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|
Attributes | |
ACN | 399062 |
Time | |
Date | 199804 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ord |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 399062 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : commercial pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 7000 flight time type : 1200 |
ASRS Report | 399091 |
Events | |
Anomaly | other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
Release #2 called for the flight path after passing lin to proceed via J84 MVA, J198 ilc, J80 jnc, etc. Shortly before flight arrived over ilc, the ATC controller cleared us without crew request to 'proceed to direct to hbu, on course.' on referring to the FMC loaded flight plan, the ATC clearance and the high altitude navigation map (H 1/2), the crew responded to the ATC controller that hbu was not on the filed flight plan route. The ATC controller then responded 'well, I do show it on the route. Let's try this: you are cleared direct hbu, J146.' the crew attempted a route modification to the flight plan which had been originally loaded into the FMC. It was immediately noted that there existed a route discontinuity after passing hbu. By then, we had been switched to another ATC controller frequency. The crew requested that ATC be made aware that the crew was confused as to what the last ATC controller had actually wanted us to do. The controller stated that flight crew was to proceed, after passing hbu, on J146. Crew then told ATC that the flight plan coupled with that clearance would result in a route discontinuity in that these were 2 different rtes. Further discussion resulted in the discovery that the flight plan route loaded into the FMC was in fact totally different than the ATC computer flight plan filed by our dispatch. The route divergence began at mlf. Eventually, our flight was reclred by ATC to proceed on course via the course which had been originally loaded into the FMC by the crew in reference to release #2. Crew then became further concerned that our dispatch should know about this confusion. Via ACARS, contact was established with the dispatcher who had originally filed the flight plan for us. During nearly 30 mins of conversation, it was discovered that the flight plan in the company's computer was the same as the flight plan in the ATC computer. Thus, this was a flight plan route which was decidedly different from the one appearing on release #2! The dispatcher revealed to the crew that release #1 had been officially canceled with ATC, that a new flight plan route filed with and approved by ATC, and after that a new release, release #2, had been generated and sent to sfo flight operations. For some absolutely unknown reason, the canceled flight plan route appearing on release #1 also appeared on release #2, but not in the company computer, nor in the ATC computer. The program used for cancellation was referred to by the dispatcher as 'xxxxx' and is a function of our company's computer system. Somehow xxxxx had canceled the release #1 flight plan route in both the company's and the ATC computers, but it had allowed release #2 to be generated with the same flight plan route which appeared to the dispatcher to have been canceled! The crew could not have known this, for it was never afforded the opportunity to compare release #1 with release #2 to observe the differences in the 2 rtes. In summary, at this point, our dispatch does not have an answer as to what may have happened, nor how the program allowed this error to occur. Further, no excursion from the filed route ever took place. However, had there been no unsolicited ATC clearance to proceed direct to hbu, our flight would in fact have deviated from the filed route immediately after passing mlf on J80! It would have proceeded down track on J80 toward jnc vice J28 toward hve and hbu (if that was the route filed, for the crew to this point in time does not have knowledge of exactly which route was filed, and which was intended to have been reflected on release #2). Release #2 does in fact contain within its body a previously canceled flight plan route, one that had been canceled by both our dispatch and by ATC. Further, dispatch and ATC had approved and issued a new flight plan route. Release #2 does not reflect that change. There exists, therefore, by this example, an opportunity for a flight crew to flight plan, approve, load into the airplane flight computer, receive for all practical purposes all possible confirmation as to its currency and validity, and them attempt to fly a completely invalid flight plan. The ramifications of such an event, given more urgent circumstances, could be very unfavorable. It appears that there is no validation check in place which assures a dispatcher that, when a flight plan route change is made, that the crew actually receives that change. It only validates that the crew is aware that the sequential number of the current release has been received. It seems that the transmission of nomenclature such as release #1 or release #2 is not enough to insure that the crew has in hand the proper flight plan route when route changes have been made, regardless of the time line.
