|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||airport : oak.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B737-500|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : preflight|
ground : parked
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||non adherence : far|
non adherence : company policies
|Independent Detector||other flight crewa|
|Problem Areas||Environmental Factor|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
Prior to the leg from ZOA to sfo following a WX divert, the dispatcher sent a new flight plan for our continuation to sfo (originally departed from yvr). I failed to sign the release prior to departure. The following facts contributed to the oversight: 1) the door at runway 1L was never opened, so company computers never realized we had been blocked in at ZOA and all the messages from the just completed flight were still listed, 2) when I went to check to see what the release number was from the message log, I found release 01. It didn't dawn on me that it was from the previous leg until we were airborne, 3) I hadn't done a divert where the door at runway 1L wasn't opened, so I wasn't aware of the pitfalls here and was not diligent enough to ensure the proper leg was released, 4) several of the passenger were very upset about having missed their connections and were showing up at the flight deck door to inquire what we were going to do and if they could get off, etc, so I was dealing with them, leaving my first officer to handle the remainder of the coordination with the outside agencies. When we were ready to taxi, all the paperwork looked correct, along with my notation on the ATC clearance that we had release 01, when in fact, I had not signed the release at all.
Original NASA ASRS Text
Title: FLT CREW OF B735 FAILED TO OBTAIN AND VALIDATE A FLT RELEASE (PLAN) FOR AN UNPLANNED SHORT FLT TO THEIR DEST AFTER A WX DIVERSION.
Narrative: PRIOR TO THE LEG FROM ZOA TO SFO FOLLOWING A WX DIVERT, THE DISPATCHER SENT A NEW FLT PLAN FOR OUR CONTINUATION TO SFO (ORIGINALLY DEPARTED FROM YVR). I FAILED TO SIGN THE RELEASE PRIOR TO DEP. THE FOLLOWING FACTS CONTRIBUTED TO THE OVERSIGHT: 1) THE DOOR AT RWY 1L WAS NEVER OPENED, SO COMPANY COMPUTERS NEVER REALIZED WE HAD BEEN BLOCKED IN AT ZOA AND ALL THE MESSAGES FROM THE JUST COMPLETED FLT WERE STILL LISTED, 2) WHEN I WENT TO CHECK TO SEE WHAT THE RELEASE NUMBER WAS FROM THE MESSAGE LOG, I FOUND RELEASE 01. IT DIDN'T DAWN ON ME THAT IT WAS FROM THE PREVIOUS LEG UNTIL WE WERE AIRBORNE, 3) I HADN'T DONE A DIVERT WHERE THE DOOR AT RWY 1L WASN'T OPENED, SO I WASN'T AWARE OF THE PITFALLS HERE AND WAS NOT DILIGENT ENOUGH TO ENSURE THE PROPER LEG WAS RELEASED, 4) SEVERAL OF THE PAX WERE VERY UPSET ABOUT HAVING MISSED THEIR CONNECTIONS AND WERE SHOWING UP AT THE FLT DECK DOOR TO INQUIRE WHAT WE WERE GOING TO DO AND IF THEY COULD GET OFF, ETC, SO I WAS DEALING WITH THEM, LEAVING MY FO TO HANDLE THE REMAINDER OF THE COORDINATION WITH THE OUTSIDE AGENCIES. WHEN WE WERE READY TO TAXI, ALL THE PAPERWORK LOOKED CORRECT, ALONG WITH MY NOTATION ON THE ATC CLRNC THAT WE HAD RELEASE 01, WHEN IN FACT, I HAD NOT SIGNED THE RELEASE AT ALL.
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.