37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 394140 |
Time | |
Date | 199802 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : ape |
State Reference | OH |
Altitude | msl bound lower : 29000 msl bound upper : 29000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other other |
Route In Use | enroute : on vectors enroute other |
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 : 150 flight time total : 16950 flight time type : 5000 |
ASRS Report | 394140 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Last min holding instructions issued by ATC because ZOB could not accept handoff. Instructed to hold at ape VOR 270 degree radial, right turns, 20 DME legs, FL290, efc XA35Z. Captain (PF) entered data for holding into FMS with first officer (PNF) concurring with input. PNF used raw data for backup. Holding course entered incorrectly, resulting in incorrect entry into holding airspace. Jump seat rider noticed error and ATC was notified of correction back to holding airspace. No conflict, but very embarrassing. Contributing factors: efc would require landing short of destination due to insufficient holding fuel (maximum takeoff weight las- phl). No alternate required on flight plan. Without any prior knowledge of delays at destination, flight crew became very busy all at once: 1) cleared to a hold fix off airway. 2) minimum fuel computation. 3) flight attendant calling on interphone with cabin problem. Workload management suffered and the FMS error was not caught in a timely manner. Very little team work between captain and first officer due to earlier disagreement. Job well done by jump seat rider.
Original NASA ASRS Text
Title: A B737-300 ENTERS A HOLDING PATTERN INCORRECTLY BECAUSE HIS NAV SYS IS IMPROPERLY PROGRAMMED. THIS OCCURS IN ZID AIRSPACE.
Narrative: LAST MIN HOLDING INSTRUCTIONS ISSUED BY ATC BECAUSE ZOB COULD NOT ACCEPT HDOF. INSTRUCTED TO HOLD AT APE VOR 270 DEG RADIAL, R TURNS, 20 DME LEGS, FL290, EFC XA35Z. CAPT (PF) ENTERED DATA FOR HOLDING INTO FMS WITH FO (PNF) CONCURRING WITH INPUT. PNF USED RAW DATA FOR BACKUP. HOLDING COURSE ENTERED INCORRECTLY, RESULTING IN INCORRECT ENTRY INTO HOLDING AIRSPACE. JUMP SEAT RIDER NOTICED ERROR AND ATC WAS NOTIFIED OF CORRECTION BACK TO HOLDING AIRSPACE. NO CONFLICT, BUT VERY EMBARRASSING. CONTRIBUTING FACTORS: EFC WOULD REQUIRE LNDG SHORT OF DEST DUE TO INSUFFICIENT HOLDING FUEL (MAX TKOF WT LAS- PHL). NO ALTERNATE REQUIRED ON FLT PLAN. WITHOUT ANY PRIOR KNOWLEDGE OF DELAYS AT DEST, FLC BECAME VERY BUSY ALL AT ONCE: 1) CLRED TO A HOLD FIX OFF AIRWAY. 2) MINIMUM FUEL COMPUTATION. 3) FLT ATTENDANT CALLING ON INTERPHONE WITH CABIN PROB. WORKLOAD MGMNT SUFFERED AND THE FMS ERROR WAS NOT CAUGHT IN A TIMELY MANNER. VERY LITTLE TEAM WORK BTWN CAPT AND FO DUE TO EARLIER DISAGREEMENT. JOB WELL DONE BY JUMP SEAT RIDER.
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.