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Attributes | |
ACN | 534825 |
Time | |
Date | 200201 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : tus.airport |
State Reference | AZ |
Altitude | msl bound lower : 4800 msl bound upper : 5800 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : u90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | approach : visual arrival star : dingo 5 |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : u90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : vacating altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 244 flight time total : 7400 flight time type : 1428 |
ASRS Report | 534825 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 25000 flight time type : 18000 |
ASRS Report | 534823 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met conflict : ground critical non adherence : required legal separation non adherence : published procedure other anomaly other other spatial deviation other spatial deviation |
Independent Detector | atc equipment : msaw aircraft equipment : gpws other controllera other controllerb other flight crewb |
Resolutory Action | controller : issued alert flight crew : exited adverse environment flight crew : took evasive action |
Consequence | other |
Miss Distance | horizontal : 6000 vertical : 113 |
Supplementary | |
Problem Areas | Chart Or Publication Navigational Facility Airport Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Chart | approach : tus-ils star : dingo |
Narrative:
On approach into tus, runway 11L, approach control cleared us for visual approach approximately 30 NM northwest of the field. We were descending to 6500 ft on the dingo five when we received clearance for visual. When we were cleared for the visual, approach control directed us to 'contact tower 11 mi northwest.' I looked down, set in the localizer frequency for the ILS and tower frequency in VHF #1, but did not select tower until approximately 13-15 NM northwest of tus. While I was looking down, the captain selected 4500 ft in the altitude alerter, and I did not notice that this was well below the MSA of 5800 ft. As we turned to intercept facility around 15 mi northwest, we started to configure the aircraft and I selected tower. Shortly thereafter we received an egpws alert for terrain, I noticed the black shapes of terrain approximately 3 mi right of us and the captain started a climb out of 5200 ft to 5500 ft. Tower contacted us, as well as company flight that was 6 mi behind when approach control notified them that he had a low altitude alert on us. I failed to provide proper backup, by not noticing the new altitude in the alerter, or noting that it was below MSA. I also switched the VHF to tower prior to 11 mi, which prevented us from hearing approach control's warning. Further, while I saw the mountains on the right, I failed to verbalize anything to the captain because I assumed he was lining up on the runway and we would pass well left of them. These mountains rise to 4687 ft and have no light or beacon on top and at night, with good visibility, it is hard to judge their position relative to the aircraft and GS for runway 11L. Supplemental information from acn 534823: at approximately 20 DME the approach controller asked if we 'had the airport.' we replied affirmatively and he cleared us for the visual to runway 11, and told us to contact the tower at 11 DME. I, the PF, set in 4500 ft on the MCP, which is about 2000 ft above touchdown, disconnected the autoplt and continued a visual descent to runway 11. At approximately 15 DME and 5000 ft MSL we had an audible terrain alert from egpws. We both went to the radar scope, which showed solid green display for about 10 mi and 5-10 degrees either side of our nose. A few seconds later and a couple of hundred ft lower, egpws warned us to climb, which we complied with. The tower called us to alert us that we were too low. We found out later that approach had tried to reach us, but were unable because we had switched to tower. There is an MSA of 5700 ft on the runway 11 approach plate which I ignored due to visual conditions on a visual approach. There was no guidance from the approach controller as to when to descend below 6000 ft for our visual approach. Although VFR, we never could distinguish any hilly terrain between us and the airport. There were no lights on the hills adjacent to the ILS runway 11, and we were displaced right of course for our visual arrival. Callback conversation with reporter acn 534823 revealed the following information: the captain said that he had no feedback from the company on this incident report. He feels that the arrival chart and the approach plate should have alerts other than the MSA as published on the approach plate. A light on the mountain top he felt was a 'must.' he also desires a change in the way approach control issues the visual with a caveat for a certain altitude and DME within the clearance prior to change of frequency to the tower. Callback conversation with reporter acn 534825 revealed the following information: the first officer stated that he had information from other crew members from different flts and domiciles that indicated parallel events at previous times. This was not the first event at tus of this nature. He said that the flight crew in this instance was not very familiar with tus, with the west coast crews flying in there more frequently. He would like to see lights placed on the mountain top and have ATC use the phrase, '...maintain 6000 ft until 12 (or as deemed appropriate) DME...' he did not know of any company efforts to contact ATC regarding approach procedures.
Original NASA ASRS Text
Title: CFIT. THE FLC OF A B737 GETS A EGPWS WARNING TO CLB WHEN THE PIC DSNDS BELOW THE PUBLISHED MSA DURING A NIGHT OP VISUAL APCH TO RWY 11L AT TUS, AZ.
