DC10 makes gross navigation error over atlantic.

Attributes
ACN	351620
Time
Date	199610
Day	Fri
Local Time Of Day	1201 To 1800
Place
Locale Reference	atc facility : snn
State Reference	FO
Altitude	msl bound lower : 28000 msl bound upper : 28000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : eggx
Operator	common carrier : air carrier
Make Model Name	DC-10 Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Navigation In Use	Other
Flight Phase	cruise other
Route In Use	enroute : other oceanic enroute : atlantic enroute airway : eggx
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : instrument pilot : flight engineer pilot : commercial pilot : atp
Experience	flight time last 90 days : 220 flight time total : 27000 flight time type : 400
ASRS Report	351620
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp pilot : commercial pilot : flight engineer pilot : instrument
Experience	flight time total : 25000
ASRS Report	351617
Events
Anomaly	non adherence : clearance non adherence : far 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:

We inserted the flight plan into the 3 INS's in lgw. When we obtained oceanic clearance, the first 2 fixes were changed from the original and we were cleared to the first new fix immediately. That fix was inserted and the aircraft proceeded to the first new fix. We then lost contact with shannon VHF. Tried 4-6 (several) frequencys over the next 8-10 mins and then began trying HF frequencys. Finally made contact. Crew overload, duties, caused us to fail to insert second revised fix due to radio contact attempts. The aircraft attempted to proceed to original #2 fix. We caught the error on the 2 degree check, but by that time we were approximately 45 mi off course in unlimited visibility conditions. VFR was maintained at all times. No other aircraft was observed either ahead, above, or below us. We made an immediate correction to join the proper flight plan at fix #3. No further action was required. Another fact to show that a significant number of navigation errors occur with revised flight plans. We were no exception. Should have rechked and checked the 2 revised fixes after receiving them instead of spending mins trying to established communications.

Original NASA ASRS Text

Title: DC10 MAKES GROSS NAV ERROR OVER ATLANTIC.

Narrative: WE INSERTED THE FLT PLAN INTO THE 3 INS'S IN LGW. WHEN WE OBTAINED OCEANIC CLRNC, THE FIRST 2 FIXES WERE CHANGED FROM THE ORIGINAL AND WE WERE CLRED TO THE FIRST NEW FIX IMMEDIATELY. THAT FIX WAS INSERTED AND THE ACFT PROCEEDED TO THE FIRST NEW FIX. WE THEN LOST CONTACT WITH SHANNON VHF. TRIED 4-6 (SEVERAL) FREQS OVER THE NEXT 8-10 MINS AND THEN BEGAN TRYING HF FREQS. FINALLY MADE CONTACT. CREW OVERLOAD, DUTIES, CAUSED US TO FAIL TO INSERT SECOND REVISED FIX DUE TO RADIO CONTACT ATTEMPTS. THE ACFT ATTEMPTED TO PROCEED TO ORIGINAL #2 FIX. WE CAUGHT THE ERROR ON THE 2 DEG CHK, BUT BY THAT TIME WE WERE APPROX 45 MI OFF COURSE IN UNLIMITED VISIBILITY CONDITIONS. VFR WAS MAINTAINED AT ALL TIMES. NO OTHER ACFT WAS OBSERVED EITHER AHEAD, ABOVE, OR BELOW US. WE MADE AN IMMEDIATE CORRECTION TO JOIN THE PROPER FLT PLAN AT FIX #3. NO FURTHER ACTION WAS REQUIRED. ANOTHER FACT TO SHOW THAT A SIGNIFICANT NUMBER OF NAV ERRORS OCCUR WITH REVISED FLT PLANS. WE WERE NO EXCEPTION. SHOULD HAVE RECHKED AND CHKED THE 2 REVISED FIXES AFTER RECEIVING THEM INSTEAD OF SPENDING MINS TRYING TO ESTABLISHED COMS.

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.