Narrative:

When I pushed the power up for takeoff on flight from dal, the takeoff warning horn sounded. We aborted the takeoff and found the flaps to be in the 'up' position. We had not performed the proper checklist prior to taxiing. I would classify this as a distraction event. At the precise moment that I would normally call for the flaps to their proper position for takeoff, the first officer, upon annunciator recall, reported the low pressure light on the #1 electric hydraulic pump illuminated. We started looking for the hydraulic circuit breakers. The first officer pulled out the QRH and I called company to inform them of the problem and that we would be going back to the gate. The first officer eventually found a popped circuit breaker and it was successfully reset so I called company to inform them that the problem was corrected. This process took about 2-3 mins. It was day VFR and we pushed on time. We were not rushing and we were not fatigued nor were there any other mitigating factors other than the failure to accomplish the proper checklist. Later, I asked why my first officer had stowed the checklist and he said he didn't normally do so but this time had difficulty with the circuit breakers and needed both of his hands to accomplish the task of resetting the circuit breakers. We were both distraction with problem solving the hydraulic system. This event requires more explanation. We have recently changed the procedures just prior to takeoff, which calls for us to check the takeoff warning horn prior to takeoff by pushing up the thrust levers. It has taken me up to this last week to get comfortable with this procedure. Prior to this new procedure, my technique was to run my hands around the throttle quadrant touching all necessary items prior to takeoff. This is almost the same tactile kinetic approach that the movement of the thrust levers accomplishes. I like to touch the switches and levers to verify what my eyes are seeing. On thursday of this week, I informed my first officer that this new technique of pushing up the thrust lever to check for the proper position of the necessary items for takeoff was an excellent procedure. It did, however, take me a couple of weeks to transition from my old habit of touching all the items and looking at them to simply pushing up the thrust levers. On friday of this week I was flying with another first officer. I was using this new technique and feeling confident about it. Well, guess what? It doesn't work with a 200 model because the takeoff warning horn is not tied to the throttle movement but is tied to the EPR gauge. Now upon referring to the manual it states (in the procedure of moving the thrust levers) (-200 na). While this is obvious in print, it is obscure to me as a pilot. I am accustomed to using good habits and effective standards when it comes to the safe operation of the aircraft. This new thrust lever procedure is not an effective method for all our aircraft. The one that I used before was a very effective one because as I touched everything, I was forced to look at everything. The movement of the thrust lever to check for the takeoff warning horn is not a good procedure, because it does not require one to look at anything and is not standardized for the total fleet of airplanes. I will be returning to my previous procedure of tactile kinetic (touching and looking prior to takeoff). What can be done to prevent a recurrence of this event? 1) training should implement a procedure to train all first officer's to hold the 'handheld' checklist in their hands until all devices are in the proper position for both takeoff as well as landing. And, if for some reason the first officer needs to use his hands to accomplish a task (and the checklist is not finished), the first officer should hand the 'handheld' checklist over to the captain until the first officer can resume the duties of the challenge and response. Supplemental information from acn 593896: after pushback from gate, we did the after start checklist. We noted that the #1 electric hydraulic pump light was not on. We checked circuit breakers and did not see any circuit breakers (initially) popped. While the captain talked to maintenance, I checked the QRH to look for circuit breaker locations. I had to unstrap to look behind my seat at the bottom panel. I found 1 circuit breaker popped and informed the captain. He told me to reset the circuit breaker, resulting in solving our problem. The captain told maintenance and they agreed we were good to go. This whole business took approximately 3 mins. Normally, I leave the checklist out after completing the after start checklist. Today, in order to look for the circuit breaker, etc, I put it back in its slot (before putting flaps to 5 degrees, and then performing the before takeoff checklist). After we solved our problem, we were good to go and I called for taxi. We were rested, nobody was rushing, we were not talking about other things, we just did not do the before takeoff checklist (which we realized later). Taxiing to the runway, the captain asked for 'below the line.' I read it, and he pushed the throttle forward -- no takeoff warning horn. Tower cleared us for takeoff. After advancing the throttles, the takeoff warning horn came on. We aborted the takeoff, checked the confign, and realized that the flaps were up. After clearing the runway, we accomplished the required checks. Rest of the flight was uneventful. I was absolutely shocked! Like I said, we were rested, not rushed. By putting the checklist back into the slot, I interrupted my flow. 'Good to go' because 'all checklists completed.' the new procedure to push one throttle forward, to make sure the takeoff confign is set does not work in the -200. I read this of course. However, when the captain checked this, and got no horn, I did not even think about that. In the future, when the captain calls 'below the line,' I will change my flow to rechk the flaps and the speed brakes lever before reading the checklist.

