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|
Attributes | |
ACN | 542593 |
Time | |
Date | 200203 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | msl single value : 300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon tower : lax.tower |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial climbout : takeoff |
Route In Use | departure sid : n/s |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | observation : air carrier inspector |
Qualification | pilot : atp |
Experience | flight time last 90 days : 0 flight time total : 5800 flight time type : 3 |
ASRS Report | 542593 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 20000 flight time type : 1500 |
ASRS Report | 542603 |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | controller : issued alert flight crew : became reoriented other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I am an FAA aviation safety inspector (operations). I occupied the first observer's jump seat on a B747-400 from lax. The flight crew failed to get and review their IFR en route clearance prior to departure. I am rated in the B747-400 aircraft. I maintain currency and take a yearly proficiency check in the B747-400 simulator. I am supposed to know and adhere to SOP's. Therefore, I share responsibility for the error. Our first indication of the error came after takeoff when the socal departure controller asked the crew to check transponder and squawk XXXX, YYYY had been set in the transponder. The first officer then requested route clearance through the ACARS units. The clearance was identical to the flight plan entered into the FMS, so no ATC deviations occurred. There are several contributing factors. The captain, a highly experienced pilot with several yrs in the B747-400 was on reserve and was called out 4 hours prior to scheduled takeoff. He arrived at the aircraft about 1 hour before scheduled pushback time. He completed much of the cockpit setup and preflight procedures, including the walkaround inspection. The scheduled first officer failed to show for the flight so a reserve first officer arrived at the aircraft about 10 mins after scheduled pushback time. Therefore, there was some haste to get checklists done. The aircraft pushed back from the gate at XA17. Air carrier has elaborate procedures to ensure that the flight crew gets its predep clearance. A reference is on the captain's briefing card. Procedures appear in the B747-400 flight manual. Crews set YYYY in the transponder after landing to remind the next crew that they'll need a clearance and transponder code. In this case, all those procedures failed to prevent the error. Supplemental information from acn 542603: we pushed back and taxied to runway 24L, a runway I haven't used in yrs! We both were reading the abbreviated instructions to get to runway 24L and got totally involved in taxiing and briefing the departure plate. I looked down at the transponder and saw YYYY. I immediately realized we had not gotten our pre departure clearance.
Original NASA ASRS Text
Title: FLC FAILED TO VERIFY LOAD XPONDER CODE PRIOR TO TKOF. ATC ISSUED XPONDER CODE DURING DEP. FLC REALIZED MISTAKE.
Narrative: I AM AN FAA AVIATION SAFETY INSPECTOR (OPS). I OCCUPIED THE FIRST OBSERVER'S JUMP SEAT ON A B747-400 FROM LAX. THE FLC FAILED TO GET AND REVIEW THEIR IFR ENRTE CLRNC PRIOR TO DEP. I AM RATED IN THE B747-400 ACFT. I MAINTAIN CURRENCY AND TAKE A YEARLY PROFICIENCY CHK IN THE B747-400 SIMULATOR. I AM SUPPOSED TO KNOW AND ADHERE TO SOP'S. THEREFORE, I SHARE RESPONSIBILITY FOR THE ERROR. OUR FIRST INDICATION OF THE ERROR CAME AFTER TKOF WHEN THE SOCAL DEP CTLR ASKED THE CREW TO CHK XPONDER AND SQUAWK XXXX, YYYY HAD BEEN SET IN THE XPONDER. THE FO THEN REQUESTED RTE CLRNC THROUGH THE ACARS UNITS. THE CLRNC WAS IDENTICAL TO THE FLT PLAN ENTERED INTO THE FMS, SO NO ATC DEVS OCCURRED. THERE ARE SEVERAL CONTRIBUTING FACTORS. THE CAPT, A HIGHLY EXPERIENCED PLT WITH SEVERAL YRS IN THE B747-400 WAS ON RESERVE AND WAS CALLED OUT 4 HRS PRIOR TO SCHEDULED TKOF. HE ARRIVED AT THE ACFT ABOUT 1 HR BEFORE SCHEDULED PUSHBACK TIME. HE COMPLETED MUCH OF THE COCKPIT SETUP AND PREFLT PROCS, INCLUDING THE WALKAROUND INSPECTION. THE SCHEDULED FO FAILED TO SHOW FOR THE FLT SO A RESERVE FO ARRIVED AT THE ACFT ABOUT 10 MINS AFTER SCHEDULED PUSHBACK TIME. THEREFORE, THERE WAS SOME HASTE TO GET CHKLISTS DONE. THE ACFT PUSHED BACK FROM THE GATE AT XA17. ACR HAS ELABORATE PROCS TO ENSURE THAT THE FLC GETS ITS PREDEP CLRNC. A REF IS ON THE CAPT'S BRIEFING CARD. PROCS APPEAR IN THE B747-400 FLT MANUAL. CREWS SET YYYY IN THE XPONDER AFTER LNDG TO REMIND THE NEXT CREW THAT THEY'LL NEED A CLRNC AND XPONDER CODE. IN THIS CASE, ALL THOSE PROCS FAILED TO PREVENT THE ERROR. SUPPLEMENTAL INFO FROM ACN 542603: WE PUSHED BACK AND TAXIED TO RWY 24L, A RWY I HAVEN'T USED IN YRS! WE BOTH WERE READING THE ABBREVIATED INSTRUCTIONS TO GET TO RWY 24L AND GOT TOTALLY INVOLVED IN TAXIING AND BRIEFING THE DEP PLATE. I LOOKED DOWN AT THE XPONDER AND SAW YYYY. I IMMEDIATELY REALIZED WE HAD NOT GOTTEN OUR PDC.
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.