Narrative:

Human performance considerations: company is using a new flight plan format with 2 lines of information for each fix on the cfp. On the radio navigation segments the navigation fix is on the top line and INS coordinates on the lower line. For nat information 2 lines both have INS coordinates which seems to me to be a factor here. Another area often mentioned is the INS CDU locations. On the widebody transport #3 INS CDU is on the center console. If this aircraft had the same confign this excursion might not have happened. Certainly the crew call of XX50 am local london time XX50 am us eastern daylight time of this flight might have had some effect on the crew's performance. Our flight appeared to be totally routine up until approaching stumble (stu) VOR on the west coast of england. At that time we received a track change reroute. Instead of track F we received track east FL310 M .84 from 54 00 north 15 00 west. The captain and F/east monitored shanwick clearance and confirmed the reroute. I immediately asked the F/east for the track message to update the INS's for the new route as we were just about to enter shannon's airspace and I felt that they would route us directly to 54 00 north 15 00 west, the boundary point for track east. I reloaded the waypoints 6 through 9 using the remote feature of our system to read #6.54 00 north 15 00 west #7.55 00 north 20 00 west #8.56 00 north 30 00 west #9.55 00 north 40 00 west. A radio frequency change to shannon took place in a few moments and the controller did in fact route us directly to 54 00 north 15 00 west. I then began to complete the remainder of the paperwork involved with a track change; i.e., replotting the track on the north atlantic plotting chart, numbering the waypoints, and drawing a line through the previous track. I then numbered the waypoints on the track message and inserted the new oceanic waypoints on the computer flight plan/log but unfortunately I only printed over the top row of coordinates on the cfp. At about this time shannon cleared us to climb to FL310 and pointed out traffic at FL310 16 mn ahead that would be climbing to FL330 for the crossing. An accuracy check was accomplished due north of shannon VOR by 12.8 mn which I plotted as 11.4 mn north of the VOR due to the slant range. Sometime in this same time frame I also inserted the #1 and #2 waypoints which included the erroneous 52 00 north 50 00 west and the st anthony coordinates. I think that I took the 50 west coordinates from the lower row of coordinates on the cfp and then got the st anthony coordinates from the ca hi 1&2 chart. The next events were missed opportunities to correct the error I had made in inserting 52 00 north 50 00 west in the #1 waypoint. As we were 2 to 3 mins prior to 40 00 west we routinely checked #1 waypoint and I assume both looked at the lower line of the cfp for 50 00 west thereby accepting 52 00 north 50 00 west as correct. At 42 00 west I made a routine plot noting 54 30 north 42 00 west and misplotted by 10 NM our short check showed no change in relative cross track error and the ETA for 50 00 west was right on. Approaching 45 00 2 gander SELCAL'ed us with our rerelease to jfk IFR. Due to the heavy amount of radio traffic the transmission took a considerable amount of time with all 3 crew members monitoring. A short discussion of the release took place before we realized that we had passed the point for our 45 00 west check. Instead of plotting 46 00 west I projected where we should have been at 45 00 west and plotted that. The long check of all INS information appeared to be normal since they all had the erroneous information in them cross track and ETA still showed no change from what was expected. As we approached 50 00 west we were about to check the st anthony coordinates the captain noticed our error. We then reported to gander radio on 127.1 that we were at 52 00 north 50 00 west and were switched to gander center and once again acknowledged our error. The balance of the flight was routine.

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Original NASA ASRS Text

Title: GROSS NAVIGATION ERROR ON NAT SYSTEM.

