37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 786197 |
Time | |
Date | 200805 |
Place | |
Locale Reference | airport : aus.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | artcc : zhu.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 227 flight time type : 1100 |
ASRS Report | 786197 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 187 flight time type : 187 |
ASRS Report | 786186 |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
When receiving the pre departure clearance clearance via ACARS; I misread/misinterpreted the change clearance vs what was filed. We subsequently flew the filed route vs the reroute ATC issued. Filed route was cwk 3.tnv eic eld; changed route was cwk 3.tnv lfk eld. One solution would be to only display the actual ATC clearance vs showing both the filed and the change or use plain english stating 'change route to read.'supplemental information from acn 786186: in departure briefing after before start originating checklist I failed to notice the amended clearance above the filed clearance in the pre departure clearance; even though it was on the line right above the filed clearance. It read like this: -cwk 3 tnv lfk eld- aus cwk 3 tnv eic. First officer had loaded the company route which matched the filed clearance. I saw what I was looking for in the second line and disregarded the amended line above. My mistake for not thoroughly double checking the pre departure clearance vs FMC routing as per our procedures. After takeoff we flew to tnv then eic until queried by houston center. They then cleared us direct to eld. Memphis center passed a phone # and I talked to them after landing. They said there was no traffic conflict but wanted to make sure we knew where the problem came from. I told him it was my mistake for not recognizing the correct departure instructions on our pre departure clearance. Follow our procedures every time. The only other input I have for reducing the incidence of this mistake is to only print one routing on the pre departure clearance. As long as two routings are printed on the pre departure clearance; the filed and the amended routing; someone (this time it was me) will fly the wrong one. Not an excuse; just an observation.
Original NASA ASRS Text
Title: B737 FLT CREW MISUNDERSTANDS REVISED SEGMENT ON PDC AND HAS TRACK DEV.
Narrative: WHEN RECEIVING THE PDC CLRNC VIA ACARS; I MISREAD/MISINTERPRETED THE CHANGE CLRNC VS WHAT WAS FILED. WE SUBSEQUENTLY FLEW THE FILED RTE VS THE REROUTE ATC ISSUED. FILED RTE WAS CWK 3.TNV EIC ELD; CHANGED RTE WAS CWK 3.TNV LFK ELD. ONE SOLUTION WOULD BE TO ONLY DISPLAY THE ACTUAL ATC CLRNC VS SHOWING BOTH THE FILED AND THE CHANGE OR USE PLAIN ENGLISH STATING 'CHANGE RTE TO READ.'SUPPLEMENTAL INFO FROM ACN 786186: IN DEP BRIEFING AFTER BEFORE START ORIGINATING CHKLIST I FAILED TO NOTICE THE AMENDED CLRNC ABOVE THE FILED CLRNC IN THE PDC; EVEN THOUGH IT WAS ON THE LINE RIGHT ABOVE THE FILED CLRNC. IT READ LIKE THIS: -CWK 3 TNV LFK ELD- AUS CWK 3 TNV EIC. FO HAD LOADED THE COMPANY RTE WHICH MATCHED THE FILED CLRNC. I SAW WHAT I WAS LOOKING FOR IN THE SECOND LINE AND DISREGARDED THE AMENDED LINE ABOVE. MY MISTAKE FOR NOT THOROUGHLY DOUBLE CHKING THE PDC VS FMC ROUTING AS PER OUR PROCS. AFTER TAKEOFF WE FLEW TO TNV THEN EIC UNTIL QUERIED BY HOUSTON CENTER. THEY THEN CLEARED US DIRECT TO ELD. MEMPHIS CENTER PASSED A PHONE # AND I TALKED TO THEM AFTER LNDG. THEY SAID THERE WAS NO TFC CONFLICT BUT WANTED TO MAKE SURE WE KNEW WHERE THE PROBLEM CAME FROM. I TOLD HIM IT WAS MY MISTAKE FOR NOT RECOGNIZING THE CORRECT DEP INSTRUCTIONS ON OUR PDC. FOLLOW OUR PROCS EVERY TIME. THE ONLY OTHER INPUT I HAVE FOR REDUCING THE INCIDENCE OF THIS MISTAKE IS TO ONLY PRINT ONE ROUTING ON THE PDC. AS LONG AS TWO ROUTINGS ARE PRINTED ON THE PDC; THE FILED AND THE AMENDED ROUTING; SOMEONE (THIS TIME IT WAS ME) WILL FLY THE WRONG ONE. NOT AN EXCUSE; JUST AN OBSERVATION.
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.