37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 715069 |
Time | |
Date | 200610 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sna.airport |
State Reference | CA |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | other |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure : noise abatement |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 715069 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
New first officer; 3 weeks out of oe. First sna departure. Flaps 15 degrees takeoff due to performance. We briefed the departure and talked about other items. The first officer had no questions; but seemed a little anxious that we were pushing a few mins late; so I emphasized it was important to not to rush the cutback procedure tasks; but to perform them in a deliberate; methodical manner. Just before taking the runway we were told to maintain 4000 ft on departure; then were cleared for an 'immediate takeoff due to traffic on final' before we were in position. I called for cutback procedure at 800 ft; and just as the first officer began her flow; tower switched us over to departure. On initial contact socal cleared us to climb to 7000 ft; which the first officer acknowledged and set. Within seconds socal amended our altitude to maintain 4000 ft due to traffic at 11 O'clock position at 4700 ft. I sensed the first officer was getting a little saturated and flustered; and engaged the autoplt as soon as possible after getting the aircraft in trim; and began searching for the traffic. At that point all FMA indications seemed normal; and I was flying using the hgs and anticipating beginning to clean up at 3000 ft. After a few mins; I noticed a loud rumbling; and after a quick check of the instruments; decided that it was just that we were in a bit of non-normal confign; still at flaps 15 degrees. Because the autoplt was on; I was watching for traffic; and I had observed the speed was correct at 160 KTS (V2+20 KTS) when the first officer selected level change; I totally overlooked the fact that we were accelerating. Suddenly; the first officer; thinking she had missed a call; moved the flap handle to 5 degrees and said something to the effect that we should be cleaning up. I was starting to correct her when she said we were about to overspd the flaps. At that point I looked down and realized we were over 205 KTS. After resuming the profile and getting to cruise; we reviewed the incident and the proper sequence and agreed that at some point during or just after she performed the cutback procedure she set the speed to 220 KTS; rather than V2+20 KTS. Possibly she glanced down at the notes on the 10-7 profile and simply misread 'V2+20' as '220.' because she was quick in moving the flap handle to 5 degrees; we both felt we had not caused an exceedance; but agreed it was prudent to log a write-up of a possible overspd of 1-2 KTS; and sent an ACARS to maintenance to that effect. I have not had an incident of this type in quite some time; but it was good reminder to be more diligent of all parameters when the autoplt is on; to better monitor the first officer's actions; and very importantly; to identify the cause of any abnormal indications such as unusual sounds and vibrations.
Original NASA ASRS Text
Title: A B737-400 ON DEP OUT OF SNA EXPERIENCED A FLAP OVERSPD BECAUSE THE COMMANDED SPD WAS SET WRONG.
Narrative: NEW FO; 3 WKS OUT OF OE. FIRST SNA DEP. FLAPS 15 DEGS TKOF DUE TO PERFORMANCE. WE BRIEFED THE DEP AND TALKED ABOUT OTHER ITEMS. THE FO HAD NO QUESTIONS; BUT SEEMED A LITTLE ANXIOUS THAT WE WERE PUSHING A FEW MINS LATE; SO I EMPHASIZED IT WAS IMPORTANT TO NOT TO RUSH THE CUTBACK PROC TASKS; BUT TO PERFORM THEM IN A DELIBERATE; METHODICAL MANNER. JUST BEFORE TAKING THE RWY WE WERE TOLD TO MAINTAIN 4000 FT ON DEP; THEN WERE CLRED FOR AN 'IMMEDIATE TKOF DUE TO TFC ON FINAL' BEFORE WE WERE IN POS. I CALLED FOR CUTBACK PROC AT 800 FT; AND JUST AS THE FO BEGAN HER FLOW; TWR SWITCHED US OVER TO DEP. ON INITIAL CONTACT SOCAL CLRED US TO CLB TO 7000 FT; WHICH THE FO ACKNOWLEDGED AND SET. WITHIN SECONDS SOCAL AMENDED OUR ALT TO MAINTAIN 4000 FT DUE TO TFC AT 11 O'CLOCK POS AT 4700 FT. I SENSED THE FO WAS GETTING A LITTLE SATURATED AND FLUSTERED; AND ENGAGED THE AUTOPLT ASAP AFTER GETTING THE ACFT IN TRIM; AND BEGAN SEARCHING FOR THE TFC. AT THAT POINT ALL FMA INDICATIONS SEEMED NORMAL; AND I WAS FLYING USING THE HGS AND ANTICIPATING BEGINNING TO CLEAN UP AT 3000 FT. AFTER A FEW MINS; I NOTICED A LOUD RUMBLING; AND AFTER A QUICK CHK OF THE INSTS; DECIDED THAT IT WAS JUST THAT WE WERE IN A BIT OF NON-NORMAL CONFIGN; STILL AT FLAPS 15 DEGS. BECAUSE THE AUTOPLT WAS ON; I WAS WATCHING FOR TFC; AND I HAD OBSERVED THE SPD WAS CORRECT AT 160 KTS (V2+20 KTS) WHEN THE FO SELECTED LEVEL CHANGE; I TOTALLY OVERLOOKED THE FACT THAT WE WERE ACCELERATING. SUDDENLY; THE FO; THINKING SHE HAD MISSED A CALL; MOVED THE FLAP HANDLE TO 5 DEGS AND SAID SOMETHING TO THE EFFECT THAT WE SHOULD BE CLEANING UP. I WAS STARTING TO CORRECT HER WHEN SHE SAID WE WERE ABOUT TO OVERSPD THE FLAPS. AT THAT POINT I LOOKED DOWN AND REALIZED WE WERE OVER 205 KTS. AFTER RESUMING THE PROFILE AND GETTING TO CRUISE; WE REVIEWED THE INCIDENT AND THE PROPER SEQUENCE AND AGREED THAT AT SOME POINT DURING OR JUST AFTER SHE PERFORMED THE CUTBACK PROC SHE SET THE SPD TO 220 KTS; RATHER THAN V2+20 KTS. POSSIBLY SHE GLANCED DOWN AT THE NOTES ON THE 10-7 PROFILE AND SIMPLY MISREAD 'V2+20' AS '220.' BECAUSE SHE WAS QUICK IN MOVING THE FLAP HANDLE TO 5 DEGS; WE BOTH FELT WE HAD NOT CAUSED AN EXCEEDANCE; BUT AGREED IT WAS PRUDENT TO LOG A WRITE-UP OF A POSSIBLE OVERSPD OF 1-2 KTS; AND SENT AN ACARS TO MAINT TO THAT EFFECT. I HAVE NOT HAD AN INCIDENT OF THIS TYPE IN QUITE SOME TIME; BUT IT WAS GOOD REMINDER TO BE MORE DILIGENT OF ALL PARAMETERS WHEN THE AUTOPLT IS ON; TO BETTER MONITOR THE FO'S ACTIONS; AND VERY IMPORTANTLY; TO IDENT THE CAUSE OF ANY ABNORMAL INDICATIONS SUCH AS UNUSUAL SOUNDS AND VIBRATIONS.
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.