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Attributes | |
ACN | 791500 |
Time | |
Date | 200805 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 280 flight time total : 19800 flight time type : 5700 |
ASRS Report | 791500 |
Events | |
Anomaly | non adherence : far non adherence : company policies |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | FAA Company ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Augmented crew operations; 2 full flight crews. On inbound flight; NOTAM of wip covered with all 4 crew members by the reporter as PIC. Efb used to print an airport diagram and NOTAM of wip/lighting/approach annotated on printed chart by reporter. This copy left for outbound crew use. During initial pairing briefing; 2ND captain (return leg PIC; rtn PIC) noted to be low time. Rtn PIC recent conversion to type (experienced captain on A300; but less than 100 hours in type as PIC). PIC offered jumpseat to the rtn PIC for initial departure and landing ord; declined by rtn PIC; as he conducted 3 ord flts in last 30 days and had extensive operational experience into ord. NOTAMS for departure airport included runway wip reducing a runway by 2000 ft for asda and similar for toda. (Asda given as 8007 ft.) ATIS NOTAM information at about line 8 included same information. Briefing completed by operating crew in national language. (Reporter is english speaker.) reporter assessed conditions of plan and weather for related duty period. Reporter (augment pilot) offered to attend flight deck for departure; declined by PIC. Augment first officer attendance in flight deck for departure declined. Aircraft departed gate with PIC and primary duty first officer in cockpit; and augment crew in first class. Aircraft approached notamed runway and reporter; concerned the aircraft was likely to line up on a short runway; reporter vacated seat to attempt to contact flight crew by cabin interphone. Aircraft continued to cross runway instead of line up; and then conducted a 180 degree turn and approached same runway from opposite taxiway. Reporter considered the crew had reviewed the performance and elected to return to southern runways of which 2 were acceptable for performance. Reporter returned to seat. Aircraft entered notamed runway and conducted a rolling takeoff. 5 hours after takeoff; augment crew relieved operating crew. Load sheet assessed to see what variation of final tow had resulted (common practice for significant tow reduction from planned). Tow same as planned. Performance manual reviewed and considered that rtow was exceeded by approximately 5000 pounds for maximum thrust takeoff; on runway considering simplified runway cutback calculation. Takeoff report checked to confirm full takeoff thrust applied. Assumed thr used by crew. Estimate 55000 pound exceedance of rtow due reduced thrust use. Augment first officer confirmed that he had advised PIC of no special NOTAMS for departure in national language; on checking NOTAMS at briefing. 1) NOTAM: information accurate; but not recognized by operating crew; even after recent briefing of same issues 2 days prior. Volume of data increases risk of omission or failure of recognition. 2) briefing doesn't include an (annotated or otherwise) chart for takeoff or landing airport. NOTAM information cannot be reconciled with real world at time of review. 3) NOTAM was long-term; but performance system did not amend data (standard practice some operators with color coding of chart; reference to NOTAM). 4) efb class 3: NOTAMS do not update to standard. (Operating crew didn't use efb; however; but missed the information.) 5) ATIS NOTAM consequence overlooked by crew. Critical information 8TH row of extensive message. 6) ATC cleared a heavy long range aircraft to a runway with reduced operating length; without due regard for potential for error. Unknown if ATC stated the runway length available/confirmed this was acceptable (a practice in some other regions following serious events of rtow exceedance following late runway changes or operations on runways with reduced operating distances. 7) performance system cannot identify rtow exceedances automatically. (Reporter has previously screened performance data to assess rates of events and severity as an investigator and performance expert.) on return; company asked same day to highlight NOTAMS affecting runway declared distances. Conflict between foreign crews and national crews acts to preclude a formal safety report being made by an augment (off duty unpaid) crew member on a national captain. Data cited by vp safety; after assurance of handling event at a systemic level; non punitive to the operating captain or crew and without identifying the event.follow up: company management investigating specific event; irrespective of vp safety's assurances to contrary. Operations management considers event to be one off; non compliance issue not systemic problem of information handling and application.
