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|
Attributes | |
ACN | 199014 |
Time | |
Date | 199201 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : slc |
State Reference | UT |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 230 flight time total : 5600 flight time type : 2400 |
ASRS Report | 199014 |
Person 2 | |
Affiliation | government : faa |
Function | observation : air carrier inspector |
Qualification | pilot : commercial pilot : instrument pilot : atp |
Events | |
Anomaly | non adherence : far other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was scheduled as so on flight #XXX on 1/92, from slc to sfo. FAA representative arrived before the flight to observe the new captain's initial operating experience (IOE). He noticed before the flight that I did not have incorporated in my pilot's operating manual (pom) 3 of the 6 recently received changes. The changes also were not in my flight kit, so I went downstairs to operations, obtained the missing changes, returned them to my flight kit, and continued the flight. (Changes involved). While incorporating the changes to my pom at home before the rotation began, I became distraction, thought I had finished the job, put everything back into my flight kit except the 3 missing changes, and departed soon thereafter on my rotation. The cause of this incident was my failure to maintain concentration in completing the change incorporation, and my carelessness in not realizing I departed my residence without the changes. Contributing to the incident was the unusual number of pages involved, most of which required transferring of my notes, underlinings, and highlighting. This required an unusual amount of time, and contributed to the incident.
Original NASA ASRS Text
Title: PREFLT DEP ACI ON RAMP CHK OBSERVED SO FLT MANUAL MISSING SOME REVISIONS. SO WENT TO COMPANY SUPPLY AND OBTAINED REVISIONS AND INSERTED IN MANUAL BEFORE FLT. CKP DOING IOE ON CAPT.
Narrative: I WAS SCHEDULED AS SO ON FLT #XXX ON 1/92, FROM SLC TO SFO. FAA REPRESENTATIVE ARRIVED BEFORE THE FLT TO OBSERVE THE NEW CAPT'S INITIAL OPERATING EXPERIENCE (IOE). HE NOTICED BEFORE THE FLT THAT I DID NOT HAVE INCORPORATED IN MY PLT'S OPERATING MANUAL (POM) 3 OF THE 6 RECENTLY RECEIVED CHANGES. THE CHANGES ALSO WERE NOT IN MY FLT KIT, SO I WENT DOWNSTAIRS TO OPS, OBTAINED THE MISSING CHANGES, RETURNED THEM TO MY FLT KIT, AND CONTINUED THE FLT. (CHANGES INVOLVED). WHILE INCORPORATING THE CHANGES TO MY POM AT HOME BEFORE THE ROTATION BEGAN, I BECAME DISTR, THOUGHT I HAD FINISHED THE JOB, PUT EVERYTHING BACK INTO MY FLT KIT EXCEPT THE 3 MISSING CHANGES, AND DEPARTED SOON THEREAFTER ON MY ROTATION. THE CAUSE OF THIS INCIDENT WAS MY FAILURE TO MAINTAIN CONCENTRATION IN COMPLETING THE CHANGE INCORPORATION, AND MY CARELESSNESS IN NOT REALIZING I DEPARTED MY RESIDENCE WITHOUT THE CHANGES. CONTRIBUTING TO THE INCIDENT WAS THE UNUSUAL NUMBER OF PAGES INVOLVED, MOST OF WHICH REQUIRED TRANSFERRING OF MY NOTES, UNDERLININGS, AND HIGHLIGHTING. THIS REQUIRED AN UNUSUAL AMOUNT OF TIME, AND CONTRIBUTED TO THE INCIDENT.
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.