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|
Attributes | |
ACN | 794363 |
Time | |
Date | 200807 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phx.airport |
State Reference | AZ |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : phx.tower tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sjn |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 200 flight time total : 16000 flight time type : 5000 |
ASRS Report | 794363 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 794289 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departed phx on the maxxo 1 departure. ATC asked us our heading and I replied '240.' ATC then asked what SID we were on. I told them that we were on the maxxo 1. ATC then said that we were supposed to be on the sjn 3. At this time I realized that I had missed the 'revised segment' note on the pre departure clearance. The controller told us to turn to a heading of 270 degrees. I set 270 degrees in the heading window and pulled the knob. As the captain started the turn I went 'heads down' to enter the sjn 3 departure in the FMGC. By the time I looked up the captain had gone through the 270 degree heading by approximately 90 degrees. Just as I told him that we were supposed to be on a 270 degree heading; the controller asked us about our heading again. I told them that we were correcting to 270 degrees. ATC then assigned us a heading of 350 degrees. ATC was not happy. The captain said he thought we were assigned a heading of 070 degrees and that's why he turned past 270 degrees. The flight director was giving him correct commands for 270 degrees. I'm not sure why he flew through the FD commands. We continued without further incident. Both pilots missed the 'revised segment' note on the pre departure clearance; that was the first mistake. The biggest mistake; however; was the turning error. I should not have been so preoccupied with the programming of the FMGC and monitored the captain's turn better. Also; when the captain saw that the FD command bars were not giving him what he thought was the correct information; he should have asked for verification. While our not putting the correct SID in the FMGC caused this whole problem; the turning error was the most dangerous.supplemental information from acn 794289: events that led up to the error were late equipment arrival at the gate; non normal release for a fuel stop prior to being released to ZZZ; mels and aircraft downgraded approach performance. Minor maintenance work was also being done on the flight deck during preflight preparation. Because of the mels and the maintenance work being done on the flight deck I told the first officer to load the flight plan for me while I focused my attention of these items. After all the dust settled and I completed my flows I checked the routing on the release with the routing that was in the fmcg. At that time I did not look at the pre departure clearance routing printout. I finished my flows then briefed the departure. During my departure I actually picked up the printout of the pre departure clearance routing and looked at it and briefed the filed clearance as the maxxo 1. This is what I had expected and this was what was on the release and in the computer. I saw what I wanted to see and did not even see the line above the filed clearance that showed a revised segment had been added that put us on the sjn 3 to sjn then J74 as filed. We simply missed this obvious routing change. I believe that background noise relating to the state of the airline and current labor relations also contributed to the mental state of both the first officer and myself when other factors entered in to make this a non routine preflight and departure. The first officer stated later in the flight that he was finding it hard to want to come to work anymore. Stress levels are high.
Original NASA ASRS Text
Title: ACR FLT CREW DEPARTS PHX ON WRONG SID; MISSING THEIR REROUTE ON THE PDC; ONCE CORRECTED BY ATC THEY PROCEED TO FLY THROUGH ASSIGNED HEADING.
