37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 726360 |
Time | |
Date | 200702 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Rain Ice |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : dca.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 | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 726360 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 726359 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Company |
Primary Problem | Ambiguous |
Narrative:
It was night takeoff and a light drizzle and mist had just stopped. It was 2 degrees celsius and last reported winds were 290 at 3 KTS. We had deiced frost and thin ice layer from under the wings caused by fueling and then used type iv anti-ice fluid for the light drizzle on a cold soaked wing. Engine heat was used as well. The active runway was runway 01. Winds had been out of the south; and we could not accept a tailwind; so we requested runway 19. The maximum power takeoff on runway 19 called for flaps 17; and an a/C on EPR setting of 2.00 with runway limit of 151.2K pounds. As we taxied out; the winds shifted to 290; so we accepted runway 01. Runway 01 called for flaps 15; an a/C off EPR of 2.03; new V speeds and had a runway limit of 148.7. The new data was read to me for review; and we changed our flaps and V speeds for runway 01. We reviewed the new weight limit and other new settings but somehow missed the a/C off setting and took off a/C on. Our actual weight just prior to brake release was 148.2K pounds (rounded up). The first officer was PF. We were cleared for takeoff and while turning onto the runway were told by tower to 'keep it rolling air carrier X. Landing traffic on a 2 mile final.' by the time I had the aircraft turned onto the centerline; the throttles were at 1.6 EPR and accelerating. Automatic throttles were engaged and were at 2.00 EPR almost immediately. Aircraft acceleration seemed normal for a maximum weight takeoff at the runway limit. As PNF I called 'V-1' and 'rotate' at the appropriate speeds. The distance down the runway was longer than the usual winter takeoff and was more consistent with a summer day maximum weight effort. The nose of the aircraft had started up simultaneously with the start of my 'rotate' call; and we rotated to 7 degrees nose up. The plane flew normally; and at 20 ft on the radio altimeter the first officer increased the deck angle from the initial 7 degrees nose up to about 12 degrees nose up. Radio altimeter at the end of the runway showed about 50 to 70 ft AGL. Above 1000 ft AGL the airfoil anti ice was turned on and the 'no mode' light illuminated on the tri. I confirmed the bleed setup was correct. I then turned all anti-ice systems off with pneumatic crossfeeds closed; then crossfeeds open and systems back on twice with the same results. At that point I left the switches in the normal anti-ice on positions and; after verifying that anti-ice appeared to be operating normally; went back to the PNF duties and checklists. Above 10000 ft MSL I looked in the QRH for any abnormal procedure for the 'no mode' light and found there were none. At 17000 ft MSL the 'no mode' light went out. I momentarily turned off the engine heat to force a 'no mode' situation to verify the light did not merely burn out. In this condition the light illuminated normally and went out as I put the engine heat back on. At FL180 we exited the icing conditions so I activated the tail anti-ice cycle. It was normal; then I secured the systems. The a/C off note on the tps was still missed despite reviewing the data numerous times. I finally saw it when looking at the tps at home for a report on the possible bleed problem. In flight; after our discussion; I felt that we must have been heavier than our closeout showed; based primarily on the many heavy roll aboard bags brought on by the 132 passenger. I contacted dispatch and requested a weight audit on arrival. When completed; the audit showed 3 bags more in the cargo area than the final load count showed. Using the FAA averages I was told this amounted to 108 additional pounds. Maintenance on scene agreed they saw many large roll aboard bags being taken off the plane; so they completed an overweight inspection while awaiting the audit results. The audit showed weight as in the closeout with the addition of the 108 pounds indicated above; based upon FAA procedures. Maintenance also looked at the 'no mode' problem and was going to placard the tri until they found there was a history of this from a week earlier. The aircraft went out of service for the repair. The three contributing factors here are a missed performance setting; a faulty bleed sensor; and a preponderance of big roll aboard bags. The one item I can control is my procedures for a runway change. I had the new data read to me for review as I set it on my instruments. We then re-did the applicable checklist items to verify the new settings. In the future I will add to the review process by rereading the hard copy of the data on a runway change myself prior to reviewing the new data with the first officer and redoing the checklist.
