Narrative:

Flaps not set, ensuing takeoff warning horn. As we pushed back, I noticed a lengthy line of aircraft waiting for takeoff at our anticipated runway, which was just a short distance behind us. We were pushed well clear of the ramp, so I made a decision to just taxi the short distance on 1 engine, instead of 2 and then shutting the engine back off. The primary reason was not to start an engine for 2 or 3 mins and then shut it back down. This break in our normal flow was distractive enough that I didn't call for flaps. Ground control then assigned us a different, distant runway (runway 18L) with more complicated than normal instructions. I elected to continue with the 1 engine taxi. As we were already moving, we held short as instructed of the inner parallel for aircraft in line there. Then ground instructed us to go to the outer parallel and continue to the end. Still anticipating a wait at the end, I continued taxiing on 1 engine. During the taxi, we continually evaluated the heavy rain showers we would encounter on our departure to the west. We stopped at the end of the parallel and ground sent us to tower. Tower told us to pull up #1. We started #1 engine and with rollback, I started moving immediately to #1, fearing delay might make ATC change their mind about us being next. Again, the break in flow resulted in not calling for takeoff flaps. We continued scanning the WX as we moved ahead and turned, running the checklist. The combination of doing these things resulted in passing through the flaps item on the checklist without confirming their position. We were cleared for departure and as I pushed the throttle up we got 2 chirps from the takeoff warning horn before I instinctively pulled the power back. My training was to stop, exit, and taxi back. As I looked down the runway, I saw the 11000 ft marker and remembered we had a 4000+ stopping margin. I called for flaps 5 degrees allowing the aircraft to continue forward. When they were stopped at flaps 5 degrees, I confirmed the green light and pushed the power to takeoff thrust and called for 'takeoff thrust.' the hesitancy in the voice of the first officer as she stated set made me realize that was a very bad decision. I made it based on not wanting to add further delay, perhaps being resequenced behind other aircraft and having so much runway ahead and stopping margin. All these factors were wrong reasons and I truly wished I had followed my training. By the time this went through my head, the first officer called '90 KTS.' I cannot state enough my regret over this decision. I violated company procedures by not exiting, reconfiguring and reaccomplishing the checklist. I broke trust with the first officer by not following procedures. I continued the takeoff because I felt it was the safest course of action at that moment. The takeoff was normal from that point forward. A major contributing factor was my decision not to start both engines at the terminal. A normal flow would have followed, without analyzing air conditioning pack confign, etc. A safety net was removed. Another major contributing factor was moving forward to #1 while looking at departure WX and accomplishing the checklist (flaps were missed). Another safety net was removed. The final major contributing factor was my 'orientation' of not wanting to take any additional delay. Wrong thinking. Corrective actions and lessons: always do it the same way. Take time with the checklist, at the most taxiing while accomplishing it and not being distraction by other things. Don't let 'self imposed' pressures override what I know is right. The first officer and I debriefed this extensively since the event. I placed the first officer in a difficult position. When she expected an 'abort' call on my part, I called 'flaps 5 degrees.' still waiting for the abort call, I unexpectedly pushed the throttles up and called for 'takeoff thrust.' even in hindsight, she made responsible decisions with the sits as they occurred. My apologies are not enough to her or to the company. Supplemental information from can 519285: the event of being in position and hold without the flaps at 5 degrees happened due to many interruptions from the pushback, taxi to position and hold.we taxied out on 1 engine expecting a long delay. This interrupted our flow. Ground called after the #2 engine was started and I stated 'after start checklist complete.' I always place my hand on the flap handle to remind me. Ground called at that time with new taxi instructions and we both missed the flaps. On the takeoff roll, we got the horn, which was a surprise and I first looked at the speed brake and then the flaps. When the flaps were at 5 degrees, the captain unexpectedly pushed the power up and called for takeoff thrust. In a matter of seconds, I was expecting an abort call. So I went from the abort mode to the go mode. My thoughts were, it's a 12000 ft runway with a 4519 ft stopping margin, so it would be a safe takeoff. In my mind the safest course of action was to continue. I continued to make my callouts and called 10 KTS, the flaps were at 5 degrees and the power set. We completed a safe takeoff and departure. In hindsight, we should have aborted and reconfigured for another takeoff. I was not rushed but more than usual radio calls and taxiing out on 1 engine were contributing factors. I feel terrible that I missed the flaps and never looked at them because I always do. The captain apologized to me for putting me in that position. We have debriefed the event and learned a lesson. The captain routinely makes excellent decisions, judgements, and is standardized. This event is an aberration.

