FLT CREW FAILS TO HEED REVISED SEGMENT OF PDC CLRNC TO FLY ST JOHNS SID VICE MAXXO.

2008-05 · NASA ASRS report 784845

Date: 2008-05 · Aircraft: Commercial Fixed Wing · Phase: initial_climb

Anomalies: deviation-discrepancy-procedural-clearance

Synopsis

FLT CREW FAILS TO HEED REVISED SEGMENT OF PDC CLRNC TO FLY ST JOHNS SID VICE MAXXO.

Narrative

THIS EVENT IS IN REGARDS TO OUR NEW PDC CAPABILITY AND THE WAY THE PDC MESSAGES ARE FORMATTED. WE HAD A DISPATCH RELEASE THAT HAD US FLYING THE SJN3 DEP TO STJ AS FILED. THE PDC MESSAGE INDICATED 'PHX SJN3 SJN J74 ZZZ.' THE FO FOLDED THE PDC SO THE FILED CLRNC WAS SHOWING AND LAID IT ON THE CENTER CONSOLE WHERE I LOOKED AT IT. THE PROBLEM WAS THAT THE PDC ALSO CONTAINED A 'REVISED SEGMENT' OF 'MAXXO1 CNX' WHICH I DIDN'T SEE. I HAVE NEVER SEEN THIS TYPE OF ANNOTATION ON THE PDCS. I SHOULD HAVE LOOKED AT THE ENTIRE PDC. THE FO TOLD ME HE WAS USED TO THE CLRNC DELIVERY CTLR READING THE ACTUAL CLRNC WE ARE CLRED FOR WHICH WOULD ALREADY INCORPORATE ANY REVISIONS SUCH AS 'CLRED AS FILED EXCEPT FLY MAXXO1 CNX AS FILED.' THE FORMAT OF THE PDC WITH EXCEPTIONS IS DIFFERENT ENOUGH FROM THE PAST PRACTICES USED FOR VERBAL CLRNC TRANSMISSIONS THAT THERE CAN BE MISCOM; SUCH AS THIS. AFTER THIS HAPPENED I REQUIRED THE FO TO WRITE THE CLRNC ON THE TAKEOFF DATA SHEET BY READING FROM THE TOP DOWN TO THE BOTTOM AND TO GIVE ME THE PDC PAPER UNFOLDED; WHICH I VERIFY FROM THE TOP DOWN CONFIRMING ROUTING IN THE MCDU; TRANSPONDER; ALTITUDE AND HEADING SELECTORS; AND RADIO FREQUENCY SELECTOR. THE ACTUAL EVENT DIDN'T INVOLVE US FLYING IN THE WRONG DIRECTION AS THE CTLR IMMEDIATELY ASKED US WHICH DEP WE WERE CLRED FOR WHEN WE MADE THE INITIAL RADIO CONTACT AFTER LEAVING TOWER FREQ. IN OTHER WORDS WE WERE STILL FLYING RWY HDG. WHEN WE RESPONDED THAT WE WERE FLYING THE SJN3 HE TOLD US THAT HIS PAPERWORK INDICATED THE MAXXO1 CNX AND TOLD US TO TURN L TO A SOUTHBOUND HDG. WHEN WE RE-PRINTED THE PDC CLRNC WE DISCOVERED OUR MISTAKE. AFTER REACHING OUR DESTINATION I CALLED THE PHX TRACON SUPVR AND DISCUSSED THE MATTER WITH HIM. HE TOLD US THERE HAD BEEN NO CONFLICTS OR PROBLEMS AND THERE WOULD BE NO VIOLATION FILED. HOWEVER; I THINK THAT ALTHOUGH THIS WAS MY ERROR IN NOT CATCHING THE PDC INTERPRETATION ERROR BY THE FO; THERE IS A POTENTIAL PROBLEM WITH THE FORMAT OF CLRNC CHANGES/DIFFERENCES SHOWN ON THE PDC. IT WOULD MAKE MORE SENSE TO HAVE THE PDC READ 'CLRNC' FOLLOWED BY THE RTE ATC WANTS THE PLTS TO FLY. IF A 'REVISED SEGMENT' IS NECESSARY; IT SHOULD READ 'DEP REVISED FROM SJN3 SJN J74 ATL TO MAXXO1 CNX'. THIS WOULD HAVE HELPED AVOID ANY CONFUSION. CONTRIBUTING FACTORS WERE TIME COMPRESSION CAUSED BY SOME MINOR MAINT AND ACFT SERVICING ISSUES WHICH DEMANDED MY ATTENTION. ALTHOUGH I NORMALLY READ THE PDC CLRNC IN ITS ENTIRETY; THIS TIME WE WERE PRESSED FOR TIME AND THE PDC PAPER WAS FOLDED IN SUCH A WAY THAT I DIDN'T SEE THE REVISION SECTION. THIS FO IS VERY QUALIFIED AND COMPETENT AND HAS NEVER MADE AN ERROR OF THIS TYPE BEFORE WITH ME; SO I TRUSTED WHAT I WAS SEEING AS CORRECT. THAT IT HAPPENED AT ALL WAS MY RESPONSIBILITY AS I DIDN'T READ THE ENTIRE PDC THIS TIME. THE REVISED SEGMENT FORMAT IS A BIT CONFUSING. THE PDC SHOULD SHOW EXACTLY WHAT A FLT IS CLRED FOR RATHER THAN WHAT IT IS NOT CLRED FOR. THE FORMAT OF THE PDC SHOULD BE CHANGED AS INDICATED ABOVE. IN THE PAST WHEN CLRNCS WERE DELIVERED BY VOICE RADIO TRANSMISSIONS; THE CAPT SELDOM LISTENED IN ON THIS AND TRUSTED THE FO TO WRITE DOWN THE CLRNC CORRECTLY. THAT THE CAPT SHOULD NOW HAVE TO REVIEW THE PDC IS SOMEWHAT COUNTER TO PAST PRACTICES BEFORE THE CLRNC RECEIPT PROCESS WAS AUTOMATED.

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

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