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
Leading/Trailing Character Entry Errors
<FL350
FLs 350-390
>FL 390
Waypoint Insertion Errors Due to Double Entry of
Longitude
<FL350
FLs 350-390
>FL 390
Total
Total
IGA
COM
30
4
14
12
17
2
3
12
13
2
11
-
3
-
2
1
1
1
1
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
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
degree of latitude waypoints named in the ARINC 424 paragraph 7.2.5 convention and ultimately flight crew
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
1
2
3
CMA Ref:
C/14/03/01
Gross Navigation
Error
– Class “C”
Aircraft ID:
XXXXXX
01MAR14
B/14/04/01
Gross Navigation
Error
Class “B”
XXXXXX
09APR14
B/14/04/02
Gross Navigation
Error - Class “B”
XXXXXX
11APR14
Summary:
PA31 BGKK/BIRK cleared
(OA) VAXAN 65/30 GIMLI
F120 observed at
6530N030W 30NM N of
cleared track. Crew
advised “minor deviation
due icing”.
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.
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
Remarks/Action/Reported by:
Questionnaire Results
Op: XXXXXX
A1b. Radar
Follow-up with operator (R )
A1d. Not ADS-C
B1. Garmin 530
(Reykjavik report)
OPEN
Ferry (delivery) flight
BIKF/KBGR
Follow-up with operator (R )
Questionnaire Comments
A1b. Radar
A1d. Not ADS-C
(Reykjavik report)
OPEN
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. 29mins
Company NOTAM issued
A1a. Pilot was confused as and crew briefings
their map was indicating scheduled.
they were only 1nm off
track due to SLOP, and
queried ATC’s findings on
numerous occasions. FMC
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.
4
5
B/14/04/03
Gross Navigation
Error - Class “B
B/14/04/04
B/14/04/03
Gross Navigation
Error - Class “B
XXXXXX
11APR14
XXXXXX
12APR14
(Shanwick report)
OPEN
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: XXXXXX
Crew stated “nav data
problem” affecting 20W and
30W waypoints only.
Follow-up with operator (S)
(Shanwick report)
GLF4 E/B RAN cleared
(HF) LOACH 57/50 59/40
F390 M079 observed
(ADS-B) heading 35NM N
Op: XXXXXX
Follow-up with operator (G)
(Gander report)
OPEN
was checked on request
by ATC and incorrect
position confirmed.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1a. No
B1b. HF
B3cii. Airborne prior to
oceanic entry
B3ciii. reroute
A1. 29mins
A1a. Pilot checked FMC
after several queries to
confirm correct routing,
and stated a nav data
problem had arisen.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1a. No
B1b. HF
3cii. airborne prior to
oceanic entry
3d. 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.
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
6
7
8
A/14/04/05
Gross Navigation
Error –
Class “A”
XXXXXX
14APR14
C/14/04/06
Gross Navigation
Error –
Class “C”
XXXXXX
14APR14
L/14/04/04/C
XXXXXX
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.
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.
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.
GLEX W/B RAN cleared
OPEN
Op: XXXXXX
Operator 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
Op: XXXXXX
Follow-up with operator (G)
B1. Collins 6100
B1. Honeywell NZ2000
(Gander report)
OPEN
Op: XXXXXX
B1. Collins GVFD
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
Lateral Deviation
<25NM
9
L/14/04/07/B
Lateral Deviation of
Less than 25NM
18APR14
XXXXXX
21APR14
(datalink) RODEL 51/20
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.
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.
Follow-up with operator (S)
(Shanwick report)
OPEN
Op: XXXXXX
A1b. Radar
A1d. Not ADS-C
Report from operator 1/5/14
(Reykjavik report)
CLOSED
B1. Collins 6100,
Honeywell Laseref IV
B1. Honeywell IV
B1a. No CPDLC.
B1b. VHF.
B2. Jeppesen NavData
1404
B3ai. Entry method
(6340N)
B3ci, Entered prior to
departure
B3d., 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
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
and RVSM refresher course
as well as CRM c/o Flight
Safety International, where
all the training are normally
performed
10 L/14/04/08/B
Lateral Deviation of
Less than 25NM
11 L/14/04/09/B
Lateral Deviation of
Less than 25NM
XXXXXX
24APR14
XXXXXX
24APR14
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.
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
Follow-up with operator (G)
(Gander report)
OPEN
Op: XXXXXX (Bermuda)
Follow-up with operator (S)
(Shanwick report)
OPEN
A1. 22mins
A1a. 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-C
A1c. HF
A1d. ADS-C
B1a. No
B1b. HF
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
12 L/14/04/13/B
Lateral Deviation of
Less than 25NM
13 B/14/04/08
Gross Navigation
Error –
Class B
XXXXXX
24APR14
XXXXXX
25APR14
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.
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
Op: XXXXXX
Follow-up with operator (S)
(Shanwick report)
OPEN
Follow-up with operator (S)
(Shanwick report)
OPEN
3cii. airborne prior to
oceanic entry
3d. No reroute
A1. 27mins
A1a. Pilot reported correct
routing via HF until asked
to check and route as per
flight planned route.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1a. Yes
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
A1. 68mins
A1a. 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
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
error – improper
operation of FMS.
