37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 785121 |
Time | |
Date | 200805 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl single value : 7000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure sid : tralr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 234 flight time type : 6000 |
ASRS Report | 785121 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 309 flight time type : 1450 |
ASRS Report | 785129 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication FAA |
Primary Problem | Flight Crew Human Performance |
Narrative:
Original filed route used. ATC reassigned staav departure; we began flying tralr. This has been reviewed before but it seems to be a human failing to 'see' what you expect. Even though the route and pre departure clearance pages were reviewed and discussed; the change was not noticed. It seems counter productive to continue to put the original route on the pre departure clearance page. By putting only the new route there is not a 'two route' choice where one being the one expected. This is the first error I have made with the pre departure clearance. There has been considerable information released by the company. I have always made a review of the pre departure clearance versus the filed versus what has been programmed. I find it strange how in this instance I and the other pilot fixated on the original filed route; as though the amendment was invisible. The original route should not be placed in the pre departure clearance page. ATC could help by not over using the amendment line for amendments that don't exist; ie; putting an amendment in when there is no change.supplemental information from acn 785129: we received our pre departure clearance on ACARS and above our clearance line was -staav departure-. Then our clearance line read las tralr. (Basically as filed per the release.) that is what we loaded and checked twice in the FMC. No excuses; but a pre departure clearance should have only one route in there (the route that we are filed). On departure; departure control asked us what we were cleared. After several transmissions back and forth; we figured out what our mistake was. Lesson learned; look all around the clearance on a pre departure clearance for a 'gotcha' and when in doubt; call clearance delivery. Put only what we are cleared through the pre departure clearance.
Original NASA ASRS Text
Title: A B737 FLT CREW COMMENTS PUTTING THE OLD AND NEW CLRNCS ON A PDC LEADS TO ERRORS. THEY SUGGEST A PDC SHOULD HAVE ONLY THE ACTIVE RTE TO BE FLOWN.
Narrative: ORIGINAL FILED ROUTE USED. ATC REASSIGNED STAAV DEPARTURE; WE BEGAN FLYING TRALR. THIS HAS BEEN REVIEWED BEFORE BUT IT SEEMS TO BE A HUMAN FAILING TO 'SEE' WHAT YOU EXPECT. EVEN THOUGH THE ROUTE AND PDC PAGES WERE REVIEWED AND DISCUSSED; THE CHANGE WAS NOT NOTICED. IT SEEMS COUNTER PRODUCTIVE TO CONTINUE TO PUT THE ORIGINAL ROUTE ON THE PDC PAGE. BY PUTTING ONLY THE NEW ROUTE THERE IS NOT A 'TWO ROUTE' CHOICE WHERE ONE BEING THE ONE EXPECTED. THIS IS THE FIRST ERROR I HAVE MADE WITH THE PDC. THERE HAS BEEN CONSIDERABLE INFORMATION RELEASED BY THE COMPANY. I HAVE ALWAYS MADE A REVIEW OF THE PDC VERSUS THE FILED VERSUS WHAT HAS BEEN PROGRAMMED. I FIND IT STRANGE HOW IN THIS INSTANCE I AND THE OTHER PILOT FIXATED ON THE ORIGINAL FILED ROUTE; AS THOUGH THE AMENDMENT WAS INVISIBLE. THE ORIGINAL ROUTE SHOULD NOT BE PLACED IN THE PDC PAGE. ATC COULD HELP BY NOT OVER USING THE AMENDMENT LINE FOR AMENDMENTS THAT DON'T EXIST; IE; PUTTING AN AMENDMENT IN WHEN THERE IS NO CHANGE.SUPPLEMENTAL INFO FROM ACN 785129: WE RECEIVED OUR PDC ON ACARS AND ABOVE OUR CLEARANCE LINE WAS -STAAV DEPARTURE-. THEN OUR CLEARANCE LINE READ LAS TRALR. (BASICALLY AS FILED PER THE RELEASE.) THAT IS WHAT WE LOADED AND CHECKED TWICE IN THE FMC. NO EXCUSES; BUT A PDC SHOULD HAVE ONLY ONE ROUTE IN THERE (THE ROUTE THAT WE ARE FILED). ON DEPARTURE; DEPARTURE CONTROL ASKED US WHAT WE WERE CLEARED. AFTER SEVERAL TRANSMISSIONS BACK AND FORTH; WE FIGURED OUT WHAT OUR MISTAKE WAS. LESSON LEARNED; LOOK ALL AROUND THE CLEARANCE ON A PDC FOR A 'GOTCHA' AND WHEN IN DOUBT; CALL CLEARANCE DELIVERY. PUT ONLY WHAT WE ARE CLEARED THROUGH 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.