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Attributes | |
ACN | 614719 |
Time | |
Date | 200404 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : tch.vortac |
State Reference | UT |
Altitude | msl single value : 8000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : s56.tracon |
Operator | common carrier : air taxi |
Make Model Name | Citationjet, C525/C526 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure : on vectors departure sid : slc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 5100 flight time type : 250 |
ASRS Report | 614719 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera other flight crewa |
Resolutory Action | controller : issued alert controller : issued new clearance flight crew : became reoriented flight crew : overrode automation flight crew : returned to intended or assigned course |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : s46.tracon |
Chart | sid : salt lake eight |
Narrative:
Clearance given was to cos via the slc 8 departure, radar vectors to the tch 094 degree radial to the mtu 303 degree radial, mtu as filed, maintain 10000 ft. The clearance was taken by the sic who also loaded the route into the FMS navigation system. The route was reviewed by the PIC. During the initial setup for departure, with the initial departure segment being radar vectors to intercept a radial, the autoplt was preset to fly headings and the navigation track mode was inadvertently armed to track the tch 094 degree radial. During the subsequent briefing, the PIC did not catch that this mode was active. Clearance for takeoff was received with the initial heading of 340 degrees assigned and initial climb to 10000 ft was established. Per the slc 8 departure, no turns were expected until reaching 11000 ft due to high terrain. The initial radar vector flight path quickly crossed tch VOR, causing the 094 degree radial to come alive which initiated a turn to track outbound on the tch 094 degree radial. This initial climb segment was in VFR conditions and the crew had ground reference at the beginning of the incident. The flight crew was currently occupied with the after takeoff and climb checklists, quickly noted that the turn was premature and within several seconds, reselected the heading mode and began corrective action to return to the assigned heading before the heading deviation became very significant. I feel sure that the eastward variance could have been less than 1 mi. I cannot give an exact heading excursion, but definitely know that it was significantly less than 90 degrees and more likely in the 45-60 degree range limited mostly by the roll rate at which the autoplt itself responded to the return to the heading mode and turn reversal. The crew could have disengaged the autoplt and made a more aggressive manual turn to the west, but felt quite confident that the minor lateral deviation to the east did not warrant an aggressive reaction with passenger on board. There were no TCASII or GPWS alerts in the aircraft. At exactly the same time, the departure controller commanded an immediate turn back to the west. The speed at which the controller noticed and reacted indicated, in retrospect, that he was very alert to the potential for a problem at this location. The controller issued a telephone number to be contacted upon arrival at the next destination. I provided the supervisor the same account and assured him that the crew was very much on top of the situation when it occurred. He acknowledged that the quick reaction to correct was obvious after the fact. He also confirmed that the minor excursion caused no safety issues, no terrain separation issues and no problems relative to other traffic. He further clarified his concern and vigilance as being the result of a long history of problems relative to the tch 094 degree radial. He indicated that it is a constant low level source of concern for the controllers in this sector. Further discussion seemed to reveal to me that the ATC controllers and their management very much want to affect a change relative to this radial and that there is some reluctance to make any changes by the overlying agency that has such authority/authorized. The current mechanism for pursuing this desired change seems to be the use of any pilot deviation, no matter how insignificant, to keep the matter in the limelight in hopes of encouraging a procedural change. First and foremost, I strongly feel that there is very little practical justification for pursuing a pilot deviation on this matter. The second reason is to urge the FSDO and other involved agencies to recognize that the source of this issue has a long history prior to this incident under investigation. An immediate solution to this issue would be to simply quit issuing the tch 094 degree radial as part of the pre departure clearance. Nothing would make it more clear, and subsequently more safe, than for the departing aircraft to have an initial vector that does not prematurely cross any subsequent eastbound route segment until issued by the controller in-flight, or by procedure after reaching a safe altitude. A possible example of a safer but equivalent clearance would have been: '...via the slc 8 departure to the mtu 303 degree radial (with DME fix if an exact point is necessary), mtu, as filed, maintain 11000 ft...etc.' I humbly ask to recognize that this incident is more a vehicle to call attention to an ongoing problem that could result in other accidents and fatalities if not corrected.
Original NASA ASRS Text
Title: C525 AIR TAXI FLT CREW INCORRECTLY LOADS THEIR PDC IN THEIR FMS RESULTING IN A SID RTE DEV ON DEP.
