Meetings Seminars and... · Web viewATTACHMENT D – Results from Preliminary Error Analysis of...
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ATTACHMENT D – Results from Preliminary Error Analysis of Available Data A preliminary analysis based on limited factual data was conducted to identify the root cause for an observed surge in North Atlantic (NAT) lateral deviation errors associated with half-degree of latitude waypoints for the period March-June 2014. The data sources considered were preliminary CMA reports and additional data from Isavia, Nav Portugal, and UK NATS for thirty-three Gross Navigation Errors (GNEs) involving lateral deviations with aircraft having deviated 30 nautical miles North of their intended course. It is noted that additional data from the events, such as flight crew and controller statements, would permit a more conclusive finding. The data sources as provided contained limited data to conduct a thorough analysis for determining the causal factors and assess if and how currently existing controls were utilized and their effectiveness in mitigating the occurrence of these events. Jeppesen released NavData cycle 1404, effective 3 April 2014, containing new half-degree latitude/full degree longitude waypoints. The surge in lateral deviation events following this change suggests these new waypoints posed a source of confusion for flight crews as the ARINC 424 standard requires a trailing character be used to denote full degree of latitude while a leading character is used for a half degree of latitude. Without having prior knowledge of the new waypoints in the database and proper knowledge of the procedures necessary for their proper entry, crews could have been unaware of the latent error properties and prepared to guard against entry error due to any prefix/suffix confusion. Available data for thirty-three (33) events was reviewed and analyzed to determine the probable root cause leading to the events. It is noted that International General Aviation (IGA) business aviation aircraft having the range capability for intercontinental flight were involved in a disproportionate number of events as 19 of the 33 occurrences are attributed to these aircraft types yet they only generate 5.2% of total NAT operations. Two event types are evident within the available data: probable leading/trailing character entry errors and errors involving the potential double entry of longitude. The distribution of the observed events is as follows: Distribution of Events by Type Tota l IGA COM
Transcript of Meetings Seminars and... · Web viewATTACHMENT D – Results from Preliminary Error Analysis of...
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
A preliminary analysis based on limited factual data was conducted to identify the root cause for an observed surge in North Atlantic (NAT) lateral deviation errors associated with half-degree of latitude waypoints for the period March-June 2014. The data sources considered were preliminary CMA reports and additional data from Isavia, Nav Portugal, and UK NATS for thirty-three Gross Navigation Errors (GNEs) involving lateral deviations with aircraft having deviated 30 nautical miles North of their intended course. It is noted that additional data from the events, such as flight crew and controller statements, would permit a more conclusive finding. The data sources as provided contained limited data to conduct a thorough analysis for determining the causal factors and assess if and how currently existing controls were utilized and their effectiveness in mitigating the occurrence of these events.
Jeppesen released NavData cycle 1404, effective 3 April 2014, containing new half-degree latitude/full degree longitude waypoints. The surge in lateral deviation events following this change suggests these new waypoints posed a source of confusion for flight crews as the ARINC 424 standard requires a trailing character be used to denote full degree of latitude while a leading character is used for a half degree of latitude. Without having prior knowledge of the new waypoints in the database and proper knowledge of the procedures necessary for their proper entry, crews could have been unaware of the latent error properties and prepared to guard against entry error due to any prefix/suffix confusion.
