37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 785080 |
Time | |
Date | 200804 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure sid : loop |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 162 |
ASRS Report | 785080 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | FAA Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During normal preflight duties; the first officer entered a non standard route into the FMC. After reviewing the pre departure clearance; the first officer focused on the filed route on the reply. The first officer missed the change from the filed LOOP4 departure to the OSHNN5 departure. When the first officer returned to the ACARS pre departure clearance page; the -OSHNN5 dag- was present on the page. After departing lax on runway 24L; we were given an initial vector of 180 degrees. We were then cleared to a point on the OSHNN5 departure pevee; which we asked for clarification. We informed ATC that we thought we were on the LOOP4 and they replied that the LOOP4 departure was not utilized during that part of the day. They requested that we update our FMC with the OSHNN5 and notify them when we were ready for clearance. They then cleared us to oshnn and the rest of the departure. First; the first officer needs to review each line of the pre departure clearance to ensure that changes are noted. It is easy to just focus on what you are expecting to see. I realize that I made an error and will work to not allow that to happen to me again. However; a note on the LOOP4 stating when it is or is not utilized may also help a crew catch this before they are airborne on the departure. Another technique would be to pull up the pre departure clearance page after looking at the route page 2 as a crew.
Original NASA ASRS Text
Title: A B737 FO ENTERED A ROUTE INTO THE FMC INCORRECTLY READ FROM THE PDC. AFTER TKOF; ATC QUERIED ABOUT THE ROUTE.
Narrative: DURING NORMAL PREFLIGHT DUTIES; THE FO ENTERED A NON STD ROUTE INTO THE FMC. AFTER REVIEWING THE PDC; THE FO FOCUSED ON THE FILED ROUTE ON THE REPLY. THE FO MISSED THE CHANGE FROM THE FILED LOOP4 DEPARTURE TO THE OSHNN5 DEPARTURE. WHEN THE FO RETURNED TO THE ACARS PDC PAGE; THE -OSHNN5 DAG- WAS PRESENT ON THE PAGE. AFTER DEPARTING LAX ON RWY 24L; WE WERE GIVEN AN INITIAL VECTOR OF 180 DEGS. WE WERE THEN CLEARED TO A POINT ON THE OSHNN5 DEPARTURE PEVEE; WHICH WE ASKED FOR CLARIFICATION. WE INFORMED ATC THAT WE THOUGHT WE WERE ON THE LOOP4 AND THEY REPLIED THAT THE LOOP4 DEPARTURE WAS NOT UTILIZED DURING THAT PART OF THE DAY. THEY REQUESTED THAT WE UPDATE OUR FMC WITH THE OSHNN5 AND NOTIFY THEM WHEN WE WERE READY FOR CLEARANCE. THEY THEN CLEARED US TO OSHNN AND THE REST OF THE DEPARTURE. FIRST; THE FO NEEDS TO REVIEW EACH LINE OF THE PDC TO ENSURE THAT CHANGES ARE NOTED. IT IS EASY TO JUST FOCUS ON WHAT YOU ARE EXPECTING TO SEE. I REALIZE THAT I MADE AN ERROR AND WILL WORK TO NOT ALLOW THAT TO HAPPEN TO ME AGAIN. HOWEVER; A NOTE ON THE LOOP4 STATING WHEN IT IS OR IS NOT UTILIZED MAY ALSO HELP A CREW CATCH THIS BEFORE THEY ARE AIRBORNE ON THE DEPARTURE. ANOTHER TECHNIQUE WOULD BE TO PULL UP THE PDC PAGE AFTER LOOKING AT THE ROUTE PAGE 2 AS A CREW.
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.