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|
Attributes | |
ACN | 601104 |
Time | |
Date | 200311 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : aus.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 189 flight time total : 5812 flight time type : 279 |
ASRS Report | 601104 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 5400 flight time type : 1300 |
ASRS Report | 601522 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
My captain and I operated a flight from aus to ord with the wrong aircraft fleet number on the dispatch release and weight and balance crew work sheet. A classic aviation 'chain of events' occurred to cause this incident to happen. If one person would have broken the chain, it would not have happened. Firstly (as told to us by dispatch and our pilot manager), there were 3 airplanes on the ground for the overnight. A flight crew on a previous departure made the mistake of taking the wrong aircraft for their flight, taking the airplane that we were supposed to have flown, as indicated on our release. Secondly, was that the dispatch release and weight and balance crew work sheet for that flight contained the aircraft number they were supposed to be in, and the operations personnel in austin did not catch that they were in the wrong aircraft. The dispatch release for our flight was generated about 2 hours prior to our actual departure time. It contained the wrong aircraft fleet number on the release. I don't know when the error was discovered in our dispatch office, but by the time we heard about it, it was too late. The dispatch release was given to us by the local (austin) operations, which failed to realize that the release did not match tot sitting on the ramp. The operations/load planner even entered the wrong aircraft fleet number into the weight and balance computer and generated the crew work sheet with the wrong aircraft weight and balance data. By now, all of this had occurred prior to us, as the flight crew, even getting to the airport. As the last morning departure we went to our gate as indicated on the departure monitors, and got on the aircraft. It was the only airplane on the ramp, so we had gotten into the right airplane for our flight to O'hare. It might have been the wrong planned aircraft, but after the initial mistake as described earlier took place, it was still the right aircraft for us. We did our normal preflight duties, loaded the people, took off, and all was well with the world. So we were flying north, enjoying the scenic flight as it was a VFR day. We got a call on commercial radio from our dispatch, to give them a call when we got on the ground concerning 'a minor paperwork problem.' so we were thinking, do we have our certificates? Is the airplane maintenance log on board? Are the airplane documents on board? Is our dispatch release legal, etc. We could not find a 'no' answer to any of those questions. Then the captain realized the mistake. The wrong fleet number was on the dispatch release. I then looked at the performance sheets, the flight navigation log, and the weight and balance crew work sheet. They all contained the wrong aircraft fleet number. The captain got upset with himself as he said he always checks the release for the proper flight number, aircraft fleet number, destination, fuel, etc. He simply overlooked the fleet number, most likely, as we had loaded up the only airplane on the ramp. As the final link, I could have broken the chain. It is my responsibility, as the first officer, to compute the takeoff performance and do the weight and balance per company procedures. If I would have simply looked at the performance pages, navigation log, and weight and balance crew work sheet for the correct fleet number, I would have brought it to the attention of the captain, and we would have called dispatch, got a corrected release, and all would have been well with the world. My only excuse is that we were sitting in the only airplane on the ramp, and got complacent. To remedy the situation, a flight manager pulled us off our last round trip of the day, and had us, as a flight crew, complete 2 hours of additional training. We were asked to answer 4 questions: 1) how many different ways are there to tell the aircraft number? 2) how can flying the wrong aircraft negatively affect the airplane and/or the airline? 3) what are all the items required to be on a dispatch release? 4) how will you adjust your techniques to ensure you fly the correct aircraft in the future? One of the lessons learned is that it is possible to take off or land over the maximum gross weights of the aircraft by simply having the basic operating weight of another airplane. We were heavily loaded, but luckily the weight and balance numbers were allwithin limits. My answer to the 4TH question is how I will, from now on, check the legality of all the paperwork to ensure we are in the correct airplane, in compliance with company procedures: I will verify that the aircraft fleet numbers match the aircraft that we, as a crew, are in by using a pen to circle the flight number, fleet number and other items as I had done while serving as captain at a previous airline. I had gotten out of that habit when I switched back to the right seat when I changed jobs. So from now on, I will ensure I thoroughly review the release, along with the captain, so that this type of situation does not happen again. Supplemental information from acn 601522: we saw that our flight departed from gate xx. We went to the gate and got the aircraft ready for our flight. The operations person brought out our required paperwork and told us that we had a 1 hour ATC delay for our flight to ord. We decided to run and get some breakfast as we had not eaten yet that morning. When we returned to the aircraft, we were then told that the delay had been lifted and we could depart as soon as we were ready. I signed one copy of the release and gave it to the operations agent without doing my usual check of it.