Available data for thirty-three (33) events was reviewed and analyzed to determine the probable root cause leading to the events. It is noted that International General Aviation (IGA) business aviation aircraft having the range capability for intercontinental flight were involved in a disproportionate number of events as 19 of the 33 occurrences are attributed to these aircraft types yet they only generate 5.2% of total NAT operations. Two event types are evident within the available data: probable leading/trailing character entry errors and errors involving the potential double entry of longitude. The distribution of the observed events is as follows:
Distribution of Events by Type Total IGA COM
Leading/Trailing Character Entry Errors 30 17 13 <FL350 4 2 2 FLs 350-390 14 3 11 >FL 390 12 12 -Waypoint Insertion Errors Due to Double Entry of Longitude 3 2 1 <FL350 - 1 - FLs 350-390 - - - >FL 390 - 1 1Total 33 19 14
The preliminary root cause analysis was conducted by FAA contract support personnel using the 5 Whys Technique. This process involved stating the problem of how the recent surge in gross navigational errors (GNEs) could adversely impact NAT risk. The Tree Diagram Tool was used to ask why the problem exists and then show the logical relationship for each response to the preceding cause. The process was stopped when the probable root cause was identified from the available data. Through reviewing the available data, the probable root cause for the recent surge in GNEs within the NAT, nonetheless, can be attributed to a recent update of ½ degree of latitude waypoints named in the ARINC 424 paragraph 7.2.5 convention and ultimately flight crew
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
confusion with the trailing and leading characters when entering waypoints using latitude and longitude coordinates.
The diagram is presented below:
It is recognized that further review of NAT GNE events involving lateral deviations is necessary to more definitively arrive at the root cause. The 29 May 2014 removal of the waypoints by Jeppesen for NavData cycle 1406 may result in a reduction in GNE events to the previously observed rate of occurrence.
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
CMA Ref: Aircraft ID: Summary: Remarks/Action/Reported by: Questionnaire Results Questionnaire Comments1 C/14/03/01
Gross Navigation Error– Class “C”
XXXXXX 01MAR14
PA31 BGKK/BIRK cleared (OA) VAXAN 65/30 GIMLI F120 observed at 6530N030W 30NM N of cleared track. Crew advised “minor deviation due icing”.
Op: XXXXXXFollow-up with operator (R )
(Reykjavik report)OPEN
A1b. RadarA1d. Not ADS-CB1. Garmin 530
2 B/14/04/01Gross Navigation ErrorClass “B”
XXXXXX09APR14
MD82 W/B RAN cleared (VHF) EMBLA 63/30 61/40 F360 M075 observed (radar) routing EMBLA 6330N030W. Crew advised one navigation system showing 63N030W and the other 6330N030W. Recleared via 6330N030W. 30NM deviation from cleared route.
Ferry (delivery) flight BIKF/KBGRFollow-up with operator (R )
(Reykjavik report)
OPEN
A1b. RadarA1d. Not ADS-C
3 B/14/04/02Gross Navigation Error - Class “B”
XXXXXX 11APR14
B772 W/B OTS “D” cleared (datalink) BEDRA 48/20 47/30 46/40 F360 M084 failed to report at BEDRA due CPDLC/ADS logon failure. Late logon revealed a/c to be 30NM
Crew advised map display showed on course as cleared; however FMC position found to be 30NM N of expected route.
Follow- up with operator (S)
A1. 29minsA1a. Pilot was confused as their map was indicating they were only 1nm off track due to SLOP, and queried ATC’s findings on numerous occasions. FMC
Company NOTAM issued and crew briefings scheduled.
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
N of track “D”, routing via 4831N020W to 4731N030W. Cleared to rejoin Trk.D at 47/30. No L-o-S.
(Shanwick report)
OPEN
was checked on request by ATC and incorrect position confirmed.A1b. ADS-CA1c. HFA1d. ADS-CB1a. NoB1b. HFB3cii. Airborne prior to oceanic entryB3ciii. reroute
4 B/14/04/03Gross Navigation Error - Class “B
XXXXXX 11APR14
B738 W/B OTS “A” cleared (HF) LIMRI 51/20 50/30 F350 M080 reported (HF) at LIMRI routing as cleared but by ADS-C routing 30NM N of track – 5131N020W 5031N030W. Route correction achieved at 5103N02351W and routed as cleared thereafter. 31NM lateral deviation at 20W.
Op: XXXXXXCrew stated “nav data problem” affecting 20W and 30W waypoints only.Follow-up with operator (S)(Shanwick report)
OPEN
A1. 29minsA1a. Pilot checked FMC after several queries to confirm correct routing, and stated a nav data problem had arisen.A1b. ADS-CA1c. HFA1d. ADS-CB1a. NoB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
Corrective action: Crew contacted Oceanic Supervisor on landing to discuss matter, and were fully co-operative during investigation process, and honest in their comments. Airline had very pro-active attitude towards remedying the issue.
