Narrative:

Scheduled itinerary: kabe-kiad-cyqx-loww. Actual itinerary: kabe-kiad-cyyt-loww. At AM03Z, oct/sat/91, the pilot made a position report of 50000n015000w to shannon radar and was notified that the aircraft's actual position was 51000n015000w (1 degree north of track). The aircrew immediately started checking the onboard navigation system (dual INS, VLF omega). All system were found to be functioning properly at the time. Further investigation disclosed the position 50n015w had been installed as 51n015w into both inertial navigation system. Contributing factors: approximately 45 mins out of cyqx (gander nfld) the aircrew discovered landing WX was below mins and elected to divert to cyyt (st johns nfld). Due to other diversions, the aircraft had to hold at the OM prior to commencing approach into deteriorating WX conditions. During approach, aircraft encountered light to moderate turbulence and wind shear. The aircrew then had to coordinate handling (fuel, customs, etc), routing clearance and passenger comfort. The stressful environment, long day, task saturation, sense of urgency to expedite departure requirements and programming total rerte into the inertial navigation system led to the route navigation error. Both pilots normally coordinate waypoint installation into the inertial navigation system. Due to the multiple interruptions in normal cockpit sequences on the ground, crew coordination deteriorated allowing the navigation input error to go unnoticed. Corrective actions: a) reemphasize the necessity for crew coordination and standardized procedures for aircraft operation from preflight, ground operations, all phases of flight and post-flight duties. B) both pilots should check inertial navigation programming inputs on the ground and again following oceanic clearance reception. C) pilots should plot routing clearance on an oceanic planning chart (opc 1) or its equivalent and plot the inertial and VLF-omega position at each waypoint to ensure aircraft remains within the mnps navigation performance parameters. D) pilots should receive annual training in the operation of united states registered civil aircraft outside of the united states (specifically north atlantic mnps airspace).

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Original NASA ASRS Text

Title: CPR MLG FLC EXPERIENCES A GROSS NAV ERROR IN OCEANIC AIRSPACE DURING EXTENDED OVERWATER OP.

Narrative: SCHEDULED ITINERARY: KABE-KIAD-CYQX-LOWW. ACTUAL ITINERARY: KABE-KIAD-CYYT-LOWW. AT AM03Z, OCT/SAT/91, THE PLT MADE A POS RPT OF 50000N015000W TO SHANNON RADAR AND WAS NOTIFIED THAT THE ACFT'S ACTUAL POS WAS 51000N015000W (1 DEG N OF TRACK). THE AIRCREW IMMEDIATELY STARTED CHKING THE ONBOARD NAV SYS (DUAL INS, VLF OMEGA). ALL SYS WERE FOUND TO BE FUNCTIONING PROPERLY AT THE TIME. FURTHER INVESTIGATION DISCLOSED THE POS 50N015W HAD BEEN INSTALLED AS 51N015W INTO BOTH INERTIAL NAV SYS. CONTRIBUTING FACTORS: APPROX 45 MINS OUT OF CYQX (GANDER NFLD) THE AIRCREW DISCOVERED LNDG WX WAS BELOW MINS AND ELECTED TO DIVERT TO CYYT (ST JOHNS NFLD). DUE TO OTHER DIVERSIONS, THE ACFT HAD TO HOLD AT THE OM PRIOR TO COMMENCING APCH INTO DETERIORATING WX CONDITIONS. DURING APCH, ACFT ENCOUNTERED LIGHT TO MODERATE TURB AND WIND SHEAR. THE AIRCREW THEN HAD TO COORDINATE HANDLING (FUEL, CUSTOMS, ETC), RTING CLRNC AND PAX COMFORT. THE STRESSFUL ENVIRONMENT, LONG DAY, TASK SATURATION, SENSE OF URGENCY TO EXPEDITE DEP REQUIREMENTS AND PROGRAMMING TOTAL RERTE INTO THE INERTIAL NAV SYS LED TO THE RTE NAV ERROR. BOTH PLTS NORMALLY COORDINATE WAYPOINT INSTALLATION INTO THE INERTIAL NAV SYS. DUE TO THE MULTIPLE INTERRUPTIONS IN NORMAL COCKPIT SEQUENCES ON THE GND, CREW COORD DETERIORATED ALLOWING THE NAV INPUT ERROR TO GO UNNOTICED. CORRECTIVE ACTIONS: A) REEMPHASIZE THE NECESSITY FOR CREW COORD AND STANDARDIZED PROCS FOR ACFT OP FROM PREFLT, GND OPS, ALL PHASES OF FLT AND POST-FLT DUTIES. B) BOTH PLTS SHOULD CHK INERTIAL NAV PROGRAMMING INPUTS ON THE GND AND AGAIN FOLLOWING OCEANIC CLRNC RECEPTION. C) PLTS SHOULD PLOT RTING CLRNC ON AN OCEANIC PLANNING CHART (OPC 1) OR ITS EQUIVALENT AND PLOT THE INERTIAL AND VLF-OMEGA POS AT EACH WAYPOINT TO ENSURE ACFT REMAINS WITHIN THE MNPS NAV PERFORMANCE PARAMETERS. D) PLTS SHOULD RECEIVE ANNUAL TRAINING IN THE OP OF UNITED STATES REGISTERED CIVIL ACFT OUTSIDE OF THE UNITED STATES (SPECIFICALLY N ATLANTIC MNPS AIRSPACE).

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.