37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 297921 |
Time | |
Date | 199503 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 2000 msl bound upper : 2000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : initial ground : preflight |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | controller non radar : 3 controller radar : 3 flight time last 90 days : 175 flight time total : 6500 flight time type : 300 |
ASRS Report | 297921 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : became reoriented other other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
It was the first flight of the first leg of the identification, all 3 of us new to each other and after days off for all of us. We took off of sfo without a clearance -- without receiving our pre departure clearance which we didn't' realize until ATC asked us to squawk a discrete code after departure. Factors contributing to the incident were several distrs prior to pushback. The captain's final flight prior to retirement with his entire family on board, his son (a commuter pilot) in the cockpit, an aircraft model we were not used to flying (a dc-10-30 as opposed to a dc-10-10). The relevance of the last point is that the ACARS (through which the pre departure clearance is received) is positioned differently (back on the so's panel) and out of my normal cockpit set-up scan and reach. I generally call up the clearance pre departure clearance from the right seat as I proceed through my cockpit setup. Also, I spent a few mins studying INS procedures with 3 INS's, slightly different than 2 INS procedures. The captain had not flown a dash 30 in over a yr, and myself in several months, the so only a couple of times over the last yr. Ultimately though, it may have been the sameness of the situation rather than differences which caused this bone-headed event. We were all so plugged into the routine of another hnl trip that we missed the fact that a clearance wasn't around, even though we followed all other checklists and SOP's to the letter. After realizing our error, we called up the clearance immediately on ACARS and continued to hnl. Callback conversation with reporter revealed the following information: the reporting first officer believes that the problem with the pre departure clearance hinged on 2 points: they were flying the dc-10-30 vice the -10 and the captain was flying his last trip. The captain made several 'little boo boo's' that the first officer believes would not have happened on any other trip or in the -10. The last flight was 'a distraction we were all into' with well wishers in the cockpit during preflight. The so got the clearance out of ACARS shortly after takeoff and the reporter believes that ATC was not aware of the occurrence. The reporter believes that this could be prevented by crews being required to readback their squawk codes and initial departure fix to clearance delivery or ground control.
Original NASA ASRS Text
Title: WDB AIR CREW TOOK OFF WITHOUT AIRWAY CLRNC.
Narrative: IT WAS THE FIRST FLT OF THE FIRST LEG OF THE ID, ALL 3 OF US NEW TO EACH OTHER AND AFTER DAYS OFF FOR ALL OF US. WE TOOK OFF OF SFO WITHOUT A CLRNC -- WITHOUT RECEIVING OUR PDC WHICH WE DIDN'T' REALIZE UNTIL ATC ASKED US TO SQUAWK A DISCRETE CODE AFTER DEP. FACTORS CONTRIBUTING TO THE INCIDENT WERE SEVERAL DISTRS PRIOR TO PUSHBACK. THE CAPT'S FINAL FLT PRIOR TO RETIREMENT WITH HIS ENTIRE FAMILY ON BOARD, HIS SON (A COMMUTER PLT) IN THE COCKPIT, AN ACFT MODEL WE WERE NOT USED TO FLYING (A DC-10-30 AS OPPOSED TO A DC-10-10). THE RELEVANCE OF THE LAST POINT IS THAT THE ACARS (THROUGH WHICH THE PDC IS RECEIVED) IS POSITIONED DIFFERENTLY (BACK ON THE SO'S PANEL) AND OUT OF MY NORMAL COCKPIT SET-UP SCAN AND REACH. I GENERALLY CALL UP THE CLRNC PDC FROM THE R SEAT AS I PROCEED THROUGH MY COCKPIT SETUP. ALSO, I SPENT A FEW MINS STUDYING INS PROCS WITH 3 INS'S, SLIGHTLY DIFFERENT THAN 2 INS PROCS. THE CAPT HAD NOT FLOWN A DASH 30 IN OVER A YR, AND MYSELF IN SEVERAL MONTHS, THE SO ONLY A COUPLE OF TIMES OVER THE LAST YR. ULTIMATELY THOUGH, IT MAY HAVE BEEN THE SAMENESS OF THE SIT RATHER THAN DIFFERENCES WHICH CAUSED THIS BONE-HEADED EVENT. WE WERE ALL SO PLUGGED INTO THE ROUTINE OF ANOTHER HNL TRIP THAT WE MISSED THE FACT THAT A CLRNC WASN'T AROUND, EVEN THOUGH WE FOLLOWED ALL OTHER CHKLISTS AND SOP'S TO THE LETTER. AFTER REALIZING OUR ERROR, WE CALLED UP THE CLRNC IMMEDIATELY ON ACARS AND CONTINUED TO HNL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTING FO BELIEVES THAT THE PROB WITH THE PDC HINGED ON 2 POINTS: THEY WERE FLYING THE DC-10-30 VICE THE -10 AND THE CAPT WAS FLYING HIS LAST TRIP. THE CAPT MADE SEVERAL 'LITTLE BOO BOO'S' THAT THE FO BELIEVES WOULD NOT HAVE HAPPENED ON ANY OTHER TRIP OR IN THE -10. THE LAST FLT WAS 'A DISTR WE WERE ALL INTO' WITH WELL WISHERS IN THE COCKPIT DURING PREFLT. THE SO GOT THE CLRNC OUT OF ACARS SHORTLY AFTER TKOF AND THE RPTR BELIEVES THAT ATC WAS NOT AWARE OF THE OCCURRENCE. THE RPTR BELIEVES THAT THIS COULD BE PREVENTED BY CREWS BEING REQUIRED TO READBACK THEIR SQUAWK CODES AND INITIAL DEP FIX TO CLRNC DELIVERY OR GND CTL.
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.