Narrative:

On a fuel stop at slc an IFR flight plan was filed to depart slc and join the J-154 nebound to the destination. The WX, which was a factor in this case, was 'numerous heavy rainshowers with some cloud to ground lightning.' the clearance was copied and read back routinely. The clearance included the salt lake 5 departure. All flight preparations were routine including the taxiing, although due to the non familiarity with the airfield, the airfield layout page 10-9 was used to proceed to the runup area of runway 35. Flying in the right seat of the cockpit was an instrument rated, multi-engine pilot helping with some of the duties. Once all of the pre-takeoff procedures were complete and the plane was in the #1 position, a review of the departure, route, and altitude limit was accomplished. The copilot had, at my request, located the departure plate and, after his review, handed the open approach book to me for my review. We discussed it in depth since it was not the easiest to understand. After that discussion we were in agreement that the departure for runway 35 included a left turn to intercept the radial 249, then a climbing right turn back to the VOR. The traffic density was quite heavy with a lot of jet departures on all runways. The rain cells at the time were significant, but not serious. There was about 50 percent coverage on the radar in the direction of the flight. The takeoff and climb was normal for the short distance to the VOR. Upon commencing the left turn to intercept the 249 radial, after passing the VOR, the controller questioned our intentions. At that time, the heading was passing about 290 degrees. He correctly analyzed that we were not following the flight path that he had anticipated and told us to turn left to 360 degrees. He also stated that there was traffic in the vicinity and asked that we expedite the turn. It was apparent that there was some urgency to expedite, which we did. The flight conditions at the time was in and out of rainshowers. No traffic was observed at any time in our vicinity. The decision to comply with the 290 degree left turn to the assigned heading of 360 was not questioned. It occurred to me that the shortest deviation would have been to turn right. We followed his directions. It may have been the right decision. I still don't know the location or flight path of the other plane. The flight was quickly established on the correct heading and proceeded without further deviation to the planned destination. The controller indicated that some conflict had occurred which had worried him. My reply was apologetic in that I thought that I was flying the correct course. Prior to leaving the frequency, the controller gave me a phone number to call, which I presumed was to discuss the problem. Once the flight was safely en route and the time was available to figure out what had happened, the copilot and I reviewed every detail. I have always prided myself on flying to a high degree of perfection. We discovered, in our review, that there was a trap laying within the pages of the plates. It is subtle, but it can cause an unsuspecting pilot to do exactly as I did. As the copilot turned the pages from page 10-9 to 10-3A he was reading the titles of the departures. The standard format of the plates is to print the title in a familiar style and right across the top of the page. Please see the attached copy of the page used on sep/xx/94. The page he actually stopped on was the 'lost communication for the salt lake 5 departure.' the location, title, position on the page, and name are exactly the same as the actual departure page. Agreed the line below modifies the title to say it is a lost communication procedure, but with 23 pages of plats dealing just with slc, it necessitates rapid reading and skim reading. As the copilot handed me the open book of plates, my first task was to confirm that he had the correct page. Salt lake 5 departure was written clearly in proper format across the page and left no doubt that it was the correct page. Then I got down to the details of how to depart from runway 35. The mistake had already been made and was unlikely to be corrected unless something caused one of us to question the route. I have written a letter of this concern to the production manager at commercial company so that others may benefit from the observation. Contributing factors to the situation were the deteriorating WX in that it was a distraction and a concern. I feel that the high traffic density was a factor in that the traffic control system was operating at its maximum capacity. However, the primary contributing factor was the titling of the page with lost communication procedures in the same format and style that is also used for the departure page. Also, an important facet is that page 10-3 and 10-3A are back-to-back. An error would be much more likely to be discovered if the were on facing pages. Callback conversation with reporter revealed the following information: reporter states he has not heard from commercial chart company as yet. He is concerned because the lost communication procedures are usually found at the bottom of the page narrative for the airport they reference. This is a different setup and too similar to the actual departure page. Mistake admitted but still believes this is a poor arrangement for the information.

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Original NASA ASRS Text

Title: SMT ON SID PICKS UP WRONG PAGE AND BEGINS TO FLY LOST COM PROC INSTEAD OF THE PROPER SID PROC.

