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|
Attributes | |
ACN | 676640 |
Time | |
Date | 200511 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | msl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Rain |
Aircraft 1 | |
Controlling Facilities | tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 15 flight time total : 8000 flight time type : 140 |
ASRS Report | 676640 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : ecam other flight crewa |
Resolutory Action | flight crew : overcame equipment problem flight crew : overrode automation |
Supplementary | |
Problem Areas | Aircraft Environmental Factor Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Plane arrived late at gate. Since we were continuing to ord; we were trying to make up time. APU was deferred which added to our workload. First officer was late arriving to his seat due to bathroom congestion and was not ready for pneumatic start. With light load; only 59 passenger; aircraft was turned very quickly and ground crew was pressing us to turn #1. We told them to stand by while we finished briefing and running checklists. We started #1 at the gate and disconnected air and electrics and pushed for runway 28L. On taxi out; flight attendant called and said the passenger entertainment system was not working. Having just read a bulletin regarding movement of passenger entertainment system to galleys; I asked where unit was. It was still in overhead bin (thinking galley busses shed with single generator). I advised flight attendant to do a live demonstration. After crossing 1 left&right; I called for #2 to be started. First officer made 3 attempts to crank; but kept getting 'start valve will not open' ECAM. I told him to handle ECAM and re-read xbleed checklist. First officer seemed to be struggling with procedure; but finally had engine running. Numbers then arrived and we had a forward center of gravity. First officer handled this procedure fine. We were then #1 for takeoff and tower cleared us into position and hold. First officer responded and began reading the before takeoff checklist. Looking back; we should have asked for 30 seconds; but we pressed on. First officer advised me as we crossed hold line that the flight attendants were finished with briefing; but were 'rambling on PA.' I said 'give them 'prepare for immediate takeoff' and don't wait for them to finish yapping.' we were shortly cleared for takeoff. I aligned aircraft for takeoff and began advancing thrust levers as first officer was talking to tower. I then handed aircraft off to first officer who was to be PF. Due to our light gross weight (less than 122.0) we accelerated very rapidly and at 80 KTS I checked EPR (approximately 1.3) and other engine gauges and announced '80 KTS thrust set.' I do not recall any SOP callouts by first officer. After V1; vr; V2; positive climb was called and gear retracted. Aircraft responded with 'level 3 landing gear not down' ECAM. I silenced using emergency cancel and was handed to departure. First officer was hand flying; but not making any FMA callouts. We cleaned up aircraft and realized autothrottle was not engaged. I pulled for open climb; and engaged the autothrottle on FCU. First officer engaged autoplt and we climbed to cruise altitude. Once level; we then tried to decipher what happened. I believe that the thrust levers never reached flex detent and aircraft never entered takeoff phase of flight which gave us gear warning. Because of our light weight; there was no lagging performance to speak of. Some SOP callouts; ie; 'manual flex; srs; runway' or 'thr climb; climb; navigation' may have alerted us to our situation; but were never made. It is my opinion that this event was the result of us trying to make up time and numerous distraction from cabin; ATC; poor addition poc adherence and the aircraft itself (APU). We should have pulled to the side and asked for more time. The pressure on an on-time operation and a looming red eye return flight caused us to exercise poor judgement. I did not display good leadership and allowed the situation to deteriorate. As a side note; the flight attendant said that the passenger entertainment system began working once the second generator was placed on line. I talked to maintenance the day after and he said that the passenger entertainment system power source was not on galley bus and should have worked.
Original NASA ASRS Text
Title: A320 FLT CREW ALLOWS THEMSELVES TO GET RUSHED BY SCHEDULE PRESSURES. MULTIPLE ANOMALIES ASSOCIATED WITH INCOMPLETE PRE TKOF CHKLIST ITEMS AND SOP CALLOUTS RESULT.
