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|
Attributes | |
ACN | 553394 |
Time | |
Date | 200207 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : las.vortac |
State Reference | NV |
Altitude | msl bound lower : 8000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : idale one |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Experience | controller radar : 19 controller time certified in position1 : 12 |
ASRS Report | 553394 |
Person 2 | |
Affiliation | government : faa |
Function | controller : supervisor |
Events | |
Anomaly | inflight encounter other non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar/mode c other controllera other flight crewa |
Resolutory Action | controller : issued advisory flight crew : returned to intended or assigned course flight crew : exited adverse environment |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
B737, on idale 1 departure (RNAV departure) on the departure turned 3-4 mi too early, before idale, turned west into higher terrain. Pilot turned early without ATC's instruction. Pilot deviation supervisor informed. This occurred while working west departure at XA27Z. I observed B737 at about 8000 ft in a 4500 ft MOA. Supplemental information from acn 553775: after engine start and taxi, ground control issued a runway and departure routing change, runway 25R on the idale departure. Original runway was runway 7L on the miney departure. First officer reprogrammed FMC during taxi to runway 25R. The departure was normal until the idale fix. With the autoplt engaged and the LNAV mode selected, the aircraft started a right northwesterly turn. We recognized that something was wrong due to our proximity to high terrain. FMC routing showed the next fix, coaldale (oak) at 304 degrees. After turning 60 degrees, departure control asked 'are you turning? You turned 3 mi early.' he then gave us a turn to heading 220 degrees (toward high terrain?) and a climb to 11000 ft. We started the turn and climb and advised that 'we have the terrain in sight.' we then discovered that 2 fixes (shead and bikkr) had been deleted from the departure routing. We were then cleared to shead fix which we had to enter manually into the FMC. Cause of incident: FMC routing error. 2 fixes deleted/omitted from the departure routing. Contributing factors: change of runway/departure routing while taxiing. Location of single FMC installation in cockpit requiring xcockpit scan while taxiing and flying.
Original NASA ASRS Text
Title: A B737 CREW DEPARTING LAS TURNED EARLY ON THE IDALE 1 DEP INTO HIGHER TERRAIN.
Narrative: B737, ON IDALE 1 DEP (RNAV DEP) ON THE DEP TURNED 3-4 MI TOO EARLY, BEFORE IDALE, TURNED W INTO HIGHER TERRAIN. PLT TURNED EARLY WITHOUT ATC'S INSTRUCTION. PLTDEV SUPVR INFORMED. THIS OCCURRED WHILE WORKING W DEP AT XA27Z. I OBSERVED B737 AT ABOUT 8000 FT IN A 4500 FT MOA. SUPPLEMENTAL INFO FROM ACN 553775: AFTER ENG START AND TAXI, GND CTL ISSUED A RWY AND DEP ROUTING CHANGE, RWY 25R ON THE IDALE DEP. ORIGINAL RWY WAS RWY 7L ON THE MINEY DEP. FO REPROGRAMMED FMC DURING TAXI TO RWY 25R. THE DEP WAS NORMAL UNTIL THE IDALE FIX. WITH THE AUTOPLT ENGAGED AND THE LNAV MODE SELECTED, THE ACFT STARTED A R NORTHWESTERLY TURN. WE RECOGNIZED THAT SOMETHING WAS WRONG DUE TO OUR PROX TO HIGH TERRAIN. FMC ROUTING SHOWED THE NEXT FIX, COALDALE (OAK) AT 304 DEGS. AFTER TURNING 60 DEGS, DEP CTL ASKED 'ARE YOU TURNING? YOU TURNED 3 MI EARLY.' HE THEN GAVE US A TURN TO HDG 220 DEGS (TOWARD HIGH TERRAIN?) AND A CLB TO 11000 FT. WE STARTED THE TURN AND CLB AND ADVISED THAT 'WE HAVE THE TERRAIN IN SIGHT.' WE THEN DISCOVERED THAT 2 FIXES (SHEAD AND BIKKR) HAD BEEN DELETED FROM THE DEP ROUTING. WE WERE THEN CLRED TO SHEAD FIX WHICH WE HAD TO ENTER MANUALLY INTO THE FMC. CAUSE OF INCIDENT: FMC ROUTING ERROR. 2 FIXES DELETED/OMITTED FROM THE DEP ROUTING. CONTRIBUTING FACTORS: CHANGE OF RWY/DEP ROUTING WHILE TAXIING. LOCATION OF SINGLE FMC INSTALLATION IN COCKPIT REQUIRING XCOCKPIT SCAN WHILE TAXIING AND FLYING.
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.