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Attributes | |
ACN | 577426 |
Time | |
Date | 200303 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : eddf.airport |
State Reference | FO |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : eddf.tower |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : noise abatement departure sid : n/s |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : commercial pilot : flight engineer pilot : multi engine pilot : atp pilot : instrument |
Experience | flight time last 90 days : 149 flight time total : 10899 flight time type : 6379 |
ASRS Report | 577426 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : ins other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : returned to intended or assigned course flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Airport Airspace Structure Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
After an early morning takeoff, aircraft track momentarily deviated off assigned SID to the right (west) of planned course. The deviation was minor, but in a highly noise sensitive area. The local controller queried the turn and assigned a direct-to point clearance. Cause of deviation is due to the PF (first officer) viewing the wrong DME display and starting a right turn as depicted on the SID, but at the wrong distance. The PNF's (captain's) VOR was set to a 'do not cross' (noise abatement) radial on a different station than required for primary navigation. The primary VOR and course were set on the first officer's side as the PF and was covered in the crew briefing. Further, this would be a typical navigation panel set-up for this departure. The error was corrected immediately upon recognition (within 5 seconds). Note: this was a non-FMS equipped aircraft (INS with DME update capability only), so this SID was conducted via class 1 navigation (VOR's) with INS used only as a back-up. Although this vintage INS platform is legal to fly RNAV SID's and STAR's if certain accuracy indexes are acquired via radio updates, it was clearly not designed to perform the task as an FMS and does a poor job attempting to emulate one. The reason for this error is primarily contributed to crew fatigue resulting from a long crew duty day that was full of task saturating events throughout the 2-LEG international trip from the united states to germany, then belgium. I'm confident that the PNF would not have made this error in a more rested state, plus this final leg was operated on the back side of the clock. Additionally, the aircraft was empty, making the vertical navigation performance a real challenge on a complex, noise sensitive SID, with low initial leveloff. Then a flap retraction problem occurred during the event to which ATC was advised. However, I do not believe this pilot navigation error created a noise problem due to the low thrust setting, low density altitude (dry, low temperature and PA) and high climb rate of the empty aircraft. Since fatigue can be so insidious, at times it creeps up on you without realization until a noticeable human error occurs. I hope the FAA will eventually mandate changes to the regulations that will require int'l duty time limits for us. Part 121 restred (flag or supplemental) acrs. This would serve as a stop-gap for the lack of duty limits at some carriers and/or to lesson the excessively long duty time that other airlines consider as 'normal'. The dispatcher working the flight is given more regulatory 'duty' consideration than the crews actually operating the aircraft dispatched. It would almost seem that his concept is backwards. Imho, the maximum safe international duty time should be regulated to be no more than fourteen hours for a basic (un-augmented) crew, unless a diversion to an alternate airport is required. It then could be extended with additional rest requirements at the destination commensurate to double the extension time, but not to exceed seventeen hours under any circumstances. Had this been the case, I'm confident that this mistake wouldn't have occurred.
Original NASA ASRS Text
Title: B747 DEPARTING EDFF VARIED FROM ASSIGNED SID OVER NOISE SENSITIVE AREA.
