Narrative:

Our routing was djb direct cxr. I was the PF and did not make the turn at djb. Center corrected our error -- an embarrassment itself. Up to this point, we were diligent in the cockpit with charts out and in use, navaids tuned and properly set up. Meals were served at this time. The distraction obviously drew my attention from the job at hand. I would end this report here since I feel further explanation sounds like excuse making, but I have been trying to run my cockpit in a manner that ensures this stuff does not happen and I am disappointed that it did. Perhaps the contributing factors are worth reporting to you. 1) fatigue was a factor. This is a long hard trip and each leg presented us with an unusual challenge or problem to solve. The first leg of this day started with fog at lga -- 1 runway operation initially with lighting out -- eventually 3 runway changes, 6 climb out changes, etc. By the time we blew by djb, we were approaching 11 hours on duty and over 7 hours in the seat. 2) hunger -- we are fed on both legs and I ate before flying this leg, but I was not eating any full meals that day and was beginning to fade prior to this incident. After eating, I became noticeably more alert. 3) this was our first non GPS aircraft on this trip. But, lack of GPS is more common and we were on top of the navigation prior to this incident. Nothing occurred here that was unusual or taxiing on its own. I needed a little extra at this point, but just had nothing extra to give when we missed the turn. Supplemental information from acn 452249: we both had had a snack at dfw, but the meals on this sequence are few and far between. Neither one of us had had a proper breakfast because the hotel restaurant opened late on the wkends. We were exercising due caution and were not engaged in spurious conversation, but I was hungry and feeling the effects of the long day. Just prior to djb, the #1 flight attendant came up with our meals. We settled down together to eat quickly because we had only 1 hour until landing at lga. At this time, cle called us and asked if we were in the right turn to cxr. I responded in the affirmative as the captain turned the aircraft. Cle gave us a heading to intercept the course out of cxr which spared us a large s-turn to return to the proper flight path. We asked cle if there had been any problems and he responded calmly in the negative. This is not a problem with complacency. We were not negligent. We were tired, and I was extremely hungry -- indicative of a low blood sugar state. It does affect your decision making process. We made a mistake and we did fail to turn to the outbound course and I did fail to select the inbound course to cxr. But I think a significant factor to having this small, normal distraction affect a crew acting in a professional manner was our physical condition of fatigue coupled with a lack of proper nutrition. After we had eaten, we both felt better, and the rest of the flight was normal.

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Original NASA ASRS Text

Title: AN S80 FLC FAILS TO TURN WHEN PASSING DJB VOR DIRECT CXR WHILE IN COM WITH ZOB, OH.

Narrative: OUR ROUTING WAS DJB DIRECT CXR. I WAS THE PF AND DID NOT MAKE THE TURN AT DJB. CTR CORRECTED OUR ERROR -- AN EMBARRASSMENT ITSELF. UP TO THIS POINT, WE WERE DILIGENT IN THE COCKPIT WITH CHARTS OUT AND IN USE, NAVAIDS TUNED AND PROPERLY SET UP. MEALS WERE SERVED AT THIS TIME. THE DISTR OBVIOUSLY DREW MY ATTN FROM THE JOB AT HAND. I WOULD END THIS RPT HERE SINCE I FEEL FURTHER EXPLANATION SOUNDS LIKE EXCUSE MAKING, BUT I HAVE BEEN TRYING TO RUN MY COCKPIT IN A MANNER THAT ENSURES THIS STUFF DOES NOT HAPPEN AND I AM DISAPPOINTED THAT IT DID. PERHAPS THE CONTRIBUTING FACTORS ARE WORTH RPTING TO YOU. 1) FATIGUE WAS A FACTOR. THIS IS A LONG HARD TRIP AND EACH LEG PRESENTED US WITH AN UNUSUAL CHALLENGE OR PROB TO SOLVE. THE FIRST LEG OF THIS DAY STARTED WITH FOG AT LGA -- 1 RWY OP INITIALLY WITH LIGHTING OUT -- EVENTUALLY 3 RWY CHANGES, 6 CLBOUT CHANGES, ETC. BY THE TIME WE BLEW BY DJB, WE WERE APCHING 11 HRS ON DUTY AND OVER 7 HRS IN THE SEAT. 2) HUNGER -- WE ARE FED ON BOTH LEGS AND I ATE BEFORE FLYING THIS LEG, BUT I WAS NOT EATING ANY FULL MEALS THAT DAY AND WAS BEGINNING TO FADE PRIOR TO THIS INCIDENT. AFTER EATING, I BECAME NOTICEABLY MORE ALERT. 3) THIS WAS OUR FIRST NON GPS ACFT ON THIS TRIP. BUT, LACK OF GPS IS MORE COMMON AND WE WERE ON TOP OF THE NAV PRIOR TO THIS INCIDENT. NOTHING OCCURRED HERE THAT WAS UNUSUAL OR TAXIING ON ITS OWN. I NEEDED A LITTLE EXTRA AT THIS POINT, BUT JUST HAD NOTHING EXTRA TO GIVE WHEN WE MISSED THE TURN. SUPPLEMENTAL INFO FROM ACN 452249: WE BOTH HAD HAD A SNACK AT DFW, BUT THE MEALS ON THIS SEQUENCE ARE FEW AND FAR BTWN. NEITHER ONE OF US HAD HAD A PROPER BREAKFAST BECAUSE THE HOTEL RESTAURANT OPENED LATE ON THE WKENDS. WE WERE EXERCISING DUE CAUTION AND WERE NOT ENGAGED IN SPURIOUS CONVERSATION, BUT I WAS HUNGRY AND FEELING THE EFFECTS OF THE LONG DAY. JUST PRIOR TO DJB, THE #1 FLT ATTENDANT CAME UP WITH OUR MEALS. WE SETTLED DOWN TOGETHER TO EAT QUICKLY BECAUSE WE HAD ONLY 1 HR UNTIL LNDG AT LGA. AT THIS TIME, CLE CALLED US AND ASKED IF WE WERE IN THE R TURN TO CXR. I RESPONDED IN THE AFFIRMATIVE AS THE CAPT TURNED THE ACFT. CLE GAVE US A HDG TO INTERCEPT THE COURSE OUT OF CXR WHICH SPARED US A LARGE S-TURN TO RETURN TO THE PROPER FLT PATH. WE ASKED CLE IF THERE HAD BEEN ANY PROBS AND HE RESPONDED CALMLY IN THE NEGATIVE. THIS IS NOT A PROB WITH COMPLACENCY. WE WERE NOT NEGLIGENT. WE WERE TIRED, AND I WAS EXTREMELY HUNGRY -- INDICATIVE OF A LOW BLOOD SUGAR STATE. IT DOES AFFECT YOUR DECISION MAKING PROCESS. WE MADE A MISTAKE AND WE DID FAIL TO TURN TO THE OUTBOUND COURSE AND I DID FAIL TO SELECT THE INBOUND COURSE TO CXR. BUT I THINK A SIGNIFICANT FACTOR TO HAVING THIS SMALL, NORMAL DISTR AFFECT A CREW ACTING IN A PROFESSIONAL MANNER WAS OUR PHYSICAL CONDITION OF FATIGUE COUPLED WITH A LACK OF PROPER NUTRITION. AFTER WE HAD EATEN, WE BOTH FELT BETTER, AND THE REST OF THE FLT WAS NORMAL.

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.