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|
Attributes | |
ACN | 274238 |
Time | |
Date | 199406 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : jfk |
State Reference | NY |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : mli |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 163 flight time total : 17998 flight time type : 1347 |
ASRS Report | 274238 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance non adherence other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We are almost ready to depart the gate at jfk for a nonstop flight to lax. A fully trained and competent crew. Aircraft was an international version which we rarely fly domestically with some of the buttons and switches in slightly different places and some slight differences in procedures. Had computer flight plan and had loaded first 9 waypoints into INS's. (No FMS on this aircraft so waypoints must be keyed in manually.) fairly simple flight plan: direct rbv, J230 air, etc, to lax. Finished checklists and ask agent about getting the WX so that I could brief the flight attendants and was informed that the computers were down. No WX, no pre departure clearance, and no weight and balance information. As departure time arrived, still nothing, so I made an announcement to the passenger that we would be slightly delayed because of a delay in getting our final paperwork from the computers and that everything else was ready to go. Flight attendant brings a very distraught passenger to the cockpit who is afraid of flying and I spent a great deal of time trying to alleviate her fears. She had just gone back when the gate agent comes in with the final paperwork, leaves, closes door and removes jetway. So says yes we have weight and balance, fuel record, pre departure clearance, and final WX. Tug driver is asking about pushback on the interphone. A quick glance at the pre departure clearance says to contact gate hold on 125.05 and advise on initial contact you have ATIS. Done. No gate hold, cleared to go. Contact ramp control, cleared to pushback. Brakes released at 12 mins after schedule. Looking at pre departure clearance, it shows a greki 1 departure martn transition, look up that departure. Strange, it turns left instead of right toward rbv, 'must be some of these rain showers down that way!' -- first clue: missed ! From tug 'brakes set, cleared to start.' asked first officer to key in coordinates for greki and judds in INS while so and I started first 2 engines for initial taxi. Checklists complete started taxi for runway 13R. Allowed into the traffic stream fairly quickly. Taxi check, including careful attention to additional flight control checks for this version, complete. Delayed start of#3 initiated. Engine won't accelerate past about 30 percent on start. Air pressure good, fuel flow good, no overtemp, just won't accelerate. Shut it down. Used 2 mins on starter time, okay, try it again. Normal start. Complete delayed start checklist. Barely the required 3 mins stabilized idle before takeoff remaining. Before takeoff checklist. Takeoff briefing: pre departure clearance initial heading 110 degrees, maintain 5000 ft. That's strange, heading here is usually 155 degrees. Second clue: missed! Cleared into position and hold. 'Look the aircraft just taking off is making a right turn, it must be clearing up to the south now, we will probably get to go that way now too.' third clue: look again at pre departure clearance. Panic. Wrong flight number. I tell tower that we want to taxi clear of the runway to check something with the company. Long line of traffic behind us on the taxiway. Tower said he didn't understand what our problem was. I told him that I thought I had the wrong transponder code. He said that he showed my squawk as abcd. What did I have. I told him that I had bcde. In the meantime the so had contacted clearance delivery who said that they showed that we had already received our clearance. Tower said to 'squawk abcd, winds are XXX/yy, cleared for takeoff. Rather than argue, I put in the proper code, added takeoff power and we left. After takeoff we turned to the normal heading for a southeast departure. After contacting departure control I asked if he needed a different heading. He said that we were fine and he would be turning us directly to rbv in a couple of mins which he did. After contacting center we were given direct air and later direct pgs, all on our normal flight plan. The remainder of the flight went very smooth and as planned. I made a number of mistakes. The major one was not insisting on clearing the runway until we had the clearance problem solved. The others were letting myself get overloaded in the scramble to get out as close to on-time as possible and not recognizing the hugh clues that presented themselves to me. I have never had a wrong flight pre departure clearance come with the paperwork. I am always very careful that I have the required paperwork and that the release number on the flight plan and other paperwork matches. You can bet that I will never accept the wrong pre departure clearance again. At some airports you are required to give your assigned transponder code to ground control or gate control before you are released to taxi. I would like to suggest, no, request that this procedure become standard at all airports where the pre departure clearance system is in use or any large airport where VFR is not the norm. This would insure that you have received your clearance and would also cross check that it is the correct one for your flight. I believe that this would prevent an incident such as I experienced from happening.
