H25C FLC INCORRECTLY INPUT PHX MOBIE SID DATA IN FMS MFD; AND TURN EARLY; COMING INTO CONFLICT WITH PRIOR ACR.

Date: 2001-01 · Aircraft: BAe 125 Series 1000 (Hawker Horizon) · Phase: initial_climb

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

Synopsis

H25C FLC INCORRECTLY INPUT PHX MOBIE SID DATA IN FMS MFD; AND TURN EARLY; COMING INTO CONFLICT WITH PRIOR ACR.

Narrative

WHILE THIS DID NOT RESULT IN A RPTABLE INCIDENT; IT COULD HAVE IF IT WERE NOT FOR THE ATTN AND QUICK THINKING OF A DEP CTLR. WE WERE DEPARTING PHX TO SAN ON A ROUTINE FLT TO REPOS THE ACFT FOR TOMORROW'S FLT. THE DEP WAS ON RWY 7L WITH MOBIE 3 SID ASSIGNED. THE SID WAS PROGRAMMED IN THE FMS AND BRIEFED PRIOR TO DEP. THE SID CALLED FOR DEPARTING ON A HDG OF 075 DEGS TO 4 DME OFF THE PHX VOR. ON THE MFD; FMS WAS SELECTED SINCE THE SID WAS 'IN THE BOX' AND THAT WAS THE COMMON PRACTICE. AFTER TKOF; THE 075N DEG HDG WAS ESTABLISHED AND THE AIRPLANE WAS CLEANED UP. CLBING RAPIDLY TO THE ASSIGNED ALT OF 15000 FT; THE PF GLANCED AT HIS MFD AND NOTICED THE DISTANCE READOUT READING 5.1 NM. IMMEDIATELY THINKING THAT THEY WERE PAST THE 4 NM REQUIREMENT ON THE SID STARTED HIS R TURN TO 190 DEG HDG ASSIGNED ON THE SID. THE PNF; BECAUSE OF THE EXPERIENCE OF THE PF; DID NOT DOUBLECHK OR QUESTION THE TURN. IMMEDIATELY; THE DEP CTLR INSTRUCTED US TO TURN BACK L TO 060 DEGS AND INSTRUCTED A REGIONAL ACR TO LEVEL OFF AND THAT THEY WOULD HAVE A HAWKER 1000 FT ABOVE THEM. JUST PRIOR TO REACHING 060 DEG HDG; WE WERE THEN TOLD TO RETURN TO THE 190 DEG HDG. SO WHAT HAD HAPPENED. WHILE A THOROUGH DEP BRIEF WAS CONDUCTED; WHICH INCLUDED THE SID AND NAVAIDS TUNED AND IDENTED; CONSIDERATION TO WHAT WAS BEING DISPLAYED ON THE MFD WAS NOT CONSIDERED. THIS WAS A VERY BIG MISTAKE. IN THIS CASE; AS IS IN SEVERAL OTHER SID'S IN THE COUNTRY; THE BOX DOES NOT HAVE A COMPLETE ROUTING IN IT. WITH FMS SELECTED; THE FMS WAS GIVING DISTANCE TO THE DEP FIELD AND NOT THE VOR. THE ACFT DOES NOT ADEQUATELY DISPLAY BOTH FMS AND VOR INDICATIONS FOR DISTANCE AT THE SAME TIME. IN THIS CASE THE VOR WAS 1.9 NM E OF THE FIELD. FIRST; PF SEEING HIS DISTANCE AT 5.1 (WHICH WAS OFF THE FIELD) MISTAKENLY THOUGHT THAT HE WAS PAST THE VOR AND STARTED HIS TURN; ONLY IT WAS .8 NM TOO EARLY. THIS; PLUS A 30 DEG ANGLE OF BANK; CAUSED HIM TO TURN INSIDE THE ACR THAT WAS IN FRONT OF HIM AND GOING THE SAME WAY. BECAUSE OF THE EXPERIENCE LEVEL OF THE PF THE PNF; THINKING THAT THE PF KNEW WHAT HE WAS DOING; BECAME COMPLACENT PREVENTING THE DOUBLECHK SYS FROM WORKING SINCE THE ONLY VOR READOUT WAS ON HIS SIDE OF THE COCKPIT. AS A SIDE LIGHT TO A DIM PERFORMANCE BY A VERY EXPERIENCED AIRCREW; THERE WAS NO TCASII INSTALLED ON THIS ACFT. THE LIKES OF WHICH WOULD HAVE GIVEN THE AIR CREW BETTER SITUATIONAL AWARENESS AND MAYBE PREVENTED THIS SIT FROM HAPPENING. TO ME; THIS IMPRESSES THE IMPORTANCE OF TCASII AND ITS USE IN OUR EVER-INCREASING CROWDED SKIES. SO WAS THIS A PREVENTABLE INCIDENT? TOTALLY. WERE LESSON LEARNED? ABSOLUTELY. EVEN WITH A VERY EXPERIENCED CREW (IN THIS CASE; 31 YRS MIL AND CIVILIAN FLYING EXPERIENCE IN THE PF AND 18000 HRS BTWN THE CREW MEMBERS) COMPLACENCY AND OVERSIGHTS CAN HAPPEN VERY QUICKLY IF ATTN TO DETAIL IS NOT CONSTANTLY ADHERED TO. THE IMPORTANCE OF A THOUGHT BRIEF OF ALL ASPECTS OF A DEP AND ARR AND A TOTAL UNDERSTANDING OF WHAT IS BEING DISPLAYED TO THE AIRCREW BY BOTH CREW MEMBERS CANNOT BE OVERSTATED. WHILE THE RESPONSIBILITY OF THIS INCIDENT CAN ONLY REST OF THE AIR CREW; AND THE AIR CREW ALONE; IT ALSO POINTS OUT THE IMPORTANCE OF A GOOD TCASII SYS. WHILE THIS AIR CREW TOTALLY UNDERSTANDS THE CHAIN OF EVENTS THAT LED UP TO WHAT HAPPENED AND HAVE PLEDGED A RENEWED COMMITMENT TO INCREASED VIGILANCE; WE HOPE THAT OTHERS WILL LEARN FROM THIS EVENT.

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