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|
Attributes | |
ACN | 115460 |
Time | |
Date | 198907 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sju |
State Reference | PR |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : mjzs |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute : atlantic enroute : other oceanic enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 160 flight time total : 11000 flight time type : 2400 |
ASRS Report | 115460 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | inflight encounter : weather non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight departure time was scheduled for XA30 am local. Crew arrived in terminal off deadhead flight approximately XA15. I sent the copilot and engineer to the aircraft to start preflight while I went to operations for the paperwork. I arrived at aircraft at approximately XA20 and proceeded with preflight of my cockpit items. Copilot had loaded both omegas with first 5 waypoints. (Note: this was copilot's 3RD leg as a copilot.) checklists were completed, including a check of waypoint coordinates as per procedure, though admittedly rushed. Pushback on schedule. Severe WX surrounded airport and departure route. After first turn out of traffic deviations were necessary to remain clear of numerous heavy cells along our route. After handoff from departure control to san juan center, we were cleared on the vermo 2 departure, draft transition to deviate as necessary to avoid WX. During the entire climbout, we were never able to get on the departure route because of the WX. Also during the climbout some confusion arose in the cockpit over a subsequent clearance sju center had issued us. The copilot and engineer were certain we were told to join amber 300 to kraft intersection, then flight plan route. I did not think I heard it quite that way, but since I was engrossed in flying in the turbulent WX and working the radar I must have missed the exact wording, and it sounded logical since we were well west of course. We changed on #2 waypoint to dorado so as to navigate along A-300 to draft, cross-checking the coordinates together. After selecting track change 2 to 3 (kraft) the course line appeared to me to be too far west of our position so I asked sju center for clearance direct to kraft to expedite our return to flight plan course. Shortly after level off, as we were approaching draft intersection (so we thought) we checked our next waypoint #4 (ender) coordinates and the track and distance. I immediately noticed an incorrect course line. We then cross-checked the coordinates in both sets for #3 kraft. Both sets had 68430W instead of 67430W! The correct coordinates were inserted and an immediate correction was made to return to proper course. At the time omegas showed us to be 48 mi west of course. No other aircraft were observed during this whole period. The primary cause of this problem was the haste in which the aircraft was preflted and checklists done. All for the sake of making schedule, also on my part for not paying closer attention to the copilot's cross-checks being that he was so new to the position. The fact that WX caused us to never be near the original course line compounded the problem and prevented it from being discovered sooner.
Original NASA ASRS Text
Title: ACR LGT DEVIATED FROM CLRNC ROUTE BECAUSE WRONG COORDINATES SET IN OMEGA BEFORE TKOF.
Narrative: FLT DEP TIME WAS SCHEDULED FOR XA30 AM LOCAL. CREW ARRIVED IN TERMINAL OFF DEADHEAD FLT APPROX XA15. I SENT THE COPLT AND ENGINEER TO THE ACFT TO START PREFLT WHILE I WENT TO OPERATIONS FOR THE PAPERWORK. I ARRIVED AT ACFT AT APPROX XA20 AND PROCEEDED WITH PREFLT OF MY COCKPIT ITEMS. COPLT HAD LOADED BOTH OMEGAS WITH FIRST 5 WAYPOINTS. (NOTE: THIS WAS COPLT'S 3RD LEG AS A COPLT.) CHECKLISTS WERE COMPLETED, INCLUDING A CHECK OF WAYPOINT COORDINATES AS PER PROC, THOUGH ADMITTEDLY RUSHED. PUSHBACK ON SCHEDULE. SEVERE WX SURROUNDED ARPT AND DEP ROUTE. AFTER FIRST TURN OUT OF TFC DEVIATIONS WERE NECESSARY TO REMAIN CLEAR OF NUMEROUS HEAVY CELLS ALONG OUR ROUTE. AFTER HANDOFF FROM DEP CTL TO SAN JUAN CENTER, WE WERE CLRED ON THE VERMO 2 DEP, DRAFT TRANSITION TO DEVIATE AS NECESSARY TO AVOID WX. DURING THE ENTIRE CLIMBOUT, WE WERE NEVER ABLE TO GET ON THE DEP ROUTE BECAUSE OF THE WX. ALSO DURING THE CLIMBOUT SOME CONFUSION AROSE IN THE COCKPIT OVER A SUBSEQUENT CLRNC SJU CENTER HAD ISSUED US. THE COPLT AND ENGINEER WERE CERTAIN WE WERE TOLD TO JOIN AMBER 300 TO KRAFT INTXN, THEN FLT PLAN ROUTE. I DID NOT THINK I HEARD IT QUITE THAT WAY, BUT SINCE I WAS ENGROSSED IN FLYING IN THE TURBULENT WX AND WORKING THE RADAR I MUST HAVE MISSED THE EXACT WORDING, AND IT SOUNDED LOGICAL SINCE WE WERE WELL W OF COURSE. WE CHANGED ON #2 WAYPOINT TO DORADO SO AS TO NAVIGATE ALONG A-300 TO DRAFT, CROSS-CHECKING THE COORDINATES TOGETHER. AFTER SELECTING TRACK CHANGE 2 TO 3 (KRAFT) THE COURSE LINE APPEARED TO ME TO BE TOO FAR W OF OUR POSITION SO I ASKED SJU CENTER FOR CLRNC DIRECT TO KRAFT TO EXPEDITE OUR RETURN TO FLT PLAN COURSE. SHORTLY AFTER LEVEL OFF, AS WE WERE APCHING DRAFT INTXN (SO WE THOUGHT) WE CHECKED OUR NEXT WAYPOINT #4 (ENDER) COORDINATES AND THE TRACK AND DISTANCE. I IMMEDIATELY NOTICED AN INCORRECT COURSE LINE. WE THEN CROSS-CHECKED THE COORDINATES IN BOTH SETS FOR #3 KRAFT. BOTH SETS HAD 68430W INSTEAD OF 67430W! THE CORRECT COORDINATES WERE INSERTED AND AN IMMEDIATE CORRECTION WAS MADE TO RETURN TO PROPER COURSE. AT THE TIME OMEGAS SHOWED US TO BE 48 MI W OF COURSE. NO OTHER ACFT WERE OBSERVED DURING THIS WHOLE PERIOD. THE PRIMARY CAUSE OF THIS PROBLEM WAS THE HASTE IN WHICH THE ACFT WAS PREFLTED AND CHECKLISTS DONE. ALL FOR THE SAKE OF MAKING SCHEDULE, ALSO ON MY PART FOR NOT PAYING CLOSER ATTN TO THE COPLT'S CROSS-CHECKS BEING THAT HE WAS SO NEW TO THE POSITION. THE FACT THAT WX CAUSED US TO NEVER BE NEAR THE ORIGINAL COURSE LINE COMPOUNDED THE PROBLEM AND PREVENTED IT FROM BEING DISCOVERED SOONER.
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.