Widebody transport flight crew fails to note a substantive change in assigned SID from vidp because ...

Attributes
ACN	786387
Time
Date	200805
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : vidp.airport
State Reference	FO
Altitude	agl single value : 0 msl single value : 5500
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	Widebody Transport
Operating Under FAR Part	Part 121
Navigation In Use	other
Route In Use	departure sid : ani 1a
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 139 flight time total : 6000 flight time type : 1700
ASRS Report	786387
Person 2
Affiliation	government : foreign
Function	controller : departure
Events
Anomaly	other spatial deviation
Independent Detector	other controllera
Resolutory Action	none taken : detected after the fact
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	ATC Human Performance Chart Or Publication Environmental Factor Flight Crew Human Performance
Primary Problem	Chart Or Publication
Air Traffic Incident	Pilot Deviation

Narrative:

During preflight; with flight plan and WX and NOTAMS delivered to the aircraft; captain and first officer failed to see a NOTAM imbedded on page 13 of 19 pages. The NOTAMS were all incorrectly printed with no indents to distinguish new subjects. The NOTAM changed; completely; the ani 1A SID. The SID is not given until approximately 20 mins before push back; and both pilots failed to realize the change. The aircraft is FMS and the database had been changed within the last two days; but the new database didn't have the new ani 1A SID. The commercial chart change pages did not contain the information of the change either. The only place to find it was embedded on page 13 of 19. The ani 1A SID was flown as depicted in the FMS. At approximately 9000 ft; a controller came on the radio informing us of our error; but she spoke so quickly we couldn't understand anything she said. We asked her several times for clarification and to slow down so we could understand her; but we never could. It was only later when we were above 10000 ft and we could pull out the NOTAMS and recheck did we realize what she was saying about the change in the ground track of the SID. We were VFR; no other aircraft were affected that we know of and no safety of flight was jeopardized.

Original NASA ASRS Text

Title: WDB FLT CREW FAILS TO NOTE A SUBSTANTIVE CHANGE IN ASSIGNED SID FROM VIDP BECAUSE THE INFO WAS BURIED IN 19 PAGES OF UN-ANNOTATED NOTAMS.

Narrative: DURING PREFLT; WITH FLT PLAN AND WX AND NOTAMS DELIVERED TO THE ACFT; CAPT AND FO FAILED TO SEE A NOTAM IMBEDDED ON PAGE 13 OF 19 PAGES. THE NOTAMS WERE ALL INCORRECTLY PRINTED WITH NO INDENTS TO DISTINGUISH NEW SUBJECTS. THE NOTAM CHANGED; COMPLETELY; THE ANI 1A SID. THE SID IS NOT GIVEN UNTIL APPROX 20 MINS BEFORE PUSH BACK; AND BOTH PLTS FAILED TO REALIZE THE CHANGE. THE ACFT IS FMS AND THE DATABASE HAD BEEN CHANGED WITHIN THE LAST TWO DAYS; BUT THE NEW DATABASE DIDN'T HAVE THE NEW ANI 1A SID. THE COMMERCIAL CHART CHANGE PAGES DID NOT CONTAIN THE INFORMATION OF THE CHANGE EITHER. THE ONLY PLACE TO FIND IT WAS EMBEDDED ON PAGE 13 OF 19. THE ANI 1A SID WAS FLOWN AS DEPICTED IN THE FMS. AT APPROX 9000 FT; A CTLR CAME ON THE RADIO INFORMING US OF OUR ERROR; BUT SHE SPOKE SO QUICKLY WE COULDN'T UNDERSTAND ANYTHING SHE SAID. WE ASKED HER SEVERAL TIMES FOR CLARIFICATION AND TO SLOW DOWN SO WE COULD UNDERSTAND HER; BUT WE NEVER COULD. IT WAS ONLY LATER WHEN WE WERE ABOVE 10000 FT AND WE COULD PULL OUT THE NOTAMS AND RECHECK DID WE REALIZE WHAT SHE WAS SAYING ABOUT THE CHANGE IN THE GND TRACK OF THE SID. WE WERE VFR; NO OTHER ACFT WERE AFFECTED THAT WE KNOW OF AND NO SAFETY OF FLT WAS JEOPARDIZED.

Data retrieved from NASA's ASRS site as of May 2009 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.

Widebody transport flight crew fails to note a substantive change in assigned SID from vidp because the information was buried in 19 pages of un-annotated NOTAMS.