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Attributes | |
ACN | 587430 |
Time | |
Date | 200307 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bwi.airport |
State Reference | MD |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : cvg.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 250 flight time total : 10500 flight time type : 4500 |
ASRS Report | 587430 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 70 flight time total : 11000 flight time type : 7500 |
ASRS Report | 587283 |
Events | |
Anomaly | aircraft equipment problem : critical cabin event other non adherence : far non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : tkof confign horn |
Resolutory Action | aircraft : equipment problem dissipated controller : issued new clearance flight crew : became reoriented flight crew : rejected takeoff other |
Supplementary | |
Problem Areas | Passenger Human Performance Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
This event occurred on the last leg of the day, second day, of a 4-DAY trip. We were having what I would call a good day. On time, good airplane, decent WX, and pleasant hard-working flight attendants. Then the festivities began: an aircraft swap which put us behind schedule, then a particularly ugly customer service problem involving a 'person of size' who was not at all pleased with the execution of the company ticket policy. This delayed boarding another 15 mins. I would classify the mood in the cockpit at this point as mildly irritated. After pushback and during the course of doing the after start checklist master caution check, the doors light on first officer recall panel would not illuminate. The captain and I attempted to get the light to illuminate using lights test switch, captain's recall panel, rebussing between APU generator and engine generators. Now we've gone from mildly irritated to irritated. We then consulted the MEL for possible dispatch issues. About this time, the problem decided to cure itself. After being off on the master caution tangent for several mins, the fact that our job wasn't finished with the pretkof checklist did not register. I called for taxi, and everything in our world seemed okay until the takeoff confign horn sounded as I advanced the thrust levers for takeoff. Ground speed was zero and I returned the thrust levers to idle and the captain called for taxi off of the runway. We realized that we had allowed the distraction after pushback, to cause us to miss the pre-takeoff checklist and flaps were not extended. We performed the pre-takeoff check and continued the flight uneventfully. After spending a considerable amount of time kicking myself for my part in this breach of procedure, I've been able to look back and find some changes that I can make in the way I run the first officer side of the cockpit that might have prevented this from ever happening. 1) I've been leaving the checklist in its holder, pulling it out for the cleared to start checklist and returning it to the holder. I used to leave it down on the first officer instrument panel until I flew with some capts that didn't like it partially covering the panel. I'm going to now clip the checklist to the first officer yoke until the pre-takeoff checklist is complete. If the checklist is still out of its holder during taxi, I should be asking myself why. 2) I've been leaving the FMC on the takeoff reference page, mainly because that is the last page on which entries (v-spds) are made after computing performance with the opc. This is also the page we use for takeoff. I now plan on selecting the N1 limit page after opc data has been reviewed prior to push. It will be the correct page for the captain to look at during pre-takeoff check N1 indicators check. On the B-700, it would be the page with takeoff derate information. Anything but the takeoff reference page. If I get out to the runway and the FMC is not on the takeoff reference page, maybe we've missed something. Obviously clues left in the cockpit that a checklist has been missed can be easily disposed of. It's too easy to just reach down and select the takeoff reference page, or put the checklist back where it belongs, which brings me to my third suggestion. 3) if the load sheet is sitting in front of the thrust levers covering up the WX radar screaming for some attention, don't just grab it and stow it assuming that you forgot to stow it while running the checklist. It occurred to me some time later that I had done just that. I should have said to myself, 'what the...is this doing here?' finally, the aircraft swap, customer service issue, and the cockpit distraction leading to this event are not an excuse for bad procedure. It's up to me to see when events are stacking up and take measures to make sure I don't get pulled into the twilight zone. Supplemental information from acn 587283: since company has split our operations between the 2 concourses there has been much more traffic in the alley. There is almost always someone waiting to push or taxi to a gate and so we have become used to hustling while in the alley. We had sat in the alley much longer than usual so my internal clock said it was time to get moving and so we did. Once moving we had nothing to cue us to check our confign. My only suggestion would be one we have all heard many times. When you are feeling rushed it's time to slow down.
Original NASA ASRS Text
Title: AN ABORTED TKOF IS PERFORMED AFTER THE TKOF WARNING HORN ALERTS THE B737-300 CREW TO THE FACT THAT THE FLAPS HAVE NOT BEEN EXTENDED FOR TKOF AT BWI, MD.
