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Attributes | |
ACN | 521584 |
Time | |
Date | 200108 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dtw.airport |
State Reference | MI |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d21.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude ground : preflight |
Route In Use | departure : on vectors departure sid : geneva |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 12000 flight time type : 3000 |
ASRS Report | 521584 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Company |
Air Traffic Incident | Pilot Deviation |
Narrative:
The problem: shortly after taking off from dtw for phl, it was discovered, through talking to departure control, that the routing ATC had on file was not the same one that was received on the release and thought to have been obtained from the clearance delivery. Over 1 hour prior to departure, the dispatcher created the release for the flight. It was submitted to the company and the flight plan was filed with the FAA. The company computer system accepted the release but the flight plan was not accepted by the FAA. Before the dispatcher could change the release and resubmit a new flight plan to the FAA, the gate agent in detroit printed out the release for the aircrew. Since this was well before the flight was scheduled to depart, and in fact the working crew had not even arrived in detroit yet, the dispatcher did not think that having a release in the air carrier system for such a short period of time mattered. A new release was created by the dispatcher and subsequently input into the air carrier system. Unfortunately, the cockpit crew never received the updated release which reflected a completely different routing. The error might have been detected upon obtaining the clearance. Unfortunately, pre-departure clearance through the ACARS were unobtainable for some reason at that time. The format of the pre-departure clearance may have shown the error. The clearance was received on the radio from clearance delivery. The clearance received was 'cleared as filed via geneva 2 departure, maintain 10000 ft.' this was not enough to flag the discrepancy. The error was only detected after takeoff when departure gave a heading to intercept on course and it was not pointing the aircraft in the right direction. The ATC filed routing was obtained by the crew and subsequently flown to destination. Why the flight plan changed: the aircraft had its RNAV equipment on the MEL. This changed its navigation status to /a for ATC filing of flight plans. The original flight plan had intersection of 2 jet routes that is acceptable for an RNAV equipped aircraft but not for a /a equipped aircraft. 1) it is possible for a crew to have an invalid release and not know it. 2) since route that was flown was different than the planned route, the crew had no way of knowing if they had enough gas to fly the route since the FMC was unavailable, essentially eliminating any automated fuel calculations. Also they had no hard copy of the flight plan that was flown that would have shown fuel burn information. The crew determined that they had enough gas due to the fact that the fuel slip showed more fuel than the release. It was reasoned that the additional gas was needed to fly the filed route. The crew did ensure through their own calculations that enough fuel was available to fly the route. Questions that remain: 1) why is there not a procedure in place to insure that when a release is changed, the captain is informed? 2) is there a way for the aircrew to determine if they have the most current version of the release in their possession?
Original NASA ASRS Text
Title: A B737-300 CREW WAS FLYING A DIFFERENT FLT PLAN THAN ATC THOUGHT THEY WERE FLYING.
Narrative: THE PROB: SHORTLY AFTER TAKING OFF FROM DTW FOR PHL, IT WAS DISCOVERED, THROUGH TALKING TO DEP CTL, THAT THE ROUTING ATC HAD ON FILE WAS NOT THE SAME ONE THAT WAS RECEIVED ON THE RELEASE AND THOUGHT TO HAVE BEEN OBTAINED FROM THE CLRNC DELIVERY. OVER 1 HR PRIOR TO DEP, THE DISPATCHER CREATED THE RELEASE FOR THE FLT. IT WAS SUBMITTED TO THE COMPANY AND THE FLT PLAN WAS FILED WITH THE FAA. THE COMPANY COMPUTER SYS ACCEPTED THE RELEASE BUT THE FLT PLAN WAS NOT ACCEPTED BY THE FAA. BEFORE THE DISPATCHER COULD CHANGE THE RELEASE AND RESUBMIT A NEW FLT PLAN TO THE FAA, THE GATE AGENT IN DETROIT PRINTED OUT THE RELEASE FOR THE AIRCREW. SINCE THIS WAS WELL BEFORE THE FLT WAS SCHEDULED TO DEPART, AND IN FACT THE WORKING CREW HAD NOT EVEN ARRIVED IN DETROIT YET, THE DISPATCHER DID NOT THINK THAT HAVING A RELEASE IN THE ACR SYS FOR SUCH A SHORT PERIOD OF TIME MATTERED. A NEW RELEASE WAS CREATED BY THE DISPATCHER AND SUBSEQUENTLY INPUT INTO THE ACR SYS. UNFORTUNATELY, THE COCKPIT CREW NEVER RECEIVED THE UPDATED RELEASE WHICH REFLECTED A COMPLETELY DIFFERENT ROUTING. THE ERROR MIGHT HAVE BEEN DETECTED UPON OBTAINING THE CLRNC. UNFORTUNATELY, PRE-DEP CLRNC THROUGH THE ACARS WERE UNOBTAINABLE FOR SOME REASON AT THAT TIME. THE FORMAT OF THE PRE-DEP CLRNC MAY HAVE SHOWN THE ERROR. THE CLRNC WAS RECEIVED ON THE RADIO FROM CLRNC DELIVERY. THE CLRNC RECEIVED WAS 'CLRED AS FILED VIA GENEVA 2 DEP, MAINTAIN 10000 FT.' THIS WAS NOT ENOUGH TO FLAG THE DISCREPANCY. THE ERROR WAS ONLY DETECTED AFTER TKOF WHEN DEP GAVE A HDG TO INTERCEPT ON COURSE AND IT WAS NOT POINTING THE ACFT IN THE RIGHT DIRECTION. THE ATC FILED ROUTING WAS OBTAINED BY THE CREW AND SUBSEQUENTLY FLOWN TO DEST. WHY THE FLT PLAN CHANGED: THE ACFT HAD ITS RNAV EQUIP ON THE MEL. THIS CHANGED ITS NAV STATUS TO /A FOR ATC FILING OF FLT PLANS. THE ORIGINAL FLT PLAN HAD INTXN OF 2 JET ROUTES THAT IS ACCEPTABLE FOR AN RNAV EQUIPPED ACFT BUT NOT FOR A /A EQUIPPED ACFT. 1) IT IS POSSIBLE FOR A CREW TO HAVE AN INVALID RELEASE AND NOT KNOW IT. 2) SINCE RTE THAT WAS FLOWN WAS DIFFERENT THAN THE PLANNED RTE, THE CREW HAD NO WAY OF KNOWING IF THEY HAD ENOUGH GAS TO FLY THE RTE SINCE THE FMC WAS UNAVAILABLE, ESSENTIALLY ELIMINATING ANY AUTOMATED FUEL CALCULATIONS. ALSO THEY HAD NO HARD COPY OF THE FLT PLAN THAT WAS FLOWN THAT WOULD HAVE SHOWN FUEL BURN INFO. THE CREW DETERMINED THAT THEY HAD ENOUGH GAS DUE TO THE FACT THAT THE FUEL SLIP SHOWED MORE FUEL THAN THE RELEASE. IT WAS REASONED THAT THE ADDITIONAL GAS WAS NEEDED TO FLY THE FILED RTE. THE CREW DID ENSURE THROUGH THEIR OWN CALCULATIONS THAT ENOUGH FUEL WAS AVAILABLE TO FLY THE RTE. QUESTIONS THAT REMAIN: 1) WHY IS THERE NOT A PROC IN PLACE TO INSURE THAT WHEN A RELEASE IS CHANGED, THE CAPT IS INFORMED? 2) IS THERE A WAY FOR THE AIRCREW TO DETERMINE IF THEY HAVE THE MOST CURRENT VERSION OF THE RELEASE IN THEIR POSSESSION?
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.