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|
Attributes | |
ACN | 454456 |
Time | |
Date | 199911 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | msl bound lower : 2000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : a90.tracon tower : bos.tower tracon : a90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial climbout : takeoff ground : takeoff roll ground : taxi |
Route In Use | departure : noise abatement departure sid : wylyyl.wylly |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 150 flight time total : 19000 flight time type : 1700 |
ASRS Report | 454456 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to original clearance |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
As we were ready for pushback on an XA50 departure out of bos, the aircraft was preflted and the FMS programmed for the first officer's leg to cvg. He was new to the B757 and trying hard to master the FMS technology. As the first officer called for pushback, clearance control changed our departure to the wylie 3 FMS and asked if we could accept it. Simultaneously the tug driver called several times asking if we were ready for push and the flight attendants were not responding to our requests for clearance to push. I told the first officer, yes we could accept the departure, I thought he programmed the departure in correctly, and was finally able to coordinate the pushback and start segment. When cleared for taxi, we were given the most distant runway on the airport and were told we had a wheels up time of XB00, only mins away. We taxied quickly but uneventfully to the end of the runway where tower immediately cleared us for takeoff to make the wheels up time. I told tower there would be a delay (because the wylie 3 FMS departure requires a quick IRS alignment by programming in the correct coordinates for the end of the runway), but with his questions as to how much longer, we felt pressure to expedite. Since it was the first officer's leg it was up to him to program the coordinates. Unfortunately we used the coordinates supplied by the commercial chart departure page instead of those in the remarks section of the flight plan. Because commercial chart uses latitude/longitude coordinates down to the hundredths instead of tenths, the inexperienced first officer could not get the FMS to accept the inputs. Finally I realized, and then corrected, the problem and the system started the +/-30 second alignment. The first officer then tried to start the takeoff roll while the aircraft was still in alignment and I had to stop him. All this kept adding stress and confusion to the already hurried departure. Finally we were ready for takeoff and the departure was normal (gear up, LNAV, frequency change, flap change, etc) until I realized he was not making the required turn at the fix garve (2.6 DME) to proceed to wylie. After several questions and then a forceful command to turn left and proceed to wylie, he hit heading select, which made matters worse by turning us the wrong direction until I told him to turn the other way to go to wylie. We did not fly the noise sensitive departure as it was depicted. He later told me that throughout the departure he had thought that my commands to turn were wrong, because in his mind he had seen a totally different fix (glyde), appearing near the magenta centerline of the FMS, and thought it was the correct fix, garve (also starting with 'G'). Evidently, during the original confusion of pushback, I assumed, and he thought, he had programmed the FMS correctly with the wylie 3 departure, but he probably never executed it correctly. Being an FMS only based departure, there were no VOR or DME raw data backups to warn us that we were off course during this very concentrated and hectic portion of our flight.
Original NASA ASRS Text
Title: B757 CREW DEVIATES FROM DEP PATH AT BOS.
