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|
Attributes | |
ACN | 592564 |
Time | |
Date | 200309 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : vgzr.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 9000 flight time type : 2000 |
ASRS Report | 592564 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : far other anomaly other |
Independent Detector | other flight crewa other flight crewb other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In dhaka, bangladesh, on a stop-over from madras, india to istanbul, turkey, an oversight occurred regarding the planned versus actual payload. Our flight, already in delay, was being loaded with freight. My crew and I had completed as much of the preflight as possible. I had received the flight plan package and reviewed the information contained in it, which indicated a planned payload of 61 metric tons. 2 hours later, once the loading had been completed. I reviewed the weight and balance sheet which ZZZ representative had prepared. The weight and balance showed a new payload of 87 metric tons. The representative made no mention of the additional 26 metric tons of freight beyond the planned payload to anyone in the crew, nor did I catch this fact on the weight and balance when I looked at it. Flight engineer also checked over the weight and balance and found it to be in order. I completed the data entry into the operations computer, which the first officer had begun, by adding the actual takeoff gross weight and center of gravity from the weight and balance. I printed a takeoff data card from it, which the other 2 crew members doublechked. An uneventful takeoff and departure ensued. Later at cruise, about 1 hour 50 mins into the flight, we received a message via HF radio from dispatch asking us to confirm our payload of 87 metric tons, which had been sent to them previously in our departure message. Naturally, this caught my attention. I then compared the planned payload from the computer flight plan to the actual payload off of the weight and balance sheet and noted the 26 metric ton difference. I asked the flight engineer to roughly calculate how much extra fuel we would burn because of the extra unplanned weight we were carrying. I then reconfirmed that the destination WX was still VMC and forecasted to remain so well after our arrival time. I then initiated a phone patch with dispatch to request that they remove the need for an alternate airport, as we were within 6 hours of our destination on an international flight plan and the WX at the destination was VMC. This would provide the additional fuel necessary to compensate for the extra unanticipated fuel burn. Dispatch then computed the fuel numbers and provided us with a redispatch, enabling us to continue on to our intended destination without incident. Had the representative notified me or had I discovered the additional unexpected payload prior to departure, I would have requested a new computer flight plan from dispatch. However, after this oversight had been discovered, I took an appropriate course of action to ensure the safe completion of this flight. After these events took place, my crew and I discussed the lessons learned from this experience. Breaking this habit pattern allowed the unannounced additional cargo to go unnoticed. The lesson learned here is to doublechk the paperwork lest a particular habit pattern is broken. Moreover, YYY has since published the following 'intam' in an effort to prevent this sort of mistake from recurring by strengthening the procedure. This new procedure provides a method to make crews consciously aware of any large weight differences that may exist between the planned takeoff gross weight and payload compared to the actual ones. Although this event had a positive ending, that being the aircraft reached its intended destination in a safe and timely manner, the lessons learned from this situation have proved to be valuable ones.
Original NASA ASRS Text
Title: B747 CREW HAS OVERSIGHT IN WT CALCULATIONS BY 27 METRIC TONS AND DEPARTS WITHOUT ADJUSTING CALCULATIONS FOR TRIM, FUEL, OR V SPDS.
