Narrative:

I was the PF on this leg. The WX in atl was raining. Prior to departure, while on the crew bus, my wife called very upset and said she was in a car accident. Several calls later, I determined she was unhurt and the car was driveable. She continued to work, albeit shaken up. (Note: whether her incident played a role in the subsequent error I cannot say, however, the fact it happened added stress before preflight.) preflight was normal. I completed loading the FMS and rechked the route. Takeoff and climb out were peppered with intermittent moderate turbulence until south of szw. Our clearance took us south along the gulf coast to clear warning area as filed, then across the gulf. The clearance segment where the error occurred was plyer direct hilti direct cigar. The first indication that a navigation error occurred was a query from ATC, just after plyer, asking if we were going direct hilti intersection. We looked at the FMS and responded that we were going direct cigar. ZJX gave us a 180 degree heading and handed us off to ZMA who shortly cleared us on course across the gulf. Discussion: I am not sure why the error occurred. In this situation redundancy in the ATC system detected the error before it became a problem and it was quickly and uneventfully resolved. As far as we know, no conflicts occurred, nothing further was said by ATC. The first officer and I debriefed during and after the flight. I honestly do not know why the error occurred. After thinking about the event, I can offer several possible explanations: 1) as PF I missed loading the waypoint and during the preflight check the PNF did not catch the error. 2) on this aircraft the PNF routinely change waypoints on the FMS as a memory jogger for position reports, fir reports, center fuel pump shutoff points, etc. The fix page has an abeam function which allows the waypoint to be transposed along the actual route. In our company, first officer's routinely add these points to the route, even when they are not the PF. It is possible during an FMS clean-up to inadvertently delete an intermediate point, especially if there is something else carried to the scratch pad. 3) FMS dropped waypoint. 4) hilti incorrectly manually entered. Hilti intersection is a point we routinely fly over, however, despite numerous requests to add it to our database, it remains a point we have to add manually, increasing the possibility it can be entered incorrectly. 5) on FMS equipped aircraft the database contains significantly more intxns along airways than print on our flight plans. Although we xchk the waypoints at the gate during preflight, these intermediate waypoints come and go quickly and are very difficult to xchk. I believe that we tend to 'trust' and depend on the automation especially during high workload times. 6) the PNF is a senior instructor and outstanding airman. I believe that my confidence level in his abilities allowed me to relax and 'lower my guard.' of greatest concern to me is the fact that this error occurred and was undetected by us. I have spent yrs (almost 30) training pilots and instructors. We teach that there is no such thing as an error free cockpit. We emphasize that the hardest error to catch is something that should occur but does not. Lessons learned: 1) professional ATC controllers and professional pilots working together do catch errors (routinely) and pass needed information back and forth in a timely fashion to maintain the highest levels of safety and performance. In this case, controller/pilot CRM functioned as designed. 2) extreme vigilance by the PF and the check by the PNF on FMS equipped aircraft during preflight, and any time any waypoint change (even minor changes), should be verified visually and verbally by both pilots. 3) our company needs to re-emphasize that only the PF should change waypoints in the FMS, even for routine position reports off the fix page. Once accomplished, a complete review of active and down line waypoints should be re-crosschecked to insure no FMS waypoints were inadvertently changed during the addition and clean-up. I have made this suggestion in writing to our company. 4) hilti intersection needs to be added to the database. I personally requested this over 2 yrs ago. I have re-requested the addition to the database in writing. With respect to intermediate intxns that appear in the FMS route page and not on our flight plan, I suggest that the major flyover points that define the route, including intermediate waypoints where a heading change should occur, be highlighted directly on our flight plans (eg, bold, capital letters, underlined, etc). I will discuss this issue with the chief line check pilot for feedback and feasibility. In summary, I cannot definitely say why the error occurred. It probably occurred during either FMS loading or a waypoint fix page clean-up. The fact it occurred and was not caught by our crew still troubles me. Bottom line, adherence to established procedure and constant vigilance is the key to safe operations.

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Original NASA ASRS Text

Title: B737-800 CREW HAD A TRACK DEV AFTER THE FMC WAS NOT GOING TO THE CLRED WAYPOINT.

