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|
Attributes | |
ACN | 795705 |
Time | |
Date | 200807 |
Place | |
Locale Reference | airport : clt.airport |
State Reference | NC |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
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 : bobcat 1 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 795705 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
ASRS Report | 795706 |
Events | |
Anomaly | non adherence : far non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
The original flight plan route for flight XXX clt-ZZZ was clt.oakum..hours..gqo. Clearance delivery gave us the routing as the bobcat 1 departure; zaver transition; ZZZ1 124RAD.ZZZ1; than 'as filed.' I had programmed the FMS with the original route prior to the first officer obtaining the clearance for our flight to ZZZ. Once our clearance was received; I reprogrammed the FMS route with the first officer adding assistance. All other duties were as normal til the take-off roll; when the first officer inadvertently nudged the #2 throttle past a worn toga detent; tripping the T/O resv 1 power setting. Not sensing a safety issue; I allowed the take-off to continue. The automatic-throttles tripped off shortly after gear-up; which was identified and cancelled. I tried to re-engage them when we above 3000 ft AGL but the throttles wanted to reduce power instead of maintaining the power setting so I turned them back off; meanwhile clt ATC gave us an assigned heading to intercept the zaver transition. The FMS did not automatic sequence so I elected to enter the 'direct to' to the fix prior to zaver and monitored the course til it overlaid the transition. Once on the transition I re-engaged the automatic-throttles which was successful around 6000 ft AGL. Flight proceeded uneventfully till passing zaver intersection and started heading toward ZZZ2; I had not noticed that we did not turn towards ZZZ1 but I had an uneasy feeling that something was not right but could not identify it. Within minutes of our passing zaver; ATC inquired if we were on an assigned heading; I replied that we were heading to ZZZ2 (which was in our original flight plan). About a minute later; ATC cleared us direct to ZZZ1. Other than deviating for thunderstorm build-ups; flight proceeded and landed uneventfully. Upon talking to the on-duty supervisor at the TRACON as was requested; he informed me that the bobcat 1 departure with the zaver transition has been an ongoing problem for center and that some other aircrews weren't making the turn towards ZZZ1 as well. I normally check the plan page to review the flight plan; especially after a reroute from clearance delivery. I do remember reprogramming the FMS with the reroute because the first officer and I had discussed the programming of a VOR radial as I was putting it in. Somehow I missed this step prior to pushing back from the gate. Why or how ZZZ1 dropped out we can not be certain. Contributing factors was the automatic-throttles disconnecting; as well as the FMS not automatic-sequencing for the departure transition (I have had this problem out of clt before). I normally request to have the route of flight situated above the start/stop switches; but on this leg I had not.callback conversation with reporter revealed the following information: the reporter is certain the honeywell FMS was programmed correctly for the zaver transition. He is also fairly certain the transition was activated. After takeoff; the vectors were to intercept the transition on a heading before ZZZ2. In this particular case; the reporter kept the aircraft on a heading until within a half mile of the track then selected direct to ZZZ2. At that point the aircraft tracked properly to zaver but he did not look at the routing and does not know what was beyond zaver. However; after zaver he had a funny feeling that something was not right and then atlanta called verifying the routing. He does not recall what the routing was beyond zaver just that they were not going to ZZZ. They were then cleared direct ZZZ on course. Reporter stated that this type of event has apparently been a problem in the past.
Original NASA ASRS Text
Title: AN ACR CREW DEPARTED CLT ON THE XYZ ONE ZAVER TRANSITION AFTER A CLRNC CHANGE BEFORE TAXI. THE FMS WAS VERIFIED TO BE CORRECT BUT THE ACFT DID NOT TRANSITION TO ZZZ AFTER ZAVER.