Narrative: AS WE WERE READY FOR PUSHBACK ON AN XA50 DEP OUT OF BOS, THE ACFT WAS PREFLTED AND THE FMS PROGRAMMED FOR THE FO'S LEG TO CVG. HE WAS NEW TO THE B757 AND TRYING HARD TO MASTER THE FMS TECHNOLOGY. AS THE FO CALLED FOR PUSHBACK, CLRNC CTL CHANGED OUR DEP TO THE WYLIE 3 FMS AND ASKED IF WE COULD ACCEPT IT. SIMULTANEOUSLY THE TUG DRIVER CALLED SEVERAL TIMES ASKING IF WE WERE READY FOR PUSH AND THE FLT ATTENDANTS WERE NOT RESPONDING TO OUR REQUESTS FOR CLRNC TO PUSH. I TOLD THE FO, YES WE COULD ACCEPT THE DEP, I THOUGHT HE PROGRAMMED THE DEP IN CORRECTLY, AND WAS FINALLY ABLE TO COORDINATE THE PUSHBACK AND START SEGMENT. WHEN CLRED FOR TAXI, WE WERE GIVEN THE MOST DISTANT RWY ON THE ARPT AND WERE TOLD WE HAD A WHEELS UP TIME OF XB00, ONLY MINS AWAY. WE TAXIED QUICKLY BUT UNEVENTFULLY TO THE END OF THE RWY WHERE TWR IMMEDIATELY CLRED US FOR TKOF TO MAKE THE WHEELS UP TIME. I TOLD TWR THERE WOULD BE A DELAY (BECAUSE THE WYLIE 3 FMS DEP REQUIRES A QUICK IRS ALIGNMENT BY PROGRAMMING IN THE CORRECT COORDINATES FOR THE END OF THE RWY), BUT WITH HIS QUESTIONS AS TO HOW MUCH LONGER, WE FELT PRESSURE TO EXPEDITE. SINCE IT WAS THE FO'S LEG IT WAS UP TO HIM TO PROGRAM THE COORDINATES. UNFORTUNATELY WE USED THE COORDINATES SUPPLIED BY THE COMMERCIAL CHART DEP PAGE INSTEAD OF THOSE IN THE REMARKS SECTION OF THE FLT PLAN. BECAUSE COMMERCIAL CHART USES LATITUDE/LONGITUDE COORDINATES DOWN TO THE HUNDREDTHS INSTEAD OF TENTHS, THE INEXPERIENCED FO COULD NOT GET THE FMS TO ACCEPT THE INPUTS. FINALLY I REALIZED, AND THEN CORRECTED, THE PROB AND THE SYS STARTED THE +/-30 SECOND ALIGNMENT. THE FO THEN TRIED TO START THE TKOF ROLL WHILE THE ACFT WAS STILL IN ALIGNMENT AND I HAD TO STOP HIM. ALL THIS KEPT ADDING STRESS AND CONFUSION TO THE ALREADY HURRIED DEP. FINALLY WE WERE READY FOR TKOF AND THE DEP WAS NORMAL (GEAR UP, LNAV, FREQ CHANGE, FLAP CHANGE, ETC) UNTIL I REALIZED HE WAS NOT MAKING THE REQUIRED TURN AT THE FIX GARVE (2.6 DME) TO PROCEED TO WYLIE. AFTER SEVERAL QUESTIONS AND THEN A FORCEFUL COMMAND TO TURN L AND PROCEED TO WYLIE, HE HIT HDG SELECT, WHICH MADE MATTERS WORSE BY TURNING US THE WRONG DIRECTION UNTIL I TOLD HIM TO TURN THE OTHER WAY TO GO TO WYLIE. WE DID NOT FLY THE NOISE SENSITIVE DEP AS IT WAS DEPICTED. HE LATER TOLD ME THAT THROUGHOUT THE DEP HE HAD THOUGHT THAT MY COMMANDS TO TURN WERE WRONG, BECAUSE IN HIS MIND HE HAD SEEN A TOTALLY DIFFERENT FIX (GLYDE), APPEARING NEAR THE MAGENTA CTRLINE OF THE FMS, AND THOUGHT IT WAS THE CORRECT FIX, GARVE (ALSO STARTING WITH 'G'). EVIDENTLY, DURING THE ORIGINAL CONFUSION OF PUSHBACK, I ASSUMED, AND HE THOUGHT, HE HAD PROGRAMMED THE FMS CORRECTLY WITH THE WYLIE 3 DEP, BUT HE PROBABLY NEVER EXECUTED IT CORRECTLY. BEING AN FMS ONLY BASED DEP, THERE WERE NO VOR OR DME RAW DATA BACKUPS TO WARN US THAT WE WERE OFF COURSE DURING THIS VERY CONCENTRATED AND HECTIC PORTION OF OUR FLT.
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.