Narrative:

We are flying an airbus A320. It is my (captain's) leg and I have elected to fly this leg in 'raw data.' our clearance to ord includes the whitestone climb for the runway 13 departure. The LNAV is correctly loaded and verified and available to the first officer. I have the initial turn heading set (175 degrees), the lga 220 degree crossing radial tuned (to be at or above 4500 ft). (This is part of the problem -- read on.) the whitestone climb profile is as follows: turn right, climb on 175 degree heading to lga 2.5 DME, turn left to a 040 degree heading, maintain 5000 ft.' the maspeth climb procedure is climb on heading 175 degrees to 3000 ft, then right to 340 degree heading, cross lga R-220 degree at or above 4500 ft, maintain 5000 ft. Our deviation was to load the correct whitestone climb in the 'box,' but set up and fly 'raw data' the maspeth climb. How did this happen! As always, a chain of events, mostly crew clerical error and contributed to by the chart format. The first link was my choice to fly raw data (to maintain basic airmanship skills) thus depriving me of the map display. Second link, due to similarity and proximity of maspeth and whitestone climbs on lga 10-3 page mixed up the briefing of maspeth and whitestone so that I actually briefed and set up maspeth on raw data and in my mind. Link 3, first officer listened to but 'did not hear' my briefing of maspeth parameters versus whitestone. Fourth link, delay in contacting departure. Fifth link, my firm mindedness that I was right. Sixth link, direction of flight and proximity of jfk field. Execution: during takeoff hold, again checked crossing radial and altitude further cementing wrong procedure in my mind. Verbalized same to first officer but again failed to trigger his awareness. After takeoff turned to 175 degrees. For some reason contact was not established with departure. 3000 ft occurs at about 2.5 mi DME (similar turn points). At that point I turned right going to heading 340 degrees. As turn is established, first officer says I should turn left (he is of course looking at the map). A rapid discussion of which departure we are on occurs during which the turn continues. At 60-90 degrees into the turn I accept my error. I also realize that we are not talking to departure. I exhort my first officer off to contact departure and continue turn to heading and altitude. At this point my concern is that a turn reversal would put me in jfk's airspace, thus complicating our error. Upon establishing contact with departure we were cleared to 7000 ft. No other instructions. A short time later we were given a frequency change, along with the frequency. A comment was made that 'you turned the wrong way on the departure.' we acknowledged and proceeded. Conclusions: the decision to fly raw data allowed this incident to occur by depriving me of my map. However, the practice of raw data flying is, I believe, vital to maintaining basic airmanship skills and scans. The proximity and similarity of these 2 procedures facilitates confusing them. It is vital that when briefing procedures we 'hear, see and think' about what is being said. Had there not been the delay in our establishing contact with departure they would have undoubtedly noted the error and given us appropriate action to follow. In this instance I had so completely prepared myself for the maspeth climb while believing I was preparing the whitestone climb, that I was reluctant to accept my first officer's statement that I was turning the wrong way. Solutions/recommendations: 1) follow SOP's and briefing requirements. An effort must be made to validate that all parties understand the briefing. 2) I would suggest that the format of lga 10-3 page be modified so that the takeoff briefing/description in lower right corner be set up with indentations, line separations, or some method of further separating the very similar climb profiles. This would preclude starting with one 'name' ie 'maspeth' and reading the text for another climb, ie, 'whitestone.' this incident occurred despite thorough briefing and preparations, including a final rechk just prior to departure. One must guard against committing a procedure to memory in error. The concentration to execute the procedure apparently resulted in a distraction from the required requirement to switch to departure. Therefore, emphasis, again, on division of duties and adherence to SOP's, is demonstrated, especially under adverse conditions. This was a very serious error! Our concern over traffic conflicts with inbound traffic to lga runway 4 if we continued and possible conflict in jfk's airspace if we reversed course was tremendous. It does humble one to realize after yrs and thousands of hours that I could make such a blunder.

Google
 

Original NASA ASRS Text

Title: CLRNC DEV. SID CONFUSION. INITIALLY FLEW THE WRONG SID.

