37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 407773 |
Time | |
Date | 199807 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 5000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 |
Operator | common carrier : air carrier |
Make Model Name | DC-9 50 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 225 flight time total : 12140 flight time type : 900 |
ASRS Report | 407773 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera other flight crewa |
Resolutory Action | controller : issued new clearance none taken : unable other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
I briefed the SID twice and the captain briefed it as well (see copy). We are departing runway 22L. I started briefing it as it reads on the top right side of the page, 'newark, nj, arthur kill 2 departure (vector).' going down the page to where it reads: arthur kill 2 departure (vector) I read 'takeoff runways 22L/right.' but I stopped after maintain 5000 ft. Needless to say, that is all we did. Neither me nor my captain caught this error. We took off and turned 190 degrees to 2.3 DME, then 260 degrees and maintained that until ATC told us that we need to read the SID a little better and to turn right to 270 degrees to join the 100 degree radial off the solberg VOR to parke intersection. We made our turn, but never had to complete the SID. We later got vectors to intercept J60, which we were set up for in the first place. We know of no conflicts to this situation. There seems to be 2 contributing factors that led up to this occurrence. #1 and most important is fatigue. Let me explain. My company had changed my 4 day trip into a 3 day trip, where on my original 4TH day I would situation time available. Another word for reserve. The captain I flew with for my 3 day trip was the same one that came out on that 4TH day to do this trip to ewr. He is on reserve anyway. I finished my 3 day trip on jul/xx/98 around XA30. I called scheduling and told them what hotel I was going to stay at. I finally got to sleep around XK30. At XO15 I received a call from scheduling telling me that they have a trip for me that departs at XR15. I then set my alarm clock for XP15 so as to try and get some more sleep, but to no avail. I was up for good. I felt ok for the first leg, but while on the ground in ewr I started to doze off while sitting in the back of the aircraft. With only 3 hours and 45 mins of sleep, it was taking its toll on me in ewr. I did not read past 'maintain 5000 ft.' this is where I am getting into the second factor of the occurrence. I consider this SID a little confusing. When it reads vector at the top and again right before you read the takeoff portion of the SID, it would seem that this whole SID would be vectors. The corrective action in this situation would be to get the sleep required to function properly. Even if it may cause delays. Some changes in the SID may help, such as: removing the words 'vector' from the SID. It is not vectors if you have to intercept radials to a VOR and then to an intersection. Also make the word 'thence' in bold letters as they do with the word 'maintain.'
Original NASA ASRS Text
Title: TIRED CREW GIVES ARTHUR KILL 2 SID CURSORY GLANCE AND EXPECTS TO BE PROVIDED A VECTOR AFTER THE INITIAL HDG.
Narrative: I BRIEFED THE SID TWICE AND THE CAPT BRIEFED IT AS WELL (SEE COPY). WE ARE DEPARTING RWY 22L. I STARTED BRIEFING IT AS IT READS ON THE TOP R SIDE OF THE PAGE, 'NEWARK, NJ, ARTHUR KILL 2 DEP (VECTOR).' GOING DOWN THE PAGE TO WHERE IT READS: ARTHUR KILL 2 DEP (VECTOR) I READ 'TKOF RWYS 22L/R.' BUT I STOPPED AFTER MAINTAIN 5000 FT. NEEDLESS TO SAY, THAT IS ALL WE DID. NEITHER ME NOR MY CAPT CAUGHT THIS ERROR. WE TOOK OFF AND TURNED 190 DEGS TO 2.3 DME, THEN 260 DEGS AND MAINTAINED THAT UNTIL ATC TOLD US THAT WE NEED TO READ THE SID A LITTLE BETTER AND TO TURN R TO 270 DEGS TO JOIN THE 100 DEG RADIAL OFF THE SOLBERG VOR TO PARKE INTXN. WE MADE OUR TURN, BUT NEVER HAD TO COMPLETE THE SID. WE LATER GOT VECTORS TO INTERCEPT J60, WHICH WE WERE SET UP FOR IN THE FIRST PLACE. WE KNOW OF NO CONFLICTS TO THIS SIT. THERE SEEMS TO BE 2 CONTRIBUTING FACTORS THAT LED UP TO THIS OCCURRENCE. #1 AND MOST IMPORTANT IS FATIGUE. LET ME EXPLAIN. MY COMPANY HAD CHANGED MY 4 DAY TRIP INTO A 3 DAY TRIP, WHERE ON MY ORIGINAL 4TH DAY I WOULD SIT TIME AVAILABLE. ANOTHER WORD FOR RESERVE. THE CAPT I FLEW WITH FOR MY 3 DAY TRIP WAS THE SAME ONE THAT CAME OUT ON THAT 4TH DAY TO DO THIS TRIP TO EWR. HE IS ON RESERVE ANYWAY. I FINISHED MY 3 DAY TRIP ON JUL/XX/98 AROUND XA30. I CALLED SCHEDULING AND TOLD THEM WHAT HOTEL I WAS GOING TO STAY AT. I FINALLY GOT TO SLEEP AROUND XK30. AT XO15 I RECEIVED A CALL FROM SCHEDULING TELLING ME THAT THEY HAVE A TRIP FOR ME THAT DEPARTS AT XR15. I THEN SET MY ALARM CLOCK FOR XP15 SO AS TO TRY AND GET SOME MORE SLEEP, BUT TO NO AVAIL. I WAS UP FOR GOOD. I FELT OK FOR THE FIRST LEG, BUT WHILE ON THE GND IN EWR I STARTED TO DOZE OFF WHILE SITTING IN THE BACK OF THE ACFT. WITH ONLY 3 HRS AND 45 MINS OF SLEEP, IT WAS TAKING ITS TOLL ON ME IN EWR. I DID NOT READ PAST 'MAINTAIN 5000 FT.' THIS IS WHERE I AM GETTING INTO THE SECOND FACTOR OF THE OCCURRENCE. I CONSIDER THIS SID A LITTLE CONFUSING. WHEN IT READS VECTOR AT THE TOP AND AGAIN RIGHT BEFORE YOU READ THE TKOF PORTION OF THE SID, IT WOULD SEEM THAT THIS WHOLE SID WOULD BE VECTORS. THE CORRECTIVE ACTION IN THIS SIT WOULD BE TO GET THE SLEEP REQUIRED TO FUNCTION PROPERLY. EVEN IF IT MAY CAUSE DELAYS. SOME CHANGES IN THE SID MAY HELP, SUCH AS: REMOVING THE WORDS 'VECTOR' FROM THE SID. IT IS NOT VECTORS IF YOU HAVE TO INTERCEPT RADIALS TO A VOR AND THEN TO AN INTXN. ALSO MAKE THE WORD 'THENCE' IN BOLD LETTERS AS THEY DO WITH THE WORD 'MAINTAIN.'
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.