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|
Attributes | |
ACN | 189119 |
Time | |
Date | 199109 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bwi |
State Reference | MD |
Altitude | agl bound lower : 0 agl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : bwi tower : bwi |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff climbout : intermediate altitude ground : preflight |
Route In Use | enroute airway : bwi |
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 : 120 flight time total : 7000 flight time type : 80 |
ASRS Report | 189119 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : far non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
The departure station (bwi) was inadvertently entered as the departure and arrival stations in ACARS (e.g., bwi/bwi). Clearance for the trip was received through ACARS. Since I had flown this trip sequence several times with the same first officer and the routing was always the same I only checked the transponder code and altitude. I did not question why we were cleared to 10000 ft instead of the usual 4000 ft. No check of our clearance was made with bwi since none is required (usually at least the reading back of the transponder code is required at some airports). We received the correct load closeout during taxi and then took off. The first clue that something was amiss was when departure control wouldn't answer us. A quick return to tower got us on the right frequency. I called departure control and said that we were climbing to 10000 ft. He didn't question why we were climbing to 10000 ft instead of 4000 ft (the real clearance altitude), but instead cleared us to 17000 ft and told us to change our squawk (clue #2). Clue #3 came when we requested our flight plan from ACARS and it gave us a flight plan for a dfw direct bwi trip that was flown the day before. Now it all came into focus. I checked our ACARS clearance and it was indeed for flight #1 dfw to bwi flown the day before instead of flight #2 bwi to ord! Factors that I feel contributed to this include: 1) fatigue -- it was an early morning go plus I had flown 7 out of the previous 9 days. 2) complacency -- I had flown the same trip with the same first officer several times before. 3) procedures -- if we were required to at least read back the transponder code to clearance delivery we would have found out something was wrong. 4) computer programming -- bias the computer to prevent it from giving out clrncs that are 12 hours old. We did get the correct load closeout so why not the correct clearance?
Original NASA ASRS Text
Title: ADVANCED COCKPIT MLG FLC ENTERS WRONG ARR ARPT INTO ACARS AND GETS YESTERDAY'S FLT PLAN AND FOLLOWS IT.
Narrative: THE DEP STATION (BWI) WAS INADVERTENTLY ENTERED AS THE DEP AND ARR STATIONS IN ACARS (E.G., BWI/BWI). CLRNC FOR THE TRIP WAS RECEIVED THROUGH ACARS. SINCE I HAD FLOWN THIS TRIP SEQUENCE SEVERAL TIMES WITH THE SAME FO AND THE ROUTING WAS ALWAYS THE SAME I ONLY CHKED THE TRANSPONDER CODE AND ALT. I DID NOT QUESTION WHY WE WERE CLRED TO 10000 FT INSTEAD OF THE USUAL 4000 FT. NO CHK OF OUR CLRNC WAS MADE WITH BWI SINCE NONE IS REQUIRED (USUALLY AT LEAST THE READING BACK OF THE TRANSPONDER CODE IS REQUIRED AT SOME ARPTS). WE RECEIVED THE CORRECT LOAD CLOSEOUT DURING TAXI AND THEN TOOK OFF. THE FIRST CLUE THAT SOMETHING WAS AMISS WAS WHEN DEP CTL WOULDN'T ANSWER US. A QUICK RETURN TO TWR GOT US ON THE RIGHT FREQ. I CALLED DEP CTL AND SAID THAT WE WERE CLBING TO 10000 FT. HE DIDN'T QUESTION WHY WE WERE CLBING TO 10000 FT INSTEAD OF 4000 FT (THE REAL CLRNC ALT), BUT INSTEAD CLRED US TO 17000 FT AND TOLD US TO CHANGE OUR SQUAWK (CLUE #2). CLUE #3 CAME WHEN WE REQUESTED OUR FLT PLAN FROM ACARS AND IT GAVE US A FLT PLAN FOR A DFW DIRECT BWI TRIP THAT WAS FLOWN THE DAY BEFORE. NOW IT ALL CAME INTO FOCUS. I CHKED OUR ACARS CLRNC AND IT WAS INDEED FOR FLT #1 DFW TO BWI FLOWN THE DAY BEFORE INSTEAD OF FLT #2 BWI TO ORD! FACTORS THAT I FEEL CONTRIBUTED TO THIS INCLUDE: 1) FATIGUE -- IT WAS AN EARLY MORNING GO PLUS I HAD FLOWN 7 OUT OF THE PREVIOUS 9 DAYS. 2) COMPLACENCY -- I HAD FLOWN THE SAME TRIP WITH THE SAME FO SEVERAL TIMES BEFORE. 3) PROCS -- IF WE WERE REQUIRED TO AT LEAST READ BACK THE TRANSPONDER CODE TO CLRNC DELIVERY WE WOULD HAVE FOUND OUT SOMETHING WAS WRONG. 4) COMPUTER PROGRAMMING -- BIAS THE COMPUTER TO PREVENT IT FROM GIVING OUT CLRNCS THAT ARE 12 HRS OLD. WE DID GET THE CORRECT LOAD CLOSEOUT SO WHY NOT THE CORRECT CLRNC?
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.