Narrative: AFTER AN EARLY MORNING TKOF, ACFT TRACK MOMENTARILY DEVIATED OFF ASSIGNED SID TO THE R (W) OF PLANNED COURSE. THE DEV WAS MINOR, BUT IN A HIGHLY NOISE SENSITIVE AREA. THE LCL CTLR QUERIED THE TURN AND ASSIGNED A DIRECT-TO POINT CLRNC. CAUSE OF DEV IS DUE TO THE PF (FO) VIEWING THE WRONG DME DISPLAY AND STARTING A R TURN AS DEPICTED ON THE SID, BUT AT THE WRONG DISTANCE. THE PNF'S (CAPT'S) VOR WAS SET TO A 'DO NOT CROSS' (NOISE ABATEMENT) RADIAL ON A DIFFERENT STATION THAN REQUIRED FOR PRIMARY NAV. THE PRIMARY VOR AND COURSE WERE SET ON THE FO'S SIDE AS THE PF AND WAS COVERED IN THE CREW BRIEFING. FURTHER, THIS WOULD BE A TYPICAL NAV PANEL SET-UP FOR THIS DEP. THE ERROR WAS CORRECTED IMMEDIATELY UPON RECOGNITION (WITHIN 5 SECONDS). NOTE: THIS WAS A NON-FMS EQUIPPED ACFT (INS WITH DME UPDATE CAPABILITY ONLY), SO THIS SID WAS CONDUCTED VIA CLASS 1 NAV (VOR'S) WITH INS USED ONLY AS A BACK-UP. ALTHOUGH THIS VINTAGE INS PLATFORM IS LEGAL TO FLY RNAV SID'S AND STAR'S IF CERTAIN ACCURACY INDEXES ARE ACQUIRED VIA RADIO UPDATES, IT WAS CLRLY NOT DESIGNED TO PERFORM THE TASK AS AN FMS AND DOES A POOR JOB ATTEMPTING TO EMULATE ONE. THE REASON FOR THIS ERROR IS PRIMARILY CONTRIBUTED TO CREW FATIGUE RESULTING FROM A LONG CREW DUTY DAY THAT WAS FULL OF TASK SATURATING EVENTS THROUGHOUT THE 2-LEG INTL TRIP FROM THE UNITED STATES TO GERMANY, THEN BELGIUM. I'M CONFIDENT THAT THE PNF WOULD NOT HAVE MADE THIS ERROR IN A MORE RESTED STATE, PLUS THIS FINAL LEG WAS OPERATED ON THE BACK SIDE OF THE CLOCK. ADDITIONALLY, THE ACFT WAS EMPTY, MAKING THE VERT NAV PERFORMANCE A REAL CHALLENGE ON A COMPLEX, NOISE SENSITIVE SID, WITH LOW INITIAL LEVELOFF. THEN A FLAP RETRACTION PROB OCCURRED DURING THE EVENT TO WHICH ATC WAS ADVISED. HOWEVER, I DO NOT BELIEVE THIS PLT NAV ERROR CREATED A NOISE PROB DUE TO THE LOW THRUST SETTING, LOW DENSITY ALT (DRY, LOW TEMP AND PA) AND HIGH CLB RATE OF THE EMPTY ACFT. SINCE FATIGUE CAN BE SO INSIDIOUS, AT TIMES IT CREEPS UP ON YOU WITHOUT REALIZATION UNTIL A NOTICEABLE HUMAN ERROR OCCURS. I HOPE THE FAA WILL EVENTUALLY MANDATE CHANGES TO THE REGULATIONS THAT WILL REQUIRE INT'L DUTY TIME LIMITS FOR US. PART 121 RESTRED (FLAG OR SUPPLEMENTAL) ACRS. THIS WOULD SERVE AS A STOP-GAP FOR THE LACK OF DUTY LIMITS AT SOME CARRIERS AND/OR TO LESSON THE EXCESSIVELY LONG DUTY TIME THAT OTHER AIRLINES CONSIDER AS 'NORMAL'. THE DISPATCHER WORKING THE FLT IS GIVEN MORE REGULATORY 'DUTY' CONSIDERATION THAN THE CREWS ACTUALLY OPERATING THE ACFT DISPATCHED. IT WOULD ALMOST SEEM THAT HIS CONCEPT IS BACKWARDS. IMHO, THE MAXIMUM SAFE INTERNATIONAL DUTY TIME SHOULD BE REGULATED TO BE NO MORE THAN FOURTEEN HOURS FOR A BASIC (UN-AUGMENTED) CREW, UNLESS A DIVERSION TO AN ALTERNATE ARPT IS REQUIRED. IT THEN COULD BE EXTENDED WITH ADDITIONAL REST REQUIREMENTS AT THE DEST COMMENSURATE TO DOUBLE THE EXTENSION TIME, BUT NOT TO EXCEED SEVENTEEN HRS UNDER ANY CIRCUMSTANCES. HAD THIS BEEN THE CASE, I'M CONFIDENT THAT THIS MISTAKE WOULDN'T HAVE OCCURRED.
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.