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Attributes | |
ACN | 806722 |
Time | |
Date | 200810 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 806722 |
Events | |
Anomaly | non adherence : company policies |
Independent Detector | other flight crewa |
Consequence | other |
Supplementary | |
Problem Areas | Airport Company |
Primary Problem | Company |
Narrative:
Ferry flight with reserve pilots called out toward the end of their duty period; dispatched to an unfamiliar; uncontrolled airport at night. Flight was dispatched without proper approach charts; planning and oversight. The only available instrument runway was notamed closed and charts were not included in the ferry packet. Upon request; the dispatcher did facsimile approach charts to the flight crew but they were FAA charts that did not contain adequate airport diagrams. The captain tried to contact the technical representative that was listed on the ferry form; only to discover that the contact listed has not worked for air carrier for the last 6 months. This was not a real confidence builder knowing that our ferry packet was not based on timely accurate information. The captain called the destination tower and was informed that runway 14/32 was in fact closed. He also informed the flight crew that if runway 36 was used; a 180 degree turn would be required to back-taxi to taxiway a; portions of which were closed and unlighted. The pilot's handbook has several notes and cautions about executing such a turn on a 150 ft wide runway. Runway 18/36 did not have a usable instrument approach for the B767. The crew would have been tasked to execute a night VFR approach to an unfamiliar airport. It was the flight crew that discovered the deficiencies and expressed serious concern about adequate safety margins the dispatcher was not totally convinced of flight crew's concerns and turned the situation over to a supervisory pilot. This created a subtle pressure on the flight crew that the mission had to 'go' despite our feedback. Several mins later; a flight manager discussed this situation with the flight crew and confirmed to us that the ferry flight would be canceled because of inadequate safety margins. Command and control failure. There were numerous 'red flags' which should have been discovered by operations before the flight was dispatched and a reserve crew called out to fly. It appears that this was a 'mission critical' event that was not properly scheduled; planned; and released. Events such as this seriously undermine a pilot's perception of their company's commitment to safety. Perhaps an overall safety audit of the command and control functions at air carrier is in order. Last min scheduling of reserve crews to fly these 'special' missions fails the test of adequate risk assessment. Luckily; this was a latent failure that was mitigated by the vigilance of a professional flight crew. That will not always be the case.
Original NASA ASRS Text
Title: B767 CAPT REPORTS BEING DISPATCHED ON FERRY FLT AT NIGHT TO UNFAMILIAR ARPT WITH THE ONLY INSTRUMENT RWY CLOSED. AFTER SOME DISCUSSION WITH CHIEF PILOT; FLT IS CANCELED.
Narrative: FERRY FLT WITH RESERVE PLTS CALLED OUT TOWARD THE END OF THEIR DUTY PERIOD; DISPATCHED TO AN UNFAMILIAR; UNCTLED ARPT AT NIGHT. FLT WAS DISPATCHED WITHOUT PROPER APCH CHARTS; PLANNING AND OVERSIGHT. THE ONLY AVAILABLE INST RWY WAS NOTAMED CLOSED AND CHARTS WERE NOT INCLUDED IN THE FERRY PACKET. UPON REQUEST; THE DISPATCHER DID FAX APCH CHARTS TO THE FLT CREW BUT THEY WERE FAA CHARTS THAT DID NOT CONTAIN ADEQUATE ARPT DIAGRAMS. THE CAPT TRIED TO CONTACT THE TECHNICAL REPRESENTATIVE THAT WAS LISTED ON THE FERRY FORM; ONLY TO DISCOVER THAT THE CONTACT LISTED HAS NOT WORKED FOR ACR FOR THE LAST 6 MONTHS. THIS WAS NOT A REAL CONFIDENCE BUILDER KNOWING THAT OUR FERRY PACKET WAS NOT BASED ON TIMELY ACCURATE INFO. THE CAPT CALLED THE DEST TWR AND WAS INFORMED THAT RWY 14/32 WAS IN FACT CLOSED. HE ALSO INFORMED THE FLT CREW THAT IF RWY 36 WAS USED; A 180 DEG TURN WOULD BE REQUIRED TO BACK-TAXI TO TXWY A; PORTIONS OF WHICH WERE CLOSED AND UNLIGHTED. THE PLT'S HANDBOOK HAS SEVERAL NOTES AND CAUTIONS ABOUT EXECUTING SUCH A TURN ON A 150 FT WIDE RWY. RWY 18/36 DID NOT HAVE A USABLE INST APCH FOR THE B767. THE CREW WOULD HAVE BEEN TASKED TO EXECUTE A NIGHT VFR APCH TO AN UNFAMILIAR ARPT. IT WAS THE FLT CREW THAT DISCOVERED THE DEFICIENCIES AND EXPRESSED SERIOUS CONCERN ABOUT ADEQUATE SAFETY MARGINS THE DISPATCHER WAS NOT TOTALLY CONVINCED OF FLT CREW'S CONCERNS AND TURNED THE SITUATION OVER TO A SUPERVISORY PLT. THIS CREATED A SUBTLE PRESSURE ON THE FLT CREW THAT THE MISSION HAD TO 'GO' DESPITE OUR FEEDBACK. SEVERAL MINS LATER; A FLT MGR DISCUSSED THIS SITUATION WITH THE FLT CREW AND CONFIRMED TO US THAT THE FERRY FLT WOULD BE CANCELED BECAUSE OF INADEQUATE SAFETY MARGINS. COMMAND AND CTL FAILURE. THERE WERE NUMEROUS 'RED FLAGS' WHICH SHOULD HAVE BEEN DISCOVERED BY OPS BEFORE THE FLT WAS DISPATCHED AND A RESERVE CREW CALLED OUT TO FLY. IT APPEARS THAT THIS WAS A 'MISSION CRITICAL' EVENT THAT WAS NOT PROPERLY SCHEDULED; PLANNED; AND RELEASED. EVENTS SUCH AS THIS SERIOUSLY UNDERMINE A PLT'S PERCEPTION OF THEIR COMPANY'S COMMITMENT TO SAFETY. PERHAPS AN OVERALL SAFETY AUDIT OF THE COMMAND AND CTL FUNCTIONS AT ACR IS IN ORDER. LAST MIN SCHEDULING OF RESERVE CREWS TO FLY THESE 'SPECIAL' MISSIONS FAILS THE TEST OF ADEQUATE RISK ASSESSMENT. LUCKILY; THIS WAS A LATENT FAILURE THAT WAS MITIGATED BY THE VIGILANCE OF A PROFESSIONAL FLT CREW. THAT WILL NOT ALWAYS BE THE CASE.
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.