|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Controlling Facilities||tower : lax.tower|
|Operator||common carrier : air carrier|
|Make Model Name||B737-300|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : pushback|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 209|
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Experience||flight time last 90 days : 194|
flight time type : 450
|Anomaly||non adherence : company policies|
|Independent Detector||aircraft equipment other aircraft equipment : tkof warning|
other flight crewa
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
Prior to pushback; just prior to the before push check; ground crew climbed on pushback tug and gave 'no headset' push signal to captain. I gave the ground crew 'thumbs up' noting I understood. The before push check was completed. Within a matter of seconds; the first officer called for push; and ground control gave push clearance and notified us the runway was changing for departure. Simultaneously; as the captain was leaning right to stow the weight and balance sheet; the ground crew banged on left side of aircraft to initiate 'no headset' push. Captain gave the hold signal and since weight and balance sheet had not been stowed due to distraction from banging on left side of aircraft; captain entered new runway; laid weight and balance sheet on right side of glare shield in front of the first officer and then the push commenced. Pushback; engine start were uneventful. As ground crew cleared off; post start flows commenced by captain and first officer. However; after the generators were placed on; the captain grabbed the weight and balance sheet from glare shield and reviewed/confirmed takeoff data (no changes) and called for before push checklist once more since the takeoff data had been recalculated for a different runway. Unfortunately; the captain did not complete any item on the post engine start flow after generators placed on since his hands grabbed the opc on the way down from the generator switches. The before push checklist was completed once again. At that time the first officer called for taxi. As I began to taxi; I glanced up once again to see the generators were in fact on (habit pattern) and the generators were on and the taxi commenced from the alley way. As the aircraft approached the takeoff runway; captain called for before takeoff checklist and completed throttle burst and the takeoff warning horn sounded. At that time I realized the flaps were still up. The aircraft was stopped and the before taxi checklist was completed. Taxi was resumed and the before takeoff checklist completed and the flight resumed uneventfully. The captain should have completed the stowing of the weight and balance sheet prior to pushback. Then the post start flows after engine start would have been completed as per normal flows and then the weight and balance sheet could have been retrieved by the first officer from the cradle; the takeoff data could have been entered; then weight and balance sheet handed to the captain and reviewed prior to taxi. The distraction of the banging on the left side of the aircraft in conjunction with the no headset push coupled with the runway change was just too convenient for the captain to enter the data since the weight and balance sheet was still in hand. Had the weight and balance sheet been re-stowed in the cradle as in every other pushback; this would have been prevented. Additionally; this weight and balance sheet manipulation by the captain probably threw the 5 month on line first officer out of his normal mode of operation that contributed to his not catching the omission of the before taxi checklist. Only the first officer should do the takeoff data calculations for review by the captain to keep the flows/checklists in the same type format. Supplemental information from acn 753933: per normal operations I finished calculating data on the weight and balance sheet and gave it to the captain so we could complete the before push checklist. We did the before push checklist and as I got clearance from ATC to push; the captain was beginning to stow the weight and balance sheet. Ground crew banged on the side of the jet and he held on to the weight and balance sheet instead of stowing it. I got clearance to push. The captain communicated via hand signals to push; he then put the weight and balance sheet on the glare shield because I needed to recalculate data because ground told us to expect runway change. We pushed back; ground crew disconnected and pulled away. We both began our after start flows and when the captain finished his he grabbed the weight and balance sheet to run the data for new runway. I was distraction by this and did not finish my flow (specifically 'standing by flaps'). The captain finished loading the box and we did another before push checklist. At the completion of that before push checklist I called ground for taxi and we got clearance. When the captain did his throttle burst we got a confign warning and realized we had never done a taxi checklist. The captain stopped the aircraft at this point and we did the taxi checklist. I think the disruption of my after start flow threw us out of the routine and after we did the before push checklist for the second time I put the checklist away and this is when I normally would key the microphone to call ground for taxi. I think 2 things could have prevented us from missing the checklist. 1) if we would have just canceled the push and run the data for new runway done the before push checklist; stowed the weight and balance sheet everything would have returned to our normal routine. This wasn't as easy to do as usual though because ground crew did not have a headset and communication was hindered. Another way that would have prevented this would have been to push back; do our after start flows and taxi checklist normally; then run the numbers for the new runway then taxi out. Also this was our 5TH leg on day 3 (although neither the captain nor I felt fatigued). Maybe had this been earlier in the day we would have caught it.
