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Attributes | |
ACN | 265265 |
Time | |
Date | 199403 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : kip |
State Reference | FO |
Altitude | msl bound lower : 2800 msl bound upper : 2800 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : sel |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid |
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 : 150 flight time total : 5000 flight time type : 1100 |
ASRS Report | 265265 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The problem arose due to fatigue. I flew in from narita, and the captain gave me the option of flying back to narita. I jump at all chances to fly. As it turns out I was not so subtly incapacitated! Crossing the next VOR I momentarily thought we had lost the VOR at station passage. Descending into narita I leveled off to lose airspeed, and started a slight climb. Realizing I just was not with it that night I gave the plane over to the captain to land. I have heard of guys having bad days at work or in the simulators, now I can understand how it happens. The captain instantly realized I was turning the wrong way (last thing any of us wants to do is fly into north korea) but did not realize I was still on kip. When he did, he flipped me to sel. Thinking I was changing to sel I flipped the switch back to kip. Meantime departure was all over us with vectors and navigation was out of our hands. We were 'cleaning' up the aircraft for climb, the so was talking on the radio we were using to monitor 121.5 (as required when operating around seoul) and there were foreign voices on the radio. In other words, everything was happening at once. It was 0100 body time and we were tired. This was one of 3 nonstandard dc 10-30's we have in our fleet. The VOR heads are on the center console, below and behind us, making positive xchking difficult while in the initial/final phases of flight. I know this experience will make the 3 of us much more careful in the future. On a flight subsequent to this one I caught/stopped a fellow from making the same type of mistake again! Captain's narrative: flight departed gate at kimpo international airport. Flight was cleared for takeoff. Copilot was making takeoff as briefed. Clearance was golf departure, as filed, maintain FL330, departure control 124.8' golf departure is runway heading 323 degrees to start a turn left to 220 degree heading at 2300 ft or sel 16 DME (kip 5 DME) to proceed and intercept the sel radial 300 degrees to sel to cross sel at or above 3200 ft then maintain 7000 ft until instructed by ATC. #2 VOR was pretuned to kip to pick up 5 DME and provide reference for return to airport in case of emergency. Aircraft heading selector was set to 323 degrees. #1 VOR selector was tuned to sel to check 16 DME, with 120 degrees set in window for the intercept. Takeoff was normal. Approaching kip 5 DME heading selector was positioned to 220 degrees and left turn commenced climbing through approximately 2500 ft, climbing through 3000 ft aircraft was cleaned up and accelerated to clean maneuvering speed. The after takeoff checklist was being accomplished and the so was attempting to contact operations for off time report. #2 VOR radio had been pretuned to 300 degree radial but selector switch had not been changed to sel. As aircraft rapidly approached the 300 degree radial of kip, copilot initiated a right turn to intercept the 300 degree radial. The captain caught the wrong direction of turn and said 'it's a left turn to intercept, not right.' copilot immediately reversed turn and started to turn left to 120 degrees. Departure control came on and asked 'where are you going.' captain said we are turning left to 120 degrees for sel.' departure control came back up in a panicked voice and said to continue turn to 060 degrees. Captain noticed that #2 VOR selector switch was still on kip vice sel. He told copilot and switched selector switch to sel. Departure control issued climb clearance and called for a right turn to heading 180 degrees, followed by an immediate right turn to 240 degrees. Copilot appeared momentarily confused so captain took over flight controls and increased rate of turn to a 40 degree bank. Departure control then said turn left to a 90 degree heading which took us almost directly over sel. After crossing just south of sel, we were given heading of 080 degrees to intercept G597 (086 degree radial of sel). Shortly thereafter outbound heading was changed to 070 degrees to intercept. Flight was then switched over to taegu control with the comment 'a report will be filed.'
Original NASA ASRS Text
Title: WDB FLC MAKES WRONG DIRECTION TURN WHEN USING SID.
