B747-200 CREW HAD A TRACK DEV DEPARTING VHHH; AFTER THEY FLEW THE WRONG SID.

Date: 2003-12 · Aircraft: B747-200

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

Synopsis

B747-200 CREW HAD A TRACK DEV DEPARTING VHHH; AFTER THEY FLEW THE WRONG SID.

Narrative

ACR X DISPATCH FILED THE FLT FOR THE OCEAN ONE ALPHA DEP (10-3C) TO OCEAN AND TERMINAL TRANSITION RTE V3 TO ENVAR (10-3H); THENCE VIA AIRWAY ROUTING TO RKSI. THE FO LOADED ALL FLT-PLANNED WAYPOINTS IN THE INS. ALL PRE-DEP INS PROCS WERE COMPLETED ACCORDING TO ACR FLT HANDBOOK (FHR) PROCS. 5 MINS PRIOR TO BLOCK TIME; THE FO REQUESTED THE ATC IFR RTE CLRNC. I MONITORED CLRNC DELIVERY'S XMISSION OF THE CLRNC AS THE FO RECORDED IT ON THE FLT LOG. WE WERE CLRED FOR THE OCEAN ONE ECHO DEP (10-3C) INSTEAD OF THE FILED RTE AND I FAILED TO NOTE THIS WAS NOT OUR FILED SID. THE FO ALSO FAILED TO NOTE THIS WAS A CHANGE FROM OUR FILED SID. MY TKOF BRIEFING FOLLOWED FHB PROC AND THE FLT DECK QUICK REF CHKLIST. DURING THE BRIEFING; I BRIEFED THE ACR SPECIFIC SOP FOR HONG KONG DEPS RWY 7R (10-0). HOWEVER; I OVERLOOKED AND FAILED TO BRIEF ITEMS 6(G) AND 6(H) OF THE PROC. ITEMS 6(H) DIRECTS THE CREW TO TURN R TOWARDS BREAM (APPROX 180 DEGS MAGNETIC) AFTER REACHING ISR 7.0 DME. ITEM 6(H) DIRECTS THE CREW TO SET UP THE INS TO FLY DIRECT TO BREAM WHEN APCHING 180 DEGS MAGNETIC. I ALSO ERRED BY BRIEFING THAT AFTER XING PORPA; THE FO WOULD TUNE TD VOR IN MY VOR AND SET MY HSI COURSE TO 116 DEGS MAGNETIC. THIS IS THE OCEAN ONE ALPHA RTE THAT ACR X DISPATCH HAD FILED FOR US. I STILL HAD THE WRONG RTE FIXED IN MY MIND DUE TO MY AFOREMENTIONED FAILURE TO NOTE OUR ASSIGNED SID HAD BEEN CHANGED BY ATC. AGAIN; THE FO AND FE ALSO FAILED TO NOTE MY ERROR OF OMITTING BRIEFING ITEMS 6(G) AND 6(H) AND THE DIFFERENCE BTWN THE CLRNC AND THE RTE I BRIEFED. ALL REMAINING GND OPS WERE NORMAL AND UNEVENTFUL. TKOF WAS NORMAL AND UNEVENTFUL. AFTER LIFTOFF; I FLEW HEADING 073 DEGS MAGNETIC. THE FO METICULOUSLY MONITORED THE DRIFT AND CORRECTLY SET THE HEADING BUG TO COMPENSATE FOR IT. AT D7.0 ISR; I COMMANDED THE FO TO TUNE TD VOR AND SET COURSE 116 DEGS AND I TURNED TO INTERCEPT THE COURSE INBOUND TO TD; OUR NEXT FILED AND INS LOADED WAYPOINT. JUST AS I WAS QUIETLY TAKING MENTAL PRIDE OUR SID PERFORMANCE AND IN MY INTERCEPT AND TRACKING OF THE 116 DEG COURSE INBOUND TO TD; HKG RADAR DIRECTED US TO TURN R TO HEADING 180 DEGS. I IMMEDIATELY INITIATED A R TURN TO THE ASSIGNED HEADING. I COMMANDED THE FO TO SET HEADING 180 DEGS AND SIMULTANEOUSLY I FELT ANGUISH; EMBARRASSMENT; GUILT AND REMORSE