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|
Attributes | |
ACN | 269068 |
Time | |
Date | 199404 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground other : taxi other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 225 flight time total : 3900 flight time type : 1600 |
ASRS Report | 269068 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : rejected takeoff |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft was taxied out single engine to conserve fuel. Crew anticipated runway 32L and had preset programmed mode control panel and FMC accordingly. During taxi-out, crew issued instructions to runway 9L. Crew then became very busy reprogramming computers, referencing taxi charts, starting 2ND engine, notifying flight attendants of impending takeoff, switching radio frequencys, following normal flow patterns of configuring aircraft for takeoff, including positioning of flaps, and running before takeoff checklists. Airline 737 300 and 500 series aircraft utilize flaps position 1 for takeoff 95 percent of all takeoffs (approximately). This particular 737-500 had not been modified to accept flaps 1 takeoffs as most previously had. Crew, during its rush, accidentally set flaps to position 1 versus planned position 5. During checklist (first officer reads, captain responds) captain acknowledged flaps position 1 and first officer (who had originally positioned flaps) did not catch error. Takeoff was initiated and discontinued due to takeoff warning horn. Crew discovered error and retaxied for 2ND takeoff attempt. Crew believes 2 largest problems were rushed departure (aggravated by delaying starting of 2ND engine) and complacency of accepting 'normal' responses to checklist items and not verifying 'correct' position.
Original NASA ASRS Text
Title: TKOF ABORTED IN B-737-500. TKOF PROC.
Narrative: ACFT WAS TAXIED OUT SINGLE ENG TO CONSERVE FUEL. CREW ANTICIPATED RWY 32L AND HAD PRESET PROGRAMMED MODE CTL PANEL AND FMC ACCORDINGLY. DURING TAXI-OUT, CREW ISSUED INSTRUCTIONS TO RWY 9L. CREW THEN BECAME VERY BUSY REPROGRAMMING COMPUTERS, REFING TAXI CHARTS, STARTING 2ND ENG, NOTIFYING FLT ATTENDANTS OF IMPENDING TKOF, SWITCHING RADIO FREQS, FOLLOWING NORMAL FLOW PATTERNS OF CONFIGURING ACFT FOR TKOF, INCLUDING POSITIONING OF FLAPS, AND RUNNING BEFORE TKOF CHKLISTS. AIRLINE 737 300 AND 500 SERIES ACFT UTILIZE FLAPS POS 1 FOR TKOF 95 PERCENT OF ALL TKOFS (APPROX). THIS PARTICULAR 737-500 HAD NOT BEEN MODIFIED TO ACCEPT FLAPS 1 TKOFS AS MOST PREVIOUSLY HAD. CREW, DURING ITS RUSH, ACCIDENTALLY SET FLAPS TO POS 1 VERSUS PLANNED POS 5. DURING CHKLIST (FO READS, CAPT RESPONDS) CAPT ACKNOWLEDGED FLAPS POS 1 AND FO (WHO HAD ORIGINALLY POSITIONED FLAPS) DID NOT CATCH ERROR. TKOF WAS INITIATED AND DISCONTINUED DUE TO TKOF WARNING HORN. CREW DISCOVERED ERROR AND RETAXIED FOR 2ND TKOF ATTEMPT. CREW BELIEVES 2 LARGEST PROBS WERE RUSHED DEP (AGGRAVATED BY DELAYING STARTING OF 2ND ENG) AND COMPLACENCY OF ACCEPTING 'NORMAL' RESPONSES TO CHKLIST ITEMS AND NOT VERIFYING 'CORRECT' POS.
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.