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CL60 flight crew become distraction with windshield crack and forget to xchk route of flight which results in gross navigation error.
| Attributes | |
| ACN | 512491 |
| Time | |
| Date | 200105 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : bird.artcc |
| State Reference | FO |
| Altitude | msl single value : 35000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : bird.artcc tower : iad.tower |
| Operator | general aviation : corporate |
| Make Model Name | Challenger CL601 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | cruise : level |
| Route In Use | enroute : atlantic |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : corporate |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 150 flight time total : 8000 flight time type : 2500 |
| ASRS Report | 512491 |
| Person 2 | |
| Affiliation | company : corporate |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : clearance other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued advisory flight crew : overcame equipment problem flight crew : returned to intended or assigned course |
| Consequence | faa : reviewed incident with flight crew other |
| Supplementary | |
| Problem Areas | Aircraft Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
This is an international trip. As we were doing the crossing to europe out of cyfb (frobisher) on a random route to france, we entered a wrong waypoint. This trip began late at night out of west coast and by the time we reached 30W it was 'late' body-clockwise. We were given the route airborne out of cyfb on our way to 65/60. We followed procedures and independently entered all waypoints and crosschecked. We ran 10 min checks on headings and drew courses, etc, by hand plotting for backups. Although we entered (pilot side) 64/30 as the waypoint, the 'defined fix' entered was 65/30. This could have come about by repetition in the clearance route which was 65/60, 65/50, 65/40, 64/30, 62/20. We had noticed a difference in the 2 long range navs and said we would plot and find the discrepancy on that leg at 64/30. As we reached that turn, we cracked a windshield and began discussing the alternatives of how we could complete the trip and take care of our passenger. We never got back to the 'discrepancy' and when we passed radar in icelandic control they said we were at 65/30 versus 64/30. Contributing factor was the lack of rest. Not due to schedule but more of anticipation. Not restful thinking of all the detail. Repetitive waypoints that 'lead' you into entering the next sequence but not the correct one. Even though a xchk was performed, we both did not see the error -- even though it was staring us in the face 64/30 = N65.00.00w30.00.0. Failure of the final check of plotting -- due to cracked windshield distraction. We have all the correct procedures in place to prevent just such an occurrence -- and when they are not followed to the letter, this is what happens. And I thought 'it will never happen to me.'
Original NASA ASRS Text
Title: CL60 FLC BECOME DISTR WITH WINDSHIELD CRACK AND FORGET TO XCHK RTE OF FLT WHICH RESULTS IN GROSS NAV ERROR.
Narrative: THIS IS AN INTL TRIP. AS WE WERE DOING THE XING TO EUROPE OUT OF CYFB (FROBISHER) ON A RANDOM RTE TO FRANCE, WE ENTERED A WRONG WAYPOINT. THIS TRIP BEGAN LATE AT NIGHT OUT OF WEST COAST AND BY THE TIME WE REACHED 30W IT WAS 'LATE' BODY-CLOCKWISE. WE WERE GIVEN THE RTE AIRBORNE OUT OF CYFB ON OUR WAY TO 65/60. WE FOLLOWED PROCS AND INDEPENDENTLY ENTERED ALL WAYPOINTS AND XCHKED. WE RAN 10 MIN CHKS ON HDGS AND DREW COURSES, ETC, BY HAND PLOTTING FOR BACKUPS. ALTHOUGH WE ENTERED (PLT SIDE) 64/30 AS THE WAYPOINT, THE 'DEFINED FIX' ENTERED WAS 65/30. THIS COULD HAVE COME ABOUT BY REPETITION IN THE CLRNC RTE WHICH WAS 65/60, 65/50, 65/40, 64/30, 62/20. WE HAD NOTICED A DIFFERENCE IN THE 2 LONG RANGE NAVS AND SAID WE WOULD PLOT AND FIND THE DISCREPANCY ON THAT LEG AT 64/30. AS WE REACHED THAT TURN, WE CRACKED A WINDSHIELD AND BEGAN DISCUSSING THE ALTERNATIVES OF HOW WE COULD COMPLETE THE TRIP AND TAKE CARE OF OUR PAX. WE NEVER GOT BACK TO THE 'DISCREPANCY' AND WHEN WE PASSED RADAR IN ICELANDIC CTL THEY SAID WE WERE AT 65/30 VERSUS 64/30. CONTRIBUTING FACTOR WAS THE LACK OF REST. NOT DUE TO SCHEDULE BUT MORE OF ANTICIPATION. NOT RESTFUL THINKING OF ALL THE DETAIL. REPETITIVE WAYPOINTS THAT 'LEAD' YOU INTO ENTERING THE NEXT SEQUENCE BUT NOT THE CORRECT ONE. EVEN THOUGH A XCHK WAS PERFORMED, WE BOTH DID NOT SEE THE ERROR -- EVEN THOUGH IT WAS STARING US IN THE FACE 64/30 = N65.00.00W30.00.0. FAILURE OF THE FINAL CHK OF PLOTTING -- DUE TO CRACKED WINDSHIELD DISTR. WE HAVE ALL THE CORRECT PROCS IN PLACE TO PREVENT JUST SUCH AN OCCURRENCE -- AND WHEN THEY ARE NOT FOLLOWED TO THE LETTER, THIS IS WHAT HAPPENS. AND I THOUGHT 'IT WILL NEVER HAPPEN TO ME.'
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.