Date: 201403
Local time of day: 1201-1800
Location: IAD.Airport, DC
Flight conditions: IMC
Weather elements / visibility: Cloudy; Rain; 2
Light: Daylight
Aircraft: Cessna Aircraft Undifferentiated or Other Model
Operating under: Part 135
Flight plan: IFR
Flight phase: Final Approach
Airspace: Class B IAD
ATC / advisory: Tower IAD
Second aircraft: Large Transport
Reporter organization: Government
Reporter function: Other / Unknown
Reporter qualification: Air Traffic Control Fully Certified
Human factors: Communication Breakdown; Confusion
Second reporter function: Local
Anomaly: ATC Issue All Types; Conflict Airborne Conflict; Deviation - Altitude Excursion From Assigned Altitude; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy
Detector: Person Air Traffic Control
When detected: In-flight
Result: Air Traffic Control Issued New Clearance; Air Traffic Control Separated Traffic; Flight Crew Diverted; Flight Crew Executed Go Around / Missed Approach
Contributing factors: Weather; Human Factors; Aircraft
Primary problem: Weather

Narrative: This is a known event reported by the Tower FLM; possible loss of separation between Aircraft X and Aircraft Y on missed approach from ILS 19C with Aircraft Y; a 19L departure.  IAD [METAR] 00000KT 2SM  -RA  BR  BKN007  OVC022  03/02  A3014  RMK: SFC VIS 2 1/2;  Dependent ILS's to RYs 19C/19R; Departing RYs 19L/30.  Upon breaking out of the overcast; Aircraft X did an unexpected maneuver; counter to Local Control Three's (LC3) instructions to turn right to heading 300.  The aircraft; instead; turned east -- in front of the Tower -- at approximately 800 FT MSL.  This caused great alarm in the Tower cab (height 637 MSL).  When Aircraft X finally complied with ATC instructions to fly westbound and climb and maintain 2000; the aircraft entered the cloud layer; out of sight of local control; and separation was lost with the departing Aircraft Y.  It became a risk analysis event.  Aircraft X; whose outbound flight progress strip showed him on a medevac flight; tried a second approach.  This also ended in a missed approach.  A review of the radar replays show that Aircraft X flew unstable approaches.  On the first approach; he was very late descending out of 5;000 -- not capturing the glide slope or stepping down at the fixes between HOOSR and FEMKO.  He ended up 1;600 FT high over FEMKO; the FAF (3.7 NM fr/threshold); and was at 1;500 FT MSL over the 19C threshold.  The Decision Height (DH) for the ILS 19C is 472 ft MSL.  The radar also shows the aircraft kept tracking off the final approach course; not staying centered on the localizer.  He appeared to break out of the overcast at about 800 FT MSL; too high; too fast; and too far down the runway to complete a straight-in landing.  At this point; the decision point; the PIC should have announced a missed approach.  Instead; he wanted to maneuver to a base leg; claiming he was VFR.  With the Class B surface area IMC; the only way that would have been approved is if he asked for a contact approach or declared an emergency.  The contact approach probably would not have been approved because of traffic departing RYs 19L and 30 during a busy departure phase of the day (as the ASDE-X replay showed).  By turning left on his own; crossing just in front of the Tower; Aircraft X performed a dangerous maneuver.  During the subsequent approach; the aircraft had trouble flying assigned heading and maintaining an altitude.  LC3; as a precaution; issued 'in-the-event-of-missed-approach' instructions when Aircraft X checked on.  However; when the aircraft appeared to be descending too low; too far out; probably diving to the localizer only minimums of 660 ft; LC3 canceled the approach clearance and sent him around; even though the pilot said he had the field in sight.  During the read back of go around instructions; Aircraft X incorrectly read back heading 270 instead of 200. The aircraft then diverted to RDG; but for some reason; could not land there and diverted to home base; PTW.  When asked if he needed assistance; Aircraft X said he had trouble with the ILS; probably aircraft equipment.  No other arrivals complained about the ILS.  The Tower FLM asked Potomac Approach to have the PIC call the Tower after landing.  When asked about his left turn in front of the Tower; the PIC responded that he had a yaw damper issue which forced him into a left turn.  I'm sorry; but I believe this PIC did not possess the skills necessary to fly IFR; or if someone else was flying; the PIC failed to exercise command authority and good judgment.  Is this another instance of over-reliance on automation?  I believe this PIC is dangerous and needs to have some training before he flies again.  This company is a Part 135 company and; as of this report; Aircraft X has flown about six more times since the flight evolution described above.  FSDO has taken the lead on this after coordinating with a nearby FSDO.  I have spoken with the front line manager in charge at FSDO and I believe he will do some quick intervention.  As for ATC's actions: 1) LC3 should have recognized an unstable approach.  Yes; he was busy with RY 30 departures; but he took the time to reach out and give Aircraft X a landing clearance; before the aircraft was on his frequency.  Did he not notice the Mode C altitude?  After issuing the landing clearance and giving a base report to Aircraft X; did LC3 scan the R-ACD to track position and altitude; or if the aircraft went missed approach?  It was {Person Identified] who first noticed where the aircraft was and pointed out his position to the Tower team.  Local controllers are so accustomed to pilots correctly flying the approach that they sometimes forget to scan Mode C altitude.  LC3 did do good coordination with LC1.  2) LC3 did not take positive control of the situation by telling Aircraft X to go-around.  He did assign a heading; but no altitude to maintain.  Instead of asking the aircraft's intentions; he should have preemptively and emphatically issued correct go-around instructions. 3) On the subsequent approach; PCT final cleared Aircraft X reference FEMKO; maintain 2000 until established on the localizer; cleared ILS 19C approach.  LC3 gave incorrect information to Aircraft X about his minimum altitude being 2000 on that segment of the approach.  He was legitimate at 1500 ft.  This might have confused the pilot. 4) After canceling the approach and issuing go-around instructions; when Aircraft X said he had the field in sight; LC3 should have cleared him to land.  It's better to get the aircraft on the ground and talk about what went wrong later; than have him climb back into the overcast for another potential (mis)adventure. 5) The Tower FLM did not have PCT issue the Brasher warning.  6) When the PIC called the Tower FLM; no Brasher warning was issued. 1) Quick action by FSDO to make this pilot safe.2) Individual Performance Management (IPM) with LC3 controller reviewing the positives and negatives.3) IPM with FLM regarding Brasher Warnings.4) Refresher training on IMC approaches/missed approaches.  Show video.  Disguise voices if necessary.5) Hasten the implementation of the Local Safety Council (LSC) process.  Let them review this scenario.


