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A B737 has an ACARS printer jam resulting in the flight crew not receiving the revised flight plan with a SID change. The flight crew flew the wrong SID until P50 TRACON intervened.
| Attributes | |
| ACN | 622253 |
| Time | |
| Date | 200405 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : phx.airport |
| State Reference | AZ |
| Altitude | msl single value : 3000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : p50.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure sid : st. john |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 3000 flight time total : 21000 flight time type : 240 |
| ASRS Report | 622253 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial pilot : multi engine |
| Experience | flight time last 90 days : 240 flight time total : 16000 flight time type : 1000 |
| ASRS Report | 622254 |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : far non adherence : published procedure other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued new clearance |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Environmental Factor Aircraft |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Cockpit printer paper jam during pre departure clearance printout. What folded up and printed over was the 'crew alert -- ATC route has changed' message portion of the pre departure clearance. Due to unusually high cockpit workload conditions at the time, it was assumed that the pre departure clearance just printed twice and that the original clearance remained the same. We both came to this conclusion separately and at different times. The original DRYHT2 was changed to the SJN2 and this was the crew message alert. We used runway 25R, turning left to 140 degree heading on the DRYHT2 at pxr 9.0 DME when, in fact, we were supposed to turn right to 330 degree heading on the SJN2. Departure controller turned us back to 330 degree heading and queried about our SID clearance. After things finally settled down during climb out, a further investigation of the pre departure clearance revealed the SID change when we read 'between the lines.' no traffic conflicts to our knowledge. High cockpit workload due to: 1) aircraft arrived 1+ hour late, so we were in the rush mode. 2) pushback crew did not know company pushback phraseology.
Original NASA ASRS Text
Title: A B737 HAS AN ACARS PRINTER JAM RESULTING IN THE FLT CREW NOT RECEIVING THE REVISED FLT PLAN WITH A SID CHANGE. THE FLT CREW FLEW THE WRONG SID UNTIL P50 TRACON INTERVENED.
Narrative: COCKPIT PRINTER PAPER JAM DURING PDC PRINTOUT. WHAT FOLDED UP AND PRINTED OVER WAS THE 'CREW ALERT -- ATC RTE HAS CHANGED' MESSAGE PORTION OF THE PDC. DUE TO UNUSUALLY HIGH COCKPIT WORKLOAD CONDITIONS AT THE TIME, IT WAS ASSUMED THAT THE PDC JUST PRINTED TWICE AND THAT THE ORIGINAL CLRNC REMAINED THE SAME. WE BOTH CAME TO THIS CONCLUSION SEPARATELY AND AT DIFFERENT TIMES. THE ORIGINAL DRYHT2 WAS CHANGED TO THE SJN2 AND THIS WAS THE CREW MESSAGE ALERT. WE USED RWY 25R, TURNING L TO 140 DEG HDG ON THE DRYHT2 AT PXR 9.0 DME WHEN, IN FACT, WE WERE SUPPOSED TO TURN R TO 330 DEG HDG ON THE SJN2. DEP CTLR TURNED US BACK TO 330 DEG HDG AND QUERIED ABOUT OUR SID CLRNC. AFTER THINGS FINALLY SETTLED DOWN DURING CLBOUT, A FURTHER INVESTIGATION OF THE PDC REVEALED THE SID CHANGE WHEN WE READ 'BTWN THE LINES.' NO TFC CONFLICTS TO OUR KNOWLEDGE. HIGH COCKPIT WORKLOAD DUE TO: 1) ACFT ARRIVED 1+ HR LATE, SO WE WERE IN THE RUSH MODE. 2) PUSHBACK CREW DID NOT KNOW COMPANY PUSHBACK PHRASEOLOGY.
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.