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A B777 crew entered the depicted holding at lhr's bnn incorrectly by holding on the 299 degree inbound versus the 119 degree outbound.
| Attributes | |
| ACN | 677390 |
| Time | |
| Date | 200511 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | navaid : bnn.vortac |
| State Reference | FO |
| Altitude | msl single value : 12000 |
| Environment | |
| Weather Elements | Thunderstorm |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : egll.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B777-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | descent : approach descent : holding |
| Route In Use | arrival star : bnn |
| Flight Plan | IFR |
| Aircraft 2 | |
| Controlling Facilities | tracon : mco.tracon |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Flight Phase | descent : approach |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| ASRS Report | 677390 |
| 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 |
| Resolutory Action | controller : issued advisory flight crew : became reoriented |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Chart Or Publication |
| Primary Problem | Flight Crew Human Performance |
| Situations | |
| Chart | airport : egll.airport star : bnn3a |
Narrative:
Holding at bnn published holding; misread inbound course as 299 degrees instead of 119 degrees off of bnn made turn on wrong side. ATC asked us to enter other side when we got back to bnn. While we did put the wrong course in the arrival plate leads you down the wrong path due to putting the 299 degree radial near the arrow. No excuses; but I am sure that this is not the first time this has happened. Why not ask commercial chart makers to move the 299 degree radial away from arrow. Callback conversation with reporter revealed the following information: reporter stated that his fellow crew members have noted this input error occurring before. This was the reporter's first error on this arrival. He stated that the 299 degrees on the charted inbound holding leg leads pilots to put 299 degrees into the FMS requested holding inbound radial. Since the FMS asks for inbound course; that is what should be on the chart. Us crews using this arrival have been up all night; are tired; and operating on the back side of the clock. A simple chart change by putting 119 degrees on the inbound would clarify the error.
Original NASA ASRS Text
Title: A B777 CREW ENTERED THE DEPICTED HOLDING AT LHR'S BNN INCORRECTLY BY HOLDING ON THE 299 DEG INBOUND VERSUS THE 119 DEG OUTBOUND.
Narrative: HOLDING AT BNN PUBLISHED HOLDING; MISREAD INBOUND COURSE AS 299 DEGS INSTEAD OF 119 DEGS OFF OF BNN MADE TURN ON WRONG SIDE. ATC ASKED US TO ENTER OTHER SIDE WHEN WE GOT BACK TO BNN. WHILE WE DID PUT THE WRONG COURSE IN THE ARR PLATE LEADS YOU DOWN THE WRONG PATH DUE TO PUTTING THE 299 DEG RADIAL NEAR THE ARROW. NO EXCUSES; BUT I AM SURE THAT THIS IS NOT THE FIRST TIME THIS HAS HAPPENED. WHY NOT ASK COMMERCIAL CHART MAKERS TO MOVE THE 299 DEG RADIAL AWAY FROM ARROW. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT HIS FELLOW CREW MEMBERS HAVE NOTED THIS INPUT ERROR OCCURRING BEFORE. THIS WAS THE RPTR'S FIRST ERROR ON THIS ARR. HE STATED THAT THE 299 DEGS ON THE CHARTED INBOUND HOLDING LEG LEADS PLTS TO PUT 299 DEGS INTO THE FMS REQUESTED HOLDING INBOUND RADIAL. SINCE THE FMS ASKS FOR INBOUND COURSE; THAT IS WHAT SHOULD BE ON THE CHART. US CREWS USING THIS ARR HAVE BEEN UP ALL NIGHT; ARE TIRED; AND OPERATING ON THE BACK SIDE OF THE CLOCK. A SIMPLE CHART CHANGE BY PUTTING 119 DEGS ON THE INBOUND WOULD CLARIFY THE ERROR.
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.