37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 639048 |
Time | |
Date | 200411 |
Day | Sat |
Place | |
Locale Reference | navaid : ewc.vortac |
State Reference | PA |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : vacating altitude cruise : level |
Route In Use | departure sid : pittsburgh |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 5000 flight time type : 1000 |
ASRS Report | 639048 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure non adherence : far non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
When I got to the aircraft it was already pwred up. I did my flow and got to the part of FMS programming. I pulled out the pre-stored flight plan (pit-bdl), looked it over, and compared it to the details of flight plan on release. There were several mistakes in the pre-stored version of the flight plan. The main error that caught my attention concerned arrival, which I corrected. While going over the programming, the first officer pointed out that the INS was displaying 'battery failure' caution on the advise panel. Since I had never seen this failure advisory before, I did not know how to correct it. I called maintenance control to ask for instructions. Maintenance control told me that the only way to correct the problem was to shut down the electrical power and then re-start the system. This would require not only shutting down the electrical power, but also the plane itself. I did not consider the recommendation advisable, since most of the passenger were already on board and we were very close to departure time. Furthermore, the procedure would require shutting down both the air conditioning system and the lights throughout the whole plane, which would immediately cause concern among the passenger. In addition, I knew that in order for INS to align would require an additional 5-7 mins, which would cause a delay in our departure time. But since this was the only solution according to maintenance control, I proceeded to do the shut down. After power re-set, I started programming all over again. I was aware of the mistakes that the FMS included in the STAR portion of the procedure, which I reprogrammed and verified. However, the departure never caught my attention due to the fact that the new clearance never mentioned the route we were supposed to fly. Clearance ATC issued was 'cleared as filed.' SID did not depict the route we were assigned. The only specific information on clearance we got was on the release portion, and we were not aware that the information on the release portion was different than the one included in the flight plan and the FMS. The detailed flight plan and FMS agreed (pit..elw..slt and so on). However, the clearance stated (pit..elw.ELW050..J587.slt). We overlooked the differences between both because we were focused on an on-time departure and assumed that the programmed departure was correct. On the taxi out, we briefed the departure from the SID, still unaware that there was a mistake. After takeoff, pit departure switched us to ZOB, while the aircraft was on LNAV. We had just crossed over elw and were proceeding to slt when the center asked what our intentions were. I was the PNF, so I responded that we were proceeding according to our clearance direct to slt, which I believed to be correct. Cle questioned us about who had issued this clearance, and whether this agreed with what we had received from ATC. I immediately realized our mistake and offered to correct it. I also asked whether the controller wanted us to return to the proper course. We received a negative reply and clearance to proceed to slt. Cle pointed out that flying the route we were flying was 'undesirable' because slt was used by arrs. On the switchover, I asked the controller for the telephone number where he could be contacted so that we could further discuss the event. He gave me the telephone of the center facility. I attempted to contact the center facility upon arriving to bdl, but was not able to reach anyone because nobody picked up the phone. In my opinion, one of the main factors that contributed to this incident was the lack of clarity on the SID. The information is not clear concerning specific departure procedures. It seems to be for local crews who operate out of pit and who are very familiar with the specific procedure of the airport. If this is the standard procedure it should be clearly depicted on the chart.
Original NASA ASRS Text
Title: AN ERJ145 CREW MISREAD A PDC AND FLEW A RTE INTO AN ARR ROUTING (STAR).
