37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 438691 |
Time | |
Date | 199905 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : jfk.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-C/F |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 110 flight time total : 7100 flight time type : 1350 |
ASRS Report | 438691 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Crew of 3 (captain, first officer, flight engineer) on a cargo flight from jfk to atlanta and then on to anc. (Local time XA30.) initial departure had been delayed about 2 hours due to the late arrival of aircraft to jfk. This was the first flight for first officer after completing IOE 2 weeks earlier. The captain and flight engineer had flown a trip together the week prior. After engine starts and taxi clearance received, captain called for 'flaps 10 degrees.' first officer moved the flap handle and called 'flaps 10 degrees.' while taxiing to hold short, taxi checklist was accomplished. At the checklist step for 'flaps and runway' (for which the captain has no response), I happened to glance at the airport diagram to check on a taxi routing instruction which we had just received. At 'flaps and runway' on the checklist, the first officer called out '10, 10, green light for runway 22R' (indicating that the inboard and outboard flap indicators actually show flaps at 10 degrees and the flap position light is green). The flight engineer then called out '10, 10, 8 green lights for runway 22R,' which acknowledged his confirmation of flap position. Through it all, the flaps were at 5 degrees. We completed the rest of the checklist. As we approached the hold short, the flight engineer noticed the flaps were set at 10 degrees and the checklist reviewed. Factors at work were, in my opinion, 1) fatigue. I suspect both flight engineer and first officer were not as well rested as they would be if the takeoff were scheduled at a more 'normal' time of the day. 2) inexperience. While I had instructed the first officer to take as much time as he needed to do his job, I suspect he rushed through some of his duties, which led to his mis-setting the flaps.
Original NASA ASRS Text
Title: A B747 FLC REALIZED AN INCORRECT FLAP SETTING AFTER THE BEFORE TKOF CHKLIST WAS RUN ON TAXI OUT OF JFK.
Narrative: CREW OF 3 (CAPT, FO, FE) ON A CARGO FLT FROM JFK TO ATLANTA AND THEN ON TO ANC. (LCL TIME XA30.) INITIAL DEP HAD BEEN DELAYED ABOUT 2 HRS DUE TO THE LATE ARR OF ACFT TO JFK. THIS WAS THE FIRST FLT FOR FO AFTER COMPLETING IOE 2 WKS EARLIER. THE CAPT AND FE HAD FLOWN A TRIP TOGETHER THE WK PRIOR. AFTER ENG STARTS AND TAXI CLRNC RECEIVED, CAPT CALLED FOR 'FLAPS 10 DEGS.' FO MOVED THE FLAP HANDLE AND CALLED 'FLAPS 10 DEGS.' WHILE TAXIING TO HOLD SHORT, TAXI CHKLIST WAS ACCOMPLISHED. AT THE CHKLIST STEP FOR 'FLAPS AND RWY' (FOR WHICH THE CAPT HAS NO RESPONSE), I HAPPENED TO GLANCE AT THE ARPT DIAGRAM TO CHK ON A TAXI ROUTING INSTRUCTION WHICH WE HAD JUST RECEIVED. AT 'FLAPS AND RWY' ON THE CHKLIST, THE FO CALLED OUT '10, 10, GREEN LIGHT FOR RWY 22R' (INDICATING THAT THE INBOARD AND OUTBOARD FLAP INDICATORS ACTUALLY SHOW FLAPS AT 10 DEGS AND THE FLAP POS LIGHT IS GREEN). THE FE THEN CALLED OUT '10, 10, 8 GREEN LIGHTS FOR RWY 22R,' WHICH ACKNOWLEDGED HIS CONFIRMATION OF FLAP POS. THROUGH IT ALL, THE FLAPS WERE AT 5 DEGS. WE COMPLETED THE REST OF THE CHKLIST. AS WE APCHED THE HOLD SHORT, THE FE NOTICED THE FLAPS WERE SET AT 10 DEGS AND THE CHKLIST REVIEWED. FACTORS AT WORK WERE, IN MY OPINION, 1) FATIGUE. I SUSPECT BOTH FE AND FO WERE NOT AS WELL RESTED AS THEY WOULD BE IF THE TKOF WERE SCHEDULED AT A MORE 'NORMAL' TIME OF THE DAY. 2) INEXPERIENCE. WHILE I HAD INSTRUCTED THE FO TO TAKE AS MUCH TIME AS HE NEEDED TO DO HIS JOB, I SUSPECT HE RUSHED THROUGH SOME OF HIS DUTIES, WHICH LED TO HIS MIS-SETTING THE FLAPS.
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.