37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 390648 |
Time | |
Date | 199712 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : bkw |
State Reference | WV |
Altitude | msl bound lower : 24000 msl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30F |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : commercial pilot : atp |
ASRS Report | 390648 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 15000 flight time type : 3000 |
ASRS Report | 390530 |
Events | |
Anomaly | other anomaly other |
Independent Detector | other controllera |
Resolutory Action | other other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | other |
Narrative:
After departing beckley VOR on the jasen 1 arrival to iad, we were given a descent to FL310 from FL370, and to cross puttz intersection at FL240. Though I was flying and SOP is for the captain to handle the radios, he had gone to the restroom and I handled the call from center. I had already put puttz into my INS when the captain returned, and informed him of the call. I then told him about the crossing restr at puttz and told him where puttz needed to be inserted. That is how both INS's were in error. We were then given another crossing restr at doccs at 11000 ft, just prior to reaching puttz (which canceled our puttz restr), and when the controller said 'I show you at puttz' a few seconds later, we realized something was awry, since the INS showed puttz 30 NM ahead. We began an immediate descent to comply with the doccs restr, flying off the VOR information, and the rest of the flight was uneventful. I believe that if the captain had been in the left seat at the time of this transmission, normal procedure would've caught this error, or eliminated it entirely. I don't think fatigue was a factor at all. I learned that I should rechk my procedures before entering information in the INS, and that I should allow the other crew members to digest information from center themselves, rather than interping it for them. Supplemental information from acn 390530: we verified each other's latitude/longitude entry. We had, however, loaded puttz after finks rather than before. The ZDC controller cleared us to cross doccs at 11000 ft and then added 'I show you over puttz now.' we were still at FL330. Our INS's still showed puttz to be 30 NM ahead. Since the first officer was flying, it was my responsibility to back up our INS navigation with the vors. I was tracking buckley VOR, but was not paying attention to the DME. Our first error was loading puttz in the incorrect order on the waypoint page. My second error was relying on the INS and not xchking the VOR DME. Although this was the last leg of a long day for me, I don't believe fatigue was a factor. This was a lack of attention to detail and not checking, rechking and checking the rechk.
Original NASA ASRS Text
Title: AN ACR DC10 FLC INCORRECTLY ENTERED A WAYPOINT ON A STAR INTO THEIR FMS, BUT THE XING RESTR WAS CANCELED BEFORE THEY CROSSED THE POINT.
Narrative: AFTER DEPARTING BECKLEY VOR ON THE JASEN 1 ARR TO IAD, WE WERE GIVEN A DSCNT TO FL310 FROM FL370, AND TO CROSS PUTTZ INTXN AT FL240. THOUGH I WAS FLYING AND SOP IS FOR THE CAPT TO HANDLE THE RADIOS, HE HAD GONE TO THE RESTROOM AND I HANDLED THE CALL FROM CTR. I HAD ALREADY PUT PUTTZ INTO MY INS WHEN THE CAPT RETURNED, AND INFORMED HIM OF THE CALL. I THEN TOLD HIM ABOUT THE XING RESTR AT PUTTZ AND TOLD HIM WHERE PUTTZ NEEDED TO BE INSERTED. THAT IS HOW BOTH INS'S WERE IN ERROR. WE WERE THEN GIVEN ANOTHER XING RESTR AT DOCCS AT 11000 FT, JUST PRIOR TO REACHING PUTTZ (WHICH CANCELED OUR PUTTZ RESTR), AND WHEN THE CTLR SAID 'I SHOW YOU AT PUTTZ' A FEW SECONDS LATER, WE REALIZED SOMETHING WAS AWRY, SINCE THE INS SHOWED PUTTZ 30 NM AHEAD. WE BEGAN AN IMMEDIATE DSCNT TO COMPLY WITH THE DOCCS RESTR, FLYING OFF THE VOR INFO, AND THE REST OF THE FLT WAS UNEVENTFUL. I BELIEVE THAT IF THE CAPT HAD BEEN IN THE L SEAT AT THE TIME OF THIS XMISSION, NORMAL PROC WOULD'VE CAUGHT THIS ERROR, OR ELIMINATED IT ENTIRELY. I DON'T THINK FATIGUE WAS A FACTOR AT ALL. I LEARNED THAT I SHOULD RECHK MY PROCS BEFORE ENTERING INFO IN THE INS, AND THAT I SHOULD ALLOW THE OTHER CREW MEMBERS TO DIGEST INFO FROM CTR THEMSELVES, RATHER THAN INTERPING IT FOR THEM. SUPPLEMENTAL INFO FROM ACN 390530: WE VERIFIED EACH OTHER'S LATITUDE/LONGITUDE ENTRY. WE HAD, HOWEVER, LOADED PUTTZ AFTER FINKS RATHER THAN BEFORE. THE ZDC CTLR CLRED US TO CROSS DOCCS AT 11000 FT AND THEN ADDED 'I SHOW YOU OVER PUTTZ NOW.' WE WERE STILL AT FL330. OUR INS'S STILL SHOWED PUTTZ TO BE 30 NM AHEAD. SINCE THE FO WAS FLYING, IT WAS MY RESPONSIBILITY TO BACK UP OUR INS NAV WITH THE VORS. I WAS TRACKING BUCKLEY VOR, BUT WAS NOT PAYING ATTN TO THE DME. OUR FIRST ERROR WAS LOADING PUTTZ IN THE INCORRECT ORDER ON THE WAYPOINT PAGE. MY SECOND ERROR WAS RELYING ON THE INS AND NOT XCHKING THE VOR DME. ALTHOUGH THIS WAS THE LAST LEG OF A LONG DAY FOR ME, I DON'T BELIEVE FATIGUE WAS A FACTOR. THIS WAS A LACK OF ATTN TO DETAIL AND NOT CHKING, RECHKING AND CHKING THE RECHK.
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.