37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 108067 |
Time | |
Date | 198904 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : fmy |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : fmy tower : fmy tower : stl |
Operator | general aviation : corporate |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : initial climbout : takeoff |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 55 flight time total : 12750 |
ASRS Report | 108067 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the PIC. The first officer was flying the aircraft. Taxiing out, clearance was not available because flight plan was not in the center computer. Therefore, it was necessary to refile while taxiing out. Received clearance ('cleared as filed') just after completing takeoff checklist, and immediately after readback, ground control asked if we could take it out rolling. I replied, 'affirmative,' and we received takeoff clearance (on the ground control frequency, a non standard procedure) and after switching to the tower frequency, departed. After takeoff, I was preoccupied with attempting to contact departure control, having inadvertently misread our clearance form and tuned the wrong departure control frequency. When we did contact departure. We were asked if tower had instructed us to maintain runway heading. I noted that the first officer had made a turn to the on course heading. I could not recall the clearance to maintain runway heading, and neither could the first officer. He advised that he had traffic to the east, which was, however, no factor, and that we could continue on course. However, later communication with the tower controller revealed that the hurried takeoff clearance had included instruction to 'fly runway heading,' and that a review of their tape indicated that I had indeed read it back. In the rush of that non standard departure procedure. I am sure that I simply did not adequately address the matter mentally, that while busy retuning radios I relied upon the first officer to hear and adhere to pertinent instructions, and that my readback was an automatic response. He had missed the runway heading instruction, however, probably due to the manner in which the takeoff clearance deviated from our normal procedures. Further preoccupation with the communications problem led to a complete failure on my part to monitor the departure procedure. We had let a non standard situation get us into a hurry, quite unnecessarily, and lead to a breakdown in our crew coordination. We frequently encounter situations where controllers, who are simply trying to expedite their traffic and do their jobs well, seem to be pouring it on with somewhat of a large rush. We are a highly experienced professional crew and tend to feel that we can deal with the frenetic handling. This incident seems to argue otherwise, and to indicate that we, the aircrew, must be willing to slow it down when necessary, in order to properly manage our responsibility. Food for thought.
Original NASA ASRS Text
Title: CPR SMT NON ADHERENCE TO ATC CLRNC DEVIATION FROM CLRNC ROUTE. TRACK DEVIATION.
Narrative: I WAS THE PIC. THE F/O WAS FLYING THE ACFT. TAXIING OUT, CLRNC WAS NOT AVAILABLE BECAUSE FLT PLAN WAS NOT IN THE CENTER COMPUTER. THEREFORE, IT WAS NECESSARY TO REFILE WHILE TAXIING OUT. RECEIVED CLRNC ('CLRED AS FILED') JUST AFTER COMPLETING TKOF CHKLIST, AND IMMEDIATELY AFTER READBACK, GND CTL ASKED IF WE COULD TAKE IT OUT ROLLING. I REPLIED, 'AFFIRMATIVE,' AND WE RECEIVED TKOF CLRNC (ON THE GND CTL FREQ, A NON STANDARD PROC) AND AFTER SWITCHING TO THE TWR FREQ, DEPARTED. AFTER TKOF, I WAS PREOCCUPIED WITH ATTEMPTING TO CONTACT DEP CTL, HAVING INADVERTENTLY MISREAD OUR CLRNC FORM AND TUNED THE WRONG DEP CTL FREQ. WHEN WE DID CONTACT DEP. WE WERE ASKED IF TWR HAD INSTRUCTED US TO MAINTAIN RWY HDG. I NOTED THAT THE F/O HAD MADE A TURN TO THE ON COURSE HDG. I COULD NOT RECALL THE CLRNC TO MAINTAIN RWY HDG, AND NEITHER COULD THE F/O. HE ADVISED THAT HE HAD TFC TO THE E, WHICH WAS, HOWEVER, NO FACTOR, AND THAT WE COULD CONTINUE ON COURSE. HOWEVER, LATER COM WITH THE TWR CTLR REVEALED THAT THE HURRIED TKOF CLRNC HAD INCLUDED INSTRUCTION TO 'FLY RWY HDG,' AND THAT A REVIEW OF THEIR TAPE INDICATED THAT I HAD INDEED READ IT BACK. IN THE RUSH OF THAT NON STANDARD DEP PROC. I AM SURE THAT I SIMPLY DID NOT ADEQUATELY ADDRESS THE MATTER MENTALLY, THAT WHILE BUSY RETUNING RADIOS I RELIED UPON THE F/O TO HEAR AND ADHERE TO PERTINENT INSTRUCTIONS, AND THAT MY READBACK WAS AN AUTOMATIC RESPONSE. HE HAD MISSED THE RWY HDG INSTRUCTION, HOWEVER, PROBABLY DUE TO THE MANNER IN WHICH THE TKOF CLRNC DEVIATED FROM OUR NORMAL PROCS. FURTHER PREOCCUPATION WITH THE COMS PROB LED TO A COMPLETE FAILURE ON MY PART TO MONITOR THE DEP PROC. WE HAD LET A NON STANDARD SITUATION GET US INTO A HURRY, QUITE UNNECESSARILY, AND LEAD TO A BREAKDOWN IN OUR CREW COORD. WE FREQUENTLY ENCOUNTER SITUATIONS WHERE CTLRS, WHO ARE SIMPLY TRYING TO EXPEDITE THEIR TFC AND DO THEIR JOBS WELL, SEEM TO BE POURING IT ON WITH SOMEWHAT OF A LARGE RUSH. WE ARE A HIGHLY EXPERIENCED PROFESSIONAL CREW AND TEND TO FEEL THAT WE CAN DEAL WITH THE FRENETIC HANDLING. THIS INCIDENT SEEMS TO ARGUE OTHERWISE, AND TO INDICATE THAT WE, THE AIRCREW, MUST BE WILLING TO SLOW IT DOWN WHEN NECESSARY, IN ORDER TO PROPERLY MANAGE OUR RESPONSIBILITY. FOOD FOR THOUGHT.
Data retrieved from NASA's ASRS site as of August 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.