Missed Expectations

The interaction between pilots and ATC depends on trust that certain procedures will be followed in order.


Way back when I was training for the instrument rating, I was enraptured by the entire concept of operating an aircraft without visual reference to the world outside. Part of that love affair-which continues today-had to do with the elaborate rules and procedures designed both to keep the airplane and its occupants out of the weeds while ensuring everyone associated with its operation knew what to expect. For the average VFR-only pilot contemplating the instrument rating, theres a lot to learn-and by no means do I know it all-but theres also a very clear philosophy behind it. Once the underlying rules are understood, the actual flying often is easier than doing the same trip VFR.

One of the keys to it all is performing various procedures in a certain sequence. The rules associated with communication failure under IFR are an excellent example: Routing, altitude and time are considered. Both the pilot and ATC know what to expect, what to do and when to do it.

Executing a missed approach is similar, except that each procedure is different. Well-trained and experienced pilots know to study and brief the miss prior to beginning the approach and to execute the procedure at the appropriate point.

Of course, there are exceptions to most every rule, in life and in instrument operations. One of them is that ATC instructions override published procedures. The presumption is ATC knows more than the pilot about equipment and facility status, traffic, weather and other factors, so whatever ATC instructs the pilot to do-within reason and subject to operational considerations, among other concerns-is “okay.” Sometimes, however, one participant in the constant negotiations between pilots and ATC can get ahead of the other. When that happens and the specified sequence of events isnt followed, significant errors can occur, as this months accident examination reveals.


On February 16, 2008, at about 0828 Pacific time, a Lancair LC41 550-FG was destroyed after impacting terrain while maneuvering near the Portland International Airport (PDX), Portland, Oregon. The solo pilot and owner was killed. Instrument conditions prevailed and the aircraft was operating under IFR. Earlier, at 0752, the pilot switched to the Portland Approach Control and began receiving vectors for the ILS Runway 10R approach.

The weather at PDX was pretty poor, with observed runway visual ranges varying between 600 and 800 feet. Soon, at 0812, the pilot called a missed approach and began receiving vectors for another approach. At 0827, while nearing the runway threshold on the second approach attempt, ATC issued missed approach instructions. The pilot replied with an unintelligible transmission, followed by “were gonna crash.” The aircrafts initial impact with terrain occurred about 3200 feet southeast of the approach end of Runway 10R, on a magnetic heading of about 160 degrees.


Radar data revealed the airplane was stabilized on the localizer at 0826:59, just prior to the runway threshold. Ten seconds later, at 0827:09, radar depicted the airplane about 500 feet east of taxiway Bravo-1 and the runway threshold, starting a right turn. Radar depictions at 0827:13, 0827:18 and 0827:23 indicate the airplane had made a right turn to a south-southeasterly heading. The airplanes altitude at this point is not included in the NTSB data.

The main wreckage was almost entirely consumed by fire. The throttle, propeller and mixture control levers were in the full-forward positions. All primary and secondary flight controls were accounted for at the accident site. There were no pre-impact failures or malfunctions identified which would have precluded normal operation.

Probable Cause

The National Transportation Safety Board determined the probable causes of this accident to include: “The pilots failure to follow the missed approach procedure. Contributing to the accident were the fog and below landing minimums visibility conditions.” Thats the formal NTSB statement.

In the online summary of the investigation into this accident, the Board states, “When the tower controller observed the airplane turning to the south of the runway on her radar display, she issued missed approach instructions, which was (sic) followed by an inaudible transmission.” The summary continues: “The airplanes turn to the southeast was consistent with the missed approach course of 160 degrees; however, a climb to 900 feet is required prior to commencing the right turn, as outlined on [the] approach plates missed approach instructions. It appears the pilot likely misinterpreted the missed approach instructions by making the right hand turn prior to initiating a climb to 900 feet, which resulted in the subsequent impact with the tree.” Well, yes, except for the controllers instructions to turn and failure to include anything about a climb.

Well never know what the pilot saw as he approached the runway threshold, whether he was beginning to execute the missed approach or whether he had the runway in sight and was about to land. We do know, however, the controller issued missed approach instructions after observing on the radar display the beginning of a turn toward the missed approach course. Apparently, the controller saw the turn and presumed the pilot was executing the miss but had not yet made that radio call.

Which came first, the pilots decision to execute the miss or the controllers turn instruction? Why was that instruction to turn not accompanied by one to climb? Was the pilot blindly following an ATC instruction with the expectation it was a safe maneuver? Regardless of the answers, its troubling here that the NTSB-at least in the public record-failed to explore this sequence of events.

As noted earlier, IFR operations come with a well-defined set of rules: If A occurs, then do B, followed by C. Failing to sight the runway environment at decision height on an ILS is a prime example: You then execute the missed approach instructions.

But the IFR rules also include exceptions: When ATC instructs us to do something, theres an expectation its safe. In this instance, it appears ATC failed to include a climb as part of its missed-approach instructions. Yes, the pilot should have begun a climb, anyway, but he had a reasonable expectation the controllers failure to include a climb in the instruction was safe.


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