ACR MLG TRACK HDG DEV FLYING SID OUT OF ONT. THEY WENT TOO FAR W BEFORE TURNING TO PDZ.

Date: 1991-08 · Aircraft: Medium Large Transport; Low Wing; 2 Turbojet Eng · Phase: climb

Anomalies: deviation-track-heading-all-types|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy

Synopsis

ACR MLG TRACK HDG DEV FLYING SID OUT OF ONT. THEY WENT TOO FAR W BEFORE TURNING TO PDZ.

Narrative

TOOK OFF FROM ONTARIO; CA; TO W ON A PRADO DEP; WHICH CALLS FOR A L TURN TO PARADISE VOR. INSTEAD; MAINTAINED RWY HDG; WAITING FOR DEP CTL TO SAY; 'CLRED DIRECT PARADISE.' TURNED AT ABOUT 7 MI AND 6000 FT WHEN CTLR NOTICED. ALTHOUGH I DON'T THINK I TECHNICALLY VIOLATED THE SID SINCE IT DOESN'T SAY WHEN TO TURN; I DON'T THINK THIS IS WHAT THEY INTENDED. I BELIEVE THE PRIMARY CAUSE WAS PLT FATIGUE. AWOKE AT XA30. HAD BREAKFAST AT XFOO BUT NO LUNCH. HAD HEADACHE...PROBABLY FROM LACK OF FOOD. FO HAD SIMILAR DAY. OTHER CAUSES: PRADO 2 SID PLATE ON WESTWARD TKOF SHOWS A L TURN; BUT DOES NOT SHOW WHERE. (IT CALLS FOR A R TURN WITHIN 1 NM WHEN LEAVING TO THE E). SOP CALLS FOR HDG SELECT INDICATOR TO BE ON RWY HDG FOR TKOF IN CASE OF ENG FAILURE...NOT INITIAL CLRED HDG. AT 400 FT FLYING FO CALLED; BY MISTAKE; FOR 'HDG SELECT' INSTEAD OF 'LNAV'; WHICH WOULD HAVE DIRECTED US TO PARADISE VOR. DURING THE TKOF CHKLIST; SOP CALLS FOR CAPT TO STATE 'HDG SELECT' AND THE INDICATED HDG; WHICH WAS RWY HDG. HIS MENTALLY REENFORCED MY TIRED MIND TO THINKING WE WERE GOING TO FLY RWY HDG. USUALLY; I ADD THE INITIAL CLRED HDG AND ALTS TO THE RESPONSE. HOWEVER; BEING TIRED; I REVERTED BACK TO THE MIN REQUIRED SOP. SINCE THE FO WAS FLYING AND WAS IN THE 'MAP' MODE; I WAS IN RAW DATA. BEING TIRED; I DID NOT REVIEW THE PROC IN THE MAP MODE. NORMALLY I DO THIS SINCE IT VISUALLY SHOWS ME WHAT THE COMPUTER THINKS WE SHOULD DO. THIS WAS A NEW DEP FOR ME FROM ONTARIO. ALL PREVIOUS DEPS GO W THEN N...USUALLY WITH A VECTOR. I WAS EXPECTING THE SAME. I BELIEVE THIS COULD HAVE BEEN PREVENTED BY: EATING R! DOUBLE CHKING A SID WHEN FLYING IT FOR THE FIRST TIME. CHK TO SEE WHAT THE ACFT COMPUTER MAP THINKS WE SHOULD DO. DON'T BACK OFF TO THE MIN SOP WHEN TIRED. THIS IS WHEN EXTRA CARE SHOULD BE TAKEN. REVISE THE PRADO SID PLATE TO SHOW ON A WESTWARD DEP WHEN THE L TURN TO PARADISE VOR SHOULD BE MADE.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.