Original NASA ASRS Text
Title: AN MD80 TKOF DISTANCE WAS EXCESSIVE DUE TO INACCURATE BAGGAGE WT; A BLEED AIR MALFUNCTION; AND THE CREW FAILING TO TURN OFF AIR CONDITIONING.
Narrative: IT WAS NIGHT TAKEOFF AND A LIGHT DRIZZLE AND MIST HAD JUST STOPPED. IT WAS 2 DEGS CELSIUS AND LAST RPTED WINDS WERE 290 AT 3 KTS. WE HAD DEICED FROST AND THIN ICE LAYER FROM UNDER THE WINGS CAUSED BY FUELING AND THEN USED TYPE IV ANTI-ICE FLUID FOR THE LIGHT DRIZZLE ON A COLD SOAKED WING. ENG HEAT WAS USED AS WELL. THE ACTIVE RWY WAS RWY 01. WINDS HAD BEEN OUT OF THE SOUTH; AND WE COULD NOT ACCEPT A TAILWIND; SO WE REQUESTED RWY 19. THE MAXIMUM POWER TKOF ON RWY 19 CALLED FOR FLAPS 17; AND AN A/C ON EPR SETTING OF 2.00 WITH RWY LIMIT OF 151.2K LBS. AS WE TAXIED OUT; THE WINDS SHIFTED TO 290; SO WE ACCEPTED RWY 01. RWY 01 CALLED FOR FLAPS 15; AN A/C OFF EPR OF 2.03; NEW V SPDS AND HAD A RWY LIMIT OF 148.7. THE NEW DATA WAS READ TO ME FOR REVIEW; AND WE CHANGED OUR FLAPS AND V SPDS FOR RWY 01. WE REVIEWED THE NEW WT LIMIT AND OTHER NEW SETTINGS BUT SOMEHOW MISSED THE A/C OFF SETTING AND TOOK OFF A/C ON. OUR ACTUAL WT JUST PRIOR TO BRAKE RELEASE WAS 148.2K LBS (ROUNDED UP). THE FO WAS PF. WE WERE CLRED FOR TKOF AND WHILE TURNING ONTO THE RWY WERE TOLD BY TWR TO 'KEEP IT ROLLING ACR X. LNDG TFC ON A 2 MILE FINAL.' BY THE TIME I HAD THE ACFT TURNED ONTO THE CTRLINE; THE THROTTLES WERE AT 1.6 EPR AND ACCELERATING. AUTO THROTTLES WERE ENGAGED AND WERE AT 2.00 EPR ALMOST IMMEDIATELY. ACFT ACCELERATION SEEMED NORMAL FOR A MAXIMUM WT TKOF AT THE RWY LIMIT. AS PNF I CALLED 'V-1' AND 'ROTATE' AT THE APPROPRIATE SPDS. THE DISTANCE DOWN THE RWY WAS LONGER THAN THE USUAL WINTER TKOF AND WAS MORE CONSISTENT WITH A SUMMER DAY MAXIMUM WEIGHT EFFORT. THE NOSE OF THE ACFT HAD STARTED UP SIMULTANEOUSLY WITH THE START OF MY 'ROTATE' CALL; AND WE ROTATED TO 7 DEGS NOSE UP. THE PLANE FLEW NORMALLY; AND AT 20 FT ON THE RADIO ALTIMETER THE FO INCREASED THE DECK ANGLE FROM THE INITIAL 7 DEGS NOSE UP TO ABOUT 12 DEGS NOSE UP. RADIO ALTIMETER AT THE END OF THE RWY SHOWED ABOUT 50 TO 70 FT AGL. ABOVE 1000 FT AGL THE AIRFOIL ANTI ICE WAS TURNED ON AND THE 'NO MODE' LIGHT ILLUMINATED ON THE TRI. I CONFIRMED THE BLEED SETUP WAS CORRECT. I THEN TURNED ALL ANTI-ICE SYSTEMS OFF WITH PNEUMATIC CROSSFEEDS CLOSED; THEN CROSSFEEDS