37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 294125 |
Time | |
Date | 199501 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : cvg |
State Reference | OH |
Altitude | msl bound lower : 8000 msl bound upper : 9000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | enroute : on vectors enroute airway : cvg |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 10000 flight time type : 1000 |
ASRS Report | 294125 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented other |
Consequence | Other |
Miss Distance | horizontal : 18000 vertical : 1000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
My leg, initial heading approximately 230 degrees to join V-5 southwest of cvg. Course had been set prior to engine start, 217 degrees. Takeoff heading of 195 degrees assigned, departure issued a new heading of (?) 230-240 degrees to join V-5 and a climb to 12000 ft. Climbing on autoplt at 250 KTS, VOR navigation mode armed, the autoplt captured a course and turned left and captured not the 217 degree radial but the 184 degree radial. I suspect, while in position and holding on runway 18R I had reached to sync the heading bug to runway heading and inadvertently sync'd the obs to 184 degrees, or, I may not have ever set radial 217 degrees and retained the localizer course 184 degrees from the previous leg. It is most likely the 217 degrees was never set, even though I had briefed the departure, described the NAVAID settings, and had run a challenge and response checklist covering those items. Departure stopped our climb at 9000 ft, said traffic was at 8000 ft and 3 mi. Factors: only the previous day I had a 6 month line check performed in compliance with our 'single visit' currency program. The check airman was very complimentary about the ride. Both the first officer and I were having a bad day. Each leg, several little mistakes were made by both of us, nothing major -- we were both aware that extra diligence would be required. 3 days prior I had a tumor diagnosed in my breast, and while I don't care to admit this, I may have been somewhat distracted during the trip. FMS installed in the aircraft had now been enabled. Only crew members both schooled and both line checked on usage are allowed to use and couple. My first officer had been to school several days previous and spent much time playing with it, displaying information on his side and exploring the FMS in general. I displayed only normal navigation information and tried to ignore the FMS screen. He may have been distracted with our new toy. It is important to not that he merely followed the progress of our flts, flown the 'old' way, on his FMS display.
Original NASA ASRS Text
Title: MDT HAS HDG DEV ON CLBOUT.
Narrative: MY LEG, INITIAL HDG APPROX 230 DEGS TO JOIN V-5 SW OF CVG. COURSE HAD BEEN SET PRIOR TO ENG START, 217 DEGS. TKOF HDG OF 195 DEGS ASSIGNED, DEP ISSUED A NEW HDG OF (?) 230-240 DEGS TO JOIN V-5 AND A CLB TO 12000 FT. CLBING ON AUTOPLT AT 250 KTS, VOR NAV MODE ARMED, THE AUTOPLT CAPTURED A COURSE AND TURNED L AND CAPTURED NOT THE 217 DEG RADIAL BUT THE 184 DEG RADIAL. I SUSPECT, WHILE IN POS AND HOLDING ON RWY 18R I HAD REACHED TO SYNC THE HDG BUG TO RWY HDG AND INADVERTENTLY SYNC'D THE OBS TO 184 DEGS, OR, I MAY NOT HAVE EVER SET RADIAL 217 DEGS AND RETAINED THE LOC COURSE 184 DEGS FROM THE PREVIOUS LEG. IT IS MOST LIKELY THE 217 DEGS WAS NEVER SET, EVEN THOUGH I HAD BRIEFED THE DEP, DESCRIBED THE NAVAID SETTINGS, AND HAD RUN A CHALLENGE AND RESPONSE CHKLIST COVERING THOSE ITEMS. DEP STOPPED OUR CLB AT 9000 FT, SAID TFC WAS AT 8000 FT AND 3 MI. FACTORS: ONLY THE PREVIOUS DAY I HAD A 6 MONTH LINE CHK PERFORMED IN COMPLIANCE WITH OUR 'SINGLE VISIT' CURRENCY PROGRAM. THE CHK AIRMAN WAS VERY COMPLIMENTARY ABOUT THE RIDE. BOTH THE FO AND I WERE HAVING A BAD DAY. EACH LEG, SEVERAL LITTLE MISTAKES WERE MADE BY BOTH OF US, NOTHING MAJOR -- WE WERE BOTH AWARE THAT EXTRA DILIGENCE WOULD BE REQUIRED. 3 DAYS PRIOR I HAD A TUMOR DIAGNOSED IN MY BREAST, AND WHILE I DON'T CARE TO ADMIT THIS, I MAY HAVE BEEN SOMEWHAT DISTRACTED DURING THE TRIP. FMS INSTALLED IN THE ACFT HAD NOW BEEN ENABLED. ONLY CREW MEMBERS BOTH SCHOOLED AND BOTH LINE CHKED ON USAGE ARE ALLOWED TO USE AND COUPLE. MY FO HAD BEEN TO SCHOOL SEVERAL DAYS PREVIOUS AND SPENT MUCH TIME PLAYING WITH IT, DISPLAYING INFO ON HIS SIDE AND EXPLORING THE FMS IN GENERAL. I DISPLAYED ONLY NORMAL NAV INFO AND TRIED TO IGNORE THE FMS SCREEN. HE MAY HAVE BEEN DISTRACTED WITH OUR NEW TOY. IT IS IMPORTANT TO NOT THAT HE MERELY FOLLOWED THE PROGRESS OF OUR FLTS, FLOWN THE 'OLD' WAY, ON HIS FMS DISPLAY.
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.