FLC OF A BRASILIA-120 TURNS WRONG DIRECTION AFTER DEPARTING SFO ON CLRED SID.
Synopsis
FLC OF A BRASILIA-120 TURNS WRONG DIRECTION AFTER DEPARTING SFO ON CLRED SID.
Narrative
AIR CREW WAS ASSIGNED THE LUVVE 2 DEP; VECTORS SCAGGS ISLAND 112.1; AS FILED BY SFO CLRNC. AIR CREW TAXIED TO AND HELD SHORT OF RWY 10R AS ASSIGNED. THE FO AND THE CAPT REVIEWED THE SID AND THE INITIALLY ASSIGNED ROUTING. A CONTRIBUTING FACTOR WAS THAT THE FO LOOKED AT WHERE SCAGGS ISLAND WAS IN RELATION TO LUVVE INTXN ON THE SID IT IS AT THE SFO 120 DEG RADIAL FOR 10 DME. SCAGGS ISLAND IS TO THE N; L OF LUVVE INTXN. ALSO; CONTRIBUTING WAS THAT THE CREW WAS USED TO TAKING OFF ON EITHER RWY 1R OR RWY 1L AT SFO AND PROCEEDING N TO SCAGGS ISLAND. ON REFLECTION; THE FO SHOULD HAVE BEEN AWARE THAT ARRS AND APCHS WHICH WERE BEING CONDUCTED TO RWY 19L PRECLUDED TURNS TO THE N DURING DEP. ACFT WAS CLRED FOR TKOF AND DID SO UNEVENTFULLY. PASSING ABOVE APPROX 3000 FT MSL; ACFT WAS DIRECTED TO TURN R TO HDG 310 DEGS; DIRECT SFO WHEN ABLE. THE FO COMMENCED A TURN TO THE L TO 310 DEGS AND WAS CLRED TO DO SO BY THE CAPT AS THE ACFT WAS BTWN LAYERS AND IN VMC CONDITIONS FOR THE MOMENT. ATC QUICKLY NOTICED THE WRONG TURN AND DIRECTED THE AIR CREW TO REVERSE THE TURN AND GO R TO 310 DEG HDG. THE REST OF THE FLT WAS CONDUCTED UNEVENTFULLY. THE HUMAN FACTOR THAT CONTRIBUTED MOST TO THE ERROR WAS THE FO'S PERCEPTION THAT THE TURN WOULD GO L (N) AND WAS USED TO THAT HABITUALLY TO CORRECT: 1)VIGILANCE TO LISTENING; ESPECIALLY WHEN RECEIVING A NEW CLRNC; 2) A BETTER REVIEW OF WHAT'S HAPPENING IN TERMS OF HOW ACFT ARE BEING ROUTED INTO AND OUT OF THE TERMINAL AREA; IE; UPDATE YOUR SITUATIONAL AWARENESS RESULTING FROM CHANGES TO YOUR PRECONCEIVED IDEA OF WHAT'S NORMAL IN YOUR TYPICAL ROUTINE OR BETTER YET; REALIZE THERE ISN'T A 'TYPICAL ROUTINE' IN AVIATION; AND 3) DEVELOP A HABIT PATTERN OF SPECIFICALLY READING BACK THE DIRECTION OF TURN; PLUS USE SOME KIND OF VISUAL AID TO REINFORCE THE INSTRUCTION SUCH AS USING A RADIO KNOB WITH AN ARROW PAINTED ON IT TO SHOW THE DIRECTION OF TURN.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.