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|
Attributes | |
ACN | 341650 |
Time | |
Date | 199607 |
Day | Thu |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : mem |
State Reference | TN |
Altitude | msl bound lower : 4000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : mem |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | other : unknown |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 160 flight time total : 10000 flight time type : 160 |
ASRS Report | 341650 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : private pilot : atp pilot : commercial |
Experience | flight time last 90 days : 90 flight time total : 4300 flight time type : 890 |
ASRS Report | 341215 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Miss Distance | horizontal : 6000 vertical : 100 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We departed memphis at XX40 am for a flight to baltimore. I was the PNF and the copilot was flying. Passing through 1000 ft, we were given a clearance to climb to 16000 ft and turn left to a heading. I selected the altitude and verified it per company procedures with the copilot. As the copilot began the left turn, he asked me if the heading assigned was 060 degrees. I looked at the HSI and noticed that the heading bug had not been set. I set 060 degrees but was not absolutely sure that it was the correct heading. It was an 'expected' heading, however, so I accepted it without verifying it with ATC. Departure control then asked what heading we were flying. When we told them '060 degrees,' they stated that the assigned heading had been 100 degrees and that we needed to turn left to 360 degrees now to avoid a light aircraft which we now saw at about 1 O'clock and at our altitude, approximately a mi away. I believe the primary cause of this incident was fatigue. It was the third day of all-night flying, and I hadn't been sleeping well during the day layovers. I was just coming back from over 2 weeks of time off. The copilot had relayed to me earlier that he was also tired. I can think of no other reason that I didn't verify the heading with ATC when I wasn't positive that it was correct. Other factors include the fact that 060 degrees 'seemed right' to me because our outbound airway was 064 degrees and we normally were issued heading in that direction shortly after takeoff. Another important factor involves the flight director system. Our B727 fleet is mixed and many aircraft have heading bugs individually selected by each pilot. This aircraft happened to be one that has a common heading bug selector and I had noticed some confusion in the past as to whose responsibility it was to set the bug. In the future, I will make certain that the PF always selects the assigned heading, and the PNF verifies it. I believe this incident would never have happened had I been briefing and using that procedure. Supplemental information from acn 341877: I noticed an aircraft crossing our flight path from approximately the 1-2 O'clock position, from left to right, almost co-altitude. I could see his starboard (green) position light and his tail light distinctly. Supplemental information from acn 341215: the clearance was issued during a critical phase of flight (cleaning up the aircraft after takeoff). My concentration was directed mainly at flying the airplane. I heard the clearance but I can honestly say the 100 degree heading clearance did not register with me. I must have mistakenly interpreted the altitude clearance of 16000 ft to a 060 degree heading. When I asked the captain to confirm the 060 degree heading he indicated yes as I rotated the heading knob to 060 degrees. Crew coordination between myself and the captain was probably the major factor. The flight director on this particular aircraft is on the center forward panel. One heading control knob on the panel controlled both the captain's and first officer's heading bug. Prior to takeoff we should have coordinated who would control both the heading control knob and the altitude control knob (ie, the PNF controls both or the PF controlling the heading knob). Because I was flying the aircraft I thought the captain was controlling both knobs and I'm sure he thought I had control of the heading knob.
Original NASA ASRS Text
Title: HDG DEV. ASSIGNED HDG WAS 060 DEGS, BUT PF, FO, THOUGHT THE HDG WAS 100 DEGS, ASKED THE CAPT, PNF, TO CONFIRM THE HDG, AND THE CAPT SET 060 DEGS ON THE HDG BUG. CTLR INTERVENED AND TOLD THEM THE ASSIGNED HDG WAS 100 DEGS AND BECAUSE OF THE HDG DEV, THEY CONFLICTED WITH ANOTHER ACFT. FLC ATTRIBUTES FATIGUE TO THE LACK OF VIGILANCE AND FLC COORD.
