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|
Attributes | |
ACN | 303368 |
Time | |
Date | 199504 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : ydp |
State Reference | NB |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqm |
Operator | other |
Make Model Name | Military Transport |
Operating Under FAR Part | other : other |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : atlantic enroute : other oceanic enroute airway : czqm enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : military |
Function | instruction : instructor oversight : pic |
Qualification | pilot : military pilot : atp pilot : commercial pilot : instrument pilot : private |
Experience | flight time last 90 days : 100 flight time total : 4200 flight time type : 2000 |
ASRS Report | 303368 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : captain |
Qualification | pilot : military pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 260 flight time total : 2200 flight time type : 2000 |
ASRS Report | 303143 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : clearance non adherence : far other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After crossing the north atlantic, wbound, moncton center made radar contact and informed the crew that he showed them 50 mi north of track and that this was a 'gross navigation error.' the aircraft was equipped with TACAN, VOR, ADF, INS, GPS, stellar, doppler radar, ground mapping radar, and qualified air force navigators doing celestial navigation. However, there were several malfunctions discovered after takeoff. The INS was realigned several times in-flight with limited success, and the autoplt started making small uncommanded turns in 'heading select' mode (not coupled to the navigation system). The navigators were performing 'grid navigation' with the aircraft's compasses slewed to the appropriate grid reference. However, it was discovered after flight that the charts being used had the wrong grid convergence factor printed on them. This would appear to be the most significant contributing factor in this incident. Although this error, combined with navigation system problems, led to the actual navigation error, it is understood that the crew failed to report the system malfunctions to ATC in accordance with far 91.187 which may have changed ATC's traffic separation criteria or precluded operating in nat mnps airspace. The human factors which may have contributed to our lack of judgement and compliance were: a very long crew duty day. This incident occurred approximately 13 hours after takeoff and 16 hours after reporting for duty. Multiple 'seat swapping' with extra pilots and navigators. Although not required, we happened to have 2 extra pilots and 1 extra navigator on the aircraft. There could have been better communication between crew members switching out with each other regarding what aircraft system problems existed and what to do about them, particularly in regard to ATC coordination. To prevent an occurrence of this type of incident I intend to: 1) inform ATC without delay of any malfunctions of navigation, approach, or communication equipment occurring in-flight. 2) ensure adequate preflight planning is conducted, with particular emphasis on using current and correct navigation charts. 3) be more conscientious in coordinating actions and intentions with other crew members, particularly in sits involving seat swapping for the purpose of in-flight rest periods. Supplemental information from acn 303143: the INS had gone bad and was shut down. Abeam greenland, the aircraft was no more than 5 mi to the right of track based on a radar fix off the coast of greenland. The GPS was within 3 mi of the radar fix. After proceeding past greenland, the GPS began wandering and displaying error codes. Navigator had compasses in grid and was using pressure lop's for course line and sun lop's for speed line. The last fix prior to prawn showed the aircraft no more than 10 mi right of track based on celestial and doppler, however, the GPS showed the aircraft 50 mi right of track. The navigator felt the GPS was unreliable and his manual position was correct. The copilot contacted moncton center, who queried us about our oceanic clearance and why we weren't proceeding to the prawn coastal fix. Biggest factor contributing to this incident is failure of the INS, only periodic and sporadic readings from the GPS and an unstable autoplt.
Original NASA ASRS Text
Title: A MIL TRANSPORT FLC EXPERIENCED NAV PROBS AS A RESULT OF INS AND GPS MALFUNCTIONS, AND THE USE OF INCORRECT CHARTS. THE NAVIGATOR'S MANUAL POS, WHICH WAS UTILIZED, WAS SHOWN WITH MONCTON CTR AS 50 MI N OF TRACK.
