37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 263325 |
Time | |
Date | 199401 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : den |
State Reference | CO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : commercial pilot : private pilot : instrument pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 3500 flight time type : 1500 |
ASRS Report | 263325 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : rejected takeoff flight crew : became reoriented flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Publication | Unspecified |
Narrative:
We got into denver 2 hours late and were told to fly den- oma instead of deadhead due to delays. This was the beginning of the chain of events leading up to this incident. We were tired due to a long day with delays, we had a change and were told to fly instead of ride, and we now had to rush over to the other side of the airport and hurry and takeoff. The pre flight checks were rushed, we had to be deiced and there was packed ice and snow on the txwys. With these icy conditions, our company procedure is to taxi out with the flaps up to prevent ice accumulation on the flaps, then set the flaps to takeoff position right before takeoff. This is a major change from our normal flap procedure. The before takeoff checklist was recently changed to attempt to standardize the checklists for all the different fleets of aircraft. Several important items were removed (such as checking heading indications, anti-skid switches, flight directors, etc). The flap position check is now the first item on the before takeoff check (which is done while taxiing out) and is never checked again. As we taxied out for takeoff, I ran the checklist and left the flaps up as per the cold WX procedure. I informed the captain of this. As we approached the runway for takeoff, tower asked us if we were ready, we said 'yes,' and they cleared us for immediate takeoff. The checklist then leads you to check the 'final items' as you take the runway. These final items do not include another check of the flap position. I said 'checklist complete,' the captain advanced the throttles to takeoff power setting, and we got the takeoff warning horn. It was at this point that we realized that we had attempted to takeoff with no flaps -- a potentially fatal error. We aborted the takeoff, reset the flaps, and took off. I believe the contributing factors to this incident were: a changed and consequently, inadequate checklist, a change in flap procedure due to icy conditions, a rushed takeoff, and crew fatigue. Fortunately, the takeoff warning horn system worked as it is supposed to, otherwise we would have been just another crash statistic. My new personal procedure is to clip the checklist to the yoke note if any check is changed.
Original NASA ASRS Text
Title: TKOF ABORTED WHEN FLC RECEIVES A TKOF WARNING. FLAPS NOT EXTENDED FOR TKOF.
Narrative: WE GOT INTO DENVER 2 HRS LATE AND WERE TOLD TO FLY DEN- OMA INSTEAD OF DEADHEAD DUE TO DELAYS. THIS WAS THE BEGINNING OF THE CHAIN OF EVENTS LEADING UP TO THIS INCIDENT. WE WERE TIRED DUE TO A LONG DAY WITH DELAYS, WE HAD A CHANGE AND WERE TOLD TO FLY INSTEAD OF RIDE, AND WE NOW HAD TO RUSH OVER TO THE OTHER SIDE OF THE ARPT AND HURRY AND TKOF. THE PRE FLT CHKS WERE RUSHED, WE HAD TO BE DEICED AND THERE WAS PACKED ICE AND SNOW ON THE TXWYS. WITH THESE ICY CONDITIONS, OUR COMPANY PROC IS TO TAXI OUT WITH THE FLAPS UP TO PREVENT ICE ACCUMULATION ON THE FLAPS, THEN SET THE FLAPS TO TKOF POS RIGHT BEFORE TKOF. THIS IS A MAJOR CHANGE FROM OUR NORMAL FLAP PROC. THE BEFORE TKOF CHKLIST WAS RECENTLY CHANGED TO ATTEMPT TO STANDARDIZE THE CHKLISTS FOR ALL THE DIFFERENT FLEETS OF ACFT. SEVERAL IMPORTANT ITEMS WERE REMOVED (SUCH AS CHKING HDG INDICATIONS, ANTI-SKID SWITCHES, FLT DIRECTORS, ETC). THE FLAP POS CHK IS NOW THE FIRST ITEM ON THE BEFORE TKOF CHK (WHICH IS DONE WHILE TAXIING OUT) AND IS NEVER CHKED AGAIN. AS WE TAXIED OUT FOR TKOF, I RAN THE CHKLIST AND LEFT THE FLAPS UP AS PER THE COLD WX PROC. I INFORMED THE CAPT OF THIS. AS WE APCHED THE RWY FOR TKOF, TWR ASKED US IF WE WERE READY, WE SAID 'YES,' AND THEY CLRED US FOR IMMEDIATE TKOF. THE CHKLIST THEN LEADS YOU TO CHK THE 'FINAL ITEMS' AS YOU TAKE THE RWY. THESE FINAL ITEMS DO NOT INCLUDE ANOTHER CHK OF THE FLAP POS. I SAID 'CHKLIST COMPLETE,' THE CAPT ADVANCED THE THROTTLES TO TKOF PWR SETTING, AND WE GOT THE TKOF WARNING HORN. IT WAS AT THIS POINT THAT WE REALIZED THAT WE HAD ATTEMPTED TO TKOF WITH NO FLAPS -- A POTENTIALLY FATAL ERROR. WE ABORTED THE TKOF, RESET THE FLAPS, AND TOOK OFF. I BELIEVE THE CONTRIBUTING FACTORS TO THIS INCIDENT WERE: A CHANGED AND CONSEQUENTLY, INADEQUATE CHKLIST, A CHANGE IN FLAP PROC DUE TO ICY CONDITIONS, A RUSHED TKOF, AND CREW FATIGUE. FORTUNATELY, THE TKOF WARNING HORN SYS WORKED AS IT IS SUPPOSED TO, OTHERWISE WE WOULD HAVE BEEN JUST ANOTHER CRASH STATISTIC. MY NEW PERSONAL PROC IS TO CLIP THE CHKLIST TO THE YOKE NOTE IF ANY CHK IS CHANGED.
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.