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|
Attributes | |
ACN | 356629 |
Time | |
Date | 199612 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : einn |
State Reference | FO |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : eisn tower : sat |
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 : atlantic enroute : other oceanic |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : atlantic enroute : other oceanic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | pilot : atp |
ASRS Report | 356629 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 356630 |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : clearance non adherence : required legal separation other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | faa : investigated |
Miss Distance | horizontal : 90000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ATC facility: shannon. Location: 75 NM west of 5115N. Upon receiving data link clearance before coast-out at bancs, the crew determined that the only change to the original flight plan was the replacement of position giper with position kenuk and changed the FMC accordingly. Because of the similar appearance of 5015N and 5115N, the change from 5115N to 5015N was overlooked. At XX50Z and approximately 75 NM west of 5115N, the crew noted an aircraft on TCASII at the same altitude off the left wing at a range of 15 mi. The crew immediately started to check the current position and the next position. The PNF switched to shannon on VHF to inquire about the proximity of the other aircraft. As soon as VHF was selected, the crew was contacted by shannon and given a squawk that was followed immediately by a directed 30 degree turn to the right. Soon thereafter, shannon informed the crew that it was expected at 5015N and not 5115N. After rechking the FMC versus the flight plan versus the data link clearance, the crew determined that the clearance had, in fact, included the change 5015N, kenuk. It had 5115N, kenuk in the FMC. Captain's observations, in retrospect, we continuously referred to 5115N as 5015N and were mentally locked onto the fact that kenuk was the only change to our flight plan. Obviously, we are all very upset that this error occurred and have discussed at length between ourselves how to prevent this from happening again. Supplemental information from acn 356630: we feel that using the actual data link clearance as a final check against the waypoints entered into the FMS prior to coastout would prevent any possible improper xfer of data.
Original NASA ASRS Text
Title: GROSS NAV ERROR. FLC DEV OCCURS IN AN OVERWATER NIGHT OP. POTENTIAL CONFLICT LTSS.
Narrative: ATC FACILITY: SHANNON. LOCATION: 75 NM W OF 5115N. UPON RECEIVING DATA LINK CLRNC BEFORE COAST-OUT AT BANCS, THE CREW DETERMINED THAT THE ONLY CHANGE TO THE ORIGINAL FLT PLAN WAS THE REPLACEMENT OF POS GIPER WITH POS KENUK AND CHANGED THE FMC ACCORDINGLY. BECAUSE OF THE SIMILAR APPEARANCE OF 5015N AND 5115N, THE CHANGE FROM 5115N TO 5015N WAS OVERLOOKED. AT XX50Z AND APPROX 75 NM W OF 5115N, THE CREW NOTED AN ACFT ON TCASII AT THE SAME ALT OFF THE L WING AT A RANGE OF 15 MI. THE CREW IMMEDIATELY STARTED TO CHK THE CURRENT POS AND THE NEXT POS. THE PNF SWITCHED TO SHANNON ON VHF TO INQUIRE ABOUT THE PROX OF THE OTHER ACFT. AS SOON AS VHF WAS SELECTED, THE CREW WAS CONTACTED BY SHANNON AND GIVEN A SQUAWK THAT WAS FOLLOWED IMMEDIATELY BY A DIRECTED 30 DEG TURN TO THE R. SOON THEREAFTER, SHANNON INFORMED THE CREW THAT IT WAS EXPECTED AT 5015N AND NOT 5115N. AFTER RECHKING THE FMC VERSUS THE FLT PLAN VERSUS THE DATA LINK CLRNC, THE CREW DETERMINED THAT THE CLRNC HAD, IN FACT, INCLUDED THE CHANGE 5015N, KENUK. IT HAD 5115N, KENUK IN THE FMC. CAPT'S OBSERVATIONS, IN RETROSPECT, WE CONTINUOUSLY REFERRED TO 5115N AS 5015N AND WERE MENTALLY LOCKED ONTO THE FACT THAT KENUK WAS THE ONLY CHANGE TO OUR FLT PLAN. OBVIOUSLY, WE ARE ALL VERY UPSET THAT THIS ERROR OCCURRED AND HAVE DISCUSSED AT LENGTH BTWN OURSELVES HOW TO PREVENT THIS FROM HAPPENING AGAIN. SUPPLEMENTAL INFO FROM ACN 356630: WE FEEL THAT USING THE ACTUAL DATA LINK CLRNC AS A FINAL CHK AGAINST THE WAYPOINTS ENTERED INTO THE FMS PRIOR TO COASTOUT WOULD PREVENT ANY POSSIBLE IMPROPER XFER OF DATA.
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.