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|
Attributes | |
ACN | 148451 |
Time | |
Date | 199006 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : bgr |
State Reference | ME |
Altitude | msl bound lower : 21000 msl bound upper : 21000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zbw |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | cruise other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 9800 flight time type : 5300 |
ASRS Report | 148451 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | other anomaly other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Deviation Pilot Deviation |
Narrative:
We had departed bgr en route to bos. On climb out, the ZBW controller cleared us to intercept and fly the bgr 253 degree right outbnd to intercept the bos 261 degree right inbound. The first officer was flying and I was communicating. During cruise we were handed off to another ZBW controller. A short while later, the new controller asked us which radial we were navigating on. He then informed us that we weren't anywhere near where we should have been and were heading off toward concord. He suggested that perhaps we were navigating off the augusta VOR by mistake. He gave us a turn to 190 degrees and slowed us to 280 KIAS (we were cruising at 350 KIAS). The first officer turned to a 190 degree heading and we went into a harried restructuring of events so as to determine if it was us who'd screwed up. I queried the first officer and second officer thoroughly to determine that we'd copied the correct radial (253 degrees), read it back and tuned and idented the bgr VOR. Then I made a rough pilot of the radial on a low altitude chart and determined that, indeed, the 253 degree right was taking us far off our intended course and would not intercept the bos 261 degree right inbound. Then we entered into a spirited cockpit discussion as to our degree of culpability in accepting a clearance that wasn't valid. During this discussion, with the possibility of being violated of high concern, I noticed that we were still doing 350 KIAS. I informed the first officer, who'd missed that portion of the clearance, and he initiated a deceleration to 280 KIAS. At that time, the controller asked us what our speed was. I reported 310 KIAS slowing to 280 KIAS. He disgustedly asked us how long ago he'd given us that speed reduction, and I reported that we had, in fact, been slow to comply. Then, second-guessing the controller's thoughts, I assumed that he must have considered us totally inept. Not only could we not navigation, we also couldn't fly an assigned airspeed. I convinced myself that F the radial hadn't gotten us violated, surely the airspeed had. Assuming that our licenses and checking accounts were now in jeopardy, we settled down in tense self-disgust to the task at hand and completed the flight to bos. After landing I phoned the supervisor at ZBW to express to him that, in spite of what had transpired, we still possessed professional pride and were not as inept as the controller's demeanor would have suggested. He informed us that the first controller had given us the 253 degree right by mistake. He assured me that the individual would be dealt with by his supervisor and apologized for the incident. He stated that there was no problem as far as they were concerned with our performance. The discussion was very cordial and it eased my mind immensely. What I'd like to report on is a system that's so laden with the threat of violation and punitive measures that safety is hampered. Both pilots and controllers are held captive by a need to defend themselves from possibly violation. The last thing I wanted to do was bring discredit upon the controller who'd given us the bad radial. Such an error is easily made (believe me, I know)--no big problem--but the system makes it a big problem. Then, one or more of the parties becomes obsessed with being exonerated. Flying and the control of air traffic demand constant attention to hundreds of details. The possibilities of mistake are infinite. When license preservation becomes a higher priority than the relaxed, common sense, fluid accomplishment of the task, then a hazard exists. Something went wrong in the administration of the system. Punishments became the order of the day. Fines and license suspensions became commonplace. Someone in power decided that if one who errs is threatened with a large enough punishment, then errors will cease. I believe that this reasoning does not consider human nature and the complexity of the air transportation system. It causes each of us to build a professional shell around ourselves. This inhibits the give and take of information and lessens the human aspect of the man/machine interfacility on which the system depends.
Original NASA ASRS Text
Title: ACR LGT TRACK DEVIATION IN COMPLIANCE WITH ARTCC RADAR VECTOR. SPEED DEVIATION ALSO OCCURRED WHILE TRYING TO RESOLVE TRACK ERROR.
