37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 740231 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : eysa.airport |
State Reference | FO |
Altitude | msl single value : 20000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : eysa.artcc tower : pub.tower |
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 : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 92 flight time total : 3300 flight time type : 495 |
ASRS Report | 740231 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was a repositioning flight from siauliai lithuania and I was the PIC for this segment. We anticipated a quick turn with an early departure and immediately loaded the FMC and performed the flight deck setup in accordance with company operating procedures. Due to circumstances beyond our control; the anticipated early departure turned into a two hour delay. This particular airport was not contained in our FMC database and during our arrival I overheard ATC tell another aircraft they were off course by eight miles. Due to this report and the length of time the aircraft had been on the ground; I elected to perform a quick align and re-input the coordinates into the FMC. I loaded the present position from the commercial chart and gave chart to the other pilot; where he independently verified it. After he confirmed our position I line selected the position into the FMC. Our clearance on departure was to fly direct to mirma and then flight plan route. Enroute to mirma; ATC called and reported our position seven miles south of course. VOR bearing distance information was cross checked; which confirmed the deviation. We informed ATC of our situation and they re-cleared us direct to kolja and gave us an initial heading to fly. With radio update reselected; the FMC position up-dated and our bearing distance information cross checked. At this time; our position showed us on course and no further discrepancy was observed or reported. At no time did ATC give us priority service or request us to call anyone upon arrival. The flight continued without further incident. It was my initial impression that we had some sort of malfunction associated with the siauliai navigation facility. I believed this to be the case due to the report of the other aircraft being off course eight miles. The VOR at siauliai was not available for DME updates and given the exchange between ATC; the other aircraft and our current situation; I was confident the problem was with their navigation system. Subsequent examination of our three IRU's after update revealed that our latitude was off by nine-minutes. It appears that during the quick align I transposed two numbers; which gave me a nine mile error. The loaded position should have been: N5554.5 E02323.2. I loaded: N5545.5 E02323.2; this would account for the nine mile error in latitude. At no time did I or the other pilot circumvent our verification procedures. The position was loaded and independently verified by each pilot. Obviously the probability of two people transposing the same numbers; on the same day is extremely remote; but here it is in black and white. Proving the flight plan once again; after doing a quick align may have prevented this error; maybe. This airport was not contained in the FMC database and therefore a latitude/long was manually loaded into the route page into position one. If we had checked the bearing distance information we may have found our error. But the discrepancy would only have been apparent for the first waypoint and it may not have been significant enough to alert us to this insidious problem. Because this field was not in the database; the runway was not displayed on the map page to independently verify our location; once we were in position for departure. There were four separate but important factors in this chain and removing any one of them could have prevented this from occurring. 1) working fatigued. 2) airport not contained in FMC database. 3) navigation aid out of service. 4) proving the flight plan after performing the quick align.
