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|
Attributes | |
ACN | 794134 |
Time | |
Date | 200807 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : cyyz.airport |
State Reference | ON |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure sid : lstr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 185 flight time total : 10000 flight time type : 2640 |
Events | |
Anomaly | non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Narrative:
It was the end of a long 7 days of flying. We had just finished a leg into yyz from ZZZ with the autothrottles inoperative. There was also bad WX on departure that resulted in a 1 hour ground hold since ZZZ had shut down east departures. By the time I got to yyz I felt I could do one more leg home but I was beginning to feel the cumulative effects of fatigue after being on duty for 7 days in a row. We departed yyz after a quick turn since we were late arriving due to the WX delay in ZZZ. We taxied out and got a rerte to ZZZ; as we got near the runway we received another route modification. The first officer was putting in the rertes as I taxied the aircraft. We were then given a wheels up time to ZZZ of XA43Z; which we were waiting on at the end of runway 23. Then all of a sudden we were asked if we were ready to copy another route modification. We did and then yyz tower said that if we were not ready to go immediately we would receive an extensive delay. We proceeded to take the runway for takeoff. We started the takeoff roll without the autothrottles since they were deferred inoperative. I adjusted takeoff power for the first officer; who was PF. After she rotated she asked for positive climb gear up. I did that and then we continued climbing out on a noise abatement climb profile which is something we don't do all that often. As we were approaching our ytp 1.9 DME turn on the LSTR7 departure to 245 degrees I noticed the first officer was not initiating the turn and I said 'heading 245' and turned the heading bug for her. I noticed now that she was turning through 245 degrees and was pulling back the power. I became fixated on why she was pulling back the power and said 'we should be climbing. Use climb thrust.' while she was pulling back the power and reducing pitch the aircraft began to accelerate. Then ATC called and said; 'turn direct to bigby.' the first officer said 'why are we buffeting?' I looked down and saw that the flaps were still at position #1; the takeoff setting we had used. Needless to say I immediately brought the flaps up and now the aircraft was at 260 KTS. Thus; we had overspd the flaps by 30 KTS. As we got up to cruise I asked the first officer if she had ever asked for flaps up? She said she had. I never heard her; and had noticed that throughout the last 7 days I was having difficulty hearing her because of the volume she used to talk. At any rate; it is my responsibility that I should have gotten the flaps up whether she asked for them or not. However; the abnormal sequence of events due to the noise abatement climb out; the autothrottle being inoperative; being rushed into the takeoff position by ATC and fixating on why the parameters she was flying were not what I would expect; not being able to hear first officer; as well as flying the absolute maximum one can fly in 7 days all were contributing factors in this flap overspd. Also; everything happening at the same time (eg; a turn that was not happening; ATC clearing us direct bigbe; first officer not doing what I expected; the noise abatement profile difference requiring acceleration and flap retraction at 3000 ft AGL rather than 800 ft when less things are happening) also contributed. I spoke to the first officer once we got to cruise altitude and asked her why she was going through heading and then reducing pitch and she said she was wondering why the airspeed tape was red; and became fixated on that. Well; that was due to the flaps being still at position #1 while we were accelerating through the flap limit speed. I think the best thing I could have done differently would have been to brief much more thoroughly on how things needed to happen on a noise abatement takeoff with autothrottles inoperative. Also; not rushing into the takeoff position. Also; in hindsight it would have been a good idea; early on; to tell the first officer that I often could not hear her when she spoke. That way she could have spoken louder so I could have maybe heard her ask for the flaps up.
Original NASA ASRS Text
Title: B737 FLT CREW OVERSPEED FLAPS BY 30KTS ON DEPARTURE FROM CYYZ AFTER SEVEN FATIGUING DAYS OF FLYING AND NUMEROUS DELAYS.
