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|
Attributes | |
ACN | 217774 |
Time | |
Date | 199208 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : sli airport : lax |
State Reference | CA |
Altitude | msl bound lower : 50 msl bound upper : 21000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure other departure sid : sid enroute airway : zla |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 6000 flight time type : 500 |
ASRS Report | 217774 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 200 |
ASRS Report | 217471 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : became reoriented flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Departing lax, runway 25R, cleared for loop 9. After takeoff, departure control turned us to heading 160 degrees which is not the normal loop 9 heading. A few mins later, he told us that we were on the laxx 1 departure and would be turning to sli soon. When turned to sli, we were cleared to 'seal beach and the daggett transition.' since the laxx 1 is not in the FMC data base, and since we were very close to sli, I entered sli, direct dag. At the same time, we switched the TCASII from TA to TA/RA and got an immediate full down RA which was obviously a 'glitch,' but which was still distracting. After passing sli, the controller asked us where we were going, and we, of course, realized that something was amiss. We checked the laxx 1 departure page and discovered the 'dog leg' between sli and dag. The controller seemed to be unconcerned, and cleared us direct to las. This was a typical 'combination of ingredients' error which is what leads to accidents. Supplemental information from acn 217471: this was a typical example of multiple inputs in a short time. Having the laxx 1 departure in the data base would have been a big help in avoiding this situation. TCASII false RA was a major distraction to normal operations in this case pointing out the importance of working out all 'bugs' in this system.
Original NASA ASRS Text
Title: AN LGT ACR CREW HAD A FALSE TCASII ALERT AT THE SAME TIME THAT THEIR CLRNC WAS BEING CHANGED TO A DEP THAT WAS NOT IN THEIR FMC DATA BASE.
Narrative: DEPARTING LAX, RWY 25R, CLRED FOR LOOP 9. AFTER TKOF, DEP CTL TURNED US TO HDG 160 DEGS WHICH IS NOT THE NORMAL LOOP 9 HDG. A FEW MINS LATER, HE TOLD US THAT WE WERE ON THE LAXX 1 DEP AND WOULD BE TURNING TO SLI SOON. WHEN TURNED TO SLI, WE WERE CLRED TO 'SEAL BEACH AND THE DAGGETT TRANSITION.' SINCE THE LAXX 1 IS NOT IN THE FMC DATA BASE, AND SINCE WE WERE VERY CLOSE TO SLI, I ENTERED SLI, DIRECT DAG. AT THE SAME TIME, WE SWITCHED THE TCASII FROM TA TO TA/RA AND GOT AN IMMEDIATE FULL DOWN RA WHICH WAS OBVIOUSLY A 'GLITCH,' BUT WHICH WAS STILL DISTRACTING. AFTER PASSING SLI, THE CTLR ASKED US WHERE WE WERE GOING, AND WE, OF COURSE, REALIZED THAT SOMETHING WAS AMISS. WE CHKED THE LAXX 1 DEP PAGE AND DISCOVERED THE 'DOG LEG' BTWN SLI AND DAG. THE CTLR SEEMED TO BE UNCONCERNED, AND CLRED US DIRECT TO LAS. THIS WAS A TYPICAL 'COMBINATION OF INGREDIENTS' ERROR WHICH IS WHAT LEADS TO ACCIDENTS. SUPPLEMENTAL INFO FROM ACN 217471: THIS WAS A TYPICAL EXAMPLE OF MULTIPLE INPUTS IN A SHORT TIME. HAVING THE LAXX 1 DEP IN THE DATA BASE WOULD HAVE BEEN A BIG HELP IN AVOIDING THIS SITUATION. TCASII FALSE RA WAS A MAJOR DISTR TO NORMAL OPS IN THIS CASE POINTING OUT THE IMPORTANCE OF WORKING OUT ALL 'BUGS' IN THIS SYS.
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.