CRJ200 flight crew enters the filed RNAV departure in the FMS instead of the cleared departure and has a track deviation and loss of separation. Fatigue and work load are cited as factors along with several items of company poloicy.
Synopsis
CRJ200 flight crew enters the filed RNAV departure in the FMS instead of the cleared departure and has a track deviation and loss of separation. Fatigue and work load are cited as factors along with several items of company poloicy.
Narrative
After three consecutive days of very early shows; we were preparing for our 15th flight on the third aircraft of the day. After doing a maintenance write up for the last aircraft flown; I had 30 minutes to grab some food for lunch and to prepare and board our flight. I arrived at the aircraft at about 20 minutes before departure time. My First Officer; Flight Attendant; and I quickly prepared the flight and boarded a full aircraft. There were multiple distractions which my First Officer and I fought to overcome. We checked a transformer rectifier unit MEL (24-31-01) which I thought was done incorrectly; because a stray but related circuit breaker was popped and not collared. I checked the MEL book and determined that the circuit breaker should be closed. Not wanting to delay the flight to deal with Maintenance on this issue; I decided to close the breaker and proceed with the item MEL'd as it already was. My First Officer had a difficult time getting the ACARS to receive and transmit Takeoff data. We received a message from Dispatch saying that the aero data portion of ACARS was inoperative currently. In the remaining time I tried to have a few bites of food; as it was lunchtime for us and we originally had a 1:19 break scheduled; and I try to stay nourished in the interest of safety. We performed all the required checklists and got the plane out on time; but we both missed the fact that I had programmed the FMS with the filed flight plan routing; NOT what the clearance which we were given by ATC. I did verify that the FMS waypoints were the same as on the legs printout of the flight release; in error; by myself; without my First Officer reviewing it with me; as I always try to do. I think we missed that it was programmed wrong on the Before Start checklist partially because the departures share the same first three fixes. In line for takeoff with the parking brake on I ate my meal as we waited for three other aircraft to pass in front of us. I had the wrong departure out and the First Officer had the correct one; but we didn't notice. Right after takeoff we received a caution CAS message; and that QRH and the after takeoff flow consumed my time that I could have utilized to notice that we were flying the wrong departure. The First Officer continued to hand fly the aircraft. After completing the QRH and After Takeoff checklist; we were at 10;000. Departure gave us a 160 degree heading and advised traffic at 2 o'clock; 6 miles; and our altitude. He then gave us a 140 heading. We both saw the target on TCAS 100 feet below us and at about 5 miles distance at about our 3 o'clock position; but we never had it in sight and we didn't receive a TCAS TA or RA. We were then given a direct routing; a climb to 12000; and later gave us a phone number to call. The Manager confirmed my certificate number and stated they would be filing paperwork for the deviation; and that we had 'just gotten inside of 3 miles separation with the other aircraft'.Obviously; this occurrence comes down to the fact that I and my First Officer didn't confirm that the given clearance was programmed in the FMS; and as pilot in command that is ultimately my responsibility and my fault. However; in addition to changes I can make; I'd like to make other suggestions as well. Normally I check with my First Officer as to what the clearance is; and confirm the correct routing in the flight plan pages and the legs pages is programmed; before executing the flight plan. Even when distracted and rushed; I should always determine what our clearance from ATC is; before executing the flight plan programmed in the FMS. Do not execute the FMS flight plan until both crew members have verified that it is the same as the ATC clearance. Because of the distractions previously mentioned and in the rush to get an on time departure; we didn't have the time to verify that everything looked good regarding our route and clearance. In the future I will take this time; even if it means a late departure. The distractions took our focus away from determining what the clearance was in the first place. I ask First Officer's in the initial crew briefing to tell me if our clearance is different than as filed; but the distractions took our attention away from communicating that. Maybe a change in the Before Start checklist would be good; to require in the response portion to FMS/ACARS or Departure Briefing to state the departure SID and transition. This trip I'm on is certainly fatiguing; and when flying five and six legs a day for three days straight with these show times; it all becomes a blur. Aircraft swaps increase the tendency for errors and rushing; and increase fatigue as well. We have always had early shows; but I do not remember having to fly six short legs in eleven hours of duty after an early show in the past. This sort of pairing is unacceptable and unsafe in my opinion. I was tempted to call in fatigued on day two of this trip and I have never done that before. Finally; I don't want to point fingers at Dispatch; our Dispatcher only filed what the standard flight plan is on file; I assume. But it's clear that if we had been filed the routing which ATC prefers; we would not be in trouble. This has occurred before; I believe; on another flight of mine; and we noticed the change. Dispatch should have regular correspondence with ATC regarding preferred routings for our flights; if this is not done already. Finally; Pilots should be more aware of Departure SIDS in our system which shares the first few fixes; like many of the RNAV SIDS do. I'm humbled and a little shaken that this transpired under my watch; and will continue to be as professional and vigilant as I can possibly be.Fighting complacency is elusive at times; because 'in the heat of battle' one has to realize (1) you are complacent; and (2) take the extra time to slow down and determine what's wrong. That is difficult to do when tired and fatigued; and trying to make on time departures.
