Narrative:

Was flying from mildenhall, england to dover AFB, de, on the night of 4/tue/91. The mission was delayed for 7 hours for maintenance problems and finally an aircraft change and took off at yz:50Z on monday. Original takeoff time was yh:45Z. Prior to coast-out, we were reported to nat track tango which was completely different from the filed routing making our flight plan worthless. The new route was programmed into the INS by the copilot and pilot through to the clearance limit of klamm, 1 point past the cyqx fir boundary. The copilot took the coordinates for oyster from DOD canada le 10 high chart and they were placed in a stored waypoint in the fsas system which would automatically load into the instruments when a waypoint came available. Throughout the night position reports were very difficult to send mainly due to 1 very weak HF radio and no backup. The other radio was inoperative. At the last waypoint prior to coast-in 55 degree north 50 degree west gander radio accepted a position report which had a time for oyster (the fir boundary) of ab:29. Gander radio informed us to call moncton center 10 mins prior to oyster on 133.42 VHF. At ab:04Z moncton transmitted on the frequency to us requesting a squawk and identify. The controller asked if we were cleared another route besides oyster and when told we were proceeding to oyster informed us that we were northwest of oyster by 70 mi. When the coordinates were checked the error was indeed ours. The copilot had misread the chart and loaded W064 58 instead of W054 58. Looking back at the chart is is somewhat hard to read. We failed to confirm the coordinates and the lack of a flight plan prevented us from using it to xchk leg distances. Contributing factors that caused this navigation error were crew fatigue. The crew had been on a 17 day mission in support of desert storm. We had flown 82 hours, 16 sorties and had made 4 trips from europe 'down range' into turkey and saudi arabia. Everyone on the crew had flown over 125 hours in the previous 30 days and the pilot had flown 320 hours in the past 90 days. We had 9 days during this time when our legal crew duty day (show time until landing time) exceeded 18 hours. On this day we were expecting a 20 hour day since we only were offloading in dover and proceeding onto charleston, sc. At the time of the incident, the pilot had been up for 19 hours and the mission was still 7 hours from completion. Additional factors were bad HF radios which caused delays in position reporting; failure of gander center to recognize an obviously flawed time estimate for oyster (over 20 mins longer than it should have been); and a plotting chart used by the crew that had oyster preprinted. If they had been required to preplot the coordinates they had loaded instead of drawing their route and assuming oyster was correct they would not have let the mistake go by. An oprep 3 (x-nav error) was filed by the crew in accordance with mac regulations and a military investigation is underway. The controller advised the crew that a x-nav error report would be filed against our flight. Supplemental information from acn 177617: I inserted the coordinates for nat T into the INS and then the coordinates for oyster that I obtained off the canadian DOD chart le-10. Several factors contributing to the problem were: the cockpit lighting, nighttime and a brown hashed line and blue hash marks for the fir made the coordinate difficult to read.

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Original NASA ASRS Text

Title: GROSS NAVIGATION ERROR BY MIL FLT CREW.

