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were on the TRISS2 however, the previous controller had
given us a shortcut direct TRISS. ATC advised that we
had missed the SHERO waypoint and went on to say that,
although there was no traffic conflict, it did appear to be a
pilot deviation. We examined the FMS Legs page and noted
that for some unknown reason, SHERO was no longer stored
on the FMS flight plan. After TRISS we should have tracked
to SHERO, but did not. The controller was correct and I
believe we were about 3-4 miles north of course. The question
is, why did SHERO disappear from the FMS flight plan?
ASRS examination of many reports similar to the
above — occurring on DFW RNAV SIDs — has
illuminated several recurring factors. The majority
of the reported track deviations occurred on the
TRANSITION portion of the RNAV SID procedure.
Review of the reports indicates one of two things likely
happened. Either the TRANSITION was never installed
during FMC programming, or some ATC initiated
modification, such as a departure runway change, resulted
in the transition waypoints being eliminated.
Pilots should be aware that three distinct departure
elements must be line selected from the FMS Dep/Arr
Page when programming the FMS for every RNAV SID
from DFW. First, the assigned Runway must be line
selected; second, the “Cleared” SID must be line selected
and; third, the associated TRANSITION must be line
selected. Note that every SID requires all three
elements: Assigned Runway, the SID, and the appropriate
TRANSITION.
If, at any time, any ATC directed modification is made to
any of these three essential elements, the FMS Legs
page must be reviewed to ensure all waypoints have
been retained or appropriately modified.
Finally, users of an ACARS PDC must be aware that
the format for the printed clearance may not display
the transition in the same manner it is shown on
the departure plate, i.e., a clearance via the TRISS 2
departure TEXARKANA TRANSITION may be printed:
TRISS2 (space) TXK, not: TRISS2.(dot)TXK as shown on
the departure plate itself. This must not be interpreted as
direct to TXK after TRISS but, properly, as a clearance to
fly the TXK TRANSITION.
Safety Depends on “Lessons Learned”
The ASRS Celebrates Its 30th Anniversary
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/
Number 317 March/April 2006
On April 15, 2006, the NASA Aviation Safety
Reporting System (ASRS) celebrated its 30th year of
continuous operation.
The longevity and success of the ASRS program
are remarkable examples of how aviation system
users can contribute their “lessons learned” to a
government program that collects and analyzes this
information to solve the issues associated with our
modern aviation system.
The ASRS concept embodies a circle of information
feedback that begins with pilots, controllers,
maintenance technicians, flight attendants,
dispatchers and others who voluntarily report their
safety experiences to the program. During its 30-
year history, the ASRS has analyzed this information
and returned it to the aviation community through
a wealth of safety products.
More than 4,000 Safety Alert Messages
provided to government and aviation industry
decision makers.
7,100 database Search Requests in response
to aviation community task force efforts,
research studies, publications, safety
promotion activities, accident investigations,
and more.
317 issues of ASRS’s award-winning monthly
safety bulletin, CALLBACK, which is delivered
to more than 70,000 individual addresses by
e-mail notification and U.S. Mail.
Publication of more than 70 topical research
studies, including completion of more than 124
Quick Response efforts examining all aspects
of human and system performance.
Public access to program information,
publications, immunity policies, database
report sets, reporting forms, and more on the
ASRS web site at: http://asrs.arc.nasa.gov.
ASRS information feedback to the aviation user
community allows a learning process to take place,
and helps ensure that corrective actions will be
appropriate and effective.
The Price of Progress
Progress towards safety goals often comes at a price, and
the founding of the ASRS program was no exception. A
tragic and potentially preventable airline accident became
the catalyst for establishing a national aviation incident
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