THE FLC FAILED TO SET THE FLAPS AS PER THE BEFORE TKOF CHKLIST. THE FLC ABORTED AT PROMPTING OF THE TKOF CONFIGN WARNING. THE CREW DID A SINGLE ENG TAXI OUT AND WAS DISTRACTED BY TRYING TO START THE OTHER ENG WHILE ATTEMPTING TO COMPLY WITH THE COMPLICATED TAXI INSTRUCTIONS AT NIGHT.
Synopsis
THE FLC FAILED TO SET THE FLAPS AS PER THE BEFORE TKOF CHKLIST. THE FLC ABORTED AT PROMPTING OF THE TKOF CONFIGN WARNING. THE CREW DID A SINGLE ENG TAXI OUT AND WAS DISTRACTED BY TRYING TO START THE OTHER ENG WHILE ATTEMPTING TO COMPLY WITH THE COMPLICATED TAXI INSTRUCTIONS AT NIGHT.
Narrative
FLAPS WERE UP WHEN PWR WAS APPLIED FOR TKOF. TKOF INITIATION WAS DISCONTINUED PRIOR TO 15 KTS. DUE TO THE OBVIOUS OMISSION OF AN IMPORTANT CHKLIST ITEM; WE REQUESTED AND RECEIVED PERMISSION TO EXIT RWY. ONCE CLR OF RWY THE FLAPS WERE CONFIRMED PROPERLY SET AT 15 DEGS; FOLLOWED BY A THOROUGH TAXI AND BEFORE TKOF CHKLIST. THE TKOF WAS THEN ACCOMPLISHED FROM FULL LENGTH OF RWY 28 WITH REMAINDER OF FLT UNEVENTFUL. THIS WAS A MAJOR DEV FROM PRESCRIBED PROC DUE TO POOR CHKLIST DISCIPLINE. CONTRIBUTING FACTORS WERE FATIGUE AND CONFUSION. FATIGUE OCCURRED DUE TO A VERY STRESSFUL 4 DAY TRIP. THIS FLT WAS THE LAST LEG. THE TRIP WAS UNUSUAL IN THAT IT HAD SEVERAL DELAYS; ONE INFLT EMER REQUIRING AN ENG SHUTDOWN; AND OPS AT AN ARPT WITH ADVERSE WINTER WX CONDITIONS. THE DELAYS RESULTED IN CREW REST BEING CUT TO THE MINIMUM 8 HRS THE PRECEDING NIGHT. ALSO; THE TAXI CHKLIST WAS INTERRUPTED BY CONFUSION WITH COMPLEX TAXI INSTRUCTIONS. AS COPLT I DEVOTED TOO MUCH TIME TO THE TAXI RTE CLARIFICATION BECAUSE IT WAS NIGHT; CONFUSING AND INVOLVED XING AN ACTIVE RWY. ONCE THE RTE WAS VERIFIED; A TIME CRUNCH WAS FELT IN GETTING THE REMAINING ENG STARTED; CABIN NOTIFIED FOR TKOF AND THE REMAINDER OF CHKLIST ACCOMPLISHED. IT BECAME OBVIOUS THE REMAINDER OF CHKLIST WAS NOT PROPERLY ACCOMPLISHED. A VALUABLE LESSON WAS LEARNED; ALTHOUGH I WOULD RATHER HAVE NOT BLUNDERED. I THOUGHT I HAD VERY STRONG CHKLIST DISCIPLINE; HOWEVER I ALLOWED FATIGUE AND DISTR TO CHANGE MY PRIORITIES. FATIGUE AND DISTR NOW MEANS SLOW DOWN AND DO THE JOB RIGHT.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.