37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 521239 |
Time | |
Date | 200108 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dro.airport |
State Reference | CO |
Altitude | agl single value : 12000 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Ice Rain |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zdv.artcc artcc : czvr.artcc |
Operator | common carrier : air carrier |
Make Model Name | Do 328 TP (Turboprop) |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zdv.artcc |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | descent : approach |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 3500 flight time type : 960 |
ASRS Report | 521239 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather inflight encounter other non adherence : far non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued alert controller : issued new clearance flight crew : returned to original clearance none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew faa : investigated other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Company |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had a mechanical failure of our de-ice boots on the descent into durango. So, we were unable to depart along our normally filed route which would take us into icing conditions. The dispatcher and I decided to re-route the flight to the southwest where the MEA's would keep our flight out of icing conditions. The dispatcher instructed me to pick up the clearance as 'zzxy' instead of 'xy.' I passed this information on to my first officer, as he is the one who would pick up the clearance. We boarded our flight and taxied out. I was on the #1 radio talking on the CTAF to our inbound aircraft, getting a current WX report while my first officer was on the #2 radio with center picking up our clearance. He inadvertently picked up the clearance as 'xy' and 'as filed.' we assumed this was our newer flight plan. It turns out this was not. I assumed our 'old plan' had dropped out of the system because it was over 2 hours old. We departed to the southwest and upon coming into radar coverage the controller queried us to where we were proceeding to. We went over our flight plan with ATC and found it was wrong. He reclred us and told us he had an aircraft landing at farmington that could have been an 'issue.' his supervisor called our dispatch and was calling the chief pilot the next day. The contributing issues were the mechanical, the WX, night, new first officer to the equipment, a newly upgraded captain (had flown the equipment as an first officer). Ways to prevent this: requiring full route clrncs when things change, both crew members listening to the clearance, having the dispatch pull the old flight plan when filing a new one.
Original NASA ASRS Text
Title: DO328 CREW HAD TRACK DEV IN ZDV CLASS E.
Narrative: WE HAD A MECHANICAL FAILURE OF OUR DE-ICE BOOTS ON THE DSCNT INTO DURANGO. SO, WE WERE UNABLE TO DEPART ALONG OUR NORMALLY FILED RTE WHICH WOULD TAKE US INTO ICING CONDITIONS. THE DISPATCHER AND I DECIDED TO RE-RTE THE FLT TO THE SW WHERE THE MEA'S WOULD KEEP OUR FLT OUT OF ICING CONDITIONS. THE DISPATCHER INSTRUCTED ME TO PICK UP THE CLRNC AS 'ZZXY' INSTEAD OF 'XY.' I PASSED THIS INFO ON TO MY FO, AS HE IS THE ONE WHO WOULD PICK UP THE CLRNC. WE BOARDED OUR FLT AND TAXIED OUT. I WAS ON THE #1 RADIO TALKING ON THE CTAF TO OUR INBOUND ACFT, GETTING A CURRENT WX RPT WHILE MY FO WAS ON THE #2 RADIO WITH CTR PICKING UP OUR CLRNC. HE INADVERTENTLY PICKED UP THE CLRNC AS 'XY' AND 'AS FILED.' WE ASSUMED THIS WAS OUR NEWER FLT PLAN. IT TURNS OUT THIS WAS NOT. I ASSUMED OUR 'OLD PLAN' HAD DROPPED OUT OF THE SYS BECAUSE IT WAS OVER 2 HRS OLD. WE DEPARTED TO THE SW AND UPON COMING INTO RADAR COVERAGE THE CTLR QUERIED US TO WHERE WE WERE PROCEEDING TO. WE WENT OVER OUR FLT PLAN WITH ATC AND FOUND IT WAS WRONG. HE RECLRED US AND TOLD US HE HAD AN ACFT LNDG AT FARMINGTON THAT COULD HAVE BEEN AN 'ISSUE.' HIS SUPVR CALLED OUR DISPATCH AND WAS CALLING THE CHIEF PLT THE NEXT DAY. THE CONTRIBUTING ISSUES WERE THE MECHANICAL, THE WX, NIGHT, NEW FO TO THE EQUIP, A NEWLY UPGRADED CAPT (HAD FLOWN THE EQUIP AS AN FO). WAYS TO PREVENT THIS: REQUIRING FULL RTE CLRNCS WHEN THINGS CHANGE, BOTH CREW MEMBERS LISTENING TO THE CLRNC, HAVING THE DISPATCH PULL THE OLD FLT PLAN WHEN FILING A NEW ONE.
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.