37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 305500 |
Time | |
Date | 199505 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iln |
State Reference | OH |
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 | DC-8 63 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer |
Experience | flight time last 90 days : 60 flight time total : 4700 flight time type : 60 |
ASRS Report | 305500 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
An aircraft mechanic arrived on the flight deck with aircraft logbook and to install MEL placard in #3 thrust reverser. Upon completion of this, the mechanic remained on board to discuss the logbook entry. The load master arrived with the load plan and the captain announced 'tapes up' to which all conversation stopped. Captain read off the '0' fuel weight, which the flight engineer copies down on his form, followed by the takeoff weight. I wrote down on my weight data record as 208314 pounds because that's what I heard but the captain said and the flight engineer wrote down a takeoff weight of 287314 pounds which reflected the correct takeoff weight. Note: this is the first area where the problem occurred. Our company procedures require the first officer and flight engineer to individually consult our aircraft performance manuals/charts for the V1, vr, V2, V2+25, 1.25 vsecond officer 1.5 and stabilizer setting. It's our procedure for the first officer to announce the weight and columns that will be used to compute this information. I announced based upon a 208314 weight, that we would use 210000 pounds: 1 KT, columns 2 and 6 to which the flight engineer said 'ok.' this is the first place where the flight engineer should have caught the error but did not. After completing my numbers, I called ready for xchk and the flight engineer said, go ahead. Both the flight engineer and myself had the exact same airspeed numbers for 210000 pounds. The engine start checklist and after start checklist were called for and completed by the crew. After pushback, I called flight control on #2 VHF and gave them our blockout time and then changed frequency to dayton approach for our IFR release and I left the volume on #2 up slightly. During our day operations we did not have our private control tower/ground in operation, so we are required to make a blanket call on our CTAF frequency that we are taxiing for departure, which I did. The captain called for flaps 18 degrees and taxi checklist. When we got down to the takeoff briefing on the taxi checklist, the captain announced takeoff briefing that began with reduced power, flaps 18 degrees takeoff at XXXX. At that moment when he started to say the takeoff weight, I was distracted by the #2 VHF radio, because another of our company aircraft had called dayton and asked for release off of our airport. The reason this was so distracting is because I did not hear or see any other aircraft around us. So I began to look around which is why I did not hear the captain say that this would be a 288000 pound takeoff. After seeing no other aircraft in the area, I again turned my attention to the captain who was about to brief the speeds off of the takeoff card. He read the speeds out and then questioned me that those speeds did not look 'right.' I immediately picked up the performance manual and confirmed the speeds. I then told the captain that another aircraft had called for release, to which he replied that they must be behind us and going to takeoff from an intersection rather than full length as we were. We then completed the taxi checklist, as we turned the corner the captain was correct as a dc-9 was departing from the intersection behind us. We got our release, made our calls on the CTAF, completed the before takeoff checklist and started our takeoff. I called 80 KTS and the captain replied 'checked.' I called V1 at 105 KTS, vr at 118 KTS, rotate at 136 KTS. The aircraft became airborne then settled back onto the runway. The captain called for maximum power. The aircraft accelerated and became airborne. We requested and received delayed vectors from day departure control to sort out our problem. We left the gear and flaps extended, accomplished the quick return checklist and requested a fly-by for maintenance to check our gear and flaps. We accomplished the fly-by with maintenance indicating that they observed no problems. We recycled the landing gear and the flaps with no problems. The captain made the decision and we concurred that we should continue to long beach, ca. After leveloff we began to discuss what had occurred and what might have caused our problem. It was then that I just happened to look at the load plan and discovered that our actual takeoff weight was 287314 and that I had made an 80000 pound error. Our company procedures and checklists were adhered to. However, I feel that a contributing factor was that the mechanic, that was on the flight deck, began to speak to the fewhen I turned to him and told him 210, 1 KT, columns 2 and 6. The flight engineer indicated, and all his paper work to include the takeoff card indicated, 288000 pounds. He also indicated that he heard me say 210000 but it didn't register. The second time that the error should have been caught was during the captain's takeoff briefing. But I was distracted by a radio call. Our private airport operates as an uncontrolled airport during day operations. We are required to call day departure for release but we must provide our own local control with other aircraft that might be in the pattern. It has been my past experience that in order to keep situational awareness, you must monitor both VHF #1 and #2. The third time that the error could have been caught was when the captain questioned me about the speeds not looking right. If either one of us had mentioned the weight, the error would have been caught but it wasn't. So here is a classic case of cockpit resource management breakdown. The aircraft's tail skid was the only area that had to be replaced.