Original NASA ASRS Text
Title: B737 FLT CREW OMITS TAXI CHECKLIST DUE TO INTERRUPTIONS DURING NO HEADSET PUSH BACK. FLAPS ARE LEFT UP AND ERROR IS CAUGHT BY TKOF WARNING DURING TAXI OUT.
Narrative: PRIOR TO PUSHBACK; JUST PRIOR TO THE BEFORE PUSH CHK; GND CREW CLBED ON PUSHBACK TUG AND GAVE 'NO HEADSET' PUSH SIGNAL TO CAPT. I GAVE THE GND CREW 'THUMBS UP' NOTING I UNDERSTOOD. THE BEFORE PUSH CHK WAS COMPLETED. WITHIN A MATTER OF SECONDS; THE FO CALLED FOR PUSH; AND GND CTL GAVE PUSH CLRNC AND NOTIFIED US THE RWY WAS CHANGING FOR DEP. SIMULTANEOUSLY; AS THE CAPT WAS LEANING R TO STOW THE WT AND BAL SHEET; THE GND CREW BANGED ON L SIDE OF ACFT TO INITIATE 'NO HEADSET' PUSH. CAPT GAVE THE HOLD SIGNAL AND SINCE WT AND BAL SHEET HAD NOT BEEN STOWED DUE TO DISTR FROM BANGING ON L SIDE OF ACFT; CAPT ENTERED NEW RWY; LAID WT AND BAL SHEET ON R SIDE OF GLARE SHIELD IN FRONT OF THE FO AND THEN THE PUSH COMMENCED. PUSHBACK; ENG START WERE UNEVENTFUL. AS GND CREW CLRED OFF; POST START FLOWS COMMENCED BY CAPT AND FO. HOWEVER; AFTER THE GENERATORS WERE PLACED ON; THE CAPT GRABBED THE WT AND BAL SHEET FROM GLARE SHIELD AND REVIEWED/CONFIRMED TKOF DATA (NO CHANGES) AND CALLED FOR BEFORE PUSH CHKLIST ONCE MORE SINCE THE TKOF DATA HAD BEEN RECALCULATED FOR A DIFFERENT RWY. UNFORTUNATELY; THE CAPT DID NOT COMPLETE ANY ITEM ON THE POST ENG START FLOW AFTER GENERATORS PLACED ON SINCE HIS HANDS GRABBED THE OPC ON THE WAY DOWN FROM THE GENERATOR SWITCHES. THE BEFORE PUSH CHKLIST WAS COMPLETED ONCE AGAIN. AT THAT TIME THE FO CALLED FOR TAXI. AS I BEGAN TO TAXI; I GLANCED UP ONCE AGAIN TO SEE THE GENERATORS WERE IN FACT ON (HABIT PATTERN) AND THE GENERATORS WERE ON AND THE TAXI COMMENCED FROM THE ALLEY WAY. AS THE ACFT APCHED THE TKOF RWY; CAPT CALLED FOR BEFORE TKOF CHKLIST AND COMPLETED THROTTLE BURST AND THE TKOF WARNING HORN SOUNDED. AT THAT TIME I REALIZED THE FLAPS WERE STILL UP. THE ACFT WAS STOPPED AND THE BEFORE TAXI CHKLIST WAS COMPLETED. TAXI WAS RESUMED AND THE BEFORE TKOF CHKLIST COMPLETED AND THE FLT RESUMED UNEVENTFULLY. THE CAPT SHOULD HAVE COMPLETED THE STOWING OF THE WT AND BAL SHEET PRIOR TO PUSHBACK. THEN THE POST START FLOWS AFTER ENG START WOULD HAVE BEEN COMPLETED AS PER NORMAL FLOWS AND THEN THE WT AND BAL SHEET COULD HAVE BEEN RETRIEVED BY THE FO FROM THE CRADLE; THE TKOF DATA COULD HAVE BEEN ENTERED; THEN WT AND BAL SHEET HANDED TO THE CAPT AND REVIEWED PRIOR TO TAXI. THE DISTR OF THE BANGING ON THE L SIDE OF THE ACFT IN CONJUNCTION WITH THE NO HEADSET PUSH COUPLED WITH THE RWY CHANGE WAS JUST TOO CONVENIENT FOR THE CAPT TO ENTER THE DATA SINCE THE WT AND BAL SHEET WAS STILL IN HAND. HAD THE WT AND