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An L1011 flight crew takes a flight to dfw from atl with dispatch release and weight and balance papers indicating another aircraft number. Maintenance had made a last min aircraft swap.
| Attributes | |
| ACN | 400040 |
| Time | |
| Date | 199804 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : atl |
| State Reference | GA |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | L-1011-500 Series |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other |
| Flight Phase | ground : preflight |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : second officer |
| Qualification | pilot : commercial pilot : flight engineer pilot : instrument |
| Experience | flight time last 90 days : 100 flight time total : 6000 flight time type : 3000 |
| ASRS Report | 400040 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
| Experience | flight time last 90 days : 150 flight time total : 9000 flight time type : 1200 |
| ASRS Report | 399928 |
| Events | |
| Anomaly | non adherence : far non adherence other other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
The planned flight consisted of L1011 service from atl-dfw using ship yzz. The problem arose as a result of removing (unbeknownst to the crew) the original ship yzs and substituting with ship yzz. Upon reaching dfw, the captain was looking at the flight plan and noticed that the flight plan indicated ship yzs, but the ship was actually yzz. The weight and balance also indicated the incorrect ship number. Several lines of defense broke down. Load planning, flight control, and lastly, we, the cockpit crew, all failed to notice the mistake. Contributing factors for the flight crew could be early morning and first flight of the rotation. It's possible that putting the tail number in a conspicuous location on the flight plan and weight and balance would highlight the tail number better.
Original NASA ASRS Text
Title: AN L1011 FLC TAKES A FLT TO DFW FROM ATL WITH DISPATCH RELEASE AND WT AND BAL PAPERS INDICATING ANOTHER ACFT NUMBER. MAINT HAD MADE A LAST MIN ACFT SWAP.
Narrative: THE PLANNED FLT CONSISTED OF L1011 SVC FROM ATL-DFW USING SHIP YZZ. THE PROB AROSE AS A RESULT OF REMOVING (UNBEKNOWNST TO THE CREW) THE ORIGINAL SHIP YZS AND SUBSTITUTING WITH SHIP YZZ. UPON REACHING DFW, THE CAPT WAS LOOKING AT THE FLT PLAN AND NOTICED THAT THE FLT PLAN INDICATED SHIP YZS, BUT THE SHIP WAS ACTUALLY YZZ. THE WT AND BAL ALSO INDICATED THE INCORRECT SHIP NUMBER. SEVERAL LINES OF DEFENSE BROKE DOWN. LOAD PLANNING, FLT CTL, AND LASTLY, WE, THE COCKPIT CREW, ALL FAILED TO NOTICE THE MISTAKE. CONTRIBUTING FACTORS FOR THE FLC COULD BE EARLY MORNING AND FIRST FLT OF THE ROTATION. IT'S POSSIBLE THAT PUTTING THE TAIL NUMBER IN A CONSPICUOUS LOCATION ON THE FLT PLAN AND WT AND BAL WOULD HIGHLIGHT THE TAIL NUMBER BETTER.
Data retrieved from NASA's ASRS site as of July 2007 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.