37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 778822 |
Time | |
Date | 200803 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Route In Use | departure sid : n/s |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time total : 163 flight time type : 10500 |
ASRS Report | 778822 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 192 flight time type : 1290 |
ASRS Report | 779092 |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Day 3 of a 3-DAY. Unscheduled overnight; much shorter than scheduled. Did not sleep well; XA30 lobby for an evening trip. Flew 1 leg; 1 hour 40 min ground time; deadhead (first officer flew leg); 1 hour 40 min ground time. So; after being on duty 6 hours we were resuming sequence to ZZZ1. Excellent first officer; third day of second trip together. Preflight checks normal. As captain; I either failed or did not notice route in FMC was to ZZZ2. Fly that route so often; likely would not have realized wrong route in box; but either way; my fault for not catching wrong programming. Flew the departure programmed in box. At approximately 17000 ft; ATC queried if we were on the route. ATC gave us a radar vector VOR. Gave direct VOR then switched us to center; who gave us vector; then direct VOR. Poor sleep; interrupted day; 5 hour gap between flts contributed to fatigue and lack of situational awareness; but do not account for my lack of verification of FMC. Hope I would have caught error; but not sure as this flight to ZZZ2 is a very common route. We often brief what we need to (as we did brief and had correct charts out) but fail to see what is really in front of us. Overconfidence in a good first officer can also lead us down the path. Trust but verify is written for a reason. 1) trust but verify; even the best first officer's make mistakes. 2) be extra vigilant on long; interrupted days that take us out of our normal cadence/patterns. 3) be more aware of effects of fatigue on performance.
Original NASA ASRS Text
Title: B737-700 FLT CREW PROGRAMMED THE FMC TO THE WRONG DEST. AFTER AIRBORNE; ATC QUERIED THE FLT CREW ABOUT THE ROUTING; AND THE FLT CREW BECAME AWARE OF THE ERROR.
Narrative: DAY 3 OF A 3-DAY. UNSCHEDULED OVERNIGHT; MUCH SHORTER THAN SCHEDULED. DID NOT SLEEP WELL; XA30 LOBBY FOR AN EVENING TRIP. FLEW 1 LEG; 1 HR 40 MIN GND TIME; DEADHEAD (FO FLEW LEG); 1 HR 40 MIN GND TIME. SO; AFTER BEING ON DUTY 6 HRS WE WERE RESUMING SEQUENCE TO ZZZ1. EXCELLENT FO; THIRD DAY OF SECOND TRIP TOGETHER. PREFLT CHKS NORMAL. AS CAPT; I EITHER FAILED OR DID NOT NOTICE RTE IN FMC WAS TO ZZZ2. FLY THAT RTE SO OFTEN; LIKELY WOULD NOT HAVE REALIZED WRONG RTE IN BOX; BUT EITHER WAY; MY FAULT FOR NOT CATCHING WRONG PROGRAMMING. FLEW THE DEP PROGRAMMED IN BOX. AT APPROX 17000 FT; ATC QUERIED IF WE WERE ON THE RTE. ATC GAVE US A RADAR VECTOR VOR. GAVE DIRECT VOR THEN SWITCHED US TO CTR; WHO GAVE US VECTOR; THEN DIRECT VOR. POOR SLEEP; INTERRUPTED DAY; 5 HR GAP BTWN FLTS CONTRIBUTED TO FATIGUE AND LACK OF SITUATIONAL AWARENESS; BUT DO NOT ACCOUNT FOR MY LACK OF VERIFICATION OF FMC. HOPE I WOULD HAVE CAUGHT ERROR; BUT NOT SURE AS THIS FLT TO ZZZ2 IS A VERY COMMON RTE. WE OFTEN BRIEF WHAT WE NEED TO (AS WE DID BRIEF AND HAD CORRECT CHARTS OUT) BUT FAIL TO SEE WHAT IS REALLY IN FRONT OF US. OVERCONFIDENCE IN A GOOD FO CAN ALSO LEAD US DOWN THE PATH. TRUST BUT VERIFY IS WRITTEN FOR A REASON. 1) TRUST BUT VERIFY; EVEN THE BEST FO'S MAKE MISTAKES. 2) BE EXTRA VIGILANT ON LONG; INTERRUPTED DAYS THAT TAKE US OUT OF OUR NORMAL CADENCE/PATTERNS. 3) BE MORE AWARE OF EFFECTS OF FATIGUE ON PERFORMANCE.
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.