Narrative:

Kodiak, ak, has an ILS approach where the pilot must transition from the IAF DME to the DME on another NAVAID (the ILS) at the lr (lead in right). Because of the complexity of this approach, we have had several incidents of pilot disorientation during IFR flying conditions of which the following is only one example. There are 2 factors which are noteworthy. The pilot, navigated approach is not radar monitored so there is no back up as to position fixing. The approach itself is too complicated for transient IFR pilots to comply with when associated with cockpit task saturartion. If either one of these situations is not dealt with in a dramatic manner, we are looking at a series of fatalities. 4 yrs ago, a twin engine aircraft, 2 fatalities, ILS approach, 11/X/88, military Z, ftg, 1 fatality, ILS approach; you will receive another report shortly of another ILS approach to kodiak incident concerning this incident; small aircraft X cleared the ILS approach, reported on the localizer at 3.2 DME (see plate, inside the DH point) was informed of position and missed approach procedure, reported 'circling over the bay trying to receive the G/south.' again encouraged to fly missed approach segment which was followed, apparently erratically, subsequently cleared for the VOR approach to kodiak at which point pilot reported drifting VOR signal and requested a return to anchorage. Pilot returned the next day on a visibility approach which was successfully completed. It is apparent to us that several pilots have attempted to fly inbound on the localizer while using the VOR DME. The result has been either disorientation or death. The radar was removed from kodiak after the air traffic controller's strike in 1981 because the number of aircraft didn't justify one. There have been at least a dozen other incidents which have not been recorded because the situation was resolved usually by the controllers at kodiak tower or luck. I strongly suggest a review of all of the so called dual DME approachs which are not radar monitored.

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Original NASA ASRS Text

Title: PLT COMPLAINS OF COMPLICATED APCH TO KODIAK ARPT UTILIZING 2 DUAL DME.

Narrative: KODIAK, AK, HAS AN ILS APCH WHERE THE PLT MUST TRANSITION FROM THE IAF DME TO THE DME ON ANOTHER NAVAID (THE ILS) AT THE LR (LEAD IN R). BECAUSE OF THE COMPLEXITY OF THIS APCH, WE HAVE HAD SEVERAL INCIDENTS OF PLT DISORIENTATION DURING IFR FLYING CONDITIONS OF WHICH THE FOLLOWING IS ONLY ONE EXAMPLE. THERE ARE 2 FACTORS WHICH ARE NOTEWORTHY. THE PLT, NAVIGATED APCH IS NOT RADAR MONITORED SO THERE IS NO BACK UP AS TO POS FIXING. THE APCH ITSELF IS TOO COMPLICATED FOR TRANSIENT IFR PLTS TO COMPLY WITH WHEN ASSOCIATED WITH COCKPIT TASK SATURARTION. IF EITHER ONE OF THESE SITUATIONS IS NOT DEALT WITH IN A DRAMATIC MANNER, WE ARE LOOKING AT A SERIES OF FATALITIES. 4 YRS AGO, A TWIN ENG ACFT, 2 FATALITIES, ILS APCH, 11/X/88, MIL Z, FTG, 1 FATALITY, ILS APCH; YOU WILL RECEIVE ANOTHER RPT SHORTLY OF ANOTHER ILS APCH TO KODIAK INCIDENT CONCERNING THIS INCIDENT; SMA X CLRED THE ILS APCH, RPTED ON THE LOC AT 3.2 DME (SEE PLATE, INSIDE THE DH POINT) WAS INFORMED OF POS AND MISSED APCH PROC, RPTED 'CIRCLING OVER THE BAY TRYING TO RECEIVE THE G/S.' AGAIN ENCOURAGED TO FLY MISSED APCH SEGMENT WHICH WAS FOLLOWED, APPARENTLY ERRATICALLY, SUBSEQUENTLY CLRED FOR THE VOR APCH TO KODIAK AT WHICH POINT PLT RPTED DRIFTING VOR SIGNAL AND REQUESTED A RETURN TO ANCHORAGE. PLT RETURNED THE NEXT DAY ON A VIS APCH WHICH WAS SUCCESSFULLY COMPLETED. IT IS APPARENT TO US THAT SEVERAL PLTS HAVE ATTEMPTED TO FLY INBND ON THE LOC WHILE USING THE VOR DME. THE RESULT HAS BEEN EITHER DISORIENTATION OR DEATH. THE RADAR WAS REMOVED FROM KODIAK AFTER THE AIR TFC CTLR'S STRIKE IN 1981 BECAUSE THE NUMBER OF ACFT DIDN'T JUSTIFY ONE. THERE HAVE BEEN AT LEAST A DOZEN OTHER INCIDENTS WHICH HAVE NOT BEEN RECORDED BECAUSE THE SITUATION WAS RESOLVED USUALLY BY THE CTLRS AT KODIAK TWR OR LUCK. I STRONGLY SUGGEST A REVIEW OF ALL OF THE SO CALLED DUAL DME APCHS WHICH ARE NOT RADAR MONITORED.

Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.