1995-04 · NASA ASRS report 301239
IMPROPERLY LOADED INS TAKES ACFT ON A TRACK DEV.
FOR A TRIP TO NRT FROM GUAM; SHOW WAS XA00 FOR FLT PLANNING AND XB00 FOR TKOF. OUR FLT PLAN WAS A CANNED RTE IN OUR INS EXCEPT FOR ONE WAYPOINT 'BIPEP.' BIPEP WAS TO BE LOADED BTWN NOGAK AND ADKAK ON A337 TO CLR AN AREA OF AIRSPACE. EVEN THOUGH THIS CHANGE HAS BEEN IN PLACE FOR APPROX 1 YR; IT HAS NOT BEEN ADDED TO OUR CANNED RTE. THE REASON FOR THIS DIVERSION FROM THE AIRWAY IS ALSO NOT DEPICTED ON THE MAP WE USE 'FAR FAST 7 AND 8 HI.' FO LOADED BIPEP AFTER ADKAK INSTEAD OF AFTER NOGAK. THIS WAS THE FIRST CAUSE OF OUR DEV. PRIOR TO TKOF WHEN WE WERE CHKING INS WAYPOINTS AND COORDINATES AGAINST FLT PLAN WAYPO INTS AND COORDINATES; SOME TIME PRIOR TO REACHING NOGAK; I WAS CALLED FROM THE COCKPIT BY GND STAFF. WHEN I RETURNED TO THE COCKPIT ANOTHER PROB WAS TAKING PLACE AND CHKING WAYPOINTS FELL THROUGH A CRACK. IN MY ABSENCE FROM THE COCKPIT; FO NUMBERED WAYPOINTS ON FLT PLAN WITHOUT COMPARING THE WAYPOINTS WITH THE INS NUMBERS. THIS LED ME TO BELIEVE HE HAD CHKED THE WAYPOINTS. THIS WAS CAUSE #2 FOR OUR DEV. DURING FLT AFTER PASSING NOGAK; FO MADE POS RPT 'NOGAK; ADKAK BIPEP' ON HF AND TYO CTR ACCEPTED THE RPT AS SPOKEN BY MY FO EVEN THOUGH IT WAS INCORRECT! THIS WAS THE THIRD CAUSE OF THE DEV. THE FO USES AN EAR PIECE WHEN MAKING POS RPTS. NORMALLY I TURN MY SPEAKER ON HIGH AND MONITOR. HOWEVER; FOR SOME REASON; I DID NOT THIS TIME. THIS WAS THE FOURTH CAUSE OF THE DEV. AT OUR COMPANY; THE PNF TALKS ON THE RADIO AND HANDLES NAV WHICH INCLUDES CHKING MAGNETIC HDGS FROM FLT PLAN AGAINST ACFT HDGS. THIS WAS NOT DONE BY FO AT NOGAK. TYO CTR INSTRUCTED US TO 'CONTACT TYO CTR AT 33 DEGS N ON 133.6.' ON OUR FLT PLAN 33 DEGS N IS BIPEP. IN OUR CASE 33 DEGS N WAS IN A RESTR AREA WHICH WE AND TYO CTR DISCOVERED AFTER A SQUAWK WAS ASSIGNED AND RADAR CONTACT MADE. FORTUNATELY; THE DAY WAS SUNDAY AND NO CONFLICTS OCCURRED. FROM THIS INCIDENT I WAS REMINDED NOT TO ALLOW MYSELF TO GET DISTRACTED BY GND SITS WHEN PERFORMING TASKS RELATED TO FLT AND NOT TO TRUST OTHER CREW MEMBERS TO PERFORM THEIR DUTIES WITHOUT CHKING UP ON THEM. I KNOW WHERE THE BUCK STOPS. THE ITEMS CONTRIBUTING TO THIS DIVERSION FROM FLT PLAN ARE MY RESPONSIBILITY. I SHOULD MONITOR EVERYTHING; AS THIS FO HAS MADE OTHER ERRORS. ANOTHER FACTOR AFFECTING ME WAS I HAD BEEN ON THE ROAD 21 DAYS AND WAS READY TO GET HOME! HOME WAS ON MY MIND.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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