37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 723601 |
Time | |
Date | 200701 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : rebrg |
State Reference | CA |
Altitude | msl single value : 40000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 280 flight time type : 5600 |
ASRS Report | 723601 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance |
Supplementary | |
Problem Areas | Airport Company Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
This is a classic get distraction and not stick to your normal flows and techniques event. 10 mins prior to push on an originator; everything was normal. I used the lavatory and noticed there was no potable water. As I came out; there was a ramper on the aircraft to tell me the water was frozen in the hose and flowing slowly; as well as a leak from the #2 motor. I went with him to look at the leak and found fuel dripping and called for maintenance. During this we established there was enough water on board; so that was no longer an issue. Maintenance showed up and told me the answer was that I was on a -700 and the WX was cold; that's why it was leaking. He stayed to watch us start and make sure it stopped leaking and talked to me on the headset at the gate to confirm all this. With these 2 events occurring; now we are running the checklist at push time and this is where I made my error and deviated from my normal flow. I always (except for today) brief the route from the box on page 2; etc. This time with the constraint of time I briefed it from page 1 and didn't notice the typo of smf ZZZ01 instead of smf ZZZ201. Our destination was ZZZ2. We were going to go to ZZZ later that day. We started; talked to maintenance about the leak stopping; and proceeded normally through taxi; takeoff; departure; and the beginning of cruise. It wasn't until we didn't turn towards rebrg; I believe; that ATC asked if we were assigned a heading and what we were doing. At this time we discovered the route error. We obviously weren't checking the fixes as we went; but it was an easy mistake when you're headed almost the exact same direction. ATC was very good about this. They set us straight and we proceeded without incident to ZZZ2. I feel like I'm very methodical about what I do. I simply deviated from my own personal norm and got bit. The answer for me is to operate at the same speed regardless of what's going on. Pushing late doesn't bother me. I don't know why I deviated.
Original NASA ASRS Text
Title: DISTR BY MAINT AND ACFT SVC ISSUES THE CAPT ENTERED AN INCORRECT FLT PLAN IN THE FMC. ATC DISCOVERED THE ERROR DURING A COURSE DEV.
Narrative: THIS IS A CLASSIC GET DISTR AND NOT STICK TO YOUR NORMAL FLOWS AND TECHNIQUES EVENT. 10 MINS PRIOR TO PUSH ON AN ORIGINATOR; EVERYTHING WAS NORMAL. I USED THE LAVATORY AND NOTICED THERE WAS NO POTABLE WATER. AS I CAME OUT; THERE WAS A RAMPER ON THE ACFT TO TELL ME THE WATER WAS FROZEN IN THE HOSE AND FLOWING SLOWLY; AS WELL AS A LEAK FROM THE #2 MOTOR. I WENT WITH HIM TO LOOK AT THE LEAK AND FOUND FUEL DRIPPING AND CALLED FOR MAINT. DURING THIS WE ESTABLISHED THERE WAS ENOUGH WATER ON BOARD; SO THAT WAS NO LONGER AN ISSUE. MAINT SHOWED UP AND TOLD ME THE ANSWER WAS THAT I WAS ON A -700 AND THE WX WAS COLD; THAT'S WHY IT WAS LEAKING. HE STAYED TO WATCH US START AND MAKE SURE IT STOPPED LEAKING AND TALKED TO ME ON THE HEADSET AT THE GATE TO CONFIRM ALL THIS. WITH THESE 2 EVENTS OCCURRING; NOW WE ARE RUNNING THE CHKLIST AT PUSH TIME AND THIS IS WHERE I MADE MY ERROR AND DEVIATED FROM MY NORMAL FLOW. I ALWAYS (EXCEPT FOR TODAY) BRIEF THE RTE FROM THE BOX ON PAGE 2; ETC. THIS TIME WITH THE CONSTRAINT OF TIME I BRIEFED IT FROM PAGE 1 AND DIDN'T NOTICE THE TYPO OF SMF ZZZ01 INSTEAD OF SMF ZZZ201. OUR DEST WAS ZZZ2. WE WERE GOING TO GO TO ZZZ LATER THAT DAY. WE STARTED; TALKED TO MAINT ABOUT THE LEAK STOPPING; AND PROCEEDED NORMALLY THROUGH TAXI; TKOF; DEP; AND THE BEGINNING OF CRUISE. IT WASN'T UNTIL WE DIDN'T TURN TOWARDS REBRG; I BELIEVE; THAT ATC ASKED IF WE WERE ASSIGNED A HDG AND WHAT WE WERE DOING. AT THIS TIME WE DISCOVERED THE RTE ERROR. WE OBVIOUSLY WEREN'T CHKING THE FIXES AS WE WENT; BUT IT WAS AN EASY MISTAKE WHEN YOU'RE HEADED ALMOST THE EXACT SAME DIRECTION. ATC WAS VERY GOOD ABOUT THIS. THEY SET US STRAIGHT AND WE PROCEEDED WITHOUT INCIDENT TO ZZZ2. I FEEL LIKE I'M VERY METHODICAL ABOUT WHAT I DO. I SIMPLY DEVIATED FROM MY OWN PERSONAL NORM AND GOT BIT. THE ANSWER FOR ME IS TO OPERATE AT THE SAME SPD REGARDLESS OF WHAT'S GOING ON. PUSHING LATE DOESN'T BOTHER ME. I DON'T KNOW WHY I DEVIATED.
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.