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Pilot’s mistake ‘could have had a tragic ending’

By NASA · September 21, 2023 ·

This is an excerpt from a report made to the Aviation Safety Reporting System. The narrative is written by the pilot, rather than FAA or NTSB officials. To maintain anonymity, many details, such as aircraft model or airport, are often scrubbed from the reports.

Upon receiving the ATIS, I input 30.87 instead of 29.87. This led me to fly the initial phase of my flight 1,000 feet lower than I thought.

Upon takeoff from ZZZ, I climbed in the downwind, surprised that I made it to 2,600 feet already and turned on course, which would have taken me directly over the adjacent and overlapping Class D airspace at ZZZ1.

I almost certainly entered the adjacent airspace without a clearance.

I then started a practice approach into ZZZ2, and my iPad gave me a terrain warning. When I intercepted the glideslope later than anticipated, I noted the error and executed a miss approach.

Complacency was the main factor.

While busting airspace could have been dangerous, there were no known aircraft operating at ZZZ1 at the time. However, an instrument approach off by 1,000 feet vertical could have had a tragic ending.

For this reason, I will carry this lesson with me through the rest of my flying career and be hyper vigilant about entering the correct altimeter setting.

Primary Problem: Human Factors

ACN: 1992044

About NASA

NASA's Aviation Safety Reporting System (ASRS) captures confidential reports, analyzes the resulting aviation safety data, and disseminates vital information to the aviation community.

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Comments

  1. Ian Saville says

    September 23, 2023 at 10:34 pm

    The mark one eyeball is Paramount in all things Aviation.

    A UK pilot flying in restricted airspace for 45yrs.

  2. JimH in CA says

    September 23, 2023 at 3:39 pm

    Since US air pressures rarely are outside the range of 29.6 to 30.2, setting the kollsman window to 30.80 should have set off some alarm bells…!!!
    Gee. maybe it’s really 29.80…?
    Then checking the altimeter with the known field elevation, and he should have noted that it was ‘way off’.

    So, a ‘stupid pilot trick’…..but no harm, fortunately.

  3. Michael Murdock says

    September 22, 2023 at 9:52 am

    Hey – I appreciate your honesty and bravery to share your story and the lesson you learned. We all make mistakes and what’s important is we learn from them and not repeat them. Thanks for your story.

  4. Tom Curran says

    September 22, 2023 at 7:46 am

    Here’s a thought:
    According to the ASRS report, the pilot was conducting a “practice approach” in VMC with 10 miles visibility. The pilot admitted that things didn’t look quite right on his/her climb to “2,600 feet”.
    I agree that attention to detail is critical when performing tasks like setting the altimeter correctly. But…if you’re trolling around in VMC at a relatively low AGL altitude, I’d like to think it would be pretty obvious, by looking out the window, that you are 1,000’ (+\-) off your planned altitude. It shouldn’t take a “terrain warning” from your iPad to confirm it.

    • are cie says

      September 23, 2023 at 4:32 am

      there is that.

  5. Warren Webb Jr says

    September 22, 2023 at 6:17 am

    A complete check isn’t just the number you dial in the Kollsman window, it’s also verifying the needles are within 75ft of airport elevation. He never mentioned checking the needles – I hope he became aware of that.

    • Mark Scardino says

      September 23, 2023 at 5:00 am

      Old CFII here. I stress this check (+-75’) for every private and instrument student I instruct. Also if the airport you’re departing doesn’t have weather (ASOS, AWOS, etc) set your field elevation on your altimeter and you’ll be very close to the current altimeter setting.

  6. are cie says

    September 22, 2023 at 5:30 am

    Wow.
    Surprised you didn’t notice the altimeter winding up when adjusting the setting, but it was a valuable lessons.
    Use that same vigilance when setting other things they can kill you, like ils freqs,
    approach minimums, etc….

  7. jan zboril says

    September 22, 2023 at 4:35 am

    Great story. The Devil is in the details.

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