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Original NASA ASRS Text

Title: B737-300 CREW HAD TKOF WARNING HORN SOUND AT THRUST APPLICATION BECAUSE THEY FORGOT TO SET THE FLAPS.

Narrative: FLAPS NOT SET, ENSUING TKOF WARNING HORN. AS WE PUSHED BACK, I NOTICED A LENGTHY LINE OF ACFT WAITING FOR TKOF AT OUR ANTICIPATED RWY, WHICH WAS JUST A SHORT DISTANCE BEHIND US. WE WERE PUSHED WELL CLR OF THE RAMP, SO I MADE A DECISION TO JUST TAXI THE SHORT DISTANCE ON 1 ENG, INSTEAD OF 2 AND THEN SHUTTING THE ENG BACK OFF. THE PRIMARY REASON WAS NOT TO START AN ENG FOR 2 OR 3 MINS AND THEN SHUT IT BACK DOWN. THIS BREAK IN OUR NORMAL FLOW WAS DISTRACTIVE ENOUGH THAT I DIDN'T CALL FOR FLAPS. GND CTL THEN ASSIGNED US A DIFFERENT, DISTANT RWY (RWY 18L) WITH MORE COMPLICATED THAN NORMAL INSTRUCTIONS. I ELECTED TO CONTINUE WITH THE 1 ENG TAXI. AS WE WERE ALREADY MOVING, WE HELD SHORT AS INSTRUCTED OF THE INNER PARALLEL FOR ACFT IN LINE THERE. THEN GND INSTRUCTED US TO GO TO THE OUTER PARALLEL AND CONTINUE TO THE END. STILL ANTICIPATING A WAIT AT THE END, I CONTINUED TAXIING ON 1 ENG. DURING THE TAXI, WE CONTINUALLY EVALUATED THE HVY RAIN SHOWERS WE WOULD ENCOUNTER ON OUR DEP TO THE W. WE STOPPED AT THE END OF THE PARALLEL AND GND SENT US TO TWR. TWR TOLD US TO PULL UP #1. WE STARTED #1 ENG AND WITH ROLLBACK, I STARTED MOVING IMMEDIATELY TO #1, FEARING DELAY MIGHT MAKE ATC CHANGE THEIR MIND ABOUT US BEING NEXT. AGAIN, THE BREAK IN FLOW RESULTED IN NOT CALLING FOR TKOF FLAPS. WE CONTINUED SCANNING THE WX AS WE MOVED AHEAD AND TURNED, RUNNING THE CHKLIST. THE COMBINATION OF DOING THESE THINGS RESULTED IN PASSING THROUGH THE FLAPS ITEM ON THE CHKLIST WITHOUT CONFIRMING THEIR POS. WE WERE CLRED FOR DEP AND AS I PUSHED THE THROTTLE UP WE GOT 2 CHIRPS FROM THE TKOF WARNING HORN BEFORE I INSTINCTIVELY PULLED THE PWR BACK. MY TRAINING WAS TO STOP, EXIT, AND TAXI BACK. AS I LOOKED DOWN THE RWY, I SAW THE 11000 FT MARKER AND REMEMBERED WE HAD A 4000+ STOPPING MARGIN. I CALLED FOR FLAPS 5 DEGS ALLOWING THE ACFT TO CONTINUE FORWARD. WHEN THEY WERE STOPPED AT FLAPS 5 DEGS, I CONFIRMED THE GREEN LIGHT AND PUSHED THE PWR TO TKOF THRUST AND CALLED FOR 'TKOF THRUST.' THE HESITANCY IN THE VOICE OF THE FO AS SHE STATED SET MADE ME REALIZE THAT WAS A VERY BAD DECISION. I MADE IT BASED ON NOT WANTING TO ADD FURTHER DELAY, PERHAPS BEING RESEQUENCED BEHIND OTHER ACFT AND HAVING SO MUCH RWY AHEAD AND STOPPING MARGIN. ALL THESE FACTORS WERE WRONG REASONS AND I TRULY WISHED I HAD FOLLOWED MY TRAINING. BY THE TIME THIS WENT THROUGH MY HEAD, THE FO CALLED '90 KTS.' I CANNOT STATE ENOUGH MY REGRET OVER THIS DECISION. I VIOLATED COMPANY PROCS BY NOT EXITING, RECONFIGURING AND REACCOMPLISHING THE CHKLIST. I BROKE TRUST WITH THE FO BY NOT FOLLOWING PROCS. I CONTINUED THE TKOF BECAUSE I FELT IT WAS