Narrative:

On the second leg of a european to united states trip (loww - bikf - cyqx - kyip), from bikf to cyqx. A gross navigation error occurred as follows: the flight plan was stored in the primary omega and the GPS as filed by the captain. The flight plan was issued 'as filed' and the flight began. Before takeoff the first officer verified the primary omega and GPS, along with calibrating and programming the secondary omega for the flight plan. During climb to altitude to the 'coast out' point, a reissuance of the flight plan was issued by ATC. The final 2 points on the track were changed, along with an additional point added to the flight plan. The first officer wrote down and verified this change in the flight plan. The new issuance included the 'coast in' point of loach, which is depicted on the north atlantic orientation chart. The longitude and latitude for loach were then copied down on the original flight plan by the first officer, including a mistake of 53 degrees north instead of 55 degree north. The incorrect coordinates were then entered into the navigation system by the first officer for loach along with the correct information for the other changes in the flight plan. The changes were not then verified by either pilot. The flight did proceed as planned. On the last leg inbound to canada, ATC notified the crew of a discrepancy between ATC and the flight of 10 mins to loach. The crew confirmed the waypoint in all 3 navigation system as identical, and against the erroneous information written on the flight plan by the first officer and captain. Here a procedural mistake was made in not confirming the latitude and longitude of loach against the orientation chart by the crew. ATC then questioned the crew with estimates to destination, cyqx, which while would provide information to ATC, distracted the crew from locating the error. The flight then lost communications with gander oceanic control and had to get a new frequency from a candair flight, which cost valuable time in the location of the error. The first officer then plotted the position of the aircraft and the location was slightly north of the predicted track, which falsely satisfied the crew that the discrepancy was not legitimate. The first officer again made a mistake here, the latitude and longitude were plotted inversely, and in the location of approximately 53 degree north and 52 degree west when plotted inversely put the flight on the intended course. This error was the last chance for the crew to catch the original error of entering the location of loach incorrectly. The flight came into radar contact approximately 80 mi southwest of course, and the gross navigation error was filed against the flight. In retrospect, the crew failed to follow procedures in the instance of the reissuance of the flight plan by not checking each other on the information gathered on the location of loach and entering the information into the navigation computers. The crew missed the opportunity to correct the error when the position of loach was reviewed by both crew members by not comparing the coordinates to the orientation chart. The crew further neglected to investigate further by being distracted by ATC's request for estimates to cyqx and the loss of communications on the assigned frequency. The proper xchk of navigation points, more timely plotting of the current position the aircraft against the intended flight path, and reference to source materials such as the orientation chart would have prevented this navigational error, or minimized its effect. As described in the add- on, the controller verified our estimates for loach intersection, which were off by 10 mins from their estimates. Although full responsibility lies with the PIC of the aircraft, I feel that the controller should have a bigger input for safety's sake. This controller dismissed a 10 min discrepancy in estimates, between ATC and aircraft. If the crew is unable to identify the problem, ATC should try to assist in solving such a possible fatal mistake as described above.

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Original NASA ASRS Text

Title: GROSS NAV ERROR.

