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|
Attributes | |
ACN | 441593 |
Time | |
Date | 199906 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : slc.airport |
State Reference | UT |
Altitude | msl single value : 26000 |
Environment | |
Flight Conditions | VMC VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zlc.artcc |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : mlf2.slc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : multi engine pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 14000 flight time type : 2266 |
ASRS Report | 441593 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Resolutory Action | controller : issued alert controller : provided flight assist flight crew : returned to intended course |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
FMS loading finished, the pre departure clearance was obtained and numerous distrs including flight attendant requests and visiting kids, as well as the usual ground (ramp) calls, had things pretty busy. The pre departure clearance showed a change to the MLF2 departure, which I remember pulling up in the FMS and I also put the outbound radial in raw data. However, for whatever reason, the departure did not end up on the active route. Either I did not execute the change or the execute did not work. Whatever the case, with all that was happening, neither of us noticed it was not in the box. We departed on runway 34L slc and eventually we were given a 170 degree heading to intercept the MLF2. Distrs during climb included unexpected turbulence and having to make at least 3 attempts from scratch to try and trim a very out of rig aircraft. In the meantime, we continued towards the FMS course until departure control asked us what our clearance was, and then said we had flown through the radial. Switching to raw data confirmed that they were correct, and we immediately corrected back. To our knowledge no loss of separation occurred. Conclusions: although the FMS flight plan loading was doublechked, the changes obviously were not. Possible reasons: distrs in the cockpit, complacency. Solutions: 1) obtain pre departure clearance sooner allowing more time for checking as distrs will always be there. 2) check raw data more often -- especially on intercepts -- one VOR in raw data would have prevented this even with the FMS programmed wrong.
Original NASA ASRS Text
Title: FLC OF A B767 FAILED TO FOLLOW DEP SID DUE TO MISPROGRAMMING THE FMS. ARTCC RADAR CTLR QUESTIONED CREW FOR CLRNC GIVEN AND PROVIDED VECTORS TO ON COURSE.
Narrative: FMS LOADING FINISHED, THE PDC WAS OBTAINED AND NUMEROUS DISTRS INCLUDING FLT ATTENDANT REQUESTS AND VISITING KIDS, AS WELL AS THE USUAL GND (RAMP) CALLS, HAD THINGS PRETTY BUSY. THE PDC SHOWED A CHANGE TO THE MLF2 DEP, WHICH I REMEMBER PULLING UP IN THE FMS AND I ALSO PUT THE OUTBOUND RADIAL IN RAW DATA. HOWEVER, FOR WHATEVER REASON, THE DEP DID NOT END UP ON THE ACTIVE RTE. EITHER I DID NOT EXECUTE THE CHANGE OR THE EXECUTE DID NOT WORK. WHATEVER THE CASE, WITH ALL THAT WAS HAPPENING, NEITHER OF US NOTICED IT WAS NOT IN THE BOX. WE DEPARTED ON RWY 34L SLC AND EVENTUALLY WE WERE GIVEN A 170 DEG HDG TO INTERCEPT THE MLF2. DISTRS DURING CLB INCLUDED UNEXPECTED TURB AND HAVING TO MAKE AT LEAST 3 ATTEMPTS FROM SCRATCH TO TRY AND TRIM A VERY OUT OF RIG ACFT. IN THE MEANTIME, WE CONTINUED TOWARDS THE FMS COURSE UNTIL DEP CTL ASKED US WHAT OUR CLRNC WAS, AND THEN SAID WE HAD FLOWN THROUGH THE RADIAL. SWITCHING TO RAW DATA CONFIRMED THAT THEY WERE CORRECT, AND WE IMMEDIATELY CORRECTED BACK. TO OUR KNOWLEDGE NO LOSS OF SEPARATION OCCURRED. CONCLUSIONS: ALTHOUGH THE FMS FLT PLAN LOADING WAS DOUBLECHKED, THE CHANGES OBVIOUSLY WERE NOT. POSSIBLE REASONS: DISTRS IN THE COCKPIT, COMPLACENCY. SOLUTIONS: 1) OBTAIN PDC SOONER ALLOWING MORE TIME FOR CHKING AS DISTRS WILL ALWAYS BE THERE. 2) CHK RAW DATA MORE OFTEN -- ESPECIALLY ON INTERCEPTS -- ONE VOR IN RAW DATA WOULD HAVE PREVENTED THIS EVEN WITH THE FMS PROGRAMMED WRONG.
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.