37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 931888 |
Time | |
Date | 201102 |
Place | |
Locale Reference | ORD.Airport |
State Reference | IL |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | Takeoff |
Flight Plan | IFR |
Person 1 | |
Function | Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
I had planned and briefed a runway 28 departure with 1/4 inch slush correction. Runway 32L T-10 opened and we were assigned this with our taxi clearance. I quickly sent a 1/4 inch slush correction request to dispatch via ACARS just before taxiing. Taxi out was unusual as we were behind the seven-truck plow team on alpha. Only the right half of the taxiway was plowed 2-3 inches of snow on the left half (distraction). Shortly after liftoff I had the epiphany that I screwed up and had requested 32L and not 32LX (T-10) with dispatch. They would have no way of knowing. Had we lost an engine I can only imagine what the outcome might have been. Not to distract from the seriousness of this situation I do want to expand on the human factor side of this; again; not to make excuses but to explain the pitfalls of a sequence such as ours. I woke this morning at xa:30 am so as to make a xd:05 sign in. We had one simple leg to ord then a scheduled 10:35 layover followed by this flight scheduled to land at xu:25L which equates to 02:25 body time. On this layover; other than 30 minutes on the treadmill I was a hermit in my room. I slept from roughly xl:00 pm to xf:00 pm ord time. Our flight was delayed two hours due to inbound equipment. [We were] now departing at xu:00L which is 00:00 body time; so while the sequence 'appears' to provide 10 plus hours to reset our body clocks; and despite my best efforts at minimal caffeine; proper diet; exercise and sleep I actually pushed back from the gate in ord with 3 hours sleep in the previous 20 hours. Landing at xw:30 local time equates to 3 hours sleep in the previous 25 hours. Fatigued? Not apparent at departure; actually felt energized. Clearly I wasn't firing on all cylinders to make a rookie mistake like I did. My point is that we should not build a sequence like this expecting a pilot to recognize his situation and remove him/herself from the trip. Those warning signs may not be apparent at that stage until it is too late. We should proactively protect our crews. At the hotel I called dispatch to try and get another aircraft but none were available. When tracking called I voiced my concerns about the time of day and was told 'to hang in there...you can do it captain.' I try to be a team player; tried to hang in there (as I mentioned; actually felt good). Clearly the results are not what we would consider sterling. We go out of our way to regulate and monitor safety (i.e.; landing flaps by 1;000 ft -not 950 ft- and still 3.3 miles from touchdown) but allow sequences to be built that on paper look good yet have no grasp of human physiology. We want to be aggressively safe yet ask our aging pilot force to perform in unsafe circumstances. And while the mid-sequence fatigue policy can be an excellent tool; clearly the triggers were not apparent until the damage had been done last night. Sorry for being verbose. However this is the kind of scenario the safety team should examine. The outcome could have been terrible.
Original NASA ASRS Text
Title: B737-800 flight crew fails to advise Dispatch of a takeoff from Runway 32L at T10. Numbers provided were for Runway 32L full length; takeoff was normal and pilot fatigue cited as a contributing factor.
Narrative: I had planned and briefed a Runway 28 departure with 1/4 inch slush correction. Runway 32L T-10 opened and we were assigned this with our taxi clearance. I quickly sent a 1/4 inch slush correction request to Dispatch via ACARS just before taxiing. Taxi out was unusual as we were behind the seven-truck plow team on Alpha. Only the right half of the taxiway was plowed 2-3 inches of snow on the left half (distraction). Shortly after liftoff I had the epiphany that I screwed up and had requested 32L and not 32LX (T-10) with Dispatch. They would have no way of knowing. Had we lost an engine I can only imagine what the outcome might have been. Not to distract from the seriousness of this situation I do want to expand on the human factor side of this; again; not to make excuses but to explain the pitfalls of a sequence such as ours. I woke this morning at XA:30 am so as to make a XD:05 sign in. We had one simple leg to ORD then a scheduled 10:35 layover followed by this flight scheduled to land at XU:25L which equates to 02:25 body time. On this layover; other than 30 minutes on the treadmill I was a hermit in my room. I slept from roughly XL:00 pm to XF:00 pm ORD time. Our flight was delayed two hours due to inbound equipment. [We were] now departing at XU:00L which is 00:00 body time; so while the sequence 'appears' to provide 10 plus hours to reset our body clocks; and despite my best efforts at minimal caffeine; proper diet; exercise and sleep I actually pushed back from the gate in ORD with 3 hours sleep in the previous 20 hours. Landing at XW:30 local time equates to 3 hours sleep in the previous 25 hours. Fatigued? Not apparent at departure; actually felt energized. Clearly I wasn't firing on all cylinders to make a rookie mistake like I did. My point is that we should not build a sequence like this expecting a pilot to recognize his situation and remove him/herself from the trip. Those warning signs may not be apparent at that stage until it is too late. We should proactively protect our crews. At the hotel I called Dispatch to try and get another aircraft but none were available. When Tracking called I voiced my concerns about the time of day and was told 'to hang in there...you can do it Captain.' I try to be a team player; tried to hang in there (as I mentioned; actually felt good). Clearly the results are not what we would consider sterling. We go out of our way to regulate and monitor safety (i.e.; landing flaps by 1;000 FT -not 950 FT- and still 3.3 miles from touchdown) but allow sequences to be built that on paper look good yet have no grasp of human physiology. We want to be aggressively safe yet ask our aging pilot force to perform in unsafe circumstances. And while the mid-sequence fatigue policy can be an excellent tool; clearly the triggers were not apparent until the damage had been done last night. Sorry for being verbose. However this is the kind of scenario the safety team should examine. The outcome could have been terrible.
Data retrieved from NASA's ASRS site as of April 2012 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.