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An MD11 flight crew loads the wrong flight plan into their FMS and proceeds towards the wrong, not filed, entry fix related to the wrong airway while on frequency with rjtg, first officer.
| Attributes | |
| ACN | 478660 |
| Time | |
| Date | 200007 |
| Day | Tue |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| State Reference | FO |
| Altitude | msl bound lower : 25000 msl bound upper : 28000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : rjtg.artcc tower : rfd.tower |
| Operator | common carrier : air carrier |
| Make Model Name | MD-11 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | climbout : vacating altitude |
| Route In Use | enroute : pacific enroute : direct |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 24000 flight time type : 3200 |
| ASRS Report | 478660 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : commercial |
| Events | |
| Anomaly | non adherence : company policies non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued new clearance controller : issued advisory |
| Consequence | Other |
| Supplementary | |
| Problem Areas | ATC Human Performance Flight Crew Human Performance Company |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We received 2 flight releases -- a primary (filed) and backup one, via airway A-590 and the backup via R-591. We loaded the backup in error and did not catch it during clearance delivery or readback. During climb, tokyo control noticed we had departed 'kagis' to 'adnip' (R-591 entry fix) versus 'pabba' (A-590 entry fix). They asked us to confirm our routing. When I said we were 'filed' R-591, they reclred us with no further incident. Upon reflection, it was my error and we had been filed on A-590. Contributing to the error was predep concern over a 'slot time' discrepancy. Also, the company customarily marks flight plans with red letters 'primary' and 'backup' whenever there are 2 different routings. This was not done in this case. I do not believe the en route airway was included in the clearance delivery because the first officer did not note it when he wrote down the clearance. Under different circumstances, this might have been a very serious event.
Original NASA ASRS Text
Title: AN MD11 FLC LOADS THE WRONG FLT PLAN INTO THEIR FMS AND PROCEEDS TOWARDS THE WRONG, NOT FILED, ENTRY FIX RELATED TO THE WRONG AIRWAY WHILE ON FREQ WITH RJTG, FO.
Narrative: WE RECEIVED 2 FLT RELEASES -- A PRIMARY (FILED) AND BACKUP ONE, VIA AIRWAY A-590 AND THE BACKUP VIA R-591. WE LOADED THE BACKUP IN ERROR AND DID NOT CATCH IT DURING CLRNC DELIVERY OR READBACK. DURING CLB, TOKYO CTL NOTICED WE HAD DEPARTED 'KAGIS' TO 'ADNIP' (R-591 ENTRY FIX) VERSUS 'PABBA' (A-590 ENTRY FIX). THEY ASKED US TO CONFIRM OUR ROUTING. WHEN I SAID WE WERE 'FILED' R-591, THEY RECLRED US WITH NO FURTHER INCIDENT. UPON REFLECTION, IT WAS MY ERROR AND WE HAD BEEN FILED ON A-590. CONTRIBUTING TO THE ERROR WAS PREDEP CONCERN OVER A 'SLOT TIME' DISCREPANCY. ALSO, THE COMPANY CUSTOMARILY MARKS FLT PLANS WITH RED LETTERS 'PRIMARY' AND 'BACKUP' WHENEVER THERE ARE 2 DIFFERENT ROUTINGS. THIS WAS NOT DONE IN THIS CASE. I DO NOT BELIEVE THE ENRTE AIRWAY WAS INCLUDED IN THE CLRNC DELIVERY BECAUSE THE FO DID NOT NOTE IT WHEN HE WROTE DOWN THE CLRNC. UNDER DIFFERENT CIRCUMSTANCES, THIS MIGHT HAVE BEEN A VERY SERIOUS EVENT.
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.