Narrative: ON A FUEL STOP AT SLC AN IFR FLT PLAN WAS FILED TO DEPART SLC AND JOIN THE J-154 NEBOUND TO THE DEST. THE WX, WHICH WAS A FACTOR IN THIS CASE, WAS 'NUMEROUS HVY RAINSHOWERS WITH SOME CLOUD TO GND LIGHTNING.' THE CLRNC WAS COPIED AND READ BACK ROUTINELY. THE CLRNC INCLUDED THE SALT LAKE 5 DEP. ALL FLT PREPARATIONS WERE ROUTINE INCLUDING THE TAXIING, ALTHOUGH DUE TO THE NON FAMILIARITY WITH THE AIRFIELD, THE AIRFIELD LAYOUT PAGE 10-9 WAS USED TO PROCEED TO THE RUNUP AREA OF RWY 35. FLYING IN THE R SEAT OF THE COCKPIT WAS AN INST RATED, MULTI-ENG PLT HELPING WITH SOME OF THE DUTIES. ONCE ALL OF THE PRE-TKOF PROCS WERE COMPLETE AND THE PLANE WAS IN THE #1 POS, A REVIEW OF THE DEP, RTE, AND ALT LIMIT WAS ACCOMPLISHED. THE COPLT HAD, AT MY REQUEST, LOCATED THE DEP PLATE AND, AFTER HIS REVIEW, HANDED THE OPEN APCH BOOK TO ME FOR MY REVIEW. WE DISCUSSED IT IN DEPTH SINCE IT WAS NOT THE EASIEST TO UNDERSTAND. AFTER THAT DISCUSSION WE WERE IN AGREEMENT THAT THE DEP FOR RWY 35 INCLUDED A L TURN TO INTERCEPT THE RADIAL 249, THEN A CLBING R TURN BACK TO THE VOR. THE TFC DENSITY WAS QUITE HVY WITH A LOT OF JET DEPS ON ALL RWYS. THE RAIN CELLS AT THE TIME WERE SIGNIFICANT, BUT NOT SERIOUS. THERE WAS ABOUT 50 PERCENT COVERAGE ON THE RADAR IN THE DIRECTION OF THE FLT. THE TKOF AND CLB WAS NORMAL FOR THE SHORT DISTANCE TO THE VOR. UPON COMMENCING THE L TURN TO INTERCEPT THE 249 RADIAL, AFTER PASSING THE VOR, THE CTLR QUESTIONED OUR INTENTIONS. AT THAT TIME, THE HDG WAS PASSING ABOUT 290 DEGS. HE CORRECTLY ANALYZED THAT WE WERE NOT FOLLOWING THE FLT PATH THAT HE HAD ANTICIPATED AND TOLD US TO TURN L TO 360 DEGS. HE ALSO STATED THAT THERE WAS TFC IN THE VICINITY AND ASKED THAT WE EXPEDITE THE TURN. IT WAS APPARENT THAT THERE WAS SOME URGENCY TO EXPEDITE, WHICH WE DID. THE FLT CONDITIONS AT THE TIME WAS IN AND OUT OF RAINSHOWERS. NO TFC WAS OBSERVED AT ANY TIME IN OUR VICINITY. THE DECISION TO COMPLY WITH THE 290 DEG L TURN TO THE ASSIGNED HDG OF 360 WAS NOT QUESTIONED. IT OCCURRED TO ME THAT THE SHORTEST DEV WOULD HAVE BEEN TO TURN R. WE FOLLOWED HIS DIRECTIONS. IT MAY HAVE BEEN THE RIGHT DECISION. I STILL DON'T KNOW THE LOCATION OR FLT PATH OF THE OTHER PLANE. THE FLT WAS QUICKLY ESTABLISHED ON THE CORRECT HDG AND PROCEEDED WITHOUT FURTHER DEV TO THE PLANNED DEST. THE CTLR INDICATED THAT SOME CONFLICT HAD OCCURRED WHICH HAD WORRIED HIM. MY REPLY WAS APOLOGETIC IN THAT I THOUGHT THAT I WAS FLYING THE CORRECT COURSE. PRIOR TO LEAVING THE FREQ, THE CTLR GAVE ME A