A B737-800 FLT CREW TURNS OFF THE EXPECTED SID DEP HEADING UPON DEP FROM RWY 16L DURING A NIGHT OP AT SLC; UT.

Date: 2003-10 · Aircraft: B737-800 · Phase: initial_climb

Anomalies: deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-clearance|other-rwy-change-wrong-sid-used

Synopsis

A B737-800 FLT CREW TURNS OFF THE EXPECTED SID DEP HEADING UPON DEP FROM RWY 16L DURING A NIGHT OP AT SLC; UT.

Narrative

WHILE DEPARTING RWY 16L WE ERRONEOUSLY BEGAN TO COMPLY WITH THE SEVYR ONE DEP; WHICH DESIGNATES A TURN TO HEADING 260 DEGS. THE TWR CTLR RADIOED TO MAINTAIN HEADING 160 DEGS AND SUBSEQUENTLY QUERIED IF WE HAD THE FAIRFIELD SIX DEP. WE REPLIED IN THE AFFIRMATIVE AND COMPLIED WITH THAT DEP. DURING COCKPIT PREFLT; FILED ROUTING ON THE FLT PLAN CALLED FOR THE SEVYR ONE DEP PROC DUE TO A NORTHERLY ARPT OP. AFTER PUSHBACK AND TAXI; THE OP CHANGED TO SOUTHERLY. THIS REQUIRED RE-CONFIGURING THE COCKPIT AND FMS DURING TAXI-OUT; WHICH IS ALWAYS A HIGH WORKLOAD EVENT IN A GLASS COCKPIT. THE PRE-DEP CLRNC DID SHOW THE CHANGE IN ROUTING. HOWEVER; IT ALSO INDICATED THE ORIGINAL ROUTING AFTER THE PHRASE 'FILED AS.' BOTH PLTS KEYED ON THAT PHRASE AND BOTH MISSED THE NEW ROUTING. SUGGESTIONS FOR PREVENTION: 1) CHANGES OF ROUTING ON PDC'S SHOULD USE AN ASTERISK BOX OR SUCH TO HIGHLIGHT THE NEW RTE. 2) ALTHOUGH THE SEVYR ONE DEP PROC INDICATES '(RWYS 32; 34L/R; 35)' UNDER THE TITLE; WE MISSED THAT. IN THE ROUTING BOX AT THE BOTTOM IT STATES 'FLY HEADING 260 DEGS...' I WOULD POSSIBLY HAVE BEEN KEYED TO INVESTIGATE FURTHER IF IT SAID 'TURN L TO FLY HEADING 260 DEGS...' SINCE WE BEGAN A R TURN TO INTERCEPT THE TCH 193 DEG RADIAL. 3) A RWY CHANGE AFTER PUSHBACK REQUIRES MANY FMS CORRECTIONS IN A GLASS COCKPIT. USUALLY; THE FIRST A CREW LEARNS OF THIS SURPRISE IS ON INITIAL CONTACT WITH GND CTL FOR TAXI INSTRUCTIONS. AT THIS POINT THE FMS; FLT DIRECTOR; HGS AND NAV RADIOS ALL MUST BE CHANGED WHILE SIMULTANEOUSLY RUNNING TAXI AND TKOF CHKS AND KEEPING THE ARPT CLR OF OBSTACLES AND ON THE SPECIFIED TAXI CLRNC. BY THE TIME A FLT CREW LEARNS OF A RWY CHANGE; IT IS USUALLY OLD NEWS TO GND AND TWR CTLRS. ANTICIPATION IS A KEY TO AVIATION SAFETY. THERE SHOULD BE SOME METHOD OF INFORMING A CREW DURING PREFLT SET-UP THAT THE ARPT WILL 'TURN AROUND' WITH THE NEXT ATIS. SUPPLEMENTAL INFO FROM ACN 595998: IT WAS LATE AND I WAS TIRED. IT DOES NOT HELP TO HAVE BOTH ROUTINGS ON THE PDC OR IF BOTH MUST BE ON A BOX SHOULD HIGHLIGHT THE CHANGE FOR CLARITY. WHEN I LOOK NOW IT SEEMS CLR BUT LATE AT NIGHT IT WAS NOT SO CLR.

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