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Attributes | |
ACN | 802782 |
Time | |
Date | 200809 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : rjgg.airport |
State Reference | FO |
Altitude | msl single value : 2000 |
Aircraft 1 | |
Controlling Facilities | tracon : rjtg.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 : initial |
Route In Use | departure sid : kazkl1r |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 60 flight time total : 14000 flight time type : 435 |
ASRS Report | 802782 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 200 flight time total : 9000 flight time type : 3200 |
ASRS Report | 802784 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departing nagoya; we had a navigation deviation while departing runway 36 due to the improper departure being selected in the FMC database; and failure of our crew to verify the proper departure information on both the legs page and the navigation display. This was my second flight in to rjgg; and based on my previous flight I was expecting the kazki reversal 1 departure. I was the PNF on this leg. We had a very light passenger load; and the station was ready to push us approximately 15 mins earlier than our scheduled departure time. This caused us to become rushed as we received our clearance and began final FMC programming and predep briefing and checklists. We received our clearance which was the kazki reversal 1 departure; which is what we had expected. Unfortunately; I selected from the FMC the kazki 2 departure (KAZKI2); which was missed by all crew members. We had briefed the kazki reversal 1 departure (kazkir); but failed to verify on the legs page the correct departure. On our initial climb out; the departure controller asked us to verify which departure we were flying. I told him the correct one; but he immediately realized that we weren't turning where we should have; and gave us a heading to get us going in the right direction. This is when I realized that we had the wrong departure selected in our FMC. We do not believe there was any conflict with any other airplane or traffic. The controller seemed cool about the confusion and deviation on our part; and gave us a direct routing to a fix further along on our departure at which point we resumed our own navigation. Although I had slept well; our departure had us pushing late; based on our home time zone. No good excuses for me; but by sharing some of the finer details of this event I think it is easy to see how the mistakes were made. However; the important thing is to realize that if I had slowed down and just done the air carrier SOP's; this event would have been avoided. The FMC database for rjgg has 3 pages of departures that come up. Allowing myself to be rushed; when I selected the departure page; I saw the one I thought I was looking for. On page 1 of 3 the very last departure on that page shows the KAZKI2. If I had selected page 2 of 3 I would have seen a second kazki departure listed as the first choice on page 2 of 3. It was the kazkir; which is the one I should have chosen. Part of the confusion is the fact that the FMC database has been coded for the various departures; but there is not an accurate way to confirm with the commercial departure plate (page) that you have the correct departure selected. I would recommend that review committee consider contacting commercial chart company; possibly avionics mtg; to see if it would be possible to update the charts to show the same coding as what is in the FMC database. For example; if you look at the 1R chart it says it is the kazki reversal one departure. I would recommend to chart company that just below this title that they consider adding kazkir. This is the FMC selection that would have given us that departure procedure. Likewise; if you look at the 2 chart; it would be nice if below the title of kazki 2 departure; it also showed KAZKI2. Although this is normally fairly easy to match up; this extra bit of into on the commercial chart could have prevented us from selecting the wrong procedure.
Original NASA ASRS Text
Title: ACR FLT CREW IS CLEARED VIA THE KAZKI 1R DEPARTING RJGG AND SELECTS KAZKI 2 SID FROM THE FMC BY MISTAKE. TRACK DEV RESULTS.