FOR MY ERROR FOR I HAD IMMEDIATELY REALIZED MY FAILURE TO IMPLEMENT THE SID CHANGE TO THE FILED FLT PLAN. AFTER I WAS ESTABLISHED ON THE ASSIGNED HEADING; I PERSONALLY CALLED HKG RADAR. I IDENTED MYSELF AS THE CAPT. I BRIEFLY ADMITTED MY MISTAKE AND HUMBLY APOLOGIZED FOR MY ERROR AND FOR ANY INCONVENIENCE IT MAY HAVE CAUSED ATC. HKG RADAR RESPONDED IN A MANNER THAT CLRLY INDICATED TO ME AND TO THE CREW THAT THEY WERE NONCHALANT ABOUT IT AND WERE FORGIVING OF OUR MISTAKE. MOMENTS LATER; HKG RADAR CLRED US FROM OUR PRESENT POS TO THE FINAL WAYPOINT ON THE TRANSITION RTE; ENVAR. I ASKED THE FO TO LET ME ACKNOWLEDGE THE CLRNC. I ACKNOWLEDGED THE CLRNC AND RESTATED MY SINCERE REGRET AS CAPT FOR OUR SID DEV ERROR. AS I RECALL; THE CTLR THANKED ME AND WAS AGAIN NONCHALANT ABOUT MY MISTAKE. ON EVERY LEG; AT TOP OF CLB; IT IS CUSTOMARY FOR ME TO BRIEFLY DISCUSS OUR DEP PERFORMANCE WITH THE CREW. I BRIEFLY ASSESS OUR PERFORMANCE AND I INVITE FO AND FE COMMENTS AND CRITIQUE. I SEEK CONSTRUCTIVE CRITIQUE OF MY PERFORMANCE AND TRY TO OFFER THE SAME TO OTHERS IN A COURTEOUS MANNER. THE FO; FE AND I WERE ALL FORTHRIGHT TO ONE ANOTHER ABOUT ACCEPTING RESPONSIBILITY FOR OUR PERSONAL AND CPR FAILURES. I WAS AND I AM FAR MORE CRITICAL OF MYSELF THAN ANYONE ELSE EVER COULD BE FOR HAVING COMMITTED THIS MISTAKE. THE HKG SOP FOR ACR X FOR RWY 7R (10-0) DESCRIBES ONLY THE PROC TO FLY THE OCEAN ONE ECHO RTE AND NO OTHER SID RTE. THEREFORE; I ASSUME THE OCEAN ONE ECHO IS THE ONLY SID AUTH FOR ACR X FOR RWY 7R. HKG ATC KNOWS THAT THE OCEAN ONE ECHO SID IS THE ONLY RTE AUTH FOR ACR X ACFT FOR RWY 7R. FOR AN UNKNOWN REASON; IT HAS BEEN MY MINDSET THAT THE SOLE CAUSES OF ACR HISTORY OF SID DEVS FOR HKG DEPS HAVEBEEN FAILURES OF FLTS TO MAINTAIN THE PRECISE TKOF LEG GND TRACK AND FAILURES TO OVERFLY PORPA PRIOR TO INITIATING ANY TURN ON THE SID RTE. SO; I HAVE BEEN ESPECIALLY VIGILANT IN THESE REGARDS. NEITHER OF THESE FACTORS CAUSED MY DEV. BUT; WITH THIS MINDSET; AND GIVEN MY 5 YR RECORD OF INCIDENT FREE DEPS FROM HKG; I BELIEVE I BECAME COMPLACENT WITH THE ACR PROC AND I CONSEQUENTLY FAILED TO BRIEF ITEMS 6(G) AND 6(H). I ALSO DO NOT RECALL PREVIOUSLY NOTING THEIR SIGNIFICANCE IN SUBTLY DEFINING OCEAN ONE ECHO RTE AS THE ONLY AUTH RTE FOR ACR ACFT AFTER PORPA FOR RWY 7R. THE ACR SOP (10-0) IS A TEXT DESCRIPTION OF HOW TO FLY THE OCEAN ONE ECHO SID RTE FOR RWY 7R. BUT; PAGE (10-0) IS NOT A SID PAGE NUMBER. THERE IS NO ACCOMPANYING RTE GRAPHIC AS IN REGULAR SID PAGES THAT WOULD HIGHLIGHT TO CREW MEMBERS THAT PAGE (10-0) IS A SID WITHOUT A