Narrative:

Flight filed for crossing atlantic on nat track D. Flight plan received by crew also for nat track D. Entry point on track D was ackel, with exit point carpe, then redby. Over U.K. Flight was cleared present position during to dogga, which had been loaded into the INS as waypoint #9. At this point flight was told to contact shanwick for oceanic clearance. Upon contacting shanwick, flight was reclred to cross on nat track C. Track C was 1 degree north of track D. The coordinates for track C were then loaded by captain. The coordinates that were loaded were up through waypoint #8. #9 was not loaded at time as we were proceeding to #9 dogga. Captain made the changes to the flight plan by crossing out some of the old waypoints and writing in the new ones in the above the old. As an example, if the old waypoint read 55/20, he scratched out the 55 and wrote 56 above which were the new track coordinates. Underneath each waypoint were the coordinates for the specific waypoint. These #south were never changed on any of the waypoints. At each waypoint during the crossing, the proper procedures were followed by myself. 2 mins prior to each waypoint the alert light will illuminate, each crew member will select the next waypoint, the PNF will read the coordinates for the next waypoint and each crew member will verify the coordinates loaded into each INS matches with the next waypoint. Once this is complete I continue on with the procedures for a fuel score. Sometime during the crossing the captain loaded waypoints 9 and 1, which were to be oystr and klamm, respectively. Once new waypoints are loaded, the captain is supposed to make it known to the other crew members that new waypoints have been loaded. This apparently was never done as the first officer and I cannot recall having every been told that new waypoints were loaded. The captain is not sure himself when he loaded the new points. The reason that no more than waypoints 9 and 1 were loaded was due to the fact that the flight had not received a north american routing or clearance. The original flight plan was not valid as the flight entered the coast at a different entry point than the flight was originally filed. When the alert light illuminated for waypoint #8, the procedures for that position were followed. The coordinates for the next waypoint were read out by the captain and checked by each crew member as correct. When apparently what actually happened was carpe had been crossed out and oystr written in above, but the coordinates had not been written in for oystr. So what actually was loaded into the INS was carpe. After crossing waypoint #8, I left cockpit to stretch, drive and go to lav. Upon my return, I was asked by first officer if I had checked coordinates for #9. Informed him that I'd checked them when they were read out to us prior to #8. He said that wasn't what he meant--had I checked them against the flight plan? I said that I could not recall checking them and I didn't remember being told the new coordinates had been loaded. I was then told there had been a slash line put across waypoint #9. Whenever the second officer checks the loading of waypoints by the captain, he is supposed to put a slashed line through the waypoints he has checked. There was a slashed line through #9 because the captain put an 'X' through each waypoint that he gives a position report. This was made known to us by the captain. The 'X' through the waypoint is not a company requirement or procedure. 10 mins after crossing each waypoint, PNF is supposed to put one INS into hold and select position. The coordinates that are on the INS are to then be plotted on the chart to check and see if the flight is indeed on course. This procedure is known as the tk roe check. The captain had done one for each waypoint across the atlantic with the exception of waypoint #8. Had this been done, it would have been discovered that the flight was indeed off course at about 20 mi and returned to its proper course. Apparently the aircraft proceed from over carpe with everyone believing that it was proceeding over oystr. The next waypoint was #1 klamm. This waypoint was apparently loaded correctly as the flight proceeded over klamm. I believe that the captain loaded this waypoint off the chart and not the flight plan as it was loaded correctly. Callback conversation with reporter revealed the following: only 1 flight plan is made available to the flight crew. The captain just forgot to due tk roe check. Probably because of fatigue the crew had been on a long flight check. Second officer is not issued en route charts, so he really cannot back up to the extent he could. Crew was given 40 hours off for the incident. FAA apparently is still investigating. Advised of the 5 yr limit on immunity.

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Original NASA ASRS Text

Title: WAYPOINT #9 COORDINATE NOT CHANGED WHEN REVISED FLT PLAN NOT ENTERED.

