37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 503380 |
Time | |
Date | 200103 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : pns.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 15000 flight time type : 12000 |
ASRS Report | 503380 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Original flight was phx direct msy. Due to thunderstorms, WX diverted to pns with full load of passenger. We received 2 faxed copies of dispatch release and WX sheets and refueled the plane for the flight to msy. 2 passenger chose to deplane and continue on their own. In discussion with dispatch regarding irregular operations and passenger deplaning, we agreed that it was proper to note their names, addresses and phone numbers on a sheet and naturally assumed that everything else remains the same. I inserted copies of the dispatch release, load schedule and (I thought) the WX sheet into the envelope from the irregular operations packet and gave it to the folks who were handling us with instructions to mail it as soon as possible. I was assured that it would be mailed as soon as possible. Satisfied with WX conditions and all other aspects of the flight, we took off and flew an uneventful flight pns-msy where I turned the airplane over to a new crew. I told the captain that the off-line alternate packages had been used and that they needed to be replaced. I also told msy operations that they needed to be replaced. Problems: 1) I think I inadvertently omitted a copy of the WX sheet in the envelope as I discovered this morning while looking over saved paperwork that I had both WX packets with me. (I am sending a copy this afternoon to include in the envelope I originally sent.) 2) again, this morning while reviewing the events of the previous day and reviewing the fom and instruction packet I the irregular operations packet, I noted that because 1 or more people deplaned, I am assuming that procedure is to go through the airplane and get the name of every single person. I assumed that noting the 2 deplaning pas was sufficient. 3) I missed the note in the fom regarding making a maintenance note in the logbook when the irregular operations packet is used. (I have already notified maintenance and they are going to have the packet replaced.) at no time was safety compromised. We had just finished a long flight from phx, through turbulent IMC, attempted an approach to msy and chose to divert to pns. We passed through holes in the line of thunderstorms and landed safely at pns. I have a whole plane full of passenger who are hot and understandably concerned about WX and scheduled, etc, and have been cooped up in the airplane and have about 1 hour on the ground, working with ground people (who were greatly, incidentally) and an approaching line of thunderstorms threatening pns. Cell phone calls ensued with dispatch concerning WX. Feeling a little rushed, but satisfied that we had 'covered all the based.' obviously, I hadn't paperwork-wise. Thus, the report. I believe the first officer and I did everything safely. I missed some paperwork catches which I have already remedied. (Sent copy of WX sheet along with another copy of the 2 deplaning passenger.) notified maintenance of need to replace the irregular operations packet. What caused the event: my oversight of some provisions in the fom and on the instruction sheet in the irregular operations packet. Perhaps being a little rushed with the approaching WX. (No excuses, however. I missed some things.) problem remedies to prevent further like occurrences; 1) make a note in the fom in diversion paragraph referencing the detailed instruction sheet in the packet (I overlooked it). 2) during initial and upgrade training, include a short exercise in off-line operations and required steps and paperwork. 3) when dispatch faxes copies of releases and WX to an off-line station, make 3 copies of each just like we get in normal operations (each of us had a WX sheet, I forgot to include one in the envelope).
Original NASA ASRS Text
Title: AN ACR CREW FINDS, AFTER THE FACT, THAT THEY DID NOT COMPLETE ALL THE PAPERWORK INVOLVED IN A DIVERSION TO AND FROM AND ENRTE STATION CORRECTLY.
