Narrative:

A dehavilland twin otter made a 0 degree flap takeoff when the crew missed the flaps set 10 degree step in the taxi checklist. Engine start was normal. Tour tapes were still being rewound during the after start checklist as the #1 tape player was not rewinding properly. The taped tour narration was eventually started in the runup area. Tower cleared the aircraft to taxi to runway 19R. The taxi checklist was initiated as the aircraft moved out of parking spot. As the first officer called 'PA complete,' the tower directed the aircraft to give way to an aircraft coming out of the ramp. The first officer stopped the taxi checklist to acknowledge the tower instructions before returning to the checklist. The first officer resumed the checklist with 'fuel quantity' to which the captain responded '1100 pounds, one way.' thus, the first officer omitted the flaps set to 10 degrees step, which follows the PA complete step in the taxi checklist. The crew initiated takeoff with the 0 degree flap setting. As the captain rotated at 75 KIAS, he noted heavier than normal pitch force was required attain takeoff altitude. The aircraft lifted off after the first officer called V2 at the briefed speed of 78 KIAS. The captain accelerated the aircraft to 90 KIAS and climbed on runway heading. He then called for flaps up at 1000 ft AGL as per company procedures. The first officer discovered the flap selector to be in the up position when he went to raise the flaps. The flight continued normally to gcn. The flight should have been routine. A malfunctioning tour tape system with an FAA representative monitoring the flight crew created a minor yet undeniable stress factor. The captain had done what many other capts in the company practiced and set the flaps to 10 degrees while the first officer was conducting the passenger briefing, but then retracted the flaps fearing a reprimand from the FAA representative for deviating from aircraft checklist. The first officer was crewed with 4 different capts on the 5 legs that he flew that day. Crew coordination broke down when the first officer inadvertently jumped past a step in the checklist and the captain did not question the deviation from normal checklist sequence. Many minor anomalies combined to create a situation that fostered a significant deviation from normal procedure.

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Original NASA ASRS Text

Title: FLC MISSED FLAPS ON BEFORE TKOF CHKLIST.

Narrative: A DEHAVILLAND TWIN OTTER MADE A 0 DEG FLAP TKOF WHEN THE CREW MISSED THE FLAPS SET 10 DEG STEP IN THE TAXI CHKLIST. ENG START WAS NORMAL. TOUR TAPES WERE STILL BEING REWOUND DURING THE AFTER START CHKLIST AS THE #1 TAPE PLAYER WAS NOT REWINDING PROPERLY. THE TAPED TOUR NARRATION WAS EVENTUALLY STARTED IN THE RUNUP AREA. TWR CLRED THE ACFT TO TAXI TO RWY 19R. THE TAXI CHKLIST WAS INITIATED AS THE ACFT MOVED OUT OF PARKING SPOT. AS THE FO CALLED 'PA COMPLETE,' THE TWR DIRECTED THE ACFT TO GIVE WAY TO AN ACFT COMING OUT OF THE RAMP. THE FO STOPPED THE TAXI CHKLIST TO ACKNOWLEDGE THE TWR INSTRUCTIONS BEFORE RETURNING TO THE CHKLIST. THE FO RESUMED THE CHKLIST WITH 'FUEL QUANTITY' TO WHICH THE CAPT RESPONDED '1100 LBS, ONE WAY.' THUS, THE FO OMITTED THE FLAPS SET TO 10 DEGS STEP, WHICH FOLLOWS THE PA COMPLETE STEP IN THE TAXI CHKLIST. THE CREW INITIATED TKOF WITH THE 0 DEG FLAP SETTING. AS THE CAPT ROTATED AT 75 KIAS, HE NOTED HEAVIER THAN NORMAL PITCH FORCE WAS REQUIRED ATTAIN TKOF ALT. THE ACFT LIFTED OFF AFTER THE FO CALLED V2 AT THE BRIEFED SPD OF 78 KIAS. THE CAPT ACCELERATED THE ACFT TO 90 KIAS AND CLBED ON RWY HDG. HE THEN CALLED FOR FLAPS UP AT 1000 FT AGL AS PER COMPANY PROCS. THE FO DISCOVERED THE FLAP SELECTOR TO BE IN THE UP POS WHEN HE WENT TO RAISE THE FLAPS. THE FLT CONTINUED NORMALLY TO GCN. THE FLT SHOULD HAVE BEEN ROUTINE. A MALFUNCTIONING TOUR TAPE SYS WITH AN FAA REPRESENTATIVE MONITORING THE FLC CREATED A MINOR YET UNDENIABLE STRESS FACTOR. THE CAPT HAD DONE WHAT MANY OTHER CAPTS IN THE COMPANY PRACTICED AND SET THE FLAPS TO 10 DEGS WHILE THE FO WAS CONDUCTING THE PAX BRIEFING, BUT THEN RETRACTED THE FLAPS FEARING A REPRIMAND FROM THE FAA REPRESENTATIVE FOR DEVIATING FROM ACFT CHKLIST. THE FO WAS CREWED WITH 4 DIFFERENT CAPTS ON THE 5 LEGS THAT HE FLEW THAT DAY. CREW COORD BROKE DOWN WHEN THE FO INADVERTENTLY JUMPED PAST A STEP IN THE CHKLIST AND THE CAPT DID NOT QUESTION THE DEV FROM NORMAL CHKLIST SEQUENCE. MANY MINOR ANOMALIES COMBINED TO CREATE A SIT THAT FOSTERED A SIGNIFICANT DEV FROM NORMAL PROC.

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.