37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 351119 |
Time | |
Date | 199610 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : msp |
State Reference | MN |
Altitude | msl bound lower : 1000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : msp |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | other other : other pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 7000 flight time type : 300 |
ASRS Report | 351119 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 7000 flight time type : 300 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | 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:
Maintenance was on the aircraft when the flight engineer arrived to start his preflight. The mechanic was working on the captain's flight director, said the horizontal pitch trim was sticking. The mechanic furnished up and told the flight engineer he would leave the INS's on since he already had them aligning. However, the mechanic had only turned the INS's on to 'align' instead of 'navigation' which is air carrier X procedure. As a result, the flight crew did not notice this until pushback, at which time the INS's began flashing. The captain realized what happened and switched both INS's to 'attitude reference' electing to go without the INS rather than wait for them to re-align, since we were only going msp to ord, a heading of 118 degrees was set with the heading bug as per procedure for runway 11R at msp. On takeoff, tower said to fly heading 110 degrees. The captain reset the heading bug while I (first officer) was flying. I looked at 110 degrees on the compass and turned approximately 30 degrees south to rollout on 110 degrees, tower called and said to fly heading 110 degrees, that they observed us going well south. Checking the standby compass was not rechked in the turn but, the captain re-slaved the compass and I turned back left towards 110 degrees, leveling at 500 ft MSL. Factors: the flight crew should have noticed the INS were not on 'navigation' during preflight, the capts should have noticed during the before start checklist when he called out INS's 'navigation and checked.' after selecting 'attitude reference' which is not a normal procedure the compasses should have been slaved again but were not. When taking the runway for takeoff, both pilots should have noticed the compass heading was not aligned with the runway heading. Due to hurryitis, fatigue, complacency, and inattn to detail this chain of events went unbroken.
Original NASA ASRS Text
Title: FLC OF A WDB FAILED TO TURN TO THE DEP HDG AFTER TKOF DUE TO THE ACFT COMPASSES NOT SLAVED TO THE APPROPRIATE HDG AND THE FLT DIRECTOR MODE WAS ON ATTITUDE INSTEAD OF THE NAV MODE.
Narrative: MAINT WAS ON THE ACFT WHEN THE FE ARRIVED TO START HIS PREFLT. THE MECH WAS WORKING ON THE CAPT'S FLT DIRECTOR, SAID THE HORIZ PITCH TRIM WAS STICKING. THE MECH FURNISHED UP AND TOLD THE FE HE WOULD LEAVE THE INS'S ON SINCE HE ALREADY HAD THEM ALIGNING. HOWEVER, THE MECH HAD ONLY TURNED THE INS'S ON TO 'ALIGN' INSTEAD OF 'NAV' WHICH IS ACR X PROC. AS A RESULT, THE FLC DID NOT NOTICE THIS UNTIL PUSHBACK, AT WHICH TIME THE INS'S BEGAN FLASHING. THE CAPT REALIZED WHAT HAPPENED AND SWITCHED BOTH INS'S TO 'ATTITUDE REF' ELECTING TO GO WITHOUT THE INS RATHER THAN WAIT FOR THEM TO RE-ALIGN, SINCE WE WERE ONLY GOING MSP TO ORD, A HDG OF 118 DEGS WAS SET WITH THE HDG BUG AS PER PROC FOR RWY 11R AT MSP. ON TKOF, TWR SAID TO FLY HDG 110 DEGS. THE CAPT RESET THE HDG BUG WHILE I (FO) WAS FLYING. I LOOKED AT 110 DEGS ON THE COMPASS AND TURNED APPROX 30 DEGS S TO ROLLOUT ON 110 DEGS, TWR CALLED AND SAID TO FLY HDG 110 DEGS, THAT THEY OBSERVED US GOING WELL S. CHKING THE STANDBY COMPASS WAS NOT RECHKED IN THE TURN BUT, THE CAPT RE-SLAVED THE COMPASS AND I TURNED BACK L TOWARDS 110 DEGS, LEVELING AT 500 FT MSL. FACTORS: THE FLC SHOULD HAVE NOTICED THE INS WERE NOT ON 'NAV' DURING PREFLT, THE CAPTS SHOULD HAVE NOTICED DURING THE BEFORE START CHKLIST WHEN HE CALLED OUT INS'S 'NAV AND CHKED.' AFTER SELECTING 'ATTITUDE REF' WHICH IS NOT A NORMAL PROC THE COMPASSES SHOULD HAVE BEEN SLAVED AGAIN BUT WERE NOT. WHEN TAKING THE RWY FOR TKOF, BOTH PLTS SHOULD HAVE NOTICED THE COMPASS HDG WAS NOT ALIGNED WITH THE RWY HDG. DUE TO HURRYITIS, FATIGUE, COMPLACENCY, AND INATTN TO DETAIL THIS CHAIN OF EVENTS WENT UNBROKEN.
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.