37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 787674 |
Time | |
Date | 200805 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
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 : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 186 flight time total : 14500 flight time type : 2300 |
ASRS Report | 787674 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 14000 flight time type : 3500 |
ASRS Report | 787675 |
Events | |
Anomaly | non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
During the preparation of the load manifest; critical numerical information was transposed from the load information sheet to the load manifest. This data is manually xferred to the load manifest; and then manually converted into an index number that is placed on the load manifest. The process is conducted in a high workload environment with many interruptions and distrs. On the day of the incident we were operating as an international 2 pilot crew. This is very unusual for operations at this airline and increases the workload normally encountered by the flight deck crews. As the load manifest was being prepared; many people came and went from the flight deck. These workers included maintenance personnel; flight attendants; ground service agent; the local handler and others each with an inquiry or need from either myself or the captain. During a 3 pilot operation; much of this traffic to and from the flight deck is avoided or intercepted by third pilot. On this day it fell to whichever of the 2 pilots least engaged to hand the inquires. Although I have not yet reviewed the documentation from this flight; I am told that load figures were transposed resulting in an 8800 KG weight discrepancy. This could have only resulted from the amount of traffic moving on and off the flight deck creating many distrs. At times during the preflight perpetrations as many as 5 people at once were on the flight deck of the B757; all trying to accomplish task necessary for our departure. Prevention of a possible recurrence could be achieved by limiting the traffic to and from the flight deck. Additionally; adding a protocol that requires a person entering the flight deck to wait for acknowledgement by the flight crew before presenting information or making inquiries could also help in reducing distrs at critical points. Distrs in a high workload environment cannot completely be avoided. However; adding the suggested protocol to the company procedures might reduce the number of critical point distraction encounters on the flight deck.
Original NASA ASRS Text
Title: B757 FLT CREW REPORTS 19000 POUND LOAD MANIFEST ERROR INTRODUCED DURING MANUAL CALCULATIONS BY FO. ERROR DISCOVERED POST FLIGHT.
Narrative: DURING THE PREPARATION OF THE LOAD MANIFEST; CRITICAL NUMERICAL INFO WAS TRANSPOSED FROM THE LOAD INFO SHEET TO THE LOAD MANIFEST. THIS DATA IS MANUALLY XFERRED TO THE LOAD MANIFEST; AND THEN MANUALLY CONVERTED INTO AN INDEX NUMBER THAT IS PLACED ON THE LOAD MANIFEST. THE PROCESS IS CONDUCTED IN A HIGH WORKLOAD ENVIRONMENT WITH MANY INTERRUPTIONS AND DISTRS. ON THE DAY OF THE INCIDENT WE WERE OPERATING AS AN INTL 2 PLT CREW. THIS IS VERY UNUSUAL FOR OPS AT THIS AIRLINE AND INCREASES THE WORKLOAD NORMALLY ENCOUNTERED BY THE FLT DECK CREWS. AS THE LOAD MANIFEST WAS BEING PREPARED; MANY PEOPLE CAME AND WENT FROM THE FLT DECK. THESE WORKERS INCLUDED MAINT PERSONNEL; FLT ATTENDANTS; GND SVC AGENT; THE LCL HANDLER AND OTHERS EACH WITH AN INQUIRY OR NEED FROM EITHER MYSELF OR THE CAPT. DURING A 3 PLT OP; MUCH OF THIS TFC TO AND FROM THE FLT DECK IS AVOIDED OR INTERCEPTED BY THIRD PLT. ON THIS DAY IT FELL TO WHICHEVER OF THE 2 PLTS LEAST ENGAGED TO HAND THE INQUIRES. ALTHOUGH I HAVE NOT YET REVIEWED THE DOCUMENTATION FROM THIS FLT; I AM TOLD THAT LOAD FIGURES WERE TRANSPOSED RESULTING IN AN 8800 KG WT DISCREPANCY. THIS COULD HAVE ONLY RESULTED FROM THE AMOUNT OF TFC MOVING ON AND OFF THE FLT DECK CREATING MANY DISTRS. AT TIMES DURING THE PREFLT PERPETRATIONS AS MANY AS 5 PEOPLE AT ONCE WERE ON THE FLT DECK OF THE B757; ALL TRYING TO ACCOMPLISH TASK NECESSARY FOR OUR DEP. PREVENTION OF A POSSIBLE RECURRENCE COULD BE ACHIEVED BY LIMITING THE TFC TO AND FROM THE FLT DECK. ADDITIONALLY; ADDING A PROTOCOL THAT REQUIRES A PERSON ENTERING THE FLT DECK TO WAIT FOR ACKNOWLEDGEMENT BY THE FLT CREW BEFORE PRESENTING INFO OR MAKING INQUIRIES COULD ALSO HELP IN REDUCING DISTRS AT CRITICAL POINTS. DISTRS IN A HIGH WORKLOAD ENVIRONMENT CANNOT COMPLETELY BE AVOIDED. HOWEVER; ADDING THE SUGGESTED PROTOCOL TO THE COMPANY PROCS MIGHT REDUCE THE NUMBER OF CRITICAL POINT DISTR ENCOUNTERS ON THE FLT DECK.
Data retrieved from NASA's ASRS site as of May 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.