Narrative:

My first officer was flying into portland, or. I was PNF. WX was 700 ft broken, 5 mi visibility, and calm wind. We were expecting to shoot ILS runway 10R at pdx. We briefed the approach plate 11-2 together during the cruise phase as a part of our descent procedure. The final approach instruction from portland approach to intercept localizer on ILS runway 10R was something like, 'you are 4 mi from yorky (FAF), turn right heading 070 degrees, maintain 3000 ft till established on localizer, cleared ILS runway 10R approach, GS had just gone OTS.' we quickly looked at the approach plate to review localizer approach. When the first officer started a revised approach briefing, localizer was alive (intercepting localizer). So the first officer made a quick briefing such as, 'this will be a localizer only approach, everything is same as briefed earlier except 2100 ft until yorky, MDA is 380 ft, required visibility is 1/2 mi or 2400 ft RVR, and missed approach is 2.0 DME,' while he was flying the localizer and descending to 2100 ft. The approach controller told us to contact portland tower before yorky. When I checked on tower frequency, the tower controller reminded us again about glide path OTS, saying 'cleared to land runway 10R, ILS glide path OTS.' at yorky, I, as a PNF, called 'yorky, instruments and altitude crosschecked, missed approach 2.0 DME,' and set MDA 380 ft on altitude alerter. The first officer as a PF started descent. The first officer made a descent steeper than 3 degrees glide path, as we usually do for the non precision approach, and was slowing the airspeed to the final approach speed. At 880 ft, I made a '500 ft to go' call to remind our MDA as is our standard procedures. I was not checking the DME. The tower controller suddenly told us 'altitude alert!,' and asked us 'what is your DME readout?' at that moment, I realized that there is a stepdown fix at 4.5 DME and the minimum crossing altitude is 860 ft. We both completely missed the existence of the 4.5 DME fix. We were already below and descending. The controller further said 'check your altitude, altimeter 30.15 inches.' the first officer realized it too and immediately stopped descent and climbed. We reached approximately 700 ft MSL. I saw DME showing 4.2, and the runway. The first officer called 'runway in sight, landing.' we were established on the 3 degree glide path with a reference to VASI, and landed on runway 10R uneventfully. Contributing factors: sudden notice of glide path OTS (it was not on NOTAM or on ATIS) gave us an insufficient time to review the approach chart and prepare for the approach. Increased workload: the first officer had to do the approach briefing while hand flying the localizer, descending and leveling off. I had to review the approach briefing while setting the altitude alerter, making the required callouts, and talking to ATC. Distraction: the WX condition was changing from IMC to VMC. We didn't see the runway yet when this event occurred, but had visual reference with the terrain below us. Our focus became more to the outside of the cockpit when we should have concentrated more on our approach plate and flight instruments. Familiarity: this is the approach plate we most frequently use. We use it on a daily basis which has allowed us to almost memorize it. Even when unusual instructions like this occurred, we didn't take time to carefully review the chart as we would have if we were shooting an approach at another airport. Fatigue: it was the last day of our 4-DAY trip. The first 3 days were an afternoon to late night shift, but the last day changed to an early morning shift after the 9 hours reduced rest. We didn't feel tired, but it might be a part of the cause for making a simple mistake. Corrective actions: flight crew: we should review the chart more carefully. If we require more time to prepare for the approach, we should request a delay vector. We could have used the autoplt to reduce pilot's workload. Company: the company must respect importance of quality rest. They should avoid making mix-match trips (ie, changing a duty time from early morning to late night, or vice versa, especially after reduced rest). ATC: it would be helpful if they give pilots any unexpected changes as soon as possible. Supplemental information from acn 632807: my hands were then completely full, trying to slow this thing down to gear speed so we could configure for landing. Captain had failed to set stepdown altitude after FAF and had set MDA. I should have hit the autoplt 'on' button. Other factors: our approach plate holders are too small! They support the upper 2/3 of the plate, below that the plate droops over. If you want to read the visibility requirements or look at the profile, you have to reach down and pick it up with your fingers! Language barrier: captain is a japanese national with good english skills, but not to where you can chit-chat back-and-forth on approach to discuss it and ascertain if they're still in the loop or not.

