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Attributes | |
ACN | 130495 |
Time | |
Date | 198911 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : crk |
State Reference | FO |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : eggx |
Operator | general aviation : corporate |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : other oceanic enroute : atlantic enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 105 flight time total : 6325 flight time type : 2000 |
ASRS Report | 130495 |
Person 2 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This is a report of a gross navigation error while cleared and navigating in the north atlantic track system (mnps). I was the copilot flying in the right seat and making my first crossing with this company. We received a flight plan from a computer service prior to departure from the us and programmed our one omega/VLF and two INS systems with the oceanic clearance fixes en route to gander and double- and cross-checked them. We were delayed on the ground at gander by ATC and received and copied our clearance while taxiing out. The issued clearance was the same as the vendor filed flight plan except at 15W. Requested was 51N/15W, received was 52N/15W. I recognized the change, crossed out the old fix and wrote in the clearance fix on the computer flight plan, made a point to tell the captain of the change, and at some point changed the plotting chart but, due to the rush to complete checklists, etc, did not make the change in the long range navigation system until climbout en route to 50W. I reprogrammed the omega/VLF but did not reprogram the INS systems. (My experience with this company was that all long-range navigation was done on the omega/VLF system.) at or just past 50W the captain indicated he was changing from the omega to #1 INS for autoplt control of lrn. This struck me as a change from the norm but I did not recognize that the navigation program was now in error. I kept a plotting chart, with the correct track plotted, open and a north atlantic chart at hand plus the computer flight plan on which I made notes on fuel, wind, and position reports. At the first two compulsory fixes I checked all the navigation sources for cross-track errors, drift, etc. All was well. As we progressed into the second half of the flight one of our passenger pointed out that the arranged transportation was going to the wrong airport and would we take care of it. We were pushing a curfew at our planned destination and were trying to figure out how to make up time and of course crew meals were served. At the point where we made our turn from the correct track to the wrong one, I was not paying attention to the navigation. I was either trying to fix transportation or eating but I did not notice the course change and did not double-check that we were in fact going to the correct position (nor did the captain). On arrival at 15W I made the position report and after a short delay the controller who now had us in radar contact told us we were 60 NM south of course. On a double-check I concurred. We were then cleared on course to our destination. I have just finished reading (again) the north atlantic mnps airspace operations manual and can say that had I used but one of the many suggested record keeping backups I could have detected our error. I recommend a) a continuous plot be kept of the aircraft position, B) the master navigation document be kept current and, most important, C) insure that someone is doing the navigating.
Original NASA ASRS Text
Title: CPR MLG TRACK HEADING DEVIATION. NON ADHERENCE TO ATC CLRNC ON NORTH ATLANTIC TRACK.
Narrative: THIS IS A REPORT OF A GROSS NAVIGATION ERROR WHILE CLRED AND NAVIGATING IN THE NORTH ATLANTIC TRACK SYSTEM (MNPS). I WAS THE COPLT FLYING IN THE RIGHT SEAT AND MAKING MY FIRST XING WITH THIS COMPANY. WE RECEIVED A FLT PLAN FROM A COMPUTER SERVICE PRIOR TO DEP FROM THE U.S. AND PROGRAMMED OUR ONE OMEGA/VLF AND TWO INS SYSTEMS WITH THE OCEANIC CLRNC FIXES ENRTE TO GANDER AND DOUBLE- AND CROSS-CHECKED THEM. WE WERE DELAYED ON THE GND AT GANDER BY ATC AND RECEIVED AND COPIED OUR CLRNC WHILE TAXIING OUT. THE ISSUED CLRNC WAS THE SAME AS THE VENDOR FILED FLT PLAN EXCEPT AT 15W. REQUESTED WAS 51N/15W, RECEIVED WAS 52N/15W. I RECOGNIZED THE CHANGE, CROSSED OUT THE OLD FIX AND WROTE IN THE CLRNC FIX ON THE COMPUTER FLT PLAN, MADE A POINT TO TELL THE CAPT OF THE CHANGE, AND AT SOME POINT CHANGED THE PLOTTING CHART BUT, DUE TO THE RUSH TO COMPLETE CHECKLISTS, ETC, DID NOT MAKE THE CHANGE IN THE LONG RANGE NAV SYSTEM UNTIL CLIMBOUT ENRTE TO 50W. I REPROGRAMMED THE OMEGA/VLF BUT DID NOT REPROGRAM THE INS SYSTEMS. (MY EXPERIENCE WITH THIS COMPANY WAS THAT ALL LONG-RANGE NAV WAS DONE ON THE OMEGA/VLF SYSTEM.) AT OR JUST PAST 50W THE CAPT INDICATED HE WAS CHANGING FROM THE OMEGA TO #1 INS FOR AUTOPLT CONTROL OF LRN. THIS STRUCK ME AS A CHANGE FROM THE NORM BUT I DID NOT RECOGNIZE THAT THE NAVIGATION PROGRAM WAS NOW IN ERROR. I KEPT A PLOTTING CHART, WITH THE CORRECT TRACK PLOTTED, OPEN AND A NORTH ATLANTIC CHART AT HAND PLUS THE COMPUTER FLT PLAN ON WHICH I MADE NOTES ON FUEL, WIND, AND POSITION REPORTS. AT THE FIRST TWO COMPULSORY FIXES I CHECKED ALL THE NAV SOURCES FOR CROSS-TRACK ERRORS, DRIFT, ETC. ALL WAS WELL. AS WE PROGRESSED INTO THE SECOND HALF OF THE FLT ONE OF OUR PAX POINTED OUT THAT THE ARRANGED TRANSPORTATION WAS GOING TO THE WRONG ARPT AND WOULD WE TAKE CARE OF IT. WE WERE PUSHING A CURFEW AT OUR PLANNED DEST AND WERE TRYING TO FIGURE OUT HOW TO MAKE UP TIME AND OF COURSE CREW MEALS WERE SERVED. AT THE POINT WHERE WE MADE OUR TURN FROM THE CORRECT TRACK TO THE WRONG ONE, I WAS NOT PAYING ATTN TO THE NAVIGATION. I WAS EITHER TRYING TO FIX TRANSPORTATION OR EATING BUT I DID NOT NOTICE THE COURSE CHANGE AND DID NOT DOUBLE-CHECK THAT WE WERE IN FACT GOING TO THE CORRECT POSITION (NOR DID THE CAPT). ON ARR AT 15W I MADE THE POSITION REPORT AND AFTER A SHORT DELAY THE CTLR WHO NOW HAD US IN RADAR CONTACT TOLD US WE WERE 60 NM S OF COURSE. ON A DOUBLE-CHECK I CONCURRED. WE WERE THEN CLRED ON COURSE TO OUR DEST. I HAVE JUST FINISHED READING (AGAIN) THE NORTH ATLANTIC MNPS AIRSPACE OPERATIONS MANUAL AND CAN SAY THAT HAD I USED BUT ONE OF THE MANY SUGGESTED RECORD KEEPING BACKUPS I COULD HAVE DETECTED OUR ERROR. I RECOMMEND A) A CONTINUOUS PLOT BE KEPT OF THE ACFT POSITION, B) THE MASTER NAVIGATION DOCUMENT BE KEPT CURRENT AND, MOST IMPORTANT, C) INSURE THAT SOMEONE IS DOING THE NAVIGATING.
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.