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Incidents related to Issue 31 incidents related to this issue.

Issue: database may be erroneous or incomplete (Issue #110)
Description: Automation system databases may be incomplete, contain erroneous data, or be inconsistent with other information used by the pilots, possibly increasing pilot workload and/or creating the opportunity for navigation or other errors.

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  2. Accession Number: 84480
    Synopsis: ACR LGT DEVIATED FROM CLRNC ROUTE.
    Narrative: FAILED TO NOTICE DURING ARWY PROGRAMMING THAT FMC DATA BASE WAS NOT CURRENT DUE TO MASSIVE E COAST ATC PROGRAM CHANGE EFFECTIVE 3/88. AS A RESULT OF OLD DATABASE, J75 S OF LOPES, PROCEEDED TO TURN ACFT ON AUTOPLT FARTHER W THAN LOCATION OF NEW J75, ATC DID NOTICE DEVIATION AND INSTRUCTED US TO INTERCEPT J75 AS CURRENTLY PUBLISHED TO BE 240 DEG R OF MXE. WE DID AS DIRECTED. VERIFIED REMAINDER OF ROUTE AND REALIZED DATA BASE ERROR. POSSIBLY ALREADY INCORRECTLY USED SINCE 3/88. THIS SIGNIFICANT ARWY CHANGE IS A SPECIAL ATC RADAR WATCH AREA. APPARENTLY, OUR KIND OF ERROR HAS BEEN ANTICIPATED AND ALMOST IMMEDIATELY VERIFIED BY GND ARTCC PERSONNEL. I APPRECIATE THIS VIGILANCE. DATA BASE CURRENTLY COULD HAVE BEEN INADVERTENTLY CHANGED. LESSON LEARNED IS TO DOUBLE CHK DATA BASE AND ENRTE CHARTS. RECOMMEND THAT FUTURE ARWY CHANGES OF THIS DEGREE BE CONCURRENT WITH NEW ROUTE NUMBERS.

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  4. Accession Number: 92431
    Synopsis: ACR MLG DEVIATES FROM COURSE AND ENTERS RESTRICTED AREA.
    Narrative: FILED FLT PLAN FROM BUR TO DEN WAS THE VNY 5 DEP, PMD TRANSITION, PMD J6 J146 HBU. CLRNC DELIVERY GAVE US THE VNY 5, PMD TRANSITION, PMD--THE PMD 046 DEG R DAG 239 DEG R DAG FLT PLAN ROUTE. LAST WK I WAS ABLE TO REPROGRAM THE FMC WITH THE NEW ROUTING. THIS TIME IT WOULDN'T ACCEPT IT. AS WE PASSED PMD ON OUR CLBOUT I WAS STILL TRYING TO REPROGRAM. WE WENT OUT J6 (PMD 067 DEG R) FOR A COUPLE OF MILES BEFORE WE WENT TO MANUAL VOR NAV. IN MAKING A LEFT TURN TO ABOUT 020 DEGS TO INTERCEPT THE PMD 046 DEG R, WE ENTERED THE EDGE OF THE EDWARDS AFB RESTRICTED AREA AS WE LEVELED AT FL370. ATC INFORMED US WE WERE IN THE AREA, GAVE US A TURN TO 080 DEGS FOR DAG AND SAID WE WERE OUT OF THE RESTRICTED AREA. (THE CAPT WAS FLYING AND I WAS ON THE RADIO.) THE PROB BEGAN WITH THE NEW ROUTING WHICH THE FMC WOULD NOT ACCEPT. ALSO, THIS ROUTING BRINGS YOU RIGHT TO THE EDGE OF THE RESTRICTED AREA--J6/J146 GIVES YOU A LOT MORE CLRNC. WE'VE BECOME SO USED TO USING THE EFIS MAP MODE AND AUTOFLT, THAT WE'VE GOTTEN AWAY FROM VOR NAV. PARTLY COMPLACENCY, PARTLY CONFUSION. UNFORTUNATELY, MY AIRLINE'S MLG B TRNING WAS ATROCIOUS AND THE FAA'S RUBBER STAMP OF THE SYLLABUS WAS CRIMINAL. (A SURVEY OF THOSE OF US FLYING THIS ACFT OVERWHELMINGLY CONDEMNED THE TRNING AND ONLY BY THREATENING TO GO PUBLIC CONVINCED THE COMPANY TO SPLIT THE MLG B FLEET FROM THE MLG A.) THIS TYPE OF INCIDENT HAS HAPPENED TO SEVERAL OF OUR CREWS AND AFTER FLYING THE MLG B FOR 18 MONTHS I FINALLY SCREWED UP, TOO! CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: WHEN ANALYST POINTED OUT THAT THE PMD 046 DEG R DID NOT INTERCEPT THE DAG 239 DEG R, RPTR SEEMED FLUSTERED AND SAID HE WAS POSITIVE THAT THE RADIALS HE RPTED WERE THE RADIALS HE WAS GIVEN BY BUR CLRNC DELIVERY, AND THAT HE HAD READ THEM BACK. HE ALSO SAID THAT HE THOUGHT THE ROUTE BTWN PMD AND DAG WAS AMENDED MORE OFTER THAN NOT AND HE WONDERED WHY THEY DIDN'T SIMPLY CHANGE THE CENTER STORED ROUTE.

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  6. Accession Number: 117306
    Synopsis: AFTER RECEIVING AIR HOLDING CLRNC REPORTER ACFT INADVERTENTLY OVERFLEW HOLDING FIX WHILE TRYING TO LOCATE SAME ON NAVIGATION CHART.
    Narrative: I WAS THE F/O ON ACR FLT XX IN JULY 1989, FLYING A WDB. I WAS THE PLT AT THE CONTROLS. WE WERE IN THE APCH PORTION OF THE FLT, AMONG SCATTERED CUMULUS AND TSTMS, ON AUTOPLT, FMS 2-NAV AND V-NAV ENGAGED, AND LEVEL AT 11,000', INDICATING 250 KTS, AS ASSIGNED BY APCH CTL. WE WERE SEBND ON V-97 AIRWAY, ABOUT 30 MI NW OF KRENA INTXN. WE HAD BEEN TOLD BY A PREVIOUS CENTER CTLR TO EXPECT NO DELAYS, AND TFC SEEMED TO BE MOVING WELL. APCH CTL THEN GAVE THE ACFT AHEAD OF US HOLDING INSTRUCTIONS FOR KRENA INTXN. THAT ACFT ASKED FOR RIGHT TURNS AT KRENA VICE THE PUBLISHED LEFT TURNS BECAUSE OF A TSTM CELL. THAT REQUEST WAS GRANTED. WE VERIFIED THE TSTM CELL LOCATION ON OUR RADAR AND AT THAT MOMENT APCH CTL ISSUED US HOLDING INSTRUCTIONS FOR THE KRENA INTXN, AS PUBLISHED, 11,000'. THE CAPT REQUESTED RIGHT TURNS IN THE PATTERN DUE TO THE TSTM CELL. THE REQUEST WAS GRANTED. I BEGAN SLOWING TO HOLDING SPEED. AS THE CAPT BEGAN ENTERING THE HOLD IN THE FMS, THE ACFT AHEAD OF US REQUESTED HOLDING AT POPPS INTXN DUE TO THE CELL AT KRENA. THAT REQUEST WAS GRANTED. WE WERE BY NOW ABOUT 20 MI FROM KRENA. THE CTLR THEN ASSIGNED US HOLDING AT POPPS. WE GLANCED AT OUR CHARTS, LOCATED POPPS ON THEM, AND THE CAPT TRIED TO ENTER IT AS A WAYPOINT IN THE FMS. THE FMS REJECTED IT AS "NOT IN DATA BASE". BY THE TIME WE DETERMINED THE DISTANCE FROM THE NORTHBROOK VOR TO POPPS, AND I SWITCHED TO THE VOR MODE, WE WERE 2-3 MI PAST POPPS. I BEGAN A RIGHT TURN. AT THAT POINT, THE CTLR ASKED IF WE KNEW WE WERE "5 MILES" PAST POPPS. WE TOLD HIM WE WERE IN THE TURN. HE THEN ISSUED US A HDG OF 270 DEG. WE WERE TURNING THROUGH 180-190 DEG. WE COMPLIED, WERE SOON VECTORED BACK TOWARD ORD, AND CONTINUED ON TO LAND (WITHOUT HOLDING) WITHOUT FURTHER PROBLEMS. THE PROBLEM AROSE, I FEEL FROM 3 FACTORS: 1) LATE ISSUANCE OF HOLDING INSTRUCTIONS FOR POPPS, 2) POPPS NOT PROGRAMMED IN THE DATA BASE OF OUR FMS, AND 3) OUR DEPENDENCE ON FMS NAVIGATION AND SLOW CHANGEOVER TO THE NAV-VOR MODE. THE SOLUTIONS: 1) WE SHOULD HAVE REFUSED THE LATE HOLD AT POPPS AND REQUESTED HOLD AT KRENA OR VECTORS, 2) CTLRS SHOULD AVOID LATE/SHORT NOTICE HOLDING, 3) OUR FMS DATA BASE SHOULD INCLUDE MOST, IF NOT ALL, POTENTIAL HOLDING FIXES NEAR ARPTS.

