37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 894018 |
Time | |
Date | 201006 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Regional Jet 200 ER/LR (CRJ200) |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb |
Person 1 | |
Function | Captain Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer Pilot Flying |
Qualification | Flight Crew Commercial |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Deviation - Track / Heading All Types |
Narrative:
After three consecutive days of very early shows; we were preparing for our 15th flight on the third aircraft of the day. After doing a maintenance write up for the last aircraft flown; I had 30 minutes to grab some food for lunch and to prepare and board our flight. I arrived at the aircraft at about 20 minutes before departure time. My first officer; flight attendant; and I quickly prepared the flight and boarded a full aircraft. There were multiple distractions which my first officer and I fought to overcome. We checked a transformer rectifier unit MEL (24-31-01) which I thought was done incorrectly; because a stray but related circuit breaker was popped and not collared. I checked the MEL book and determined that the circuit breaker should be closed. Not wanting to delay the flight to deal with maintenance on this issue; I decided to close the breaker and proceed with the item MEL'd as it already was. My first officer had a difficult time getting the ACARS to receive and transmit takeoff data. We received a message from dispatch saying that the aero data portion of ACARS was inoperative currently. In the remaining time I tried to have a few bites of food; as it was lunchtime for us and we originally had a 1:19 break scheduled; and I try to stay nourished in the interest of safety. We performed all the required checklists and got the plane out on time; but we both missed the fact that I had programmed the FMS with the filed flight plan routing; not what the clearance which we were given by ATC. I did verify that the FMS waypoints were the same as on the legs printout of the flight release; in error; by myself; without my first officer reviewing it with me; as I always try to do. I think we missed that it was programmed wrong on the before start checklist partially because the departures share the same first three fixes. In line for takeoff with the parking brake on I ate my meal as we waited for three other aircraft to pass in front of us. I had the wrong departure out and the first officer had the correct one; but we didn't notice. Right after takeoff we received a caution cas message; and that QRH and the after takeoff flow consumed my time that I could have utilized to notice that we were flying the wrong departure. The first officer continued to hand fly the aircraft. After completing the QRH and after takeoff checklist; we were at 10;000. Departure gave us a 160 degree heading and advised traffic at 2 o'clock; 6 miles; and our altitude. He then gave us a 140 heading. We both saw the target on TCAS 100 feet below us and at about 5 miles distance at about our 3 o'clock position; but we never had it in sight and we didn't receive a TCAS TA or RA. We were then given a direct routing; a climb to 12000; and later gave us a phone number to call. The manager confirmed my certificate number and stated they would be filing paperwork for the deviation; and that we had 'just gotten inside of 3 miles separation with the other aircraft'.obviously; this occurrence comes down to the fact that I and my first officer didn't confirm that the given clearance was programmed in the FMS; and as pilot in command that is ultimately my responsibility and my fault. However; in addition to changes I can make; I'd like to make other suggestions as well. Normally I check with my first officer as to what the clearance is; and confirm the correct routing in the flight plan pages and the legs pages is programmed; before executing the flight plan. Even when distracted and rushed; I should always determine what our clearance from ATC is; before executing the flight plan programmed in the FMS. Do not execute the FMS flight plan until both crew members have verified that it is the same as the ATC clearance. Because of the distractions previously mentioned and in the rush to get an on time departure; we didn't have the time to verify that everything looked good regarding our route and clearance. In the future I will take this time; even if it means a late departure. The distractions took our focus away from determining what the clearance was in the first place. I ask first officer's in the initial crew briefing to tell me if our clearance is different than as filed; but the distractions took our attention away from communicating that. Maybe a change in the before start checklist would be good; to require in the response portion to FMS/ACARS or departure briefing to state the departure SID and transition. This trip I'm on is certainly fatiguing; and when flying five and six legs a day for three days straight with these show times; it all becomes a blur. Aircraft swaps increase the tendency for errors and rushing; and increase fatigue as well. We have always had early shows; but I do not remember having to fly six short legs in eleven hours of duty after an early show in the past. This sort of pairing is unacceptable and unsafe in my opinion. I was tempted to call in fatigued on day two of this trip and I have never done that before. Finally; I don't want to point fingers at dispatch; our dispatcher only filed what the standard flight plan is on file; I assume. But it's clear that if we had been filed the routing which ATC prefers; we would not be in trouble. This has occurred before; I believe; on another flight of mine; and we noticed the change. Dispatch should have regular correspondence with ATC regarding preferred routings for our flights; if this is not done already. Finally; pilots should be more aware of departure sids in our system which shares the first few fixes; like many of the RNAV sids do. I'm humbled and a little shaken that this transpired under my watch; and will continue to be as professional and vigilant as I can possibly be.fighting complacency is elusive at times; because 'in the heat of battle' one has to realize (1) you are complacent; and (2) take the extra time to slow down and determine what's wrong. That is difficult to do when tired and fatigued; and trying to make on time departures.
