37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 321454 |
Time | |
Date | 199511 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : bos |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : takeoff |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 270 flight time total : 12000 flight time type : 3500 |
ASRS Report | 321454 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : cfi pilot : instrument |
Experience | flight time last 90 days : 255 flight time total : 8200 flight time type : 3000 |
ASRS Report | 321460 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
All checklists were used, runway 9 was departure runway. We briefed the normal departure as runway heading and 5000 ft. We also briefed the engine failure on takeoff as the same. Our weight was too heavy for runway 9 and we requested runway 4R for weight. While taxiing, the controller was busy and we were carefully listening for the new taxi instructions which had a hold short of the runway 4L arrival area. I briefed the change to the engine failure chart procedures for runway 4R and they were the same. I neglected to brief the normal SID (runway heading to 4 DME, then right turn to 090 degrees). The first officer flew straight out like briefed for runway 9. ATC asked us if we were in our right turn. I said 'no, runway heading.' he said you were supposed to turn to 090 degrees. We complied immediately. There was no traffic conflict. The engine out procedure was straight ahead on runway heading, there was no safety problem. I strive for perfection and proper procedures. I cannot say how both of us missed this. I definitely learned from this. All I can think of is that fatigue and too many legs in too few days had an effect. Also, tower controller never issued the turn, which seems to be SOP at most facilities, even dca with the 328 degree turn up the river.
Original NASA ASRS Text
Title: FLC FAILED TO FOLLOW DEP PROC. TRACK DEV.
Narrative: ALL CHKLISTS WERE USED, RWY 9 WAS DEP RWY. WE BRIEFED THE NORMAL DEP AS RWY HDG AND 5000 FT. WE ALSO BRIEFED THE ENG FAILURE ON TKOF AS THE SAME. OUR WT WAS TOO HVY FOR RWY 9 AND WE REQUESTED RWY 4R FOR WT. WHILE TAXIING, THE CTLR WAS BUSY AND WE WERE CAREFULLY LISTENING FOR THE NEW TAXI INSTRUCTIONS WHICH HAD A HOLD SHORT OF THE RWY 4L ARR AREA. I BRIEFED THE CHANGE TO THE ENG FAILURE CHART PROCS FOR RWY 4R AND THEY WERE THE SAME. I NEGLECTED TO BRIEF THE NORMAL SID (RWY HDG TO 4 DME, THEN R TURN TO 090 DEGS). THE FO FLEW STRAIGHT OUT LIKE BRIEFED FOR RWY 9. ATC ASKED US IF WE WERE IN OUR R TURN. I SAID 'NO, RWY HDG.' HE SAID YOU WERE SUPPOSED TO TURN TO 090 DEGS. WE COMPLIED IMMEDIATELY. THERE WAS NO TFC CONFLICT. THE ENG OUT PROC WAS STRAIGHT AHEAD ON RWY HDG, THERE WAS NO SAFETY PROB. I STRIVE FOR PERFECTION AND PROPER PROCS. I CANNOT SAY HOW BOTH OF US MISSED THIS. I DEFINITELY LEARNED FROM THIS. ALL I CAN THINK OF IS THAT FATIGUE AND TOO MANY LEGS IN TOO FEW DAYS HAD AN EFFECT. ALSO, TWR CTLR NEVER ISSUED THE TURN, WHICH SEEMS TO BE SOP AT MOST FACILITIES, EVEN DCA WITH THE 328 DEG TURN UP THE RIVER.
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.