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Attributes | |
ACN | 352373 |
Time | |
Date | 199611 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : yqx |
State Reference | NF |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqm |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : other oceanic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 23000 flight time type : 5000 |
ASRS Report | 352373 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 8000 flight time type : 200 |
ASRS Report | 352714 |
Events | |
Anomaly | non adherence : clearance non adherence : far 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:
Flight copenhagen-jfk, nov/xx/96, B767-332ER. I was captain of flight, not flying the leg. 2 other pilots, 1 copilot and 1 acting as relief pilot (both rated in the plane). The 3 of us on second or so transoceanic flight, having been recently qualified. We were flight planned for a 'random route' across the north atlantic, 1 degree above the northern most 'nat' track 'a.' our exit point from the random track was flight planned to be direct cymon intersection then direct to topps intersection (nar 146B). From there direct kennebunk VOR and the ene.ENE4 arrival to jfk. After receiving nat track message 316 (best recollection), we called english control and asked for a clearance to enter the track system and were given a rerte. Shanwick oceanic cleared us via track 'a' exiting at 50n50w direct to yqx (gander). This led to some confusion as our flight plan had us exiting at cymon intersection with N146B the nar to follow thereafter. Although N130B would cover us direct from gander to topps intersection, we did not have a clearance as such. A crew discussion ensued about what to do in the event of a radio failure and according to our knowledge direct to topps intersection would follow gander. (During this time the relief pilot went to the rear for the first rest break.) a call to shanwick clearance resulted in our being told a further clearance would be given on the other side at 50W. We left the discontinuity between cymon intersection and gander in the ACARS as a reminder. An uplink via ACARS was sent to the company dispatcher, advising of the new routing and clearance. Sometime after, an ACARS message from atlanta was received. It acknowledged our new nat routing and appeared to be a revised flight plan might have been filed. This message had us on track 'a', exiting to gander and then N126B to allex thence direct to ene VOR and the ENE4 arrival. Although it was our understanding we had been cleared only to gander by shanwick, this new company plan filled a perceived void: N126B was entered in the ACARS after 50W. This would take us to gander and then direct to allex. We (myself and the regular copilot) discussed and understood our clearance limit was still just to gander, yet if gander followed through were prepared for being rted the way atlanta thought it would go. Prior to 50W the relief pilot relieved the copilot. Upon approaching 50W, I gave gander the required position report on VHF 122.37. Shortly thereafter we were told 'radar contact' and received a clearance from gander center: cleared to gander, direct topps, direct kenebunk and flight planned route. I repeated it back loudly in order that the relief pilot could hear and execute the clearance on his FMS. I observed his doing this. I recorded the new clearance on our log, crossed out (the tentative) allex and reinserted topps as the airplane headed toward topps (what I thought the relief pilot flying had inserted in the FMC). I made a quick check of the DME which correctly read 578+/-, the LNAV engagement was checked ok as well as the lateral xtrack error on progress page 2 of my FMC. The copilot came in then. A bit later we exchanged seats as I gave him the log, briefed him on with whom I was in radio contact, and where we were going (where I thought we were going). Shortly thereafter, he and the relief pilot decided to exchange seats as it was his leg and landing with but 2 hours of flight time remaining. I then reassumed my seat while the copilot got seated on the right side, then I exchanged seats with the relief pilot to take a short break on the jump seat. After a while I heard a discussion between the relief pilot in my seat and moncton center. Moncton asked where we were headed and the relief pilot told him allex. Moncton informed the clearance limit was topps (side-by-side about 50 mi between them and perhaps a hundred or so mi ahead). My relief pilot asked moncton if there were any conflict or problem and was told by moncton everything was ok. When we landed at kennedy, we were told by company staff that moncton and gander were filing charges against us for being off course. The relief pilot says he heard the clearance to gander and topps, but upon looking at his screen, thought that was what we were doing anyhow as we passed over gander. Somehow or other topps went over his head and allex took its place. Having seen him execute the clearance via keys in his FMS, I checked only the distance, track to topps and the xtrack error. I failed to bring up the 'legs' page and doublechk his entering topps at the next waypoint. There is no way of mitigating the fact that we were off the course the center had given us. Had there been better briefing between pilots as seats were exchanged, the error may have been caught. The 3 of us are recent domestic B767 pilots and not accustomed to changing seats nor the necessary briefing thereof. Way back at 20W, had we left the route discontinuity in the first filed flight plan, the FMS would have been set to go to topps (after removing cymon).
