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|
Attributes | |
ACN | 747410 |
Time | |
Date | 200707 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : oathe |
State Reference | KS |
Altitude | msl single value : 360 |
Aircraft 1 | |
Controlling Facilities | artcc : zdv.artcc tower : mfe.tower |
Operator | common carrier : air carrier |
Make Model Name | B777-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : level |
Route In Use | arrival star : dando 5 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 230 flight time total : 16000 flight time type : 375 |
ASRS Report | 747410 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 260 flight time total : 15000 flight time type : 400 |
ASRS Report | 747411 |
Events | |
Anomaly | 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 FAA |
Primary Problem | Ambiguous |
Narrative:
We were cleared J24. Oathe.DANDD5.den. Upon reaching oathe; we proceeded direct dandd; and ATC quickly inquired if we were cleared direct dandd. During programming the FMC at the gate in iad; there was no oathe transition in the FMC; so we closed up oathe to dandd; and assumed that was our clearance. Another 'gotcha' is that there are two places on the dandd 5 arrival plate where oathe is spelled out; within about 1 inch of each other. In reviewing the plate while holding it in my hand; my thumb covered the actual oathe fix; so I read oathe and the remarks associated with it (the left-most 'oathe' on the plate); located near sells intersection; and missed the fact that the intersection was actually sells. Our error did not produce a loss of separation; but there are several human factors issues here that need to be addressed. First; why is the name of a fix written twice -- once near the actual fix and once near another fix -- in the same font? Second; why did the oathe transition not appear in the FMC? I will be reading stars much more closely; and watching how I hold them!callback conversation with reporter revealed the following information: reporter stated that when the clearance was programmed manually into the FMC; the oathe transition was not an option when selecting the DANDD5 arrival on the 'arrivals' page. This created a discontinuity between oathe and dandd; so they closed the discontinuity between the fixes on the 'legs' page. The flight crew felt the route was entered as specified in their clearance; and even though the transition is depicted in the arrival graphic; it is not included in text form on the chart.
Original NASA ASRS Text
Title: FLT CREW EXPERIENCED FMC PROGRAMMING ISSUE FOR DANDD5 STAR; CITING CHART FONT AND DEPICTION OF OATHE AS CONTRIBUTORY.
Narrative: WE WERE CLRED J24. OATHE.DANDD5.DEN. UPON REACHING OATHE; WE PROCEEDED DIRECT DANDD; AND ATC QUICKLY INQUIRED IF WE WERE CLRED DIRECT DANDD. DURING PROGRAMMING THE FMC AT THE GATE IN IAD; THERE WAS NO OATHE TRANSITION IN THE FMC; SO WE CLOSED UP OATHE TO DANDD; AND ASSUMED THAT WAS OUR CLRNC. ANOTHER 'GOTCHA' IS THAT THERE ARE TWO PLACES ON THE DANDD 5 ARR PLATE WHERE OATHE IS SPELLED OUT; WITHIN ABOUT 1 INCH OF EACH OTHER. IN REVIEWING THE PLATE WHILE HOLDING IT IN MY HAND; MY THUMB COVERED THE ACTUAL OATHE FIX; SO I READ OATHE AND THE REMARKS ASSOCIATED WITH IT (THE LEFT-MOST 'OATHE' ON THE PLATE); LOCATED NEAR SELLS INTXN; AND MISSED THE FACT THAT THE INTXN WAS ACTUALLY SELLS. OUR ERROR DID NOT PRODUCE A LOSS OF SEPARATION; BUT THERE ARE SEVERAL HUMAN FACTORS ISSUES HERE THAT NEED TO BE ADDRESSED. FIRST; WHY IS THE NAME OF A FIX WRITTEN TWICE -- ONCE NEAR THE ACTUAL FIX AND ONCE NEAR ANOTHER FIX -- IN THE SAME FONT? SECOND; WHY DID THE OATHE TRANSITION NOT APPEAR IN THE FMC? I WILL BE READING STARS MUCH MORE CLOSELY; AND WATCHING HOW I HOLD THEM!CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT WHEN THE CLRNC WAS PROGRAMMED MANUALLY INTO THE FMC; THE OATHE TRANSITION WAS NOT AN OPTION WHEN SELECTING THE DANDD5 ARR ON THE 'ARRIVALS' PAGE. THIS CREATED A DISCONTINUITY BETWEEN OATHE AND DANDD; SO THEY CLOSED THE DISCONTINUITY BETWEEN THE FIXES ON THE 'LEGS' PAGE. THE FLT CREW FELT THE RTE WAS ENTERED AS SPECIFIED IN THEIR CLRNC; AND EVEN THOUGH THE TRANSITION IS DEPICTED IN THE ARR GRAPHIC; IT IS NOT INCLUDED IN TEXT FORM ON THE CHART.
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.