 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
An MD11 cargo flight flies the wrong arrival after acknowledging the amended clearance but fail to change the FMC approach over venus intersection, first officer.
| Attributes | |
| ACN | 556276 |
| Time | |
| Date | 200208 |
| Day | Wed |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : rjaa.airport |
| State Reference | FO |
| Altitude | msl single value : 11000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : a80.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | MD-11 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | descent : intermediate altitude |
| Route In Use | arrival star : venus |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time total : 11000 |
| ASRS Report | 556276 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | non adherence : published procedure non adherence : clearance non adherence : company policies other anomaly other other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
| Supplementary | |
| Problem Areas | Environmental Factor ATC Human Performance Flight Crew Human Performance |
| Primary Problem | Environmental Factor |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Crew missed changing FMS arrival while on descent to narita airport, tokyo, japan. An FMS arrival was loaded into FMS that contained IAF and flight plan for appropriate runway. ATC issued a new arrival while 20 mi prior to IAF. Crew read back new clearance, but did not change FMS arrival. Both arrs start at same IAF (venus intersection) and have same second fix in arrival (very similar rtes). As first officer noticed difference in routing, first officer went to change arrival. At same moment, ATC issued a heading change and issued vectors for remainder of arrival. ATC did not mention the 2-3 mi off course arrival. The aircraft had deviated from ATC arrival. Factors that caused event were crew fatigue and ATC arrival clearance issued close to IAF while aircraft was in high rate of descent to make crossing restr at IAF. Captain had interrupted sleep due to jet lag (approximately 5 hours of sleep in last 36 hours). Crew had been on duty approximately 9 hours at occurrence of event.
Original NASA ASRS Text
Title: AN MD11 CARGO FLT FLIES THE WRONG ARR AFTER ACKNOWLEDGING THE AMENDED CLRNC BUT FAIL TO CHANGE THE FMC APCH OVER VENUS INTXN, FO.
Narrative: CREW MISSED CHANGING FMS ARR WHILE ON DSCNT TO NARITA ARPT, TOKYO, JAPAN. AN FMS ARR WAS LOADED INTO FMS THAT CONTAINED IAF AND FLT PLAN FOR APPROPRIATE RWY. ATC ISSUED A NEW ARR WHILE 20 MI PRIOR TO IAF. CREW READ BACK NEW CLRNC, BUT DID NOT CHANGE FMS ARR. BOTH ARRS START AT SAME IAF (VENUS INTXN) AND HAVE SAME SECOND FIX IN ARR (VERY SIMILAR RTES). AS FO NOTICED DIFFERENCE IN ROUTING, FO WENT TO CHANGE ARR. AT SAME MOMENT, ATC ISSUED A HDG CHANGE AND ISSUED VECTORS FOR REMAINDER OF ARR. ATC DID NOT MENTION THE 2-3 MI OFF COURSE ARR. THE ACFT HAD DEVIATED FROM ATC ARR. FACTORS THAT CAUSED EVENT WERE CREW FATIGUE AND ATC ARR CLRNC ISSUED CLOSE TO IAF WHILE ACFT WAS IN HIGH RATE OF DSCNT TO MAKE XING RESTR AT IAF. CAPT HAD INTERRUPTED SLEEP DUE TO JET LAG (APPROX 5 HRS OF SLEEP IN LAST 36 HRS). CREW HAD BEEN ON DUTY APPROX 9 HRS AT OCCURRENCE OF EVENT.
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.