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|
Attributes | |
ACN | 81091 |
Time | |
Date | 198801 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : eno |
State Reference | DE |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tower : bdl |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 6000 flight time type : 2000 |
ASRS Report | 81091 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 14000 |
ASRS Report | 81092 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Miss Distance | horizontal : 30000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While leveling off at FL350 captain proceeded to make passenger announcement with first officer flying and handling radios. First officer set 216 degrees in HSI and proceeded to track outbnd. The correct course should have been 229 degrees (216 degree radial was the next fix down the road, richmond VOR). At about 18 NM the mistake was caught. As correction was started back to course, ATC called and asked what jetway we were flying out of kenton VOR. We said we were correcting back to course. They told us to turn 30 degrees left and the following aircraft behind us was given an immediate right turn. During our correction back to the proper arwy, we decreased the spacing with the aircraft directly behind us, also at FL350, who was flying on the arwy we had filed. The following factors were present when first officer selected and flew the wrong arwy: 1) at kenton VOR you transition from the SID to the en route chart. Even though first officer knew he was over kenton, he selected the next arwy out of richmond. Ric VOR frequency is 114.1 and kenton is 111.4.it is very easy to transpose numbers during the transition to a very busy chart during a busy time in the aircraft. 2) captain was 'out of the loop' during the short time this incident occurred. Upon re-entering the loop he immediately detected the first officer's error. This identical mistake happened 1 1/2 yrs ago to the first officer. At that time no other aircraft were involved. At that time the first officer decided to always confirm outbnd heading at each fix to verify proper heading. If this technique had been used at kenton this incident probably would have not occurred. Supplemental information from acn 81092: ATC called us to correct our course at about the time we realized our error and began taking corrective action on our own. Apparently the first and second transmission from ATC was not heard by us in the cockpit. Our corrective turn back to course then caused a situation where our spacing with air carrier Y, who was directly behind us, was not satisfactory.
Original NASA ASRS Text
Title: ACR X FLEW WRONG RADIAL FROM ENO. SET UP POTENTIAL LOSS OF SEPARATION WITH ACR Y.
Narrative: WHILE LEVELING OFF AT FL350 CAPT PROCEEDED TO MAKE PAX ANNOUNCEMENT WITH F/O FLYING AND HANDLING RADIOS. F/O SET 216 DEGS IN HSI AND PROCEEDED TO TRACK OUTBND. THE CORRECT COURSE SHOULD HAVE BEEN 229 DEGS (216 DEG RADIAL WAS THE NEXT FIX DOWN THE ROAD, RICHMOND VOR). AT ABOUT 18 NM THE MISTAKE WAS CAUGHT. AS CORRECTION WAS STARTED BACK TO COURSE, ATC CALLED AND ASKED WHAT JETWAY WE WERE FLYING OUT OF KENTON VOR. WE SAID WE WERE CORRECTING BACK TO COURSE. THEY TOLD US TO TURN 30 DEGS LEFT AND THE FOLLOWING ACFT BEHIND US WAS GIVEN AN IMMEDIATE RIGHT TURN. DURING OUR CORRECTION BACK TO THE PROPER ARWY, WE DECREASED THE SPACING WITH THE ACFT DIRECTLY BEHIND US, ALSO AT FL350, WHO WAS FLYING ON THE ARWY WE HAD FILED. THE FOLLOWING FACTORS WERE PRESENT WHEN F/O SELECTED AND FLEW THE WRONG ARWY: 1) AT KENTON VOR YOU TRANSITION FROM THE SID TO THE ENRTE CHART. EVEN THOUGH F/O KNEW HE WAS OVER KENTON, HE SELECTED THE NEXT ARWY OUT OF RICHMOND. RIC VOR FREQ IS 114.1 AND KENTON IS 111.4.IT IS VERY EASY TO TRANSPOSE NUMBERS DURING THE TRANSITION TO A VERY BUSY CHART DURING A BUSY TIME IN THE ACFT. 2) CAPT WAS 'OUT OF THE LOOP' DURING THE SHORT TIME THIS INCIDENT OCCURRED. UPON RE-ENTERING THE LOOP HE IMMEDIATELY DETECTED THE F/O'S ERROR. THIS IDENTICAL MISTAKE HAPPENED 1 1/2 YRS AGO TO THE F/O. AT THAT TIME NO OTHER ACFT WERE INVOLVED. AT THAT TIME THE F/O DECIDED TO ALWAYS CONFIRM OUTBND HDG AT EACH FIX TO VERIFY PROPER HDG. IF THIS TECHNIQUE HAD BEEN USED AT KENTON THIS INCIDENT PROBABLY WOULD HAVE NOT OCCURRED. SUPPLEMENTAL INFORMATION FROM ACN 81092: ATC CALLED US TO CORRECT OUR COURSE AT ABOUT THE TIME WE REALIZED OUR ERROR AND BEGAN TAKING CORRECTIVE ACTION ON OUR OWN. APPARENTLY THE FIRST AND SECOND XMISSION FROM ATC WAS NOT HEARD BY US IN THE COCKPIT. OUR CORRECTIVE TURN BACK TO COURSE THEN CAUSED A SITUATION WHERE OUR SPACING WITH ACR Y, WHO WAS DIRECTLY BEHIND US, WAS NOT SATISFACTORY.
Data retrieved from NASA's ASRS site as of August 2007 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.