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|
Attributes | |
ACN | 699490 |
Time | |
Date | 200606 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Rain Fog |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : instrument pilot : flight engineer pilot : atp pilot : multi engine pilot : private |
Experience | flight time last 90 days : 195 flight time total : 18173 flight time type : 12200 |
ASRS Report | 699490 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 15000 flight time type : 5000 |
ASRS Report | 699492 |
Events | |
Anomaly | non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
Predep review of takeoff performance system (tps) departure plan indicated we were legal to depart on runway 27 with engine bleeds off; 124 passenger and fuel of 21600 pounds. During single engine taxi out; final weight and balance message did not arrive. After start of second engine; weight and balance message finally came with only runway 33L indicated and only 2 aircraft in use for departures. We had now advanced to next for takeoff; so we again checked the tps to reconfirm runway 27 legality. The fuel load hadn't changed and passenger count had increased by 1 passenger. Inexplicably; the gross takeoff weight had increased by about 5500 pounds which went unnoticed even though we reset the takeoff speeds to reflect the higher weight. We then performed the bleeds off takeoff on runway 27 when cleared by bos tower. Aircraft we picked up arrived approximately 90 mins late; causing compressed time to complete all required preflight checks. Subsequent departure was 1 hour 35 mins late. Automatic pre departure clearance issued an RNAV departure which first officer had to verbally decline which resulted in a new clearance issued requiring readback. During single engine taxi out; ground control instructed us to again call clearance delivery. We then received a completely new WX related rerte necessitating another full route readback; entered new route in FMS computer; and verified with company dispatcher that new route was acceptable. Therefore; first officer's 'heads down' time was greatly increased while captain handled the communications with ground and tower while taxiing on the prescribed route which included the crossing of runways 22L; 22R; and 33L which was being used for lndgs. Additional factors were the aforementioned start of the second engine and associated checklists coupled with the late arrival of the final weight and balance message. More thorough review of the takeoff performance system departure plan and final weight and balance message during the climb out above 10000 ft MSL when flight deck workload was greatly reduced. Cessation of using the tps to verify takeoff legality when a different runway is transmitted on the final weight and balance message after taxiing has begun. If 2 highly experienced and diligent pilots can make this error of omission; I believe this company encouraged training practice and confusing procedure to be seriously flawed.
Original NASA ASRS Text
Title: A B737-300 CREW TOOK OFF OVERWT AT BOS BECAUSE OF TIME PRESSURES AND CONFUSING COMPANY PROC.
Narrative: PREDEP REVIEW OF TKOF PERFORMANCE SYS (TPS) DEP PLAN INDICATED WE WERE LEGAL TO DEPART ON RWY 27 WITH ENG BLEEDS OFF; 124 PAX AND FUEL OF 21600 LBS. DURING SINGLE ENG TAXI OUT; FINAL WT AND BAL MESSAGE DID NOT ARRIVE. AFTER START OF SECOND ENG; WT AND BAL MESSAGE FINALLY CAME WITH ONLY RWY 33L INDICATED AND ONLY 2 ACFT IN USE FOR DEPS. WE HAD NOW ADVANCED TO NEXT FOR TKOF; SO WE AGAIN CHKED THE TPS TO RECONFIRM RWY 27 LEGALITY. THE FUEL LOAD HADN'T CHANGED AND PAX COUNT HAD INCREASED BY 1 PAX. INEXPLICABLY; THE GROSS TKOF WT HAD INCREASED BY ABOUT 5500 LBS WHICH WENT UNNOTICED EVEN THOUGH WE RESET THE TKOF SPDS TO REFLECT THE HIGHER WT. WE THEN PERFORMED THE BLEEDS OFF TKOF ON RWY 27 WHEN CLRED BY BOS TWR. ACFT WE PICKED UP ARRIVED APPROX 90 MINS LATE; CAUSING COMPRESSED TIME TO COMPLETE ALL REQUIRED PREFLT CHKS. SUBSEQUENT DEP WAS 1 HR 35 MINS LATE. AUTOMATIC PDC ISSUED AN RNAV DEP WHICH FO HAD TO VERBALLY DECLINE WHICH RESULTED IN A NEW CLRNC ISSUED REQUIRING READBACK. DURING SINGLE ENG TAXI OUT; GND CTL INSTRUCTED US TO AGAIN CALL CLRNC DELIVERY. WE THEN RECEIVED A COMPLETELY NEW WX RELATED RERTE NECESSITATING ANOTHER FULL RTE READBACK; ENTERED NEW RTE IN FMS COMPUTER; AND VERIFIED WITH COMPANY DISPATCHER THAT NEW RTE WAS ACCEPTABLE. THEREFORE; FO'S 'HEADS DOWN' TIME WAS GREATLY INCREASED WHILE CAPT HANDLED THE COMS WITH GND AND TWR WHILE TAXIING ON THE PRESCRIBED RTE WHICH INCLUDED THE XING OF RWYS 22L; 22R; AND 33L WHICH WAS BEING USED FOR LNDGS. ADDITIONAL FACTORS WERE THE AFOREMENTIONED START OF THE SECOND ENG AND ASSOCIATED CHKLISTS COUPLED WITH THE LATE ARR OF THE FINAL WT AND BAL MESSAGE. MORE THOROUGH REVIEW OF THE TKOF PERFORMANCE SYS DEP PLAN AND FINAL WT AND BAL MESSAGE DURING THE CLBOUT ABOVE 10000 FT MSL WHEN FLT DECK WORKLOAD WAS GREATLY REDUCED. CESSATION OF USING THE TPS TO VERIFY TKOF LEGALITY WHEN A DIFFERENT RWY IS XMITTED ON THE FINAL WT AND BAL MESSAGE AFTER TAXIING HAS BEGUN. IF 2 HIGHLY EXPERIENCED AND DILIGENT PLTS CAN MAKE THIS ERROR OF OMISSION; I BELIEVE THIS COMPANY ENCOURAGED TRAINING PRACTICE AND CONFUSING PROC TO BE SERIOUSLY FLAWED.
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.