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|
Attributes | |
ACN | 784629 |
Time | |
Date | 200804 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 8000 msl bound upper : 8500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : las.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream Jet Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 85 flight time total : 8900 flight time type : 10 |
ASRS Report | 784629 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar controller : departure |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance controller : provided flight assist |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were issued a departure clearance thru pre departure clearance at las for a flight to ZZZ. The captain (who was more familiar with the aircraft FMS than I); sent for the clearance thru the FMS; and I copied it on a T.O.left.D. Card. The clearance received showed the same routing that was filed except there was a change issued that I was not familiar with for the departure SID that was to be used. This was my first use of pre departure clearance on the collins FMS; and was unfamiliar where changes were placed in the text. Consequently; I wrote down what I thought was the SID filed on the flight plan; and not the clearance issued thru ATC. The captain and I briefed the departure per company procedures; but off the T.O.left.D. Card; not the pre departure clearance received and stored on the FMS. On climb out; ATC asked why we were turning left and not right as depicted on the SID. We advised him of the SID we were complying with and was promptly told we were not on the SID cleared for. We were subsequently given a heading to follow and to maintain 8000 ft. We were already climbing thru that altitude; and had to level off and descend back to it. We were advised by the controller that our assigned altitude was 8000 ft and he was showing 8500 ft. We told him we were in the process of stopping the climb and would descend back down to level at 8000 ft. Once level; we were told to proceed to xyz fix; and continue on the appropriate SID. There were no conflicts on TCAS; nor with any other arriving or departing aircraft as we were turning left when most other aircraft were turning right (the runway in use for departures was runway 25R; and arrivals were on runway 25L and runway 19). After a few minutes; the controller inquired whether we had the pre departure clearance stored on the FMS; and if we could bring it up to confirm what we were given; because they were having problems with their pre departure clearance system because other aircraft were doing the same thing as us. The captain reviewed the clearance on the FMS and saw the change issued by ATC; but not recorded by me. He explained that the collins FMS will always show the route filed by us; regardless of the changes made by ATC. There was a separate area in the text (that I was not aware of) that showed any changes in the original flight plan. He apologized to the controller as the mistake was ours; and we were told not to worry; but make sure we were more careful about that in the future. We were also given a phone number to call to talk further about the problem; which the captain did right away. The supervising controller just wanted to confirm what was discussed; because evidently one of our other company aircraft did the exact same thing earlier in the day. The captain said he would make sure everybody was fully aware of how to interpret the information given on this particular FMS. She advised that his recommendation would suffice; and that no enforcement action would take place. He thanked her and again apologized for any confusion on our part. My recommendation is that full CRM needs to take place on items as important as the clearance issued by ATC thru the pre departure clearance system. I should have asked the captain what the coded item meant in the clearance issued. We also should have reviewed the pre departure clearance clearance on the FMS; not my interpretation of it that I had written down. I will see to it that this is clear company wide.callback conversation with reporter revealed the following information: the reporter stated that because he was new to this aircraft (10 hours) and the pre departure clearance presentation on the FMS CDU; he did not understand that the text between the hyphens was the new cleared routing. He saw the filed routing also with the other text and therefore incorrectly assumed they were flying the original routing. The reason ATC wanted to talk with the crew was because of the number of pre departure clearance errors being made; some of which were caused by erroneous pre departure clearance information. In this case pilot error was involved and the crew readily admitted what had caused them to begin following an incorrect SID.
Original NASA ASRS Text
Title: A G150 PLT MISREAD A PDC FORMATTED WITH A CHANGE AND PRESENTED ON AN FMC CDU WITH NO PRINTED COPY. ACFT TURNED INCORRECTLY AFTER TKOF BECAUSE THE ORIGINAL ROUTING WAS IN THE FMC.
