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Runway 35 on the previous leg. 2)...Cumulative fatigue. 3)
The First Officer was capable and conscientious, so I let
my guard down. 4) I did not act on the uneasy feeling I
had after turning onto Runway 35.
runway from the intersection was sufficient. I shifted my
attention to the “shorter” end of the runway, confirmed
that it was sufficient, and was cleared into “position and
hold.” Turning onto the runway, I aligned the directional
and held in position to await takeoff clearance. After a
short period, I was cleared for takeoff. On climb out, Tower
advised that I had departed on Runway 24L rather than
Runway 6R and I was told to turn to a specific heading. I
immediately began a steep turn to the assigned heading.
About halfway through the turn, the clearance was
repeated, in such a way that I assumed I was turning in
the wrong direction. In my readback, I confirmed the new
direction of turn to the assigned heading. Soon the
controller, sounding more concerned, assigned a new
heading. I immediately turned to that heading and was
flying it when the controller repeated the assignment. I
confirmed that I was flying the assigned heading. At this
point, the controller advised an airliner on approach to
Runway 6L that a light aircraft was not listening to
directions. Simultaneously, I recognized that I must not
have been flying the heading that I thought I was flying. I
determined that the directional gyro was incorrectly set,
reset the directional gyro, and turned to the actual
assigned heading.... I advised the controller that I was
now on the correct heading.... The remainder of the flight
was uneventful....
The primary factors...: 1) failure to correctly set the
directional gyro (in spite of following a printed
checklist).... 2) failure to corroborate with available aids in
the aircraft - airport diagram on the moving map display.
3) failure to heed the “inner voice” that recognized
something was not right as the takeoff roll began.
The calm professionalism of the controller directly and
significantly contributed to the “containment” of this
incident. He issued instructions in a manner that did not
compound the stress inherent in dealing with what was
clearly a major error....
In 2004 the highest report intake in the
history of the Aviation Safety Reporting
System was recorded — 37, 752 reports.
CCAALLLLBBAACCKK From NASA's Aviation Safety Reporting System
Number 305 February 2005
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
ASRS Recently Issued Alerts On…
LR25 engine flameout incidents
SAAB 340B floor connector wiring fire
MD80 dual erroneous Primary Flight Displays
Western U.S. airport taxiway lighting deficiency
Midwest U.S. airport erratic localizer indications
January 2005 Report Intake
Domestic RVSM Reporting
On January 20, 2005 the FAA and NAV
CANADA implemented Reduced Vertical
Separation Minimum (RVSM) from FL290
through FL410 inclusive. The vertical separation
minimum is reduced from 2,000 feet to 1,000 feet
and provides six additional flight levels. RVSM
is effective in the lower 48 states of the United
States, Alaska, Atlantic and Gulf of Mexico High
Offshore Airspace, and the San Juan FIR.
Canada, Mexico, Caribbean, and South
American regions have also implemented RVSM
in their airspace.
Details on documentation, certification, and
operational policy and procedures related to U.S.
Domestic RVSM airspace are found in FAA
Notice GEN04009.
Reports on incidents or concerns related to
any aspect of Domestic RVSM operations
can be submitted to NASA ASRS on the
appropriate NASA ARC 277 General
reporting form.
In addition, the FAA is specifically
requesting that pilots report wake
turbulence events that occur in RVSM
airspace in the lower 48 states of the
United States, Alaska, Offshore Airspace,
and the San Juan FIR.
Report Forms:
The “Safety Reporting” section of the FAA’s RVSM
Documentation Web Page provides links to the
NASA ASRS General Report form and the
“Supplemental Wake Turbulence Information”
form. The links are found at the bottom of the page.
( http://www.faa.gov/ats/ato/rvsm_documentation.htm [Fig. 2] ).
Air Carrier/Air Taxi Pilots 2736
General Aviation Pilots 625
Controllers 38
Cabin/Mechanics/Military/Other 154
Total 3553
　
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