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  8. Accession Number: 128009
    Synopsis: FLT CREW OF 2 ENGINE WDB ACFT DESCENDING ON AUTOPLT. FMC DID NOT FOLLOW DOG LEG IN THE AIRWAY. CENTER CTLR GAVE A VECTOR.
    Narrative: OUR CLRNC DICTATED THAT WE FLY V526 TO WAKEM INTXN. V526 HAS A DOG LEG TURN AT PLAER INTXN BEFORE GOING TO WAKEM. AN ERROR IN THE ON BOARD COMPUTER NAV DATA BASE SHOWS V526 TO BE A STRAIGHT LINE BTWN VWV VOR AND WAKEM. ATC NOTICED WE WERE OFF COURSE AFTER VWV AND GAVE US A HDG TO REINTERCEPT ARWY. WE HAD A CHANCE TO CATCH ERROR IN ROUTE DURING PREFLT WHILE STEPPING THROUGH THE ROUTE, BUT MISSED IT.

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  10. Accession Number: 128735
    Synopsis: ACR LGT ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION BECAUSE FIX WAS NOT IN THE FMC.
    Narrative: TOLD TO CROSS 60 MI W OF FNT AT FL230. FNT WAS NOT ON OUR ROUTE, NOR HAD IT BEEN PROGRAMMED INTO THE FMC. BY THE TIME WE HAD PROPERLY PROGRAMMED THE FMC, WE WERE ONLY ABLE TO DSND TO 23900' AT 60 ME W OF FNT. FLT PLAN HAD US FILED TO A POINT FORMED BY V450 AND THE DXO 342 DEG R, THEN DIRECT POLAR. THE POINT FORMED BY V450 AND THE DXO 342 DEG R WAS NOT PROGRAMMED IN THE FMC DATA BASE. WHEN IN INSERTED THE ORIGINAL ROUTE, I SKIPPED THE POINT, INTENDING TO FIGURE THE PROPER PROGRAMMING WHILE ENRTE, AND THEN FORGOT ABOUT IT. TO CORRECT BOTH THESE SITUATIONS, I WOULD RECOMMEND THAT ON AUTOMATED COCKPITS, THE NECESSARY CHKPOINTS BE IN THE FMC DATA BASE, OR ATC NOT USE POINTS NOT PROGRAMMED INTO THE DATA BASE. ALSO, BOTH THESE SITUATIONS COULD HAVE BEEN PREVENTED IF WE HAD NOT DEPENDED SO MUCH ON THE AUTOMATION AND GONE BACK TO BASIC FLYING.

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  12. Accession Number: 137943
    Synopsis: HEADING AND TRACK DEVIATION ON STAR ARR.
    Narrative: SHINE ARR INTO CLT FROM OVER TYS GOES TYS DIRECT BURLS INTXN, THEN SHINE INTXN, THEN JOHNS INTXN, THEN CLT VOR. FMC DATA BASE DATED 2/XX/90 WAS MISSING BURLS INTXN, AND HAD TYS DIRECT SHINE, THEN THE ARR. WE HAD NOT NOTICED THE MISTAKE IN THE DATA BASE, AND AS WE PASSED TYS THE FMC AND AUTOPLT TOOK US S OF THE PUBLISHED ARR. ZTL CALLED THIS TO OUR ATTN JUST AS MY COPLT NOTICED THE DEVIATION ON HIS VOR NEEDLE. WE CORRECTED BACK TO THE ARR AND PROCEEDED TO CLT. MY EXPERIENCE HAS BEEN THAT THE FMC CAN FLY YOU FOR HUNDREDS OF HOURS AND NEVER MAKE A MISTAKE. THIS CAN LULL YOU INTO TRUSTING IT MORE THAN A PLT SHOULD UNTIL IT LEADS HIM ASTRAY.

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  14. Accession Number: 146839
    Synopsis: ACR MLG ALT DEVIATION ALT UNDERSHOT. ALT CROSSING RESTRICTION NOT MET.
    Narrative: FLT 5/90, CLT-SFO, DSNDING INTO SFO WBND TO MOD VOR. BEING VECTORED AND ASSIGNED 250 KIAS, GIVEN LOCKE ARR TO SFO, WE FOUND THAT THE LOCKE ARR IS NOT IN OUR RNAV/FMC DATA BASE. WHILE BLDG THE ARR INTO FMC (WITH F/O READING DATA AND CAPT INPUTTING FMC) FOUND ACFT NO LONGER IN AUTOTHROTTLE SPD MODE, AND AIRSPD UP TO 290 KIAS. BEGAN REDUCING BACK TO 250 KTS AS CTLR ASKED ABOUT OUR SPD. CONTINUED DSNT W OF MODESTO IN FMC VNAV MODE WITH CLRNC TO CROSS LOCKE INTXN AT 10000'. CTLR ASKED US DURING DSNT IF WE WOULD MAKE THE RESTRICTION; F/O AFFIRMED WE WOULD. A MINUTE OR SO LATER I TOLD F/O TO TUNE IN SCAGGS ISLE VORTAC AND VERIFY OUR POS. WE FOUND WE WERE AT LOCKE, NOT THE 10-12 MI SE SHOWN BY FMC. CTLR THEN TOLD US WE WERE AT LOCKE. OUR ALT WAS APPROX 14000'. I ACKNOWLEDGED OUR ERROR ON THE RADIO AND EXTENDED THE SPD BRAKES, HURRYING DOWN TO 10000'. AFTER STABILIZED AT 10000', I HAD THE F/O CHK THE POS WE HAD PUT INTO THE FMC FOR LOCKE. WE FOUND THAT HE HAD GIVEN ME THE DISTANCE FROM UPEND TO LOCKE, RATHER THAN THE MILEAGE OF LOCKE FROM SCAGGS ISLE VORTAC. RECOMMENDATIONS: AIRLINE SHOULD PROVIDE COMPLETE DATA BASE IN RNAV (FMC). WHEN NECESSARY TO BUILD DATE, ONE PLT BUILDS INTO FMC WHILE OTHER MONITORS ACFT. SECOND PLT THEN VERIFIED VALIDITY OF NEW DATA BY CHKING LAT/LONG COORDINATES BEFORE DATA IS ACTIVATED. USE VORTAC BACKUP AS SOON AS ALT RESTRICTIONS ARE ISSUED. SUPPLEMENTAL INFO FROM ACN 146837: COCKPIT WORKLOAD WX, SB AM, WALKUP CALL TO START THIS TRIP.

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  16. Accession Number: 146839
    Synopsis: ACR MLG ALT DEVIATION ALT UNDERSHOT. ALT CROSSING RESTRICTION NOT MET.
    Narrative: FLT 5/90, CLT-SFO, DSNDING INTO SFO WBND TO MOD VOR. BEING VECTORED AND ASSIGNED 250 KIAS, GIVEN LOCKE ARR TO SFO, WE FOUND THAT THE LOCKE ARR IS NOT IN OUR RNAV/FMC DATA BASE. WHILE BLDG THE ARR INTO FMC (WITH F/O READING DATA AND CAPT INPUTTING FMC) FOUND ACFT NO LONGER IN AUTOTHROTTLE SPD MODE, AND AIRSPD UP TO 290 KIAS. BEGAN REDUCING BACK TO 250 KTS AS CTLR ASKED ABOUT OUR SPD. CONTINUED DSNT W OF MODESTO IN FMC VNAV MODE WITH CLRNC TO CROSS LOCKE INTXN AT 10000'. CTLR ASKED US DURING DSNT IF WE WOULD MAKE THE RESTRICTION; F/O AFFIRMED WE WOULD. A MINUTE OR SO LATER I TOLD F/O TO TUNE IN SCAGGS ISLE VORTAC AND VERIFY OUR POS. WE FOUND WE WERE AT LOCKE, NOT THE 10-12 MI SE SHOWN BY FMC. CTLR THEN TOLD US WE WERE AT LOCKE. OUR ALT WAS APPROX 14000'. I ACKNOWLEDGED OUR ERROR ON THE RADIO AND EXTENDED THE SPD BRAKES, HURRYING DOWN TO 10000'. AFTER STABILIZED AT 10000', I HAD THE F/O CHK THE POS WE HAD PUT INTO THE FMC FOR LOCKE. WE FOUND THAT HE HAD GIVEN ME THE DISTANCE FROM UPEND TO LOCKE, RATHER THAN THE MILEAGE OF LOCKE FROM SCAGGS ISLE VORTAC. RECOMMENDATIONS: AIRLINE SHOULD PROVIDE COMPLETE DATA BASE IN RNAV (FMC). WHEN NECESSARY TO BUILD DATE, ONE PLT BUILDS INTO FMC WHILE OTHER MONITORS ACFT. SECOND PLT THEN VERIFIED VALIDITY OF NEW DATA BY CHKING LAT/LONG COORDINATES BEFORE DATA IS ACTIVATED. USE VORTAC BACKUP AS SOON AS ALT RESTRICTIONS ARE ISSUED. SUPPLEMENTAL INFO FROM ACN 146837: COCKPIT WORKLOAD WX, SB AM, WALKUP CALL TO START THIS TRIP.