Narrative: I WAS THE PF ON THIS LEG. THE WX IN ATL WAS RAINING. PRIOR TO DEP, WHILE ON THE CREW BUS, MY WIFE CALLED VERY UPSET AND SAID SHE WAS IN A CAR ACCIDENT. SEVERAL CALLS LATER, I DETERMINED SHE WAS UNHURT AND THE CAR WAS DRIVEABLE. SHE CONTINUED TO WORK, ALBEIT SHAKEN UP. (NOTE: WHETHER HER INCIDENT PLAYED A ROLE IN THE SUBSEQUENT ERROR I CANNOT SAY, HOWEVER, THE FACT IT HAPPENED ADDED STRESS BEFORE PREFLT.) PREFLT WAS NORMAL. I COMPLETED LOADING THE FMS AND RECHKED THE RTE. TKOF AND CLBOUT WERE PEPPERED WITH INTERMITTENT MODERATE TURB UNTIL S OF SZW. OUR CLRNC TOOK US S ALONG THE GULF COAST TO CLR WARNING AREA AS FILED, THEN ACROSS THE GULF. THE CLRNC SEGMENT WHERE THE ERROR OCCURRED WAS PLYER DIRECT HILTI DIRECT CIGAR. THE FIRST INDICATION THAT A NAV ERROR OCCURRED WAS A QUERY FROM ATC, JUST AFTER PLYER, ASKING IF WE WERE GOING DIRECT HILTI INTXN. WE LOOKED AT THE FMS AND RESPONDED THAT WE WERE GOING DIRECT CIGAR. ZJX GAVE US A 180 DEG HDG AND HANDED US OFF TO ZMA WHO SHORTLY CLRED US ON COURSE ACROSS THE GULF. DISCUSSION: I AM NOT SURE WHY THE ERROR OCCURRED. IN THIS SIT REDUNDANCY IN THE ATC SYS DETECTED THE ERROR BEFORE IT BECAME A PROB AND IT WAS QUICKLY AND UNEVENTFULLY RESOLVED. AS FAR AS WE KNOW, NO CONFLICTS OCCURRED, NOTHING FURTHER WAS SAID BY ATC. THE FO AND I DEBRIEFED DURING AND AFTER THE FLT. I HONESTLY DO NOT KNOW WHY THE ERROR OCCURRED. AFTER THINKING ABOUT THE EVENT, I CAN OFFER SEVERAL POSSIBLE EXPLANATIONS: 1) AS PF I MISSED LOADING THE WAYPOINT AND DURING THE PREFLT CHK THE PNF DID NOT CATCH THE ERROR. 2) ON THIS ACFT THE PNF ROUTINELY CHANGE WAYPOINTS ON THE FMS AS A MEMORY JOGGER FOR POS RPTS, FIR RPTS, CTR FUEL PUMP SHUTOFF POINTS, ETC. THE FIX PAGE HAS AN ABEAM FUNCTION WHICH ALLOWS THE WAYPOINT TO BE TRANSPOSED ALONG THE ACTUAL RTE. IN OUR COMPANY, FO'S ROUTINELY ADD THESE POINTS TO THE RTE, EVEN WHEN THEY ARE NOT THE PF. IT IS POSSIBLE DURING AN FMS CLEAN-UP TO INADVERTENTLY DELETE AN INTERMEDIATE POINT, ESPECIALLY IF THERE IS SOMETHING ELSE CARRIED TO THE SCRATCH PAD. 3) FMS DROPPED WAYPOINT. 4) HILTI INCORRECTLY MANUALLY ENTERED. HILTI INTXN IS A POINT WE ROUTINELY FLY OVER, HOWEVER, DESPITE NUMEROUS REQUESTS TO ADD IT TO OUR DATABASE, IT REMAINS A POINT WE HAVE TO ADD MANUALLY, INCREASING THE POSSIBILITY IT CAN BE ENTERED INCORRECTLY. 