Flight Crew Last 90 Days 163; Flight Crew Total 4636; Flight Crew Type 163
Communication Breakdown
Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy
Flight Crew Became Reoriented
Company Policy; Chart Or Publication
Navigation deviation (didn't fly over STINS) departing SFO on GUNNR2 Departure SID due to incomplete loading and improper confirmation of AMAKR transition on the before takeoff checklist. Normally the First Officer (FO) loads the route; but the flight manual allows either pilot to do so. In this instance the relief pilot and I were in the cockpit; done with our required checks; and the FO was still in back talking to flight attendants. When the route uplinked; I loaded it; verified it against the cleared route and checked the legs against the flight plan. I handed the relief pilot the master flight plan so that he could verify and mark each leg as per SOP; which we accomplished. Shortly thereafter the FO; who was to be Pilot Monitoring (PM); came up to the cockpit; I told her I had loaded and verified the route with the relief pilot but had not yet entered the departures/arrivals because I was waiting for the winds to upload. I then went in the back to brief the flight attendants. On departure; NORCAL asked us if we had been cleared to AMAKR. At this point; we realized we had a navigation deviation problem. As we started to review the process; the FO said she had seen the discontinuity after GUNNR and had 'closed it up' putting AMAKR next in sequence... not STINS. I was quite dismayed. Without questioning it; or checking it; or asking; or telling either of the other pilots we lost an opportunity for us to discover the mistake. Our SOP is very simple in that regard; we communicate with other pilots via the FMC; and we advise when we make changes. She knew this; and there was no reason to belabor that point. We were cleared the GUNNR2 Departure; AMAKR transition; and she obviously thought AMAKR was the next and only waypoint after GUNNR when she closed the discontinuity. I cannot blame her in her thinking. I too reviewed the transition chart and I did not see STINS after GUNNR either! I have been flying a steady diet of GUNNR Departures lately and my eye went to the left side of the page; to the outbound oceanic fixes in my search for AMAKR. I found it; the last one right at the top of the page. All the other transition fixes; including the ones I have been flying lately; were direct from GUNNR...except of course; AMAKR. Since I did not load the departure I didn't catch the fact that the transition had not been entered at all. Nonetheless; my mistake.  Just recently the checklists were revised to include an actual reading of the runway; DEP and SID transition. Everyone I know is happy to see this much-needed change come about. Surely this last chance to catch any missteps up to now would save us. Unfortunately our new SOP still let us down. The FO read exactly what she thought she saw on the route page. '28L; GUNNR2 DEP; AMAKR transition.' I was taxing and did not look down to verify it as I sometimes do. I heard exactly what I expected to hear; and what I was supposed to hear; but that wasn't what was loaded. The FO and I'm assuming the relief pilot saw all the right words; '28L; GUNNR; AMAKR;' but those were always on the route; there was no 'transition'.If there is anything good that comes out of this unfortunate incident; let it be this: neither the FO or the relief pilot were familiar with EXACTLY what the transition should look like on the route page. It's 'GUNNR2.AMAKR' we need to see; not 'GUNNR2' and then 'AMAKR.' It's all in the 'dot' AMAKR part. In our debrief conversations none of us could find any reference to this fact in the flight manual.Breaking the accident chain. How many mistakes were made before improper reading of Before Takeoff Checklist?  Captain entering route but not departures/arrivals. Class 2 Ops requires one pilot load it all; which is what I thought I did. But the departures/arrivals don't get loaded until after the winds. Did I break SOP by not loading SID in addition to class 2 route? SIDs change frequently on taxi out; who loads then?Expectation error. When you brief a transition; don't look at the oceanic fix; look at it the way you are going to fly it: from the runway to the oceanic fix... GUNNR; STINS; then AMAKR. Effect: Missing transition was not discovered. Any changes to FMC route should be confirmed with the other pilot. Maybe the discontinuity after GUNNR would have alerted us to the incomplete transition selection. Missing transition not discovered. Confirmation using Route Page DEP SID and Transition verification. Everyone needs to know to look for the exact 'dot' transition coding so as to avoid being led astray. AND; it's just too important; the captain may just need to look down and verify it personally even though the PM specifically states that it's not required or maybe the captain needs to hear 'GUNNR2; DOT AMAKR transition' Either one would have avoided this deviation. Let's hope this info gets out there and helps someone else.
During preflight a B777 crew entered the incorrect transition for the cleared SID. Crew did not discover the error during subsequent checklist review. ATC issued corrective clearance upon departure.