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|
Attributes | |
ACN | 230971 |
Time | |
Date | 199301 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : las |
State Reference | NV |
Altitude | msl bound lower : 3500 msl bound upper : 3700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : las artcc : zse |
Operator | common carrier : air carrier |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : intermediate altitude climbout : takeoff ground other : taxi |
Route In Use | departure other departure sid : sid |
Flight Plan | VFR |
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 : 180 flight time total : 3000 flight time type : 2000 |
ASRS Report | 230971 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3700 flight time type : 500 |
ASRS Report | 230974 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance non adherence : far other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The first officer got 2 clrncs. 1 VFR and 1 IFR. The first officer called ground control for taxi under the VFR call sign, not remembering that it was a VFR call sign, when I requested an IFR departure. The before takeoff checklist was done, and the departure brief was partially done by the first officer, when asked by the captain 'what clearance did you get?' the first officer responded by giving the following brief: 'turn right heading 270 degrees, radar vectors for the mead 8, peach springs transition as filed, climb and maintain 7000 ft, squawk XXXX.' (that transponder code and clearance were both an obvious indication of an IFR clearance, all VFR departures are given a code of YYYY.) the first officer called tower ready to go on 19L, under the VFR call sign. Takeoff clearance was given and radar contact was acknowledged with departure control climbing out of 3700 ft. This is where the confusion started, because of my concern of an mdt IFR departure slightly ahead of us, that departed off 19R. I did not start the right turn because of concern of separation with the mdt. I had the first officer ask for clearance to start the right turn. ATC mistook us for a similar sounding call sign of a company aircraft ahead of us on an IFR departure, because ATC issued us a VFR departure: a left turn. This is when the first officer realized his mistake in call signs and tried to get the IFR clearance under the correct call sign, but it had dropped out of the system by this time (67 mins). VMC was maintained until out of the TCA and a pop-up IFR clearance was received through ZLA. There were possible altitude and course deviation violations for not maintaining the VFR 'C' departure (initial altitude 3500 ft MSL and a left turn) runway heading was maintained due to the confusion of a right turn IFR or a left turn VFR. Also possible violations for ATC IFR separation requirements, especially if the right turn would have been made and IFR traffic were released off 25R, not to mention the mdt. Contributing factors: normal word-of-mouth company policy was to use the assigned flight number for VFR clrncs and the aircraft serial number for IFR clrncs, this was not a hard-fast rule and many times not observed, but the call sign used (assigned flight number) should have alerted me to the wrong call sign being used. There was an 800 pound fuel imbal, because of a previous crew leaving the xflow valve open all night, which needed to be balanced prior to takeoff. An aborted engine start, due to an automatic speed switch failure, which meant having to do a manual engine start and system checks of the srl computer and temperature limiter functions normally done by maintenance. These out-of-the-ordinary, nonstandard functions caused distraction from routine duties which helped to contribute to the error of using the wrong call sign. ATC decided to let the matter be handled by the company in-house. A warning letter was given to each crew member to be on file for 90 days. The crew received ground training of ATC procedures and communications, and crew coordination. Company policy has been put into writing on usage of call signs. And the crew will explain the occurrence to all company pilots at the next pilot meeting. Supplemental information from acn 230974: the captain elected to go IFR. During engine start a minor malfunction distracted me and I picked up our VFR clearance. The captain briefed the IFR departure and a further fuel imbal at the departure end of the runway distracted us. The factors contributing to the incident were complacency, several distractors, and improper procedure on my part for obtaining 2 flight plans. The incident could have been prevented by filing only 1 flight plan, better phraseology, i.e., 'ground, air carrier xyz, taxi IFR to the grand canyon.'
Original NASA ASRS Text
Title: FLC NOT CERTAIN OF FLT PLAN TYPE REQUESTED OR FILED. IFR VERSUS VFR. HDG TRACK DEV.
