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|
Attributes | |
ACN | 534192 |
Time | |
Date | 200112 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : egll.airport |
State Reference | FO |
Altitude | msl single value : 500 |
Aircraft 1 | |
Controlling Facilities | tower : egll.tower tower : ewr.tower |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 534192 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time none taken : anomaly accepted |
Consequence | other Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Airspace Structure Aircraft ATC Human Performance Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Location: lhr departure. Departure was at XA00, which translated to XQ00 body time, which meant an XM00 wake-up call body time. Preflight was conducted with numerous interruptions by ground and cabin personnel. As captain, it was my first month flying european international. It was our first leg with the relief pilot and it was his third trip to lhr. The first officer had the most time in the airplane and the most recent european experience. He was flying the airplane. The flight plan was uplinked to the FMC with a departure runway of runway 27R. I selected the CPT3F SID, for which we were filed and subsequently cleared. I tuned the lon 260 degree radial on the #1 VOR and the wes NDB on the #2 ADF. Route and legs checks were performed. Due to time constraints, the first officer's apparent familiarity with the departure, and against my better judgement, I checked only the legs on the flight plan and not on the SID. On this departure the first turn occurs after clearing 500 ft, 6 mi from the lon VOR and about 2 mi from the end of the runway -- a very busy time in the profile. As we crossed the lon 260 degree radial, I noticed the airplane was slightly right of the FMC routing and the first officer had not commenced his turn. While changing frequencys, monitoring airplane performance and retracting the flaps, I told him to turn left. He corrected back to the FMC routing. At that point I noted that the depiction of the FMC route did not properly overlay the lon 260 degree radial, and that we were proceeding directly to cpt instead of flying the departure which involves a couple of doglegs to get to cpt. By the time I sorted out what the problem was, it was too late to do an appropriate correction. We proceeded directly to cpt and on course. Nothing was said by ATC about the deviation. I do not know why the SID was not in our active route. Possibly it was inadvertently deleted in the route copy process. There were some interruptions occurring while that was being accomplished and route 1 may have been originally copied to route 2 without the SID, and then route 2 may have erroneously been copied back to route 1 after the SID had been inserted into route 1. In any event, there were numerous subsequent opportunities to catch the error, and we failed to take advantage of any of them. The legs check must include the SID. Make sure the FMC route properly overlays the raw data. On the departure runway, make a final check of the active waypoint. If the raw data and FMC disagree, follow the raw data. Don't let someone else's apparent comfort lead you to drop your vigilance.
Original NASA ASRS Text
Title: A B777 DEP PROC IS FLAWED WHEN THE FMC AND THE FLC FAIL TO FOLLOW THE CPT 3F DEP PROC OUT OF EGLL, FO.
Narrative: LOCATION: LHR DEP. DEP WAS AT XA00, WHICH TRANSLATED TO XQ00 BODY TIME, WHICH MEANT AN XM00 WAKE-UP CALL BODY TIME. PREFLT WAS CONDUCTED WITH NUMEROUS INTERRUPTIONS BY GND AND CABIN PERSONNEL. AS CAPT, IT WAS MY FIRST MONTH FLYING EUROPEAN INTL. IT WAS OUR FIRST LEG WITH THE RELIEF PLT AND IT WAS HIS THIRD TRIP TO LHR. THE FO HAD THE MOST TIME IN THE AIRPLANE AND THE MOST RECENT EUROPEAN EXPERIENCE. HE WAS FLYING THE AIRPLANE. THE FLT PLAN WAS UPLINKED TO THE FMC WITH A DEP RWY OF RWY 27R. I SELECTED THE CPT3F SID, FOR WHICH WE WERE FILED AND SUBSEQUENTLY CLRED. I TUNED THE LON 260 DEG RADIAL ON THE #1 VOR AND THE WES NDB ON THE #2 ADF. RTE AND LEGS CHKS WERE PERFORMED. DUE TO TIME CONSTRAINTS, THE FO'S APPARENT FAMILIARITY WITH THE DEP, AND AGAINST MY BETTER JUDGEMENT, I CHKED ONLY THE LEGS ON THE FLT PLAN AND NOT ON THE SID. ON THIS DEP THE FIRST TURN OCCURS AFTER CLRING 500 FT, 6 MI FROM THE LON VOR AND ABOUT 2 MI FROM THE END OF THE RWY -- A VERY BUSY TIME IN THE PROFILE. AS WE CROSSED THE LON 260 DEG RADIAL, I NOTICED THE AIRPLANE WAS SLIGHTLY R OF THE FMC ROUTING AND THE FO HAD NOT COMMENCED HIS TURN. WHILE CHANGING FREQS, MONITORING AIRPLANE PERFORMANCE AND RETRACTING THE FLAPS, I TOLD HIM TO TURN L. HE CORRECTED BACK TO THE FMC ROUTING. AT THAT POINT I NOTED THAT THE DEPICTION OF THE FMC RTE DID NOT PROPERLY OVERLAY THE LON 260 DEG RADIAL, AND THAT WE WERE PROCEEDING DIRECTLY TO CPT INSTEAD OF FLYING THE DEP WHICH INVOLVES A COUPLE OF DOGLEGS TO GET TO CPT. BY THE TIME I SORTED OUT WHAT THE PROB WAS, IT WAS TOO LATE TO DO AN APPROPRIATE CORRECTION. WE PROCEEDED DIRECTLY TO CPT AND ON COURSE. NOTHING WAS SAID BY ATC ABOUT THE DEV. I DO NOT KNOW WHY THE SID WAS NOT IN OUR ACTIVE RTE. POSSIBLY IT WAS INADVERTENTLY DELETED IN THE RTE COPY PROCESS. THERE WERE SOME INTERRUPTIONS OCCURRING WHILE THAT WAS BEING ACCOMPLISHED AND RTE 1 MAY HAVE BEEN ORIGINALLY COPIED TO RTE 2 WITHOUT THE SID, AND THEN RTE 2 MAY HAVE ERRONEOUSLY BEEN COPIED BACK TO RTE 1 AFTER THE SID HAD BEEN INSERTED INTO RTE 1. IN ANY EVENT, THERE WERE NUMEROUS SUBSEQUENT OPPORTUNITIES TO CATCH THE ERROR, AND WE FAILED TO TAKE ADVANTAGE OF ANY OF THEM. THE LEGS CHK MUST INCLUDE THE SID. MAKE SURE THE FMC RTE PROPERLY OVERLAYS THE RAW DATA. ON THE DEP RWY, MAKE A FINAL CHK OF THE ACTIVE WAYPOINT. IF THE RAW DATA AND FMC DISAGREE, FOLLOW THE RAW DATA. DON'T LET SOMEONE ELSE'S APPARENT COMFORT LEAD YOU TO DROP YOUR VIGILANCE.
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.