Narrative:

At approximately XA20Z we were given a clearance out of the holding pattern at artip. The clearance was for a right turn direct to spl, descend to 6000 ft. As the PF, I asked the first officer to set spl as a 'direct to' fix on the legs page. All I got on my navigation display was a magenta line with no waypoint visible at the end. At this time, we were on a heading of about 230 degrees. I decided to discontinue LNAV, roll out on current heading and use heading select to go direct to spl, which had been set in the left VOR on the navrad page. I then tried to assess why I did not have a #1 VOR needle on my navigation display. While I was focused on the navrad page, the aircraft began a left turn back to the heading bug which must have still been somewhere behind the left wing. We were in the WX and I had my head down trying to troubleshoot the problem with the spl VOR. I did not notice that the aircraft had started a turn to the left. Meanwhile, we requested, 3 times, a radar heading from approach. Shortly after the third request, we got the RA on the pfd. I disconnected the autoplt and started a descent at about 6800 ft and leveled off at 6000 ft. At almost the same time as I responded to the RA, we received a transmission from radar control to descend immediately to 6000 ft. Apparently, I had not immediately selected flight level change when we received the initial clearance out of the holding pattern. I manually set spl in the left VOR and spy in the right VOR at least 1 hour prior to start of descent. Spl is the same identify for another VOR on the frequency of 115.7. This discrepancy (should have read 108.4) in the numeric frequency was not noted on the navrad page when I briefed the approach. Supplemental information from acn 573637: first officer #1 read back clearance and at captain's command brought spl down to the scratchpad on the legs page and back to the top of legs page and executed. This procedure allowed the aircraft to 'exit the hold' that had been programmed into the FMS. The aircraft was on heading approximately 180 degrees from spl and proceeding outbound in the artip holding pattern. Captain selected direct heading select mode on the MCP during this time, thus canceling LNAV mode that the aircraft was previously in. The aircraft immediately began a turn back to the left because the heading bug had not been previously aligned with the current course. Captain noted aircraft altering back to left and began scrolling heading bug to course. First officer #1 and first officer #2 had also noted that spl was not properly identing itself. However, because the runway environment was visible on the navigation display and knowing that the spl fix was generally in the same location, first officer #1 advised captain to continue direct right turn that had been previously direct by ATC. Also, at the same moment, first officer #1 noted that captain had been slow to descend and advised captain to more aggressively descend to 6000 ft. At this same moment, the aircraft traffic (TCASII warning alert) initiated. During this entire scenario, from exiting holding to descent to 6000 ft, first officer #1 was continually distraction from other first officer duties due to almost continual communications with ATC. ATC inquired if we knew that we almost had an incident. First officer #1 replied in the affirmative. ATC then repeated to continue right to proceed direct spl. Captain re-coupled autoflt system and proceeded direct to spl. En route to spl, first officer #2 reviewed instrument approach procedure and discovered that the FMS was manually tuned to 115.7 versus 108.4 for spl. It was later discovered that the FMS computer was tuned to a NAVAID in germany and not spl at schipol airport. It should be noted that ATC neither gave an announcement of conflicting traffic nor avoidance vectors. After rollout and clearing the runway, ground control asked crew to contact air carrier Y. Air carrier Y asked if we had experienced an RA. First officer #1 confirmed the RA. Manual tuning of the FMS navrad page must be accomplished with great care and attention. Subsequent tuning must take into consideration any manual tuning that was previously accomplished. In the end analysis, one must closely confirm that the frequency and identify inserted match the desired location. The approach briefing should reconfirm the data programmed in the FMS reflects accurately the data necessary to accomplish a safe descent,approach, and landing. All operating pilots are responsible to ensure FMS data is accurate. It was not clearly apparent that the frequency associated with the spl inserted was in fact a frequency associated with a different spl NAVAID other than the destination. However, because the approach portion of the FMS was programmed properly, spl orientation, although cluttered on the display, was visible and should have aided general situational awareness. Because the PF was distraction by the NAVAID discontinuity, he was also slow to descend from 7000 ft to 6000 ft. This re-emphasizes the fact that the PF must fly the aircraft first and all else is secondary. Supplemental information from acn 573630: en route to ams prior to top of descent, the captain set up the FMS for the ILS runway 27, which he expected. Prior to top of descent, ATIS was received and the ILS runway 18R was active and the new approach was loaded into the FMS and briefed. Approach never gave any announcement of conflicting TA or avoidance vectors. It would appear that when the situation presented itself to the controller, she 'locked up,' and said nothing until after the RA took place. This was evident in the tone of her voice. En route to spl, jumpseat pilot reviewed IAP and discovered that the FMS computer tuned 115.7 versus 108.4 for spl. It was later discovered that the FMS computer tuned in a NAVAID in germany and not spl at schipol airport. The crew encountered several delays adding to crew duty day. Additionally, minimum crew rest was received at nbo position at end of crew duty day. This all had a cumulative effect of fatigue on all 3 crew members.

