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|
Attributes | |
ACN | 578340 |
Time | |
Date | 200304 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lga.airport |
State Reference | NY |
Altitude | agl bound lower : 400 agl bound upper : 2500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : lga.tower |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure sid : lga |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 188 flight time total : 4816 flight time type : 1913 |
ASRS Report | 578340 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | airspace violation : entry non adherence : published procedure non adherence : clearance non adherence : far other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : exited penetrated airspace flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight was running 15 mins late due to a last min, unexpected aircraft swap. ATIS was advertising the lga 9 departure off of runway 13, flushing climb. Since turbo propeller aircraft departing runway 13 almost exclusively use the whitestone climb, I made note of the change. However, when I looked up the procedure in my manual, I apparently xposed the first part of the whitestone climb ('turn right, climb on a 180 degree heading until lga 2.5 DME') with that of the flushing climb ('climb on runway heading until lga 2.5 DME). Though I read this out loud, the first officer was working on the weight and balance form, and so did not catch my error. During taxi, I restated the erroneous departure procedure. The first officer, again, made no comment. He may have been distraction by interping our complex taxi clearance. After takeoff, I turned right to the 180 degree heading. The first officer stated 'flushing climb' several times, to which I queried 'isn't this the flushing climb?' he didn't answer. At this moment, the bright lights of shea stadium appeared at our 12 O'clock position. New york departure instructed us to turn left to a heading of 130 degrees. Nothing further was said, and the flight proceeded uneventfully. What went wrong? 1) I started the ball rolling by misreading the departure procedure. This error was amplified by our perception of a time crunch, which led to my allowing the first officer to continue working on the weight and balance form when we both should have been reading the departure procedure. 2) departure brief during taxi: it must be verified that both crew members are paying full attention to the brief, particularly when there are variations to normal procedures or clrncs. If this can't be accomplished 'on the roll,' stop the aircraft. 3) communication between crew members must be unambiguous. If the first officer knew the flushing climb required runway heading, he should have said so. Given a specific course, I would have followed his direction and sorted out my mistake later.
Original NASA ASRS Text
Title: DEP SF340 FLT CREW ENTERS THE AIRSPACE OVER SHEA STADIUM DURING AN IMPROPER DEP PROC FROM LGA, NY.
Narrative: FLT WAS RUNNING 15 MINS LATE DUE TO A LAST MIN, UNEXPECTED ACFT SWAP. ATIS WAS ADVERTISING THE LGA 9 DEP OFF OF RWY 13, FLUSHING CLB. SINCE TURBO PROP ACFT DEPARTING RWY 13 ALMOST EXCLUSIVELY USE THE WHITESTONE CLB, I MADE NOTE OF THE CHANGE. HOWEVER, WHEN I LOOKED UP THE PROC IN MY MANUAL, I APPARENTLY XPOSED THE FIRST PART OF THE WHITESTONE CLB ('TURN R, CLB ON A 180 DEG HDG UNTIL LGA 2.5 DME') WITH THAT OF THE FLUSHING CLB ('CLB ON RWY HDG UNTIL LGA 2.5 DME). THOUGH I READ THIS OUT LOUD, THE FO WAS WORKING ON THE WT AND BAL FORM, AND SO DID NOT CATCH MY ERROR. DURING TAXI, I RESTATED THE ERRONEOUS DEP PROC. THE FO, AGAIN, MADE NO COMMENT. HE MAY HAVE BEEN DISTR BY INTERPING OUR COMPLEX TAXI CLRNC. AFTER TKOF, I TURNED R TO THE 180 DEG HDG. THE FO STATED 'FLUSHING CLB' SEVERAL TIMES, TO WHICH I QUERIED 'ISN'T THIS THE FLUSHING CLB?' HE DIDN'T ANSWER. AT THIS MOMENT, THE BRIGHT LIGHTS OF SHEA STADIUM APPEARED AT OUR 12 O'CLOCK POS. NEW YORK DEP INSTRUCTED US TO TURN L TO A HDG OF 130 DEGS. NOTHING FURTHER WAS SAID, AND THE FLT PROCEEDED UNEVENTFULLY. WHAT WENT WRONG? 1) I STARTED THE BALL ROLLING BY MISREADING THE DEP PROC. THIS ERROR WAS AMPLIFIED BY OUR PERCEPTION OF A TIME CRUNCH, WHICH LED TO MY ALLOWING THE FO TO CONTINUE WORKING ON THE WT AND BAL FORM WHEN WE BOTH SHOULD HAVE BEEN READING THE DEP PROC. 2) DEP BRIEF DURING TAXI: IT MUST BE VERIFIED THAT BOTH CREW MEMBERS ARE PAYING FULL ATTN TO THE BRIEF, PARTICULARLY WHEN THERE ARE VARIATIONS TO NORMAL PROCS OR CLRNCS. IF THIS CAN'T BE ACCOMPLISHED 'ON THE ROLL,' STOP THE ACFT. 3) COM BTWN CREW MEMBERS MUST BE UNAMBIGUOUS. IF THE FO KNEW THE FLUSHING CLB REQUIRED RWY HDG, HE SHOULD HAVE SAID SO. GIVEN A SPECIFIC COURSE, I WOULD HAVE FOLLOWED HIS DIRECTION AND SORTED OUT MY MISTAKE LATER.
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.