Narrative: THE FO GOT 2 CLRNCS. 1 VFR AND 1 IFR. THE FO CALLED GND CTL FOR TAXI UNDER THE VFR CALL SIGN, NOT REMEMBERING THAT IT WAS A VFR CALL SIGN, WHEN I REQUESTED AN IFR DEP. THE BEFORE TKOF CHKLIST WAS DONE, AND THE DEP BRIEF WAS PARTIALLY DONE BY THE FO, WHEN ASKED BY THE CAPT 'WHAT CLRNC DID YOU GET?' THE FO RESPONDED BY GIVING THE FOLLOWING BRIEF: 'TURN R HDG 270 DEGS, RADAR VECTORS FOR THE MEAD 8, PEACH SPRINGS TRANSITION AS FILED, CLB AND MAINTAIN 7000 FT, SQUAWK XXXX.' (THAT XPONDER CODE AND CLRNC WERE BOTH AN OBVIOUS INDICATION OF AN IFR CLRNC, ALL VFR DEPS ARE GIVEN A CODE OF YYYY.) THE FO CALLED TWR READY TO GO ON 19L, UNDER THE VFR CALL SIGN. TKOF CLRNC WAS GIVEN AND RADAR CONTACT WAS ACKNOWLEDGED WITH DEP CTL CLBING OUT OF 3700 FT. THIS IS WHERE THE CONFUSION STARTED, BECAUSE OF MY CONCERN OF AN MDT IFR DEP SLIGHTLY AHEAD OF US, THAT DEPARTED OFF 19R. I DID NOT START THE R TURN BECAUSE OF CONCERN OF SEPARATION WITH THE MDT. I HAD THE FO ASK FOR CLRNC TO START THE R TURN. ATC MISTOOK US FOR A SIMILAR SOUNDING CALL SIGN OF A COMPANY ACFT AHEAD OF US ON AN IFR DEP, BECAUSE ATC ISSUED US A VFR DEP: A L TURN. THIS IS WHEN THE FO REALIZED HIS MISTAKE IN CALL SIGNS AND TRIED TO GET THE IFR CLRNC UNDER THE CORRECT CALL SIGN, BUT IT HAD DROPPED OUT OF THE SYS BY THIS TIME (67 MINS). VMC WAS MAINTAINED UNTIL OUT OF THE TCA AND A POP-UP IFR CLRNC WAS RECEIVED THROUGH ZLA. THERE WERE POSSIBLE ALT AND COURSE DEV VIOLATIONS FOR NOT MAINTAINING THE VFR 'C' DEP (INITIAL ALT 3500 FT MSL AND A L TURN) RWY HDG WAS MAINTAINED DUE TO THE CONFUSION OF A R TURN IFR OR A L TURN VFR. ALSO POSSIBLE VIOLATIONS FOR ATC IFR SEPARATION REQUIREMENTS, ESPECIALLY IF THE R TURN WOULD HAVE BEEN MADE AND IFR TFC WERE RELEASED OFF 25R, NOT TO MENTION THE MDT. CONTRIBUTING FACTORS: NORMAL WORD-OF-MOUTH COMPANY POLICY WAS TO USE THE ASSIGNED FLT NUMBER FOR VFR CLRNCS AND THE ACFT SERIAL NUMBER FOR IFR CLRNCS, THIS WAS NOT A HARD-FAST RULE AND MANY TIMES NOT OBSERVED, BUT THE CALL SIGN USED (ASSIGNED FLT NUMBER) SHOULD HAVE ALERTED ME TO THE WRONG CALL SIGN BEING USED. THERE WAS AN 800 LB FUEL IMBAL, BECAUSE OF A PREVIOUS CREW LEAVING THE XFLOW VALVE OPEN ALL NIGHT, WHICH NEEDED TO BE BALANCED PRIOR TO TKOF. AN ABORTED ENG START, DUE TO AN AUTOMATIC SPD SWITCH FAILURE, WHICH MEANT HAVING TO DO A MANUAL ENG START AND SYS CHKS OF THE SRL COMPUTER AND TEMP LIMITER FUNCTIONS NORMALLY DONE BY MAINT. THESE OUT-OF-THE-ORDINARY, NONSTANDARD FUNCTIONS CAUSED DISTR FROM ROUTINE DUTIES WHICH HELPED TO CONTRIBUTE TO THE ERROR OF USING THE WRONG CALL SIGN. ATC DECIDED TO LET THE MATTER BE HANDLED BY THE COMPANY IN-HOUSE. A WARNING LETTER WAS GIVEN TO EACH CREW MEMBER TO BE ON FILE FOR 90 DAYS. THE CREW RECEIVED GND TRAINING OF ATC PROCS AND COMS, AND CREW COORD. COMPANY POLICY HAS BEEN PUT INTO WRITING ON USAGE OF CALL SIGNS. AND THE CREW WILL EXPLAIN THE OCCURRENCE TO ALL COMPANY PLTS AT THE NEXT PLT MEETING. SUPPLEMENTAL INFO FROM ACN 230974: THE CAPT ELECTED TO GO IFR. DURING ENG START A MINOR MALFUNCTION DISTRACTED ME AND I PICKED UP OUR VFR CLRNC. THE CAPT BRIEFED THE IFR DEP AND A FURTHER FUEL IMBAL AT THE DEP END OF THE RWY DISTRACTED US. THE FACTORS CONTRIBUTING TO THE INCIDENT WERE COMPLACENCY, SEVERAL DISTRACTORS, AND IMPROPER PROC ON MY PART FOR OBTAINING 2 FLT PLANS. THE INCIDENT COULD HAVE BEEN PREVENTED BY FILING ONLY 1 FLT PLAN, BETTER PHRASEOLOGY, I.E., 'GND, ACR XYZ, TAXI IFR TO THE GRAND CANYON.'
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.