RTE DEPICTION. IT DESCRIBES THE ONLY ACR AUTH SID RTE FOR RWY 7R; THE OCEAN ONE ECHO. I BELIEVE IT MAY BE HELPFUL TO DELETE THIS PAGE AND PUBLISH THIS PROC AS AN ACR SPECIFIC OCEAN ONE ECHO SID PAGE WITH A SID PAGE NUMBER. MY DEV HIGHLIGHTS TO ME THE CRITICAL ELEMENTS OF THIS PROC. THEY ARE: A) MAINTAINING THE PRECISE FLT PATH FROM LIFTOFF TO PORPA; B) OVERFLYING PORPA PRIOR TO BEGINNING ANY TURN; AND EQUALLY IMPORTANT; C) EXECUTING THE R TURN TO 180 DEGS MAGNETIC TO FOLLOW THE RTE TO BREAM FOR THE OCEAN ONE ECHO SID RTE AFTER OVERFLYING PORPA. THE MAJORITY OF THE PROC DESCRIBES IN DETAIL AND EMPHASIZES HOW TO MAINTAIN PROPER TKOF LEG GND TRACK. IT ALSO EMPHASIZES THE IMPORTANCE OF OVERFLYING PORPA. THE ADDITION OF A GRAPHIC RTE DEPICTION WOULD HIGHLIGHT AND EMPHASIZE THE ONLY ACR AUTH RTE AFTER PORPA TO FLT CREWS. A PICTURE IS WORTH A THOUSAND WORDS. I HAD PREVIOUSLY FAILED TO MENTALLY ASSOCIATE THE OCEAN ONE ECHO SID WITH THIS PROC. I AM ULTIMATELY RESPONSIBLE FOR THIS OVERSIGHT. I BELIEVE A CONTRIBUTING CAUSE MAY HAVE BEEN MY UNDERSTANDING OR MISUNDERSTANDING THAT THE FOCUS OF PREVIOUS ACR DEP INCIDENTS AT HKG WAS DUE ONLY TO FAILURES TO MAINTAIN PROPER TKOF LEG TRACK AND FAILURES TO OVERFLY PORPA. FOR AN UNDETERMINED REASON; ACR DISPATCHED THIS FLT AND FILED IT FOR THE OCEAN ONE ALPHA SID WHICH DOES NOT COMPLY WITH THE ONLY ACR SPECIFIC SOP FOR HONG KONG DEPS RWY 7R (10-0); THE OCEAN ONE ECHO SID. IT IS ULTIMATELY MY RESPONSIBILITY AS CAPT TO ENSURE THE FLT COMPLIES WITH THE ASSIGNED CLRNC. I AM THE FINAL AUTH IN THE EVENT SEQUENCE. BUT; TO FURTHER REDUCE THE POSSIBILITY FOR ERROR; ALL FLTS SHOULD BE FILED FOR THE OCEAN ONE ECHO ACCORDING TO THE ACR SOP. AS CAPT; I DID NOT NOTE THE DISPATCH ERROR AND TAKE POSITIVE ACTION TO CORRECT THIS DISCREPANCY. HAD I NOTED THE ERROR; I WOULD HAVE CALLED THE DISPATCHER WHO WAS FOLLOWING OUR FLT AND I WOULD HAVE ASKED HIM TO RE-FILE OUR FLT PLAN WITH THE CORRECT SID ACCORDING TO ACR (10-0). HKG ATC APPARENTLY NOTED THE DISPATCH ERROR IN THE FILED SID AND ASSIGNED OUR FLT THE STANDARD OCEAN ONE ECHO RTE. BUT; SINCE I HAD NOT NOTED THE SIGNIFICANCE OF ITEMS 6(G) AND 6(H) IN THE PROC; I DID NOT PICK UP ON THE SID RTE CHANGE AND IMPLEMENT IT. AS I HAVE ANALYZED THIS INCIDENT; I RECALL ONE FACTOR THAT HAS CONTRIBUTED TO MY LONG RECORD OF PREVIOUS INCIDENT FREE HKG DEPS. IN THE PAST; I HAVE ALWAYS CALLED HKG DELIVERY DURING MY PRE-DEP PREPARATIONS TO ASK THEM WHAT SID I COULD EXPECT AND I HAVE COMPARED THIS WITH MY FIELD FLT PLAN. WHEN I HAVE BEEN TOLD TO EXPECT THE OCEAN ONE