Original NASA ASRS Text
Title: B767 CAPT RECEIVES A RECLRNC AND ASSUMES FO HAS COPIED AND ENTERED IT IN THE FMS. HE HADN'T AND THEREFORE THEY HAD A GROSS NAV ERROR.
Narrative: FLT COPENHAGEN-JFK, NOV/XX/96, B767-332ER. I WAS CAPT OF FLT, NOT FLYING THE LEG. 2 OTHER PLTS, 1 COPLT AND 1 ACTING AS RELIEF PLT (BOTH RATED IN THE PLANE). THE 3 OF US ON SECOND OR SO TRANSOCEANIC FLT, HAVING BEEN RECENTLY QUALIFIED. WE WERE FLT PLANNED FOR A 'RANDOM RTE' ACROSS THE NORTH ATLANTIC, 1 DEG ABOVE THE NORTHERN MOST 'NAT' TRACK 'A.' OUR EXIT POINT FROM THE RANDOM TRACK WAS FLT PLANNED TO BE DIRECT CYMON INTXN THEN DIRECT TO TOPPS INTXN (NAR 146B). FROM THERE DIRECT KENNEBUNK VOR AND THE ENE.ENE4 ARR TO JFK. AFTER RECEIVING NAT TRACK MESSAGE 316 (BEST RECOLLECTION), WE CALLED ENGLISH CTL AND ASKED FOR A CLRNC TO ENTER THE TRACK SYS AND WERE GIVEN A RERTE. SHANWICK OCEANIC CLRED US VIA TRACK 'A' EXITING AT 50N50W DIRECT TO YQX (GANDER). THIS LED TO SOME CONFUSION AS OUR FLT PLAN HAD US EXITING AT CYMON INTXN WITH N146B THE NAR TO FOLLOW THEREAFTER. ALTHOUGH N130B WOULD COVER US DIRECT FROM GANDER TO TOPPS INTXN, WE DID NOT HAVE A CLRNC AS SUCH. A CREW DISCUSSION ENSUED ABOUT WHAT TO DO IN THE EVENT OF A RADIO FAILURE AND ACCORDING TO OUR KNOWLEDGE DIRECT TO TOPPS INTXN WOULD FOLLOW GANDER. (DURING THIS TIME THE RELIEF PLT WENT TO THE REAR FOR THE FIRST REST BREAK.) A CALL TO SHANWICK CLRNC RESULTED IN OUR BEING TOLD A FURTHER CLRNC WOULD BE GIVEN ON THE OTHER SIDE AT 50W. WE LEFT THE DISCONTINUITY BTWN CYMON INTXN AND GANDER IN THE ACARS AS A REMINDER. AN UPLINK VIA ACARS WAS SENT TO THE COMPANY DISPATCHER, ADVISING OF THE NEW ROUTING AND CLRNC. SOMETIME AFTER, AN ACARS MESSAGE FROM ATLANTA WAS RECEIVED. IT ACKNOWLEDGED OUR NEW NAT ROUTING AND APPEARED TO BE A REVISED FLT PLAN MIGHT HAVE BEEN FILED. THIS MESSAGE HAD US ON TRACK 'A', EXITING TO GANDER AND THEN N126B TO ALLEX THENCE DIRECT TO ENE VOR AND THE ENE4 ARR. ALTHOUGH IT WAS OUR UNDERSTANDING WE HAD BEEN CLRED ONLY TO GANDER BY SHANWICK, THIS NEW COMPANY PLAN FILLED A PERCEIVED VOID: N126B WAS ENTERED IN THE ACARS AFTER 50W. THIS WOULD TAKE US TO GANDER AND THEN DIRECT TO ALLEX. WE (MYSELF AND THE REGULAR COPLT) DISCUSSED AND UNDERSTOOD OUR CLRNC LIMIT WAS STILL JUST TO GANDER, YET IF GANDER FOLLOWED THROUGH WERE PREPARED FOR BEING RTED THE WAY ATLANTA THOUGHT IT WOULD GO. PRIOR TO 50W THE RELIEF PLT RELIEVED THE COPLT. UPON APCHING 50W, I GAVE GANDER THE REQUIRED POS RPT ON VHF 122.37. SHORTLY THEREAFTER WE WERE TOLD 'RADAR