37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 668638 |
Time | |
Date | 200508 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : san.airport |
State Reference | CA |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 668638 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure other spatial deviation other anomaly other |
Independent Detector | aircraft equipment : tcas aircraft equipment other aircraft equipment : fmc other controllera other flight crewa |
Resolutory Action | flight crew : overcame equipment problem flight crew : overrode automation |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
After takeoff from runway 9 at san; the #2 autoplt was connected. Our flight was cleared direct to ipl VOR. I was performing the after takeoff checklist after confirming ipl selected by the copilot in the database of the FMC. Several seconds later; I called 'after takeoff checklist complete' at about the same time as I noticed that the course line to ipl was essentially showing a heading of 270 degrees. Our aircraft was passing through a heading of about 160 degrees at that time. We had been cleared to climb to an altitude of 10000 ft. I reached for the controls to disconnect the autoplt and manually turn the aircraft back to the east at approximately the same time that the socal controller asked us what in #$** we were doing. He issued a terse command for us to level off at 5000 ft and turn left immediately! I informed him that we were already doing that. At the same time we received a TA for traffic. While in the turn; I noticed that inw VORTAC was showing on the navigation display screen. Further inspection showed that the aircraft had actually thought it had departed phoenix; bound for san diego -- instead of the other way around. With no other options at that particular time; I notified ATC that we had lost our RNAV capability; and that we would be navigating as a /west aircraft. The flight was too short for us to reassess our predicament and rectify the situation. So; we flew to phoenix with only VOR/DME capabilities. No other problems occurred during the flight. After inspection of the IRS system by the avionics technician at the gate in phoenix; it was noted that he had particular trouble getting the system to realign itself. He had to clear a re-alignment fault several times before the system would accept alignment in phoenix. I asked the first officer if he had mistakenly entered phoenix as the reference airport upon initial alignment in san diego instead of san diego itself. He admitted that he had; but immediately caught the mistake and re-entered the correct airport; san; as the reference airport on the 'init' page. Before we departed san; the page looked fine; as well as the flight plan sequence in the FMS. The takeoff check confirmed that runway 9 was updated just before power application. In short; everything looked normal to the first officer and myself after all the checklists and flows were completed. I feel certain that we must have missed something somewhere. However; I cannot imagine where it was. After takeoff; the only indication on the navigation display -- 10 mi range -- that something was terribly wrong; was a VOR named inw; and a course line that made a 180 degree turn to the right. Neither should have been seen anywhere near san diego. Both the first officer and I do remember seeing the FMC light on the thrust mode annunciator panel flash one time as we completed the takeoff checklist; but neither of us connected it with anything so consequential. It may have been the only clue we could have had. However; we do both feel like if we had increased the range on the navigation display we would have seen many clues that something was amiss. The question remains though; when did the original error arise to display itself on the screen? Was it at alignment of the IRS at the gate? Or the update at the runway threshold? Callback conversation with reporter revealed the following information: the reporter received no feedback on the cause of the anomaly. He believes the crew made an error not detectable by normal checklist items. He feels that if they had expanded the navigation display to a range larger than 10 NM or looked at the plan page; he would have seen the error. As it is; they do not know for sure the cause. He does know the aircraft departed later that day.
Original NASA ASRS Text
Title: A B737-300; INITIALIZED WITH AN INCORRECT ARPT POS; ALLOWED THE CREW TO DEPART WITHOUT ALERTING THEM TO THE DISCREPANCY IN EXCESS OF 60 NM.
