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|
Attributes | |
ACN | 692787 |
Time | |
Date | 200604 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | msl single value : 10500 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : vacating altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 692787 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 692661 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
After landing at den; I asked the first officer to determine if we exceeded our quick turn limit. We determined that we were over our weight; and after conferring with ZZZ dispatch we revised our departure time to reflect the time limit imposed on the quick turn limits. After the maintenance inspection was performed; we proceeded to do a normal before start and pushback procedure and then taxied out. We were advised to expect a different runway than originally anticipated. I asked ground where they would like us to hold while we updated our data. We taxied to that location; entered the data and proceeded to take off. As a side note; when I am #1 for takeoff; it is a memory jogger for me to engage the autothrottles; extend the landing lights and push recall for any abnormalities. Upon completing these items no fault was found. We proceeded to take off with bleeds off; improved climb profile; the first officer was flying and after flying an appropriate departure for the conditions; I re-established the bleeds and told the first officer the bleeds are established; upon which the first officer said that we were waiting for the APU to cool down. After at least 1 min had elapsed; I shut the APU down and saw we were coming up to 10000 ft and I proceeded with my 10000 ft flow. It is at this time to the best of my recollection; I first noticed that we had a speed trim fail light and shortly thereafter; an autoplt disconnect and loss of navigation/flight guidance. Upon looking on the overhead panel; I noticed both IRS's were in the off position. Instinctively; I turned them both on hoping to realign or to get any navigation/flight guidance back. We were unable to re-align or establish normal navigation/flight guidance information. At this time I decided it was best to return to den. We contacted den operations and told them to contact dispatch and tell them we are returning to den and we will contact them on the ground. The WX at den was clear with windshear and shifting winds. We asked den approach for vectors back to runway 26K the runway which we had previously landed on. Knowing that this would be an overweight landing; we burnt off as much fuel as we could by lowering the landing gear and selecting flaps 1 degree to keep us within the flight realm of ATC's request. It took both of us a while to reacquaint ourselves with flying the wet compass. After considering our options; of flying around trying to burn off excessive fuel in order to avoid an overweight landing; I thought in the interest of safety; it would be more appropriate to land the aircraft in an overweight condition than to fly around with limited raw data; no 'tacas.' at some point on arrival the first officer asked if I could take controls for a moment. I took over the control of the aircraft; and told him I would fly the aircraft to landing. We visually acquired the landing runway and asked for a visual approach. We were granted a visual to our runway. We landed in an overweight condition but a smooth touchdown was accomplished. Dispatch was repeatedly calling us for information about our situation while we were taxiing in. When we had a spare moment at the gate; we briefly answered some of her questions. After shutdown; we made the necessary maintenance logbook entries; and followed up with calls to appropriate personnel including ZZZ maintenance control; ZZZ dispatch; and the on-call. While I have no conclusive evidence of what actually happened; I can only speculate that in the high altitude environment of denver; while accomplishing a bleeds off takeoff and being concerned about a pressurization issue; I may have inadvertently turned off the IRS's while performing a flow. I have been concerned about chronic fatigue for some time; and I think it probably was a contributing factor in this incident. While I wish I could state exactly what happened; and how it could be avoided; I truly do not know what transpired to cause this incident. I think a simulator training session of basic pitch power airspeed; wet compass; basic raw data and partial panel maneuvers would be beneficial to crew members when the normal IRS information is not available.