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Original NASA ASRS Text

Title: FLT CREW OF DH8B, ADVISED OF GS OUT JUST PRIOR TO STARTING AN ILS TO RWY 10R AT PDX, FAIL TO DETECT STEPDOWN FIX AND DSND BELOW PROC ALT. MSAW FROM TWR ALERTS THEM TO CORRECT.

Narrative: MY FO WAS FLYING INTO PORTLAND, OR. I WAS PNF. WX WAS 700 FT BROKEN, 5 MI VISIBILITY, AND CALM WIND. WE WERE EXPECTING TO SHOOT ILS RWY 10R AT PDX. WE BRIEFED THE APCH PLATE 11-2 TOGETHER DURING THE CRUISE PHASE AS A PART OF OUR DSCNT PROC. THE FINAL APCH INSTRUCTION FROM PORTLAND APCH TO INTERCEPT LOC ON ILS RWY 10R WAS SOMETHING LIKE, 'YOU ARE 4 MI FROM YORKY (FAF), TURN R HDG 070 DEGS, MAINTAIN 3000 FT TILL ESTABLISHED ON LOC, CLRED ILS RWY 10R APCH, GS HAD JUST GONE OTS.' WE QUICKLY LOOKED AT THE APCH PLATE TO REVIEW LOC APCH. WHEN THE FO STARTED A REVISED APCH BRIEFING, LOC WAS ALIVE (INTERCEPTING LOC). SO THE FO MADE A QUICK BRIEFING SUCH AS, 'THIS WILL BE A LOC ONLY APCH, EVERYTHING IS SAME AS BRIEFED EARLIER EXCEPT 2100 FT UNTIL YORKY, MDA IS 380 FT, REQUIRED VISIBILITY IS 1/2 MI OR 2400 FT RVR, AND MISSED APCH IS 2.0 DME,' WHILE HE WAS FLYING THE LOC AND DSNDING TO 2100 FT. THE APCH CTLR TOLD US TO CONTACT PORTLAND TWR BEFORE YORKY. WHEN I CHKED ON TWR FREQ, THE TWR CTLR REMINDED US AGAIN ABOUT GLIDE PATH OTS, SAYING 'CLRED TO LAND RWY 10R, ILS GLIDE PATH OTS.' AT YORKY, I, AS A PNF, CALLED 'YORKY, INSTS AND ALT XCHKED, MISSED APCH 2.0 DME,' AND SET MDA 380 FT ON ALT ALERTER. THE FO AS A PF STARTED DSCNT. THE FO MADE A DSCNT STEEPER THAN 3 DEGS GLIDE PATH, AS WE USUALLY DO FOR THE NON PRECISION APCH, AND WAS SLOWING THE AIRSPD TO THE FINAL APCH SPD. AT 880 FT, I MADE A '500 FT TO GO' CALL TO REMIND OUR MDA AS IS OUR STANDARD PROCS. I WAS NOT CHKING THE DME. THE TWR CTLR SUDDENLY TOLD US 'ALT ALERT!,' AND ASKED US 'WHAT IS YOUR DME READOUT?' AT THAT MOMENT, I REALIZED THAT THERE IS A STEPDOWN FIX AT 4.5 DME AND THE MINIMUM XING ALT IS 860 FT. WE BOTH COMPLETELY MISSED THE EXISTENCE OF THE 4.5 DME FIX. WE WERE ALREADY BELOW AND DSNDING. THE CTLR FURTHER SAID 'CHK YOUR ALT, ALTIMETER 30.15 INCHES.' THE FO REALIZED IT TOO AND IMMEDIATELY STOPPED DSCNT AND CLBED. WE REACHED APPROX 700 FT MSL. I SAW DME SHOWING 4.2, AND THE RWY. THE FO CALLED 'RWY IN SIGHT, LNDG.' WE WERE ESTABLISHED ON THE 3 DEG GLIDE PATH WITH A REF TO VASI, AND LANDED ON RWY 10R UNEVENTFULLY. CONTRIBUTING FACTORS: SUDDEN NOTICE OF GLIDE PATH OTS (IT WAS