Original NASA ASRS Text
Title: WDB ACFT RECEIVES WRONG PDC. DOES NOT NOTICE UNTIL AFTER START UP AND TAXI.
Narrative: WE ARE ALMOST READY TO DEPART THE GATE AT JFK FOR A NONSTOP FLT TO LAX. A FULLY TRAINED AND COMPETENT CREW. ACFT WAS AN INTL VERSION WHICH WE RARELY FLY DOMESTICALLY WITH SOME OF THE BUTTONS AND SWITCHES IN SLIGHTLY DIFFERENT PLACES AND SOME SLIGHT DIFFERENCES IN PROCS. HAD COMPUTER FLT PLAN AND HAD LOADED FIRST 9 WAYPOINTS INTO INS'S. (NO FMS ON THIS ACFT SO WAYPOINTS MUST BE KEYED IN MANUALLY.) FAIRLY SIMPLE FLT PLAN: DIRECT RBV, J230 AIR, ETC, TO LAX. FINISHED CHKLISTS AND ASK AGENT ABOUT GETTING THE WX SO THAT I COULD BRIEF THE FLT ATTENDANTS AND WAS INFORMED THAT THE COMPUTERS WERE DOWN. NO WX, NO PDC, AND NO WT AND BAL INFO. AS DEP TIME ARRIVED, STILL NOTHING, SO I MADE AN ANNOUNCEMENT TO THE PAX THAT WE WOULD BE SLIGHTLY DELAYED BECAUSE OF A DELAY IN GETTING OUR FINAL PAPERWORK FROM THE COMPUTERS AND THAT EVERYTHING ELSE WAS READY TO GO. FLT ATTENDANT BRINGS A VERY DISTRAUGHT PAX TO THE COCKPIT WHO IS AFRAID OF FLYING AND I SPENT A GREAT DEAL OF TIME TRYING TO ALLEVIATE HER FEARS. SHE HAD JUST GONE BACK WHEN THE GATE AGENT COMES IN WITH THE FINAL PAPERWORK, LEAVES, CLOSES DOOR AND REMOVES JETWAY. SO SAYS YES WE HAVE WT AND BAL, FUEL RECORD, PDC, AND FINAL WX. TUG DRIVER IS ASKING ABOUT PUSHBACK ON THE INTERPHONE. A QUICK GLANCE AT THE PDC SAYS TO CONTACT GATE HOLD ON 125.05 AND ADVISE ON INITIAL CONTACT YOU HAVE ATIS. DONE. NO GATE HOLD, CLRED TO GO. CONTACT RAMP CTL, CLRED TO PUSHBACK. BRAKES RELEASED AT 12 MINS AFTER SCHEDULE. LOOKING AT PDC, IT SHOWS A GREKI 1 DEP MARTN TRANSITION, LOOK UP THAT DEP. STRANGE, IT TURNS L INSTEAD OF R TOWARD RBV, 'MUST BE SOME OF THESE RAIN SHOWERS DOWN THAT WAY!' -- FIRST CLUE: MISSED ! FROM TUG 'BRAKES SET, CLRED TO START.' ASKED FO TO KEY IN COORDINATES FOR GREKI AND JUDDS IN INS WHILE SO AND I STARTED FIRST 2 ENGS FOR INITIAL TAXI. CHKLISTS COMPLETE STARTED TAXI FOR RWY 13R. ALLOWED INTO THE TFC STREAM FAIRLY QUICKLY. TAXI CHK, INCLUDING CAREFUL ATTN TO ADDITIONAL FLT CTL CHKS FOR THIS VERSION, COMPLETE. DELAYED START OF#3 INITIATED. ENG WON'T ACCELERATE PAST ABOUT 30 PERCENT ON START. AIR PRESSURE GOOD, FUEL FLOW GOOD, NO OVERTEMP, JUST WON'T ACCELERATE. SHUT IT DOWN. USED 2 MINS ON STARTER TIME, OKAY, TRY IT AGAIN. NORMAL START. COMPLETE DELAYED START CHKLIST. BARELY THE REQUIRED 3 MINS STABILIZED IDLE BEFORE TKOF REMAINING. BEFORE TKOF CHKLIST. TKOF BRIEFING: PDC INITIAL HDG 110 DEGS, MAINTAIN 5000 FT. THAT'S STRANGE, HDG HERE IS USUALLY 155 DEGS. SECOND CLUE: MISSED! CLRED INTO POS AND HOLD. 