Narrative: THIS EVENT OCCURRED ON THE LAST LEG OF THE DAY, SECOND DAY, OF A 4-DAY TRIP. WE WERE HAVING WHAT I WOULD CALL A GOOD DAY. ON TIME, GOOD AIRPLANE, DECENT WX, AND PLEASANT HARD-WORKING FLT ATTENDANTS. THEN THE FESTIVITIES BEGAN: AN ACFT SWAP WHICH PUT US BEHIND SCHEDULE, THEN A PARTICULARLY UGLY CUSTOMER SVC PROB INVOLVING A 'PERSON OF SIZE' WHO WAS NOT AT ALL PLEASED WITH THE EXECUTION OF THE COMPANY TICKET POLICY. THIS DELAYED BOARDING ANOTHER 15 MINS. I WOULD CLASSIFY THE MOOD IN THE COCKPIT AT THIS POINT AS MILDLY IRRITATED. AFTER PUSHBACK AND DURING THE COURSE OF DOING THE AFTER START CHKLIST MASTER CAUTION CHK, THE DOORS LIGHT ON FO RECALL PANEL WOULD NOT ILLUMINATE. THE CAPT AND I ATTEMPTED TO GET THE LIGHT TO ILLUMINATE USING LIGHTS TEST SWITCH, CAPT'S RECALL PANEL, REBUSSING BTWN APU GENERATOR AND ENG GENERATORS. NOW WE'VE GONE FROM MILDLY IRRITATED TO IRRITATED. WE THEN CONSULTED THE MEL FOR POSSIBLE DISPATCH ISSUES. ABOUT THIS TIME, THE PROB DECIDED TO CURE ITSELF. AFTER BEING OFF ON THE MASTER CAUTION TANGENT FOR SEVERAL MINS, THE FACT THAT OUR JOB WASN'T FINISHED WITH THE PRETKOF CHKLIST DID NOT REGISTER. I CALLED FOR TAXI, AND EVERYTHING IN OUR WORLD SEEMED OKAY UNTIL THE TKOF CONFIGN HORN SOUNDED AS I ADVANCED THE THRUST LEVERS FOR TKOF. GND SPD WAS ZERO AND I RETURNED THE THRUST LEVERS TO IDLE AND THE CAPT CALLED FOR TAXI OFF OF THE RWY. WE REALIZED THAT WE HAD ALLOWED THE DISTR AFTER PUSHBACK, TO CAUSE US TO MISS THE PRE-TKOF CHKLIST AND FLAPS WERE NOT EXTENDED. WE PERFORMED THE PRE-TKOF CHK AND CONTINUED THE FLT UNEVENTFULLY. AFTER SPENDING A CONSIDERABLE AMOUNT OF TIME KICKING MYSELF FOR MY PART IN THIS BREACH OF PROC, I'VE BEEN ABLE TO LOOK BACK AND FIND SOME CHANGES THAT I CAN MAKE IN THE WAY I RUN THE FO SIDE OF THE COCKPIT THAT MIGHT HAVE PREVENTED THIS FROM EVER HAPPENING. 1) I'VE BEEN LEAVING THE CHKLIST IN ITS HOLDER, PULLING IT OUT FOR THE CLRED TO START CHKLIST AND RETURNING IT TO THE HOLDER. I USED TO LEAVE IT DOWN ON THE FO INST PANEL UNTIL I FLEW WITH SOME CAPTS THAT DIDN'T LIKE IT PARTIALLY COVERING THE PANEL. I'M GOING TO NOW CLIP THE CHKLIST TO THE FO YOKE UNTIL THE PRE-TKOF CHKLIST IS COMPLETE. IF THE CHKLIST IS STILL OUT OF ITS HOLDER DURING TAXI, I SHOULD BE ASKING MYSELF WHY. 2) I'VE BEEN LEAVING THE FMC ON THE TKOF REF PAGE, MAINLY BECAUSE THAT IS THE LAST PAGE ON WHICH ENTRIES (V-SPDS) ARE MADE AFTER COMPUTING PERFORMANCE WITH THE OPC. THIS IS ALSO THE PAGE WE USE FOR TKOF. I NOW PLAN ON SELECTING THE N1 LIMIT PAGE AFTER OPC DATA HAS BEEN REVIEWED PRIOR TO PUSH. IT WILL BE THE CORRECT PAGE FOR THE CAPT TO LOOK AT DURING PRE-TKOF CHK N1 INDICATORS CHK. ON THE B-700, IT WOULD BE THE PAGE WITH TKOF DERATE INFO. ANYTHING BUT THE TKOF REF PAGE. IF I GET OUT TO THE RWY AND THE FMC IS NOT ON THE TKOF REF PAGE, MAYBE WE'VE MISSED SOMETHING. OBVIOUSLY CLUES LEFT IN THE COCKPIT THAT A CHKLIST HAS BEEN MISSED CAN BE EASILY DISPOSED OF. IT'S TOO EASY TO JUST REACH DOWN AND SELECT THE TKOF REF PAGE, OR PUT THE CHKLIST BACK WHERE IT BELONGS, WHICH BRINGS ME TO MY THIRD SUGGESTION. 3) IF THE LOAD SHEET IS SITTING IN FRONT OF THE THRUST LEVERS COVERING UP THE WX RADAR SCREAMING FOR SOME ATTN, DON'T JUST GRAB IT AND STOW IT ASSUMING THAT YOU FORGOT TO STOW IT WHILE RUNNING THE CHKLIST. IT OCCURRED TO ME SOME TIME LATER THAT I HAD DONE JUST THAT. I SHOULD HAVE SAID TO MYSELF, 'WHAT THE...IS THIS DOING HERE?' FINALLY, THE ACFT SWAP, CUSTOMER SVC ISSUE, AND THE COCKPIT DISTR LEADING TO THIS EVENT ARE NOT AN EXCUSE FOR BAD PROC. IT'S UP TO ME TO SEE WHEN EVENTS ARE STACKING UP AND TAKE MEASURES TO MAKE SURE I DON'T GET PULLED INTO THE TWILIGHT ZONE. SUPPLEMENTAL INFO FROM ACN 587283: SINCE COMPANY HAS SPLIT OUR OPS BTWN THE 2 CONCOURSES THERE HAS BEEN MUCH MORE TFC IN THE ALLEY. THERE IS ALMOST ALWAYS SOMEONE WAITING TO PUSH OR TAXI TO A GATE AND SO WE HAVE BECOME USED TO HUSTLING WHILE IN THE ALLEY. WE HAD SAT IN THE ALLEY MUCH LONGER THAN USUAL SO MY INTERNAL CLOCK SAID IT WAS TIME TO GET MOVING AND SO WE DID. ONCE MOVING WE HAD NOTHING TO CUE US TO CHK OUR CONFIGN. MY ONLY SUGGESTION WOULD BE ONE WE HAVE ALL HEARD MANY TIMES. WHEN YOU ARE FEELING RUSHED IT'S TIME TO SLOW DOWN.
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.