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|
Attributes | |
ACN | 310880 |
Time | |
Date | 199507 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : yyr |
State Reference | NB |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqm |
Operator | general aviation : corporate |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise other |
Route In Use | enroute : atlantic |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp pilot : cfi |
Experience | flight time last 90 days : 119 flight time total : 14149 flight time type : 4384 |
ASRS Report | 310880 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | Other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Upon establishing radar contact with moncton center (canada) coasting in from north atlantic crossing wbound, I was asked by center if we were proceeding direct to oystr. Our affirmative response brought the reply from moncton that we were 40 mi north of oystr and we were given a 15 degree heading change to the south. A short time later the controller stated there had been a loss of separation and several mins later stated a gross navigation error had occurred. Contributing factors: 1) fatigue. Multiple day trip involving numerous time zones, operations on 'the back side of the clock,' and many frustrating operational delays and problems. The night prior to flight involved very late arrival, solving maintenance problems after arrival and getting to bed even later, after taking care of administrative affairs. Returned to the aircraft early to complete maintenance and prepare for flight. 2) oceanic rerte. Crossing track changed while in-flight, prior to oca entry. New coordinates were entered and checked by captain. Coordinates entered for oystr were actually those for scrod, resulting in track divergence after last oceanic point. No other aircraft were involved. We are TCASII equipped and noted the nearest aircraft was estimated to be approximately 40 NM away. 3) chart design. The atlantic orientation chart, jan/95, was used to obtain coordinates for oystr and its succeeding point, steam. Examination of this chart after the incident revealed that the 'fish points' for canadian airspace are very close together, of small print and have very little space between them, making it possible to mistake coordinates for another point.
Original NASA ASRS Text
Title: CORPORATE ACFT USES WRONG COORDINATES ON ATLANTIC XING. GROSS NAV ERROR.
Narrative: UPON ESTABLISHING RADAR CONTACT WITH MONCTON CTR (CANADA) COASTING IN FROM NORTH ATLANTIC XING WBOUND, I WAS ASKED BY CTR IF WE WERE PROCEEDING DIRECT TO OYSTR. OUR AFFIRMATIVE RESPONSE BROUGHT THE REPLY FROM MONCTON THAT WE WERE 40 MI N OF OYSTR AND WE WERE GIVEN A 15 DEG HDG CHANGE TO THE S. A SHORT TIME LATER THE CTLR STATED THERE HAD BEEN A LOSS OF SEPARATION AND SEVERAL MINS LATER STATED A GROSS NAV ERROR HAD OCCURRED. CONTRIBUTING FACTORS: 1) FATIGUE. MULTIPLE DAY TRIP INVOLVING NUMEROUS TIME ZONES, OPS ON 'THE BACK SIDE OF THE CLOCK,' AND MANY FRUSTRATING OPERATIONAL DELAYS AND PROBS. THE NIGHT PRIOR TO FLT INVOLVED VERY LATE ARR, SOLVING MAINT PROBS AFTER ARR AND GETTING TO BED EVEN LATER, AFTER TAKING CARE OF ADMINISTRATIVE AFFAIRS. RETURNED TO THE ACFT EARLY TO COMPLETE MAINT AND PREPARE FOR FLT. 2) OCEANIC RERTE. XING TRACK CHANGED WHILE INFLT, PRIOR TO OCA ENTRY. NEW COORDINATES WERE ENTERED AND CHKED BY CAPT. COORDINATES ENTERED FOR OYSTR WERE ACTUALLY THOSE FOR SCROD, RESULTING IN TRACK DIVERGENCE AFTER LAST OCEANIC POINT. NO OTHER ACFT WERE INVOLVED. WE ARE TCASII EQUIPPED AND NOTED THE NEAREST ACFT WAS ESTIMATED TO BE APPROX 40 NM AWAY. 3) CHART DESIGN. THE ATLANTIC ORIENTATION CHART, JAN/95, WAS USED TO OBTAIN COORDINATES FOR OYSTR AND ITS SUCCEEDING POINT, STEAM. EXAMINATION OF THIS CHART AFTER THE INCIDENT REVEALED THAT THE 'FISH POINTS' FOR CANADIAN AIRSPACE ARE VERY CLOSE TOGETHER, OF SMALL PRINT AND HAVE VERY LITTLE SPACE BTWN THEM, MAKING IT POSSIBLE TO MISTAKE COORDINATES FOR ANOTHER POINT.
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.