Narrative:

During preflight duties; captain had set MCP heading to 055 degrees per initial heading as shown on the SID at the 3 DME of lax and during the before takeoff checklist read back heading 055 degrees on the MCP. Shortly after that; we received our takeoff clearance from lax tower and as captain lined up aircraft on runway; first officer changed the MCP heading to 070 degrees without making this change known to the captain or the reason why he was changing it. After the captain gave the aircraft to the first officer as the PF; captain queried the first officer if we had been issued a runway heading of 070 degrees as captain noticed the MCP heading. First officer said no; and in the confusion this caused; captain was not sure at that point whether we had received takeoff clearance so asked the first officer if we were cleared for takeoff or just position and hold. The first officer then said he thought we were cleared for takeoff but was not sure either. That was a scary moment for sure. The tower frequency was very busy so passing 100 KTS captain could not confirm with the tower that we in fact had been cleared for takeoff but looking down the runway there was no reason to believe that an abort at this point would be the safer course of action so we continued the takeoff. After liftoff per the SID; a left turn to 055 degrees should have been made at the lax 3 DME; but because the first officer had put 070 degrees in the heading display we began the turn late just as ATC was issuing us a new heading of 040 degrees to correct. Captain put 040 degrees in the MCP display but had not noticed the first officer had since punched LNAV just after takeoff because first officer thought that would allow him to comply with the SID turns as required. Captain did not notice the first officer doing this and after the new heading of 040 degrees was in the MCP the command bars did not command a turn to the left since we were in LNAV. ATC then reissued the left turn to 040 degrees and to continue climb to a higher altitude. Finally the captain noticed the MCP was not in heading select and putting it there we finally began the desired turn. There was traffic on the parallel runway also departing off to our right at about our altitude so a turn to the left was certainly desirable as called for in the SID. It was a chain of errors that all started with a deviation of SOP made by changing MCP values and modes without the awareness of the other pilot; especially while hand flying. ATC did not indicate any particular problem or that they had lost separation but we knew we had gotten behind the airplane for a brief period at a very busy time when maximum alertness is essential. And due to the late turn to the left; separation minimums might easily have been breached during the heat of the battle. It was really a good thing that ATC noticed our late turn and acted appropriately to get the turn initiated before a more serious condition developed.

Related reports:

Google
 

Original NASA ASRS Text

Title: BREAKDOWN IN COCKPIT SOP AND CRM RESULTS IN B777-200 TRACK DEV ON TKOF FROM LAX.

Narrative: DURING PREFLT DUTIES; CAPT HAD SET MCP HDG TO 055 DEGS PER INITIAL HDG AS SHOWN ON THE SID AT THE 3 DME OF LAX AND DURING THE BEFORE TKOF CHKLIST READ BACK HDG 055 DEGS ON THE MCP. SHORTLY AFTER THAT; WE RECEIVED OUR TKOF CLRNC FROM LAX TWR AND AS CAPT LINED UP ACFT ON RWY; FO CHANGED THE MCP HDG TO 070 DEGS WITHOUT MAKING THIS CHANGE KNOWN TO THE CAPT OR THE REASON WHY HE WAS CHANGING IT. AFTER THE CAPT GAVE THE ACFT TO THE FO AS THE PF; CAPT QUERIED THE FO IF WE HAD BEEN ISSUED A RWY HDG OF 070 DEGS AS CAPT NOTICED THE MCP HDG. FO SAID NO; AND IN THE CONFUSION THIS CAUSED; CAPT WAS NOT SURE AT THAT POINT WHETHER WE HAD RECEIVED TKOF CLRNC SO ASKED THE FO IF WE WERE CLRED FOR TKOF OR JUST POS AND HOLD. THE FO THEN SAID HE THOUGHT WE WERE CLRED FOR TKOF BUT WAS NOT SURE EITHER. THAT WAS A SCARY MOMENT FOR SURE. THE TWR FREQ WAS VERY BUSY SO PASSING 100 KTS CAPT COULD NOT CONFIRM WITH THE TWR THAT WE IN FACT HAD BEEN CLRED FOR TKOF BUT LOOKING DOWN THE RWY THERE WAS NO REASON TO BELIEVE THAT AN ABORT AT THIS POINT WOULD BE THE SAFER COURSE OF ACTION SO WE CONTINUED THE TKOF. AFTER LIFTOFF PER THE SID; A L TURN TO 055 DEGS SHOULD HAVE BEEN MADE AT THE LAX 3 DME; BUT BECAUSE THE FO HAD PUT 070 DEGS IN THE HDG DISPLAY WE BEGAN THE TURN LATE JUST AS ATC WAS ISSUING US A NEW HDG OF 040 DEGS TO CORRECT. CAPT PUT 040 DEGS IN THE MCP DISPLAY BUT HAD NOT NOTICED THE FO HAD SINCE PUNCHED LNAV JUST AFTER TKOF BECAUSE FO THOUGHT THAT WOULD ALLOW HIM TO COMPLY WITH THE SID TURNS AS REQUIRED. CAPT DID NOT NOTICE THE FO DOING THIS AND AFTER THE NEW HDG OF 040 DEGS WAS IN THE MCP THE COMMAND BARS DID NOT COMMAND A TURN TO THE L SINCE WE WERE IN LNAV. ATC THEN REISSUED THE L TURN TO 040 DEGS AND TO CONTINUE CLB TO A HIGHER ALT. FINALLY THE CAPT NOTICED THE MCP WAS NOT IN HDG SELECT AND PUTTING IT THERE WE FINALLY BEGAN THE DESIRED TURN. THERE WAS TFC ON THE PARALLEL RWY ALSO DEPARTING OFF TO OUR R AT ABOUT OUR ALT SO A TURN TO THE L WAS CERTAINLY DESIRABLE AS CALLED FOR IN THE SID. IT WAS A CHAIN OF ERRORS THAT ALL STARTED WITH A DEV OF SOP MADE BY CHANGING MCP VALUES AND MODES WITHOUT THE AWARENESS OF THE OTHER PLT; ESPECIALLY WHILE HAND FLYING. ATC DID NOT INDICATE ANY PARTICULAR PROB OR THAT THEY HAD LOST SEPARATION BUT WE KNEW WE HAD GOTTEN BEHIND THE AIRPLANE FOR A BRIEF PERIOD AT A VERY BUSY TIME WHEN MAX ALERTNESS IS ESSENTIAL. AND DUE TO THE LATE TURN TO THE L; SEPARATION MINIMUMS MIGHT EASILY HAVE BEEN BREACHED DURING THE HEAT OF THE BATTLE. IT WAS REALLY A GOOD THING THAT ATC NOTICED OUR LATE TURN AND ACTED APPROPRIATELY TO GET THE TURN INITIATED BEFORE A MORE SERIOUS CONDITION DEVELOPED.

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.