Narrative: PLANE ARRIVED LATE AT GATE. SINCE WE WERE CONTINUING TO ORD; WE WERE TRYING TO MAKE UP TIME. APU WAS DEFERRED WHICH ADDED TO OUR WORKLOAD. FO WAS LATE ARRIVING TO HIS SEAT DUE TO BATHROOM CONGESTION AND WAS NOT READY FOR PNEUMATIC START. WITH LIGHT LOAD; ONLY 59 PAX; ACFT WAS TURNED VERY QUICKLY AND GND CREW WAS PRESSING US TO TURN #1. WE TOLD THEM TO STAND BY WHILE WE FINISHED BRIEFING AND RUNNING CHKLISTS. WE STARTED #1 AT THE GATE AND DISCONNECTED AIR AND ELECTRICS AND PUSHED FOR RWY 28L. ON TAXI OUT; FLT ATTENDANT CALLED AND SAID THE PAX ENTERTAINMENT SYS WAS NOT WORKING. HAVING JUST READ A BULLETIN REGARDING MOVEMENT OF PAX ENTERTAINMENT SYS TO GALLEYS; I ASKED WHERE UNIT WAS. IT WAS STILL IN OVERHEAD BIN (THINKING GALLEY BUSSES SHED WITH SINGLE GENERATOR). I ADVISED FLT ATTENDANT TO DO A LIVE DEMO. AFTER XING 1 L&R; I CALLED FOR #2 TO BE STARTED. FO MADE 3 ATTEMPTS TO CRANK; BUT KEPT GETTING 'START VALVE WILL NOT OPEN' ECAM. I TOLD HIM TO HANDLE ECAM AND RE-READ XBLEED CHKLIST. FO SEEMED TO BE STRUGGLING WITH PROC; BUT FINALLY HAD ENG RUNNING. NUMBERS THEN ARRIVED AND WE HAD A FORWARD CTR OF GRAVITY. FO HANDLED THIS PROC FINE. WE WERE THEN #1 FOR TKOF AND TWR CLRED US INTO POS AND HOLD. FO RESPONDED AND BEGAN READING THE BEFORE TKOF CHKLIST. LOOKING BACK; WE SHOULD HAVE ASKED FOR 30 SECONDS; BUT WE PRESSED ON. FO ADVISED ME AS WE CROSSED HOLD LINE THAT THE FLT ATTENDANTS WERE FINISHED WITH BRIEFING; BUT WERE 'RAMBLING ON PA.' I SAID 'GIVE THEM 'PREPARE FOR IMMEDIATE TKOF' AND DON'T WAIT FOR THEM TO FINISH YAPPING.' WE WERE SHORTLY CLRED FOR TKOF. I ALIGNED ACFT FOR TKOF AND BEGAN ADVANCING THRUST LEVERS AS FO WAS TALKING TO TWR. I THEN HANDED ACFT OFF TO FO WHO WAS TO BE PF. DUE TO OUR LIGHT GROSS WT (LESS THAN 122.0) WE ACCELERATED VERY RAPIDLY AND AT 80 KTS I CHKED EPR (APPROX 1.3) AND OTHER ENG GAUGES AND ANNOUNCED '80 KTS THRUST SET.' I DO NOT RECALL ANY SOP CALLOUTS BY FO. AFTER V1; VR; V2; POSITIVE CLB WAS CALLED AND GEAR RETRACTED. ACFT RESPONDED WITH 'LEVEL 3 LNDG GEAR NOT DOWN' ECAM. I SILENCED USING EMER CANCEL AND WAS HANDED TO DEP. FO WAS HAND FLYING; BUT NOT MAKING ANY FMA CALLOUTS. WE CLEANED UP ACFT AND REALIZED AUTOTHROTTLE WAS NOT ENGAGED. I PULLED FOR OPEN CLB; AND ENGAGED THE AUTOTHROTTLE ON FCU. FO ENGAGED AUTOPLT AND WE CLBED TO CRUISE ALT. ONCE LEVEL; WE THEN TRIED TO DECIPHER WHAT HAPPENED. I BELIEVE THAT THE THRUST LEVERS NEVER REACHED FLEX DETENT AND ACFT NEVER ENTERED TKOF PHASE OF FLT WHICH GAVE US GEAR WARNING. BECAUSE OF OUR LIGHT WT; THERE WAS NO LAGGING PERFORMANCE TO SPEAK OF. SOME SOP CALLOUTS; IE; 'MANUAL FLEX; SRS; RWY' OR 'THR CLB; CLB; NAV' MAY HAVE ALERTED US TO OUR SITUATION; BUT WERE NEVER MADE. IT IS MY OPINION THAT THIS EVENT WAS THE RESULT OF US TRYING TO MAKE UP TIME AND NUMEROUS DISTR FROM CABIN; ATC; POOR ADDITION POC ADHERENCE AND THE ACFT ITSELF (APU). WE SHOULD HAVE PULLED TO THE SIDE AND ASKED FOR MORE TIME. THE PRESSURE ON AN ON-TIME OP AND A LOOMING RED EYE RETURN FLT CAUSED US TO EXERCISE POOR JUDGEMENT. I DID NOT DISPLAY GOOD LEADERSHIP AND ALLOWED THE SITUATION TO DETERIORATE. AS A SIDE NOTE; THE FLT ATTENDANT SAID THAT THE PAX ENTERTAINMENT SYS BEGAN WORKING ONCE THE SECOND GENERATOR WAS PLACED ON LINE. I TALKED TO MAINT THE DAY AFTER AND HE SAID THAT THE PAX ENTERTAINMENT SYS PWR SOURCE WAS NOT ON GALLEY BUS AND SHOULD HAVE WORKED.
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.