<< >> NASA ASRS Report 583329, May 2003

Heading track deviation when a crj PIC makes an inappropriate turn after departure from runway 28R on the sfo 8 SID from sfo, ca.

Attributes
ACN	583329
Time
Date	200305
Day	Sat
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : sfo.airport
State Reference	CA
Altitude	agl bound lower : 0 agl bound upper : 1000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : nct.tracon tower : sfo.tower
Operator	common carrier : air carrier
Make Model Name	Regional Jet CL65, Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Navigation In Use	other
Flight Phase	climbout : takeoff climbout : initial
Route In Use	departure sid : sfo 8
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 200 flight time total : 9600 flight time type : 300
ASRS Report	583329
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Events
Anomaly	non adherence : published procedure non adherence : clearance other anomaly other other spatial deviation
Independent Detector	other controllera
Resolutory Action	none taken : detected after the fact
Supplementary
Problem Areas	Chart Or Publication Flight Crew Human Performance Environmental Factor ATC Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Departing sfo via sfo 8. The first officer and I had reviewed the departure at the gate. Ground advised we could expect runway 28L. At runway end, #1 for departure, tower cleared us across runway 28L and into position runway 28R. While holding in position I quickly reviewed the departure for differences between runways 28L and 28R, and mistakenly read the procedure for runway 1L/right which is a heading rather than tracking a radial, and advised the first officer. Consequently we made a turn to heading 030 degrees rather than track the sfo 281 degree radial. Human performance considerations: 1) clearly I made a mistake, so am changing how I brief departures. Not just brief the departure for different runways, but specifically brief the differences between runways, 2) additionally, when ATC gives last second changes, it creates room for error, 3) also, although a relatively simple departure, the sfo 8 is really 2 completely different types of procedures and probably should be separated so they do not appear on the same page.

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Original NASA ASRS Text

Title: HEADING TRACK DEV WHEN A CRJ PIC MAKES AN INAPPROPRIATE TURN AFTER DEP FROM RWY 28R ON THE SFO 8 SID FROM SFO, CA.

Narrative: DEPARTING SFO VIA SFO 8. THE FO AND I HAD REVIEWED THE DEP AT THE GATE. GND ADVISED WE COULD EXPECT RWY 28L. AT RWY END, #1 FOR DEP, TWR CLRED US ACROSS RWY 28L AND INTO POS RWY 28R. WHILE HOLDING IN POS I QUICKLY REVIEWED THE DEP FOR DIFFERENCES BTWN RWYS 28L AND 28R, AND MISTAKENLY READ THE PROC FOR RWY 1L/R WHICH IS A HEADING RATHER THAN TRACKING A RADIAL, AND ADVISED THE FO. CONSEQUENTLY WE MADE A TURN TO HEADING 030 DEGS RATHER THAN TRACK THE SFO 281 DEG RADIAL. HUMAN PERFORMANCE CONSIDERATIONS: 1) CLRLY I MADE A MISTAKE, SO AM CHANGING HOW I BRIEF DEPS. NOT JUST BRIEF THE DEP FOR DIFFERENT RWYS, BUT SPECIFICALLY BRIEF THE DIFFERENCES BTWN RWYS, 2) ADDITIONALLY, WHEN ATC GIVES LAST SECOND CHANGES, IT CREATES ROOM FOR ERROR, 3) ALSO, ALTHOUGH A RELATIVELY SIMPLE DEP, THE SFO 8 IS REALLY 2 COMPLETELY DIFFERENT TYPES OF PROCS AND PROBABLY SHOULD BE SEPARATED SO THEY DO NOT APPEAR ON THE SAME PAGE.

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.