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|
Attributes | |
ACN | 256655 |
Time | |
Date | 199311 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ktn |
State Reference | AK |
Altitude | msl bound lower : 6000 msl bound upper : 7000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zan |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 14000 flight time type : 150 |
ASRS Report | 256655 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other other : unspecified |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ILS DME 2 runway 11 approach flown into ketchikan, ak, from over ann VOR using the ann 30 DME arc. Crew was not aware that a NOTAM existed saying the arc was not authorized. I scanned about 20 pages of paperwork (WX, forecasts, en route winds, area WX, facilities reports, NOTAMS, etc.), checked the flight plans for 5 legs, ordered fuel, signed the release, and hurried to the aircraft. Flight departed on time for ktn, wrg, psg, situation, and jnu. ATIS in ktn reported scattered to broken clouds and winds that favored runway 11. Zan told us to 'maintain 7000 until on a published portion of the approach, radar service terminated, contact ktn FSS over ann.' neither zan nor ATIS mentioned that the arc was not authorized. Over ann, we contacted ktn FSS and reported 'over ann on the lda DME 2 runway 11.' ktn said to 'report the 11 DME fix for TA's.' so far, everything seemed standard. But, as we turned onto the arc, ktn FSS called and said, 'air carrier are you aware that the arc is not authorized?' I said, 'no sir, we're not.' he said, 'maintain 6000 until intercepting the localizer.' we acknowledged and completed the approach. After landing we found the NOTAM: '30 DME arc from dwarf north/a.' then below that it said, 'this also pertains to the lda DME 2.' I'm responsible for checking the NOTAMS, and I did. But, the importance of the NOTAM did not register. We always use the arc, but we never use dwarf, and I didn't notice the 'also pertains' portion. I believe that the system let me down when: 1) something so important was buried in 20 pages of paperwork. 2) dispatch didn't mention it. 3) ATIS didn't mention it. 4) zan didn't mention it. 5) ktn FSS didn't mention it until I was on the arc. I assure you I've learned an important lesson. But, I hope this report will help you make changes to the system so that something important can be emphasized a little better.
Original NASA ASRS Text
Title: FLC OF AN MLG ACR ACFT COMMENCED AN INST DME ARC APCH NO LONGER AUTH. FAA FSS INQUIRY AT THE START OF THE ARC HELPED RPTR TO MAINTAIN ALT AND ABANDON THE ARC.
Narrative: ILS DME 2 RWY 11 APCH FLOWN INTO KETCHIKAN, AK, FROM OVER ANN VOR USING THE ANN 30 DME ARC. CREW WAS NOT AWARE THAT A NOTAM EXISTED SAYING THE ARC WAS NOT AUTHORIZED. I SCANNED ABOUT 20 PAGES OF PAPERWORK (WX, FORECASTS, ENRTE WINDS, AREA WX, FACILITIES RPTS, NOTAMS, ETC.), CHKED THE FLT PLANS FOR 5 LEGS, ORDERED FUEL, SIGNED THE RELEASE, AND HURRIED TO THE ACFT. FLT DEPARTED ON TIME FOR KTN, WRG, PSG, SIT, AND JNU. ATIS IN KTN RPTED SCATTERED TO BROKEN CLOUDS AND WINDS THAT FAVORED RWY 11. ZAN TOLD US TO 'MAINTAIN 7000 UNTIL ON A PUBLISHED PORTION OF THE APCH, RADAR SVC TERMINATED, CONTACT KTN FSS OVER ANN.' NEITHER ZAN NOR ATIS MENTIONED THAT THE ARC WAS NOT AUTHORIZED. OVER ANN, WE CONTACTED KTN FSS AND RPTED 'OVER ANN ON THE LDA DME 2 RWY 11.' KTN SAID TO 'RPT THE 11 DME FIX FOR TA'S.' SO FAR, EVERYTHING SEEMED STANDARD. BUT, AS WE TURNED ONTO THE ARC, KTN FSS CALLED AND SAID, 'ACR ARE YOU AWARE THAT THE ARC IS NOT AUTHORIZED?' I SAID, 'NO SIR, WE'RE NOT.' HE SAID, 'MAINTAIN 6000 UNTIL INTERCEPTING THE LOC.' WE ACKNOWLEDGED AND COMPLETED THE APCH. AFTER LNDG WE FOUND THE NOTAM: '30 DME ARC FROM DWARF N/A.' THEN BELOW THAT IT SAID, 'THIS ALSO PERTAINS TO THE LDA DME 2.' I'M RESPONSIBLE FOR CHKING THE NOTAMS, AND I DID. BUT, THE IMPORTANCE OF THE NOTAM DID NOT REGISTER. WE ALWAYS USE THE ARC, BUT WE NEVER USE DWARF, AND I DIDN'T NOTICE THE 'ALSO PERTAINS' PORTION. I BELIEVE THAT THE SYS LET ME DOWN WHEN: 1) SOMETHING SO IMPORTANT WAS BURIED IN 20 PAGES OF PAPERWORK. 2) DISPATCH DIDN'T MENTION IT. 3) ATIS DIDN'T MENTION IT. 4) ZAN DIDN'T MENTION IT. 5) KTN FSS DIDN'T MENTION IT UNTIL I WAS ON THE ARC. I ASSURE YOU I'VE LEARNED AN IMPORTANT LESSON. BUT, I HOPE THIS RPT WILL HELP YOU MAKE CHANGES TO THE SYS SO THAT SOMETHING IMPORTANT CAN BE EMPHASIZED A LITTLE BETTER.
Data retrieved from NASA's ASRS site as of July 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.