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|
Attributes | |
ACN | 778460 |
Time | |
Date | 200803 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mso.airport |
State Reference | MT |
Altitude | msl bound lower : 10000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tracon : geg.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 778460 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
ASRS Report | 778461 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were descending into missoula and had been cleared via the mullan pass transition to the localizer for runway 11. We were set up for the ILS 11 approach and briefed it earlier. When we checked in with approach we were given a heading for vectors to the VOR-DME B approach to runway 29; and further descent to 12000 ft. I quickly reprogrammed the FMS for the VOR-DME B approach and the first officer (PF) began briefing the new approach. I asked the controller if we could expect vectors or the DME arc. She responded that either would be fine and that the arc would allow us to get lower than she could vector us. Since it looked like we were being vectored toward the stevi intersection and the arc was already programmed in the FMS; I asked if we could go direct ocevo the IAF approximately 5 mi ahead of our position. She cleared us direct ocevo; maintain 12000 ft until established on the arc; cleared for the approach. We proceeded direct ocevo and began to finish the approach briefing. Approximately 5-8 mi after crossing ocevo; the controller said that her approach plate indicated that we should be at 12000 ft. I looked down at the approach plate and it did indicate that we should be at 12000 ft; we were level at 10000 ft. We immediately climbed to 12000 ft at the same time the controller issued a climb clearance. We were VMC with clouds below us obscuring the terrain and did not receive a ground proximity warning. The controller confirmed that we were to be at 12000 ft until crossing the 173 degree radial at which time we could descend to 9800 ft and continue the approach and told us to contact tower. I concurred; thanked her for her help and contacted tower. We landed without incident. Here is what I believe to be some of the contributing factors that caused us to end up low on the arc. When we crossed the IAF ocevo; I may have referenced the other IAF on the approach chart that has a very similar name of oceda instead of ocevo. The minimum altitude after oceda is 10000 ft; while the minimum altitude after ocevo is 12000 ft. We were given a last min change to our planned approach which caused us to do some last min programming of the FMS and briefing of the approach. The last min changes to the approach; the approach briefing; my monitoring the first officer who was flying the approach; and the similar named initial approach fixes may have caused enough of a distraction for me to reference the wrong altitude on the chart. Supplemental information from acn 778461: we were starting our descent into missoula; leaving around 15000 ft; set up for the naptn ILS runway 11 approach. I am on IOE. It still takes me a little longer than normal to set up the approach in the FMS. The winds favored runway 29 so we asked for the VOR DME or GPS-B approach. ATC cleared us for the approach and sent us direct to ocevo to join the 16 DME arc. That's where the problem happened. We confused ocevo for oceda on the approach plate. We joined the arc at 12000 ft; and when we were established; my captain dialed in 10000 ft and we started descending down to 10000 ft. We were in VMC and could see the terrain. ATC called us when we were at around 10900 ft and told us we were in a low terrain area and needed to stop descending and climb immediately back up to 12000 ft. We did that and no further words or actions were taken. This event occurred because I was reprogramming the FMS for the new approach. My captain was watching me making sure I was following the right procedures since I am on IOE. This was the first approach I've done that's involved an arc so it probably took me a little longer than usual to make sure everything was set up correctly. That's where we confused ocevo with oceda.
Original NASA ASRS Text
Title: FLT CREW DESCENDS EARLY ON THE WESTERN ARC OF THE VOR DME B APPROACH TO MSO. ERROR IS CAUGHT BY ATC.
