WDB FLT CREW FAILS TO NOTE A SUBSTANTIVE CHANGE IN ASSIGNED SID FROM VIDP BECAUSE THE INFO WAS BURIED IN 19 PAGES OF UN-ANNOTATED NOTAMS.

Date: 2008-05 · Aircraft: Widebody Transport · Phase: initial_climb

Anomalies: deviation-track-heading-all-types

Synopsis

WDB FLT CREW FAILS TO NOTE A SUBSTANTIVE CHANGE IN ASSIGNED SID FROM VIDP BECAUSE THE INFO WAS BURIED IN 19 PAGES OF UN-ANNOTATED NOTAMS.

Narrative

DURING PREFLT; WITH FLT PLAN AND WX AND NOTAMS DELIVERED TO THE ACFT; CAPT AND FO FAILED TO SEE A NOTAM IMBEDDED ON PAGE 13 OF 19 PAGES. THE NOTAMS WERE ALL INCORRECTLY PRINTED WITH NO INDENTS TO DISTINGUISH NEW SUBJECTS. THE NOTAM CHANGED; COMPLETELY; THE ANI 1A SID. THE SID IS NOT GIVEN UNTIL APPROX 20 MINS BEFORE PUSH BACK; AND BOTH PLTS FAILED TO REALIZE THE CHANGE. THE ACFT IS FMS AND THE DATABASE HAD BEEN CHANGED WITHIN THE LAST TWO DAYS; BUT THE NEW DATABASE DIDN'T HAVE THE NEW ANI 1A SID. THE COMMERCIAL CHART CHANGE PAGES DID NOT CONTAIN THE INFORMATION OF THE CHANGE EITHER. THE ONLY PLACE TO FIND IT WAS EMBEDDED ON PAGE 13 OF 19. THE ANI 1A SID WAS FLOWN AS DEPICTED IN THE FMS. AT APPROX 9000 FT; A CTLR CAME ON THE RADIO INFORMING US OF OUR ERROR; BUT SHE SPOKE SO QUICKLY WE COULDN'T UNDERSTAND ANYTHING SHE SAID. WE ASKED HER SEVERAL TIMES FOR CLARIFICATION AND TO SLOW DOWN SO WE COULD UNDERSTAND HER; BUT WE NEVER COULD. IT WAS ONLY LATER WHEN WE WERE ABOVE 10000 FT AND WE COULD PULL OUT THE NOTAMS AND RECHECK DID WE REALIZE WHAT SHE WAS SAYING ABOUT THE CHANGE IN THE GND TRACK OF THE SID. WE WERE VFR; NO OTHER ACFT WERE AFFECTED THAT WE KNOW OF AND NO SAFETY OF FLT WAS JEOPARDIZED.

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