Air carrier large transport misunderstands ATC communication, departs hold at cedes intersection on ...

Attributes
ACN	138265
Time
Date	199003
Day	Sun
Local Time Of Day	1201 To 1800
Place
Locale Reference	atc facility : mod airport : sfo
State Reference	CA
Altitude	msl bound lower : 17000 msl bound upper : 17000
Environment
Flight Conditions	IMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : oak
Operator	common carrier : air carrier
Make Model Name	Large Transport
Flight Phase	other
Route In Use	arrival star : star
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 100 flight time total : 15000 flight time type : 100
ASRS Report	138265
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : instrument pilot : commercial
Events
Anomaly	other anomaly other 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:

Destination sfo, cleared for modesto 2 arrival to hold at cedes intersection, published pattern, but 15 NM legs. Entered holding and were inbound to cedes when center said (approximately) 'depart cedes on heading, we will work you in for an approach.' the 3 crew members understood this to mean to depart cedes on the heading (approximately 245 degrees) that we overheaded cedes. We did so, and after approximately 1 min of silence from center advised that we had done so. They advised us to turn to heading of approximately 065 degrees, or outbnd heading of holding pattern. What we assumed afterward was that they meant for us to stay in the holding pattern and that they intended to turn us in either before or after the completion of the 15 NM leg. I feel that this was a breakdown in proper communication procedure by center. We were already in the holding pattern and no further instructions were necessary until after we had turned outbnd.

Original NASA ASRS Text

Title: ACR LGT MISUNDERSTANDS ATC COM, DEPARTS HOLD AT CEDES INTERSECTION ON RANDOM HEADING.

Narrative: DEST SFO, CLRED FOR MODESTO 2 ARR TO HOLD AT CEDES INTXN, PUBLISHED PATTERN, BUT 15 NM LEGS. ENTERED HOLDING AND WERE INBND TO CEDES WHEN CENTER SAID (APPROX) 'DEPART CEDES ON HDG, WE WILL WORK YOU IN FOR AN APCH.' THE 3 CREW MEMBERS UNDERSTOOD THIS TO MEAN TO DEPART CEDES ON THE HDG (APPROX 245 DEGS) THAT WE OVERHEADED CEDES. WE DID SO, AND AFTER APPROX 1 MIN OF SILENCE FROM CENTER ADVISED THAT WE HAD DONE SO. THEY ADVISED US TO TURN TO HDG OF APPROX 065 DEGS, OR OUTBND HDG OF HOLDING PATTERN. WHAT WE ASSUMED AFTERWARD WAS THAT THEY MEANT FOR US TO STAY IN THE HOLDING PATTERN AND THAT THEY INTENDED TO TURN US IN EITHER BEFORE OR AFTER THE COMPLETION OF THE 15 NM LEG. I FEEL THAT THIS WAS A BREAKDOWN IN PROPER COM PROC BY CENTER. WE WERE ALREADY IN THE HOLDING PATTERN AND NO FURTHER INSTRUCTIONS WERE NECESSARY UNTIL AFTER WE HAD TURNED OUTBND.

Data retrieved from NASA's ASRS site as of July 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.

Air carrier large transport misunderstands ATC communication, departs hold at cedes intersection on random heading.