Narrative: AFTER XING THE NORTH ATLANTIC, WBOUND, MONCTON CTR MADE RADAR CONTACT AND INFORMED THE CREW THAT HE SHOWED THEM 50 MI N OF TRACK AND THAT THIS WAS A 'GROSS NAV ERROR.' THE ACFT WAS EQUIPPED WITH TACAN, VOR, ADF, INS, GPS, STELLAR, DOPPLER RADAR, GND MAPPING RADAR, AND QUALIFIED AIR FORCE NAVIGATORS DOING CELESTIAL NAV. HOWEVER, THERE WERE SEVERAL MALFUNCTIONS DISCOVERED AFTER TKOF. THE INS WAS REALIGNED SEVERAL TIMES INFLT WITH LIMITED SUCCESS, AND THE AUTOPLT STARTED MAKING SMALL UNCOMMANDED TURNS IN 'HDG SELECT' MODE (NOT COUPLED TO THE NAV SYS). THE NAVIGATORS WERE PERFORMING 'GRID NAV' WITH THE ACFT'S COMPASSES SLEWED TO THE APPROPRIATE GRID REF. HOWEVER, IT WAS DISCOVERED AFTER FLT THAT THE CHARTS BEING USED HAD THE WRONG GRID CONVERGENCE FACTOR PRINTED ON THEM. THIS WOULD APPEAR TO BE THE MOST SIGNIFICANT CONTRIBUTING FACTOR IN THIS INCIDENT. ALTHOUGH THIS ERROR, COMBINED WITH NAV SYS PROBS, LED TO THE ACTUAL NAV ERROR, IT IS UNDERSTOOD THAT THE CREW FAILED TO RPT THE SYS MALFUNCTIONS TO ATC IN ACCORDANCE WITH FAR 91.187 WHICH MAY HAVE CHANGED ATC'S TFC SEPARATION CRITERIA OR PRECLUDED OPERATING IN NAT MNPS AIRSPACE. THE HUMAN FACTORS WHICH MAY HAVE CONTRIBUTED TO OUR LACK OF JUDGEMENT AND COMPLIANCE WERE: A VERY LONG CREW DUTY DAY. THIS INCIDENT OCCURRED APPROX 13 HRS AFTER TKOF AND 16 HRS AFTER RPTING FOR DUTY. MULTIPLE 'SEAT SWAPPING' WITH EXTRA PLTS AND NAVIGATORS. ALTHOUGH NOT REQUIRED, WE HAPPENED TO HAVE 2 EXTRA PLTS AND 1 EXTRA NAVIGATOR ON THE ACFT. THERE COULD HAVE BEEN BETTER COM BTWN CREW MEMBERS SWITCHING OUT WITH EACH OTHER REGARDING WHAT ACFT SYS PROBS EXISTED AND WHAT TO DO ABOUT THEM, PARTICULARLY IN REGARD TO ATC COORD. TO PREVENT AN OCCURRENCE OF THIS TYPE OF INCIDENT I INTEND TO: 1) INFORM ATC WITHOUT DELAY OF ANY MALFUNCTIONS OF NAV, APCH, OR COM EQUIP OCCURRING INFLT. 2) ENSURE ADEQUATE PREFLT PLANNING IS CONDUCTED, WITH PARTICULAR EMPHASIS ON USING CURRENT AND CORRECT NAV CHARTS. 3) BE MORE CONSCIENTIOUS IN COORDINATING ACTIONS AND INTENTIONS WITH OTHER CREW MEMBERS, PARTICULARLY IN SITS INVOLVING SEAT SWAPPING FOR THE PURPOSE OF INFLT REST PERIODS. SUPPLEMENTAL INFO FROM ACN 303143: THE INS HAD GONE BAD AND WAS SHUT DOWN. ABEAM GREENLAND, THE ACFT WAS NO MORE THAN 5 MI TO THE R OF TRACK BASED ON A RADAR FIX OFF THE COAST OF GREENLAND. THE GPS WAS WITHIN 3 MI OF THE RADAR FIX. AFTER PROCEEDING PAST GREENLAND, THE GPS BEGAN WANDERING AND DISPLAYING ERROR CODES. NAVIGATOR HAD COMPASSES IN GRID AND WAS USING PRESSURE LOP'S FOR COURSE LINE AND SUN LOP'S FOR SPD LINE. THE LAST FIX PRIOR TO PRAWN SHOWED THE ACFT NO MORE THAN 10 MI R OF TRACK BASED ON CELESTIAL AND DOPPLER, HOWEVER, THE GPS SHOWED THE ACFT 50 MI R OF TRACK. THE NAVIGATOR FELT THE GPS WAS UNRELIABLE AND HIS MANUAL POS WAS CORRECT. THE COPLT CONTACTED MONCTON CTR, WHO QUERIED US ABOUT OUR OCEANIC CLRNC AND WHY WE WEREN'T PROCEEDING TO THE PRAWN COASTAL FIX. BIGGEST FACTOR CONTRIBUTING TO THIS INCIDENT IS FAILURE OF THE INS, ONLY PERIODIC AND SPORADIC READINGS FROM THE GPS AND AN UNSTABLE AUTOPLT.
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.