37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 703592 |
Time | |
Date | 200607 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : n90.tracon |
State Reference | NY |
Altitude | msl single value : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : multi engine pilot : cfi |
Experience | flight time last 90 days : 100 flight time total : 9500 flight time type : 2500 |
ASRS Report | 703592 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 12000 flight time type : 3000 |
ASRS Report | 703593 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory flight crew : returned to intended or assigned course flight crew : returned to original clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Ambiguous |
Narrative:
Climbing through 9000 ft MSL on a radar vector departing jfk (185 degree heading); we were cleared direct rbv VOR. When rbv was selected and executed on the FMS; aircraft turned in a direction opposite the proper course to rbv. The aircraft FMS was actually seeking a NAVAID called 'rbv' that was approximately 7000 mi away! This may have been an initial programming error in the FMS; but I don't think so. I believe the proper 'rbv' was selected; but for some reason; the improper 'rbv' ended up in the computer. No 'insufficient fuel' message ever displayed in the preflight or at any time prior to the incident; as would normally occur in this circumstance. Lesson learned: on departure; always back up the FMS with raw data if not thoroughly familiar with the area and all surrounding navaids. Contributing factors: runway change during pushback; maintenance issue prior to pushback which distraction from the normal flow; fatigue -- early departure; last day of 3-DAY trip; body clocks on mountain time zone. Supplemental information from acn 703593: it would have helped to have the NAVAID button active and first fix in the 'fix' page for better situational awareness. Callback conversation with reporter acn #703592 revealed the following information: reporter stated that during preflight they had loaded rbv as part of the departure/clearance. There was no 'insufficient fuel' message which would have indicated that the fix was too far away for the fuel load on the aircraft. He stated that after departure the controller cleared the aircraft direct to rbv and when selected as 'direct to' in the FMS the aircraft turned the wrong way and the controller asked 'where they were going.' at this time they realized that there was something wrong and asked for vectors from the controller. After tuning in the frequency and going to raw data they finally realized where they were and corrected the FMS. The reporter indicated that they were rushed due to a runway change and that they had not reviewed the legs page for fix/distances or the total distance for the route of flight. They did not have raw data tuned and available prior to departure and he indicated that that was their mistake as the departure came very fast and the flight crew was not familiar with the area or chart as they should have been. He also stated that they may have been slightly fatigued due to lack of proper rest.
Original NASA ASRS Text
Title: B757 FLT CREW HAS WRONG 'DIRECT TO' FIX INSTALLED IN THE FMS AND THE ACFT TURNS THE WRONG WAY ON THE KENNEDY 9 DEP.
Narrative: CLBING THROUGH 9000 FT MSL ON A RADAR VECTOR DEPARTING JFK (185 DEG HDG); WE WERE CLRED DIRECT RBV VOR. WHEN RBV WAS SELECTED AND EXECUTED ON THE FMS; ACFT TURNED IN A DIRECTION OPPOSITE THE PROPER COURSE TO RBV. THE ACFT FMS WAS ACTUALLY SEEKING A NAVAID CALLED 'RBV' THAT WAS APPROX 7000 MI AWAY! THIS MAY HAVE BEEN AN INITIAL PROGRAMMING ERROR IN THE FMS; BUT I DON'T THINK SO. I BELIEVE THE PROPER 'RBV' WAS SELECTED; BUT FOR SOME REASON; THE IMPROPER 'RBV' ENDED UP IN THE COMPUTER. NO 'INSUFFICIENT FUEL' MESSAGE EVER DISPLAYED IN THE PREFLT OR AT ANY TIME PRIOR TO THE INCIDENT; AS WOULD NORMALLY OCCUR IN THIS CIRCUMSTANCE. LESSON LEARNED: ON DEP; ALWAYS BACK UP THE FMS WITH RAW DATA IF NOT THOROUGHLY FAMILIAR WITH THE AREA AND ALL SURROUNDING NAVAIDS. CONTRIBUTING FACTORS: RWY CHANGE DURING PUSHBACK; MAINT ISSUE PRIOR TO PUSHBACK WHICH DISTR FROM THE NORMAL FLOW; FATIGUE -- EARLY DEP; LAST DAY OF 3-DAY TRIP; BODY CLOCKS ON MOUNTAIN TIME ZONE. SUPPLEMENTAL INFO FROM ACN 703593: IT WOULD HAVE HELPED TO HAVE THE NAVAID BUTTON ACTIVE AND FIRST FIX IN THE 'FIX' PAGE FOR BETTER SITUATIONAL AWARENESS. CALLBACK CONVERSATION WITH RPTR ACN #703592 REVEALED THE FOLLOWING INFO: RPTR STATED THAT DURING PREFLT THEY HAD LOADED RBV AS PART OF THE DEP/CLRNC. THERE WAS NO 'INSUFFICIENT FUEL' MESSAGE WHICH WOULD HAVE INDICATED THAT THE FIX WAS TOO FAR AWAY FOR THE FUEL LOAD ON THE ACFT. HE STATED THAT AFTER DEP THE CTLR CLRED THE ACFT DIRECT TO RBV AND WHEN SELECTED AS 'DIRECT TO' IN THE FMS THE ACFT TURNED THE WRONG WAY AND THE CTLR ASKED 'WHERE THEY WERE GOING.' AT THIS TIME THEY REALIZED THAT THERE WAS SOMETHING WRONG AND ASKED FOR VECTORS FROM THE CTLR. AFTER TUNING IN THE FREQ AND GOING TO RAW DATA THEY FINALLY REALIZED WHERE THEY WERE AND CORRECTED THE FMS. THE RPTR INDICATED THAT THEY WERE RUSHED DUE TO A RWY CHANGE AND THAT THEY HAD NOT REVIEWED THE LEGS PAGE FOR FIX/DISTANCES OR THE TOTAL DISTANCE FOR THE RTE OF FLT. THEY DID NOT HAVE RAW DATA TUNED AND AVAILABLE PRIOR TO DEP AND HE INDICATED THAT THAT WAS THEIR MISTAKE AS THE DEP CAME VERY FAST AND THE FLT CREW WAS NOT FAMILIAR WITH THE AREA OR CHART AS THEY SHOULD HAVE BEEN. HE ALSO STATED THAT THEY MAY HAVE BEEN SLIGHTLY FATIGUED DUE TO LACK OF PROPER REST.
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.