Narrative:

We were operating as flight from iah to oma. I was paired with a new first officer, and it was the last turn of a 2-DAY trip. Our aircraft was parked at a terminal some distance from our operations facility. This necessitated me having our pre departure clearance sent over to our gate. This was the first officer's second trip off IOE, and as to be expected things were going a bit slow. In order to make an on-time pushback, I was assisting the first officer with some of his cockpit duties. Approximately 3 mins to push time, the flight attendant gave us the passenger count, the first officer asked a question about weight and balance procedures, and the gate agent handed me the pre departure clearance. All this happened at once, and instead of carefully reviewing our pre departure clearance, I just glanced at it and noted that route printed there matched our company filed flight plan. Unfortunately, due to the high workload and desire to be on time, I failed to notice that there was an amendment printed just above our route, which was very different from our company filed route. After takeoff, we were cleared direct to LOA VOR and then cqy VOR. This differed slightly from our company flight plan, but because of several ATC instructions at once, and the first officer's unfamiliarity with the aircraft, we were both having to monitor the aircraft's confign very closely. Although at this time I had a feeling something was not right, I got distraction with PNF duties and never really addressed the fact that something was not going as planned. As we approached the cqy VOR, ZFW inquired if we were going direct to byp. I replied that no, our clearance showed us going from cqy to cve then via the company flight plan. He then issued a new heading and a new clearance which we copied and complied with. About 1 hour later, on frequency with ZKC, we were advised to call ZFW when we landed because we had been involved in a pilot deviation. My first officer and I discussed what we could have done to have caused this. At this point I finally re-examined the pre departure clearance and saw that an amendment to our originally filed company flight plan had been printed on the pre departure clearance. When an amendment is contained on a pre departure clearance it is printed inside 2 dashes and is placed just above the company route. I believe that because of our high cockpit workload and time constraints just before pushback, I failed to adequately review the pre departure clearance for any amendments. I believe that my desire to be on time, the first officer's lack of familiarity with the aircraft and company procedures, and the high workload just prior to pushback all contributed to this error. I also believe that because our pre departure clearance's usually match our company filed flight plan, that a bit of complacency also existed. I must also state that the first officer was doing a good job and was by no means incompetent. He just demanded a bit more of my attention which detracted a bit from my performance as a captain. I feel that this could have been prevented if we would have recognized the building chain of events. 1) a new crew member, 2) time compression, 3) high workload, 4) complacency. Finally, the lack of listening to the feeling that something wasn't right. As crew members we must all increase our vigilance when any of these conditions exist. Moreover, if something just doesn't seem right, it probably isn't, and should be brought to each other's attention and discussed and a course of action determined.

Google
 

Original NASA ASRS Text

Title: AN EMB145 FLC FLY THE INCORRECT SID AND ROUTING TO OVERHEAD CQY, TX. ATC ISSUES A NEW ROUTING TO CONFORM WITH THEIR AMENDED CLRNC THAT WAS ON THEIR ORIGINAL PDC AT IAH, TX.

