37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 523830 |
Time | |
Date | 200109 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : roa.airport |
State Reference | VA |
Altitude | msl single value : 2800 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Jetstream 32 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 170 flight time total : 6400 flight time type : 940 |
ASRS Report | 523830 |
Events | |
Anomaly | non adherence : clearance non adherence : far other spatial deviation |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ATIS we received indicated runway 15 in use for departure. We received clearance to iad including left turn to 220 degrees after takeoff (this is not the procedure used for a runway 15 departure). We discussed procedures for 1) engine failure departure procedures, then 2) obstacle departure procedure, then 3) the standard departure, all 3 using different navaids, headings and altitudes. When we called for taxi, we were given runway 24 for departure, which required we brief the different single-engine and obstacle clearance departures relevant to runway 24. Upon departure on runway 24, we flew runway heading (240 degrees) vice 220 degree heading assigned in our original clearance. The confusion in heading flown was precipitated by several events. 1) change of runways after briefing initial departure procedures, 2) the complexity of an obstacle departure procedure different from the engine failure procedure, which included DME's off of 2 different VOR's and 1 lda frequency, 3) no mention of heading to fly contained in the actual takeoff clearance. The flight crew missed/forgot the original heading of 220 degrees, but the error would have been avoided if either the tower controller repeated the heading in our takeoff clearance (best solution?) or we had reviewed and concurred on the heading to fly as we crossed the hold short line. We were at fault, but the complexity of various departure procedures, in addition to a runway change during taxi, caused us to lose track of the most important point -- heading on takeoff.
Original NASA ASRS Text
Title: A JS32 FLT CREW FORGETS ABOUT ASSIGNED HEADING AND INSTEAD FLIES RWY HEADING.
Narrative: ATIS WE RECEIVED INDICATED RWY 15 IN USE FOR DEP. WE RECEIVED CLRNC TO IAD INCLUDING L TURN TO 220 DEGS AFTER TKOF (THIS IS NOT THE PROC USED FOR A RWY 15 DEP). WE DISCUSSED PROCS FOR 1) ENG FAILURE DEP PROCS, THEN 2) OBSTACLE DEP PROC, THEN 3) THE STANDARD DEP, ALL 3 USING DIFFERENT NAVAIDS, HEADINGS AND ALTS. WHEN WE CALLED FOR TAXI, WE WERE GIVEN RWY 24 FOR DEP, WHICH REQUIRED WE BRIEF THE DIFFERENT SINGLE-ENG AND OBSTACLE CLRNC DEPS RELEVANT TO RWY 24. UPON DEP ON RWY 24, WE FLEW RWY HEADING (240 DEGS) VICE 220 DEG HDG ASSIGNED IN OUR ORIGINAL CLRNC. THE CONFUSION IN HEADING FLOWN WAS PRECIPITATED BY SEVERAL EVENTS. 1) CHANGE OF RWYS AFTER BRIEFING INITIAL DEP PROCS, 2) THE COMPLEXITY OF AN OBSTACLE DEP PROC DIFFERENT FROM THE ENG FAILURE PROC, WHICH INCLUDED DME'S OFF OF 2 DIFFERENT VOR'S AND 1 LDA FREQ, 3) NO MENTION OF HEADING TO FLY CONTAINED IN THE ACTUAL TKOF CLRNC. THE FLT CREW MISSED/FORGOT THE ORIGINAL HEADING OF 220 DEGS, BUT THE ERROR WOULD HAVE BEEN AVOIDED IF EITHER THE TWR CTLR REPEATED THE HEADING IN OUR TKOF CLRNC (BEST SOLUTION?) OR WE HAD REVIEWED AND CONCURRED ON THE HEADING TO FLY AS WE CROSSED THE HOLD SHORT LINE. WE WERE AT FAULT, BUT THE COMPLEXITY OF VARIOUS DEP PROCS, IN ADDITION TO A RWY CHANGE DURING TAXI, CAUSED US TO LOSE TRACK OF THE MOST IMPORTANT POINT -- HEADING ON TKOF.
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.