5 B/14/04/04B/14/04/03Gross Navigation Error - Class “B
XXXXXX12APR14
GLF4 E/B RAN cleared (HF) LOACH 57/50 59/40 F390 M079 observed (ADS-B) heading 35NM N
Op: XXXXXXFollow-up with operator (G)(Gander report)
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
of course at 50W. Crew advised of heading and responded that they may have a nav equipment problem. Back on course at 59/40. 35NM lateral deviation from cleared route.
OPEN
6 A/14/04/05Gross Navigation Error –Class “A”
XXXXXX14APR14
GALX W/B OTS cleared (OA) 51/30 51/40 50/50 KOBEV F400 M077 observed (radar) routing 5030N050W KOBEV. Crew had reported (HF) routing as cleared and stated that both GPS and map display showed a/c at 50/50.
Op: XXXXXXOperator investigation confirmed waypoints entered as Nxxxx instead of xxxxN, placing aircraft 30NM N of route from 20W to 50W (a/c equipped with dual Collins 6100 IRS/FMS)(Gander report)
CLOSED
B1. Collins 6100
7 C/14/04/06Gross Navigation Error –Class “C”
XXXXXX14APR14
GLF4 E/B RAN cleared (VHF) BOBTU 45/50 49/40 F430 M080 observed by radar routing 4530N050W. 25NM off track when corrected. Crew had to fly a 25NM right offset to regain course.
Op: XXXXXXFollow-up with operator (G)
(Gander report)OPEN
B1. Honeywell NZ2000
8 L/14/04/04/CLateral Deviation
XXXXXX18APR14
GLEX W/B RAN cleared (datalink) RODEL 51/20
Op: XXXXXXFollow-up with operator (S)
B1. Collins GVFD
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
<25NM 51/30 51/40 F430 M083. Reported (ADS-C) at RODEL routing 5130N020W 5130N030W. Crew advised routing as cleared. Route corrected after 13 mins/108NM and resumed cleared track at 51/20.
(Shanwick report)
OPEN
9 L/14/04/07/BLateral Deviation of Less than 25NM
XXXXXX21APR14
F2TH E/B RAN cleared (VHF) DROMI 62/30 F400 M081 observed (radar) 18NM N of track routing 6230N030W. Crew advised they believed they were flying to 62/30 as cleared. Crew error – improper operation of FMS.
Op: XXXXXX
Report from operator 1/5/14
(Reykjavik report)CLOSED
A1b. RadarA1d. Not ADS-C
B1. Collins 6100, Honeywell Laseref IVB1. Honeywell IVB1a. No CPDLC.B1b. VHF.B2. Jeppesen NavData 1404B3ai. Entry method (6340N)B3ci, Entered prior to departureB3d., No re-route
After the event, the Company set up a meeting with the Crew to discuss and analyze why the error happened. Final decision was to change the Company procedures in order to fix the first plotting point 5 minutes after the waypoint, instead of 10 min. as per previous procedures. It was also emphasized that the Crew need to be constantly vigilant against “complacency”, which was an overriding factor in this incident. In addition, XXXXX Crew will, within the next 30 days, complete a MNPS and RVSM refresher course
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
as well as CRM c/o Flight Safety International, where all the training are normally performed
10 L/14/04/08/BLateral Deviation of Less than 25NM
XXXXXX24APR14
CL60 E/B OTS cleared (VHF) HECKK 53/50 55/40 F380 M077 observed 16NM N of track heading for 5330N050W.Crew advised they believed they were flying to 53/50 as cleared. Crew error – improper operation of FMS.
