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|
Attributes | |
ACN | 188666 |
Time | |
Date | 199109 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : takeoff other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 9500 flight time type : 100 |
ASRS Report | 188666 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : commercial pilot : instrument pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 5500 flight time type : 100 |
ASRS Report | 188226 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : rejected takeoff |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Crew had been on duty for 12 hours with a final leg of flight from ewr to cle. A 3 hour situation (after a 1 hour van ride between lga and ewr) had contributed to a factor of fatigue. Additionally the airline is in the middle of a desperate fight for survival which has a continuous influence on perspective of all crew members. As much as we try to keep it out of mind while flying it is still a continuous draw on alertness. After engine start, a minor system malfunction distracted our attention and focus during initial taxi to runway for takeoff. Very large back-log of aircraft waiting for takeoff resulted in continuous chatter on the radio. Correction of system malfunction was completed with a couple of interruptions of the radio. End result: takeoff checklist never initiated or completed. Flaps never extended for takeoff. Takeoff was attempted but warning horn caused a rejection at a negligible speed. Aircraft was taxied clear, flaps extended and checklist completed. A subsequent takeoff was uneventful. This event is a blessing. Though terribly humbling to my professional pride it has served me notice that as hard as I try I am vulnerable to the subtle and not so subtle influences around me waiting to lead me astray. A crew can and will make these mistakes (critical errors of procedures) when they are exposed to and succumb to those negative influences about them. We have some control over these influences; that control has to be exercised when the task at hand is flying.
Original NASA ASRS Text
Title: FLAP WARNING ON START OF TKOF. TKOF ABORTED. FLAP LEVER RESET. SECOND TKOF ATTEMPT SUCCESSFUL.
Narrative: CREW HAD BEEN ON DUTY FOR 12 HRS WITH A FINAL LEG OF FLT FROM EWR TO CLE. A 3 HR SIT (AFTER A 1 HR VAN RIDE BTWN LGA AND EWR) HAD CONTRIBUTED TO A FACTOR OF FATIGUE. ADDITIONALLY THE AIRLINE IS IN THE MIDDLE OF A DESPERATE FIGHT FOR SURVIVAL WHICH HAS A CONTINUOUS INFLUENCE ON PERSPECTIVE OF ALL CREW MEMBERS. AS MUCH AS WE TRY TO KEEP IT OUT OF MIND WHILE FLYING IT IS STILL A CONTINUOUS DRAW ON ALERTNESS. AFTER ENG START, A MINOR SYS MALFUNCTION DISTRACTED OUR ATTN AND FOCUS DURING INITIAL TAXI TO RWY FOR TKOF. VERY LARGE BACK-LOG OF ACFT WAITING FOR TKOF RESULTED IN CONTINUOUS CHATTER ON THE RADIO. CORRECTION OF SYS MALFUNCTION WAS COMPLETED WITH A COUPLE OF INTERRUPTIONS OF THE RADIO. END RESULT: TKOF CHKLIST NEVER INITIATED OR COMPLETED. FLAPS NEVER EXTENDED FOR TKOF. TKOF WAS ATTEMPTED BUT WARNING HORN CAUSED A REJECTION AT A NEGLIGIBLE SPD. ACFT WAS TAXIED CLR, FLAPS EXTENDED AND CHKLIST COMPLETED. A SUBSEQUENT TKOF WAS UNEVENTFUL. THIS EVENT IS A BLESSING. THOUGH TERRIBLY HUMBLING TO MY PROFESSIONAL PRIDE IT HAS SERVED ME NOTICE THAT AS HARD AS I TRY I AM VULNERABLE TO THE SUBTLE AND NOT SO SUBTLE INFLUENCES AROUND ME WAITING TO LEAD ME ASTRAY. A CREW CAN AND WILL MAKE THESE MISTAKES (CRITICAL ERRORS OF PROCS) WHEN THEY ARE EXPOSED TO AND SUCCUMB TO THOSE NEGATIVE INFLUENCES ABOUT THEM. WE HAVE SOME CTL OVER THESE INFLUENCES; THAT CTL HAS TO BE EXERCISED WHEN THE TASK AT HAND IS FLYING.
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.