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Attributes | |
ACN | 711960 |
Time | |
Date | 200610 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground : maintenance |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 129 flight time total : 10000 flight time type : 4300 |
ASRS Report | 711960 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 177 flight time total : 9150 flight time type : 3950 |
ASRS Report | 711964 |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : clearance non adherence : company policies |
Independent Detector | other controllera |
Resolutory Action | flight crew : rejected takeoff |
Supplementary | |
Problem Areas | Chart Or Publication Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
This is my first pairing utilizing the new phase departure procedures in effect since sep/fri/06. Due to a short taxi distance; from the gate to runway; both engines were started prior to taxi. The new procedures call for the captain to complete his flight control check prior to the first officer commencing his flight control check and thus triggering the rest of the first officer taxi flow. This change biases the taxi checklist to a later point in the taxi timeline than the old procedures. Because of this change we were still completing the above-the-line portion of the taxi checklist when the local (tower) controller contacted us. In addition to shifting the workload to later in the taxi flow the new procedures require more verbal back and forth. There is much more talking going on than before. It was my belief that we had been cleared for takeoff and as I taxied the aircraft forward I activated the landing and takeoff lights. I heard only the local controller and was not able to listen to our readback because I was still involved in xchking. While taxiing onto the runway instead of listening for tower xmissions the first officer was pulling out the flight release in order to comply with the below-the-line provisions of the checklist; which require him to look up and verify minimum brake release fuel. I was unable to devote full attention to tower xmissions as I now have to listen to the first officer recite the below-the-line portion of the checklist while entering the runway environment. None of these items are flight critical. Prior to advancing the thrust levers I confirmed with the first officer that we were cleared for takeoff and he agreed that we were indeed cleared. I released the brakes and stood the thrust levers up for a stabilized spool up. As we started the roll I looked up and saw an MD80 rolling out on xx. Simultaneously the local controller transmitted 'air carrier X stop.' I aborted the takeoff at approximately 40 KIAS prior to takeoff thrust being set. Utilizing old procedures the taxi checklist was completed well before the hold short line. Under the old procedures the captain's flow was the last flow and upon completion he/she could call for the taxi checklist to be accomplished. The first officer flow has now been resequenced later in the taxi timeline to occur after the captain flight control check. This change; especially when coupled with a single engine taxi; causes the checklist to be completed later. In situations where a short taxi time exists this shifting increases the workload at the most critical point in the ground phase. The new procedures also split the taxi checklist into an above; and a below-the-line section. Published guidance calls for the below-the-line portion to be completed prior to taking the runway. Though there is some debate about what this means it was my understanding that this emphasized that the below the line portion should not be completed before the aircraft was at least the first one holding short of the runway. The fact that the first and only challenge-response item on this portion of the checklist is the minimum brake release fuel emphasizes the point. Though there is no question that I share culpability for this event I feel that the procedures now in effect are detrimental to safety. Our mandatory read file included information on 2 runway incursions that occurred in boston. That air carrier gets their final weight and balance data via ACARS after gate departure. In at least one of these incidents the ACARS was inoperative and the first officer was absorbed in getting the weight and balance data over the radio and inputting it into the FMS when the incursion occurred. Though we still receive a hard copy of the weight and balance prior to pushback it is my understanding that we will be adopting the ACARS method of receiving this information. I am alarmed that we seem to be adopting procedures that increase the workload during the second most critical phase of flight. In the future we will also be getting our takeoff data via ACARS and inputting it during the taxi phase. These tasks can be safely and efficiently accomplished at the gate prior to pushback. It is my belief that moving non critical tasks from the before start phase to the critical taxi for departure phase is not in the best interest of safety. The new procedures require much more cross talk than the old procedures. It is a distracting non value added change in procedure. I will insist that the taxi checklist be completed in its entirety instead of splitting it into 2 parts. Callback conversation with reporter revealed the following information: reporter stated that his air carrier is instituting more checklist procedure changes in the near future that rely on pilots memorizing procedural flows and relying less on reviewing checklists for completed tasks. In the reporter's opinion the changes made so far move away from safety concerns and into an area that disregards even simple human considerations. His air carrier is not interested in pilot's feedback about the safety impact of the changes already instituted.
