37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 787716 |
Time | |
Date | 200805 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : impel |
State Reference | IN |
Altitude | msl single value : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zid.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 117 flight time total : 5969 flight time type : 1721 |
ASRS Report | 787716 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to original clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I had the expected runway 27 loaded in the FMS. I picked up the pre departure clearance and my eyes immediately saw an unexpected departure runway of runway 18C for a westerly RNAV departure. Not wanting to insert an RNAV departure for the wrong runway; I went back into the FMS before verifying the rest of the pre departure clearance. I went into the box to change runways and verify the departure routing and altitudes for the bluegrass departure from runway 18C -- that's where I got out of my habit pattern. Then; got sidetracked with another issue and never got back to re-verify the pre departure clearance routing. I feel like I know better than anybody of the pitfalls of this pre departure clearance issue as I have extensive experience working with ATC at my airline and it still bit me. I always check the clearance box on the pre departure clearance. Always and verbally annunciate 'cleared as filed' or 'revised ATC clearance.' yet; this human factors issue tripped me up. I will include a visual pre departure clearance review in my takeoff briefing to address the human factors portion of the threat and error management possibilities relative to pdr's. I will continue to pursue alignment of ATC host and airline flight planning systems. Many if not most pdr's are actually the same route as filed by the company. But; the pdr's are generated due to differences in the filing systems. This operational reality can minimize the necessary urgency of a pdr -- because in most cases; the pdr is not a different re-route.
Original NASA ASRS Text
Title: B737 CAPT FAILS TO COMPLETE FMC CHANGES TO REFLECT REVISED SID AND DEP RWY IN PDC.
Narrative: I HAD THE EXPECTED RWY 27 LOADED IN THE FMS. I PICKED UP THE PDC AND MY EYES IMMEDIATELY SAW AN UNEXPECTED DEP RWY OF RWY 18C FOR A WESTERLY RNAV DEP. NOT WANTING TO INSERT AN RNAV DEP FOR THE WRONG RWY; I WENT BACK INTO THE FMS BEFORE VERIFYING THE REST OF THE PDC. I WENT INTO THE BOX TO CHANGE RWYS AND VERIFY THE DEP ROUTING AND ALTITUDES FOR THE BLUEGRASS DEP FROM RWY 18C -- THAT'S WHERE I GOT OUT OF MY HABIT PATTERN. THEN; GOT SIDETRACKED WITH ANOTHER ISSUE AND NEVER GOT BACK TO RE-VERIFY THE PDC ROUTING. I FEEL LIKE I KNOW BETTER THAN ANYBODY OF THE PITFALLS OF THIS PDC ISSUE AS I HAVE EXTENSIVE EXPERIENCE WORKING WITH ATC AT MY AIRLINE AND IT STILL BIT ME. I ALWAYS CHECK THE CLRNC BOX ON THE PDC. ALWAYS AND VERBALLY ANNUNCIATE 'CLEARED AS FILED' OR 'REVISED ATC CLRNC.' YET; THIS HUMAN FACTORS ISSUE TRIPPED ME UP. I WILL INCLUDE A VISUAL PDC REVIEW IN MY TAKEOFF BRIEFING TO ADDRESS THE HUMAN FACTORS PORTION OF THE THREAT AND ERROR MANAGEMENT POSSIBILITIES RELATIVE TO PDR'S. I WILL CONTINUE TO PURSUE ALIGNMENT OF ATC HOST AND AIRLINE FLT PLANNING SYSTEMS. MANY IF NOT MOST PDR'S ARE ACTUALLY THE SAME RTE AS FILED BY THE COMPANY. BUT; THE PDR'S ARE GENERATED DUE TO DIFFERENCES IN THE FILING SYSTEMS. THIS OPERATIONAL REALITY CAN MINIMIZE THE NECESSARY URGENCY OF A PDR -- BECAUSE IN MOST CASES; THE PDR IS NOT A DIFFERENT RE-ROUTE.
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.