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|
Attributes | |
ACN | 536012 |
Time | |
Date | 200201 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
State Reference | FO |
Altitude | msl single value : 17000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ewr.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : osn1a |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 7000 flight time type : 4000 |
ASRS Report | 536012 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 1100 |
ASRS Report | 535840 |
Events | |
Anomaly | non adherence : far non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance ATC Human Performance Airport Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departing inchon airport, we flew the wrong departure. The problem arose after numerous runway changes and a maintenance delay of 1 hour. We had 4 different runway assignments and 3 different departure assignments. Each change required a reprogramming of the FMS computers. The final change was a last min change which was handled by the copilot. In accomplishing this last min change, we activated the stored flight plan with the other runway. Unfortunately we had not updated it with the most current SID change. We did not catch the omission. On climb out, ATC caught our mistake when we were about 5 mi off course. The contributing factors were the numerous runway and SID changes. The maintenance delay was also a factor, as was the language differences. Future preventive steps will be: 1) modify only active flight plan in computer. 2) stop aircraft and then check changes. 3) do a point-by-point check of the changes. 4) xchk departure plate against actual FMS route of flight. 5) take one's time to accomplish all tasks. Supplemental information from acn 535840: upon taxi out, the departure runway was changed to runway 33L and the secondary flight plan was activated. However, neither crew member noticed that the OSN1A was displayed. During climb out, several traffic targets were called out by departure control and verified on TCASII. Upon arriving at the osn 305 degree radial, 25 DME, departure told us that we were on the ONS1A ground track versus the TAEA1 track. We estimated that we were 5-6 mi northeast of the TAEA1 track.
Original NASA ASRS Text
Title: AN MD11 CREW, DEPARTING SEOUL, KOREA (RKSS), FLEW THE WRONG SID, SPAWNING QUESTIONS FROM ATC.
Narrative: DEPARTING INCHON ARPT, WE FLEW THE WRONG DEP. THE PROB AROSE AFTER NUMEROUS RWY CHANGES AND A MAINT DELAY OF 1 HR. WE HAD 4 DIFFERENT RWY ASSIGNMENTS AND 3 DIFFERENT DEP ASSIGNMENTS. EACH CHANGE REQUIRED A REPROGRAMMING OF THE FMS COMPUTERS. THE FINAL CHANGE WAS A LAST MIN CHANGE WHICH WAS HANDLED BY THE COPLT. IN ACCOMPLISHING THIS LAST MIN CHANGE, WE ACTIVATED THE STORED FLT PLAN WITH THE OTHER RWY. UNFORTUNATELY WE HAD NOT UPDATED IT WITH THE MOST CURRENT SID CHANGE. WE DID NOT CATCH THE OMISSION. ON CLBOUT, ATC CAUGHT OUR MISTAKE WHEN WE WERE ABOUT 5 MI OFF COURSE. THE CONTRIBUTING FACTORS WERE THE NUMEROUS RWY AND SID CHANGES. THE MAINT DELAY WAS ALSO A FACTOR, AS WAS THE LANGUAGE DIFFERENCES. FUTURE PREVENTIVE STEPS WILL BE: 1) MODIFY ONLY ACTIVE FLT PLAN IN COMPUTER. 2) STOP ACFT AND THEN CHK CHANGES. 3) DO A POINT-BY-POINT CHK OF THE CHANGES. 4) XCHK DEP PLATE AGAINST ACTUAL FMS RTE OF FLT. 5) TAKE ONE'S TIME TO ACCOMPLISH ALL TASKS. SUPPLEMENTAL INFO FROM ACN 535840: UPON TAXI OUT, THE DEP RWY WAS CHANGED TO RWY 33L AND THE SECONDARY FLT PLAN WAS ACTIVATED. HOWEVER, NEITHER CREW MEMBER NOTICED THAT THE OSN1A WAS DISPLAYED. DURING CLBOUT, SEVERAL TFC TARGETS WERE CALLED OUT BY DEP CTL AND VERIFIED ON TCASII. UPON ARRIVING AT THE OSN 305 DEG RADIAL, 25 DME, DEP TOLD US THAT WE WERE ON THE ONS1A GND TRACK VERSUS THE TAEA1 TRACK. WE ESTIMATED THAT WE WERE 5-6 MI NE OF THE TAEA1 TRACK.
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.