Original NASA ASRS Text
Title: ERRONEOUS TKOF SPDS, TAIL STRIKE.
Narrative: AN ACFT MECH ARRIVED ON THE FLT DECK WITH ACFT LOGBOOK AND TO INSTALL MEL PLACARD IN #3 THRUST REVERSER. UPON COMPLETION OF THIS, THE MECH REMAINED ON BOARD TO DISCUSS THE LOGBOOK ENTRY. THE LOAD MASTER ARRIVED WITH THE LOAD PLAN AND THE CAPT ANNOUNCED 'TAPES UP' TO WHICH ALL CONVERSATION STOPPED. CAPT READ OFF THE '0' FUEL WT, WHICH THE FE COPIES DOWN ON HIS FORM, FOLLOWED BY THE TKOF WT. I WROTE DOWN ON MY WT DATA RECORD AS 208314 LBS BECAUSE THAT'S WHAT I HEARD BUT THE CAPT SAID AND THE FE WROTE DOWN A TKOF WT OF 287314 LBS WHICH REFLECTED THE CORRECT TKOF WT. NOTE: THIS IS THE FIRST AREA WHERE THE PROB OCCURRED. OUR COMPANY PROCS REQUIRE THE FO AND FE TO INDIVIDUALLY CONSULT OUR ACFT PERFORMANCE MANUALS/CHARTS FOR THE V1, VR, V2, V2+25, 1.25 VS/O 1.5 AND STABILIZER SETTING. IT'S OUR PROC FOR THE FO TO ANNOUNCE THE WT AND COLUMNS THAT WILL BE USED TO COMPUTE THIS INFO. I ANNOUNCED BASED UPON A 208314 WT, THAT WE WOULD USE 210000 LBS: 1 KT, COLUMNS 2 AND 6 TO WHICH THE FE SAID 'OK.' THIS IS THE FIRST PLACE WHERE THE FE SHOULD HAVE CAUGHT THE ERROR BUT DID NOT. AFTER COMPLETING MY NUMBERS, I CALLED READY FOR XCHK AND THE FE SAID, GO AHEAD. BOTH THE FE AND MYSELF HAD THE EXACT SAME AIRSPD NUMBERS FOR 210000 LBS. THE ENG START CHKLIST AND AFTER START CHKLIST WERE CALLED FOR AND COMPLETED BY THE CREW. AFTER PUSHBACK, I CALLED FLT CTL ON #2 VHF AND GAVE THEM OUR BLOCKOUT TIME AND THEN CHANGED FREQ TO DAYTON APCH FOR OUR IFR RELEASE AND I LEFT THE VOLUME ON #2 UP SLIGHTLY. DURING OUR DAY OPS WE DID NOT HAVE OUR PVT CTL TWR/GND IN OP, SO WE ARE REQUIRED TO MAKE A BLANKET CALL ON OUR CTAF FREQ THAT WE ARE TAXIING FOR DEP, WHICH I DID. THE CAPT CALLED FOR FLAPS 18 DEGS AND TAXI CHKLIST. WHEN WE GOT DOWN TO THE TKOF BRIEFING ON THE TAXI CHKLIST, THE CAPT ANNOUNCED TKOF BRIEFING THAT BEGAN WITH REDUCED PWR, FLAPS 18 DEGS TKOF AT XXXX. AT THAT MOMENT WHEN HE STARTED TO SAY THE TKOF WT, I WAS DISTRACTED BY THE #2 VHF RADIO, BECAUSE ANOTHER OF OUR COMPANY ACFT HAD CALLED DAYTON AND ASKED FOR RELEASE OFF OF OUR ARPT. THE REASON THIS WAS SO DISTRACTING IS BECAUSE I DID NOT HEAR OR SEE ANY OTHER ACFT AROUND US. SO I BEGAN TO LOOK AROUND WHICH IS WHY I DID NOT HEAR THE CAPT SAY THAT THIS WOULD BE A 288000 LB TKOF. AFTER SEEING NO OTHER ACFT IN THE AREA, I AGAIN TURNED MY ATTN TO THE CAPT WHO WAS ABOUT TO BRIEF THE SPDS OFF OF THE TKOF CARD. HE READ THE SPDS OUT AND THEN QUESTIONED ME THAT THOSE SPDS DID NOT LOOK 'RIGHT.' I IMMEDIATELY PICKED UP THE