37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 487130 |
Time | |
Date | 200010 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mdw.airport |
State Reference | IL |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : mdw.tower |
Operator | general aviation : corporate |
Make Model Name | Beechjet 400 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 2600 flight time type : 350 |
ASRS Report | 487130 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Airspace Structure Environmental Factor Flight Crew Human Performance Airport |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : mdw.tower |
Narrative:
Our departure clearance was right turn to 090 degrees up to 3000 ft. Playback of tower tape verifies my copilot reading it back. I was the PF and didn't hear right turn (or it didn't register). I took off. I had 090 degrees bugged on my HSI, which is an EFIS (ams 5000 system). I saw 090 degrees just to my left and began the turn. Tower noticed midway through the turn and told us to turn right. There was departing traffic behind us, but no conflict arose. I phoned the tower to discuss what happened. I spoke to the watch supervisor at midway. He said this happens twice a week at midway, even when read back. It is simply human error. From a 220 degree heading, a turn to 090 degrees is in sight on the HSI to the left. Maybe from training regiment we pilots have the tendency to turn in the shorter direction. Also CRM was a factor. My copilot was on the radios, he copied the clearance and read it back. I was on another task at the moment, and heard 090 degrees but not right turn, and my copilot had simply forgot and did not catch it either. Again this stresses the importance of CRM, readbacks and clearance verification.
Original NASA ASRS Text
Title: A C400 CPR FLC STARTS A TURN TO 090 DEGS IN THE WRONG DIRECTION WHEN DEPARTING SW OF MDW, IL.
Narrative: OUR DEP CLRNC WAS R TURN TO 090 DEGS UP TO 3000 FT. PLAYBACK OF TWR TAPE VERIFIES MY COPLT READING IT BACK. I WAS THE PF AND DIDN'T HEAR R TURN (OR IT DIDN'T REGISTER). I TOOK OFF. I HAD 090 DEGS BUGGED ON MY HSI, WHICH IS AN EFIS (AMS 5000 SYS). I SAW 090 DEGS JUST TO MY L AND BEGAN THE TURN. TWR NOTICED MIDWAY THROUGH THE TURN AND TOLD US TO TURN R. THERE WAS DEPARTING TFC BEHIND US, BUT NO CONFLICT AROSE. I PHONED THE TWR TO DISCUSS WHAT HAPPENED. I SPOKE TO THE WATCH SUPVR AT MIDWAY. HE SAID THIS HAPPENS TWICE A WK AT MIDWAY, EVEN WHEN READ BACK. IT IS SIMPLY HUMAN ERROR. FROM A 220 DEG HDG, A TURN TO 090 DEGS IS IN SIGHT ON THE HSI TO THE L. MAYBE FROM TRAINING REGIMENT WE PLTS HAVE THE TENDENCY TO TURN IN THE SHORTER DIRECTION. ALSO CRM WAS A FACTOR. MY COPLT WAS ON THE RADIOS, HE COPIED THE CLRNC AND READ IT BACK. I WAS ON ANOTHER TASK AT THE MOMENT, AND HEARD 090 DEGS BUT NOT R TURN, AND MY COPLT HAD SIMPLY FORGOT AND DID NOT CATCH IT EITHER. AGAIN THIS STRESSES THE IMPORTANCE OF CRM, READBACKS AND CLRNC VERIFICATION.
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.