37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 597867 |
Time | |
Date | 200310 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : clt.airport |
State Reference | NC |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : clt.tracon |
Operator | general aviation : corporate |
Make Model Name | Citation II S2/Bravo |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure sid : hornet |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 11500 flight time type : 400 |
ASRS Report | 597867 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 82.3 flight time total : 1799.9 flight time type : 800 |
ASRS Report | 598494 |
Events | |
Anomaly | non adherence : clearance non adherence : far non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were cleared for the hornet 1 departure, haray transition. We briefed the entire route on the ramp after receiving the clearance, and were expecting runway 36R as it is right next to the FBO ramp. We were cleared to runway 36L, and after some discussion with ATC about using runway 36R, we were still sent to runway 36L. During the taxi, and again at the hold short point at the end of the runway, I reread the SID instructions, at least twice. Unfortunately, I was reading the runway 36R instructions while saying out loud runway 36L during the brief. After takeoff, we flawlessly flew the runway 36R procedure, which specifies a right turn at 2.6 DME to 025 degrees. About 30 seconds after we turned, ATC asked for an immediate left turn to 270 degrees and stated that we had missed the SID turn. We made an immediate left turn, and I stated to ATC that we had read a 025 degree heading on the SID. He informed us that the runway 36L SID turn was left to 330 degrees. A little while later he gave us a phone number to call. I talked to the ATC supervisor after landing by phone. I had studied the chart repeatedly on the flight home, all the time wondering how I had read runway 36R for runway 36L. He informed us that luckily no one was taking off on runway 36R at the time and there had been no separation problems, and was very nice about the whole thing, while making sure we understood the possible severity of our mistake. I think the controller, who was fairly busy at the time, was very quick in determining our mistake and issuing corrective vectors. This possibly prevented a much more serious situation. On our part, I simply misread the SID instructions off of the commercial chart, repeatedly. I don't know if the expectation for runway 36R preset me to read that section. The only recommendation I could make is to print the separate runway SID procedures in more of a briefing format like on the approach charts. The way the procedures are written now can look jumbled in a dark cockpit. At the very least, make the runway numbers larger and all capitals (ie, runway 36L), and put a dividing line between the different runway instructions. The words 'maintain 8000 ft' are more prominent than the runway numbers which are lower case and not bolded, and there is no space between the different runway instructions. This makes the entire section look very busy. Of course, simply looking at the picture would have prevented my mistake anyway. Another procedure I am now going to do, which was suggested by the copilot, is to have both pilots read separately the SID instructions to minimize the chance of repeating our mistake. This would most likely have prevented this incident. Supplemental information from acn 598494: the instructions given by the PNF was to fly runway heading until reaching the 2.6 DME and then turn right to a heading of 025 degrees. During the taxi we had approximately 5-6 hold shorts with several sequences between large commercial aircraft. Just before reaching the runway 36L hold short point I requested another briefing of the departure instructions. Again, the PNF read the instructions for runway 36R while saying runway 36L.
Original NASA ASRS Text
Title: ON DEP FROM RWY 36L AT CLT FLT CREW OF C550 PERFORM HORNET DEP PROC FOR RWY 36R INSTEAD. ATC ALERTED THEM TO THE ERROR AND PROVIDED A VECTOR CLRNC OUT OF THE AREA OF CONFLICT.
