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|
Attributes | |
ACN | 187126 |
Time | |
Date | 199108 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ont |
State Reference | CA |
Altitude | msl bound lower : 6000 msl bound upper : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ont |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 6500 flight time type : 115 |
ASRS Report | 187126 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 160 flight time total : 12500 flight time type : 3000 |
ASRS Report | 187533 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Took off from ontario, ca, to west on a prado departure, which calls for a left turn to paradise VOR. Instead, maintained runway heading, waiting for departure control to say, 'cleared direct paradise.' turned at about 7 mi and 6000 ft when controller noticed. Although I don't think I technically violated the SID since it doesn't say when to turn, I don't think this is what they intended. I believe the primary cause was pilot fatigue. Awoke at XA30. Had breakfast at xfoo but no lunch. Had headache...probably from lack of food. First officer had similar day. Other causes: prado 2 SID plate on westward takeoff shows a left turn, but does not show where. (It calls for a right turn within 1 NM when leaving to the east). SOP calls for heading select indicator to be on runway heading for takeoff in case of engine failure...not initial cleared heading. At 400 ft flying first officer called, by mistake, for 'heading select' instead of 'LNAV', which would have directed us to paradise VOR. During the takeoff checklist, SOP calls for captain to state 'heading select' and the indicated heading, which was runway heading. His mentally reenforced my tired mind to thinking we were going to fly runway heading. Usually, I add the initial cleared heading and altitudes to the response. However, being tired, I reverted back to the min required SOP. Since the first officer was flying and was in the 'map' mode, I was in raw data. Being tired, I did not review the procedure in the map mode. Normally I do this since it visually shows me what the computer thinks we should do. This was a new departure for me from ontario. All previous departures go west then north...usually with a vector. I was expecting the same. I believe this could have been prevented by: eating right! Double checking a SID when flying it for the first time. Check to see what the aircraft computer map thinks we should do. Don't back off to the min SOP when tired. This is when extra care should be taken. Revise the prado SID plate to show on a westward departure when the left turn to paradise VOR should be made.
Original NASA ASRS Text
Title: ACR MLG TRACK HDG DEV FLYING SID OUT OF ONT. THEY WENT TOO FAR W BEFORE TURNING TO PDZ.
Narrative: TOOK OFF FROM ONTARIO, CA, TO W ON A PRADO DEP, WHICH CALLS FOR A L TURN TO PARADISE VOR. INSTEAD, MAINTAINED RWY HDG, WAITING FOR DEP CTL TO SAY, 'CLRED DIRECT PARADISE.' TURNED AT ABOUT 7 MI AND 6000 FT WHEN CTLR NOTICED. ALTHOUGH I DON'T THINK I TECHNICALLY VIOLATED THE SID SINCE IT DOESN'T SAY WHEN TO TURN, I DON'T THINK THIS IS WHAT THEY INTENDED. I BELIEVE THE PRIMARY CAUSE WAS PLT FATIGUE. AWOKE AT XA30. HAD BREAKFAST AT XFOO BUT NO LUNCH. HAD HEADACHE...PROBABLY FROM LACK OF FOOD. FO HAD SIMILAR DAY. OTHER CAUSES: PRADO 2 SID PLATE ON WESTWARD TKOF SHOWS A L TURN, BUT DOES NOT SHOW WHERE. (IT CALLS FOR A R TURN WITHIN 1 NM WHEN LEAVING TO THE E). SOP CALLS FOR HDG SELECT INDICATOR TO BE ON RWY HDG FOR TKOF IN CASE OF ENG FAILURE...NOT INITIAL CLRED HDG. AT 400 FT FLYING FO CALLED, BY MISTAKE, FOR 'HDG SELECT' INSTEAD OF 'LNAV', WHICH WOULD HAVE DIRECTED US TO PARADISE VOR. DURING THE TKOF CHKLIST, SOP CALLS FOR CAPT TO STATE 'HDG SELECT' AND THE INDICATED HDG, WHICH WAS RWY HDG. HIS MENTALLY REENFORCED MY TIRED MIND TO THINKING WE WERE GOING TO FLY RWY HDG. USUALLY, I ADD THE INITIAL CLRED HDG AND ALTS TO THE RESPONSE. HOWEVER, BEING TIRED, I REVERTED BACK TO THE MIN REQUIRED SOP. SINCE THE FO WAS FLYING AND WAS IN THE 'MAP' MODE, I WAS IN RAW DATA. BEING TIRED, I DID NOT REVIEW THE PROC IN THE MAP MODE. NORMALLY I DO THIS SINCE IT VISUALLY SHOWS ME WHAT THE COMPUTER THINKS WE SHOULD DO. THIS WAS A NEW DEP FOR ME FROM ONTARIO. ALL PREVIOUS DEPS GO W THEN N...USUALLY WITH A VECTOR. I WAS EXPECTING THE SAME. I BELIEVE THIS COULD HAVE BEEN PREVENTED BY: EATING R! DOUBLE CHKING A SID WHEN FLYING IT FOR THE FIRST TIME. CHK TO SEE WHAT THE ACFT COMPUTER MAP THINKS WE SHOULD DO. DON'T BACK OFF TO THE MIN SOP WHEN TIRED. THIS IS WHEN EXTRA CARE SHOULD BE TAKEN. REVISE THE PRADO SID PLATE TO SHOW ON A WESTWARD DEP WHEN THE L TURN TO PARADISE VOR SHOULD BE MADE.
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.