37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 238615 |
Time | |
Date | 199304 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : slc |
State Reference | UT |
Altitude | agl bound lower : 0 agl bound upper : 12500 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : slc |
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 ground : preflight |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 146 flight time total : 7541 flight time type : 1309 |
ASRS Report | 238615 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 238505 |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Missed clearance. Our company filed flight plan was kslc.slc.J9.mlf.2107.hec.J64 civet.CIVET3.klax. In our cockpit preparation, we had the pre departure clearance, but didn't catch the fairly subtle change to our actual clearance ffu.j11xj107.mlf then as filed. Didn't catch the problem until quizzed by center, and even then we initially thought we were correct. We failed to read the pre departure clearance carefully. Contributing: 1) day 4 of a long 4-DAY trip. 2) a highly experienced line check captain leading to first officer complacency in verifying the flight plan in the computer. 3) late equipment arrival, and the subsequent scramble to get out on time made me even later arriving in cockpit. 4) the heading 'flight plan routing' in the pre departure clearance, below the heading 'ATC clearance.' you can accidentally read the wrong part. Also, the pre departure clearance always says 'ATC clearance...' and 'flight plan routing....' perhaps it should only say 'as filed' if there are no changes, and 'ATC clearance' if there are -- something to get your attention. Supplemental information from acn 238505: during preflight, the first officer retrieved our ATC clearance via our touch screen ACARS. This aircraft did not have a printer. He brought it up on the screen, and we both read each page and made the appropriate settings which included the filed route then the cleared route. Neither one of us caught the difference in the route.
Original NASA ASRS Text
Title: AN ACR LGT MISREAD ITS PDC AND ATTEMPTED TO FLY THE WRONG DEP PROFILE.
Narrative: MISSED CLRNC. OUR COMPANY FILED FLT PLAN WAS KSLC.SLC.J9.MLF.2107.HEC.J64 CIVET.CIVET3.KLAX. IN OUR COCKPIT PREPARATION, WE HAD THE PDC, BUT DIDN'T CATCH THE FAIRLY SUBTLE CHANGE TO OUR ACTUAL CLRNC FFU.J11XJ107.MLF THEN AS FILED. DIDN'T CATCH THE PROB UNTIL QUIZZED BY CTR, AND EVEN THEN WE INITIALLY THOUGHT WE WERE CORRECT. WE FAILED TO READ THE PDC CAREFULLY. CONTRIBUTING: 1) DAY 4 OF A LONG 4-DAY TRIP. 2) A HIGHLY EXPERIENCED LINE CHK CAPT LEADING TO FO COMPLACENCY IN VERIFYING THE FLT PLAN IN THE COMPUTER. 3) LATE EQUIP ARR, AND THE SUBSEQUENT SCRAMBLE TO GET OUT ON TIME MADE ME EVEN LATER ARRIVING IN COCKPIT. 4) THE HDG 'FLT PLAN ROUTING' IN THE PDC, BELOW THE HDG 'ATC CLRNC.' YOU CAN ACCIDENTALLY READ THE WRONG PART. ALSO, THE PDC ALWAYS SAYS 'ATC CLRNC...' AND 'FLT PLAN ROUTING....' PERHAPS IT SHOULD ONLY SAY 'AS FILED' IF THERE ARE NO CHANGES, AND 'ATC CLRNC' IF THERE ARE -- SOMETHING TO GET YOUR ATTN. SUPPLEMENTAL INFO FROM ACN 238505: DURING PREFLT, THE FO RETRIEVED OUR ATC CLRNC VIA OUR TOUCH SCREEN ACARS. THIS ACFT DID NOT HAVE A PRINTER. HE BROUGHT IT UP ON THE SCREEN, AND WE BOTH READ EACH PAGE AND MADE THE APPROPRIATE SETTINGS WHICH INCLUDED THE FILED RTE THEN THE CLRED RTE. NEITHER ONE OF US CAUGHT THE DIFFERENCE IN THE RTE.
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.