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Attributes | |
ACN | 721923 |
Time | |
Date | 200612 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 180 |
ASRS Report | 721923 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 110 flight time type : 180 |
ASRS Report | 721920 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Bottom line was we missed some switch positions after maintenance was done on aircraft. This was the culmination of an extended maintenance delay and long situation time. Although we were not fatigued we were definitely tired. Duty start: xd:22. I had awakened that day at xa:00. Landed in ZZZ1 at xf:30. Aircraft change and scheduled to depart at xi:00. Our aircraft arrived with a 'display source' warning on both pilots outer display unit. Extended ground time awaiting part. Finally pushed back around xn:00. After engine start had 'master caution' and 'engine' annunciator illuminate. Noted that both number one and two engine electronic engine controls were in 'altn' mode. Should have just selected 'on' for both electronic engine controls but interpreted this as a malfunction. This the result of the previous display electronic unit malfunction and maintenance work. We departed with an enroute MEL unnecessarily. After takeoff 'master caution' and 'flight cont' annunciator illuminated. Noted amber 'speed trim failure' warning light on overhead flight control panel illuminated. Completed departure and after T/O check and speed trim failure checklist in QRH. Then noted that autopilot(south) would not engage. Realized that we were no longer rvsm equipped and stopped climb at FL280. Forty five minutes after takeoff noted that autopilot 'stabilizer trim' cutout switch was 'off.' reset switch; restored autopilot and resumed rvsm operations. Made the correlation that this was also the cause of the speed trim failure. Dark flight deck and stabilizer trim cutout switch panel is not backlit. Switches appeared in normal position and could not see red band in the dark. Lesson learned: don't just look; physically touch switch and guard in right position. Perhaps add a step to 'speed trim failure checklist' to include check of stabilizer trim a/P cutout switch.
Original NASA ASRS Text
Title: A B737-700 PLT DESCRIBES DEPARTING WITH THE AP 'STAB TRIM' SWITCH INADVERTENTLY 'OFF' PREVENTING RVSM OP.
Narrative: BOTTOM LINE WAS WE MISSED SOME SWITCH POSITIONS AFTER MAINT WAS DONE ON ACFT. THIS WAS THE CULMINATION OF AN EXTENDED MAINT DELAY AND LONG SIT TIME. ALTHOUGH WE WERE NOT FATIGUED WE WERE DEFINITELY TIRED. DUTY START: XD:22. I HAD AWAKENED THAT DAY AT XA:00. LANDED IN ZZZ1 AT XF:30. ACFT CHANGE AND SCHEDULED TO DEPART AT XI:00. OUR ACFT ARRIVED WITH A 'DISPLAY SOURCE' WARNING ON BOTH PLTS OUTER DISPLAY UNIT. EXTENDED GND TIME AWAITING PART. FINALLY PUSHED BACK AROUND XN:00. AFTER ENGINE START HAD 'MASTER CAUTION' AND 'ENG' ANNUNCIATOR ILLUMINATE. NOTED THAT BOTH NUMBER ONE AND TWO ENGINE ELECTRONIC ENG CONTROLS WERE IN 'ALTN' MODE. SHOULD HAVE JUST SELECTED 'ON' FOR BOTH ELECTRONIC ENG CONTROLS BUT INTERPRETED THIS AS A MALFUNCTION. THIS THE RESULT OF THE PREVIOUS DISPLAY ELECTRONIC UNIT MALFUNCTION AND MAINT WORK. WE DEPARTED WITH AN ENROUTE MEL UNNECESSARILY. AFTER TAKEOFF 'MASTER CAUTION' AND 'FLT CONT' ANNUNCIATOR ILLUMINATED. NOTED AMBER 'SPEED TRIM FAILURE' WARNING LIGHT ON OVERHEAD FLIGHT CONTROL PANEL ILLUMINATED. COMPLETED DEP AND AFTER T/O CHECK AND SPEED TRIM FAILURE CHECKLIST IN QRH. THEN NOTED THAT AUTOPILOT(S) WOULD NOT ENGAGE. REALIZED THAT WE WERE NO LONGER RVSM EQUIPPED AND STOPPED CLIMB AT FL280. FORTY FIVE MINUTES AFTER TAKEOFF NOTED THAT AUTOPILOT 'STAB TRIM' CUTOUT SWITCH WAS 'OFF.' RESET SWITCH; RESTORED AUTOPILOT AND RESUMED RVSM OPS. MADE THE CORRELATION THAT THIS WAS ALSO THE CAUSE OF THE SPEED TRIM FAILURE. DARK FLIGHT DECK AND STAB TRIM CUTOUT SWITCH PANEL IS NOT BACKLIT. SWITCHES APPEARED IN NORMAL POSITION AND COULD NOT SEE RED BAND IN THE DARK. LESSON LEARNED: DON'T JUST LOOK; PHYSICALLY TOUCH SWITCH AND GUARD IN RIGHT POSITION. PERHAPS ADD A STEP TO 'SPEED TRIM FAILURE CHECKLIST' TO INCLUDE CHECK OF STAB TRIM A/P CUTOUT SWITCH.
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.