37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 95487 |
Time | |
Date | 198810 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : dan |
State Reference | FO |
Altitude | msl bound lower : 39000 msl bound upper : 39000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : vtbb |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute airway : a1 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 175 flight time total : 13209 flight time type : 2140 |
ASRS Report | 95487 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time total : 7600 flight time type : 2400 |
ASRS Report | 95566 |
Events | |
Anomaly | inflight encounter : weather non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
FL390, A1 arwy, wbound. Just prior to cavoi-X a series of isolated circuit breaker's appeared on radar requiring diversion south of course. It appeared at first that we could avoid circuit breaker's and stay within the confines of the arwy. The autoplt was placed in heading mode during the series of diversions. Communication was difficult due to multiple agencies, multiple frequencys, language, poor ground equipment in that area, and an inoperative T/right on the aircraft, etc. Dan VOR was notamed unreliable. Required position reports were made. We crossed cavoi-X on course, still in head mode of autoplt, but still diverting for WX. Due to human factors and cockpit environment heading mode was forgotten, with a correction to course, for a short time, causing a diversion north of course. At dan by approximately 24 mi, at approximately abeam dan, mistakes noticed and immediate turn to regain course to papra-X. 'Abeam dan, diverting' reported to bkk radio. Non radar environment. Human factors contributing were primarily associated with the body wishing to be asleep while forced to be awake and the accompanying fatigue. Under these body conditions, the critical short duration stages of flight such as the approach and landing, or emergencys, can be successfully accomplished due to 'getting up' with adrenaline for the short duration event. Unfortunately the mundane, ordinary flight duties tend to be unintentionally handled with lesser intensity, accuracy and precision, leaving one susceptible to the above type of situations. Conscious effort to avoid such incidents and these conditions work successfully most times. We were failed and can only increase our efforts at precision in the future. This pilot will use heading mode very judiciously in the future and will make en route diversions using the turn knob of the autoplt as SOP.
Original NASA ASRS Text
Title: ACR WDB DEVIATION FROM CLRNC ROUTE FOLLOWING WX AVOIDANCE.
Narrative: FL390, A1 ARWY, WBOUND. JUST PRIOR TO CAVOI-X A SERIES OF ISOLATED CB'S APPEARED ON RADAR REQUIRING DIVERSION S OF COURSE. IT APPEARED AT FIRST THAT WE COULD AVOID CB'S AND STAY WITHIN THE CONFINES OF THE ARWY. THE AUTOPLT WAS PLACED IN HDG MODE DURING THE SERIES OF DIVERSIONS. COM WAS DIFFICULT DUE TO MULTIPLE AGENCIES, MULTIPLE FREQS, LANGUAGE, POOR GND EQUIP IN THAT AREA, AND AN INOP T/R ON THE ACFT, ETC. DAN VOR WAS NOTAMED UNRELIABLE. REQUIRED POS RPTS WERE MADE. WE CROSSED CAVOI-X ON COURSE, STILL IN HEAD MODE OF AUTOPLT, BUT STILL DIVERTING FOR WX. DUE TO HUMAN FACTORS AND COCKPIT ENVIRONMENT HDG MODE WAS FORGOTTEN, WITH A CORRECTION TO COURSE, FOR A SHORT TIME, CAUSING A DIVERSION N OF COURSE. AT DAN BY APPROX 24 MI, AT APPROX ABEAM DAN, MISTAKES NOTICED AND IMMEDIATE TURN TO REGAIN COURSE TO PAPRA-X. 'ABEAM DAN, DIVERTING' RPTED TO BKK RADIO. NON RADAR ENVIRONMENT. HUMAN FACTORS CONTRIBUTING WERE PRIMARILY ASSOCIATED WITH THE BODY WISHING TO BE ASLEEP WHILE FORCED TO BE AWAKE AND THE ACCOMPANYING FATIGUE. UNDER THESE BODY CONDITIONS, THE CRITICAL SHORT DURATION STAGES OF FLT SUCH AS THE APCH AND LNDG, OR EMERS, CAN BE SUCCESSFULLY ACCOMPLISHED DUE TO 'GETTING UP' WITH ADRENALINE FOR THE SHORT DURATION EVENT. UNFORTUNATELY THE MUNDANE, ORDINARY FLT DUTIES TEND TO BE UNINTENTIONALLY HANDLED WITH LESSER INTENSITY, ACCURACY AND PRECISION, LEAVING ONE SUSCEPTIBLE TO THE ABOVE TYPE OF SITUATIONS. CONSCIOUS EFFORT TO AVOID SUCH INCIDENTS AND THESE CONDITIONS WORK SUCCESSFULLY MOST TIMES. WE WERE FAILED AND CAN ONLY INCREASE OUR EFFORTS AT PRECISION IN THE FUTURE. THIS PLT WILL USE HDG MODE VERY JUDICIOUSLY IN THE FUTURE AND WILL MAKE ENRTE DIVERSIONS USING THE TURN KNOB OF THE AUTOPLT AS SOP.
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.