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|
Attributes | |
ACN | 1276412 |
Time | |
Date | 201507 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | SFO.Airport |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Initial Climb |
Route In Use | SID TRUKN2 |
Flight Plan | IFR |
Component | |
Aircraft Component | FMS/FMC |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy Deviation - Procedural FAR Deviation - Track / Heading All Types |
Narrative:
While during pre-flight things had started off smoothly and without incident. The crew had arrived at the aircraft early in order to alleviate any issues with rushing and to allow for any maintenance issues that might occur (the aircraft had been out of service for some time that day due to a liquid spill in the rear of the cabin while maintenance cleaned and replace interior carpets). While programming the FMS for departure; it was discovered that the ACARS printer was out of paper. I proceeded to use the FMS screen to read off the clearance and preform the initial programming of the route. Due to the format and/or layout of the clearance on the screen I can only surmise that I read and programmed the filed routing and not the cleared routing into the FMS. We had been cleared on the NIITE2 departure and the TRUKN2 departure had been entered. Both the first officer and myself reviewed the clearance and even went so much as to fixate and have a long discussion regarding how the fix at oed did not belong in the routing; but we simply did not notice that the departures name was not correct. To add further confusion to the mix; we noticed that the fuel load onboard was much higher than what was on the release and spent the last remaining minutes up until door closure contacting dispatch to correct that issue. An amended release had already been sent in the system. All the while we were replacing the roll of paper in the empty ACARS printer and went back to print out all the ATIS; pre departure clearance; runway numbers; and now attempted to retrieve a new amended release which was coming much slower than expected. An amended release was then retrieved from the gate podium. We were able to complete checks and push from the gate on time and taxied out and were cleared for takeoff without incident. We switched frequencies to departure control and checked in by stating the departure SID that we were flying (the incorrect one). ATC did not seem to be concerned or did not notice the difference the discrepancy as well until we reached the first fix on the SID; at which point they calmly issued a heading turn to 330 degrees. We complied; however at the time it didn't really seem all that unusual. We received an additional turn or two before we were cleared to the last fix on our currently programmed SID which as a matter of fact was also the last fix on the correct SID as well. The rest of the routing had been correct due to both the first officer and I discussing it at great lengths at the gate. It wasn't until we had finished the SID that something struck me as odd that there were as many vectors on the departure that I reviewed the pre departure clearance slip and found that we had indeed programmed the incorrect SID into the FMS. It was this realization that got us discussing what had just happened and what were the contributing factors that led to this (to be discussed further in the next box) we continued our flight to our destination and finished on time without further incident.the main root cause of the event can be contributed to the fact that the clearance was entered into the FMS after reading it incorrectly from the FMS screen and by not comparing a printed pre departure clearance copy against the legs or flight plan page. Had this been done I am almost certain this event would not have occurred.additionally; fixating on the amendment of the release and all the difficulties involved with printing a new one out contributed to losing focus on the routing; all the while trying to change a new roll of paper to print out the pre departure clearance; the initialization page; ATIS; and an amended release. This is clearly not an excuse; however more of an explanation of how easily attention to detail was lost.1. Always print out the pre departure clearance first and foremost to compare against the legs and flight plan pages of the FMS.2. Circle or highlight the actual clearance and not the filed clearance.3. Never let additional tasks saturate the situation (ie. Amended release)
Original NASA ASRS Text
Title: During preflight at SFO a flight crew discovered the ACARS printer was out of paper and so read the PDC; but incorrectly. After takeoff ATC issued sequential vectors until the filed route was acquired.
Narrative: While during pre-flight things had started off smoothly and without incident. The crew had arrived at the aircraft early in order to alleviate any issues with rushing and to allow for any maintenance issues that might occur (the aircraft had been out of service for some time that day due to a liquid spill in the rear of the cabin while maintenance cleaned and replace interior carpets). While programming the FMS for departure; it was discovered that the ACARS printer was out of paper. I proceeded to use the FMS screen to read off the clearance and preform the initial programming of the route. Due to the format and/or layout of the clearance on the screen I can only surmise that I read and programmed the filed routing and not the cleared routing into the FMS. We had been cleared on the NIITE2 departure and the TRUKN2 departure had been entered. Both the First Officer and myself reviewed the clearance and even went so much as to fixate and have a long discussion regarding how the fix at OED did not belong in the routing; but we simply did not notice that the departures name was not correct. To add further confusion to the mix; we noticed that the fuel load onboard was much higher than what was on the release and spent the last remaining minutes up until door closure contacting Dispatch to correct that issue. An amended release had already been sent in the system. All the while we were replacing the roll of paper in the empty ACARS printer and went back to print out all the ATIS; PDC; runway numbers; and now attempted to retrieve a new amended release which was coming much slower than expected. An amended release was then retrieved from the gate podium. We were able to complete checks and push from the gate on time and taxied out and were cleared for takeoff without incident. We switched frequencies to departure control and checked in by stating the departure SID that we were flying (the incorrect one). ATC did not seem to be concerned or did not notice the difference the discrepancy as well until we reached the first fix on the SID; at which point they calmly issued a heading turn to 330 degrees. We complied; however at the time it didn't really seem all that unusual. We received an additional turn or two before we were cleared to the last fix on our currently programmed SID which as a matter of fact was also the last fix on the CORRECT SID as well. The rest of the routing had been correct due to both the FO and I discussing it at great lengths at the gate. It wasn't until we had finished the SID that something struck me as odd that there were as many vectors on the departure that I reviewed the PDC slip and found that we had indeed programmed the incorrect SID into the FMS. It was this realization that got us discussing what had just happened and what were the contributing factors that led to this (to be discussed further in the next box) We continued our flight to our destination and finished on time without further incident.The main root cause of the event can be contributed to the fact that the clearance was entered into the FMS after reading it incorrectly from the FMS screen and by not comparing a printed PDC copy against the Legs or Flight Plan page. Had this been done I am almost certain this event would not have occurred.Additionally; fixating on the amendment of the release and all the difficulties involved with printing a new one out contributed to losing focus on the routing; all the while trying to change a new roll of paper to print out the PDC; the Initialization page; ATIS; and an amended release. This is clearly not an excuse; however more of an explanation of how easily attention to detail was lost.1. Always print out the PDC first and foremost to compare against the Legs and Flight Plan pages of the FMS.2. Circle or highlight the ACTUAL clearance and not the filed clearance.3. Never let additional tasks saturate the situation (IE. amended release)
Data retrieved from NASA's ASRS site 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.