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|
Attributes | |
ACN | 456860 |
Time | |
Date | 199912 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
State Reference | CA |
Altitude | msl single value : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : level |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : multi engine pilot : instrument pilot : flight engineer pilot : cfi |
Experience | flight time last 90 days : 190 flight time total : 11000 flight time type : 2700 |
ASRS Report | 456860 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument |
Experience | flight time last 90 days : 120 flight time type : 120 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Original clearance of flight from ord-oak included the madwin 3 arrival MVA transition, which was loaded in FMC. En route, reclred direct MVA direct eca direct oak. Entered above into FMC with the exception of after eca, there eca arrival legs in because we knew we would be reclred for the arrival and we verbalized as such. Eventually, we were reclred as expected. I looked at legs page and saw MVA, eca. I had the arrival on the yoke clip. But I did not connect in my mind that the legs page had direct MVA direct eca rather than MVA, MVA 230 degrees/eca 068 degrees eca. We flew MVA direct eca. Contributing factors: copilot with only 2 months experience. ATC queried us. Immediately I recognized the situation and corrected the FMC routing. ATC provided 20 degrees left heading change. Descend and maintain 33000 ft and eventually direct eca. Human performance considerations: there is no doubt in my mind that fatigue played a major factor in this event. The scheduled trip was 4 days long, flown by a west coast based crew. Day 1 had a report time in oak in early am. Day 2 had a hotel pick-up time at early am in maine. Day 3 had a hotel pick-up time at early am in california. Day 4 had a hotel pick-up time early am in cle, oh. While the trip provided adequate layover time, it is unrealistic to think of west coast based crew can force themselves to sleep on an east coast clock. I have been subjected to this type sleep/non-sleep pattern for more than 10 yrs and know that it is extremely wearing on the body and mental acuity. Add to the sleep deprivation problems with WX, irregular procedures, traffic delays, etc, and it is easy to become overloaded.
Original NASA ASRS Text
Title: FLC OF A TWIN ENGINED ACR EXPERIENCES AN OFF COURSE DEV WHEN THE FMC IS IMPROPERLY PROGRAMMED FOR THE STAR ARR PROC W OF MVA, CA.
Narrative: ORIGINAL CLRNC OF FLT FROM ORD-OAK INCLUDED THE MADWIN 3 ARR MVA TRANSITION, WHICH WAS LOADED IN FMC. ENRTE, RECLRED DIRECT MVA DIRECT ECA DIRECT OAK. ENTERED ABOVE INTO FMC WITH THE EXCEPTION OF AFTER ECA, THERE ECA ARR LEGS IN BECAUSE WE KNEW WE WOULD BE RECLRED FOR THE ARR AND WE VERBALIZED AS SUCH. EVENTUALLY, WE WERE RECLRED AS EXPECTED. I LOOKED AT LEGS PAGE AND SAW MVA, ECA. I HAD THE ARR ON THE YOKE CLIP. BUT I DID NOT CONNECT IN MY MIND THAT THE LEGS PAGE HAD DIRECT MVA DIRECT ECA RATHER THAN MVA, MVA 230 DEGS/ECA 068 DEGS ECA. WE FLEW MVA DIRECT ECA. CONTRIBUTING FACTORS: COPLT WITH ONLY 2 MONTHS EXPERIENCE. ATC QUERIED US. IMMEDIATELY I RECOGNIZED THE SIT AND CORRECTED THE FMC ROUTING. ATC PROVIDED 20 DEGS L HDG CHANGE. DSND AND MAINTAIN 33000 FT AND EVENTUALLY DIRECT ECA. HUMAN PERFORMANCE CONSIDERATIONS: THERE IS NO DOUBT IN MY MIND THAT FATIGUE PLAYED A MAJOR FACTOR IN THIS EVENT. THE SCHEDULED TRIP WAS 4 DAYS LONG, FLOWN BY A W COAST BASED CREW. DAY 1 HAD A RPT TIME IN OAK IN EARLY AM. DAY 2 HAD A HOTEL PICK-UP TIME AT EARLY AM IN MAINE. DAY 3 HAD A HOTEL PICK-UP TIME AT EARLY AM IN CALIFORNIA. DAY 4 HAD A HOTEL PICK-UP TIME EARLY AM IN CLE, OH. WHILE THE TRIP PROVIDED ADEQUATE LAYOVER TIME, IT IS UNREALISTIC TO THINK OF W COAST BASED CREW CAN FORCE THEMSELVES TO SLEEP ON AN E COAST CLOCK. I HAVE BEEN SUBJECTED TO THIS TYPE SLEEP/NON-SLEEP PATTERN FOR MORE THAN 10 YRS AND KNOW THAT IT IS EXTREMELY WEARING ON THE BODY AND MENTAL ACUITY. ADD TO THE SLEEP DEPRIVATION PROBS WITH WX, IRREGULAR PROCS, TFC DELAYS, ETC, AND IT IS EASY TO BECOME OVERLOADED.
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.