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While flying VOR-a approach to smo, flight crew of BE40 misinterp procedural note regarding culve fix and descend directly to MDA after passing bevey.
| Attributes | |
| ACN | 605834 |
| Time | |
| Date | 200401 |
| Day | Mon |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : smo.airport |
| State Reference | CA |
| Altitude | msl single value : 700 |
| Environment | |
| Flight Conditions | Marginal |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : smo.tower |
| Operator | general aviation : corporate |
| Make Model Name | Beechjet 400 |
| Operating Under FAR Part | Part 91 |
| Navigation In Use | other |
| Flight Phase | descent : approach |
| Route In Use | approach : instrument non precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : corporate |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : multi engine pilot : atp |
| Experience | flight time last 90 days : 90 flight time total : 4500 flight time type : 2600 |
| ASRS Report | 605834 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : multi engine |
| Experience | flight time last 90 days : 40 flight time total : 4700 flight time type : 1100 |
| ASRS Report | 606016 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : published procedure |
| Independent Detector | other controllera |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Environmental Factor Chart Or Publication |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Oversight on full procedural note relevant to a step-down fix/altitude on VOR approach to smo, led to an altitude deviation. Crew coordination was intact during this short leg and VOR-a approach was briefed early on descent from altitude. I, as PNF, though only silently, noted the procedural note for the step-down fix altitude at 'culve' (2.4 DME from smo VOR), inside the 'bevey' FAF. It reads, 'when tower inoperative, DME required.' this pertaining to the 'culve' step-down fix. I caught only the first part of the procedural note regarding 'when tower inoperative' -- internalized this as note irrelevant as tower was operative, so 'culve' was not applicable to our approach criteria. My oversight, and oversight as crew, let us to situation where we were already at MDA at 'culve' (2.4 DME) when we should have been at higher step-down altitude. Flight conditions were MVFR. Smo tower commented that we were low. At the time, this made no sense to us. Upon landing, I phoned smo tower for an explanation and on further review learned that we had erred by not catching the full procedural note for this approach. Contributing factors: this was a short leg with a departure procedure (SID) outbound and arrival inbound and multiple heading and altitude changes from socal prior to approach. The approach was briefed early, but cockpit was busy during this leg which led to oversight of the step-down fix which was perceived by us to be non applicable. We, as crew, learned from this and will be much more attentive to procedural notes in the future. Supplemental information from acn 606016: on the approach plate, there are 2 different MDA's noted. One is the MDA column that states 'with culve.' the other states 'without culve.' we know that we could identify culve as the 2.4 DME from smo VOR. This is the only way to identify culve and the procedural note and the 2 different MDA's can be confusing to pilots reviewing this chart.
Original NASA ASRS Text
Title: WHILE FLYING VOR-A APCH TO SMO, FLT CREW OF BE40 MISINTERP PROCEDURAL NOTE REGARDING CULVE FIX AND DSND DIRECTLY TO MDA AFTER PASSING BEVEY.
Narrative: OVERSIGHT ON FULL PROCEDURAL NOTE RELEVANT TO A STEP-DOWN FIX/ALT ON VOR APCH TO SMO, LED TO AN ALTDEV. CREW COORD WAS INTACT DURING THIS SHORT LEG AND VOR-A APCH WAS BRIEFED EARLY ON DSCNT FROM ALT. I, AS PNF, THOUGH ONLY SILENTLY, NOTED THE PROCEDURAL NOTE FOR THE STEP-DOWN FIX ALT AT 'CULVE' (2.4 DME FROM SMO VOR), INSIDE THE 'BEVEY' FAF. IT READS, 'WHEN TWR INOP, DME REQUIRED.' THIS PERTAINING TO THE 'CULVE' STEP-DOWN FIX. I CAUGHT ONLY THE FIRST PART OF THE PROCEDURAL NOTE REGARDING 'WHEN TWR INOP' -- INTERNALIZED THIS AS NOTE IRRELEVANT AS TWR WAS OPERATIVE, SO 'CULVE' WAS NOT APPLICABLE TO OUR APCH CRITERIA. MY OVERSIGHT, AND OVERSIGHT AS CREW, LET US TO SIT WHERE WE WERE ALREADY AT MDA AT 'CULVE' (2.4 DME) WHEN WE SHOULD HAVE BEEN AT HIGHER STEP-DOWN ALT. FLT CONDITIONS WERE MVFR. SMO TWR COMMENTED THAT WE WERE LOW. AT THE TIME, THIS MADE NO SENSE TO US. UPON LNDG, I PHONED SMO TWR FOR AN EXPLANATION AND ON FURTHER REVIEW LEARNED THAT WE HAD ERRED BY NOT CATCHING THE FULL PROCEDURAL NOTE FOR THIS APCH. CONTRIBUTING FACTORS: THIS WAS A SHORT LEG WITH A DEP PROC (SID) OUTBOUND AND ARR INBOUND AND MULTIPLE HDG AND ALT CHANGES FROM SOCAL PRIOR TO APCH. THE APCH WAS BRIEFED EARLY, BUT COCKPIT WAS BUSY DURING THIS LEG WHICH LED TO OVERSIGHT OF THE STEP-DOWN FIX WHICH WAS PERCEIVED BY US TO BE NON APPLICABLE. WE, AS CREW, LEARNED FROM THIS AND WILL BE MUCH MORE ATTENTIVE TO PROCEDURAL NOTES IN THE FUTURE. SUPPLEMENTAL INFO FROM ACN 606016: ON THE APCH PLATE, THERE ARE 2 DIFFERENT MDA'S NOTED. ONE IS THE MDA COLUMN THAT STATES 'WITH CULVE.' THE OTHER STATES 'WITHOUT CULVE.' WE KNOW THAT WE COULD IDENT CULVE AS THE 2.4 DME FROM SMO VOR. THIS IS THE ONLY WAY TO IDENT CULVE AND THE PROCEDURAL NOTE AND THE 2 DIFFERENT MDA'S CAN BE CONFUSING TO PLTS REVIEWING THIS CHART.
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.