FLC OF LGT DOES NOT FOLLOW PUBLISHED DEP PROCS ON CLBOUT AND CTLR INDICATES THEY MISSED THE TURN OVER THE VOR. PROBLEM PARTIALLY DUE TO LANGUAGE PROBLEM.

Date: 1998-04 · Aircraft: Commercial Fixed Wing

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

Synopsis

FLC OF LGT DOES NOT FOLLOW PUBLISHED DEP PROCS ON CLBOUT AND CTLR INDICATES THEY MISSED THE TURN OVER THE VOR. PROBLEM PARTIALLY DUE TO LANGUAGE PROBLEM.

Narrative

ACFT DEPARTED SJD ARRIVED LAX. WX WAS CLR WITH NO CLOUDS IN SIGHT. NO ATIS RECEIVED THAT DAY. 10-7 PAGES WERE REVIEWED (COMPANY PROCS). DEP PROC WAS DISCUSSED BY CAPT; NEW DEP PROC TO ME; BOTH IN TERMS OF ROUTE TO BE FLOWN AND RWY 34 DEP. 10-7 PAGE SAYS; 'MOST DEPS WILL BE A VFR CLB TO ON COURSE.' UJ51 TO LMM 5300 FT MCA IS LISTED ON THE BACK OF THE APCH PLATE FOR DEP. RWY 34 DEP PROC. CLB ON SJD VOR R348; MAKE R TEARDROP TURN TO SJD VOR WITHIN 10 NM TO MCA FOR DEPARTING RWY. WHILE COMS IN ENGLISH WERE NOT IMPOSSIBLE THAT DAY; KNOWING WHAT TO EXPECT THE CTLR TO SAY WAS WHAT MADE IT POSSIBLE TO UNDERSTAND THE DEP CLRNC. EVERYTHING WAS READ BACK IN THE CLRNCS TO CONFIRM UNDERSTANDING. I WAS THE PNF AND THEREFORE RESPONSIBLE FOR COMS ON GND AS WELL AS AIRBORNE. CLRNC WAS DISCUSSED AT GATE BETWEEN CREW; EXPECT NEW PROC (FOR ME) TO TAKE THE 003 R TO MARUX INTXN THEN A 310 DEG HDG. RWY 34 WAS THE LNDG RWY; SO RWY 34 WAS THE EXPECTED DEP RWY. ALREADY; WITH ALL THE THINGS KNOWN TO ME; 10-7; CREW REVIEW OF DEP; VFR DAY; ETC; WE WERE GOING TO DO A STRAIGHT OUT DEP; WITH THE EXCEPTION OF THE SLIGHT R TURN TO JOIN THE UJ51. I BELIEVE I HAD DONE ONE PREVIOUS DEP ON RWY 34 WEEKS EARLIER AND IT WAS A STRAIGHT OUT DEP ON THE 340 R. CLRNC FROM TWR WAS RECEIVED AND COPIED AND READ BACK AS I HAD IT WRITTEN DOWN. TWR MAY HAVE TOLD US TO REPORT XING OVER THE VOR; ON THAT POINT I CANNOT REMEMBER; HOWEVER THAT I DIDN'T READ BACK IN THE CLRNC BECAUSE I DID NOT EXPECT TO DO THAT AND I ASSUMED I MUST HAVE UNDERSTOOD HIM IMPROPERLY; AND THAT HE JUST WANTED US TO REPORT ON THE 003 R (DIFFICULT TO UNDERSTAND HIS ENGLISH). THAT SHOULD HAVE BEEN RED FLAG NUMBER ONE. I REMEMBER THAT ONE OF THE REASONS I GOT THE CLRNC CORRECT THE FIRST TIME WAS DUE TO THE FACT THAT WE HAD DISCUSSED THE CLRNC AT THE GATE; AND THOSE TWO VERSIONS MATCHED. CTLR'S ACCENT WAS DIFFICULT. IT IS IMPORTANT TO UNDERSTAND AT THIS POINT; THAT I HAD EXPECTED A VFR CLB ON COURSE EVEN THOUGH NOTHING DURING THE BRIEF OR THE CLRNC WAS STATED THAT WAY. I BELIEVE THAT IT WAS ASSUMED BY THE CAPT THAT I HAD REQUESTED A VFR CLB; WHICH I SHOULD HAVE DONE. ACR B WAS DEPARTING AHEAD OF US. WHILE I HAD NOT HEARD THEIR ORIGINAL CLRNC WHEN THEY WERE LEAVING 1500 FT; I HEARD THEM REPORT THEY WERE MAKING A