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Attributes | |
ACN | 600720 |
Time | |
Date | 200311 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mci.airport |
State Reference | MO |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : takeoff ground : preflight other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 4000 flight time type : 2800 |
ASRS Report | 600720 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 230 flight time total : 3600 flight time type : 2000 |
ASRS Report | 600241 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : landed as precaution flight crew : diverted to another airport other |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
The flight departed mci with an incorrect crew member shown on dispatch release. The crew discovered this error immediately after departure, advised company of necessity to return, and called ATC requesting return to field. Flight landed and returned to gate. Flight was re-dispatched with new release and crew member, and flight continued without incident. This flight had originally been scheduled for both crew members to deadhead, and a separate crew to fly. Crew scheduling had advised us of multiple changes throughout the week. For 3 days prior to this occurrence, we had been reassigned to fly the flight. On nov/thu/03, only the captain was assigned to fly, the involved first officer to deadhead, and the originally scheduled first officer to fly with the newly assigned captain -- confusing, isn't it? These scheduling changes have become daily occurrences (we are told due to understaffing), and for this flight nobody caught the change. Not operations, who printed and distributed the release, not the first officer who was to fly it, and not myself. In addition, the pressures and challenges to stay on-time have been increasing. More utilization of crews and planes means shortened turn-around times, which, if not scheduled responsibly, are impossible to safely accomplish. Additionally point-to-point block times have been shortened to below the 'historic averages' that the union and company recalculate every 6 months. These are tabulated and recorded figures. As a result, flts will run late, they are set up to do so. A conscientious crew desires to operate safely, legally, and on-time. The fact that we were running late, and on a 15 min turn to include fueling, passenger deplaning and boarding, and crew physiological needs (as we are flying a 1900 with no lavatory or beverage service) helped to create a hurried environment. Additionally, operations had notified the crew to contact dispatch. The call was made while affording a quick turnaround of the flight. A hurried environment is bound to be the case from time to time in this industry. However, to set it up and plan it to be so seems irresponsible, and results in an increased factor of human error that could result in something much more serious than not observing an incorrect name on a release.
Original NASA ASRS Text
Title: BE-1900D CREW RETURNED TO THE DEP ARPT WHEN THE FO ON THE FLT WAS NOT THE SAME ONE LISTED ON THE CREW MANIFEST.
Narrative: THE FLT DEPARTED MCI WITH AN INCORRECT CREW MEMBER SHOWN ON DISPATCH RELEASE. THE CREW DISCOVERED THIS ERROR IMMEDIATELY AFTER DEP, ADVISED COMPANY OF NECESSITY TO RETURN, AND CALLED ATC REQUESTING RETURN TO FIELD. FLT LANDED AND RETURNED TO GATE. FLT WAS RE-DISPATCHED WITH NEW RELEASE AND CREW MEMBER, AND FLT CONTINUED WITHOUT INCIDENT. THIS FLT HAD ORIGINALLY BEEN SCHEDULED FOR BOTH CREW MEMBERS TO DEADHEAD, AND A SEPARATE CREW TO FLY. CREW SCHEDULING HAD ADVISED US OF MULTIPLE CHANGES THROUGHOUT THE WK. FOR 3 DAYS PRIOR TO THIS OCCURRENCE, WE HAD BEEN REASSIGNED TO FLY THE FLT. ON NOV/THU/03, ONLY THE CAPT WAS ASSIGNED TO FLY, THE INVOLVED FO TO DEADHEAD, AND THE ORIGINALLY SCHEDULED FO TO FLY WITH THE NEWLY ASSIGNED CAPT -- CONFUSING, ISN'T IT? THESE SCHEDULING CHANGES HAVE BECOME DAILY OCCURRENCES (WE ARE TOLD DUE TO UNDERSTAFFING), AND FOR THIS FLT NOBODY CAUGHT THE CHANGE. NOT OPS, WHO PRINTED AND DISTRIBUTED THE RELEASE, NOT THE FO WHO WAS TO FLY IT, AND NOT MYSELF. IN ADDITION, THE PRESSURES AND CHALLENGES TO STAY ON-TIME HAVE BEEN INCREASING. MORE UTILIZATION OF CREWS AND PLANES MEANS SHORTENED TURN-AROUND TIMES, WHICH, IF NOT SCHEDULED RESPONSIBLY, ARE IMPOSSIBLE TO SAFELY ACCOMPLISH. ADDITIONALLY POINT-TO-POINT BLOCK TIMES HAVE BEEN SHORTENED TO BELOW THE 'HISTORIC AVERAGES' THAT THE UNION AND COMPANY RECALCULATE EVERY 6 MONTHS. THESE ARE TABULATED AND RECORDED FIGURES. AS A RESULT, FLTS WILL RUN LATE, THEY ARE SET UP TO DO SO. A CONSCIENTIOUS CREW DESIRES TO OPERATE SAFELY, LEGALLY, AND ON-TIME. THE FACT THAT WE WERE RUNNING LATE, AND ON A 15 MIN TURN TO INCLUDE FUELING, PAX DEPLANING AND BOARDING, AND CREW PHYSIOLOGICAL NEEDS (AS WE ARE FLYING A 1900 WITH NO LAVATORY OR BEVERAGE SVC) HELPED TO CREATE A HURRIED ENVIRONMENT. ADDITIONALLY, OPS HAD NOTIFIED THE CREW TO CONTACT DISPATCH. THE CALL WAS MADE WHILE AFFORDING A QUICK TURNAROUND OF THE FLT. A HURRIED ENVIRONMENT IS BOUND TO BE THE CASE FROM TIME TO TIME IN THIS INDUSTRY. HOWEVER, TO SET IT UP AND PLAN IT TO BE SO SEEMS IRRESPONSIBLE, AND RESULTS IN AN INCREASED FACTOR OF HUMAN ERROR THAT COULD RESULT IN SOMETHING MUCH MORE SERIOUS THAN NOT OBSERVING AN INCORRECT NAME ON A RELEASE.
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.