Original NASA ASRS Text
Title: AN ACR B767 FLC DISCOVERED THAT THE FLT ROUTING IN THEIR FMC WAS DIFFERENT FROM THE ROUTING THAT ATC EXPECTED AND THEIR DISPATCHER FILED. THE PROB WAS RESOLVED BEFORE A DEV OCCURRED, HOWEVER THE CAUSE IS STILL BEING INVESTIGATED BY THEIR COMPANY'S DISPATCH DEPT.
Narrative: RELEASE #2 CALLED FOR THE FLT PATH AFTER PASSING LIN TO PROCEED VIA J84 MVA, J198 ILC, J80 JNC, ETC. SHORTLY BEFORE FLT ARRIVED OVER ILC, THE ATC CTLR CLRED US WITHOUT CREW REQUEST TO 'PROCEED TO DIRECT TO HBU, ON COURSE.' ON REFERRING TO THE FMC LOADED FLT PLAN, THE ATC CLRNC AND THE HIGH ALT NAV MAP (H 1/2), THE CREW RESPONDED TO THE ATC CTLR THAT HBU WAS NOT ON THE FILED FLT PLAN RTE. THE ATC CTLR THEN RESPONDED 'WELL, I DO SHOW IT ON THE RTE. LET'S TRY THIS: YOU ARE CLRED DIRECT HBU, J146.' THE CREW ATTEMPTED A RTE MODIFICATION TO THE FLT PLAN WHICH HAD BEEN ORIGINALLY LOADED INTO THE FMC. IT WAS IMMEDIATELY NOTED THAT THERE EXISTED A RTE DISCONTINUITY AFTER PASSING HBU. BY THEN, WE HAD BEEN SWITCHED TO ANOTHER ATC CTLR FREQ. THE CREW REQUESTED THAT ATC BE MADE AWARE THAT THE CREW WAS CONFUSED AS TO WHAT THE LAST ATC CTLR HAD ACTUALLY WANTED US TO DO. THE CTLR STATED THAT FLC WAS TO PROCEED, AFTER PASSING HBU, ON J146. CREW THEN TOLD ATC THAT THE FLT PLAN COUPLED WITH THAT CLRNC WOULD RESULT IN A RTE DISCONTINUITY IN THAT THESE WERE 2 DIFFERENT RTES. FURTHER DISCUSSION RESULTED IN THE DISCOVERY THAT THE FLT PLAN RTE LOADED INTO THE FMC WAS IN FACT TOTALLY DIFFERENT THAN THE ATC COMPUTER FLT PLAN FILED BY OUR DISPATCH. THE RTE DIVERGENCE BEGAN AT MLF. EVENTUALLY, OUR FLT WAS RECLRED BY ATC TO PROCEED ON COURSE VIA THE COURSE WHICH HAD BEEN ORIGINALLY LOADED INTO THE FMC BY THE CREW IN REF TO RELEASE #2. CREW THEN BECAME FURTHER CONCERNED THAT OUR DISPATCH SHOULD KNOW ABOUT THIS CONFUSION. VIA ACARS, CONTACT WAS ESTABLISHED WITH THE DISPATCHER WHO HAD ORIGINALLY FILED THE FLT PLAN FOR US. DURING NEARLY 30 MINS OF CONVERSATION, IT WAS DISCOVERED THAT THE FLT PLAN IN THE COMPANY'S COMPUTER WAS THE SAME AS THE FLT PLAN IN THE ATC COMPUTER. THUS, THIS WAS A FLT PLAN RTE WHICH WAS DECIDEDLY DIFFERENT FROM THE ONE APPEARING ON RELEASE #2! THE DISPATCHER REVEALED TO THE CREW THAT RELEASE #1 HAD BEEN OFFICIALLY CANCELED WITH ATC, THAT A NEW FLT PLAN RTE FILED WITH AND APPROVED BY ATC, AND AFTER THAT A NEW RELEASE, RELEASE #2, HAD BEEN GENERATED AND SENT TO SFO FLT OPS. FOR SOME ABSOLUTELY UNKNOWN REASON, THE