Narrative: WE WERE DSNDING INTO MISSOULA AND HAD BEEN CLRED VIA THE MULLAN PASS TRANSITION TO THE LOC FOR RWY 11. WE WERE SET UP FOR THE ILS 11 APCH AND BRIEFED IT EARLIER. WHEN WE CHKED IN WITH APCH WE WERE GIVEN A HDG FOR VECTORS TO THE VOR-DME B APCH TO RWY 29; AND FURTHER DSCNT TO 12000 FT. I QUICKLY REPROGRAMMED THE FMS FOR THE VOR-DME B APCH AND THE FO (PF) BEGAN BRIEFING THE NEW APCH. I ASKED THE CTLR IF WE COULD EXPECT VECTORS OR THE DME ARC. SHE RESPONDED THAT EITHER WOULD BE FINE AND THAT THE ARC WOULD ALLOW US TO GET LOWER THAN SHE COULD VECTOR US. SINCE IT LOOKED LIKE WE WERE BEING VECTORED TOWARD THE STEVI INTXN AND THE ARC WAS ALREADY PROGRAMMED IN THE FMS; I ASKED IF WE COULD GO DIRECT OCEVO THE IAF APPROX 5 MI AHEAD OF OUR POS. SHE CLRED US DIRECT OCEVO; MAINTAIN 12000 FT UNTIL ESTABLISHED ON THE ARC; CLRED FOR THE APCH. WE PROCEEDED DIRECT OCEVO AND BEGAN TO FINISH THE APCH BRIEFING. APPROX 5-8 MI AFTER XING OCEVO; THE CTLR SAID THAT HER APCH PLATE INDICATED THAT WE SHOULD BE AT 12000 FT. I LOOKED DOWN AT THE APCH PLATE AND IT DID INDICATE THAT WE SHOULD BE AT 12000 FT; WE WERE LEVEL AT 10000 FT. WE IMMEDIATELY CLBED TO 12000 FT AT THE SAME TIME THE CTLR ISSUED A CLB CLRNC. WE WERE VMC WITH CLOUDS BELOW US OBSCURING THE TERRAIN AND DID NOT RECEIVE A GND PROX WARNING. THE CTLR CONFIRMED THAT WE WERE TO BE AT 12000 FT UNTIL XING THE 173 DEG RADIAL AT WHICH TIME WE COULD DSND TO 9800 FT AND CONTINUE THE APCH AND TOLD US TO CONTACT TWR. I CONCURRED; THANKED HER FOR HER HELP AND CONTACTED TWR. WE LANDED WITHOUT INCIDENT. HERE IS WHAT I BELIEVE TO BE SOME OF THE CONTRIBUTING FACTORS THAT CAUSED US TO END UP LOW ON THE ARC. WHEN WE CROSSED THE IAF OCEVO; I MAY HAVE REFED THE OTHER IAF ON THE APCH CHART THAT HAS A VERY SIMILAR NAME OF OCEDA INSTEAD OF OCEVO. THE MINIMUM ALT AFTER OCEDA IS 10000 FT; WHILE THE MINIMUM ALT AFTER OCEVO IS 12000 FT. WE WERE GIVEN A LAST MIN CHANGE TO OUR PLANNED APCH WHICH CAUSED US TO DO SOME LAST MIN PROGRAMMING OF THE FMS AND BRIEFING OF THE APCH. THE LAST MIN CHANGES TO THE APCH; THE APCH BRIEFING; MY MONITORING THE FO WHO WAS FLYING THE APCH; AND THE SIMILAR NAMED INITIAL APCH FIXES MAY HAVE CAUSED ENOUGH OF A DISTR FOR ME TO REF THE WRONG ALT ON THE CHART. SUPPLEMENTAL INFO FROM ACN 778461: WE WERE STARTING OUR DSCNT INTO MISSOULA; LEAVING AROUND 15000 FT; SET UP FOR THE NAPTN ILS RWY 11 APCH. I AM ON IOE. IT STILL TAKES ME A LITTLE LONGER THAN NORMAL TO SET UP THE APCH IN THE FMS. THE WINDS FAVORED RWY 29 SO WE ASKED FOR THE VOR DME OR GPS-B APCH. ATC CLRED US FOR THE APCH AND SENT US DIRECT TO OCEVO TO JOIN THE 16 DME ARC. THAT'S WHERE THE PROB HAPPENED. WE CONFUSED OCEVO FOR OCEDA ON THE APCH PLATE. WE JOINED THE ARC AT 12000 FT; AND WHEN WE WERE ESTABLISHED; MY CAPT DIALED IN 10000 FT AND WE STARTED DSNDING DOWN TO 10000 FT. WE WERE IN VMC AND COULD SEE THE TERRAIN. ATC CALLED US WHEN WE WERE AT AROUND 10900 FT AND TOLD US WE WERE IN A LOW TERRAIN AREA AND NEEDED TO STOP DSNDING AND CLB IMMEDIATELY BACK UP TO 12000 FT. WE DID THAT AND NO FURTHER WORDS OR ACTIONS WERE TAKEN. THIS EVENT OCCURRED BECAUSE I WAS REPROGRAMMING THE FMS FOR THE NEW APCH. MY CAPT WAS WATCHING ME MAKING SURE I WAS FOLLOWING THE RIGHT PROCS SINCE I AM ON IOE. THIS WAS THE FIRST APCH I'VE DONE THAT'S INVOLVED AN ARC SO IT PROBABLY TOOK ME A LITTLE LONGER THAN USUAL TO MAKE SURE EVERYTHING WAS SET UP CORRECTLY. THAT'S WHERE WE CONFUSED OCEVO WITH OCEDA.
Data retrieved from NASA's ASRS site as of May 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.