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A B737-400 crew returned to the gate from a takeoff position and after a 2 hour WX delay departed with IRS's off because they failed to re-energize them.
| Attributes | |
| ACN | 674746 |
| Time | |
| Date | 200510 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : takeoff roll |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 17000 flight time type : 4000 |
| ASRS Report | 674746 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 90 flight time total : 18000 flight time type : 4000 |
| ASRS Report | 674844 |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : far non adherence : company policies |
| Independent Detector | aircraft equipment other aircraft equipment : off flags: compass adi other flight crewa |
| Resolutory Action | flight crew : declared emergency other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
Taxied out originally at about XA20. Ground stop to dca. Completed all prior to takeoff checklists prior to ground stop. Went to penalty box (taxi pad) to wait. ATC said get ready to go at XC00. Bad information from ATC (tower). Delayed estimated departure time till XD03. Went back to gate. IRS's turned off (did not know/realize this). Off the gate at XC55. Performed before start; after start and before takeoff checklist. Took off without IRS's on. Did not see any flags in captain's or first officer's flight instruments until 200 ft AGL. Declared emergency; stayed in traffic pattern and returned to ZZZ. Uneventful landing and taxi to gate. Note: air carrier checklist has a set-up for pilot failure. (I personally tried to get it changed with air carrier training department.) on our originating (receiving) checklist; we have 'IRS mode selectors...verify...navigation' but not on before start checklist. This was ok when the airplane was new to air carrier because originally (yrs ago) the IRS's were not turned off after each flight. Now they are; and there is no 'specific' IRS mode selector...verify...navigation for each before start; ie; it should be on the 'before start' checklist; ie; this is a classic set-up for failure due to a checklist anomaly.
Original NASA ASRS Text
Title: A B737-400 CREW RETURNED TO THE GATE FROM A TKOF POS AND AFTER A 2 HR WX DELAY DEPARTED WITH IRS'S OFF BECAUSE THEY FAILED TO RE-ENERGIZE THEM.
Narrative: TAXIED OUT ORIGINALLY AT ABOUT XA20. GND STOP TO DCA. COMPLETED ALL PRIOR TO TKOF CHKLISTS PRIOR TO GND STOP. WENT TO PENALTY BOX (TAXI PAD) TO WAIT. ATC SAID GET READY TO GO AT XC00. BAD INFO FROM ATC (TWR). DELAYED ESTIMATED DEP TIME TILL XD03. WENT BACK TO GATE. IRS'S TURNED OFF (DID NOT KNOW/REALIZE THIS). OFF THE GATE AT XC55. PERFORMED BEFORE START; AFTER START AND BEFORE TKOF CHKLIST. TOOK OFF WITHOUT IRS'S ON. DID NOT SEE ANY FLAGS IN CAPT'S OR FO'S FLT INSTS UNTIL 200 FT AGL. DECLARED EMER; STAYED IN TFC PATTERN AND RETURNED TO ZZZ. UNEVENTFUL LNDG AND TAXI TO GATE. NOTE: ACR CHKLIST HAS A SET-UP FOR PLT FAILURE. (I PERSONALLY TRIED TO GET IT CHANGED WITH ACR TRAINING DEPT.) ON OUR ORIGINATING (RECEIVING) CHKLIST; WE HAVE 'IRS MODE SELECTORS...VERIFY...NAV' BUT NOT ON BEFORE START CHKLIST. THIS WAS OK WHEN THE AIRPLANE WAS NEW TO ACR BECAUSE ORIGINALLY (YRS AGO) THE IRS'S WERE NOT TURNED OFF AFTER EACH FLT. NOW THEY ARE; AND THERE IS NO 'SPECIFIC' IRS MODE SELECTOR...VERIFY...NAV FOR EACH BEFORE START; IE; IT SHOULD BE ON THE 'BEFORE START' CHKLIST; IE; THIS IS A CLASSIC SET-UP FOR FAILURE DUE TO A CHKLIST ANOMALY.
Data retrieved from NASA's ASRS site as of January 2009 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.