CANCELED FLT PLAN RTE APPEARING ON RELEASE #1 ALSO APPEARED ON RELEASE #2, BUT NOT IN THE COMPANY COMPUTER, NOR IN THE ATC COMPUTER. THE PROGRAM USED FOR CANCELLATION WAS REFERRED TO BY THE DISPATCHER AS 'XXXXX' AND IS A FUNCTION OF OUR COMPANY'S COMPUTER SYS. SOMEHOW XXXXX HAD CANCELED THE RELEASE #1 FLT PLAN RTE IN BOTH THE COMPANY'S AND THE ATC COMPUTERS, BUT IT HAD ALLOWED RELEASE #2 TO BE GENERATED WITH THE SAME FLT PLAN RTE WHICH APPEARED TO THE DISPATCHER TO HAVE BEEN CANCELED! THE CREW COULD NOT HAVE KNOWN THIS, FOR IT WAS NEVER AFFORDED THE OPPORTUNITY TO COMPARE RELEASE #1 WITH RELEASE #2 TO OBSERVE THE DIFFERENCES IN THE 2 RTES. IN SUMMARY, AT THIS POINT, OUR DISPATCH DOES NOT HAVE AN ANSWER AS TO WHAT MAY HAVE HAPPENED, NOR HOW THE PROGRAM ALLOWED THIS ERROR TO OCCUR. FURTHER, NO EXCURSION FROM THE FILED RTE EVER TOOK PLACE. HOWEVER, HAD THERE BEEN NO UNSOLICITED ATC CLRNC TO PROCEED DIRECT TO HBU, OUR FLT WOULD IN FACT HAVE DEVIATED FROM THE FILED RTE IMMEDIATELY AFTER PASSING MLF ON J80! IT WOULD HAVE PROCEEDED DOWN TRACK ON J80 TOWARD JNC VICE J28 TOWARD HVE AND HBU (IF THAT WAS THE RTE FILED, FOR THE CREW TO THIS POINT IN TIME DOES NOT HAVE KNOWLEDGE OF EXACTLY WHICH RTE WAS FILED, AND WHICH WAS INTENDED TO HAVE BEEN REFLECTED ON RELEASE #2). RELEASE #2 DOES IN FACT CONTAIN WITHIN ITS BODY A PREVIOUSLY CANCELED FLT PLAN RTE, ONE THAT HAD BEEN CANCELED BY BOTH OUR DISPATCH AND BY ATC. FURTHER, DISPATCH AND ATC HAD APPROVED AND ISSUED A NEW FLT PLAN RTE. RELEASE #2 DOES NOT REFLECT THAT CHANGE. THERE EXISTS, THEREFORE, BY THIS EXAMPLE, AN OPPORTUNITY FOR A FLC TO FLT PLAN, APPROVE, LOAD INTO THE AIRPLANE FLT COMPUTER, RECEIVE FOR ALL PRACTICAL PURPOSES ALL POSSIBLE CONFIRMATION AS TO ITS CURRENCY AND VALIDITY, AND THEM ATTEMPT TO FLY A COMPLETELY INVALID FLT PLAN. THE RAMIFICATIONS OF SUCH AN EVENT, GIVEN MORE URGENT CIRCUMSTANCES, COULD BE VERY UNFAVORABLE. IT APPEARS THAT THERE IS NO VALIDATION CHK IN PLACE WHICH ASSURES A DISPATCHER THAT, WHEN A FLT PLAN RTE CHANGE IS MADE, THAT THE CREW ACTUALLY RECEIVES THAT CHANGE. IT ONLY VALIDATES THAT THE CREW IS AWARE THAT THE SEQUENTIAL NUMBER OF THE CURRENT RELEASE HAS BEEN RECEIVED. IT SEEMS THAT THE XMISSION OF NOMENCLATURE SUCH AS RELEASE #1 OR RELEASE #2 IS NOT ENOUGH TO INSURE THAT THE CREW HAS IN HAND THE PROPER FLT PLAN RTE WHEN RTE CHANGES HAVE BEEN MADE, REGARDLESS OF THE TIME LINE.
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.