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|
Attributes | |
ACN | 328280 |
Time | |
Date | 199602 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : oak |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 260 flight time total : 28000 flight time type : 2400 |
ASRS Report | 328280 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 180 flight time total : 9000 |
ASRS Report | 328278 |
Events | |
Anomaly | non adherence : far non adherence 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 other |
Narrative:
Planned destination of san francisco. Flight engineer entered 2 minor maintenance items in ACARS. Due to inadequate fuel aircraft diverted to oakland for fuel. While on the ground, I went to cabin to handle some significant passenger problems caused by diversion. Aircraft was fueled for flight to sfo. While taxiing for takeoff (narrow txwys, dark night, rain) engineer made comment about ACARS entry followed by a comment similar to 'it's all right, they were only insignificant items.' as a result the aircraft took off without clearing logbook items. I realized error after landing at sfo. Engineer had entered ACARS and logbook items without my knowledge. Language used to communicate problem once discovered was not specific and left room for interpretation that even though a problem existed it had been resolved. Attention of captain and first officer was concentrated on taxi maneuver. As this problem was discovered and uncertainty of best solution developed a clear request for assistance followed by a synergistic solution (with aircraft parked, if necessary) would have eliminated technical error. Supplemental information from acn 328278: open logbook items were cockpit floor and cockpit dirty and 2 lavs without water to flush. After blocking out of oakland I realized I forgot to call up maintenance to clear items written up. I mentioned log items to crew. I can't be sure if the captain heard me, and I did not believe items were safety related to our flight, so I said 'never mind.' I attribute above to fatigue after a 13 or 14 hour duty day. It was brought to my attention by the captain the following day. Supplemental information from acn 328279: WX delays at sfo caused 30 mins of holding (airborne) followed by diversion to oak. During ground refueling and flight planning, flight attendant came forward with problems of one 'gentleman' grabbing another's crotch, an executive going ballistic and 300 passenger wanting connection information at sfo. We were given a departure time slot for the return leg to sfo. The captain and I were using the airport diagram and following progressive taxi instructions to the runway because of rain/low visibility, and unfamiliarity with the field. That one last distraction didn't register and we subsequently took off in violation of FARS. Given a similar sequence of events I can't honestly say it won't happen again.
Original NASA ASRS Text
Title: A DC10-30 FLC HAD DIVERTED TO OAK AS A RESULT OF WX DELAYS AND FUEL REQUIREMENTS. AS THEY WERE TAXIING FOR DEP TO SFO, THEIR ORIGINAL DEST, THE SO NOTED THAT THEY FAILED TO CLR THE LOGBOOK ENTRIES, BUT THE FLC DID NOT RECOGNIZE SIGNIFICANCE OF THE OVERSIGHT. BEFORE DEP THEY HAD BEEN GIVEN A TIME SLOT AND WERE TAXIING AT NIGHT IN THE RAIN AT AN UNFAMILIAR ARPT.
Narrative: PLANNED DEST OF SAN FRANCISCO. FE ENTERED 2 MINOR MAINT ITEMS IN ACARS. DUE TO INADEQUATE FUEL ACFT DIVERTED TO OAKLAND FOR FUEL. WHILE ON THE GND, I WENT TO CABIN TO HANDLE SOME SIGNIFICANT PAX PROBS CAUSED BY DIVERSION. ACFT WAS FUELED FOR FLT TO SFO. WHILE TAXIING FOR TKOF (NARROW TXWYS, DARK NIGHT, RAIN) ENGINEER MADE COMMENT ABOUT ACARS ENTRY FOLLOWED BY A COMMENT SIMILAR TO 'IT'S ALL RIGHT, THEY WERE ONLY INSIGNIFICANT ITEMS.' AS A RESULT THE ACFT TOOK OFF WITHOUT CLRING LOGBOOK ITEMS. I REALIZED ERROR AFTER LNDG AT SFO. ENGINEER HAD ENTERED ACARS AND LOGBOOK ITEMS WITHOUT MY KNOWLEDGE. LANGUAGE USED TO COMMUNICATE PROB ONCE DISCOVERED WAS NOT SPECIFIC AND LEFT ROOM FOR INTERP THAT EVEN THOUGH A PROB EXISTED IT HAD BEEN RESOLVED. ATTN OF CAPT AND FO WAS CONCENTRATED ON TAXI MANEUVER. AS THIS PROB WAS DISCOVERED AND UNCERTAINTY OF BEST SOLUTION DEVELOPED A CLR REQUEST FOR ASSISTANCE FOLLOWED BY A SYNERGISTIC SOLUTION (WITH ACFT PARKED, IF NECESSARY) WOULD HAVE ELIMINATED TECHNICAL ERROR. SUPPLEMENTAL INFO FROM ACN 328278: OPEN LOGBOOK ITEMS WERE COCKPIT FLOOR AND COCKPIT DIRTY AND 2 LAVS WITHOUT WATER TO FLUSH. AFTER BLOCKING OUT OF OAKLAND I REALIZED I FORGOT TO CALL UP MAINT TO CLR ITEMS WRITTEN UP. I MENTIONED LOG ITEMS TO CREW. I CAN'T BE SURE IF THE CAPT HEARD ME, AND I DID NOT BELIEVE ITEMS WERE SAFETY RELATED TO OUR FLT, SO I SAID 'NEVER MIND.' I ATTRIBUTE ABOVE TO FATIGUE AFTER A 13 OR 14 HR DUTY DAY. IT WAS BROUGHT TO MY ATTN BY THE CAPT THE FOLLOWING DAY. SUPPLEMENTAL INFO FROM ACN 328279: WX DELAYS AT SFO CAUSED 30 MINS OF HOLDING (AIRBORNE) FOLLOWED BY DIVERSION TO OAK. DURING GND REFUELING AND FLT PLANNING, FLT ATTENDANT CAME FORWARD WITH PROBS OF ONE 'GENTLEMAN' GRABBING ANOTHER'S CROTCH, AN EXECUTIVE GOING BALLISTIC AND 300 PAX WANTING CONNECTION INFO AT SFO. WE WERE GIVEN A DEP TIME SLOT FOR THE RETURN LEG TO SFO. THE CAPT AND I WERE USING THE ARPT DIAGRAM AND FOLLOWING PROGRESSIVE TAXI INSTRUCTIONS TO THE RWY BECAUSE OF RAIN/LOW VISIBILITY, AND UNFAMILIARITY WITH THE FIELD. THAT ONE LAST DISTR DIDN'T REGISTER AND WE SUBSEQUENTLY TOOK OFF IN VIOLATION OF FARS. GIVEN A SIMILAR SEQUENCE OF EVENTS I CAN'T HONESTLY SAY IT WON'T HAPPEN AGAIN.
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.