Narrative: HUMAN PERFORMANCE CONSIDERATIONS: COMPANY IS USING A NEW FLT PLAN FORMAT WITH 2 LINES OF INFO FOR EACH FIX ON THE CFP. ON THE RADIO NAV SEGMENTS THE NAV FIX IS ON THE TOP LINE AND INS COORDINATES ON THE LOWER LINE. FOR NAT INFO 2 LINES BOTH HAVE INS COORDINATES WHICH SEEMS TO ME TO BE A FACTOR HERE. ANOTHER AREA OFTEN MENTIONED IS THE INS CDU LOCATIONS. ON THE WDB #3 INS CDU IS ON THE CENTER CONSOLE. IF THIS ACFT HAD THE SAME CONFIGN THIS EXCURSION MIGHT NOT HAVE HAPPENED. CERTAINLY THE CREW CALL OF XX50 AM LCL LONDON TIME XX50 AM US EASTERN DAYLIGHT TIME OF THIS FLT MIGHT HAVE HAD SOME EFFECT ON THE CREW'S PERFORMANCE. OUR FLT APPEARED TO BE TOTALLY ROUTINE UP UNTIL APCHING STUMBLE (STU) VOR ON THE W COAST OF ENGLAND. AT THAT TIME WE RECEIVED A TRACK CHANGE REROUTE. INSTEAD OF TRACK F WE RECEIVED TRACK E FL310 M .84 FROM 54 00 NORTH 15 00 WEST. THE CAPT AND F/E MONITORED SHANWICK CLRNC AND CONFIRMED THE REROUTE. I IMMEDIATELY ASKED THE F/E FOR THE TRACK MESSAGE TO UPDATE THE INS'S FOR THE NEW ROUTE AS WE WERE JUST ABOUT TO ENTER SHANNON'S AIRSPACE AND I FELT THAT THEY WOULD ROUTE US DIRECTLY TO 54 00 NORTH 15 00 WEST, THE BOUNDARY POINT FOR TRACK E. I RELOADED THE WAYPOINTS 6 THROUGH 9 USING THE REMOTE FEATURE OF OUR SYSTEM TO READ #6.54 00 N 15 00 W #7.55 00 N 20 00 W #8.56 00 N 30 00 W #9.55 00 N 40 00 W. A RADIO FREQ CHANGE TO SHANNON TOOK PLACE IN A FEW MOMENTS AND THE CTLR DID IN FACT ROUTE US DIRECTLY TO 54 00 N 15 00 W. I THEN BEGAN TO COMPLETE THE REMAINDER OF THE PAPERWORK INVOLVED WITH A TRACK CHANGE; I.E., REPLOTTING THE TRACK ON THE NORTH ATLANTIC PLOTTING CHART, NUMBERING THE WAYPOINTS, AND DRAWING A LINE THROUGH THE PREVIOUS TRACK. I THEN NUMBERED THE WAYPOINTS ON THE TRACK MESSAGE AND INSERTED THE NEW OCEANIC WAYPOINTS ON THE COMPUTER FLT PLAN/LOG BUT UNFORTUNATELY I ONLY PRINTED OVER THE TOP ROW OF COORDINATES ON THE CFP. AT ABOUT THIS TIME SHANNON CLRED US TO CLIMB TO FL310 AND POINTED OUT TFC AT FL310 16 MN AHEAD THAT WOULD BE CLIMBING TO FL330 FOR THE XING. AN ACCURACY CHECK WAS ACCOMPLISHED DUE NORTH OF SHANNON VOR BY 12.8 MN WHICH I PLOTTED AS 11.4 MN NORTH OF THE VOR DUE TO THE SLANT RANGE. SOMETIME IN THIS SAME TIME FRAME I ALSO INSERTED THE #1 AND #2 WAYPOINTS WHICH INCLUDED THE ERRONEOUS 52 00 N 50 00 W AND THE ST ANTHONY COORDINATES. I THINK THAT I TOOK THE 50 W COORDINATES FROM THE LOWER ROW OF COORDINATES ON THE CFP AND THEN GOT THE ST ANTHONY COORDINATES FROM THE CA HI 1&2 CHART. THE NEXT EVENTS WERE MISSED OPPORTUNITIES TO CORRECT THE ERROR I HAD MADE IN INSERTING 52 00 N 50 00 W IN THE #1 WAYPOINT. AS WE WERE 2 TO 3 MINS PRIOR TO 40 00 W WE ROUTINELY CHECKED #1 WAYPOINT AND I ASSUME BOTH LOOKED AT THE LOWER LINE OF THE CFP FOR 50 00 W THEREBY ACCEPTING 52 00 N 50 00 W AS CORRECT. AT 42 00 W I MADE A ROUTINE PLOT NOTING 54 30 N 42 00 W AND MISPLOTTED BY 10 NM OUR SHORT CHECK SHOWED NO CHANGE IN RELATIVE CROSS TRACK ERROR AND THE ETA FOR 50 00 W WAS RIGHT ON. APCHING 45 00 2 GANDER SELCAL'ED US WITH OUR RERELEASE TO JFK IFR. DUE TO THE HEAVY AMOUNT OF RADIO TFC THE XMISSION TOOK A CONSIDERABLE AMOUNT OF TIME WITH ALL 3 CREW MEMBERS MONITORING. A SHORT DISCUSSION OF THE RELEASE TOOK PLACE BEFORE WE REALIZED THAT WE HAD PASSED THE POINT FOR OUR 45 00 W CHECK. INSTEAD OF PLOTTING 46 00 W I PROJECTED WHERE WE SHOULD HAVE BEEN AT 45 00 W AND PLOTTED THAT. THE LONG CHECK OF ALL INS INFO APPEARED TO BE NORMAL SINCE THEY ALL HAD THE ERRONEOUS INFO IN THEM CROSS TRACK AND ETA STILL SHOWED NO CHANGE FROM WHAT WAS EXPECTED. AS WE APCHED 50 00 W WE WERE ABOUT TO CHECK THE ST ANTHONY COORDINATES THE CAPT NOTICED OUR ERROR. WE THEN REPORTED TO GANDER RADIO ON 127.1 THAT WE WERE AT 52 00 N 50 00 W AND WERE SWITCHED TO GANDER CENTER AND ONCE AGAIN ACKNOWLEDGED OUR ERROR. THE BALANCE OF THE FLT WAS ROUTINE.

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.