A B737-300; INITIALIZED WITH AN INCORRECT ARPT POS; ALLOWED THE CREW TO DEPART WITHOUT ALERTING THEM TO THE DISCREPANCY IN EXCESS OF 60 NM.
Synopsis
A B737-300; INITIALIZED WITH AN INCORRECT ARPT POS; ALLOWED THE CREW TO DEPART WITHOUT ALERTING THEM TO THE DISCREPANCY IN EXCESS OF 60 NM.
Narrative
AFTER TKOF FROM RWY 9 AT SAN; THE #2 AUTOPLT WAS CONNECTED. OUR FLT WAS CLRED DIRECT TO IPL VOR. I WAS PERFORMING THE AFTER TKOF CHKLIST AFTER CONFIRMING IPL SELECTED BY THE COPLT IN THE DATABASE OF THE FMC. SEVERAL SECONDS LATER; I CALLED 'AFTER TKOF CHKLIST COMPLETE' AT ABOUT THE SAME TIME AS I NOTICED THAT THE COURSE LINE TO IPL WAS ESSENTIALLY SHOWING A HDG OF 270 DEGS. OUR ACFT WAS PASSING THROUGH A HDG OF ABOUT 160 DEGS AT THAT TIME. WE HAD BEEN CLRED TO CLB TO AN ALT OF 10000 FT. I REACHED FOR THE CTLS TO DISCONNECT THE AUTOPLT AND MANUALLY TURN THE ACFT BACK TO THE E AT APPROX THE SAME TIME THAT THE SOCAL CTLR ASKED US WHAT IN #$** WE WERE DOING. HE ISSUED A TERSE COMMAND FOR US TO LEVEL OFF AT 5000 FT AND TURN L IMMEDIATELY! I INFORMED HIM THAT WE WERE ALREADY DOING THAT. AT THE SAME TIME WE RECEIVED A TA FOR TFC. WHILE IN THE TURN; I NOTICED THAT INW VORTAC WAS SHOWING ON THE NAV DISPLAY SCREEN. FURTHER INSPECTION SHOWED THAT THE ACFT HAD ACTUALLY THOUGHT IT HAD DEPARTED PHOENIX; BOUND FOR SAN DIEGO -- INSTEAD OF THE OTHER WAY AROUND. WITH NO OTHER OPTIONS AT THAT PARTICULAR TIME; I NOTIFIED ATC THAT WE HAD LOST OUR RNAV CAPABILITY; AND THAT WE WOULD BE NAVING AS A /W ACFT. THE FLT WAS TOO SHORT FOR US TO REASSESS OUR PREDICAMENT AND RECTIFY THE SIT. SO; WE FLEW TO PHOENIX WITH ONLY VOR/DME CAPABILITIES. NO OTHER PROBS OCCURRED DURING THE FLT. AFTER INSPECTION OF THE IRS SYS BY THE AVIONICS TECHNICIAN AT THE GATE IN PHOENIX; IT WAS NOTED THAT HE HAD PARTICULAR TROUBLE GETTING THE SYS TO REALIGN ITSELF. HE HAD TO CLR A RE-ALIGNMENT FAULT SEVERAL TIMES BEFORE THE SYS WOULD ACCEPT ALIGNMENT IN PHOENIX. I ASKED THE FO IF HE HAD MISTAKENLY ENTERED PHOENIX AS THE REF ARPT UPON INITIAL ALIGNMENT IN SAN DIEGO INSTEAD OF SAN DIEGO ITSELF. HE ADMITTED THAT HE HAD; BUT IMMEDIATELY CAUGHT THE MISTAKE AND RE-ENTERED THE CORRECT ARPT; SAN; AS THE REF ARPT ON THE 'INIT' PAGE. BEFORE WE DEPARTED SAN; THE PAGE LOOKED FINE; AS WELL AS THE FLT PLAN SEQUENCE IN THE FMS. THE TKOF CHK CONFIRMED THAT RWY 9 WAS UPDATED JUST BEFORE PWR APPLICATION. IN SHORT; EVERYTHING LOOKED NORMAL TO THE FO AND MYSELF AFTER ALL THE CHKLISTS AND FLOWS WERE COMPLETED. I FEEL CERTAIN THAT WE MUST HAVE MISSED SOMETHING SOMEWHERE. HOWEVER; I CANNOT IMAGINE WHERE IT WAS. AFTER TKOF; THE ONLY INDICATION ON THE NAV DISPLAY -- 10 MI RANGE -- THAT SOMETHING WAS TERRIBLY WRONG; WAS A VOR NAMED INW; AND A COURSE LINE THAT MADE A 180 DEG TURN TO THE R. NEITHER SHOULD HAVE BEEN SEEN ANYWHERE NEAR SAN DIEGO. BOTH THE FO AND I DO REMEMBER SEEING THE FMC LIGHT ON THE THRUST MODE ANNUNCIATOR PANEL FLASH ONE TIME AS WE COMPLETED THE TKOF CHKLIST; BUT NEITHER OF US CONNECTED IT WITH ANYTHING SO CONSEQUENTIAL. IT MAY HAVE BEEN THE ONLY CLUE WE COULD HAVE HAD. HOWEVER; WE DO BOTH FEEL LIKE IF WE HAD INCREASED THE RANGE ON THE NAV DISPLAY WE WOULD HAVE SEEN MANY CLUES THAT SOMETHING WAS AMISS. THE QUESTION REMAINS THOUGH; WHEN DID THE ORIGINAL ERROR ARISE TO DISPLAY ITSELF ON THE SCREEN? WAS IT AT ALIGNMENT OF THE IRS AT THE GATE? OR THE UPDATE AT THE RWY THRESHOLD? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR RECEIVED NO FEEDBACK ON THE CAUSE OF THE ANOMALY. HE BELIEVES THE CREW MADE AN ERROR NOT DETECTABLE BY NORMAL CHKLIST ITEMS. HE FEELS THAT IF THEY HAD EXPANDED THE NAV DISPLAY TO A RANGE LARGER THAN 10 NM OR LOOKED AT THE PLAN PAGE; HE WOULD HAVE SEEN THE ERROR. AS IT IS; THEY DO NOT KNOW FOR SURE THE CAUSE. HE DOES KNOW THE ACFT DEPARTED LATER THAT DAY.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.