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Attributes | |
ACN | 539666 |
Time | |
Date | 200203 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : stl.airport |
State Reference | MO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : stl.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 12500 flight time type : 800 |
ASRS Report | 539666 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 120 flight time total : 6500 flight time type : 2000 |
ASRS Report | 539851 |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : far other anomaly other |
Independent Detector | other other : 7 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Airport |
Primary Problem | Flight Crew Human Performance |
Narrative:
While operating a scheduled airline flight from stl to dtw, I inadvertently took off without obtaining a final weight closeout slip. The first event in this chain was being informed, just before departure, that the agent could not input our final passenger count into the computer system because of a technical problem. Because of the delay with the final closeout weight slip, ground had us pull out of the departure sequence. The load agent informed us that he would have to wait for the computer entered passenger count so that the computer system could reconcile passenger information with passenger checked bags. This is done out of concern for flight security. The first officer told the load agent that he would monitor his frequency. While the first officer was doing this, I decided to call up and print a new takeoff performance slip via the ACARS system. A min or 2 went by and then I heard the ACARS printer run. The first officer told the load agent that the numbers were printing and thanked him signing off. We set the aircraft stabilizer trim based on the data, checked the gross weight against the maximum takeoff weight and then completed our checklists. After informing ATC, we made a normal takeoff and departure. After landing at dtw, a company agent told me that my dispatcher needed me to call and speak to him. He informed me that the load control supervisor had called and informed him that I had departed before the computer security reconciliation was completed. After conferring with the first officer and looking through my flight paperwork, I discovered that I had mistaken the computer takeoff data slip (the new one I had requested) with the official load closeout slip. Realizing my error, I informed my company duty manager about what had occurred. Since the takeoff performance data was generated after the load agent had entered the passenger count we provided, the gross weight and center of gravity were correct for our takeoff. The official closeout weight slip had not printed because the passenger/baggage reconciliation was not complete. This caused a violation of new security procedures. Contributing to this incident was the recent purchase of my airline by another, larger carrier. We recently switched to this new company's computerized weight and balance, and takeoff performance system. The takeoff performance slip and the weight and balance closeout slip are similar in appearance, and when the printer started, the first officer and I mistakenly assumed that this was the final weight slip that we were waiting for. We saw what we expected to see. In the future, I will not fall into the trap of assuming that certain actions will always result in the expected results.
Original NASA ASRS Text
Title: AN MD80 CREW DEPARTED STL WITHOUT PROPER DOCUMENTATION OF PAX COUNT VERSUS PAX CHKED BAGS.
Narrative: WHILE OPERATING A SCHEDULED AIRLINE FLT FROM STL TO DTW, I INADVERTENTLY TOOK OFF WITHOUT OBTAINING A FINAL WT CLOSEOUT SLIP. THE FIRST EVENT IN THIS CHAIN WAS BEING INFORMED, JUST BEFORE DEP, THAT THE AGENT COULD NOT INPUT OUR FINAL PAX COUNT INTO THE COMPUTER SYS BECAUSE OF A TECHNICAL PROB. BECAUSE OF THE DELAY WITH THE FINAL CLOSEOUT WT SLIP, GND HAD US PULL OUT OF THE DEP SEQUENCE. THE LOAD AGENT INFORMED US THAT HE WOULD HAVE TO WAIT FOR THE COMPUTER ENTERED PAX COUNT SO THAT THE COMPUTER SYS COULD RECONCILE PAX INFO WITH PAX CHKED BAGS. THIS IS DONE OUT OF CONCERN FOR FLT SECURITY. THE FO TOLD THE LOAD AGENT THAT HE WOULD MONITOR HIS FREQ. WHILE THE FO WAS DOING THIS, I DECIDED TO CALL UP AND PRINT A NEW TKOF PERFORMANCE SLIP VIA THE ACARS SYS. A MIN OR 2 WENT BY AND THEN I HEARD THE ACARS PRINTER RUN. THE FO TOLD THE LOAD AGENT THAT THE NUMBERS WERE PRINTING AND THANKED HIM SIGNING OFF. WE SET THE ACFT STABILIZER TRIM BASED ON THE DATA, CHKED THE GROSS WT AGAINST THE MAX TKOF WT AND THEN COMPLETED OUR CHKLISTS. AFTER INFORMING ATC, WE MADE A NORMAL TKOF AND DEP. AFTER LNDG AT DTW, A COMPANY AGENT TOLD ME THAT MY DISPATCHER NEEDED ME TO CALL AND SPEAK TO HIM. HE INFORMED ME THAT THE LOAD CTL SUPVR HAD CALLED AND INFORMED HIM THAT I HAD DEPARTED BEFORE THE COMPUTER SECURITY RECONCILIATION WAS COMPLETED. AFTER CONFERRING WITH THE FO AND LOOKING THROUGH MY FLT PAPERWORK, I DISCOVERED THAT I HAD MISTAKEN THE COMPUTER TKOF DATA SLIP (THE NEW ONE I HAD REQUESTED) WITH THE OFFICIAL LOAD CLOSEOUT SLIP. REALIZING MY ERROR, I INFORMED MY COMPANY DUTY MGR ABOUT WHAT HAD OCCURRED. SINCE THE TKOF PERFORMANCE DATA WAS GENERATED AFTER THE LOAD AGENT HAD ENTERED THE PAX COUNT WE PROVIDED, THE GROSS WT AND CTR OF GRAVITY WERE CORRECT FOR OUR TKOF. THE OFFICIAL CLOSEOUT WT SLIP HAD NOT PRINTED BECAUSE THE PAX/BAGGAGE RECONCILIATION WAS NOT COMPLETE. THIS CAUSED A VIOLATION OF NEW SECURITY PROCS. CONTRIBUTING TO THIS INCIDENT WAS THE RECENT PURCHASE OF MY AIRLINE BY ANOTHER, LARGER CARRIER. WE RECENTLY SWITCHED TO THIS NEW COMPANY'S COMPUTERIZED WT AND BAL, AND TKOF PERFORMANCE SYS. THE TKOF PERFORMANCE SLIP AND THE WT AND BAL CLOSEOUT SLIP ARE SIMILAR IN APPEARANCE, AND WHEN THE PRINTER STARTED, THE FO AND I MISTAKENLY ASSUMED THAT THIS WAS THE FINAL WT SLIP THAT WE WERE WAITING FOR. WE SAW WHAT WE EXPECTED TO SEE. IN THE FUTURE, I WILL NOT FALL INTO THE TRAP OF ASSUMING THAT CERTAIN ACTIONS WILL ALWAYS RESULT IN THE EXPECTED RESULTS.
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.