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|
Attributes | |
ACN | 341570 |
Time | |
Date | 199607 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bwi |
State Reference | MD |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : bwi |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other landing other |
Route In Use | approach : visual enroute airway : bwi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 172 flight time total : 6600 flight time type : 908 |
ASRS Report | 341570 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 10100 flight time type : 250 |
ASRS Report | 341037 |
Events | |
Anomaly | non adherence : published procedure non adherence : far non adherence other 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 | other |
Narrative:
Upon preparing for the descent for landing at bwi destination (7/sat/96, from dtw to bwi), I discovered that the first officer were both missing most of the commercial airport pages for bwi. All that either of us had was the bare minimum. (Airport diagrams and 11-B-1 pages). We were missing the arrs, departures and some approachs. With clear WX, we flew a visual approach using FMC database approach and ILS backup with no problems. However, had the WX been poor or had it been an 'older technology' airplane, we would have had to have diverted to another airport. This problem arose because both pilots had recently been qualified on the B757, which necessitated a change in our commercial airport coverage. This process involved removing certain pages from our old manual and inserting certain new pages. An exact list of which pages were required for each airport was not provided, so there was no way to xchk against all the obvious potential human errors that could occur. In other words, I have a good idea from this incident that bwi fell through some crack in the system, I do not know if it is a unique occurrence. I suggest we need a way to catch this problem before the point where we caught it in this instance.
Original NASA ASRS Text
Title: FLC DIDN'T HAVE APPROPRIATE STARS, SIDS, OR APCH PLATES FOR DEST ARPT. ACR PROCS OF PROVIDING APCH CHART CHANGES WITHOUT A CHKLIST SET UP THE FLC MISSING THEIR PUBS.
Narrative: UPON PREPARING FOR THE DSCNT FOR LNDG AT BWI DEST (7/SAT/96, FROM DTW TO BWI), I DISCOVERED THAT THE FO WERE BOTH MISSING MOST OF THE COMMERCIAL ARPT PAGES FOR BWI. ALL THAT EITHER OF US HAD WAS THE BARE MINIMUM. (ARPT DIAGRAMS AND 11-B-1 PAGES). WE WERE MISSING THE ARRS, DEPS AND SOME APCHS. WITH CLR WX, WE FLEW A VISUAL APCH USING FMC DATABASE APCH AND ILS BACKUP WITH NO PROBS. HOWEVER, HAD THE WX BEEN POOR OR HAD IT BEEN AN 'OLDER TECHNOLOGY' AIRPLANE, WE WOULD HAVE HAD TO HAVE DIVERTED TO ANOTHER ARPT. THIS PROB AROSE BECAUSE BOTH PLTS HAD RECENTLY BEEN QUALIFIED ON THE B757, WHICH NECESSITATED A CHANGE IN OUR COMMERCIAL ARPT COVERAGE. THIS PROCESS INVOLVED REMOVING CERTAIN PAGES FROM OUR OLD MANUAL AND INSERTING CERTAIN NEW PAGES. AN EXACT LIST OF WHICH PAGES WERE REQUIRED FOR EACH ARPT WAS NOT PROVIDED, SO THERE WAS NO WAY TO XCHK AGAINST ALL THE OBVIOUS POTENTIAL HUMAN ERRORS THAT COULD OCCUR. IN OTHER WORDS, I HAVE A GOOD IDEA FROM THIS INCIDENT THAT BWI FELL THROUGH SOME CRACK IN THE SYS, I DO NOT KNOW IF IT IS A UNIQUE OCCURRENCE. I SUGGEST WE NEED A WAY TO CATCH THIS PROB BEFORE THE POINT WHERE WE CAUGHT IT IN THIS INSTANCE.
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.