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|
Attributes | |
ACN | 113594 |
Time | |
Date | 198906 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : las |
State Reference | NV |
Altitude | msl bound lower : 23000 msl bound upper : 23000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 240 flight time total : 4400 flight time type : 480 |
ASRS Report | 113594 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Programmed FMC to match 'afpac's' computer flight plan (mirrors ATC strip). Captain read 'oveto 8-DOVE creek' (flight plan read OVETO8.dvc). I activated oveto 8 departure, then selected dvc as next fix in route of flight on FMC. This is a 'gotcha', because the expected routing is the 'cove creek transition' to dvc, not oveto (las 039 degree/39) direct dvc. Clearance delivery may have compounded the situation by reading 'oveto 8 dove creek as filed'. Easy enough to do, easy enough to omit the dvc transition during programming of FMC. Resulted in early turn direct dvc! The crux of the problem is that the flight management computer can be mis-programmed and look exactly right, unless one is trained to be alert for potential programming pitfalls, departure/transition legs such as las oveto 8 dvc are a good example. Pilot awareness and more aggressive backup using conventional VOR/HSI display to confirm correct FMC execution of the SID or STAR (or any leg in the route of flight that is not RNAV direct). Computers may theoretically ease pilot workload, but maybe not! The amount of energy a pilot must invest in correct programming (else garbage in/garbage out) and aggressive monitoring of navigation system execution (of SID/STAR, etc) may put us right back where we were, in terms of workload. Still, I'd rather have the FMC than not. Training: during initial training the pilot isn't 'computer literate' enough to understand the issue. But during recurrent and/or via pilot awareness bulletins the problem can be effectively addressed!
Original NASA ASRS Text
Title: TRACK AND HEADING DEVIATION ON SID AS ACFT'S FMC COMPUTER WAS MISPROGRAMMED.
Narrative: PROGRAMMED FMC TO MATCH 'AFPAC'S' COMPUTER FLT PLAN (MIRRORS ATC STRIP). CAPT READ 'OVETO 8-DOVE CREEK' (FLT PLAN READ OVETO8.DVC). I ACTIVATED OVETO 8 DEP, THEN SELECTED DVC AS NEXT FIX IN RTE OF FLT ON FMC. THIS IS A 'GOTCHA', BECAUSE THE EXPECTED ROUTING IS THE 'COVE CREEK TRANSITION' TO DVC, NOT OVETO (LAS 039 DEG/39) DIRECT DVC. CLRNC DELIVERY MAY HAVE COMPOUNDED THE SIT BY READING 'OVETO 8 DOVE CREEK AS FILED'. EASY ENOUGH TO DO, EASY ENOUGH TO OMIT THE DVC TRANSITION DURING PROGRAMMING OF FMC. RESULTED IN EARLY TURN DIRECT DVC! THE CRUX OF THE PROB IS THAT THE FLT MGMNT COMPUTER CAN BE MIS-PROGRAMMED AND LOOK EXACTLY RIGHT, UNLESS ONE IS TRAINED TO BE ALERT FOR POTENTIAL PROGRAMMING PITFALLS, DEP/TRANSITION LEGS SUCH AS LAS OVETO 8 DVC ARE A GOOD EXAMPLE. PLT AWARENESS AND MORE AGGRESSIVE BACKUP USING CONVENTIONAL VOR/HSI DISPLAY TO CONFIRM CORRECT FMC EXECUTION OF THE SID OR STAR (OR ANY LEG IN THE RTE OF FLT THAT IS NOT RNAV DIRECT). COMPUTERS MAY THEORETICALLY EASE PLT WORKLOAD, BUT MAYBE NOT! THE AMOUNT OF ENERGY A PLT MUST INVEST IN CORRECT PROGRAMMING (ELSE GARBAGE IN/GARBAGE OUT) AND AGGRESSIVE MONITORING OF NAV SYS EXECUTION (OF SID/STAR, ETC) MAY PUT US RIGHT BACK WHERE WE WERE, IN TERMS OF WORKLOAD. STILL, I'D RATHER HAVE THE FMC THAN NOT. TRAINING: DURING INITIAL TRAINING THE PLT ISN'T 'COMPUTER LITERATE' ENOUGH TO UNDERSTAND THE ISSUE. BUT DURING RECURRENT AND/OR VIA PLT AWARENESS BULLETINS THE PROB CAN BE EFFECTIVELY ADDRESSED!
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.