14 L/14/04/11/B
Lateral Deviation of
Less than 25NM
15 B/14/04/09
Gross Navigation
Error
Class “B”
XXXXXX
26APR14
XXXXXX
26APR14
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.
B772 W/B OTS “A”
cleared (datalink) SUNOT
58/20 58/30 F370 M083
reported (ADS-C) at
SUNOT routing
5830N020W
5830N030W. Crew
Gander.
A1b. Other – Telephone
call from Gander regarding
ADS position report
received close to 30W
boundary.
A1c. HF
A1d. No
B1a. No
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
Op: XXXXXX
Follow-up with operator (G)
OPEN
Follow-up with operator (S)
(Shanwick report)
OPEN
A1. 35mins
A1a. Pilot was confused
and could not
comprehend why the
routing was showing as
incorrect. Crew advised to
call Ocean Supervisor on
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
advised they believed
they were flying to 58/20
and 58/30 as cleared.
30NM lateral deviation
before correction.Crew
error – improper
operation of FMS.
16 L/14/04/12/B
Lateral Deviation of
Less than 25NM
17 B/14/04/10
Gross Navigation
Error –
Class B
XXXXXX
26APR14
XXXXXX
29APR14
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.
C501 E/B RAN cleared
(VHF) BGSF 67/40 66/30
RATSU F410 M069
reported at 40W at
M063. Recleared at
SATCOM where situation
was explained and
remedied.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1a. No
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
Op: XXXXXX
Follow-up with operator (G)
(Gander report)
OPEN
Op: XXXXXX
Follow-up with operator (R )
(Reykjavik report)
A1a. “It took a while for
pilot to understand that
he was off track
A1b. Radar
A1d. Not ADS-C
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
&
T/14/04/03
Time/speed related
error
18 B/14/04/12
Gross Navigation
Error –
Class B
XXXXXX
30APR14
19 B/14/05/02
Gross Navigation
Error – Class “B”
XXXXXX
03MAY14
M066. Subsequently
observed on radar
heading to 6630N030W
iso 66/30. Recleared
direct RATSU BARKU at
M065 as not yet
maintaining M066.
OPEN
A158 W/B RAN cleared
(OA) BIKF EMBLA 63/30
61/40 F360 M070
observed (radar) routing
EMBLA 6330N030W.
30NM lateral deviation.
Crew error.
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
Op: XXXXXX
Follow-up with operator (R )
B1. UNS-1C, Navigation
system programme no
“604.4”
B1a. No CPDLC.
B1b. VHF.
B2. Jeppesen NavData
1404
B3ai. Entry method
(6340N)
B3ci, Entered prior to
departure
B3d., No re-route
(Reykjavik report)
OPEN
Op: XXXXXX
Follow-up with operator (S)
(Shanwick report)
OPEN
A1a. It took a while for
pilot to understand that
he was off track
A1b. Radar
A1d. Not ADS-C
A1. 25mins
A1a. Pilot was requested
by HF to check routing and
after numerous calls,
checked the FMC input
and discovered the error.
A1b. ADS-C
A1c. HF
A1d. ADS-C
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
20 B/14/05/01
Gross Navigation
Error – Class “B”
XXXXXX
04MAY14
21 L/14/05/04/C
Unauthorised lateral
deviation
XXXXX
05MAY14
deviate and crew did not
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.
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.
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
B1a. No
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
Follow-up with operator (G)
(Gander report)
OPEN
Op: XXXXX
Follow-up with Operator (S)
(Shanwick report)
OPEN
A1. 24mins
A1a. Crew alerted by voice
and asked to check
extended waypoint list.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1. Honeywell
B1a. Yes
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
22 L/14/05/07/C
Unauthorised lateral
deviation
23 L/14/05/09/B
Unauthorised lateral
deviation
24 B/14/05/04
Gross Navigation
Error – Class”B”
XXXXX
10MAY14
XXXXX
10MAY14
XXXXX
11MAY14
operation of FMS.
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.
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.
B738 (CF-LSW) E/B RAN
cleared (OA) 62/40
62/30 62/20 BALIX F390
M078 observed on radar
Op: XXXXX
Follow-up with operator (S)
(Shanwick report)
OPEN
Follow-up with Operator (R)
A1. 10mins
A1a. Pilot checked and
corrected FMC input on
first request.
A1b. ADS-C
A1c. HF
A1d. ADS-C
B1a. Yes
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
A1b. Radar
A1d. Not ADS-C
(Reykjavik report)
OPEN
Follow-up with Operator (R)
(Reykjavik report)
B1a. No CPDLC.
B1b. VHF.
B2. Jeppesen
B3ai. Entry method
(6340N)
B3cii, Entered airborne
prior to oceanic entry
B3d., No re-route
A1a. “Pilot was surprised
and it took a while for him
to understand that he was
off track
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
25 L/14/05/11/C
Unauthorised
Lateral Deviation
26 L/14/05/10/B
Unauthorised
Lateral Deviation
XXXXX
14MAY14
XXXXX
15MAY14
routing 6230N030W.