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  18. Accession Number: 148718
    Synopsis: ACR MLG TRACK HEADING DEVIATION ON SID OUR OF LAS.
    Narrative: I WAS CAPT ON FLT FROM LAS - PIT. THE EQUIP WAS AN MLG. THE F/O WAS TO FLY THE LEG, SO HE LOADED THE RMC WITH THE RTE TO BE FLOWN. THE FMC NAV DATA HAD THE DEP RWY 25 AND THE SID OVETO-8 AS WS FILED. WE WERE CLRED TO PIT OVETO-8 DOVECREEK TRANSITION AS FILE. THE DEP IN THE FMC WAS CORRECT TO OVETO INTXN, BUT THEN WENT DIRECT TO DVC INSTEAD OF CONTINUING TO THE INTXN N 3652.8 W 11346.2 (UNNAMED) THEN TO DVC (SEE INSERT). LA CTR QUESTIONED US AS TO BEING S OF COURSE AND INDICATED NO TFC CONFLICT BECAUSE OF THE LATE HR. WHEN ATC ADVISED US OF OUR DEV S, ATC ASKED IF OUR INS (IRS) SYS WAS PROGRAMMED CORRECTLY BECAUSE THEY HAD SEEN OTHER INS EQUIPPED ACFT (RNAV) MISS THIS INTXN AND PROCEED DIRECT TO DVC FROM OVETO. THIS IS A SITUATION THAT WILL REPEAT ITSELF. THE FMC IS LOADED WITH OVETO 8 SID WITH NO TRANSITION PROVIDED. THE NEXT FIX IS DVC WHICH IS ALSO THE TRANSITION. THE NORMAL LOADING IS TO INSERT THE SID OVETO 8 THEN DVC. THIS FIX WITH NO NAME N 3652.8 W 11346.2 IS EASILY MISSED. ACCORDING TO LA CTR IT HAS HAPPENED SEVERAL TIMES BEFORE, AND MAY HAPPEN AGAIN. THERE WAS NO TFC OR WX INVOLVED IN OR FLT, BUT A DIFFERENT TIME OF DAY IT COULD BE A SAFETY PROB. THE FMC NAV DATA NEEDS THE TRANSITION OR AT LEAST A NAME ON THE INTXN N365.2 W 11346.2 SO IT WILL NOT BE EASILY MISSED.

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  20. Accession Number: 160754
    Synopsis: ADVTECH ACR LFT EXPERIENCES TRACK DEVIATION DUE DIFFERENCE BETWEEN FILED FLT PLAN AND THAT STOREDIN ACFT FMS DATA BASE.
    Narrative: ATC ASKED IF OUR RTING WAS TVCJ522 YYZ. WE SAID "YES" AND THEN WERE TOLD WE WERE SO OF THEARWY AND TO TURN L HDG 070 TO AVOID A HOT MIL AREA. (THIS ATCASSIGNED AIRSPACE WAS UNKNOWN TO THE CREW UNTIL THE NEXT DAY BECAUSE THE DEPT OF DEFENSE, FOR SECURITY REASONS, WILL NOT ALLOW IT TO BE DEPICTED ON NAV CHARTS). WE THEN WERE CLRED "DIRECT AU SABLE (ASP) J552." I PROGRAMMED "DIRECT ASP" IN THE CDU AND SELECTED "MANAGED NAV" ON THE FLT MGMNT PANEL (FMP). I THEN LINE SELECTED ASP AND ENTERED "J522/YYZ" AND INSERTED. THE SCRATCH PAS SHOWED "ARWY MISMATCH". THINKING I MADE A PROGRAMMING ERROR, I TRIED AGAIN; SAME OUTCOME. I SUSPECTED A CLRNC ERROR AND I CHKED THE HL CHART AND CONFIRMED "ASP" WAS NOTON J522. MEANWHILE, VALUABLE TIME AND DISTANCE PASSED AND CTLR GAVE A 160 HDG TO VOID A HOT MIL AREA. (THIS UNKNOWN SEC AREA WAS NOT REALIZED UNTIL A FEW MINS LATER). I TURNED THE HDG BUG IN THE DIRECTION OF 160 AND ACFT GAVE ME 15 DEGS ANGLE OF BANK. I USED THIS MOMENT TO CORRECTLY ENTER THE ARWY USING "TVC J522YYZ" AND IT APPEARED. ATC THEN ASKED IF WE WERE IN 160 HDG AND WE SAID WE WERE COMING TO IT AFTER MOMENTARILY HOLDING 110. AT THE SAME TIME THE F/O IN ADDITION TO TALKING TO ATC AND VERIFYING PROGRAMMING REMOTELY TUNED TVC AND DISPLAYED IT IN VOR MODE ON HIS NAV DISPLAY (ND). AT THIS POINT MY ND SHOWED THE ACFT N OF COURSE AND THE F/O ND SHOWED ACFT INTERCEPTING THE RWY R. WE THEN TURNED L TO PROCEED USING THE F/O ND AND EVENTUALLY WERE CLRED DIRECT ALB. THE NEXT DAY I DISCUSSED THIS EVOLUTION WITH MY EMPLOYER AND VISITED ZMP CTR TO SEE THEIR DISPLAY. WHILE THERE I WATCHED THE SAME FLT PROCEED THROUGH THE AREA SAFELY BECAUSE THE CAPT ADDED "KLANT" INTXN USING PLACE/BEARING-PLACE/BEARING ON THE PRIMARY FLT PLAN PAGE. THIS WAS DONE BECAUSE THE ACFT DATA BASE AS CONFIRMED BY ME AIRBORNE AND THE COMPANY LATER, DID NOT HAVE "KLANT" IN THE DATA BASE. THIS RESULTED IN THE FOLLOWING: MCDUFLT PLAN = MSP J106 CRB J522 YYZ ROC ALB GOMZ BOS. ACTUAL FLTPLAN = MSP J106 GRB J522 TVC YYZ ROC ALB GOMZ BOS. THE CREW WAS UNKNOWINGLY PROCEEDING FROM TVC DIRECT TO YYZ WITH THE POTENTIAL TO ENTER A HOT MIL AREA. AS A RESULT OF THE INCORRECT DATA BASE AND ATC CLRNC NOT INITIALLY BEING VALID AT ASP, WE ENTERED A HOT AREA N OF THE ARWY. OUR SECONDARY FLT PLAN, WHICH WAS A COPY OF THE INITIAL PRIMARY MATCHED THE CLRNC GIVEN IN MSP.

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  22. Accession Number: 168971
    Synopsis: ACR MLG TRACK HEADING DEVIATION FOLLOWING ACFT COMPUTER STORED ARR ROUTE THAT DIFFERED FROM THE FLT PLANNED ROUTE.
    Narrative: WE WERE CLRED AT TKOF THE FLT PLAN RTE WHICH INCLUDED THE ACORD 2 ARR AT VANCOUVER, BC FROM OVER THE GEG VOR. HOWEVER, AFTER PASSING THE GEG VOR, WE NOTICED THE PUBLISHED ARR RTE DID NOT CORRESPOND WITH THE ONBOARD FMC RTE AS PICTURED ON THE HSI. IMMEDIATELY A CORRECTION WAS MADE TO THE LEFT TO FLY THE PUBLISHED RTE WHICH INCLUDED A DOGLEG TO THE S. THE CORRECTIVE PROC WOULD BE TO COMPARE AND DOUBLE-CHK THE COMPUTER STORED INFO WITH THE PUBLISHED PROC WELL IN ADVANCE OF ARRIVING AT THE PUBLISHED POINTS ALONG THE COURSE, AND NOT BEING COMPLACENT IN ASSUMING THE COMPUTER HAS ALL THE CORRECT AND UP TO DATE INFO.

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  24. Accession Number: 189119
    Synopsis: ADVANCED COCKPIT MLG FLC ENTERS WRONG ARR ARPT INTO ACARS AND GETS YESTERDAY'S FLT PLAN AND FOLLOWS IT.
    Narrative: THE DEP STATION (BWI) WAS INADVERTENTLY ENTERED AS THE DEP AND ARR STATIONS IN ACARS (E.G., BWI/BWI). CLRNC FOR THE TRIP WAS RECEIVED THROUGH ACARS. SINCE I HAD FLOWN THIS TRIP SEQUENCE SEVERAL TIMES WITH THE SAME FO AND THE RTEING WAS ALWAYS THE SAME I ONLY CHKED THE TRANSPONDER CODE AND ALT. I DID NOT QUESTION WHY WE WERE CLRED TO 10000 FT INSTEAD OF THE USUAL 4000 FT. NO CHK OF OUR CLRNC WAS MADE WITH BWI SINCE NONE IS REQUIRED (USUALLY AT LEAST THE READING BACK OF THE TRANSPONDER CODE IS REQUIRED AT SOME ARPTS). WE RECEIVED THE CORRECT LOAD CLOSEOUT DURING TAXI AND THEN TOOK OFF. THE FIRST CLUE THAT SOMETHING WAS AMISS WAS WHEN DEP CTL WOULDN'T ANSWER US. A QUICK RETURN TO TWR GOT US ON THE RIGHT FREQ. I CALLED DEP CTL AND SAID THAT WE WERE CLBING TO 10000 FT. HE DIDN'T QUESTION WHY WE WERE CLBING TO 10000 FT INSTEAD OF 4000 FT (THE REAL CLRNC ALT), BUT INSTEAD CLRED US TO 17000 FT AND TOLD US TO CHANGE OUR SQUAWK (CLUE #2). CLUE #3 CAME WHEN WE REQUESTED OUR FLT PLAN FROM ACARS AND IT GAVE US A FLT PLAN FOR A DFW DIRECT BWI TRIP THAT WAS FLOWN THE DAY BEFORE. NOW IT ALL CAME INTO FOCUS. I CHKED OUR ACARS CLRNC AND IT WAS INDEED FOR FLT #1 DFW TO BWI FLOWN THE DAY BEFORE INSTEAD OF FLT #2 BWI TO ORD! FACTORS THAT I FEEL CONTRIBUTED TO THIS INCLUDE: 1) FATIGUE -- IT WAS AN EARLY MORNING GO PLUS I HAD FLOWN 7 OUT OF THE PREVIOUS 9 DAYS. 2) COMPLACENCY -- I HAD FLOWN THE SAME TRIP WITH THE SAME FO SEVERAL TIMES BEFORE. 3) PROCS -- IF WE WERE REQUIRED TO AT LEAST READ BACK THE TRANSPONDER CODE TO CLRNC DELIVERY WE WOULD HAVE FOUND OUT SOMETHING WAS WRONG. 4) COMPUTER PROGRAMMING -- BIAS THE COMPUTER TO PREVENT IT FROM GIVING OUT CLRNCS THAT ARE 12 HRS OLD. WE DID GET THE CORRECT LOAD CLOSEOUT SO WHY NOT THE CORRECT CLRNC?

