37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 705378 |
Time | |
Date | 200608 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : papas |
State Reference | FO |
Altitude | msl single value : 13000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : vacating altitude |
Route In Use | departure sid : papas |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 80 flight time total : 10000 flight time type : 7000 |
ASRS Report | 705378 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 705379 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were cleared from runway 16L on the papas 8 fairy transition. The controller called us 3 miles south of papas and asked if we were on the fairy transition. We acknowledged 'yes.' the controller then replied turn right towards apple and resume the fairy transition. We complied with his instructions. Apple was on the legs page 3 fixes in front of us. At this point we were unsure where we were in the wrong. We reviewed the SID and the FMC choices. The FMC has the following transitions when selecting the papas 8 SID. Farte; pedal; apple; cupfa; cupte; farfa. We had selected the cupfa transition because it seemed the most logical. There is nothing intuitive about the narita transitions that would make you select the correct one. We eliminated several of the choices simply because they did not go in the correct direction of our departure course. We should have chosen farfa. Farfa paralleled/overlayed the apple transition and we did not feel this was correct. After the dust settled; we finally understood our error. It is actually labeled the apple/fairy transition. We read apple on the chart and prematurely eliminated it as a choice. Even though we selected the incorrect transition; fairy was still on the legs page. The only difference in the 2 transitions is that after papas the fairy transition is slightly shorter than the one we had chosen. The one we chose had an extra waypoint in the legs page which was incorrect. After discussing this for over 2 hours on our flight; there is absolutely nothing in the events that led to our mistake that would make us feel that we were wrong. Neither one of us ever felt that 'sinking' feeling that we were in the wrong. No red flags. Other points: the gateway said we would be late due to heavy automatic traffic in the area. This would put us past the curfew for runway 16L. This forced us to look at the longer runway that we are not allowed to use due to slot conflicts and heavy fines. We have strict instructions not to use the long runway due to the possibility of losing our landing slots. We also coordinated with flight control for a reduced take off fuel value because the other runway would require an extended taxi time. We only had 1000# of fuel for taxi. Maybe we hurried??? The first officer had stomach issues spilling over from the prior day's catering. The captain. And first officer had discussed only getting 3 hours of sleep prior to the trip. The layover hotel has noisy high speed elevators and also has a hospital located across the street with very busy ambulance activity with loud sirens.
Original NASA ASRS Text
Title: A B767 FLIGHT CREW IN INTERNATIONAL OPERATIONS LOADED AND FLEW THE WRONG SID TRANSITION.
Narrative: WE WERE CLEARED FROM RWY 16L ON THE PAPAS 8 FAIRY TRANSITION. THE CONTROLLER CALLED US 3 MILES SOUTH OF PAPAS AND ASKED IF WE WERE ON THE FAIRY TRANSITION. WE ACKNOWLEDGED 'YES.' THE CONTROLLER THEN REPLIED TURN RIGHT TOWARDS APPLE AND RESUME THE FAIRY TRANSITION. WE COMPLIED WITH HIS INSTRUCTIONS. APPLE WAS ON THE LEGS PAGE 3 FIXES IN FRONT OF US. AT THIS POINT WE WERE UNSURE WHERE WE WERE IN THE WRONG. WE REVIEWED THE SID AND THE FMC CHOICES. THE FMC HAS THE FOLLOWING TRANSITIONS WHEN SELECTING THE PAPAS 8 SID. FARTE; PEDAL; APPLE; CUPFA; CUPTE; FARFA. WE HAD SELECTED THE CUPFA TRANSITION BECAUSE IT SEEMED THE MOST LOGICAL. THERE IS NOTHING INTUITIVE ABOUT THE NARITA TRANSITIONS THAT WOULD MAKE YOU SELECT THE CORRECT ONE. WE ELIMINATED SEVERAL OF THE CHOICES SIMPLY BECAUSE THEY DID NOT GO IN THE CORRECT DIRECTION OF OUR DEPARTURE COURSE. WE SHOULD HAVE CHOSEN FARFA. FARFA PARALLELED/OVERLAYED THE APPLE TRANSITION AND WE DID NOT FEEL THIS WAS CORRECT. AFTER THE DUST SETTLED; WE FINALLY UNDERSTOOD OUR ERROR. IT IS ACTUALLY LABELED THE APPLE/FAIRY TRANSITION. WE READ APPLE ON THE CHART AND PREMATURELY ELIMINATED IT AS A CHOICE. EVEN THOUGH WE SELECTED THE INCORRECT TRANSITION; FAIRY WAS STILL ON THE LEGS PAGE. THE ONLY DIFFERENCE IN THE 2 TRANSITIONS IS THAT AFTER PAPAS THE FAIRY TRANSITION IS SLIGHTLY SHORTER THAN THE ONE WE HAD CHOSEN. THE ONE WE CHOSE HAD AN EXTRA WAYPOINT IN THE LEGS PAGE WHICH WAS INCORRECT. AFTER DISCUSSING THIS FOR OVER 2 HOURS ON OUR FLIGHT; THERE IS ABSOLUTELY NOTHING IN THE EVENTS THAT LED TO OUR MISTAKE THAT WOULD MAKE US FEEL THAT WE WERE WRONG. NEITHER ONE OF US EVER FELT THAT 'SINKING' FEELING THAT WE WERE IN THE WRONG. NO RED FLAGS. OTHER POINTS: THE GATEWAY SAID WE WOULD BE LATE DUE TO HEAVY AUTO TRAFFIC IN THE AREA. THIS WOULD PUT US PAST THE CURFEW FOR RWY 16L. THIS FORCED US TO LOOK AT THE LONGER RWY THAT WE ARE NOT ALLOWED TO USE DUE TO SLOT CONFLICTS AND HEAVY FINES. WE HAVE STRICT INSTRUCTIONS NOT TO USE THE LONG RWY DUE TO THE POSSIBILITY OF LOSING OUR LANDING SLOTS. WE ALSO COORDINATED WITH FLIGHT CONTROL FOR A REDUCED TAKE OFF FUEL VALUE BECAUSE THE OTHER RUNWAY WOULD REQUIRE AN EXTENDED TAXI TIME. WE ONLY HAD 1000# OF FUEL FOR TAXI. MAYBE WE HURRIED??? THE FO HAD STOMACH ISSUES SPILLING OVER FROM THE PRIOR DAY'S CATERING. THE CAPT. AND FO HAD DISCUSSED ONLY GETTING 3 HOURS OF SLEEP PRIOR TO THE TRIP. THE LAYOVER HOTEL HAS NOISY HIGH SPEED ELEVATORS AND ALSO HAS A HOSPITAL LOCATED ACROSS THE STREET WITH VERY BUSY AMBULANCE ACTIVITY WITH LOUD SIRENS.
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.