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|
Attributes | |
ACN | 778373 |
Time | |
Date | 200803 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl single value : 32000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zlc.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 264 flight time type : 264 |
ASRS Report | 778373 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 250 |
ASRS Report | 778372 |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I received the pre departure clearance message at the gate and failed to notice a change to our non-standard route. I loaded the filed route and missed the change which had us over mlf. I did not realize the error until we were at cruise and ZLC asked if we had been cleared direct to ksino. The captain replied; 'no; we're direct beryl; ksino and the GRANDPA1 into las vegas.' the ATC controller said we should've been over mlf and then cleared us direct ksino. We complied with the clearance and then rechked the pre departure clearance message and clearly saw the dashed change. I believe I placed an overemphasis on making sure I correctly loaded the 'non standard route' on the dispatch release and failed to pay close enough attention to what we were actually cleared. There is no excuse for this oversight. As a preventive measure I'm going to have the pre departure clearance message page displayed when I give my route and clearance brief. An extra set of eyes on the clearance may have prevented this error. Supplemental information from acn 778372: I would say that in retrospect that I needed to really check the FMC route against the pre departure clearance generated route. The pre departure clearance language is somewhat difficult to interpret. Making the message easier to read might be an improvement.
Original NASA ASRS Text
Title: B737-300 FLT CREW FAILED TO NOTICE CHANGE IN ROUTING ON PDC MESSAGE. ATC INFORMED FLT CREW OF DEVIATION AND ISSUED NEW CLRNC.
Narrative: I RECEIVED THE PDC MESSAGE AT THE GATE AND FAILED TO NOTICE A CHANGE TO OUR NON-STANDARD RTE. I LOADED THE FILED RTE AND MISSED THE CHANGE WHICH HAD US OVER MLF. I DID NOT REALIZE THE ERROR UNTIL WE WERE AT CRUISE AND ZLC ASKED IF WE HAD BEEN CLRED DIRECT TO KSINO. THE CAPT REPLIED; 'NO; WE'RE DIRECT BERYL; KSINO AND THE GRANDPA1 INTO LAS VEGAS.' THE ATC CTLR SAID WE SHOULD'VE BEEN OVER MLF AND THEN CLRED US DIRECT KSINO. WE COMPLIED WITH THE CLRNC AND THEN RECHKED THE PDC MESSAGE AND CLRLY SAW THE DASHED CHANGE. I BELIEVE I PLACED AN OVEREMPHASIS ON MAKING SURE I CORRECTLY LOADED THE 'NON STD RTE' ON THE DISPATCH RELEASE AND FAILED TO PAY CLOSE ENOUGH ATTN TO WHAT WE WERE ACTUALLY CLRED. THERE IS NO EXCUSE FOR THIS OVERSIGHT. AS A PREVENTIVE MEASURE I'M GOING TO HAVE THE PDC MESSAGE PAGE DISPLAYED WHEN I GIVE MY RTE AND CLRNC BRIEF. AN EXTRA SET OF EYES ON THE CLRNC MAY HAVE PREVENTED THIS ERROR. SUPPLEMENTAL INFO FROM ACN 778372: I WOULD SAY THAT IN RETROSPECT THAT I NEEDED TO REALLY CHK THE FMC RTE AGAINST THE PDC GENERATED RTE. THE PDC LANGUAGE IS SOMEWHAT DIFFICULT TO INTERPRET. MAKING THE MESSAGE EASIER TO READ MIGHT BE AN IMPROVEMENT.
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.