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|
Attributes | |
ACN | 533938 |
Time | |
Date | 200112 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : frogo |
State Reference | CA |
Altitude | msl single value : 25000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Ice |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | cruise : level |
Route In Use | departure sid : frogo 6 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 23000 flight time type : 20000 |
ASRS Report | 533938 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : a system low press. lights, lndg gear position lights other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued alert flight crew : returned to original clearance none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Route deviation. We had an unscheduled aircraft change in smf. Assigned aircraft was still being worked on by maintenance when we arrived. The 'a' system engine driven hydraulic pump and a landing gear 'up' were replaced. Finally pushed off the gate 1 hour late. After takeoff, I called for 'gear up,' both 'a' system lights came on and I saw 'a' system pressure drop to zero. A few seconds later, both lights were out, pressure returned to normal and the gear fully retracted. I engaged the autoplt and selected VOR/localizer to join the 090 degree radial from a 120 degree heading. We discussed the situation and decided to continue, feeling that it was a temporary condition caused by air in the hydraulic system due to the maintenance activities. We took out the QRH to assess procedures in case of further 'a' system problems. Due to preoccupation with the problem, I forgot to engage the LNAV and the first officer forgot to change his VOR to the friant radial for the turn at frogo on the departure. Somewhere past frogo, center asked us if we were turning toward friant, which we immediately started. The distraction caused by the hydraulic problem caused a breakdown in procedures by both of us. I forgot to engage the LNAV, the first officer did not turn his course selector and change VOR frequencys for the turn at frogo. A contributing factor for me was the very early check in and a very poor night's sleep.
Original NASA ASRS Text
Title: B737-300 CREW HAD TRACK DEV AFTER BEING DISTRACTED BY ACFT PROBS IN ZOA CLASS A.
Narrative: RTE DEV. WE HAD AN UNSCHEDULED ACFT CHANGE IN SMF. ASSIGNED ACFT WAS STILL BEING WORKED ON BY MAINT WHEN WE ARRIVED. THE 'A' SYS ENG DRIVEN HYD PUMP AND A LNDG GEAR 'UP' WERE REPLACED. FINALLY PUSHED OFF THE GATE 1 HR LATE. AFTER TKOF, I CALLED FOR 'GEAR UP,' BOTH 'A' SYS LIGHTS CAME ON AND I SAW 'A' SYS PRESSURE DROP TO ZERO. A FEW SECONDS LATER, BOTH LIGHTS WERE OUT, PRESSURE RETURNED TO NORMAL AND THE GEAR FULLY RETRACTED. I ENGAGED THE AUTOPLT AND SELECTED VOR/LOC TO JOIN THE 090 DEG RADIAL FROM A 120 DEG HDG. WE DISCUSSED THE SIT AND DECIDED TO CONTINUE, FEELING THAT IT WAS A TEMPORARY CONDITION CAUSED BY AIR IN THE HYD SYS DUE TO THE MAINT ACTIVITIES. WE TOOK OUT THE QRH TO ASSESS PROCS IN CASE OF FURTHER 'A' SYS PROBS. DUE TO PREOCCUPATION WITH THE PROB, I FORGOT TO ENGAGE THE LNAV AND THE FO FORGOT TO CHANGE HIS VOR TO THE FRIANT RADIAL FOR THE TURN AT FROGO ON THE DEP. SOMEWHERE PAST FROGO, CTR ASKED US IF WE WERE TURNING TOWARD FRIANT, WHICH WE IMMEDIATELY STARTED. THE DISTR CAUSED BY THE HYD PROB CAUSED A BREAKDOWN IN PROCS BY BOTH OF US. I FORGOT TO ENGAGE THE LNAV, THE FO DID NOT TURN HIS COURSE SELECTOR AND CHANGE VOR FREQS FOR THE TURN AT FROGO. A CONTRIBUTING FACTOR FOR ME WAS THE VERY EARLY CHK IN AND A VERY POOR NIGHT'S SLEEP.
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.