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  26. Accession Number: 210639
    Synopsis: AN ACR LGT CREW, WITH ALL OF THE MOST ADVANCED FLT GUIDANCE EQUIP, FAILED TO FLY A STAR AS PUBLISHED.
    Narrative: THIS EVENT INVOLVES A FEELING OF COMPLACENCY BROUGHT ON BY THE LATEST GENERATION OF HIGHLY AUTOMATED, GLASS- COCKPIT AIRPLANES (IN THIS CASE, AN LGT). THE CAPABILITY TO FULLY PROGRAM COMPLEX PROCS (SIDS, STARS, TRANSITIONS, APCHS) CAN LEAD TO A PERCEPTION ON THE PART OF THE FLC THAT THE FLT MGMNT SYS, ONCE PROGRAMMED, WILL FOLLOW A PARTICULAR PROC FULLY AND COMPLETELY. OUR FLT INVOLVED AN ARR TO MEMPHIS INTL. WE WERE CLRED FOR A 'MIDDY 8' (ARR FROM OVER PXU). WE HAD DSNDED TO 10000 FT AT 'MIDDY' INTXN. THE ATIS INDICATED APCHS IN PROGRESS TO 36L, 36R, AND 27. AFTER SOME DISCUSSION WITH THE CTLR, WE WERE TOLD TO EXPECT AN ILS TO 36R. OUR PARTICULAR PROBLEM AROSE IN THAT AS WE APCHED 'CLARK' INTXN (8 DME FROM MEM) WE WERE NOT AWARE OF OUR NEED TO TURN TO A 175 DEG HDG FOR LNDG TO THE N. ONE REASON FOR THIS WAS THAT WE WERE IN THE MIDST OF A COCKPIT BRIEFING AND AN APCH CHKLIST FOR AN AUTOLAND TO 36R. BUT THE MAJOR REASON FOR OUR LACK OF AWARENESS WAS OUR PRESENTATION OF THE MIDDY ARR ON OUR DISPLAY UNIT'S (MCDU) FLT PLAN PAGE. THE WAYPOINTS DISPLAYED WERE: MIOLA, MIDDY, H226 MANUAL, ------ FLT PLAN DISCONTINUITY. THAT IS, AFTER 'MIDDY' INTXN, OUR FMS HAD US FLYING A HDG OF 226 DEG (INDICATED BY 'H226 MANUAL') WITH NO MENTION BEING MADE OF 'CLARK' INTXN, OR THE REQUIRED TURN TO 175 DEG. OUR SENSE OF 'AUTOMATED COMPLACENCY' LEAD US TO BELIEVE THAT A HDG OF 226 DEG WAS CORRECT AS WE BUSIED OURSELVES WITH APCH BRIEFINGS AND CHKLISTS. WE THUS FLEW PAST 'CLARK' INTXN UNTIL ROUGHLY 6 DME FROM MEM, WHEN THE CTLR REALIZED WE HAD NOT TURNED AND TOLD US WE SHOULD BE ON A HDG OF 175 DEG. WE THEN TURNED, CHKED THE CHART, AND REALIZED WE HAD, IN FACT, MISSED THE TURN POINT. WE KNOW THAT THE CHART IS THE GOSPEL AND THAT THE FMS SHOULD ALWAYS BE VERIFIED AGAINST THE CHARTS, YET WE ALLOWED OURSELVES, DURING A BUSY WORK PERIOD, TO FULLY TRUST THE AUTOMATED SYS, WHICH WE ERRONEOUSLY ASSUMED WAS COMPLETE AND CORRECT. THIS BRINGS UP 2 POINTS REGARDING HIGHLY-AUTOMATED SYSTEMS: WHY WAS 'CLARK' INTXN NOT IN THE DATA BASE PROGRAM? BECAUSE OF CAPACITY CONSTRAINTS? IF SO, WHY NOT INCREASE CAPACITY? IT SEEMS TO CREATE CONFUSION WHEN SOME, BUT NOT ALL, INTXNS ARE INCLUDED IN PROCS.

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  28. Accession Number: 217774
    Synopsis: AN LGT ACR CREW HAD A FALSE TCASII ALERT AT THE SAME TIME THAT THEIR CLRNC WAS BEING CHANGED TO A DEP THAT WAS NOT IN THEIR FMC DATA BASE.
    Narrative: DEPARTING LAX, RWY 25R, CLRED FOR LOOP 9. AFTER TKOF, DEP CTL TURNED US TO HDG 160 DEGS WHICH IS NOT THE NORMAL LOOP 9 HDG. A FEW MINS LATER, HE TOLD US THAT WE WERE ON THE LAXX 1 DEP AND WOULD BE TURNING TO SLI SOON. WHEN TURNED TO SLI, WE WERE CLRED TO 'SEAL BEACH AND THE DAGGETT TRANSITION.' SINCE THE LAXX 1 IS NOT IN THE FMC DATA BASE, AND SINCE WE WERE VERY CLOSE TO SLI, I ENTERED SLI, DIRECT DAG. AT THE SAME TIME, WE SWITCHED THE TCASII FROM TA TO TA/RA AND GOT AN IMMEDIATE FULL DOWN RA WHICH WAS OBVIOUSLY A 'GLITCH,' BUT WHICH WAS STILL DISTRACTING. AFTER PASSING SLI, THE CTLR ASKED US WHERE WE WERE GOING, AND WE, OF COURSE, REALIZED THAT SOMETHING WAS AMISS. WE CHKED THE LAXX 1 DEP PAGE AND DISCOVERED THE 'DOG LEG' BTWN SLI AND DAG. THE CTLR SEEMED TO BE UNCONCERNED, AND CLRED US DIRECT TO LAS. THIS WAS A TYPICAL 'COMBINATION OF INGREDIENTS' ERROR WHICH IS WHAT LEADS TO ACCIDENTS. SUPPLEMENTAL INFO FROM ACN 217471: THIS WAS A TYPICAL EXAMPLE OF MULTIPLE INPUTS IN A SHORT TIME. HAVING THE LAXX 1 DEP IN THE DATA BASE WOULD HAVE BEEN A BIG HELP IN AVOIDING THIS SITUATION. TCASII FALSE RA WAS A MAJOR DISTR TO NORMAL OPS IN THIS CASE POINTING OUT THE IMPORTANCE OF WORKING OUT ALL 'BUGS' IN THIS SYS.

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  30. Accession Number: 360010
    Synopsis: FLC OF AN FK10 FAILED TO FOLLOW ATC INSTRUCTIONS WHEN THEY FLEW A HDG FROM A DIFFERENT FIX THAN THAT INTENDED, OR GIVEN, BY ATC. FURTHERMORE, THE CTLR DID NOT HEAR THE WRONG FIX WHEN THE FO READ BACK THE CLRNC. THE FLC THOUGHT THAT THEIR FMS WAS NOT RIGHT FOR NOT INCLUDING THE STAR FIX INTENDED BY ATC. HOWEVER, REVIEW OF STARS INDICATE THAT THE FIX IS NOT INCLUDED FOR THE IAD ARPT, ONLY THE DCA, WHICH WAS THE ARPT AT WHICH RPTR LANDED.
    Narrative: AT APPROX XX00Z FLT WAS ON DULLES APCH (FREQ 119.85) AND GIVEN A 185 DEG HDG FROM AML. THE FO READ BACK '185 DEG HDG OUT OF AML.' AT THAT TIME A DISCONTINUITY WAS INDICATED ON THE FMS F-PLAN PAGE AT THE LAST FIX ON THE STAR. THE CAPT DIALED IN 185 DEGS ON THE EFIS PANEL AND PULLED THE HDG KNOB THUS SELECT 185 DEGS. SHORTLY THEREAFTER (1 MIN), DULLES ATC SAID CLRED DIRECT SHAKI. THE FO STATED WE WERE ON A 185 DEG HDG FROM AML. ATC SAID, 'NO, THE 185 DEG HDG WAS TO BE FROM SHAKI, NOT ARMEL. I DON'T KNOW WHAT YOU READ BACK BUT THE HDG IS 185 DEGS FROM SHAKI, FLY HDG 090 DEGS.' THE FO STATED HE HAD READ BACK 185 DEGS FROM ARMEL. (I DO NOT BELIEVE THAT WAS WHAT THE CTLR SAID.) THERE WAS SOME ADDITIONAL DISCUSSION BTWN THE CAPT AND ATC IN REGARDS TO THE DISCREPANCY IN WAYPOINTS AND FIX. CAPT STATED THAT SHAKI IS NOT IN OUR FMS DATABASE FOR THE STAR AND THAT WE WOULD FORWARD THIS TO THE COMPANY FOR CORRECTION AND CHANGE. THE CAPT ASKED ATC IF THE DEV HAD CAUSED ANY PROBS AND ATC STATED NONE. FLT COMPLETED APCH AND LNDG AT DCA. AS A FOOTNOTE, ATC INDICATED THAT OTHER ACRS HAD SIMILAR PROBS WITH FMS DATABASES AND AREA STARS IN SPECIFIC DULLES DEPS. CTLR (ATC) SHOULD HAVE CAUGHT THE INCORRECT READBACK (IF IN FACT IT WAS INCORRECT) AND CORRECTED THE VOICE COM.

