Narrative:

Navigation error -- it could never happen to me! Sounds familiar? I was the captain of a flight that included copilot, relief pilot, and myself. It was the third ocean crossing in just over 48 hours. Our rest period had been interrupted because of threatened change in schedule that in fact never occurred. Neither the copilot nor I had been able to sleep just prior to the flight despite, in my case, over 5 hours of tossing and turning in the hotel bed. I had only been able to sleep 6 hours the previous night and would have to admit to being very sleep deprived. I loaded the routing into the FMS and checked it with the copilot prior to departure. Since I make it a practice of not taking a rest period prior to getting the oceanic clearance I let the copilot go back for a rest after we were in cruise. The relief pilot replaced him in the right seat. The copilot came back to the cockpit just as we were obtaining the oceanic clearance. I was working the radios this leg so I accepted and read back the clearance of flight plan route which agreed with our printed flight plan. The copilot replaced me in the left seat. They woke me about 1.5 hours later after a good nap. After I returned to the cockpit I sat in the left seat and the copilot replaced the relief pilot in the right seat and the relief pilot went back to rest. As I sat down to review the flight plan I felt a tinge of horror come over me. The point we were heading to was not on our flight plan, the north coordinate was incorrect. I had the relief pilot return immediately. We were fortunate to be on a random route both below and away from the organized track system. We were VMC so I made an immediate turn to return to the flight plan track and descended 500 ft until regaining the track. The relief pilot realized he had given the previous position reports from the printed flight plan not the position report page in the FMS. Had that been done, ATC would have caught the error with the next from the previous position report. The plotting chart had been plotted using the route taken off the FMS and not the printed flight plan so the error was not caught there. I had not reviewed each position after receiving the clearance because I was in a hurry to get a nap, and it was flight plan route, which had been checked prior to takeoff. I know that I would have caught the error if I had been in the seat since I always double, and triple check position across the ocean. I was not in the cockpit at the time we started getting off the cleared route, but I am responsible because that's my job. Aviation now has 3 more pilots that will never make another ocean crossing error, not because 'it can't happen to us' but because 'it did!' supplemental information from acn 386107: human considerations: single digit latitude entered incorrectly. Numerous opportunities to discover error (during xchk after initialization, receipt of oceanic clearance, position reporting, post fix verification, etc). Human factors: second crossing within 2 days and late night/early morning flight contributed to fatigue and subsequent breakdown in habit patterns/procedures along with overreliance in advanced/automated cockpit reliability.

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Original NASA ASRS Text

Title: FLC OF WDB ON ATLANTIC OCEANIC RTE INPUTS WRONG N COORDINATES AND HAS MAJOR NAV ERROR. WHEN IT IS NOTICED, THEY ADVISE CTR AND CORRECT.

