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|
Attributes | |
ACN | 93170 |
Time | |
Date | 198808 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sli airport : lax |
State Reference | CA |
Altitude | msl bound lower : 9500 msl bound upper : 9500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 225 flight time total : 14000 flight time type : 110 |
ASRS Report | 93170 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 8500 flight time type : 40 |
ASRS Report | 93264 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
FMC entered flight plan into CDU initially as runway 25R departure, then direct trm. HSI legs stepped through and verified. Clearance received as flipper 2 thermal transition (first mistake--HSI legs not stepped through to verify flipper 2 departure entered into FMC by crew). Departure normal given climb to 10000' speed 250 KTS, then about 8500' given heading 160 degrees to intercept and proceed via flipper 2. This type of clearance by departure control leaves crew unsure as to which radial will be intercepted first, the ventura 114 degree right or the sli 040 degree right. Since the flipper 2 was not entered into the CDU, it was not pictorially displayed. Therefore the crew had the task of determining which radial would be intercepted. (Second mistake: ventura VOR manually tuned for the 114 degree right on ca VOR. Ca glanced at SID and incorrectly tuned first officer VOR to sli 080 degree right thereby displaying the radials for the wrong transition.) at this time crew given frequency change to another controller taking one crew member out of navigation activity for a time. Then controller noted aircraft headed for sli on 220 degree right and prior to reaching coastline gave crew 140 degree heading to resume SID. Corrections or precautions to be taken to prevent this type of situation are as follows: 1) the initial entry of the flight plan into the FMC should leave a departure discontinuity rather than an incorrect clearance such as direct to a VOR when a SID will most certainly be given. 2) crew should wait until the final clearance received from ATC before stepping through the legs on the HSI to verify the correct pictorial display. 3) when a departure controller gives a clearance such as a heading to intercept a SID, the clearance should be 'turn to a heading and intercept the appropriate radial and resume the SID.' this takes all the mystery out of where the aircraft is and which radial departure control is expecting the aircraft to intercept.
Original NASA ASRS Text
Title: ADV LGT FAILS TO INTERCEPT SID.
Narrative: FMC ENTERED FLT PLAN INTO CDU INITIALLY AS RWY 25R DEP, THEN DIRECT TRM. HSI LEGS STEPPED THROUGH AND VERIFIED. CLRNC RECEIVED AS FLIPPER 2 THERMAL TRANSITION (FIRST MISTAKE--HSI LEGS NOT STEPPED THROUGH TO VERIFY FLIPPER 2 DEP ENTERED INTO FMC BY CREW). DEP NORMAL GIVEN CLB TO 10000' SPD 250 KTS, THEN ABOUT 8500' GIVEN HDG 160 DEGS TO INTERCEPT AND PROCEED VIA FLIPPER 2. THIS TYPE OF CLRNC BY DEP CTL LEAVES CREW UNSURE AS TO WHICH RADIAL WILL BE INTERCEPTED FIRST, THE VENTURA 114 DEG R OR THE SLI 040 DEG R. SINCE THE FLIPPER 2 WAS NOT ENTERED INTO THE CDU, IT WAS NOT PICTORIALLY DISPLAYED. THEREFORE THE CREW HAD THE TASK OF DETERMINING WHICH RADIAL WOULD BE INTERCEPTED. (SECOND MISTAKE: VENTURA VOR MANUALLY TUNED FOR THE 114 DEG R ON CA VOR. CA GLANCED AT SID AND INCORRECTLY TUNED F/O VOR TO SLI 080 DEG R THEREBY DISPLAYING THE RADIALS FOR THE WRONG TRANSITION.) AT THIS TIME CREW GIVEN FREQ CHANGE TO ANOTHER CTLR TAKING ONE CREW MEMBER OUT OF NAV ACTIVITY FOR A TIME. THEN CTLR NOTED ACFT HEADED FOR SLI ON 220 DEG R AND PRIOR TO REACHING COASTLINE GAVE CREW 140 DEG HDG TO RESUME SID. CORRECTIONS OR PRECAUTIONS TO BE TAKEN TO PREVENT THIS TYPE OF SITUATION ARE AS FOLLOWS: 1) THE INITIAL ENTRY OF THE FLT PLAN INTO THE FMC SHOULD LEAVE A DEP DISCONTINUITY RATHER THAN AN INCORRECT CLRNC SUCH AS DIRECT TO A VOR WHEN A SID WILL MOST CERTAINLY BE GIVEN. 2) CREW SHOULD WAIT UNTIL THE FINAL CLRNC RECEIVED FROM ATC BEFORE STEPPING THROUGH THE LEGS ON THE HSI TO VERIFY THE CORRECT PICTORIAL DISPLAY. 3) WHEN A DEP CTLR GIVES A CLRNC SUCH AS A HDG TO INTERCEPT A SID, THE CLRNC SHOULD BE 'TURN TO A HDG AND INTERCEPT THE APPROPRIATE RADIAL AND RESUME THE SID.' THIS TAKES ALL THE MYSTERY OUT OF WHERE THE ACFT IS AND WHICH RADIAL DEP CTL IS EXPECTING THE ACFT TO INTERCEPT.
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.