  31.  
  32. Accession Number: 360830
    Synopsis: FLC OF A CL65, REGIONAL JET, FAILED TO FOLLOW THEIR FLT PLAN CLRNC ROUTING RESULTING IN ATC INTERVENTION AND REDIRECTION TO GET BACK ON INTENDED RTE. THE ACFT FMS WAS PROGRAMMED IN ERROR AND THE FLC USING THIS PROGRAM HAD BEEN OFF COURSE AND HAD NOT KNOWN IT.
    Narrative: OUR CLRNC FROM YYZ-BOS: (TORONTO 2 V252 J16 ALB AS FILED.) AFTER RECEIVING THE ABOVE CLRNC WE PROGRAMMED THE FLT MGMNT SYS (FMS) FOR THE FLT. THE COMPANY RTE WHICH WAS STORED IN THE FMS MEMORY WAS AS FOLLOWS.....(YYZ01 EHMAN HANKK ALB ALB01 GDM...). AS WE LOOKED OVER THE 2 PLANS WE NOTICED THE DISCREPANCY BTWN THE CLRNC OF V252 J16 AND THE FMS VERSION OF EHMAN...HANKK. ON THE CHARTS THERE IS NO INTXN WHERE V252 AND J16 MEET BUT THE 2 LISTED INTXNS ON THE FMS WERE WITHIN A FEW MI AND WE ASSUMED THAT THE FMS RTE WAS HOW THE COMPANY HAD CHOSEN US TO MAKE THE TRANSITION FROM V252 TO J16. FLYING ALONG BTWN EHMAN AND HANKK ZOB ASKED US IF WE SHOWED OURSELVES ON THE AIRWAY. WE REPLIED, 'YES,' AND ASKED IF THERE WAS A PROB. THE CTLR SAID HE SHOWED US TO BE 7 MI N OF J16 AND WE IMMEDIATELY KNEW THAT THE FMS RTE WAS NOT IN FACT IN CORRELATION WITH WHERE THE CTR HAD INTENDED US TO FLY. WE DID MATCH OUR CLRNC WITH THE FMS ON THE GND, BUT WE MADE THE WRONG ASSUMPTION WITH USING THE INTXNS INSTEAD OF PROGRAMMING EXACTLY WHERE V252 AND J16 MEET. I'VE NOTICED SEVERAL TIMES IN USING THE FMS THAT THE NUMBERS REPRESENTING THE RADIAL OF AN AIRWAY DO NOT EXACTLY COME UP THE SAME AS WHAT IS LISTED ON THE CHARTS, BUT IT HAS NEVER BEEN QUESTIONED BEFORE. I THINK THIS FACTORED IN WITH OUR ACCEPTANCE OF THE PREPROGRAMMED COMPANY RTE. IT WAS VERY CLOSE AND IN THE PAST THAT HAS ALWAYS WORKED. WE HAVE CONTACTED THE COMPANY AND HAVE BEEN INFORMED A NOTICE WILL BE PUT ON ALL TORONTO TO BOSTON FLT RELEASES NOTIFYING CREW MEMBERS OF THIS PARTICULAR CONFUSING ISSUE. IN SPEAKING WITH SEVERAL OTHER PLTS AT THE COMPANY WHO HAVE FLOWN THE SAME RTE, SOME HAD NOTICED, SOME HAD NOT. IT'S NOT THAT WE DIDN'T CHK THE ACCURACY OF THE FMS DATA, WE JUST ASSUMED IT WAS WHAT WAS INTENDED DUE TO THE CLOSE PROX OF THE TWO. SHORTLY AFTER THE CTLR ASKED US ABOUT THIS ISSUE, HE CLRED US DIRECT TO ALBANY VOR AND SEEMED TO HAVE NO FURTHER QUESTIONS. I UNDERSTAND WHAT HAPPENED AND WILL BE MORE VIGILANT IN THE FUTURE AS TO CORRELATING FMS COMPANY PLANS AND OUR CLRNCS.

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  34. Accession Number: 363420
    Synopsis: ATC INTERVENED TO ADVISE FLC OF A B737-300 THAT THEY WERE 20 MI OFF COURSE. FLC DISCOVERED THAT THE ACFT FMC ROUTING WAS DIFFERENT THAN THE ACTUAL CLRNC GIVEN BY ATC.
    Narrative: ROUTING IN FMC WAS DIFFERENT THAN FLT PLAN ROUTING. THE FMC ROUTING WAS A COMPANY PRELOADED ROUTING. CTR CTLR INFORMED US THAT WE WERE 20 MI FROM FLT PLAN RTE. WE THEN DISCOVERED DISCREPANCY. BOTH PLTS FAILED TO VERIFY FMC ROUTING WITH ROUTING ON DISPATCH RELEASE. IT WAS THE LAST LEG OF A 4 DAY TRIP WHERE WE HAD GONE FROM NIGHT FLYING (XA30 AM ARR IN BALTIMORE) ON FIRST DAY TO YA00 AM DEP FROM COLUMBUS ON LAST DAY.

  35.  
  36. Accession Number: 365550
    Synopsis: FLC OF A DO328 FAILED TO FOLLOW THEIR FPR DUE TO AN ERROR IN THEIR FMC STORED FLT PLAN RESULTING IN ATC INTERVENTION TO BRING THEM BACK ON COURSE.
    Narrative: I WAS THE CAPT OF FLT FROM GJT TO COS. OUR CLRNC WAS AS FILED WHICH WAS GJT-JNC-HBU J28 DIRECT COS 168 DEG RADIAL AT 38 DME TO COS. WE PROGRAMMED THE FMS WITH A STORED FLT PLAN WHICH WE THOUGHT WAS CORRECT, BUT THE STORED FLT PLAN WAS IN ERROR FROM THE POINT AFTER HBU VOR. THE STORED FLT PLAN WENT FROM HBU DIRECT COS AND NOT J28 TO THE COS 168 DEG RADIAL AT 38 DME. AS WE APCHED THE HBU VOR, I BEGAN TO LOOK UP SOME PERFORMANCE DATA IN THE ACFT'S POH. THE FO WAS THE PF AND HE WAS TRACKING THE FMS COURSE. I WAS BACKING HIM UP USING VOR NAV. AFTER PASSING THE HBU VOR, THE FO TRACKED A COURSE DIRECT TO COS WHICH WAS APPROX THE 050 DEG RADIAL FROM HBU AND NOT THE 080 DEG RADIAL, WHICH WOULD HAVE BEEN J28. I HAD NEGLECTED TO MONITOR THIS BECAUSE I WAS LOOKING UP SOME PERFORMANCE DATA. AFTER ABOUT 30 MI, CTR CAME ON FREQ AND SAID, FLT XX TURN R 20 DEGS -- YOU ARE NOW CLRED J28 TO THE COS 168 DEG RADIAL AT 38 DME COS, WHICH WAS HOW WE WERE CLRED BEFORE. I THEN REALIZED WHAT WAS WRONG AND REPROGRAMMED THE FMS CORRECTLY. ANOTHER CONTRIBUTING FACTOR WAS THAT THE FO WAS NOT MONITORING HIS MOVING MAP DISPLAY CORRECTLY BECAUSE HE HAD THE SCALE DOWN TO LOW SO THAT IT DID NOT SHOW HIS NEXT WAYPOINT WHICH IF HE HAD SEEN IT, HE WOULD HAVE REALIZED HE WAS PROCEEDING DIRECT TO COS AND NOT THE 168 DEG RADIAL AT 38 DME OFF COS FIX.

