B737-800 CREW FORGOT TO TURN ON THE PITOT STATIC HEAT AFTER BEING DEICED. THE ACFT EXPERIENCED PROBE ICING ON CLBOUT.
Synopsis
B737-800 CREW FORGOT TO TURN ON THE PITOT STATIC HEAT AFTER BEING DEICED. THE ACFT EXPERIENCED PROBE ICING ON CLBOUT.
Narrative
WE PUSHED BACK EARLY AND DEICED WITH TYPE 1 DEICE FLUID DUE TO FROST ON THE ACFT FROM OVERNIGHT. WE FOLLOWED THE DEICE CHKLIST. I STARTED TO ACCOMPLISH THE AFTER DEICE CHKLIST. THE CAPTAIN COMMENTED WE SHOULD START THE ENGS FIRST SINCE THE DEICE CHKLIST ASSUMES THE ENGS ARE RUNNING. I PUT THE BOOK WITH THE DEICE CHKLIST IN IT ASIDE FOR THE MOMENT AND STARTED THE ENGS. AFTER STARTING THE R ENGINE; I REFERENCED THE DEICE CHKLIST IN THE BOOK AGAIN TO NOTE THE MODIFICATION I NEED TO MAKE TO THE NORMAL AFTER START SEQUENCE DUE TO DELAYING THE PACKS COMING ON TO PREVENT DEICE ODORS FROM ENTERING THE CABIN. WHILE I WAS DOING THIS; THE CAPTAIN TOLD ME TO START THE OTHER ENGINE. I WAS DISTRACTED BY HAVING MY NORMAL AFTER START FLOW INTERUPTED AND CHANGED BY HAVING TO REFERENCE A CHKLIST ON A BOOK; INSTEAD OF A HARD CARD; THE MODIFICATION OF THE AFTER START CHKLIST DUE TO DE-ICE AND STOPPING MY THOUGHT PROCESS TO START THE OTHER ENGINE. WE TALKED ABOUT THE CHKLIST HAVING US USE WING ANTI-ICE FOR TKOF EVEN THOUGH THERE WAS NO ICING CONDITIONS. WE TALKED ABOUT HOW THIS WAS DIFFERENT THAN MOST AIRPLANES; THAT WE DIDN'T NEED IT; BUT PUT ON THE WING ANTI-ICE AS PER THE CHKLIST. WE DID THE AFTER START CHKLIST; AND COMPLETED THE DEICE CHKLIST. WE TAXIED AND COMPLETED ALL CHKLISTS. ON THE BEFORE TKOF CHECK; ON MASTER CAUTION RECALL; THE 'ANTI-ICE' ANNUNCIATED DISPLAYED. (ON THIS AIRPLANE THAT MEANS SOMETHING ON THE ANTI-ICE PANEL IS NOT SET FOR TKOF.) WE BOTH LOOKED UP TO SEE THE ANTI-ICE PANEL. THE ONLY INDICATIONS I SAW WAS THE WING ANTI-ICE ON. WE AGAIN TALKED ABOUT WING ANTI-ICE ON FOR TKOF; AND TALKED ABOUT HOW THIS MUST BE WHY THE 'ANTI-ICE ANNUNCIATOR' WAS ON WITH MASTER CAUTION RECALL. WE TOOK OFF AND CLBED OUT IN AND OUT OF LAYERS. AT APPROX 16000 FT MSL I NOTICED MY AIRSPD DECREASING AND AN IAS DISAGREEMENT MESSAGE ON MY PFD. I CALLED OUT THE DISAGREEMENT AND NOTED MY AIRSPD; THE CAPTAINS AIRSPD AND THE STANDBY AIRSPD ALL DIFFERENT AND ALL DECREASING. THE CAPTAIN DISCONNECTED THE AUTOPLT AND LOWERED THE CLB RATE SLIGHTLY AND CALLED TO CHK THE PROBE HEAT ON. I CHKED THE PROBE HEAT AND FOUND IT OFF. I TURNED IT ON AND THE AIRSPD DISPLAY RAPIDLY INCREASED TO APPROX 345 KTS AND THE OVER SPEED CLACKER WENT OFF. I IMMEDIATELY PULLED THE THROTTLES BACK AND THE AIRSPD REDUCED; AND THE OVER SPEED CLACKER STOPPED. THE OVER SPEED WAS APPROX 10 KTS FOR ABOUT 3 SECONDS. THE REMAINDER OF THE FLT WAS NORMAL AND UNEVENTFUL. THE EVENTS THAT CONTRIBUTED TO THIS WERE: 1) HAVING THE DEICE CHKLIST IN A BOOK INSTEAD OF A HARD CARD LIKE IT USED TO BE; IS A DISTRACTION AND REQUIRES EXTRA EFFORT TO MANAGE. 2) THE PROBE HEAT IS NOT A DUAL RESPONSE ITEM. FOR SOMETHING THAT CAN HAVE UNFAVORABLE CONSEQUENCES; IT SHOULD BE A DUAL RESPONSE ITEM JUST LIKE ENG ANTI-ICE. 3) THE DISTRACTION OF MODIFYING THE NORMAL AFTER START FLOW AND CHKLIST DUE TO DEICE AND STARTING THE OTHER ENG WHILE DECIDING THE MODIFICATIONS LEAD TO ME PROBABLY NOT TURNING ON THE PROBE HEAT DURING THE AFTER START FLOW. 3) I DON'T KNOW HOW I MISSED THE PROBE HEAT BEING OFF DURING THE AFTER START CHKLIST. 4) THE DISCUSSION OF HOW THE WING ANTI-ICE SHOULD NOT BE ON FOR TKOF LEAD US BOTH TO CONCLUDE THE WING ANTI-ICE ANNUNCIATOR LIGHT WAS ON DUE TO THE WING ANTI-ICE BEING ON. I DON'T KNOW HOW I LOOKED AT THE ANTI-ICE PANEL LOOKING FOR SOMETHING ABNORMAL AND DIDN'T SEE THAT THE PROBE HEAT WAS OFF. MY CONCLUSION IS THAT THE PROBE HEAT WAS EITHER NEVER TURNED ON; OR WAS SOMEHOW TURNED OFF PRIOR TO THE BEFORE TKOF CHK WHEN THE MASTER CAUTION WAS RECALLED. IN RETROSPECT; THE WING ANTI-ICE BEING ON WILL NOT ILLUMINATE THE ANTI-ICE ANNUNCIATOR WITH MASTER CAUTION RECALL. THE PROBE HEAT SHOULD BE A DUAL RESPONSE ITEM ON THE AFTER START CHKLIST. SUPPLEMENTAL INFO FROM ACN 566029: WE PUSHED BACK EARLY FROM THE GATE AND BECAUSE FROST HAD FORMED ON THE WINGS OVERNIGHT; WE ELECTED TO BE DEICED. THE FO CALLED THE PROBE HEAT ON DURING THE AFTER START CHKLIST; BUT IN FACT IT WAS LEFT OFF. OUR AIRSPD BECAME ERRATIC.I TOLD THE FO TO CHK THE PROBE HEAT ON. HE TURNED THE PROBE HEAT ON AND THE AIRSPD CORRECTED ITSELF IMMEDIATELY. I THINK THAT THE FO'S HABIT PATTERN WAS BROKEN WHILE FOLLOWING THE CHKLIST FOR DEICING. ALSO; THE PROBE HEAT IS NOT A DUAL RESPONSE ITEM ON OUR CHKLIST.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.