PERFORMANCE MANUAL AND CONFIRMED THE SPDS. I THEN TOLD THE CAPT THAT ANOTHER ACFT HAD CALLED FOR RELEASE, TO WHICH HE REPLIED THAT THEY MUST BE BEHIND US AND GOING TO TKOF FROM AN INTXN RATHER THAN FULL LENGTH AS WE WERE. WE THEN COMPLETED THE TAXI CHKLIST, AS WE TURNED THE CORNER THE CAPT WAS CORRECT AS A DC-9 WAS DEPARTING FROM THE INTXN BEHIND US. WE GOT OUR RELEASE, MADE OUR CALLS ON THE CTAF, COMPLETED THE BEFORE TKOF CHKLIST AND STARTED OUR TKOF. I CALLED 80 KTS AND THE CAPT REPLIED 'CHKED.' I CALLED V1 AT 105 KTS, VR AT 118 KTS, ROTATE AT 136 KTS. THE ACFT BECAME AIRBORNE THEN SETTLED BACK ONTO THE RWY. THE CAPT CALLED FOR MAX PWR. THE ACFT ACCELERATED AND BECAME AIRBORNE. WE REQUESTED AND RECEIVED DELAYED VECTORS FROM DAY DEP CTL TO SORT OUT OUR PROB. WE LEFT THE GEAR AND FLAPS EXTENDED, ACCOMPLISHED THE QUICK RETURN CHKLIST AND REQUESTED A FLY-BY FOR MAINT TO CHK OUR GEAR AND FLAPS. WE ACCOMPLISHED THE FLY-BY WITH MAINT INDICATING THAT THEY OBSERVED NO PROBS. WE RECYCLED THE LNDG GEAR AND THE FLAPS WITH NO PROBS. THE CAPT MADE THE DECISION AND WE CONCURRED THAT WE SHOULD CONTINUE TO LONG BEACH, CA. AFTER LEVELOFF WE BEGAN TO DISCUSS WHAT HAD OCCURRED AND WHAT MIGHT HAVE CAUSED OUR PROB. IT WAS THEN THAT I JUST HAPPENED TO LOOK AT THE LOAD PLAN AND DISCOVERED THAT OUR ACTUAL TKOF WT WAS 287314 AND THAT I HAD MADE AN 80000 LB ERROR. OUR COMPANY PROCS AND CHKLISTS WERE ADHERED TO. HOWEVER, I FEEL THAT A CONTRIBUTING FACTOR WAS THAT THE MECH, THAT WAS ON THE FLT DECK, BEGAN TO SPEAK TO THE FEWHEN I TURNED TO HIM AND TOLD HIM 210, 1 KT, COLUMNS 2 AND 6. THE FE INDICATED, AND ALL HIS PAPER WORK TO INCLUDE THE TKOF CARD INDICATED, 288000 LBS. HE ALSO INDICATED THAT HE HEARD ME SAY 210000 BUT IT DIDN'T REGISTER. THE SECOND TIME THAT THE ERROR SHOULD HAVE BEEN CAUGHT WAS DURING THE CAPT'S TKOF BRIEFING. BUT I WAS DISTRACTED BY A RADIO CALL. OUR PVT ARPT OPERATES AS AN UNCTLED ARPT DURING DAY OPS. WE ARE REQUIRED TO CALL DAY DEP FOR RELEASE BUT WE MUST PROVIDE OUR OWN LCL CTL WITH OTHER ACFT THAT MIGHT BE IN THE PATTERN. IT HAS BEEN MY PAST EXPERIENCE THAT IN ORDER TO KEEP SITUATIONAL AWARENESS, YOU MUST MONITOR BOTH VHF #1 AND #2. THE THIRD TIME THAT THE ERROR COULD HAVE BEEN CAUGHT WAS WHEN THE CAPT QUESTIONED ME ABOUT THE SPDS NOT LOOKING RIGHT. IF EITHER ONE OF US HAD MENTIONED THE WT, THE ERROR WOULD HAVE BEEN CAUGHT BUT IT WASN'T. SO HERE IS A CLASSIC CASE OF COCKPIT RESOURCE MGMNT BREAKDOWN. THE ACFT'S TAIL SKID WAS THE ONLY AREA THAT HAD TO BE REPLACED.
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.