Investigation number
199503110
Occurrence date
State
Victoria
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Operational non-compliance
Occurrence category
Incident

The crew was issued with a runway 27 Dosel 2 standard instrument departure (SID) clearance which was acknowledged correctly. This clearance required that the aircraft maintain a track of 263 degrees after takeoff and at 5 NM turn right onto 330 degrees. After becomimg airborne the aircraft initially tracked 263 degrees before turning right at 2 NM. An instruction was then issued by air traffic control to turn right onto 330 degrees and to cancel the SID. There was no loss of separation. The investigation revealed that the crew inadvertently entered the Dosel 1 SID into the flight management computer and then followed that procedure. The Dosel 1 SID had the same initial track as the Dosel 2 SID but at 2 NM required a right turn onto 010 degrees. Significant Factors The following factors were considered relevant to the development of the accident: 1. The Dosel 1 and Dosel 2 SIDs had similar sounding names. 2. The crew selected the wrong SID. Safety Action There have been a number of occurrences where pilots have mistakenly flown the incorrect SID, with the same name but different numbers. The Bureau of Air Safety Investigation issued interim recommendation, IR950203, to Airservices Australia on 21 September 1995 which stated in part "It is also recommended that the number and naming of departure procedures should be reviewed to ensure that any likelihood of flight crew selecting the wrong procedure is reduced." The Civil Aviation Safety Authority has advised that the problems associated with the 'Dosel' SID have been recognised and addressed. Effective from 7 December 1995, the two 'Dosel' SIDs have been combined and renamed into one procedure.

Aircraft Details
Manufacturer
The Boeing Company
Model
747-438
Registration
VH-OJI
Sector
Jet
Departure point
Melbourne VIC
Destination
Sydney NSW
Damage
Nil