37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 122363 |
Time | |
Date | 198909 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : yqi |
State Reference | NS |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqx |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : other oceanic enroute : atlantic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 161 flight time total : 5000 flight time type : 368 |
ASRS Report | 122363 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route from frankfurt to dfw we contacted gander oceanic on VHF at 50 degree west longitude. Our coast in fix was vysta intersection and prior to vysta we were given a frequency change to gander center. After checking in with gander center, the controller responded 'squawk XXXX cleared to dfw via north american route 102.' we were filed na 108 and the INS's were programmed for na 108. I did not xchk the new clearance against the filed route nor did I check na 102 and thus did not reprogram the INS's. Approximately 40 mi past vysta, erroneously en route to mills (the next point on na 108), the controller queried us and we corrected our course to tusky (the next point on na 102). The controller prevented my mistake from having any adverse consequences but I also believe he contributed to the problem by not using the correct phraseology of 'reclred via...'. The captain claimed he was out of the seat during receipt of the clearance but I believe he was in the seat with his radio either off or he failed to respond. The clearance did not come across the speaker as the captain had a personal policy against using the speaker in cruise as I am used to. I will change one personal technique that I feel will insure the problem does not happen again. It is company policy to write all clrncs on the master flight plan which I have always done, but not always in a standardized manner. Henceforth I will write all clrncs directly beneath the route of flight verbage at the header of the master flight plan. This technique will ensure that the filed route and the cleared route are crosschecked. Additionally, I will think of coast in fixes as clearance limit fixes and thereby be mentally keyed to obtain and verify a new clearance.
Original NASA ASRS Text
Title: FAILED TO PROGRAM INS FOR REVISED FLT ROUTING.
Narrative: ENRTE FROM FRANKFURT TO DFW WE CONTACTED GANDER OCEANIC ON VHF AT 50 DEG W LONGITUDE. OUR COAST IN FIX WAS VYSTA INTXN AND PRIOR TO VYSTA WE WERE GIVEN A FREQ CHANGE TO GANDER CENTER. AFTER CHECKING IN WITH GANDER CENTER, THE CTLR RESPONDED 'SQUAWK XXXX CLRED TO DFW VIA NORTH AMERICAN ROUTE 102.' WE WERE FILED NA 108 AND THE INS'S WERE PROGRAMMED FOR NA 108. I DID NOT XCHK THE NEW CLRNC AGAINST THE FILED ROUTE NOR DID I CHECK NA 102 AND THUS DID NOT REPROGRAM THE INS'S. APPROX 40 MI PAST VYSTA, ERRONEOUSLY ENRTE TO MILLS (THE NEXT POINT ON NA 108), THE CTLR QUERIED US AND WE CORRECTED OUR COURSE TO TUSKY (THE NEXT POINT ON NA 102). THE CTLR PREVENTED MY MISTAKE FROM HAVING ANY ADVERSE CONSEQUENCES BUT I ALSO BELIEVE HE CONTRIBUTED TO THE PROBLEM BY NOT USING THE CORRECT PHRASEOLOGY OF 'RECLRED VIA...'. THE CAPT CLAIMED HE WAS OUT OF THE SEAT DURING RECEIPT OF THE CLRNC BUT I BELIEVE HE WAS IN THE SEAT WITH HIS RADIO EITHER OFF OR HE FAILED TO RESPOND. THE CLRNC DID NOT COME ACROSS THE SPEAKER AS THE CAPT HAD A PERSONAL POLICY AGAINST USING THE SPEAKER IN CRUISE AS I AM USED TO. I WILL CHANGE ONE PERSONAL TECHNIQUE THAT I FEEL WILL INSURE THE PROBLEM DOES NOT HAPPEN AGAIN. IT IS COMPANY POLICY TO WRITE ALL CLRNCS ON THE MASTER FLT PLAN WHICH I HAVE ALWAYS DONE, BUT NOT ALWAYS IN A STANDARDIZED MANNER. HENCEFORTH I WILL WRITE ALL CLRNCS DIRECTLY BENEATH THE ROUTE OF FLT VERBAGE AT THE HEADER OF THE MASTER FLT PLAN. THIS TECHNIQUE WILL ENSURE THAT THE FILED ROUTE AND THE CLRED ROUTE ARE XCHKED. ADDITIONALLY, I WILL THINK OF COAST IN FIXES AS CLRNC LIMIT FIXES AND THEREBY BE MENTALLY KEYED TO OBTAIN AND VERIFY A NEW CLRNC.
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.