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|
Attributes | |
ACN | 710246 |
Time | |
Date | 200609 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon tower : den.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff climbout : intermediate altitude climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 224 flight time total : 11000 flight time type : 5961 |
ASRS Report | 710246 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Experience | flight time last 90 days : 90 flight time total : 14500 flight time type : 5000 |
ASRS Report | 710099 |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Failed to get final weights prior to takeoff. The flight into den was late due to equipment problems prior to us getting the plane. We turned it quickly; pushed back; got behind a B757 and waited. We moved around him and continued on 1 engine to runway 8. I started the second engine (#1) approaching taxiway ed. The tower gave us takeoff clearance shortly after 'roll back' on the #1 engine. I went through the before takeoff checklist and thought I had just forgotten to type in the speeds. So I did that based on the planned weight manifest and continued with the checklist. I had forgotten that I had not received the final weights. We took off and just 2 mins later we got the ACARS note 'weights printed' still I thought I had just somehow hit an ACARS button causing it to print the weights again. I wouldn't say I was ever rushed or distraction. I just missed the fact that we never got the final weights. Once we got around the B757 the timing was 'spirited' with tower clearing us for takeoff about rollback and before taxiway Z in denver; but I don't think that was the root cause. We had a lot of things going on with the ramp exit at a nonstandard point; the new maintenance release and release verify; and the quick clearance for takeoff. We had lots of time between pushback and takeoff (15 mins) during which the centralized load planning 'always' sends us the final weights. As you will undoubtedly look up; the zero fuel weight changed from 100854 pounds planned to 100616 pounds actual and the trim changed from 4.4 degrees to 4.6 degrees. The count changed by only 1 person so the weights written on the planned weight manifest were as they were expected to be; and did not cause any discussion about how the final weights would be significant. In conclusion: in hindsight; there were plenty of triggers for each of us to catch the lack of final weights. No procedures need to be changed. I simply missed the fact that they were not printed and installed. The captain missed the same thing during the 'trim weights and speeds' checklist item because another piece of paper (the ATIS printout) was in the 'normal' place on the throttle quadrant for the final weights and it was dark. Supplemental information from acn 710099: due to late inbound we departed den 54 mins late. The ramp was congested but we finally were cleared to runway 8 via taxiway left. Once on taxiway left we saw there was no line so first officer began start of #1 engine. I hadn't noticed if weights had come and was about to ask but just then we were switched to tower quickly followed by cutout on #1. I don't feel this mistake was all about rushing. This was a serious mistake neither of us imagined we'd ever make and we didn't have the habit patterns in place to catch it. We do now!
Original NASA ASRS Text
Title: B737-300 FLT CREW DEPARTS WITHOUT FINAL WTS THAT SUBSEQUENTLY ARRIVE VIA ACARS 32 MINS AFTER DEP.
Narrative: FAILED TO GET FINAL WTS PRIOR TO TKOF. THE FLT INTO DEN WAS LATE DUE TO EQUIP PROBS PRIOR TO US GETTING THE PLANE. WE TURNED IT QUICKLY; PUSHED BACK; GOT BEHIND A B757 AND WAITED. WE MOVED AROUND HIM AND CONTINUED ON 1 ENG TO RWY 8. I STARTED THE SECOND ENG (#1) APCHING TXWY ED. THE TWR GAVE US TKOF CLRNC SHORTLY AFTER 'ROLL BACK' ON THE #1 ENG. I WENT THROUGH THE BEFORE TKOF CHKLIST AND THOUGHT I HAD JUST FORGOTTEN TO TYPE IN THE SPDS. SO I DID THAT BASED ON THE PLANNED WT MANIFEST AND CONTINUED WITH THE CHKLIST. I HAD FORGOTTEN THAT I HAD NOT RECEIVED THE FINAL WTS. WE TOOK OFF AND JUST 2 MINS LATER WE GOT THE ACARS NOTE 'WTS PRINTED' STILL I THOUGHT I HAD JUST SOMEHOW HIT AN ACARS BUTTON CAUSING IT TO PRINT THE WTS AGAIN. I WOULDN'T SAY I WAS EVER RUSHED OR DISTR. I JUST MISSED THE FACT THAT WE NEVER GOT THE FINAL WTS. ONCE WE GOT AROUND THE B757 THE TIMING WAS 'SPIRITED' WITH TWR CLRING US FOR TKOF ABOUT ROLLBACK AND BEFORE TXWY Z IN DENVER; BUT I DON'T THINK THAT WAS THE ROOT CAUSE. WE HAD A LOT OF THINGS GOING ON WITH THE RAMP EXIT AT A NONSTANDARD POINT; THE NEW MAINT RELEASE AND RELEASE VERIFY; AND THE QUICK CLRNC FOR TKOF. WE HAD LOTS OF TIME BTWN PUSHBACK AND TKOF (15 MINS) DURING WHICH THE CENTRALIZED LOAD PLANNING 'ALWAYS' SENDS US THE FINAL WTS. AS YOU WILL UNDOUBTEDLY LOOK UP; THE ZERO FUEL WT CHANGED FROM 100854 LBS PLANNED TO 100616 LBS ACTUAL AND THE TRIM CHANGED FROM 4.4 DEGS TO 4.6 DEGS. THE COUNT CHANGED BY ONLY 1 PERSON SO THE WTS WRITTEN ON THE PLANNED WT MANIFEST WERE AS THEY WERE EXPECTED TO BE; AND DID NOT CAUSE ANY DISCUSSION ABOUT HOW THE FINAL WTS WOULD BE SIGNIFICANT. IN CONCLUSION: IN HINDSIGHT; THERE WERE PLENTY OF TRIGGERS FOR EACH OF US TO CATCH THE LACK OF FINAL WTS. NO PROCS NEED TO BE CHANGED. I SIMPLY MISSED THE FACT THAT THEY WERE NOT PRINTED AND INSTALLED. THE CAPT MISSED THE SAME THING DURING THE 'TRIM WTS AND SPDS' CHKLIST ITEM BECAUSE ANOTHER PIECE OF PAPER (THE ATIS PRINTOUT) WAS IN THE 'NORMAL' PLACE ON THE THROTTLE QUADRANT FOR THE FINAL WTS AND IT WAS DARK. SUPPLEMENTAL INFO FROM ACN 710099: DUE TO LATE INBOUND WE DEPARTED DEN 54 MINS LATE. THE RAMP WAS CONGESTED BUT WE FINALLY WERE CLRED TO RWY 8 VIA TXWY L. ONCE ON TXWY L WE SAW THERE WAS NO LINE SO FO BEGAN START OF #1 ENG. I HADN'T NOTICED IF WTS HAD COME AND WAS ABOUT TO ASK BUT JUST THEN WE WERE SWITCHED TO TWR QUICKLY FOLLOWED BY CUTOUT ON #1. I DON'T FEEL THIS MISTAKE WAS ALL ABOUT RUSHING. THIS WAS A SERIOUS MISTAKE NEITHER OF US IMAGINED WE'D EVER MAKE AND WE DIDN'T HAVE THE HABIT PATTERNS IN PLACE TO CATCH IT. WE DO NOW!
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.