37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 789037 |
Time | |
Date | 200806 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dfw.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : d10.tracon |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 789037 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
ASRS Report | 789036 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance non adherence other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departed runway 17R dfw; our flight plan called for the DAL8 swb lft. When we pulled the pre departure clearance; there was a revised segment of CLARE2 swb lft lft. Both the first officer and myself failed to notice the change and proceeded with the DAL8 departure. Shortly after takeoff in the climb ATC gave us a heading of 060 degrees and an altitude of 8000 ft. At this point we still did not think anything was wrong as the controller was very calm about the clearance and thought it to be normal; as we did not receive any traffic conflicts at all or even saw another aircraft on TCAS; which I was monitoring. After switching to another frequency; that controller gave us a phone number to contact upon landing; in which we did. After receiving the phone number; we researched what the problem could've been and that is when we realized that the clearance had been changed to the CLARE2. The remainder of the flight was uneventful. I believe that this event occurred due to the following facts. My first officer and flight attendant were running late from other flight. I pulled the clearance and programmed it. When my first officer showed up we did our best to make up time; being as thorough as possible. We verified and briefed the DAL8 departure and both agreed on that procedure. Where we failed was in verifying the revised segment. To our knowledge; we checked and verified everything as we should have; except we missed the revised; new departure. Part of the contribution to the problem was that we had a wing anti-ice system MEL'ed and as per the MEL; I called and chatted with the dispatcher about icing conditions. He informed me that we were given enough fuel to fly at a lower altitude if need to meet the requirements. Although; this is not an excuse; I had it in my mind that was the reason for the DAL8; non-RNAV departure; so I didn't think that would change. A set of unfortunate issues led to this incident. I believe that we were very thorough in our preflight and followed our procedures exactly for all points leading up to this event. The breakdown was in the failure to read the entire pre departure clearance. I did see the revised segment; but overlooked the departure change. I thought the change to be only swb lft; lft instead of swb lft. I just failed to look at the entire revised clearance and had it in my mind that the DAL8 departure would not change; due to the MEL.
Original NASA ASRS Text
Title: FLT CREW OF AN EMB145 OVERLOOKED THE REVISED DEP ISSUED ON THE PDC AND FLEW THE ORIGINAL DEP.
Narrative: DEPARTED RWY 17R DFW; OUR FLT PLAN CALLED FOR THE DAL8 SWB LFT. WHEN WE PULLED THE PDC; THERE WAS A REVISED SEGMENT OF CLARE2 SWB LFT LFT. BOTH THE FO AND MYSELF FAILED TO NOTICE THE CHANGE AND PROCEEDED WITH THE DAL8 DEP. SHORTLY AFTER TAKEOFF IN THE CLB ATC GAVE US A HEADING OF 060 DEGS AND AN ALTITUDE OF 8000 FT. AT THIS POINT WE STILL DID NOT THINK ANYTHING WAS WRONG AS THE CTLR WAS VERY CALM ABOUT THE CLRNC AND THOUGHT IT TO BE NORMAL; AS WE DID NOT RECEIVE ANY TFC CONFLICTS AT ALL OR EVEN SAW ANOTHER ACFT ON TCAS; WHICH I WAS MONITORING. AFTER SWITCHING TO ANOTHER FREQUENCY; THAT CTLR GAVE US A PHONE NUMBER TO CONTACT UPON LNDG; IN WHICH WE DID. AFTER RECEIVING THE PHONE NUMBER; WE RESEARCHED WHAT THE PROBLEM COULD'VE BEEN AND THAT IS WHEN WE REALIZED THAT THE CLRNC HAD BEEN CHANGED TO THE CLARE2. THE REMAINDER OF THE FLT WAS UNEVENTFUL. I BELIEVE THAT THIS EVENT OCCURRED DUE TO THE FOLLOWING FACTS. MY FO AND FLT ATTENDANT WERE RUNNING LATE FROM OTHER FLT. I PULLED THE CLRNC AND PROGRAMMED IT. WHEN MY FO SHOWED UP WE DID OUR BEST TO MAKE UP TIME; BEING AS THOROUGH AS POSSIBLE. WE VERIFIED AND BRIEFED THE DAL8 DEP AND BOTH AGREED ON THAT PROCEDURE. WHERE WE FAILED WAS IN VERIFYING THE REVISED SEGMENT. TO OUR KNOWLEDGE; WE CHKED AND VERIFIED EVERYTHING AS WE SHOULD HAVE; EXCEPT WE MISSED THE REVISED; NEW DEP. PART OF THE CONTRIBUTION TO THE PROBLEM WAS THAT WE HAD A WING ANTI-ICE SYSTEM MEL'ED AND AS PER THE MEL; I CALLED AND CHATTED WITH THE DISPATCHER ABOUT ICING CONDITIONS. HE INFORMED ME THAT WE WERE GIVEN ENOUGH FUEL TO FLY AT A LOWER ALTITUDE IF NEED TO MEET THE REQUIREMENTS. ALTHOUGH; THIS IS NOT AN EXCUSE; I HAD IT IN MY MIND THAT WAS THE REASON FOR THE DAL8; NON-RNAV DEP; SO I DIDN'T THINK THAT WOULD CHANGE. A SET OF UNFORTUNATE ISSUES LED TO THIS INCIDENT. I BELIEVE THAT WE WERE VERY THOROUGH IN OUR PREFLIGHT AND FOLLOWED OUR PROCS EXACTLY FOR ALL POINTS LEADING UP TO THIS EVENT. THE BREAKDOWN WAS IN THE FAILURE TO READ THE ENTIRE PDC. I DID SEE THE REVISED SEGMENT; BUT OVERLOOKED THE DEP CHANGE. I THOUGHT THE CHANGE TO BE ONLY SWB LFT; LFT INSTEAD OF SWB LFT. I JUST FAILED TO LOOK AT THE ENTIRE REVISED CLRNC AND HAD IT IN MY MIND THAT THE DAL8 DEP WOULD NOT CHANGE; DUE TO THE MEL.
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.