TRACK DEV. INCORRECTLY PROGRAMMED FMS.

Date: 1995-09 · Aircraft: Commercial Fixed Wing · Phase: climb

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

Synopsis

TRACK DEV. INCORRECTLY PROGRAMMED FMS.

Narrative

OUR CLRNC OUT OF ONT WAS THE POMONA 6 DEP; DAGGETT TRANSITION; MAINTAIN 14000 FT. ATIS SAID DEP RWY WAS RWY 8L FOR NOISE ABATEMENT. FMS WAS CORRECTLY LOADED TO REFLECT OUR CLRNC; BY THE CAPT. JUST AT PUSHBACK; NEW ATIS CHANGED THE RWY TO RWY 26R. THE CAPT CHANGED THE RWY ON THE 'RTE' PAGE OF THE FMS TO REFLECT RWY 26R. DUE TO SOFTWARE PROBS; WE HAVE BEEN WARNED TO MAKE ALL CHANGES TO DEPS ON THE DEP/ARR PAGE; BUT THIS DID NOT OCCUR TO US FOR A SIMPLE RWY CHANGE. FOR SOME UNEXPLAINED REASON; CHANGING THE RWY ON THE 'RTE' PAGE CHANGED DOWNTRACK FIXES TO REFLECT THE 'HASSA 4' DEP. THE RTE PAGE SHOWED 'POMONA 6' TO DAGGETT; BUT THE LEGS PAGE HAD THE 'HASSA 4' WAYPOINTS. SINCE WE WEREN'T USING THE LEGS PAGE; THIS DID NOT SHOW ON OUR DISPLAY UNIT AND WENT UNNOTICED. AT END OF RWY 26R; WE WERE GIVEN A 7000 FT HOLD DOWN. WE TOOK OFF AND FLEW THE DEP. LNAV WAS ENGAGED AT ABOUT 2000 FT AND THE CAPT HAND FLEW THE LNAV COURSE. IT COMMANDED A TURN TO INTERCEPT THE POM 323 DEG COURSE; PER 'HASSA 4' DEP. ABOUT 5 MI PAST POM; AT 7000 FT; INDICATING ON COURSE; I TOLD DEP WE NEED A CLB TO CLR THE MOUNTAINS. WE WERE CLRED TO 14000 FT AND WERE TOLD WE WERE N OF COURSE; TURN IMMEDIATELY TO 270 DEGS TO INTERCEPT POM 300 DEG COURSE. I RELOADED THE DEP AND THE ENTIRE FMS PICTURE CHANGED TO REFLECT THE CORRECT DEP. AT FIRST; I THOUGHT THE CAPT MUST HAVE LOADED THE DEP IMPROPERLY. HOWEVER; WE REPEATED THE STEPS OUTLINED ABOVE SEVERAL TIMES ON 2 DIFFERENT ACFT WITH THE SAME RESULTS. A SIMPLE RWY CHANGE ON THE RTE PAGE CAUSED A DIFFERENT DEP TO BE LOADED ON THE LEGS PAGE; WITHOUT REFLECTING THE CHANGE ON THE RTE PAGE. TO AVOID THIS PROB; THE RWY CHANGE HAD TO BE LOADED ON THE DEP/ARR PAGES. ADD TO THIS THE LAST MIN CHANGE AT PUSHBACK AND THE HIGH WORKLOAD TAXI ENVIRONMENT (CHKLISTS; ETC) AND WE WERE LED INTO A TRAP BY THE SOFTWARE ANOMALY.

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