37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 793915 |
Time | |
Date | 200807 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
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 | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 178 flight time total : 7000 flight time type : 4000 |
ASRS Report | 793915 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was notified by the crew who later came to the aircraft after I left to go home that I had left the external power on the aircraft. I had just completed a 6 day; 29 hour and 33 min trip. I was extended twice on this trip. The first time at the end of the 4TH day; and again on the 6TH day for one more 'low stress out and back to ZZZ.' well; the last out and back was to ZZZ1. Additionally; I flew it with a first officer who had less than 100 hours in the crj and had never been to ZZZ1. With this as background; we departed for ZZZ1. Thankfully; the out and back to ZZZ1 went flawlessly! When we pulled up to the gate and shut down the engines; I let out a huge sigh of relief. The 6 day trip from hell was over! I completed the parking checklist and began taking the crew bags off the aircraft. The first officer completed the postflt and went home. I talked to the flight attendant for a few mins; she was going to fly the same aircraft to ZZZ2 (that's what I remember anyway) with a new flight crew. I said goodbye and then left the aircraft to sign-out and go home. What I forgot to do was the terminating checklist. This painfully obvious oversight was caused by my fatigue; causing the erroneous conclusion that since the flight attendant was on board; the 'flight crew' was present and I could go home. I never gave it a second thought about the confign of the aircraft (ie; the external power was still powering the aircraft). Beyond a shadow of a doubt this mistake was a direct result of fatigue. I was so tired that good judgment and checklist discipline was replaced with faulty judgment and checklist compliance. Bottom line: it ain't over until it's over! Regardless of how tired you are! Or in pilotese: 'termination checklist -- complete.
Original NASA ASRS Text
Title: A CRJ200 CAPT REPORTS BEING SO FATIGUED AFTER A 6 DAY 29 HR 33 MIN TRIP THAT HE FAILED TO REMOVED ELECTRICAL POWER AND SECURE THE ACFT BEFORE GOING HOME.
Narrative: I WAS NOTIFIED BY THE CREW WHO LATER CAME TO THE ACFT AFTER I LEFT TO GO HOME THAT I HAD LEFT THE EXTERNAL PWR ON THE ACFT. I HAD JUST COMPLETED A 6 DAY; 29 HR AND 33 MIN TRIP. I WAS EXTENDED TWICE ON THIS TRIP. THE FIRST TIME AT THE END OF THE 4TH DAY; AND AGAIN ON THE 6TH DAY FOR ONE MORE 'LOW STRESS OUT AND BACK TO ZZZ.' WELL; THE LAST OUT AND BACK WAS TO ZZZ1. ADDITIONALLY; I FLEW IT WITH A FO WHO HAD LESS THAN 100 HRS IN THE CRJ AND HAD NEVER BEEN TO ZZZ1. WITH THIS AS BACKGROUND; WE DEPARTED FOR ZZZ1. THANKFULLY; THE OUT AND BACK TO ZZZ1 WENT FLAWLESSLY! WHEN WE PULLED UP TO THE GATE AND SHUT DOWN THE ENGS; I LET OUT A HUGE SIGH OF RELIEF. THE 6 DAY TRIP FROM HELL WAS OVER! I COMPLETED THE PARKING CHKLIST AND BEGAN TAKING THE CREW BAGS OFF THE ACFT. THE FO COMPLETED THE POSTFLT AND WENT HOME. I TALKED TO THE FLT ATTENDANT FOR A FEW MINS; SHE WAS GOING TO FLY THE SAME ACFT TO ZZZ2 (THAT'S WHAT I REMEMBER ANYWAY) WITH A NEW FLT CREW. I SAID GOODBYE AND THEN LEFT THE ACFT TO SIGN-OUT AND GO HOME. WHAT I FORGOT TO DO WAS THE TERMINATING CHKLIST. THIS PAINFULLY OBVIOUS OVERSIGHT WAS CAUSED BY MY FATIGUE; CAUSING THE ERRONEOUS CONCLUSION THAT SINCE THE FLT ATTENDANT WAS ON BOARD; THE 'FLT CREW' WAS PRESENT AND I COULD GO HOME. I NEVER GAVE IT A SECOND THOUGHT ABOUT THE CONFIGN OF THE ACFT (IE; THE EXTERNAL PWR WAS STILL POWERING THE ACFT). BEYOND A SHADOW OF A DOUBT THIS MISTAKE WAS A DIRECT RESULT OF FATIGUE. I WAS SO TIRED THAT GOOD JUDGMENT AND CHKLIST DISCIPLINE WAS REPLACED WITH FAULTY JUDGMENT AND CHKLIST COMPLIANCE. BOTTOM LINE: IT AIN'T OVER UNTIL IT'S OVER! REGARDLESS OF HOW TIRED YOU ARE! OR IN PILOTESE: 'TERMINATION CHKLIST -- COMPLETE.
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.