Narrative: DEPARTING NAGOYA; WE HAD A NAV DEV WHILE DEPARTING RWY 36 DUE TO THE IMPROPER DEP BEING SELECTED IN THE FMC DATABASE; AND FAILURE OF OUR CREW TO VERIFY THE PROPER DEP INFO ON BOTH THE LEGS PAGE AND THE NAV DISPLAY. THIS WAS MY SECOND FLT IN TO RJGG; AND BASED ON MY PREVIOUS FLT I WAS EXPECTING THE KAZKI REVERSAL 1 DEP. I WAS THE PNF ON THIS LEG. WE HAD A VERY LIGHT PAX LOAD; AND THE STATION WAS READY TO PUSH US APPROX 15 MINS EARLIER THAN OUR SCHEDULED DEP TIME. THIS CAUSED US TO BECOME RUSHED AS WE RECEIVED OUR CLRNC AND BEGAN FINAL FMC PROGRAMMING AND PREDEP BRIEFING AND CHKLISTS. WE RECEIVED OUR CLRNC WHICH WAS THE KAZKI REVERSAL 1 DEP; WHICH IS WHAT WE HAD EXPECTED. UNFORTUNATELY; I SELECTED FROM THE FMC THE KAZKI 2 DEP (KAZKI2); WHICH WAS MISSED BY ALL CREW MEMBERS. WE HAD BRIEFED THE KAZKI REVERSAL 1 DEP (KAZKIR); BUT FAILED TO VERIFY ON THE LEGS PAGE THE CORRECT DEP. ON OUR INITIAL CLBOUT; THE DEP CTLR ASKED US TO VERIFY WHICH DEP WE WERE FLYING. I TOLD HIM THE CORRECT ONE; BUT HE IMMEDIATELY REALIZED THAT WE WEREN'T TURNING WHERE WE SHOULD HAVE; AND GAVE US A HDG TO GET US GOING IN THE RIGHT DIRECTION. THIS IS WHEN I REALIZED THAT WE HAD THE WRONG DEP SELECTED IN OUR FMC. WE DO NOT BELIEVE THERE WAS ANY CONFLICT WITH ANY OTHER AIRPLANE OR TFC. THE CTLR SEEMED COOL ABOUT THE CONFUSION AND DEV ON OUR PART; AND GAVE US A DIRECT ROUTING TO A FIX FURTHER ALONG ON OUR DEP AT WHICH POINT WE RESUMED OUR OWN NAV. ALTHOUGH I HAD SLEPT WELL; OUR DEP HAD US PUSHING LATE; BASED ON OUR HOME TIME ZONE. NO GOOD EXCUSES FOR ME; BUT BY SHARING SOME OF THE FINER DETAILS OF THIS EVENT I THINK IT IS EASY TO SEE HOW THE MISTAKES WERE MADE. HOWEVER; THE IMPORTANT THING IS TO REALIZE THAT IF I HAD SLOWED DOWN AND JUST DONE THE ACR SOP'S; THIS EVENT WOULD HAVE BEEN AVOIDED. THE FMC DATABASE FOR RJGG HAS 3 PAGES OF DEPS THAT COME UP. ALLOWING MYSELF TO BE RUSHED; WHEN I SELECTED THE DEP PAGE; I SAW THE ONE I THOUGHT I WAS LOOKING FOR. ON PAGE 1 OF 3 THE VERY LAST DEP ON THAT PAGE SHOWS THE KAZKI2. IF I HAD SELECTED PAGE 2 OF 3 I WOULD HAVE SEEN A SECOND KAZKI DEP LISTED AS THE FIRST CHOICE ON PAGE 2 OF 3. IT WAS THE KAZKIR; WHICH IS THE ONE I SHOULD HAVE CHOSEN. PART OF THE CONFUSION IS THE FACT THAT THE FMC DATABASE HAS BEEN CODED FOR THE VARIOUS DEPS; BUT THERE IS NOT AN ACCURATE WAY TO CONFIRM WITH THE COMMERCIAL DEP PLATE (PAGE) THAT YOU HAVE THE CORRECT DEP SELECTED. I WOULD RECOMMEND THAT REVIEW COMMITTEE CONSIDER CONTACTING COMMERCIAL CHART COMPANY; POSSIBLY AVIONICS MTG; TO SEE IF IT WOULD BE POSSIBLE TO UPDATE THE CHARTS TO SHOW THE SAME CODING AS WHAT IS IN THE FMC DATABASE. FOR EXAMPLE; IF YOU LOOK AT THE 1R CHART IT SAYS IT IS THE KAZKI REVERSAL ONE DEP. I WOULD RECOMMEND TO CHART COMPANY THAT JUST BELOW THIS TITLE THAT THEY CONSIDER ADDING KAZKIR. THIS IS THE FMC SELECTION THAT WOULD HAVE GIVEN US THAT DEP PROC. LIKEWISE; IF YOU LOOK AT THE 2 CHART; IT WOULD BE NICE IF BELOW THE TITLE OF KAZKI 2 DEP; IT ALSO SHOWED KAZKI2. ALTHOUGH THIS IS NORMALLY FAIRLY EASY TO MATCH UP; THIS EXTRA BIT OF INTO ON THE COMMERCIAL CHART COULD HAVE PREVENTED US FROM SELECTING THE WRONG PROC.
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.