Op: XXXXXXFollow-up with operator (G)
(Gander report)
OPEN
11 L/14/04/09/BLateral Deviation of Less than 25NM
XXXXXX24APR14
FA7X W/B OTS”F” cleared (HF) MALOT 54/20 54/30 F400 M080 reported (ADS-C) at MALOT routing 5430N020W 5430N030W. Crew also made voice report at MALOT advising they were flying to 54/20 as cleared. Crew error – improper operation of FMS.
Op: XXXXXX (Bermuda)Follow-up with operator (S)
(Shanwick report)
OPEN
A1. 22minsA1a. ATC asked crew to confirm routing and gave correct routing via HF but ADS reports continued to show incorrect routing. After 3 calls by ATC and final call to check FMS, routing was corrected.A1b. ADS-CA1c. HFA1d. ADS-CB1a. NoB1b. HF3cii. airborne prior to
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
oceanic entry3d. No reroute
12 L/14/04/13/BLateral Deviation of Less than 25NM
XXXXXX24APR14
GLF5 W/B RAN cleared (HF) NEBIN 52/20 50/25 F400 M080 reported (ADS-C) at NEBIN routing 5230N020W – 30NM N of course at 20W. When challenged, crew reported routing as cleared. No response to ADS demands after this time and crew reported correctly at subsequent positions. Crew error – improper operation of FMS.
Op: XXXXXXFollow-up with operator (S)
(Shanwick report)
OPEN
A1. 27minsA1a. Pilot reported correct routing via HF until asked to check and route as per flight planned route.A1b. ADS-CA1c. HFA1d. ADS-CB1a. YesB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
13 B/14/04/08Gross Navigation Error –Class B
XXXXXX25APR14
A332 W/B OTS “D” cleared (HF) DOGAL 55/20 55/30 54/40 F360 M082. Gander advised that aircraft reported (ADS-C) at 5530N027W 30NM N of track and indicating 30NM and subsequent positions. Voice position reports to Shanwick had indicated routing as cleared. Crew error – improper
Follow-up with operator (S)
(Shanwick report)
OPEN
A1. 68minsA1a. Oceanic entry time passed by voice, and subsequent position reports passed by HF. Pilot was asked to confirm correct routing as Gander had received ADS report close to 30W boundary showing aircraft off route. Aircraft crossed 30W and continued off route with Gander.
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
operation of FMS. A1b. Other – Telephone call from Gander regarding ADS position report received close to 30W boundary.A1c. HFA1d. NoB1a. NoB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
14 L/14/04/11/BLateral Deviation of Less than 25NM
XXXXXX26APR14
CL60 E/B OTS cleared (VHF) VIXUN 49/50 51/40 F390 M080 observed on radar N of course heading for 4930N050W. Corrected prior to 25NM . deviation. Crew error – improper operation of FMS.
Op: XXXXXX
Follow-up with operator (G)
OPEN
15 B/14/04/09Gross Navigation ErrorClass “B”
XXXXXX26APR14
B772 W/B OTS “A” cleared (datalink) SUNOT 58/20 58/30 F370 M083 reported (ADS-C) at SUNOT routing 5830N020W 5830N030W. Crew advised they believed
Follow-up with operator (S)
(Shanwick report)
OPEN
A1. 35minsA1a. Pilot was confused and could not comprehend why the routing was showing as incorrect. Crew advised to call Ocean Supervisor on SATCOM where situation
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
they were flying to 58/20 and 58/30 as cleared. 30NM lateral deviation before correction.Crew error – improper operation of FMS.
was explained and remedied.A1b. ADS-CA1c. HFA1d. ADS-CB1a. NoB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
16 L/14/04/12/BLateral Deviation of Less than 25NM
XXXXXX26APR14
B738 E/B RAN cleared (VHF) LOACH 58/50 OZN 61/40 F370 M078 observed (radar) deviating N of course heading for 5830N050W. Corrected after ATC intervened at 12NM deviation. Crew advised they believed they were flying to 58/50 as cleared. Crew error – improper operation of FMS.