Narrative: FLT FILED FOR XING ATLANTIC ON NAT TRACK D. FLT PLAN RECEIVED BY CREW ALSO FOR NAT TRACK D. ENTRY POINT ON TRACK D WAS ACKEL, WITH EXIT POINT CARPE, THEN REDBY. OVER U.K. FLT WAS CLRED PRESENT POS DURING TO DOGGA, WHICH HAD BEEN LOADED INTO THE INS AS WAYPOINT #9. AT THIS POINT FLT WAS TOLD TO CONTACT SHANWICK FOR OCEANIC CLRNC. UPON CONTACTING SHANWICK, FLT WAS RECLRED TO CROSS ON NAT TRACK C. TRACK C WAS 1 DEG N OF TRACK D. THE COORDINATES FOR TRACK C WERE THEN LOADED BY CAPT. THE COORDINATES THAT WERE LOADED WERE UP THROUGH WAYPOINT #8. #9 WAS NOT LOADED AT TIME AS WE WERE PROCEEDING TO #9 DOGGA. CAPT MADE THE CHANGES TO THE FLT PLAN BY XING OUT SOME OF THE OLD WAYPOINTS AND WRITING IN THE NEW ONES IN THE ABOVE THE OLD. AS AN EXAMPLE, IF THE OLD WAYPOINT READ 55/20, HE SCRATCHED OUT THE 55 AND WROTE 56 ABOVE WHICH WERE THE NEW TRACK COORDINATES. UNDERNEATH EACH WAYPOINT WERE THE COORDINATES FOR THE SPECIFIC WAYPOINT. THESE #S WERE NEVER CHANGED ON ANY OF THE WAYPOINTS. AT EACH WAYPOINT DURING THE XING, THE PROPER PROCS WERE FOLLOWED BY MYSELF. 2 MINS PRIOR TO EACH WAYPOINT THE ALERT LIGHT WILL ILLUMINATE, EACH CREW MEMBER WILL SELECT THE NEXT WAYPOINT, THE PNF WILL READ THE COORDINATES FOR THE NEXT WAYPOINT AND EACH CREW MEMBER WILL VERIFY THE COORDINATES LOADED INTO EACH INS MATCHES WITH THE NEXT WAYPOINT. ONCE THIS IS COMPLETE I CONTINUE ON WITH THE PROCS FOR A FUEL SCORE. SOMETIME DURING THE XING THE CAPT LOADED WAYPOINTS 9 AND 1, WHICH WERE TO BE OYSTR AND KLAMM, RESPECTIVELY. ONCE NEW WAYPOINTS ARE LOADED, THE CAPT IS SUPPOSED TO MAKE IT KNOWN TO THE OTHER CREW MEMBERS THAT NEW WAYPOINTS HAVE BEEN LOADED. THIS APPARENTLY WAS NEVER DONE AS THE F/O AND I CANNOT RECALL HAVING EVERY BEEN TOLD THAT NEW WAYPOINTS WERE LOADED. THE CAPT IS NOT SURE HIMSELF WHEN HE LOADED THE NEW POINTS. THE REASON THAT NO MORE THAN WAYPOINTS 9 AND 1 WERE LOADED WAS DUE TO THE FACT THAT THE FLT HAD NOT RECEIVED A NORTH AMERICAN ROUTING OR CLRNC. THE ORIGINAL FLT PLAN WAS NOT VALID AS THE FLT ENTERED THE COAST AT A DIFFERENT ENTRY POINT THAN THE FLT WAS ORIGINALLY FILED. WHEN THE ALERT LIGHT ILLUMINATED FOR WAYPOINT #8, THE PROCS FOR THAT POS WERE FOLLOWED. THE COORDINATES FOR THE NEXT WAYPOINT WERE READ OUT BY THE CAPT AND CHKED BY EACH CREW MEMBER AS CORRECT. WHEN APPARENTLY WHAT ACTUALLY HAPPENED WAS CARPE HAD BEEN CROSSED OUT AND OYSTR WRITTEN IN ABOVE, BUT THE COORDINATES HAD NOT BEEN WRITTEN IN FOR OYSTR. SO WHAT ACTUALLY WAS LOADED INTO THE INS WAS CARPE. AFTER XING WAYPOINT #8, I LEFT COCKPIT TO STRETCH, DRIVE AND GO TO LAV. UPON MY RETURN, I WAS ASKED BY F/O IF I HAD CHKED COORDINATES FOR #9. INFORMED HIM THAT I'D CHKED THEM WHEN THEY WERE READ OUT TO US PRIOR TO #8. HE SAID THAT WASN'T WHAT HE MEANT--HAD I CHKED THEM AGAINST THE FLT PLAN? I SAID THAT I COULD NOT RECALL CHKING THEM AND I DIDN'T REMEMBER BEING TOLD THE NEW COORDINATES HAD BEEN LOADED. I WAS THEN TOLD THERE HAD BEEN A SLASH LINE PUT ACROSS WAYPOINT #9. WHENEVER THE S/O CHKS THE LOADING OF WAYPOINTS BY THE CAPT, HE IS SUPPOSED TO PUT A SLASHED LINE THROUGH THE WAYPOINTS HE HAS CHKED. THERE WAS A SLASHED LINE THROUGH #9 BECAUSE THE CAPT PUT AN 'X' THROUGH EACH WAYPOINT THAT HE GIVES A POS RPT. THIS WAS MADE KNOWN TO US BY THE CAPT. THE 'X' THROUGH THE WAYPOINT IS NOT A COMPANY REQUIREMENT OR PROC. 10 MINS AFTER XING EACH WAYPOINT, PNF IS SUPPOSED TO PUT ONE INS INTO HOLD AND SELECT POS. THE COORDINATES THAT ARE ON THE INS ARE TO THEN BE PLOTTED ON THE CHART TO CHK AND SEE IF THE FLT IS INDEED ON COURSE. THIS PROC IS KNOWN AS THE TK ROE CHK. THE CAPT HAD DONE ONE FOR EACH WAYPOINT ACROSS THE ATLANTIC WITH THE EXCEPTION OF WAYPOINT #8. HAD THIS BEEN DONE, IT WOULD HAVE BEEN DISCOVERED THAT THE FLT WAS INDEED OFF COURSE AT ABOUT 20 MI AND RETURNED TO ITS PROPER COURSE. APPARENTLY THE ACFT PROCEED FROM OVER CARPE WITH EVERYONE BELIEVING THAT IT WAS PROCEEDING OVER OYSTR. THE NEXT WAYPOINT WAS #1 KLAMM. THIS WAYPOINT WAS APPARENTLY LOADED CORRECTLY AS THE FLT PROCEEDED OVER KLAMM. I BELIEVE THAT THE CAPT LOADED THIS WAYPOINT OFF THE CHART AND NOT THE FLT PLAN AS IT WAS LOADED CORRECTLY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: ONLY 1 FLT PLAN IS MADE AVAILABLE TO THE FLT CREW. THE CAPT JUST FORGOT TO DUE TK ROE CHK. PROBABLY BECAUSE OF FATIGUE THE CREW HAD BEEN ON A LONG FLT CHK. S/O IS NOT ISSUED ENRTE CHARTS, SO HE REALLY CANNOT BACK UP TO THE EXTENT HE COULD. CREW WAS GIVEN 40 HRS OFF FOR THE INCIDENT. FAA APPARENTLY IS STILL INVESTIGATING. ADVISED OF THE 5 YR LIMIT ON IMMUNITY.

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.