Narrative: WE DEPARTED MEMPHIS AT XX40 AM FOR A FLT TO BALTIMORE. I WAS THE PNF AND THE COPLT WAS FLYING. PASSING THROUGH 1000 FT, WE WERE GIVEN A CLRNC TO CLB TO 16000 FT AND TURN L TO A HDG. I SELECTED THE ALT AND VERIFIED IT PER COMPANY PROCS WITH THE COPLT. AS THE COPLT BEGAN THE L TURN, HE ASKED ME IF THE HDG ASSIGNED WAS 060 DEGS. I LOOKED AT THE HSI AND NOTICED THAT THE HDG BUG HAD NOT BEEN SET. I SET 060 DEGS BUT WAS NOT ABSOLUTELY SURE THAT IT WAS THE CORRECT HDG. IT WAS AN 'EXPECTED' HDG, HOWEVER, SO I ACCEPTED IT WITHOUT VERIFYING IT WITH ATC. DEP CTL THEN ASKED WHAT HDG WE WERE FLYING. WHEN WE TOLD THEM '060 DEGS,' THEY STATED THAT THE ASSIGNED HDG HAD BEEN 100 DEGS AND THAT WE NEEDED TO TURN L TO 360 DEGS NOW TO AVOID A LIGHT ACFT WHICH WE NOW SAW AT ABOUT 1 O'CLOCK AND AT OUR ALT, APPROX A MI AWAY. I BELIEVE THE PRIMARY CAUSE OF THIS INCIDENT WAS FATIGUE. IT WAS THE THIRD DAY OF ALL-NIGHT FLYING, AND I HADN'T BEEN SLEEPING WELL DURING THE DAY LAYOVERS. I WAS JUST COMING BACK FROM OVER 2 WKS OF TIME OFF. THE COPLT HAD RELAYED TO ME EARLIER THAT HE WAS ALSO TIRED. I CAN THINK OF NO OTHER REASON THAT I DIDN'T VERIFY THE HDG WITH ATC WHEN I WASN'T POSITIVE THAT IT WAS CORRECT. OTHER FACTORS INCLUDE THE FACT THAT 060 DEGS 'SEEMED RIGHT' TO ME BECAUSE OUR OUTBOUND AIRWAY WAS 064 DEGS AND WE NORMALLY WERE ISSUED HDG IN THAT DIRECTION SHORTLY AFTER TKOF. ANOTHER IMPORTANT FACTOR INVOLVES THE FLT DIRECTOR SYS. OUR B727 FLEET IS MIXED AND MANY ACFT HAVE HDG BUGS INDIVIDUALLY SELECTED BY EACH PLT. THIS ACFT HAPPENED TO BE ONE THAT HAS A COMMON HDG BUG SELECTOR AND I HAD NOTICED SOME CONFUSION IN THE PAST AS TO WHOSE RESPONSIBILITY IT WAS TO SET THE BUG. IN THE FUTURE, I WILL MAKE CERTAIN THAT THE PF ALWAYS SELECTS THE ASSIGNED HDG, AND THE PNF VERIFIES IT. I BELIEVE THIS INCIDENT WOULD NEVER HAVE HAPPENED HAD I BEEN BRIEFING AND USING THAT PROC. SUPPLEMENTAL INFO FROM ACN 341877: I NOTICED AN ACFT XING OUR FLT PATH FROM APPROX THE 1-2 O'CLOCK POS, FROM L TO R, ALMOST CO-ALT. I COULD SEE HIS STARBOARD (GREEN) POS LIGHT AND HIS TAIL LIGHT DISTINCTLY. SUPPLEMENTAL INFO FROM ACN 341215: THE CLRNC WAS ISSUED DURING A CRITICAL PHASE OF FLT (CLEANING UP THE ACFT AFTER TKOF). MY CONCENTRATION WAS DIRECTED MAINLY AT FLYING THE AIRPLANE. I HEARD THE CLRNC BUT I CAN HONESTLY SAY THE 100 DEG HDG CLRNC DID NOT REGISTER WITH ME. I MUST HAVE MISTAKENLY INTERPRETED THE ALT CLRNC OF 16000 FT TO A 060 DEG HDG. WHEN I ASKED THE CAPT TO CONFIRM THE 060 DEG HDG HE INDICATED YES AS I ROTATED THE HDG KNOB TO 060 DEGS. CREW COORD BTWN MYSELF AND THE CAPT WAS PROBABLY THE MAJOR FACTOR. THE FLT DIRECTOR ON THIS PARTICULAR ACFT IS ON THE CENTER FORWARD PANEL. ONE HDG CTL KNOB ON THE PANEL CONTROLLED BOTH THE CAPT'S AND FO'S HDG BUG. PRIOR TO TKOF WE SHOULD HAVE COORDINATED WHO WOULD CONTROL BOTH THE HDG CONTROL KNOB AND THE ALT CONTROL KNOB (IE, THE PNF CONTROLS BOTH OR THE PF CONTROLLING THE HDG KNOB). BECAUSE I WAS FLYING THE ACFT I THOUGHT THE CAPT WAS CONTROLLING BOTH KNOBS AND I'M SURE HE THOUGHT I HAD CONTROL OF THE HDG KNOB.
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.