PHONE NUMBER TO CALL, WHICH I PRESUMED WAS TO DISCUSS THE PROB. ONCE THE FLT WAS SAFELY ENRTE AND THE TIME WAS AVAILABLE TO FIGURE OUT WHAT HAD HAPPENED, THE COPLT AND I REVIEWED EVERY DETAIL. I HAVE ALWAYS PRIDED MYSELF ON FLYING TO A HIGH DEG OF PERFECTION. WE DISCOVERED, IN OUR REVIEW, THAT THERE WAS A TRAP LAYING WITHIN THE PAGES OF THE PLATES. IT IS SUBTLE, BUT IT CAN CAUSE AN UNSUSPECTING PLT TO DO EXACTLY AS I DID. AS THE COPLT TURNED THE PAGES FROM PAGE 10-9 TO 10-3A HE WAS READING THE TITLES OF THE DEPS. THE STANDARD FORMAT OF THE PLATES IS TO PRINT THE TITLE IN A FAMILIAR STYLE AND RIGHT ACROSS THE TOP OF THE PAGE. PLEASE SEE THE ATTACHED COPY OF THE PAGE USED ON SEP/XX/94. THE PAGE HE ACTUALLY STOPPED ON WAS THE 'LOST COM FOR THE SALT LAKE 5 DEP.' THE LOCATION, TITLE, POS ON THE PAGE, AND NAME ARE EXACTLY THE SAME AS THE ACTUAL DEP PAGE. AGREED THE LINE BELOW MODIFIES THE TITLE TO SAY IT IS A LOST COM PROC, BUT WITH 23 PAGES OF PLATS DEALING JUST WITH SLC, IT NECESSITATES RAPID READING AND SKIM READING. AS THE COPLT HANDED ME THE OPEN BOOK OF PLATES, MY FIRST TASK WAS TO CONFIRM THAT HE HAD THE CORRECT PAGE. SALT LAKE 5 DEP WAS WRITTEN CLRLY IN PROPER FORMAT ACROSS THE PAGE AND LEFT NO DOUBT THAT IT WAS THE CORRECT PAGE. THEN I GOT DOWN TO THE DETAILS OF HOW TO DEPART FROM RWY 35. THE MISTAKE HAD ALREADY BEEN MADE AND WAS UNLIKELY TO BE CORRECTED UNLESS SOMETHING CAUSED ONE OF US TO QUESTION THE RTE. I HAVE WRITTEN A LETTER OF THIS CONCERN TO THE PRODUCTION MGR AT COMMERCIAL COMPANY SO THAT OTHERS MAY BENEFIT FROM THE OBSERVATION. CONTRIBUTING FACTORS TO THE SIT WERE THE DETERIORATING WX IN THAT IT WAS A DISTR AND A CONCERN. I FEEL THAT THE HIGH TFC DENSITY WAS A FACTOR IN THAT THE TFC CTL SYS WAS OPERATING AT ITS MAX CAPACITY. HOWEVER, THE PRIMARY CONTRIBUTING FACTOR WAS THE TITLING OF THE PAGE WITH LOST COM PROCS IN THE SAME FORMAT AND STYLE THAT IS ALSO USED FOR THE DEP PAGE. ALSO, AN IMPORTANT FACET IS THAT PAGE 10-3 AND 10-3A ARE BACK-TO-BACK. AN ERROR WOULD BE MUCH MORE LIKELY TO BE DISCOVERED IF THE WERE ON FACING PAGES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES HE HAS NOT HEARD FROM COMMERCIAL CHART COMPANY AS YET. HE IS CONCERNED BECAUSE THE LOST COM PROCS ARE USUALLY FOUND AT THE BOTTOM OF THE PAGE NARRATIVE FOR THE ARPT THEY REF. THIS IS A DIFFERENT SETUP AND TOO SIMILAR TO THE ACTUAL DEP PAGE. MISTAKE ADMITTED BUT STILL BELIEVES THIS IS A POOR ARRANGEMENT FOR THE INFO.

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.