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|
Attributes | |
ACN | 266000 |
Time | |
Date | 199403 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : yay |
State Reference | NF |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : czqx |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 230 flight time total : 6500 flight time type : 3300 |
ASRS Report | 266000 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 17000 flight time type : 400 |
ASRS Report | 265999 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During cruise flight over northeastern canada, gander center cleared the aircraft direct to redby while still in radar contact. Oceanic clearance had just been received when other aircraft in the area asked center of any upcoming ride reports. #3 INS was taken from 'xtx/tke position' to 'wind position' to monitor winds aloft. Crew meals were also being brought up to cockpit which caused momentary distraction. Shortly thereafter, gander center advises crew the aircraft appeared south of course and then cleared the aircraft direct carpe. Aircraft proceeds direct to carpe with no further incident. #3 INS confirmed aircraft heading direct carpe and on course. Leaving gander's airspace, center advised crew that no problems or conflicts had been created. Discrepancy in course location found to be location of redby had been changed but old location was still in FMS database. Also, no note on flight plan mentioned change in redby location. Aircraft enter nat system and continued on course to destination. Supplemental information from acn 265999: during preflight the route of flight was loaded into the FMS by the captain and checked by the first officer according to company procedures. However, distraction in the cockpit due to an electrical problem that maintenance was working on may have caused the crew to miss the fact that the FMS coordinates for redby were wrong. Evidently the FMS database had not been updated since the latest chart revision when redby coordinates were changed. Redby coordinates were in the FMS by 1 digit, which was easy to miss during the xchk. Since we were on a direct route, the final xchk (correct heading, time, and distance) was impossible. Supplemental information from acn 266003: aircraft had not entered nat system at time of excursion. Aircraft was in radar contact with ATC at time of excursion, reinforcing flight crew's belief that 'all was well.'
Original NASA ASRS Text
Title: GROSS NAV ERROR. HDG TRACK POS DEV. NON ADHERENCE TO ATC CLRNC. FOREIGN AIRSPACE.
Narrative: DURING CRUISE FLT OVER NORTHEASTERN CANADA, GANDER CTR CLRED THE ACFT DIRECT TO REDBY WHILE STILL IN RADAR CONTACT. OCEANIC CLRNC HAD JUST BEEN RECEIVED WHEN OTHER ACFT IN THE AREA ASKED CTR OF ANY UPCOMING RIDE RPTS. #3 INS WAS TAKEN FROM 'XTX/TKE POS' TO 'WIND POS' TO MONITOR WINDS ALOFT. CREW MEALS WERE ALSO BEING BROUGHT UP TO COCKPIT WHICH CAUSED MOMENTARY DISTR. SHORTLY THEREAFTER, GANDER CTR ADVISES CREW THE ACFT APPEARED S OF COURSE AND THEN CLRED THE ACFT DIRECT CARPE. ACFT PROCEEDS DIRECT TO CARPE WITH NO FURTHER INCIDENT. #3 INS CONFIRMED ACFT HDG DIRECT CARPE AND ON COURSE. LEAVING GANDER'S AIRSPACE, CTR ADVISED CREW THAT NO PROBS OR CONFLICTS HAD BEEN CREATED. DISCREPANCY IN COURSE LOCATION FOUND TO BE LOCATION OF REDBY HAD BEEN CHANGED BUT OLD LOCATION WAS STILL IN FMS DATABASE. ALSO, NO NOTE ON FLT PLAN MENTIONED CHANGE IN REDBY LOCATION. ACFT ENTER NAT SYS AND CONTINUED ON COURSE TO DEST. SUPPLEMENTAL INFORMATION FROM ACN 265999: DURING PREFLT THE RTE OF FLT WAS LOADED INTO THE FMS BY THE CAPT AND CHKED BY THE FO ACCORDING TO COMPANY PROCS. HOWEVER, DISTR IN THE COCKPIT DUE TO AN ELECTRICAL PROB THAT MAINT WAS WORKING ON MAY HAVE CAUSED THE CREW TO MISS THE FACT THAT THE FMS COORDINATES FOR REDBY WERE WRONG. EVIDENTLY THE FMS DATABASE HAD NOT BEEN UPDATED SINCE THE LATEST CHART REVISION WHEN REDBY COORDINATES WERE CHANGED. REDBY COORDINATES WERE IN THE FMS BY 1 DIGIT, WHICH WAS EASY TO MISS DURING THE XCHK. SINCE WE WERE ON A DIRECT RTE, THE FINAL XCHK (CORRECT HDG, TIME, AND DISTANCE) WAS IMPOSSIBLE. SUPPLEMENTAL INFORMATION FROM ACN 266003: ACFT HAD NOT ENTERED NAT SYS AT TIME OF EXCURSION. ACFT WAS IN RADAR CONTACT WITH ATC AT TIME OF EXCURSION, REINFORCING FLC'S BELIEF THAT 'ALL WAS WELL.'
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.