Narrative: ON THE SECOND LEG OF A EUROPEAN TO UNITED STATES TRIP (LOWW - BIKF - CYQX - KYIP), FROM BIKF TO CYQX. A GROSS NAV ERROR OCCURRED AS FOLLOWS: THE FLT PLAN WAS STORED IN THE PRIMARY OMEGA AND THE GPS AS FILED BY THE CAPT. THE FLT PLAN WAS ISSUED 'AS FILED' AND THE FLT BEGAN. BEFORE TKOF THE FO VERIFIED THE PRIMARY OMEGA AND GPS, ALONG WITH CALIBRATING AND PROGRAMMING THE SECONDARY OMEGA FOR THE FLT PLAN. DURING CLB TO ALT TO THE 'COAST OUT' POINT, A REISSUANCE OF THE FLT PLAN WAS ISSUED BY ATC. THE FINAL 2 POINTS ON THE TRACK WERE CHANGED, ALONG WITH AN ADDITIONAL POINT ADDED TO THE FLT PLAN. THE FO WROTE DOWN AND VERIFIED THIS CHANGE IN THE FLT PLAN. THE NEW ISSUANCE INCLUDED THE 'COAST IN' POINT OF LOACH, WHICH IS DEPICTED ON THE NORTH ATLANTIC ORIENTATION CHART. THE LONGITUDE AND LATITUDE FOR LOACH WERE THEN COPIED DOWN ON THE ORIGINAL FLT PLAN BY THE FO, INCLUDING A MISTAKE OF 53 DEGS N INSTEAD OF 55 DEG N. THE INCORRECT COORDINATES WERE THEN ENTERED INTO THE NAV SYS BY THE FO FOR LOACH ALONG WITH THE CORRECT INFO FOR THE OTHER CHANGES IN THE FLT PLAN. THE CHANGES WERE NOT THEN VERIFIED BY EITHER PLT. THE FLT DID PROCEED AS PLANNED. ON THE LAST LEG INBOUND TO CANADA, ATC NOTIFIED THE CREW OF A DISCREPANCY BTWN ATC AND THE FLT OF 10 MINS TO LOACH. THE CREW CONFIRMED THE WAYPOINT IN ALL 3 NAV SYS AS IDENTICAL, AND AGAINST THE ERRONEOUS INFO WRITTEN ON THE FLT PLAN BY THE FO AND CAPT. HERE A PROCEDURAL MISTAKE WAS MADE IN NOT CONFIRMING THE LATITUDE AND LONGITUDE OF LOACH AGAINST THE ORIENTATION CHART BY THE CREW. ATC THEN QUESTIONED THE CREW WITH ESTIMATES TO DEST, CYQX, WHICH WHILE WOULD PROVIDE INFO TO ATC, DISTRACTED THE CREW FROM LOCATING THE ERROR. THE FLT THEN LOST COMS WITH GANDER OCEANIC CTL AND HAD TO GET A NEW FREQ FROM A CANDAIR FLT, WHICH COST VALUABLE TIME IN THE LOCATION OF THE ERROR. THE FO THEN PLOTTED THE POS OF THE ACFT AND THE LOCATION WAS SLIGHTLY N OF THE PREDICTED TRACK, WHICH FALSELY SATISFIED THE CREW THAT THE DISCREPANCY WAS NOT LEGITIMATE. THE FO AGAIN MADE A MISTAKE HERE, THE LATITUDE AND LONGITUDE WERE PLOTTED INVERSELY, AND IN THE LOCATION OF APPROX 53 DEG N AND 52 DEG W WHEN PLOTTED INVERSELY PUT THE FLT ON THE INTENDED COURSE. THIS ERROR WAS THE LAST CHANCE FOR THE CREW TO CATCH THE ORIGINAL ERROR OF ENTERING THE LOCATION OF LOACH INCORRECTLY. THE FLT CAME INTO RADAR CONTACT APPROX 80 MI SW OF COURSE, AND THE GROSS NAV ERROR WAS FILED AGAINST THE FLT. IN RETROSPECT, THE CREW FAILED TO FOLLOW PROCS IN THE INSTANCE OF THE REISSUANCE OF THE FLT PLAN BY NOT CHKING EACH OTHER ON THE INFO GATHERED ON THE LOCATION OF LOACH AND ENTERING THE INFO INTO THE NAV COMPUTERS. THE CREW MISSED THE OPPORTUNITY TO CORRECT THE ERROR WHEN THE POS OF LOACH WAS REVIEWED BY BOTH CREW MEMBERS BY NOT COMPARING THE COORDINATES TO THE ORIENTATION CHART. THE CREW FURTHER NEGLECTED TO INVESTIGATE FURTHER BY BEING DISTRACTED BY ATC'S REQUEST FOR ESTIMATES TO CYQX AND THE LOSS OF COMS ON THE ASSIGNED FREQ. THE PROPER XCHK OF NAV POINTS, MORE TIMELY PLOTTING OF THE CURRENT POS THE ACFT AGAINST THE INTENDED FLT PATH, AND REF TO SOURCE MATERIALS SUCH AS THE ORIENTATION CHART WOULD HAVE PREVENTED THIS NAVIGATIONAL ERROR, OR MINIMIZED ITS EFFECT. AS DESCRIBED IN THE ADD- ON, THE CTLR VERIFIED OUR ESTIMATES FOR LOACH INTXN, WHICH WERE OFF BY 10 MINS FROM THEIR ESTIMATES. ALTHOUGH FULL RESPONSIBILITY LIES WITH THE PIC OF THE ACFT, I FEEL THAT THE CTLR SHOULD HAVE A BIGGER INPUT FOR SAFETY'S SAKE. THIS CTLR DISMISSED A 10 MIN DISCREPANCY IN ESTIMATES, BTWN ATC AND ACFT. IF THE CREW IS UNABLE TO IDENT THE PROB, ATC SHOULD TRY TO ASSIST IN SOLVING SUCH A POSSIBLE FATAL MISTAKE AS DESCRIBED ABOVE.

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.