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|
Attributes | |
ACN | 571542 |
Time | |
Date | 200301 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : eddf.airport |
State Reference | FO |
Altitude | msl single value : 2500 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Snow |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : edff.artcc tower : pie.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | climbout : initial |
Route In Use | departure sid : bibos 2d |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : commercial pilot : flight engineer pilot : instrument pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 16200 flight time type : 2510 |
ASRS Report | 571542 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : clearance non adherence : company policies non adherence : far non adherence other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : fms other controllera other flight crewa |
Resolutory Action | controller : issued alert controller : issued new clearance flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Chart Or Publication Airport Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The first officer was flying the aircraft. During initial climb, he verbalized that the FMS map display (magenta line) did not agree with the departure clearance (bibos 2D) from runway 7. I was involved with frequency and altitude changes and told him to fly the departure via manual backup. He selected manual VOR, but began to incorrectly navigation via the bibos ze departure transition. Soon after, the controller asked us to verify our clearance -- I responded that it was the bibos zd. He stated that we were not flying it properly. I confirmed (via the chart and FMS display) that we were left of the correct radial and directed the first officer to steer back to the right to re-establish. The departure controller then cleared us direct to a downline departure (SID) intersection on the bibos 2D. There was no apparent traffic conflict noted at any time. The proper departure SID had been briefed between all 3 crew members prior to both the pushback and takeoff. (It was noted that it was a change from the bibos zg indicated on the flight plan). After the occurrence, the first officer indicated that he was actually thinking of the bibos ze. There were several distrs during the briefing that likely contributed to the confusion. A change to an earlier slot time by ATC, discussion of deicing due to very light snow flurries, pressure to push away from the gate by operations personnel, and ultimately takeoff clearance before the updated slot time. However, I did visually confirm that the proper departure was loaded in the FMS and did compare the legs page information with the SID. I was certain of the expected route. Human factors considerations -- the first officer was apparently unsure of the departure procedure, but did not so indicate. I deferred to him during climb in part because he sounded so certain. (I am relatively new to international operations -- he had more experience in the arena of operations). The relief pilot failed to follow the departure procedure even though he had the chart in hand -- he offered no assistance. The controller could have offered an initial vector rather than to allow us to deviation farther away from proper course. I will not again push away from the gate unless I have confirmation from each crew member that we are confident of the intended flight path.
Original NASA ASRS Text
Title: FLT CREW OF B763 INADVERTENTLY FLEW SID OTHER THAN THAT CLRED.
Narrative: THE FO WAS FLYING THE ACFT. DURING INITIAL CLB, HE VERBALIZED THAT THE FMS MAP DISPLAY (MAGENTA LINE) DID NOT AGREE WITH THE DEP CLRNC (BIBOS 2D) FROM RWY 7. I WAS INVOLVED WITH FREQ AND ALT CHANGES AND TOLD HIM TO FLY THE DEP VIA MANUAL BACKUP. HE SELECTED MANUAL VOR, BUT BEGAN TO INCORRECTLY NAV VIA THE BIBOS ZE DEP TRANSITION. SOON AFTER, THE CTLR ASKED US TO VERIFY OUR CLRNC -- I RESPONDED THAT IT WAS THE BIBOS ZD. HE STATED THAT WE WERE NOT FLYING IT PROPERLY. I CONFIRMED (VIA THE CHART AND FMS DISPLAY) THAT WE WERE L OF THE CORRECT RADIAL AND DIRECTED THE FO TO STEER BACK TO THE R TO RE-ESTABLISH. THE DEP CTLR THEN CLRED US DIRECT TO A DOWNLINE DEP (SID) INTXN ON THE BIBOS 2D. THERE WAS NO APPARENT TFC CONFLICT NOTED AT ANY TIME. THE PROPER DEP SID HAD BEEN BRIEFED BTWN ALL 3 CREW MEMBERS PRIOR TO BOTH THE PUSHBACK AND TKOF. (IT WAS NOTED THAT IT WAS A CHANGE FROM THE BIBOS ZG INDICATED ON THE FLT PLAN). AFTER THE OCCURRENCE, THE FO INDICATED THAT HE WAS ACTUALLY THINKING OF THE BIBOS ZE. THERE WERE SEVERAL DISTRS DURING THE BRIEFING THAT LIKELY CONTRIBUTED TO THE CONFUSION. A CHANGE TO AN EARLIER SLOT TIME BY ATC, DISCUSSION OF DEICING DUE TO VERY LIGHT SNOW FLURRIES, PRESSURE TO PUSH AWAY FROM THE GATE BY OPS PERSONNEL, AND ULTIMATELY TKOF CLRNC BEFORE THE UPDATED SLOT TIME. HOWEVER, I DID VISUALLY CONFIRM THAT THE PROPER DEP WAS LOADED IN THE FMS AND DID COMPARE THE LEGS PAGE INFO WITH THE SID. I WAS CERTAIN OF THE EXPECTED RTE. HUMAN FACTORS CONSIDERATIONS -- THE FO WAS APPARENTLY UNSURE OF THE DEP PROC, BUT DID NOT SO INDICATE. I DEFERRED TO HIM DURING CLB IN PART BECAUSE HE SOUNDED SO CERTAIN. (I AM RELATIVELY NEW TO INTL OPS -- HE HAD MORE EXPERIENCE IN THE ARENA OF OPS). THE RELIEF PLT FAILED TO FOLLOW THE DEP PROC EVEN THOUGH HE HAD THE CHART IN HAND -- HE OFFERED NO ASSISTANCE. THE CTLR COULD HAVE OFFERED AN INITIAL VECTOR RATHER THAN TO ALLOW US TO DEV FARTHER AWAY FROM PROPER COURSE. I WILL NOT AGAIN PUSH AWAY FROM THE GATE UNLESS I HAVE CONFIRMATION FROM EACH CREW MEMBER THAT WE ARE CONFIDENT OF THE INTENDED FLT PATH.
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.