37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 209399 |
Time | |
Date | 199205 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : yxl |
State Reference | ON |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute airway : czeg enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | pilot : atp |
Experience | flight time last 90 days : 173 flight time total : 13000 flight time type : 400 |
ASRS Report | 209399 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 207 flight time total : 4537 flight time type : 487 |
ASRS Report | 209393 |
Events | |
Anomaly | non adherence : clearance non adherence : far other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight scheduled to depart osa, japan at XX25Z mon/xx/92. The crew entered the cockpit at XX10Z because the mechanics had just finished their work. When I entered the routing in the FMC, it would not accept our routing yfs J521 to yth. After several tries I entered yfs J521 to th which was accepted by the FMC. The next segment called for yth NCA22 to ysb. Once again the FMC failed to accept this routing. At this time I elected to go direct to the next chkpoint on the flight plan. It was 41YXL which I incorrectly entered as yxl. The rest of the flight plan was entered and we departed osa. There was a crew change at YY00Z. When the aircraft passed over th it went directly toward yxl which resulted in a 130 mi deviation from the filed course. Edmonton center called and cleared us direct to vqc to return to the planned track. The causes of this error were 1) a flight plan that did not match the canadian airway system. Yth (a VOR) is not on J521. Th (an ADF) is not on NCA22. The FMC will not accept either clearance. These 2 points are not colocated and are a constant source of irritation. 2) the identifier 41YXL on our flight plan as the chkpoint for 90W on NCA22 was very misleading and led to yxl being loaded. The edmonton controller referred to this position as 902. This was of no help to the crew to identify their mistake (see ca hi 2). It would help if this chkpoint had a name. 3) the original crew never completely checked the entire route before leaving osa. This was the result of 2 things. First, it took too long to enter the original route because the FMC failed to accept it. Secondly, the crew only had 15 mins to complete the preflight because maintenance personnel were not able to complete the necessary work until XX10Z. A debriefing was held with company training and safety personnel at which time an effort was made to change the flight plan inadequacies and to work with canadian authorities to rectify the airway system so they will be programmable in computer operated aircraft. (Ie, no route discontinuity at yth and th -- destination was jfk.)
Original NASA ASRS Text
Title: AN ACR WDB CREW MISLOADED THEIR NAV COMPUTER PRIOR TO DEP. THE RELIEF CREW DID NOT KNOW OF THE PROBLEMS THAT COULD BE ENCOUNTERED AND FOUND THEMSELVES OFF COURSE 130 MI.
Narrative: FLT SCHEDULED TO DEPART OSA, JAPAN AT XX25Z MON/XX/92. THE CREW ENTERED THE COCKPIT AT XX10Z BECAUSE THE MECHANICS HAD JUST FINISHED THEIR WORK. WHEN I ENTERED THE ROUTING IN THE FMC, IT WOULD NOT ACCEPT OUR ROUTING YFS J521 TO YTH. AFTER SEVERAL TRIES I ENTERED YFS J521 TO TH WHICH WAS ACCEPTED BY THE FMC. THE NEXT SEGMENT CALLED FOR YTH NCA22 TO YSB. ONCE AGAIN THE FMC FAILED TO ACCEPT THIS ROUTING. AT THIS TIME I ELECTED TO GO DIRECT TO THE NEXT CHKPOINT ON THE FLT PLAN. IT WAS 41YXL WHICH I INCORRECTLY ENTERED AS YXL. THE REST OF THE FLT PLAN WAS ENTERED AND WE DEPARTED OSA. THERE WAS A CREW CHANGE AT YY00Z. WHEN THE ACFT PASSED OVER TH IT WENT DIRECTLY TOWARD YXL WHICH RESULTED IN A 130 MI DEV FROM THE FILED COURSE. EDMONTON CTR CALLED AND CLRED US DIRECT TO VQC TO RETURN TO THE PLANNED TRACK. THE CAUSES OF THIS ERROR WERE 1) A FLT PLAN THAT DID NOT MATCH THE CANADIAN AIRWAY SYS. YTH (A VOR) IS NOT ON J521. TH (AN ADF) IS NOT ON NCA22. THE FMC WILL NOT ACCEPT EITHER CLRNC. THESE 2 POINTS ARE NOT COLOCATED AND ARE A CONSTANT SOURCE OF IRRITATION. 2) THE IDENTIFIER 41YXL ON OUR FLT PLAN AS THE CHKPOINT FOR 90W ON NCA22 WAS VERY MISLEADING AND LED TO YXL BEING LOADED. THE EDMONTON CTLR REFERRED TO THIS POS AS 902. THIS WAS OF NO HELP TO THE CREW TO IDENT THEIR MISTAKE (SEE CA HI 2). IT WOULD HELP IF THIS CHKPOINT HAD A NAME. 3) THE ORIGINAL CREW NEVER COMPLETELY CHKED THE ENTIRE RTE BEFORE LEAVING OSA. THIS WAS THE RESULT OF 2 THINGS. FIRST, IT TOOK TOO LONG TO ENTER THE ORIGINAL RTE BECAUSE THE FMC FAILED TO ACCEPT IT. SECONDLY, THE CREW ONLY HAD 15 MINS TO COMPLETE THE PREFLT BECAUSE MAINT PERSONNEL WERE NOT ABLE TO COMPLETE THE NECESSARY WORK UNTIL XX10Z. A DEBRIEFING WAS HELD WITH COMPANY TRAINING AND SAFETY PERSONNEL AT WHICH TIME AN EFFORT WAS MADE TO CHANGE THE FLT PLAN INADEQUACIES AND TO WORK WITH CANADIAN AUTHORITIES TO RECTIFY THE AIRWAY SYS SO THEY WILL BE PROGRAMMABLE IN COMPUTER OPERATED ACFT. (IE, NO RTE DISCONTINUITY AT YTH AND TH -- DEST WAS JFK.)
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.