OPEN AND SYSTEMS BACK ON TWICE WITH THE SAME RESULTS. AT THAT POINT I LEFT THE SWITCHES IN THE NORMAL ANTI-ICE ON POSITIONS AND; AFTER VERIFYING THAT ANTI-ICE APPEARED TO BE OPERATING NORMALLY; WENT BACK TO THE PNF DUTIES AND CHKLISTS. ABOVE 10000 FT MSL I LOOKED IN THE QRH FOR ANY ABNORMAL PROC FOR THE 'NO MODE' LIGHT AND FOUND THERE WERE NONE. AT 17000 FT MSL THE 'NO MODE' LIGHT WENT OUT. I MOMENTARILY TURNED OFF THE ENG HEAT TO FORCE A 'NO MODE' SITUATION TO VERIFY THE LIGHT DID NOT MERELY BURN OUT. IN THIS CONDITION THE LIGHT ILLUMINATED NORMALLY AND WENT OUT AS I PUT THE ENG HEAT BACK ON. AT FL180 WE EXITED THE ICING CONDITIONS SO I ACTIVATED THE TAIL ANTI-ICE CYCLE. IT WAS NORMAL; THEN I SECURED THE SYSTEMS. THE A/C OFF NOTE ON THE TPS WAS STILL MISSED DESPITE REVIEWING THE DATA NUMEROUS TIMES. I FINALLY SAW IT WHEN LOOKING AT THE TPS AT HOME FOR A RPT ON THE POSSIBLE BLEED PROB. IN FLT; AFTER OUR DISCUSSION; I FELT THAT WE MUST HAVE BEEN HEAVIER THAN OUR CLOSEOUT SHOWED; BASED PRIMARILY ON THE MANY HEAVY ROLL ABOARD BAGS BROUGHT ON BY THE 132 PAX. I CONTACTED DISPATCH AND REQUESTED A WT AUDIT ON ARR. WHEN COMPLETED; THE AUDIT SHOWED 3 BAGS MORE IN THE CARGO AREA THAN THE FINAL LOAD COUNT SHOWED. USING THE FAA AVERAGES I WAS TOLD THIS AMOUNTED TO 108 ADDITIONAL POUNDS. MAINT ON SCENE AGREED THEY SAW MANY LARGE ROLL ABOARD BAGS BEING TAKEN OFF THE PLANE; SO THEY COMPLETED AN OVERWT INSPECTION WHILE AWAITING THE AUDIT RESULTS. THE AUDIT SHOWED WT AS IN THE CLOSEOUT WITH THE ADDITION OF THE 108 POUNDS INDICATED ABOVE; BASED UPON FAA PROCS. MAINT ALSO LOOKED AT THE 'NO MODE' PROB AND WAS GOING TO PLACARD THE TRI UNTIL THEY FOUND THERE WAS A HISTORY OF THIS FROM A WEEK EARLIER. THE ACFT WENT OUT OF SVC FOR THE REPAIR. THE THREE CONTRIBUTING FACTORS HERE ARE A MISSED PERFORMANCE SETTING; A FAULTY BLEED SENSOR; AND A PREPONDERANCE OF BIG ROLL ABOARD BAGS. THE ONE ITEM I CAN CONTROL IS MY PROCS FOR A RWY CHANGE. I HAD THE NEW DATA READ TO ME FOR REVIEW AS I SET IT ON MY INSTRUMENTS. WE THEN RE-DID THE APPLICABLE CHKLIST ITEMS TO VERIFY THE NEW SETTINGS. IN THE FUTURE I WILL ADD TO THE REVIEW PROCESS BY REREADING THE HARD COPY OF THE DATA ON A RWY CHANGE MYSELF PRIOR TO REVIEWING THE NEW DATA WITH THE FO AND REDOING THE 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.