B737 FLC FAILS TO SET FLAPS TO TKOF POS AND REJECTS TKOF AT LAS.

2002-12 · NASA ASRS report 569708

Date: 2002-12 · Aircraft: B737-300 · Phase: takeoff

Anomalies: aircraft-equipment-problem-less-severe|deviation-discrepancy-procedural-published-material-policy

Synopsis

B737 FLC FAILS TO SET FLAPS TO TKOF POS AND REJECTS TKOF AT LAS.

Narrative

AS A CREW; WE FAILED TO SET FLAPS 5 DEGS FOR TKOF AFTER IT WAS CALLED FOR. AS A CREW; WE FAILED TO CATCH THE ERROR ON THE CHKLIST; NOR DID WE CATCH IT ON OUR PERSONAL REVIEW APCHING THE RWY. THE TKOF WARNING HORN ALERTED US AS I TURNED TO LINE UP AIRPLANE. FATIGUE/BODY CLOCK WAS A MAIN FACTOR IN OUR INATTENTIVENESS. I WAS IN BED THE PREVIOUS 2 NIGHTS BEFORE THAT TIME. THE SEQUENCE WAS DELAYED 1 HR DUE TO LOADING ISSUES IN MSY; PAX ISSUES IN HOU. WORKLOAD WAS HVY DUE TO TSTMS IN TEXAS. I ALSO HAD A MEAL (LEFTOVERS) ENRTE AND WAS FEELING 'LOGY' TO THE POINT I HAD GONE TO ARPT BATHROOM AND WASHED MY FACE IN COLD WATER TRYING TO REFRESH MYSELF. EARLIER IN THE PAIRING; I HAD FELT LEFT OUT IN SITUATIONAL AWARENESS ISSUES THAT AROSE DURING PRETKOF CHKLIST; AND I HAD MADE A CONSCIOUS DECISION TO RUN THE PRETKOF CHKLIST WHILE MONITORING GND RADIO XMISSIONS. THIS WAS A CHANGE FROM MY HABIT PATTERN OF RUNNING THAT CHKLIST IN A STERILE HEADSET ENVIRONMENT. I WAS OFF GATE IN LAS AND WAS DEEP IN THE RAMP CTL AREA. I MADE ANOTHER MISTAKE OF HABIT PATTERN OF CALLING 'FLAPS FIVE CHKLIST' (1 WORD) INSTEAD OF; 'FLAPS 5 DEGS;' WAIT UNTIL I SEE THE FO'S HAND MOVE THE FLAP LEVER; 'PRETKOF CHKLIST.' I KNOW IMMEDIATELY THAT I HAD DONE THAT; BUT WHY I DIDN'T STOP AND START AGAIN I DON'T KNOW. I BECAME DISTR BY 2 RADIO CALLS AS WE WORKED OUR WAY THROUGH THE CHKLIST. THE FIRST RADIO CALL WAS A PUSHBACK AT GATE AND THE SECOND WAS A PUSH APPROVAL AT ANOTHER GATE. I DID NOT KNOW WHERE THAT GATE WAS; AND I GLANCED UP TO SEE IF A PLANE WAS BEING PUSHED INTO US; OR BLOCKING US. AT THAT POINT MY HAND WENT TO THE FLAP LEVER; BUT MY EYES WERE OUTSIDE COCKPIT LOOKING FOR A CONFLICT. I DON'T KNOW WHERE THE FO'S MINDSET WAS. I AM NOT SURE WHAT THE FO'S FLOWS WERE; BUT THEY WERE NOT QUITE THE SAME AS THE OTHER FO'S I HAD FLOWN WITH IN DECEMBER. I MAY HAVE BEEN UNCONSCIOUSLY RUSHING HIM; EVEN THOUGH I WAITED FOR HIM TO CALL AFTER START CHKLIST COMPLETE EVERY TIME. THERE WAS A 'BUMP' IN THE ACCUSTOMED FLOW AT THAT POINT THE ENTIRE 3-DAY PAIRING; BUT I STILL COULDN'T SAY WHAT THAT BUMP WAS. PERHAPS IT WAS STOWAGE/UNSTOWAGE OF OPC. THERE WAS SOME SLOW MANEUVERING TO WORK OUR WAY OUT OF 'ALLEYWAY' RAMP AREA. DUE TO CONGESTION; I WAS UNABLE TO BRIEFLY BRING A THROTTLE UP ENOUGH TO TKOF WARNING HORN ACTIVATION POINT; WHICH IS ANOTHER HABIT OR SELF CHK. TWR PROMPTED ME FOR TKOF; AGAIN RUSHING OR PREEMPTING A FINAL LOOK; AS I BECAME PREOCCUPIED WITH DOUBLECHKING ALL PARAMETERS FOR THE LNAV DEP. THEY WERE CORRECT; THE FLAPS WERE NOT. WE WERE BOTH VERY SHOCKED AND SORRY ABOUT THIS EVENT. I HAVE PREVIOUSLY SUGGESTED THAT THE FLAPS NOT BE RAISED PAST 5 DEGS; THE FLAPS UP; CLEAN UP CHKLIST. I STILL FEEL THAT IS THE WAY TO GO ON THIS RECURRING PROB.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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