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  38. Accession Number: 365690
    Synopsis: CL65 FLC FLY THE WRONG HDG OUT OF IIU VOR WHILE ON FMS. THE DATABASE HAD A KNOWN ERROR BUT THE FLC PASSED OVER THE FLT RELEASE WARNING OF SAME WITH A SHORT AND ERRED ASSESSMENT.
    Narrative: FMS CANNED FLT PLAN WAYPOINT GRNIN INTXN WAS INCORRECTLY SPELLED GRINN IN FMS UPDATE. FMS PLOTTED THE MISSPELLED WAYPOINT 260 DEGS FROM IIU VOR. THE CORRECT HDG AFTER IIU FOR GRNIN IS 195 DEGS. FMS COMMANDED THE TURN TO 260 DEGS. THIS WAS FLOWN FOR ABOUT 10 MI (80 SECONDS) UNKNOWN TO FLC. ATC ADVISED US OF THE DEV AND CORRECTED OUR HDG ON COURSE. WE WERE NOT ADVISED OF ANY SEPARATION PROB. THE FLT RELEASE DID INCLUDE AN ADVISORY STATING THE PROB WITH THE MISSPELLED WAYPOINT. THE WAYPOINT WAS REVIEWED BY THE CAPT PRIOR TO THE FLT. HE SAW NO PROB WITH THE WAYPOINT IN QUESTION. I WAS RUSHED IN MY PREFLT DUTIES AND WAS UNABLE TO REVIEW THE RTE MYSELF. FACTORS THAT LED TO THE DEV: 1) SMALL ERRORS IN SPELLING ARE DIFFICULT TO DETECT WHEN THE LETTER 'I' IS MOVED -- GRNIN VERSUS GRINN. 2) THE FLC'S INATTN ON THE GND AND IN THE AIR. 3) THE FLC'S COMPLACENCY WITH THE FMS'S ABILITY TO NAV. TAKES FLC OUT OF THE NAV LOOP TO A CERTAIN DEGREE.

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  40. Accession Number: 365700
    Synopsis: B757 CREW FLIES TO WRONG POS WHEN CLRED TO A FIX ON FMS. THE DATABASE HAD A KNOWN ERROR IN COORDINATES BUT FLC FAILED TO READ THE COMPANY NOTAM THAT HAD BEEN ISSUED.
    Narrative: ATC CLRED US TO THE LIN 89 FIX, SO WE USED THE FMC DATABASE LIN89. THE DATABASE LIN89 COORDINATES ARE N3846.5/W11911.3 WHICH IS WHAT WE FLEW TO. THE LIN89 (LIN062089) COORDINATES ATC WANTED US TO FLY TO WAS N3820.6/W11909.2. THESE COORDINATES WERE ON THE FLT PLAN, BUT NOT IN THE DATABASE CORRECTLY. CALLED DISPATCH AND THEY ARE AWARE AND HAVE POSTED NOTAMS, BUT DATABASE HAS NOT BEEN UPDATED.

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  42. Accession Number: 368880
    Synopsis: AN ACR B757 FLC FLEW THE WRONG COURSE ON DEP FROM MIA. ALERT DEP CTLR CORRECTED THEM.
    Narrative: I FLEW LEG AS CAPT. I DID NOT FOLLOW PROPERLY THE VALLY TRANSITION ON THE MIA 7 SID. AFTER TKOF, DEP CTL GAVE US 090 DEG HDG TO INTERCEPT VALLY TRANSITION. I SET 090 DEGS IN HDG WINDOW AND PRESSED HDG SELECT. I ARMED LNAV. HSI/FLT DIRECTOR ENGAGED LNAV A FEW SECONDS LATER. I OBSERVED THAT COURSE LINE ON HSI CONNECTED WITH VALLY INTXN. I FOLLOWED THE FLT DIRECTOR COMMANDS. DEP CTL THEN ASKED FOR VERIFICATION OF OUR HDG. WE REALIZED THEN THAT WE HAD FAILED TO CORRECT THE LNAV RTE TO REFLECT THE SID COURSE FROM VKZ TO VALLY, BUT HAD FLOWN INSTEAD THE MIA DIRECT VALLY COURSE THAT HAD BEEN DOWNLOADED TO THE FMS. CAPT AND FO HAD VERIFIED THAT ACARS PDC MATCHED FLT PLAN AND THAT FLT PLAN FIXES MATCHED FMC DOWNLOADED RTE FIXES. THESE ACTIONS ALONE DID NOT CATCH THE ERROR IN THE LNAV RTE RELATED TO THE SID. I SUSPECT THAT OURS WAS NOT AN UNCOMMON ERROR. PERHAPS PLACING THE SID ABOVE AND ADJACENT TO THE ACARS PDC RTE, INSTEAD OF IN THE TEXT AT THE BOTTOM OF THE MESSAGE, WOULD HELP PREVENT THIS TYPE OF MISTAKE. ALSO, A MESSAGE ADVISING CREWS TO BE ALERT FOR THIS PARTICULAR MISTAKE MIGHT HELP, SINCE THE POTENTIAL ERROR IS BUILT INTO THE DOWNLOADED FMC RTE. OF COURSE, BOTTOM LINE IS THAT MY INADEQUATE ATTN TO DETAIL CAUSED THE DEV. CONTRIBUTING FACTORS WERE FATIGUE FROM SHORT LAYOVER AND PICKUP AND CONFUSION IN THE COCKPIT RELATED TO MAINT AND PAX PROBS, BOTH BEFORE AND AFTER WE LEFT THE GATE.

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  44. Accession Number: 375123
    Synopsis: B757 ACFT ON ILS AUTOLAND APCH WAS INSTRUCTED TO CROSS INTXN AT 3500 FT. FLC HAD ENGAGED AUTOLAND AND WERE ON GS WHICH TOOK ACFT BELOW RESTR ALT.
    Narrative: WE WERE ON AN ILS APCH TO RWY 25L TO LAX. THE COMPANY HAD REQUESTED AN AUTOLAND APCH AND LNDG SO THE ACFT WAS ON AUTOPLT FOR THE AUTOLAND. WE WERE SLOWED SEVERAL TIMES ON THE APCH AND WERE TOLD TO CROSS 'HUNDA' INTXN AT 3500 FT. WE WERE ON OR ABOVE THE GS UNTIL 'GAATE' INTXN AND ON THE GS FROM 'GAATE' INTXN TO TOUCHDOWN. HUNDA IS NOT DEPICTED ON OUR FMS, BUT WE FIGURED IT TO BE 4.8 MI FROM 'LIMMA' INTXN WHICH IS DEPICTED. WE CROSSED 4.8 MI FROM 'LIMMA' (HUNDA) AT 3460 FT TO 3500 FT. REST OF APCH WAS NORMAL WITH A NORMAL AUTOLAND TOUCHDOWN. WE BELIEVE WE DID EVERYTHING AS REQUESTED, HOWEVER, WE WERE TOLD TO CONTACT SOCAL APCH CTL BY TELEPHONE. WHEN I DID I WAS TOLD THEY WOULD CHK THEIR EQUIP TOMORROW AND WOULD CONTACT ME IF ANY ACTION WAS TO BE TAKEN AGAINST ME DUE TO GS DEV. I DO BELIEVE 'HUNDA' INTXN SHOULD BE DEPICTED ON OUR FMS RATHER THAN HAVING TO FIGURE IT OUT ON APCH.

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  46. Accession Number: 378826
    Synopsis: B757-200 ENTERS THE HOLDING PATTERN AT ARNES INTXN WITH A R TURN AS PER THE FMC DATABASE AS SELECTED BY THE FLC. THE 'PUBLISHED' PATTERN CALLS FOR A L TURN ENTRY. APCH CTLR CATCHES THEIR ERROR AND GIVES THEM A NEW HDG FOR THE L PATTERN. RPTRS CITE COMPANY POLICY OF ENTERING STANDARD R-HAND TURNS FOR ARR WAYPOINTS IN THE DATABASE, EVEN IF NOT CORRECT.
    Narrative: CLRED FOR CIVET 1 ARR AND IN CONTACT WITH SOCAL/LAX APCH FLT WAS 2 MI E OF ARNES AT 12000 FT ASSIGNED BY ATC. CTLR TOLD FLT TO HOLD AT ARNES AS PUBLISHED AS EMER WAS IN PROGRESS AT LAX AND MAINTAIN 12000 FT UNTIL EAC OF AM48Z. FO PROGRAMMED FMC'S FOR ARNES HOLDING BY LINE SELECTING THE ARNES WAYPOINT TO THE SCRATCHPAD AND LNDG IT IN THE HOLD PAGE. THE HOLDING PATTERN DEPICTED ON THE CRT SHOWED A STANDARD HOLDING PATTERN AND BECAUSE OF THE SHORT DISTANCE TO THE FIX, THE ACFT ENTERED THE HOLDING PATTERN WHILE BEING SLOWED TO HOLDING SPD OF 210 KTS. AS THE R- HAND TURN WAS COMMENCED, BOTH PLTS NOTICED AND COMMENTED ON THE FACT THAT THE PUBLISHED HOLDING PATTERN SHOWED L- HAND TURNS AND AS COMS WITH APCH CTL WERE ABOUT TO ADDRESS THE WRONG TURN, THE CTLR TOLD THE FLT THAT THE HOLDING PATTERN WAS L TURNS AND GAVE US AN IMMEDIATE TURN FOR A VECTOR BACK TO THE HOLDING FIX (ARNES) TO RE-ENTER THE PATTERN WITHOUT COMMENT. SINCE ALL MISSED APCH HOLDING PATTERNS IN THE FMC DATABASE SHOW THE CORRECT PATTERN TURN WHEN THE ARNES WAYPOINT WAS SELECTED ON THE HOLD PAGE, AND DUE TO THE CLOSENESS OF THE FIX WHEN THE CLRNC WAS RECEIVED, THE CREW PRESUPPOSED THAT THE DEPICTED PATTERN TURNS WERE CORRECT AND THE FMS EXECUTED SAME UNTIL THE HOLDING PATTERN WAS XCHKED WITH THE PUBLISHED ARR PAGE. APPARENTLY, THE HOLDING PATTERNS FOR ARR WAYPOINTS ARE NOT STORED IN THE DATABASE AS PUBLISHED BUT AS STANDARD PATTERNS, THUS MAKING CONFIRMATION WITH THE COMMERCIAL CHART'S PUBLISHED ARR MANDATORY. THIS IS CONTRARY TO THE PUBLISHED MISSED APCH HOLDING PATTERNS DEPICTED IN THE DATABASE WHICH SHOW THE PROPER TURN FOR THE DEPICTED PATTERN. ONE CANNOT ASSUME THAT ALL WAYPOINTS IN THE FMC DATABASE WITH AN ASSOCIATED HOLDING PATTERN WILL SHOW THE CORRECT PATTERN TURNS AND THEREFORE MUST BE VERIFIED. SUPPLEMENTAL INFO FROM ACN 378491: I WENT TO THE HOLD PAGE AND PROCEEDED TO PAGE 2. I ENTERED OUR HOLD INSTRUCTIONS AND EXECUTED. BECAUSE WE WERE ALREADY AT ARNES, I DID NOT HAVE TIME TO LOOK AT THE APCH SHEET IN THE CLIP ON THE WINDOW. BECAUSE SO MANY OF OUR HOLDING PROCS ARE DEPICTED CORRECTLY, I ASSUMED THE STANDARD PROC OF R TURNS WAS CORRECT.

