37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 352406 |
Time | |
Date | 199611 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : scc airport : slc |
State Reference | UT |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : slc |
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 : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 18000 flight time type : 7000 |
ASRS Report | 352406 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance 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:
Flight originally cleared IFR salt lake 5 SID departing south over ffu. While deicing at remote pad, departures changed to the north. After deice and engine start and prior to taxi, we got verbal clearance from clearance delivery (to the affect -- I do not know exact wording) '...salt lake 5 to the slc 094 degree radial to the mtu 300 degree radial as filed, maintain 11000 ft.' I misunderstood clearance to mean '340 degree heading to intercept slc 094 degree radial.' on taxi out, I briefed the first officer that the slc 5/slc 094 X mtu 303 was in the FMS and that I would be calling for LNAV at 400 ft AGL after takeoff to follow flight director commands from LNAV. After takeoff LNAV flew the 340 degree SID heading to the slc 094 degree and so on. Departure control asked where we were going and if we had terrain in sight (mountains to east). If clearance delivery had said slc 5 'radar vectors to the slc 094 degree' or tower had said 'runway heading' we would not have turned. However, the manner in which the clearance was delivered made us think 340 degree heading to intercept the 094 degree outbound. Our route was not depicted on the SID. Had I read the SID more carefully prior to moving the aircraft or the first officer read the SID more carefully while I taxied/briefed the departure we may have become curious enough to question the procedure. Perhaps if clearance delivery/tower had not omitted certain key words we would not have mentally misplaced those omissions with our own beliefs/expectations (CRM). Also contributing: 39+9 hard time and 6 months check in previous 9 days (2 days off). Short night rest (9+45 block-to-block) and fighting chest infection for last month (fatigue?).
Original NASA ASRS Text
Title: MLG ACFT DEPARTING, RWY CHANGED AS ACFT WAS BEING DEICED, CLRNC DELIVERY ISSUED REVISED DEP INSTRUCTIONS. RPTR CAPT MISUNDERSTOOD THE CLRNC AND SET AN INTERCEPT HDG IN THE FMS AND BRIEFED FO AT 400 FT THEY WOULD USE LNAV. NEITHER PLT READ THE NEW SID CAREFULLY AND DURING CLB WERE QUESTIONED ABOUT HDG. RPTR CAPT ATTRIBUTES LONG HRS OF FLYING IN THE PRECEDING WK PLUS ILLNESS RESULTING IN FATIGUE.
Narrative: FLT ORIGINALLY CLRED IFR SALT LAKE 5 SID DEPARTING S OVER FFU. WHILE DEICING AT REMOTE PAD, DEPS CHANGED TO THE N. AFTER DEICE AND ENG START AND PRIOR TO TAXI, WE GOT VERBAL CLRNC FROM CLRNC DELIVERY (TO THE AFFECT -- I DO NOT KNOW EXACT WORDING) '...SALT LAKE 5 TO THE SLC 094 DEG RADIAL TO THE MTU 300 DEG RADIAL AS FILED, MAINTAIN 11000 FT.' I MISUNDERSTOOD CLRNC TO MEAN '340 DEG HDG TO INTERCEPT SLC 094 DEG RADIAL.' ON TAXI OUT, I BRIEFED THE FO THAT THE SLC 5/SLC 094 X MTU 303 WAS IN THE FMS AND THAT I WOULD BE CALLING FOR LNAV AT 400 FT AGL AFTER TKOF TO FOLLOW FLT DIRECTOR COMMANDS FROM LNAV. AFTER TKOF LNAV FLEW THE 340 DEG SID HDG TO THE SLC 094 DEG AND SO ON. DEP CTL ASKED WHERE WE WERE GOING AND IF WE HAD TERRAIN IN SIGHT (MOUNTAINS TO E). IF CLRNC DELIVERY HAD SAID SLC 5 'RADAR VECTORS TO THE SLC 094 DEG' OR TWR HAD SAID 'RWY HDG' WE WOULD NOT HAVE TURNED. HOWEVER, THE MANNER IN WHICH THE CLRNC WAS DELIVERED MADE US THINK 340 DEG HDG TO INTERCEPT THE 094 DEG OUTBOUND. OUR RTE WAS NOT DEPICTED ON THE SID. HAD I READ THE SID MORE CAREFULLY PRIOR TO MOVING THE ACFT OR THE FO READ THE SID MORE CAREFULLY WHILE I TAXIED/BRIEFED THE DEP WE MAY HAVE BECOME CURIOUS ENOUGH TO QUESTION THE PROC. PERHAPS IF CLRNC DELIVERY/TWR HAD NOT OMITTED CERTAIN KEY WORDS WE WOULD NOT HAVE MENTALLY MISPLACED THOSE OMISSIONS WITH OUR OWN BELIEFS/EXPECTATIONS (CRM). ALSO CONTRIBUTING: 39+9 HARD TIME AND 6 MONTHS CHK IN PREVIOUS 9 DAYS (2 DAYS OFF). SHORT NIGHT REST (9+45 BLOCK-TO-BLOCK) AND FIGHTING CHEST INFECTION FOR LAST MONTH (FATIGUE?).
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.