Narrative: WE HAD DEPARTED BGR ENRTE TO BOS. ON CLBOUT, THE ZBW CTLR CLRED US TO INTERCEPT AND FLY THE BGR 253 DEG R OUTBND TO INTERCEPT THE BOS 261 DEG R INBND. THE F/O WAS FLYING AND I WAS COMMUNICATING. DURING CRUISE WE WERE HANDED OFF TO ANOTHER ZBW CTLR. A SHORT WHILE LATER, THE NEW CTLR ASKED US WHICH RADIAL WE WERE NAVIGATING ON. HE THEN INFORMED US THAT WE WEREN'T ANYWHERE NEAR WHERE WE SHOULD HAVE BEEN AND WERE HDG OFF TOWARD CONCORD. HE SUGGESTED THAT PERHAPS WE WERE NAVIGATING OFF THE AUGUSTA VOR BY MISTAKE. HE GAVE US A TURN TO 190 DEGS AND SLOWED US TO 280 KIAS (WE WERE CRUISING AT 350 KIAS). THE F/O TURNED TO A 190 DEG HDG AND WE WENT INTO A HARRIED RESTRUCTURING OF EVENTS SO AS TO DETERMINE IF IT WAS US WHO'D SCREWED UP. I QUERIED THE F/O AND S/O THOROUGHLY TO DETERMINE THAT WE'D COPIED THE CORRECT RADIAL (253 DEGS), READ IT BACK AND TUNED AND IDENTED THE BGR VOR. THEN I MADE A ROUGH PLT OF THE RADIAL ON A LOW ALT CHART AND DETERMINED THAT, INDEED, THE 253 DEG R WAS TAKING US FAR OFF OUR INTENDED COURSE AND WOULD NOT INTERCEPT THE BOS 261 DEG R INBND. THEN WE ENTERED INTO A SPIRITED COCKPIT DISCUSSION AS TO OUR DEGREE OF CULPABILITY IN ACCEPTING A CLRNC THAT WASN'T VALID. DURING THIS DISCUSSION, WITH THE POSSIBILITY OF BEING VIOLATED OF HIGH CONCERN, I NOTICED THAT WE WERE STILL DOING 350 KIAS. I INFORMED THE F/O, WHO'D MISSED THAT PORTION OF THE CLRNC, AND HE INITIATED A DECELERATION TO 280 KIAS. AT THAT TIME, THE CTLR ASKED US WHAT OUR SPD WAS. I RPTED 310 KIAS SLOWING TO 280 KIAS. HE DISGUSTEDLY ASKED US HOW LONG AGO HE'D GIVEN US THAT SPD REDUCTION, AND I RPTED THAT WE HAD, IN FACT, BEEN SLOW TO COMPLY. THEN, SECOND-GUESSING THE CTLR'S THOUGHTS, I ASSUMED THAT HE MUST HAVE CONSIDERED US TOTALLY INEPT. NOT ONLY COULD WE NOT NAV, WE ALSO COULDN'T FLY AN ASSIGNED AIRSPD. I CONVINCED MYSELF THAT F THE RADIAL HADN'T GOTTEN US VIOLATED, SURELY THE AIRSPD HAD. ASSUMING THAT OUR LICENSES AND CHKING ACCOUNTS WERE NOW IN JEOPARDY, WE SETTLED DOWN IN TENSE SELF-DISGUST TO THE TASK AT HAND AND COMPLETED THE FLT TO BOS. AFTER LNDG I PHONED THE SUPVR AT ZBW TO EXPRESS TO HIM THAT, IN SPITE OF WHAT HAD TRANSPIRED, WE STILL POSSESSED PROFESSIONAL PRIDE AND WERE NOT AS INEPT AS THE CTLR'S DEMEANOR WOULD HAVE SUGGESTED. HE INFORMED US THAT THE FIRST CTLR HAD GIVEN US THE 253 DEG R BY MISTAKE. HE ASSURED ME THAT THE INDIVIDUAL WOULD BE DEALT WITH BY HIS SUPVR AND APOLOGIZED FOR THE INCIDENT. HE STATED THAT THERE WAS NO PROB AS FAR AS THEY WERE CONCERNED WITH OUR PERFORMANCE. THE DISCUSSION WAS VERY CORDIAL AND IT EASED MY MIND IMMENSELY. WHAT I'D LIKE TO RPT ON IS A SYS THAT'S SO LADEN WITH THE THREAT OF VIOLATION AND PUNITIVE MEASURES THAT SAFETY IS HAMPERED. BOTH PLTS AND CTLRS ARE HELD CAPTIVE BY A NEED TO DEFEND THEMSELVES FROM POSSIBLY VIOLATION. THE LAST THING I WANTED TO DO WAS BRING DISCREDIT UPON THE CTLR WHO'D GIVEN US THE BAD RADIAL. SUCH AN ERROR IS EASILY MADE (BELIEVE ME, I KNOW)--NO BIG PROB--BUT THE SYS MAKES IT A BIG PROB. THEN, ONE OR MORE OF THE PARTIES BECOMES OBSESSED WITH BEING EXONERATED. FLYING AND THE CTL OF AIR TFC DEMAND CONSTANT ATTN TO HUNDREDS OF DETAILS. THE POSSIBILITIES OF MISTAKE ARE INFINITE. WHEN LICENSE PRESERVATION BECOMES A HIGHER PRIORITY THAN THE RELAXED, COMMON SENSE, FLUID ACCOMPLISHMENT OF THE TASK, THEN A HAZARD EXISTS. SOMETHING WENT WRONG IN THE ADMINISTRATION OF THE SYS. PUNISHMENTS BECAME THE ORDER OF THE DAY. FINES AND LICENSE SUSPENSIONS BECAME COMMONPLACE. SOMEONE IN PWR DECIDED THAT IF ONE WHO ERRS IS THREATENED WITH A LARGE ENOUGH PUNISHMENT, THEN ERRORS WILL CEASE. I BELIEVE THAT THIS REASONING DOES NOT CONSIDER HUMAN NATURE AND THE COMPLEXITY OF THE AIR TRANSPORTATION SYS. IT CAUSES EACH OF US TO BUILD A PROFESSIONAL SHELL AROUND OURSELVES. THIS INHIBITS THE GIVE AND TAKE OF INFO AND LESSENS THE HUMAN ASPECT OF THE MAN/MACHINE INTERFAC ON WHICH THE SYS DEPENDS.
Data retrieved from NASA's ASRS site as of July 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.