37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1426360 |
Time | |
Date | 201702 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZGZU.ARTCC |
State Reference | FO |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Flight Phase | Parked |
Route In Use | SID SIE9W |
Flight Plan | IFR |
Component | |
Aircraft Component | FMS/FMC |
Person 1 | |
Function | Pilot Not Flying Relief Pilot |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 225 Flight Crew Total 13500 Flight Crew Type 2000 |
Person 2 | |
Function | First Officer Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 100 Flight Crew Total 11000 Flight Crew Type 3300 |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Deviation - Track / Heading All Types |
Narrative:
We arrived at the aircraft 1:15 prior. Loading had just begun; and paperwork was at the aircraft waiting for us. We went through our normal pre-flight routine; including requesting/receiving the route via FMS. Our copy of the flight plan did not have a departure (SID) listed or filed. Knowing that we always fly a SID out of zgsz (there are 47 different ones); the first officer entered runway 15 based on the ATIS; and the SIE7W departure because the points on that SID exactly matched the points on our filed flight plan. Since it was the captain's leg; the first officer briefed the captain that he expected the SIE7W based on what had been filed for us. During his initial brief; this was the SID we all referenced; since we didn't have our pre departure clearance yet. An hour later; after dealing with a fueling issue; a load issue; a possible maintenance issue; and an ATC delay; we were late but finally ready to go. Our pre departure clearance came through; but all three of us immediately cued in on the fact that we were assigned a squawk code. The first officer stated that he would clear that up with clearance delivery; we confirmed the initial altitude of 1200M; myself and the first officer double checked the conversion to feet. Not one of us caught that the assigned SID on the pre departure clearance was the SIE9W; not the SIE7W. The first officer called clearance delivery to clarify our squawk and request pushback and engine start. Clearance assigned us a squawk and said SIE9W to us. The first officer repeated that information back to him; wrote both down on the mfp and entered the new squawk into the transponder. We started push back during this; and we were also discussing our fuel; since we were currently too heavy for takeoff and would have to ensure a minimum burn off during taxi. Once again; all three of us missed the '9' west versus the '7' west that was loaded in the FMS. We started engines and taxied slower than usual because we had to burn off fuel. During the captain's before takeoff briefing; the tower controller called us twice to ask us to expedite our taxi. Tower gave us no indication why he was rushing us; but we were cleared for immediate departure; given a radio frequency; winds and our level off altitude in very fast; difficult to understand speech. Our fuel quantity was now correct; so we took off. Tower did not switch us over to departure frequency; so at about 1000' as we were commencing our turn on the SIE7W; the first officer switched frequencies on his own and turned on the autopilot at the captain's request. The first officer checked in with departure passing through about 1200' and in a right turn to our next waypoint; nlg. Within 10 seconds; departure assigned us a heading of 230 degrees and asked us what heading we were on. As we turned 20 degrees back left to 230; the first officer read back 230 degrees and told her we were flying the SIE7W. She then cleared us to climb; and cleared us direct zuh; the next point on the SIE7W and the point that both sids match each other. About 2 minutes later; she gave us a frequency change. At no time did she say anything about flying the wrong departure. The rest of our departure was very busy; stuck at low altitude; dodging thunderstorms; bouncing around in turbulence; switching from meters to feet; and navigating through hong kong's departure and arrival corridors with lots of other traffic. When we finally leveled off at cruise altitude nearly 30 minutes later; we discussed the fact that we entered and flew the wrong departure. Contributing factors: expectation bias. We matched our filed flight plan with the SID and entered it into the FMS without an actual pre departure clearance to reference. Communication. The language barrier is always a concern flying internationally; and often we hear what we expect to hear if the annunciation is not clear. Distractions. We were dealing with a number of issues that threatened to delay our departure; and our attention was split in too many directions. Time pressure. First; we were delayed pushand start by ATC due to hong kong airspace limitations. Then; for some reason; tower wanted us to taxi faster than the 13 knots we were doing; and called us multiple times with just the word 'expedite'. The language barrier would not allow the first officer to explain to him that we had to burn off fuel before takeoff; so we did the best we could under the circumstances. Bottom line; we made a mistake. At least twice we saw or heard sierra nine whiskey; but processed it as what we expected to hear - sierra seven whiskey. ATC caught the problem immediately and corrected it.