Narrative: WE WERE OPERATING AS FLT FROM IAH TO OMA. I WAS PAIRED WITH A NEW FO, AND IT WAS THE LAST TURN OF A 2-DAY TRIP. OUR ACFT WAS PARKED AT A TERMINAL SOME DISTANCE FROM OUR OPS FACILITY. THIS NECESSITATED ME HAVING OUR PDC SENT OVER TO OUR GATE. THIS WAS THE FO'S SECOND TRIP OFF IOE, AND AS TO BE EXPECTED THINGS WERE GOING A BIT SLOW. IN ORDER TO MAKE AN ON-TIME PUSHBACK, I WAS ASSISTING THE FO WITH SOME OF HIS COCKPIT DUTIES. APPROX 3 MINS TO PUSH TIME, THE FLT ATTENDANT GAVE US THE PAX COUNT, THE FO ASKED A QUESTION ABOUT WT AND BAL PROCS, AND THE GATE AGENT HANDED ME THE PDC. ALL THIS HAPPENED AT ONCE, AND INSTEAD OF CAREFULLY REVIEWING OUR PDC, I JUST GLANCED AT IT AND NOTED THAT RTE PRINTED THERE MATCHED OUR COMPANY FILED FLT PLAN. UNFORTUNATELY, DUE TO THE HIGH WORKLOAD AND DESIRE TO BE ON TIME, I FAILED TO NOTICE THAT THERE WAS AN AMENDMENT PRINTED JUST ABOVE OUR RTE, WHICH WAS VERY DIFFERENT FROM OUR COMPANY FILED RTE. AFTER TKOF, WE WERE CLRED DIRECT TO LOA VOR AND THEN CQY VOR. THIS DIFFERED SLIGHTLY FROM OUR COMPANY FLT PLAN, BUT BECAUSE OF SEVERAL ATC INSTRUCTIONS AT ONCE, AND THE FO'S UNFAMILIARITY WITH THE ACFT, WE WERE BOTH HAVING TO MONITOR THE ACFT'S CONFIGN VERY CLOSELY. ALTHOUGH AT THIS TIME I HAD A FEELING SOMETHING WAS NOT RIGHT, I GOT DISTR WITH PNF DUTIES AND NEVER REALLY ADDRESSED THE FACT THAT SOMETHING WAS NOT GOING AS PLANNED. AS WE APCHED THE CQY VOR, ZFW INQUIRED IF WE WERE GOING DIRECT TO BYP. I REPLIED THAT NO, OUR CLRNC SHOWED US GOING FROM CQY TO CVE THEN VIA THE COMPANY FLT PLAN. HE THEN ISSUED A NEW HDG AND A NEW CLRNC WHICH WE COPIED AND COMPLIED WITH. ABOUT 1 HR LATER, ON FREQ WITH ZKC, WE WERE ADVISED TO CALL ZFW WHEN WE LANDED BECAUSE WE HAD BEEN INVOLVED IN A PLTDEV. MY FO AND I DISCUSSED WHAT WE COULD HAVE DONE TO HAVE CAUSED THIS. AT THIS POINT I FINALLY RE-EXAMINED THE PDC AND SAW THAT AN AMENDMENT TO OUR ORIGINALLY FILED COMPANY FLT PLAN HAD BEEN PRINTED ON THE PDC. WHEN AN AMENDMENT IS CONTAINED ON A PDC IT IS PRINTED INSIDE 2 DASHES AND IS PLACED JUST ABOVE THE COMPANY RTE. I BELIEVE THAT BECAUSE OF OUR HIGH COCKPIT WORKLOAD AND TIME CONSTRAINTS JUST BEFORE PUSHBACK, I FAILED TO ADEQUATELY REVIEW THE PDC FOR ANY AMENDMENTS. I BELIEVE THAT MY DESIRE TO BE ON TIME, THE FO'S LACK OF FAMILIARITY WITH THE ACFT AND COMPANY PROCS, AND THE HIGH WORKLOAD JUST PRIOR TO PUSHBACK ALL CONTRIBUTED TO THIS ERROR. I ALSO BELIEVE THAT BECAUSE OUR PDC'S USUALLY MATCH OUR COMPANY FILED FLT PLAN, THAT A BIT OF COMPLACENCY ALSO EXISTED. I MUST ALSO STATE THAT THE FO WAS DOING A GOOD JOB AND WAS BY NO MEANS INCOMPETENT. HE JUST DEMANDED A BIT MORE OF MY ATTN WHICH DETRACTED A BIT FROM MY PERFORMANCE AS A CAPT. I FEEL THAT THIS COULD HAVE BEEN PREVENTED IF WE WOULD HAVE RECOGNIZED THE BUILDING CHAIN OF EVENTS. 1) A NEW CREW MEMBER, 2) TIME COMPRESSION, 3) HIGH WORKLOAD, 4) COMPLACENCY. FINALLY, THE LACK OF LISTENING TO THE FEELING THAT SOMETHING WASN'T RIGHT. AS CREW MEMBERS WE MUST ALL INCREASE OUR VIGILANCE WHEN ANY OF THESE CONDITIONS EXIST. MOREOVER, IF SOMETHING JUST DOESN'T SEEM RIGHT, IT PROBABLY ISN'T, AND SHOULD BE BROUGHT TO EACH OTHER'S ATTN AND DISCUSSED AND A COURSE OF ACTION DETERMINED.

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.