Narrative: THE PROB AROSE DUE TO FATIGUE. I FLEW IN FROM NARITA, AND THE CAPT GAVE ME THE OPTION OF FLYING BACK TO NARITA. I JUMP AT ALL CHANCES TO FLY. AS IT TURNS OUT I WAS NOT SO SUBTLY INCAPACITATED! XING THE NEXT VOR I MOMENTARILY THOUGHT WE HAD LOST THE VOR AT STATION PASSAGE. DSNDING INTO NARITA I LEVELED OFF TO LOSE AIRSPD, AND STARTED A SLIGHT CLB. REALIZING I JUST WAS NOT WITH IT THAT NIGHT I GAVE THE PLANE OVER TO THE CAPT TO LAND. I HAVE HEARD OF GUYS HAVING BAD DAYS AT WORK OR IN THE SIMULATORS, NOW I CAN UNDERSTAND HOW IT HAPPENS. THE CAPT INSTANTLY REALIZED I WAS TURNING THE WRONG WAY (LAST THING ANY OF US WANTS TO DO IS FLY INTO NORTH KOREA) BUT DID NOT REALIZE I WAS STILL ON KIP. WHEN HE DID, HE FLIPPED ME TO SEL. THINKING I WAS CHANGING TO SEL I FLIPPED THE SWITCH BACK TO KIP. MEANTIME DEP WAS ALL OVER US WITH VECTORS AND NAV WAS OUT OF OUR HANDS. WE WERE 'CLEANING' UP THE ACFT FOR CLB, THE SO WAS TALKING ON THE RADIO WE WERE USING TO MONITOR 121.5 (AS REQUIRED WHEN OPERATING AROUND SEOUL) AND THERE WERE FOREIGN VOICES ON THE RADIO. IN OTHER WORDS, EVERYTHING WAS HAPPENING AT ONCE. IT WAS 0100 BODY TIME AND WE WERE TIRED. THIS WAS ONE OF 3 NONSTANDARD DC 10-30'S WE HAVE IN OUR FLEET. THE VOR HEADS ARE ON THE CTR CONSOLE, BELOW AND BEHIND US, MAKING POSITIVE XCHKING DIFFICULT WHILE IN THE INITIAL/FINAL PHASES OF FLT. I KNOW THIS EXPERIENCE WILL MAKE THE 3 OF US MUCH MORE CAREFUL IN THE FUTURE. ON A FLT SUBSEQUENT TO THIS ONE I CAUGHT/STOPPED A FELLOW FROM MAKING THE SAME TYPE OF MISTAKE AGAIN! CAPT'S NARRATIVE: FLT DEPARTED GATE AT KIMPO INTL ARPT. FLT WAS CLRED FOR TKOF. COPLT WAS MAKING TKOF AS BRIEFED. CLRNC WAS GOLF DEP, AS FILED, MAINTAIN FL330, DEP CTL 124.8' GOLF DEP IS RWY HDG 323 DEGS TO START A TURN L TO 220 DEG HDG AT 2300 FT OR SEL 16 DME (KIP 5 DME) TO PROCEED AND INTERCEPT THE SEL RADIAL 300 DEGS TO SEL TO CROSS SEL AT OR ABOVE 3200 FT THEN MAINTAIN 7000 FT UNTIL INSTRUCTED BY ATC. #2 VOR WAS PRETUNED TO KIP TO PICK UP 5 DME AND PROVIDE REF FOR RETURN TO ARPT IN CASE OF EMER. ACFT HDG SELECTOR WAS SET TO 323 DEGS. #1 VOR SELECTOR WAS TUNED TO SEL TO CHK 16 DME, WITH 120 DEGS SET IN WINDOW FOR THE INTERCEPT. TKOF WAS NORMAL. APCHING KIP 5 DME HDG SELECTOR WAS POSITIONED TO 220 DEGS AND L TURN COMMENCED CLBING THROUGH APPROX 2500 FT, CLBING THROUGH 3000 FT ACFT WAS CLEANED UP AND ACCELERATED TO CLEAN MANEUVERING SPD. THE AFTER TKOF CHKLIST WAS BEING ACCOMPLISHED AND THE SO WAS ATTEMPTING TO CONTACT OPS FOR OFF TIME RPT. #2 VOR RADIO HAD BEEN PRETUNED TO 300 DEG RADIAL BUT SELECTOR SWITCH HAD NOT BEEN CHANGED TO SEL. AS ACFT RAPIDLY APCHED THE 300 DEG RADIAL OF KIP, COPLT INITIATED A R TURN TO INTERCEPT THE 300 DEG RADIAL. THE CAPT CAUGHT THE WRONG DIRECTION OF TURN AND SAID 'IT'S A L TURN TO INTERCEPT, NOT R.' COPLT IMMEDIATELY REVERSED TURN AND STARTED TO TURN L TO 120 DEGS. DEP CTL CAME ON AND ASKED 'WHERE ARE YOU GOING.' CAPT SAID WE ARE TURNING L TO 120 DEGS FOR SEL.' DEP CTL CAME BACK UP IN A PANICKED VOICE AND SAID TO CONTINUE TURN TO 060 DEGS. CAPT NOTICED THAT #2 VOR SELECTOR SWITCH WAS STILL ON KIP VICE SEL. HE TOLD COPLT AND SWITCHED SELECTOR SWITCH TO SEL. DEP CTL ISSUED CLB CLRNC AND CALLED FOR A R TURN TO HDG 180 DEGS, FOLLOWED BY AN IMMEDIATE R TURN TO 240 DEGS. COPLT APPEARED MOMENTARILY CONFUSED SO CAPT TOOK OVER FLT CTLS AND INCREASED RATE OF TURN TO A 40 DEG BANK. DEP CTL THEN SAID TURN L TO A 90 DEG HDG WHICH TOOK US ALMOST DIRECTLY OVER SEL. AFTER XING JUST S OF SEL, WE WERE GIVEN HDG OF 080 DEGS TO INTERCEPT G597 (086 DEG RADIAL OF SEL). SHORTLY THEREAFTER OUTBOUND HDG WAS CHANGED TO 070 DEGS TO INTERCEPT. FLT WAS THEN SWITCHED OVER TO TAEGU CTL WITH THE COMMENT 'A RPT WILL BE FILED.'
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.