Second narrative: IAD was in a departure configuration at the time of the event. The weather conditions were IFR with a ceiling of 700 feet MSL. I was working LC1; and was departing runway 19L with south and west bound departures. ILS approaches were being conducted to runway 19C by the LC3 Controller. I was leaving all my departures on a runway heading off 19L with reference to a possible missed approach by an airplane off runway 19C since visual separation could not be applied. I cleared Aircraft Y for takeoff off runway 19L and issued runway heading since Aircraft X was on a 2 mile final to runway 19C. I was watching the approach of Aircraft X on the radar and noticed by the time he was at the approach end of runway 19C; he was too high and was definitely not landing. I told LC3 that Aircraft X was going missed; and at that point LC3 assigned him a right turn; in order to stay separated from my departure; Aircraft Y.  What we didn't know at the time the right turn was issued to Aircraft X was that he had already taken it on his own to start a left turn; towards runway 19L and Aircraft Y.  Aircraft X then appeared out of the clouds and flew right by the east side of the Tower; at an altitude barely higher than the Tower. Once Aircraft X had passed south of the Tower and was established on a northwesterly heading away from my departure; I knew that no evasive action was needed by Aircraft Y so I switched the departure to Potomac Approach.In order to prevent an event like this to re-occur; it is critical that pilots adhere to ATC instruction. If they are on a missed approach; they should not be turning on their own in any direction other than the published missed approach. The published missed approach for runway 19C is a runway heading; so absolutely no turn should have occurred other than one instructed by ATC.


Synopsis: Reporters describe incident with one aircraft trying multiple approaches and buzzing the Tower.  Aircraft turns into departing traffic path; pilot later reports to ATC that aircraft had a yaw problem leading to the left turn.