37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 303024 |
Time | |
Date | 199504 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : tje |
State Reference | FO |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : rjtg |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute : pacific enroute : other oceanic enroute airway : rjtg enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 12000 flight time type : 900 |
ASRS Report | 303024 |
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 other flight crewa |
Resolutory Action | none taken : unable other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Navigational error caused by improper loading of 'present position' in litton 92 INS. Present position was loaded by first officer and verified by captain but not by so as required by company policy. So was not available during check due to maintenance problem. 'Present position' in INS is not a checklist item. Error initially noted during climb out when VOR and INS position did not agree. This was confirmed several mi later when tokyo control advised we were 15 mi right of course. Due to complete dependence on INS for navigation to destination, flight was terminated and returned to fukuoka. INS error's noted on gate was 6.2 mi. There are 2 items that cannot be changed after takeoff: one is on-board fuel and the other is INS 'present position.' considering its importance, 'present position on INS should be a checklist item. Had the so checked, it is possible he would have noted the mistake.
Original NASA ASRS Text
Title: A NAVIGATIONAL ERROR (INS) WAS DISCOVERED ENRTE, AND RESULTED IN ACR'S RETURN.
Narrative: NAVIGATIONAL ERROR CAUSED BY IMPROPER LOADING OF 'PRESENT POS' IN LITTON 92 INS. PRESENT POS WAS LOADED BY FO AND VERIFIED BY CAPT BUT NOT BY SO AS REQUIRED BY COMPANY POLICY. SO WAS NOT AVAILABLE DURING CHK DUE TO MAINT PROB. 'PRESENT POS' IN INS IS NOT A CHKLIST ITEM. ERROR INITIALLY NOTED DURING CLBOUT WHEN VOR AND INS POS DID NOT AGREE. THIS WAS CONFIRMED SEVERAL MI LATER WHEN TOKYO CTL ADVISED WE WERE 15 MI R OF COURSE. DUE TO COMPLETE DEPENDENCE ON INS FOR NAV TO DEST, FLT WAS TERMINATED AND RETURNED TO FUKUOKA. INS ERROR'S NOTED ON GATE WAS 6.2 MI. THERE ARE 2 ITEMS THAT CANNOT BE CHANGED AFTER TKOF: ONE IS ON-BOARD FUEL AND THE OTHER IS INS 'PRESENT POS.' CONSIDERING ITS IMPORTANCE, 'PRESENT POS ON INS SHOULD BE A CHKLIST ITEM. HAD THE SO CHKED, IT IS POSSIBLE HE WOULD HAVE NOTED THE MISTAKE.
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.