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|
Attributes | |
ACN | 598986 |
Time | |
Date | 200311 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | agl single value : 10000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure sid : aaces |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 5200 flight time type : 450 |
ASRS Report | 598986 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | inflight encounter : weather non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : l30.tracon |
Narrative:
ATC stated we deviated from the real intended departure clearance which was the tralr RNAV 1 departure with the AACES2 RNAV departure. 1) company dispatch release: noted only the aaces RNAV departure. 2) flight plan summary's stated the aaces RNAV departure. 3) ATC fdc: a one line statement placed on the pre departure clearance above the flight full route clearance and was not recognized by the crew as information indicating an amendment to the clearance from one RNAV departure to another. 4) no verbal contact with las vegas clearance was made about the revision of the aaces RNAV departure to the tralr RNAV 1 departure, nor was it required. 5) dispatch ATC NOTAMS showed no changes to the departure processes, nor was it mentioned from ground or tower at las vegas, nv. 6) company memo on oct/thu/03 about las TRACON beta testing in progress lacked information on the change-over of RNAV's departures being added and removed on nov/tue/03 and their implications. At the gate, prior to the checklist, the first officer performed duties with clearance via pre departure clearance and the FMGS. When it came time to brief the departure, I stated that it was my leg and briefed his takeoff card. Items covered were the logbook, WX, runway conditions, clearance (aaces RNAV), performance, engine out and rejected takeoff procedure off of runway 19L. We began our pushback and engine start. The before takeoff checklist was completed and the departure briefing was conducted. We then waited in line behind 4 other air carrier Y aircraft. On tower frequency 118.75, we were given clearance to position and hold runway 19L. I called below the line on the takeoff checklist. We waited about 2 mins or so in position and then we were cleared for takeoff. The autoplt was used immediately after liftoff passing above 100 ft AGL and navigation was displayed on the FMA. We were told to climb to FL190. This communication between ATC and us occurred on the AACES2, near the waypoint of idale on climb out. As the turn was commenced to the waypoint of hitme, the controller issued us an amended altitude of 14000 ft. At that moment, ATC queried us as to the departure we were flying. The first officer replied the aaces 2. She stated the aaces 2 was deleted as of today and that an amendment was on our pre departure clearance. The first officer looked at the pre departure clearance again and stated 'it shows the aaces 2.' she then stated in a stern voice that the aaces 2 was no longer an RNAV departure and that we were supposed to be on the tralr RNAV departure. She then instructed us of a heading, I believe was 140 degrees, the altitude was 16000 ft. As I was trying to grasp the part of flying only and ensuring that no traffic was near us, I requested reconfirmation of the new altitude and heading. She responded and requested we copy a phone number. We were then switched off to another controller. We were given direct to hbu. We began to review and assess all our information about the departure. It was found that the flight plan stated in the summaries section aaces 2 as did the pre departure clearance. We also found a statement 'tralr 1 dvc -- above the full clearance of las aaces 2 dvc.' after all the passenger deplaned, I left the aircraft and called the chief pilot. I told him what happened. I showed him the pre departure clearance and the flight plan and he agreed that it was the aaces 2. I showed him the one line statement on the pre departure clearance not reflected anywhere else and he seemed surprised. I stated that I had never seen an amendment to the pre departure clearance nor was an example shown in the section supplemental about pre departure clearance's. I told him we needed to alert dispatch immediately so that the next crew would have the new information on the departure RNAV. I called the TRACON. I spoke to quality assurance. In my discussion, he pointed out that las vegas has had a tremendous problem with pre departure clearance's on other airlines as well. He asked me to file a NASA report. He told me he would call the next day to inform me of their intention to file for a deviation. As of today, the company has been handling the issues. In my opinion, the issues that transpired could have been avoided had several steps been in place by the FAA, ATC, and company. The bottom line is that this is clearly a lack of communication, a one line statement made on a pre departure clearance with no standardized format was not understood by all agencies other than the amending agency. Callback conversation with reporter revealed the following information: reporter stated that company was 'now on track' with the new RNAV procedures and is involved with the FAA/user meetings to resolve and identify issues associated with the new RNAV procedures. Reporter suggested, to assist flight crews in ensuring new procedural recognition, that tower state the SID name in the takeoff clearance.
