Narrative:

On nov/sat/03, first officer and myself were departing in our lear 31A, from las to boeing field, wa (bfi). After arriving from tucson, az, about 30 mins prior, I exited the airplane at las vegas executive air terminal to help load our passenger's bags and arrange for services at the FBO. During this time, the first officer remained in the cockpit and proceeded to copy down the current ATIS and pick up our clearance to bfi. After loading our passenger, we called for taxi clearance with the current ATIS and taxied out of the FBO's parking. As the taxi to the 19 runways at las is short, we briefed the clearance that was given to us and confirmed that our FMS was set up prior to taxi. I was not aware at this time that the clearance we were briefing was not the correct one. Our briefing consisted of the departure procedure to be flown, STAAV2 departure, and confirmation of takeoff speeds for the aircraft condition. I was told by the FBO that we were to fly the STAAV2 departure, no the SHEAD2. We had 2 sets of charts on board and 1 set did not have the SHEAD2. Shortly thereafter, we were contacted by the tower controller, once all checks were completed, and cleared for takeoff on runway 19L. Once airborne, we started flying the STAAV2 departure. The FMS and flight director initiated the turn after dealr intersection towards staav intersection. About 1/3 of the way into the turn towards staav intersection, we were contacted promptly by the departure controller that we were going in the wrong direction. We quickly reviewed the staav departure procedure and responded that we were flying the staav departure. Shortly thereafter, we were given a heading towards shead intersection and to expect the shead departure. As we scrambled to get the shead departure set up, we told ATC we were originally flying the staav departure and going directly to staav intersection. We then complied with all instructions to fly direct to shead and the remainder of the departure towards oal. At this point, I realized my mistake and when we got on the ground in bfi, we would call and help figure out what exactly had happened. We were given a phone number to copy once safely established directly to shead intersection. At no time during the situation did we receive an RA or TA alert on the TCASII, nor a GPWS call. We were told by the departure controller that no aircraft separation was lost. We proceeded to fly the new clearance and climb instructions on our way to bfi. Once at cruise, we were able to review what had happened and how it happened. After reviewing the charts and what had been copied down in the original clearance, we soon realized the mix-up. Within the copilot's set of charts, he did not have the SHEAD2 departure only the staav departure. There was confusion in his writing and he went directly to the departure list and found only 1 'south' departure for las. We should have verified both sets of charts at this point. The staav departure was the one programmed into the FMS. We directly see our breakdown in current operations and have already implemented new changes to pre-departure sops to further enhance safety. The additions are as follows: 1) both pilots are present during the initial call and readback of the clearance. 2) readback of clearance is completed in full and not abbreviated at any time. 3) immediately after readback, there is a full review of the departure procedure and correct transition to be flown. 4) full review of current charts prior to flight for both pilot/copilot to ensure each pilot has all charts applicable for the airport of arrival/destination. As we are very upset with this current breakdown, we are pleased that separation of aircraft was never compromised. I have taken immediate action including a personal review of our sops for this aircraft. These changes are now in the operational process. Safety and efficiency have always been top priorities. Supplemental information from acn 599817: this clearance was issued in a very rapid manner, as clearance delivery was busy. I copied and read back that I have and understand the clearance and that the squawk code is XXXX to minimize time on the frequency. The morning of departure, I printed out all of the charts for proposed trip itinerary, including the 43 charts for las vegas, which included 13 departure procedure charts. I went through my 10-3 series of departure procedure charts to find a chart that started with the letter 'south.' I came upon the staav RNAV two departure. I then checked to see if there was another departure procedure chart that started with the letter 'south.' when I did not find one, I assumed that I had the correct departure procedure and that I had misinterpreted shead for staav. I also should have caught it was the shead one departure, and I was looking at the staav two departure. Where the error chain started was with printing out the charts from an out of date disk. The captain had current, up to date charts in the cockpit, but the captain told me earlier in the day that they were somewhat unorganized and out of order. I did not even think to look at his charts to see if there was another departure. Obviously, I should have checked his charts or contacted clearance delivery again to verify the correct departure procedure. A recommendation that I might make is that, is it really necessary to have an airport with 13 or more arrival and departure procedures? Can this not be simplified? And if not, can we at least use a different letter of the alphabet for each individual procedure?

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Original NASA ASRS Text

Title: L31 TRANSPOSES LAS CLRNC SID PROC DUE TO PRINTING OUT-OF-DATE SIDS PRIOR TO FLT, RESULTING ENRTE DEV.