Second reporter narrative
We were all exhausted by this point in the trip and becoming complacent with 17 flights scheduled in the span of less than 58 hours. We had done this trip the week before; and we still hadn't fully recovered from the exhaustion and burnout of that trip. What made this day particularly frustrating was the fact that we were already in our 3rd aircraft of the day; and only on our 4th flight. During the aircraft swap; I arrived at the aircraft first because the Captain was busy writing up the previous aircraft that we had been swapped into for the second and third flights of the day. I performed my duties including getting the clearance. The Captain arrived while I was doing the walk around. There was an involved MEL associated with the plane; and we delved into that together as the Captain attempted to hurriedly choke down his meal during what had turned into yet another completely unnecessary 'quick turn'. (The crew we swapped with was doing a turn and we were doing a turn. Both of us were returning to the same airport and there is almost no difference in the block time.) We found the MEL was actually unnecessary due to a misdiagnosed squawk. Because of the MEL discussion; I completely forgot to brief the Captain on the current weather and the ATC clearance. I immediately returned to working with the ACARS desperately trying to get it to function as the passengers boarded and the Captain programmed the FMS. We ended up having to calculate the takeoff distance manually due to an ACARS failure; and we became distracted with this process. A more timely notice about the failure of the system would have greatly helped. We hurriedly handed the paperwork out the door and got the push time for an on time departure. During the push; we received a different runway for departure than we had briefed. I entered the new runway; and verified that the first 3 fixes were correct for the departure. I had become distracted by the caution message and did not follow along on my chart as I flew the departure. I could have engaged the autopilot instead of hand flying; although I prefer to hand fly the aircraft to keep me focused on the aircraft and what it is doing. 1. Aircraft swaps are EXTREMELY distracting and fatiguing; especially during a 6 leg day. 3 different aircraft for 4 flights is unacceptable. It eliminates any chance to catch your breath and regroup between flights.2. A 5; 6; or 7 leg day is dangerous at best under any circumstances. Adding unnecessary swaps makes it worse. 3. Beginning each day with an extremely early wakeup and then being expected to complete 5 or 6 flights and 9-12 hours of duty is unreasonable. 4. It is difficult to remain focused; avoid complacency; and remember if you did a checklist for this flight or the last one when you complete 17 flights in less than 58 hours. 5. Dispatch needs to stop filing the incorrect route on flights. Pilots tell the Dispatchers about the reroutes all of the time; but I do not see any change in the routes filed. This is a big problem and very aggravating to the pilot group.6. We should have taken the time to review the legs page of the release together as a crew; no matter what my workload. I should have caught the mistake. I blame myself for being complacent. I really struggle to stay focused when I am expected to complete 40 flights in 8 days of flying. 7. RNAV departures should not share the same fixes; it makes mistakes too easy.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.