Narrative: CLRNC GIVEN WAS TO COS VIA THE SLC 8 DEP, RADAR VECTORS TO THE TCH 094 DEG RADIAL TO THE MTU 303 DEG RADIAL, MTU AS FILED, MAINTAIN 10000 FT. THE CLRNC WAS TAKEN BY THE SIC WHO ALSO LOADED THE RTE INTO THE FMS NAV SYS. THE RTE WAS REVIEWED BY THE PIC. DURING THE INITIAL SETUP FOR DEP, WITH THE INITIAL DEP SEGMENT BEING RADAR VECTORS TO INTERCEPT A RADIAL, THE AUTOPLT WAS PRESET TO FLY HDGS AND THE NAV TRACK MODE WAS INADVERTENTLY ARMED TO TRACK THE TCH 094 DEG RADIAL. DURING THE SUBSEQUENT BRIEFING, THE PIC DID NOT CATCH THAT THIS MODE WAS ACTIVE. CLRNC FOR TKOF WAS RECEIVED WITH THE INITIAL HDG OF 340 DEGS ASSIGNED AND INITIAL CLB TO 10000 FT WAS ESTABLISHED. PER THE SLC 8 DEP, NO TURNS WERE EXPECTED UNTIL REACHING 11000 FT DUE TO HIGH TERRAIN. THE INITIAL RADAR VECTOR FLT PATH QUICKLY CROSSED TCH VOR, CAUSING THE 094 DEG RADIAL TO COME ALIVE WHICH INITIATED A TURN TO TRACK OUTBOUND ON THE TCH 094 DEG RADIAL. THIS INITIAL CLB SEGMENT WAS IN VFR CONDITIONS AND THE CREW HAD GND REF AT THE BEGINNING OF THE INCIDENT. THE FLT CREW WAS CURRENTLY OCCUPIED WITH THE AFTER TKOF AND CLB CHKLISTS, QUICKLY NOTED THAT THE TURN WAS PREMATURE AND WITHIN SEVERAL SECONDS, RESELECTED THE HDG MODE AND BEGAN CORRECTIVE ACTION TO RETURN TO THE ASSIGNED HDG BEFORE THE HDG DEV BECAME VERY SIGNIFICANT. I FEEL SURE THAT THE EASTWARD VARIANCE COULD HAVE BEEN LESS THAN 1 MI. I CANNOT GIVE AN EXACT HDG EXCURSION, BUT DEFINITELY KNOW THAT IT WAS SIGNIFICANTLY LESS THAN 90 DEGS AND MORE LIKELY IN THE 45-60 DEG RANGE LIMITED MOSTLY BY THE ROLL RATE AT WHICH THE AUTOPLT ITSELF RESPONDED TO THE RETURN TO THE HDG MODE AND TURN REVERSAL. THE CREW COULD HAVE DISENGAGED THE AUTOPLT AND MADE A MORE AGGRESSIVE MANUAL TURN TO THE W, BUT FELT QUITE CONFIDENT THAT THE MINOR LATERAL DEV TO THE E DID NOT WARRANT AN AGGRESSIVE REACTION WITH PAX ON BOARD. THERE WERE NO TCASII OR GPWS ALERTS IN THE ACFT. AT EXACTLY THE SAME TIME, THE DEP CTLR COMMANDED AN IMMEDIATE TURN BACK TO THE W. THE SPD AT WHICH THE CTLR NOTICED AND REACTED INDICATED, IN RETROSPECT, THAT HE WAS VERY ALERT TO THE POTENTIAL FOR A PROB AT THIS LOCATION. THE CTLR ISSUED A TELEPHONE NUMBER TO BE CONTACTED UPON ARR AT THE NEXT DEST. I PROVIDED THE SUPVR THE SAME ACCOUNT AND ASSURED HIM THAT THE CREW WAS VERY MUCH ON TOP OF THE SIT WHEN IT OCCURRED. HE ACKNOWLEDGED THAT THE QUICK REACTION TO CORRECT WAS OBVIOUS AFTER THE FACT. HE ALSO CONFIRMED THAT THE MINOR EXCURSION CAUSED NO SAFETY ISSUES, NO TERRAIN SEPARATION ISSUES AND NO PROBS RELATIVE TO OTHER TFC. HE FURTHER CLARIFIED HIS CONCERN AND VIGILANCE AS BEING THE RESULT OF A LONG HISTORY OF PROBS RELATIVE TO THE TCH 094 DEG RADIAL. HE INDICATED THAT IT IS A CONSTANT LOW LEVEL SOURCE OF CONCERN FOR THE CTLRS IN THIS SECTOR. FURTHER DISCUSSION SEEMED TO REVEAL TO ME THAT THE ATC CTLRS AND THEIR MGMNT VERY MUCH WANT TO AFFECT A CHANGE RELATIVE TO THIS RADIAL AND THAT THERE IS SOME RELUCTANCE TO MAKE ANY CHANGES BY THE OVERLYING AGENCY THAT HAS SUCH AUTH. THE CURRENT MECHANISM FOR PURSUING THIS DESIRED CHANGE SEEMS TO BE THE USE OF ANY PLTDEV, NO MATTER HOW INSIGNIFICANT, TO KEEP THE MATTER IN THE LIMELIGHT IN HOPES OF ENCOURAGING A PROCEDURAL CHANGE. FIRST AND FOREMOST, I STRONGLY FEEL THAT THERE IS VERY LITTLE PRACTICAL JUSTIFICATION FOR PURSUING A PLTDEV ON THIS MATTER. THE SECOND REASON IS TO URGE THE FSDO AND OTHER INVOLVED AGENCIES TO RECOGNIZE THAT THE SOURCE OF THIS ISSUE HAS A LONG HISTORY PRIOR TO THIS INCIDENT UNDER INVESTIGATION. AN IMMEDIATE SOLUTION TO THIS ISSUE WOULD BE TO SIMPLY QUIT ISSUING THE TCH 094 DEG RADIAL AS PART OF THE PDC. NOTHING WOULD MAKE IT MORE CLR, AND SUBSEQUENTLY MORE SAFE, THAN FOR THE DEPARTING ACFT TO HAVE AN INITIAL VECTOR THAT DOES NOT PREMATURELY CROSS ANY SUBSEQUENT EBOUND RTE SEGMENT UNTIL ISSUED BY THE CTLR INFLT, OR BY PROC AFTER REACHING A SAFE ALT. A POSSIBLE EXAMPLE OF A SAFER BUT EQUIVALENT CLRNC WOULD HAVE BEEN: '...VIA THE SLC 8 DEP TO THE MTU 303 DEG RADIAL (WITH DME FIX IF AN EXACT POINT IS NECESSARY), MTU, AS FILED, MAINTAIN 11000 FT...ETC.' I HUMBLY ASK TO RECOGNIZE THAT THIS INCIDENT IS MORE A VEHICLE TO CALL ATTN TO AN ONGOING PROB THAT COULD RESULT IN OTHER ACCIDENTS AND FATALITIES IF NOT CORRECTED.
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.