Narrative: ORIGINAL FLT WAS PHX DIRECT MSY. DUE TO TSTMS, WX DIVERTED TO PNS WITH FULL LOAD OF PAX. WE RECEIVED 2 FAXED COPIES OF DISPATCH RELEASE AND WX SHEETS AND REFUELED THE PLANE FOR THE FLT TO MSY. 2 PAX CHOSE TO DEPLANE AND CONTINUE ON THEIR OWN. IN DISCUSSION WITH DISPATCH REGARDING IRREGULAR OPS AND PAX DEPLANING, WE AGREED THAT IT WAS PROPER TO NOTE THEIR NAMES, ADDRESSES AND PHONE NUMBERS ON A SHEET AND NATURALLY ASSUMED THAT EVERYTHING ELSE REMAINS THE SAME. I INSERTED COPIES OF THE DISPATCH RELEASE, LOAD SCHEDULE AND (I THOUGHT) THE WX SHEET INTO THE ENVELOPE FROM THE IRREGULAR OPS PACKET AND GAVE IT TO THE FOLKS WHO WERE HANDLING US WITH INSTRUCTIONS TO MAIL IT ASAP. I WAS ASSURED THAT IT WOULD BE MAILED ASAP. SATISFIED WITH WX CONDITIONS AND ALL OTHER ASPECTS OF THE FLT, WE TOOK OFF AND FLEW AN UNEVENTFUL FLT PNS-MSY WHERE I TURNED THE AIRPLANE OVER TO A NEW CREW. I TOLD THE CAPT THAT THE OFF-LINE ALTERNATE PACKAGES HAD BEEN USED AND THAT THEY NEEDED TO BE REPLACED. I ALSO TOLD MSY OPS THAT THEY NEEDED TO BE REPLACED. PROBS: 1) I THINK I INADVERTENTLY OMITTED A COPY OF THE WX SHEET IN THE ENVELOPE AS I DISCOVERED THIS MORNING WHILE LOOKING OVER SAVED PAPERWORK THAT I HAD BOTH WX PACKETS WITH ME. (I AM SENDING A COPY THIS AFTERNOON TO INCLUDE IN THE ENVELOPE I ORIGINALLY SENT.) 2) AGAIN, THIS MORNING WHILE REVIEWING THE EVENTS OF THE PREVIOUS DAY AND REVIEWING THE FOM AND INSTRUCTION PACKET I THE IRREGULAR OPS PACKET, I NOTED THAT BECAUSE 1 OR MORE PEOPLE DEPLANED, I AM ASSUMING THAT PROC IS TO GO THROUGH THE AIRPLANE AND GET THE NAME OF EVERY SINGLE PERSON. I ASSUMED THAT NOTING THE 2 DEPLANING PAS WAS SUFFICIENT. 3) I MISSED THE NOTE IN THE FOM REGARDING MAKING A MAINT NOTE IN THE LOGBOOK WHEN THE IRREGULAR OPS PACKET IS USED. (I HAVE ALREADY NOTIFIED MAINT AND THEY ARE GOING TO HAVE THE PACKET REPLACED.) AT NO TIME WAS SAFETY COMPROMISED. WE HAD JUST FINISHED A LONG FLT FROM PHX, THROUGH TURBULENT IMC, ATTEMPTED AN APCH TO MSY AND CHOSE TO DIVERT TO PNS. WE PASSED THROUGH HOLES IN THE LINE OF TSTMS AND LANDED SAFELY AT PNS. I HAVE A WHOLE PLANE FULL OF PAX WHO ARE HOT AND UNDERSTANDABLY CONCERNED ABOUT WX AND SCHEDULED, ETC, AND HAVE BEEN COOPED UP IN THE AIRPLANE AND HAVE ABOUT 1 HR ON THE GND, WORKING WITH GND PEOPLE (WHO WERE GREATLY, INCIDENTALLY) AND AN APCHING LINE OF TSTMS THREATENING PNS. CELL PHONE CALLS ENSUED WITH DISPATCH CONCERNING WX. FEELING A LITTLE RUSHED, BUT SATISFIED THAT WE HAD 'COVERED ALL THE BASED.' OBVIOUSLY, I HADN'T PAPERWORK-WISE. THUS, THE RPT. I BELIEVE THE FO AND I DID EVERYTHING SAFELY. I MISSED SOME PAPERWORK CATCHES WHICH I HAVE ALREADY REMEDIED. (SENT COPY OF WX SHEET ALONG WITH ANOTHER COPY OF THE 2 DEPLANING PAX.) NOTIFIED MAINT OF NEED TO REPLACE THE IRREGULAR OPS PACKET. WHAT CAUSED THE EVENT: MY OVERSIGHT OF SOME PROVISIONS IN THE FOM AND ON THE INSTRUCTION SHEET IN THE IRREGULAR OPS PACKET. PERHAPS BEING A LITTLE RUSHED WITH THE APCHING WX. (NO EXCUSES, HOWEVER. I MISSED SOME THINGS.) PROB REMEDIES TO PREVENT FURTHER LIKE OCCURRENCES; 1) MAKE A NOTE IN THE FOM IN DIVERSION PARAGRAPH REFING THE DETAILED INSTRUCTION SHEET IN THE PACKET (I OVERLOOKED IT). 2) DURING INITIAL AND UPGRADE TRAINING, INCLUDE A SHORT EXERCISE IN OFF-LINE OPS AND REQUIRED STEPS AND PAPERWORK. 3) WHEN DISPATCH FAXES COPIES OF RELEASES AND WX TO AN OFF-LINE STATION, MAKE 3 COPIES OF EACH JUST LIKE WE GET IN NORMAL OPS (EACH OF US HAD A WX SHEET, I FORGOT TO INCLUDE ONE IN THE ENVELOPE).
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.