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|
Attributes | |
ACN | 637815 |
Time | |
Date | 200411 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Ice Snow |
Aircraft 1 | |
Controlling Facilities | tracon : a90.tracon |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : initial |
Route In Use | departure sid : logan 2 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 7700 flight time type : 300 |
ASRS Report | 637815 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : pneumatic system warning other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory flight crew : became reoriented |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the relief first officer seated in the observer seat. While the crew briefed the departure, I was handling paperwork duties, but heard the clearance and the first officer brief the logan 2 departure direct pease as filed. I think the delay we experienced after the brief contributed to confusion. We had over 1 hour delay after the brief. I also remember some confusion reading back the clearance when the first officer read back direct (pease) after departure. The clearance controller said 'negative, logan 2, direct (pease).' controller said negative, logan two, direct (pease) shortly after takeoff, climbing through 1500 ft, I noticed a red manifold fail light on the #3 engine. The captain was on the radio with ATC and the first officer was hand flying the aircraft. I was very concerned with the manifold fail light an started a quick mental diagnostic of the problem. I failed to notice the first officer passing the 4 DME fix from bos which required a right turn to 090 degrees (we were departing from runway 4R). When the captain finished his radio transmission, I stated we had a manifold failure and that the automatic air system controller closed the #3 bleed, which also meant we had no anti-ice on the right wing. During the short time I briefed the captain on our problem, ATC questioned where we were going. The captain responded direct (pease). The controller said 'who gave you that?' he then said we were to fly the logan 2 direct. I could have prevented this mistake if I divided my attention between the maintenance problem and observing the flight crew actions. I also think a quick review just before takeoff of the departure page is a good solution. 'Never assume the PF will do what he briefs' is an important lesson.
Original NASA ASRS Text
Title: FLT CREW OF WDB HAVE A TRACK DEV WHEN A MECHANICAL PROB DISTRACTS THEM FROM THEIR CLRED DEP ROUTING.
Narrative: I WAS THE RELIEF FO SEATED IN THE OBSERVER SEAT. WHILE THE CREW BRIEFED THE DEP, I WAS HANDLING PAPERWORK DUTIES, BUT HEARD THE CLRNC AND THE FO BRIEF THE LOGAN 2 DEP DIRECT PEASE AS FILED. I THINK THE DELAY WE EXPERIENCED AFTER THE BRIEF CONTRIBUTED TO CONFUSION. WE HAD OVER 1 HR DELAY AFTER THE BRIEF. I ALSO REMEMBER SOME CONFUSION READING BACK THE CLRNC WHEN THE FO READ BACK DIRECT (PEASE) AFTER DEP. THE CLRNC CTLR SAID 'NEGATIVE, LOGAN 2, DIRECT (PEASE).' CTLR SAID NEGATIVE, LOGAN TWO, DIRECT (PEASE) SHORTLY AFTER TKOF, CLBING THROUGH 1500 FT, I NOTICED A RED MANIFOLD FAIL LIGHT ON THE #3 ENG. THE CAPT WAS ON THE RADIO WITH ATC AND THE FO WAS HAND FLYING THE ACFT. I WAS VERY CONCERNED WITH THE MANIFOLD FAIL LIGHT AN STARTED A QUICK MENTAL DIAGNOSTIC OF THE PROB. I FAILED TO NOTICE THE FO PASSING THE 4 DME FIX FROM BOS WHICH REQUIRED A R TURN TO 090 DEGS (WE WERE DEPARTING FROM RWY 4R). WHEN THE CAPT FINISHED HIS RADIO XMISSION, I STATED WE HAD A MANIFOLD FAILURE AND THAT THE AUTOMATIC AIR SYS CONTROLLER CLOSED THE #3 BLEED, WHICH ALSO MEANT WE HAD NO ANTI-ICE ON THE R WING. DURING THE SHORT TIME I BRIEFED THE CAPT ON OUR PROB, ATC QUESTIONED WHERE WE WERE GOING. THE CAPT RESPONDED DIRECT (PEASE). THE CTLR SAID 'WHO GAVE YOU THAT?' HE THEN SAID WE WERE TO FLY THE LOGAN 2 DIRECT. I COULD HAVE PREVENTED THIS MISTAKE IF I DIVIDED MY ATTN BTWN THE MAINT PROB AND OBSERVING THE FLT CREW ACTIONS. I ALSO THINK A QUICK REVIEW JUST BEFORE TKOF OF THE DEP PAGE IS A GOOD SOLUTION. 'NEVER ASSUME THE PF WILL DO WHAT HE BRIEFS' IS AN IMPORTANT LESSON.
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.