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|
Attributes | |
ACN | 644981 |
Time | |
Date | 200501 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : dryht |
State Reference | NM |
Altitude | msl single value : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zab.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Route In Use | departure sid : maxxo |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 200 flight time total : 11500 flight time type : 6500 |
ASRS Report | 644981 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory flight crew : became reoriented |
Supplementary | |
Problem Areas | Company Aircraft Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Publication | FMS Database |
Narrative:
While flying the MAXXO1 SID from phx we were cleared direct to bayta intersection on course. Approximately three minutes after passing dryht intersection; abq center questioned our next fix. It suddenly became painfully obvious we had missed the turn. At cruise speed this put us approximately 24 miles off course. There was no traffic conflict involved and we were cleared direct to vulcan VOR direct. The reason this happened was I did not read the last statement in the adyan intersection box of the SID which states; 'RNAV-equipped aircraft proceed direct to dryht.' furthermore; when the FMC loads the route; PHXBHM01; the legs page includes a vector heading 055 degrees after adyan intersection; then dryht intersection with no route discontinuity between them. So unless you select direct dryht; the FMC will pass adyan and continue on a 055 degree heading forever. I have never seen this combination of software routing and procedure well downstream of the departure in a SID. This certainly does not excuse the error on my part as all would have been well had I read the last block of notes. Be assured I have a renewed passion for reading every line of the SID I am about to fly. Also; please look at the SID and how it is loaded in the FMC database. Maybe this should be corrected in the database. In the new age of the rvsm this was no small error and I realize that. Thankfully there were no other aircraft anywhere near us. Please give serious consideration to a software change or at least a 'read before fly' that would alert others to the possibility of an unresolved heading in the legs page of this SID. Callback conversation with reporter revealed the following information: the reporter readily admits the flight crew got a bit lazy and complacent in not reading the notes regarding adyan intersection more carefully. Reporter did feel the archaic single FMS fpdi type visual display of the routing was a significant factor in their failure to recognize their error. Analyst learned that the manner in which such unusual leg data coding is displayed is the result of an individual navigation system manufacturer preference and will not be exactly the same from manufacturer to manufacturer as a result. Flight crew familiarity with the particular characteristics of their units is therefore even more important.
Original NASA ASRS Text
Title: FLT CRW OF B737-300 HAVE TRACK DEVIATION ON MAXXO SID FROM PHX.
Narrative: WHILE FLYING THE MAXXO1 SID FROM PHX WE WERE CLRED DIRECT TO BAYTA INTXN ON COURSE. APPROX THREE MINUTES AFTER PASSING DRYHT INTXN; ABQ CTR QUESTIONED OUR NEXT FIX. IT SUDDENLY BECAME PAINFULLY OBVIOUS WE HAD MISSED THE TURN. AT CRUISE SPD THIS PUT US APPROX 24 MILES OFF COURSE. THERE WAS NO TFC CONFLICT INVOLVED AND WE WERE CLRED DIRECT TO VULCAN VOR DIRECT. THE REASON THIS HAPPENED WAS I DID NOT READ THE LAST STATEMENT IN THE ADYAN INTXN BOX OF THE SID WHICH STATES; 'RNAV-EQUIPPED ACFT PROCEED DIRECT TO DRYHT.' FURTHERMORE; WHEN THE FMC LOADS THE RTE; PHXBHM01; THE LEGS PAGE INCLUDES A VECTOR HDG 055 DEGS AFTER ADYAN INTXN; THEN DRYHT INTXN WITH NO RTE DISCONTINUITY BETWEEN THEM. SO UNLESS YOU SELECT DIRECT DRYHT; THE FMC WILL PASS ADYAN AND CONTINUE ON A 055 DEG HDG FOREVER. I HAVE NEVER SEEN THIS COMBINATION OF SOFTWARE ROUTING AND PROC WELL DOWNSTREAM OF THE DEP IN A SID. THIS CERTAINLY DOES NOT EXCUSE THE ERROR ON MY PART AS ALL WOULD HAVE BEEN WELL HAD I READ THE LAST BLOCK OF NOTES. BE ASSURED I HAVE A RENEWED PASSION FOR READING EVERY LINE OF THE SID I AM ABOUT TO FLY. ALSO; PLEASE LOOK AT THE SID AND HOW IT IS LOADED IN THE FMC DATABASE. MAYBE THIS SHOULD BE CORRECTED IN THE DATABASE. IN THE NEW AGE OF THE RVSM THIS WAS NO SMALL ERROR AND I REALIZE THAT. THANKFULLY THERE WERE NO OTHER ACFT ANYWHERE NEAR US. PLEASE GIVE SERIOUS CONSIDERATION TO A SOFTWARE CHANGE OR AT LEAST A 'READ BEFORE FLY' THAT WOULD ALERT OTHERS TO THE POSSIBILITY OF AN UNRESOLVED HDG IN THE LEGS PAGE OF THIS SID. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR READILY ADMITS THE FLC GOT A BIT LAZY AND COMPLACENT IN NOT READING THE NOTES REGARDING ADYAN INTXN MORE CAREFULLY. RPTR DID FEEL THE ARCHAIC SINGLE FMS FPDI TYPE VISUAL DISPLAY OF THE ROUTING WAS A SIGNIFICANT FACTOR IN THEIR FAILURE TO RECOGNIZE THEIR ERROR. ANALYST LEARNED THAT THE MANNER IN WHICH SUCH UNUSUAL LEG DATA CODING IS DISPLAYED IS THE RESULT OF AN INDIVIDUAL NAV SYSTEM MANUFACTURER PREFERENCE AND WILL NOT BE EXACTLY THE SAME FROM MANUFACTURER TO MANUFACTURER AS A RESULT. FLT CREW FAMILIARITY WITH THE PARTICULAR CHARACTERISTICS OF THEIR UNITS IS THEREFORE EVEN MORE IMPORTANT.
Data retrieved from NASA's ASRS site as of January 2009 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.