SMT ON SID PICKS UP WRONG PAGE AND BEGINS TO FLY LOST COM PROC INSTEAD OF THE PROPER SID PROC.

Date: 1994-09 · Aircraft: Small Transport; Low Wing; 2 Turboprop Eng · Phase: initial_climb

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

Synopsis

SMT ON SID PICKS UP WRONG PAGE AND BEGINS TO FLY LOST COM PROC INSTEAD OF THE PROPER SID PROC.

Narrative

ON A FUEL STOP AT SLC AN IFR FLT PLAN WAS FILED TO DEPART SLC AND JOIN THE J-154 NEBOUND TO THE DEST. THE WX; WHICH WAS A FACTOR IN THIS CASE; WAS 'NUMEROUS HVY RAINSHOWERS WITH SOME CLOUD TO GND LIGHTNING.' THE CLRNC WAS COPIED AND READ BACK ROUTINELY. THE CLRNC INCLUDED THE SALT LAKE 5 DEP. ALL FLT PREPARATIONS WERE ROUTINE INCLUDING THE TAXIING; ALTHOUGH DUE TO THE NON FAMILIARITY WITH THE AIRFIELD; THE AIRFIELD LAYOUT PAGE 10-9 WAS USED TO PROCEED TO THE RUNUP AREA OF RWY 35. FLYING IN THE R SEAT OF THE COCKPIT WAS AN INST RATED; MULTI-ENG PLT HELPING WITH SOME OF THE DUTIES. ONCE ALL OF THE PRE-TKOF PROCS WERE COMPLETE AND THE PLANE WAS IN THE #1 POS; A REVIEW OF THE DEP; RTE; AND ALT LIMIT WAS ACCOMPLISHED. THE COPLT HAD; AT MY REQUEST; LOCATED THE DEP PLATE AND; AFTER HIS REVIEW; HANDED THE OPEN APCH BOOK TO ME FOR MY REVIEW. WE DISCUSSED IT IN DEPTH SINCE IT WAS NOT THE EASIEST TO UNDERSTAND. AFTER THAT DISCUSSION WE WERE IN AGREEMENT THAT THE DEP FOR RWY 35 INCLUDED A L TURN TO INTERCEPT THE RADIAL 249; THEN A CLBING R TURN BACK TO THE VOR. THE TFC DENSITY WAS QUITE HVY WITH A LOT OF JET DEPS ON ALL RWYS. THE RAIN CELLS AT THE TIME WERE SIGNIFICANT; BUT NOT SERIOUS. THERE WAS ABOUT 50 PERCENT COVERAGE ON THE RADAR IN THE DIRECTION OF THE FLT. THE TKOF AND CLB WAS NORMAL FOR THE SHORT DISTANCE TO THE VOR. UPON COMMENCING THE L TURN TO INTERCEPT THE 249 RADIAL; AFTER PASSING THE VOR; THE CTLR QUESTIONED OUR INTENTIONS. AT THAT TIME; THE HDG WAS PASSING ABOUT 290 DEGS. HE CORRECTLY ANALYZED THAT WE WERE NOT FOLLOWING THE FLT PATH THAT HE HAD ANTICIPATED AND TOLD US TO TURN L TO 360 DEGS. HE ALSO STATED THAT THERE WAS TFC IN THE VICINITY AND ASKED THAT WE EXPEDITE THE TURN. IT WAS APPARENT THAT THERE WAS SOME URGENCY TO EXPEDITE; WHICH WE DID. THE FLT CONDITIONS AT THE TIME WAS IN AND OUT OF RAINSHOWERS. NO TFC WAS OBSERVED AT ANY TIME IN OUR VICINITY. THE DECISION TO COMPLY WITH THE 290 DEG L TURN TO THE ASSIGNED HDG OF 360 WAS NOT QUESTIONED. IT OCCURRED TO ME THAT THE SHORTEST DEV WOULD HAVE BEEN TO TURN R. WE FOLLOWED HIS DIRECTIONS. IT MAY HAVE BEEN THE RIGHT DECISION. I STILL DON'T KNOW THE LOCATION OR FLT PATH OF THE OTHER PLANE. THE FLT WAS QUICKLY ESTABLISHED ON THE CORRECT HDG AND PROCEEDED WITHOUT FURTHER DEV TO THE PLANNED DEST. THE CTLR INDICATED THAT SOME