THE SAFEST COURSE OF ACTION AT THAT MOMENT. THE TKOF WAS NORMAL FROM THAT POINT FORWARD. A MAJOR CONTRIBUTING FACTOR WAS MY DECISION NOT TO START BOTH ENGS AT THE TERMINAL. A NORMAL FLOW WOULD HAVE FOLLOWED, WITHOUT ANALYZING AIR CONDITIONING PACK CONFIGN, ETC. A SAFETY NET WAS REMOVED. ANOTHER MAJOR CONTRIBUTING FACTOR WAS MOVING FORWARD TO #1 WHILE LOOKING AT DEP WX AND ACCOMPLISHING THE CHKLIST (FLAPS WERE MISSED). ANOTHER SAFETY NET WAS REMOVED. THE FINAL MAJOR CONTRIBUTING FACTOR WAS MY 'ORIENTATION' OF NOT WANTING TO TAKE ANY ADDITIONAL DELAY. WRONG THINKING. CORRECTIVE ACTIONS AND LESSONS: ALWAYS DO IT THE SAME WAY. TAKE TIME WITH THE CHKLIST, AT THE MOST TAXIING WHILE ACCOMPLISHING IT AND NOT BEING DISTR BY OTHER THINGS. DON'T LET 'SELF IMPOSED' PRESSURES OVERRIDE WHAT I KNOW IS RIGHT. THE FIRST OFFICER AND I DEBRIEFED THIS EXTENSIVELY SINCE THE EVENT. I PLACED THE FO IN A DIFFICULT POS. WHEN SHE EXPECTED AN 'ABORT' CALL ON MY PART, I CALLED 'FLAPS 5 DEGS.' STILL WAITING FOR THE ABORT CALL, I UNEXPECTEDLY PUSHED THE THROTTLES UP AND CALLED FOR 'TKOF THRUST.' EVEN IN HINDSIGHT, SHE MADE RESPONSIBLE DECISIONS WITH THE SITS AS THEY OCCURRED. MY APOLOGIES ARE NOT ENOUGH TO HER OR TO THE COMPANY. SUPPLEMENTAL INFO FROM CAN 519285: THE EVENT OF BEING IN POS AND HOLD WITHOUT THE FLAPS AT 5 DEGS HAPPENED DUE TO MANY INTERRUPTIONS FROM THE PUSHBACK, TAXI TO POS AND HOLD.WE TAXIED OUT ON 1 ENG EXPECTING A LONG DELAY. THIS INTERRUPTED OUR FLOW. GND CALLED AFTER THE #2 ENG WAS STARTED AND I STATED 'AFTER START CHKLIST COMPLETE.' I ALWAYS PLACE MY HAND ON THE FLAP HANDLE TO REMIND ME. GND CALLED AT THAT TIME WITH NEW TAXI INSTRUCTIONS AND WE BOTH MISSED THE FLAPS. ON THE TKOF ROLL, WE GOT THE HORN, WHICH WAS A SURPRISE AND I FIRST LOOKED AT THE SPD BRAKE AND THEN THE FLAPS. WHEN THE FLAPS WERE AT 5 DEGS, THE CAPT UNEXPECTEDLY PUSHED THE PWR UP AND CALLED FOR TKOF THRUST. IN A MATTER OF SECONDS, I WAS EXPECTING AN ABORT CALL. SO I WENT FROM THE ABORT MODE TO THE GO MODE. MY THOUGHTS WERE, IT'S A 12000 FT RWY WITH A 4519 FT STOPPING MARGIN, SO IT WOULD BE A SAFE TKOF. IN MY MIND THE SAFEST COURSE OF ACTION WAS TO CONTINUE. I CONTINUED TO MAKE MY CALLOUTS AND CALLED 10 KTS, THE FLAPS WERE AT 5 DEGS AND THE PWR SET. WE COMPLETED A SAFE TKOF AND DEP. IN HINDSIGHT, WE SHOULD HAVE ABORTED AND RECONFIGURED FOR ANOTHER TKOF. I WAS NOT RUSHED BUT MORE THAN USUAL RADIO CALLS AND TAXIING OUT ON 1 ENG WERE CONTRIBUTING FACTORS. I FEEL TERRIBLE THAT I MISSED THE FLAPS AND NEVER LOOKED AT THEM BECAUSE I ALWAYS DO. THE CAPT APOLOGIZED TO ME FOR PUTTING ME IN THAT POS. WE HAVE DEBRIEFED THE EVENT AND LEARNED A LESSON. THE CAPT ROUTINELY MAKES EXCELLENT DECISIONS, JUDGEMENTS, AND IS STANDARDIZED. THIS EVENT IS AN ABERRATION.

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.