Narrative: WE WERE CLRED FOR THE HORNET 1 DEP, HARAY TRANSITION. WE BRIEFED THE ENTIRE RTE ON THE RAMP AFTER RECEIVING THE CLRNC, AND WERE EXPECTING RWY 36R AS IT IS RIGHT NEXT TO THE FBO RAMP. WE WERE CLRED TO RWY 36L, AND AFTER SOME DISCUSSION WITH ATC ABOUT USING RWY 36R, WE WERE STILL SENT TO RWY 36L. DURING THE TAXI, AND AGAIN AT THE HOLD SHORT POINT AT THE END OF THE RWY, I REREAD THE SID INSTRUCTIONS, AT LEAST TWICE. UNFORTUNATELY, I WAS READING THE RWY 36R INSTRUCTIONS WHILE SAYING OUT LOUD RWY 36L DURING THE BRIEF. AFTER TKOF, WE FLAWLESSLY FLEW THE RWY 36R PROC, WHICH SPECIFIES A R TURN AT 2.6 DME TO 025 DEGS. ABOUT 30 SECONDS AFTER WE TURNED, ATC ASKED FOR AN IMMEDIATE L TURN TO 270 DEGS AND STATED THAT WE HAD MISSED THE SID TURN. WE MADE AN IMMEDIATE L TURN, AND I STATED TO ATC THAT WE HAD READ A 025 DEG HDG ON THE SID. HE INFORMED US THAT THE RWY 36L SID TURN WAS L TO 330 DEGS. A LITTLE WHILE LATER HE GAVE US A PHONE NUMBER TO CALL. I TALKED TO THE ATC SUPVR AFTER LNDG BY PHONE. I HAD STUDIED THE CHART REPEATEDLY ON THE FLT HOME, ALL THE TIME WONDERING HOW I HAD READ RWY 36R FOR RWY 36L. HE INFORMED US THAT LUCKILY NO ONE WAS TAKING OFF ON RWY 36R AT THE TIME AND THERE HAD BEEN NO SEPARATION PROBS, AND WAS VERY NICE ABOUT THE WHOLE THING, WHILE MAKING SURE WE UNDERSTOOD THE POSSIBLE SEVERITY OF OUR MISTAKE. I THINK THE CTLR, WHO WAS FAIRLY BUSY AT THE TIME, WAS VERY QUICK IN DETERMINING OUR MISTAKE AND ISSUING CORRECTIVE VECTORS. THIS POSSIBLY PREVENTED A MUCH MORE SERIOUS SIT. ON OUR PART, I SIMPLY MISREAD THE SID INSTRUCTIONS OFF OF THE COMMERCIAL CHART, REPEATEDLY. I DON'T KNOW IF THE EXPECTATION FOR RWY 36R PRESET ME TO READ THAT SECTION. THE ONLY RECOMMENDATION I COULD MAKE IS TO PRINT THE SEPARATE RWY SID PROCS IN MORE OF A BRIEFING FORMAT LIKE ON THE APCH CHARTS. THE WAY THE PROCS ARE WRITTEN NOW CAN LOOK JUMBLED IN A DARK COCKPIT. AT THE VERY LEAST, MAKE THE RWY NUMBERS LARGER AND ALL CAPITALS (IE, RWY 36L), AND PUT A DIVIDING LINE BTWN THE DIFFERENT RWY INSTRUCTIONS. THE WORDS 'MAINTAIN 8000 FT' ARE MORE PROMINENT THAN THE RWY NUMBERS WHICH ARE LOWER CASE AND NOT BOLDED, AND THERE IS NO SPACE BTWN THE DIFFERENT RWY INSTRUCTIONS. THIS MAKES THE ENTIRE SECTION LOOK VERY BUSY. OF COURSE, SIMPLY LOOKING AT THE PICTURE WOULD HAVE PREVENTED MY MISTAKE ANYWAY. ANOTHER PROC I AM NOW GOING TO DO, WHICH WAS SUGGESTED BY THE COPLT, IS TO HAVE BOTH PLTS READ SEPARATELY THE SID INSTRUCTIONS TO MINIMIZE THE CHANCE OF REPEATING OUR MISTAKE. THIS WOULD MOST LIKELY HAVE PREVENTED THIS INCIDENT. SUPPLEMENTAL INFO FROM ACN 598494: THE INSTRUCTIONS GIVEN BY THE PNF WAS TO FLY RWY HEADING UNTIL REACHING THE 2.6 DME AND THEN TURN R TO A HEADING OF 025 DEGS. DURING THE TAXI WE HAD APPROX 5-6 HOLD SHORTS WITH SEVERAL SEQUENCES BTWN LARGE COMMERCIAL ACFT. JUST BEFORE REACHING THE RWY 36L HOLD SHORT POINT I REQUESTED ANOTHER BRIEFING OF THE DEP INSTRUCTIONS. AGAIN, THE PNF READ THE INSTRUCTIONS FOR RWY 36R WHILE SAYING RWY 36L.
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.