AN FA50 CREW TURNED R AFTER DEP INSTEAD OF L AS INSTRUCTED.

2001-05 · NASA ASRS report 510557

Date: 2001-05 · Aircraft: Falcon 50 · Phase: takeoff

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

Synopsis

AN FA50 CREW TURNED R AFTER DEP INSTEAD OF L AS INSTRUCTED.

Narrative

TAXIING FOR TKOF FROM RWY 18 AT MEIGS FIELD; WE WERE CLRED FOR TKOF AND TOLD 'TURN L HDG 140 DEGS; CLRED FOR TKOF RWY 18; BACK TAXI APPROVED.' I CHOSE TO TAKE OFF WITH THE FLT DIRECTOR IN HDG MODE AND WITH THE HDG BUG SET TO 140 DEGS. AFTER TKOF; CLBING THROUGH 400 FT AGL; I WOULD THEN TURN THE ACFT TO THE SET HDG. I SELECTED HDG MODE; SET 140 DEGS ON THE HDG BUG; AND TAXIED ONTO THE RWY. I TURNED L 90 DEGS AND TAXIED TO THE END OF THE RWY THEN MADE A L 180 DEG TURN TO LINE UP ON THE RWY. WE MADE A NORMAL TKOF. CLBING THROUGH 400 FT AGL; I CALLED FOR 'FLAPS UP' AND I TURNED THE ACFT INTO THE FLT DIRECTOR COMMAND BARS. APPROX 5-10 SECONDS LATER; I REALIZED THAT I HAD TURNED R INSTEAD OF L. I QUICKLY CORRECTED AND TURNED L HDG 140 DEGS. EVALUATING THE FLT DIRECTOR MODES AND HDG BUG TO SEE WHAT WAS WRONG; I FOUND THAT THE FLT DIRECTOR WAS IN FACT STILL IN HDG MODE AND THE HDG BUG WAS STILL SET TO 140 DEGS. HOWEVER; THE COMMAND BARS WERE COMMANDING A TURN TO THE R INSTEAD OF TO THE L. APPARENTLY; THE FLT DIRECTOR WAS 'CONFUSED' BY OUR TURN AROUND AT THE END OF THE RWY. THEREFORE; IT WAS TURNING IN THE DIRECTION OF THE DESIRED HDG AT THE TIME I SELECTED HDG MODE. REGARDLESS; I FAILED TO RECOGNIZE THAT THE FLT DIRECTOR WAS TURNING THE WRONG WAY AND I INSTINCTIVELY FOLLOWED IT. FROM NOW ON; WHEN USING THE FLT DIRECTOR DURING TKOF I WILL SET THE BUG TO RWY HDG INITIALLY; OR TKOF IN ROLL MODE AND SELECT HDG MODE WHEN READY TO TURN AT 400 FT. MANY TECHNIQUES EXIST FOR MANAGING AUTOMATION IN DIFFERENT PHASES OF FLT. UNFORTUNATELY IN CPR AVIATION; THESE TECHNIQUES ARE RARELY VERY STANDARDIZED. OBVIOUSLY; HOW A PLT INTERACTS WITH AND MANAGES AUTOMATION IN THE COCKPIT IS GETTING A LOT OF ATTN THESE DAYS. WE'RE ALL LEARNING MORE ALL THE TIME. IN THIS CASE; I OBVIOUSLY WAS TOO FOCUSED ON; AND RELYING TOO HEAVILY ON MY FLT DIRECTOR. I FAILED TO TAKE IN THE BIG PICTURE. MY SITUATIONAL AWARENESS WAS NARROWED BY MY FOCUS ON THE COMMAND BARS. I WOULD LOVE TO SEE SIMILAR SITS ARISE DURING MY TRAINING SESSIONS. I THINK IT WOULD BE USEFUL TO PRACTICE RECOGNIZING WHEN THE AUTOMATION MAKES A MISTAKE. OF COURSE WE KNOW THAT MOST ERRORS WITH AUTOMATION ARE THE RESULT OF HUMAN ERROR. BUT WE NEED TO LEARN THAT IF AN ERROR OCCURS; WE SHOULD BE SITUATIONALLY AWARE ENOUGH TO IMMEDIATELY RECOGNIZE IT. I KNOW I'LL NEVER MAKE THIS EXACT SAME MISTAKE AGAIN. I'M NOW TRYING TO APPLY THIS LESSON LEARNED TO OTHER SITS IN OTHER PHASES OF FLT.

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

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