Narrative: WAS FLYING FROM MILDENHALL, ENGLAND TO DOVER AFB, DE, ON THE NIGHT OF 4/TUE/91. THE MISSION WAS DELAYED FOR 7 HRS FOR MAINT PROBS AND FINALLY AN ACFT CHANGE AND TOOK OFF AT YZ:50Z ON MONDAY. ORIGINAL TKOF TIME WAS YH:45Z. PRIOR TO COAST-OUT, WE WERE RPTED TO NAT TRACK TANGO WHICH WAS COMPLETELY DIFFERENT FROM THE FILED ROUTING MAKING OUR FLT PLAN WORTHLESS. THE NEW RTE WAS PROGRAMMED INTO THE INS BY THE COPLT AND PLT THROUGH TO THE CLRNC LIMIT OF KLAMM, 1 POINT PAST THE CYQX FIR BOUNDARY. THE COPLT TOOK THE COORDINATES FOR OYSTER FROM DOD CANADA LE 10 HIGH CHART AND THEY WERE PLACED IN A STORED WAYPOINT IN THE FSAS SYS WHICH WOULD AUTOMATICALLY LOAD INTO THE INSTS WHEN A WAYPOINT CAME AVAILABLE. THROUGHOUT THE NIGHT POS RPTS WERE VERY DIFFICULT TO SEND MAINLY DUE TO 1 VERY WEAK HF RADIO AND NO BACKUP. THE OTHER RADIO WAS INOP. AT THE LAST WAYPOINT PRIOR TO COAST-IN 55 DEG N 50 DEG W GANDER RADIO ACCEPTED A POS RPT WHICH HAD A TIME FOR OYSTER (THE FIR BOUNDARY) OF AB:29. GANDER RADIO INFORMED US TO CALL MONCTON CENTER 10 MINS PRIOR TO OYSTER ON 133.42 VHF. AT AB:04Z MONCTON XMITTED ON THE FREQ TO US REQUESTING A SQUAWK AND IDENT. THE CTLR ASKED IF WE WERE CLRED ANOTHER RTE BESIDES OYSTER AND WHEN TOLD WE WERE PROCEEDING TO OYSTER INFORMED US THAT WE WERE NW OF OYSTER BY 70 MI. WHEN THE COORDINATES WERE CHKED THE ERROR WAS INDEED OURS. THE COPLT HAD MISREAD THE CHART AND LOADED W064 58 INSTEAD OF W054 58. LOOKING BACK AT THE CHART IS IS SOMEWHAT HARD TO READ. WE FAILED TO CONFIRM THE COORDINATES AND THE LACK OF A FLT PLAN PREVENTED US FROM USING IT TO XCHK LEG DISTANCES. CONTRIBUTING FACTORS THAT CAUSED THIS NAV ERROR WERE CREW FATIGUE. THE CREW HAD BEEN ON A 17 DAY MISSION IN SUPPORT OF DESERT STORM. WE HAD FLOWN 82 HRS, 16 SORTIES AND HAD MADE 4 TRIPS FROM EUROPE 'DOWN RANGE' INTO TURKEY AND SAUDI ARABIA. EVERYONE ON THE CREW HAD FLOWN OVER 125 HRS IN THE PREVIOUS 30 DAYS AND THE PLT HAD FLOWN 320 HRS IN THE PAST 90 DAYS. WE HAD 9 DAYS DURING THIS TIME WHEN OUR LEGAL CREW DUTY DAY (SHOW TIME UNTIL LNDG TIME) EXCEEDED 18 HRS. ON THIS DAY WE WERE EXPECTING A 20 HR DAY SINCE WE ONLY WERE OFFLOADING IN DOVER AND PROCEEDING ONTO CHARLESTON, SC. AT THE TIME OF THE INCIDENT, THE PLT HAD BEEN UP FOR 19 HRS AND THE MISSION WAS STILL 7 HRS FROM COMPLETION. ADDITIONAL FACTORS WERE BAD HF RADIOS WHICH CAUSED DELAYS IN POS RPTING; FAILURE OF GANDER CENTER TO RECOGNIZE AN OBVIOUSLY FLAWED TIME ESTIMATE FOR OYSTER (OVER 20 MINS LONGER THAN IT SHOULD HAVE BEEN); AND A PLOTTING CHART USED BY THE CREW THAT HAD OYSTER PREPRINTED. IF THEY HAD BEEN REQUIRED TO PREPLOT THE COORDINATES THEY HAD LOADED INSTEAD OF DRAWING THEIR RTE AND ASSUMING OYSTER WAS CORRECT THEY WOULD NOT HAVE LET THE MISTAKE GO BY. AN OPREP 3 (X-NAV ERROR) WAS FILED BY THE CREW IN ACCORDANCE WITH MAC REGS AND A MIL INVESTIGATION IS UNDERWAY. THE CTLR ADVISED THE CREW THAT A X-NAV ERROR RPT WOULD BE FILED AGAINST OUR FLT. SUPPLEMENTAL INFO FROM ACN 177617: I INSERTED THE COORDINATES FOR NAT T INTO THE INS AND THEN THE COORDINATES FOR OYSTER THAT I OBTAINED OFF THE CANADIAN DOD CHART LE-10. SEVERAL FACTORS CONTRIBUTING TO THE PROB WERE: THE COCKPIT LIGHTING, NIGHTTIME AND A BROWN HASHED LINE AND BLUE HASH MARKS FOR THE FIR MADE THE COORDINATE DIFFICULT TO READ.

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.