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|
Attributes | |
ACN | 419977 |
Time | |
Date | 199811 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : bird |
State Reference | FO |
Altitude | msl bound lower : 29000 msl bound upper : 29000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czqx |
Operator | other |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Flight Phase | cruise other |
Route In Use | enroute : atlantic |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : military |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 150 flight time total : 6500 flight time type : 1600 |
ASRS Report | 419977 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were flying over the north atlantic from keflavik NAS (bikf) to the states in non radar environment. Approximately 1/2 way across, and after crossing a check point, the aircraft made an unexpected significant left turn (approximately 30 degree heading change). The autoplt was coupled to the INS at the time. I uncoupled the INS and returned the aircraft to a heading we expected would take us to the next fix. However, my navigator insisted we needed to come further left to head toward the next fix. This didn't make sense because there should never have been a turn that significant along the route of flight. After analyzing the problem, the navigator determined that he had entered the incorrect latitude coordinates by a margin of 1 degree. This placed us 60 NM north of the chkpoint. ATC was promptly notified of this deviation and requested that we report when we return to course. We were back on course in 15 mins. The human factors underlining this situation are highlighted because of the method by which the coordinates are entered, and the way the information is presented to the pilots for xchking. The coordinates for each chkpoint are manually programmed into the INS by the navigator. After the navigator enters the route of flight, the pilot then can xchk those points by comparing what he sees on a small display to what he reads on the chart. The position of this display (which is closer to the copilot) and the size of the lighted lettering sometimes makes it difficult to read the coordinate information the navigator has entered. The crew's ability to back each other up is degraded by this design flaw. Depending on external lighting conditions, it sometimes takes a lot of effort to visually xchk the information, thereby on occasion making an error likely.
Original NASA ASRS Text
Title: KC135 CREW DEVIATES FROM ASSIGNED TRACK DUE TO DATA INPUT ERROR IN NAV SYS IN CZQX AIRSPACE.
Narrative: WE WERE FLYING OVER THE NORTH ATLANTIC FROM KEFLAVIK NAS (BIKF) TO THE STATES IN NON RADAR ENVIRONMENT. APPROX 1/2 WAY ACROSS, AND AFTER XING A CHK POINT, THE ACFT MADE AN UNEXPECTED SIGNIFICANT L TURN (APPROX 30 DEG HDG CHANGE). THE AUTOPLT WAS COUPLED TO THE INS AT THE TIME. I UNCOUPLED THE INS AND RETURNED THE ACFT TO A HDG WE EXPECTED WOULD TAKE US TO THE NEXT FIX. HOWEVER, MY NAVIGATOR INSISTED WE NEEDED TO COME FURTHER L TO HEAD TOWARD THE NEXT FIX. THIS DIDN'T MAKE SENSE BECAUSE THERE SHOULD NEVER HAVE BEEN A TURN THAT SIGNIFICANT ALONG THE RTE OF FLT. AFTER ANALYZING THE PROB, THE NAVIGATOR DETERMINED THAT HE HAD ENTERED THE INCORRECT LATITUDE COORDINATES BY A MARGIN OF 1 DEG. THIS PLACED US 60 NM N OF THE CHKPOINT. ATC WAS PROMPTLY NOTIFIED OF THIS DEV AND REQUESTED THAT WE RPT WHEN WE RETURN TO COURSE. WE WERE BACK ON COURSE IN 15 MINS. THE HUMAN FACTORS UNDERLINING THIS SIT ARE HIGHLIGHTED BECAUSE OF THE METHOD BY WHICH THE COORDINATES ARE ENTERED, AND THE WAY THE INFO IS PRESENTED TO THE PLTS FOR XCHKING. THE COORDINATES FOR EACH CHKPOINT ARE MANUALLY PROGRAMMED INTO THE INS BY THE NAVIGATOR. AFTER THE NAVIGATOR ENTERS THE RTE OF FLT, THE PLT THEN CAN XCHK THOSE POINTS BY COMPARING WHAT HE SEES ON A SMALL DISPLAY TO WHAT HE READS ON THE CHART. THE POS OF THIS DISPLAY (WHICH IS CLOSER TO THE COPLT) AND THE SIZE OF THE LIGHTED LETTERING SOMETIMES MAKES IT DIFFICULT TO READ THE COORDINATE INFO THE NAVIGATOR HAS ENTERED. THE CREW'S ABILITY TO BACK EACH OTHER UP IS DEGRADED BY THIS DESIGN FLAW. DEPENDING ON EXTERNAL LIGHTING CONDITIONS, IT SOMETIMES TAKES A LOT OF EFFORT TO VISUALLY XCHK THE INFO, THEREBY ON OCCASION MAKING AN ERROR LIKELY.
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.