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|
Attributes | |
ACN | 673308 |
Time | |
Date | 200510 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : reefi |
State Reference | PA |
Altitude | msl single value : 15000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : phl.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure sid : phl |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 204 flight time total : 11000 flight time type : 5200 |
ASRS Report | 673308 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were flying a B737-300 and it was the last leg of a 4-DAY trip. We had been rerouted due to a mechanical problem on day 2; and it resulted in the last leg having a showtime of xa:15; with a 12+ hour duty day. We had a 9:50 ron and I tried to get to sleep early; but ended up only getting about 4-5 hours of sleep. We deadheaded to jax and then flew jax to another city; then our final destination. After completing the checklist for the final leg; my first officer briefed the route; and I checked the routing on the FMC. The route matched; however; I failed to catch that it didn't make a whole lot of sense. I am not sure where the error happened; but there was a miscommunication when the clearance was received. The route was stoen reefi mxe and then as filed which was pensy.J48.mol.J22.vuz..jan..aex.DAS6.hou. The problem is that reefie to mxe is about a 160 degree right turn. After departure; we were cleared direct to reefi. Just before arriving at reefi; we were given a clearance of cross 10 northeast of EMI or above FL260; climb and maintain FL280. I was focusing on making the crossing restriction; and again failed to notice the route in the FMC was not good. At reefi; the autoplt started a right turn and I immediately knew something was not right. Pensy is only 7 NM north of reefi and we were almost there. The next point along the route was EMI; so I started to turn back to EMI. We were about to query ATC about our route; when he called and asked where we were going. He asked if the last controller had given us direct to EMI; which he had not. ATC then gave us a heading roughly to EMI. There were no conflicts with any other aircraft. The responsibility is ultimately mine. I had several opportunities to catch the error; which I missed. Had I been monitoring the radio when the clearance was received; I might have caught it then. I also should have double checked the first few fixes on the legs page; especially departing an airport I am not familiar with. We were both very tired and happy to be heading home; and I think we let our guard down. If we had been flying a -700; I don't think this would have happened. We would have seen the route was not right long before arriving at reefi. Additionally; stoen is on the PHL7 departure; but reefi is not depicted. If stoen; reefi; EMI is the normal route; then having it depicted on a SID would help to raise situational awareness. Finally; if this is not a normal routing; changing the route to match would also help.
Original NASA ASRS Text
Title: A B737-300 CREW FAILED TO CHK THE ROUTING AND ACCEPTED AN ILLOGICAL DEP CLRNC THEN MISSED A DIRECT CLRNC VACATING THE ORIGINAL ILLOGICAL CLRNC. FATIGUE MAY BE A FACTOR.
Narrative: WE WERE FLYING A B737-300 AND IT WAS THE LAST LEG OF A 4-DAY TRIP. WE HAD BEEN REROUTED DUE TO A MECHANICAL PROB ON DAY 2; AND IT RESULTED IN THE LAST LEG HAVING A SHOWTIME OF XA:15; WITH A 12+ HOUR DUTY DAY. WE HAD A 9:50 RON AND I TRIED TO GET TO SLEEP EARLY; BUT ENDED UP ONLY GETTING ABOUT 4-5 HOURS OF SLEEP. WE DEADHEADED TO JAX AND THEN FLEW JAX TO ANOTHER CITY; THEN OUR FINAL DEST. AFTER COMPLETING THE CHKLIST FOR THE FINAL LEG; MY FO BRIEFED THE RTE; AND I CHKED THE ROUTING ON THE FMC. THE RTE MATCHED; HOWEVER; I FAILED TO CATCH THAT IT DIDN'T MAKE A WHOLE LOT OF SENSE. I AM NOT SURE WHERE THE ERROR HAPPENED; BUT THERE WAS A MISCOMMUNICATION WHEN THE CLRNC WAS RECEIVED. THE RTE WAS STOEN REEFI MXE AND THEN AS FILED WHICH WAS PENSY.J48.MOL.J22.VUZ..JAN..AEX.DAS6.HOU. THE PROB IS THAT REEFIE TO MXE IS ABOUT A 160 DEG R TURN. AFTER DEP; WE WERE CLRED DIRECT TO REEFI. JUST BEFORE ARRIVING AT REEFI; WE WERE GIVEN A CLRNC OF CROSS 10 NE OF EMI OR ABOVE FL260; CLB AND MAINTAIN FL280. I WAS FOCUSING ON MAKING THE CROSSING RESTRICTION; AND AGAIN FAILED TO NOTICE THE RTE IN THE FMC WAS NOT GOOD. AT REEFI; THE AUTOPLT STARTED A R TURN AND I IMMEDIATELY KNEW SOMETHING WAS NOT RIGHT. PENSY IS ONLY 7 NM N OF REEFI AND WE WERE ALMOST THERE. THE NEXT POINT ALONG THE RTE WAS EMI; SO I STARTED TO TURN BACK TO EMI. WE WERE ABOUT TO QUERY ATC ABOUT OUR RTE; WHEN HE CALLED AND ASKED WHERE WE WERE GOING. HE ASKED IF THE LAST CTLR HAD GIVEN US DIRECT TO EMI; WHICH HE HAD NOT. ATC THEN GAVE US A HDG ROUGHLY TO EMI. THERE WERE NO CONFLICTS WITH ANY OTHER ACFT. THE RESPONSIBILITY IS ULTIMATELY MINE. I HAD SEVERAL OPPORTUNITIES TO CATCH THE ERROR; WHICH I MISSED. HAD I BEEN MONITORING THE RADIO WHEN THE CLRNC WAS RECEIVED; I MIGHT HAVE CAUGHT IT THEN. I ALSO SHOULD HAVE DOUBLE CHKED THE FIRST FEW FIXES ON THE LEGS PAGE; ESPECIALLY DEPARTING AN ARPT I AM NOT FAMILIAR WITH. WE WERE BOTH VERY TIRED AND HAPPY TO BE HEADING HOME; AND I THINK WE LET OUR GUARD DOWN. IF WE HAD BEEN FLYING A -700; I DON'T THINK THIS WOULD HAVE HAPPENED. WE WOULD HAVE SEEN THE RTE WAS NOT RIGHT LONG BEFORE ARRIVING AT REEFI. ADDITIONALLY; STOEN IS ON THE PHL7 DEP; BUT REEFI IS NOT DEPICTED. IF STOEN; REEFI; EMI IS THE NORMAL RTE; THEN HAVING IT DEPICTED ON A SID WOULD HELP TO RAISE SITUATIONAL AWARENESS. FINALLY; IF THIS IS NOT A NORMAL ROUTING; CHANGING THE RTE TO MATCH WOULD ALSO HELP.
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.