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to be a greater tendency for this error to be made when a track, after passing through the same
latitude at several waypoints (e.g. 57°N 50°W, 57°N 40°W, 57°N 30°W) then changes by one
degree of latitude (e.g. 56°N 20°W). Other circumstances which can lead to this mistake being
made include receiving a re-clearance in flight.
c) the autopilot has been inadvertently left in the heading or de-coupled mode after avoiding
weather, or left in the VOR position after leaving the last domestic airspace VOR. In some
cases, the mistake has arisen during distraction caused by SELCAL or by some flight deck
warning indication.
d) an error has arisen in the ATC Controller/Pilot communications loop, so that the controller and
the crew have had different understandings of the clearance. In some cases, the pilot has heard
not what was said, but what he/she was expecting to hear.
NORTH ATLANTIC MNPSA OPERATIONS MANUAL CHAPTER 13
NAT MNPS 80 Edition 2008
Rare Causes Of Lateral Navigation Errors
13.3.2 To illustrate the surprising nature of things which can go wrong, the following are examples
of some extremely rare faults which have occurred:
a) the lat/long co-ordinates displayed near the gate position at one international airport were
wrong.
b) because of a defective component in one of the INS systems on an aircraft, although the correct
forward waypoint latitude was inserted by the crew (51°) it subsequently jumped by one degree
(to 52°).
c) the aircraft was equipped with an advanced system with all the co-ordinates of the waypoints of
the intended route already in a database; the crew assumed that these co-ordinates were correct,
but one was not.
d) when crossing longitude 40°W westbound the Captain asked what co-ordinates he should insert
for the 50°W waypoint and was told 48 50. He wrongly assumed this to mean 48°50'N at
50°00W (when it really meant 48°N 50°W ) and as a result deviated 50 NM from track.
e) the flight crew had available to them the correct co-ordinates for their cleared track, but
unfortunately the data which they inserted into the navigation computer was from the company
flight plan, in which an error had been made.
f) at least twice since 1989, longitude has been inserted with an error of magnitude of times 10.
e.g. 100°W instead of 10°W, or 5°W instead of 50°W. Because of low angles of bank, the
aircraft departed from track without the crews being aware, and both lateral and longitudinal
separations with other aircraft were compromised.
g) a crew based at and usually operating from London Heathrow was positioned at London
Gatwick for a particular flight. One pilot inadvertently loaded the Heathrow co-ordinates into
the INS, instead of those for Gatwick. This initialisation error was only discovered when the
aircraft had turned back within the NAT after experiencing a GNE.
h) the pilot of a flight departing from the Caribbean area input the wrong departure airfield coordinates
prior to departure. This error was discovered when deviation from cleared route
seriously eroded separation with two other opposite direction aircraft.
13.4 LESSONS TO BE LEARNED
􀂾 Never relax or be casual in respect of cross-check procedures. This is especially important
towards the end of a long night flight.
􀂾 Avoid casual R/T procedures. A number of GNEs have been the result of a misunderstanding
between pilot and controller as to the cleared route and/or flight level. Adhere strictly to proper
R/T phraseology and do not be tempted to clip or abbreviate details of waypoint co-ordinates.
􀂾 Make an independent check on the gate position. Do not assume that the gate co-ordinates
are correct without cross-checking with an authoritative source. Normally one expects coordinates
to be to the nearest tenth of a minute. Therefore, ensure that the display is not to the
hundredth, or in minutes and seconds. If the aircraft is near to the Zero Degree E/W
(Greenwich) Meridian, remember the risk of confusing east and west.
􀂾 Before entering Oceanic Airspace make a careful check of LRNS positions at or near to the
last navigation facility – or perhaps the last but one.
􀂾 Never initiate an on-track uncleared level change. If a change of level is essential and prior
ATC clearance cannot be obtained, treat this situation as a contingency and execute the
NORTH ATLANTIC MNPSA OPERATIONS MANUAL CHAPTER 13
NAT MNPS 81 Edition 2008
appropriate contingency offset procedure, when possible before leaving the last cleared flight
level. Inform ATC as soon as practicable.
􀂾 Do not assume that the aircraft is at a waypoint merely because the alert annunciator so
　
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