I’ve always found instrument approach procedures to be fascinating. There’s a detailed map, with altitudes, headings, descent angles, airport lighting details, frequencies and nearby navigation facilities, all combined onto one “plate,” a masterpiece of technical artistry. Once one learns about profile and plan views, plus notes and holding patterns/course reversals, a whole new world seemingly opens up our operational flexibility.
But that same technical artistry can work against us by obscuring or deemphasizing details which, at first glance, may not seem significant. But they are. In fact, the sheer amount of information means some of it can be difficult to pinpoint on the chart, especially in a pinch. So much so, in fact, that many training organizations develop quizzes that dissect an approach plate to help us recognize where some of the pitfalls can be.
One of those pitfalls is the missed approach procedure. There are a lot of reasons for that, not least of which is, perhaps thanks to complacency, some pilots seem safety-wired in the position of always expecting to land after executing the various steps required. Yes, it’s more likely than not that we’ll successfully land out of an approach in the real world when the weather is above minimums. But we still need to be ready for the missed approach since the guy in front of us on the procedure may blow a tire on the runway, forcing it closed.
Or, we could be “taking a look,” a time-honored attempt at an approach when the weather is below minimums, which is really available only to Part 91 not-for hire operations. Planning for the miss is mandatory in all instances, but especially when required weather just isn’t available.
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According to the Aeronautical Information Manual (AIM), “To become established on the prescribed missed approach course, the pilot should make an initial climbing turn toward the landing runway and continue the turn until established on the missed approach course…. If the aircraft initiates a missed approach at a point other than the missed approach point…from below MDA or DA (H), or on a circling approach, obstacle clearance is not necessarily provided by following the published missed approach procedure….”[/su_box]
Missing an approach typically is a straightforward procedure in itself. Climb, turn, hold. Or climb out and go somewhere else. Or accept vectors for another try. One big exception is when flying a circling approach. The problem is when and where to begin the missed approach procedure. Turn too soon, before becoming established on the missed approach segment and pointed in the right direction, and there could be terrain or obstructions ahead, even at the circling minimum altitude. So, when circling, we always want to return to the missed approach point (MAP) and then turn onto the prescribed course or heading before initiating a climb. We certainly don’t want to turn before reaching the MAP. Here’s an example of why.
Background
On December 10, 2021, at about 1809 Mountain time, a Piper PA-46-500TP Malibu Meridian was substantially damaged when it collided with terrain while attempting a missed approach procedure near Steamboat Springs, Colorado. The solo instrument-rated private pilot (male, 43) was fatally injured. The airplane departed Cody, Wyoming, at about 1705 and, at 1757, the flight was cleared for the RNAV (GPS)-E approach procedure at Steamboat Springs.
Steamboat’s field elevation, 6882 feet, is relatively high, as is the surrounding terrain: The procedure required the airplane to cross the final approach fix (FAF) at or above 9700 feet msl and the stepdown fix at or above 8740 feet msl. The minimum descent altitude (MDA) for the approach is 8140 feet, 1258 feet above the aerodrome. According to ADS-B data, the accident airplane crossed the FAF at about 9100 feet msl—some 600 feet low—and flew over the stepdown fix at about 8200 feet msl, more than 500 feet low. After passing the stepdown fix, the airplane descended to about 7850 feet, almost 300 feet below the MDA and about 1000 feet above field elevation. The missed approach point (MAP) for the procedure was the Runway 32 approach end. The miss called for a climbing left turn to 11,300 feet msl and an almost complete course reversal before entering a holding pattern.
Passing the stepdown fix and well before reaching the MAP, the airplane made a left turn but delayed its climb. The last ADS-B data point recorded at 1808:49 indicated an altitude of about 8125 feet msl some 3.5 miles north of the accident site. The airplane impacted terrain at about 8172 feet msl and came to rest at about 8216 feet.
Investigation
The Leidos Flight Service system had no record of the pilot obtaining a preflight briefing. The pilot’s ForeFlight activity showed he filed a flight plan using the app, which also produced a weather briefing for the route. That briefing included the then-current Metar for the destination airport, which was a broken ceiling at 4500 feet agl with seven miles of visibility.
According to the NTSB, observed weather at the time of the accident included an overcast at 1200 feet agl with one mile of visibility. The lowest published weather minimums for the approach, for a Category A aircraft, were 1258 feet above field elevation and 1¼ miles visibility.
Examination of the airframe, engine and propeller revealed no pre-accident anomalies precluding normal operation. The landing gear and flap actuator positions were consistent with both systems being in transit at the time of impact. Data recovered from the installed avionics showed the airplane’s airspeed varied between 89 and 110 knots during the approach.
Approach categories are based on either the reference landing speed, VREF, when one is specified by the manufacturer, or 1.3 VSO at the aircraft’s maximum certificated landing weight. In this case, a VREF was not specified, so the airplane’s approach category is determined by multiplying the VSO at maximum certificated landing weight of 69 knots by 1.3, yielding 89.7 knots and placing the airplane in approach Category A when flown at that speed.
It’s not known at which speed the approach was flown, and it’s not clear if it would have made a difference. Category B minima for the approach were 8140 feet msl and 1½ miles, instead of Category A’s 8140 feet and 1¼ miles of visibility.
Probable Cause
The NTSB determined the probable cause(s) of this accident to include: “The pilot’s failure to adhere to the published instrument approach procedure, which resulted in controlled flight into terrain.”
Also according to the NTSB, “After passing the final approach fix and before the missed approach point, the pilot, for an unknown reason, executed a left turn, consistent with the missed approach procedure. During the turn toward the holding waypoint, the airplane did not climb. Shortly thereafter, the airplane impacted steep rising terrain.” The NTSB continued: “Data retrieved from the onboard avionics revealed that although the pilot flew the published route in accordance with the instrument approach procedure, the minimum required altitudes were not adhered to.”
The pilot descended below the minimum altitudes and began the missed approach procedure too soon, initiating his left turn at the stepdown fix instead of the runway threshold 2.3 nm away. In addition to his too-low altitude, beginning the turn before reaching the MAP put him too close to terrain. His failure to clean up the airplane’s extended landing gear and flaps, and then climb, helped seal the deal.
