Narrative:

Aircraft cleared by shanwick oceanic 'via 52N/15W, 51N/20W, 51N/30W, 48N/50W. Aircraft flight path followed original flight plan clearance: 52N/15W, 52N/20W, 51N/30W, 48N/50W. Oceanic clearance from shanwick was the same as flight plan with the exception that the second waypoint was changed. Deviation from the clearance was not noticed by the crew until at position 52N/20W. Flight proceeded to 48N/50W and then fpr with no further incident. Possible contributing factors: 1) shannon controller did not pick up irregularity when ETA was given for 52N/20W at 52N/15W. 2) shanwick oceanic did not use the word 'amended' or 'change' to flight plan when passing the clearance to the crew, to alert them to a possible change. 3) flight plan readability was very poor and clarity bad on both copies. Lights were dim at the time of the xchk and the waypoint change was not picked up. 4) possible flight crew fatigue. None of the crew had received more than 3 hours sleep in the preceding 24 hours. Due to a last min trip change, the crew had a full night's sleep on the night of oct/xa/99 expecting a departure during the day on oct/xc/99. Trip change resulted in an XA00Z wake-up on oct/xb/99 to travel lux-fra (passenger) then rest during the day for an evening departure on oct/xb/99. Flight fra was delayed 3 hours. Therefore the crew departed approximately 22 hours after the time they went to sleep the previous day. Very little sleep achieved during the day rest in fra prior to departure. 5) partial crew preoccupation and distraction caused by 2 abnormal problems that they were dealing with at the same time the clearance was received: 1) sat gauge was overreading by 20 degrees -- affecting the maximum cruise altitude decision. 2) adp pump run light was on for #1 hydraulic system.

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Original NASA ASRS Text

Title: A B747-200 NAV ERROR MNPS SHANWICK CTL.

Narrative: ACFT CLRED BY SHANWICK OCEANIC 'VIA 52N/15W, 51N/20W, 51N/30W, 48N/50W. ACFT FLT PATH FOLLOWED ORIGINAL FLT PLAN CLRNC: 52N/15W, 52N/20W, 51N/30W, 48N/50W. OCEANIC CLRNC FROM SHANWICK WAS THE SAME AS FLT PLAN WITH THE EXCEPTION THAT THE SECOND WAYPOINT WAS CHANGED. DEV FROM THE CLRNC WAS NOT NOTICED BY THE CREW UNTIL AT POS 52N/20W. FLT PROCEEDED TO 48N/50W AND THEN FPR WITH NO FURTHER INCIDENT. POSSIBLE CONTRIBUTING FACTORS: 1) SHANNON CTLR DID NOT PICK UP IRREGULARITY WHEN ETA WAS GIVEN FOR 52N/20W AT 52N/15W. 2) SHANWICK OCEANIC DID NOT USE THE WORD 'AMENDED' OR 'CHANGE' TO FLT PLAN WHEN PASSING THE CLRNC TO THE CREW, TO ALERT THEM TO A POSSIBLE CHANGE. 3) FLT PLAN READABILITY WAS VERY POOR AND CLARITY BAD ON BOTH COPIES. LIGHTS WERE DIM AT THE TIME OF THE XCHK AND THE WAYPOINT CHANGE WAS NOT PICKED UP. 4) POSSIBLE FLT CREW FATIGUE. NONE OF THE CREW HAD RECEIVED MORE THAN 3 HRS SLEEP IN THE PRECEDING 24 HRS. DUE TO A LAST MIN TRIP CHANGE, THE CREW HAD A FULL NIGHT'S SLEEP ON THE NIGHT OF OCT/XA/99 EXPECTING A DEP DURING THE DAY ON OCT/XC/99. TRIP CHANGE RESULTED IN AN XA00Z WAKE-UP ON OCT/XB/99 TO TRAVEL LUX-FRA (PAX) THEN REST DURING THE DAY FOR AN EVENING DEP ON OCT/XB/99. FLT FRA WAS DELAYED 3 HRS. THEREFORE THE CREW DEPARTED APPROX 22 HRS AFTER THE TIME THEY WENT TO SLEEP THE PREVIOUS DAY. VERY LITTLE SLEEP ACHIEVED DURING THE DAY REST IN FRA PRIOR TO DEP. 5) PARTIAL CREW PREOCCUPATION AND DISTR CAUSED BY 2 ABNORMAL PROBS THAT THEY WERE DEALING WITH AT THE SAME TIME THE CLRNC WAS RECEIVED: 1) SAT GAUGE WAS OVERREADING BY 20 DEGS -- AFFECTING THE MAX CRUISE ALT DECISION. 2) ADP PUMP RUN LIGHT WAS ON FOR #1 HYD SYS.

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.