Narrative: AFTER TKOF FROM RWY 9 AT SAN; THE #2 AUTOPLT WAS CONNECTED. OUR FLT WAS CLRED DIRECT TO IPL VOR. I WAS PERFORMING THE AFTER TKOF CHKLIST AFTER CONFIRMING IPL SELECTED BY THE COPLT IN THE DATABASE OF THE FMC. SEVERAL SECONDS LATER; I CALLED 'AFTER TKOF CHKLIST COMPLETE' AT ABOUT THE SAME TIME AS I NOTICED THAT THE COURSE LINE TO IPL WAS ESSENTIALLY SHOWING A HDG OF 270 DEGS. OUR ACFT WAS PASSING THROUGH A HDG OF ABOUT 160 DEGS AT THAT TIME. WE HAD BEEN CLRED TO CLB TO AN ALT OF 10000 FT. I REACHED FOR THE CTLS TO DISCONNECT THE AUTOPLT AND MANUALLY TURN THE ACFT BACK TO THE E AT APPROX THE SAME TIME THAT THE SOCAL CTLR ASKED US WHAT IN #$** WE WERE DOING. HE ISSUED A TERSE COMMAND FOR US TO LEVEL OFF AT 5000 FT AND TURN L IMMEDIATELY! I INFORMED HIM THAT WE WERE ALREADY DOING THAT. AT THE SAME TIME WE RECEIVED A TA FOR TFC. WHILE IN THE TURN; I NOTICED THAT INW VORTAC WAS SHOWING ON THE NAV DISPLAY SCREEN. FURTHER INSPECTION SHOWED THAT THE ACFT HAD ACTUALLY THOUGHT IT HAD DEPARTED PHOENIX; BOUND FOR SAN DIEGO -- INSTEAD OF THE OTHER WAY AROUND. WITH NO OTHER OPTIONS AT THAT PARTICULAR TIME; I NOTIFIED ATC THAT WE HAD LOST OUR RNAV CAPABILITY; AND THAT WE WOULD BE NAVING AS A /W ACFT. THE FLT WAS TOO SHORT FOR US TO REASSESS OUR PREDICAMENT AND RECTIFY THE SIT. SO; WE FLEW TO PHOENIX WITH ONLY VOR/DME CAPABILITIES. NO OTHER PROBS OCCURRED DURING THE FLT. AFTER INSPECTION OF THE IRS SYS BY THE AVIONICS TECHNICIAN AT THE GATE IN PHOENIX; IT WAS NOTED THAT HE HAD PARTICULAR TROUBLE GETTING THE SYS TO REALIGN ITSELF. HE HAD TO CLR A RE-ALIGNMENT FAULT SEVERAL TIMES BEFORE THE SYS WOULD ACCEPT ALIGNMENT IN PHOENIX. I ASKED THE FO IF HE HAD MISTAKENLY ENTERED PHOENIX AS THE REF ARPT UPON INITIAL ALIGNMENT IN SAN DIEGO INSTEAD OF SAN DIEGO ITSELF. HE ADMITTED THAT HE HAD; BUT IMMEDIATELY CAUGHT THE MISTAKE AND RE-ENTERED THE CORRECT ARPT; SAN; AS THE REF ARPT ON THE 'INIT' PAGE. BEFORE WE DEPARTED SAN; THE PAGE LOOKED FINE; AS WELL AS THE FLT PLAN SEQUENCE IN THE FMS. THE TKOF CHK CONFIRMED THAT RWY 9 WAS UPDATED JUST BEFORE PWR APPLICATION. IN SHORT; EVERYTHING LOOKED NORMAL TO THE FO AND MYSELF AFTER ALL THE CHKLISTS AND FLOWS WERE COMPLETED. I FEEL CERTAIN THAT WE MUST HAVE MISSED SOMETHING SOMEWHERE. HOWEVER; I CANNOT IMAGINE WHERE IT WAS. AFTER TKOF; THE ONLY INDICATION ON THE NAV DISPLAY -- 10 MI RANGE -- THAT SOMETHING WAS TERRIBLY WRONG; WAS A VOR NAMED INW; AND A COURSE LINE THAT MADE A 180 DEG TURN TO THE R. NEITHER SHOULD HAVE BEEN SEEN ANYWHERE NEAR SAN DIEGO. BOTH THE FO AND I DO REMEMBER SEEING THE FMC LIGHT ON THE THRUST MODE ANNUNCIATOR PANEL FLASH ONE TIME AS WE COMPLETED THE TKOF CHKLIST; BUT NEITHER OF US CONNECTED IT WITH ANYTHING SO CONSEQUENTIAL. IT MAY HAVE BEEN THE ONLY CLUE WE COULD HAVE HAD. HOWEVER; WE DO BOTH FEEL LIKE IF WE HAD INCREASED THE RANGE ON THE NAV DISPLAY WE WOULD HAVE SEEN MANY CLUES THAT SOMETHING WAS AMISS. THE QUESTION REMAINS THOUGH; WHEN DID THE ORIGINAL ERROR ARISE TO DISPLAY ITSELF ON THE SCREEN? WAS IT AT ALIGNMENT OF THE IRS AT THE GATE? OR THE UPDATE AT THE RWY THRESHOLD? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR RECEIVED NO FEEDBACK ON THE CAUSE OF THE ANOMALY. HE BELIEVES THE CREW MADE AN ERROR NOT DETECTABLE BY NORMAL CHKLIST ITEMS. HE FEELS THAT IF THEY HAD EXPANDED THE NAV DISPLAY TO A RANGE LARGER THAN 10 NM OR LOOKED AT THE PLAN PAGE; HE WOULD HAVE SEEN THE ERROR. AS IT IS; THEY DO NOT KNOW FOR SURE THE CAUSE. HE DOES KNOW THE ACFT DEPARTED LATER THAT DAY.
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.