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Attributes | |
ACN | 779281 |
Time | |
Date | 200803 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
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 : oshnn |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 255 flight time type : 6000 |
ASRS Report | 779281 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 196 |
ASRS Report | 779279 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Chart Or Publication Company ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I've read all the bulletins; etc; but they didn't prevent me from a human error that others have recently made. I already knew my mistake; what led to it; and how to prevent it; the very moment it happened while departing lax. I had missed on pre departure clearance that we were issued oshnn 3 departure; and rather; had entered our filed departure of loop 4 into the FMC. It was an early originator from lax. We were cleared for takeoff from runway 24L and issued a heading of 210 degrees after departure. After takeoff and checking in with socal departure; we were eventually issued direct pevee. I; the first officer and pm; stated that it wasn't on our departure. Socal returns with; where did we receive our clearance? (At this point I already knew what had happened.) I said pre departure clearance. He said; 'pre departure clearance should have shown the oshnn departure (which it did; but we missed on preflight) because loop departure is essentially not used during late night and early morning hours.' we entered the oshnn departure into the FMC while receiving a couple of vectors from ATC; and soon after we were established direct to seal beach to resume the oshnn departure with no further events. It has already been emphasized how to read the pre departure clearance on ACARS and that the crew should review the clearance together including initial legs of the SID. We had both reviewed the pre departure clearance individually and briefed the loop 4 departure from lax; including fixes and required altitudes. However; we still had both missed the preferred departure routing of oshnn 3 from lax included on pre departure clearance. I take blame in not paying closer attention and missing what pre departure clearance had issued to us; however; I do believe this will remain a common error due to the way pre departure clearance is issued. When calling ATC for a clearance via radio; and if cleared as filed; the controller states 'cleared as filed.' in contrast; pre departure clearance seems to present a jumbled mess of information. If 'cleared as filed' was typed; then the pilot could simply refer to their release. If not cleared as filed; then the route should be shown on pre departure clearance and that would be a cue to the pilot that something is different compared to what is on the release. Instead; the filed route is shown on the pre departure clearance; sometimes completely; sometimes 'truncated;' sometimes with a pdr; etc. But I find it very easy to make a mistake to see the filed departure included on the pre departure clearance along with a pdr that calls for a different departure. My eyes saw the loop departure on pre departure clearance and the release while missing oshnn which was also included in the pdr. In addition for this particular case; if the oshnn 3 departure is the pdr for early morning hours out of lax; should it be filed that way from the beginning?supplemental information from acn 779278: I never actually pulled up the pre departure clearance page on the ACARS and verified any changes. We are both familiar with pdcs and their different formats. No excuses; I need to make checking the pre departure clearance page part of my habit pattern like I do the route page. Like I mentioned earlier; I have to physically pull the pre departure clearance page up myself and make it a habit. Not that time (feeling rushed) was an issue here; but it does take quite a lot of button pushing on the ACARS to get to the pre departure clearance.
Original NASA ASRS Text
Title: B737-700 FLT CREW FAILS TO RECOGNIZE REVISED RTE SEGMENT OF PDC. PROGRAMS AND FLIES FILED RTE UNTIL ALERTED BY DEP CTLR.
