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Attributes | |
ACN | 628397 |
Time | |
Date | 200408 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : rno.airport |
State Reference | NV |
Altitude | msl single value : 8000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : rno.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial climbout : takeoff |
Route In Use | departure sid : mustang |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 220 flight time total : 7500 flight time type : 2500 |
ASRS Report | 628397 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 300 flight time total : 15000 flight time type : 10000 |
ASRS Report | 628028 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : published procedure other anomaly other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : returned to original clearance flight crew : became reoriented other |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | ATC Human Performance Aircraft Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Fmg.6 departure off runway 16R at rno. Crew failed to initiate turn at 3 DME fix in compliance with SID procedure. Last min MEL interrupted checklist and inadequate departure/NAVAID briefing by the captain was a result. On initial climb out, PF was confused on turnout procedures and began a dialogue with pilot monitoring, and then with ATC to resolve his confusion. He had the single engine emergency procedure on his yoke plate and was convinced he needed to continue straight ahead on the departure. During this brief period of confusion, aircraft accelerated to 250 KIAS and blew through the 3 DME fix before a left turn was initiated. PF continued dialogue with ATC and it was evident that they were frustrated with company crews deviating on this departure on a regular basis. Contributing factors: poor, non-standard briefing techniques. I will not proceed to the before push checklist again without a thorough, standard departure briefing. 2) poor crew coordination. I will immediately challenge the PF on who has aircraft control when PF assumes radio communication responsibility during a critical phase of flight. 3) interruptions to final preparation for pushback. I will more firmly intervene to slow the process down when last min amended release, MEL research and maintenance paperwork interrupts the departure briefing process. Human factors: PF retires in 2 weeks. As a company, we should recognize that this is a significant life event and provide counsel/monitoring at the chief pilot level during their final year on board. Informal, quarterly is my recommendation. I was informed by my wife, the day before at the jetway, that my mother had a heart attack and was in the hospital. In hindsight, I would have been more responsible to blow off the trip. It was at the back of my mind the entire trip. Supplemental information from acn 628028: briefed mustang 6 departure. Then briefed loss of engine for runway 16R. We both had loss of engine plates on control column. For some reason, I was expecting a vector to mustang. At 5 DME I asked controller for a turn and he said we should have already turned. I screwed up and first officer did not catch it. Preoccupation with single engine procedure. Fix: would be, 'not to do that.'
Original NASA ASRS Text
Title: HDG TRACK DEV WHEN PIC OF A DEP B737 FAILS TO MAKE THE L TURN AT 3 DME ON THE FMG6 DEP PROC OUT OF RNO.
Narrative: FMG.6 DEP OFF RWY 16R AT RNO. CREW FAILED TO INITIATE TURN AT 3 DME FIX IN COMPLIANCE WITH SID PROC. LAST MIN MEL INTERRUPTED CHKLIST AND INADEQUATE DEP/NAVAID BRIEFING BY THE CAPT WAS A RESULT. ON INITIAL CLBOUT, PF WAS CONFUSED ON TURNOUT PROCS AND BEGAN A DIALOGUE WITH PLT MONITORING, AND THEN WITH ATC TO RESOLVE HIS CONFUSION. HE HAD THE SINGLE ENG EMER PROC ON HIS YOKE PLATE AND WAS CONVINCED HE NEEDED TO CONTINUE STRAIGHT AHEAD ON THE DEP. DURING THIS BRIEF PERIOD OF CONFUSION, ACFT ACCELERATED TO 250 KIAS AND BLEW THROUGH THE 3 DME FIX BEFORE A L TURN WAS INITIATED. PF CONTINUED DIALOGUE WITH ATC AND IT WAS EVIDENT THAT THEY WERE FRUSTRATED WITH COMPANY CREWS DEVIATING ON THIS DEP ON A REGULAR BASIS. CONTRIBUTING FACTORS: POOR, NON-STANDARD BRIEFING TECHNIQUES. I WILL NOT PROCEED TO THE BEFORE PUSH CHKLIST AGAIN WITHOUT A THOROUGH, STANDARD DEP BRIEFING. 2) POOR CREW COORD. I WILL IMMEDIATELY CHALLENGE THE PF ON WHO HAS ACFT CTL WHEN PF ASSUMES RADIO COM RESPONSIBILITY DURING A CRITICAL PHASE OF FLT. 3) INTERRUPTIONS TO FINAL PREPARATION FOR PUSHBACK. I WILL MORE FIRMLY INTERVENE TO SLOW THE PROCESS DOWN WHEN LAST MIN AMENDED RELEASE, MEL RESEARCH AND MAINT PAPERWORK INTERRUPTS THE DEP BRIEFING PROCESS. HUMAN FACTORS: PF RETIRES IN 2 WKS. AS A COMPANY, WE SHOULD RECOGNIZE THAT THIS IS A SIGNIFICANT LIFE EVENT AND PROVIDE COUNSEL/MONITORING AT THE CHIEF PLT LEVEL DURING THEIR FINAL YEAR ON BOARD. INFORMAL, QUARTERLY IS MY RECOMMENDATION. I WAS INFORMED BY MY WIFE, THE DAY BEFORE AT THE JETWAY, THAT MY MOTHER HAD A HEART ATTACK AND WAS IN THE HOSPITAL. IN HINDSIGHT, I WOULD HAVE BEEN MORE RESPONSIBLE TO BLOW OFF THE TRIP. IT WAS AT THE BACK OF MY MIND THE ENTIRE TRIP. SUPPLEMENTAL INFO FROM ACN 628028: BRIEFED MUSTANG 6 DEP. THEN BRIEFED LOSS OF ENG FOR RWY 16R. WE BOTH HAD LOSS OF ENG PLATES ON CTL COLUMN. FOR SOME REASON, I WAS EXPECTING A VECTOR TO MUSTANG. AT 5 DME I ASKED CTLR FOR A TURN AND HE SAID WE SHOULD HAVE ALREADY TURNED. I SCREWED UP AND FO DID NOT CATCH IT. PREOCCUPATION WITH SINGLE ENG PROC. FIX: WOULD BE, 'NOT TO DO THAT.'
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.