2008-06 · NASA ASRS report 794223
AN ACR CAPT RPTS HE AND THE FO MISSED SEEING A CRITICAL NAVAID OUT OF SERVICE NOTICE EVEN AFTER CONSCIENTIOUSLY READING THE MANY PAGES OF NOTAMS.
HOW PROBLEM AROSE: WE DEPARTED ZZZ RWY XX. ALLOWABLE TAKE-OFF WTS FOR THIS RWY ARE BASED ON A SINGLE ENGINE-OUT PROC. WE REVIEWED THE DISPATCH RELEASE TO CONFIRM THAT THIS PROC REMAINED VALID THOUGH OTHER PROCS IN THE AREA WERE ALTERED BY NOTAM DUE TO 'TEMPORARY' (INDEFINITE) RELOCATION OF THE ZZZ VOR. APPARENTLY; BOTH THE ZZZ VOR AND THE LOM HAD BEEN NOTAMED OTS; THUS MAKING THE DEP UNUSABLE; AND OUR DISPATCH RELEASE EITHER DID NOT CONTAIN OR HAD INCORRECT TEMPORARY DATA FOR THIS CONDITION. HOW DISCOVERED: I REMAINED COMPLETELY UNAWARE OF THIS CONDITION UNTIL NOTIFIED VIA ANSWERING MACHINE MESSAGE BY A CHIEF PLT. CONTRIBUTING FACTORS: THE FO OBTAINED THE ATIS AND CLRNC WHILE I ATTENDED TO OTHER TASKS. GIVEN HIS EXPERIENCE AND MY FAMILIARITY WITH HIS WORK; I FELT COMFORTABLE WITH THIS SHARING OF DUTIES. GIVEN THE CACOPHONY IN THE COCKPIT; HE WENT ON HEADSET FOR HIS TASKS WHILE I MONITORED THE OPS FREQUENCY; MADE OTHER PREPARATIONS; AND REMAINED ACCESSIBLE TO THE FLT ATTENDANT. IF THE NAVAID OUTAGE WAS BROADCAST ON THE ATIS; I DIDN'T HEAR IT AND THE FO MADE NO SPECIAL NOTE OR COMMENT IF IT WAS. FURTHER; DESPITE SPECIFICALLY LOOKING THROUGH THE NOTAMS; I DID NOT SEE THAT THESE NAVAIDS WERE OTS IF SUCH DATA WAS PRESENT. BEING AWARE THAT IT WAS GETTING LATE; ZZZ WAS BUSY; AND WE WERE BOTH EXPERIENCED AT ZZZ; I MADE A CONCERTED EFFORT TO GUARD AGAINST COMPLACENCY. IT WAS THE FO'S LEG AND HE BRIEFED THE TAKE-OFF AND DEP. AT MY REQUEST; HE SPECIFICALLY BRIEFED THE ZZZ DEP PROC AND I VERIFIED FROM THE RELEASE THAT THE PROC REMAINED VALID. I RECALL THAT THE DEP GIVEN IN OUR CLRNC WAS TO FLY 180 HEADING UNTIL REACHING A DME DISTANCE FROM THE ZZZ1 VOR; THEN LEFT TO A 040 HEADING. WHILE THAT SHOULD HAVE ALERTED ME TO INVESTIGATE FURTHER; IT'S NOT UNCOMMON TO RECEIVE '...EXCEPT AMEND YOUR CLIMB-OUT INSTRUCTIONS TO READ X; Y; Z...' WHEN OPERATING FROM ZZZ; SO THE CHANGE DID NOT RAISE THE FLAG THAT IT MIGHT HAVE ELSEWHERE. HE SET UP IN GREEN DATA TO IDENTIFY THE ZZZ1 DME AND I SET UP IN GREEN DATA TO IDENTIFY THE ZZZ DME IN CASE WE NEEDED IT FOR THE ENGINE-OUT PROC. THE ZZZ VOR APPEARED COMPLETELY OPERATIVE. THERE WAS NO GREEN DATA INDICATIONS TO SUGGEST OTHERWISE. THE CDI MOVED WHEN THE 'BEZEL' WAS ROTATED AND THE DME CHANGED AS WE MOVED AROUND THE AIRFIELD. RECOMMENDATIONS: 1. DESPITE RECENT CHANGES; NOTAMS REMAIN VOLUMINOUS AND CAMOUFLAGED. AT MINIMUM; THEY NEED TO BE GROUPED WITH HEADING LABELS SUCH AS 'NAVAIDS'; 'STARS'; 'SIDS'; 'TXWYS'; 'RWYS'; 'WITHIN 7 DAYS'; ETC; SUCH THAT INFORMATION RELEVANT TO THE PHASE OF FLT CAN BE READILY DISTINGUISHED. 2. CONFLICTING DATA CANNOT BE PERMITTED TO CO-EXIST ON THE DISPATCH RELEASE. SAFETY IS SEVERELY IMPINGED WHEN ONE PIECE OF DATA AFFIRMS THE APPLICABILITY OF A PROC WHILE ANOTHER; BURIED SOMEPLACE ELSE; RENDERS THE PROC UNUSABLE. 3. WHEN NAVAIDS ARE NOTAMED OUT-OF-SERVICE OR UNUSABLE; TURN THEM OFF!
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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