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|
Attributes | |
ACN | 143092 |
Time | |
Date | 199004 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : phl |
State Reference | PA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 57 flight time total : 6500 flight time type : 57 |
ASRS Report | 143092 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 154 flight time total : 11000 flight time type : 2500 |
ASRS Report | 143002 |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Situations | |
Publication | Unspecified |
Narrative:
I reported to the aircraft to begin my duties as flight engineer. The captain arrived a few mins later followed afterward by the first officer and they started their preflight duties. I finished my cockpit preparation checklist and the ground personnel brought aboard the aircraft's weight and balance sheet. I performed my duties concerning the weight and balance sheet, signed it and passed it to the captain for his review. Then he put our copy in the flight envelope. I started our takeoff data card when we were interrupted by a radio call from operations concerning a call from crew scheduling concerning duty day limitations for a crew member and therefore we were supposed to delay engines start. The captain immediately turned to me and started asking me questions concerning my duty limitations thinking I was the crew member in question. I stopped working on the takeoff data card to answer the captain's questions and participated in the conversations concerning this duty problem with the crew and operations. Finally, after several mins, the captain got disgusted with the progress of discussions with operations and left the aircraft to talk with scheduling on the phone. This caused him to be interrupted from his normal performance of duties. After the captain left, I restarted the takeoff data card computations. At this time, several mins had gone by since I read the weight and balance sheet, and it was in the flight envelope. Our takeoff speeds come from a chart which you enter with aircraft weight and temperature. By now, my recall of our gross weight was affected by the delay and cockpit confusion and I got the digits of our gross weight mixed up; i.e., 650000 pounds and 560000 pounds when I entered the chart. The captain returned and preflight resumed. We started engines and taxied to the runway. The only xchk in our company procedures is for the airspeed bugs rechked with takeoff data card in case of last min weight adjustments by company. Our procedures do not have a xchk or backup for accuracy of the takeoff data card. The captain normally does that on his own, but didn't because he was preoccupied with the scheduling department. The takeoff started, aircraft rotated to normal takeoff attitude but acted sluggishly and hesitated. A few seconds later it lifted off the ground and slowly climbed and accelerated for climb out. We did not feel any contact with the runway. Suspecting nothing wrong, we proceeded to our destination, ont. During post-flight inspection no damage was observed except the paint scraped off the tail, which is noticed on many of our aircraft. Problem could have been avoided had takeoff data come from FLIP cards that have the gross weight on each page with the applicable takeoff speeds for that weight. Also, the company checklist definitely needs to be rewritten to include a safety xchk for accuracy as a backup for potential human error. Given the fact that the so is responsible for all paperwork and performance computations, and the added burden of having to deal with a scheduling system totally unaware of fed restraints on the assignment of crews, a high probability exists that this will be one of several similar incidents. Supplemental information from acn 143002: before start checklist completed before pushback. Airspeed bugs set in accordance with takeoff and landing data card which flight engineer prepared after receiving load manifest from loading supervisor. Takeoff weight: 654000 pounds and computed speeds as follows: va-127 KTS, vr-136 KTS, vs-146 KTS. Speeds didn't look unusual because I had been flying short legs for past month and on every leg speeds were similar to these. This was a longer leg however (phl-ont), and even though similar payload, aircraft was heavier with more fuel. Taxied out and did all checklists. Airspeed bugs verified and set. First officer made takeoff. I called 'V1,' and 'rotate,' in accordance with airspeed bugs. First officer rotated at prescribed rate of 2-3 degrees/second. As aircraft passed 10 degrees nose-up, aircraft did not break ground as expected. Told first officer, 'hold it there,' and reached for control yoke. By then he had started the nose back down, so I didn't take control. Asked flight engineer to check speeds and he said he'd erred. I checked and got correct speeds. After arrival at ont, post-flight inspection by maintenance revealed tail strike damage. Thought damage major and notified NTSB. Inspection by structural engineer next day showed damage minor and NTSB determined an accident hadn't occurred and that no investigation was warranted. Causes: first officer's overrotation during takeoff. Also contributing: incorrect speed computations (flight engineer), failure of captain & first officer to catch the computational error, failure of captain to prevent first officer from overrotation, and failure of company to make safety improvements to checklists and procedures in spite of numerous crew members' complaints. I don't think I could have stopped the first officer from overrotating. Company procedures state that aircraft should be rotated at 2-3 degrees/second to climb attitude. First officer approximately 15 degrees nose up. There is a caveat that the aircraft should not be rotated above 10 degrees until it has been verified that aircraft will get airborne. I would like a procedure where aircraft is rotated to 10 degrees, is verified airborne and then rotation is continued to climb attitude. Flight engineer misread speeds from takeoff speed chart. In his defense, chart is cluttered and prone to misreading. Speeds are printed in chart which has 16 columns and 40 rows and is printed in a 4'x5' area. Flight engineer is usually always rushed when computing takeoff data. He receives load manifest just before doors are closed, and there is a sense of urgency to get flight out of the chocks. Company imposes a time limit from the time the load is complete until aircraft should be ready to taxi which adds to the sense of rush. I and many colleagues have asked for the company to provide takeoff speeds in a card deck type of arrangement where each weight in 20000# increments is printed on a separate card with all the appropriate speeds. The company I worked for previously had this type of arrangement for widebody transport, but this company has so far refused to act. If a card deck system were in place, this incident wouldn't have occurred.
