37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 772706 |
Time | |
Date | 200802 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mlf.airport |
State Reference | UT |
Altitude | msl single value : 32000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Route In Use | departure sid : edeth1.beryl |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 213 flight time type : 213 |
ASRS Report | 772706 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 265 flight time type : 4900 |
ASRS Report | 772827 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
While in cruise after departing slc on the EDETH1.beryl departure procedure; ZLC inquired as to our clearance; also asking what method we received the clearance through and what route we had filed. This was the first indication that we may not be on the cleared route which we later discovered was EDETH1.mlf. The chain of errors began while at the gate preparing to fly from slc to our destination. There was no rush as we had arrived a few mins early and the WX was clear and dry. I reviewed the dispatch release then went to the top of the jetbridge to give the paperwork to the operations agent and check on any special passenger needs. Finding my assistance wasn't needed there I returned to the aircraft to help the flight attendants finish cleaning the cabin in preparation for a full 137+2 load. During this time the first officer; a relatively senior individual with 6 1/2 yrs at company; performed the duties needed to get the airplane ready for departure. Approximately 5 mins prior to push time; I strapped into the captain's seat; performed my flows; and we completed the before start checklist. The clearance brief given by the first officer was as expected including an 'as filed' route plus his highlighting the 230 KIAS airspeed restr and receipt of an altitude assignment of 10000 ft. I checked the FMC against the flight plan and concurred that what was filed had been programmed accurately. At this point I had not considered the possibility of an incorrect route being programmed because to my knowledge our clearance was 'as filed.' however; as it turns out; the first officer; despite his longevity with the company; was not completely proficient at the newly-implemented demand of interpreting clrncs receiving through the pre departure clearance system. Thus; he did not recognize the ATC amended section of the route clearance located between the dashes ('-XXX-') on the pre departure clearance screen. Instead; he saw the filed route shown on the next line and entered that in the FMC. Only after being queried by ATC while accurately flying the beryl transition route; was there an obvious reason to call up the 'received messages' page of the ACARS and look at the pre departure clearance clearance. Alas; there it was; the amended clearance. We asked the controller if he needed us over milford and he said no though he did remark that the route over milford was the preferred route. The implementation of pre departure clearance-received clrncs injects a new source of errors into the crew coordination process. Because I have rarely encountered pre departure clearance-enabled airports; I had not considered the possibility that an error would arise when the clearance briefing included the 'as filed' comment. In most cases; errors are idented through the readback process; a step that is unavailable when no verbal contact with ATC is made. Still; it is the captain's responsibility to assure that all is right with the flight. I believe that a statement by the first officer indicating how the clearance was received (eg; we're cleared through pre departure clearance as filed...) would trigger the initiation of a review of the pre departure clearance page of the ACARS. From that page would continue the review of the route. Once we were aware that an error had been made we attempted to find a document that clearly indicated the symbology of the pre departure clearance message. None could be found in the fom and the message that had been printed on the WX packets in weeks earlier is no longer present. A short 1 page document that could be inserted into the commercial chart binder highlighting pre departure clearance formatting procedures would be helpful. Obviously; it is also quite beneficial for the dispatch-filed flight plan to reflect the preferred rtes. As slc gathers more experience with their new departure procedures I'm sure dispatch will become more in tune with ATC's desires. Until then; crews must be cognizant of discrepancies. Lastly; this was a lesson in remembering that no matter how experienced and infallible you believe an individual is; always verify what they're doing or have done. Supplemental information from acn 772827: I'm pretty new to pre departure clearance and didn't understand the clearance in the dashed line route of the pre departure clearance. I find it rather confusing to have multiple rtes listed in the route section of the pre departure clearance; so I called clearance delivery to ask about the clearance. It seems to defeat the purpose of the pre departure clearance program. It would be easy and not lead to confusion to just pre departure clearance 1 route and not 2 rtes.
Original NASA ASRS Text
Title: MLG FLT CREW EXPERIENCES TRACK DEVIATION WHEN PDC CLRNC IS MISINTERPRETED BY FO AND NOT VERIFIED BY CAPTAIN PRIOR TO DEP.