Original NASA ASRS Text
Title: B777 FLT CREW DEPARTS RWY 32R AT ORD OVER MAX ALLOWABLE GW DUE TO IGNORANCE OF NOTAM CONCERNING WIP REDUCING RWY LENGTH.
Narrative: AUGMENTED CREW OPERATIONS; 2 FULL FLT CREWS. ON INBOUND FLT; NOTAM OF WIP COVERED WITH ALL 4 CREW MEMBERS BY THE RPTR AS PIC. EFB USED TO PRINT AN ARPT DIAGRAM AND NOTAM OF WIP/LIGHTING/APCH ANNOTATED ON PRINTED CHART BY RPTR. THIS COPY LEFT FOR OUTBOUND CREW USE. DURING INITIAL PAIRING BRIEFING; 2ND CAPT (RETURN LEG PIC; RTN PIC) NOTED TO BE LOW TIME. RTN PIC RECENT CONVERSION TO TYPE (EXPERIENCED CAPT ON A300; BUT LESS THAN 100 HOURS IN TYPE AS PIC). PIC OFFERED JUMPSEAT TO THE RTN PIC FOR INITIAL DEPARTURE AND LNDG ORD; DECLINED BY RTN PIC; AS HE CONDUCTED 3 ORD FLTS IN LAST 30 DAYS AND HAD EXTENSIVE OPERATIONAL EXPERIENCE INTO ORD. NOTAMS FOR DEP ARPT INCLUDED RWY WIP REDUCING A RWY BY 2000 FT FOR ASDA AND SIMILAR FOR TODA. (ASDA GIVEN AS 8007 FT.) ATIS NOTAM INFO AT ABOUT LINE 8 INCLUDED SAME INFO. BRIEFING COMPLETED BY OPERATING CREW IN NATIONAL LANGUAGE. (RPTR IS ENGLISH SPEAKER.) RPTR ASSESSED CONDITIONS OF PLAN AND WEATHER FOR RELATED DUTY PERIOD. RPTR (AUGMENT PLT) OFFERED TO ATTEND FLT DECK FOR DEP; DECLINED BY PIC. AUGMENT FO ATTENDANCE IN FLT DECK FOR DEP DECLINED. ACFT DEPARTED GATE WITH PIC AND PRIMARY DUTY FO IN COCKPIT; AND AUGMENT CREW IN FIRST CLASS. ACFT APCHED NOTAMED RWY AND RPTR; CONCERNED THE ACFT WAS LIKELY TO LINE UP ON A SHORT RWY; RPTR VACATED SEAT TO ATTEMPT TO CONTACT FLT CREW BY CABIN INTERPHONE. ACFT CONTINUED TO CROSS RWY INSTEAD OF LINE UP; AND THEN CONDUCTED A 180 DEG TURN AND APCHED SAME RWY FROM OPPOSITE TXWY. RPTR CONSIDERED THE CREW HAD REVIEWED THE PERFORMANCE AND ELECTED TO RETURN TO SOUTHERN RWYS OF WHICH 2 WERE ACCEPTABLE FOR PERFORMANCE. RPTR RETURNED TO SEAT. ACFT ENTERED NOTAMED RWY AND CONDUCTED A ROLLING TKOF. 5 HOURS AFTER TKOF; AUGMENT CREW RELIEVED OPERATING CREW. LOAD SHEET ASSESSED TO SEE WHAT VARIATION OF FINAL TOW HAD RESULTED (COMMON PRACTICE FOR SIGNIFICANT TOW REDUCTION FROM PLANNED). TOW SAME AS PLANNED. PERFORMANCE MANUAL REVIEWED AND CONSIDERED THAT RTOW WAS EXCEEDED BY APPROX 5000 LBS FOR MAX THRUST TKOF; ON RWY CONSIDERING SIMPLIFIED RWY CUTBACK CALCULATION. TKOF REPORT CHECKED TO CONFIRM FULL TKOF THRUST APPLIED. ASSUMED THR USED BY CREW. ESTIMATE 55000 LB EXCEEDANCE OF RTOW DUE REDUCED THRUST USE. AUGMENT FO CONFIRMED THAT HE HAD ADVISED PIC OF NO SPECIAL NOTAMS FOR DEPARTURE IN NATIONAL LANGUAGE; ON CHECKING NOTAMS AT BRIEFING. 