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|
Attributes | |
ACN | 241297 |
Time | |
Date | 199305 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : yyt |
State Reference | NF |
Altitude | msl bound lower : 31000 msl bound upper : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqx |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : atlantic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 208 flight time total : 10792 flight time type : 33 |
ASRS Report | 241297 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were operating a trip from lagos nigeria to jfk with a tech stop in santa maria azones. As we left the minneapolis airspace at N45/50W direct bancs intersection. We contacted gander center. They changed our routing after bancs intersection to north american route 22 (bancs direct kanni intersection part of the plymouth 3 arrival into jfk). We entered the coordinates for kanni into waypoint position #2. The captain then inserted into the INS track change #7 to #2. #7 was the waypoint behind us #8 was bancs. The aircraft then turned to a southerly heading to intercept the waypoint behind us. We realized the heading was in error and went to heading mode and turned back to bancs intersection. Gander center called radar contact 20 mi south of bancs, still in gander domestic airspace. We should have been over bancs at that time. He then cleared us direct kanni. We all felt that fatigue played a major part in the error. The previous day we operated jfk-small aircraft-los 10:38 block hours. 12 hour crew rest at a hotel then the return trip which ended up to be 11:37 block. I was called in to operate the trip on a day off, so I was up 24 hours before reaching the hotel. I also believed once we departed the minneapolis airspace we became more complacent. We didn't check the waypoints as conscientiously as we were doing in the minneapolis airspace and through africa. Another factor is the other aircraft in the fleet home FMS's. The display where we were and where we were going would have been more evident.
Original NASA ASRS Text
Title: FLC OF ACR WDB ACFT INADVERTENTLY PROGRAMMED THE ACFT NAV COMPUTER IN ERROR RESULTING IN A 'GROSS' NAV ERROR DURING OP IN OCEANIC AIRSPACE.
Narrative: WE WERE OPERATING A TRIP FROM LAGOS NIGERIA TO JFK WITH A TECH STOP IN SANTA MARIA AZONES. AS WE LEFT THE MINNEAPOLIS AIRSPACE AT N45/50W DIRECT BANCS INTXN. WE CONTACTED GANDER CTR. THEY CHANGED OUR ROUTING AFTER BANCS INTXN TO NORTH AMERICAN RTE 22 (BANCS DIRECT KANNI INTXN PART OF THE PLYMOUTH 3 ARR INTO JFK). WE ENTERED THE COORDINATES FOR KANNI INTO WAYPOINT POS #2. THE CAPT THEN INSERTED INTO THE INS TRACK CHANGE #7 TO #2. #7 WAS THE WAYPOINT BEHIND US #8 WAS BANCS. THE ACFT THEN TURNED TO A SOUTHERLY HDG TO INTERCEPT THE WAYPOINT BEHIND US. WE REALIZED THE HDG WAS IN ERROR AND WENT TO HDG MODE AND TURNED BACK TO BANCS INTXN. GANDER CTR CALLED RADAR CONTACT 20 MI S OF BANCS, STILL IN GANDER DOMESTIC AIRSPACE. WE SHOULD HAVE BEEN OVER BANCS AT THAT TIME. HE THEN CLRED US DIRECT KANNI. WE ALL FELT THAT FATIGUE PLAYED A MAJOR PART IN THE ERROR. THE PREVIOUS DAY WE OPERATED JFK-SMA-LOS 10:38 BLOCK HRS. 12 HR CREW REST AT A HOTEL THEN THE RETURN TRIP WHICH ENDED UP TO BE 11:37 BLOCK. I WAS CALLED IN TO OPERATE THE TRIP ON A DAY OFF, SO I WAS UP 24 HRS BEFORE REACHING THE HOTEL. I ALSO BELIEVED ONCE WE DEPARTED THE MINNEAPOLIS AIRSPACE WE BECAME MORE COMPLACENT. WE DIDN'T CHK THE WAYPOINTS AS CONSCIENTIOUSLY AS WE WERE DOING IN THE MINNEAPOLIS AIRSPACE AND THROUGH AFRICA. ANOTHER FACTOR IS THE OTHER ACFT IN THE FLEET HOME FMS'S. THE DISPLAY WHERE WE WERE AND WHERE WE WERE GOING WOULD HAVE BEEN MORE EVIDENT.
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.