37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 151305 |
Time | |
Date | 199007 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : wer airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 2500 msl bound upper : 2500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 8000 flight time type : 300 |
ASRS Report | 151305 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Miss Distance | horizontal : 12000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We departed runway 4L at ewr on the ewr 3 departure. The departure calls for a right turn to 060 then a left turn at the canarsie 327 right to a heading of 290. This is about 3 miles from the end of the runway. In the mode control panel I had set 290 in the heading window. Positive rate, gear up, heading select is company procedure and following the command bars my turn to a heading of 290 was premature. I should have set 060 degree instead. My first officer caught the mistake and I began turning back to 060. ATC noticed called out traffic at 12 O'clock. We saw the traffic and indicated we would maintain visual. Apparently there was a loss of sep. The incorrect heading setting was the main cause of the error. The main contributing factor was not conducive to 100% performance. It was however, legal. In the 12 days prior to the occurrence I had an 24 hour period off, and not one calendar day off. Also in the same period of time I flew 48 hours of block time, plus 10 hours dead head. Duty time was about 80 hours. This in itself would not necessarily be detrimental, but in my case the flying was on all sides of the clock, day and night. Although I was legal with the FARS, this schedule (one which I will not accept in the future) was not in accordance with 100% performance. Callback conversation with reporter revealed the following: reporter explained why he was so tired. He is a reserve captain and has had to fly many hours recently. The trip he was flying at the time sets the stage for a poor night's sleep. This coupled with the progressive onset of fatigue over the past 11 days affected his performance.
Original NASA ASRS Text
Title: LGT FAILED TO FOLLOW THE SID, TURNED THE WRONG WAY IMMEDIATELY AFTER TKOF.
Narrative: WE DEPARTED RWY 4L AT EWR ON THE EWR 3 DEP. THE DEP CALLS FOR A R TURN TO 060 THEN A L TURN AT THE CANARSIE 327 R TO A HDG OF 290. THIS IS ABOUT 3 MILES FROM THE END OF THE RWY. IN THE MODE CTL PANEL I HAD SET 290 IN THE HDG WINDOW. POSITIVE RATE, GEAR UP, HDG SELECT IS COMPANY PROC AND FOLLOWING THE COMMAND BARS MY TURN TO A HDG OF 290 WAS PREMATURE. I SHOULD HAVE SET 060 DEG INSTEAD. MY F/O CAUGHT THE MISTAKE AND I BEGAN TURNING BACK TO 060. ATC NOTICED CALLED OUT TFC AT 12 O'CLOCK. WE SAW THE TFC AND INDICATED WE WOULD MAINTAIN VISUAL. APPARENTLY THERE WAS A LOSS OF SEP. THE INCORRECT HDG SETTING WAS THE MAIN CAUSE OF THE ERROR. THE MAIN CONTRIBUTING FACTOR WAS NOT CONDUCIVE TO 100% PERFORMANCE. IT WAS HOWEVER, LEGAL. IN THE 12 DAYS PRIOR TO THE OCCURRENCE I HAD AN 24 HOUR PERIOD OFF, AND NOT ONE CALENDAR DAY OFF. ALSO IN THE SAME PERIOD OF TIME I FLEW 48 HOURS OF BLOCK TIME, PLUS 10 HOURS DEAD HEAD. DUTY TIME WAS ABOUT 80 HOURS. THIS IN ITSELF WOULD NOT NECESSARILY BE DETRIMENTAL, BUT IN MY CASE THE FLYING WAS ON ALL SIDES OF THE CLOCK, DAY AND NIGHT. ALTHOUGH I WAS LEGAL WITH THE FARS, THIS SCHEDULE (ONE WHICH I WILL NOT ACCEPT IN THE FUTURE) WAS NOT IN ACCORDANCE WITH 100% PERFORMANCE. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: RPTR EXPLAINED WHY HE WAS SO TIRED. HE IS A RESERVE CAPT AND HAS HAD TO FLY MANY HOURS RECENTLY. THE TRIP HE WAS FLYING AT THE TIME SETS THE STAGE FOR A POOR NIGHT'S SLEEP. THIS COUPLED WITH THE PROGRESSIVE ONSET OF FATIGUE OVER THE PAST 11 DAYS AFFECTED HIS PERFORMANCE.
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.