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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 co-ordinates 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 co-ordinates 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.
NORTH ATLANTIC MNPSA OPERATIONS MANUAL CHAPTER 13
NAT MNPS 84 Edition 2009
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 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 indicates. Cross-check by reading present position.
Flight deck drills. There are some tasks on the flight deck which can safely be delegated to one member of the crew, but navigation using automated systems is emphatically not one of them, and the Captain should participate in all navigation cross-check procedures. All such cross-checks should be performed independently by at least two pilots.
Initialisation errors. Always return to the ramp and re-initialise inertial systems if the aircraft is moved before the navigation mode is selected. If after getting airborne, it is found that during initialisation a longitude insertion error has been made, unless the crew thoroughly understand what they are doing, and have also either had recent training on the method or carry written drills on how to achieve the objective, the aircraft should not proceed into MNPS Airspace, but should turn back or make an en route stop.
Waypoint loading. Before departure, at least two pilots should independently check that the following agree: computer flight plan, ICAO flight plan, track plotted on chart, and if appropriate, the track message. In flight, involve two different sources in the cross-checking, if possible. Do not be so hurried in loading waypoints that mistakes become likely, and always check waypoints against the current ATC clearance. Always be aware that the cleared route may differ from that contained in the filed flight plan. Prior to entering the NAT MNPSA ensure that the waypoints programmed into the navigation computer reflect the Oceanic Clearance received and not any different previously entered planned or requested route.
Use a flight progress chart on the flight deck. It has been found that making periodic plots of position on a suitable chart and comparing with current cleared track, greatly helps in the identification of errors before getting too far from track.
Consider making a simple use of basic DR Navigation as a back-up. Outside polar regions, provided that the magnetic course (track) is available on the flight log, a check against the magnetic heading being flown, plus or minus drift, is likely to indicate any gross tracking error.
Always remember that something absurd may have happened in the last half-hour. There are often ways in which an overall awareness of directional progress can be maintained; the position of the sun or stars; disposition of contrails; islands or coast-lines which can be seen directly or by using radar; radio navaids, and so forth. This is obvious and basic, but some of the errors which have occurred could have been prevented if the crew had shown more of this type of awareness.
If the crew suspects that equipment failure may be leading to divergence from cleared track, it is better to advise ATC sooner rather than later.
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NORTH ATLANTIC MNPS AIRSPACE OPERATIONS MANUAL(60)
