2003-03 · NASA ASRS report 577426
B747 DEPARTING EDFF VARIED FROM ASSIGNED SID OVER NOISE SENSITIVE AREA.
AFTER AN EARLY MORNING TKOF; ACFT TRACK MOMENTARILY DEVIATED OFF ASSIGNED SID TO THE R (W) OF PLANNED COURSE. THE DEV WAS MINOR; BUT IN A HIGHLY NOISE SENSITIVE AREA. THE LCL CTLR QUERIED THE TURN AND ASSIGNED A DIRECT-TO POINT CLRNC. CAUSE OF DEV IS DUE TO THE PF (FO) VIEWING THE WRONG DME DISPLAY AND STARTING A R TURN AS DEPICTED ON THE SID; BUT AT THE WRONG DISTANCE. THE PNF'S (CAPT'S) VOR WAS SET TO A 'DO NOT CROSS' (NOISE ABATEMENT) RADIAL ON A DIFFERENT STATION THAN REQUIRED FOR PRIMARY NAV. THE PRIMARY VOR AND COURSE WERE SET ON THE FO'S SIDE AS THE PF AND WAS COVERED IN THE CREW BRIEFING. FURTHER; THIS WOULD BE A TYPICAL NAV PANEL SET-UP FOR THIS DEP. THE ERROR WAS CORRECTED IMMEDIATELY UPON RECOGNITION (WITHIN 5 SECONDS). NOTE: THIS WAS A NON-FMS EQUIPPED ACFT (INS WITH DME UPDATE CAPABILITY ONLY); SO THIS SID WAS CONDUCTED VIA CLASS 1 NAV (VOR'S) WITH INS USED ONLY AS A BACK-UP. ALTHOUGH THIS VINTAGE INS PLATFORM IS LEGAL TO FLY RNAV SID'S AND STAR'S IF CERTAIN ACCURACY INDEXES ARE ACQUIRED VIA RADIO UPDATES; IT WAS CLRLY NOT DESIGNED TO PERFORM THE TASK AS AN FMS AND DOES A POOR JOB ATTEMPTING TO EMULATE ONE. THE REASON FOR THIS ERROR IS PRIMARILY CONTRIBUTED TO CREW FATIGUE RESULTING FROM A LONG CREW DUTY DAY THAT WAS FULL OF TASK SATURATING EVENTS THROUGHOUT THE 2-LEG INTL TRIP FROM THE UNITED STATES TO GERMANY; THEN BELGIUM. I'M CONFIDENT THAT THE PNF WOULD NOT HAVE MADE THIS ERROR IN A MORE RESTED STATE; PLUS THIS FINAL LEG WAS OPERATED ON THE BACK SIDE OF THE CLOCK. ADDITIONALLY; THE ACFT WAS EMPTY; MAKING THE VERT NAV PERFORMANCE A REAL CHALLENGE ON A COMPLEX; NOISE SENSITIVE SID; WITH LOW INITIAL LEVELOFF. THEN A FLAP RETRACTION PROB OCCURRED DURING THE EVENT TO WHICH ATC WAS ADVISED. HOWEVER; I DO NOT BELIEVE THIS PLT NAV ERROR CREATED A NOISE PROB DUE TO THE LOW THRUST SETTING; LOW DENSITY ALT (DRY; LOW TEMP AND PA) AND HIGH CLB RATE OF THE EMPTY ACFT. SINCE FATIGUE CAN BE SO INSIDIOUS; AT TIMES IT CREEPS UP ON YOU WITHOUT REALIZATION UNTIL A NOTICEABLE HUMAN ERROR OCCURS. I HOPE THE FAA WILL EVENTUALLY MANDATE CHANGES TO THE REGULATIONS THAT WILL REQUIRE INT'L DUTY TIME LIMITS FOR US. PART 121 RESTRED (FLAG OR SUPPLEMENTAL) ACRS. THIS WOULD SERVE AS A STOP-GAP FOR THE LACK OF DUTY LIMITS AT SOME CARRIERS AND/OR TO LESSON THE EXCESSIVELY LONG DUTY TIME THAT OTHER AIRLINES CONSIDER AS 'NORMAL'. THE DISPATCHER WORKING THE FLT IS GIVEN MORE REGULATORY 'DUTY' CONSIDERATION THAN THE CREWS ACTUALLY OPERATING THE ACFT DISPATCHED. IT WOULD ALMOST SEEM THAT HIS CONCEPT IS BACKWARDS. IMHO; THE MAXIMUM SAFE INTERNATIONAL DUTY TIME SHOULD BE REGULATED TO BE NO MORE THAN FOURTEEN HOURS FOR A BASIC (UN-AUGMENTED) CREW; UNLESS A DIVERSION TO AN ALTERNATE ARPT IS REQUIRED. IT THEN COULD BE EXTENDED WITH ADDITIONAL REST REQUIREMENTS AT THE DEST COMMENSURATE TO DOUBLE THE EXTENSION TIME; BUT NOT TO EXCEED SEVENTEEN HRS UNDER ANY CIRCUMSTANCES. HAD THIS BEEN THE CASE; I'M CONFIDENT THAT THIS MISTAKE WOULDN'T HAVE OCCURRED.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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