Pilots Erroneously Follow Incorrect Missed Approach Path Following Overlooked Flight Notices (NOTAMs)
In a recent incident at airport XXX, a corporate jet crew found themselves flying the wrong missed approach procedure, potentially due to a lack of attention to NOTAMs. The mishap serves as a reminder of the crucial role NOTAMs play in ensuring flight safety, particularly during instrument flights.
Every approach, visual or instrument, should be flown to a go-around until a landing is assured. In Instrument Meteorological Conditions (IMC), as in the case at airport XXX, the crew requested runway heading for their missed approach and vectors to return. However, the crew's expectation bias played a significant role in the incident, as they didn't anticipate needing a missed approach.
To prevent such errors, pilots employ multiple layers of preparation and in-flight verification. A thorough pre-flight briefing involves reviewing all available NOTAMs, notices, and updated charts before the flight. Pilots often obtain briefings from Flight Service Stations to capture any changes or temporary instructions affecting approaches and missed approaches.
Pre-approach briefings are equally crucial, as they include expected approach procedures, missed approach routes, and any NOTAM-driven changes. This step is crucial for anticipating and mentally preparing for alternate missed approach instructions.
Pilots also use multiple sources and technologies to cross-check NOTAMs with published approach charts, onboard navigation systems, and company procedures. The integration of GPS, Flight Management Systems (FMS), and electronic flight bags (EFBs) helps confirm the correct missed approach procedure.
Regular simulator sessions emphasize handling unexpected missed approach instructions and adapting quickly to changes, including those from last-minute NOTAMs. This training helps pilots maintain proficiency and readiness to execute the correct missed approach without hesitation.
Adherence to standard operating procedures and checklists is another key practice. Pilots follow checklists and official procedures strictly during approaches and go-arounds, which include executing missed approaches as published or as amended by ATC instructions.
Communication and ATC coordination are also essential. Pilots confirm any changes to missed approach procedures with Air Traffic Control during approach and immediately after any clearance alterations. This ensures alignment and reduces the risk of flying an outdated procedure.
Airlines also emphasize fatigue management and pre-approach situational awareness to keep pilots alert to all relevant information, including changes in NOTAMs affecting missed approaches. Enhanced training encourages vigilance during critical phases of flight.
For IFR flights, it's essential to review NOTAMs, particularly those related to instrument approach procedures. In the U.S., Flight Data Center NOTAMs (FDC) outline changes to instrument approach procedures and airways. NOTAMs may contain information about equipment outages, changes to missed approach procedures, new approach minimums, and changes for altimeter settings.
In the case of airport XXX, it's unclear whether the crew had checked the NOTAMs regarding the XXX VOR being out of service before the flight. However, it's common to find NOTAMs for various reasons when flying IFR.
The incident could potentially have been avoided if the crew had been more vigilant about reviewing the approach, even if the ceilings had been right at minimums. The ceilings were reported at 400 feet AGL, and the minimums for the ILS were 200 feet. There was likely an area of fog or low clouds along the approach corridor that was not being reported by airport weather.
The correct missed approach procedure required flying direct to XXX and holding, which was different from what the crew briefed. The crew failed to notice a change in the missed approach procedure due to a NOTAM regarding the XXX VOR being out of service.
Boldmethod offers an Instrument Procedures course to help pilots improve their instrument flying skills. A thorough review of NOTAMs should be a standard practice before every IFR flight. Pilots must always remember that a solid missed approach plan should always be in mind, and a full briefing, including NOTAMs, should never be skipped.
- A maneuver, the missed approach, should be flown to a go-around until a landing is assured, especially in Instrument Meteorological Conditions (IMC).
- To prevent errors during flights, pilots review all NOTAMs, notices, and updated charts before taking off as part of their thorough pre-flight briefing.
- Obtaining briefings from Flight Service Stations is often valuable for pilots, as it captures any changes or temporary instructions affecting approaches and missed approaches.
- Pre-approach briefings are crucial, as they include expected approach procedures, missed approach routes, and any NOTAM-driven changes.
- Pilots use multiple sources and technologies to cross-check NOTAMs with published approach charts, onboard navigation systems, and company procedures.
- Regular simulator sessions emphasize handling unexpected missed approach instructions and adapting quickly to changes, including those from last-minute NOTAMs.
- Adherence to standard operating procedures and checklists is another key practice, including executing missed approaches as published or as amended by ATC instructions.
- Pilots confirm any changes to missed approach procedures with Air Traffic Control during approach and immediately after any clearance alterations.
- For IFR flights, it's essential to review NOTAMs related to instrument approach procedures, such as changes to missed approach procedures, new approach minimums, and changes for altimeter settings.
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