Narrative: IT WAS THE END OF A LONG 7 DAYS OF FLYING. WE HAD JUST FINISHED A LEG INTO YYZ FROM ZZZ WITH THE AUTOTHROTTLES INOP. THERE WAS ALSO BAD WX ON DEP THAT RESULTED IN A 1 HR GND HOLD SINCE ZZZ HAD SHUT DOWN E DEPS. BY THE TIME I GOT TO YYZ I FELT I COULD DO ONE MORE LEG HOME BUT I WAS BEGINNING TO FEEL THE CUMULATIVE EFFECTS OF FATIGUE AFTER BEING ON DUTY FOR 7 DAYS IN A ROW. WE DEPARTED YYZ AFTER A QUICK TURN SINCE WE WERE LATE ARRIVING DUE TO THE WX DELAY IN ZZZ. WE TAXIED OUT AND GOT A RERTE TO ZZZ; AS WE GOT NEAR THE RWY WE RECEIVED ANOTHER RTE MODIFICATION. THE FO WAS PUTTING IN THE RERTES AS I TAXIED THE ACFT. WE WERE THEN GIVEN A WHEELS UP TIME TO ZZZ OF XA43Z; WHICH WE WERE WAITING ON AT THE END OF RWY 23. THEN ALL OF A SUDDEN WE WERE ASKED IF WE WERE READY TO COPY ANOTHER RTE MODIFICATION. WE DID AND THEN YYZ TWR SAID THAT IF WE WERE NOT READY TO GO IMMEDIATELY WE WOULD RECEIVE AN EXTENSIVE DELAY. WE PROCEEDED TO TAKE THE RWY FOR TKOF. WE STARTED THE TKOF ROLL WITHOUT THE AUTOTHROTTLES SINCE THEY WERE DEFERRED INOP. I ADJUSTED TKOF PWR FOR THE FO; WHO WAS PF. AFTER SHE ROTATED SHE ASKED FOR POSITIVE CLB GEAR UP. I DID THAT AND THEN WE CONTINUED CLBING OUT ON A NOISE ABATEMENT CLB PROFILE WHICH IS SOMETHING WE DON'T DO ALL THAT OFTEN. AS WE WERE APCHING OUR YTP 1.9 DME TURN ON THE LSTR7 DEP TO 245 DEGS I NOTICED THE FO WAS NOT INITIATING THE TURN AND I SAID 'HDG 245' AND TURNED THE HDG BUG FOR HER. I NOTICED NOW THAT SHE WAS TURNING THROUGH 245 DEGS AND WAS PULLING BACK THE PWR. I BECAME FIXATED ON WHY SHE WAS PULLING BACK THE PWR AND SAID 'WE SHOULD BE CLBING. USE CLB THRUST.' WHILE SHE WAS PULLING BACK THE PWR AND REDUCING PITCH THE ACFT BEGAN TO ACCELERATE. THEN ATC CALLED AND SAID; 'TURN DIRECT TO BIGBY.' THE FO SAID 'WHY ARE WE BUFFETING?' I LOOKED DOWN AND SAW THAT THE FLAPS WERE STILL AT POS #1; THE TKOF SETTING WE HAD USED. NEEDLESS TO SAY I IMMEDIATELY BROUGHT THE FLAPS UP AND NOW THE ACFT WAS AT 260 KTS. THUS; WE HAD OVERSPD THE FLAPS BY 30 KTS. AS WE GOT UP TO CRUISE I ASKED THE FO IF SHE HAD EVER ASKED FOR FLAPS UP? SHE SAID SHE HAD. I NEVER HEARD HER; AND HAD NOTICED THAT THROUGHOUT THE LAST 7 DAYS I WAS HAVING DIFFICULTY HEARING HER BECAUSE OF THE VOLUME SHE USED TO TALK. AT ANY RATE; IT IS MY RESPONSIBILITY THAT I SHOULD HAVE GOTTEN THE FLAPS UP WHETHER SHE ASKED FOR THEM OR NOT. HOWEVER; THE ABNORMAL SEQUENCE OF EVENTS DUE TO THE NOISE ABATEMENT CLBOUT; THE AUTOTHROTTLE BEING INOP; BEING RUSHED INTO THE TKOF POS BY ATC AND FIXATING ON WHY THE PARAMETERS SHE WAS FLYING WERE NOT WHAT I WOULD EXPECT; NOT BEING ABLE TO HEAR FO; AS WELL AS FLYING THE ABSOLUTE MAX ONE CAN FLY IN 7 DAYS ALL WERE CONTRIBUTING FACTORS IN THIS FLAP OVERSPD. ALSO; EVERYTHING HAPPENING AT THE SAME TIME (EG; A TURN THAT WAS NOT HAPPENING; ATC CLRING US DIRECT BIGBE; FO NOT DOING WHAT I EXPECTED; THE NOISE ABATEMENT PROFILE DIFFERENCE REQUIRING ACCELERATION AND FLAP RETRACTION AT 3000 FT AGL RATHER THAN 800 FT WHEN LESS THINGS ARE HAPPENING) ALSO CONTRIBUTED. I SPOKE TO THE FO ONCE WE GOT TO CRUISE ALT AND ASKED HER WHY SHE WAS GOING THROUGH HDG AND THEN REDUCING PITCH AND SHE SAID SHE WAS WONDERING WHY THE AIRSPD TAPE WAS RED; AND BECAME FIXATED ON THAT. WELL; THAT WAS DUE TO THE FLAPS BEING STILL AT POS #1 WHILE WE WERE ACCELERATING THROUGH THE FLAP LIMIT SPD. I THINK THE BEST THING I COULD HAVE DONE DIFFERENTLY WOULD HAVE BEEN TO BRIEF MUCH MORE THOROUGHLY ON HOW THINGS NEEDED TO HAPPEN ON A NOISE ABATEMENT TKOF WITH AUTOTHROTTLES INOP. ALSO; NOT RUSHING INTO THE TKOF POS. ALSO; IN HINDSIGHT IT WOULD HAVE BEEN A GOOD IDEA; EARLY ON; TO TELL THE FO THAT I OFTEN COULD NOT HEAR HER WHEN SHE SPOKE. THAT WAY SHE COULD HAVE SPOKEN LOUDER SO I COULD HAVE MAYBE HEARD HER ASK FOR THE FLAPS UP.
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.