Narrative: WE WERE ISSUED A DEP CLRNC THRU PDC AT LAS FOR A FLT TO ZZZ. THE CAPT (WHO WAS MORE FAMILIAR WITH THE ACFT FMS THAN I); SENT FOR THE CLRNC THRU THE FMS; AND I COPIED IT ON A T.O.L.D. CARD. THE CLRNC RECEIVED SHOWED THE SAME ROUTING THAT WAS FILED EXCEPT THERE WAS A CHANGE ISSUED THAT I WAS NOT FAMILIAR WITH FOR THE DEP SID THAT WAS TO BE USED. THIS WAS MY FIRST USE OF PDC ON THE COLLINS FMS; AND WAS UNFAMILIAR WHERE CHANGES WERE PLACED IN THE TEXT. CONSEQUENTLY; I WROTE DOWN WHAT I THOUGHT WAS THE SID FILED ON THE FLT PLAN; AND NOT THE CLRNC ISSUED THRU ATC. THE CAPT AND I BRIEFED THE DEP PER COMPANY PROCS; BUT OFF THE T.O.L.D. CARD; NOT THE PDC RECEIVED AND STORED ON THE FMS. ON CLBOUT; ATC ASKED WHY WE WERE TURNING L AND NOT R AS DEPICTED ON THE SID. WE ADVISED HIM OF THE SID WE WERE COMPLYING WITH AND WAS PROMPTLY TOLD WE WERE NOT ON THE SID CLRED FOR. WE WERE SUBSEQUENTLY GIVEN A HDG TO FOLLOW AND TO MAINTAIN 8000 FT. WE WERE ALREADY CLBING THRU THAT ALTITUDE; AND HAD TO LEVEL OFF AND DSND BACK TO IT. WE WERE ADVISED BY THE CTLR THAT OUR ASSIGNED ALTITUDE WAS 8000 FT AND HE WAS SHOWING 8500 FT. WE TOLD HIM WE WERE IN THE PROCESS OF STOPPING THE CLB AND WOULD DSND BACK DOWN TO LEVEL AT 8000 FT. ONCE LEVEL; WE WERE TOLD TO PROCEED TO XYZ FIX; AND CONTINUE ON THE APPROPRIATE SID. THERE WERE NO CONFLICTS ON TCAS; NOR WITH ANY OTHER ARRIVING OR DEPARTING ACFT AS WE WERE TURNING L WHEN MOST OTHER ACFT WERE TURNING R (THE RWY IN USE FOR DEPS WAS RWY 25R; AND ARRIVALS WERE ON RWY 25L AND RWY 19). AFTER A FEW MINUTES; THE CTLR INQUIRED WHETHER WE HAD THE PDC STORED ON THE FMS; AND IF WE COULD BRING IT UP TO CONFIRM WHAT WE WERE GIVEN; BECAUSE THEY WERE HAVING PROBLEMS WITH THEIR PDC SYSTEM BECAUSE OTHER ACFT WERE DOING THE SAME THING AS US. THE CAPT REVIEWED THE CLRNC ON THE FMS AND SAW THE CHANGE ISSUED BY ATC; BUT NOT RECORDED BY ME. HE EXPLAINED THAT THE COLLINS FMS WILL ALWAYS SHOW THE RTE FILED BY US; REGARDLESS OF THE CHANGES MADE BY ATC. THERE WAS A SEPARATE AREA IN THE TEXT (THAT I WAS NOT AWARE OF) THAT SHOWED ANY CHANGES IN THE ORIGINAL FLT PLAN. HE APOLOGIZED TO THE CTLR AS THE MISTAKE WAS OURS; AND WE WERE TOLD NOT TO WORRY; BUT MAKE SURE WE WERE MORE CAREFUL ABOUT THAT IN THE FUTURE. WE WERE ALSO GIVEN A PHONE NUMBER TO CALL TO TALK FURTHER ABOUT THE PROBLEM; WHICH THE CAPT DID RIGHT AWAY. THE SUPERVISING CTLR JUST WANTED TO CONFIRM WHAT WAS DISCUSSED; BECAUSE EVIDENTLY ONE OF OUR OTHER COMPANY ACFT DID THE EXACT SAME THING EARLIER IN THE DAY. THE CAPT SAID HE WOULD MAKE SURE EVERYBODY WAS FULLY AWARE OF HOW TO INTERPRET THE INFORMATION GIVEN ON THIS PARTICULAR FMS. SHE ADVISED THAT HIS RECOMMENDATION WOULD SUFFICE; AND THAT NO ENFORCEMENT ACTION WOULD TAKE PLACE. HE THANKED HER AND AGAIN APOLOGIZED FOR ANY CONFUSION ON OUR PART. MY RECOMMENDATION IS THAT FULL CRM NEEDS TO TAKE PLACE ON ITEMS AS IMPORTANT AS THE CLRNC ISSUED BY ATC THRU THE PDC SYSTEM. I SHOULD HAVE ASKED THE CAPT WHAT THE CODED ITEM MEANT IN THE CLRNC ISSUED. WE ALSO SHOULD HAVE REVIEWED THE PDC CLRNC ON THE FMS; NOT MY INTERPRETATION OF IT THAT I HAD WRITTEN DOWN. I WILL SEE TO IT THAT THIS IS CLR COMPANY WIDE.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT BECAUSE HE WAS NEW TO THIS ACFT (10 HRS) AND THE PDC PRESENTATION ON THE FMS CDU; HE DID NOT UNDERSTAND THAT THE TEXT BETWEEN THE HYPHENS WAS THE NEW CLRED ROUTING. HE SAW THE FILED ROUTING ALSO WITH THE OTHER TEXT AND THEREFORE INCORRECTLY ASSUMED THEY WERE FLYING THE ORIGINAL ROUTING. THE REASON ATC WANTED TO TALK WITH THE CREW WAS BECAUSE OF THE NUMBER OF PDC ERRORS BEING MADE; SOME OF WHICH WERE CAUSED BY ERRONEOUS PDC INFORMATION. IN THIS CASE PLT ERROR WAS INVOLVED AND THE CREW READILY ADMITTED WHAT HAD CAUSED THEM TO BEGIN FOLLOWING AN INCORRECT SID.
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.