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|
Attributes | |
ACN | 811758 |
Time | |
Date | 200811 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dfw.airport |
State Reference | TX |
Altitude | msl bound lower : 3000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d10.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream 200 [G200] (IAI 1126 Galaxy) |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure sid : worth |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 69 flight time total : 13702 flight time type : 1594 |
ASRS Report | 811758 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was the PIC and PF on this flight from dfw to bfi. While I was engaged in other preflight activities; the PNF; also a rated captain; received a pre departure clearance for the flight. He wrote down the clearance on our flight plan log and loaded the route into the FMS's. Upon returning to the cockpit; I reviewed the written clearance; checked the FMS flight plan page; reviewed the departure and then briefed the PNF on the ft worth 5 departure; which was our filed route. Shortly after contacting regional departure; the controller asked if we were on the RNAV departure. The PNF replied we were heading 185 degrees. The controller immediately gave us a right turn followed shortly by a clearance direct to ferra. The rest of the flight was uneventful. During the departure climb; I had maintained visual contact with an MD80 that had taken off in front of us. While our tracks were somewhat similar; we had a substantially higher climb rate and had outclbed him. Our TCAS never gave any TA or RA. There never appeared to be any traffic conflict with the preceding aircraft or any other aircraft. After reaching cruise altitude; the PNF and I started to debrief what had happened with the departure. This was the first time I realized we had been given a pre departure clearance and that the other pilot had not received the clearance from clearance delivery. We then both reviewed the pre departure clearance message and at that time saw that there had been an amendment to our filed route. This amendment was a change in the SID. The new SID was the ferra 2 RNAV SID with a different ground track; although the initial tracks on both SID's were very close. Since the controller gave us the turn so very close to where we should have turned; it would appear that he was watching and waiting for us to either turn or not. About 1 hour 30 mins into the flight; and after we had debriefed the departure; ARTCC contacted us and asked that we call dfw TRACON upon landing. In hindsight; I can see a number of things that contributed to our flying the wrong SID. First; this had been a 'quick turn' for us. We had landed less than 90 mins before. During that time we ordered fuel for the plane; got a rental car and drove off site for a late fast food lunch and just after returning to the GA terminal; received a call from our passenger that they were 10 mins away. While not feeling particularly rushed; both crew members went about their jobs and this led to both of us not being in the cockpit at the time the clearance was received. Secondly while we have been flying together for over 8 yrs and in this aircraft for over 6 yrs; only recently have we enabled the data functions of the FMS. Since most of our flying is from airports not served by pre departure clearance; it is still new to us and I find the formatting of clrncs to be confusing. Lastly; I see that there is an advisory notice published in our company manual that addresses this very issue. While it is directed toward flight crew procedures; it does contain a section that says that ground control may ask for a confirmation of departure runway and first fix. Unfortunately; they didn't for our flight. The pre departure clearance program was initiated in 1990 and according to an ASRS paper written in 1996 the mistake we made has been happening since the beginning. I would like to suggest that the FAA make the following changes to their pre departure clearance program: 1) eliminate the amendment section. Make the pre departure clearance like any other clearance. Just give the clearance as amended; just like any verbal clearance we receive. 2) require flight crews to confirm departure runway and first fix to ground control. Don't assume that the crew received and understood the pre departure clearance as intended. By the way; this is one of the first concepts they teach (preach) about CRM; closed loop communications. The pre departure clearance program is akin to putting a message in a bottle; throwing it into the ocean and hoping it is received and understood.
Original NASA ASRS Text
Title: CORPORATE JET FLIGHT CREW DEVIATED FROM THEIR CLEARED SID ON DEPARTURE WHEN THE PNF FAILED TO NOTICE THE CHANGES IN THEIR ROUTE SPECIFIED ON THE PDC.