Original NASA ASRS Text
Title: CL65 CREW WAS REMOVED FROM FLT AND ISSUED DISCIPLINARY TRAINING FOR DEPARTING WITH A DIFFERENT ACFT THAN WAS LISTED ON THE FLT RELEASE.
Narrative: MY CAPT AND I OPERATED A FLT FROM AUS TO ORD WITH THE WRONG ACFT FLEET NUMBER ON THE DISPATCH RELEASE AND WT AND BAL CREW WORK SHEET. A CLASSIC AVIATION 'CHAIN OF EVENTS' OCCURRED TO CAUSE THIS INCIDENT TO HAPPEN. IF ONE PERSON WOULD HAVE BROKEN THE CHAIN, IT WOULD NOT HAVE HAPPENED. FIRSTLY (AS TOLD TO US BY DISPATCH AND OUR PLT MGR), THERE WERE 3 AIRPLANES ON THE GND FOR THE OVERNIGHT. A FLT CREW ON A PREVIOUS DEP MADE THE MISTAKE OF TAKING THE WRONG ACFT FOR THEIR FLT, TAKING THE AIRPLANE THAT WE WERE SUPPOSED TO HAVE FLOWN, AS INDICATED ON OUR RELEASE. SECONDLY, WAS THAT THE DISPATCH RELEASE AND WT AND BAL CREW WORK SHEET FOR THAT FLT CONTAINED THE ACFT NUMBER THEY WERE SUPPOSED TO BE IN, AND THE OPS PERSONNEL IN AUSTIN DID NOT CATCH THAT THEY WERE IN THE WRONG ACFT. THE DISPATCH RELEASE FOR OUR FLT WAS GENERATED ABOUT 2 HRS PRIOR TO OUR ACTUAL DEP TIME. IT CONTAINED THE WRONG ACFT FLEET NUMBER ON THE RELEASE. I DON'T KNOW WHEN THE ERROR WAS DISCOVERED IN OUR DISPATCH OFFICE, BUT BY THE TIME WE HEARD ABOUT IT, IT WAS TOO LATE. THE DISPATCH RELEASE WAS GIVEN TO US BY THE LCL (AUSTIN) OPS, WHICH FAILED TO REALIZE THAT THE RELEASE DID NOT MATCH TOT SITTING ON THE RAMP. THE OPS/LOAD PLANNER EVEN ENTERED THE WRONG ACFT FLEET NUMBER INTO THE WT AND BAL COMPUTER AND GENERATED THE CREW WORK SHEET WITH THE WRONG ACFT WT AND BAL DATA. BY NOW, ALL OF THIS HAD OCCURRED PRIOR TO US, AS THE FLT CREW, EVEN GETTING TO THE ARPT. AS THE LAST MORNING DEP WE WENT TO OUR GATE AS INDICATED ON THE DEP MONITORS, AND GOT ON THE ACFT. IT WAS THE ONLY AIRPLANE ON THE RAMP, SO WE HAD GOTTEN INTO THE R AIRPLANE FOR OUR FLT TO O'HARE. IT MIGHT HAVE BEEN THE WRONG PLANNED ACFT, BUT AFTER THE INITIAL MISTAKE AS DESCRIBED EARLIER TOOK PLACE, IT WAS STILL THE RIGHT ACFT FOR US. WE DID OUR NORMAL PREFLT DUTIES, LOADED THE PEOPLE, TOOK OFF, AND ALL WAS WELL WITH THE WORLD. SO WE WERE FLYING N, ENJOYING THE SCENIC FLT AS IT WAS A VFR DAY. WE GOT A CALL ON COMMERCIAL RADIO FROM OUR DISPATCH, TO GIVE THEM A CALL WHEN WE GOT ON THE GND CONCERNING 'A MINOR PAPERWORK PROB.' SO WE WERE THINKING, DO WE HAVE OUR CERTIFICATES? IS THE AIRPLANE MAINT LOG ON BOARD? ARE THE AIRPLANE DOCUMENTS ON BOARD? IS OUR DISPATCH RELEASE LEGAL, ETC. WE COULD NOT FIND A 'NO' ANSWER TO ANY OF THOSE QUESTIONS. THEN THE CAPT REALIZED THE MISTAKE. THE WRONG FLEET NUMBER WAS ON THE DISPATCH RELEASE. I THEN LOOKED AT THE PERFORMANCE SHEETS, THE FLT NAV LOG, AND THE WT AND BAL CREW WORK SHEET. THEY ALL CONTAINED THE WRONG ACFT FLEET NUMBER. THE