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The flight crew of a B737-800 misprograms their FMS with the aircraft taking a sudden turn over the VOR to the northwest instead of following the 176 degree radial of the VOR at cri, ny.
| Attributes | |
| ACN | 528305 |
| Time | |
| Date | 200110 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : jfk.airport |
| State Reference | NY |
| Altitude | msl single value : 10000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : n90.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-800 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure other departure sid : kennedy 9 |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : cfi pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 180 flight time total : 8000 flight time type : 500 |
| ASRS Report | 528305 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | non adherence : company policies non adherence : published procedure non adherence : clearance other anomaly other other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued alert controller : issued new clearance flight crew : returned to intended or assigned course |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Departed jfk from runway 31L. Clearance (pre departure clearance) was kennedy 9, canarsie climb. Route of flight was then coate, J136... After takeoff and initial contact with departure we were cleared to 17000 ft. The captain was flying with the autoplt engaged and LNAV/VNAV engaged. As we approached canarsie (cri) the aircraft began a right hard turn to the northwest instead of a left turn on the cri 176 degree radial as per the canarsie climb. As soon as we began the turn ATC assigned us a left turn to the south and reassigned us to climb to 11000 ft. ATC asked 'where were you going?' the captain had modified the kennedy 9 departure, canarsie climb in the FMS, to proceed direct to coate after cri which resulted in a turn in the wrong direction. Contributing factors: both crew members had very little experience in jfk. First officer checked route of flight prior to captain modifying data, but not after the captain modified the departure. Problem was discovered: after ATC vectored us to the south, first officer was aware/realized that a deviation had occurred. Captain did not understand until the first officer explained the departure to him. Corrective action: vectors by ATC. Human performance considerations: excessive or blind reliance on FMC (LNAV). Crew did not brief the canarsie climb segment of departure. It was not adequately understood while it was being loaded/modified. Improve crew coordination of navigation data loading and xchking each other. Garbage in, garbage out!
Original NASA ASRS Text
Title: THE FLC OF A B737-800 MISPROGRAMS THEIR FMS WITH THE ACFT TAKING A SUDDEN TURN OVER THE VOR TO THE NW INSTEAD OF FOLLOWING THE 176 DEG RADIAL OF THE VOR AT CRI, NY.
Narrative: DEPARTED JFK FROM RWY 31L. CLRNC (PDC) WAS KENNEDY 9, CANARSIE CLB. RTE OF FLT WAS THEN COATE, J136... AFTER TKOF AND INITIAL CONTACT WITH DEP WE WERE CLRED TO 17000 FT. THE CAPT WAS FLYING WITH THE AUTOPLT ENGAGED AND LNAV/VNAV ENGAGED. AS WE APCHED CANARSIE (CRI) THE ACFT BEGAN A R HARD TURN TO THE NW INSTEAD OF A L TURN ON THE CRI 176 DEG RADIAL AS PER THE CANARSIE CLB. AS SOON AS WE BEGAN THE TURN ATC ASSIGNED US A L TURN TO THE S AND REASSIGNED US TO CLB TO 11000 FT. ATC ASKED 'WHERE WERE YOU GOING?' THE CAPT HAD MODIFIED THE KENNEDY 9 DEP, CANARSIE CLB IN THE FMS, TO PROCEED DIRECT TO COATE AFTER CRI WHICH RESULTED IN A TURN IN THE WRONG DIRECTION. CONTRIBUTING FACTORS: BOTH CREW MEMBERS HAD VERY LITTLE EXPERIENCE IN JFK. FO CHKED RTE OF FLT PRIOR TO CAPT MODIFYING DATA, BUT NOT AFTER THE CAPT MODIFIED THE DEP. PROB WAS DISCOVERED: AFTER ATC VECTORED US TO THE S, FO WAS AWARE/REALIZED THAT A DEV HAD OCCURRED. CAPT DID NOT UNDERSTAND UNTIL THE FO EXPLAINED THE DEP TO HIM. CORRECTIVE ACTION: VECTORS BY ATC. HUMAN PERFORMANCE CONSIDERATIONS: EXCESSIVE OR BLIND RELIANCE ON FMC (LNAV). CREW DID NOT BRIEF THE CANARSIE CLB SEGMENT OF DEP. IT WAS NOT ADEQUATELY UNDERSTOOD WHILE IT WAS BEING LOADED/MODIFIED. IMPROVE CREW COORD OF NAV DATA LOADING AND XCHKING EACH OTHER. GARBAGE IN, GARBAGE OUT!
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.