CAPT OF AN MLG BECAME DISORIENTED DURING DSCNT FOR A DME ARC APCH AND DSNDED BELOW THE MSA PRESCRIBED.

Date: 1994-11 · Aircraft: MD-83

Anomalies: aircraft-equipment-problem-less-severe|deviation-altitude-overshoot|deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-cftt-cfit

Synopsis

CAPT OF AN MLG BECAME DISORIENTED DURING DSCNT FOR A DME ARC APCH AND DSNDED BELOW THE MSA PRESCRIBED.

Narrative

THE FLT WAS A CHARTER FROM PDX TO EKO ON NOV/XX/94. CAPT WAS PF; APPROX 6700 TOTAL; 1700 IN TYPE; 60 AS PIC. FO WAS A NEW HIRE; APPROX 1 MONTH ON LINE. TIME IN TYPE UNKNOWN. FLT INTO EKO WAS FIRST TIME FOR CAPT; SECOND TIME FOR FO. DURING PREFLT BRIEF; I DISCUSSED THE FACT THAT THE COMPANY OP SPECS DID NOT ALLOW FOR LDA APCHS; AND IF VISUAL WAS NOT AVAILABLE; A VOR DME-B CIRCLING WOULD BE NECESSARY TO SUCCESSFULLY COMPLETE THE FLT. OP SPECS DICTATE THAT ANY CIRCLING APCH BE CONDUCTED IN CONDITIONS NOT LESS THAN 1000 FT 3 MI. SINCE I WAS A 'HI- MINS' CAPT; THE MANEUVER WOULD BE FLOWN AT 1200 FT TO 3 1/2 MI. AT DEP TIME; WX WAS RPTED AS 13 SCATTERED M22 OVCST 10 SW; RWY 34/30/0000/997. WE DISCUSSED OUR CONCERNS REGARDING ICING CONDITIONS AND TERRAIN; NOTING THE LOCATION OF PEAKS NEAR THE ARPT. THE 2600 FT DIFFERENCE IN MSA ALT REQUIREMENTS WAS ALSO MENTIONED; WITH MYSELF EXPRESSING A DESIRE TO STAY IN THE 'LESS MOUNTAINOUS' SECTOR OF THE MSA. ALL NORMAL PROCS WERE CONDUCTED TO LEVEL CRUISE. CONTRIBUTING FACTORS: IN-RANGE OF EKO; FO PICKED UP LCL WX FROM AWOS-3 WHICH RPTED 22 SCATTERED 27 BROKEN 32 BROKEN 10 SW RWY 36/31/0000/998. AFTER THAT; COMS WAS ATTEMPTED WITH CONTRACT CUSTOMER OPS; BUT WAS UNANSWERED. SINCE WE HAD PAX REQUIRING WHEELCHAIRS; I ADVISED FO TO MAKE ANOTHER ATTEMPT CLOSER TO EKO. AS WE APCHED EKO; ZLC INQUIRED IF WE WOULD LIKE THE LDA APCH. AFTER ADVISING THAT WE WERE UNABLE LDA; I ASKED WHAT THE MINIMUM VECTORING ALT WAS ALONG THE LDA COURSE; AND WAS ADVISED BY CTR THAT IT WAS 11000 FT MSL. SEEING THAT A VISUAL APCH WAS IMPOSSIBLE; I INSTRUCTED FO TO GET THE LATEST AWOS-3; AND REQUESTED VECTORS TO THE BQU 241 DEG RADIAL 10 DME ARC IAF; REASONING THAT I WANTED TO STAY AS FAR AWAY AS POSSIBLE FROM THE 11000 FT PLUS PEAKS JUST E OF THE ARPT. NORMAL DSCNT CHK AND APCH BRIEFING WERE ACCOMPLISHED PRIOR TO TRANSITION FROM FL180. CTR CLRED US DOWN TO 11000 FT AS WE APCHED THE 10 DME ARC. I WAS STILL CONCERNED ABOUT THE WX; AND SINCE WE WERE ABOVE 10000 FT MSL; I TOLD THE FO TO CHK AWOS-3 ONCE MORE; AND GIVE THE CONTRACT OPS 1 MORE TRY. ALMOST SIMULTANEOUSLY; CTR ADVISED: 'MAINTAIN 11000 FT UNTIL ESTABLISHED ON THE 10 DME ARC; CLRED FOR THE VOR-B APCH. CONTACT ELKO TWR 126.5.' I COULD SEE THAT THE FO WAS EITHER GETTING LATEST WX OR TALKING TO CONTRACT OPS; (WHICH INDEED WAS THE CASE) AND THOUGHT THAT HE WOULD BE BACK UP WITH ME VERY SOON; SO I CALLED THE TWR MYSELF. THEY ADVISED: 'RPT INBOUND.' THE 10 DME ARC (W) SPECIFIES 9500 FT MSL AND AS I APCHED 11000 FT THE FO ADVISED THAT HE WAS 'BACK WITH ME.' THE FOLLOWING EVENTS OCCURRED IN A TIME SPAN OF APPROX 15 SECONDS. WHEN WE PASSED THROUGH 10500 FT; THE FO ADVISED '1000 FT TO GO.' AS WE PASSED 9700 FT; I NOTICED THAT THE FLT MODE ANNUNCIATOR DID NOT SHOW ALT ARM. SINCE THE DIGITAL FLT GUIDANCE SYS DID NOT CAPTURE ALT; AND WE WERE STILL DSNDING AT APPROX 1000 FPM; I INSTRUCTED THE FO TO SELECT ALT HOLD. WHEN IT WAS APPARENT THAT THE AUTOPLT