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|
Attributes | |
ACN | 449006 |
Time | |
Date | 199909 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : initial climbout : takeoff ground : preflight ground : taxi |
Route In Use | departure sid : gapp 3 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
ASRS Report | 449006 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 449007 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | ATC Human Performance Aircraft Chart Or Publication Company Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Chart | sid : gapp 3 |
Narrative:
During preflight while the captain and I were working on an FMC problem trying to get the departure page to accept our runway (runway 1R) at sfo, we received a revised segment on the ACARS pre departure clearance. We immediately reviewed the charts and wrongly assumed a downline route problem typical of most revised segments we had received in the past. We both overlooked the SID change and left the original filed SID (the GAPP3) in the FMC instead of putting in the SF08. The GAPP3 departure for runway 1R called for us to fly a 350 degree heading or as assigned for vector and that is what we flew. The revised SID (SF08) would have had us fly a 030 degree heading after takeoff. Although both the captain and I looked at the revised segment twice, neither of us caught the SID change until after leveloff at altitude. When questioned by the departure controller, we said we were flying our filed and ACARS received clearance, the GAPP3, and he said tower must have made an error. While there were several mitigating factors, the bottom line is that I failed to read the revised segment closely and did not catch the SID change. Had I read back the entire clearance to clearance delivery before we left the gate, I would have created another chance to catch the error. I realized after the fact that I had allowed myself to become somewhat complacent in reading the revised segments. Expecting a problem with the downline routing as opposed to just reading it for what it was. Supplemental information from acn 449007: when I tried to enter the GAPP3 sfo departure only runways 28R&left would come up as possible runways to select. This puzzled me why company would give me a routing and departure that was not in the FMC database. I asked the first officer if he could figure out why it would not 'take' the departure and he entered it without the runway and it seemed to 'take' the departure. We realized our mistake when the departure/approach controller questioned our departure heading and which departure we were flying. There are 9 sids from sfo -- 4 go to the lin or sac departure fixes for a possible routing to bos. The GAPP3 is not one of them. I do not know why company route 44 offers the GAPP3 because this only generates a revision process with ATC and a resulting change to the flight plan for the cockpit crew. This equipment was late on arrival and the crew somewhat rushed to be ready for scheduled departure.
Original NASA ASRS Text
Title: A B757 FLC FLIES THE WRONG SID AND HDG ON THEIR DEP FROM SFO, CA.
Narrative: DURING PREFLT WHILE THE CAPT AND I WERE WORKING ON AN FMC PROB TRYING TO GET THE DEP PAGE TO ACCEPT OUR RWY (RWY 1R) AT SFO, WE RECEIVED A REVISED SEGMENT ON THE ACARS PDC. WE IMMEDIATELY REVIEWED THE CHARTS AND WRONGLY ASSUMED A DOWNLINE RTE PROB TYPICAL OF MOST REVISED SEGMENTS WE HAD RECEIVED IN THE PAST. WE BOTH OVERLOOKED THE SID CHANGE AND LEFT THE ORIGINAL FILED SID (THE GAPP3) IN THE FMC INSTEAD OF PUTTING IN THE SF08. THE GAPP3 DEP FOR RWY 1R CALLED FOR US TO FLY A 350 DEG HDG OR AS ASSIGNED FOR VECTOR AND THAT IS WHAT WE FLEW. THE REVISED SID (SF08) WOULD HAVE HAD US FLY A 030 DEG HDG AFTER TKOF. ALTHOUGH BOTH THE CAPT AND I LOOKED AT THE REVISED SEGMENT TWICE, NEITHER OF US CAUGHT THE SID CHANGE UNTIL AFTER LEVELOFF AT ALT. WHEN QUESTIONED BY THE DEP CTLR, WE SAID WE WERE FLYING OUR FILED AND ACARS RECEIVED CLRNC, THE GAPP3, AND HE SAID TWR MUST HAVE MADE AN ERROR. WHILE THERE WERE SEVERAL MITIGATING FACTORS, THE BOTTOM LINE IS THAT I FAILED TO READ THE REVISED SEGMENT CLOSELY AND DID NOT CATCH THE SID CHANGE. HAD I READ BACK THE ENTIRE CLRNC TO CLRNC DELIVERY BEFORE WE LEFT THE GATE, I WOULD HAVE CREATED ANOTHER CHANCE TO CATCH THE ERROR. I REALIZED AFTER THE FACT THAT I HAD ALLOWED MYSELF TO BECOME SOMEWHAT COMPLACENT IN READING THE REVISED SEGMENTS. EXPECTING A PROB WITH THE DOWNLINE ROUTING AS OPPOSED TO JUST READING IT FOR WHAT IT WAS. SUPPLEMENTAL INFO FROM ACN 449007: WHEN I TRIED TO ENTER THE GAPP3 SFO DEP ONLY RWYS 28R&L WOULD COME UP AS POSSIBLE RWYS TO SELECT. THIS PUZZLED ME WHY COMPANY WOULD GIVE ME A ROUTING AND DEP THAT WAS NOT IN THE FMC DATABASE. I ASKED THE FO IF HE COULD FIGURE OUT WHY IT WOULD NOT 'TAKE' THE DEP AND HE ENTERED IT WITHOUT THE RWY AND IT SEEMED TO 'TAKE' THE DEP. WE REALIZED OUR MISTAKE WHEN THE DEP/APCH CTLR QUESTIONED OUR DEP HDG AND WHICH DEP WE WERE FLYING. THERE ARE 9 SIDS FROM SFO -- 4 GO TO THE LIN OR SAC DEP FIXES FOR A POSSIBLE ROUTING TO BOS. THE GAPP3 IS NOT ONE OF THEM. I DO NOT KNOW WHY COMPANY RTE 44 OFFERS THE GAPP3 BECAUSE THIS ONLY GENERATES A REVISION PROCESS WITH ATC AND A RESULTING CHANGE TO THE FLT PLAN FOR THE COCKPIT CREW. THIS EQUIP WAS LATE ON ARR AND THE CREW SOMEWHAT RUSHED TO BE READY FOR SCHEDULED DEP.
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.