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|
Attributes | |
ACN | 792575 |
Time | |
Date | 200806 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dfw.airport |
State Reference | TX |
Altitude | agl single value : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : d10.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
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 |
ASRS Report | 792575 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 792576 |
Events | |
Anomaly | non adherence : far non adherence : clearance non adherence : published procedure non adherence other other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | FAA Flight Crew Human Performance |
Primary Problem | Ambiguous |
Narrative:
We received pre departure clearance via ACARS and noticed a revised segment. Revised segments on clrncs are received often and are usually different verbiage to mean the same thing -- usually adding a VOR on the airway that was not listed on the clearance; but would have been passed over anyway. We looked at that part of the clearance and agreed that there was no change. But really there was. We had been filed on the dallas 8 departure; but on the revised segment; the departure was changed to the clare 2; which we did not notice. Climbing through about 6000 ft; the controller gave us a left turn to join the departure and said; 'it looks like you missed your turn.' we thought we were on vectors and were waiting for departure to turn us; but we should have been on the RNAV departure and already turned toward the east. I believe a few factors contributed to our oversight. First; the revised segment clearance happens all the time; but nothing has really changed; so our guard was down. Second; we had a XB30 sign in and I got up at XA00. Although I went to bed early with enough time to get a good night's sleep and set two battery powered alarms; I did not sleep well; so I was tired even though we were just starting out. Neither of these reasons are an excuse for missing an important detail; and in the future; I will be more diligent in checking revised clrncs.supplemental information from acn 792576: possible contributing factor was very early sign-in with six hours of disruptive sleep.
Original NASA ASRS Text
Title: A B737 CREW DEPARTING DFW MISSED A PDC CLRNC CHANGE ASSIGNING A SID. BOTH PILOTS HAD EXAMINED THE PDC CAREFULLY. FATIGUE MAY HAVE BEEN A FACTOR.
Narrative: WE RECEIVED PDC VIA ACARS AND NOTICED A REVISED SEGMENT. REVISED SEGMENTS ON CLRNCS ARE RECEIVED OFTEN AND ARE USUALLY DIFFERENT VERBIAGE TO MEAN THE SAME THING -- USUALLY ADDING A VOR ON THE AIRWAY THAT WAS NOT LISTED ON THE CLRNC; BUT WOULD HAVE BEEN PASSED OVER ANYWAY. WE LOOKED AT THAT PART OF THE CLRNC AND AGREED THAT THERE WAS NO CHANGE. BUT REALLY THERE WAS. WE HAD BEEN FILED ON THE DALLAS 8 DEP; BUT ON THE REVISED SEGMENT; THE DEP WAS CHANGED TO THE CLARE 2; WHICH WE DID NOT NOTICE. CLBING THROUGH ABOUT 6000 FT; THE CTLR GAVE US A LEFT TURN TO JOIN THE DEP AND SAID; 'IT LOOKS LIKE YOU MISSED YOUR TURN.' WE THOUGHT WE WERE ON VECTORS AND WERE WAITING FOR DEP TO TURN US; BUT WE SHOULD HAVE BEEN ON THE RNAV DEP AND ALREADY TURNED TOWARD THE EAST. I BELIEVE A FEW FACTORS CONTRIBUTED TO OUR OVERSIGHT. FIRST; THE REVISED SEGMENT CLRNC HAPPENS ALL THE TIME; BUT NOTHING HAS REALLY CHANGED; SO OUR GUARD WAS DOWN. SECOND; WE HAD A XB30 SIGN IN AND I GOT UP AT XA00. ALTHOUGH I WENT TO BED EARLY WITH ENOUGH TIME TO GET A GOOD NIGHT'S SLEEP AND SET TWO BATTERY POWERED ALARMS; I DID NOT SLEEP WELL; SO I WAS TIRED EVEN THOUGH WE WERE JUST STARTING OUT. NEITHER OF THESE REASONS ARE AN EXCUSE FOR MISSING AN IMPORTANT DETAIL; AND IN THE FUTURE; I WILL BE MORE DILIGENT IN CHECKING REVISED CLRNCS.SUPPLEMENTAL INFO FROM ACN 792576: POSSIBLE CONTRIBUTING FACTOR WAS VERY EARLY SIGN-IN WITH SIX HOURS OF DISRUPTIVE SLEEP.
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.