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|
Attributes | |
ACN | 372411 |
Time | |
Date | 199706 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : men airport : mem |
State Reference | TN |
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 | ATR 42 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 155 flight time total : 2700 flight time type : 850 |
ASRS Report | 372411 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : overcame equipment problem other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Event occurred during departure from mem. Captain had 850 hours in type and 59 hours in left seat. First officer was PF and was on his first line trip after IOE. Crew took runway for departure without having started the left engine. Sound and yaw made this immediately evident as power came up. First officer said, 'this is wrong.' simultaneously, captain said, 'wait' and both pilots reduced power to idle. Captain told first officer to advise tower that we would need a moment. Tower replied that we could remain on the runway and do a 180 degree turn if desired. Captain started left engine and pilot's reviewed all system and departed. During cruise flight, possible prevention measures were discussed. I feel that the following factors caused or contributed to the event. An inexperienced captain was being careful to monitor the actions of a new first officer. In doing so, captain fixated on first officer's actions without monitoring the effects of those actions. Both pilots failed to properly monitor all system. Proper command terms were not used. Captain failed to properly direct the taxi process. I think that the best way to prevent such an incident is to address these factors. Additionally, the company plans to change the before takeoff checklist.
Original NASA ASRS Text
Title: FLC OF AN ATR42-500 DELAYED TKOF WHEN THEY DISCOVERED THAT THEY HAD NOT STARTED THE L ENG. TWR DIRECTED THEM BACK TO THE TKOF POS WHERE THE OTHER ENG WAS STARTED AND A SUBSEQUENT TKOF WAS MADE WITHOUT INCIDENT. CAPT NEW IN POS, FO RECEIVING IOE.
Narrative: EVENT OCCURRED DURING DEP FROM MEM. CAPT HAD 850 HRS IN TYPE AND 59 HRS IN L SEAT. FO WAS PF AND WAS ON HIS FIRST LINE TRIP AFTER IOE. CREW TOOK RWY FOR DEP WITHOUT HAVING STARTED THE L ENG. SOUND AND YAW MADE THIS IMMEDIATELY EVIDENT AS PWR CAME UP. FO SAID, 'THIS IS WRONG.' SIMULTANEOUSLY, CAPT SAID, 'WAIT' AND BOTH PLTS REDUCED PWR TO IDLE. CAPT TOLD FO TO ADVISE TWR THAT WE WOULD NEED A MOMENT. TWR REPLIED THAT WE COULD REMAIN ON THE RWY AND DO A 180 DEG TURN IF DESIRED. CAPT STARTED L ENG AND PLT'S REVIEWED ALL SYS AND DEPARTED. DURING CRUISE FLT, POSSIBLE PREVENTION MEASURES WERE DISCUSSED. I FEEL THAT THE FOLLOWING FACTORS CAUSED OR CONTRIBUTED TO THE EVENT. AN INEXPERIENCED CAPT WAS BEING CAREFUL TO MONITOR THE ACTIONS OF A NEW FO. IN DOING SO, CAPT FIXATED ON FO'S ACTIONS WITHOUT MONITORING THE EFFECTS OF THOSE ACTIONS. BOTH PLTS FAILED TO PROPERLY MONITOR ALL SYS. PROPER COMMAND TERMS WERE NOT USED. CAPT FAILED TO PROPERLY DIRECT THE TAXI PROCESS. I THINK THAT THE BEST WAY TO PREVENT SUCH AN INCIDENT IS TO ADDRESS THESE FACTORS. ADDITIONALLY, THE COMPANY PLANS TO CHANGE THE BEFORE TKOF CHKLIST.
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.