Related reports:

Google
 

Original NASA ASRS Text

Title: LOSS OF SITUATIONAL AWARENESS BY A B747-400 CARGO CREW CREATES A POTENTIAL CONFLICT WITH ANOTHER ACR FLT NEAR ARTIP INTXN, 35 MI NE OF EHAM, FO.

Narrative: AT APPROX XA20Z WE WERE GIVEN A CLRNC OUT OF THE HOLDING PATTERN AT ARTIP. THE CLRNC WAS FOR A R TURN DIRECT TO SPL, DSND TO 6000 FT. AS THE PF, I ASKED THE FO TO SET SPL AS A 'DIRECT TO' FIX ON THE LEGS PAGE. ALL I GOT ON MY NAV DISPLAY WAS A MAGENTA LINE WITH NO WAYPOINT VISIBLE AT THE END. AT THIS TIME, WE WERE ON A HDG OF ABOUT 230 DEGS. I DECIDED TO DISCONTINUE LNAV, ROLL OUT ON CURRENT HDG AND USE HDG SELECT TO GO DIRECT TO SPL, WHICH HAD BEEN SET IN THE L VOR ON THE NAVRAD PAGE. I THEN TRIED TO ASSESS WHY I DID NOT HAVE A #1 VOR NEEDLE ON MY NAV DISPLAY. WHILE I WAS FOCUSED ON THE NAVRAD PAGE, THE ACFT BEGAN A L TURN BACK TO THE HDG BUG WHICH MUST HAVE STILL BEEN SOMEWHERE BEHIND THE L WING. WE WERE IN THE WX AND I HAD MY HEAD DOWN TRYING TO TROUBLESHOOT THE PROB WITH THE SPL VOR. I DID NOT NOTICE THAT THE ACFT HAD STARTED A TURN TO THE L. MEANWHILE, WE REQUESTED, 3 TIMES, A RADAR HDG FROM APCH. SHORTLY AFTER THE THIRD REQUEST, WE GOT THE RA ON THE PFD. I DISCONNECTED THE AUTOPLT AND STARTED A DSCNT AT ABOUT 6800 FT AND LEVELED OFF AT 6000 FT. AT ALMOST THE SAME TIME AS I RESPONDED TO THE RA, WE RECEIVED A XMISSION FROM RADAR CTL TO DSND IMMEDIATELY TO 6000 FT. APPARENTLY, I HAD NOT IMMEDIATELY SELECTED FLT LEVEL CHANGE WHEN WE RECEIVED THE INITIAL CLRNC OUT OF THE HOLDING PATTERN. I MANUALLY SET SPL IN THE L VOR AND SPY IN THE R VOR AT LEAST 1 HR PRIOR TO START OF DSCNT. SPL IS THE SAME IDENT FOR ANOTHER VOR ON THE FREQ OF 115.7. THIS DISCREPANCY (SHOULD HAVE READ 108.4) IN THE NUMERIC FREQ WAS NOT NOTED ON THE NAVRAD PAGE WHEN I BRIEFED THE APCH. SUPPLEMENTAL INFO FROM ACN 573637: FO #1 READ BACK CLRNC AND AT CAPT'S COMMAND BROUGHT SPL DOWN TO THE SCRATCHPAD ON THE LEGS PAGE AND BACK TO THE TOP OF LEGS PAGE AND EXECUTED. THIS PROC ALLOWED THE ACFT TO 'EXIT THE HOLD' THAT HAD BEEN PROGRAMMED INTO THE FMS. THE ACFT WAS ON HDG APPROX 180 DEGS FROM SPL AND PROCEEDING OUTBOUND IN THE ARTIP HOLDING PATTERN. CAPT SELECTED DIRECT HDG SELECT MODE ON THE MCP DURING THIS TIME, THUS CANCELING LNAV MODE THAT THE ACFT WAS PREVIOUSLY IN. THE ACFT IMMEDIATELY BEGAN A TURN BACK TO THE L BECAUSE THE HDG BUG HAD NOT BEEN PREVIOUSLY ALIGNED WITH THE CURRENT COURSE. CAPT NOTED ACFT ALTERING BACK TO L AND BEGAN SCROLLING HDG BUG TO COURSE. FO #1 AND FO #2 HAD ALSO NOTED THAT SPL WAS NOT PROPERLY IDENTING ITSELF. HOWEVER, BECAUSE THE RWY ENVIRONMENT WAS VISIBLE ON THE NAV DISPLAY AND KNOWING THAT THE SPL FIX WAS GENERALLY IN THE SAME LOCATION, FO #1 ADVISED CAPT TO CONTINUE DIRECT R TURN THAT HAD BEEN PREVIOUSLY DIRECT BY ATC. ALSO, AT THE SAME MOMENT, FO #1 NOTED THAT CAPT HAD BEEN SLOW TO DSND AND ADVISED CAPT TO MORE AGGRESSIVELY DSND TO 6000 FT. AT THIS