Original NASA ASRS Text
Title: A319 FLT CREW FAILED TO RECOGNIZE PDC RNAV SID AMENDMENT PRIOR TO DEP AND FLEW THE AACES RNAV DEP INSTEAD OF THE NEW TRALR RNAV SID PROC. L30 QUESTIONED SID FLOWN APCHING HITME WAYPOINT.
Narrative: ATC STATED WE DEVIATED FROM THE REAL INTENDED DEP CLRNC WHICH WAS THE TRALR RNAV 1 DEP WITH THE AACES2 RNAV DEP. 1) COMPANY DISPATCH RELEASE: NOTED ONLY THE AACES RNAV DEP. 2) FLT PLAN SUMMARY'S STATED THE AACES RNAV DEP. 3) ATC FDC: A ONE LINE STATEMENT PLACED ON THE PDC ABOVE THE FLT FULL RTE CLRNC AND WAS NOT RECOGNIZED BY THE CREW AS INFO INDICATING AN AMENDMENT TO THE CLRNC FROM ONE RNAV DEP TO ANOTHER. 4) NO VERBAL CONTACT WITH LAS VEGAS CLRNC WAS MADE ABOUT THE REVISION OF THE AACES RNAV DEP TO THE TRALR RNAV 1 DEP, NOR WAS IT REQUIRED. 5) DISPATCH ATC NOTAMS SHOWED NO CHANGES TO THE DEP PROCESSES, NOR WAS IT MENTIONED FROM GND OR TWR AT LAS VEGAS, NV. 6) COMPANY MEMO ON OCT/THU/03 ABOUT LAS TRACON BETA TESTING IN PROGRESS LACKED INFO ON THE CHANGE-OVER OF RNAV'S DEPS BEING ADDED AND REMOVED ON NOV/TUE/03 AND THEIR IMPLICATIONS. AT THE GATE, PRIOR TO THE CHKLIST, THE FO PERFORMED DUTIES WITH CLRNC VIA PDC AND THE FMGS. WHEN IT CAME TIME TO BRIEF THE DEP, I STATED THAT IT WAS MY LEG AND BRIEFED HIS TKOF CARD. ITEMS COVERED WERE THE LOGBOOK, WX, RWY CONDITIONS, CLRNC (AACES RNAV), PERFORMANCE, ENG OUT AND REJECTED TKOF PROC OFF OF RWY 19L. WE BEGAN OUR PUSHBACK AND ENG START. THE BEFORE TKOF CHKLIST WAS COMPLETED AND THE DEP BRIEFING WAS CONDUCTED. WE THEN WAITED IN LINE BEHIND 4 OTHER ACR Y ACFT. ON TWR FREQ 118.75, WE WERE GIVEN CLRNC TO POS AND HOLD RWY 19L. I CALLED BELOW THE LINE ON THE TKOF CHKLIST. WE WAITED ABOUT 2 MINS OR SO IN POS AND THEN WE WERE CLRED FOR TKOF. THE AUTOPLT WAS USED IMMEDIATELY AFTER LIFTOFF PASSING ABOVE 100 FT AGL AND NAV WAS DISPLAYED ON THE FMA. WE WERE TOLD TO CLB TO FL190. THIS COM BTWN ATC AND US OCCURRED ON THE AACES2, NEAR THE WAYPOINT OF IDALE ON CLBOUT. AS THE TURN WAS COMMENCED TO THE WAYPOINT OF HITME, THE CTLR ISSUED US AN AMENDED ALT OF 14000 FT. AT THAT MOMENT, ATC QUERIED US AS TO THE DEP WE WERE FLYING. THE FO REPLIED THE AACES 2. SHE STATED THE AACES 2 WAS DELETED AS OF TODAY AND THAT AN AMENDMENT WAS ON OUR PDC. THE FO LOOKED AT THE PDC AGAIN AND STATED 