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|
Attributes | |
ACN | 587747 |
Time | |
Date | 200307 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : phx.airport |
State Reference | AZ |
Altitude | agl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : p50.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : dryht |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 17000 flight time type : 3000 |
ASRS Report | 587747 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 250 flight time total : 8000 flight time type : 1300 |
ASRS Report | 587904 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The captain loaded the company flight plan routing into the FMS then was checked for accuracy by the first officer. Prior to departure, the pre departure clearance containing the final ATC clearance was delivered to the aircraft via ACARS followed by a hard copy from the gate agent who delivered the final paperwork. The final ATC clearance on the pre departure clearance changed the departure SID. Both pilots failed to note the change of the SJN2 to the DRYHT2. This, despite the fact the flight number was verified, and the departure frequency, transponder code, and first filed altitude were all noted and loaded into the radios and flight guidance. Prior to departure off of runway 25R the SNJ2 SID was briefed then we flew the departure as briefed. When the aircraft reached 1550 ft MSL, a shallow right turn to a heading of 260 degrees was initiated, as required by the SJN2 SID, instead of turn to the left to a heading of 240 degrees as was required by the DRYHT2 SID. Within a few seconds of contacting departure control at around 2000 ft MSL, our error was detected by the controller and we were immediately turned to comply with the DRYHT2 SID. We were not aware of any traffic conflicts during this incident. There were no TCASII alerts. While en route, the pilots reviewed the events that led up to this error. Both pilots are aware of the pitfall of missing the revised ATC clearance on the pre departure clearance and have habit patterns that we use to help us to keep this from happening. Our habit patterns failed us in this instance. We both feel that a contributing factor to this type of error is the format of the pre departure clearance itself which breaks up clearance instead of presenting it in one piece. We found that we both read the pre departure clearance in a similar manner. We check the flight number and transponder code near the top of the pre departure clearance then drop down to the bottom of the pre departure clearance to get the initial altitude and departure frequency. Next we move back to the middle of the message for departure routing and ATC clearance. In this case we both, for whatever reason, stopped at the filed route block and did not proceed up to the ATC 'cleared as filed' block.
Original NASA ASRS Text
Title: B757 FLT CREW DEP FROM PHX FAILED TO RECOGNIZE PDC ROUTING CHANGE.
Narrative: THE CAPT LOADED THE COMPANY FLT PLAN ROUTING INTO THE FMS THEN WAS CHKED FOR ACCURACY BY THE FO. PRIOR TO DEP, THE PDC CONTAINING THE FINAL ATC CLRNC WAS DELIVERED TO THE ACFT VIA ACARS FOLLOWED BY A HARD COPY FROM THE GATE AGENT WHO DELIVERED THE FINAL PAPERWORK. THE FINAL ATC CLRNC ON THE PDC CHANGED THE DEP SID. BOTH PLTS FAILED TO NOTE THE CHANGE OF THE SJN2 TO THE DRYHT2. THIS, DESPITE THE FACT THE FLT NUMBER WAS VERIFIED, AND THE DEP FREQ, XPONDER CODE, AND FIRST FILED ALT WERE ALL NOTED AND LOADED INTO THE RADIOS AND FLT GUIDANCE. PRIOR TO DEP OFF OF RWY 25R THE SNJ2 SID WAS BRIEFED THEN WE FLEW THE DEP AS BRIEFED. WHEN THE ACFT REACHED 1550 FT MSL, A SHALLOW R TURN TO A HEADING OF 260 DEGS WAS INITIATED, AS REQUIRED BY THE SJN2 SID, INSTEAD OF TURN TO THE L TO A HEADING OF 240 DEGS AS WAS REQUIRED BY THE DRYHT2 SID. WITHIN A FEW SECONDS OF CONTACTING DEP CTL AT AROUND 2000 FT MSL, OUR ERROR WAS DETECTED BY THE CTLR AND WE WERE IMMEDIATELY TURNED TO COMPLY WITH THE DRYHT2 SID. WE WERE NOT AWARE OF ANY TFC CONFLICTS DURING THIS INCIDENT. THERE WERE NO TCASII ALERTS. WHILE ENRTE, THE PLTS REVIEWED THE EVENTS THAT LED UP TO THIS ERROR. BOTH PLTS ARE AWARE OF THE PITFALL OF MISSING THE REVISED ATC CLRNC ON THE PDC AND HAVE HABIT PATTERNS THAT WE USE TO HELP US TO KEEP THIS FROM HAPPENING. OUR HABIT PATTERNS FAILED US IN THIS INSTANCE. WE BOTH FEEL THAT A CONTRIBUTING FACTOR TO THIS TYPE OF ERROR IS THE FORMAT OF THE PDC ITSELF WHICH BREAKS UP CLRNC INSTEAD OF PRESENTING IT IN ONE PIECE. WE FOUND THAT WE BOTH READ THE PDC IN A SIMILAR MANNER. WE CHK THE FLT NUMBER AND XPONDER CODE NEAR THE TOP OF THE PDC THEN DROP DOWN TO THE BOTTOM OF THE PDC TO GET THE INITIAL ALT AND DEP FREQ. NEXT WE MOVE BACK TO THE MIDDLE OF THE MESSAGE FOR DEP ROUTING AND ATC CLRNC. IN THIS CASE WE BOTH, FOR WHATEVER REASON, STOPPED AT THE FILED RTE BLOCK AND DID NOT PROCEED UP TO THE ATC 'CLRED AS FILED' BLOCK.
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.