SAME MOMENT, THE ACFT TFC (TCASII WARNING ALERT) INITIATED. DURING THIS ENTIRE SCENARIO, FROM EXITING HOLDING TO DSCNT TO 6000 FT, FO #1 WAS CONTINUALLY DISTR FROM OTHER FO DUTIES DUE TO ALMOST CONTINUAL COMS WITH ATC. ATC INQUIRED IF WE KNEW THAT WE ALMOST HAD AN INCIDENT. FO #1 REPLIED IN THE AFFIRMATIVE. ATC THEN REPEATED TO CONTINUE R TO PROCEED DIRECT SPL. CAPT RE-COUPLED AUTOFLT SYS AND PROCEEDED DIRECT TO SPL. ENRTE TO SPL, FO #2 REVIEWED INST APCH PROC AND DISCOVERED THAT THE FMS WAS MANUALLY TUNED TO 115.7 VERSUS 108.4 FOR SPL. IT WAS LATER DISCOVERED THAT THE FMS COMPUTER WAS TUNED TO A NAVAID IN GERMANY AND NOT SPL AT SCHIPOL ARPT. IT SHOULD BE NOTED THAT ATC NEITHER GAVE AN ANNOUNCEMENT OF CONFLICTING TFC NOR AVOIDANCE VECTORS. AFTER ROLLOUT AND CLRING THE RWY, GND CTL ASKED CREW TO CONTACT ACR Y. ACR Y ASKED IF WE HAD EXPERIENCED AN RA. FO #1 CONFIRMED THE RA. MANUAL TUNING OF THE FMS NAVRAD PAGE MUST BE ACCOMPLISHED WITH GREAT CARE AND ATTN. SUBSEQUENT TUNING MUST TAKE INTO CONSIDERATION ANY MANUAL TUNING THAT WAS PREVIOUSLY ACCOMPLISHED. IN THE END ANALYSIS, ONE MUST CLOSELY CONFIRM THAT THE FREQ AND IDENT INSERTED MATCH THE DESIRED LOCATION. THE APCH BRIEFING SHOULD RECONFIRM THE DATA PROGRAMMED IN THE FMS REFLECTS ACCURATELY THE DATA NECESSARY TO ACCOMPLISH A SAFE DSCNT,APCH, AND LNDG. ALL OPERATING PLTS ARE RESPONSIBLE TO ENSURE FMS DATA IS ACCURATE. IT WAS NOT CLRLY APPARENT THAT THE FREQ ASSOCIATED WITH THE SPL INSERTED WAS IN FACT A FREQ ASSOCIATED WITH A DIFFERENT SPL NAVAID OTHER THAN THE DEST. HOWEVER, BECAUSE THE APCH PORTION OF THE FMS WAS PROGRAMMED PROPERLY, SPL ORIENTATION, ALTHOUGH CLUTTERED ON THE DISPLAY, WAS VISIBLE AND SHOULD HAVE AIDED GENERAL SITUATIONAL AWARENESS. BECAUSE THE PF WAS DISTR BY THE NAVAID DISCONTINUITY, HE WAS ALSO SLOW TO DSND FROM 7000 FT TO 6000 FT. THIS RE-EMPHASIZES THE FACT THAT THE PF MUST FLY THE ACFT FIRST AND ALL ELSE IS SECONDARY. SUPPLEMENTAL INFO FROM ACN 573630: ENRTE TO AMS PRIOR TO TOP OF DSCNT, THE CAPT SET UP THE FMS FOR THE ILS RWY 27, WHICH HE EXPECTED. PRIOR TO TOP OF DSCNT, ATIS WAS RECEIVED AND THE ILS RWY 18R WAS ACTIVE AND THE NEW APCH WAS LOADED INTO THE FMS AND BRIEFED. APCH NEVER GAVE ANY ANNOUNCEMENT OF CONFLICTING TA OR AVOIDANCE VECTORS. IT WOULD APPEAR THAT WHEN THE SIT PRESENTED ITSELF TO THE CTLR, SHE 'LOCKED UP,' AND SAID NOTHING UNTIL AFTER THE RA TOOK PLACE. THIS WAS EVIDENT IN THE TONE OF HER VOICE. ENRTE TO SPL, JUMPSEAT PLT REVIEWED IAP AND DISCOVERED THAT THE FMS COMPUTER TUNED 115.7 VERSUS 108.4 FOR SPL. IT WAS LATER DISCOVERED THAT THE FMS COMPUTER TUNED IN A NAVAID IN GERMANY AND NOT SPL AT SCHIPOL ARPT. THE CREW ENCOUNTERED SEVERAL DELAYS ADDING TO CREW DUTY DAY. ADDITIONALLY, MINIMUM CREW REST WAS RECEIVED AT NBO POS AT END OF CREW DUTY DAY. THIS ALL HAD A CUMULATIVE EFFECT OF FATIGUE ON ALL 3 CREW MEMBERS.

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.