Fatigued due to circadian disruptions on their layover; aircraft fuel system anomalies; a long flight and traffic delays; the flight crew of a B757-200 mis-programmed their FMS. A track deviation resulted.

Date: 2009-07 · Aircraft: B757-200 · Phase: descent

Anomalies: aircraft-equipment-problem-less-severe|deviation-track-heading-all-types|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-fuel-issue

Synopsis

Fatigued due to circadian disruptions on their layover; aircraft fuel system anomalies; a long flight and traffic delays; the flight crew of a B757-200 mis-programmed their FMS. A track deviation resulted.

Narrative

We had dealt with a fuel quantity indication problem before takeoff and also during the flight. Our workload; and consequently fatigue; had been significantly higher throughout the flight as we monitored and recorded the problem and communicated the issue to the company via ACARS. About an hour before arrival; even before coast-in; Center began giving us altitude changes and vectors (at one point as much as 90 degrees off course) apparently due to a significant volume of traffic. Arriving in TRACON airspace; the vectors and repeated changes in speed and altitude assignment continued. Our workload and fatigue were steadily increasing. At one point during descent we discussed this. I asked my First Officer to 'back me up.' We had planned for a Runway YR visual approach backed up by the ILS; with the hope of possibly getting Runway X. After the constant vectors off course and altitude restrictions; we commented that there was little chance of getting Runway X. Runway YR was the active route in the FMC; tuned and identified in the ILS receiver; and I had the YR approach chart on top of the Runway X chart clipped on my yoke. We were cleared direct to an interserction with charted altitude and speed restrictions; after being vectored off course and held significantly high on profile. Just prior to reaching the intersection; we were given a heading to intercept the YR localizer; and then almost immediately a change to fly present heading to intercept the Runway X localizer. At that point I was using Level 3 automation with the speed brakes extended to get back on descent profile. I asked my First Officer to program the Runway X approach and re-tune the ILS. We were about 25 miles from the airport; and I asked for an intercept leg to XXXXX intersection; not realizing that I was still looking at my Runway YR approach plate. My First Officer said he didn't know where XXXXX was; so I programmed an intercept leg 078 degrees to XXXXX direct WWWWW and the rest of the Runway X approach. We agreed that it looked good; and I engaged LNAV. Shortly after LNAV intercepted the 078 leg to XXXXX; Approach called and said it looked like we had intercepted the YR localizer; and gave us a heading to intercept the Runway X localizer. I went back to Level 3 automation and then saw that I still had the Runway YR chart out and had incorrectly programmed XXXXX instead of ZZZZZ. We were still more than 20 miles out. Shortly thereafter the autopilot captured the Runway X localizer with considerable bracketing; and then engaged altitude hold instead of capturing the glideslope as I intended. I disconnected the autopilot and flew the remainder of the approach in Level 2 automation. Fatigue and high workload were factors; and this was the third of three operational errors on our part during this flight. My poor attention to detail and cross-checking were symptoms of fatigue due to disruption of circadian rhythm. I had been awake for about nineteen hours. During the layover I had one complete; uninterrupted sleep cycle but then later was unable to sleep when I tried to nap. Fatigue is typical for most crewmembers on most of our Hawaiian pairings; which are constructed in a way that; according to NASA sleep research; is highly likely to cause significant fatigue. In my experience; the only Hawaiian pairings that don't produce this much fatigue have extended layovers of fifty plus hours; allowing an opportunity for two complete sleep cycles instead of only one and a half; as happens with most of our pairings. To reduce fatigue; Hawaiian layovers (all layovers; actually) should be designed considering existing guidance resulting from sleep research. The air traffic management system must be significantly upgraded to adequately deal with the current level of air traffic congestion; which will continue to cause incidents due to high workload for pilots and controllers.

More incidents for this aircraft family →

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