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Attributes | |
ACN | 692932 |
Time | |
Date | 200603 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : zla.artcc |
State Reference | CA |
Altitude | msl single value : 30000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : level |
Route In Use | enroute : pacific enroute airway : r576.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine pilot : flight engineer pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 94 flight time total : 8653 flight time type : 1922 |
ASRS Report | 692932 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 5000 flight time type : 2400 |
ASRS Report | 691402 |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllerb other flight crewa |
Resolutory Action | controller : issued new clearance controller : issued advisory flight crew : returned to intended or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was the captain and PF. Other crew members included first officer and relief pilot. Flight was uneventful until overhead lax VOR. At that time ZLA cleared us 'R576 to denns.' company had filed us lax-direct 33n127w direct dopps R576 denns.... The FMS had been loaded accordingly. Upon receiving the clearance from center I did a quick check of the flight plan release and confirmed that we were currently proceeding to dinty; which happens to be the beginning of R576; then scanned down to see denns; also on R576. I forgot about the latitude/longitude point; which is on the oakland oceanic fir but not on R576. I forgot about the latitude/longitude point; which is on the oakland oceanic fir but not on R576. After seeing dinty and denns on the flight plan release; I concluded that we were already proceeding as cleared and did not reprogram the FMS. About 20 mins later; I was awakened from my rest period by the relief pilot and informed about the discrepancy between our clearance and our FMS. Sfo commercial radio had discovered our error from an earlier position report. He informed me sfo radio had already cleared us direct to dopps to join R576. We had flown about 24 NM north of R576 by the time we were corrected. There was no mention of conflict from ATC. Remainder of flight was uneventful. Supplemental information from acn 691402: we quickly checked over points and missed a position on the box (FMS) from our original clearance which was n33w127 that was not on R576. This position was instead at doner. This position was 24 mi north of doner N32124; W12807.3. At the time R576 was given; we had just completed a pilot swap; and were in the process of converting commercial charts. Doner was on both charts and point was missed during cockpit chart check of clearance. Due to early morning time; and pilot swap immediately prior to clearance; chart confirmation with navigation equipment (FMS) on aircraft was not correct causing the error in what was flown versus clearance. No conflicts were noted and corrections were made as soon as mistake was realized.
Original NASA ASRS Text
Title: MD11 FLT CREW PROGRAMS THE FMC WITH THE INCORRECT POS FOR THE CLRNC ASSIGNED. THE CTLR ADVISES THE FLT CREW AND ISSUES A MODIFIED CLRNC.
Narrative: I WAS THE CAPT AND PF. OTHER CREW MEMBERS INCLUDED FO AND RELIEF PLT. FLT WAS UNEVENTFUL UNTIL OVERHEAD LAX VOR. AT THAT TIME ZLA CLRED US 'R576 TO DENNS.' COMPANY HAD FILED US LAX-DIRECT 33N127W DIRECT DOPPS R576 DENNS.... THE FMS HAD BEEN LOADED ACCORDINGLY. UPON RECEIVING THE CLRNC FROM CTR I DID A QUICK CHK OF THE FLT PLAN RELEASE AND CONFIRMED THAT WE WERE CURRENTLY PROCEEDING TO DINTY; WHICH HAPPENS TO BE THE BEGINNING OF R576; THEN SCANNED DOWN TO SEE DENNS; ALSO ON R576. I FORGOT ABOUT THE LATITUDE/LONGITUDE POINT; WHICH IS ON THE OAKLAND OCEANIC FIR BUT NOT ON R576. I FORGOT ABOUT THE LATITUDE/LONGITUDE POINT; WHICH IS ON THE OAKLAND OCEANIC FIR BUT NOT ON R576. AFTER SEEING DINTY AND DENNS ON THE FLT PLAN RELEASE; I CONCLUDED THAT WE WERE ALREADY PROCEEDING AS CLRED AND DID NOT REPROGRAM THE FMS. ABOUT 20 MINS LATER; I WAS AWAKENED FROM MY REST PERIOD BY THE RELIEF PLT AND INFORMED ABOUT THE DISCREPANCY BTWN OUR CLRNC AND OUR FMS. SFO COMMERCIAL RADIO HAD DISCOVERED OUR ERROR FROM AN EARLIER POS RPT. HE INFORMED ME SFO RADIO HAD ALREADY CLRED US DIRECT TO DOPPS TO JOIN R576. WE HAD FLOWN ABOUT 24 NM N OF R576 BY THE TIME WE WERE CORRECTED. THERE WAS NO MENTION OF CONFLICT FROM ATC. REMAINDER OF FLT WAS UNEVENTFUL. SUPPLEMENTAL INFO FROM ACN 691402: WE QUICKLY CHKED OVER POINTS AND MISSED A POS ON THE BOX (FMS) FROM OUR ORIGINAL CLRNC WHICH WAS N33W127 THAT WAS NOT ON R576. THIS POS WAS INSTEAD AT DONER. THIS POS WAS 24 MI N OF DONER N32124; W12807.3. AT THE TIME R576 WAS GIVEN; WE HAD JUST COMPLETED A PLT SWAP; AND WERE IN THE PROCESS OF CONVERTING COMMERCIAL CHARTS. DONER WAS ON BOTH CHARTS AND POINT WAS MISSED DURING COCKPIT CHART CHK OF CLRNC. DUE TO EARLY MORNING TIME; AND PLT SWAP IMMEDIATELY PRIOR TO CLRNC; CHART CONFIRMATION WITH NAV EQUIP (FMS) ON ACFT WAS NOT CORRECT CAUSING THE ERROR IN WHAT WAS FLOWN VERSUS CLRNC. NO CONFLICTS WERE NOTED AND CORRECTIONS WERE MADE AS SOON AS MISTAKE WAS REALIZED.
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.