CONFLICT HAD OCCURRED WHICH HAD WORRIED HIM. MY REPLY WAS APOLOGETIC IN THAT I THOUGHT THAT I WAS FLYING THE CORRECT COURSE. PRIOR TO LEAVING THE FREQ; THE CTLR GAVE ME A PHONE NUMBER TO CALL; WHICH I PRESUMED WAS TO DISCUSS THE PROB. ONCE THE FLT WAS SAFELY ENRTE AND THE TIME WAS AVAILABLE TO FIGURE OUT WHAT HAD HAPPENED; THE COPLT AND I REVIEWED EVERY DETAIL. I HAVE ALWAYS PRIDED MYSELF ON FLYING TO A HIGH DEG OF PERFECTION. WE DISCOVERED; IN OUR REVIEW; THAT THERE WAS A TRAP LAYING WITHIN THE PAGES OF THE PLATES. IT IS SUBTLE; BUT IT CAN CAUSE AN UNSUSPECTING PLT TO DO EXACTLY AS I DID. AS THE COPLT TURNED THE PAGES FROM PAGE 10-9 TO 10-3A HE WAS READING THE TITLES OF THE DEPS. THE STANDARD FORMAT OF THE PLATES IS TO PRINT THE TITLE IN A FAMILIAR STYLE AND RIGHT ACROSS THE TOP OF THE PAGE. PLEASE SEE THE ATTACHED COPY OF THE PAGE USED ON SEP/XX/94. THE PAGE HE ACTUALLY STOPPED ON WAS THE 'LOST COM FOR THE SALT LAKE 5 DEP.' THE LOCATION; TITLE; POS ON THE PAGE; AND NAME ARE EXACTLY THE SAME AS THE ACTUAL DEP PAGE. AGREED THE LINE BELOW MODIFIES THE TITLE TO SAY IT IS A LOST COM PROC; BUT WITH 23 PAGES OF PLATS DEALING JUST WITH SLC; IT NECESSITATES RAPID READING AND SKIM READING. AS THE COPLT HANDED ME THE OPEN BOOK OF PLATES; MY FIRST TASK WAS TO CONFIRM THAT HE HAD THE CORRECT PAGE. SALT LAKE 5 DEP WAS WRITTEN CLRLY IN PROPER FORMAT ACROSS THE PAGE AND LEFT NO DOUBT THAT IT WAS THE CORRECT PAGE. THEN I GOT DOWN TO THE DETAILS OF HOW TO DEPART FROM RWY 35. THE MISTAKE HAD ALREADY BEEN MADE AND WAS UNLIKELY TO BE CORRECTED UNLESS SOMETHING CAUSED ONE OF US TO QUESTION THE RTE. I HAVE WRITTEN A LETTER OF THIS CONCERN TO THE PRODUCTION MGR AT COMMERCIAL COMPANY SO THAT OTHERS MAY BENEFIT FROM THE OBSERVATION. CONTRIBUTING FACTORS TO THE SIT WERE THE DETERIORATING WX IN THAT IT WAS A DISTR AND A CONCERN. I FEEL THAT THE HIGH TFC DENSITY WAS A FACTOR IN THAT THE TFC CTL SYS WAS OPERATING AT ITS MAX CAPACITY. HOWEVER; THE PRIMARY CONTRIBUTING FACTOR WAS THE TITLING OF THE PAGE WITH LOST COM PROCS IN THE SAME FORMAT AND STYLE THAT IS ALSO USED FOR THE DEP PAGE. ALSO; AN IMPORTANT FACET IS THAT PAGE 10-3 AND 10-3A ARE BACK-TO-BACK. AN ERROR WOULD BE MUCH MORE LIKELY TO BE DISCOVERED IF THE WERE ON FACING PAGES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES HE HAS NOT HEARD FROM COMMERCIAL CHART COMPANY AS YET. HE IS CONCERNED BECAUSE THE LOST COM PROCS ARE USUALLY FOUND AT THE BOTTOM OF THE PAGE NARRATIVE FOR THE ARPT THEY REF. THIS IS A DIFFERENT SETUP AND TOO SIMILAR TO THE ACTUAL DEP PAGE. MISTAKE ADMITTED BUT STILL BELIEVES THIS IS A POOR ARRANGEMENT FOR THE INFO.

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