Op: XXXXXXFollow-up with operator (G)
(Gander report)
OPEN
17 B/14/04/10Gross Navigation Error –Class B
&
XXXXXX29APR14
C501 E/B RAN cleared (VHF) BGSF 67/40 66/30 RATSU F410 M069 reported at 40W at M063. Recleared at M066. Subsequently
Op: XXXXXXFollow-up with operator (R )
(Reykjavik report)
OPEN
A1a. “It took a while for pilot to understand that he was off trackA1b. RadarA1d. Not ADS-C
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
T/14/04/03Time/speed related error
observed on radar heading to 6630N030W iso 66/30. Recleared direct RATSU BARKU at M065 as not yet maintaining M066.
B1. UNS-1C, Navigation system programme no “604.4”B1a. No CPDLC.B1b. VHF.B2. Jeppesen NavData 1404B3ai. Entry method (6340N)B3ci, Entered prior to departureB3d., No re-route
18 B/14/04/12Gross Navigation Error –Class B
XXXXXX30APR14
A158 W/B RAN cleared (OA) BIKF EMBLA 63/30 61/40 F360 M070 observed (radar) routing EMBLA 6330N030W. 30NM lateral deviation. Crew error.
Op: XXXXXXFollow-up with operator (R )
(Reykjavik report)OPEN
A1a. It took a while for pilot to understand that he was off trackA1b. RadarA1d. Not ADS-C
19 B/14/05/02Gross Navigation Error – Class “B”
XXXXXX03MAY14
A332 W/B OTS “E” cleared (datalink) MALOT 54/20 56/30 F370 M082 reported (ADS-C) at MALOT routing 5430N020W 5630N030W. Despite prompt ATC action aircraft continued to deviate and crew did not
Op: XXXXXXFollow-up with operator (S)
(Shanwick report)
OPEN
A1. 25minsA1a. Pilot was requested by HF to check routing and after numerous calls, checked the FMC input and discovered the error.A1b. ADS-CA1c. HFA1d. ADS-CB1a. No
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
identify FMC inout error for 20 mins after oceanic entry. No L-o-S (despite 30NM from adjacent track). Crew error - improper operation of FMS.
B1b. HF3cii. airborne prior to oceanic entry3d. No reroute
20 B/14/05/01Gross Navigation Error – Class “B”
XXXXXX04MAY14
B763 E/B RAN cleared (VHF) RONPO 47/50 F370 M080 observed routing to 4730N050W. 30NM lateral deviation when corrected. Crew error - improper operation of FMS.
Follow-up with operator (G)
(Gander report)OPEN
21 L/14/05/04/CUnauthorised lateral deviation
XXXXX05MAY14
GLF6 W/B RAN cleared (datalink) GOMUP 59/20 60/30 F430 M088 reported (ADS-C) at GOMUP routing 5930N020W 6030N030W. When challenged, crew reported routing as cleared. Crew advised to check expanded coordinates. Corrected prior to 25NM deviation. Crew error – improper operation of FMS.
Op: XXXXXFollow-up with Operator (S)
(Shanwick report)
OPEN
A1. 24minsA1a. Crew alerted by voice and asked to check extended waypoint list.A1b. ADS-CA1c. HFA1d. ADS-CB1. HoneywellB1a. YesB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
22 L/14/05/07/CUnauthorised lateral deviation
XXXXX10MAY14
GLEX (OE-IRM) E/B RAN cleared (VHF) ETARI 57/20 59/30 F430 M080 reported (ADS-C) at ETARI routing 5730N020W 5930N030W. Crew advised to check expanded coordinates. 12NM deviation. Crew error – improper operation of FMS.
Op: XXXXXFollow-up with operator (S)
(Shanwick report)
OPEN
A1. 10minsA1a. Pilot checked and corrected FMC input on first request.A1b. ADS-CA1c. HFA1d. ADS-CB1a. YesB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
23 L/14/05/09/BUnauthorised lateral deviation
XXXXX 10MAY14
B752 (TF-ISK) W/B RAN cleared (datalink) GUNPA 63/10 GAKTU PIVUR F380 M080 observed 10NM north of track routing 6330N010W. When challenged, crew corrected track. Corrected prior to 25NM deviation. Crew error.