Narrative: NAV ERROR -- IT COULD NEVER HAPPEN TO ME! SOUNDS FAMILIAR? I WAS THE CAPT OF A FLT THAT INCLUDED COPLT, RELIEF PLT, AND MYSELF. IT WAS THE THIRD OCEAN XING IN JUST OVER 48 HRS. OUR REST PERIOD HAD BEEN INTERRUPTED BECAUSE OF THREATENED CHANGE IN SCHEDULE THAT IN FACT NEVER OCCURRED. NEITHER THE COPLT NOR I HAD BEEN ABLE TO SLEEP JUST PRIOR TO THE FLT DESPITE, IN MY CASE, OVER 5 HRS OF TOSSING AND TURNING IN THE HOTEL BED. I HAD ONLY BEEN ABLE TO SLEEP 6 HRS THE PREVIOUS NIGHT AND WOULD HAVE TO ADMIT TO BEING VERY SLEEP DEPRIVED. I LOADED THE ROUTING INTO THE FMS AND CHKED IT WITH THE COPLT PRIOR TO DEP. SINCE I MAKE IT A PRACTICE OF NOT TAKING A REST PERIOD PRIOR TO GETTING THE OCEANIC CLRNC I LET THE COPLT GO BACK FOR A REST AFTER WE WERE IN CRUISE. THE RELIEF PLT REPLACED HIM IN THE R SEAT. THE COPLT CAME BACK TO THE COCKPIT JUST AS WE WERE OBTAINING THE OCEANIC CLRNC. I WAS WORKING THE RADIOS THIS LEG SO I ACCEPTED AND READ BACK THE CLRNC OF FLT PLAN RTE WHICH AGREED WITH OUR PRINTED FLT PLAN. THE COPLT REPLACED ME IN THE L SEAT. THEY WOKE ME ABOUT 1.5 HRS LATER AFTER A GOOD NAP. AFTER I RETURNED TO THE COCKPIT I SAT IN THE L SEAT AND THE COPLT REPLACED THE RELIEF PLT IN THE R SEAT AND THE RELIEF PLT WENT BACK TO REST. AS I SAT DOWN TO REVIEW THE FLT PLAN I FELT A TINGE OF HORROR COME OVER ME. THE POINT WE WERE HDG TO WAS NOT ON OUR FLT PLAN, THE N COORDINATE WAS INCORRECT. I HAD THE RELIEF PLT RETURN IMMEDIATELY. WE WERE FORTUNATE TO BE ON A RANDOM RTE BOTH BELOW AND AWAY FROM THE ORGANIZED TRACK SYS. WE WERE VMC SO I MADE AN IMMEDIATE TURN TO RETURN TO THE FLT PLAN TRACK AND DSNDED 500 FT UNTIL REGAINING THE TRACK. THE RELIEF PLT REALIZED HE HAD GIVEN THE PREVIOUS POS RPTS FROM THE PRINTED FLT PLAN NOT THE POS RPT PAGE IN THE FMS. HAD THAT BEEN DONE, ATC WOULD HAVE CAUGHT THE ERROR WITH THE NEXT FROM THE PREVIOUS POS RPT. THE PLOTTING CHART HAD BEEN PLOTTED USING THE RTE TAKEN OFF THE FMS AND NOT THE PRINTED FLT PLAN SO THE ERROR WAS NOT CAUGHT THERE. I HAD NOT REVIEWED EACH POS AFTER RECEIVING THE CLRNC BECAUSE I WAS IN A HURRY TO GET A NAP, AND IT WAS FLT PLAN RTE, WHICH HAD BEEN CHKED PRIOR TO TKOF. I KNOW THAT I WOULD HAVE CAUGHT THE ERROR IF I HAD BEEN IN THE SEAT SINCE I ALWAYS DOUBLE, AND TRIPLE CHK POS ACROSS THE OCEAN. I WAS NOT IN THE COCKPIT AT THE TIME WE STARTED GETTING OFF THE CLRED RTE, BUT I AM RESPONSIBLE BECAUSE THAT'S MY JOB. AVIATION NOW HAS 3 MORE PLTS THAT WILL NEVER MAKE ANOTHER OCEAN XING ERROR, NOT BECAUSE 'IT CAN'T HAPPEN TO US' BUT BECAUSE 'IT DID!' SUPPLEMENTAL INFO FROM ACN 386107: HUMAN CONSIDERATIONS: SINGLE DIGIT LATITUDE ENTERED INCORRECTLY. NUMEROUS OPPORTUNITIES TO DISCOVER ERROR (DURING XCHK AFTER INITIALIZATION, RECEIPT OF OCEANIC CLRNC, POS RPTING, POST FIX VERIFICATION, ETC). HUMAN FACTORS: SECOND XING WITHIN 2 DAYS AND LATE NIGHT/EARLY MORNING FLT CONTRIBUTED TO FATIGUE AND SUBSEQUENT BREAKDOWN IN HABIT PATTERNS/PROCS ALONG WITH OVERRELIANCE IN ADVANCED/AUTOMATED COCKPIT RELIABILITY.

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.