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  48. Accession Number: 380641
    Synopsis: AN ACR B757 FLC RPTS THAT THERE IS A DISCREPANCY BTWN THE PRINTED COMMERCIAL CIVET STAR AND THE COMMERCIALLY SUPPLIED FMC DATABASE FOR THIS STAR. THE RPTR NOTED THAT THIS PROB ALSO EXISTED AT ANOTHER ACR.
    Narrative: I DON'T EXPECT THIS TO BE A PROB, HOWEVER, I CONSIDER THE SIT LESS THAN SATISFACTORY. CIVET 1 ARR HAS RECENTLY BEEN CHANGED TO CIVET 2 ARR. ARNES XING ALT USED TO BE BTWN 10000 FT AND 11000 FT. IT IS NOW 10000 FT FIRM. THE FMC'S DATABASE SHOWS 10000 FT OR ABOVE. FO WAS FLYING AND WAS SLOWING AS REQUESTED TO 210 KTS. THIS MAKES IT HARD TO DSND AT SAME TIME. I NOTICED THAT HE WAS GETTING HIGH ON PROFILE, AND TOLD HIM TO BE SURE TO CROSS ARNES AT 10000 FT AS I COULD SEE HE WAS REFING DATABASE INFO. HE DUMPED IT OVER AND MADE IT MORE OR LESS. HE REACHED 10000 FT ABOUT 1/2 MI AFTER XING ARNES. IT WASN'T PRETTY. IT SEEMS AN UNSATISFACTORY SIT WHEN BOTH PAPER CHART AND ELECTRONIC DATABASE ARE PRODUCED BY THE SAME COMPANY AND YET HAVE DIFFERENT DATA. I RODE JUMP SEAT ON ANOTHER CARRIER ON SEP/XA/97. THE PLTS NOTICED THAT THE CIVET XING ALT HAD BEEN CHANGED FROM BTWN FL180 AND 14000 FT TO BTWN 17000 FT AND 14000 FT. THE NEW DATABASE WAS NOT DUE TO CHANGE UNTIL THE FOLLOWING DAY. ALSO, THE EFFECTIVE DATES OF DATABASE CHANGES IS CONFUSING TO MOST PEOPLE. THE LAST DAY FOR THE OLD DATABASE WAS SEP/XB/97 AND THE FIRST DAY FOR THE NEW DATABASE WAS ALSO SEP/XB/97. AN OBVIOUS IMPOSSIBILITY. AN ACR CAPT SAID THAT HIS B757- 200'S FMC DATABASE DIFFERED FROM HIS APCH PLATE FOR THE CIVET STAR AT LAX IN SEVERAL IMPORTANT AREAS. HE SAID THAT HE HAS NOTED OTHER LESS IMPORTANT DISCREPANCIES IN COMMERCIALLY SUPPLIED CHARTS AND DATABASE INFO RECENTLY AND SO HE WATCHES THESE AREAS MORE CAREFULLY. HE SAID THAT HE WAS ABLE TO AVOID ANY GROSS ERRORS IN THESE CASES, BUT HE WAS CURIOUS AS TO WHETHER ANY OTHER RPTS HAVE BEEN MADE. HE SAID THAT HE HAS ALSO REPORTED THESE ERRORS TO HIS COMPANY.

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  50. Accession Number: 385330
    Synopsis: FLC OF AN ACR MDT FAILED TO FOLLOW FLT PLAN ROUTING DUE TO A MISPROGRAMMED FMS RESULTING IN ATC INTERVENTION AND A VECTOR HEADING TO ASSIGNED COURSE.
    Narrative: ON A SCHEDULED FLT FROM HPN TO CVG FO AND I BOTH CHKED FLT PLAN ON RELEASE (FLT RELEASE) AND COMPARED IT TO FLT PLAN IN THE FMS (CANNED WITH ONCE A MONTH CHANGE). THE FLT PLAN IN THE BOX (FMS) WAS WRONG (J6). WE MODIFIED THE FLT PLAN TO PUT THE ARR FOR CVG IN. HOWEVER, I DID NOT CLR THE OLD FLT PLAN BUT CHOSE TO MODIFY IT. BTWN ETX AND AIR ON J80 ARE 5 INTXNS WITH A TURN AT KIPPI INTXN (SUZIE AND HOUTN INTXNS ARE NEXT EACH OTHER ON J80 AND J6). WE DID NOT TAKE OUT (OR CLR) HOUTN FROM FLT PLAN AND WE CHKED THE COMMERCIAL CHARTS AND MISTAKENLY THOUGHT HOUTN INTXN WAS ON J80 WHEN IT WAS ON J6. ZNY GAVE US A 270 DEG HDG BACK TO J80 ABOUT HALF WAY BTWN ETX AND HOUTN INTXN. NO CONFLICTS NOTED, FMS CORRECTED.

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  52. Accession Number: 400010
    Synopsis: A B757 DSNDING INTO LIMA, PERU, HAS AN INTERSECTION CROSSING RESTRICTION DRAWN TOO FAR AWAY FROM DESTINATION. THIS PLACES ACFT AT LOWER ALT IN MOUNTAINOUS TERRAIN.
    Narrative: DSCNT INTO LIMA PERU. ATC FACILITY: LIMA CENTER. LOCATION: 115 MI N OF SLS VOR. ON ARRIVAL INTO LIMA PERU ON THE SLS1 ARRIVAL TOKAN TRANSITION THERE IS A FIX NAMED WPT16. FMC SHOWS TO CROSS THIS FIX AT FL250 OR ABOVE. THE ONLY FIX ON THE ARRIVAL PAGE OF THE COMMERCIAL CHART SAYS TO CROSS 110 MI FROM LIMA VOR AT FL250 OR ABOVE. THIS FIX IS APPROX 56 MI TOO FAR N FOR THE CROSSING ON THE APCH PLATE. THIS FIX IS APPROX 115 MI N OF SLS VOR, NOT LIM VOR AS IT SHOULD BE. THIS COULD LET A CREW THINK IT IS SAFE TO DSND 56 MI TOO EARLY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR NOTICED THE CROSSING RESTRICTION WAS DRAWN FROM SLS INSTEAD OF LIM. IN THE PROGRAM THE FLT CREW USES, IT GAVE A WPT16, WHICH CAN BE SYMBOLIC FOR 116 MI N OF SLS. HOWEVER, THE DISTANCE SHOULD BE FROM LIM, NOT SLS. WITH THE DISTANCE DRAWN FROM SLS, THIS PLACES ACFT AT A LOWER ALT IN MOUNTAINOUS TERRAIN. RPTR FEELS THAT FMC WAS MISPROGRAMMED BY THE GND CREW OR DISPATCH. THIS PROGRAMMING UPDATE OCCURS ON AN EVERY 5 TO 6 WEEK BASIS. RPTR HAS MADE CONTACT WITH HIS DISPATCH OFFICE AND THEY STATED THEY WERE WORKING ON THE PROBLEM. DISPATCH HAS THE RESPONSIBILITY FOR THIS TYPE OF PROBLEM.

