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|
Attributes | |
ACN | 397388 |
Time | |
Date | 199803 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dtw |
State Reference | MI |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
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 | climbout : takeoff ground other : taxi other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 225 flight time total : 15000 flight time type : 1200 |
ASRS Report | 397388 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : became reoriented other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departed gate on time, day 4 of 5 after early morning get up for first leg of day. 3 hour situation in dtw before this flight leg. Captain, 2ND trip of the month, first officer, last trip (on reserve) completing 78 hours in 17 days. After pushback and disconnect, asked for taxi instructions, received non standard instructions with numerous aircraft movements on taxiway K ahead, told to taxi onto taxiway Y back on taxiway K at K14, silver to runway 3C, caution jetstream on taxiway Y. Looked for jetstream on taxiway Y, not immediately there. After jetstream passing and starting taxi, saw a DC10 pushing but not far enough north on taxiway K for us to re-enter at K14, but a sbound DC9 was on taxiway Y, stopped to re- enter K14. Didn't think enough room, tried to talk with ground control, was very busy frequency. He saw we stopped, asked if there was enough room which time there was. Back on taxiway K on silver taxi. Several aircraft on both txwys K and Y waiting to go sbound to gates and aircraft on taxiway V waiting for other concourse gates. Frequency change, busy once again. Told who to follow, stayed in line of aircraft. When 2ND for takeoff, 1ST aircraft was cleared for takeoff. We were told position and hold. The 1ST aircraft was slow taking the runway, while we were told 'again' position and hold. There was no room to move until the aircraft ahead departed but numerous aircraft behind us. We then had room to take the runway. First officer's leg, moved thrust levers to takeoff position and received takeoff warning, flaps, on upper EICAS, power back, taxied down runway, put flaps down and got back in line for takeoff. Crew failed on above due to: initially change in standard taxi, procedures. My routine is after taxi instructions call for flaps before moving aircraft. The non standard routing and advisement of aircraft on our right were a distraction at the wrong time. If flaps were called for first officer's attentions were diverted outside the aircraft. When checklist were later called for, more distractions as numerous other aircraft taxiing and congested ground frequency and frequency changes. Final pre-takeoff check read and responded while tower was questioning why we hadn't moved when there was no place to go, another distraction at the wrong time. Crew member fatigue with first officer having flown a full month completing up early and an added early morning departure for first leg with minimums landing arrival add to crew fatigue. Crew fatigue, busy airport with non standard taxi instructions, constant radio communications, put the crew into just taking care of distractions and not standard operations. Fortunately the warning system did the job, caught our attention, and allowed us to complete our leg safely. At cruise, first officer and I discussed all the causes which led up to our situation, wanting not to have to have another occurrence of the same.
Original NASA ASRS Text
Title: B757 ACFT DEPARTING DTW HAD NUMEROUS TAXI INSTRUCTIONS AND DISTRACTIONS. FLC FORGOT TO LOWER FLAPS TO TKOF POS AND COMMENCING TKOF ROLL RECEIVED TKOF WARNING.
Narrative: DEPARTED GATE ON TIME, DAY 4 OF 5 AFTER EARLY MORNING GET UP FOR FIRST LEG OF DAY. 3 HR SIT IN DTW BEFORE THIS FLT LEG. CAPT, 2ND TRIP OF THE MONTH, FO, LAST TRIP (ON RESERVE) COMPLETING 78 HRS IN 17 DAYS. AFTER PUSHBACK AND DISCONNECT, ASKED FOR TAXI INSTRUCTIONS, RECEIVED NON STANDARD INSTRUCTIONS WITH NUMEROUS ACFT MOVEMENTS ON TXWY K AHEAD, TOLD TO TAXI ONTO TXWY Y BACK ON TXWY K AT K14, SILVER TO RWY 3C, CAUTION JETSTREAM ON TXWY Y. LOOKED FOR JETSTREAM ON TXWY Y, NOT IMMEDIATELY THERE. AFTER JETSTREAM PASSING AND STARTING TAXI, SAW A DC10 PUSHING BUT NOT FAR ENOUGH N ON TXWY K FOR US TO RE-ENTER AT K14, BUT A SBOUND DC9 WAS ON TXWY Y, STOPPED TO RE- ENTER K14. DIDN'T THINK ENOUGH ROOM, TRIED TO TALK WITH GND CTL, WAS VERY BUSY FREQ. HE SAW WE STOPPED, ASKED IF THERE WAS ENOUGH ROOM WHICH TIME THERE WAS. BACK ON TXWY K ON SILVER TAXI. SEVERAL ACFT ON BOTH TXWYS K AND Y WAITING TO GO SBOUND TO GATES AND ACFT ON TXWY V WAITING FOR OTHER CONCOURSE GATES. FREQ CHANGE, BUSY ONCE AGAIN. TOLD WHO TO FOLLOW, STAYED IN LINE OF ACFT. WHEN 2ND FOR TKOF, 1ST ACFT WAS CLRED FOR TKOF. WE WERE TOLD POS AND HOLD. THE 1ST ACFT WAS SLOW TAKING THE RWY, WHILE WE WERE TOLD 'AGAIN' POS AND HOLD. THERE WAS NO ROOM TO MOVE UNTIL THE ACFT AHEAD DEPARTED BUT NUMEROUS ACFT BEHIND US. WE THEN HAD ROOM TO TAKE THE RWY. FO'S LEG, MOVED THRUST LEVERS TO TKOF POS AND RECEIVED TKOF WARNING, FLAPS, ON UPPER EICAS, PWR BACK, TAXIED DOWN RWY, PUT FLAPS DOWN AND GOT BACK IN LINE FOR TKOF. CREW FAILED ON ABOVE DUE TO: INITIALLY CHANGE IN STANDARD TAXI, PROCS. MY ROUTINE IS AFTER TAXI INSTRUCTIONS CALL FOR FLAPS BEFORE MOVING ACFT. THE NON STANDARD ROUTING AND ADVISEMENT OF ACFT ON OUR R WERE A DISTR AT THE WRONG TIME. IF FLAPS WERE CALLED FOR FO'S ATTENTIONS WERE DIVERTED OUTSIDE THE ACFT. WHEN CHKLIST WERE LATER CALLED FOR, MORE DISTRACTIONS AS NUMEROUS OTHER ACFT TAXIING AND CONGESTED GND FREQ AND FREQ CHANGES. FINAL PRE-TKOF CHK READ AND RESPONDED WHILE TWR WAS QUESTIONING WHY WE HADN'T MOVED WHEN THERE WAS NO PLACE TO GO, ANOTHER DISTR AT THE WRONG TIME. CREW MEMBER FATIGUE WITH FO HAVING FLOWN A FULL MONTH COMPLETING UP EARLY AND AN ADDED EARLY MORNING DEP FOR FIRST LEG WITH MINIMUMS LNDG ARR ADD TO CREW FATIGUE. CREW FATIGUE, BUSY ARPT WITH NON STANDARD TAXI INSTRUCTIONS, CONSTANT RADIO COMS, PUT THE CREW INTO JUST TAKING CARE OF DISTRACTIONS AND NOT STANDARD OPS. FORTUNATELY THE WARNING SYS DID THE JOB, CAUGHT OUR ATTN, AND ALLOWED US TO COMPLETE OUR LEG SAFELY. AT CRUISE, FO AND I DISCUSSED ALL THE CAUSES WHICH LED UP TO OUR SIT, WANTING NOT TO HAVE TO HAVE ANOTHER OCCURRENCE OF THE SAME.
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.