37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 740405 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | msl single value : 7000 |
Aircraft 1 | |
Controlling Facilities | tracon : c90.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | arrival star : janesville |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 740405 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On the jvl arrival to ord; we were given holding instructions to hold in an atypical pattern at fix approximately 50 NM ahead. The aircraft ahead of us was issued the same instruction a few mins earlier; but the controller changed their instruction to a right turn to 360 degrees. (Both the aircraft ahead and our flight were heading 090 degrees; so this is a right 270 degree turn -- the long way around.) mins later; we were issued the same instruction: 'XXX; turn right; right turn heading 360 degrees.' since the captain was flying with the autoplt; he selected a heading of 180 degrees until the airplane was heading south; then selected a heading of 270 degrees; then 360 degrees as the airplane was passing through a heading of 200 degrees or so. We do this to avoid the autoplt from turning the wrong direction as the heading bug passes through 180 degrees relative to ship's heading. When I saw the captain was using this technique (as good practice dictates); I stopped monitoring his action when I saw he had selected heading 360 degrees; as per the controller's instruction. I then went heads down to remove the holding pattern from the FMS. During that procedure; the TCAS system annunciated 'traffic; traffic.' simultaneously; the controller asked for our heading. When I looked up; we were passing 070 degrees. The controller issued an immediate 30 degree left turn to us and a 30 degree left turn to another flight heading towards us; thus the TA from the TCAS. The 2 airplanes passed within 2 mi at closest approach. I realized the captain had heard the instruction as; 'make a right three-sixty.' since other aircraft were being vectored direct to teddy intersection (about 090 degrees); this made sense to him even though my readback was; 'right heading three-six-zero.' I had made the assumption that the captain was steady on 360 degrees. Workload was high and I had decided that priority task was to remove the holding pattern from the FMS and set up the intercept for the approach I knew was to follow. Being heads down; I didn't notice the airplane continuing the turn through the assigned heading. I think this was an honest mistake in interpretation/expectation in a busy environment under nonstandard conditions: 1) we never hold at teddy in a reverse pattern. 2) we usually expect the same clearance as the traffic we're following. 3) we always expect that the PF will act on what the pilot monitoring reads back to ATC.
Original NASA ASRS Text
Title: A MD80 PILOT REPORTS RESPONDING INCORRECTLY TO A NON NORMAL AND NOT EXPECTED CLEARANCE. A TCAS TA OCCURRED BECAUSE OF A HDG DEVIATION.
Narrative: ON THE JVL ARR TO ORD; WE WERE GIVEN HOLDING INSTRUCTIONS TO HOLD IN AN ATYPICAL PATTERN AT FIX APPROX 50 NM AHEAD. THE ACFT AHEAD OF US WAS ISSUED THE SAME INSTRUCTION A FEW MINS EARLIER; BUT THE CTLR CHANGED THEIR INSTRUCTION TO A R TURN TO 360 DEGS. (BOTH THE ACFT AHEAD AND OUR FLT WERE HDG 090 DEGS; SO THIS IS A R 270 DEG TURN -- THE LONG WAY AROUND.) MINS LATER; WE WERE ISSUED THE SAME INSTRUCTION: 'XXX; TURN R; R TURN HDG 360 DEGS.' SINCE THE CAPT WAS FLYING WITH THE AUTOPLT; HE SELECTED A HDG OF 180 DEGS UNTIL THE AIRPLANE WAS HDG S; THEN SELECTED A HDG OF 270 DEGS; THEN 360 DEGS AS THE AIRPLANE WAS PASSING THROUGH A HDG OF 200 DEGS OR SO. WE DO THIS TO AVOID THE AUTOPLT FROM TURNING THE WRONG DIRECTION AS THE HDG BUG PASSES THROUGH 180 DEGS RELATIVE TO SHIP'S HDG. WHEN I SAW THE CAPT WAS USING THIS TECHNIQUE (AS GOOD PRACTICE DICTATES); I STOPPED MONITORING HIS ACTION WHEN I SAW HE HAD SELECTED HDG 360 DEGS; AS PER THE CTLR'S INSTRUCTION. I THEN WENT HEADS DOWN TO REMOVE THE HOLDING PATTERN FROM THE FMS. DURING THAT PROC; THE TCAS SYS ANNUNCIATED 'TFC; TFC.' SIMULTANEOUSLY; THE CTLR ASKED FOR OUR HDG. WHEN I LOOKED UP; WE WERE PASSING 070 DEGS. THE CTLR ISSUED AN IMMEDIATE 30 DEG L TURN TO US AND A 30 DEG L TURN TO ANOTHER FLT HEADING TOWARDS US; THUS THE TA FROM THE TCAS. THE 2 AIRPLANES PASSED WITHIN 2 MI AT CLOSEST APCH. I REALIZED THE CAPT HAD HEARD THE INSTRUCTION AS; 'MAKE A R THREE-SIXTY.' SINCE OTHER ACFT WERE BEING VECTORED DIRECT TO TEDDY INTXN (ABOUT 090 DEGS); THIS MADE SENSE TO HIM EVEN THOUGH MY READBACK WAS; 'R HDG THREE-SIX-ZERO.' I HAD MADE THE ASSUMPTION THAT THE CAPT WAS STEADY ON 360 DEGS. WORKLOAD WAS HIGH AND I HAD DECIDED THAT PRIORITY TASK WAS TO REMOVE THE HOLDING PATTERN FROM THE FMS AND SET UP THE INTERCEPT FOR THE APCH I KNEW WAS TO FOLLOW. BEING HEADS DOWN; I DIDN'T NOTICE THE AIRPLANE CONTINUING THE TURN THROUGH THE ASSIGNED HDG. I THINK THIS WAS AN HONEST MISTAKE IN INTERP/EXPECTATION IN A BUSY ENVIRONMENT UNDER NONSTANDARD CONDITIONS: 1) WE NEVER HOLD AT TEDDY IN A REVERSE PATTERN. 2) WE USUALLY EXPECT THE SAME CLRNC AS THE TFC WE'RE FOLLOWING. 3) WE ALWAYS EXPECT THAT THE PF WILL ACT ON WHAT THE PLT MONITORING READS BACK TO ATC.
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.