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|
Attributes | |
ACN | 1693897 |
Time | |
Date | 201910 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Route In Use | None |
Flight Plan | IFR |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Multiengine Flight Crew Instrument Flight Crew Flight Instructor Flight Crew Flight Engineer Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 61 Flight Crew Total 13400 Flight Crew Type 2700 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
On [date]; I failed to electronically sign an electronic load manifest over my ACARS unit for my flight. I had just came back from having most of the summer off for vacation; and the company had just recently transitioned from a paper weight and balance to an electronic form over our ACARS unit. The process takes 5 steps. First you request the load manifest by entering the number of gallons of fuel uploaded and your previous and current fuel load. You enter those figures into the ACARS load manifest request page and send. Then; a load manifest with a specific verification number is returned to you. The load manifest has your weight and balance information for takeoff and it also informs you if you have hazmat on board. If hazmat is loaded then the loading supervisor is required to bring me a notification to sign. The load manifest is read aloud and entered into the FMS. Next you request your performance data over ACARS. The performance data is then received and crossed checked to ensure that the correct load manifest number is on the performance data. Once loading is complete; the loading supervisor is then supposed to electronically send you a signing verification over the ACARS unit; and he is to present the notification of hazmat to me for signing. This load manifest verification has the load manifest number on it and the time loading was complete. If I agree with the time and the load manifest number matches; then I electronically sign the load manifest. After that a verification of the load manifest signing page is then sent to the ACARS unit.the first 3 steps of this process were performed. Unfortunately; the loading supervisor did not send me a load manifest sign request and I did not catch it. The switch from paper to electronic was very recently. I think when the loading supervisor came up to have me sign the notification of hazmat; subconsciously in my mind; that filled the square as far as how I have been receiving my weight and balance paperwork for the past 29 years. When the loading supervisor also forgot to send me the signing request; then none of the three of us in the cockpit caught it. Fortunately the weight and balance was correct and everything went normally for the flight.what was learned from this occurrence is that change is a threat! My company has been implementing an extraordinary number of changes to our operating procedures over the past few years. It has been somewhat difficult to keep up with them. You establish habit patterns over the years with procedures. Then when things change frequently; your mind can become somewhat lost. Then when it sees or feels something from the old ordinary; such as a person coming up to receive a notification of hazmat; it can quickly feel that the old habit pattern has been fulfilled and everything is ok. When in actuality you have missed something. Combine this with an extended absence from work and you have the start of an accident chain.again as an aviation professional I'm always on the lookout for threats to safety. And I feel I have been able to keep up with the many changes at my company. But; as I experienced; it can come up at anytime in different ways. As always I will have to keep up my vigilance and learn from this occurrence.
Original NASA ASRS Text
Title: B767 Captain reported unfamiliarity with a new electronic weight and balance program caused him to miss a sign off via ACARS.
Narrative: On [date]; I failed to electronically sign an Electronic Load Manifest over my ACARS unit for my flight. I had just came back from having most of the summer off for vacation; and the Company had just recently transitioned from a paper weight and balance to an electronic form over our ACARS unit. The process takes 5 steps. First you request the Load Manifest by entering the number of gallons of fuel uploaded and your previous and current fuel load. You enter those figures into the ACARS Load Manifest request page and send. Then; a Load Manifest with a specific verification number is returned to you. The Load Manifest has your weight and balance information for takeoff and it also informs you if you have Hazmat on board. If Hazmat is loaded then the Loading Supervisor is required to bring me a Notification to sign. The Load Manifest is read aloud and entered into the FMS. Next you request your Performance Data over ACARS. The Performance Data is then received and crossed checked to ensure that the correct Load Manifest number is on the Performance Data. Once loading is complete; the Loading Supervisor is then supposed to electronically send you a signing verification over the ACARS unit; and he is to present the notification of Hazmat to me for signing. This Load Manifest verification has the Load Manifest number on it and the time loading was complete. If I agree with the time and the Load Manifest number matches; then I electronically sign the Load Manifest. After that a verification of the Load Manifest Signing page is then sent to the ACARS unit.The first 3 steps of this process were performed. Unfortunately; the Loading Supervisor did not send me a Load Manifest Sign request and I did not catch it. The switch from paper to electronic was very recently. I think when the Loading Supervisor came up to have me sign the notification of Hazmat; subconsciously in my mind; that filled the square as far as how I have been receiving my Weight and Balance paperwork for the past 29 years. When the Loading Supervisor also forgot to send me the signing request; then none of the three of us in the cockpit caught it. Fortunately the weight and balance was correct and everything went normally for the flight.What was learned from this occurrence is that change is a threat! My company has been implementing an extraordinary number of changes to our operating procedures over the past few years. It has been somewhat difficult to keep up with them. You establish habit patterns over the years with procedures. Then when things change frequently; your mind can become somewhat lost. Then when it sees or feels something from the old ordinary; such as a person coming up to receive a notification of Hazmat; it can quickly feel that the old habit pattern has been fulfilled and everything is OK. When in actuality you have missed something. Combine this with an extended absence from work and you have the start of an accident chain.Again as an aviation professional I'm always on the lookout for threats to safety. And I feel I have been able to keep up with the many changes at my company. But; as I experienced; it can come up at anytime in different ways. As always I will have to keep up my vigilance and learn from this occurrence.
Data retrieved from NASA's ASRS site 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.