Narrative: WE ARE FLYING AN AIRBUS A320. IT IS MY (CAPT'S) LEG AND I HAVE ELECTED TO FLY THIS LEG IN 'RAW DATA.' OUR CLRNC TO ORD INCLUDES THE WHITESTONE CLB FOR THE RWY 13 DEP. THE LNAV IS CORRECTLY LOADED AND VERIFIED AND AVAILABLE TO THE FO. I HAVE THE INITIAL TURN HDG SET (175 DEGS), THE LGA 220 DEG XING RADIAL TUNED (TO BE AT OR ABOVE 4500 FT). (THIS IS PART OF THE PROB -- READ ON.) THE WHITESTONE CLB PROFILE IS AS FOLLOWS: TURN R, CLB ON 175 DEG HDG TO LGA 2.5 DME, TURN L TO A 040 DEG HDG, MAINTAIN 5000 FT.' THE MASPETH CLB PROC IS CLB ON HDG 175 DEGS TO 3000 FT, THEN R TO 340 DEG HDG, CROSS LGA R-220 DEG AT OR ABOVE 4500 FT, MAINTAIN 5000 FT. OUR DEV WAS TO LOAD THE CORRECT WHITESTONE CLB IN THE 'BOX,' BUT SET UP AND FLY 'RAW DATA' THE MASPETH CLB. HOW DID THIS HAPPEN! AS ALWAYS, A CHAIN OF EVENTS, MOSTLY CREW CLERICAL ERROR AND CONTRIBUTED TO BY THE CHART FORMAT. THE FIRST LINK WAS MY CHOICE TO FLY RAW DATA (TO MAINTAIN BASIC AIRMANSHIP SKILLS) THUS DEPRIVING ME OF THE MAP DISPLAY. SECOND LINK, DUE TO SIMILARITY AND PROX OF MASPETH AND WHITESTONE CLBS ON LGA 10-3 PAGE MIXED UP THE BRIEFING OF MASPETH AND WHITESTONE SO THAT I ACTUALLY BRIEFED AND SET UP MASPETH ON RAW DATA AND IN MY MIND. LINK 3, FO LISTENED TO BUT 'DID NOT HEAR' MY BRIEFING OF MASPETH PARAMETERS VERSUS WHITESTONE. FOURTH LINK, DELAY IN CONTACTING DEP. FIFTH LINK, MY FIRM MINDEDNESS THAT I WAS RIGHT. SIXTH LINK, DIRECTION OF FLT AND PROX OF JFK FIELD. EXECUTION: DURING TKOF HOLD, AGAIN CHKED XING RADIAL AND ALT FURTHER CEMENTING WRONG PROC IN MY MIND. VERBALIZED SAME TO FO BUT AGAIN FAILED TO TRIGGER HIS AWARENESS. AFTER TKOF TURNED TO 175 DEGS. FOR SOME REASON CONTACT WAS NOT ESTABLISHED WITH DEP. 3000 FT OCCURS AT ABOUT 2.5 MI DME (SIMILAR TURN POINTS). AT THAT POINT I TURNED R GOING TO HDG 340 DEGS. AS TURN IS ESTABLISHED, FO SAYS I SHOULD TURN L (HE IS OF COURSE LOOKING AT THE MAP). A RAPID DISCUSSION OF WHICH DEP WE ARE ON OCCURS DURING WHICH THE TURN CONTINUES. AT 60-90 DEGS INTO THE TURN I ACCEPT MY ERROR. I ALSO REALIZE THAT WE ARE NOT TALKING TO DEP. I EXHORT MY FO OFF TO CONTACT DEP AND CONTINUE TURN TO HDG AND ALT. AT THIS POINT MY CONCERN IS THAT A TURN REVERSAL WOULD PUT ME IN JFK'S AIRSPACE, THUS COMPLICATING OUR ERROR. UPON ESTABLISHING CONTACT WITH DEP WE WERE CLRED TO 7000 FT. NO OTHER INSTRUCTIONS. A SHORT TIME LATER WE WERE GIVEN A FREQ CHANGE, ALONG WITH THE FREQ. A COMMENT WAS MADE THAT 'YOU TURNED THE WRONG WAY ON THE DEP.' WE ACKNOWLEDGED AND PROCEEDED. CONCLUSIONS: THE DECISION TO FLY RAW DATA ALLOWED THIS INCIDENT TO OCCUR BY DEPRIVING ME OF MY MAP. HOWEVER, THE PRACTICE OF RAW DATA FLYING IS, I BELIEVE, VITAL TO MAINTAINING BASIC AIRMANSHIP SKILLS AND SCANS. THE PROX AND SIMILARITY OF THESE 2 PROCS FACILITATES CONFUSING THEM. IT IS VITAL THAT WHEN BRIEFING PROCS WE 'HEAR, SEE AND THINK' ABOUT WHAT IS BEING SAID. HAD THERE NOT BEEN THE DELAY IN OUR ESTABLISHING CONTACT WITH DEP THEY WOULD HAVE UNDOUBTEDLY NOTED THE ERROR AND GIVEN US APPROPRIATE ACTION TO FOLLOW. IN THIS INSTANCE I HAD SO COMPLETELY PREPARED MYSELF FOR THE MASPETH CLB WHILE BELIEVING I WAS PREPARING THE WHITESTONE CLB, THAT I WAS RELUCTANT TO ACCEPT MY FO'S STATEMENT THAT I WAS TURNING THE WRONG WAY. SOLUTIONS/RECOMMENDATIONS: 1) FOLLOW SOP'S AND BRIEFING REQUIREMENTS. AN EFFORT MUST BE MADE TO VALIDATE THAT ALL PARTIES UNDERSTAND THE BRIEFING. 2) I WOULD SUGGEST THAT THE FORMAT OF LGA 10-3 PAGE BE MODIFIED SO THAT THE TKOF BRIEFING/DESCRIPTION IN LOWER R CORNER BE SET UP WITH INDENTATIONS, LINE SEPARATIONS, OR SOME METHOD OF FURTHER SEPARATING THE VERY SIMILAR CLB PROFILES. THIS WOULD PRECLUDE STARTING WITH ONE 'NAME' IE 'MASPETH' AND READING THE TEXT FOR ANOTHER CLB, IE, 'WHITESTONE.' THIS INCIDENT OCCURRED DESPITE THOROUGH BRIEFING AND PREPARATIONS, INCLUDING A FINAL RECHK JUST PRIOR TO DEP. ONE MUST GUARD AGAINST COMMITTING A PROC TO MEMORY IN ERROR. THE CONCENTRATION TO EXECUTE THE PROC APPARENTLY RESULTED IN A DISTR FROM THE REQUIRED REQUIREMENT TO SWITCH TO DEP. THEREFORE, EMPHASIS, AGAIN, ON DIVISION OF DUTIES AND ADHERENCE TO SOP'S, IS DEMONSTRATED, ESPECIALLY UNDER ADVERSE CONDITIONS. THIS WAS A VERY SERIOUS ERROR! OUR CONCERN OVER TFC CONFLICTS WITH INBOUND TFC TO LGA RWY 4 IF WE CONTINUED AND POSSIBLE CONFLICT IN JFK'S AIRSPACE IF WE REVERSED COURSE WAS TREMENDOUS. IT DOES HUMBLE ONE TO REALIZE AFTER YRS AND THOUSANDS OF HRS THAT I COULD MAKE SUCH A BLUNDER.

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.