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|
Attributes | |
ACN | 122723 |
Time | |
Date | 198909 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : oal |
State Reference | CA |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5500 |
ASRS Report | 122723 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
We had departed sea very early and went to pdx. We have a relatively new RNAV system called the FMS installed on most of our large transport's. It is reinitialized before every leg, and since it is on the first officer's side of the console, the first officer usually does the reinitialization (west/O being asked) while I go into operations to get the paperwork. The reinitialization process includes entering aircraft position at the gate, the projected gross weight and fuel load and the flight plan. (The FMS data bank is checked on the first preflight of the day to be sure that the information has not expired.) the first officer on this particular flight was very competent and I assumed when we did the before start checklist that he had reinitialized it properly, so I replied, 'initialized' to his 'FMS' item on the checklist. In actuality, he had not checked the flight plan that was stored against the way we were filed. The FMC followed the routing that we were used to. A few mins later, we were asked what routing we showed on our flight plan. I read it back. I asked if there had been a problem, and he said that they had shown us on J92 after bty and headed for bld. We immediately checked the FMC and realized that the routing it stored was oal J92 bld, and the first officer admitted that indeed he had not checked the flight plan upon FMS initialization. Center made the comment that this was 'not the first time that this very same thing has happened with your company,' and that 'we'll call them up there to see if we can't do something to keep this from happening again in the future.' (when I returned to sea 2 days later I found out that the flight the next day did exactly the same thing we had done.) I called our dispatch and ATC specialists upon arrival in phx and suggested that they put out a company NOTAM explaining that the FMS is updated every 28 days and reminding everyone to compare flight plan routing with FMS. I also asked why this new routing was not listed on the 'ATC must read' list that notifies us when we have routing changes. He explained that it had been there 'last week when we made the change.' I feel this kind of routing problem could be fairly common with our company because the dispatchers will frequently pull up a flight plan from the computer and pay no attention as to whether or not the computer has stored the proper routing (this was very common this summer on one of our other routes).
Original NASA ASRS Text
Title: ACR FLT DOES NOT FOLLOW FLT PLAN AS FILED WITH ATC. FMS SYSTEM PROGRAMMED WITH DIFFERENT ROUTE SO THAT AUTOPLT FOLLOWED WRONG ROUTE.
Narrative: WE HAD DEPARTED SEA VERY EARLY AND WENT TO PDX. WE HAVE A RELATIVELY NEW RNAV SYS CALLED THE FMS INSTALLED ON MOST OF OUR LGT'S. IT IS REINITIALIZED BEFORE EVERY LEG, AND SINCE IT IS ON THE F/O'S SIDE OF THE CONSOLE, THE F/O USUALLY DOES THE REINITIALIZATION (W/O BEING ASKED) WHILE I GO INTO OPS TO GET THE PAPERWORK. THE REINITIALIZATION PROCESS INCLUDES ENTERING ACFT POS AT THE GATE, THE PROJECTED GROSS WT AND FUEL LOAD AND THE FLT PLAN. (THE FMS DATA BANK IS CHKED ON THE FIRST PREFLT OF THE DAY TO BE SURE THAT THE INFO HAS NOT EXPIRED.) THE F/O ON THIS PARTICULAR FLT WAS VERY COMPETENT AND I ASSUMED WHEN WE DID THE BEFORE START CHKLIST THAT HE HAD REINITIALIZED IT PROPERLY, SO I REPLIED, 'INITIALIZED' TO HIS 'FMS' ITEM ON THE CHKLIST. IN ACTUALITY, HE HAD NOT CHKED THE FLT PLAN THAT WAS STORED AGAINST THE WAY WE WERE FILED. THE FMC FOLLOWED THE ROUTING THAT WE WERE USED TO. A FEW MINS LATER, WE WERE ASKED WHAT ROUTING WE SHOWED ON OUR FLT PLAN. I READ IT BACK. I ASKED IF THERE HAD BEEN A PROB, AND HE SAID THAT THEY HAD SHOWN US ON J92 AFTER BTY AND HEADED FOR BLD. WE IMMEDIATELY CHKED THE FMC AND REALIZED THAT THE ROUTING IT STORED WAS OAL J92 BLD, AND THE F/O ADMITTED THAT INDEED HE HAD NOT CHKED THE FLT PLAN UPON FMS INITIALIZATION. CENTER MADE THE COMMENT THAT THIS WAS 'NOT THE FIRST TIME THAT THIS VERY SAME THING HAS HAPPENED WITH YOUR COMPANY,' AND THAT 'WE'LL CALL THEM UP THERE TO SEE IF WE CAN'T DO SOMETHING TO KEEP THIS FROM HAPPENING AGAIN IN THE FUTURE.' (WHEN I RETURNED TO SEA 2 DAYS LATER I FOUND OUT THAT THE FLT THE NEXT DAY DID EXACTLY THE SAME THING WE HAD DONE.) I CALLED OUR DISPATCH AND ATC SPECIALISTS UPON ARR IN PHX AND SUGGESTED THAT THEY PUT OUT A COMPANY NOTAM EXPLAINING THAT THE FMS IS UPDATED EVERY 28 DAYS AND REMINDING EVERYONE TO COMPARE FLT PLAN ROUTING WITH FMS. I ALSO ASKED WHY THIS NEW ROUTING WAS NOT LISTED ON THE 'ATC MUST READ' LIST THAT NOTIFIES US WHEN WE HAVE ROUTING CHANGES. HE EXPLAINED THAT IT HAD BEEN THERE 'LAST WK WHEN WE MADE THE CHANGE.' I FEEL THIS KIND OF ROUTING PROB COULD BE FAIRLY COMMON WITH OUR COMPANY BECAUSE THE DISPATCHERS WILL FREQUENTLY PULL UP A FLT PLAN FROM THE COMPUTER AND PAY NO ATTN AS TO WHETHER OR NOT THE COMPUTER HAS STORED THE PROPER ROUTING (THIS WAS VERY COMMON THIS SUMMER ON ONE OF OUR OTHER ROUTES).
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.