AN ERJ145 CREW MISREAD A PDC AND FLEW A RTE INTO AN ARR ROUTING (STAR).

Date: 2004-11 · Aircraft: EMB ERJ 145 ER/LR

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

Synopsis

AN ERJ145 CREW MISREAD A PDC AND FLEW A RTE INTO AN ARR ROUTING (STAR).

Narrative

WHEN I GOT TO THE ACFT IT WAS ALREADY PWRED UP. I DID MY FLOW AND GOT TO THE PART OF FMS PROGRAMMING. I PULLED OUT THE PRE-STORED FLT PLAN (PIT-BDL); LOOKED IT OVER; AND COMPARED IT TO THE DETAILS OF FLT PLAN ON RELEASE. THERE WERE SEVERAL MISTAKES IN THE PRE-STORED VERSION OF THE FLT PLAN. THE MAIN ERROR THAT CAUGHT MY ATTN CONCERNED ARR; WHICH I CORRECTED. WHILE GOING OVER THE PROGRAMMING; THE FO POINTED OUT THAT THE INS WAS DISPLAYING 'BATTERY FAILURE' CAUTION ON THE ADVISE PANEL. SINCE I HAD NEVER SEEN THIS FAILURE ADVISORY BEFORE; I DID NOT KNOW HOW TO CORRECT IT. I CALLED MAINT CTL TO ASK FOR INSTRUCTIONS. MAINT CTL TOLD ME THAT THE ONLY WAY TO CORRECT THE PROB WAS TO SHUT DOWN THE ELECTRICAL PWR AND THEN RE-START THE SYS. THIS WOULD REQUIRE NOT ONLY SHUTTING DOWN THE ELECTRICAL PWR; BUT ALSO THE PLANE ITSELF. I DID NOT CONSIDER THE RECOMMENDATION ADVISABLE; SINCE MOST OF THE PAX WERE ALREADY ON BOARD AND WE WERE VERY CLOSE TO DEP TIME. FURTHERMORE; THE PROC WOULD REQUIRE SHUTTING DOWN BOTH THE AIR CONDITIONING SYS AND THE LIGHTS THROUGHOUT THE WHOLE PLANE; WHICH WOULD IMMEDIATELY CAUSE CONCERN AMONG THE PAX. IN ADDITION; I KNEW THAT IN ORDER FOR INS TO ALIGN WOULD REQUIRE AN ADDITIONAL 5-7 MINS; WHICH WOULD CAUSE A DELAY IN OUR DEP TIME. BUT SINCE THIS WAS THE ONLY SOLUTION ACCORDING TO MAINT CTL; I PROCEEDED TO DO THE SHUT DOWN. AFTER PWR RE-SET; I STARTED PROGRAMMING ALL OVER AGAIN. I WAS AWARE OF THE MISTAKES THAT THE FMS INCLUDED IN THE STAR PORTION OF THE PROC; WHICH I REPROGRAMMED AND VERIFIED. HOWEVER; THE DEP NEVER CAUGHT MY ATTN DUE TO THE FACT THAT THE NEW CLRNC NEVER MENTIONED THE RTE WE WERE SUPPOSED TO FLY. CLRNC ATC ISSUED WAS 'CLRED AS FILED.' SID DID NOT DEPICT THE RTE WE WERE ASSIGNED. THE ONLY SPECIFIC INFO ON CLRNC WE GOT WAS ON THE RELEASE PORTION; AND WE WERE NOT AWARE THAT THE INFO ON THE RELEASE PORTION WAS DIFFERENT THAN THE ONE INCLUDED IN THE FLT PLAN AND THE FMS. THE DETAILED FLT PLAN AND FMS AGREED (PIT..ELW..SLT AND SO ON). HOWEVER; THE CLRNC STATED (PIT..ELW.ELW050..J587.SLT). WE OVERLOOKED THE DIFFERENCES BTWN BOTH BECAUSE WE WERE FOCUSED ON AN ON-TIME DEP AND ASSUMED THAT THE PROGRAMMED DEP WAS CORRECT. ON THE TAXI OUT; WE BRIEFED THE DEP FROM THE SID; STILL UNAWARE THAT THERE WAS A MISTAKE. AFTER TKOF; PIT DEP SWITCHED US TO ZOB; WHILE THE ACFT WAS ON LNAV. WE HAD JUST CROSSED OVER ELW AND WERE PROCEEDING TO SLT WHEN THE CTR ASKED WHAT OUR INTENTIONS WERE. I WAS THE PNF; SO I RESPONDED THAT WE WERE PROCEEDING ACCORDING TO OUR CLRNC DIRECT TO SLT; WHICH I BELIEVED TO BE CORRECT. CLE QUESTIONED US ABOUT WHO HAD ISSUED THIS CLRNC; AND WHETHER THIS AGREED WITH WHAT WE HAD RECEIVED FROM ATC. I IMMEDIATELY REALIZED OUR MISTAKE AND OFFERED TO CORRECT IT. I ALSO ASKED WHETHER THE CTLR WANTED US TO RETURN TO THE PROPER COURSE. WE RECEIVED A NEGATIVE REPLY AND CLRNC TO PROCEED TO SLT. CLE POINTED OUT THAT FLYING THE RTE WE WERE FLYING WAS 'UNDESIRABLE' BECAUSE SLT WAS USED BY ARRS. ON THE SWITCHOVER; I ASKED THE CTLR FOR THE TELEPHONE NUMBER WHERE HE COULD BE CONTACTED SO THAT WE COULD FURTHER DISCUSS THE EVENT. HE GAVE ME THE TELEPHONE OF THE CTR FACILITY. I ATTEMPTED TO CONTACT THE CTR FACILITY UPON ARRIVING TO BDL; BUT WAS NOT ABLE TO REACH ANYONE BECAUSE NOBODY PICKED UP THE PHONE. IN MY OPINION; ONE OF THE MAIN FACTORS THAT CONTRIBUTED TO THIS INCIDENT WAS THE LACK OF CLARITY ON THE SID. THE INFO IS NOT CLR CONCERNING SPECIFIC DEP PROCS. IT SEEMS TO BE FOR LCL CREWS WHO OPERATE OUT OF PIT AND WHO ARE VERY FAMILIAR WITH THE SPECIFIC PROC OF THE ARPT. IF THIS IS THE STANDARD PROC IT SHOULD BE CLRLY DEPICTED ON THE CHART.

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