'LOOK THE ACFT JUST TAKING OFF IS MAKING A R TURN, IT MUST BE CLRING UP TO THE S NOW, WE WILL PROBABLY GET TO GO THAT WAY NOW TOO.' THIRD CLUE: LOOK AGAIN AT PDC. PANIC. WRONG FLT NUMBER. I TELL TWR THAT WE WANT TO TAXI CLR OF THE RWY TO CHK SOMETHING WITH THE COMPANY. LONG LINE OF TFC BEHIND US ON THE TXWY. TWR SAID HE DIDN'T UNDERSTAND WHAT OUR PROB WAS. I TOLD HIM THAT I THOUGHT I HAD THE WRONG XPONDER CODE. HE SAID THAT HE SHOWED MY SQUAWK AS ABCD. WHAT DID I HAVE. I TOLD HIM THAT I HAD BCDE. IN THE MEANTIME THE SO HAD CONTACTED CLRNC DELIVERY WHO SAID THAT THEY SHOWED THAT WE HAD ALREADY RECEIVED OUR CLRNC. TWR SAID TO 'SQUAWK ABCD, WINDS ARE XXX/YY, CLRED FOR TKOF. RATHER THAN ARGUE, I PUT IN THE PROPER CODE, ADDED TKOF PWR AND WE LEFT. AFTER TKOF WE TURNED TO THE NORMAL HDG FOR A SE DEP. AFTER CONTACTING DEP CTL I ASKED IF HE NEEDED A DIFFERENT HDG. HE SAID THAT WE WERE FINE AND HE WOULD BE TURNING US DIRECTLY TO RBV IN A COUPLE OF MINS WHICH HE DID. AFTER CONTACTING CTR WE WERE GIVEN DIRECT AIR AND LATER DIRECT PGS, ALL ON OUR NORMAL FLT PLAN. THE REMAINDER OF THE FLT WENT VERY SMOOTH AND AS PLANNED. I MADE A NUMBER OF MISTAKES. THE MAJOR ONE WAS NOT INSISTING ON CLRING THE RWY UNTIL WE HAD THE CLRNC PROB SOLVED. THE OTHERS WERE LETTING MYSELF GET OVERLOADED IN THE SCRAMBLE TO GET OUT AS CLOSE TO ON-TIME AS POSSIBLE AND NOT RECOGNIZING THE HUGH CLUES THAT PRESENTED THEMSELVES TO ME. I HAVE NEVER HAD A WRONG FLT PDC COME WITH THE PAPERWORK. I AM ALWAYS VERY CAREFUL THAT I HAVE THE REQUIRED PAPERWORK AND THAT THE RELEASE NUMBER ON THE FLT PLAN AND OTHER PAPERWORK MATCHES. YOU CAN BET THAT I WILL NEVER ACCEPT THE WRONG PDC AGAIN. AT SOME ARPTS YOU ARE REQUIRED TO GIVE YOUR ASSIGNED XPONDER CODE TO GND CTL OR GATE CTL BEFORE YOU ARE RELEASED TO TAXI. I WOULD LIKE TO SUGGEST, NO, REQUEST THAT THIS PROCEDURE BECOME STANDARD AT ALL ARPTS WHERE THE PDC SYS IS IN USE OR ANY LARGE ARPT WHERE VFR IS NOT THE NORM. THIS WOULD INSURE THAT YOU HAVE RECEIVED YOUR CLRNC AND WOULD ALSO CROSS CHK THAT IT IS THE CORRECT ONE FOR YOUR FLT. I BELIEVE THAT THIS WOULD PREVENT AN INCIDENT SUCH AS I EXPERIENCED FROM HAPPENING.
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.