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|
Attributes | |
ACN | 1483064 |
Time | |
Date | 201709 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | SCT.TRACON |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Light Transport Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 91 |
Flight Phase | Climb |
Route In Use | SID Cathedral 1 |
Flight Plan | IFR |
Person 1 | |
Function | First Officer Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | Pilot Not Flying Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Deviation - Track / Heading All Types |
Narrative:
I was the pilot flying and had minimal rest the night before due to sleep disruption from a neighboring hotel room. We had just completed a long; international flight. The inbound landing was challenging with high winds; shears and temps. Ramp temperatures were also high; and the post flight cabin duties were extensive and laborious. The clearance received assigned us the cathedral 1 departure to deway then direct to pom. This departure is not in the coded FMS database. Upon reading the chart I noticed that deway was the next fix directly after crossing psp VOR being that it is also on V388 it was already programmed in the FMS flight plan. So the programmed sequence was RW31L; psp; deway. This all looked good. The crossing requirement to continue enroute from psp to deway was 6;300 ft as a annotated by a ball flag. This seemed pretty simple. Take off; continue runway heading until the turn (raw data) then turn back to psp cross it above 6;300 ft and continue out to deway using the most expedient right turn. Wrong. We missed the routing instructions that include continuing southeast past the VOR to the emrud fix (an additional 10 NM east) before making a right turn to come back to the psp VOR and then on V388 to deway. The initial climb was very turbulent and ATC was giving us additional speed restrictions; level offs; and traffic advisories. I made the decision to hand-fly as the multiple changes; paired with environmental conditions made automation more complicated than the situation allowed. So when we reached psp VOR at approx 7;000 ft I made the right turn as programmed in the flight plan. The 104deg; 10NM fix; emrud was not programmed. In the right turn ATC asked us to make a left turn back to a northerly heading. He did not say if we had created a traffic or terrain conflict; nor did TCAS or egpws provide any advisories. We were in VMC and apart from the deviation the safety of flight did not appear to be at risk. Multiple contributing factors are worth mentioning in this instance. The most significant issue with this flight was mounting fatigue. Despite only feeling somewhat tired; the math simply would show I was fatigued. I had been awake more than 14 hours on the heels of 4-hours sleep when the mistake occurred. This paired with a lengthy flight into psp with high winds and turbulent conditions ensured I was much more tired than I felt. My mind was more focused on mitigation strategies for wind shear avoidance than on navigation. Having previously had a serious wind shear encounter at this airport; I was focused on energy management and trying to manage speed in the climb. Despite that fact; the error had been made on the ground. I simply followed the path precisely how I programmed it: in error. The final factor was simply not taking the time to double check the SID against what was in the FMS flight plan. The SID does indeed call for psp VOR direct to deway; and that's what I had programmed. But the SID also requires a tear-drop maneuver out to emrud. I saw only what I was expecting. I failed to look for what I was not expecting and this made all the difference. Being that this procedure is not a coded procedure; I had to rely on my interpretation on the chart and my ability to reconcile the procedure to the FMS flight plan. This confirmation bias caught me and my crew out.
Original NASA ASRS Text
Title: Light Transport flight crew reported a track deviation on the Cathedral 1 departure from KPSP attributed to fatigue and FMS departure confusion.
Narrative: I was the pilot flying and had minimal rest the night before due to sleep disruption from a neighboring hotel room. We had just completed a long; international flight. The inbound landing was challenging with high winds; shears and temps. Ramp temperatures were also high; and the post flight cabin duties were extensive and laborious. The clearance received assigned us the CATHEDRAL 1 departure to DEWAY then direct to POM. This departure is not in the coded FMS database. Upon reading the chart I noticed that DEWAY was the next fix directly after crossing PSP VOR being that it is also on V388 it was already programmed in the FMS flight plan. So the programmed sequence was RW31L; PSP; DEWAY. This all looked good. The crossing requirement to continue enroute from PSP to DEWAY was 6;300 ft as a annotated by a ball flag. This seemed pretty simple. Take off; continue runway heading until the turn (raw data) then turn back to PSP cross it above 6;300 ft and continue out to DEWAY using the most expedient right turn. Wrong. We missed the routing instructions that include continuing SE past the VOR to the EMRUD fix (an additional 10 NM east) before making a right turn to come back to the PSP VOR and THEN on V388 to DEWAY. The initial climb was very turbulent and ATC was giving us additional speed restrictions; level offs; and traffic advisories. I made the decision to hand-fly as the multiple changes; paired with environmental conditions made automation more complicated than the situation allowed. So when we reached PSP VOR at approx 7;000 ft I made the right turn as programmed in the flight plan. The 104deg; 10NM fix; EMRUD was not programmed. In the right turn ATC asked us to make a left turn back to a northerly heading. He did not say if we had created a traffic or terrain conflict; nor did TCAS or EGPWS provide any advisories. We were in VMC and apart from the deviation the safety of flight did not appear to be at risk. Multiple contributing factors are worth mentioning in this instance. The most significant issue with this flight was mounting fatigue. Despite only feeling somewhat tired; the math simply would show I was fatigued. I had been awake more than 14 hours on the heels of 4-hours sleep when the mistake occurred. This paired with a lengthy flight into PSP with high winds and turbulent conditions ensured I was much more tired than I felt. My mind was more focused on mitigation strategies for wind shear avoidance than on navigation. Having previously had a serious wind shear encounter at this airport; I was focused on energy management and trying to manage speed in the climb. Despite that fact; the error had been made on the ground. I simply followed the path precisely how I programmed it: in error. The final factor was simply not taking the time to double check the SID against what was in the FMS flight plan. The SID does indeed call for PSP VOR direct to DEWAY; and that's what I had programmed. But the SID also requires a tear-drop maneuver out to EMRUD. I saw only what I was expecting. I failed to look for what I was not expecting and this made all the difference. Being that this procedure is not a coded procedure; I had to rely on my interpretation on the chart and my ability to reconcile the procedure to the FMS flight plan. This confirmation bias caught me and my crew out.
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.