Narrative: WHILE IN CRUISE AFTER DEPARTING SLC ON THE EDETH1.BERYL DEP PROC; ZLC INQUIRED AS TO OUR CLRNC; ALSO ASKING WHAT METHOD WE RECEIVED THE CLRNC THROUGH AND WHAT RTE WE HAD FILED. THIS WAS THE FIRST INDICATION THAT WE MAY NOT BE ON THE CLRED RTE WHICH WE LATER DISCOVERED WAS EDETH1.MLF. THE CHAIN OF ERRORS BEGAN WHILE AT THE GATE PREPARING TO FLY FROM SLC TO OUR DEST. THERE WAS NO RUSH AS WE HAD ARRIVED A FEW MINS EARLY AND THE WX WAS CLR AND DRY. I REVIEWED THE DISPATCH RELEASE THEN WENT TO THE TOP OF THE JETBRIDGE TO GIVE THE PAPERWORK TO THE OPS AGENT AND CHK ON ANY SPECIAL PAX NEEDS. FINDING MY ASSISTANCE WASN'T NEEDED THERE I RETURNED TO THE ACFT TO HELP THE FLT ATTENDANTS FINISH CLEANING THE CABIN IN PREPARATION FOR A FULL 137+2 LOAD. DURING THIS TIME THE FO; A RELATIVELY SENIOR INDIVIDUAL WITH 6 1/2 YRS AT COMPANY; PERFORMED THE DUTIES NEEDED TO GET THE AIRPLANE READY FOR DEP. APPROX 5 MINS PRIOR TO PUSH TIME; I STRAPPED INTO THE CAPT'S SEAT; PERFORMED MY FLOWS; AND WE COMPLETED THE BEFORE START CHKLIST. THE CLRNC BRIEF GIVEN BY THE FO WAS AS EXPECTED INCLUDING AN 'AS FILED' RTE PLUS HIS HIGHLIGHTING THE 230 KIAS AIRSPD RESTR AND RECEIPT OF AN ALT ASSIGNMENT OF 10000 FT. I CHKED THE FMC AGAINST THE FLT PLAN AND CONCURRED THAT WHAT WAS FILED HAD BEEN PROGRAMMED ACCURATELY. AT THIS POINT I HAD NOT CONSIDERED THE POSSIBILITY OF AN INCORRECT RTE BEING PROGRAMMED BECAUSE TO MY KNOWLEDGE OUR CLRNC WAS 'AS FILED.' HOWEVER; AS IT TURNS OUT; THE FO; DESPITE HIS LONGEVITY WITH THE COMPANY; WAS NOT COMPLETELY PROFICIENT AT THE NEWLY-IMPLEMENTED DEMAND OF INTERPRETING CLRNCS RECEIVING THROUGH THE PDC SYS. THUS; HE DID NOT RECOGNIZE THE ATC AMENDED SECTION OF THE RTE CLRNC LOCATED BTWN THE DASHES ('-XXX-') ON THE PDC SCREEN. INSTEAD; HE SAW THE FILED RTE SHOWN ON THE NEXT LINE AND ENTERED THAT IN THE FMC. ONLY AFTER BEING QUERIED BY ATC WHILE ACCURATELY FLYING THE BERYL TRANSITION RTE; WAS THERE AN OBVIOUS REASON TO CALL UP THE 'RECEIVED MESSAGES' PAGE OF THE ACARS AND LOOK AT THE PDC CLRNC. ALAS; THERE IT WAS; THE AMENDED CLRNC. WE ASKED THE CTLR IF HE NEEDED US OVER MILFORD AND HE SAID NO THOUGH HE DID REMARK THAT THE RTE OVER MILFORD WAS THE PREFERRED RTE. THE IMPLEMENTATION OF PDC-RECEIVED CLRNCS INJECTS A NEW SOURCE OF ERRORS INTO THE CREW COORD PROCESS. BECAUSE I HAVE RARELY ENCOUNTERED PDC-ENABLED ARPTS; I HAD NOT CONSIDERED THE POSSIBILITY THAT AN ERROR WOULD ARISE WHEN THE CLRNC BRIEFING INCLUDED THE 'AS FILED' COMMENT. IN MOST CASES; ERRORS ARE IDENTED THROUGH THE READBACK PROCESS; A STEP THAT IS UNAVAILABLE WHEN NO VERBAL CONTACT WITH ATC IS MADE. STILL; IT IS THE CAPT'S RESPONSIBILITY TO ASSURE THAT ALL IS RIGHT WITH THE FLT. I BELIEVE THAT A STATEMENT BY THE FO INDICATING HOW THE CLRNC WAS RECEIVED (EG; WE'RE CLRED THROUGH PDC AS FILED...) WOULD TRIGGER THE INITIATION OF A REVIEW OF THE PDC PAGE OF THE ACARS. FROM THAT PAGE WOULD CONTINUE THE REVIEW OF THE RTE. ONCE WE WERE AWARE THAT AN ERROR HAD BEEN MADE WE ATTEMPTED TO FIND A DOCUMENT THAT CLRLY INDICATED THE SYMBOLOGY OF THE PDC MESSAGE. NONE COULD BE FOUND IN THE FOM AND THE MESSAGE THAT HAD BEEN PRINTED ON THE WX PACKETS IN WKS EARLIER IS NO LONGER PRESENT. A SHORT 1 PAGE DOCUMENT THAT COULD BE INSERTED INTO THE COMMERCIAL CHART BINDER HIGHLIGHTING PDC FORMATTING PROCS WOULD BE HELPFUL. OBVIOUSLY; IT IS ALSO QUITE BENEFICIAL FOR THE DISPATCH-FILED FLT PLAN TO REFLECT THE PREFERRED RTES. AS SLC GATHERS MORE EXPERIENCE WITH THEIR NEW DEP PROCS I'M SURE DISPATCH WILL BECOME MORE IN TUNE WITH ATC'S DESIRES. UNTIL THEN; CREWS MUST BE COGNIZANT OF DISCREPANCIES. LASTLY; THIS WAS A LESSON IN REMEMBERING THAT NO MATTER HOW EXPERIENCED AND INFALLIBLE YOU BELIEVE AN INDIVIDUAL IS; ALWAYS VERIFY WHAT THEY'RE DOING OR HAVE DONE. SUPPLEMENTAL INFO FROM ACN 772827: I'M PRETTY NEW TO PDC AND DIDN'T UNDERSTAND THE CLRNC IN THE DASHED LINE RTE OF THE PDC. I FIND IT RATHER CONFUSING TO HAVE MULTIPLE RTES LISTED IN THE RTE SECTION OF THE PDC; SO I CALLED CLRNC DELIVERY TO ASK ABOUT THE CLRNC. IT SEEMS TO DEFEAT THE PURPOSE OF THE PDC PROGRAM. IT WOULD BE EASY AND NOT LEAD TO CONFUSION TO JUST PDC 1 RTE AND NOT 2 RTES.
Data retrieved from NASA's ASRS site as of May 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.