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B737 flight crew alerted by ZLA about route deviation, who discover preflight coordination and route upload error.
| Attributes | |
| ACN | 527957 |
| Time | |
| Date | 200110 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | navaid : pgs.vortac |
| State Reference | AZ |
| Altitude | msl single value : 24000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zla.artcc tower : sfo.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | cruise : level |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 220 flight time total : 10500 flight time type : 7000 |
| ASRS Report | 527957 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 300 flight time total : 4000 flight time type : 450 |
| ASRS Report | 529959 |
| Events | |
| Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued advisory flight crew : became reoriented flight crew : returned to intended or assigned course |
| Consequence | faa : reviewed incident with flight crew other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Company |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
En route from tpa to las, we were given direct pgs. I then entered what I thought to be the arrival, the pgs 1 arrival to las. Based on past experience, this has always been the arrival when given direct pgs. As we flew out the 282 degree radial(?), ATC asked us if we were going to lynsy intersection or the 282 degree radial. Neither informed us that we had filed the mirok 1 arrival and I proceeded direct to lynsy intersection. We turned and never were more than 3.5 mi north of course. After investigating what went wrong, I discovered that the release did in fact have the mirok 1 arrival and I did not notice the change. The NOTAMS did have a note that the pgs 1 arrival was discontinued on oct/xa/01. This note did take some time to find as it was included with many other NOTAMS. Contributing factors: there was not any company NOTAMS about arrival and departure changes in las. In fact, the last information I had was the changes would not take place until november and that is why we were filed as /I. The FMC did not have the new arrs programmed to key us of the changes. Bottom line: I assumed the arrival without xchking the release, I did not catch the NOTAM change. Supplemental information from acn 527959: assumed we were on the pgs 1 arrival. Over the VOR, I viewed the clearance and noticed we were filed for the mirok 1. I quickly found the mirok 1 arrival and dialed in 257 degrees(?). Since we were over the VOR, I wasn't surprised to see we weren't on the radial yet. At this point I was distraction by my simultaneous computations on the opc. ATC pointed out our course deviation, at which point I realized the captain thought we were on the pgs 1 as well. Clearly, we both made assumptions about our clearance which should have been backed up with communication. Furthermore, I should have verified the clearance with the captain upon my first realization instead of my opc computations.
Original NASA ASRS Text
Title: B737 FLC ALERTED BY ZLA ABOUT RTE DEV, WHO DISCOVER PREFLT COORD AND RTE UPLOAD ERROR.
Narrative: ENRTE FROM TPA TO LAS, WE WERE GIVEN DIRECT PGS. I THEN ENTERED WHAT I THOUGHT TO BE THE ARR, THE PGS 1 ARR TO LAS. BASED ON PAST EXPERIENCE, THIS HAS ALWAYS BEEN THE ARR WHEN GIVEN DIRECT PGS. AS WE FLEW OUT THE 282 DEG RADIAL(?), ATC ASKED US IF WE WERE GOING TO LYNSY INTXN OR THE 282 DEG RADIAL. NEITHER INFORMED US THAT WE HAD FILED THE MIROK 1 ARR AND I PROCEEDED DIRECT TO LYNSY INTXN. WE TURNED AND NEVER WERE MORE THAN 3.5 MI N OF COURSE. AFTER INVESTIGATING WHAT WENT WRONG, I DISCOVERED THAT THE RELEASE DID IN FACT HAVE THE MIROK 1 ARR AND I DID NOT NOTICE THE CHANGE. THE NOTAMS DID HAVE A NOTE THAT THE PGS 1 ARR WAS DISCONTINUED ON OCT/XA/01. THIS NOTE DID TAKE SOME TIME TO FIND AS IT WAS INCLUDED WITH MANY OTHER NOTAMS. CONTRIBUTING FACTORS: THERE WAS NOT ANY COMPANY NOTAMS ABOUT ARR AND DEP CHANGES IN LAS. IN FACT, THE LAST INFO I HAD WAS THE CHANGES WOULD NOT TAKE PLACE UNTIL NOVEMBER AND THAT IS WHY WE WERE FILED AS /I. THE FMC DID NOT HAVE THE NEW ARRS PROGRAMMED TO KEY US OF THE CHANGES. BOTTOM LINE: I ASSUMED THE ARR WITHOUT XCHKING THE RELEASE, I DID NOT CATCH THE NOTAM CHANGE. SUPPLEMENTAL INFO FROM ACN 527959: ASSUMED WE WERE ON THE PGS 1 ARR. OVER THE VOR, I VIEWED THE CLRNC AND NOTICED WE WERE FILED FOR THE MIROK 1. I QUICKLY FOUND THE MIROK 1 ARR AND DIALED IN 257 DEGS(?). SINCE WE WERE OVER THE VOR, I WASN'T SURPRISED TO SEE WE WEREN'T ON THE RADIAL YET. AT THIS POINT I WAS DISTR BY MY SIMULTANEOUS COMPUTATIONS ON THE OPC. ATC POINTED OUT OUR COURSE DEV, AT WHICH POINT I REALIZED THE CAPT THOUGHT WE WERE ON THE PGS 1 AS WELL. CLRLY, WE BOTH MADE ASSUMPTIONS ABOUT OUR CLRNC WHICH SHOULD HAVE BEEN BACKED UP WITH COM. FURTHERMORE, I SHOULD HAVE VERIFIED THE CLRNC WITH THE CAPT UPON MY FIRST REALIZATION INSTEAD OF MY OPC COMPUTATIONS.
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.