37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 124225 |
Time | |
Date | 198910 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dca |
State Reference | DC |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other ground : preflight |
Route In Use | enroute airway : j64 enroute airway : j211 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 3900 flight time type : 145 |
ASRS Report | 124225 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 15700 flight time type : 2800 |
ASRS Report | 124263 |
Events | |
Anomaly | non adherence : clearance non adherence : far other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During preflight, loaded FMC with company route 'dcacle'. The flight was a turn (ie, cleveland, washington national, cleveland) and allowed minimum ground time. The correct route should have been 'DCACLE1'. Compared initial en route fix with flight plan. This fix is common to both 'dcacle' and 'DCACLE1'. During cruise, at junction of J211 and J64, we turned towards ellwood city along J64 rather than continuing along J211 towards youngstown. Upon noticing our deviation from our filed flight plan, ZOB asked where we were going. They then cleared us direct noels, then on to cleveland. The majority of company routes which are entered into the FMC have no twins for a particular city-pair. Washington national to cleveland does have two routes, 'dcecle' and 'DCACLE1'. ZOB said one route was used during high density traffic and the other during off hours. Nowhere on the printed flight plan is the company route designated as 'dcacle' or 'DCACLE1' when multiple choices are available. This problem could have been avoided had a thorough check of the FMC flight plan been accomplished and compared to the printed flight plan which was filed with ATC. This should have been done by the pilot who 'loaded' the route, and backed up by the other pilot. Also, printing the company route on the pilot's copy of the flight plan would help avoid repetitions of this problem. It is very easy to fall into the trap of trusting the FMC so much that xchks are not made and complacency sets in. Supplemental information from acn 124262: factors affecting the quality of human performance was eating of crew meals on the ground and not leaving enough time for proper cockpit setup.
Original NASA ASRS Text
Title: ACR MLG DEVIATED FROM CLRNC ROUTE. FMC PROGRAMMED INCORRECTLY AND NOT VERIFIED BY PNF AS REQUIRED BY AIRLINE OPERATING PROC.
Narrative: DURING PREFLT, LOADED FMC WITH COMPANY ROUTE 'DCACLE'. THE FLT WAS A TURN (IE, CLEVELAND, WASHINGTON NATIONAL, CLEVELAND) AND ALLOWED MINIMUM GND TIME. THE CORRECT ROUTE SHOULD HAVE BEEN 'DCACLE1'. COMPARED INITIAL ENRTE FIX WITH FLT PLAN. THIS FIX IS COMMON TO BOTH 'DCACLE' AND 'DCACLE1'. DURING CRUISE, AT JUNCTION OF J211 AND J64, WE TURNED TOWARDS ELLWOOD CITY ALONG J64 RATHER THAN CONTINUING ALONG J211 TOWARDS YOUNGSTOWN. UPON NOTICING OUR DEVIATION FROM OUR FILED FLT PLAN, ZOB ASKED WHERE WE WERE GOING. THEY THEN CLRED US DIRECT NOELS, THEN ON TO CLEVELAND. THE MAJORITY OF COMPANY ROUTES WHICH ARE ENTERED INTO THE FMC HAVE NO TWINS FOR A PARTICULAR CITY-PAIR. WASHINGTON NATIONAL TO CLEVELAND DOES HAVE TWO ROUTES, 'DCECLE' AND 'DCACLE1'. ZOB SAID ONE ROUTE WAS USED DURING HIGH DENSITY TFC AND THE OTHER DURING OFF HRS. NOWHERE ON THE PRINTED FLT PLAN IS THE COMPANY ROUTE DESIGNATED AS 'DCACLE' OR 'DCACLE1' WHEN MULTIPLE CHOICES ARE AVAILABLE. THIS PROBLEM COULD HAVE BEEN AVOIDED HAD A THOROUGH CHECK OF THE FMC FLT PLAN BEEN ACCOMPLISHED AND COMPARED TO THE PRINTED FLT PLAN WHICH WAS FILED WITH ATC. THIS SHOULD HAVE BEEN DONE BY THE PLT WHO 'LOADED' THE ROUTE, AND BACKED UP BY THE OTHER PLT. ALSO, PRINTING THE COMPANY ROUTE ON THE PLT'S COPY OF THE FLT PLAN WOULD HELP AVOID REPETITIONS OF THIS PROBLEM. IT IS VERY EASY TO FALL INTO THE TRAP OF TRUSTING THE FMC SO MUCH THAT XCHKS ARE NOT MADE AND COMPLACENCY SETS IN. SUPPLEMENTAL INFORMATION FROM ACN 124262: FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE WAS EATING OF CREW MEALS ON THE GND AND NOT LEAVING ENOUGH TIME FOR PROPER COCKPIT SETUP.
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.