Narrative: WHEN I GOT TO THE ACFT IT WAS ALREADY PWRED UP. I DID MY FLOW AND GOT TO THE PART OF FMS PROGRAMMING. I PULLED OUT THE PRE-STORED FLT PLAN (PIT-BDL), LOOKED IT OVER, AND COMPARED IT TO THE DETAILS OF FLT PLAN ON RELEASE. THERE WERE SEVERAL MISTAKES IN THE PRE-STORED VERSION OF THE FLT PLAN. THE MAIN ERROR THAT CAUGHT MY ATTN CONCERNED ARR, WHICH I CORRECTED. WHILE GOING OVER THE PROGRAMMING, THE FO POINTED OUT THAT THE INS WAS DISPLAYING 'BATTERY FAILURE' CAUTION ON THE ADVISE PANEL. SINCE I HAD NEVER SEEN THIS FAILURE ADVISORY BEFORE, I DID NOT KNOW HOW TO CORRECT IT. I CALLED MAINT CTL TO ASK FOR INSTRUCTIONS. MAINT CTL TOLD ME THAT THE ONLY WAY TO CORRECT THE PROB WAS TO SHUT DOWN THE ELECTRICAL PWR AND THEN RE-START THE SYS. THIS WOULD REQUIRE NOT ONLY SHUTTING DOWN THE ELECTRICAL PWR, BUT ALSO THE PLANE ITSELF. I DID NOT CONSIDER THE RECOMMENDATION ADVISABLE, SINCE MOST OF THE PAX WERE ALREADY ON BOARD AND WE WERE VERY CLOSE TO DEP TIME. FURTHERMORE, THE PROC WOULD REQUIRE SHUTTING DOWN BOTH THE AIR CONDITIONING SYS AND THE LIGHTS THROUGHOUT THE WHOLE PLANE, WHICH WOULD IMMEDIATELY CAUSE CONCERN AMONG THE PAX. IN ADDITION, I KNEW THAT IN ORDER FOR INS TO ALIGN WOULD REQUIRE AN ADDITIONAL 5-7 MINS, WHICH WOULD CAUSE A DELAY IN OUR DEP TIME. BUT SINCE THIS WAS THE ONLY SOLUTION ACCORDING TO MAINT CTL, I PROCEEDED TO DO THE SHUT DOWN. AFTER PWR RE-SET, I STARTED PROGRAMMING ALL OVER AGAIN. I WAS AWARE OF THE MISTAKES THAT THE FMS INCLUDED IN THE STAR PORTION OF THE PROC, WHICH I REPROGRAMMED AND VERIFIED. HOWEVER, THE DEP NEVER CAUGHT MY ATTN DUE TO THE FACT THAT THE NEW CLRNC NEVER MENTIONED THE RTE WE WERE SUPPOSED TO FLY. CLRNC ATC ISSUED WAS 'CLRED AS FILED.' SID DID NOT DEPICT THE RTE WE WERE ASSIGNED. THE ONLY SPECIFIC INFO ON CLRNC WE GOT WAS ON THE RELEASE PORTION, AND WE WERE NOT AWARE THAT THE INFO ON THE RELEASE PORTION WAS DIFFERENT THAN THE ONE INCLUDED IN THE FLT PLAN AND THE FMS. THE DETAILED FLT PLAN AND FMS AGREED (PIT..ELW..SLT AND SO ON). HOWEVER, THE CLRNC STATED (PIT..ELW.ELW050..J587.SLT). WE OVERLOOKED THE DIFFERENCES BTWN BOTH BECAUSE WE WERE FOCUSED ON AN ON-TIME DEP AND ASSUMED THAT THE PROGRAMMED DEP WAS CORRECT. ON THE TAXI OUT, WE BRIEFED THE DEP FROM THE SID, STILL UNAWARE THAT THERE WAS A MISTAKE. AFTER TKOF, PIT DEP SWITCHED US TO ZOB, WHILE THE ACFT WAS ON LNAV. WE HAD JUST CROSSED OVER ELW AND WERE PROCEEDING TO SLT WHEN THE CTR ASKED WHAT OUR INTENTIONS WERE. I WAS THE PNF, SO I RESPONDED THAT WE WERE PROCEEDING ACCORDING TO OUR CLRNC DIRECT TO SLT, WHICH I BELIEVED TO BE CORRECT. CLE QUESTIONED US ABOUT WHO HAD ISSUED THIS CLRNC, AND WHETHER THIS AGREED WITH WHAT WE HAD RECEIVED FROM ATC. I IMMEDIATELY REALIZED OUR MISTAKE AND OFFERED TO CORRECT IT. I ALSO ASKED WHETHER THE CTLR WANTED US TO RETURN TO THE PROPER COURSE. WE RECEIVED A NEGATIVE REPLY AND CLRNC TO PROCEED TO SLT. CLE POINTED OUT THAT FLYING THE RTE WE WERE FLYING WAS 'UNDESIRABLE' BECAUSE SLT WAS USED BY ARRS. ON THE SWITCHOVER, I ASKED THE CTLR FOR THE TELEPHONE NUMBER WHERE HE COULD BE CONTACTED SO THAT WE COULD FURTHER DISCUSS THE EVENT. HE GAVE ME THE TELEPHONE OF THE CTR FACILITY. I ATTEMPTED TO CONTACT THE CTR FACILITY UPON ARRIVING TO BDL, BUT WAS NOT ABLE TO REACH ANYONE BECAUSE NOBODY PICKED UP THE PHONE. IN MY OPINION, ONE OF THE MAIN FACTORS THAT CONTRIBUTED TO THIS INCIDENT WAS THE LACK OF CLARITY ON THE SID. THE INFO IS NOT CLR CONCERNING SPECIFIC DEP PROCS. IT SEEMS TO BE FOR LCL CREWS WHO OPERATE OUT OF PIT AND WHO ARE VERY FAMILIAR WITH THE SPECIFIC PROC OF THE ARPT. IF THIS IS THE STANDARD PROC IT SHOULD BE CLRLY DEPICTED ON THE CHART.
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.