37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 206269 |
Time | |
Date | 199204 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : spi |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 3500 flight time type : 2000 |
ASRS Report | 206269 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Following a reduced rest (8 hours) after more than a 14 hour duty day, we were beginning our first takeoff of the day. As we were cleared for takeoff, I called for the before takeoff checklist. We completed that and I called for the memory items on the takeoff checklist: 'air flows -- OFF10 MIS10 MI206270, speeds -- high.' the first officer called out 'off and high' and advanced the power levers for target torque. Due to the design of the aircraft, the first officer (it was his takeoff) cannot steer the plane until 70 KTS. At 70 KTS, a transfer of controls takes place, and the captain releases the tiller and looks inside to verify that all engine instruments, C.a.P. Lights, etc. Are indicating correctly. I realized shortly after we transferred controls that the engine speed levers were in 'low' and engine RPM was low. I advanced the RPM levers and the takeoff continued without incident. It could have turned out differently. We were both extremely fatigued and easily distracted. I don't know why my first officer didn't advance the speeds or why I failed to notice that they hadn't been advanced until late into the roll, but I think long duty days and min legal rests were certainly contributing factors. As long as part 135 carriers are allowed to schedule pilots to fly fatigued, they will do so. Line pilots fear using the word fatigue to schedulers because they fear disciplinary action. My company's viewpoint is that, if it's legal you should be able to do it. To prevent this kind of inattentive inaction type of incident from occurring requires pilots to be mentally alert. The only way any scheduling changes will occur is if the FAA changes its rest requirement policy to include adequate rest for flcs. Right now, the rest requirements are really an accident waiting to happen.
Original NASA ASRS Text
Title: COMMUTER TURBOPROP ATTEMPTS TKOF WITH SPD LEVERS IN LOW POS.
Narrative: FOLLOWING A REDUCED REST (8 HRS) AFTER MORE THAN A 14 HR DUTY DAY, WE WERE BEGINNING OUR FIRST TKOF OF THE DAY. AS WE WERE CLRED FOR TKOF, I CALLED FOR THE BEFORE TKOF CHKLIST. WE COMPLETED THAT AND I CALLED FOR THE MEMORY ITEMS ON THE TKOF CHKLIST: 'AIR FLOWS -- OFF10 MIS10 MI206270, SPDS -- HIGH.' THE FO CALLED OUT 'OFF AND HIGH' AND ADVANCED THE PWR LEVERS FOR TARGET TORQUE. DUE TO THE DESIGN OF THE ACFT, THE FO (IT WAS HIS TKOF) CANNOT STEER THE PLANE UNTIL 70 KTS. AT 70 KTS, A TRANSFER OF CTLS TAKES PLACE, AND THE CAPT RELEASES THE TILLER AND LOOKS INSIDE TO VERIFY THAT ALL ENG INSTS, C.A.P. LIGHTS, ETC. ARE INDICATING CORRECTLY. I REALIZED SHORTLY AFTER WE TRANSFERRED CTLS THAT THE ENG SPD LEVERS WERE IN 'LOW' AND ENG RPM WAS LOW. I ADVANCED THE RPM LEVERS AND THE TKOF CONTINUED WITHOUT INCIDENT. IT COULD HAVE TURNED OUT DIFFERENTLY. WE WERE BOTH EXTREMELY FATIGUED AND EASILY DISTRACTED. I DON'T KNOW WHY MY FO DIDN'T ADVANCE THE SPDS OR WHY I FAILED TO NOTICE THAT THEY HADN'T BEEN ADVANCED UNTIL LATE INTO THE ROLL, BUT I THINK LONG DUTY DAYS AND MIN LEGAL RESTS WERE CERTAINLY CONTRIBUTING FACTORS. AS LONG AS PART 135 CARRIERS ARE ALLOWED TO SCHEDULE PLTS TO FLY FATIGUED, THEY WILL DO SO. LINE PLTS FEAR USING THE WORD FATIGUE TO SCHEDULERS BECAUSE THEY FEAR DISCIPLINARY ACTION. MY COMPANY'S VIEWPOINT IS THAT, IF IT'S LEGAL YOU SHOULD BE ABLE TO DO IT. TO PREVENT THIS KIND OF INATTENTIVE INACTION TYPE OF INCIDENT FROM OCCURRING REQUIRES PLTS TO BE MENTALLY ALERT. THE ONLY WAY ANY SCHEDULING CHANGES WILL OCCUR IS IF THE FAA CHANGES ITS REST REQUIREMENT POLICY TO INCLUDE ADEQUATE REST FOR FLCS. RIGHT NOW, THE REST REQUIREMENTS ARE REALLY AN ACCIDENT WAITING TO HAPPEN.
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.