ALERT
BULLETIN
AB 2016:6/7-1
4/14/2015
1325107, 1316858, 1301204, 1294119
TO:
FAA (AJV-1, ATM NCT TRACON)
INFO:
FAA (AVP-1, AVP-200, ATM SFO Tower, AWP-600, AFS-280, AFS-200, AFS -400,
Director of Air Traffic Operations WSA South), A4A, ALPA, AOPA, APA, ASAP,
CAPA, ATSAP, ATSG, IATA, ICAO, ICASS, IFALPA, IPA, NATCA, NBAA, NTSB,
RAA, USAPA
FROM: Linda J. Connell, Director
NASA Aviation Safety Reporting System
SUBJ: SFO DYAMD2 RNAV STAR ARCHI NOTAM
We recently received an ASRS report describing a safety concern which may involve your area of operational
responsibility. We do not have sufficient details to assess either the factual accuracy or possible gravity of the
report. It is our policy to relay the reported information to the appropriate authority for evaluation and any
necessary follow-up. We feel you should be aware of the following:
ASRS has received several reports from flight crews describing altitude and
airspace deviations while on the SFO DYAMD2 RNAV STAR. Reporters have
stated the altitude crossing restriction at ARCHI was changed from 7,000 FT to
8,000 FT via NOTAM, which is frequently missed by flight crews.
(ACN 1325107) An A320 crew missed the SFO DYAMD TWO Arrival ARCHI
NOTAM changing the ARCHI waypoint crossing restriction to 8,000 feet from the
published 7,000 feet. Crew descended below SFO Class B.
(ACN 1316858) A Captain reported he was concerned with the SFO DYAMD TWO
arrival crossing restriction appearing in NOTAM form but not yet charted.
(ACN 1301204) Air Carrier flight crew flying the SFO DYAMD RNAV arrival crossed
ARCHI at 7,000 feet and were informed by NCT a NOTAM was issued changing the
ARCHI constraint to 8,000 feet, the SFO Class B floor in that area.
(ACN 1294119) An air carrier pilot described the design error and conflict between
the SFO DYAMD RNAV Arrival 7,000 foot ARCHI constraint below Class B and the
FMS BRIDGE Visual and the QUIET BRIDGE Visual 8,000 foot ARCHI constraint.
To properly assess the usefulness of our alert message service, we would appreciate it if
you would take the time to give us your feedback on the value of the information that we
have provided. Please contact Dennis Doyle at (408) 541-2831 or email at
[email protected]
Aviation Safety Reporting System
P.O. Box 189 | Moffett Field, CA | 94035-0189
ACN: 1325107
Time
Date: 201601
Local Time Of Day: 1801-2400
Place
Locale Reference.Airport: SFO.Airport
State Reference: CA
Altitude.MSL.Single Value: 7000
Environment
Aircraft 1
ATC / Advisory.TRACON: NCT
Make Model Name: A320
Component 1
Aircraft Component: Aero Charts
Person 1
Function.Flight Crew: Pilot Flying
ASRS Report Number: 1325107
Events
Anomaly.Airspace Violation: All Types
Anomaly.Deviation - Altitude: Crossing Restriction Not Met
Anomaly.Deviation - Altitude: Overshoot
Anomaly.Deviation - Procedural: Clearance
Anomaly.Deviation - Procedural: FAR
Anomaly.Deviation - Procedural: Published Material / Policy
Detector.Person: Air Traffic Control
Result.General: None Reported / Taken
Narrative 1
DYAMD TWO ARRIVAL NOTAMed of a change of altitude restriction at ARCHI to 8,000 feet. We
missed the change as shown on the paperwork. Paperwork should show NOTAMs in order of
importance. Maybe show relevance with BOLD type.
Synopsis
An A320 crew missed the SFO DYAMD TWO Arrival ARCHI NOTAM changing the ARCHI
waypoint crossing restriction to 8,000 feet from the published 7,000 feet. Crew descended
below SFO Class B.
ACN: 1316858
Time
Date: 201512
Place
Locale Reference.Airport: SFO.Airport
State Reference: CA
Altitude.MSL.Single Value: 8000
Aircraft 1
Make Model Name: Any Unknown or Unlisted Aircraft Manufacturer
Person 1
Function.Flight Crew: Captain
ASRS Report Number: 1316858
Events
Anomaly.No Specific Anomaly Occurred: All Types
Detector.Person: Flight Crew
Result.General: None Reported / Taken
Narrative 1
FDC NOTAM for SFO amends an altitude on an RNAV STAR:
FDC 5/0051 SFO STAR SAN FRANCISCO INTL, SAN FRANCISCO, CA. DYAMD
TWO ARRIVAL (RNAV) CHANGE ALTITUDE RESTRICTION AT ARCHI TO READ:
8000. ALL OTHER DATA REMAINS AS PUBLISHED.
Having a critical crossing altitude on a heavily used arrival procedure amended via NOTAM with
no other ATC notification, while legal, is inadvisable. This is evidenced by reported violations of
the NOTAMed altitude in a recently released [aviation organization] Safety Briefing.
