37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 372739 |
Time | |
Date | 199706 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mht |
State Reference | NH |
Altitude | agl bound lower : 400 agl bound upper : 400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mht tracon : phl |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 8000 flight time type : 5000 |
ASRS Report | 372739 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 170 flight time total : 8000 flight time type : 1500 |
ASRS Report | 372310 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure 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:
After takeoff from runway 35, we began the departure procedure. At 400 ft AGL we initiated a right turn to 220 degrees and shortly after were instructed to contact departure control. After I checked on, the controller asked what heading we were on. I told him that we were turning right to a 220 degree heading. He then told us to roll out on a 120 degree heading, which we did. He then informed us that the right turn to 220 degrees was only for runway 17 and that runway 35 was just to fly runway heading. There was no traffic conflict. I feel that the problem mainly arose because of crew fatigue. We had a very long day the day before due to thunderstorms and didn't arrive in mht until XE30 (5 hours late). We had a minimum layover in mht (9 hours) before we departed. We also didn't have a chance to eat which may have contributed to the fatigue. Our flight out of mht was now a ferry flight and everything in respect to departure was hurried and confused (paperwork, fueling, ramp personnel, arming the doors, etc). When we finally received our clearance, it included a SID which we had not been filed for so it was read (independently) quicker than it normally would have been. I missed the 'runway 17' notation because I had the plate clipped in my yoke clip (and didn't bother to remove it) and wasn't able to read the top line. I think that the fatigue degraded my performance by making me sloppy and dulled my judgement because I never questioned such a large turn (with no terrain) and in the opposite direction of what would be expected. Also, the hurried and awkward nature of the operation made it difficult to concentrate. I should have realized that we needed more time and slowed things down a bit.
Original NASA ASRS Text
Title: MLG ACFT ON DEP SID READ DEP HEADING FOR WRONG RWY. AFTER TKOF DEP CTLR CORRECTED THE HEADING. RPTR'S ATTRIBUTE PART OF LACK OF AWARENESS TO FATIGUE.
Narrative: AFTER TKOF FROM RWY 35, WE BEGAN THE DEP PROC. AT 400 FT AGL WE INITIATED A R TURN TO 220 DEGS AND SHORTLY AFTER WERE INSTRUCTED TO CONTACT DEP CTL. AFTER I CHKED ON, THE CTLR ASKED WHAT HEADING WE WERE ON. I TOLD HIM THAT WE WERE TURNING R TO A 220 DEG HDG. HE THEN TOLD US TO ROLL OUT ON A 120 DEG HDG, WHICH WE DID. HE THEN INFORMED US THAT THE R TURN TO 220 DEGS WAS ONLY FOR RWY 17 AND THAT RWY 35 WAS JUST TO FLY RWY HEADING. THERE WAS NO TFC CONFLICT. I FEEL THAT THE PROB MAINLY AROSE BECAUSE OF CREW FATIGUE. WE HAD A VERY LONG DAY THE DAY BEFORE DUE TO TSTMS AND DIDN'T ARRIVE IN MHT UNTIL XE30 (5 HRS LATE). WE HAD A MINIMUM LAYOVER IN MHT (9 HRS) BEFORE WE DEPARTED. WE ALSO DIDN'T HAVE A CHANCE TO EAT WHICH MAY HAVE CONTRIBUTED TO THE FATIGUE. OUR FLT OUT OF MHT WAS NOW A FERRY FLT AND EVERYTHING IN RESPECT TO DEP WAS HURRIED AND CONFUSED (PAPERWORK, FUELING, RAMP PERSONNEL, ARMING THE DOORS, ETC). WHEN WE FINALLY RECEIVED OUR CLRNC, IT INCLUDED A SID WHICH WE HAD NOT BEEN FILED FOR SO IT WAS READ (INDEPENDENTLY) QUICKER THAN IT NORMALLY WOULD HAVE BEEN. I MISSED THE 'RWY 17' NOTATION BECAUSE I HAD THE PLATE CLIPPED IN MY YOKE CLIP (AND DIDN'T BOTHER TO REMOVE IT) AND WASN'T ABLE TO READ THE TOP LINE. I THINK THAT THE FATIGUE DEGRADED MY PERFORMANCE BY MAKING ME SLOPPY AND DULLED MY JUDGEMENT BECAUSE I NEVER QUESTIONED SUCH A LARGE TURN (WITH NO TERRAIN) AND IN THE OPPOSITE DIRECTION OF WHAT WOULD BE EXPECTED. ALSO, THE HURRIED AND AWKWARD NATURE OF THE OP MADE IT DIFFICULT TO CONCENTRATE. I SHOULD HAVE REALIZED THAT WE NEEDED MORE TIME AND SLOWED THINGS DOWN A BIT.
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.