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|
Attributes | |
ACN | 338361 |
Time | |
Date | 199606 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : roc |
State Reference | NY |
Altitude | agl bound lower : 1500 agl bound upper : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : roc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 10000 flight time type : 1000 |
ASRS Report | 338361 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 9000 flight time type : 3000 |
ASRS Report | 338351 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Stand-up overnight. 4 hours sleep. Destination change for ferry flight. Late getting aircraft from maintenance. Very short taxi. Company computers incapable of providing derated thrust or assumed temperature. Full power takeoff made at very light weight. Climbing at 5000 FPM, overtemp on #1 engine. Retarded throttle, egt back within limits. Continued to destination. Maximum egt and duration noted in logbook. Standard procedure or so we thought. After arriving home, first officer took out pilot's handbook and discovered that the egt reached on our flight called for an engine shutdown! Factors: fatigue -- less than normal sleep had left us not as sharp as usual. Complacency: both of us had experienced egt out of limits and were sure we knew how to handle it. Book not consulted in-flight! Casual attitude: no passenger, relaxed operation. Lessons learned: always get out the book -- no one has it all memorized. Supplemental information from acn 338351: because of extremely rapid acceleration due to full power and light weight, 80 KT callout and V1 came very quickly. I was diverted from making a final engine check because of this. On climb out, deck angle was very high, airspeed approximately 145 KIAS. Out of 1500 ft MSL (1000 ft AGL), I was reaching for the N1 button to be ready when he called for it, when at about 2000 ft MSL he called 'overtemp on #1!' he immediately disengaged the autothrottle and reduced power, and lowered the nose. Overtemp light went out, all engine readings returned to normal. When this aircraft is at very light weights, the acceleration is, putting it mildly 'breathtaking.' unfortunately things also happen very fast, and required callouts (eg, 80 KTS, V1, etc) come up in no time at all, because v-spds are very low you hardly have enough time to set power before liftoff speeds are reached. A derated thrust setting would have most likely prevented this situation. We also did not properly accomplish the abnormal checklist items in a timely fashion. The best course of action, even on a no passenger ferry flight would have been to return to the point of departure and have the aircraft chkout. This, combined with a new to the aircraft captain, made for a busy situation. I believed his relative inexperience as captain of our B737 contributed to the incident. Also, had I known he was new to the airplane before takeoff, I would have had a more heightened sense of awareness about the whole operation.
Original NASA ASRS Text
Title: B737-300 OVERTEMP ON TKOF, INITIAL CLB USING MAX THRUST TKOF PROC. CREW FAILS TO COMPLETE ABNORMAL CHKLIST USE, THUS ABROGATING ACCEPTED PROCS.
Narrative: STAND-UP OVERNIGHT. 4 HRS SLEEP. DEST CHANGE FOR FERRY FLT. LATE GETTING ACFT FROM MAINT. VERY SHORT TAXI. COMPANY COMPUTERS INCAPABLE OF PROVIDING DERATED THRUST OR ASSUMED TEMP. FULL PWR TKOF MADE AT VERY LIGHT WT. CLBING AT 5000 FPM, OVERTEMP ON #1 ENG. RETARDED THROTTLE, EGT BACK WITHIN LIMITS. CONTINUED TO DEST. MAX EGT AND DURATION NOTED IN LOGBOOK. STANDARD PROC OR SO WE THOUGHT. AFTER ARRIVING HOME, FO TOOK OUT PLT'S HANDBOOK AND DISCOVERED THAT THE EGT REACHED ON OUR FLT CALLED FOR AN ENG SHUTDOWN! FACTORS: FATIGUE -- LESS THAN NORMAL SLEEP HAD LEFT US NOT AS SHARP AS USUAL. COMPLACENCY: BOTH OF US HAD EXPERIENCED EGT OUT OF LIMITS AND WERE SURE WE KNEW HOW TO HANDLE IT. BOOK NOT CONSULTED INFLT! CASUAL ATTITUDE: NO PAX, RELAXED OP. LESSONS LEARNED: ALWAYS GET OUT THE BOOK -- NO ONE HAS IT ALL MEMORIZED. SUPPLEMENTAL INFO FROM ACN 338351: BECAUSE OF EXTREMELY RAPID ACCELERATION DUE TO FULL PWR AND LIGHT WT, 80 KT CALLOUT AND V1 CAME VERY QUICKLY. I WAS DIVERTED FROM MAKING A FINAL ENG CHK BECAUSE OF THIS. ON CLBOUT, DECK ANGLE WAS VERY HIGH, AIRSPD APPROX 145 KIAS. OUT OF 1500 FT MSL (1000 FT AGL), I WAS REACHING FOR THE N1 BUTTON TO BE READY WHEN HE CALLED FOR IT, WHEN AT ABOUT 2000 FT MSL HE CALLED 'OVERTEMP ON #1!' HE IMMEDIATELY DISENGAGED THE AUTOTHROTTLE AND REDUCED PWR, AND LOWERED THE NOSE. OVERTEMP LIGHT WENT OUT, ALL ENG READINGS RETURNED TO NORMAL. WHEN THIS ACFT IS AT VERY LIGHT WTS, THE ACCELERATION IS, PUTTING IT MILDLY 'BREATHTAKING.' UNFORTUNATELY THINGS ALSO HAPPEN VERY FAST, AND REQUIRED CALLOUTS (EG, 80 KTS, V1, ETC) COME UP IN NO TIME AT ALL, BECAUSE V-SPDS ARE VERY LOW YOU HARDLY HAVE ENOUGH TIME TO SET PWR BEFORE LIFTOFF SPDS ARE REACHED. A DERATED THRUST SETTING WOULD HAVE MOST LIKELY PREVENTED THIS SIT. WE ALSO DID NOT PROPERLY ACCOMPLISH THE ABNORMAL CHKLIST ITEMS IN A TIMELY FASHION. THE BEST COURSE OF ACTION, EVEN ON A NO PAX FERRY FLT WOULD HAVE BEEN TO RETURN TO THE POINT OF DEP AND HAVE THE ACFT CHKOUT. THIS, COMBINED WITH A NEW TO THE ACFT CAPT, MADE FOR A BUSY SIT. I BELIEVED HIS RELATIVE INEXPERIENCE AS CAPT OF OUR B737 CONTRIBUTED TO THE INCIDENT. ALSO, HAD I KNOWN HE WAS NEW TO THE AIRPLANE BEFORE TKOF, I WOULD HAVE HAD A MORE HEIGHTENED SENSE OF AWARENESS ABOUT THE WHOLE OP.
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.