Heading track deviation by a B757 flight crew when their assigned clearance was thought to be the MC...

Attributes
ACN	598184
Time
Date	200310
Day	Tue
Local Time Of Day	0601 To 1200
Place
Locale Reference	navaid : las.vortac
State Reference	NV
Altitude	msl bound lower : 7000 msl bound upper : 9000
Environment
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : l30.tracon
Operator	common carrier : air carrier
Make Model Name	B757-200
Operating Under FAR Part	Part 121
Flight Phase	climbout : intermediate altitude
Route In Use	departure sid : mccrn
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : commercial pilot : instrument pilot : multi engine
ASRS Report	598184
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : published procedure non adherence : company policies non adherence : clearance other spatial deviation
Independent Detector	other controllera
Resolutory Action	controller : issued new clearance controller : issued advisory flight crew : became reoriented
Consequence	faa : reviewed incident with flight crew faa : investigated
Supplementary
Problem Areas	Cabin Crew Human Performance Environmental Factor Flight Crew Human Performance ATC Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

We were flying the departure and departure control asked if we were direct shead yet. We answered that we were on the SID and anticipating a vector. Controller asked if we were flying the idale 2 departure. We told him no, that we were assigned the MCCRN2.las departure. He asked if that was assigned and we replied in the affirmative. He cleared us bty and as filed. We then realized that we both missed the revised segment on the pre departure clearance. En route to sfo, ZLA asked us to call las TRACON on the ground in sfo. During the call, we admitted we missed the clearance change. He told us that required separation was never violated. He also told us that this happened regularly and that they wre trying to get company to file the RNAV departure as standard routing. He thanked us for our candor and said it was a dead issue. The captain and I were both called at XA30 for an XD30 report. We both had less than 4 hours sleep prior to takeoff from den to las on the first leg. This was the main contributing factor as I felt extremely tired and fatigued all day long and in fact found myself missing little things. You cannot plan proper rest on reserve when a call can come at any time day or night with an assignment to fly. Required rest is not addressing what it was designed to do. Crew scheduling is using the loose rules to fit their needs, not the needs of the pilots to get proper rest. During the departure briefing, we both used the (non RNAV SID) note on the fpf to confirm the proper departure routing. We both should have recognized our fatigue earlier and used slower more deliberate briefings to avoid the mistakes we made. This is the second time in the last 2 months that I have experienced a fatigue incident, although the first did not result in a company report. It is easy to say that pilots should not fly when fatigued, but the condition is so insidious that it is easily missed. I expect these incidents to continue and increase system-wide and hope someone takes notice and addresses the root causes.

Original NASA ASRS Text

Title: HDG TRACK DEV BY A B757 FLT CREW WHEN THEIR ASSIGNED CLRNC WAS THOUGHT TO BE THE MCCRN2 DEP VERSUS THE ATC ASSUMED IDALE2 DEP FROM LAS, NV.

Narrative: WE WERE FLYING THE DEP AND DEP CTL ASKED IF WE WERE DIRECT SHEAD YET. WE ANSWERED THAT WE WERE ON THE SID AND ANTICIPATING A VECTOR. CTLR ASKED IF WE WERE FLYING THE IDALE 2 DEP. WE TOLD HIM NO, THAT WE WERE ASSIGNED THE MCCRN2.LAS DEP. HE ASKED IF THAT WAS ASSIGNED AND WE REPLIED IN THE AFFIRMATIVE. HE CLRED US BTY AND AS FILED. WE THEN REALIZED THAT WE BOTH MISSED THE REVISED SEGMENT ON THE PDC. ENRTE TO SFO, ZLA ASKED US TO CALL LAS TRACON ON THE GND IN SFO. DURING THE CALL, WE ADMITTED WE MISSED THE CLRNC CHANGE. HE TOLD US THAT REQUIRED SEPARATION WAS NEVER VIOLATED. HE ALSO TOLD US THAT THIS HAPPENED REGULARLY AND THAT THEY WRE TRYING TO GET COMPANY TO FILE THE RNAV DEP AS STANDARD ROUTING. HE THANKED US FOR OUR CANDOR AND SAID IT WAS A DEAD ISSUE. THE CAPT AND I WERE BOTH CALLED AT XA30 FOR AN XD30 RPT. WE BOTH HAD LESS THAN 4 HRS SLEEP PRIOR TO TKOF FROM DEN TO LAS ON THE FIRST LEG. THIS WAS THE MAIN CONTRIBUTING FACTOR AS I FELT EXTREMELY TIRED AND FATIGUED ALL DAY LONG AND IN FACT FOUND MYSELF MISSING LITTLE THINGS. YOU CANNOT PLAN PROPER REST ON RESERVE WHEN A CALL CAN COME AT ANY TIME DAY OR NIGHT WITH AN ASSIGNMENT TO FLY. REQUIRED REST IS NOT ADDRESSING WHAT IT WAS DESIGNED TO DO. CREW SCHEDULING IS USING THE LOOSE RULES TO FIT THEIR NEEDS, NOT THE NEEDS OF THE PLTS TO GET PROPER REST. DURING THE DEP BRIEFING, WE BOTH USED THE (NON RNAV SID) NOTE ON THE FPF TO CONFIRM THE PROPER DEP ROUTING. WE BOTH SHOULD HAVE RECOGNIZED OUR FATIGUE EARLIER AND USED SLOWER MORE DELIBERATE BRIEFINGS TO AVOID THE MISTAKES WE MADE. THIS IS THE SECOND TIME IN THE LAST 2 MONTHS THAT I HAVE EXPERIENCED A FATIGUE INCIDENT, ALTHOUGH THE FIRST DID NOT RESULT IN A COMPANY RPT. IT IS EASY TO SAY THAT PLTS SHOULD NOT FLY WHEN FATIGUED, BUT THE CONDITION IS SO INSIDIOUS THAT IT IS EASILY MISSED. I EXPECT THESE INCIDENTS TO CONTINUE AND INCREASE SYS-WIDE AND HOPE SOMEONE TAKES NOTICE AND ADDRESSES THE ROOT CAUSES.

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.

Heading track deviation by a B757 flight crew when their assigned clearance was thought to be the MCCRN2 departure versus the ATC assumed IDALE2 departure from las, nv.