37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 789974 |
Time | |
Date | 200806 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : slc.airport |
State Reference | UT |
Altitude | msl bound lower : 7000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zlc.artcc tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : vacating altitude |
Route In Use | arrival star : watts |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 301 flight time type : 7500 |
ASRS Report | 789974 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 264 flight time type : 264 |
ASRS Report | 789968 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Aircraft Chart Or Publication |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying the watts two arrival into slc and advised to expect runway 16R. Passing slagg intersection; we were advised to expect runway 16L. The first officer tried to input the change but executed without asking me to verify the changes. By the time I looked at the CDU; we had a present position discontinuity. ATC immediately assigned us a heading as we had flown past the fix quipa and not made the hard turn north. We never completely recovered and ended up going around to start over. Standardization/training. Most pilots are now asking the other pilot to verify changes. However; what I see most lacking is an attempt to execute without reviewing the legs page. This will become an even greater issue as we move to full-up LNAV/VNAV/rnp. I tell first officer's to never execute unless you're on the legs page; ie; don't execute from the departure/arrival page.callback conversation with reporter revealed the following information: the reporter subsequently has been unable to duplicate the event. He thinks the first officer may have misprogrammed and executed a faulty selection. The reporter stressed that firm SOP and appropriate training will be mandatory to eliminate errors of this sort to the greatest degree possible.
Original NASA ASRS Text
Title: ARC FLT CREW HAS TRACK DEV ON WATTS RNAV STAR TO SLC WHEN PROGRAMMING OF LATE RWY CHANGE CAUSES LOSS OF ARR ROUTING APCHING QUIPA WAYPOINT.
Narrative: I WAS FLYING THE WATTS TWO ARR INTO SLC AND ADVISED TO EXPECT RWY 16R. PASSING SLAGG INTXN; WE WERE ADVISED TO EXPECT RWY 16L. THE FO TRIED TO INPUT THE CHANGE BUT EXECUTED WITHOUT ASKING ME TO VERIFY THE CHANGES. BY THE TIME I LOOKED AT THE CDU; WE HAD A PRESENT POSITION DISCONTINUITY. ATC IMMEDIATELY ASSIGNED US A HEADING AS WE HAD FLOWN PAST THE FIX QUIPA AND NOT MADE THE HARD TURN NORTH. WE NEVER COMPLETELY RECOVERED AND ENDED UP GOING AROUND TO START OVER. STANDARDIZATION/TRAINING. MOST PLTS ARE NOW ASKING THE OTHER PLT TO VERIFY CHANGES. HOWEVER; WHAT I SEE MOST LACKING IS AN ATTEMPT TO EXECUTE WITHOUT REVIEWING THE LEGS PAGE. THIS WILL BECOME AN EVEN GREATER ISSUE AS WE MOVE TO FULL-UP LNAV/VNAV/RNP. I TELL FO'S TO NEVER EXECUTE UNLESS YOU'RE ON THE LEGS PAGE; IE; DON'T EXECUTE FROM THE DEP/ARR PAGE.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SUBSEQUENTLY HAS BEEN UNABLE TO DUPLICATE THE EVENT. HE THINKS THE FO MAY HAVE MISPROGRAMMED AND EXECUTED A FAULTY SELECTION. THE RPTR STRESSED THAT FIRM SOP AND APPROPRIATE TRAINING WILL BE MANDATORY TO ELIMINATE ERRORS OF THIS SORT TO THE GREATEST DEGREE POSSIBLE.
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.