A B747 ARRIVING IN THE SFO AREA OVERSHOT ITS ASSIGNED HOLDING POINT WHEN THE FLC DOES NOT HEAR THE NAME OF THE FIX IN THE HOLDING CLRNC. ATC MISSES THE INCOMPLETE READBACK.
Synopsis
A B747 ARRIVING IN THE SFO AREA OVERSHOT ITS ASSIGNED HOLDING POINT WHEN THE FLC DOES NOT HEAR THE NAME OF THE FIX IN THE HOLDING CLRNC. ATC MISSES THE INCOMPLETE READBACK.
Narrative
ON DSCNT TO SFO WE WERE CLRED FROM FL350 TO FL290 AT PLT DISCRETION WITH AN EXPECTED CLRNC TO CROSS PIRAT AT 8000 FT AND 230 KTS. THE LATTER CLRNC WAS LATER AMENDED TO 9000 FT. ON DSCNT OUR CLRNC WAS FURTHER REVISED TO WHAT WE HEARD TO BE HOLD SW ON OAKLAND 219 DEG RADIAL 8000 FT R TURNS WITH EFC (EXPECT FURTHER CLRNC) OF AB35Z. WE MISSED THE PART ABOUT HOLDING AT RAINES AND PROCEEDED TO PIRAT. THE CLRNC WAS READ BACK EXACTLY AS STATED ABOVE WITHOUT A HOLDING FIX NAMED AND WAS TOLD READBACK CORRECT. OUR NAV INDICATIONS WERE CONSISTENT WITH PIRAT AND 219 DEG RADIAL OFF OF OAK. WE WERE ASKED IF WE WERE ON THE 219 DEG RADIAL AND WE REPLIED YES AT WHICH TIME WE WERE AT PIRAT AND THEN ADVISED WE WERE SUPPOSED TO BE AT RAINES. WE THEN COMPLIED PROMPTLY. CONTRIBUTING FACTORS: WE DIDN'T QUESTION WHY WE DIDN'T HEAR A HOLDING FIX AND ASSUMED SINCE WE WERE ALREADY ON THE 219 DEG RADIAL AND OUR PREVIOUS CLRNC WAS TO PIRAT THEN THAT WAS WHERE WE WERE TO HOLD. ALSO SINCE THE CTLR DIDN'T SAY ANYTHING WHEN I READ BACK THE CLRNC (WITHOUT A FIX) WE THOUGHT IT WAS CORRECT. A BIG PART OF IT ALSO IS THAT THE FIXES NORMALLY USED BY CTR/APCH WHEN YOU'RE INBOUND FROM THE W ARE SCATTERED OVER 3 CHARTS WITH NOT ALL THE PERTINENT OR SAME INFO ON ANY ONE CHART; WHICH ADDED TO THE CONFUSION. IT PROBABLY DIDN'T HELP EITHER THAT IT HAD BEEN A LONG DAY AND THIS WAS ABOUT OUR 10TH HR OF A LONG TRIP. SUPPLEMENTAL INFO FROM ACN 412026: I AM STILL UNSURE WHETHER WE MISUNDERSTOOD THE HOLD FIX OR WHETHER IT WAS MIS-STATED; BUT WE DID HAVE SOME CONFUSION OVER THE 219 DEG RADIAL AND WE DIDN'T RESOLVE THE CONFUSION WITH ATC. WE WERE TIRED AT THE END OF A HONOLULU TURN (LONG WORK DAY) AND ENTERING THE HIGH WORKLOAD PERIOD OF HOLDING WITH AN EFC EQUAL TO OUR HOLD FUEL ONBOARD. I AM FAIRLY NEW ON THE PLANE; AND BOTH MY FO AND SO WERE VERY NEW ON THE PLANE. RAINES WAS NOT ON OUR FLT PLAN; AND NOT CHARTED (WITH COORDINATES) ON EITHER THE SFO AREA CHART OR PACIFIC HI 2 CHART. ITS COORDINATES WERE ON US HI 1(2) CHART BUT WITHOUT RADIAL/DME INFO.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.