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|
Attributes | |
ACN | 251459 |
Time | |
Date | 199309 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : fra |
State Reference | FO |
Altitude | msl bound lower : 28000 msl bound upper : 28000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : eggx |
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 : other oceanic enroute : atlantic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : cfi |
Experience | flight time last 90 days : 130 flight time total : 11000 flight time type : 130 |
ASRS Report | 254459 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 13000 flight time type : 1500 |
ASRS Report | 251987 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : overcame equipment problem flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On a flight from fra, germany, to ewr using INS as the primary navigation system, we approached the north atlantic mnps fix 59N, 10W. Reaching this fix I made a position report to shanwick radio and continued navigational plotting on the plotting chart. At this point, I noticed that the aircraft had made a right turn as much as 70 degrees deviation off course (heading). I immediately disconnected the autoplt and manually turned the aircraft around towards the next fix in line, 61N, 20W. After checking the next waypoint 61N, 20W, I noticed the coordinates of 61N, 20E had been incorrectly entered. After that we then re-verified the rest of the waypoints and the aircraft continued as flight planned to ewr without future incidence. Prior to the departure from fra, numerous maintenance items had to be corrected. One of those items was a failed air data computer that could have contributed to the wrong coordinates being entered. Numerous maintenance personnel were present inside the cockpit during the critical phase of the programming the INS's, and interruptions from them. During these interruptions, the wrong coordinates could possibly have been entered incorrectly. Supplemental information from acn 251754: captain had earlier given oceanic navigation log and plotting chart to first officer (PF) and asked him to do these duties. First officer, who was relatively new to the airplane and oceanic navigation (approximately 150 hours in type), had his head down and was reading the 59N, 10W position report to shanwick control and did not notice continuing turn until sun began to come in right side cockpit windows. During preflight and loading and checking inu's we were dealing with several maintenance problems and customer service problems. Captain was trying to 'micro-manage' things that he should have left to other people to handle.
Original NASA ASRS Text
Title: WDB ON OCEANIC FLT MIS-PROGRAMS INS. HDG DEV.
Narrative: ON A FLT FROM FRA, GERMANY, TO EWR USING INS AS THE PRIMARY NAV SYS, WE APCHED THE N ATLANTIC MNPS FIX 59N, 10W. REACHING THIS FIX I MADE A POS RPT TO SHANWICK RADIO AND CONTINUED NAVIGATIONAL PLOTTING ON THE PLOTTING CHART. AT THIS POINT, I NOTICED THAT THE ACFT HAD MADE A R TURN AS MUCH AS 70 DEGS DEV OFF COURSE (HDG). I IMMEDIATELY DISCONNECTED THE AUTOPLT AND MANUALLY TURNED THE ACFT AROUND TOWARDS THE NEXT FIX IN LINE, 61N, 20W. AFTER CHKING THE NEXT WAYPOINT 61N, 20W, I NOTICED THE COORDINATES OF 61N, 20E HAD BEEN INCORRECTLY ENTERED. AFTER THAT WE THEN RE-VERIFIED THE REST OF THE WAYPOINTS AND THE ACFT CONTINUED AS FLT PLANNED TO EWR WITHOUT FUTURE INCIDENCE. PRIOR TO THE DEP FROM FRA, NUMEROUS MAINT ITEMS HAD TO BE CORRECTED. ONE OF THOSE ITEMS WAS A FAILED AIR DATA COMPUTER THAT COULD HAVE CONTRIBUTED TO THE WRONG COORDINATES BEING ENTERED. NUMEROUS MAINT PERSONNEL WERE PRESENT INSIDE THE COCKPIT DURING THE CRITICAL PHASE OF THE PROGRAMMING THE INS'S, AND INTERRUPTIONS FROM THEM. DURING THESE INTERRUPTIONS, THE WRONG COORDINATES COULD POSSIBLY HAVE BEEN ENTERED INCORRECTLY. SUPPLEMENTAL INFO FROM ACN 251754: CAPT HAD EARLIER GIVEN OCEANIC NAV LOG AND PLOTTING CHART TO FO (PF) AND ASKED HIM TO DO THESE DUTIES. FO, WHO WAS RELATIVELY NEW TO THE AIRPLANE AND OCEANIC NAV (APPROX 150 HRS IN TYPE), HAD HIS HEAD DOWN AND WAS READING THE 59N, 10W POS RPT TO SHANWICK CTL AND DID NOT NOTICE CONTINUING TURN UNTIL SUN BEGAN TO COME IN R SIDE COCKPIT WINDOWS. DURING PREFLT AND LOADING AND CHKING INU'S WE WERE DEALING WITH SEVERAL MAINT PROBS AND CUSTOMER SVC PROBS. CAPT WAS TRYING TO 'MICRO-MANAGE' THINGS THAT HE SHOULD HAVE LEFT TO OTHER PEOPLE TO HANDLE.
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.