37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 228435 |
Time | |
Date | 199212 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : initial |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 740 flight time total : 20000 flight time type : 7000 |
ASRS Report | 228435 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Miss Distance | horizontal : 6000 vertical : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We set our radios for the offshore 1 departure while doing our initial cockpit set up and preflight checks, I left the cockpit for a short time, when I returned the first officer said we had received the porte 8 departure. He had reset his HSI to 095 and mine to 135 and reset the navigation receivers to oak and sfo. Ramp called ready to push so we completed the before start checklist and pushed back from the gate. I had not noticed the improperly set navigation frequency during departure brief or the checklist. He had set mine on 115.8 and his on 116.8. We departed 10L a min or so after an light transport air carrier aircraft departed on 10R. I should have questioned following slower traffic so close, but I assumed they were on a diverging course. Out of 1500 ft I was raising flaps, adjusting power, and calling bay departure. When I notice the first officer was turning right, I knew we had a strong southeast wind but I still expected him to make a left turn to intercept the sfo 095 radial. I discovered the reversed navigation frequency as the TCASII said traffic, traffic. I saw the yellow DOT on the screen and told the first officer to correct left and climb. As we maneuvered the DOT went red and the TCASII said monitor vertical speed then climb, climb. We passed over and to the left of the traffic. By that time we were steady on the 095 degree radial of sfo. After we started evasive action the controller came on and said 'verify you departed 10L' then 'verify you were given the port 8' then 'verify your destination san diego.' we had our hands full at the time and did not need to play 20 questions with him. A simple call to 'turn left heading 080 degree to intercept the 095 degree radial' would have been helpful. We would have been glad to answer his interrogation after the danger was past. Contributing factors: the first officer was very experienced and I did not double check his work. Similar navigation frequencys were transposed and possibly missed due to the type. I did not check the first officer navigation until we were banked 20 degree right possibly because I had confidence in his abilities. His error was not immediately obvious because he had set my HSI for the intercept on the 135 degree radial of oak. I thought the 135 degree radial of oak was closer to the sfo airport. There is no distance shown on the departure chart. Lessons learned: no matter how experienced, any crew member can make a mistake when there is a change to an unfamiliar procedure, stop everything and become thoroughly familiar with it, then brief it thoroughly and rechk all navigation equipment again at that time. I will personally want the initial departure radial on my side from now on even though the first officer is flying.
Original NASA ASRS Text
Title: FLC OF ACR MLG ACFT DEVIATED FROM ASSIGNED DEP TRACK DUE TO SETTING THE WRONG FREQS INTO THE 2 PRIMARY NAVIGATIONAL RADIOS.
Narrative: WE SET OUR RADIOS FOR THE OFFSHORE 1 DEP WHILE DOING OUR INITIAL COCKPIT SET UP AND PREFLT CHKS, I LEFT THE COCKPIT FOR A SHORT TIME, WHEN I RETURNED THE FO SAID WE HAD RECEIVED THE PORTE 8 DEP. HE HAD RESET HIS HSI TO 095 AND MINE TO 135 AND RESET THE NAV RECEIVERS TO OAK AND SFO. RAMP CALLED READY TO PUSH SO WE COMPLETED THE BEFORE START CHKLIST AND PUSHED BACK FROM THE GATE. I HAD NOT NOTICED THE IMPROPERLY SET NAV FREQ DURING DEP BRIEF OR THE CHKLIST. HE HAD SET MINE ON 115.8 AND HIS ON 116.8. WE DEPARTED 10L A MIN OR SO AFTER AN LTT ACR ACFT DEPARTED ON 10R. I SHOULD HAVE QUESTIONED FOLLOWING SLOWER TFC SO CLOSE, BUT I ASSUMED THEY WERE ON A DIVERGING COURSE. OUT OF 1500 FT I WAS RAISING FLAPS, ADJUSTING PWR, AND CALLING BAY DEP. WHEN I NOTICE THE FO WAS TURNING R, I KNEW WE HAD A STRONG SE WIND BUT I STILL EXPECTED HIM TO MAKE A L TURN TO INTERCEPT THE SFO 095 RADIAL. I DISCOVERED THE REVERSED NAV FREQ AS THE TCASII SAID TFC, TFC. I SAW THE YELLOW DOT ON THE SCREEN AND TOLD THE FO TO CORRECT L AND CLB. AS WE MANEUVERED THE DOT WENT RED AND THE TCASII SAID MONITOR VERT SPD THEN CLB, CLB. WE PASSED OVER AND TO THE L OF THE TFC. BY THAT TIME WE WERE STEADY ON THE 095 DEG RADIAL OF SFO. AFTER WE STARTED EVASIVE ACTION THE CTLR CAME ON AND SAID 'VERIFY YOU DEPARTED 10L' THEN 'VERIFY YOU WERE GIVEN THE PORT 8' THEN 'VERIFY YOUR DEST SAN DIEGO.' WE HAD OUR HANDS FULL AT THE TIME AND DID NOT NEED TO PLAY 20 QUESTIONS WITH HIM. A SIMPLE CALL TO 'TURN L HDG 080 DEG TO INTERCEPT THE 095 DEG RADIAL' WOULD HAVE BEEN HELPFUL. WE WOULD HAVE BEEN GLAD TO ANSWER HIS INTERROGATION AFTER THE DANGER WAS PAST. CONTRIBUTING FACTORS: THE FO WAS VERY EXPERIENCED AND I DID NOT DOUBLE CHK HIS WORK. SIMILAR NAV FREQS WERE TRANSPOSED AND POSSIBLY MISSED DUE TO THE TYPE. I DID NOT CHK THE FO NAV UNTIL WE WERE BANKED 20 DEG R POSSIBLY BECAUSE I HAD CONFIDENCE IN HIS ABILITIES. HIS ERROR WAS NOT IMMEDIATELY OBVIOUS BECAUSE HE HAD SET MY HSI FOR THE INTERCEPT ON THE 135 DEG RADIAL OF OAK. I THOUGHT THE 135 DEG RADIAL OF OAK WAS CLOSER TO THE SFO ARPT. THERE IS NO DISTANCE SHOWN ON THE DEP CHART. LESSONS LEARNED: NO MATTER HOW EXPERIENCED, ANY CREW MEMBER CAN MAKE A MISTAKE WHEN THERE IS A CHANGE TO AN UNFAMILIAR PROC, STOP EVERYTHING AND BECOME THOROUGHLY FAMILIAR WITH IT, THEN BRIEF IT THOROUGHLY AND RECHK ALL NAV EQUIP AGAIN AT THAT TIME. I WILL PERSONALLY WANT THE INITIAL DEP RADIAL ON MY SIDE FROM NOW ON EVEN THOUGH THE FO IS FLYING.
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.