CONTACT' AND RECEIVED A CLRNC FROM GANDER CTR: CLRED TO GANDER, DIRECT TOPPS, DIRECT KENEBUNK AND FLT PLANNED RTE. I REPEATED IT BACK LOUDLY IN ORDER THAT THE RELIEF PLT COULD HEAR AND EXECUTE THE CLRNC ON HIS FMS. I OBSERVED HIS DOING THIS. I RECORDED THE NEW CLRNC ON OUR LOG, CROSSED OUT (THE TENTATIVE) ALLEX AND REINSERTED TOPPS AS THE AIRPLANE HEADED TOWARD TOPPS (WHAT I THOUGHT THE RELIEF PLT FLYING HAD INSERTED IN THE FMC). I MADE A QUICK CHK OF THE DME WHICH CORRECTLY READ 578+/-, THE LNAV ENGAGEMENT WAS CHKED OK AS WELL AS THE LATERAL XTRACK ERROR ON PROGRESS PAGE 2 OF MY FMC. THE COPLT CAME IN THEN. A BIT LATER WE EXCHANGED SEATS AS I GAVE HIM THE LOG, BRIEFED HIM ON WITH WHOM I WAS IN RADIO CONTACT, AND WHERE WE WERE GOING (WHERE I THOUGHT WE WERE GOING). SHORTLY THEREAFTER, HE AND THE RELIEF PLT DECIDED TO EXCHANGE SEATS AS IT WAS HIS LEG AND LNDG WITH BUT 2 HRS OF FLT TIME REMAINING. I THEN REASSUMED MY SEAT WHILE THE COPLT GOT SEATED ON THE R SIDE, THEN I EXCHANGED SEATS WITH THE RELIEF PLT TO TAKE A SHORT BREAK ON THE JUMP SEAT. AFTER A WHILE I HEARD A DISCUSSION BTWN THE RELIEF PLT IN MY SEAT AND MONCTON CTR. MONCTON ASKED WHERE WE WERE HEADED AND THE RELIEF PLT TOLD HIM ALLEX. MONCTON INFORMED THE CLRNC LIMIT WAS TOPPS (SIDE-BY-SIDE ABOUT 50 MI BTWN THEM AND PERHAPS A HUNDRED OR SO MI AHEAD). MY RELIEF PLT ASKED MONCTON IF THERE WERE ANY CONFLICT OR PROB AND WAS TOLD BY MONCTON EVERYTHING WAS OK. WHEN WE LANDED AT KENNEDY, WE WERE TOLD BY COMPANY STAFF THAT MONCTON AND GANDER WERE FILING CHARGES AGAINST US FOR BEING OFF COURSE. THE RELIEF PLT SAYS HE HEARD THE CLRNC TO GANDER AND TOPPS, BUT UPON LOOKING AT HIS SCREEN, THOUGHT THAT WAS WHAT WE WERE DOING ANYHOW AS WE PASSED OVER GANDER. SOMEHOW OR OTHER TOPPS WENT OVER HIS HEAD AND ALLEX TOOK ITS PLACE. HAVING SEEN HIM EXECUTE THE CLRNC VIA KEYS IN HIS FMS, I CHKED ONLY THE DISTANCE, TRACK TO TOPPS AND THE XTRACK ERROR. I FAILED TO BRING UP THE 'LEGS' PAGE AND DOUBLECHK HIS ENTERING TOPPS AT THE NEXT WAYPOINT. THERE IS NO WAY OF MITIGATING THE FACT THAT WE WERE OFF THE COURSE THE CTR HAD GIVEN US. HAD THERE BEEN BETTER BRIEFING BTWN PLTS AS SEATS WERE EXCHANGED, THE ERROR MAY HAVE BEEN CAUGHT. THE 3 OF US ARE RECENT DOMESTIC B767 PLTS AND NOT ACCUSTOMED TO CHANGING SEATS NOR THE NECESSARY BRIEFING THEREOF. WAY BACK AT 20W, HAD WE LEFT THE RTE DISCONTINUITY IN THE FIRST FILED FLT PLAN, THE FMS WOULD HAVE BEEN SET TO GO TO TOPPS (AFTER REMOVING CYMON).
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.