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|
Attributes | |
ACN | 786091 |
Time | |
Date | 200805 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl single value : 3500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon tower : zbaa.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 : las 3 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 308 flight time type : 4800 |
ASRS Report | 786091 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 196 |
ASRS Report | 786086 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Fourth and final flight on first day of pairing. I was the captain and pm on flight from las. During preflight; both of us failed to see that the pre departure clearance clearance differed from the filed departure. Dispatch had us filed on the las 3 departure; which we never use. Pre departure clearance clearance amended us to the staav 4 departure. The two errors that occurred were the first officer's lack of experience with amended pdcs and my failure to look at the pre departure clearance clearance to catch the error. I should have checked more thoroughly knowing that las never gives us the las 3. There was no threat; just a lack of attention. I will be more diligent to pre departure clearance and route verification in the future.supplemental information from acn 786096: expecting an RNAV out of las. I saw las 3 on release. Dispatch release said 'non standard route.' never having flown it; I dug it out of manual. We both failed to understand the way the pre departure clearance read; even after discussing it. We entered las 3 into FMC. We flew las 3. When questioned by las departure if we were on the staav; we said no; las 3. Departure asked us a few questions; and then told us to continue on las 3. A better understanding of pre departure clearance amendments and punctuation would have been helpful in this situation. Once we discussed the abnormality of flying the las 3; that should have been a hint to verify with ATC as to which departure we were expected to fly.
Original NASA ASRS Text
Title: B737 FLT CREW FAILS TO REALIZE PDC HAS CHANGED THEIR DEP FROM LAS 3 TO STAAV 4.
Narrative: FOURTH AND FINAL FLT ON FIRST DAY OF PAIRING. I WAS THE CAPT AND PM ON FLT FROM LAS. DURING PREFLT; BOTH OF US FAILED TO SEE THAT THE PDC CLRNC DIFFERED FROM THE FILED DEP. DISPATCH HAD US FILED ON THE LAS 3 DEP; WHICH WE NEVER USE. PDC CLRNC AMENDED US TO THE STAAV 4 DEP. THE TWO ERRORS THAT OCCURRED WERE THE FO'S LACK OF EXPERIENCE WITH AMENDED PDCS AND MY FAILURE TO LOOK AT THE PDC CLRNC TO CATCH THE ERROR. I SHOULD HAVE CHKED MORE THOROUGHLY KNOWING THAT LAS NEVER GIVES US THE LAS 3. THERE WAS NO THREAT; JUST A LACK OF ATTENTION. I WILL BE MORE DILIGENT TO PDC AND RTE VERIFICATION IN THE FUTURE.SUPPLEMENTAL INFO FROM ACN 786096: EXPECTING AN RNAV OUT OF LAS. I SAW LAS 3 ON RELEASE. DISPATCH RELEASE SAID 'NON STANDARD RTE.' NEVER HAVING FLOWN IT; I DUG IT OUT OF MANUAL. WE BOTH FAILED TO UNDERSTAND THE WAY THE PDC READ; EVEN AFTER DISCUSSING IT. WE ENTERED LAS 3 INTO FMC. WE FLEW LAS 3. WHEN QUESTIONED BY LAS DEP IF WE WERE ON THE STAAV; WE SAID NO; LAS 3. DEP ASKED US A FEW QUESTIONS; AND THEN TOLD US TO CONTINUE ON LAS 3. A BETTER UNDERSTANDING OF PDC AMENDMENTS AND PUNCTUATION WOULD HAVE BEEN HELPFUL IN THIS SITUATION. ONCE WE DISCUSSED THE ABNORMALITY OF FLYING THE LAS 3; THAT SHOULD HAVE BEEN A HINT TO VERIFY WITH ATC AS TO WHICH DEP WE WERE EXPECTED TO FLY.
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.