 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B737-400 crew, en route clt to mco, discovered they had improperly programmed the FMS prior to departure.
| Attributes | |
| ACN | 532872 |
| Time | |
| Date | 200112 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : sav.airport |
| State Reference | GA |
| Altitude | msl single value : 35000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zjx.artcc tower : phl.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | cruise : level |
| Route In Use | enroute airway : j103.airway |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 150 flight time total : 20000 flight time type : 15500 |
| ASRS Report | 532872 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | none taken : unable |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance ATC Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
At gate in clt when programming FMC, stored route #41 clt-mco was 'not in database' programmed manually using pre departure clearance clearance. Screen on comrdo showed clt bucki cae J51 sav J103 umn bitho 7 mco. When entering the route, I read right over the J103. FMC now programmed sav direct omn. Now we were en route, past sav when ATC said 'you're getting close to my warning areas...cleared direct beeno J103 omn, cross beeno at FL310.' first officer read back clearance. Looking at FMC legs page there was no beeno. I questioned first officer, 'did he say bitho?' asked ATC again 'bitho or beeno?' ATC responds, 'beeno.' I typed in 'beano.' FMC took it, plane turned left, FMC shows beano over 1100 mi away on about 120 degree heading. 'What's going on here?' again asked ATC 'beeno?' 'yes, beeno and you need to start your turn, you're heading into my warning area!' asked ATC, 'spell beano!' 'B-east-east-north-O' was the reply. Made FMC connection and turned toward beeno. By this time cross beeno at FL310 was totally forgotten. ATC asked 3.8 mi from beeno if we were going to make our restr. I told him no. We tried but were 1300 ft high. One oversight at the gate caused mass confusion -- almost a warning area violation, had us so consumed with 'beeno' that we missed a crossing restr. Yes, we were on the second to last leg of 4 day trip, 13 hour day, wanted to hurry up, again many factors before hand led up to the one mistake.
Original NASA ASRS Text
Title: A B737-400 CREW, ENRTE CLT TO MCO, DISCOVERED THEY HAD IMPROPERLY PROGRAMMED THE FMS PRIOR TO DEP.
Narrative: AT GATE IN CLT WHEN PROGRAMMING FMC, STORED RTE #41 CLT-MCO WAS 'NOT IN DATABASE' PROGRAMMED MANUALLY USING PDC CLRNC. SCREEN ON COMRDO SHOWED CLT BUCKI CAE J51 SAV J103 UMN BITHO 7 MCO. WHEN ENTERING THE RTE, I READ RIGHT OVER THE J103. FMC NOW PROGRAMMED SAV DIRECT OMN. NOW WE WERE ENRTE, PAST SAV WHEN ATC SAID 'YOU'RE GETTING CLOSE TO MY WARNING AREAS...CLRED DIRECT BEENO J103 OMN, CROSS BEENO AT FL310.' FO READ BACK CLRNC. LOOKING AT FMC LEGS PAGE THERE WAS NO BEENO. I QUESTIONED FO, 'DID HE SAY BITHO?' ASKED ATC AGAIN 'BITHO OR BEENO?' ATC RESPONDS, 'BEENO.' I TYPED IN 'BEANO.' FMC TOOK IT, PLANE TURNED L, FMC SHOWS BEANO OVER 1100 MI AWAY ON ABOUT 120 DEG HDG. 'WHAT'S GOING ON HERE?' AGAIN ASKED ATC 'BEENO?' 'YES, BEENO AND YOU NEED TO START YOUR TURN, YOU'RE HEADING INTO MY WARNING AREA!' ASKED ATC, 'SPELL BEANO!' 'B-E-E-N-O' WAS THE REPLY. MADE FMC CONNECTION AND TURNED TOWARD BEENO. BY THIS TIME CROSS BEENO AT FL310 WAS TOTALLY FORGOTTEN. ATC ASKED 3.8 MI FROM BEENO IF WE WERE GOING TO MAKE OUR RESTR. I TOLD HIM NO. WE TRIED BUT WERE 1300 FT HIGH. ONE OVERSIGHT AT THE GATE CAUSED MASS CONFUSION -- ALMOST A WARNING AREA VIOLATION, HAD US SO CONSUMED WITH 'BEENO' THAT WE MISSED A XING RESTR. YES, WE WERE ON THE SECOND TO LAST LEG OF 4 DAY TRIP, 13 HR DAY, WANTED TO HURRY UP, AGAIN MANY FACTORS BEFORE HAND LED UP TO THE ONE MISTAKE.
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.