37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 625181 |
Time | |
Date | 200402 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : geg.airport |
State Reference | WA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 225 flight time total : 8500 flight time type : 5000 |
ASRS Report | 625181 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 200 flight time total : 11000 flight time type : 2500 |
ASRS Report | 625620 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : tkof warning system |
Resolutory Action | flight crew : rejected takeoff |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
A takeoff was attempted by the first officer from runway 7 with the improper confign for takeoff (no flaps were extended). Upon hearing the takeoff warning horn, I immediately initiated a rejection at approximately 10 KTS. Contributing factors: ground control informed us of a 25 min delay required for takeoff on runway 25, however, if we wanted runway 7 it would be available with a 7 KT tailwind. We told the controller we would have to get back to him, since we were full/heavy and the tailwind might be a factor. We were asked to inform the controller as soon as possible, so he could build a hole for us. The reason runway 25 was unavailable was due to a special event at fairchild AFB (5 mi away). The radio call from the ground controller came just after the first officer called 'standing by flaps.' I asked the first officer to hold off on selecting the flaps until we determined which, if any, flap setting and bleed confign would work off of runway 7. (Broken habit pattern!) he computed the data in the performance computer and we determined it was possible with flaps 5 degrees and bleeds off. I asked the first officer to relay this to the ground controller, as we were 45 mins behind schedule and he wanted to know as soon as possible. The first officer informed the ground controller, whose response was 'roger, you are cleared to taxi to runway 7.' getting caught up in the moment, we began to taxi without the first officer stating 'standing by flaps' a second time. In our minds we had already accomplished the before taxi checklist since we were given taxi clearance. (We don't call for taxi until this checklist is complete.) in our minds we simply fast forwarded past the before taxi checklist and complied with the taxi instructions. The event was just off of the final approach to runway 7. We were both so mesmerized by the show that I failed to check the takeoff warning horn after ringing the flight attendants and performing the before takeoff checklist. The rest is history. My humble apologies with much learned about the human factors side of checklist usage. Supplemental information from acn 625620: we informed the tower of the aborted takeoff and were told we could do a 180 degree turn on the runway and taxi back for departure, since there was no arriving traffic. We did so and completed the appropriate checklist: before taxi, and before takeoff, set the correct flaps setting, and accomplished the takeoff without any further complications. Lesson learned: don't be in a hurry! Watch for breaks in the 'normal' chain of events. Be sure you have accomplished all the appropriate checklists during each phase of operation! Do not become distraction with outside influences that do not pertain to the safety of flight. Back up the captain and make sure all checks are being accomplished. And, my own personal habit will be from now on to doublechk flaps, trim speed and autobrake settings prior to each and every takeoff.
Original NASA ASRS Text
Title: A B737 FLT CREW BECOMES DISTR AND FORGETS TO SET THE FLAPS FOR TKOF RESULTING IN AN ABORTED TKOF.
Narrative: A TKOF WAS ATTEMPTED BY THE FO FROM RWY 7 WITH THE IMPROPER CONFIGN FOR TKOF (NO FLAPS WERE EXTENDED). UPON HEARING THE TKOF WARNING HORN, I IMMEDIATELY INITIATED A REJECTION AT APPROX 10 KTS. CONTRIBUTING FACTORS: GND CTL INFORMED US OF A 25 MIN DELAY REQUIRED FOR TKOF ON RWY 25, HOWEVER, IF WE WANTED RWY 7 IT WOULD BE AVAILABLE WITH A 7 KT TAILWIND. WE TOLD THE CTLR WE WOULD HAVE TO GET BACK TO HIM, SINCE WE WERE FULL/HVY AND THE TAILWIND MIGHT BE A FACTOR. WE WERE ASKED TO INFORM THE CTLR ASAP, SO HE COULD BUILD A HOLE FOR US. THE REASON RWY 25 WAS UNAVAILABLE WAS DUE TO A SPECIAL EVENT AT FAIRCHILD AFB (5 MI AWAY). THE RADIO CALL FROM THE GND CTLR CAME JUST AFTER THE FO CALLED 'STANDING BY FLAPS.' I ASKED THE FO TO HOLD OFF ON SELECTING THE FLAPS UNTIL WE DETERMINED WHICH, IF ANY, FLAP SETTING AND BLEED CONFIGN WOULD WORK OFF OF RWY 7. (BROKEN HABIT PATTERN!) HE COMPUTED THE DATA IN THE PERFORMANCE COMPUTER AND WE DETERMINED IT WAS POSSIBLE WITH FLAPS 5 DEGS AND BLEEDS OFF. I ASKED THE FO TO RELAY THIS TO THE GND CTLR, AS WE WERE 45 MINS BEHIND SCHEDULE AND HE WANTED TO KNOW ASAP. THE FO INFORMED THE GND CTLR, WHOSE RESPONSE WAS 'ROGER, YOU ARE CLRED TO TAXI TO RWY 7.' GETTING CAUGHT UP IN THE MOMENT, WE BEGAN TO TAXI WITHOUT THE FO STATING 'STANDING BY FLAPS' A SECOND TIME. IN OUR MINDS WE HAD ALREADY ACCOMPLISHED THE BEFORE TAXI CHKLIST SINCE WE WERE GIVEN TAXI CLRNC. (WE DON'T CALL FOR TAXI UNTIL THIS CHKLIST IS COMPLETE.) IN OUR MINDS WE SIMPLY FAST FORWARDED PAST THE BEFORE TAXI CHKLIST AND COMPLIED WITH THE TAXI INSTRUCTIONS. THE EVENT WAS JUST OFF OF THE FINAL APCH TO RWY 7. WE WERE BOTH SO MESMERIZED BY THE SHOW THAT I FAILED TO CHK THE TKOF WARNING HORN AFTER RINGING THE FLT ATTENDANTS AND PERFORMING THE BEFORE TKOF CHKLIST. THE REST IS HISTORY. MY HUMBLE APOLOGIES WITH MUCH LEARNED ABOUT THE HUMAN FACTORS SIDE OF CHKLIST USAGE. SUPPLEMENTAL INFO FROM ACN 625620: WE INFORMED THE TWR OF THE ABORTED TKOF AND WERE TOLD WE COULD DO A 180 DEG TURN ON THE RWY AND TAXI BACK FOR DEP, SINCE THERE WAS NO ARRIVING TFC. WE DID SO AND COMPLETED THE APPROPRIATE CHKLIST: BEFORE TAXI, AND BEFORE TKOF, SET THE CORRECT FLAPS SETTING, AND ACCOMPLISHED THE TKOF WITHOUT ANY FURTHER COMPLICATIONS. LESSON LEARNED: DON'T BE IN A HURRY! WATCH FOR BREAKS IN THE 'NORMAL' CHAIN OF EVENTS. BE SURE YOU HAVE ACCOMPLISHED ALL THE APPROPRIATE CHKLISTS DURING EACH PHASE OF OP! DO NOT BECOME DISTR WITH OUTSIDE INFLUENCES THAT DO NOT PERTAIN TO THE SAFETY OF FLT. BACK UP THE CAPT AND MAKE SURE ALL CHKS ARE BEING ACCOMPLISHED. AND, MY OWN PERSONAL HABIT WILL BE FROM NOW ON TO DOUBLECHK FLAPS, TRIM SPD AND AUTOBRAKE SETTINGS PRIOR TO EACH AND EVERY TKOF.
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.