NOT ON NOTAM OR ON ATIS) GAVE US AN INSUFFICIENT TIME TO REVIEW THE APCH CHART AND PREPARE FOR THE APCH. INCREASED WORKLOAD: THE FO HAD TO DO THE APCH BRIEFING WHILE HAND FLYING THE LOC, DSNDING AND LEVELING OFF. I HAD TO REVIEW THE APCH BRIEFING WHILE SETTING THE ALT ALERTER, MAKING THE REQUIRED CALLOUTS, AND TALKING TO ATC. DISTR: THE WX CONDITION WAS CHANGING FROM IMC TO VMC. WE DIDN'T SEE THE RWY YET WHEN THIS EVENT OCCURRED, BUT HAD VISUAL REF WITH THE TERRAIN BELOW US. OUR FOCUS BECAME MORE TO THE OUTSIDE OF THE COCKPIT WHEN WE SHOULD HAVE CONCENTRATED MORE ON OUR APCH PLATE AND FLT INSTS. FAMILIARITY: THIS IS THE APCH PLATE WE MOST FREQUENTLY USE. WE USE IT ON A DAILY BASIS WHICH HAS ALLOWED US TO ALMOST MEMORIZE IT. EVEN WHEN UNUSUAL INSTRUCTIONS LIKE THIS OCCURRED, WE DIDN'T TAKE TIME TO CAREFULLY REVIEW THE CHART AS WE WOULD HAVE IF WE WERE SHOOTING AN APCH AT ANOTHER ARPT. FATIGUE: IT WAS THE LAST DAY OF OUR 4-DAY TRIP. THE FIRST 3 DAYS WERE AN AFTERNOON TO LATE NIGHT SHIFT, BUT THE LAST DAY CHANGED TO AN EARLY MORNING SHIFT AFTER THE 9 HRS REDUCED REST. WE DIDN'T FEEL TIRED, BUT IT MIGHT BE A PART OF THE CAUSE FOR MAKING A SIMPLE MISTAKE. CORRECTIVE ACTIONS: FLT CREW: WE SHOULD REVIEW THE CHART MORE CAREFULLY. IF WE REQUIRE MORE TIME TO PREPARE FOR THE APCH, WE SHOULD REQUEST A DELAY VECTOR. WE COULD HAVE USED THE AUTOPLT TO REDUCE PLT'S WORKLOAD. COMPANY: THE COMPANY MUST RESPECT IMPORTANCE OF QUALITY REST. THEY SHOULD AVOID MAKING MIX-MATCH TRIPS (IE, CHANGING A DUTY TIME FROM EARLY MORNING TO LATE NIGHT, OR VICE VERSA, ESPECIALLY AFTER REDUCED REST). ATC: IT WOULD BE HELPFUL IF THEY GIVE PLTS ANY UNEXPECTED CHANGES AS SOON AS POSSIBLE. SUPPLEMENTAL INFO FROM ACN 632807: MY HANDS WERE THEN COMPLETELY FULL, TRYING TO SLOW THIS THING DOWN TO GEAR SPD SO WE COULD CONFIGURE FOR LNDG. CAPT HAD FAILED TO SET STEPDOWN ALT AFTER FAF AND HAD SET MDA. I SHOULD HAVE HIT THE AUTOPLT 'ON' BUTTON. OTHER FACTORS: OUR APCH PLATE HOLDERS ARE TOO SMALL! THEY SUPPORT THE UPPER 2/3 OF THE PLATE, BELOW THAT THE PLATE DROOPS OVER. IF YOU WANT TO READ THE VISIBILITY REQUIREMENTS OR LOOK AT THE PROFILE, YOU HAVE TO REACH DOWN AND PICK IT UP WITH YOUR FINGERS! LANGUAGE BARRIER: CAPT IS A JAPANESE NATIONAL WITH GOOD ENGLISH SKILLS, BUT NOT TO WHERE YOU CAN CHIT-CHAT BACK-AND-FORTH ON APCH TO DISCUSS IT AND ASCERTAIN IF THEY'RE STILL IN THE LOOP OR NOT.

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.