TURN; AND I ASSUMED THAT THEY WERE TURNING TO JOIN THE UJ51 AS WELL. EVEN THOUGH I KNEW SO LITTLE ABOUT WHAT THEY WERE DOING; THAT I HAD NO RIGHT TO ASSUME ANYTHING. I DID KNOW HOWEVER THEY WERE DEPARTING TO THE N. THIS WAS JUST ANOTHER PIECE; WHICH IN MY MIND WAS CEMENTING THE FACT THAT WE WERE GOING TO CLB ON COURSE. THE ACR B REPORTED THIS 'LEAVING 1500 FT; STARTING THE TURN' WHILE WE WERE RUNNING THE TAXI CHKLIST; SO MY CONCENTRATION ON WHAT THEY WERE DOING; WAS POOR AT BEST. PRIOR TO LINING UP ON RWY 34 WE TOLD TWR WE WERE READY AND WE WERE GIVEN TKOF CLRNC; AND TO REPORT XING OVER THE VOR. NOW; WITH MY ALREADY PRECONCEIVED IDEA OF WHAT WE WERE DOING; XING OVER THE VOR WAS NOT WHAT I HAD EXPECTED TO DO; OR PLANNED ON DOING; AND WHILE THAT SHOULD HAVE BEEN ANOTHER FLAG IN MY HEAD; I READ BACK; 'ROGER; WILL REPORT ON THE 003 RADIAL.' NO RESPONSE WAS READ BACK; SO I ASSUMED I WAS CORRECT IN ASSUMING HE WANTED US TO TURN TO THE 003 RADIAL AFTER TKOF. AGAIN THERE WAS NO THOUGHT IN MY MIND THAT WE WERE GOING TO FLY THE IFR DEP PROC STATED ON THE PLATE. I CALLED TWR AT 7.2 DME AND REPORTED THAT WE WERE 8 DME ON THE 003 RADIAL AND OUR LEAVING ALT. I DON'T KNOW WHY I REMEMBER THE 7.2 DME AND NOT THE OTHER PARTICULARS. TWR ASKED WHEN WE CROSSED OVER THE VOR. ASSUMING I DIDN'T UNDERSTAND HIM; I AGAIN REPEATED THAT WE WERE ESTABLISHED ON THE 003 RADIAL. TWR THEN ADVISED ME THAT WE WERE TO CROSS OVER THE VOR BEFORE JOINING THE AIRWAY. I READ BACK THE CLRNC TO TWR AS I HAD COPIED IT DOWN ON THE FLT PLAN; BECAUSE IN MY MIND WE WERE DOING EVERYTHING CORRECTLY. TWR ADVISED ME THE CLRNC WAS CORRECT; EXCEPT WE HAD TO FLY THE IFR DEP PROC FIRST. IT IS IMPORTANT TO UNDERSTAND AND THAT I KNOW AN IFR DEP PROC MUST BE FLOWN IF A VFR CLB IS NOT GIVEN. WHY THAT DIDN'T MAKE SENSE THAT DAY WAS DUE TO A SERIES OF EVENTS WHICH WERE SET INTO MOTION WITH THE INITIAL READING OF THE 10-7 PLATE; WHICH STATED EXPECT A VFR CLB TO ON COURSE. I HAVE NO EXCUSE FOR NOT FOLLOWING THE PROC; THIS WAS JUST A CLASSIC MISTAKE OF A SERIES OF EVENTS DEALING WITH COMS; WHICH LED TO MY NOT FOLLOWING PROPER PROC. TO FURTHER ILLUSTRATE THIS IF MY CAPT HAD MADE THE TURN TO CROSS OVER THE VOR I WOULD HAVE QUESTIONED HIM AS TO WHAT HE WAS DOING; THAT'S HOW SET IN MY MIND IT WAS THAT WE WERE DOING A VFR CLB TO JOIN THE 003 RADIAL. THIS WAS A CLASSIC EXAMPLE OF NOT LOOKING FAR ENOUGH INTO THE DETAILS AT AN ARPT'S PARTICULAR DEP. AND WHILE COMPLACENCY MIGHT NOT BE THE RIGHT WORD; BECAUSE I HAVEN'T BEEN THERE ENOUGH TO BECOME COMPLACENT; IT CERTAINLY WAS A CASE OF UNTHOUGHTFULNESS COMPOUNDED BY A LACK OF PROPER COMS BETWEEN ATC AND MYSELF; AND THE CAPT.

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