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|
Attributes | |
ACN | 430156 |
Time | |
Date | 199903 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : sli.vortac |
State Reference | CA |
Altitude | msl single value : 14000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Navigation In Use | other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : peble 2 |
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 : 100 flight time total : 13000 flight time type : 3500 |
ASRS Report | 430156 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time total : 4000 flight time type : 1200 |
ASRS Report | 429989 |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued new clearance controller : issued alert |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departed mem at XA30 on trip to san, second leg to lak. On ramp at san, flight plan/release to oak was received with WX reports. Just prior to closing doors, a pre departure clearance was handed to us. First officer placed pre departure clearance on panel in front of us. We prepared for departure, and first officer briefed departure procedure. We flew peble 2 with the plan to fly to sli according to our flight plan. As we turned for peble, san departure gave us a vector and told us to intercept the 97 degree radial from sxc. This was the first clue that something was not right. Still at peble, we turned toward sli. ZLA gave us a vector towards sxc. They were concerned with our adherence to our clearance. I pulled the pre departure clearance out and checked. Both routings were on the pre departure clearance, but the one to sxc had the small dashed lines. We had flown the wrong clearance. I admitted our mistake to lax who got us back on course. Our flight plan showed the sli routing. The pre departure clearance showed both routings. We should have caught it. Fatigue was a factor. Had only one route been on the pre departure clearance, I think we would not have made the mistake. Supplemental information from acn 430247: received pre departure clearance in san with amendment -- looked like this: peble 2 sxc lax gmn PXN2 oak. San peble 2 sli gmn***oak maintain 15000 ft, etc. Crew (captain and first officer) didn't recognize the filed clearance was 'amended' by the 'dashed lines.' they looked for what they expected to see and flew it until corrected by ATC. I strongly recommend if a filed clearance is to be amended, delete any reference to it! When only one clearance is published and sent, it focuses the mind on the correct route of flight -- no confusion. Supplemental information from acn 429989: crew missed change in clearance on pre departure clearance due to fatigue.
Original NASA ASRS Text
Title: A B727 FREIGHTER FLC ATTEMPTS TO FLY THE WRONG TRANSITION ON THE PEBLE2 SXC SID DEP PROC OUT OF SAN, HAVING MISSED THE CHANGE IN THEIR PDC FORM.
Narrative: DEPARTED MEM AT XA30 ON TRIP TO SAN, SECOND LEG TO LAK. ON RAMP AT SAN, FLT PLAN/RELEASE TO OAK WAS RECEIVED WITH WX RPTS. JUST PRIOR TO CLOSING DOORS, A PDC WAS HANDED TO US. FO PLACED PDC ON PANEL IN FRONT OF US. WE PREPARED FOR DEP, AND FO BRIEFED DEP PROC. WE FLEW PEBLE 2 WITH THE PLAN TO FLY TO SLI ACCORDING TO OUR FLT PLAN. AS WE TURNED FOR PEBLE, SAN DEP GAVE US A VECTOR AND TOLD US TO INTERCEPT THE 97 DEG RADIAL FROM SXC. THIS WAS THE FIRST CLUE THAT SOMETHING WAS NOT RIGHT. STILL AT PEBLE, WE TURNED TOWARD SLI. ZLA GAVE US A VECTOR TOWARDS SXC. THEY WERE CONCERNED WITH OUR ADHERENCE TO OUR CLRNC. I PULLED THE PDC OUT AND CHKED. BOTH ROUTINGS WERE ON THE PDC, BUT THE ONE TO SXC HAD THE SMALL DASHED LINES. WE HAD FLOWN THE WRONG CLRNC. I ADMITTED OUR MISTAKE TO LAX WHO GOT US BACK ON COURSE. OUR FLT PLAN SHOWED THE SLI ROUTING. THE PDC SHOWED BOTH ROUTINGS. WE SHOULD HAVE CAUGHT IT. FATIGUE WAS A FACTOR. HAD ONLY ONE RTE BEEN ON THE PDC, I THINK WE WOULD NOT HAVE MADE THE MISTAKE. SUPPLEMENTAL INFO FROM ACN 430247: RECEIVED PDC IN SAN WITH AMENDMENT -- LOOKED LIKE THIS: PEBLE 2 SXC LAX GMN PXN2 OAK. SAN PEBLE 2 SLI GMN***OAK MAINTAIN 15000 FT, ETC. CREW (CAPT AND FO) DIDN'T RECOGNIZE THE FILED CLRNC WAS 'AMENDED' BY THE 'DASHED LINES.' THEY LOOKED FOR WHAT THEY EXPECTED TO SEE AND FLEW IT UNTIL CORRECTED BY ATC. I STRONGLY RECOMMEND IF A FILED CLRNC IS TO BE AMENDED, DELETE ANY REF TO IT! WHEN ONLY ONE CLRNC IS PUBLISHED AND SENT, IT FOCUSES THE MIND ON THE CORRECT RTE OF FLT -- NO CONFUSION. SUPPLEMENTAL INFO FROM ACN 429989: CREW MISSED CHANGE IN CLRNC ON PDC DUE TO FATIGUE.
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.