5) ON FMS EQUIPPED ACFT THE DATABASE CONTAINS SIGNIFICANTLY MORE INTXNS ALONG AIRWAYS THAN PRINT ON OUR FLT PLANS. ALTHOUGH WE XCHK THE WAYPOINTS AT THE GATE DURING PREFLT, THESE INTERMEDIATE WAYPOINTS COME AND GO QUICKLY AND ARE VERY DIFFICULT TO XCHK. I BELIEVE THAT WE TEND TO 'TRUST' AND DEPEND ON THE AUTOMATION ESPECIALLY DURING HIGH WORKLOAD TIMES. 6) THE PNF IS A SENIOR INSTRUCTOR AND OUTSTANDING AIRMAN. I BELIEVE THAT MY CONFIDENCE LEVEL IN HIS ABILITIES ALLOWED ME TO RELAX AND 'LOWER MY GUARD.' OF GREATEST CONCERN TO ME IS THE FACT THAT THIS ERROR OCCURRED AND WAS UNDETECTED BY US. I HAVE SPENT YRS (ALMOST 30) TRAINING PLTS AND INSTRUCTORS. WE TEACH THAT THERE IS NO SUCH THING AS AN ERROR FREE COCKPIT. WE EMPHASIZE THAT THE HARDEST ERROR TO CATCH IS SOMETHING THAT SHOULD OCCUR BUT DOES NOT. LESSONS LEARNED: 1) PROFESSIONAL ATC CTLRS AND PROFESSIONAL PLTS WORKING TOGETHER DO CATCH ERRORS (ROUTINELY) AND PASS NEEDED INFO BACK AND FORTH IN A TIMELY FASHION TO MAINTAIN THE HIGHEST LEVELS OF SAFETY AND PERFORMANCE. IN THIS CASE, CTLR/PLT CRM FUNCTIONED AS DESIGNED. 2) EXTREME VIGILANCE BY THE PF AND THE CHK BY THE PNF ON FMS EQUIPPED ACFT DURING PREFLT, AND ANY TIME ANY WAYPOINT CHANGE (EVEN MINOR CHANGES), SHOULD BE VERIFIED VISUALLY AND VERBALLY BY BOTH PLTS. 3) OUR COMPANY NEEDS TO RE-EMPHASIZE THAT ONLY THE PF SHOULD CHANGE WAYPOINTS IN THE FMS, EVEN FOR ROUTINE POS RPTS OFF THE FIX PAGE. ONCE ACCOMPLISHED, A COMPLETE REVIEW OF ACTIVE AND DOWN LINE WAYPOINTS SHOULD BE RE-XCHKED TO INSURE NO FMS WAYPOINTS WERE INADVERTENTLY CHANGED DURING THE ADDITION AND CLEAN-UP. I HAVE MADE THIS SUGGESTION IN WRITING TO OUR COMPANY. 4) HILTI INTXN NEEDS TO BE ADDED TO THE DATABASE. I PERSONALLY REQUESTED THIS OVER 2 YRS AGO. I HAVE RE-REQUESTED THE ADDITION TO THE DATABASE IN WRITING. WITH RESPECT TO INTERMEDIATE INTXNS THAT APPEAR IN THE FMS RTE PAGE AND NOT ON OUR FLT PLAN, I SUGGEST THAT THE MAJOR FLYOVER POINTS THAT DEFINE THE RTE, INCLUDING INTERMEDIATE WAYPOINTS WHERE A HDG CHANGE SHOULD OCCUR, BE HIGHLIGHTED DIRECTLY ON OUR FLT PLANS (EG, BOLD, CAPITAL LETTERS, UNDERLINED, ETC). I WILL DISCUSS THIS ISSUE WITH THE CHIEF LINE CHK PLT FOR FEEDBACK AND FEASIBILITY. IN SUMMARY, I CANNOT DEFINITELY SAY WHY THE ERROR OCCURRED. IT PROBABLY OCCURRED DURING EITHER FMS LOADING OR A WAYPOINT FIX PAGE CLEAN-UP. THE FACT IT OCCURRED AND WAS NOT CAUGHT BY OUR CREW STILL TROUBLES ME. BOTTOM LINE, ADHERENCE TO ESTABLISHED PROC AND CONSTANT VIGILANCE IS THE KEY TO SAFE OPS.

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.