Original NASA ASRS Text
Title: WDB EXPERIENCES TAIL STRIKE ON TKOF.
Narrative: I RPTED TO THE ACFT TO BEGIN MY DUTIES AS FE. THE CAPT ARRIVED A FEW MINS LATER FOLLOWED AFTERWARD BY THE FO AND THEY STARTED THEIR PREFLT DUTIES. I FINISHED MY COCKPIT PREPARATION CHKLIST AND THE GND PERSONNEL BROUGHT ABOARD THE ACFT'S WT AND BAL SHEET. I PERFORMED MY DUTIES CONCERNING THE WT AND BAL SHEET, SIGNED IT AND PASSED IT TO THE CAPT FOR HIS REVIEW. THEN HE PUT OUR COPY IN THE FLT ENVELOPE. I STARTED OUR TKOF DATA CARD WHEN WE WERE INTERRUPTED BY A RADIO CALL FROM OPS CONCERNING A CALL FROM CREW SCHEDULING CONCERNING DUTY DAY LIMITATIONS FOR A CREW MEMBER AND THEREFORE WE WERE SUPPOSED TO DELAY ENGS START. THE CAPT IMMEDIATELY TURNED TO ME AND STARTED ASKING ME QUESTIONS CONCERNING MY DUTY LIMITATIONS THINKING I WAS THE CREW MEMBER IN QUESTION. I STOPPED WORKING ON THE TKOF DATA CARD TO ANSWER THE CAPT'S QUESTIONS AND PARTICIPATED IN THE CONVERSATIONS CONCERNING THIS DUTY PROB WITH THE CREW AND OPS. FINALLY, AFTER SEVERAL MINS, THE CAPT GOT DISGUSTED WITH THE PROGRESS OF DISCUSSIONS WITH OPS AND LEFT THE ACFT TO TALK WITH SCHEDULING ON THE PHONE. THIS CAUSED HIM TO BE INTERRUPTED FROM HIS NORMAL PERFORMANCE OF DUTIES. AFTER THE CAPT LEFT, I RESTARTED THE TKOF DATA CARD COMPUTATIONS. AT THIS TIME, SEVERAL MINS HAD GONE BY SINCE I READ THE WT AND BAL SHEET, AND IT WAS IN THE FLT ENVELOPE. OUR TKOF SPDS COME FROM A CHART WHICH YOU ENTER WITH ACFT WT AND TEMP. BY NOW, MY RECALL OF OUR GROSS WT WAS AFFECTED BY THE DELAY AND COCKPIT CONFUSION AND I GOT THE DIGITS OF OUR GROSS WT MIXED UP; I.E., 650000 LBS AND 560000 LBS WHEN I ENTERED THE CHART. THE CAPT RETURNED AND PREFLT RESUMED. WE STARTED ENGS AND TAXIED TO THE RWY. THE ONLY XCHK IN OUR COMPANY PROCS IS FOR THE AIRSPD BUGS RECHKED WITH TKOF DATA CARD IN CASE OF LAST MIN WT ADJUSTMENTS BY COMPANY. OUR PROCS DO NOT HAVE A XCHK OR BACKUP FOR ACCURACY OF THE TKOF DATA CARD. THE CAPT NORMALLY DOES THAT ON HIS OWN, BUT DIDN'T BECAUSE HE WAS PREOCCUPIED WITH THE SCHEDULING DEPT. THE TKOF STARTED, ACFT ROTATED TO NORMAL TKOF ATTITUDE BUT ACTED SLUGGISHLY AND HESITATED. A FEW SECS LATER IT LIFTED OFF THE GND AND SLOWLY CLBED AND ACCELERATED FOR CLBOUT. WE DID NOT FEEL ANY CONTACT WITH THE RWY. SUSPECTING NOTHING WRONG, WE PROCEEDED TO OUR DEST, ONT. DURING POST-FLT INSPECTION NO DAMAGE WAS OBSERVED EXCEPT THE PAINT SCRAPED OFF THE TAIL, WHICH IS NOTICED ON MANY OF OUR ACFT. PROB COULD HAVE BEEN AVOIDED HAD TKOF DATA COME FROM FLIP CARDS THAT HAVE THE GROSS WT ON EACH PAGE WITH THE APPLICABLE TKOF SPDS FOR THAT WT. ALSO, THE COMPANY CHKLIST DEFINITELY NEEDS TO BE REWRITTEN TO INCLUDE A SAFETY XCHK FOR ACCURACY AS A BACKUP FOR POTENTIAL HUMAN ERROR. GIVEN THE FACT THAT THE SO IS RESPONSIBLE FOR ALL PAPERWORK AND PERFORMANCE COMPUTATIONS, AND THE ADDED BURDEN OF HAVING TO DEAL WITH A SCHEDULING SYS TOTALLY UNAWARE OF FED RESTRAINTS ON THE ASSIGNMENT OF CREWS, A HIGH PROBABILITY