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|
Attributes | |
ACN | 236373 |
Time | |
Date | 199303 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bwi |
State Reference | MD |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : bwi tower : bwi |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : initial climbout : takeoff ground : preflight |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | other other : other pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 11700 flight time type : 1300 |
ASRS Report | 236373 |
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 : 260 flight time total : 16000 flight time type : 1800 |
ASRS Report | 236374 |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
The crew departed bwi runway 28, and followed a published SID which depicted a turn to 150 degrees at the balance 3 DME. The initial altitude assignment was 4000 ft. After accomplishing the turn at 3 DME to 150 degrees, a further climb clearance to 8000 ft was issued and acknowledged. Approaching 5000 ft, bwi departure controller issued a 'maintain 5000 ft clearance' which was accomplished without difficulty. The controller then queried the departure clearance, and indicated it should have been 'runway heading for vectors.' the crew then inquired if there had been a conflict. The controller said 'no problem.' the crew indicated that they had seen no conflict on TCASII system nor visually (clear night VFR). There was no traffic within 5 mi, nor 1000 ft. Upon review of the ACARS pre departure clearance message, the crew recalled that they had a discussion regarding the use of 'hash marks' and how that was sometimes confusing, but in this case showed no conflict with the flight plan release, so no further inquiry was made. However, the crew did miss the addendum on page 2 'fly runway heading vector assigned route/fix.' I believe the following factors relevant to this occurrence: rescheduling crew into days off. Delays due to WX and airport conditions. Use of 'hash marks' on the pre departure clearance clearance. Departure clearance on page 2 instead of with route clearance. Tower takeoff clearance included no 'fly runway heading' comment which is standard at some airports (lack of standard procedures). Crew expected a SID (sids are the norm in the part of the airline system this crew normally flies), and in this instance had placed a SID on the control column clip. To prevent a recurrence possibly the following would help: standardize the 'takeoff clearance' to always include initial heading. Standardize the placement of the initial departure instructions on all pre departure clearance/ACARS issued clrncs. Use comment 'revised routing' vice hash marks on pre departure clearance issued clrncs.
Original NASA ASRS Text
Title: AN ACR MLG CREW DID NOT NOTICE THE REVISED DEP ROUTING ON ITS PREDEP CLRNC.
Narrative: THE CREW DEPARTED BWI RWY 28, AND FOLLOWED A PUBLISHED SID WHICH DEPICTED A TURN TO 150 DEGS AT THE BAL 3 DME. THE INITIAL ALT ASSIGNMENT WAS 4000 FT. AFTER ACCOMPLISHING THE TURN AT 3 DME TO 150 DEGS, A FURTHER CLB CLRNC TO 8000 FT WAS ISSUED AND ACKNOWLEDGED. APCHING 5000 FT, BWI DEP CTLR ISSUED A 'MAINTAIN 5000 FT CLRNC' WHICH WAS ACCOMPLISHED WITHOUT DIFFICULTY. THE CTLR THEN QUERIED THE DEP CLRNC, AND INDICATED IT SHOULD HAVE BEEN 'RWY HDG FOR VECTORS.' THE CREW THEN INQUIRED IF THERE HAD BEEN A CONFLICT. THE CTLR SAID 'NO PROB.' THE CREW INDICATED THAT THEY HAD SEEN NO CONFLICT ON TCASII SYS NOR VISUALLY (CLR NIGHT VFR). THERE WAS NO TFC WITHIN 5 MI, NOR 1000 FT. UPON REVIEW OF THE ACARS PDC MESSAGE, THE CREW RECALLED THAT THEY HAD A DISCUSSION REGARDING THE USE OF 'HASH MARKS' AND HOW THAT WAS SOMETIMES CONFUSING, BUT IN THIS CASE SHOWED NO CONFLICT WITH THE FLT PLAN RELEASE, SO NO FURTHER INQUIRY WAS MADE. HOWEVER, THE CREW DID MISS THE ADDENDUM ON PAGE 2 'FLY RWY HDG VECTOR ASSIGNED RTE/FIX.' I BELIEVE THE FOLLOWING FACTORS RELEVANT TO THIS OCCURRENCE: RESCHEDULING CREW INTO DAYS OFF. DELAYS DUE TO WX AND ARPT CONDITIONS. USE OF 'HASH MARKS' ON THE PDC CLRNC. DEP CLRNC ON PAGE 2 INSTEAD OF WITH RTE CLRNC. TWR TKOF CLRNC INCLUDED NO 'FLY RWY HDG' COMMENT WHICH IS STANDARD AT SOME ARPTS (LACK OF STANDARD PROCS). CREW EXPECTED A SID (SIDS ARE THE NORM IN THE PART OF THE AIRLINE SYS THIS CREW NORMALLY FLIES), AND IN THIS INSTANCE HAD PLACED A SID ON THE CTL COLUMN CLIP. TO PREVENT A RECURRENCE POSSIBLY THE FOLLOWING WOULD HELP: STANDARDIZE THE 'TKOF CLRNC' TO ALWAYS INCLUDE INITIAL HDG. STANDARDIZE THE PLACEMENT OF THE INITIAL DEP INSTRUCTIONS ON ALL PDC/ACARS ISSUED CLRNCS. USE COMMENT 'REVISED ROUTING' VICE HASH MARKS ON PDC ISSUED CLRNCS.
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.