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Attributes | |
ACN | 194635 |
Time | |
Date | 199111 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mfr |
State Reference | OR |
Altitude | agl bound lower : 0 agl bound upper : 9000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zse tracon : mfr |
Operator | common carrier : air carrier |
Make Model Name | Small Transport, Low Wing, 2 Turboprop 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 : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 5000 flight time type : 1500 |
ASRS Report | 194635 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our scheduled morning flight from portland (pdx) to medford (mfr) was uneventful. However, the second leg of the flight, mfr to klamath falls (lmt), was cancelled due to low visibility in fog at lmt. Instead we were to repos to redmond (rdm) and continue our flight from rdm to pdx. The original schedule called for us to fly pdx-mfr-lmt-rdm- pdx. Our new flight plan routing was mfr V23 eug V121 rdm. The departure clearance from mfr ground control was runway 32, brute 1 departure, mourn transition, then as filed. There were also some altitude crossing restrictions in the clearance. Because we were a repos flight, we had no passenger or freight on board from mfr to rdm. While holding short of the runway I briefed the departure procedure with the first officer. Because neither of us had flown many trips into or out of mfr, I reviewed the procedure carefully, or so I thought. My briefing was: takeoff runway 32, climb direct to viole LMM, turn right and track outbound on the 045 relative bearing to brute intersection, cross brute at or above 3800 ft, from brute continue climb to 15 DME arc via V122 (mfr 098 radial), once on the arc continue until intercepting V23 (mfr 333 radial). This was in fact the procedure we flew while complying with the various crossing restrictions. The WX at the time was approximately 1000-2000 ft scattered with a higher overcast of approximately 11000 ft and surface and flight visibility of 10 mi. The first moment we realized my error was when mfr departure control (non radar) handed us off to sea center. The first officer checked in and center advised us what route we had just flown and what route our clearance was (continue from brute on the 045 rb to the 15 DME arc). The first officer acknowledged the transmission and then we looked at each other, mouths agape. As best we could tell by radio xmissions there had been no traffic conflict. No other radio transmission on the subject of our mistake were made. The remainder of the flight was uneventful. Throughout the remainder of the day we discussed what events had led to my improper procedure. My error to properly read the departure and follow the dashed line on the chart. Our relative unfamiliarity with the airport. While we both had flown into and out of mfr previously, the frequency was perhaps 4 times per yr. (Our company training department also shows a special video tape on the airport.) our flts are almost always rted pdx- mfr-lmt... The departure procedure is 'always' brute 1 V122. As a subjective comment, the SID is somewhat cluttered. Reviewing the procedure after the error I can see that there is not a DME arc from lanks intersection to the mourn transition. (This is a fact now forever impressed upon me.) as a suggestion to prevent further blunders such as mine, perhaps the chart format could be modified. If the identing data pointing to lanks could be moved, it would make an obvious difference in pathways for north and sbound DME arcs. Specifically, the lanks data block could be moved further right on the page making the arrow less in line with the DME arc.
Original NASA ASRS Text
Title: COMMUTER SMT TRACK HDG DEV FLYING A SID OUT OF MFR.
