Track deviation. Incorrectly programmed FMS.

Attributes
ACN	315810
Time
Date	199509
Day	Fri
Local Time Of Day	0601 To 1200
Place
Locale Reference	atc facility : pom airport : ont
State Reference	CA
Altitude	msl bound lower : 7000 msl bound upper : 7000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : ont
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 : intermediate altitude
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : instrument pilot : commercial pilot : flight engineer
Experience	flight time last 90 days : 150 flight time total : 7300 flight time type : 600
ASRS Report	315810
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Events
Anomaly	non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation
Independent Detector	aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa
Resolutory Action	controller : issued new clearance flight crew : returned to intended course or assigned course other
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Our clearance out of ont was the pomona 6 departure, daggett transition, maintain 14000 ft. ATIS said departure runway was runway 8L for noise abatement. FMS was correctly loaded to reflect our clearance, by the captain. Just at pushback, new ATIS changed the runway to runway 26R. The captain changed the runway on the 'route' page of the FMS to reflect runway 26R. Due to software problems, we have been warned to make all changes to departures on the departure/arrival page, but this did not occur to us for a simple runway change. For some unexplained reason, changing the runway on the 'route' page changed downtrack fixes to reflect the 'hassa 4' departure. The route page showed 'pomona 6' to daggett, but the legs page had the 'hassa 4' waypoints. Since we weren't using the legs page, this did not show on our display unit and went unnoticed. At end of runway 26R, we were given a 7000 ft hold down. We took off and flew the departure. LNAV was engaged at about 2000 ft and the captain hand flew the LNAV course. It commanded a turn to intercept the pom 323 degree course, per 'hassa 4' departure. About 5 mi past pom, at 7000 ft, indicating on course, I told departure we need a climb to clear the mountains. We were cleared to 14000 ft and were told we were north of course, turn immediately to 270 degrees to intercept pom 300 degree course. I reloaded the departure and the entire FMS picture changed to reflect the correct departure. At first, I thought the captain must have loaded the departure improperly. However, we repeated the steps outlined above several times on 2 different aircraft with the same results. A simple runway change on the route page caused a different departure to be loaded on the legs page, without reflecting the change on the route page. To avoid this problem, the runway change had to be loaded on the departure/arrival pages. Add to this the last min change at pushback and the high workload taxi environment (checklists, etc) and we were led into a trap by the software anomaly.

Original NASA ASRS Text

Title: TRACK DEV. INCORRECTLY PROGRAMMED FMS.

Narrative: OUR CLRNC OUT OF ONT WAS THE POMONA 6 DEP, DAGGETT TRANSITION, MAINTAIN 14000 FT. ATIS SAID DEP RWY WAS RWY 8L FOR NOISE ABATEMENT. FMS WAS CORRECTLY LOADED TO REFLECT OUR CLRNC, BY THE CAPT. JUST AT PUSHBACK, NEW ATIS CHANGED THE RWY TO RWY 26R. THE CAPT CHANGED THE RWY ON THE 'RTE' PAGE OF THE FMS TO REFLECT RWY 26R. DUE TO SOFTWARE PROBS, WE HAVE BEEN WARNED TO MAKE ALL CHANGES TO DEPS ON THE DEP/ARR PAGE, BUT THIS DID NOT OCCUR TO US FOR A SIMPLE RWY CHANGE. FOR SOME UNEXPLAINED REASON, CHANGING THE RWY ON THE 'RTE' PAGE CHANGED DOWNTRACK FIXES TO REFLECT THE 'HASSA 4' DEP. THE RTE PAGE SHOWED 'POMONA 6' TO DAGGETT, BUT THE LEGS PAGE HAD THE 'HASSA 4' WAYPOINTS. SINCE WE WEREN'T USING THE LEGS PAGE, THIS DID NOT SHOW ON OUR DISPLAY UNIT AND WENT UNNOTICED. AT END OF RWY 26R, WE WERE GIVEN A 7000 FT HOLD DOWN. WE TOOK OFF AND FLEW THE DEP. LNAV WAS ENGAGED AT ABOUT 2000 FT AND THE CAPT HAND FLEW THE LNAV COURSE. IT COMMANDED A TURN TO INTERCEPT THE POM 323 DEG COURSE, PER 'HASSA 4' DEP. ABOUT 5 MI PAST POM, AT 7000 FT, INDICATING ON COURSE, I TOLD DEP WE NEED A CLB TO CLR THE MOUNTAINS. WE WERE CLRED TO 14000 FT AND WERE TOLD WE WERE N OF COURSE, TURN IMMEDIATELY TO 270 DEGS TO INTERCEPT POM 300 DEG COURSE. I RELOADED THE DEP AND THE ENTIRE FMS PICTURE CHANGED TO REFLECT THE CORRECT DEP. AT FIRST, I THOUGHT THE CAPT MUST HAVE LOADED THE DEP IMPROPERLY. HOWEVER, WE REPEATED THE STEPS OUTLINED ABOVE SEVERAL TIMES ON 2 DIFFERENT ACFT WITH THE SAME RESULTS. A SIMPLE RWY CHANGE ON THE RTE PAGE CAUSED A DIFFERENT DEP TO BE LOADED ON THE LEGS PAGE, WITHOUT REFLECTING THE CHANGE ON THE RTE PAGE. TO AVOID THIS PROB, THE RWY CHANGE HAD TO BE LOADED ON THE DEP/ARR PAGES. ADD TO THIS THE LAST MIN CHANGE AT PUSHBACK AND THE HIGH WORKLOAD TAXI ENVIRONMENT (CHKLISTS, ETC) AND WE WERE LED INTO A TRAP BY THE SOFTWARE ANOMALY.

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.