|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : phx.airport|
|Altitude||msl single value : 14000|
|Controlling Facilities||tower : den.tower|
|Operator||common carrier : air carrier|
|Make Model Name||B737 Undifferentiated or Other Model|
|Operating Under FAR Part||Part 121|
|Flight Phase||climbout : intermediate altitude|
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Experience||flight time last 90 days : 160|
flight time type : 6400
|Affiliation||government : faa|
|Function||controller : departure|
|Anomaly||non adherence : clearance|
other spatial deviation
|Independent Detector||other controllera|
|Resolutory Action||controller : issued new clearance|
|Problem Areas||Flight Crew Human Performance|
|Primary Problem||Flight Crew Human Performance|
We arrived at the aircraft on day 4 of a 4 day trip to find that the first officer's R2 window was cracked. In addition; the APU was on MEL. Maintenance was able to procure a window from air carrier Y; but found the wiring for window heat did not match our aircraft. After a few hours of delay; the aircraft was signed off with the window heat on MEL and we proceeded to preflight and get ready for our flight. We went through all the paperwork and loaded the clearance we received via pre departure clearance into the computer and it matched the flight plan we had 'SILOW1 silow flg gcn.' subsequently we received numerous amended releases (4 of them); the second of which added the window MEL and changed the flight plan (we didn't catch that part); the third changed drift-down alternates and the fourth the minimum fuel. By the way; this is the captain's first trip off of operational experience in this aircraft. Also; the cockpit was very hot and the ground air was insufficient. During all this we were planning for the crossbleed start (captain's first) and planning on what to do if we needed to do an unpressurized takeoff as it was getting pretty hot and we had no APU. Also coordinating with operations concerning too many dogs in first class. Another distraction was that dispatch sent us a SIGMET for volcanic ash on our route. The captain made 2 phone calls to dispatch during this time and the change of flight plan did not come up. Needless to say; there were many distrs during preflight although the captain and I were very slow and methodical during the process trying to make sure we got everything amidst the confusion. Push; start; taxi and takeoff were all normal. Climb out out on departure frequency we were asked to identify and subsequently asked again on the next frequency. Then the controller asked us what our clearance was and we told him. Upon further checking; we discovered that although we were flying our pre departure clearance; the SILOW1 etc; our flight plan said BXK2.pmd.J65; etc; so it did not link up anywhere. This created much confusion and we coordination with ATC to continue on our original flight plan since that was what we were doing and the WX was clear (WX was the reason for the flight plan change by dispatch; though it was not a factor once we were airborne). We then contacted dispatch and coordination our route. The flight crew needs to be extremely vigilant when reviewing changes in the paperwork and not assume they know what the amendment is for without a thorough review. If the flight plan is completely overhauled; it would be useful to the crew to get an ACARS or radio call alerting them. I think we were being very careful to trap errors; but this one got away from us.
Original NASA ASRS Text
Title: A B737 FLT CREW MISSED A REVISION TO THEIR PDC CLEARANCE PRIOR TO DEP AND DEVIATED FROM THEIR CLEARED ROUTING.
Narrative: WE ARRIVED AT THE ACFT ON DAY 4 OF A 4 DAY TRIP TO FIND THAT THE FO'S R2 WINDOW WAS CRACKED. IN ADDITION; THE APU WAS ON MEL. MAINT WAS ABLE TO PROCURE A WINDOW FROM ACR Y; BUT FOUND THE WIRING FOR WINDOW HEAT DID NOT MATCH OUR ACFT. AFTER A FEW HRS OF DELAY; THE ACFT WAS SIGNED OFF WITH THE WINDOW HEAT ON MEL AND WE PROCEEDED TO PREFLT AND GET READY FOR OUR FLT. WE WENT THROUGH ALL THE PAPERWORK AND LOADED THE CLRNC WE RECEIVED VIA PDC INTO THE COMPUTER AND IT MATCHED THE FLT PLAN WE HAD 'SILOW1 SILOW FLG GCN.' SUBSEQUENTLY WE RECEIVED NUMEROUS AMENDED RELEASES (4 OF THEM); THE SECOND OF WHICH ADDED THE WINDOW MEL AND CHANGED THE FLT PLAN (WE DIDN'T CATCH THAT PART); THE THIRD CHANGED DRIFT-DOWN ALTERNATES AND THE FOURTH THE MINIMUM FUEL. BY THE WAY; THIS IS THE CAPT'S FIRST TRIP OFF OF OPERATIONAL EXPERIENCE IN THIS ACFT. ALSO; THE COCKPIT WAS VERY HOT AND THE GND AIR WAS INSUFFICIENT. DURING ALL THIS WE WERE PLANNING FOR THE CROSSBLEED START (CAPT'S FIRST) AND PLANNING ON WHAT TO DO IF WE NEEDED TO DO AN UNPRESSURIZED TKOF AS IT WAS GETTING PRETTY HOT AND WE HAD NO APU. ALSO COORDINATING WITH OPS CONCERNING TOO MANY DOGS IN FIRST CLASS. ANOTHER DISTR WAS THAT DISPATCH SENT US A SIGMET FOR VOLCANIC ASH ON OUR RTE. THE CAPT MADE 2 PHONE CALLS TO DISPATCH DURING THIS TIME AND THE CHANGE OF FLT PLAN DID NOT COME UP. NEEDLESS TO SAY; THERE WERE MANY DISTRS DURING PREFLT ALTHOUGH THE CAPT AND I WERE VERY SLOW AND METHODICAL DURING THE PROCESS TRYING TO MAKE SURE WE GOT EVERYTHING AMIDST THE CONFUSION. PUSH; START; TAXI AND TKOF WERE ALL NORMAL. CLBOUT OUT ON DEP FREQ WE WERE ASKED TO IDENT AND SUBSEQUENTLY ASKED AGAIN ON THE NEXT FREQ. THEN THE CTLR ASKED US WHAT OUR CLRNC WAS AND WE TOLD HIM. UPON FURTHER CHKING; WE DISCOVERED THAT ALTHOUGH WE WERE FLYING OUR PDC; THE SILOW1 ETC; OUR FLT PLAN SAID BXK2.PMD.J65; ETC; SO IT DID NOT LINK UP ANYWHERE. THIS CREATED MUCH CONFUSION AND WE COORD WITH ATC TO CONTINUE ON OUR ORIGINAL FLT PLAN SINCE THAT WAS WHAT WE WERE DOING AND THE WX WAS CLR (WX WAS THE REASON FOR THE FLT PLAN CHANGE BY DISPATCH; THOUGH IT WAS NOT A FACTOR ONCE WE WERE AIRBORNE). WE THEN CONTACTED DISPATCH AND COORD OUR RTE. THE FLT CREW NEEDS TO BE EXTREMELY VIGILANT WHEN REVIEWING CHANGES IN THE PAPERWORK AND NOT ASSUME THEY KNOW WHAT THE AMENDMENT IS FOR WITHOUT A THOROUGH REVIEW. IF THE FLT PLAN IS COMPLETELY OVERHAULED; IT WOULD BE USEFUL TO THE CREW TO GET AN ACARS OR RADIO CALL ALERTING THEM. I THINK WE WERE BEING VERY CAREFUL TO TRAP ERRORS; BUT THIS ONE GOT AWAY FROM US.
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.