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|
Attributes | |
ACN | 533157 |
Time | |
Date | 200112 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : egll.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : taxi ground : holding |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 533157 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 532986 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Airport |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the captain on day two of a six day international trip with a planned departure from lhr to ord. Flight planning and all preflight checks were completed. The fpf was uploaded through ACARS by the first officer and verified by me. The SOP for lhr is to call for your ATC clearance (which includes a SID assignment) when the flight is ready for pushback. At push time, the first officer requested ATC clearance. It was received, copied on a notepad and read back as follows 'cleared to ord fpr, compton 5J depart, code XXX.' both the relief first officer and I listened to the clearance and the read back. There was no ambiguity or questions as to the clearance from any of the crew. The compton 5J was loaded in the FMC and briefed by the first officer (PF). I entered the raw data in the left VOR for backup. After we were cleared for takeoff, we began execution for the compton SID. Lhr tower did not hand us off to depart control in a timely manner, so I asked tower if we should contact departure control. Tower stated 'negative, you are flying the wrong SID, you were assigned the buzard 3J SID. Fly heading 275 degrees, maintain 6000 ft. We were handed off to departure control and the departure was without further incident. WX was VMC during departure, no other traffic was observed, and no TCAS flight attendant's or TA's were received. Other factors: all crewmembers were experienced in lhr operations. The crew was well rested and all SOP's were complied with. Both first officer's were proficient and professional. Air carrier fom page requires that the department SID name be stated on initial contact with departure control. The late handoff by tower precluded this safety backup for proper SID compliance. The lhr procedure of only knowing your SID assignment at the last moment before pushback compromises installation, briefing and compliance. It was possible that all three crewmembers misheard the SID assignment. However, all crewmembers listened to the clearance, and heard the first officer read back the compton 5J. Clear delivery did not correct the read back if in fact it was different than the one issued. The SID should be part of the uplink process. Recommend lhr tower issue takeoff clearance as 'clear takeoff fly XXX SID.'
Original NASA ASRS Text
Title: A B767 CREW, DEPARTING LONDON (EGLL), FLEW THE SID THEY ANSWERED FOR IN THEIR READ BACK; ATC STATED THE SID FLOWN WAS NOT THE ONE THEY WERE CLRED FOR.
Narrative: I WAS THE CAPT ON DAY TWO OF A SIX DAY INTL TRIP WITH A PLANNED DEP FROM LHR TO ORD. FLT PLANNING AND ALL PREFLT CHECKS WERE COMPLETED. THE FPF WAS UPLOADED THROUGH ACARS BY THE FO AND VERIFIED BY ME. THE SOP FOR LHR IS TO CALL FOR YOUR ATC CLRNC (WHICH INCLUDES A SID ASSIGNMENT) WHEN THE FLT IS READY FOR PUSHBACK. AT PUSH TIME, THE FO REQUESTED ATC CLRNC. IT WAS RECEIVED, COPIED ON A NOTEPAD AND READ BACK AS FOLLOWS 'CLRED TO ORD FPR, COMPTON 5J DEPART, CODE XXX.' BOTH THE RELIEF FO AND I LISTENED TO THE CLRNC AND THE READ BACK. THERE WAS NO AMBIGUITY OR QUESTIONS AS TO THE CLRNC FROM ANY OF THE CREW. THE COMPTON 5J WAS LOADED IN THE FMC AND BRIEFED BY THE FO (PF). I ENTERED THE RAW DATA IN THE L VOR FOR BACKUP. AFTER WE WERE CLRED FOR TKOF, WE BEGAN EXECUTION FOR THE COMPTON SID. LHR TOWER DID NOT HAND US OFF TO DEPART CTL IN A TIMELY MANNER, SO I ASKED TWR IF WE SHOULD CONTACT DEP CTL. TWR STATED 'NEGATIVE, YOU ARE FLYING THE WRONG SID, YOU WERE ASSIGNED THE BUZARD 3J SID. FLY HEADING 275 DEGS, MAINTAIN 6000 FT. WE WERE HANDED OFF TO DEP CTL AND THE DEP WAS WITHOUT FURTHER INCIDENT. WX WAS VMC DURING DEP, NO OTHER TFC WAS OBSERVED, AND NO TCAS FA'S OR TA'S WERE RECEIVED. OTHER FACTORS: ALL CREWMEMBERS WERE EXPERIENCED IN LHR OPS. THE CREW WAS WELL RESTED AND ALL SOP'S WERE COMPLIED WITH. BOTH FO'S WERE PROFICIENT AND PROFESSIONAL. ACR FOM PAGE REQUIRES THAT THE DEPT SID NAME BE STATED ON INITIAL CONTACT WITH DEP CTL. THE LATE HANDOFF BY TWR PRECLUDED THIS SAFETY BACKUP FOR PROPER SID COMPLIANCE. THE LHR PROC OF ONLY KNOWING YOUR SID ASSIGNMENT AT THE LAST MOMENT BEFORE PUSHBACK COMPROMISES INSTALLATION, BRIEFING AND COMPLIANCE. IT WAS POSSIBLE THAT ALL THREE CREWMEMBERS MISHEARD THE SID ASSIGNMENT. HOWEVER, ALL CREWMEMBERS LISTENED TO THE CLRNC, AND HEARD THE FO READ BACK THE COMPTON 5J. CLR DELIVERY DID NOT CORRECT THE READ BACK IF IN FACT IT WAS DIFFERENT THAN THE ONE ISSUED. THE SID SHOULD BE PART OF THE UPLINK PROCESS. RECOMMEND LHR TWR ISSUE TKOF CLRNC AS 'CLR TKOF FLY XXX SID.'
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.