37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 263292 |
Time | |
Date | 199402 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : den |
State Reference | CO |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdv |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other ground : preflight other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 16000 flight time type : 300 |
ASRS Report | 263292 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In sfo we picked up aircraft at XA40 local time. When I arrived in the cockpit, after checking and signing the release, I observed the first officer putting the position in on the overhead IRS panel with the align lights flashing. He said the aircraft must have been bumped. I didn't realize that this was the second time that he had entered the position. The reason it took the wrong position on the overhead was that this was the second wrong entry. As always we were interrupted and I did not get back and rechk our position. I entered the route of the flight. Upon departure we were cleared direct to sac. When the first officer executed this I could see there was a problem. This was the first time I had a good look at the route on the map position. I flew with the VOR in manual while the first officer checked to see what was wrong. He said he had entered the wrong west coordinates. I said it looked like we could continue on using the VOR's in manual. The WX was good en route and the WX was 2000 overcast 7 mi in pit. About 200 mi east of den on a center vector heading of 90 degrees to 10W, we lost all 3 IRS, and deviated to den (WX clear 15). After maintenance checked out the system and we realigned the IRS and got re-released I called radio maintenance and system control in pit and we discussed the situation and agreed it was just and entry error that caused the problem and we could continue to pit. I also asked maintenance, my dispatcher, and radioed maintenance in pit, if they needed a log book write-up and they said that it was not needed. We continued to pit with no further problem. We landed at XA00 local. It just further proves that 2 pilots should be in on and check the important part of putting in the initial position.
Original NASA ASRS Text
Title: ACR FO MESSES UP THE FMS ON ACR MLG BY INPUTTING THE WRONG W COORDINATES. IRS GOES BELLY UP LATER AND FLT HAS TO DIVERT TO ALTERNATE FOR CORRECTIONS.
Narrative: IN SFO WE PICKED UP ACFT AT XA40 LCL TIME. WHEN I ARRIVED IN THE COCKPIT, AFTER CHKING AND SIGNING THE RELEASE, I OBSERVED THE FO PUTTING THE POS IN ON THE OVERHEAD IRS PANEL WITH THE ALIGN LIGHTS FLASHING. HE SAID THE ACFT MUST HAVE BEEN BUMPED. I DIDN'T REALIZE THAT THIS WAS THE SECOND TIME THAT HE HAD ENTERED THE POS. THE REASON IT TOOK THE WRONG POS ON THE OVERHEAD WAS THAT THIS WAS THE SECOND WRONG ENTRY. AS ALWAYS WE WERE INTERRUPTED AND I DID NOT GET BACK AND RECHK OUR POS. I ENTERED THE RTE OF THE FLT. UPON DEP WE WERE CLRED DIRECT TO SAC. WHEN THE FO EXECUTED THIS I COULD SEE THERE WAS A PROB. THIS WAS THE FIRST TIME I HAD A GOOD LOOK AT THE RTE ON THE MAP POS. I FLEW WITH THE VOR IN MANUAL WHILE THE FO CHKED TO SEE WHAT WAS WRONG. HE SAID HE HAD ENTERED THE WRONG W COORDINATES. I SAID IT LOOKED LIKE WE COULD CONTINUE ON USING THE VOR'S IN MANUAL. THE WX WAS GOOD ENRTE AND THE WX WAS 2000 OVCST 7 MI IN PIT. ABOUT 200 MI E OF DEN ON A CTR VECTOR HDG OF 90 DEGS TO 10W, WE LOST ALL 3 IRS, AND DEVIATED TO DEN (WX CLR 15). AFTER MAINT CHKED OUT THE SYS AND WE REALIGNED THE IRS AND GOT RE-RELEASED I CALLED RADIO MAINT AND SYS CTL IN PIT AND WE DISCUSSED THE SIT AND AGREED IT WAS JUST AND ENTRY ERROR THAT CAUSED THE PROB AND WE COULD CONTINUE TO PIT. I ALSO ASKED MAINT, MY DISPATCHER, AND RADIOED MAINT IN PIT, IF THEY NEEDED A LOG BOOK WRITE-UP AND THEY SAID THAT IT WAS NOT NEEDED. WE CONTINUED TO PIT WITH NO FURTHER PROB. WE LANDED AT XA00 LCL. IT JUST FURTHER PROVES THAT 2 PLTS SHOULD BE IN ON AND CHK THE IMPORTANT PART OF PUTTING IN THE INITIAL POS.
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.