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|
Attributes | |
ACN | 456763 |
Time | |
Date | 199912 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : pdx.airport |
State Reference | OR |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : multi engine pilot : instrument pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 21000 flight time type : 2000 |
ASRS Report | 456763 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : atp pilot : multi engine pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 10500 flight time type : 400 |
ASRS Report | 456766 |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : takeoff warning |
Resolutory Action | flight crew : became reoriented flight crew : overcame equipment problem flight crew : rejected takeoff |
Supplementary | |
Problem Areas | Aircraft Environmental Factor Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
At start of our takeoff roll at speed 5-10 KTS, we received a confign warning indicating the stabilizer trim was out of takeoff limitations. The takeoff was discontinued and I taxied off the runway. I asked the copilot how we missed the item on the checklist. A few days earlier, the company had changed our checklists, adding some items and moving others to different checklists. The stabilizer trim was an item that was moved from our 'taxi' check to the 'pushback/start' checklist. I called for all the checklists and know the copilot had them in his hand during reading and reported each checklist complete. However, old habits must have crept in and the stabilizer trim was not read in its new location. The copilot felt very bad about missing this item and I feel responsibility as the captain for not emphasizing caution with these new checklists using good read challenge and response technique. We all slip into habits where we think we are doing something but in actuality we're doing something else. All checklists should be read carefully because they are our salvation. Supplemental information from acn 456766: investigation showed the stabilizer trim at 8 units, outside the green band. After taxiing clear of the runway, the stabilizer trim was properly set and the checklists were re-read. The aircraft was returned to the end of the runway for a normal takeoff.
Original NASA ASRS Text
Title: A B767-300 FLC ABORTS THEIR TKOF AT A LOW SPD WHEN THE TKOF WARNING HORN ALERTS THEM TO A STABILIZER TRIM SETTING THAT WAS OUT OF LIMITS AT PDX, OR.
Narrative: AT START OF OUR TKOF ROLL AT SPD 5-10 KTS, WE RECEIVED A CONFIGN WARNING INDICATING THE STABILIZER TRIM WAS OUT OF TKOF LIMITATIONS. THE TKOF WAS DISCONTINUED AND I TAXIED OFF THE RWY. I ASKED THE COPLT HOW WE MISSED THE ITEM ON THE CHKLIST. A FEW DAYS EARLIER, THE COMPANY HAD CHANGED OUR CHKLISTS, ADDING SOME ITEMS AND MOVING OTHERS TO DIFFERENT CHKLISTS. THE STABILIZER TRIM WAS AN ITEM THAT WAS MOVED FROM OUR 'TAXI' CHK TO THE 'PUSHBACK/START' CHKLIST. I CALLED FOR ALL THE CHKLISTS AND KNOW THE COPLT HAD THEM IN HIS HAND DURING READING AND RPTED EACH CHKLIST COMPLETE. HOWEVER, OLD HABITS MUST HAVE CREPT IN AND THE STABILIZER TRIM WAS NOT READ IN ITS NEW LOCATION. THE COPLT FELT VERY BAD ABOUT MISSING THIS ITEM AND I FEEL RESPONSIBILITY AS THE CAPT FOR NOT EMPHASIZING CAUTION WITH THESE NEW CHKLISTS USING GOOD READ CHALLENGE AND RESPONSE TECHNIQUE. WE ALL SLIP INTO HABITS WHERE WE THINK WE ARE DOING SOMETHING BUT IN ACTUALITY WE'RE DOING SOMETHING ELSE. ALL CHKLISTS SHOULD BE READ CAREFULLY BECAUSE THEY ARE OUR SALVATION. SUPPLEMENTAL INFO FROM ACN 456766: INVESTIGATION SHOWED THE STABILIZER TRIM AT 8 UNITS, OUTSIDE THE GREEN BAND. AFTER TAXIING CLR OF THE RWY, THE STABILIZER TRIM WAS PROPERLY SET AND THE CHKLISTS WERE RE-READ. THE ACFT WAS RETURNED TO THE END OF THE RWY FOR A NORMAL TKOF.
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.