Narrative: I WAS THE PIC AND PF ON THIS FLT FROM DFW TO BFI. WHILE I WAS ENGAGED IN OTHER PREFLT ACTIVITIES; THE PNF; ALSO A RATED CAPT; RECEIVED A PDC FOR THE FLT. HE WROTE DOWN THE CLRNC ON OUR FLT PLAN LOG AND LOADED THE RTE INTO THE FMS'S. UPON RETURNING TO THE COCKPIT; I REVIEWED THE WRITTEN CLRNC; CHKED THE FMS FLT PLAN PAGE; REVIEWED THE DEP AND THEN BRIEFED THE PNF ON THE FT WORTH 5 DEP; WHICH WAS OUR FILED RTE. SHORTLY AFTER CONTACTING REGIONAL DEP; THE CTLR ASKED IF WE WERE ON THE RNAV DEP. THE PNF REPLIED WE WERE HDG 185 DEGS. THE CTLR IMMEDIATELY GAVE US A R TURN FOLLOWED SHORTLY BY A CLRNC DIRECT TO FERRA. THE REST OF THE FLT WAS UNEVENTFUL. DURING THE DEP CLB; I HAD MAINTAINED VISUAL CONTACT WITH AN MD80 THAT HAD TAKEN OFF IN FRONT OF US. WHILE OUR TRACKS WERE SOMEWHAT SIMILAR; WE HAD A SUBSTANTIALLY HIGHER CLB RATE AND HAD OUTCLBED HIM. OUR TCAS NEVER GAVE ANY TA OR RA. THERE NEVER APPEARED TO BE ANY TFC CONFLICT WITH THE PRECEDING ACFT OR ANY OTHER ACFT. AFTER REACHING CRUISE ALT; THE PNF AND I STARTED TO DEBRIEF WHAT HAD HAPPENED WITH THE DEP. THIS WAS THE FIRST TIME I REALIZED WE HAD BEEN GIVEN A PDC AND THAT THE OTHER PLT HAD NOT RECEIVED THE CLRNC FROM CLRNC DELIVERY. WE THEN BOTH REVIEWED THE PDC MESSAGE AND AT THAT TIME SAW THAT THERE HAD BEEN AN AMENDMENT TO OUR FILED RTE. THIS AMENDMENT WAS A CHANGE IN THE SID. THE NEW SID WAS THE FERRA 2 RNAV SID WITH A DIFFERENT GND TRACK; ALTHOUGH THE INITIAL TRACKS ON BOTH SID'S WERE VERY CLOSE. SINCE THE CTLR GAVE US THE TURN SO VERY CLOSE TO WHERE WE SHOULD HAVE TURNED; IT WOULD APPEAR THAT HE WAS WATCHING AND WAITING FOR US TO EITHER TURN OR NOT. ABOUT 1 HR 30 MINS INTO THE FLT; AND AFTER WE HAD DEBRIEFED THE DEP; ARTCC CONTACTED US AND ASKED THAT WE CALL DFW TRACON UPON LNDG. IN HINDSIGHT; I CAN SEE A NUMBER OF THINGS THAT CONTRIBUTED TO OUR FLYING THE WRONG SID. FIRST; THIS HAD BEEN A 'QUICK TURN' FOR US. WE HAD LANDED LESS THAN 90 MINS BEFORE. DURING THAT TIME WE ORDERED FUEL FOR THE PLANE; GOT A RENTAL CAR AND DROVE OFF SITE FOR A LATE FAST FOOD LUNCH AND JUST AFTER RETURNING TO THE GA TERMINAL; RECEIVED A CALL FROM OUR PAX THAT THEY WERE 10 MINS AWAY. WHILE NOT FEELING PARTICULARLY RUSHED; BOTH CREW MEMBERS WENT ABOUT THEIR JOBS AND THIS LED TO BOTH OF US NOT BEING IN THE COCKPIT AT THE TIME THE CLRNC WAS RECEIVED. SECONDLY WHILE WE HAVE BEEN FLYING TOGETHER FOR OVER 8 YRS AND IN THIS ACFT FOR OVER 6 YRS; ONLY RECENTLY HAVE WE ENABLED THE DATA FUNCTIONS OF THE FMS. SINCE MOST OF OUR FLYING IS FROM ARPTS NOT SERVED BY PDC; IT IS STILL NEW TO US AND I FIND THE FORMATTING OF CLRNCS TO BE CONFUSING. LASTLY; I SEE THAT THERE IS AN ADVISORY NOTICE PUBLISHED IN OUR COMPANY MANUAL THAT ADDRESSES THIS VERY ISSUE. WHILE IT IS DIRECTED TOWARD FLT CREW PROCS; IT DOES CONTAIN A SECTION THAT SAYS THAT GND CTL MAY ASK FOR A CONFIRMATION OF DEP RWY AND FIRST FIX. UNFORTUNATELY; THEY DIDN'T FOR OUR FLT. THE PDC PROGRAM WAS INITIATED IN 1990 AND ACCORDING TO AN ASRS PAPER WRITTEN IN 1996 THE MISTAKE WE MADE HAS BEEN HAPPENING SINCE THE BEGINNING. I WOULD LIKE TO SUGGEST THAT THE FAA MAKE THE FOLLOWING CHANGES TO THEIR PDC PROGRAM: 1) ELIMINATE THE AMENDMENT SECTION. MAKE THE PDC LIKE ANY OTHER CLRNC. JUST GIVE THE CLRNC AS AMENDED; JUST LIKE ANY VERBAL CLRNC WE RECEIVE. 2) REQUIRE FLT CREWS TO CONFIRM DEP RWY AND FIRST FIX TO GND CTL. DON'T ASSUME THAT THE CREW RECEIVED AND UNDERSTOOD THE PDC AS INTENDED. BY THE WAY; THIS IS ONE OF THE FIRST CONCEPTS THEY TEACH (PREACH) ABOUT CRM; CLOSED LOOP COMS. THE PDC PROGRAM IS AKIN TO PUTTING A MESSAGE IN A BOTTLE; THROWING IT INTO THE OCEAN AND HOPING IT IS RECEIVED AND UNDERSTOOD.
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.