BAL SHEET BEEN RE-STOWED IN THE CRADLE AS IN EVERY OTHER PUSHBACK; THIS WOULD HAVE BEEN PREVENTED. ADDITIONALLY; THIS WT AND BAL SHEET MANIPULATION BY THE CAPT PROBABLY THREW THE 5 MONTH ON LINE FO OUT OF HIS NORMAL MODE OF OP THAT CONTRIBUTED TO HIS NOT CATCHING THE OMISSION OF THE BEFORE TAXI CHKLIST. ONLY THE FO SHOULD DO THE TKOF DATA CALCULATIONS FOR REVIEW BY THE CAPT TO KEEP THE FLOWS/CHKLISTS IN THE SAME TYPE FORMAT. SUPPLEMENTAL INFO FROM ACN 753933: PER NORMAL OPS I FINISHED CALCULATING DATA ON THE WT AND BAL SHEET AND GAVE IT TO THE CAPT SO WE COULD COMPLETE THE BEFORE PUSH CHKLIST. WE DID THE BEFORE PUSH CHKLIST AND AS I GOT CLRNC FROM ATC TO PUSH; THE CAPT WAS BEGINNING TO STOW THE WT AND BAL SHEET. GND CREW BANGED ON THE SIDE OF THE JET AND HE HELD ON TO THE WT AND BAL SHEET INSTEAD OF STOWING IT. I GOT CLRNC TO PUSH. THE CAPT COMMUNICATED VIA HAND SIGNALS TO PUSH; HE THEN PUT THE WT AND BAL SHEET ON THE GLARE SHIELD BECAUSE I NEEDED TO RECALCULATE DATA BECAUSE GND TOLD US TO EXPECT RWY CHANGE. WE PUSHED BACK; GND CREW DISCONNECTED AND PULLED AWAY. WE BOTH BEGAN OUR AFTER START FLOWS AND WHEN THE CAPT FINISHED HIS HE GRABBED THE WT AND BAL SHEET TO RUN THE DATA FOR NEW RWY. I WAS DISTR BY THIS AND DID NOT FINISH MY FLOW (SPECIFICALLY 'STANDING BY FLAPS'). THE CAPT FINISHED LOADING THE BOX AND WE DID ANOTHER BEFORE PUSH CHKLIST. AT THE COMPLETION OF THAT BEFORE PUSH CHKLIST I CALLED GND FOR TAXI AND WE GOT CLRNC. WHEN THE CAPT DID HIS THROTTLE BURST WE GOT A CONFIGN WARNING AND REALIZED WE HAD NEVER DONE A TAXI CHKLIST. THE CAPT STOPPED THE ACFT AT THIS POINT AND WE DID THE TAXI CHKLIST. I THINK THE DISRUPTION OF MY AFTER START FLOW THREW US OUT OF THE ROUTINE AND AFTER WE DID THE BEFORE PUSH CHKLIST FOR THE SECOND TIME I PUT THE CHKLIST AWAY AND THIS IS WHEN I NORMALLY WOULD KEY THE MIKE TO CALL GND FOR TAXI. I THINK 2 THINGS COULD HAVE PREVENTED US FROM MISSING THE CHKLIST. 1) IF WE WOULD HAVE JUST CANCELED THE PUSH AND RUN THE DATA FOR NEW RWY DONE THE BEFORE PUSH CHKLIST; STOWED THE WT AND BAL SHEET EVERYTHING WOULD HAVE RETURNED TO OUR NORMAL ROUTINE. THIS WASN'T AS EASY TO DO AS USUAL THOUGH BECAUSE GND CREW DID NOT HAVE A HEADSET AND COM WAS HINDERED. ANOTHER WAY THAT WOULD HAVE PREVENTED THIS WOULD HAVE BEEN TO PUSH BACK; DO OUR AFTER START FLOWS AND TAXI CHKLIST NORMALLY; THEN RUN THE NUMBERS FOR THE NEW RWY THEN TAXI OUT. ALSO THIS WAS OUR 5TH LEG ON DAY 3 (ALTHOUGH NEITHER THE CAPT NOR I FELT FATIGUED). MAYBE HAD THIS BEEN EARLIER IN THE DAY WE WOULD HAVE CAUGHT IT.
Data retrieved from NASA's ASRS site as of January 2009 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.