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|
Attributes | |
ACN | 535393 |
Time | |
Date | 200201 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
State Reference | NJ |
Altitude | msl single value : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | general aviation : corporate |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 135 |
Navigation In Use | other other other vortac |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 89 flight time total : 6800 flight time type : 642 |
ASRS Report | 535393 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 91 flight time total : 11000 flight time type : 2000 |
ASRS Report | 535971 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Passenger Human Performance Flight Crew Human Performance Airspace Structure Environmental Factor ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After completing departure procedures out phl, we were cleared to 10000 ft and direct our first fix (ditch). (Phl to bdl is our most routine flight.) approximately 15 NM from ditch, we were given a climb to 12000 ft, 2 TA's, and a frequency change to ZNY on 118.97. We acknowledged the climb to 12000 ft, the TA and the frequency change. I reduced my mfd to the 10 NM range for clrer TCASII depiction. I then directed my attention outside to search visually for the traffic. Approaching ditch we were given a climb to FL190 and TA. We acknowledged the climb and I started searching visually for the traffic. The captain alerted me to an irregularity with the fuel xfer system. I acknowledged what he observed and continued to look for traffic. Shortly after, I called traffic in sight. Simultaneously, I heard the captain say, 'this isn't the right flight plan, we are going the wrong way.' the statement immediately directed me back into the cockpit. Just as the captain started a correcting turn, ATC requested that we stop our climb at 17000 ft and turn to a heading of 010 degrees. Once established on heading we were cleared to FL190 with routing to our destination (bdl). ATC inquired about our assigned routing. Before we answered, the controller said 'north-number, contact new york on 125.32?' we acknowledged and continued on to our destination. To my knowledge no other aircraft were directly affected. The wrong flight plan was entered into the FMS due to break in normal procedure. The chain of events are as follows: we started the engines and commenced with the cockpit setup. I noticed the captain had initialized his onside FMS, but had not xfilled the information to the copilot's side. I decided to help and finish the task. In hindsight, I shouldn't have done this for it does not conform to our normal procedure. I also did not verify and xchk our cleared flight against our FMS flight plan. Once the setup was complete we ran the checklist to confirm we did not omit any items. Unfortunately there are 2 rtes to bdl that we use and the initial fix on both is ditch. This similarity would have inhibited us from discovering the error on our predep brief, in which we only verify our initial fix. Contributing factors to initial error: 1) failure to verify and xchk flight plan entry with route cleared. 2) unnecessary urgency to complete cockpit procedures quickly. 3) both possible rtes had the same initial fix. Factors that distraction crew from error: 1) irregularity with aircraft system. 2) number of TA's. 3) both rtes were to the same destination and equally familiar to the crew. In this situation there were a number of missed opportunities to identify and correct the error. This is a wake-up call to how easy situational awareness can be lost in a familiar environment. Corrective action will result in a formal procedure pertaining to the role of each crew member during FMS initialization and a review of all procedures for similar weaknesses. Supplemental information from acn 535971: were given 2 TA's. The FMS range was reduced to 5 mi to enhance TCASII identify of the crossing traffic. Due to our position, this range selection prevented a visual depiction of our selected route beyond ditch intersection. The first officer's attention was directed outside and mine was directed inside at that point by a fuel xfer anomaly. No one was navigating. In our review we noted the passenger had arrived early. I selected the stored flight plan that I believed to be correct and entered it in the FMS. On this day I elected to save a few seconds and enter the V speeds during that time period with the intention of returning to the FMS for confirmation. I assumed the first officer had made the confirmation. From the beginning, this flight progressed on the assumption that the flight plan in the FMS was correct. When assumptions are made, whether consciously or unconsciously, situational awareness is easily lost and difficult to regain, even in the most familiar of environments. We now have a more formal procedure for crew acknowledgement of the correct flight plan display as well as a renewed commitment to follow existing procedures.
Original NASA ASRS Text
Title: A CPR TWIN JET STARTS TO FLY THE WRONG RTE TO A COMMON DEST WITH THE CREW BEING DISTR BY TFC, AN EQUIP PROB, AND THE WRONG RTE PLACED IN THEIR FMC AFTER DEP PHL, PA.
