A320 flight crew deviates from the SID while addressing a 'green system' hydraulic ECAM.

Attributes
ACN	700487
Time
Date	200606
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : ont.airport
State Reference	CA
Altitude	msl single value : 5000
Environment
Flight Conditions	VMC
Aircraft 1
Controlling Facilities	tracon : sct.tracon
Operator	common carrier : air carrier
Make Model Name	A320
Operating Under FAR Part	Part 91
Navigation In Use	other
Flight Phase	climbout : intermediate altitude
Route In Use	departure sid : n/s
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Experience	flight time last 90 days : 50 flight time total : 10000 flight time type : 25
ASRS Report	700487
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Experience	flight time last 90 days : 60 flight time total : 10000 flight time type : 20
ASRS Report	700707
Events
Anomaly	aircraft equipment problem : critical non adherence : clearance non adherence : published procedure non adherence : published procedure
Independent Detector	aircraft equipment other aircraft equipment : ecam other controllerb other flight crewa other flight crewb
Resolutory Action	controller : issued new clearance controller : provided flight assist flight crew : overcame equipment problem flight crew : returned to intended or assigned course
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	Flight Crew Human Performance Aircraft Environmental Factor
Primary Problem	Ambiguous

Narrative:

Flight was a type 2 ferry (special flight permit) with a temporary repair for a hydraulic (blue system) leak. Just after takeoff; an ECAM caution bell alerted to a 'green engine #1 pump low pressure' hydraulic failure. ECAM irregular procedures were completed. During resolution of the ECAM; the aircraft continued on the initial 255 degree magnetic heading beyond the inbound radial to pom as depicted on the SID. Ont approach control alerted us to the deviation and vectored us north to recapture the SID ground track. There were no TCAS events; and we were not aware of any loss of separation with other IFR traffic; although the controller made it clear that deviation from the SID was not acceptable. A major factor in this event was the untimely distraction caused by the hydraulic pump failure; which was particularly disconcerting to the crew since there was a known issue with another hydraulic system. The potential for a serious emergency due to possible multiple hydraulic system failures was immediately apparent; and the crew momentarily allowed the aircraft to deviate from the SID while assessing the condition of the aircraft. Additional human factors considerations: 1) airbus CRT displays are characteristically dim and difficult to read in bright sunlight. The low sun was directly in front of the aircraft; making the navigation displays even more difficult to see than usual. 2) although not an exceptionally long duty day or long time since waking; crew had been waiting for the aircraft for 6 hours at ont while maintenance control and line maintenance resolved issues with the confign of the aircraft for the ferry. The crew had flown an early local test flight; then deadheaded to ont via bur. Fatigue may have been a factor. 3) despite the long wait; final preparations for the flight were somewhat rushed. The station was preparing to service a line trip which led to a bit of a hurried departure. Although the SID was briefed and crosschecked in the FMC; the initial turn was delayed when the crew was distraction by the ECAM.

Original NASA ASRS Text

Title: A320 FLT CREW DEVIATES FROM THE SID WHILE ADDRESSING A 'GREEN SYS' HYD ECAM.

Narrative: FLT WAS A TYPE 2 FERRY (SPECIAL FLT PERMIT) WITH A TEMPORARY REPAIR FOR A HYD (BLUE SYS) LEAK. JUST AFTER TKOF; AN ECAM CAUTION BELL ALERTED TO A 'GREEN ENG #1 PUMP LOW PRESSURE' HYD FAILURE. ECAM IRREGULAR PROCS WERE COMPLETED. DURING RESOLUTION OF THE ECAM; THE ACFT CONTINUED ON THE INITIAL 255 DEG MAGNETIC HDG BEYOND THE INBOUND RADIAL TO POM AS DEPICTED ON THE SID. ONT APCH CTL ALERTED US TO THE DEV AND VECTORED US N TO RECAPTURE THE SID GND TRACK. THERE WERE NO TCAS EVENTS; AND WE WERE NOT AWARE OF ANY LOSS OF SEPARATION WITH OTHER IFR TFC; ALTHOUGH THE CTLR MADE IT CLR THAT DEV FROM THE SID WAS NOT ACCEPTABLE. A MAJOR FACTOR IN THIS EVENT WAS THE UNTIMELY DISTR CAUSED BY THE HYD PUMP FAILURE; WHICH WAS PARTICULARLY DISCONCERTING TO THE CREW SINCE THERE WAS A KNOWN ISSUE WITH ANOTHER HYD SYS. THE POTENTIAL FOR A SERIOUS EMER DUE TO POSSIBLE MULTIPLE HYD SYS FAILURES WAS IMMEDIATELY APPARENT; AND THE CREW MOMENTARILY ALLOWED THE ACFT TO DEVIATE FROM THE SID WHILE ASSESSING THE CONDITION OF THE ACFT. ADDITIONAL HUMAN FACTORS CONSIDERATIONS: 1) AIRBUS CRT DISPLAYS ARE CHARACTERISTICALLY DIM AND DIFFICULT TO READ IN BRIGHT SUNLIGHT. THE LOW SUN WAS DIRECTLY IN FRONT OF THE ACFT; MAKING THE NAV DISPLAYS EVEN MORE DIFFICULT TO SEE THAN USUAL. 2) ALTHOUGH NOT AN EXCEPTIONALLY LONG DUTY DAY OR LONG TIME SINCE WAKING; CREW HAD BEEN WAITING FOR THE ACFT FOR 6 HRS AT ONT WHILE MAINT CTL AND LINE MAINT RESOLVED ISSUES WITH THE CONFIGN OF THE ACFT FOR THE FERRY. THE CREW HAD FLOWN AN EARLY LCL TEST FLT; THEN DEADHEADED TO ONT VIA BUR. FATIGUE MAY HAVE BEEN A FACTOR. 3) DESPITE THE LONG WAIT; FINAL PREPARATIONS FOR THE FLT WERE SOMEWHAT RUSHED. THE STATION WAS PREPARING TO SVC A LINE TRIP WHICH LED TO A BIT OF A HURRIED DEP. ALTHOUGH THE SID WAS BRIEFED AND XCHKED IN THE FMC; THE INITIAL TURN WAS DELAYED WHEN THE CREW WAS DISTR BY THE ECAM.

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.