Narrative: I'VE READ ALL THE BULLETINS; ETC; BUT THEY DIDN'T PREVENT ME FROM A HUMAN ERROR THAT OTHERS HAVE RECENTLY MADE. I ALREADY KNEW MY MISTAKE; WHAT LED TO IT; AND HOW TO PREVENT IT; THE VERY MOMENT IT HAPPENED WHILE DEPARTING LAX. I HAD MISSED ON PDC THAT WE WERE ISSUED OSHNN 3 DEP; AND RATHER; HAD ENTERED OUR FILED DEP OF LOOP 4 INTO THE FMC. IT WAS AN EARLY ORIGINATOR FROM LAX. WE WERE CLRED FOR TAKEOFF FROM RWY 24L AND ISSUED A HEADING OF 210 DEGS AFTER DEP. AFTER TAKEOFF AND CHKING IN WITH SOCAL DEP; WE WERE EVENTUALLY ISSUED DIRECT PEVEE. I; THE FO AND PM; STATED THAT IT WASN'T ON OUR DEP. SOCAL RETURNS WITH; WHERE DID WE RECEIVE OUR CLRNC? (AT THIS POINT I ALREADY KNEW WHAT HAD HAPPENED.) I SAID PDC. HE SAID; 'PDC SHOULD HAVE SHOWN THE OSHNN DEP (WHICH IT DID; BUT WE MISSED ON PREFLIGHT) BECAUSE LOOP DEP IS ESSENTIALLY NOT USED DURING LATE NIGHT AND EARLY MORNING HOURS.' WE ENTERED THE OSHNN DEP INTO THE FMC WHILE RECEIVING A COUPLE OF VECTORS FROM ATC; AND SOON AFTER WE WERE ESTABLISHED DIRECT TO SEAL BEACH TO RESUME THE OSHNN DEP WITH NO FURTHER EVENTS. IT HAS ALREADY BEEN EMPHASIZED HOW TO READ THE PDC ON ACARS AND THAT THE CREW SHOULD REVIEW THE CLRNC TOGETHER INCLUDING INITIAL LEGS OF THE SID. WE HAD BOTH REVIEWED THE PDC INDIVIDUALLY AND BRIEFED THE LOOP 4 DEP FROM LAX; INCLUDING FIXES AND REQUIRED ALTITUDES. HOWEVER; WE STILL HAD BOTH MISSED THE PREFERRED DEP ROUTING OF OSHNN 3 FROM LAX INCLUDED ON PDC. I TAKE BLAME IN NOT PAYING CLOSER ATTENTION AND MISSING WHAT PDC HAD ISSUED TO US; HOWEVER; I DO BELIEVE THIS WILL REMAIN A COMMON ERROR DUE TO THE WAY PDC IS ISSUED. WHEN CALLING ATC FOR A CLRNC VIA RADIO; AND IF CLRED AS FILED; THE CTLR STATES 'CLRED AS FILED.' IN CONTRAST; PDC SEEMS TO PRESENT A JUMBLED MESS OF INFORMATION. IF 'CLRED AS FILED' WAS TYPED; THEN THE PLT COULD SIMPLY REFER TO THEIR RELEASE. IF NOT CLRED AS FILED; THEN THE RTE SHOULD BE SHOWN ON PDC AND THAT WOULD BE A CUE TO THE PLT THAT SOMETHING IS DIFFERENT COMPARED TO WHAT IS ON THE RELEASE. INSTEAD; THE FILED RTE IS SHOWN ON THE PDC; SOMETIMES COMPLETELY; SOMETIMES 'TRUNCATED;' SOMETIMES WITH A PDR; ETC. BUT I FIND IT VERY EASY TO MAKE A MISTAKE TO SEE THE FILED DEP INCLUDED ON THE PDC ALONG WITH A PDR THAT CALLS FOR A DIFFERENT DEP. MY EYES SAW THE LOOP DEP ON PDC AND THE RELEASE WHILE MISSING OSHNN WHICH WAS ALSO INCLUDED IN THE PDR. IN ADDITION FOR THIS PARTICULAR CASE; IF THE OSHNN 3 DEP IS THE PDR FOR EARLY MORNING HOURS OUT OF LAX; SHOULD IT BE FILED THAT WAY FROM THE BEGINNING?SUPPLEMENTAL INFO FROM ACN 779278: I NEVER ACTUALLY PULLED UP THE PDC PAGE ON THE ACARS AND VERIFIED ANY CHANGES. WE ARE BOTH FAMILIAR WITH PDCS AND THEIR DIFFERENT FORMATS. NO EXCUSES; I NEED TO MAKE CHECKING THE PDC PAGE PART OF MY HABIT PATTERN LIKE I DO THE RTE PAGE. LIKE I MENTIONED EARLIER; I HAVE TO PHYSICALLY PULL THE PDC PAGE UP MYSELF AND MAKE IT A HABIT. NOT THAT TIME (FEELING RUSHED) WAS AN ISSUE HERE; BUT IT DOES TAKE QUITE A LOT OF BUTTON PUSHING ON THE ACARS TO GET TO THE PDC.
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.