Narrative: ON APCH INTO TUS, RWY 11L, APCH CTL CLRED US FOR VISUAL APCH APPROX 30 NM NW OF THE FIELD. WE WERE DSNDING TO 6500 FT ON THE DINGO FIVE WHEN WE RECEIVED CLRNC FOR VISUAL. WHEN WE WERE CLRED FOR THE VISUAL, APCH CTL DIRECTED US TO 'CONTACT TWR 11 MI NW.' I LOOKED DOWN, SET IN THE LOC FREQ FOR THE ILS AND TWR FREQ IN VHF #1, BUT DID NOT SELECT TWR UNTIL APPROX 13-15 NM NW OF TUS. WHILE I WAS LOOKING DOWN, THE CAPT SELECTED 4500 FT IN THE ALT ALERTER, AND I DID NOT NOTICE THAT THIS WAS WELL BELOW THE MSA OF 5800 FT. AS WE TURNED TO INTERCEPT FAC AROUND 15 MI NW, WE STARTED TO CONFIGURE THE ACFT AND I SELECTED TWR. SHORTLY THEREAFTER WE RECEIVED AN EGPWS ALERT FOR TERRAIN, I NOTICED THE BLACK SHAPES OF TERRAIN APPROX 3 MI R OF US AND THE CAPT STARTED A CLB OUT OF 5200 FT TO 5500 FT. TWR CONTACTED US, AS WELL AS COMPANY FLT THAT WAS 6 MI BEHIND WHEN APCH CTL NOTIFIED THEM THAT HE HAD A LOW ALT ALERT ON US. I FAILED TO PROVIDE PROPER BACKUP, BY NOT NOTICING THE NEW ALT IN THE ALERTER, OR NOTING THAT IT WAS BELOW MSA. I ALSO SWITCHED THE VHF TO TWR PRIOR TO 11 MI, WHICH PREVENTED US FROM HEARING APCH CTL'S WARNING. FURTHER, WHILE I SAW THE MOUNTAINS ON THE R, I FAILED TO VERBALIZE ANYTHING TO THE CAPT BECAUSE I ASSUMED HE WAS LINING UP ON THE RWY AND WE WOULD PASS WELL L OF THEM. THESE MOUNTAINS RISE TO 4687 FT AND HAVE NO LIGHT OR BEACON ON TOP AND AT NIGHT, WITH GOOD VISIBILITY, IT IS HARD TO JUDGE THEIR POS RELATIVE TO THE ACFT AND GS FOR RWY 11L. SUPPLEMENTAL INFO FROM ACN 534823: AT APPROX 20 DME THE APCH CTLR ASKED IF WE 'HAD THE ARPT.' WE REPLIED AFFIRMATIVELY AND HE CLRED US FOR THE VISUAL TO RWY 11, AND TOLD US TO CONTACT THE TWR AT 11 DME. I, THE PF, SET IN 4500 FT ON THE MCP, WHICH IS ABOUT 2000 FT ABOVE TOUCHDOWN, DISCONNECTED THE AUTOPLT AND CONTINUED A VISUAL DSCNT TO RWY 11. AT APPROX 15 DME AND 5000 FT MSL WE HAD AN AUDIBLE TERRAIN ALERT FROM EGPWS. WE BOTH WENT TO THE RADAR SCOPE, WHICH SHOWED SOLID GREEN DISPLAY FOR ABOUT 10 MI AND 5-10 DEGS EITHER SIDE OF OUR NOSE. A FEW SECONDS LATER AND A COUPLE OF HUNDRED FT LOWER, EGPWS WARNED US TO CLB, WHICH WE COMPLIED WITH. THE TWR CALLED US TO ALERT US THAT WE WERE TOO LOW. WE FOUND OUT LATER THAT APCH HAD TRIED TO REACH US, BUT WERE UNABLE BECAUSE WE HAD SWITCHED TO TWR. THERE IS AN MSA OF 5700 FT ON THE RWY 11 APCH PLATE WHICH I IGNORED DUE TO VISUAL CONDITIONS ON A VISUAL APCH. THERE WAS NO GUIDANCE FROM THE APCH CTLR AS TO WHEN TO DSND BELOW 6000 FT FOR OUR VISUAL APCH. ALTHOUGH VFR, WE NEVER COULD DISTINGUISH ANY HILLY TERRAIN BTWN US AND THE ARPT. THERE WERE NO LIGHTS ON THE HILLS ADJACENT TO THE ILS RWY 11, AND WE WERE DISPLACED R OF COURSE FOR OUR VISUAL ARR. CALLBACK CONVERSATION WITH RPTR ACN 534823 REVEALED THE FOLLOWING INFO: THE CAPT SAID THAT HE HAD NO FEEDBACK FROM THE COMPANY ON THIS INCIDENT RPT. HE FEELS THAT THE ARR CHART AND THE APCH PLATE SHOULD HAVE ALERTS OTHER THAN THE MSA AS PUBLISHED ON THE APCH PLATE. A LIGHT ON THE MOUNTAIN TOP HE FELT WAS A 'MUST.' HE ALSO DESIRES A CHANGE IN THE WAY APCH CTL ISSUES THE VISUAL WITH A CAVEAT FOR A CERTAIN ALT AND DME WITHIN THE CLRNC PRIOR TO CHANGE OF FREQ TO THE TWR. CALLBACK CONVERSATION WITH RPTR ACN 534825 REVEALED THE FOLLOWING INFO: THE FO STATED THAT HE HAD INFO FROM OTHER CREW MEMBERS FROM DIFFERENT FLTS AND DOMICILES THAT INDICATED PARALLEL EVENTS AT PREVIOUS TIMES. THIS WAS NOT THE FIRST EVENT AT TUS OF THIS NATURE. HE SAID THAT THE FLC IN THIS INSTANCE WAS NOT VERY FAMILIAR WITH TUS, WITH THE W COAST CREWS FLYING IN THERE MORE FREQUENTLY. HE WOULD LIKE TO SEE LIGHTS PLACED ON THE MOUNTAIN TOP AND HAVE ATC USE THE PHRASE, '...MAINTAIN 6000 FT UNTIL 12 (OR AS DEEMED APPROPRIATE) DME...' HE DID NOT KNOW OF ANY COMPANY EFFORTS TO CONTACT ATC REGARDING APCH PROCS.
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.