AN ACR CREW REPORTS A SID LNAV DEVIATION. THE CREW WAS FATIGUED; HUNGRY; AND MISSED A HDG REQUIREMENT BECAUSE OF THE SID CHART FORMAT.

Date: 2006-12 · Aircraft: MD-11 · Phase: takeoff

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

Synopsis

AN ACR CREW REPORTS A SID LNAV DEVIATION. THE CREW WAS FATIGUED; HUNGRY; AND MISSED A HDG REQUIREMENT BECAUSE OF THE SID CHART FORMAT.

Narrative

SID/DEP PROC DEV. DEPARTED ZZZ2 EARLY MORNING FOR ZZZ3 AFTER A 4 HR LEG FROM ZZZ1-ZZZ2 FOLLOWED BY A SHORT HUB TURN. PREFLT WAS SLIGHTLY RUSHED; BUT NOTHING MORE THAN NORMAL. ACFT WAS SET UP FOR RWY 23L DEP AND BRIEFED. DURING TAXI; DEP RWY WAS CHANGED TO RWY 23R; WHICH REQUIRED THE FO TO CHANGE THE FMS; REVIEW THE NEW DEP PROC; RE-COMPUTE THE TKOF DATA; AND THEN BRIEF AND SET UP THE FMS. THIS WAS GOING ON WHILE WE WERE ALSO GIVEN TAXI INFO FOR SEQUENCE TO THE NEW RWY. ALL BRIEFINGS AND CHKLIST WERE COMPLETED. AFTER TKOF; ACFT TURNED TO INTERCEPT THE OUTBOUND RADIAL INSTEAD OF STAYING ON ASSIGNED HDG UNTIL TOLD TO INTERCEPT BY DEP. THIS IS WHERE THE DEV OCCURRED. TWR ASKED US WHAT WE WERE DOING; AND WE REPLIED THAT WE WERE INTERCEPTING THE OUTBOUND RADIAL. TWR INFORMED US THAT THEY HAD NOISE ABATEMENT PROCS AND TO TURN TO A HDG OF 230 DEGS. WE COMPLIED; THEN WERE SWITCHED TO DEP; AND CONTINUED WITH A NEW HDG AND CLB. REST OF FLT WAS UNEVENTFUL. FACTORS THAT CONTRIBUTED TO THE DEV: 1) CREW REST. BOTH CREW MEMBERS WERE TIRED. FATIGUED (DIDN'T BELIEVE SO AT THE TIME). WE HAD A 24 HR TURN WHICH SWITCHED OUR SLEEP CYCLE. THE LOCATION OF THE HOTEL WAS NEXT TO THE ARPT (ACFT NOISE) AND AN ACTIVE RAIL LINE. 2) LIMITED FOOD OPTIONS. CHOSE TO SLEEP AS OPPOSED TO GET UP 1 HR EARLY TO EAT. 1 SNACK WAS PROVIDED AT DEP; WHICH WAS EATEN AT TOP OF CLB. ANOTHER SNACK WAS PROVIDED FOR SECOND LEG; BUT THE MEAL FACILITY NORMALLY AVAILABLE DURING THE HUB TURN HAD CLOSED EARLY. THE 2 SNACKS WERE THE ONLY FOOD FOR 11 HR DUTY DAY. 3) COMMERCIAL CHART PUB FORMAT FOR SID'S. GRAPHIC AND TEXT DESCRIPTION WERE ON DIFFERENT PAGES. THIS FORM OF ATC INFO IS NEW TO US AND I AM STILL TRYING TO GET COMFORTABLE WITH THE FORMAT AND A SYS FOR BRIEFINGS. 4) RWY CHANGE DURING TAXI. MANY THINGS TO CHANGE AND SET UP IN A FEW MINS; THAT WE NORMALLY TAKE MORE TIME IN THE CHOCKS. THIS DEV WOULD NOT HAVE HAPPENED HAD WE NOT HAD THE NAV FUNCTION OF THE FMS SELECTED. WHILE THE DEP INFO DID DESCRIBE THE PROC; THE DISJOINED FORMAT CAN ADD TO CONFUSION (UNCLR PICTURE). THE FORMAT WHICH THE FMS DISPLAYED THE DEP LED US TO BELIEVE NAV COULD BE SELECTED. THAT THERE WAS NO 'DISCON' ON THE FMS FLT PLAN PAGE LED US TO BELIEVE WE COULD NAV THIS DEP. NORMALLY; RWY HDG DEPS HAVE A 'DISCON' AFTER THE RWY; THEN THE FIXES THAT DEFINE THE AIRWAYS/DEP. LESSONS LEARNED: BETTER RECOGNITION OF FATIGUE INDICATORS. ALLOW MORE TIME TO FOCUS ON ATC PROCS DUE TO FORMAT.

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