Original NASA ASRS Text
Title: CRJ200 flight crew enters the filed RNAV departure in the FMS instead of the cleared departure and has a track deviation and loss of separation. Fatigue and work load are cited as factors along with several items of company poloicy.
Narrative: After three consecutive days of very early shows; we were preparing for our 15th flight on the third aircraft of the day. After doing a maintenance write up for the last aircraft flown; I had 30 minutes to grab some food for lunch and to prepare and board our flight. I arrived at the aircraft at about 20 minutes before departure time. My First Officer; Flight Attendant; and I quickly prepared the flight and boarded a full aircraft. There were multiple distractions which my First Officer and I fought to overcome. We checked a transformer rectifier unit MEL (24-31-01) which I thought was done incorrectly; because a stray but related circuit breaker was popped and not collared. I checked the MEL book and determined that the circuit breaker should be closed. Not wanting to delay the flight to deal with Maintenance on this issue; I decided to close the breaker and proceed with the item MEL'd as it already was. My First Officer had a difficult time getting the ACARS to receive and transmit Takeoff data. We received a message from Dispatch saying that the aero data portion of ACARS was inoperative currently. In the remaining time I tried to have a few bites of food; as it was lunchtime for us and we originally had a 1:19 break scheduled; and I try to stay nourished in the interest of safety. We performed all the required checklists and got the plane out on time; but we both missed the fact that I had programmed the FMS with the filed flight plan routing; NOT what the clearance which we were given by ATC. I did verify that the FMS waypoints were the same as on the legs printout of the flight release; in error; by myself; without my First Officer reviewing it with me; as I always try to do. I think we missed that it was programmed wrong on the Before Start checklist partially because the departures share the same first three fixes. In line for takeoff with the parking brake on I ate my meal as we waited for three other aircraft to pass in front of us. I had the wrong departure out and the First Officer had the correct one; but we didn't notice. Right after takeoff we received a caution CAS message; and that QRH and the after takeoff flow consumed my time that I could have utilized to notice that we were flying the wrong departure. The First Officer continued to hand fly the aircraft. After completing the QRH and After Takeoff checklist; we were at 10;000. Departure gave us a 160 degree heading and advised traffic at 2 o'clock; 6 miles; and our altitude. He then gave us a 140 heading. We both saw the target on TCAS 100 feet below us and at about 5 miles distance at about our 3 o'clock position; but we never had it in sight and we didn't receive a TCAS TA or RA. We were then given a direct routing; a climb to 12000; and later gave us a phone number to call. The Manager confirmed my certificate number and stated they would be filing paperwork for the deviation; and that we had 'just gotten inside of 3 miles separation with the other aircraft'.Obviously; this occurrence comes down to the fact that I and my First Officer didn't confirm that the given clearance was programmed in the FMS; and as pilot in command that is ultimately my responsibility and my fault. However; in addition to changes I can make; I'd like to make other suggestions as well. Normally I check with my First Officer as to what the clearance is; and confirm the correct routing in the flight plan pages and the legs pages is programmed; before executing the flight plan. Even when distracted and rushed; I should always determine what our clearance from ATC is; before executing the flight plan programmed in the FMS. Do not execute the FMS flight plan until both crew members have verified that it is the same as the ATC clearance. Because of the distractions previously mentioned and in the rush to get an on time departure; we didn't have the time to verify that everything looked good regarding our route and clearance. In the future I will take this time; even if it means a late departure. The distractions took our focus away from determining what the clearance was in the first place. I ask First Officer's in the initial crew briefing to tell me if our clearance is different than as filed; but the distractions took our attention away from communicating that. Maybe a change in the Before Start checklist would be good; to require in the response portion to FMS/ACARS or Departure Briefing to state the departure SID and transition. This trip I'm on is certainly fatiguing; and when flying five and six legs a day for three days straight with these show times; it all becomes a blur. Aircraft swaps increase the tendency for errors and rushing; and increase fatigue as well. We have always had early shows; but I do not remember having to fly six short legs in eleven hours of duty after an early show in the past. This sort of pairing is unacceptable and unsafe in my opinion. I was tempted to call in fatigued on day two of this trip and I have never done that before. Finally; I don't want to point fingers at Dispatch; our Dispatcher only filed what the standard flight plan is on file; I assume. But it's clear that if we had been filed the routing which ATC prefers; we would not be in trouble. This has occurred before; I believe; on another flight of mine; and we noticed the change. Dispatch should have regular correspondence with ATC regarding preferred routings for our flights; if this is not done already. Finally; Pilots should be more aware of Departure SIDS in our system which shares the first few fixes; like many of the RNAV SIDS do. I'm humbled and a little shaken that this transpired under my watch; and will continue to be as professional and vigilant as I can possibly be.Fighting complacency is elusive at times; because 'in the heat of battle' one has to realize (1) you are complacent; and (2) take the extra time to slow down and determine what's wrong. That is difficult to do when tired and fatigued; and trying to make on time departures.
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.