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|
Attributes | |
ACN | 570645 |
Time | |
Date | 200301 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 5000 msl bound upper : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon tower : sea.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : aaces |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 70 flight time total : 5700 flight time type : 500 |
ASRS Report | 570645 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 120 flight time total : 7000 flight time type : 4200 |
ASRS Report | 570786 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure non adherence : company policies non adherence : far other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Captain's leg, briefed LNAV and autoplt engagement altitudes at gate for aaces 1 RNAV department las. Completed all IRS alignments/updates. Upon taking the runway, captain advised me he heard las operations trying to raise us on company frequency. We ignored the call as we were about to receive our takeoff clearance on runway 19L. After takeoff, captain engaged LNAV at 400 ft and then called for 'flaps 1 degree, climb thrust at 1000 ft.' I did not confirm whether he engaged the autoplt at that point. He requested that I check on what company wanted after we finished cleaning up the aircraft, and although we were below 10000 ft still, it didn't seem like an unreasonable time due to security concerns -- we had experienced a delay in boarding with passenger not found, then found, bags on/offirst officern again, etc. I left frequency, and company advised they had no message, apparently they were just unaware we were delayed off the gate and thought we had forgot to call times in. Upon returning to las departure frequency, the controller advised us that we hadn't yet been given a shortcut on the departure, to turn immediately to heading 180 degrees. I looked down and saw us off the departure, and inquired of the captain whether we had received a vector while I was off frequency. After some initial confusion, he realized that the autoplt had not engaged, although he had thought that he selected it. The captain's failure to confirm the autoplt engagement, my failure to back him up with the engagement, a lack of positional awareness despite that map display right in front of both of us, distraction from the operations call, and that good old 'rushed out of the gate, we're late' feeling contributed to this event. A possible solution might be to include some type of callout about the autoplt in SOP's for RNAV departures. At 1000 ft, when the autoplt should be coming on, the PNF is distraction with flaps and setting climb power and isn't deliberately placed in the loop about the autoplt engagement.
Original NASA ASRS Text
Title: B737 FLT CREW INADVERTENTLY DEVIATES FROM ASSIGNED DEP CLRNC.
Narrative: CAPT'S LEG, BRIEFED LNAV AND AUTOPLT ENGAGEMENT ALTS AT GATE FOR AACES 1 RNAV DEPT LAS. COMPLETED ALL IRS ALIGNMENTS/UPDATES. UPON TAKING THE RWY, CAPT ADVISED ME HE HEARD LAS OPS TRYING TO RAISE US ON COMPANY FREQ. WE IGNORED THE CALL AS WE WERE ABOUT TO RECEIVE OUR TKOF CLRNC ON RWY 19L. AFTER TKOF, CAPT ENGAGED LNAV AT 400 FT AND THEN CALLED FOR 'FLAPS 1 DEG, CLB THRUST AT 1000 FT.' I DID NOT CONFIRM WHETHER HE ENGAGED THE AUTOPLT AT THAT POINT. HE REQUESTED THAT I CHK ON WHAT COMPANY WANTED AFTER WE FINISHED CLEANING UP THE ACFT, AND ALTHOUGH WE WERE BELOW 10000 FT STILL, IT DIDN'T SEEM LIKE AN UNREASONABLE TIME DUE TO SECURITY CONCERNS -- WE HAD EXPERIENCED A DELAY IN BOARDING WITH PAX NOT FOUND, THEN FOUND, BAGS ON/OFF/ON AGAIN, ETC. I LEFT FREQ, AND COMPANY ADVISED THEY HAD NO MESSAGE, APPARENTLY THEY WERE JUST UNAWARE WE WERE DELAYED OFF THE GATE AND THOUGHT WE HAD FORGOT TO CALL TIMES IN. UPON RETURNING TO LAS DEP FREQ, THE CTLR ADVISED US THAT WE HADN'T YET BEEN GIVEN A SHORTCUT ON THE DEP, TO TURN IMMEDIATELY TO HDG 180 DEGS. I LOOKED DOWN AND SAW US OFF THE DEP, AND INQUIRED OF THE CAPT WHETHER WE HAD RECEIVED A VECTOR WHILE I WAS OFF FREQ. AFTER SOME INITIAL CONFUSION, HE REALIZED THAT THE AUTOPLT HAD NOT ENGAGED, ALTHOUGH HE HAD THOUGHT THAT HE SELECTED IT. THE CAPT'S FAILURE TO CONFIRM THE AUTOPLT ENGAGEMENT, MY FAILURE TO BACK HIM UP WITH THE ENGAGEMENT, A LACK OF POSITIONAL AWARENESS DESPITE THAT MAP DISPLAY RIGHT IN FRONT OF BOTH OF US, DISTR FROM THE OPS CALL, AND THAT GOOD OLD 'RUSHED OUT OF THE GATE, WE'RE LATE' FEELING CONTRIBUTED TO THIS EVENT. A POSSIBLE SOLUTION MIGHT BE TO INCLUDE SOME TYPE OF CALLOUT ABOUT THE AUTOPLT IN SOP'S FOR RNAV DEPS. AT 1000 FT, WHEN THE AUTOPLT SHOULD BE COMING ON, THE PNF IS DISTR WITH FLAPS AND SETTING CLB PWR AND ISN'T DELIBERATELY PLACED IN THE LOOP ABOUT THE AUTOPLT ENGAGEMENT.
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.