Original NASA ASRS Text
Title: Commercial flight crew reported departing ZGSZ on the SIE7W while the clearance was actually the SIE9W. Many distractions during preflight and the language barrier allowed the error to go undetected.
Narrative: We arrived at the aircraft 1:15 prior. Loading had just begun; and paperwork was at the aircraft waiting for us. We went through our normal pre-flight routine; including requesting/receiving the route via FMS. Our copy of the flight plan did not have a departure (SID) listed or filed. Knowing that we ALWAYS fly a SID out of ZGSZ (there are 47 different ones); the First Officer entered Runway 15 based on the ATIS; and the SIE7W departure because the points on that SID EXACTLY matched the points on our filed flight plan. Since it was the Captain's leg; the First Officer briefed the Captain that he expected the SIE7W based on what had been filed for us. During his initial brief; this was the SID we all referenced; since we didn't have our PDC yet. An hour later; after dealing with a fueling issue; a load issue; a possible maintenance issue; and an ATC delay; we were late but finally ready to go. Our PDC came through; but all three of us immediately cued in on the fact that we were assigned a squawk code. The First Officer stated that he would clear that up with Clearance Delivery; we confirmed the initial altitude of 1200M; myself and the First Officer double checked the conversion to feet. Not one of us caught that the assigned SID on the PDC was the SIE9W; not the SIE7W. The First Officer called Clearance Delivery to clarify our squawk and request pushback and engine start. Clearance assigned us a squawk and said SIE9W to us. The First Officer repeated that information back to him; wrote both down on the MFP and entered the new squawk into the transponder. We started push back during this; and we were also discussing our fuel; since we were currently too heavy for takeoff and would have to ensure a minimum burn off during taxi. Once again; all three of us missed the '9' W versus the '7' W that was loaded in the FMS. We started engines and taxied slower than usual because we had to burn off fuel. During the Captain's Before Takeoff briefing; the tower controller called us twice to ask us to expedite our taxi. Tower gave us no indication why he was rushing us; but we were cleared for immediate departure; given a radio frequency; winds and our level off altitude in very fast; difficult to understand speech. Our fuel quantity was now correct; so we took off. Tower did not switch us over to departure frequency; so at about 1000' as we were commencing our turn on the SIE7W; the First Officer switched frequencies on his own and turned on the autopilot at the Captain's request. The First Officer checked in with departure passing through about 1200' and in a right turn to our next waypoint; NLG. Within 10 seconds; departure assigned us a heading of 230 degrees and asked us what heading we were on. As we turned 20 degrees back left to 230; the First Officer read back 230 degrees and told her we were flying the SIE7W. She then cleared us to climb; and cleared us direct ZUH; the next point on the SIE7W and the point that both SIDs match each other. About 2 minutes later; she gave us a frequency change. At no time did she say anything about flying the wrong departure. The rest of our departure was very busy; stuck at low altitude; dodging thunderstorms; bouncing around in turbulence; switching from meters to feet; and navigating through Hong Kong's departure and arrival corridors with lots of other traffic. When we finally leveled off at cruise altitude nearly 30 minutes later; we discussed the fact that we entered and flew the wrong departure. Contributing factors: Expectation bias. We matched our filed flight plan with the SID and entered it into the FMS without an actual PDC to reference. Communication. The language barrier is always a concern flying internationally; and often we hear what we expect to hear if the annunciation is not clear. Distractions. We were dealing with a number of issues that threatened to delay our departure; and our attention was split in too many directions. Time Pressure. First; we were delayed pushand start by ATC due to Hong Kong airspace limitations. Then; for some reason; Tower wanted us to taxi faster than the 13 knots we were doing; and called us multiple times with just the word 'expedite'. The language barrier would not allow the First Officer to explain to him that we had to burn off fuel before takeoff; so we did the best we could under the circumstances. Bottom line; we made a mistake. At least twice we saw or heard Sierra NINE Whiskey; but processed it as what we expected to hear - Sierra SEVEN Whiskey. ATC caught the problem immediately and corrected it.
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.