Narrative: IN DHAKA, BANGLADESH, ON A STOP-OVER FROM MADRAS, INDIA TO ISTANBUL, TURKEY, AN OVERSIGHT OCCURRED REGARDING THE PLANNED VERSUS ACTUAL PAYLOAD. OUR FLT, ALREADY IN DELAY, WAS BEING LOADED WITH FREIGHT. MY CREW AND I HAD COMPLETED AS MUCH OF THE PREFLT AS POSSIBLE. I HAD RECEIVED THE FLT PLAN PACKAGE AND REVIEWED THE INFO CONTAINED IN IT, WHICH INDICATED A PLANNED PAYLOAD OF 61 METRIC TONS. 2 HRS LATER, ONCE THE LOADING HAD BEEN COMPLETED. I REVIEWED THE WT AND BAL SHEET WHICH ZZZ REPRESENTATIVE HAD PREPARED. THE WT AND BAL SHOWED A NEW PAYLOAD OF 87 METRIC TONS. THE REPRESENTATIVE MADE NO MENTION OF THE ADDITIONAL 26 METRIC TONS OF FREIGHT BEYOND THE PLANNED PAYLOAD TO ANYONE IN THE CREW, NOR DID I CATCH THIS FACT ON THE WT AND BAL WHEN I LOOKED AT IT. FE ALSO CHKED OVER THE WT AND BAL AND FOUND IT TO BE IN ORDER. I COMPLETED THE DATA ENTRY INTO THE OPS COMPUTER, WHICH THE FO HAD BEGUN, BY ADDING THE ACTUAL TKOF GROSS WT AND CTR OF GRAVITY FROM THE WT AND BAL. I PRINTED A TKOF DATA CARD FROM IT, WHICH THE OTHER 2 CREW MEMBERS DOUBLECHKED. AN UNEVENTFUL TKOF AND DEP ENSUED. LATER AT CRUISE, ABOUT 1 HR 50 MINS INTO THE FLT, WE RECEIVED A MESSAGE VIA HF RADIO FROM DISPATCH ASKING US TO CONFIRM OUR PAYLOAD OF 87 METRIC TONS, WHICH HAD BEEN SENT TO THEM PREVIOUSLY IN OUR DEP MESSAGE. NATURALLY, THIS CAUGHT MY ATTN. I THEN COMPARED THE PLANNED PAYLOAD FROM THE COMPUTER FLT PLAN TO THE ACTUAL PAYLOAD OFF OF THE WT AND BAL SHEET AND NOTED THE 26 METRIC TON DIFFERENCE. I ASKED THE FE TO ROUGHLY CALCULATE HOW MUCH EXTRA FUEL WE WOULD BURN BECAUSE OF THE EXTRA UNPLANNED WT WE WERE CARRYING. I THEN RECONFIRMED THAT THE DEST WX WAS STILL VMC AND FORECASTED TO REMAIN SO WELL AFTER OUR ARR TIME. I THEN INITIATED A PHONE PATCH WITH DISPATCH TO REQUEST THAT THEY REMOVE THE NEED FOR AN ALTERNATE ARPT, AS WE WERE WITHIN 6 HRS OF OUR DEST ON AN INTL FLT PLAN AND THE WX AT THE DEST WAS VMC. THIS WOULD PROVIDE THE ADDITIONAL FUEL NECESSARY TO COMPENSATE FOR THE EXTRA UNANTICIPATED FUEL BURN. DISPATCH THEN COMPUTED THE FUEL NUMBERS AND PROVIDED US WITH A REDISPATCH, ENABLING US TO CONTINUE ON TO OUR INTENDED DEST WITHOUT INCIDENT. HAD THE REPRESENTATIVE NOTIFIED ME OR HAD I DISCOVERED THE ADDITIONAL UNEXPECTED PAYLOAD PRIOR TO DEP, I WOULD HAVE REQUESTED A NEW COMPUTER FLT PLAN FROM DISPATCH. HOWEVER, AFTER THIS OVERSIGHT HAD BEEN DISCOVERED, I TOOK AN APPROPRIATE COURSE OF ACTION TO ENSURE THE SAFE COMPLETION OF THIS FLT. AFTER THESE EVENTS TOOK PLACE, MY CREW AND I DISCUSSED THE LESSONS LEARNED FROM THIS EXPERIENCE. BREAKING THIS HABIT PATTERN ALLOWED THE UNANNOUNCED ADDITIONAL CARGO TO GO UNNOTICED. THE LESSON LEARNED HERE IS TO DOUBLECHK THE PAPERWORK LEST A PARTICULAR HABIT PATTERN IS BROKEN. MOREOVER, YYY HAS SINCE PUBLISHED THE FOLLOWING 'INTAM' IN AN EFFORT TO PREVENT THIS SORT OF MISTAKE FROM RECURRING BY STRENGTHENING THE PROC. THIS NEW PROC PROVIDES A METHOD TO MAKE CREWS CONSCIOUSLY AWARE OF ANY LARGE WT DIFFERENCES THAT MAY EXIST BTWN THE PLANNED TKOF GROSS WT AND PAYLOAD COMPARED TO THE ACTUAL ONES. ALTHOUGH THIS EVENT HAD A POSITIVE ENDING, THAT BEING THE ACFT REACHED ITS INTENDED DEST IN A SAFE AND TIMELY MANNER, THE LESSONS LEARNED FROM THIS SIT HAVE PROVED TO BE VALUABLE ONES.
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.