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|
Attributes | |
ACN | 633705 |
Time | |
Date | 200410 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | msl bound lower : 1000 msl bound upper : 2000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tracon : nct.tracon tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : nct.tracon tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 235 flight time total : 12500 flight time type : 3500 |
ASRS Report | 633705 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 125 flight time total : 3800 flight time type : 1551 |
ASRS Report | 633704 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure non adherence : far non adherence : company policies other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : compass other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance controller : issued alert flight crew : returned to intended or assigned course other |
Consequence | other |
Supplementary | |
Problem Areas | FAA |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our clearance was the sfo 8 SID with a heading of 030 degrees. After takeoff, I went to turn the 20 degrees right to a 030 degree heading but noticed that according to the ehsi's we were already on a 030 degree heading and approximately tracking runway 1R centerline. I mentioned the ambiguity to the first officer. At about this point of time we were passing approximately 2000 ft and norcal departure called and asked us to fly heading 030 degrees. I immediately turned about 20 degrees right to what I thought to be about a 030 degree heading. At that point I noticed the word 'tru' on the ehsi and looked to see the heading reference selector selected to 'true' instead of the normal 'norm.' I then selected norm and the ehsi slewed 20 degrees back to the left where it should be. The flight proceeded normally. Factors leading to the event were the fact that the airplane had been in maintenance for 3 days and someone obviously selected true and I failed to notice it on my preflight duties. This is a selector that, in my nearly 2 decades at air carrier, I have never noticed to be out of the norm position. We also failed to notice the misalignment of the runway on the map during runway line-up. Complacency also played a role. Supplemental information from acn 633704: on predep I noticed that the plane had not been flown in 3 days due to maintenance work. I told the captain that we should 'watch out for switches' in the wrong place. I also noticed that the aircraft symbol was aligned with runway 1 but our heading was about 14 degrees off. I made a mental note to check it on taxi after full INS alignment but forgot. The captain did the takeoff and I cleared him right for the turn to 030 degrees on the sfo 8 departure. He turned a little and then I started to watch the B777 in front of us after cleaning up the aircraft. I looked down and saw we were not on the LNAV line but were heading 030 degrees. I then checked the standby compass and saw it at 010 degrees. The captain then said 'we are paralleling the runway centerline?' I told him to turn right just as norcal asked us if we were heading 030 degrees. I told them we were having a problem but did not declare anything. The captain turned to 050 degrees on our heading indicator and then saw the magnetic/true heading switch was in the true position. After placing the switch in the magnetic heading, the headings corrected back to 030 degrees. Norcal then cleared us direct lin. We lost some separation from the B777 but not much and I had him in visual contact the entire time. The WX was severe clear. Good lesson on checking the runway heading with HSI before you take off. Missed it this time!
Original NASA ASRS Text
Title: B767-300 CREW HAD A TRACK DEV DEPARTING SFO ON THE SFO 8 SID.
Narrative: OUR CLRNC WAS THE SFO 8 SID WITH A HDG OF 030 DEGS. AFTER TKOF, I WENT TO TURN THE 20 DEGS R TO A 030 DEG HDG BUT NOTICED THAT ACCORDING TO THE EHSI'S WE WERE ALREADY ON A 030 DEG HDG AND APPROX TRACKING RWY 1R CTRLINE. I MENTIONED THE AMBIGUITY TO THE FO. AT ABOUT THIS POINT OF TIME WE WERE PASSING APPROX 2000 FT AND NORCAL DEP CALLED AND ASKED US TO FLY HDG 030 DEGS. I IMMEDIATELY TURNED ABOUT 20 DEGS R TO WHAT I THOUGHT TO BE ABOUT A 030 DEG HDG. AT THAT POINT I NOTICED THE WORD 'TRU' ON THE EHSI AND LOOKED TO SEE THE HDG REF SELECTOR SELECTED TO 'TRUE' INSTEAD OF THE NORMAL 'NORM.' I THEN SELECTED NORM AND THE EHSI SLEWED 20 DEGS BACK TO THE L WHERE IT SHOULD BE. THE FLT PROCEEDED NORMALLY. FACTORS LEADING TO THE EVENT WERE THE FACT THAT THE AIRPLANE HAD BEEN IN MAINT FOR 3 DAYS AND SOMEONE OBVIOUSLY SELECTED TRUE AND I FAILED TO NOTICE IT ON MY PREFLT DUTIES. THIS IS A SELECTOR THAT, IN MY NEARLY 2 DECADES AT ACR, I HAVE NEVER NOTICED TO BE OUT OF THE NORM POS. WE ALSO FAILED TO NOTICE THE MISALIGNMENT OF THE RWY ON THE MAP DURING RWY LINE-UP. COMPLACENCY ALSO PLAYED A ROLE. SUPPLEMENTAL INFO FROM ACN 633704: ON PREDEP I NOTICED THAT THE PLANE HAD NOT BEEN FLOWN IN 3 DAYS DUE TO MAINT WORK. I TOLD THE CAPT THAT WE SHOULD 'WATCH OUT FOR SWITCHES' IN THE WRONG PLACE. I ALSO NOTICED THAT THE ACFT SYMBOL WAS ALIGNED WITH RWY 1 BUT OUR HDG WAS ABOUT 14 DEGS OFF. I MADE A MENTAL NOTE TO CHK IT ON TAXI AFTER FULL INS ALIGNMENT BUT FORGOT. THE CAPT DID THE TKOF AND I CLRED HIM RIGHT FOR THE TURN TO 030 DEGS ON THE SFO 8 DEP. HE TURNED A LITTLE AND THEN I STARTED TO WATCH THE B777 IN FRONT OF US AFTER CLEANING UP THE ACFT. I LOOKED DOWN AND SAW WE WERE NOT ON THE LNAV LINE BUT WERE HDG 030 DEGS. I THEN CHKED THE STANDBY COMPASS AND SAW IT AT 010 DEGS. THE CAPT THEN SAID 'WE ARE PARALLELING THE RWY CTRLINE?' I TOLD HIM TO TURN R JUST AS NORCAL ASKED US IF WE WERE HDG 030 DEGS. I TOLD THEM WE WERE HAVING A PROB BUT DID NOT DECLARE ANYTHING. THE CAPT TURNED TO 050 DEGS ON OUR HDG INDICATOR AND THEN SAW THE MAGNETIC/TRUE HDG SWITCH WAS IN THE TRUE POS. AFTER PLACING THE SWITCH IN THE MAGNETIC HDG, THE HDGS CORRECTED BACK TO 030 DEGS. NORCAL THEN CLRED US DIRECT LIN. WE LOST SOME SEPARATION FROM THE B777 BUT NOT MUCH AND I HAD HIM IN VISUAL CONTACT THE ENTIRE TIME. THE WX WAS SEVERE CLR. GOOD LESSON ON CHKING THE RWY HDG WITH HSI BEFORE YOU TAKE OFF. MISSED IT THIS TIME!
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.