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|
Attributes | |
ACN | 797294 |
Time | |
Date | 200807 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sju.airport |
State Reference | PR |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tracon : sju.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 : jaws |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 797294 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 797295 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance non adherence : far non adherence : company policies other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | FAA Flight Crew Human Performance Chart Or Publication |
Primary Problem | FAA |
Situations | |
Publication | PDC |
Narrative:
We were filed for the 'jaws nine' departure. The pre departure clearance printed from the ACARS displayed a 'revised segment;' the 'vermo four' departure. We mistakenly overlooked the change; and flew the jaws nine. While preparing for departure; we specifically briefed the full routing; because of the many recent changes. The routing was properly compared from FMC to flight plan. By this point; we had missed the departure procedure change; and the jaws nine was briefed with the full routing. This was a major error; probably the worst and potentially dangerous of my career. In discussing this with the first officer after the fact; we determined that there were small contributing factors. 1) for a long time; probably more than 1 yr; the standard pre departure clearance with the jaws nine contained a 'revised segment' that was worded slightly differently than the filed jaws nine; but was exactly the same otherwise. I called ATC one day about this; and they said they were required to insert this; but agreed that the flight path was exactly the same. 2) the flight was hours late; with the captain and first officer coming in from different flts; with the usual last min rushing. Despite this; we were careful with a preparation and I don't believe this had any notable influence. There was no excuse for this error. Complacency with carefully reviewing the pre departure clearance was the cause; which I find disturbing because we were not complacent in reviewing the routing. A small human factor issue could be attributed to the issue I mentioned in item #1 above; but this is minor. Remedial action and suggestions: I will never again not read a pre departure clearance carefully and fully; comparing it to our filed clearance for changes. Suggestion: when a revision to a filed clearance is issued by ATC via pre departure clearance; a feedback system to ATC would provide assurance that the crew is aware of the revision. The feedback could be in the form of an asterisk or other symbology attached to the data strip for the flight; which would be removed by ATC when confirmation by the crew is received by ATC. Supplemental information from acn 797295: the clearance printed by ACARS showed JAWS9 departure and had an amended departure line with a different departure. I did not notice the amended departure and so the wrong departure was in our FMS. The headings for the JAWS9 is 350 degrees; and the other 020 degrees after departing runway 8 at sju. The next fix is different on each departure; and then the following fix was the same. An amended clearance is not uncommon for departures out of sju; but it is common for the amended clearance at sju to have no change to our departure. This may have played a role in my missing the changed departure.
Original NASA ASRS Text
Title: AN ACR CREW DEPARTING SJU MISSED A SID REVISION BECAUSE OF A PDC FORMATTING CHANGE
Narrative: WE WERE FILED FOR THE 'JAWS NINE' DEP. THE PDC PRINTED FROM THE ACARS DISPLAYED A 'REVISED SEGMENT;' THE 'VERMO FOUR' DEP. WE MISTAKENLY OVERLOOKED THE CHANGE; AND FLEW THE JAWS NINE. WHILE PREPARING FOR DEP; WE SPECIFICALLY BRIEFED THE FULL ROUTING; BECAUSE OF THE MANY RECENT CHANGES. THE ROUTING WAS PROPERLY COMPARED FROM FMC TO FLT PLAN. BY THIS POINT; WE HAD MISSED THE DEP PROC CHANGE; AND THE JAWS NINE WAS BRIEFED WITH THE FULL ROUTING. THIS WAS A MAJOR ERROR; PROBABLY THE WORST AND POTENTIALLY DANGEROUS OF MY CAREER. IN DISCUSSING THIS WITH THE FO AFTER THE FACT; WE DETERMINED THAT THERE WERE SMALL CONTRIBUTING FACTORS. 1) FOR A LONG TIME; PROBABLY MORE THAN 1 YR; THE STANDARD PDC WITH THE JAWS NINE CONTAINED A 'REVISED SEGMENT' THAT WAS WORDED SLIGHTLY DIFFERENTLY THAN THE FILED JAWS NINE; BUT WAS EXACTLY THE SAME OTHERWISE. I CALLED ATC ONE DAY ABOUT THIS; AND THEY SAID THEY WERE REQUIRED TO INSERT THIS; BUT AGREED THAT THE FLT PATH WAS EXACTLY THE SAME. 2) THE FLT WAS HRS LATE; WITH THE CAPT AND FO COMING IN FROM DIFFERENT FLTS; WITH THE USUAL LAST MIN RUSHING. DESPITE THIS; WE WERE CAREFUL WITH A PREPARATION AND I DON'T BELIEVE THIS HAD ANY NOTABLE INFLUENCE. THERE WAS NO EXCUSE FOR THIS ERROR. COMPLACENCY WITH CAREFULLY REVIEWING THE PDC WAS THE CAUSE; WHICH I FIND DISTURBING BECAUSE WE WERE NOT COMPLACENT IN REVIEWING THE ROUTING. A SMALL HUMAN FACTOR ISSUE COULD BE ATTRIBUTED TO THE ISSUE I MENTIONED IN ITEM #1 ABOVE; BUT THIS IS MINOR. REMEDIAL ACTION AND SUGGESTIONS: I WILL NEVER AGAIN NOT READ A PDC CAREFULLY AND FULLY; COMPARING IT TO OUR FILED CLRNC FOR CHANGES. SUGGESTION: WHEN A REVISION TO A FILED CLRNC IS ISSUED BY ATC VIA PDC; A FEEDBACK SYS TO ATC WOULD PROVIDE ASSURANCE THAT THE CREW IS AWARE OF THE REVISION. THE FEEDBACK COULD BE IN THE FORM OF AN ASTERISK OR OTHER SYMBOLOGY ATTACHED TO THE DATA STRIP FOR THE FLT; WHICH WOULD BE REMOVED BY ATC WHEN CONFIRMATION BY THE CREW IS RECEIVED BY ATC. SUPPLEMENTAL INFO FROM ACN 797295: THE CLRNC PRINTED BY ACARS SHOWED JAWS9 DEP AND HAD AN AMENDED DEP LINE WITH A DIFFERENT DEP. I DID NOT NOTICE THE AMENDED DEP AND SO THE WRONG DEP WAS IN OUR FMS. THE HDGS FOR THE JAWS9 IS 350 DEGS; AND THE OTHER 020 DEGS AFTER DEPARTING RWY 8 AT SJU. THE NEXT FIX IS DIFFERENT ON EACH DEP; AND THEN THE FOLLOWING FIX WAS THE SAME. AN AMENDED CLRNC IS NOT UNCOMMON FOR DEPS OUT OF SJU; BUT IT IS COMMON FOR THE AMENDED CLRNC AT SJU TO HAVE NO CHANGE TO OUR DEP. THIS MAY HAVE PLAYED A ROLE IN MY MISSING THE CHANGED DEP.
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.