GROSS NAV ERROR. HDG TRACK POS DEV. NON ADHERENCE TO ATC CLRNC. FOREIGN AIRSPACE.

Date: 1994-03 · Aircraft: Commercial Fixed Wing

Anomalies: aircraft-equipment-problem-less-severe|deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-clearance|other-unspecified

Synopsis

GROSS NAV ERROR. HDG TRACK POS DEV. NON ADHERENCE TO ATC CLRNC. FOREIGN AIRSPACE.

Narrative

DURING CRUISE FLT OVER NORTHEASTERN CANADA; GANDER CTR CLRED THE ACFT DIRECT TO REDBY WHILE STILL IN RADAR CONTACT. OCEANIC CLRNC HAD JUST BEEN RECEIVED WHEN OTHER ACFT IN THE AREA ASKED CTR OF ANY UPCOMING RIDE RPTS. #3 INS WAS TAKEN FROM 'XTX/TKE POS' TO 'WIND POS' TO MONITOR WINDS ALOFT. CREW MEALS WERE ALSO BEING BROUGHT UP TO COCKPIT WHICH CAUSED MOMENTARY DISTR. SHORTLY THEREAFTER; GANDER CTR ADVISES CREW THE ACFT APPEARED S OF COURSE AND THEN CLRED THE ACFT DIRECT CARPE. ACFT PROCEEDS DIRECT TO CARPE WITH NO FURTHER INCIDENT. #3 INS CONFIRMED ACFT HDG DIRECT CARPE AND ON COURSE. LEAVING GANDER'S AIRSPACE; CTR ADVISED CREW THAT NO PROBS OR CONFLICTS HAD BEEN CREATED. DISCREPANCY IN COURSE LOCATION FOUND TO BE LOCATION OF REDBY HAD BEEN CHANGED BUT OLD LOCATION WAS STILL IN FMS DATABASE. ALSO; NO NOTE ON FLT PLAN MENTIONED CHANGE IN REDBY LOCATION. ACFT ENTER NAT SYS AND CONTINUED ON COURSE TO DEST. SUPPLEMENTAL INFORMATION FROM ACN 265999: DURING PREFLT THE RTE OF FLT WAS LOADED INTO THE FMS BY THE CAPT AND CHKED BY THE FO ACCORDING TO COMPANY PROCS. HOWEVER; DISTR IN THE COCKPIT DUE TO AN ELECTRICAL PROB THAT MAINT WAS WORKING ON MAY HAVE CAUSED THE CREW TO MISS THE FACT THAT THE FMS COORDINATES FOR REDBY WERE WRONG. EVIDENTLY THE FMS DATABASE HAD NOT BEEN UPDATED SINCE THE LATEST CHART REVISION WHEN REDBY COORDINATES WERE CHANGED. REDBY COORDINATES WERE IN THE FMS BY 1 DIGIT; WHICH WAS EASY TO MISS DURING THE XCHK. SINCE WE WERE ON A DIRECT RTE; THE FINAL XCHK (CORRECT HDG; TIME; AND DISTANCE) WAS IMPOSSIBLE. SUPPLEMENTAL INFORMATION FROM ACN 266003: ACFT HAD NOT ENTERED NAT SYS AT TIME OF EXCURSION. ACFT WAS IN RADAR CONTACT WITH ATC AT TIME OF EXCURSION; REINFORCING FLC'S BELIEF THAT 'ALL WAS WELL.'

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