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|
Attributes | |
ACN | 380502 |
Time | |
Date | 199709 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : gua |
State Reference | FO |
Altitude | msl bound lower : 22000 msl bound upper : 22000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : saez tower : lax |
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 | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 168 flight time total : 14234 flight time type : 3318 |
ASRS Report | 380502 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : far 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 | Navigational Facility |
Air Traffic Incident | Pilot Deviation |
Narrative:
Ezeiza center asked our heading, then vectored us direct pagon. Original clearance read: UA300 gua, UA301 pagon, direct vanar, pagon 1 saez. We then realized that we had been tracking direct eze after gua instead of UA301 pagon. Position approximately 10 NM northeast pagon, 4 NM east of UA301 track centerline. 10 hours of all night flying had elapsed, all 3 pilots were at stations in cockpit. FMC had been programmed for UA301 pagon, arrs page: pagon 1A, ILS 11 arsot transition. ATIS advised ILS runway 35 in use. When ILS runway 35, eze transition was selected, the STAR was omitted. When it was activated not only was pagon 1A STAR erased, but also UA301 pagon, leaving eze as the next waypoint after gua. We immediately headed direct pagon and when in contact with ezeiza approach were vectored and cleared direct eze. Improper procedures were followed in that verification of the new approach selection, ILS runway 35, eze transition, was not completed until after activation instead of before execution. Also, the discontinuity which resulted was closed without verification prior to execution. Thus, none of us caught the fact that we were tracking direct eze versus direct pagon and that the FMC had dropped UA301 pagon and pagon 1A STAR. Other contributing factors: fatigue. We were lulled into accepting eze as the next waypoint. It made sense when we looked at the HSI. The approach was not ILS runway 35, eze transition (versus ILS runway 11). But we had not yet been cleared direct eze.
Original NASA ASRS Text
Title: AN ACR B767 FLC USED IMPROPER PROC TO ENTER THE RTE INTO THE FMC AND THEN THIS DATA WAS XCHKED IMPROPERLY. THE ACFT GOT OFF COURSE UNTIL THE ARTCC CTLR GAVE A NEW CLRNC DIRECT TO A WAYPOINT.
Narrative: EZEIZA CTR ASKED OUR HDG, THEN VECTORED US DIRECT PAGON. ORIGINAL CLRNC READ: UA300 GUA, UA301 PAGON, DIRECT VANAR, PAGON 1 SAEZ. WE THEN REALIZED THAT WE HAD BEEN TRACKING DIRECT EZE AFTER GUA INSTEAD OF UA301 PAGON. POS APPROX 10 NM NE PAGON, 4 NM E OF UA301 TRACK CTRLINE. 10 HRS OF ALL NIGHT FLYING HAD ELAPSED, ALL 3 PLTS WERE AT STATIONS IN COCKPIT. FMC HAD BEEN PROGRAMMED FOR UA301 PAGON, ARRS PAGE: PAGON 1A, ILS 11 ARSOT TRANSITION. ATIS ADVISED ILS RWY 35 IN USE. WHEN ILS RWY 35, EZE TRANSITION WAS SELECTED, THE STAR WAS OMITTED. WHEN IT WAS ACTIVATED NOT ONLY WAS PAGON 1A STAR ERASED, BUT ALSO UA301 PAGON, LEAVING EZE AS THE NEXT WAYPOINT AFTER GUA. WE IMMEDIATELY HEADED DIRECT PAGON AND WHEN IN CONTACT WITH EZEIZA APCH WERE VECTORED AND CLRED DIRECT EZE. IMPROPER PROCS WERE FOLLOWED IN THAT VERIFICATION OF THE NEW APCH SELECTION, ILS RWY 35, EZE TRANSITION, WAS NOT COMPLETED UNTIL AFTER ACTIVATION INSTEAD OF BEFORE EXECUTION. ALSO, THE DISCONTINUITY WHICH RESULTED WAS CLOSED WITHOUT VERIFICATION PRIOR TO EXECUTION. THUS, NONE OF US CAUGHT THE FACT THAT WE WERE TRACKING DIRECT EZE VERSUS DIRECT PAGON AND THAT THE FMC HAD DROPPED UA301 PAGON AND PAGON 1A STAR. OTHER CONTRIBUTING FACTORS: FATIGUE. WE WERE LULLED INTO ACCEPTING EZE AS THE NEXT WAYPOINT. IT MADE SENSE WHEN WE LOOKED AT THE HSI. THE APCH WAS NOT ILS RWY 35, EZE TRANSITION (VERSUS ILS RWY 11). BUT WE HAD NOT YET BEEN CLRED DIRECT EZE.
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.