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|
Attributes | |
ACN | 256258 |
Time | |
Date | 199311 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sjc |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | controller military : 2 flight time last 90 days : 240 flight time total : 9000 |
ASRS Report | 256258 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | 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:
Both captain and first officer were totally unfamiliar with the loupe 8 departure out of sjc airport. The first officer, who is fairly new, had however, studied the departure plate the previous evening and had a good idea of the procedure. The first officer was flying and upon reaching the 1.8 DME off sjc VOR, began his right turn (as depicted) to a 120 degree heading within 4 DME of sjc. At this point, the captain misread the departure plate and persuaded the first officer that he should be on the 339 degree radial outbound for the sacramento transition. We turned back to the left to intercept the 339 degree radial and had gone out to perhaps 7 or 8 DME before the bay departure controller asked where we were going. We told him, then he pointed out the error of our way, turned us back southeast to rejoin. No apparent conflict resulted. We were lucky that nothing worse resulted from this cockpit resource management lapse. The departure procedure is confusing, however, for a first-time user. It only becomes readily apparent that everyone must turn sebound after reading all the fine print very carefully. I think the procedure should be re-drawn so as to be clearer to a first-time user.
Original NASA ASRS Text
Title: FAILURE TO COMPLY WITH SID.
Narrative: BOTH CAPT AND FO WERE TOTALLY UNFAMILIAR WITH THE LOUPE 8 DEP OUT OF SJC ARPT. THE FO, WHO IS FAIRLY NEW, HAD HOWEVER, STUDIED THE DEP PLATE THE PREVIOUS EVENING AND HAD A GOOD IDEA OF THE PROC. THE FO WAS FLYING AND UPON REACHING THE 1.8 DME OFF SJC VOR, BEGAN HIS R TURN (AS DEPICTED) TO A 120 DEG HDG WITHIN 4 DME OF SJC. AT THIS POINT, THE CAPT MISREAD THE DEP PLATE AND PERSUADED THE FO THAT HE SHOULD BE ON THE 339 DEG RADIAL OUTBOUND FOR THE SACRAMENTO TRANSITION. WE TURNED BACK TO THE L TO INTERCEPT THE 339 DEG RADIAL AND HAD GONE OUT TO PERHAPS 7 OR 8 DME BEFORE THE BAY DEP CTLR ASKED WHERE WE WERE GOING. WE TOLD HIM, THEN HE POINTED OUT THE ERROR OF OUR WAY, TURNED US BACK SE TO REJOIN. NO APPARENT CONFLICT RESULTED. WE WERE LUCKY THAT NOTHING WORSE RESULTED FROM THIS COCKPIT RESOURCE MGMNT LAPSE. THE DEP PROC IS CONFUSING, HOWEVER, FOR A FIRST-TIME USER. IT ONLY BECOMES READILY APPARENT THAT EVERYONE MUST TURN SEBOUND AFTER READING ALL THE FINE PRINT VERY CAREFULLY. I THINK THE PROC SHOULD BE RE-DRAWN SO AS TO BE CLEARER TO A FIRST-TIME USER.
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.