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|
Attributes | |
ACN | 983298 |
Time | |
Date | 201112 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | SNA.Airport |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737 Next Generation Undifferentiated |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Flight Plan | IFR |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 138 Flight Crew Type 12000 |
Person 2 | |
Function | Pilot Not Flying First Officer |
Experience | Flight Crew Last 90 Days 189 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
We inadvertently took off with flaps 1 vice flaps 5. First; let me go on record as saying I believe the sna noise abatement procedure is unsafe. Some airline will someday smack a light civilian airplane flying up or down the coast that is at the wrong altitude or airspace. Or they will stall trying to avoid it. With such a reduced power setting; there is no room for error. I did brief the profile including flaps 5; after completing the before start checklist. The first officer acknowledged it. I do not recall for sure if I called flaps 1 or 5 on the after start flow; but I think I called for flaps 5. I did not; however; catch the flaps 1 setting on the before taxi checklist. This was our final leg of nine and all others were flaps 1 takeoff. Habit patterns can work against you! We pushed on time; but were taxi delayed ten minutes due to ramp congestion. I was a little disturbed that the agent waited until the last minute to board since we could have easily pushed five minutes early and would have avoided the ramp congestion. (We arrived 30 minutes early!) I don't know if that distracted me or not; but I was distracted by something; otherwise I should have caught the wrong flap setting.as pilots; we are taught to use the same habit patterns over and over again. Our procedures expect nothing less. The company recently made a huge change in procedures by going from 'preferred flaps 5' to 'optimum flaps'. Yet; nothing was changed in our procedures. The checklists remained the same. I'm sure that I took off at least once with flaps 5 vice flaps 1 when we first changed over. Previously; I did not include the 'flaps setting' in the V speed response on the before taxi checklist until I caught myself trying to set the wrong setting. I then reread the checklist and realized I had been omitting the flap setting. No line check or check ride ever caught my mistake. Even lately I occasionally; as a result of habit; call for flaps 5 but have luckily been corrected by the first officer. This is the first time I reversed the pattern; and the first officer did not catch it. As I stated; our entire previous takeoffs were flaps 1. If I'm mistaken; how many others are doing the same? Maybe our procedures should be changed so that pilots; 'creatures of habit'; are forced to change our habit patterns. My recommendation is to move 'flaps' to the top of the before taxi checklist vice buried in the middle where they can be overlooked. The flaps are the most important item; why not treat them as such by checking them first? I was lucky; my tow was 119K pounds so the aircraft flew fine at flaps 1. Had I been at 135K plus; things might have been different. I might have lost altitude at cutback or worse yet; stalled. This is just another reason I feel the sna procedures are unsafe. Maybe the company should reconsider limiting the number of pilots who fly in/out of sna. As it is; I may go over six months between flying in/out of sna and I have to relearn the procedures all over again. Limiting the pilots would ensure more frequency and hopefully better compliance. In closing; I got the message! I may be a slow learner; but I doubt I will ever set the wrong flap setting again. Now; let's make sure everyone else gets the message too; before it's too late!
Original NASA ASRS Text
Title: A B737NG flight crew departing SNA mis-set the flaps and took off with flaps 1 rather than flaps 5. Captain cited recent changes in company checklists as contributory.
Narrative: We inadvertently took off with flaps 1 vice flaps 5. First; let me go on record as saying I believe the SNA noise abatement procedure is unsafe. Some airline will someday smack a light civilian airplane flying up or down the coast that is at the wrong altitude or airspace. Or they will stall trying to avoid it. With such a reduced power setting; there is no room for error. I did brief the profile including flaps 5; after completing the Before Start Checklist. The First Officer acknowledged it. I do not recall for sure if I called flaps 1 or 5 on the after start flow; but I think I called for flaps 5. I did not; however; catch the flaps 1 setting on the Before Taxi Checklist. This was our final leg of nine and all others were flaps 1 takeoff. Habit patterns can work against you! We pushed on time; but were taxi delayed ten minutes due to ramp congestion. I was a little disturbed that the Agent waited until the last minute to board since we could have easily pushed five minutes early and would have avoided the ramp congestion. (We arrived 30 minutes early!) I don't know if that distracted me or not; but I was distracted by something; otherwise I should have caught the wrong flap setting.As pilots; we are taught to use the same habit patterns over and over again. Our procedures expect nothing less. The Company recently made a huge change in procedures by going from 'preferred flaps 5' to 'optimum flaps'. Yet; nothing was changed in our procedures. The checklists remained the same. I'm sure that I took off at least once with flaps 5 vice flaps 1 when we first changed over. Previously; I did not include the 'flaps setting' in the V speed response on the Before Taxi Checklist until I caught myself trying to set the wrong setting. I then reread the checklist and realized I had been omitting the flap setting. No line check or check ride ever caught my mistake. Even lately I occasionally; as a result of habit; call for flaps 5 but have luckily been corrected by the First Officer. This is the first time I reversed the pattern; and the First Officer did not catch it. As I stated; our entire previous takeoffs were flaps 1. If I'm mistaken; how many others are doing the same? Maybe our procedures should be changed so that pilots; 'creatures of habit'; are forced to change our habit patterns. My recommendation is to move 'flaps' to the top of the Before Taxi Checklist vice buried in the middle where they can be overlooked. The flaps are the most important item; why not treat them as such by checking them first? I was lucky; my TOW was 119K pounds so the aircraft flew fine at flaps 1. Had I been at 135K plus; things might have been different. I might have lost altitude at cutback or worse yet; stalled. This is just another reason I feel the SNA procedures are unsafe. Maybe the Company should reconsider limiting the number of pilots who fly in/out of SNA. As it is; I may go over six months between flying in/out of SNA and I have to relearn the procedures all over again. Limiting the pilots would ensure more frequency and hopefully better compliance. In closing; I got the message! I may be a slow learner; but I doubt I will ever set the wrong flap setting again. Now; let's make sure everyone else gets the message too; before it's too late!
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.