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|
Attributes | |
ACN | 575543 |
Time | |
Date | 200303 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
State Reference | HI |
Altitude | msl bound lower : 20000 msl bound upper : 20200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zhn.artcc |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zhn.artcc |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi pilot : commercial pilot : flight engineer pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 174 flight time total : 6306 flight time type : 614 |
ASRS Report | 575543 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 11800 flight time type : 900 |
ASRS Report | 575553 |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : required legal separation other anomaly other other spatial deviation |
Independent Detector | aircraft equipment : tcas other controllera |
Resolutory Action | controller : separated traffic controller : issued alert |
Supplementary | |
Problem Areas | Airspace Structure Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During climb out en route from hnl, we were given multiple vectors. In short order, heading 80 degrees, then 60 degrees, then 40 degrees, then what I thought as 335 degrees. I believe the captain responded to the last heading assignment, although he does not remember doing so ( 40 degree heading is the last heading he remembers acknowledging). ATC did not correct, or repeat our heading assignment. Rolling out of the turn, ATC asked us what heading we were turning to (we responded 335 degree), then told us we were assigned 35 degree. Just after passing FL202, ATC then told us to level off at FL200. We responded, and returned immediately to FL200. ATC also had us hold heading 335 degrees for a couple minutes more for traffic. During this time, we received a momentary TA, and I believe the controller vectored the other aircraft around us. A new vector was assigned, and we were on our way without further discussion with the controller about the event. It appears that unless the controller gave us the wrong heading, I probably heard the wrong heading (335 degree heading instead of 35 degree heading), and set this in the heading selector. I believe the captain acknowledged the heading given (35 degree heading), and did not notice the different heading selected. Unable to hear his response through the headset, I did not detect a heading different than the one I selected. It was a very busy cockpit, especially for the captain. The controller was probably also busy as to allow us to turn 60 degrees past our assigned heading. Without reviewing the tapes, this event is likely my own fault. It was an honest mistake of hearing a different heading than that given. Normally, when there is a question of unclr or questionable instructions, I would get clarification from ATC. At the time, I did not perceive the need. There was no intentional deviation from ATC's instructions or normal operating procedures. There will be times when human factors (miscom) will interfere with an otherwise perfect game plan. I will try harder to reduce this risk. I wish that between the 3 persons involved, one of us discovered the problem before it became a problem. For this part, I do have one thing I would recommend. Whenever we are given new altitudes, as a normal operating procedure, we confirm the selected value with the other pilot. This seems to work well as a safety net in addition to the normal readbacks of ATC clrncs. As a PNF, I normally do the same for heading changes to make sure the PF is on the same page. This might be a good practice to accept as a normal operating procedure. Supplemental information from acn 575553: on climb out from hnl, I was performing PNF duties, first officer was PF. On hand-over from departure to center, we were given 60 degree heading. After contacting new frequency, we were given 40 degree heading. I put this into MCP, and autoplt initiated the turn. I then turned my attention to PNF duties -- gross error check, ETOPS WX request, printing, and reviewing some after download. There was also a qualified first officer in the jumpseat, which also contributed to the general sense of well being.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT BTWN A CLBING B767-300ER AND OTHER TFC, DURING A DEP PROC, WITH THE WRONG HDG PLACED INTO THE HDG MODE CTL, 50 NM N OF MKK VOR, HI.
