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An L1011 flight crew fails to review their departure procedure for sfo runway 28L after having briefed for a runway 1R departure procedure. They start the turn to 350 degrees as per the runway 1R departure procedure. Departure controller catches error.
| Attributes | |
| ACN | 402590 |
| Time | |
| Date | 199805 |
| Day | Sun |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : sfo |
| State Reference | CA |
| Altitude | msl bound lower : 1000 msl bound upper : 1000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | tracon : oak |
| Operator | common carrier : air carrier |
| Make Model Name | L-1011 Tri-Star All Series |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other |
| Flight Phase | climbout : initial climbout : takeoff |
| Route In Use | departure : noise abatement departure other departure sid : sid |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 210 flight time total : 24000 flight time type : 7200 |
| ASRS Report | 402590 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : atp |
| Experience | flight time last 90 days : 220 flight time total : 8000 flight time type : 1200 |
| ASRS Report | 402203 |
| Events | |
| Anomaly | non adherence : published procedure non adherence : clearance other anomaly other 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:
A takeoff on runway 1R was briefed with gapp departure (heading 350 degrees). Runway was changed to runway 28L due to weight and tailwind conditions, negating the previously briefed departure for runway 1R. I did not catch the straight out departure at takeoff brief, due to other concerns, we turned toward heading 350 degrees instead of 281 degree radial. Controller mentioned it and we immediately turned back. No mention of conflict with other aircraft was made. Supplemental information from acn 402203: on taxi out we should have consulted the SID for the new runway and rebriefed it. Instead, we turned to 350 degrees after takeoff instead of intercepting the 281 degree radial. This could have caused a loss of separation for aircraft departing on runway 1R. Always rebrief departure on runway changes.
Original NASA ASRS Text
Title: AN L1011 FLC FAILS TO REVIEW THEIR DEP PROC FOR SFO RWY 28L AFTER HAVING BRIEFED FOR A RWY 1R DEP PROC. THEY START THE TURN TO 350 DEGS AS PER THE RWY 1R DEP PROC. DEP CTLR CATCHES ERROR.
Narrative: A TKOF ON RWY 1R WAS BRIEFED WITH GAPP DEP (HDG 350 DEGS). RWY WAS CHANGED TO RWY 28L DUE TO WT AND TAILWIND CONDITIONS, NEGATING THE PREVIOUSLY BRIEFED DEP FOR RWY 1R. I DID NOT CATCH THE STRAIGHT OUT DEP AT TKOF BRIEF, DUE TO OTHER CONCERNS, WE TURNED TOWARD HDG 350 DEGS INSTEAD OF 281 DEG RADIAL. CTLR MENTIONED IT AND WE IMMEDIATELY TURNED BACK. NO MENTION OF CONFLICT WITH OTHER ACFT WAS MADE. SUPPLEMENTAL INFO FROM ACN 402203: ON TAXI OUT WE SHOULD HAVE CONSULTED THE SID FOR THE NEW RWY AND REBRIEFED IT. INSTEAD, WE TURNED TO 350 DEGS AFTER TKOF INSTEAD OF INTERCEPTING THE 281 DEG RADIAL. THIS COULD HAVE CAUSED A LOSS OF SEPARATION FOR ACFT DEPARTING ON RWY 1R. ALWAYS REBRIEF DEP ON RWY CHANGES.
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.