ECHO SID; ON SEVERAL OCCASIONS I HAVE HAD TO MAKE WRITTEN CHANGES TO THE MASTER FLT PLAN TO LINE OUT OCEAN ONE ALPHA WAYPOINTS AND ADD THE OCEAN ONE ECHO WAYPOINTS. THEN; I HAVE IMMEDIATELY BRIEFED THE CREW ON THE CHANGES AND NOTATIONS. I FAILED TO DO THIS FOR THIS FLT. I HAVE OFTEN SUBMITTED FLT CREW RPTS TO THE DIRECTOR OF OPS TO IDENT ISSUES RELATED TO IMPROVING OUR DISPATCH ROUTING ON SPECIFIC RTES. IN THE CASE OF HKG; I HAVE FAILED TO HIGHLIGHT PREVIOUS INSTANCES OF HAVING BEEN FILED FOR A NON ACR APPROVED OR AUTH SID SUCH AS OCCURRED FOR THIS FLT. I BELIEVE I MAY HAVE BEEN ABLE TO HELPPREVENT THIS INCIDENT AND ANY OTHERS LIKE IT IF I HAD ON PAST OCCASIONS SENT A FLT CREW RPT TO CAPT; OUR DUTY OFFICER TO HIGHLIGHT THIS APPARENT DISPATCH ERROR FOR FURTHER INVESTIGATION. THE OCEAN ONE ECHO SID IS THE ONLY AUTH SID FOR ACR FOR HKG RWY 7R. ACR DISPATCH FILES FLTS FOR RTES BASED ON BEST AVAILABLE DATA AND INFO. IT IS ULTIMATELY THE CAPT'S RESPONSIBILITY TO VERIFY THE FILED RTE DATA WITH CURRENT DATA AND CLRNCS. WHEN DISCREPANCIES ARE NOTED OR RTES CHANGE; SUBMIT A FLT CREW RPT TO THE DUTY OFFICER THROUGH YOUR CHIEF PLT SO THE CHANGES MAY BE INVESTIGATED AND DISPATCH PROCS MAY BE CHANGED AS MAY BE NECESSARY. CAPTS MUST DILIGENTLY COMPARE EVERY ATC RTE CLRNC WITH THEIR FILED RTE OF FLT AND RESOLVE ANY DISCREPANCIES. ACR FHB PROCS CONTAIN SUFFICIENT GUIDANCE ON THIS MATTER. MY FAILURE WAS THE RESULT OF A SIMPLE HUMAN ERROR OF OVERSIGHT. THROUGHOUT MY PROFESSIONAL PLT CAREER; I HAVE KNOWN THERE IS NO PLACE FOR COMPLACENCY IN AVIATION. I REGRET THAT THIS MOST EMBARRASSING AND PAINFUL MISTAKE HAS BEEN A BITTER WAY FOR ME TO RE-LEARN THIS MOST IMPORTANT LESSON. RECOMMENDATIONS: ACR SHOULD CONSIDER DELETING HKG PAGE (10-0) AND PUBLISHING THE PROC AS AN ACR SPECIFIC OCEAN ONE ECHO SID PAGE WITH A GRAPHIC RTE DEPICTION ONLY TO BREAM ON THE FACE OF THE SID. INCLUDE THE CURRENT PROC TEXT IN THE SID. RENUMBER THE PAGE AS AN ACR UNIQUE SID PAGE AND SEQUENCE IT AMONG THE CURRENT SID PAGES. IF THE CURRENT PROC IS RETAINED AND AN ACR SPECIFIC SID IS NOT PUBLISHED; IN RECURRENT GND SCHOOL; HIGHLIGHT THE SIGNIFICANCE OF ITEMS 6(G) AND 6(H) TO ALL CREWS TO ENSURE THEY ARE AWARE THAT IT'S NOT JUST THE FLT TRACK FROM TKOF TO PORPA AND THE OVERFLT OF PORPA THAT ARE SIGNIFICANT. CREWS MUST FOLLOW THE OCEAN ONE ECHO SID RTE FROM PORPA TO BREAM AS PUBLISHED IN THE TEXT. TRAIN ALL ACR DISPATCHERS TO ENSURE ALL ACR FLTS FROM HKG RWY 7R ARE FILED ARE FILED FOR ONLY THE OCEAN ONE ECHO SID.

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