Narrative: OUR SCHEDULED MORNING FLT FROM PORTLAND (PDX) TO MEDFORD (MFR) WAS UNEVENTFUL. HOWEVER, THE SECOND LEG OF THE FLT, MFR TO KLAMATH FALLS (LMT), WAS CANCELLED DUE TO LOW VISIBILITY IN FOG AT LMT. INSTEAD WE WERE TO REPOS TO REDMOND (RDM) AND CONTINUE OUR FLT FROM RDM TO PDX. THE ORIGINAL SCHEDULE CALLED FOR US TO FLY PDX-MFR-LMT-RDM- PDX. OUR NEW FLT PLAN RTING WAS MFR V23 EUG V121 RDM. THE DEP CLRNC FROM MFR GND CTL WAS RWY 32, BRUTE 1 DEP, MOURN TRANSITION, THEN AS FILED. THERE WERE ALSO SOME ALT XING RESTRICTIONS IN THE CLRNC. BECAUSE WE WERE A REPOS FLT, WE HAD NO PAX OR FREIGHT ON BOARD FROM MFR TO RDM. WHILE HOLDING SHORT OF THE RWY I BRIEFED THE DEP PROC WITH THE FO. BECAUSE NEITHER OF US HAD FLOWN MANY TRIPS INTO OR OUT OF MFR, I REVIEWED THE PROC CAREFULLY, OR SO I THOUGHT. MY BRIEFING WAS: TKOF RWY 32, CLB DIRECT TO VIOLE LMM, TURN R AND TRACK OUTBOUND ON THE 045 RELATIVE BEARING TO BRUTE INTXN, CROSS BRUTE AT OR ABOVE 3800 FT, FROM BRUTE CONTINUE CLB TO 15 DME ARC VIA V122 (MFR 098 RADIAL), ONCE ON THE ARC CONTINUE UNTIL INTERCEPTING V23 (MFR 333 RADIAL). THIS WAS IN FACT THE PROC WE FLEW WHILE COMPLYING WITH THE VARIOUS XING RESTRICTIONS. THE WX AT THE TIME WAS APPROX 1000-2000 FT SCATTERED WITH A HIGHER OVCST OF APPROX 11000 FT AND SURFACE AND FLT VISIBILITY OF 10 MI. THE FIRST MOMENT WE REALIZED MY ERROR WAS WHEN MFR DEP CTL (NON RADAR) HANDED US OFF TO SEA CENTER. THE FO CHKED IN AND CENTER ADVISED US WHAT RTE WE HAD JUST FLOWN AND WHAT RTE OUR CLRNC WAS (CONTINUE FROM BRUTE ON THE 045 RB TO THE 15 DME ARC). THE FO ACKNOWLEDGED THE XMISSION AND THEN WE LOOKED AT EACH OTHER, MOUTHS AGAPE. AS BEST WE COULD TELL BY RADIO XMISSIONS THERE HAD BEEN NO TFC CONFLICT. NO OTHER RADIO XMISSION ON THE SUBJECT OF OUR MISTAKE WERE MADE. THE REMAINDER OF THE FLT WAS UNEVENTFUL. THROUGHOUT THE REMAINDER OF THE DAY WE DISCUSSED WHAT EVENTS HAD LED TO MY IMPROPER PROC. MY ERROR TO PROPERLY READ THE DEP AND FOLLOW THE DASHED LINE ON THE CHART. OUR RELATIVE UNFAMILIARITY WITH THE ARPT. WHILE WE BOTH HAD FLOWN INTO AND OUT OF MFR PREVIOUSLY, THE FREQ WAS PERHAPS 4 TIMES PER YR. (OUR COMPANY TRAINING DEPT ALSO SHOWS A SPECIAL VIDEO TAPE ON THE ARPT.) OUR FLTS ARE ALMOST ALWAYS RTED PDX- MFR-LMT... THE DEP PROC IS 'ALWAYS' BRUTE 1 V122. AS A SUBJECTIVE COMMENT, THE SID IS SOMEWHAT CLUTTERED. REVIEWING THE PROC AFTER THE ERROR I CAN SEE THAT THERE IS NOT A DME ARC FROM LANKS INTXN TO THE MOURN TRANSITION. (THIS IS A FACT NOW FOREVER IMPRESSED UPON ME.) AS A SUGGESTION TO PREVENT FURTHER BLUNDERS SUCH AS MINE, PERHAPS THE CHART FORMAT COULD BE MODIFIED. IF THE IDENTING DATA POINTING TO LANKS COULD BE MOVED, IT WOULD MAKE AN OBVIOUS DIFFERENCE IN PATHWAYS FOR N AND SBOUND DME ARCS. SPECIFICALLY, THE LANKS DATA BLOCK COULD BE MOVED FURTHER R ON THE PAGE MAKING THE ARROW LESS IN LINE WITH THE DME ARC.
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.