37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 279370 |
Time | |
Date | 199408 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : cvc |
State Reference | FO |
Altitude | msl bound lower : 20000 msl bound upper : 20000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : bwi |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : other oceanic enroute : pacific enroute airway : rjtg |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 172 flight time total : 18500 flight time type : 710 |
ASRS Report | 279370 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : atp |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Just prior to pushing back from our narita, japan jetway, we received a clearance which, as it turned out, differed from our filed flight plan--(filed and INS loaded: choshi four departure, otr 11 kagis, pabba, adnip, R591 adgor, etc. Cleared: 'choshi four departure, otr 11 kagis, abets, R591, flight plan route'). R591 is a route made up of waypoints beginning with the letter 'a.' when I copied this clearance simultaneously with the copilot, I heard a word from the japanese controller's voice which began with the letter 'a' and assumed that word to be the first filed 'a'--word on R591. Nothing was stated by the controller at clearance delivery advising of a change from filed flight plan. As procedure dictates, immediately upon receiving ATC clearance, we completed preparations for pushback. No mention of a clearance change was made by any of the 4 pilots in the cockpit. On climb out a few mi prior to kagis, I checked the coordinates of the next waypoint in the INS (pabba), engaged the autoplt to track the INS and turned the aircraft control and communication over to the copilot. This action allowed me uninterrupted time to perform my passenger PA duties, upon completing the PA, I 'rejoined the loop' to be told that we had been cleared direct to 'adgor, flight plan route from a point approximately 20 mi northeast of kagis. Additionally, I was informed we were possibly off course as our clearance was to proceed east of kagis to abets, then R591 and that the japanese radar controller, although not mentioning our course deviation, may have been kindly allowing us to continue on our northeast course as if no error had occurred. Subsequent discussion indicated that others had heard the clearance delivery change to our filed route but had had their attns diverted by the immediacy of the push-back requirements. Lessons learned: I shall compare each word of the clearance with filed flight plan. If I have difficulty understanding a controller, I shall ask for a rereading. If any doubt arises, I shall stop the procedures to check with other crew members and charts. I shall assume nothing.
Original NASA ASRS Text
Title: WDB ACFT HAS CLRNC CHANGE BUT DOES NOT REALIZE IT. NAV ERROR.
Narrative: JUST PRIOR TO PUSHING BACK FROM OUR NARITA, JAPAN JETWAY, WE RECEIVED A CLRNC WHICH, AS IT TURNED OUT, DIFFERED FROM OUR FILED FLT PLAN--(FILED AND INS LOADED: CHOSHI FOUR DEP, OTR 11 KAGIS, PABBA, ADNIP, R591 ADGOR, ETC. CLRED: 'CHOSHI FOUR DEP, OTR 11 KAGIS, ABETS, R591, FLT PLAN RTE'). R591 IS A RTE MADE UP OF WAYPOINTS BEGINNING WITH THE LETTER 'A.' WHEN I COPIED THIS CLRNC SIMULTANEOUSLY WITH THE COPLT, I HEARD A WORD FROM THE JAPANESE CTLR'S VOICE WHICH BEGAN WITH THE LETTER 'A' AND ASSUMED THAT WORD TO BE THE FIRST FILED 'A'--WORD ON R591. NOTHING WAS STATED BY THE CTLR AT CLRNC DELIVERY ADVISING OF A CHANGE FROM FILED FLT PLAN. AS PROC DICTATES, IMMEDIATELY UPON RECEIVING ATC CLRNC, WE COMPLETED PREPARATIONS FOR PUSHBACK. NO MENTION OF A CLRNC CHANGE WAS MADE BY ANY OF THE 4 PLTS IN THE COCKPIT. ON CLBOUT A FEW MI PRIOR TO KAGIS, I CHKED THE COORDINATES OF THE NEXT WAYPOINT IN THE INS (PABBA), ENGAGED THE AUTOPLT TO TRACK THE INS AND TURNED THE ACFT CTL AND COM OVER TO THE COPLT. THIS ACTION ALLOWED ME UNINTERRUPTED TIME TO PERFORM MY PAX PA DUTIES, UPON COMPLETING THE PA, I 'REJOINED THE LOOP' TO BE TOLD THAT WE HAD BEEN CLRED DIRECT TO 'ADGOR, FLT PLAN RTE FROM A POINT APPROX 20 MI NE OF KAGIS. ADDITIONALLY, I WAS INFORMED WE WERE POSSIBLY OFF COURSE AS OUR CLRNC WAS TO PROCEED E OF KAGIS TO ABETS, THEN R591 AND THAT THE JAPANESE RADAR CTLR, ALTHOUGH NOT MENTIONING OUR COURSE DEV, MAY HAVE BEEN KINDLY ALLOWING US TO CONTINUE ON OUR NE COURSE AS IF NO ERROR HAD OCCURRED. SUBSEQUENT DISCUSSION INDICATED THAT OTHERS HAD HEARD THE CLRNC DELIVERY CHANGE TO OUR FILED RTE BUT HAD HAD THEIR ATTNS DIVERTED BY THE IMMEDIACY OF THE PUSH-BACK REQUIREMENTS. LESSONS LEARNED: I SHALL COMPARE EACH WORD OF THE CLRNC WITH FILED FLT PLAN. IF I HAVE DIFFICULTY UNDERSTANDING A CTLR, I SHALL ASK FOR A REREADING. IF ANY DOUBT ARISES, I SHALL STOP THE PROCS TO CHK WITH OTHER CREW MEMBERS AND CHARTS. I SHALL ASSUME NOTHING.
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.