Original NASA ASRS Text
Title: B737-400 FLT CREW ON DEP FROM DEN LOSE BOTH IRS'S.
Narrative: AFTER LNDG AT DEN; I ASKED THE FO TO DETERMINE IF WE EXCEEDED OUR QUICK TURN LIMIT. WE DETERMINED THAT WE WERE OVER OUR WT; AND AFTER CONFERRING WITH ZZZ DISPATCH WE REVISED OUR DEP TIME TO REFLECT THE TIME LIMIT IMPOSED ON THE QUICK TURN LIMITS. AFTER THE MAINT INSPECTION WAS PERFORMED; WE PROCEEDED TO DO A NORMAL BEFORE START AND PUSHBACK PROC AND THEN TAXIED OUT. WE WERE ADVISED TO EXPECT A DIFFERENT RWY THAN ORIGINALLY ANTICIPATED. I ASKED GND WHERE THEY WOULD LIKE US TO HOLD WHILE WE UPDATED OUR DATA. WE TAXIED TO THAT LOCATION; ENTERED THE DATA AND PROCEEDED TO TAKE OFF. AS A SIDE NOTE; WHEN I AM #1 FOR TKOF; IT IS A MEMORY JOGGER FOR ME TO ENGAGE THE AUTOTHROTTLES; EXTEND THE LNDG LIGHTS AND PUSH RECALL FOR ANY ABNORMALITIES. UPON COMPLETING THESE ITEMS NO FAULT WAS FOUND. WE PROCEEDED TO TAKE OFF WITH BLEEDS OFF; IMPROVED CLB PROFILE; THE FO WAS FLYING AND AFTER FLYING AN APPROPRIATE DEP FOR THE CONDITIONS; I RE-ESTABLISHED THE BLEEDS AND TOLD THE FO THE BLEEDS ARE ESTABLISHED; UPON WHICH THE FO SAID THAT WE WERE WAITING FOR THE APU TO COOL DOWN. AFTER AT LEAST 1 MIN HAD ELAPSED; I SHUT THE APU DOWN AND SAW WE WERE COMING UP TO 10000 FT AND I PROCEEDED WITH MY 10000 FT FLOW. IT IS AT THIS TIME TO THE BEST OF MY RECOLLECTION; I FIRST NOTICED THAT WE HAD A SPD TRIM FAIL LIGHT AND SHORTLY THEREAFTER; AN AUTOPLT DISCONNECT AND LOSS OF NAV/FLT GUIDANCE. UPON LOOKING ON THE OVERHEAD PANEL; I NOTICED BOTH IRS'S WERE IN THE OFF POS. INSTINCTIVELY; I TURNED THEM BOTH ON HOPING TO REALIGN OR TO GET ANY NAV/FLT GUIDANCE BACK. WE WERE UNABLE TO RE-ALIGN OR ESTABLISH NORMAL NAV/FLT GUIDANCE INFO. AT THIS TIME I DECIDED IT WAS BEST TO RETURN TO DEN. WE CONTACTED DEN OPS AND TOLD THEM TO CONTACT DISPATCH AND TELL THEM WE ARE RETURNING TO DEN AND WE WILL CONTACT THEM ON THE GND. THE WX AT DEN WAS CLR WITH WINDSHEAR AND SHIFTING WINDS. WE ASKED DEN APCH FOR VECTORS BACK TO RWY 26K THE RWY WHICH WE HAD PREVIOUSLY LANDED ON. KNOWING THAT THIS WOULD BE AN OVERWT LNDG; WE BURNT OFF AS MUCH FUEL AS WE COULD BY LOWERING THE LNDG GEAR AND SELECTING FLAPS 1 DEG TO KEEP US WITHIN THE FLT REALM OF ATC'S REQUEST. IT TOOK BOTH OF US A WHILE TO REACQUAINT OURSELVES WITH FLYING THE WET COMPASS. AFTER CONSIDERING OUR OPTIONS; OF FLYING AROUND TRYING TO BURN OFF EXCESSIVE FUEL IN ORDER TO AVOID AN OVERWT LNDG; I THOUGHT IN THE INTEREST OF SAFETY; IT WOULD BE MORE APPROPRIATE TO LAND THE ACFT IN AN OVERWT CONDITION THAN TO FLY AROUND WITH LIMITED RAW DATA; NO 'TACAS.' AT SOME POINT ON ARR THE FO ASKED IF I COULD TAKE CTLS FOR A MOMENT. I TOOK OVER THE CTL OF THE ACFT; AND TOLD HIM I WOULD FLY THE ACFT TO LNDG. WE VISUALLY ACQUIRED THE LNDG RWY AND ASKED FOR A VISUAL APCH. WE WERE GRANTED A VISUAL TO OUR RWY. WE LANDED IN AN OVERWT CONDITION BUT A SMOOTH TOUCHDOWN WAS ACCOMPLISHED. DISPATCH WAS REPEATEDLY CALLING US FOR INFO ABOUT OUR SIT WHILE WE WERE TAXIING IN. WHEN WE HAD A SPARE MOMENT AT THE GATE; WE BRIEFLY ANSWERED SOME OF HER QUESTIONS. AFTER SHUTDOWN; WE MADE THE NECESSARY MAINT LOGBOOK ENTRIES; AND FOLLOWED UP WITH CALLS TO APPROPRIATE PERSONNEL INCLUDING ZZZ MAINT CTL; ZZZ DISPATCH; AND THE ON-CALL. WHILE I HAVE NO CONCLUSIVE EVIDENCE OF WHAT ACTUALLY HAPPENED; I CAN ONLY SPECULATE THAT IN THE HIGH ALT ENVIRONMENT OF DENVER; WHILE ACCOMPLISHING A BLEEDS OFF TKOF AND BEING CONCERNED ABOUT A PRESSURIZATION ISSUE; I MAY HAVE INADVERTENTLY TURNED OFF THE IRS'S WHILE PERFORMING A FLOW. I HAVE BEEN CONCERNED ABOUT CHRONIC FATIGUE FOR SOME TIME; AND I THINK IT PROBABLY WAS A CONTRIBUTING FACTOR IN THIS INCIDENT. WHILE I WISH I COULD STATE EXACTLY WHAT HAPPENED; AND HOW IT COULD BE AVOIDED; I TRULY DO NOT KNOW WHAT TRANSPIRED TO CAUSE THIS INCIDENT. I THINK A SIMULATOR TRAINING SESSION OF BASIC PITCH PWR AIRSPD; WET COMPASS; BASIC RAW DATA AND PARTIAL PANEL MANEUVERS WOULD BE BENEFICIAL TO CREW MEMBERS WHEN THE NORMAL IRS INFO IS NOT AVAILABLE.
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.