Cleared direct to 62/20.
28NM lateral deviation
when corrected. Crew
error.
OPEN
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: XXXXX
Follow-up with operator (R )
B744 (4X-ELD) W/B RAN
cleared (datalink) PIKIL
56/20 57/30 F340 M085
Follow-up with operator (S)
(Reykjavik report)
OPEN
A1b. Radar
A1d. Not ADS-C
B1. UNS-1C, Navigation
system programme no
“604.4”
B1a. No CPDLC.
B1b. VHF.
B3ai. Entry method
(6340N)
B3cii, Entered airborne
prior to oceanic entry
B3d., No re-route
A1b. Radar
A1d. Not ADS-C
B1. Garmin 1000
B1a. No CPDLC.
B1b. VHF.
B2. Jeppesen NavData
1405
B3ai. Entry method
(6340N)
B3cii, Entered prior to
departure
B3d., No re-route
A1. 4mins
A1a. Aircraft was confused
then advised to check
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
&
E/14/05/02
Loss of lateral
separation
27 L/14/05/13/I
Unauthorised lateral
deviation
28 B/14/05/06
Gross Navigation
Error – Class “B”
XXXXX
18MAY14
XXXXX
21MAY14
reported (DS-C) at PIKIL
routing5631N01959W
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.
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)
B738 (D-ABKP) W/B RAN
cleared (HF) ERPES
39/20 NAVPO F350
M081 observed (radar)
30NM right of track
approaching 20W. 30NM
(Shanwick report)
OPEN
expanded FMC by voice
and CPDLC. Error was then
spotted and corrected.
A1b. ADS-C
A1c. HF+CPDLC free text
A1d. ADS-C
B1a. Yes
B1b. HF
3cii. airborne prior to
oceanic entry
3d. No reroute
Op: XXXXX
Follow-up with operator (G)
(Gander report)
OPEN
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
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
lateral deviation when
corrected.
29 C/14/05/07
Gross Navigation
Error –
Class “C”
XXXXX
21MAY14
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.
time 1059. These figures
lead to conclude the flight
has been 40 minutes
deviated from the cleared
profile, with a maximum
of 30NM deviation
observed.
A1b. radar track
A1c. DCPC VHF radio
A1d. No
Follow-up with operator (R)
(Reykjavik report)
OPEN
A1a. “It took a while for
pilot to accept that he was
off track” A1b. Radar
A1d. Not ADS-C
B1. UNS-1EW
B1a. No CPDLC.
B1b. VHF.
B3cii, Entered prior to
departure
B3d., 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” -
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
6830N03000W). This let
to the selection of the
wrong nav point during
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.
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
30 A/14/05/08
Gross Navigation
Error –
Class “A”
XXXXX
22MAY14
31 B/14/05/09
Gross Navigation
Error – Class “B”
XXXXX
23MAY14
32 B/14/06/01
Gross Navigation
Error – Class “B”
XXXXX
10JUN14
F900 W/B OTS “D”
cleared (OA) 53/20
53/30 52/40 50/50
KOBEV F400 M080
observed (radar) at
5030N50W. 30NM
lateral deviation. Crew
error - improper
operation of FMS.
BE40 W/B RAN cleared
(VHF/UHF) EMBLA 63/30
F400 M070 observed
(Mode C) 6330N30W.
<30NM lateral deviation
when corrected.
Op: XXXXX
Follow-up with operator (G)
(Gander report)
OPEN
B1. Honeywell NZ2000
Op: XXXXX
Follow-up with operator (R)
(Reykjavik report)
OPEN
A1b. Radar
A1d. Not ADS-C
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
Op: XXXXX
Follow-up with operator (R )
(Reykjavik report)
OPEN
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.
B1. FMS6100
B1a. No CPDLC.
B1b. VHF.
B3ai. Entry method
(6340N)
B3cii, Entered prior to
departure
B3d., No re-route
A1a. “Did not quite
We discussed as a crew the
understand that they were way we confirm waypoint
off track”
entries into the FMS flight
A1b. Radar
plan and instead of reading
A1d. Not ADS-C
aloud just the waypoint
entered we will read an
B1. Honeywell FMZ 2000 cross check each waypoint
B1a. No CPDLC.
with its lat/long as
ATTACHMENT D – Results from Preliminary Error Analysis of Available Data
insertion error?
33 C/14/06/02
Gross Navigation
Error – Class “C”v
XXXXX
13JUN14
PA31 E/B BGBW/BIRK
cleared 62/40 63/30
EMBLA F190 N0170
observed (radar) routing
via 6330N030W. 30NM
lateral deviation.
Waypoint insertion
error?
B1b. VHF.
B3cii, Entered prior to
departure
B3d., No re-route
A1b. Radar
A1d. Not ADS-C
Op: XXXXX
(Reykjavik report)
OPEN
B1. Garmin530
B1a. No CPDLC.
B1b. VHF.
B3ai. Entry method
(6340N)
B3cii, Entered prior to
departure
B3d., No re-route
displayed from the FMS
database against the
computerized flight
plan. Additinally each
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.