CAPT GOT UPSET WITH HIMSELF AS HE SAID HE ALWAYS CHKS THE RELEASE FOR THE PROPER FLT NUMBER, ACFT FLEET NUMBER, DEST, FUEL, ETC. HE SIMPLY OVERLOOKED THE FLEET NUMBER, MOST LIKELY, AS WE HAD LOADED UP THE ONLY AIRPLANE ON THE RAMP. AS THE FINAL LINK, I COULD HAVE BROKEN THE CHAIN. IT IS MY RESPONSIBILITY, AS THE FO, TO COMPUTE THE TKOF PERFORMANCE AND DO THE WT AND BAL PER COMPANY PROCS. IF I WOULD HAVE SIMPLY LOOKED AT THE PERFORMANCE PAGES, NAV LOG, AND WT AND BAL CREW WORK SHEET FOR THE CORRECT FLEET NUMBER, I WOULD HAVE BROUGHT IT TO THE ATTN OF THE CAPT, AND WE WOULD HAVE CALLED DISPATCH, GOT A CORRECTED RELEASE, AND ALL WOULD HAVE BEEN WELL WITH THE WORLD. MY ONLY EXCUSE IS THAT WE WERE SITTING IN THE ONLY AIRPLANE ON THE RAMP, AND GOT COMPLACENT. TO REMEDY THE SIT, A FLT MGR PULLED US OFF OUR LAST ROUND TRIP OF THE DAY, AND HAD US, AS A FLT CREW, COMPLETE 2 HRS OF ADDITIONAL TRAINING. WE WERE ASKED TO ANSWER 4 QUESTIONS: 1) HOW MANY DIFFERENT WAYS ARE THERE TO TELL THE ACFT NUMBER? 2) HOW CAN FLYING THE WRONG ACFT NEGATIVELY AFFECT THE AIRPLANE AND/OR THE AIRLINE? 3) WHAT ARE ALL THE ITEMS REQUIRED TO BE ON A DISPATCH RELEASE? 4) HOW WILL YOU ADJUST YOUR TECHNIQUES TO ENSURE YOU FLY THE CORRECT ACFT IN THE FUTURE? ONE OF THE LESSONS LEARNED IS THAT IT IS POSSIBLE TO TAKE OFF OR LAND OVER THE MAX GROSS WTS OF THE ACFT BY SIMPLY HAVING THE BASIC OPERATING WT OF ANOTHER AIRPLANE. WE WERE HEAVILY LOADED, BUT LUCKILY THE WT AND BAL NUMBERS WERE ALLWITHIN LIMITS. MY ANSWER TO THE 4TH QUESTION IS HOW I WILL, FROM NOW ON, CHK THE LEGALITY OF ALL THE PAPERWORK TO ENSURE WE ARE IN THE CORRECT AIRPLANE, IN COMPLIANCE WITH COMPANY PROCS: I WILL VERIFY THAT THE ACFT FLEET NUMBERS MATCH THE ACFT THAT WE, AS A CREW, ARE IN BY USING A PEN TO CIRCLE THE FLT NUMBER, FLEET NUMBER AND OTHER ITEMS AS I HAD DONE WHILE SERVING AS CAPT AT A PREVIOUS AIRLINE. I HAD GOTTEN OUT OF THAT HABIT WHEN I SWITCHED BACK TO THE R SEAT WHEN I CHANGED JOBS. SO FROM NOW ON, I WILL ENSURE I THOROUGHLY REVIEW THE RELEASE, ALONG WITH THE CAPT, SO THAT THIS TYPE OF SIT DOES NOT HAPPEN AGAIN. SUPPLEMENTAL INFO FROM ACN 601522: WE SAW THAT OUR FLT DEPARTED FROM GATE XX. WE WENT TO THE GATE AND GOT THE ACFT READY FOR OUR FLT. THE OPS PERSON BROUGHT OUT OUR REQUIRED PAPERWORK AND TOLD US THAT WE HAD A 1 HR ATC DELAY FOR OUR FLT TO ORD. WE DECIDED TO RUN AND GET SOME BREAKFAST AS WE HAD NOT EATEN YET THAT MORNING. WHEN WE RETURNED TO THE ACFT, WE WERE THEN TOLD THAT THE DELAY HAD BEEN LIFTED AND WE COULD DEPART AS SOON AS WE WERE READY. I SIGNED ONE COPY OF THE RELEASE AND GAVE IT TO THE OPS AGENT WITHOUT DOING MY USUAL CHK OF IT.
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.