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|
Attributes | |
ACN | 458089 |
Time | |
Date | 199912 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mci.airport |
State Reference | KS |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 7000 flight time type : 100 |
ASRS Report | 458089 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Classic error chain. Departed mci-phl with wrong release and WX package. First flight of trip with crew paired together. Both low time in type, me first officer (85 hours) and captain 30 hours. Arrive at aircraft on time. Told paperwork is reprinting because of printer problem. On preflight, found maintenance discrepancy. Coordinating maintenance and operations. Jump seater shows up -- have to say hello to him. Another non revenue pops in to say hello. Finally maintenance shows up, resolves situation. Paperwork finally shows up during checklist -- about 10 mins before departure. I notice the alternate and an MEL. We discuss the MEL -- a minor lighting write-up and can't find it in the logbook (clue!). We departed and en route we discovered wrong release. Our company has numerous safeguards to verify fuel, but not release number. This should be obvious! I didn't look to verify destination, routing on release (we used ACARS), aircraft tail number or WX (once again pulled up WX on ACARS). We both learned a lot that morning. We landed with plenty of fuel (burn was only 20-25 mins longer).
Original NASA ASRS Text
Title: DC9 CREW WITH VERY LITTLE EXPERIENCE DEPARTS WITHOUT PROPER RELEASE AND WX FROM MCI.
Narrative: CLASSIC ERROR CHAIN. DEPARTED MCI-PHL WITH WRONG RELEASE AND WX PACKAGE. FIRST FLT OF TRIP WITH CREW PAIRED TOGETHER. BOTH LOW TIME IN TYPE, ME FO (85 HRS) AND CAPT 30 HRS. ARRIVE AT ACFT ON TIME. TOLD PAPERWORK IS REPRINTING BECAUSE OF PRINTER PROB. ON PREFLT, FOUND MAINT DISCREPANCY. COORDINATING MAINT AND OPS. JUMP SEATER SHOWS UP -- HAVE TO SAY HELLO TO HIM. ANOTHER NON REVENUE POPS IN TO SAY HELLO. FINALLY MAINT SHOWS UP, RESOLVES SIT. PAPERWORK FINALLY SHOWS UP DURING CHKLIST -- ABOUT 10 MINS BEFORE DEP. I NOTICE THE ALTERNATE AND AN MEL. WE DISCUSS THE MEL -- A MINOR LIGHTING WRITE-UP AND CAN'T FIND IT IN THE LOGBOOK (CLUE!). WE DEPARTED AND ENRTE WE DISCOVERED WRONG RELEASE. OUR COMPANY HAS NUMEROUS SAFEGUARDS TO VERIFY FUEL, BUT NOT RELEASE NUMBER. THIS SHOULD BE OBVIOUS! I DIDN'T LOOK TO VERIFY DEST, ROUTING ON RELEASE (WE USED ACARS), ACFT TAIL NUMBER OR WX (ONCE AGAIN PULLED UP WX ON ACARS). WE BOTH LEARNED A LOT THAT MORNING. WE LANDED WITH PLENTY OF FUEL (BURN WAS ONLY 20-25 MINS LONGER).
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.