Narrative: DURING CLBOUT ENRTE FROM HNL, WE WERE GIVEN MULTIPLE VECTORS. IN SHORT ORDER, HDG 80 DEGS, THEN 60 DEGS, THEN 40 DEGS, THEN WHAT I THOUGHT AS 335 DEGS. I BELIEVE THE CAPT RESPONDED TO THE LAST HDG ASSIGNMENT, ALTHOUGH HE DOES NOT REMEMBER DOING SO ( 40 DEG HDG IS THE LAST HDG HE REMEMBERS ACKNOWLEDGING). ATC DID NOT CORRECT, OR REPEAT OUR HDG ASSIGNMENT. ROLLING OUT OF THE TURN, ATC ASKED US WHAT HDG WE WERE TURNING TO (WE RESPONDED 335 DEG), THEN TOLD US WE WERE ASSIGNED 35 DEG. JUST AFTER PASSING FL202, ATC THEN TOLD US TO LEVEL OFF AT FL200. WE RESPONDED, AND RETURNED IMMEDIATELY TO FL200. ATC ALSO HAD US HOLD HDG 335 DEGS FOR A COUPLE MINUTES MORE FOR TFC. DURING THIS TIME, WE RECEIVED A MOMENTARY TA, AND I BELIEVE THE CTLR VECTORED THE OTHER ACFT AROUND US. A NEW VECTOR WAS ASSIGNED, AND WE WERE ON OUR WAY WITHOUT FURTHER DISCUSSION WITH THE CTLR ABOUT THE EVENT. IT APPEARS THAT UNLESS THE CTLR GAVE US THE WRONG HDG, I PROBABLY HEARD THE WRONG HDG (335 DEG HDG INSTEAD OF 35 DEG HDG), AND SET THIS IN THE HDG SELECTOR. I BELIEVE THE CAPT ACKNOWLEDGED THE HDG GIVEN (35 DEG HDG), AND DID NOT NOTICE THE DIFFERENT HDG SELECTED. UNABLE TO HEAR HIS RESPONSE THROUGH THE HEADSET, I DID NOT DETECT A HDG DIFFERENT THAN THE ONE I SELECTED. IT WAS A VERY BUSY COCKPIT, ESPECIALLY FOR THE CAPT. THE CTLR WAS PROBABLY ALSO BUSY AS TO ALLOW US TO TURN 60 DEGS PAST OUR ASSIGNED HDG. WITHOUT REVIEWING THE TAPES, THIS EVENT IS LIKELY MY OWN FAULT. IT WAS AN HONEST MISTAKE OF HEARING A DIFFERENT HDG THAN THAT GIVEN. NORMALLY, WHEN THERE IS A QUESTION OF UNCLR OR QUESTIONABLE INSTRUCTIONS, I WOULD GET CLARIFICATION FROM ATC. AT THE TIME, I DID NOT PERCEIVE THE NEED. THERE WAS NO INTENTIONAL DEVIATION FROM ATC'S INSTRUCTIONS OR NORMAL OPERATING PROCS. THERE WILL BE TIMES WHEN HUMAN FACTORS (MISCOM) WILL INTERFERE WITH AN OTHERWISE PERFECT GAME PLAN. I WILL TRY HARDER TO REDUCE THIS RISK. I WISH THAT BTWN THE 3 PERSONS INVOLVED, ONE OF US DISCOVERED THE PROB BEFORE IT BECAME A PROB. FOR THIS PART, I DO HAVE ONE THING I WOULD RECOMMEND. WHENEVER WE ARE GIVEN NEW ALTS, AS A NORMAL OPERATING PROC, WE CONFIRM THE SELECTED VALUE WITH THE OTHER PLT. THIS SEEMS TO WORK WELL AS A SAFETY NET IN ADDITION TO THE NORMAL READBACKS OF ATC CLRNCS. AS A PNF, I NORMALLY DO THE SAME FOR HDG CHANGES TO MAKE SURE THE PF IS ON THE SAME PAGE. THIS MIGHT BE A GOOD PRACTICE TO ACCEPT AS A NORMAL OPERATING PROC. SUPPLEMENTAL INFO FROM ACN 575553: ON CLBOUT FROM HNL, I WAS PERFORMING PNF DUTIES, FO WAS PF. ON HAND-OVER FROM DEP TO CTR, WE WERE GIVEN 60 DEG HDG. AFTER CONTACTING NEW FREQ, WE WERE GIVEN 40 DEG HDG. I PUT THIS INTO MCP, AND AUTOPLT INITIATED THE TURN. I THEN TURNED MY ATTN TO PNF DUTIES -- GROSS ERROR CHK, ETOPS WX REQUEST, PRINTING, AND REVIEWING SOME AFTER DOWNLOAD. THERE WAS ALSO A QUALIFIED FO IN THE JUMPSEAT, WHICH ALSO CONTRIBUTED TO THE GENERAL SENSE OF WELL BEING.
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.