Narrative: THE ORIGINAL FLT PLAN RTE FOR FLT XXX CLT-ZZZ WAS CLT.OAKUM..HRS..GQO. CLRNC DELIVERY GAVE US THE ROUTING AS THE BOBCAT 1 DEP; ZAVER TRANSITION; ZZZ1 124RAD.ZZZ1; THAN 'AS FILED.' I HAD PROGRAMMED THE FMS WITH THE ORIGINAL RTE PRIOR TO THE FO OBTAINING THE CLRNC FOR OUR FLT TO ZZZ. ONCE OUR CLRNC WAS RECEIVED; I REPROGRAMMED THE FMS RTE WITH THE FO ADDING ASSISTANCE. ALL OTHER DUTIES WERE AS NORMAL TIL THE TAKE-OFF ROLL; WHEN THE FO INADVERTENTLY NUDGED THE #2 THROTTLE PAST A WORN TOGA DETENT; TRIPPING THE T/O RESV 1 POWER SETTING. NOT SENSING A SAFETY ISSUE; I ALLOWED THE TAKE-OFF TO CONTINUE. THE AUTO-THROTTLES TRIPPED OFF SHORTLY AFTER GEAR-UP; WHICH WAS IDENTIFIED AND CANCELLED. I TRIED TO RE-ENGAGE THEM WHEN WE ABOVE 3000 FT AGL BUT THE THROTTLES WANTED TO REDUCE POWER INSTEAD OF MAINTAINING THE POWER SETTING SO I TURNED THEM BACK OFF; MEANWHILE CLT ATC GAVE US AN ASSIGNED HEADING TO INTERCEPT THE ZAVER TRANSITION. THE FMS DID NOT AUTO SEQUENCE SO I ELECTED TO ENTER THE 'DIRECT TO' TO THE FIX PRIOR TO ZAVER AND MONITORED THE COURSE TIL IT OVERLAID THE TRANSITION. ONCE ON THE TRANSITION I RE-ENGAGED THE AUTO-THROTTLES WHICH WAS SUCCESSFUL AROUND 6000 FT AGL. FLT PROCEEDED UNEVENTFULLY TILL PASSING ZAVER INTXN AND STARTED HEADING TOWARD ZZZ2; I HAD NOT NOTICED THAT WE DID NOT TURN TOWARDS ZZZ1 BUT I HAD AN UNEASY FEELING THAT SOMETHING WAS NOT RIGHT BUT COULD NOT IDENTIFY IT. WITHIN MINUTES OF OUR PASSING ZAVER; ATC INQUIRED IF WE WERE ON AN ASSIGNED HEADING; I REPLIED THAT WE WERE HEADING TO ZZZ2 (WHICH WAS IN OUR ORIGINAL FLT PLAN). ABOUT A MINUTE LATER; ATC CLEARED US DIRECT TO ZZZ1. OTHER THAN DEVIATING FOR THUNDERSTORM BUILD-UPS; FLT PROCEEDED AND LANDED UNEVENTFULLY. UPON TALKING TO THE ON-DUTY SUPVR AT THE TRACON AS WAS REQUESTED; HE INFORMED ME THAT THE BOBCAT 1 DEP WITH THE ZAVER TRANSITION HAS BEEN AN ONGOING PROBLEM FOR CENTER AND THAT SOME OTHER AIRCREWS WEREN'T MAKING THE TURN TOWARDS ZZZ1 AS WELL. I NORMALLY CHECK THE PLAN PAGE TO REVIEW THE FLT PLAN; ESPECIALLY AFTER A REROUTE FROM CLRNC DELIVERY. I DO REMEMBER REPROGRAMMING THE FMS WITH THE REROUTE BECAUSE THE FO AND I HAD DISCUSSED THE PROGRAMMING OF A VOR RADIAL AS I WAS PUTTING IT IN. SOMEHOW I MISSED THIS STEP PRIOR TO PUSHING BACK FROM THE GATE. WHY OR HOW ZZZ1 DROPPED OUT WE CAN NOT BE CERTAIN. CONTRIBUTING FACTORS WAS THE AUTO-THROTTLES DISCONNECTING; AS WELL AS THE FMS NOT AUTO-SEQUENCING FOR THE DEP TRANSITION (I HAVE HAD THIS PROBLEM OUT OF CLT BEFORE). I NORMALLY REQUEST TO HAVE THE ROUTE OF FLT SITUATED ABOVE THE START/STOP SWITCHES; BUT ON THIS LEG I HAD NOT.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR IS CERTAIN THE HONEYWELL FMS WAS PROGRAMMED CORRECTLY FOR THE ZAVER TRANSITION. HE IS ALSO FAIRLY CERTAIN THE TRANSITION WAS ACTIVATED. AFTER TKOF; THE VECTORS WERE TO INTERCEPT THE TRANSITION ON A HDG BEFORE ZZZ2. IN THIS PARTICULAR CASE; THE RPTR KEPT THE ACFT ON A HEADING UNTIL WITHIN A HALF MILE OF THE TRACK THEN SELECTED DIRECT TO ZZZ2. AT THAT POINT THE ACFT TRACKED PROPERLY TO ZAVER BUT HE DID NOT LOOK AT THE ROUTING AND DOES NOT KNOW WHAT WAS BEYOND ZAVER. HOWEVER; AFTER ZAVER HE HAD A FUNNY FEELING THAT SOMETHING WAS NOT RIGHT AND THEN ATLANTA CALLED VERIFYING THE ROUTING. HE DOES NOT RECALL WHAT THE ROUTING WAS BEYOND ZAVER JUST THAT THEY WERE NOT GOING TO ZZZ. THEY WERE THEN CLEARED DIRECT ZZZ ON COURSE. RPTR STATED THAT THIS TYPE OF EVENT HAS APPARENTLY BEEN A PROBLEM IN THE PAST.
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.