37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 673430 |
Time | |
Date | 200509 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : hln.airport |
State Reference | MT |
Altitude | msl bound lower : 8100 msl bound upper : 10000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : hln.tower tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Light Transport |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 27 |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 180 flight time total : 3800 flight time type : 1100 |
ASRS Report | 673430 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far non adherence : published procedure non adherence : company policies other spatial deviation |
Independent Detector | aircraft equipment : gpws |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance Airspace Structure Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
On a flight from gtf to hln on V21; we received clearance to intercept hln 15 mile arc (336 degree right); and maintain 10000 ft until established. We had briefed the approach (also on ground at gtf); completed appropriate checklists and set up the FMS to intercept the arc inside the 336 degree radial; between the step-down fix at the 053 degree radial. Autoplt was on. Looking at the chart; once we reported to tower we were on the arc at 10000 ft; we were cleared approach. I was pilot flying; asked for 8100 ft on alerter. Began descent to 8100 ft before the 053 degree radial. Seconds later; egpws 'terrain; terrain' -- no action taken because no visible terrain on our display. We only received one warning and shortly thereafter reached the 053 degree radial where 8100 ft was the minimum altitude. We both missed the '10000 nopt' way up on the top of the commercial plate. Captain had been flying type/model for 10 yrs with numerous trips into hln in VMC/IMC. I have been in type/model for 2 yrs also with numerous trips to hln on this approach in IMC. I feel this chart needs to be more clear. 10000 ft min altitude is easy to miss; very short segment on chart. Non radar environment also didn't help. Callback conversation with reporter revealed the following information: reporter stated that the approach chart used was the hln ILS runway 27. He also stated that his air carrier told him that they contacted the chart manufacturer about this issue. The reporter also reiterated that both he and the captain have flown this approach numerous times and had missed the descend constraint.
Original NASA ASRS Text
Title: A LIGHT TRANSPORT PLT RPTS MISREADING THE HLN RWY 27 ILS COMMERCIAL APCH CHART AND RECEIVING AN EGPWS 'TERRAIN' WARNING AFTER COMMENCING AN EARLY DSCNT FROM 10000 FT.
Narrative: ON A FLT FROM GTF TO HLN ON V21; WE RECEIVED CLRNC TO INTERCEPT HLN 15 MILE ARC (336 DEG R); AND MAINTAIN 10000 FT UNTIL ESTABLISHED. WE HAD BRIEFED THE APCH (ALSO ON GND AT GTF); COMPLETED APPROPRIATE CHKLISTS AND SET UP THE FMS TO INTERCEPT THE ARC INSIDE THE 336 DEG RADIAL; BETWEEN THE STEP-DOWN FIX AT THE 053 DEG RADIAL. AUTOPLT WAS ON. LOOKING AT THE CHART; ONCE WE RPTED TO TWR WE WERE ON THE ARC AT 10000 FT; WE WERE CLRED APCH. I WAS PLT FLYING; ASKED FOR 8100 FT ON ALERTER. BEGAN DSCNT TO 8100 FT BEFORE THE 053 DEG RADIAL. SECONDS LATER; EGPWS 'TERRAIN; TERRAIN' -- NO ACTION TAKEN BECAUSE NO VISIBLE TERRAIN ON OUR DISPLAY. WE ONLY RECEIVED ONE WARNING AND SHORTLY THEREAFTER REACHED THE 053 DEG RADIAL WHERE 8100 FT WAS THE MINIMUM ALT. WE BOTH MISSED THE '10000 NOPT' WAY UP ON THE TOP OF THE COMMERCIAL PLATE. CAPT HAD BEEN FLYING TYPE/MODEL FOR 10 YRS WITH NUMEROUS TRIPS INTO HLN IN VMC/IMC. I HAVE BEEN IN TYPE/MODEL FOR 2 YRS ALSO WITH NUMEROUS TRIPS TO HLN ON THIS APCH IN IMC. I FEEL THIS CHART NEEDS TO BE MORE CLEAR. 10000 FT MIN ALT IS EASY TO MISS; VERY SHORT SEGMENT ON CHART. NON RADAR ENVIRONMENT ALSO DIDN'T HELP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE APCH CHART USED WAS THE HLN ILS RWY 27. HE ALSO STATED THAT HIS ACR TOLD HIM THAT THEY CONTACTED THE CHART MANUFACTURER ABOUT THIS ISSUE. THE RPTR ALSO REITERATED THAT BOTH HE AND THE CAPT HAVE FLOWN THIS APCH NUMEROUS TIMES AND HAD MISSED THE DSND CONSTRAINT.
Data retrieved from NASA's ASRS site as of January 2009 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.