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  54. Accession Number: 405498
    Synopsis: AN ACR MD88 FLC PERFORMING THE HOLLY 9 STAR FORGOT TO TURN TO THE 355 DEG HDG AFTER PASSING OLIVV INTXN. THE RPTR SAID THAT THE FLC DID NOT SEE THIS REQUIREMENT BECAUSE OF THE GRAPHIC PRESENTATION AND THE FMS DOES NOT HAVE THE HDG ON ITS STORED COURSE.
    Narrative: STAR HAS HDG AFTER LAST FIX. DID NOT SEE THE HDG AND CONTINUED STRAIGHT TOWARD MEM. ASKED CTLR FOR LOWER AND WAS ASKED IF WE WERE IN THE TURN. THIS IS WHEN WE REALIZED OUR ERROR. THE HOLLY 9 STAR PLATE IS CLUSTERED AND NEEDS TO BE CHARTED SO HDG IS MORE EASILY SEEN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS MD88 CAPT SAID THAT ALTHOUGH THEY BRIEFED THE HOLLY 9 STAR BOTH HE AND THE FO MISSED THE HDG AFTER OLIVV. AFTER LNDG, THE FLC LOOKED AT THE OTHER STARS INTO MEM AND NOTICED THAT ALL OF THEM HAVE A HDG AFTER THEIR LAST INTXN THAT MAY BE REQUIRED DEPENDING ON THE RWY ASSIGNED. THESE REQUIREMENTS ALSO VARY DEPENDING ON THE TYPE OF ACFT (TURBINE VERSUS NON TURBINE). THEN THE FLC RECHKED THE RTES STORED IN THEIR FMS AND REALIZED THAT NONE OF THESE HDGS WERE STORED IN THEIR SYS. THE CAPT SAID THAT IF THEY HAD BEEN, THERE WOULD HAVE BEEN NO PROB SINCE THEY WERE USING THE LNAV MODE AND FOLLOWING ON THEIR MAP PRESENTATION WHEN THEY DEVIATED. THE RPTR RECOMMENDED THAT THE GRAPHIC BE CLRER AND THE COMPLETE STAR RTE, DEPENDING ON THE RWY ASSIGNED, BE STORED IN THE FMS. HE WAS NOT FAMILIAR WITH MEM AND NOW HE KNOWS WHAT TO WATCH FOR ON THE ARR, BUT HE IS CONCERNED ABOUT OTHER PLTS.

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  56. Accession Number: 405720
    Synopsis: A320 DATABASE MALFUNCTION DISTRACTS FLC IN SEA AIRSPACE.
    Narrative: PROGRAMMED THE GLASER 3 ARR TO SEA AND ILS TO RWY 16R. OUR CLRNC WAS THE GLASER 3 ARR AND THIS WAS SELECTED ON THE APCH PAGE OF THE MCDU COMPUTER. THE ILS RWY 16R WAS SELECTED, BUT THE MCDU COMPUTER DISPLAYED THE FMS RWY 16R. THIS WAS NOT THE APCH THAT WE WERE CLRED FOR. ALSO ON THE GLASER 3 ARR, THE LAST INTXN WAS OMITTED FROM THE ARR. ALL THESE MIS-CUES BY THE DATABASE REQUIRED US TO REPROGRAM THE ARR AND THE APCH. THIS REQUIRED ONE PLT TO FLY THE ACFT WHILE THE OTHER PLT PROGRAMMED THE CORRECT ARR AND APCH. THUS, NO ONE IS LOOKING OUTSIDE FOR TFC. FORTUNATELY NOTHING HAPPENED EXCEPT FOR A LATE TURN ON THE GLASER 3 APCH TO THE LAST NON-DISPLAYED INTXN TO RWY 16R.

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  58. Accession Number: 405970
    Synopsis: A CL65 FLC ALLOWS THE ACFT TO ENTER A STANDARD HOLDING PATTERN, NOT REALIZING THAT THE DEFAULT TURN FOR A NON PROGRAMMED HOLDING FIX IS TO THE R. THE TURN REQUIRED AT FAK WAS A L TURN.
    Narrative: AFTER BEING CLRED TO FLAT ROCK VOR (FAK) AND THE JASON 2 ARR AT FL240, WE WERE RECLRED TO 'HOLD AS PUBLISHED AT FLAT ROCK VOR.' NO HOLDING PATTERN IS PUBLISHED AT FAK ON THE JASON 2 ARR, SO WE MADE A DIRECT ENTRY WITH R-HAND TURNS BEFORE WE HAD TIME TO REALIZE THAT THE PUBLISHED HOLDING PATTERN IS ON THE HIGH ALT CHART AND IS A NON STANDARD PATTERN WITH L TURNS. THE FMS DID NOT SHOW A L- HAND PATTERN AND ITS DEFAULT FUNCTION INITIATED A STANDARD R HAND HOLDING PATTERN, BEFORE ATC NOTIFIED US OF OUR ERROR. SUBSEQUENT TURNS IN HOLDING WERE MADE TO THE L. WE WERE NOT AWARE OF ANY TFC CONFLICTS.

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  60. Accession Number: 414985
    Synopsis: EA32 CREW WAS UNABLE TO PROGRAM ACFT FMC TO COMPLY WITH A 12000 FT XING RESTR.
    Narrative: AIRBUS FMC INCOMPATIBILITY WITH SAN BARET 4 ARR (TNP/EED/PKE TRANSITION). THE AIRBUS 319/320 FMS NAV COMPUTER CANNOT BE PROGRAMMED TO COMPLY WITH THE '25 NM NE OF PGY VOR' AT 12000 FT MSL. UNLIKE BOEING AND OTHER FMS SYS, THE AIRBUS FMS DOES NOT HAVE AN 'ALONG TRACK DISPLACEMENT' CAPABILITY. RECOMMENDATIONS: 1) CREATION OF A 'NAMED WAYPOINT' (LATITUDE/LONGITUDE) AT THE 25 DME POS, OR 2) MOVE THE XING RESTR TO THE DSS PGY FIX, WHICH IS IN THE AIRBUS DATABASE, OR 3) CONVINCE AIRBUS TO UPGRADE THEIR FMS (AIN'T GONNA HAPPEN!). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: CAPT IS CONCERNED THAT WITH ALL THE EMPHASIS ON ALLOWING THE AUTOMATION TO FLY THE ACFT, THE SID AND STAR ROUTING SHOULD BE BUILT ACCORDINGLY. THE WAY THIS ARR IS BUILT, IT PRECLUDES THE USE OF ACFT AUTOMATION.

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  62. Accession Number: 416490
    Synopsis: A B737-300 FLC COMPLAINS OF THE DESIGN FEATURES OF THE OPALE 4 ARR STAR CHART. THEY SUFFERED A HDG TRACK POS DEV ON APCH TO YYC.
    Narrative: INBOUND TO CYYC FROM SFO OUR CLRNC SINCE TKOF HAD BEEN 'OPALE DIRECT YYC.' WE LISTENED TO THE ATIS AT ABOUT 10 MINS PRIOR TO START OF DSCNT AND THEY WERE USING RWY 34. ABOUT 10 NM PRIOR TO OPALE, EDMONTON CTR CLRED US FOR THE 'OPALE 4 ARR.' WE TRIED TO LOAD THE ARR FROM THE FMC DATABASE, BUT FOUND IT WAS NOT AVAILABLE. WE BOTH REACHED FOR OUR CHARTS AND THE FO BEGAN READING THE ARR FIXES AND I TYPED THEM INTO THE FMC WITHOUT ERROR. HE TOLD ME THE PLATE SAID NOT TO EXPECT LOWER THAN 10000 FT UNTIL E OF MOGOT. I DID NOT BACK UP HIS REVIEW OF THE CHART MYSELF, ALTHOUGH I GLANCED AT THE ARR FIXES. I WAS THEN DISTR FOR SEVERAL MINS BY TURB, ICING AND PREPARING FOR THE APCH. WHEN WE GOT TO MOGOT, HE DID NOT TURN THE ACFT AND I LOOKED AT THE AERO PAGE AND SAW 100 DEG HDG OFF OF MOGOT AND TOLD HIM TO TURN TO 100 DEGS. A FEW SECONDS LATER, CALGARY APCH CALLED US TO TELL US WE WERE FLYING THE ARR FOR RWY 28! LIKE MANY INCIDENTS, THERE WAS A STRING OF EVENTS THAT LED TO THE NAV DEV. THE MAIN ISSUE IS THE CHARTING CHART MAKER USES FOR THE ARRS TO CYYC. I BELIEVE CHART MAKER SHOULD PRINT IN LARGE BOLD TYPE 'RWY 10' ABOVE 'ALBRO,' 'RWY 34' ABOVE 'HANSI,' AND 'RWY 16/RWY 28' ABOVE 'MOGOT' TO BETTER ALERT THE PLT TO THE DIFFERENT RWY TRANSITIONS! ALSO, THE PRACTICE OF PLACING NOTES VERTLY (IE, RWY 34/16 NOTES) ON A PAGE WHEN EVERYTHING ELSE IS L TO R HORIZLY ORIENTED DOES NOT CATCH YOUR EYE WHEN YOU ARE HURRIED! AS PLTS, WE DON'T READ THE TEXT DESCRIPTIONS WHEN WE ARE HURRIED! ALSO CONTRIBUTING, WE HAD FAR MINIMUM REST AFTER A TOUGH DAY PREVIOUSLY AND WE WERE NOT PHYSIOLOGICALLY AT A PEAK. THE FO WAS NEW TO OUR AIRLINE. AND ATC SHOULD HAVE GIVEN US THE CLRNC MORE THAN 1 MIN BEFORE THEY EXPECTED US TO FLY IT! ALSO CONTRIBUTING: THE FACT THAT THE ARR WAS NOT IN THE FMC DATABASE WHICH GREATLY INCREASED OUR WORKLOAD.
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