 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Air carrier departed foreign airport on a SID. Vectors assigned. Cleared again direct to a fix on the SID. Crew failed to reset navigation instruments. Flew toward wrong fix. Error discovered simultaneously by pilot and controller.
| Attributes | |
| ACN | 442387 |
| Time | |
| Date | 199907 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : zsha.artcc |
| State Reference | FO |
| Altitude | msl single value : 18700 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zsha.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | B747-100 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | climbout : initial |
| Route In Use | departure sid : nhw.1d |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 120 flight time total : 12000 flight time type : 4100 |
| ASRS Report | 442508 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 120 flight time total : 13040 flight time type : 2000 |
| ASRS Report | 442387 |
| Events | |
| Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft Airspace Structure |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Departed sha on nhw 1D departure. Given radar vectors vice departure procedure. Cleared direct nhw VOR, but had sha VOR tuned and turned direct to sha. Realized error 3 DME sha and turned right to nhw. Departure then began issuing vectors. Cause: in switching from NDB navigation to VOR navigation, believed proper frequency set and failed to check. Contributing: confusing due to combination NDB/VOR procedures, altitudes in meters, constant chatter in chinese on radio. Corrective actions: check frequencys. Supplemental information from acn 442508: we have no metric altimeter, so we must chart convert. Approaching station, first officer caught error and as we turned toward nhw, controller asked why we didn't go direct nhw, gave us a vector, and we complied. He released us direct ninas, flight plan route. Factors: frequency is incredibly overloaded with xmissions -- mostly in chinese. You strain to try to catch your call amongst all the chatter. Metric conversion: checking and doublechking chart to make sure you know to what altitude you were cleared. No metric altitude or awi's.
Original NASA ASRS Text
Title: ACR DEPARTED FOREIGN ARPT ON A SID. VECTORS ASSIGNED. CLRED AGAIN DIRECT TO A FIX ON THE SID. CREW FAILED TO RESET NAV INSTS. FLEW TOWARD WRONG FIX. ERROR DISCOVERED SIMULTANEOUSLY BY PLT AND CTLR.
Narrative: DEPARTED SHA ON NHW 1D DEP. GIVEN RADAR VECTORS VICE DEP PROC. CLRED DIRECT NHW VOR, BUT HAD SHA VOR TUNED AND TURNED DIRECT TO SHA. REALIZED ERROR 3 DME SHA AND TURNED R TO NHW. DEP THEN BEGAN ISSUING VECTORS. CAUSE: IN SWITCHING FROM NDB NAV TO VOR NAV, BELIEVED PROPER FREQ SET AND FAILED TO CHK. CONTRIBUTING: CONFUSING DUE TO COMBINATION NDB/VOR PROCS, ALTS IN METERS, CONSTANT CHATTER IN CHINESE ON RADIO. CORRECTIVE ACTIONS: CHK FREQS. SUPPLEMENTAL INFO FROM ACN 442508: WE HAVE NO METRIC ALTIMETER, SO WE MUST CHART CONVERT. APCHING STATION, FO CAUGHT ERROR AND AS WE TURNED TOWARD NHW, CTLR ASKED WHY WE DIDN'T GO DIRECT NHW, GAVE US A VECTOR, AND WE COMPLIED. HE RELEASED US DIRECT NINAS, FLT PLAN RTE. FACTORS: FREQ IS INCREDIBLY OVERLOADED WITH XMISSIONS -- MOSTLY IN CHINESE. YOU STRAIN TO TRY TO CATCH YOUR CALL AMONGST ALL THE CHATTER. METRIC CONVERSION: CHKING AND DOUBLECHKING CHART TO MAKE SURE YOU KNOW TO WHAT ALT YOU WERE CLRED. NO METRIC ALT OR AWI'S.
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.