Narrative: ON NOV/SAT/03, FO AND MYSELF WERE DEPARTING IN OUR LEAR 31A, FROM LAS TO BOEING FIELD, WA (BFI). AFTER ARRIVING FROM TUCSON, AZ, ABOUT 30 MINS PRIOR, I EXITED THE AIRPLANE AT LAS VEGAS EXECUTIVE AIR TERMINAL TO HELP LOAD OUR PAX'S BAGS AND ARRANGE FOR SVCS AT THE FBO. DURING THIS TIME, THE FO REMAINED IN THE COCKPIT AND PROCEEDED TO COPY DOWN THE CURRENT ATIS AND PICK UP OUR CLRNC TO BFI. AFTER LOADING OUR PAX, WE CALLED FOR TAXI CLRNC WITH THE CURRENT ATIS AND TAXIED OUT OF THE FBO'S PARKING. AS THE TAXI TO THE 19 RWYS AT LAS IS SHORT, WE BRIEFED THE CLRNC THAT WAS GIVEN TO US AND CONFIRMED THAT OUR FMS WAS SET UP PRIOR TO TAXI. I WAS NOT AWARE AT THIS TIME THAT THE CLRNC WE WERE BRIEFING WAS NOT THE CORRECT ONE. OUR BRIEFING CONSISTED OF THE DEP PROC TO BE FLOWN, STAAV2 DEP, AND CONFIRMATION OF TKOF SPDS FOR THE ACFT CONDITION. I WAS TOLD BY THE FBO THAT WE WERE TO FLY THE STAAV2 DEP, NO THE SHEAD2. WE HAD 2 SETS OF CHARTS ON BOARD AND 1 SET DID NOT HAVE THE SHEAD2. SHORTLY THEREAFTER, WE WERE CONTACTED BY THE TWR CTLR, ONCE ALL CHKS WERE COMPLETED, AND CLRED FOR TKOF ON RWY 19L. ONCE AIRBORNE, WE STARTED FLYING THE STAAV2 DEP. THE FMS AND FLT DIRECTOR INITIATED THE TURN AFTER DEALR INTXN TOWARDS STAAV INTXN. ABOUT 1/3 OF THE WAY INTO THE TURN TOWARDS STAAV INTXN, WE WERE CONTACTED PROMPTLY BY THE DEP CTLR THAT WE WERE GOING IN THE WRONG DIRECTION. WE QUICKLY REVIEWED THE STAAV DEP PROC AND RESPONDED THAT WE WERE FLYING THE STAAV DEP. SHORTLY THEREAFTER, WE WERE GIVEN A HEADING TOWARDS SHEAD INTXN AND TO EXPECT THE SHEAD DEP. AS WE SCRAMBLED TO GET THE SHEAD DEP SET UP, WE TOLD ATC WE WERE ORIGINALLY FLYING THE STAAV DEP AND GOING DIRECTLY TO STAAV INTXN. WE THEN COMPLIED WITH ALL INSTRUCTIONS TO FLY DIRECT TO SHEAD AND THE REMAINDER OF THE DEP TOWARDS OAL. AT THIS POINT, I REALIZED MY MISTAKE AND WHEN WE GOT ON THE GND IN BFI, WE WOULD CALL AND HELP FIGURE OUT WHAT EXACTLY HAD HAPPENED. WE WERE GIVEN A PHONE NUMBER TO COPY ONCE SAFELY ESTABLISHED DIRECTLY TO SHEAD INTXN. AT NO TIME DURING THE SIT DID WE RECEIVE AN RA OR TA ALERT ON THE TCASII, NOR A GPWS CALL. WE WERE TOLD BY THE DEP CTLR THAT NO ACFT SEPARATION WAS LOST. WE PROCEEDED TO FLY THE NEW CLRNC AND CLB INSTRUCTIONS ON OUR WAY TO BFI. ONCE AT CRUISE, WE WERE ABLE TO REVIEW WHAT HAD HAPPENED AND HOW IT HAPPENED. AFTER REVIEWING THE CHARTS AND WHAT HAD BEEN COPIED DOWN IN THE ORIGINAL CLRNC, WE SOON REALIZED THE MIX-UP. WITHIN THE COPLT'S SET OF CHARTS, HE DID NOT HAVE THE SHEAD2 DEP ONLY THE STAAV DEP. THERE WAS CONFUSION IN HIS WRITING AND HE