Original NASA ASRS Text
Title: B757-200ER EXPERIENCED TRACK DEV DEPARTING EYSA DUE TO TRANSPOSITION OF MINS OF LAT DURING FMS PROGRAMMING.
Narrative: THIS WAS A REPOSITIONING FLT FROM SIAULIAI LITHUANIA AND I WAS THE PIC FOR THIS SEGMENT. WE ANTICIPATED A QUICK TURN WITH AN EARLY DEP AND IMMEDIATELY LOADED THE FMC AND PERFORMED THE FLT DECK SETUP IN ACCORDANCE WITH COMPANY OPERATING PROCS. DUE TO CIRCUMSTANCES BEYOND OUR CTL; THE ANTICIPATED EARLY DEP TURNED INTO A TWO HOUR DELAY. THIS PARTICULAR ARPT WAS NOT CONTAINED IN OUR FMC DATABASE AND DURING OUR ARR I OVERHEARD ATC TELL ANOTHER ACFT THEY WERE OFF COURSE BY EIGHT MILES. DUE TO THIS RPT AND THE LENGTH OF TIME THE ACFT HAD BEEN ON THE GND; I ELECTED TO PERFORM A QUICK ALIGN AND RE-INPUT THE COORDINATES INTO THE FMC. I LOADED THE PRESENT POSITION FROM THE COMMERCIAL CHART AND GAVE CHART TO THE OTHER PLT; WHERE HE INDEPENDENTLY VERIFIED IT. AFTER HE CONFIRMED OUR POSITION I LINE SELECTED THE POSITION INTO THE FMC. OUR CLRNC ON DEP WAS TO FLY DIRECT TO MIRMA AND THEN FLT PLAN RTE. ENROUTE TO MIRMA; ATC CALLED AND RPTED OUR POSITION SEVEN MILES S OF COURSE. VOR BEARING DISTANCE INFO WAS CROSS CHECKED; WHICH CONFIRMED THE DEV. WE INFORMED ATC OF OUR SITUATION AND THEY RE-CLEARED US DIRECT TO KOLJA AND GAVE US AN INITIAL HEADING TO FLY. WITH RADIO UPDATE RESELECTED; THE FMC POSITION UP-DATED AND OUR BEARING DISTANCE INFO CROSS CHECKED. AT THIS TIME; OUR POSITION SHOWED US ON COURSE AND NO FURTHER DISCREPANCY WAS OBSERVED OR RPTED. AT NO TIME DID ATC GIVE US PRIORITY SERVICE OR REQUEST US TO CALL ANYONE UPON ARR. THE FLT CONTINUED WITHOUT FURTHER INCIDENT. IT WAS MY INITIAL IMPRESSION THAT WE HAD SOME SORT OF MALFUNCTION ASSOCIATED WITH THE SIAULIAI NAVIGATION FACILITY. I BELIEVED THIS TO BE THE CASE DUE TO THE RPT OF THE OTHER ACFT BEING OFF COURSE EIGHT MILES. THE VOR AT SIAULIAI WAS NOT AVAILABLE FOR DME UPDATES AND GIVEN THE EXCHANGE BETWEEN ATC; THE OTHER ACFT AND OUR CURRENT SITUATION; I WAS CONFIDENT THE PROB WAS WITH THEIR NAVIGATION SYSTEM. SUBSEQUENT EXAMINATION OF OUR THREE IRU'S AFTER UPDATE REVEALED THAT OUR LATITUDE WAS OFF BY NINE-MINUTES. IT APPEARS THAT DURING THE QUICK ALIGN I TRANSPOSED TWO NUMBERS; WHICH GAVE ME A NINE MILE ERROR. THE LOADED POSITION SHOULD HAVE BEEN: N5554.5 E02323.2. I LOADED: N5545.5 E02323.2; THIS WOULD ACCOUNT FOR THE NINE MILE ERROR IN LATITUDE. AT NO TIME DID I OR THE OTHER PLT CIRCUMVENT OUR VERIFICATION PROCEDURES. THE POSITION WAS LOADED AND INDEPENDENTLY VERIFIED BY EACH PLT. OBVIOUSLY THE PROBABILITY OF TWO PEOPLE TRANSPOSING THE SAME NUMBERS; ON THE SAME DAY IS EXTREMELY REMOTE; BUT HERE IT IS IN BLACK AND WHITE. PROVING THE FLT PLAN ONCE AGAIN; AFTER DOING A QUICK ALIGN MAY HAVE PREVENTED THIS ERROR; MAYBE. THIS ARPT WAS NOT CONTAINED IN THE FMC DATABASE AND THEREFORE A LAT/LONG WAS MANUALLY LOADED INTO THE RTE PAGE INTO POSITION ONE. IF WE HAD CHECKED THE BEARING DISTANCE INFO WE MAY HAVE FOUND OUR ERROR. BUT THE DISCREPANCY WOULD ONLY HAVE BEEN APPARENT FOR THE FIRST WAYPOINT AND IT MAY NOT HAVE BEEN SIGNIFICANT ENOUGH TO ALERT US TO THIS INSIDIOUS PROBLEM. BECAUSE THIS FIELD WAS NOT IN THE DATABASE; THE RWY WAS NOT DISPLAYED ON THE MAP PAGE TO INDEPENDENTLY VERIFY OUR LOCATION; ONCE WE WERE IN POSITION FOR DEP. THERE WERE FOUR SEPARATE BUT IMPORTANT FACTORS IN THIS CHAIN AND REMOVING ANY ONE OF THEM COULD HAVE PREVENTED THIS FROM OCCURRING. 1) WORKING FATIGUED. 2) ARPT NOT CONTAINED IN FMC DATABASE. 3) NAVIGATION AID OUT OF SERVICE. 4) PROVING THE FLT PLAN AFTER PERFORMING THE QUICK ALIGN.
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.