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|
Attributes | |
ACN | 465060 |
Time | |
Date | 200003 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sna.airport |
State Reference | CA |
Altitude | msl single value : 1700 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Thunderstorm Rain Turbulence Windshear |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 19r other |
Flight Phase | descent : vacating altitude landing : go around |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 85 flight time total : 28300 flight time type : 650 |
ASRS Report | 465060 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 9000 flight time type : 4000 |
ASRS Report | 465170 |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : turbulence inflight encounter : weather non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Environmental Factor Aircraft Chart Or Publication |
Primary Problem | Aircraft |
Narrative:
On final approach when selecting flap settings, experienced a flap problem (flap disagreement warning). Made go around and completed flap disagreement abnormal procedure. Approach and next landing normal. Upon review, once on the ground, we discovered that we misread the abnormal procedure and landed with wrong flap setting. The reason we misread the procedure was due to rushing the procedure because of low fuel reserves and level 4 thunderstorms at night, in turbulence, with heavy rain and lightning, heavy workload with ATC which was saturated with aircraft, and the strong urge to get the aircraft on the ground before the WX got worse. Next time I'll take more time and more fuel. Supplemental information from acn 465170: during final approach phase of flight, 'trailing edge flap disagreement' EICAS message presented at approximately 2500 ft AGL. Missed approach was executed with subsequent vectoring and reference to abnormal checklist procedures. Alternate flap system was selected. While holding for clearance to gate, checklist for flap procedure was reviewed and discovered to have been misread. The proper procedure was to land with flaps 20 degrees, not 30 degrees as we had. This is to provide a better missed approach envelope in the event of an engine failure and go around on short final. The poorly written checklist, with reference to flaps 20 degree landing buried in the context of the abnormal procedure, caused both pilots to miss flaps 20 degree reference. Corrective action would be to rewrite abnormal flap procedure in a more bold face format, as well as careful and diligent reference to abnormal procedures.
Original NASA ASRS Text
Title: A B757-200 FLC EXPERIENCES A TRAILING EDGE FLAP DISAGREEMENT WARNING. AFTER A GAR AND CHKLIST USE, THE CREW (WHEN ON THE GND) FINDS THAT THEY USED A 30 DEG FLAP SETTING FOR LNDG VERSUS THE 20 DEG FLAP SETTING AS REQUIRED BY THE CHKLIST. SNA. CA.
Narrative: ON FINAL APCH WHEN SELECTING FLAP SETTINGS, EXPERIENCED A FLAP PROB (FLAP DISAGREEMENT WARNING). MADE GAR AND COMPLETED FLAP DISAGREEMENT ABNORMAL PROC. APCH AND NEXT LNDG NORMAL. UPON REVIEW, ONCE ON THE GND, WE DISCOVERED THAT WE MISREAD THE ABNORMAL PROC AND LANDED WITH WRONG FLAP SETTING. THE REASON WE MISREAD THE PROC WAS DUE TO RUSHING THE PROC BECAUSE OF LOW FUEL RESERVES AND LEVEL 4 TSTMS AT NIGHT, IN TURB, WITH HVY RAIN AND LIGHTNING, HVY WORKLOAD WITH ATC WHICH WAS SATURATED WITH ACFT, AND THE STRONG URGE TO GET THE ACFT ON THE GND BEFORE THE WX GOT WORSE. NEXT TIME I'LL TAKE MORE TIME AND MORE FUEL. SUPPLEMENTAL INFO FROM ACN 465170: DURING FINAL APCH PHASE OF FLT, 'TRAILING EDGE FLAP DISAGREEMENT' EICAS MESSAGE PRESENTED AT APPROX 2500 FT AGL. MISSED APCH WAS EXECUTED WITH SUBSEQUENT VECTORING AND REF TO ABNORMAL CHKLIST PROCS. ALTERNATE FLAP SYS WAS SELECTED. WHILE HOLDING FOR CLRNC TO GATE, CHKLIST FOR FLAP PROC WAS REVIEWED AND DISCOVERED TO HAVE BEEN MISREAD. THE PROPER PROC WAS TO LAND WITH FLAPS 20 DEGS, NOT 30 DEGS AS WE HAD. THIS IS TO PROVIDE A BETTER MISSED APCH ENVELOPE IN THE EVENT OF AN ENG FAILURE AND GAR ON SHORT FINAL. THE POORLY WRITTEN CHKLIST, WITH REF TO FLAPS 20 DEG LNDG BURIED IN THE CONTEXT OF THE ABNORMAL PROC, CAUSED BOTH PLTS TO MISS FLAPS 20 DEG REF. CORRECTIVE ACTION WOULD BE TO REWRITE ABNORMAL FLAP PROC IN A MORE BOLD FACE FORMAT, AS WELL AS CAREFUL AND DILIGENT REF TO ABNORMAL PROCS.
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.