WENT DIRECTLY TO THE DEP LIST AND FOUND ONLY 1 'S' DEP FOR LAS. WE SHOULD HAVE VERIFIED BOTH SETS OF CHARTS AT THIS POINT. THE STAAV DEP WAS THE ONE PROGRAMMED INTO THE FMS. WE DIRECTLY SEE OUR BREAKDOWN IN CURRENT OPS AND HAVE ALREADY IMPLEMENTED NEW CHANGES TO PRE-DEP SOPS TO FURTHER ENHANCE SAFETY. THE ADDITIONS ARE AS FOLLOWS: 1) BOTH PLTS ARE PRESENT DURING THE INITIAL CALL AND READBACK OF THE CLRNC. 2) READBACK OF CLRNC IS COMPLETED IN FULL AND NOT ABBREVIATED AT ANY TIME. 3) IMMEDIATELY AFTER READBACK, THERE IS A FULL REVIEW OF THE DEP PROC AND CORRECT TRANSITION TO BE FLOWN. 4) FULL REVIEW OF CURRENT CHARTS PRIOR TO FLT FOR BOTH PLT/COPLT TO ENSURE EACH PLT HAS ALL CHARTS APPLICABLE FOR THE ARPT OF ARR/DEST. AS WE ARE VERY UPSET WITH THIS CURRENT BREAKDOWN, WE ARE PLEASED THAT SEPARATION OF ACFT WAS NEVER COMPROMISED. I HAVE TAKEN IMMEDIATE ACTION INCLUDING A PERSONAL REVIEW OF OUR SOPS FOR THIS ACFT. THESE CHANGES ARE NOW IN THE OPERATIONAL PROCESS. SAFETY AND EFFICIENCY HAVE ALWAYS BEEN TOP PRIORITIES. SUPPLEMENTAL INFO FROM ACN 599817: THIS CLRNC WAS ISSUED IN A VERY RAPID MANNER, AS CLRNC DELIVERY WAS BUSY. I COPIED AND READ BACK THAT I HAVE AND UNDERSTAND THE CLRNC AND THAT THE SQUAWK CODE IS XXXX TO MINIMIZE TIME ON THE FREQ. THE MORNING OF DEP, I PRINTED OUT ALL OF THE CHARTS FOR PROPOSED TRIP ITINERARY, INCLUDING THE 43 CHARTS FOR LAS VEGAS, WHICH INCLUDED 13 DEP PROC CHARTS. I WENT THROUGH MY 10-3 SERIES OF DEP PROC CHARTS TO FIND A CHART THAT STARTED WITH THE LETTER 'S.' I CAME UPON THE STAAV RNAV TWO DEP. I THEN CHKED TO SEE IF THERE WAS ANOTHER DEP PROC CHART THAT STARTED WITH THE LETTER 'S.' WHEN I DID NOT FIND ONE, I ASSUMED THAT I HAD THE CORRECT DEP PROC AND THAT I HAD MISINTERPRETED SHEAD FOR STAAV. I ALSO SHOULD HAVE CAUGHT IT WAS THE SHEAD ONE DEP, AND I WAS LOOKING AT THE STAAV TWO DEP. WHERE THE ERROR CHAIN STARTED WAS WITH PRINTING OUT THE CHARTS FROM AN OUT OF DATE DISK. THE CAPT HAD CURRENT, UP TO DATE CHARTS IN THE COCKPIT, BUT THE CAPT TOLD ME EARLIER IN THE DAY THAT THEY WERE SOMEWHAT UNORGANIZED AND OUT OF ORDER. I DID NOT EVEN THINK TO LOOK AT HIS CHARTS TO SEE IF THERE WAS ANOTHER DEP. OBVIOUSLY, I SHOULD HAVE CHKED HIS CHARTS OR CONTACTED CLRNC DELIVERY AGAIN TO VERIFY THE CORRECT DEP PROC. A RECOMMENDATION THAT I MIGHT MAKE IS THAT, IS IT REALLY NECESSARY TO HAVE AN ARPT WITH 13 OR MORE ARR AND DEP PROCS? CAN THIS NOT BE SIMPLIFIED? AND IF NOT, CAN WE AT LEAST USE A DIFFERENT LETTER OF THE ALPHABET FOR EACH INDIVIDUAL PROC?

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.