An MD11 flight crew loads the wrong flight plan into their FMS and proceeds towards the wrong, not filed, entry fix related to the wrong airway while on frequency with rjtg, first officer.

Home

Browse by month

Random

Latest

About

Contact

Attributes
ACN	478660
Time
Date	200007
Day	Tue
Local Time Of Day	1201 To 1800
Place
State Reference	FO
Altitude	msl bound lower : 25000 msl bound upper : 28000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : rjtg.artcc tower : rfd.tower
Operator	common carrier : air carrier
Make Model Name	MD-11
Operating Under FAR Part	Part 121
Navigation In Use	other
Flight Phase	climbout : vacating altitude
Route In Use	enroute : pacific enroute : direct
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : flight engineer pilot : atp
Experience	flight time last 90 days : 200 flight time total : 24000 flight time type : 3200
ASRS Report	478660
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : multi engine pilot : instrument pilot : commercial
Events
Anomaly	non adherence : company policies non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation
Independent Detector	other controllera
Resolutory Action	controller : issued new clearance controller : issued advisory
Consequence	Other
Supplementary
Problem Areas	ATC Human Performance Flight Crew Human Performance Company
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

We received 2 flight releases -- a primary (filed) and backup one, via airway A-590 and the backup via R-591. We loaded the backup in error and did not catch it during clearance delivery or readback. During climb, tokyo control noticed we had departed 'kagis' to 'adnip' (R-591 entry fix) versus 'pabba' (A-590 entry fix). They asked us to confirm our routing. When I said we were 'filed' R-591, they reclred us with no further incident. Upon reflection, it was my error and we had been filed on A-590. Contributing to the error was predep concern over a 'slot time' discrepancy. Also, the company customarily marks flight plans with red letters 'primary' and 'backup' whenever there are 2 different routings. This was not done in this case. I do not believe the en route airway was included in the clearance delivery because the first officer did not note it when he wrote down the clearance. Under different circumstances, this might have been a very serious event.

Original NASA ASRS Text

Title: AN MD11 FLC LOADS THE WRONG FLT PLAN INTO THEIR FMS AND PROCEEDS TOWARDS THE WRONG, NOT FILED, ENTRY FIX RELATED TO THE WRONG AIRWAY WHILE ON FREQ WITH RJTG, FO.

Narrative: WE RECEIVED 2 FLT RELEASES -- A PRIMARY (FILED) AND BACKUP ONE, VIA AIRWAY A-590 AND THE BACKUP VIA R-591. WE LOADED THE BACKUP IN ERROR AND DID NOT CATCH IT DURING CLRNC DELIVERY OR READBACK. DURING CLB, TOKYO CTL NOTICED WE HAD DEPARTED 'KAGIS' TO 'ADNIP' (R-591 ENTRY FIX) VERSUS 'PABBA' (A-590 ENTRY FIX). THEY ASKED US TO CONFIRM OUR ROUTING. WHEN I SAID WE WERE 'FILED' R-591, THEY RECLRED US WITH NO FURTHER INCIDENT. UPON REFLECTION, IT WAS MY ERROR AND WE HAD BEEN FILED ON A-590. CONTRIBUTING TO THE ERROR WAS PREDEP CONCERN OVER A 'SLOT TIME' DISCREPANCY. ALSO, THE COMPANY CUSTOMARILY MARKS FLT PLANS WITH RED LETTERS 'PRIMARY' AND 'BACKUP' WHENEVER THERE ARE 2 DIFFERENT ROUTINGS. THIS WAS NOT DONE IN THIS CASE. I DO NOT BELIEVE THE ENRTE AIRWAY WAS INCLUDED IN THE CLRNC DELIVERY BECAUSE THE FO DID NOT NOTE IT WHEN HE WROTE DOWN THE CLRNC. UNDER DIFFERENT CIRCUMSTANCES, THIS MIGHT HAVE BEEN A VERY SERIOUS EVENT.

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.