Narrative: AFTER COMPLETING DEP PROCS OUT PHL, WE WERE CLRED TO 10000 FT AND DIRECT OUR FIRST FIX (DITCH). (PHL TO BDL IS OUR MOST ROUTINE FLT.) APPROX 15 NM FROM DITCH, WE WERE GIVEN A CLB TO 12000 FT, 2 TA'S, AND A FREQ CHANGE TO ZNY ON 118.97. WE ACKNOWLEDGED THE CLB TO 12000 FT, THE TA AND THE FREQ CHANGE. I REDUCED MY MFD TO THE 10 NM RANGE FOR CLRER TCASII DEPICTION. I THEN DIRECTED MY ATTN OUTSIDE TO SEARCH VISUALLY FOR THE TFC. APCHING DITCH WE WERE GIVEN A CLB TO FL190 AND TA. WE ACKNOWLEDGED THE CLB AND I STARTED SEARCHING VISUALLY FOR THE TFC. THE CAPT ALERTED ME TO AN IRREGULARITY WITH THE FUEL XFER SYS. I ACKNOWLEDGED WHAT HE OBSERVED AND CONTINUED TO LOOK FOR TFC. SHORTLY AFTER, I CALLED TFC IN SIGHT. SIMULTANEOUSLY, I HEARD THE CAPT SAY, 'THIS ISN'T THE RIGHT FLT PLAN, WE ARE GOING THE WRONG WAY.' THE STATEMENT IMMEDIATELY DIRECTED ME BACK INTO THE COCKPIT. JUST AS THE CAPT STARTED A CORRECTING TURN, ATC REQUESTED THAT WE STOP OUR CLB AT 17000 FT AND TURN TO A HDG OF 010 DEGS. ONCE ESTABLISHED ON HDG WE WERE CLRED TO FL190 WITH ROUTING TO OUR DEST (BDL). ATC INQUIRED ABOUT OUR ASSIGNED ROUTING. BEFORE WE ANSWERED, THE CTLR SAID 'N-NUMBER, CONTACT NEW YORK ON 125.32?' WE ACKNOWLEDGED AND CONTINUED ON TO OUR DEST. TO MY KNOWLEDGE NO OTHER ACFT WERE DIRECTLY AFFECTED. THE WRONG FLT PLAN WAS ENTERED INTO THE FMS DUE TO BREAK IN NORMAL PROC. THE CHAIN OF EVENTS ARE AS FOLLOWS: WE STARTED THE ENGS AND COMMENCED WITH THE COCKPIT SETUP. I NOTICED THE CAPT HAD INITIALIZED HIS ONSIDE FMS, BUT HAD NOT XFILLED THE INFO TO THE COPLT'S SIDE. I DECIDED TO HELP AND FINISH THE TASK. IN HINDSIGHT, I SHOULDN'T HAVE DONE THIS FOR IT DOES NOT CONFORM TO OUR NORMAL PROC. I ALSO DID NOT VERIFY AND XCHK OUR CLRED FLT AGAINST OUR FMS FLT PLAN. ONCE THE SETUP WAS COMPLETE WE RAN THE CHKLIST TO CONFIRM WE DID NOT OMIT ANY ITEMS. UNFORTUNATELY THERE ARE 2 RTES TO BDL THAT WE USE AND THE INITIAL FIX ON BOTH IS DITCH. THIS SIMILARITY WOULD HAVE INHIBITED US FROM DISCOVERING THE ERROR ON OUR PREDEP BRIEF, IN WHICH WE ONLY VERIFY OUR INITIAL FIX. CONTRIBUTING FACTORS TO INITIAL ERROR: 1) FAILURE TO VERIFY AND XCHK FLT PLAN ENTRY WITH RTE CLRED. 2) UNNECESSARY URGENCY TO COMPLETE COCKPIT PROCS QUICKLY. 3) BOTH POSSIBLE RTES HAD THE SAME INITIAL FIX. FACTORS THAT DISTR CREW FROM ERROR: 1) IRREGULARITY WITH ACFT SYS. 2) NUMBER OF TA'S. 3) BOTH RTES WERE TO THE SAME DEST AND EQUALLY FAMILIAR TO THE CREW. IN THIS SIT THERE WERE A NUMBER OF MISSED OPPORTUNITIES TO IDENT AND CORRECT THE ERROR. THIS IS A WAKE-UP CALL TO HOW EASY SITUATIONAL AWARENESS CAN BE LOST IN A FAMILIAR ENVIRONMENT. CORRECTIVE ACTION WILL RESULT IN A FORMAL PROC PERTAINING TO THE ROLE OF EACH CREW MEMBER DURING FMS INITIALIZATION AND A REVIEW OF ALL PROCS FOR SIMILAR WEAKNESSES. SUPPLEMENTAL INFO FROM ACN 535971: WERE GIVEN 2 TA'S. THE FMS RANGE WAS REDUCED TO 5 MI TO ENHANCE TCASII IDENT OF THE XING TFC. DUE TO OUR POS, THIS RANGE SELECTION PREVENTED A VISUAL DEPICTION OF OUR SELECTED RTE BEYOND DITCH INTXN. THE FO'S ATTN WAS DIRECTED OUTSIDE AND MINE WAS DIRECTED INSIDE AT THAT POINT BY A FUEL XFER ANOMALY. NO ONE WAS NAVING. IN OUR REVIEW WE NOTED THE PAX HAD ARRIVED EARLY. I SELECTED THE STORED FLT PLAN THAT I BELIEVED TO BE CORRECT AND ENTERED IT IN THE FMS. ON THIS DAY I ELECTED TO SAVE A FEW SECONDS AND ENTER THE V SPDS DURING THAT TIME PERIOD WITH THE INTENTION OF RETURNING TO THE FMS FOR CONFIRMATION. I ASSUMED THE FO HAD MADE THE CONFIRMATION. FROM THE BEGINNING, THIS FLT PROGRESSED ON THE ASSUMPTION THAT THE FLT PLAN IN THE FMS WAS CORRECT. WHEN ASSUMPTIONS ARE MADE, WHETHER CONSCIOUSLY OR UNCONSCIOUSLY, SITUATIONAL AWARENESS IS EASILY LOST AND DIFFICULT TO REGAIN, EVEN IN THE MOST FAMILIAR OF ENVIRONMENTS. WE NOW HAVE A MORE FORMAL PROC FOR CREW ACKNOWLEDGEMENT OF THE CORRECT FLT PLAN DISPLAY AS WELL AS A RENEWED COMMITMENT TO FOLLOW EXISTING PROCS.
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.