Until proper charts can be published with the correct altitude, it would be advisable to either
rescind the NOTAM or include information about the amended altitude restriction on the ATIS of
airports affected by this change.
Synopsis
A pilot reported he was concerned with an SFO arrival crossing restriction appearing in NOTAM
form but not yet charted.
ACN: 1301204
Time
Date: 201510
Place
Locale Reference.Airport: SFO.Airport
State Reference: CA
Altitude.MSL.Single Value: 7000
Aircraft 1
ATC / Advisory.TRACON: NCT
Make Model Name: B757 Undifferentiated or Other Model
Person 1
Function.Flight Crew: First Officer
ASRS Report Number: 1301204
Person 2
Function.Flight Crew: Captain
ASRS Report Number: 1301205
Events
Anomaly.Airspace Violation: All Types
Anomaly.Deviation - Altitude: Overshoot
Anomaly.Deviation - Procedural: Clearance
Anomaly.Deviation - Procedural: Published Material / Policy
Detector.Person: Air Traffic Control
Result.General: None Reported / Taken
Narrative 1
Assigned and cleared for the DYMND arrival into SFO. Upon reaching the initial fix of arrival, we
were cleared to descend via arrival. Set the charted minimum altitude of 7,000 feet in MCP and
executed in VNAV path and crossed ARCHI at 7,000 feet. Reviewed ops alert in route which
stated ATC would assign altitude of 8,000 feet to maintain within Class B airspace, but we were
not assigned altitude with the descend via clearance. No conflict occurred.
Narrative 2
Both of us independently read the operations alert and checked it with the database. On
crossing ARCHI intersection at 7,000 feet ATC informed us there is a NOTAM that says to
change crossing to 8,000 feet. To my knowledge, no event occurred and the approach and
landing were normal. Later on the ground I found the NOTAM. The NOTAMs were reviewed
before flight.
Synopsis
A B757 flight crew flying the SFO DYAMD RNAV arrival crossed ARCHI at 7,000 feet and were
informed by NCT a NOTAM was issued changing the ARCHI constraint to 8,000 feet, the SFO
Class B floor in that area.
ACN: 1294119
Time
Date: 201509
Local Time Of Day: 0601-1200
Place
Locale Reference.Airport: SFO.Airport
State Reference: CA
Environment
Flight Conditions: VMC
Aircraft 1
ATC / Advisory.TRACON: NCT
Make Model Name: B757 Undifferentiated or Other Model
Person 1
Function.Flight Crew: First Officer
Function.Flight Crew: Pilot Not Flying
ASRS Report Number: 1294119
Events
Anomaly.ATC Issue: All Types
Anomaly.Deviation - Procedural: Published Material / Policy
Detector.Person: Flight Crew
Result.Flight Crew: Requested ATC Assistance / Clarification
Narrative 1
This new STAR has a big design problem. The DYAMD 2 STAR altitudes conflict with the RNAV
visual approaches which causes:
- confusion
- extra automation workload for pilots
- extra radio communication for ATC & pilots
- increased potential for automation errors
The STAR has ARCHI at 7,000 and CEDES between 12,000 & 10,000
But, the FMS Bridge Visual and Quiet Bridge visual have ARCHI at 8,000 (FMS bridge visual also
has CEDES at 11,000)
As a result when a flight crew tries to build the approach and arrival in the FMS, they have to
connect the path and the altitudes are 50% wrong whichever the pilot chooses in the FMS.
This leads to more workload for controllers and automatic tactical modification of published
routes and it can lead to automation errors.
The operational solution is to clear pilots to descend via the DYAMD 2 (with the ARTCC) and
later (with approach) to modify the clearance to "except after CEDES maintain 8,000."
The controller mentioned that they were going to "fix" this with a NOTAM soon but that leads to
more issues:
1) NOTAMs that attempt to "fix" RNAV procedure design problems are themselves a non-
conformance factor because they are hard to read, find and remember; and
2) A NOTAM does not fix the original problem of the chart design flaw
I am reading FAA Order 7100.41 Performance Based Navigation Implementation Process to try
and figure out why and where in the process this design error was made and if it was
intentional or unintentional. Both are bad.
Also, the "DYAMD" name is a poor choice in my opinion because it is hard to read and say. I
think it is pronounce "diamond" but it is difficult for me and I am a native English speaker. How
would you pronounce that if you didn't speak English well and did not know that it was called
"diamond"?
Synopsis
A B757 pilot described the design error and conflict between the SFO DYAMD RNAV Arrival
7,000 foot ARCHI constraint below Class B and the FMS BRIDGE Visual and the QUIET BRIDGE
Visual 8,000 foot ARCHI constraint.