Follow-up with Operator (R)
(Reykjavik report)
OPEN
A1b. RadarA1d. Not ADS-C
B1a. No CPDLC.B1b. VHF.B2. JeppesenB3ai. Entry method (6340N)B3cii, Entered airborne prior to oceanic entryB3d., No re-route
24 B/14/05/04Gross Navigation Error – Class”B”
XXXXX11MAY14
B738 (CF-LSW) E/B RAN cleared (OA) 62/40 62/30 62/20 BALIX F390 M078 observed on radar routing 6230N030W. Cleared direct to 62/20.
Follow-up with Operator (R)
(Reykjavik report)
OPEN
A1a. “Pilot was surprised and it took a while for him to understand that he was off trackA1b. RadarA1d. Not ADS-C
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
28NM lateral deviation when corrected. Crew error.
B1. UNS-1C, Navigation system programme no “604.4”B1a. No CPDLC.B1b. VHF.B3ai. Entry method (6340N)B3cii, Entered airborne prior to oceanic entryB3d., No re-route
25 L/14/05/11/CUnauthorised Lateral Deviation
XXXXX14MAY14
TBM8 E/B BGJN/BIRK cleared (VHF) 68/40 65/30 GIMLI F280 N0300 observed (radar) 15NM N of cleared route heading 6530N030W. Crew error - improper operation of FMS.
Op: XXXXXFollow-up with operator (R )
(Reykjavik report)
OPEN
A1b. RadarA1d. Not ADS-C
B1. Garmin 1000B1a. No CPDLC.B1b. VHF.B2. Jeppesen NavData 1405B3ai. Entry method (6340N)B3cii, Entered prior to departureB3d., No re-route
26 L/14/05/10/BUnauthorised Lateral Deviation
XXXXX15MAY14
B744 (4X-ELD) W/B RAN cleared (datalink) PIKIL 56/20 57/30 F340 M085 reported (DS-C) at PIKIL routing5631N01959W
Follow-up with operator (S) A1. 4minsA1a. Aircraft was confused then advised to check expanded FMC by voice and CPDLC. Error was then
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
&E/14/05/02Loss of lateral separation
5731N030W 30NM N of cleared route. Crew reported “on track”. Error identified and corrected at 5620N01802W – 21NM N of track. L-o-S (39NM lateral) with eastbound traffic on OTS “S” routing 57/20 SUNOT. Crew error -– improper operation of FMS.
(Shanwick report)
OPEN
spotted and corrected.A1b. ADS-CA1c. HF+CPDLC free textA1d. ADS-CB1a. YesB1b. HF3cii. airborne prior to oceanic entry3d. No reroute
27 L/14/05/13/IUnauthorised lateral deviation
XXXXX18MAY14
GLF5 E/B RAN cleared (datalink) PORGY 59/50 60/40 60/30 58/20 SUNOT KESIX F450 M084 observed (radar) routing PORGY 5930/50. Route corrected <10NM off track. Crew error – improper operation of FMS)
Op: XXXXXFollow-up with operator (G)
(Gander report)
OPEN
28 B/14/05/06Gross Navigation Error – Class “B”
XXXXX 21MAY14
B738 (D-ABKP) W/B RAN cleared (HF) ERPES 39/20 NAVPO F350 M081 observed (radar) 30NM right of track approaching 20W. 30NM lateral deviation when corrected.
Follow-up with operator (SM)
(Santa Maria report)OPEN
A1. It is estimated that the flight started to deviate from cleared route at oceanic entry point ERPES at time 1019 and ATC detected the deviation at time 1059. These figures lead to conclude the flight
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
has been 40 minutes deviated from the cleared profile, with a maximum of 30NM deviation observed.A1b. radar trackA1c. DCPC VHF radioA1d. No
29 C/14/05/07Gross Navigation Error –Class “C”
XXXXX21MAY14
DH8B (OY-GRJ) W/B RAN cleared (OA) CP 68/30 DA F240 N0280 observed (radar) 30NM N of cleared route at 6830N30W. 30NM lateral deviation when corrected. Crew error.