Google
 

Original NASA ASRS Text

Title: B737-200 CREW ABORTED TKOF BECAUSE THE TKOF WARNING HORN SOUNDED AT THRUST APPLICATION. THE CREW DID NOT SET THE FLAPS FOR TKOF.

Narrative: WHEN I PUSHED THE PWR UP FOR TKOF ON FLT FROM DAL, THE TKOF WARNING HORN SOUNDED. WE ABORTED THE TKOF AND FOUND THE FLAPS TO BE IN THE 'UP' POS. WE HAD NOT PERFORMED THE PROPER CHKLIST PRIOR TO TAXIING. I WOULD CLASSIFY THIS AS A DISTR EVENT. AT THE PRECISE MOMENT THAT I WOULD NORMALLY CALL FOR THE FLAPS TO THEIR PROPER POS FOR TKOF, THE FO, UPON ANNUNCIATOR RECALL, REPORTED THE LOW PRESSURE LIGHT ON THE #1 ELECTRIC HYD PUMP ILLUMINATED. WE STARTED LOOKING FOR THE HYD CIRCUIT BREAKERS. THE FO PULLED OUT THE QRH AND I CALLED COMPANY TO INFORM THEM OF THE PROB AND THAT WE WOULD BE GOING BACK TO THE GATE. THE FO EVENTUALLY FOUND A POPPED CIRCUIT BREAKER AND IT WAS SUCCESSFULLY RESET SO I CALLED COMPANY TO INFORM THEM THAT THE PROB WAS CORRECTED. THIS PROCESS TOOK ABOUT 2-3 MINS. IT WAS DAY VFR AND WE PUSHED ON TIME. WE WERE NOT RUSHING AND WE WERE NOT FATIGUED NOR WERE THERE ANY OTHER MITIGATING FACTORS OTHER THAN THE FAILURE TO ACCOMPLISH THE PROPER CHKLIST. LATER, I ASKED WHY MY FO HAD STOWED THE CHKLIST AND HE SAID HE DIDN'T NORMALLY DO SO BUT THIS TIME HAD DIFFICULTY WITH THE CIRCUIT BREAKERS AND NEEDED BOTH OF HIS HANDS TO ACCOMPLISH THE TASK OF RESETTING THE CIRCUIT BREAKERS. WE WERE BOTH DISTR WITH PROB SOLVING THE HYD SYS. THIS EVENT REQUIRES MORE EXPLANATION. WE HAVE RECENTLY CHANGED THE PROCS JUST PRIOR TO TKOF, WHICH CALLS FOR US TO CHK THE TKOF WARNING HORN PRIOR TO TKOF BY PUSHING UP THE THRUST LEVERS. IT HAS TAKEN ME UP TO THIS LAST WK TO GET COMFORTABLE WITH THIS PROC. PRIOR TO THIS NEW PROC, MY TECHNIQUE WAS TO RUN MY HANDS AROUND THE THROTTLE QUADRANT TOUCHING ALL NECESSARY ITEMS PRIOR TO TKOF. THIS IS ALMOST THE SAME TACTILE KINETIC APCH THAT THE MOVEMENT OF THE THRUST LEVERS ACCOMPLISHES. I LIKE TO TOUCH THE SWITCHES AND LEVERS TO VERIFY WHAT MY EYES ARE SEEING. ON THURSDAY OF THIS WK, I INFORMED MY FO THAT THIS NEW TECHNIQUE OF PUSHING UP THE THRUST LEVER TO CHK FOR THE PROPER POS OF THE NECESSARY ITEMS FOR TKOF WAS AN EXCELLENT PROC. IT DID, HOWEVER, TAKE ME A COUPLE OF WKS TO TRANSITION FROM MY OLD HABIT OF TOUCHING ALL THE ITEMS AND LOOKING AT THEM TO SIMPLY PUSHING UP THE THRUST LEVERS. ON FRIDAY OF THIS WK I WAS FLYING WITH ANOTHER FO. I WAS USING THIS NEW TECHNIQUE AND FEELING CONFIDENT ABOUT IT. WELL, GUESS WHAT? IT DOESN'T WORK WITH A 200 MODEL BECAUSE THE TKOF WARNING HORN IS NOT TIED TO THE THROTTLE MOVEMENT BUT IS TIED TO THE EPR GAUGE. NOW UPON REFERRING TO THE MANUAL IT STATES (IN THE PROC OF MOVING THE THRUST LEVERS) (-200 NA). WHILE THIS IS OBVIOUS IN PRINT, IT IS OBSCURE TO ME AS A PLT. I AM ACCUSTOMED TO USING GOOD HABITS AND EFFECTIVE STANDARDS WHEN IT COMES TO THE SAFE OP OF THE ACFT. THIS NEW THRUST LEVER PROC IS NOT AN EFFECTIVE METHOD FOR ALL