Original NASA ASRS Text
Title: AN ACR PLT COMMENTS ABOUT CHKLIST PROC CHANGES RESULTING IN LESS PLT SITUATIONAL AWARENESS AND A GREATLY DECREASED SAFETY MARGIN.
Narrative: THIS IS MY FIRST PAIRING UTILIZING THE NEW PHASE DEP PROCS IN EFFECT SINCE SEP/FRI/06. DUE TO A SHORT TAXI DISTANCE; FROM THE GATE TO RWY; BOTH ENGS WERE STARTED PRIOR TO TAXI. THE NEW PROCS CALL FOR THE CAPT TO COMPLETE HIS FLT CTL CHK PRIOR TO THE FO COMMENCING HIS FLT CTL CHK AND THUS TRIGGERING THE REST OF THE FO TAXI FLOW. THIS CHANGE BIASES THE TAXI CHKLIST TO A LATER POINT IN THE TAXI TIMELINE THAN THE OLD PROCS. BECAUSE OF THIS CHANGE WE WERE STILL COMPLETING THE ABOVE-THE-LINE PORTION OF THE TAXI CHKLIST WHEN THE LCL (TWR) CTLR CONTACTED US. IN ADDITION TO SHIFTING THE WORKLOAD TO LATER IN THE TAXI FLOW THE NEW PROCS REQUIRE MORE VERBAL BACK AND FORTH. THERE IS MUCH MORE TALKING GOING ON THAN BEFORE. IT WAS MY BELIEF THAT WE HAD BEEN CLRED FOR TKOF AND AS I TAXIED THE ACFT FORWARD I ACTIVATED THE LNDG AND TKOF LIGHTS. I HEARD ONLY THE LCL CTLR AND WAS NOT ABLE TO LISTEN TO OUR READBACK BECAUSE I WAS STILL INVOLVED IN XCHKING. WHILE TAXIING ONTO THE RWY INSTEAD OF LISTENING FOR TWR XMISSIONS THE FO WAS PULLING OUT THE FLT RELEASE IN ORDER TO COMPLY WITH THE BELOW-THE-LINE PROVISIONS OF THE CHKLIST; WHICH REQUIRE HIM TO LOOK UP AND VERIFY MINIMUM BRAKE RELEASE FUEL. I WAS UNABLE TO DEVOTE FULL ATTN TO TWR XMISSIONS AS I NOW HAVE TO LISTEN TO THE FO RECITE THE BELOW-THE-LINE PORTION OF THE CHKLIST WHILE ENTERING THE RWY ENVIRONMENT. NONE OF THESE ITEMS ARE FLT CRITICAL. PRIOR TO ADVANCING THE THRUST LEVERS I CONFIRMED WITH THE FO THAT WE WERE CLRED FOR TKOF AND HE AGREED THAT WE WERE INDEED CLRED. I RELEASED THE BRAKES AND STOOD THE THRUST LEVERS UP FOR A STABILIZED SPOOL UP. AS WE STARTED THE ROLL I LOOKED UP AND SAW AN MD80 ROLLING OUT ON XX. SIMULTANEOUSLY THE LCL CTLR XMITTED 'ACR X STOP.' I ABORTED THE TKOF AT APPROX 40 KIAS PRIOR TO TKOF THRUST BEING SET. UTILIZING OLD PROCS THE TAXI CHKLIST WAS COMPLETED WELL BEFORE THE HOLD SHORT LINE. UNDER THE OLD PROCS THE CAPT'S FLOW WAS THE LAST FLOW AND UPON COMPLETION HE/SHE COULD CALL FOR THE TAXI CHKLIST TO BE ACCOMPLISHED. THE FO FLOW HAS NOW BEEN RESEQUENCED LATER IN THE TAXI TIMELINE TO OCCUR AFTER THE CAPT FLT CTL CHK. THIS CHANGE; ESPECIALLY WHEN COUPLED WITH A SINGLE ENG TAXI; CAUSES THE CHKLIST TO BE COMPLETED LATER. IN SITUATIONS WHERE A SHORT TAXI TIME EXISTS THIS SHIFTING