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|
Attributes | |
ACN | 712806 |
Time | |
Date | 200610 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mco.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 60 flight time total : 15000 flight time type : 60 |
ASRS Report | 712806 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | non adherence : published procedure non adherence : far non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : tkof warning horn |
Resolutory Action | flight crew : rejected takeoff |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Got task saturated on taxi out for takeoff. Tried to advance power for takeoff. Flaps were at zero not at required setting of 5 degrees. Event could have been catastrophic. Had it not been for takeoff warning horn installed in aircraft; end result would have been different. Entirely human factors caused this near mishap. Barriers that are in place at my airline (checklists/flows) were blown through. Captain was in a hurry because we were running late; thus jeopardizing many passenger connections. Chain of events started when captain called for non normal sequence on engine start. At our airline; you either start both engines at the gate; or start 1 engine at the gate and 1 on taxi out for fuel conservation. This particular captain; on every engine start; insisted on starting 1 engine after pushback. Then he would start rolling forward telling me to call ground control for taxi clearance; after which time he would immediately ask me to start the opposite engine. This breaks the habit pattern and procedure at my airline of calling 'flaps 5 degrees; taxi' after starting both engines or 1 engine based on captain's discretion at the gate -- not while rolling. Other human factors and considerations: 1) on taxi out; active runway changed from runway 36R to runway 18L causing a heads down scramble for weight and balance and takeoff data. 2) cockpit was extremely loud on this aircraft due to an air flow problem. 3) squawk was mistakenly set from pre departure clearance departure time. That is; 'XXXX' instead of the actual squawk. This became an issue on the ground in orlando; because mco is one of the few airports in the country with asde-X installed. They queried us and we corrected the squawk on taxi out (also heads down). 4) we forgot to do the before takeoff (now known as 'taxi') checklist.
Original NASA ASRS Text
Title: A B757 GOT A TKOF WARNING HORN ON TKOF ROLL AT MCO BECAUSE THE CREW HAD NOT SET THE FLAPS TO TKOF POS.
Narrative: GOT TASK SATURATED ON TAXI OUT FOR TKOF. TRIED TO ADVANCE PWR FOR TKOF. FLAPS WERE AT ZERO NOT AT REQUIRED SETTING OF 5 DEGS. EVENT COULD HAVE BEEN CATASTROPHIC. HAD IT NOT BEEN FOR TKOF WARNING HORN INSTALLED IN ACFT; END RESULT WOULD HAVE BEEN DIFFERENT. ENTIRELY HUMAN FACTORS CAUSED THIS NEAR MISHAP. BARRIERS THAT ARE IN PLACE AT MY AIRLINE (CHKLISTS/FLOWS) WERE BLOWN THROUGH. CAPT WAS IN A HURRY BECAUSE WE WERE RUNNING LATE; THUS JEOPARDIZING MANY PAX CONNECTIONS. CHAIN OF EVENTS STARTED WHEN CAPT CALLED FOR NON NORMAL SEQUENCE ON ENG START. AT OUR AIRLINE; YOU EITHER START BOTH ENGS AT THE GATE; OR START 1 ENG AT THE GATE AND 1 ON TAXI OUT FOR FUEL CONSERVATION. THIS PARTICULAR CAPT; ON EVERY ENG START; INSISTED ON STARTING 1 ENG AFTER PUSHBACK. THEN HE WOULD START ROLLING FORWARD TELLING ME TO CALL GND CTL FOR TAXI CLRNC; AFTER WHICH TIME HE WOULD IMMEDIATELY ASK ME TO START THE OPPOSITE ENG. THIS BREAKS THE HABIT PATTERN AND PROC AT MY AIRLINE OF CALLING 'FLAPS 5 DEGS; TAXI' AFTER STARTING BOTH ENGS OR 1 ENG BASED ON CAPT'S DISCRETION AT THE GATE -- NOT WHILE ROLLING. OTHER HUMAN FACTORS AND CONSIDERATIONS: 1) ON TAXI OUT; ACTIVE RWY CHANGED FROM RWY 36R TO RWY 18L CAUSING A HEADS DOWN SCRAMBLE FOR WT AND BAL AND TKOF DATA. 2) COCKPIT WAS EXTREMELY LOUD ON THIS ACFT DUE TO AN AIR FLOW PROB. 3) SQUAWK WAS MISTAKENLY SET FROM PDC DEP TIME. THAT IS; 'XXXX' INSTEAD OF THE ACTUAL SQUAWK. THIS BECAME AN ISSUE ON THE GND IN ORLANDO; BECAUSE MCO IS ONE OF THE FEW ARPTS IN THE COUNTRY WITH ASDE-X INSTALLED. THEY QUERIED US AND WE CORRECTED THE SQUAWK ON TAXI OUT (ALSO HEADS DOWN). 4) WE FORGOT TO DO THE BEFORE TKOF (NOW KNOWN AS 'TAXI') CHKLIST.
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.