2,000 report canceling IFR.
12,000 feet Nassau request [flight number] to contact Miami 126.37 for information.
Miami controller states that authorization was not given to descend. Please call this telephone number.
After landing captain & first officer call Miami telephone number
Supervisor, [supervisor name] receives the call
The above, description of what took place is spoken
[supervisor name] acknowledges that it’s normal protocol for 121.0 Nassau to coordinate with Miami
[supervisor name] states that this is the first he has heard of this and takes [flight number] and Captain’s name. Captain thanks [supervisor name] and the phone call ends
ERC Acceptance & Closing Notes:
- Frequency issues – frequency 125.7 has recently been updated to 126.37 due to frequency issues.
- Crew was given phone number to call, but no violations filed by ATC. Sole source event.