OUR ACFT. THE ONE THAT I USED BEFORE WAS A VERY EFFECTIVE ONE BECAUSE AS I TOUCHED EVERYTHING, I WAS FORCED TO LOOK AT EVERYTHING. THE MOVEMENT OF THE THRUST LEVER TO CHK FOR THE TKOF WARNING HORN IS NOT A GOOD PROC, BECAUSE IT DOES NOT REQUIRE ONE TO LOOK AT ANYTHING AND IS NOT STANDARDIZED FOR THE TOTAL FLEET OF AIRPLANES. I WILL BE RETURNING TO MY PREVIOUS PROC OF TACTILE KINETIC (TOUCHING AND LOOKING PRIOR TO TKOF). WHAT CAN BE DONE TO PREVENT A RECURRENCE OF THIS EVENT? 1) TRAINING SHOULD IMPLEMENT A PROC TO TRAIN ALL FO'S TO HOLD THE 'HANDHELD' CHKLIST IN THEIR HANDS UNTIL ALL DEVICES ARE IN THE PROPER POS FOR BOTH TKOF AS WELL AS LNDG. AND, IF FOR SOME REASON THE FO NEEDS TO USE HIS HANDS TO ACCOMPLISH A TASK (AND THE CHKLIST IS NOT FINISHED), THE FO SHOULD HAND THE 'HANDHELD' CHKLIST OVER TO THE CAPT UNTIL THE FO CAN RESUME THE DUTIES OF THE CHALLENGE AND RESPONSE. SUPPLEMENTAL INFO FROM ACN 593896: AFTER PUSHBACK FROM GATE, WE DID THE AFTER START CHKLIST. WE NOTED THAT THE #1 ELECTRIC HYD PUMP LIGHT WAS NOT ON. WE CHKED CIRCUIT BREAKERS AND DID NOT SEE ANY CIRCUIT BREAKERS (INITIALLY) POPPED. WHILE THE CAPT TALKED TO MAINT, I CHKED THE QRH TO LOOK FOR CIRCUIT BREAKER LOCATIONS. I HAD TO UNSTRAP TO LOOK BEHIND MY SEAT AT THE BOTTOM PANEL. I FOUND 1 CIRCUIT BREAKER POPPED AND INFORMED THE CAPT. HE TOLD ME TO RESET THE CIRCUIT BREAKER, RESULTING IN SOLVING OUR PROB. THE CAPT TOLD MAINT AND THEY AGREED WE WERE GOOD TO GO. THIS WHOLE BUSINESS TOOK APPROX 3 MINS. NORMALLY, I LEAVE THE CHKLIST OUT AFTER COMPLETING THE AFTER START CHKLIST. TODAY, IN ORDER TO LOOK FOR THE CIRCUIT BREAKER, ETC, I PUT IT BACK IN ITS SLOT (BEFORE PUTTING FLAPS TO 5 DEGS, AND THEN PERFORMING THE BEFORE TKOF CHKLIST). AFTER WE SOLVED OUR PROB, WE WERE GOOD TO GO AND I CALLED FOR TAXI. WE WERE RESTED, NOBODY WAS RUSHING, WE WERE NOT TALKING ABOUT OTHER THINGS, WE JUST DID NOT DO THE BEFORE TKOF CHKLIST (WHICH WE REALIZED LATER). TAXIING TO THE RWY, THE CAPT ASKED FOR 'BELOW THE LINE.' I READ IT, AND HE PUSHED THE THROTTLE FORWARD -- NO TKOF WARNING HORN. TWR CLRED US FOR TKOF. AFTER ADVANCING THE THROTTLES, THE TKOF WARNING HORN CAME ON. WE ABORTED THE TKOF, CHKED THE CONFIGN, AND REALIZED THAT THE FLAPS WERE UP. AFTER CLRING THE RWY, WE ACCOMPLISHED THE REQUIRED CHKS. REST OF THE FLT WAS UNEVENTFUL. I WAS ABSOLUTELY SHOCKED! LIKE I SAID, WE WERE RESTED, NOT RUSHED. BY PUTTING THE CHKLIST BACK INTO THE SLOT, I INTERRUPTED MY FLOW. 'GOOD TO GO' BECAUSE 'ALL CHKLISTS COMPLETED.' THE NEW PROC TO PUSH ONE THROTTLE FORWARD, TO MAKE SURE THE TKOF CONFIGN IS SET DOES NOT WORK IN THE -200. I READ THIS OF COURSE. HOWEVER, WHEN THE CAPT CHKED THIS, AND GOT NO HORN, I DID NOT EVEN THINK ABOUT THAT. IN THE FUTURE, WHEN THE CAPT CALLS 'BELOW THE LINE,' I WILL CHANGE MY FLOW TO RECHK THE FLAPS AND THE SPD BRAKES LEVER BEFORE READING THE CHKLIST.

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.