Narrative: DEPARTED PHX ON THE MAXXO 1 DEP. ATC ASKED US OUR HEADING AND I REPLIED '240.' ATC THEN ASKED WHAT SID WE WERE ON. I TOLD THEM THAT WE WERE ON THE MAXXO 1. ATC THEN SAID THAT WE WERE SUPPOSED TO BE ON THE SJN 3. AT THIS TIME I REALIZED THAT I HAD MISSED THE 'REVISED SEGMENT' NOTE ON THE PDC. THE CTLR TOLD US TO TURN TO A HEADING OF 270 DEGS. I SET 270 DEGS IN THE HEADING WINDOW AND PULLED THE KNOB. AS THE CAPT STARTED THE TURN I WENT 'HEADS DOWN' TO ENTER THE SJN 3 DEP IN THE FMGC. BY THE TIME I LOOKED UP THE CAPT HAD GONE THROUGH THE 270 DEG HEADING BY APPROX 90 DEGS. JUST AS I TOLD HIM THAT WE WERE SUPPOSED TO BE ON A 270 DEG HEADING; THE CTLR ASKED US ABOUT OUR HEADING AGAIN. I TOLD THEM THAT WE WERE CORRECTING TO 270 DEGS. ATC THEN ASSIGNED US A HEADING OF 350 DEGS. ATC WAS NOT HAPPY. THE CAPT SAID HE THOUGHT WE WERE ASSIGNED A HEADING OF 070 DEGS AND THAT'S WHY HE TURNED PAST 270 DEGS. THE FLT DIRECTOR WAS GIVING HIM CORRECT COMMANDS FOR 270 DEGS. I'M NOT SURE WHY HE FLEW THROUGH THE FD COMMANDS. WE CONTINUED WITHOUT FURTHER INCIDENT. BOTH PLTS MISSED THE 'REVISED SEGMENT' NOTE ON THE PDC; THAT WAS THE FIRST MISTAKE. THE BIGGEST MISTAKE; HOWEVER; WAS THE TURNING ERROR. I SHOULD NOT HAVE BEEN SO PREOCCUPIED WITH THE PROGRAMMING OF THE FMGC AND MONITORED THE CAPT'S TURN BETTER. ALSO; WHEN THE CAPT SAW THAT THE FD COMMAND BARS WERE NOT GIVING HIM WHAT HE THOUGHT WAS THE CORRECT INFORMATION; HE SHOULD HAVE ASKED FOR VERIFICATION. WHILE OUR NOT PUTTING THE CORRECT SID IN THE FMGC CAUSED THIS WHOLE PROBLEM; THE TURNING ERROR WAS THE MOST DANGEROUS.SUPPLEMENTAL INFO FROM ACN 794289: EVENTS THAT LED UP TO THE ERROR WERE LATE EQUIPMENT ARR AT THE GATE; NON NORMAL RELEASE FOR A FUEL STOP PRIOR TO BEING RELEASED TO ZZZ; MELS AND ACFT DOWNGRADED APCH PERFORMANCE. MINOR MAINT WORK WAS ALSO BEING DONE ON THE FLT DECK DURING PREFLT PREPARATION. BECAUSE OF THE MELS AND THE MAINT WORK BEING DONE ON THE FLT DECK I TOLD THE FO TO LOAD THE FLT PLAN FOR ME WHILE I FOCUSED MY ATTENTION OF THESE ITEMS. AFTER ALL THE DUST SETTLED AND I COMPLETED MY FLOWS I CHECKED THE ROUTING ON THE RELEASE WITH THE ROUTING THAT WAS IN THE FMCG. AT THAT TIME I DID NOT LOOK AT THE PDC ROUTING PRINTOUT. I FINISHED MY FLOWS THEN BRIEFED THE DEP. DURING MY DEP I ACTUALLY PICKED UP THE PRINTOUT OF THE PDC ROUTING AND LOOKED AT IT AND BRIEFED THE FILED CLRNC AS THE MAXXO 1. THIS IS WHAT I HAD EXPECTED AND THIS WAS WHAT WAS ON THE RELEASE AND IN THE COMPUTER. I SAW WHAT I WANTED TO SEE AND DID NOT EVEN SEE THE LINE ABOVE THE FILED CLRNC THAT SHOWED A REVISED SEGMENT HAD BEEN ADDED THAT PUT US ON THE SJN 3 TO SJN THEN J74 AS FILED. WE SIMPLY MISSED THIS OBVIOUS ROUTING CHANGE. I BELIEVE THAT BACKGROUND NOISE RELATING TO THE STATE OF THE AIRLINE AND CURRENT LABOR RELATIONS ALSO CONTRIBUTED TO THE MENTAL STATE OF BOTH THE FO AND MYSELF WHEN OTHER FACTORS ENTERED IN TO MAKE THIS A NON ROUTINE PREFLIGHT AND DEP. THE FO STATED LATER IN THE FLT THAT HE WAS FINDING IT HARD TO WANT TO COME TO WORK ANYMORE. STRESS LEVELS ARE HIGH.
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.