WOULD NOT LEVEL US IN TIME; I DISCONNECTED THE AUTOPLT AND HAND FLEW THE CAPT. JUST AS WE WERE LEVELING OFF; THE AUTO THROTTLES DISCONNECTED WITH THE PWR SET NEARLY IDLE. THIS WAS NOT IMMEDIATELY APPARENT; AS I WAS ATTEMPTING TO KEEP THE AIRPLANE FROM BUSTING OUR INITIAL APCH SEGMENT ALT OF 9500 FT. THE RESULTANT LOSS OF AIRSPD WAS RATHER QUICK; AND I WAS TRYING TO FIGURE OUT WHY WE WERE LOSING SPD. HOW IT WAS DISCOVERED: AS STATED BEFORE; ALL THIS OCCURRED WITHIN THAT VERY SHORT TIME SPAN; AND I REACTED TO THE SPD LOSS BY APPLYING PWR AND RE-ENGAGING AUTOTHROTTLES; WHICH WERE NOW WORKING NORMALLY. AS I WAS 'FIXING' OUR MULTIPLE PROBS; EKO TWR CALLED AND SAID ' RADIO CHK.' WHY HE DID THIS; I CAN'T SAY; BUT I WAS STILL UNABLE TO GET AN ALT CAPT AND WAS INSTRUCTING MY FO TO RE-ARM THE ALT; WHEN THIS CALL CAME FROM TWR. I ANSWERED TWR AND WAS DISTR TO THE POINT THAT I NOW HAD LOST SITUATIONAL AWARENESS; AND FOR AN INEXPLICABLE REASON; THE RMI MADE NO SENSE TO ME. WE WERE NOW AT APPROX. 8 DME AND OFF THE ARC. WE WERE IN AND OUT OF IMC AND AS I MADE OCCASIONAL VISUAL GND CONTACT; I LOOKED OUT THE FO'S WINDOW AND SAW COMPLETE 'BLACK HOLE.' THAT IS; I COULD NOT DISCERN THE GND; SKY OR EVEN A HORIZON LINE. I ASKED THE FO WHAT THE MSA WAS FOR OUR SECTOR AND HE SAID 12000 FT.' (WHICH ACTUALLY WAS THE E ARC PUBLISHED ALT.) DURING THOSE LAST FEW SECONDS; I SAW OCCASIONAL INDICATIONS ON THE RADAR ALTIMETER 'TAPE' ON THE EFIS. SINCE WE WERE SUPPOSED TO BE ABOUT 4000 FT AGL; AND THE TAPE DOESN'T START INDICATING UNTIL ABOUT 2500 FT AGL; COMBINED WITH THE 'BLACK HOLE' I WAS LOOKING AT; MY SENSES WERE TELLING ME THAT SOMETHING WAS DEFINITELY WRONG. I BECAME VERY CONCERNED THAT WE WERE IN IMMINENT DANGER OF CTLED FLT INTO TERRAIN; EVEN THOUGH THERE WAS NO GPWS WARNING. I IMMEDIATELY CALLED FOR CLB PWR AND TOLD THE FO TO SET 12000 FT. AS WE CLBED; AND HAD NO OTHER DISTRS I WAS ABLE TO 'RE-ACQUIRE' MY NAV AWARENESS AND REALIZED THAT WE WERE ONLY A MI OR SO INSIDE THE ARC; BUT WERE E OF OUR INTENDED TRACK. I GOT THE AIRPLANE RE-ESTABLISHED ON THE ARC; DSNDED BACK TO 9500 FT MSL (S OF THE 241 DEG RADIAL) AND COMPLETED THE APCH. THE CIRCLING MANEUVER ITSELF WAS RATHER CLOSE IN; BUT AGAIN I WAS SEEING THE 'BLACK HOLD' SYNDROME OUT THE R SIDE OF THE ACFT AS WE MADE OUR L DOWNWIND TO RWY 23. I WAS VERY APPREHENSIVE OF MAKING THE DOWNWIND ANY FURTHER S OF THE RWY THAN I WAS. THE SUBSEQUENT TURN TO BASE AND FINAL LEFT US ABOUT A 1/4 MI N OF THE RWY EXTENDED CTRLINE. WINDS WERE CALM AND IT TOOK MINIMAL TURNING TO GET ALIGNED WITH THE RWY. A NORMAL LNDG WAS MADE; AND WE PARKED ON THE RAMP. PERCEPTIONS; JUDGEMENTS; DECISIONS: I BELIEVE THAT A COMBINATION OF FACTORS (CREW INEXPERIENCE; MARGINAL WX; MULTIPLE DISTRS) WAS THE CAUSE OF OUR PROB. I MAY HAVE PRE-MATURELY INITIATED THE CLB TO 12000 FT; BUT NOT BEING ABLE TO SEE THE GND AND THE 'BLACK HOLE' PART OF THE GND I COULD SEE 'RAISED THE RED FLAG.' HAVING BEEN A CHK AIRMAN; GND AND SIMULATOR INSTRUCTOR; 1 OF MY CONSTANT EDICTS TO STUDENTS WAS: 'WHEN YOU DO FIND YOURSELF IN TROUBLE; DON'T HESITATE TO TAKE CORRECTIVE ACTION NOW.' I GENUINELY FELT AT THE TIME; THAT HAD I NOT INITIATED THAT CLB; THAT I COULD RUN INTO 1 OF THOSE CLOSE-BY PEAKS. I BELIEVE THAT IF WE WERE ABLE TO SHOOT THE LDA APCH; NONE OF THIS WOULD HAVE OCCURRED.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.