37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 374106 |
Time | |
Date | 199707 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mdt |
State Reference | PA |
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 | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 3400 flight time type : 300 |
ASRS Report | 374106 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure 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:
Crew elected a flaps 5 degrees takeoff at reduced thrust. Performance numbers indicated plenty of 'pad' and crew felt comfortable with margin. Takeoff roll proved extremely long, with 'V1, vr' callouts occurring uncomfortably close to runway end. Normal rotation, normal gear retraction, but aircraft seemed to barely clear trees at end of runway. Later, in flight, engine anti-ice was called for, at which point it was discovered the anti-ice valves were already open, thus accounting for poor takeoff performance. The new hire so had left valves open on origination preflight, at dulles international airport. All 3 pilots (on first leg from dulles, and second leg from harrisburg). Missed the 'open' position of valves on pre- and postflt checklists. Attribute part of this to poor design of switches (wherein no lights come on to indicate valve position, unless a rotary switch is selected to 'on,' and then the light only indicates full open or full closed). Obviously, most of the blame lies with the crew, seeing what we expected to see. Poor CRM is also partly to blame. Having flown with this captain once before, and having been actually yelled at for asking for an approach brief during a period of microburst alert, I was wary of pushing (or even asking) for any guidance. In selecting the flaps 5 degrees option, I solicited the captain's input. All he said was, 'a tailskid strike will mean more than just 30 days off...you'll go back for retraining.' as tailskid strikes are usually due to poor pilot technique, I took his response as a non response. Additionally, on takeoff roll, when the airspeed didn't accelerate as it should, believe poor CRM/clear contributed to lack of corrective response. As the throttles belong to the captain, I believed he felt comfortable with the takeoff performance. Still, I was not. But I didn't say anything (such as 'set maximum thrust') and I attribute this to my previous experience with this captain. Previously, he said I made him feel I questioned his judgement and (by asking for the microburst briefing) I acted like I was the instructor and he the student. So, I was extremely hesitant to openly question his judgement or appear to challenge his authority/authorized. What did I learn? Who cares about ego when safety is compromised. And, touch the switches to verify position (and advocate, advocate, advocate!).
Original NASA ASRS Text
Title: FLC OF B727 HAS LONG TKOF ROLL LATER FOUND TO BE CAUSED BY THE ANTI-ICE VALVES BEING OPEN DURING TKOF. THEY BARELY MADE IT ABOVE THE TREES AT THE RWY END. NEW HIRE SO LEFT VALVES OPEN AT PREFLT.
Narrative: CREW ELECTED A FLAPS 5 DEGS TKOF AT REDUCED THRUST. PERFORMANCE NUMBERS INDICATED PLENTY OF 'PAD' AND CREW FELT COMFORTABLE WITH MARGIN. TKOF ROLL PROVED EXTREMELY LONG, WITH 'V1, VR' CALLOUTS OCCURRING UNCOMFORTABLY CLOSE TO RWY END. NORMAL ROTATION, NORMAL GEAR RETRACTION, BUT ACFT SEEMED TO BARELY CLR TREES AT END OF RWY. LATER, IN FLT, ENG ANTI-ICE WAS CALLED FOR, AT WHICH POINT IT WAS DISCOVERED THE ANTI-ICE VALVES WERE ALREADY OPEN, THUS ACCOUNTING FOR POOR TKOF PERFORMANCE. THE NEW HIRE SO HAD LEFT VALVES OPEN ON ORIGINATION PREFLT, AT DULLES INTL ARPT. ALL 3 PLTS (ON FIRST LEG FROM DULLES, AND SECOND LEG FROM HARRISBURG). MISSED THE 'OPEN' POS OF VALVES ON PRE- AND POSTFLT CHKLISTS. ATTRIBUTE PART OF THIS TO POOR DESIGN OF SWITCHES (WHEREIN NO LIGHTS COME ON TO INDICATE VALVE POS, UNLESS A ROTARY SWITCH IS SELECTED TO 'ON,' AND THEN THE LIGHT ONLY INDICATES FULL OPEN OR FULL CLOSED). OBVIOUSLY, MOST OF THE BLAME LIES WITH THE CREW, SEEING WHAT WE EXPECTED TO SEE. POOR CRM IS ALSO PARTLY TO BLAME. HAVING FLOWN WITH THIS CAPT ONCE BEFORE, AND HAVING BEEN ACTUALLY YELLED AT FOR ASKING FOR AN APCH BRIEF DURING A PERIOD OF MICROBURST ALERT, I WAS WARY OF PUSHING (OR EVEN ASKING) FOR ANY GUIDANCE. IN SELECTING THE FLAPS 5 DEGS OPTION, I SOLICITED THE CAPT'S INPUT. ALL HE SAID WAS, 'A TAILSKID STRIKE WILL MEAN MORE THAN JUST 30 DAYS OFF...YOU'LL GO BACK FOR RETRAINING.' AS TAILSKID STRIKES ARE USUALLY DUE TO POOR PLT TECHNIQUE, I TOOK HIS RESPONSE AS A NON RESPONSE. ADDITIONALLY, ON TKOF ROLL, WHEN THE AIRSPD DIDN'T ACCELERATE AS IT SHOULD, BELIEVE POOR CRM/CLR CONTRIBUTED TO LACK OF CORRECTIVE RESPONSE. AS THE THROTTLES BELONG TO THE CAPT, I BELIEVED HE FELT COMFORTABLE WITH THE TKOF PERFORMANCE. STILL, I WAS NOT. BUT I DIDN'T SAY ANYTHING (SUCH AS 'SET MAX THRUST') AND I ATTRIBUTE THIS TO MY PREVIOUS EXPERIENCE WITH THIS CAPT. PREVIOUSLY, HE SAID I MADE HIM FEEL I QUESTIONED HIS JUDGEMENT AND (BY ASKING FOR THE MICROBURST BRIEFING) I ACTED LIKE I WAS THE INSTRUCTOR AND HE THE STUDENT. SO, I WAS EXTREMELY HESITANT TO OPENLY QUESTION HIS JUDGEMENT OR APPEAR TO CHALLENGE HIS AUTH. WHAT DID I LEARN? WHO CARES ABOUT EGO WHEN SAFETY IS COMPROMISED. AND, TOUCH THE SWITCHES TO VERIFY POS (AND ADVOCATE, ADVOCATE, ADVOCATE!).
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.