INCREASES THE WORKLOAD AT THE MOST CRITICAL POINT IN THE GND PHASE. THE NEW PROCS ALSO SPLIT THE TAXI CHKLIST INTO AN ABOVE; AND A BELOW-THE-LINE SECTION. PUBLISHED GUIDANCE CALLS FOR THE BELOW-THE-LINE PORTION TO BE COMPLETED PRIOR TO TAKING THE RWY. THOUGH THERE IS SOME DEBATE ABOUT WHAT THIS MEANS IT WAS MY UNDERSTANDING THAT THIS EMPHASIZED THAT THE BELOW THE LINE PORTION SHOULD NOT BE COMPLETED BEFORE THE ACFT WAS AT LEAST THE FIRST ONE HOLDING SHORT OF THE RWY. THE FACT THAT THE FIRST AND ONLY CHALLENGE-RESPONSE ITEM ON THIS PORTION OF THE CHKLIST IS THE MINIMUM BRAKE RELEASE FUEL EMPHASIZES THE POINT. THOUGH THERE IS NO QUESTION THAT I SHARE CULPABILITY FOR THIS EVENT I FEEL THAT THE PROCS NOW IN EFFECT ARE DETRIMENTAL TO SAFETY. OUR MANDATORY READ FILE INCLUDED INFO ON 2 RWY INCURSIONS THAT OCCURRED IN BOSTON. THAT ACR GETS THEIR FINAL WT AND BAL DATA VIA ACARS AFTER GATE DEP. IN AT LEAST ONE OF THESE INCIDENTS THE ACARS WAS INOP AND THE FO WAS ABSORBED IN GETTING THE WT AND BAL DATA OVER THE RADIO AND INPUTTING IT INTO THE FMS WHEN THE INCURSION OCCURRED. THOUGH WE STILL RECEIVE A HARD COPY OF THE WT AND BAL PRIOR TO PUSHBACK IT IS MY UNDERSTANDING THAT WE WILL BE ADOPTING THE ACARS METHOD OF RECEIVING THIS INFO. I AM ALARMED THAT WE SEEM TO BE ADOPTING PROCS THAT INCREASE THE WORKLOAD DURING THE SECOND MOST CRITICAL PHASE OF FLT. IN THE FUTURE WE WILL ALSO BE GETTING OUR TKOF DATA VIA ACARS AND INPUTTING IT DURING THE TAXI PHASE. THESE TASKS CAN BE SAFELY AND EFFICIENTLY ACCOMPLISHED AT THE GATE PRIOR TO PUSHBACK. IT IS MY BELIEF THAT MOVING NON CRITICAL TASKS FROM THE BEFORE START PHASE TO THE CRITICAL TAXI FOR DEP PHASE IS NOT IN THE BEST INTEREST OF SAFETY. THE NEW PROCS REQUIRE MUCH MORE CROSS TALK THAN THE OLD PROCS. IT IS A DISTRACTING NON VALUE ADDED CHANGE IN PROC. I WILL INSIST THAT THE TAXI CHKLIST BE COMPLETED IN ITS ENTIRETY INSTEAD OF SPLITTING IT INTO 2 PARTS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT HIS ACR IS INSTITUTING MORE CHKLIST PROC CHANGES IN THE NEAR FUTURE THAT RELY ON PLTS MEMORIZING PROCEDURAL FLOWS AND RELYING LESS ON REVIEWING CHKLISTS FOR COMPLETED TASKS. IN THE RPTR'S OPINION THE CHANGES MADE SO FAR MOVE AWAY FROM SAFETY CONCERNS AND INTO AN AREA THAT DISREGARDS EVEN SIMPLE HUMAN CONSIDERATIONS. HIS ACR IS NOT INTERESTED IN PLT'S FEEDBACK ABOUT THE SAFETY IMPACT OF THE CHANGES ALREADY INSTITUTED.
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.