Follow-up with operator (R)
(Reykjavik report)OPEN
A1a. “It took a while for pilot to accept that he was off track” A1b. RadarA1d. Not ADS-C
B1. UNS-1EWB1a. No CPDLC.B1b. VHF.B3cii, Entered prior to departureB3d., No re-route
Which navigational database (AIRAC cycle/ effective date) and provider (Jeppesen/ Lido/ Navtech) was loaded?
We use the UFP 25.6 Software to administrate our Company Route Database and in this we had defined a number of user defined waypoints. These waypoints were used on different routes throughout our route structure but not all of them were Arinc 424 compliant (e.g. “6830” - 6830N03000W). This let to the selection of the wrong nav point during
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
the creation of the route.
Corrective action:- The Company Route Database has been checked against our planning program which defines the Routes.- Since the need for user defined waypoint has been diminished with the introduction of UT routes most of them have been removed from the Company Route Database.- The procedure used for route changes have been reviewed and revised accordingly.- The pilot group has been informed of the importance in checking the Cleared Route against the Company Route.
30 A/14/05/08Gross Navigation
XXXXX 22MAY14
F900 W/B OTS “D” cleared (OA) 53/20
Op: XXXXXFollow-up with operator (G)
B1. Honeywell NZ2000
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
Error –Class “A”
53/30 52/40 50/50 KOBEV F400 M080 observed (radar) at 5030N50W. 30NM lateral deviation. Crew error - improper operation of FMS.
(Gander report)OPEN
31 B/14/05/09Gross Navigation Error – Class “B”
XXXXX 23MAY14
BE40 W/B RAN cleared (VHF/UHF) EMBLA 63/30 F400 M070 observed (Mode C) 6330N30W. <30NM lateral deviation when corrected.
Op: XXXXXFollow-up with operator (R)(Reykjavik report)OPEN
A1b. RadarA1d. Not ADS-C
B1. FMS6100B1a. No CPDLC.B1b. VHF.B3ai. Entry method (6340N)B3cii, Entered prior to departureB3d., No re-route
The root cause of the issue was an input error into the FMS. We will be doing additional training on LAT/LONG inputs and will have additional monitoring to mitigate for future FMS input errors.
32 B/14/06/01Gross Navigation Error – Class “B”
XXXXX10JUN14
GLF4 E/B RAN cleared (HF) EPMAN 67/50 67/40 66/30 F410 M080 observed (radar) crossing 30W at 6630N iso 66N as cleared (crew had reported routing correctly). Waypoint insertion error?
Op: XXXXXFollow-up with operator (R )(Reykjavik report)
OPEN
A1a. “Did not quite understand that they were off track”A1b. RadarA1d. Not ADS-C
B1. Honeywell FMZ 2000B1a. No CPDLC.B1b. VHF.B3cii, Entered prior to departureB3d., No re-route
We discussed as a crew the way we confirm waypoint entries into the FMS flight plan and instead of reading aloud just the waypoint entered we will read an cross check each waypoint with its lat/long as displayed from the FMS database against the computerized flight plan. Additinally each
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
A1b. RadarA1d. Not ADS-C
crewmember will independently plot both the crossing waypoint and the plot 10 minutes after passing. We are alos implementing a “Mid Leg” plot to ensure the aircraft position.
33 C/14/06/02Gross Navigation Error – Class “C”v
XXXXX13JUN14
PA31 E/B BGBW/BIRK cleared 62/40 63/30 EMBLA F190 N0170 observed (radar) routing via 6330N030W. 30NM lateral deviation. Waypoint insertion error?
Op: XXXXX
(Reykjavik report)OPEN
B1. Garmin530B1a. No CPDLC.B1b. VHF.B3ai. Entry method (6340N)B3cii, Entered prior to departureB3d., No re-route