'IT SHOWS THE AACES 2.' SHE THEN STATED IN A STERN VOICE THAT THE AACES 2 WAS NO LONGER AN RNAV DEP AND THAT WE WERE SUPPOSED TO BE ON THE TRALR RNAV DEP. SHE THEN INSTRUCTED US OF A HDG, I BELIEVE WAS 140 DEGS, THE ALT WAS 16000 FT. AS I WAS TRYING TO GRASP THE PART OF FLYING ONLY AND ENSURING THAT NO TFC WAS NEAR US, I REQUESTED RECONFIRMATION OF THE NEW ALT AND HDG. SHE RESPONDED AND REQUESTED WE COPY A PHONE NUMBER. WE WERE THEN SWITCHED OFF TO ANOTHER CTLR. WE WERE GIVEN DIRECT TO HBU. WE BEGAN TO REVIEW AND ASSESS ALL OUR INFO ABOUT THE DEP. IT WAS FOUND THAT THE FLT PLAN STATED IN THE SUMMARIES SECTION AACES 2 AS DID THE PDC. WE ALSO FOUND A STATEMENT 'TRALR 1 DVC -- ABOVE THE FULL CLRNC OF LAS AACES 2 DVC.' AFTER ALL THE PAX DEPLANED, I LEFT THE ACFT AND CALLED THE CHIEF PLT. I TOLD HIM WHAT HAPPENED. I SHOWED HIM THE PDC AND THE FLT PLAN AND HE AGREED THAT IT WAS THE AACES 2. I SHOWED HIM THE ONE LINE STATEMENT ON THE PDC NOT REFLECTED ANYWHERE ELSE AND HE SEEMED SURPRISED. I STATED THAT I HAD NEVER SEEN AN AMENDMENT TO THE PDC NOR WAS AN EXAMPLE SHOWN IN THE SECTION SUPPLEMENTAL ABOUT PDC'S. I TOLD HIM WE NEEDED TO ALERT DISPATCH IMMEDIATELY SO THAT THE NEXT CREW WOULD HAVE THE NEW INFO ON THE DEP RNAV. I CALLED THE TRACON. I SPOKE TO QUALITY ASSURANCE. IN MY DISCUSSION, HE POINTED OUT THAT LAS VEGAS HAS HAD A TREMENDOUS PROB WITH PDC'S ON OTHER AIRLINES AS WELL. HE ASKED ME TO FILE A NASA RPT. HE TOLD ME HE WOULD CALL THE NEXT DAY TO INFORM ME OF THEIR INTENTION TO FILE FOR A DEV. AS OF TODAY, THE COMPANY HAS BEEN HANDLING THE ISSUES. IN MY OPINION, THE ISSUES THAT TRANSPIRED COULD HAVE BEEN AVOIDED HAD SEVERAL STEPS BEEN IN PLACE BY THE FAA, ATC, AND COMPANY. THE BOTTOM LINE IS THAT THIS IS CLRLY A LACK OF COM, A ONE LINE STATEMENT MADE ON A PDC WITH NO STANDARDIZED FORMAT WAS NOT UNDERSTOOD BY ALL AGENCIES OTHER THAN THE AMENDING AGENCY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT COMPANY WAS 'NOW ON TRACK' WITH THE NEW RNAV PROCS AND IS INVOLVED WITH THE FAA/USER MEETINGS TO RESOLVE AND IDENT ISSUES ASSOCIATED WITH THE NEW RNAV PROCS. RPTR SUGGESTED, TO ASSIST FLT CREWS IN ENSURING NEW PROCEDURAL RECOGNITION, THAT TWR STATE THE SID NAME IN THE TKOF CLRNC.
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.