37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 383220 |
Time | |
Date | 199710 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : dqo |
State Reference | DE |
Altitude | msl bound lower : 14000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other descent other |
Route In Use | enroute airway : zdc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | other other : other pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 9000 flight time type : 1250 |
ASRS Report | 383220 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Clearance to acy was direct dqo direct eno direct sie direct acy. Normal clearance is to cross dqo at 13000 ft, assigned altitude this day was 14000 ft. Upon reaching dqo (first officer flying) crew failed to note station crossing and failed to turn toward eno. Center controller asked if we were going to turn as there was traffic in front of us. Crew immediately initiated turn and then was given vector. Traffic was not a factor at time aircraft was turned back on course, however it could have been if controller had not been alert. To my knowledge no alerts were issued, TCASII or controller. I believe that this incident was caused by crew fatigue caused by being on 24 hour reserve. Crew was called in at XA00 to relieve a crew that was about to exceed the requirements of far 121.471(B) (1). Crew departed acy at XE00 to pit arriving at hotel at XF30, departed hotel at XK00 for XL25 scheduled departure to acy. This leaves limited time for rest. The FARS allow carriers to assign crews to 24 hour reserve up to 6 consecutive days. During this time the crew member may be called to fly with minimal notice. 1 hour to show at airport is common. When are these crews supposed to rest? Once called these crews can be on duty for 16 hours and fly up to 8 hours. Other factors include: this was first time this crew flew together. First officer's low time in type. Normal crossing restr changed. Failure of captain to adequately monitor first officer.
Original NASA ASRS Text
Title: FO OF A DC9-30 FAILED TO TURN OVER A XING FIX PER FLT PLAN RESULTING IN ATC INTERVENTION TO REMIND THE CREW OF THEIR FLT PLAN ROUTING.
Narrative: CLRNC TO ACY WAS DIRECT DQO DIRECT ENO DIRECT SIE DIRECT ACY. NORMAL CLRNC IS TO CROSS DQO AT 13000 FT, ASSIGNED ALT THIS DAY WAS 14000 FT. UPON REACHING DQO (FO FLYING) CREW FAILED TO NOTE STATION XING AND FAILED TO TURN TOWARD ENO. CTR CTLR ASKED IF WE WERE GOING TO TURN AS THERE WAS TFC IN FRONT OF US. CREW IMMEDIATELY INITIATED TURN AND THEN WAS GIVEN VECTOR. TFC WAS NOT A FACTOR AT TIME ACFT WAS TURNED BACK ON COURSE, HOWEVER IT COULD HAVE BEEN IF CTLR HAD NOT BEEN ALERT. TO MY KNOWLEDGE NO ALERTS WERE ISSUED, TCASII OR CTLR. I BELIEVE THAT THIS INCIDENT WAS CAUSED BY CREW FATIGUE CAUSED BY BEING ON 24 HR RESERVE. CREW WAS CALLED IN AT XA00 TO RELIEVE A CREW THAT WAS ABOUT TO EXCEED THE REQUIREMENTS OF FAR 121.471(B) (1). CREW DEPARTED ACY AT XE00 TO PIT ARRIVING AT HOTEL AT XF30, DEPARTED HOTEL AT XK00 FOR XL25 SCHEDULED DEP TO ACY. THIS LEAVES LIMITED TIME FOR REST. THE FARS ALLOW CARRIERS TO ASSIGN CREWS TO 24 HR RESERVE UP TO 6 CONSECUTIVE DAYS. DURING THIS TIME THE CREW MEMBER MAY BE CALLED TO FLY WITH MINIMAL NOTICE. 1 HR TO SHOW AT ARPT IS COMMON. WHEN ARE THESE CREWS SUPPOSED TO REST? ONCE CALLED THESE CREWS CAN BE ON DUTY FOR 16 HRS AND FLY UP TO 8 HRS. OTHER FACTORS INCLUDE: THIS WAS FIRST TIME THIS CREW FLEW TOGETHER. FO'S LOW TIME IN TYPE. NORMAL XING RESTR CHANGED. FAILURE OF CAPT TO ADEQUATELY MONITOR FO.
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.