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|
Attributes | |
ACN | 692662 |
Time | |
Date | 200604 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bwi.airport |
State Reference | MD |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | Thunderstorm |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
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 : 165 flight time total : 14000 flight time type : 10000 |
ASRS Report | 692662 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Supplementary | |
Problem Areas | Weather Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Because of my actions; I believe L4 and R4 windows were damaged on my assigned aircraft. Description of events: due to WX; we were on an extended ground delay in bwi and elected to shut down both engines. Upon reaching our assigned parking location; I did not call for the 'dual engine shutdown checklist;' but rather ran it myself; as the first officer was busy contacting dispatch as I had instructed him to do. About this time I believe; out of habit; the first officer turned off the window heat. I did not notice this and it probably would not have occurred had we executed the shut down checklist properly; that is challenge and response. We did correctly run the taxi start checklist which; of course; did not mention window heat as it is directly related to the shutdown checklist. Resultantly and inadvertently; we departed without the window heat on. En route; we heard a few popping sounds but made no connection; if there was one. During descent; I finally noticed the error and turned on window heat and defrost air. After shutdown; the first officer noticed L4 and R4 windows were cracked. Maintenance was notified and discrepancies entered into aircraft logbook. Note: during casual conversation with maintenance; they indicated windows may have cracked due to heat being applied to a very cold window. I am not sure if cracking occurred during descent or en route (reference previously mentioned popping sounds). During descent; it seemed window heat was required due to frost on the windows. In hindsight; defrost air may have been adequate. Primary factors: 1) improper use of checklist; partly due to distraction. 2) shutdown habit patterns. 3) rarely used checklist/procedure. 4) fatigue on the descent portion of the flight.
Original NASA ASRS Text
Title: B737-700 FLT CREW SUSPECTS DAMAGE TO L4 AND R4 WINDOWS AS A RESULT OF IMPROPER CHKLIST PROCS.
Narrative: BECAUSE OF MY ACTIONS; I BELIEVE L4 AND R4 WINDOWS WERE DAMAGED ON MY ASSIGNED ACFT. DESCRIPTION OF EVENTS: DUE TO WX; WE WERE ON AN EXTENDED GND DELAY IN BWI AND ELECTED TO SHUT DOWN BOTH ENGS. UPON REACHING OUR ASSIGNED PARKING LOCATION; I DID NOT CALL FOR THE 'DUAL ENG SHUTDOWN CHKLIST;' BUT RATHER RAN IT MYSELF; AS THE FO WAS BUSY CONTACTING DISPATCH AS I HAD INSTRUCTED HIM TO DO. ABOUT THIS TIME I BELIEVE; OUT OF HABIT; THE FO TURNED OFF THE WINDOW HEAT. I DID NOT NOTICE THIS AND IT PROBABLY WOULD NOT HAVE OCCURRED HAD WE EXECUTED THE SHUT DOWN CHKLIST PROPERLY; THAT IS CHALLENGE AND RESPONSE. WE DID CORRECTLY RUN THE TAXI START CHKLIST WHICH; OF COURSE; DID NOT MENTION WINDOW HEAT AS IT IS DIRECTLY RELATED TO THE SHUTDOWN CHKLIST. RESULTANTLY AND INADVERTENTLY; WE DEPARTED WITHOUT THE WINDOW HEAT ON. ENRTE; WE HEARD A FEW POPPING SOUNDS BUT MADE NO CONNECTION; IF THERE WAS ONE. DURING DSCNT; I FINALLY NOTICED THE ERROR AND TURNED ON WINDOW HEAT AND DEFROST AIR. AFTER SHUTDOWN; THE FO NOTICED L4 AND R4 WINDOWS WERE CRACKED. MAINT WAS NOTIFIED AND DISCREPANCIES ENTERED INTO ACFT LOGBOOK. NOTE: DURING CASUAL CONVERSATION WITH MAINT; THEY INDICATED WINDOWS MAY HAVE CRACKED DUE TO HEAT BEING APPLIED TO A VERY COLD WINDOW. I AM NOT SURE IF CRACKING OCCURRED DURING DSCNT OR ENRTE (REF PREVIOUSLY MENTIONED POPPING SOUNDS). DURING DSCNT; IT SEEMED WINDOW HEAT WAS REQUIRED DUE TO FROST ON THE WINDOWS. IN HINDSIGHT; DEFROST AIR MAY HAVE BEEN ADEQUATE. PRIMARY FACTORS: 1) IMPROPER USE OF CHKLIST; PARTLY DUE TO DISTR. 2) SHUTDOWN HABIT PATTERNS. 3) RARELY USED CHKLIST/PROC. 4) FATIGUE ON THE DSCNT PORTION OF THE FLT.
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.