EXISTS THAT THIS WILL BE ONE OF SEVERAL SIMILAR INCIDENTS. SUPPLEMENTAL INFO FROM ACN 143002: BEFORE START CHKLIST COMPLETED BEFORE PUSHBACK. AIRSPD BUGS SET IN ACCORDANCE WITH TKOF AND LNDG DATA CARD WHICH FE PREPARED AFTER RECEIVING LOAD MANIFEST FROM LOADING SUPVR. TKOF WT: 654000 LBS AND COMPUTED SPDS AS FOLLOWS: VA-127 KTS, VR-136 KTS, VS-146 KTS. SPDS DIDN'T LOOK UNUSUAL BECAUSE I HAD BEEN FLYING SHORT LEGS FOR PAST MONTH AND ON EVERY LEG SPDS WERE SIMILAR TO THESE. THIS WAS A LONGER LEG HOWEVER (PHL-ONT), AND EVEN THOUGH SIMILAR PAYLOAD, ACFT WAS HEAVIER WITH MORE FUEL. TAXIED OUT AND DID ALL CHKLISTS. AIRSPD BUGS VERIFIED AND SET. FO MADE TKOF. I CALLED 'V1,' AND 'ROTATE,' IN ACCORDANCE WITH AIRSPD BUGS. FO ROTATED AT PRESCRIBED RATE OF 2-3 DEGS/SEC. AS ACFT PASSED 10 DEGS NOSE-UP, ACFT DID NOT BREAK GND AS EXPECTED. TOLD FO, 'HOLD IT THERE,' AND REACHED FOR CTL YOKE. BY THEN HE HAD STARTED THE NOSE BACK DOWN, SO I DIDN'T TAKE CTL. ASKED FE TO CHK SPDS AND HE SAID HE'D ERRED. I CHKED AND GOT CORRECT SPDS. AFTER ARR AT ONT, POST-FLT INSPECTION BY MAINT REVEALED TAIL STRIKE DAMAGE. THOUGHT DAMAGE MAJOR AND NOTIFIED NTSB. INSPECTION BY STRUCTURAL ENGINEER NEXT DAY SHOWED DAMAGE MINOR AND NTSB DETERMINED AN ACCIDENT HADN'T OCCURRED AND THAT NO INVESTIGATION WAS WARRANTED. CAUSES: FO'S OVERROTATION DURING TKOF. ALSO CONTRIBUTING: INCORRECT SPD COMPUTATIONS (FE), FAILURE OF CAPT & FO TO CATCH THE COMPUTATIONAL ERROR, FAILURE OF CAPT TO PREVENT FO FROM OVERROTATION, AND FAILURE OF COMPANY TO MAKE SAFETY IMPROVEMENTS TO CHKLISTS AND PROCS IN SPITE OF NUMEROUS CREW MEMBERS' COMPLAINTS. I DON'T THINK I COULD HAVE STOPPED THE FO FROM OVERROTATING. COMPANY PROCS STATE THAT ACFT SHOULD BE ROTATED AT 2-3 DEGS/SEC TO CLB ATTITUDE. FO APPROX 15 DEGS NOSE UP. THERE IS A CAVEAT THAT THE ACFT SHOULD NOT BE ROTATED ABOVE 10 DEGS UNTIL IT HAS BEEN VERIFIED THAT ACFT WILL GET AIRBORNE. I WOULD LIKE A PROC WHERE ACFT IS ROTATED TO 10 DEGS, IS VERIFIED AIRBORNE AND THEN ROTATION IS CONTINUED TO CLB ATTITUDE. FE MISREAD SPDS FROM TKOF SPD CHART. IN HIS DEFENSE, CHART IS CLUTTERED AND PRONE TO MISREADING. SPDS ARE PRINTED IN CHART WHICH HAS 16 COLUMNS AND 40 ROWS AND IS PRINTED IN A 4'X5' AREA. FE IS USUALLY ALWAYS RUSHED WHEN COMPUTING TKOF DATA. HE RECEIVES LOAD MANIFEST JUST BEFORE DOORS ARE CLOSED, AND THERE IS A SENSE OF URGENCY TO GET FLT OUT OF THE CHOCKS. COMPANY IMPOSES A TIME LIMIT FROM THE TIME THE LOAD IS COMPLETE UNTIL ACFT SHOULD BE READY TO TAXI WHICH ADDS TO THE SENSE OF RUSH. I AND MANY COLLEAGUES HAVE ASKED FOR THE COMPANY TO PROVIDE TKOF SPDS IN A CARD DECK TYPE OF ARRANGEMENT WHERE EACH WT IN 20000# INCREMENTS IS PRINTED ON A SEPARATE CARD WITH ALL THE APPROPRIATE SPDS. THE COMPANY I WORKED FOR PREVIOUSLY HAD THIS TYPE OF ARRANGEMENT FOR WDB, BUT THIS COMPANY HAS SO FAR REFUSED TO ACT. IF A CARD DECK SYS WERE IN PLACE, THIS INCIDENT WOULDN'T HAVE OCCURRED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.