1) NOTAM: INFO ACCURATE; BUT NOT RECOGNIZED BY OPERATING CREW; EVEN AFTER RECENT BRIEFING OF SAME ISSUES 2 DAYS PRIOR. VOLUME OF DATA INCREASES RISK OF OMISSION OR FAILURE OF RECOGNITION. 2) BRIEFING DOESN'T INCLUDE AN (ANNOTATED OR OTHERWISE) CHART FOR TKOF OR LNDG ARPT. NOTAM INFO CANNOT BE RECONCILED WITH REAL WORLD AT TIME OF REVIEW. 3) NOTAM WAS LONG-TERM; BUT PERFORMANCE SYSTEM DID NOT AMEND DATA (STANDARD PRACTICE SOME OPERATORS WITH COLOR CODING OF CHART; REFERENCE TO NOTAM). 4) EFB CLASS 3: NOTAMS DO NOT UPDATE TO STANDARD. (OPERATING CREW DIDN'T USE EFB; HOWEVER; BUT MISSED THE INFO.) 5) ATIS NOTAM CONSEQUENCE OVERLOOKED BY CREW. CRITICAL INFO 8TH ROW OF EXTENSIVE MESSAGE. 6) ATC CLEARED A HEAVY LONG RANGE ACFT TO A RWY WITH REDUCED OPERATING LENGTH; WITHOUT DUE REGARD FOR POTENTIAL FOR ERROR. UNKNOWN IF ATC STATED THE RWY LENGTH AVAILABLE/CONFIRMED THIS WAS ACCEPTABLE (A PRACTICE IN SOME OTHER REGIONS FOLLOWING SERIOUS EVENTS OF RTOW EXCEEDANCE FOLLOWING LATE RWY CHANGES OR OPERATIONS ON RWYS WITH REDUCED OPERATING DISTANCES. 7) PERFORMANCE SYSTEM CANNOT IDENTIFY RTOW EXCEEDANCES AUTOMATICALLY. (RPTR HAS PREVIOUSLY SCREENED PERFORMANCE DATA TO ASSESS RATES OF EVENTS AND SEVERITY AS AN INVESTIGATOR AND PERFORMANCE EXPERT.) ON RETURN; COMPANY ASKED SAME DAY TO HIGHLIGHT NOTAMS AFFECTING RWY DECLARED DISTANCES. CONFLICT BETWEEN FOREIGN CREWS AND NATIONAL CREWS ACTS TO PRECLUDE A FORMAL SAFETY REPORT BEING MADE BY AN AUGMENT (OFF DUTY UNPAID) CREW MEMBER ON A NATIONAL CAPTAIN. DATA CITED BY VP SAFETY; AFTER ASSURANCE OF HANDLING EVENT AT A SYSTEMIC LEVEL; NON PUNITIVE TO THE OPERATING CAPT OR CREW AND WITHOUT IDENTIFYING THE EVENT.FOLLOW UP: COMPANY MANAGEMENT INVESTIGATING SPECIFIC EVENT; IRRESPECTIVE OF VP SAFETY'S ASSURANCES TO CONTRARY. OPS MANAGEMENT CONSIDERS EVENT TO BE ONE OFF; NON COMPLIANCE ISSUE NOT SYSTEMIC PROBLEM OF INFO HANDLING AND APPLICATION.
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.