37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 824439 |
Time | |
Date | 200902 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | SFO.Airport |
State Reference | CA |
Aircraft 1 | |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | Takeoff Parked |
Route In Use | SID CUIT |
Flight Plan | IFR |
Person 1 | |
Function | Captain Pilot Flying |
Experience | Flight Crew Last 90 Days 60 Flight Crew Total 11000 Flight Crew Type 2347 |
Person 2 | |
Function | Pilot Not Flying Relief Pilot |
Experience | Flight Crew Last 90 Days 240 Flight Crew Total 14000 Flight Crew Type 3600 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Deviation - Procedural Clearance Deviation - Track / Heading All Types |
Narrative:
We missed a SID change on departure from runway 28L in sfo. There was a distraction during setup on the preflight with a maintenance issue. I picked up the pre departure clearance on the console to check the clearance and read the filed route as CUIT2 to sac and flight plan route. It occurred to me then that I had not finished checking the route in the FMC. I checked the route and the filed route on the pre departure clearance matched the flight plan route. There was a revised segment and I thought I read sfo to sac and the jet route to bam. I was surprised at the revised segment because it appeared to match what we had filed. We see too many pdcs where the revised segment is not really different. The first officer read the pre departure clearance as well; checked everything; and we taxied out. During the before takeoff checklist; the first officer confirmed the CUIT2 departure and transition. The relief pilot was out of the loop for a moment handling a fire loop status message that popped up. He missed the brief for the departure. We were cleared for takeoff and departed turning right onto the CUIT2. I did not think it unusual to get the turn since we were fairly light for a 747. In the turn; the relief pilot asked to see the pre departure clearance because he felt it unusual to get the CUIT2. It was at that point that I realized that the revised segment of the clearance said SFO8 and not sfo which changed our departure SID. Neither tower nor departure said anything about our departure and there appeared to be no loss of separation. The first officer said he did not find the CUIT2 to be unusual since they had flown it on his last trip. He is also new on the airplane and doesn't have the experience of the relief pilot. As we have seen many times; the lack of any special means to see what; if anything; has changed on the revised segment led me into a false sense that there was nothing different about this clearance and I missed the '8' after sfo. My lack of familiarity with the 'normal' departures was a factor in this event. I will be much more vigilant in the future and insure all crew members are in the loop when briefing the departure. It would be great if just the revised portion of the revised segment could be highlighted and not the whole clearance. It wouldn't look so much like the filed route and it would be easier to pick out the change.
Original NASA ASRS Text
Title: B747 flight crew departing SFO do not comprehend the revised segment of the PDC and depart on the CUIT2 instead of the SFO8. The Relief Pilot discovers the error during departure but ATC makes no comment.
Narrative: We missed a SID change on departure from Runway 28L in SFO. There was a distraction during setup on the preflight with a maintenance issue. I picked up the PDC on the console to check the clearance and read the filed route as CUIT2 to SAC and flight plan route. It occurred to me then that I had not finished checking the route in the FMC. I checked the route and the filed route on the PDC matched the flight plan route. There was a revised segment and I thought I read SFO to SAC and the jet route to BAM. I was surprised at the revised segment because it appeared to match what we had filed. We see too many PDCs where the revised segment is not really different. The First Officer read the PDC as well; checked everything; and we taxied out. During the Before Takeoff checklist; the First Officer confirmed the CUIT2 departure and transition. The Relief Pilot was out of the loop for a moment handling a Fire Loop status message that popped up. He missed the brief for the departure. We were cleared for takeoff and departed turning right onto the CUIT2. I did not think it unusual to get the turn since we were fairly light for a 747. In the turn; the Relief Pilot asked to see the PDC because he felt it unusual to get the CUIT2. It was at that point that I realized that the revised segment of the clearance said SFO8 and not SFO which changed our departure SID. Neither Tower nor Departure said anything about our departure and there appeared to be no loss of separation. The First Officer said he did not find the CUIT2 to be unusual since they had flown it on his last trip. He is also new on the airplane and doesn't have the experience of the Relief Pilot. As we have seen many times; the lack of any special means to see what; if anything; has changed on the revised segment led me into a false sense that there was nothing different about this clearance and I missed the '8' after SFO. My lack of familiarity with the 'normal' departures was a factor in this event. I will be much more vigilant in the future and insure all crew members are in the loop when briefing the departure. It would be great if just the revised portion of the revised segment could be highlighted and not the whole clearance. It wouldn't look so much like the filed route and it would be easier to pick out the change.
Data retrieved from NASA's ASRS site as of April 2012 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.