1999-12 · NASA ASRS report 456860
FLC OF A TWIN ENGINED ACR EXPERIENCES AN OFF COURSE DEV WHEN THE FMC IS IMPROPERLY PROGRAMMED FOR THE STAR ARR PROC W OF MVA; CA.
ORIGINAL CLRNC OF FLT FROM ORD-OAK INCLUDED THE MADWIN 3 ARR MVA TRANSITION; WHICH WAS LOADED IN FMC. ENRTE; RECLRED DIRECT MVA DIRECT ECA DIRECT OAK. ENTERED ABOVE INTO FMC WITH THE EXCEPTION OF AFTER ECA; THERE ECA ARR LEGS IN BECAUSE WE KNEW WE WOULD BE RECLRED FOR THE ARR AND WE VERBALIZED AS SUCH. EVENTUALLY; WE WERE RECLRED AS EXPECTED. I LOOKED AT LEGS PAGE AND SAW MVA; ECA. I HAD THE ARR ON THE YOKE CLIP. BUT I DID NOT CONNECT IN MY MIND THAT THE LEGS PAGE HAD DIRECT MVA DIRECT ECA RATHER THAN MVA; MVA 230 DEGS/ECA 068 DEGS ECA. WE FLEW MVA DIRECT ECA. CONTRIBUTING FACTORS: COPLT WITH ONLY 2 MONTHS EXPERIENCE. ATC QUERIED US. IMMEDIATELY I RECOGNIZED THE SIT AND CORRECTED THE FMC ROUTING. ATC PROVIDED 20 DEGS L HDG CHANGE. DSND AND MAINTAIN 33000 FT AND EVENTUALLY DIRECT ECA. HUMAN PERFORMANCE CONSIDERATIONS: THERE IS NO DOUBT IN MY MIND THAT FATIGUE PLAYED A MAJOR FACTOR IN THIS EVENT. THE SCHEDULED TRIP WAS 4 DAYS LONG; FLOWN BY A W COAST BASED CREW. DAY 1 HAD A RPT TIME IN OAK IN EARLY AM. DAY 2 HAD A HOTEL PICK-UP TIME AT EARLY AM IN MAINE. DAY 3 HAD A HOTEL PICK-UP TIME AT EARLY AM IN CALIFORNIA. DAY 4 HAD A HOTEL PICK-UP TIME EARLY AM IN CLE; OH. WHILE THE TRIP PROVIDED ADEQUATE LAYOVER TIME; IT IS UNREALISTIC TO THINK OF W COAST BASED CREW CAN FORCE THEMSELVES TO SLEEP ON AN E COAST CLOCK. I HAVE BEEN SUBJECTED TO THIS TYPE SLEEP/NON-SLEEP PATTERN FOR MORE THAN 10 YRS AND KNOW THAT IT IS EXTREMELY WEARING ON THE BODY AND MENTAL ACUITY. ADD TO THE SLEEP DEPRIVATION PROBS WITH WX; IRREGULAR PROCS; TFC DELAYS; ETC; AND IT IS EASY TO BECOME OVERLOADED.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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