A B737-400 ON DEP OUT OF SNA EXPERIENCED A FLAP OVERSPD BECAUSE THE COMMANDED SPD WAS SET WRONG.
Synopsis
A B737-400 ON DEP OUT OF SNA EXPERIENCED A FLAP OVERSPD BECAUSE THE COMMANDED SPD WAS SET WRONG.
Narrative
NEW FO; 3 WKS OUT OF OE. FIRST SNA DEP. FLAPS 15 DEGS TKOF DUE TO PERFORMANCE. WE BRIEFED THE DEP AND TALKED ABOUT OTHER ITEMS. THE FO HAD NO QUESTIONS; BUT SEEMED A LITTLE ANXIOUS THAT WE WERE PUSHING A FEW MINS LATE; SO I EMPHASIZED IT WAS IMPORTANT TO NOT TO RUSH THE CUTBACK PROC TASKS; BUT TO PERFORM THEM IN A DELIBERATE; METHODICAL MANNER. JUST BEFORE TAKING THE RWY WE WERE TOLD TO MAINTAIN 4000 FT ON DEP; THEN WERE CLRED FOR AN 'IMMEDIATE TKOF DUE TO TFC ON FINAL' BEFORE WE WERE IN POS. I CALLED FOR CUTBACK PROC AT 800 FT; AND JUST AS THE FO BEGAN HER FLOW; TWR SWITCHED US OVER TO DEP. ON INITIAL CONTACT SOCAL CLRED US TO CLB TO 7000 FT; WHICH THE FO ACKNOWLEDGED AND SET. WITHIN SECONDS SOCAL AMENDED OUR ALT TO MAINTAIN 4000 FT DUE TO TFC AT 11 O'CLOCK POS AT 4700 FT. I SENSED THE FO WAS GETTING A LITTLE SATURATED AND FLUSTERED; AND ENGAGED THE AUTOPLT ASAP AFTER GETTING THE ACFT IN TRIM; AND BEGAN SEARCHING FOR THE TFC. AT THAT POINT ALL FMA INDICATIONS SEEMED NORMAL; AND I WAS FLYING USING THE HGS AND ANTICIPATING BEGINNING TO CLEAN UP AT 3000 FT. AFTER A FEW MINS; I NOTICED A LOUD RUMBLING; AND AFTER A QUICK CHK OF THE INSTS; DECIDED THAT IT WAS JUST THAT WE WERE IN A BIT OF NON-NORMAL CONFIGN; STILL AT FLAPS 15 DEGS. BECAUSE THE AUTOPLT WAS ON; I WAS WATCHING FOR TFC; AND I HAD OBSERVED THE SPD WAS CORRECT AT 160 KTS (V2+20 KTS) WHEN THE FO SELECTED LEVEL CHANGE; I TOTALLY OVERLOOKED THE FACT THAT WE WERE ACCELERATING. SUDDENLY; THE FO; THINKING SHE HAD MISSED A CALL; MOVED THE FLAP HANDLE TO 5 DEGS AND SAID SOMETHING TO THE EFFECT THAT WE SHOULD BE CLEANING UP. I WAS STARTING TO CORRECT HER WHEN SHE SAID WE WERE ABOUT TO OVERSPD THE FLAPS. AT THAT POINT I LOOKED DOWN AND REALIZED WE WERE OVER 205 KTS. AFTER RESUMING THE PROFILE AND GETTING TO CRUISE; WE REVIEWED THE INCIDENT AND THE PROPER SEQUENCE AND AGREED THAT AT SOME POINT DURING OR JUST AFTER SHE PERFORMED THE CUTBACK PROC SHE SET THE SPD TO 220 KTS; RATHER THAN V2+20 KTS. POSSIBLY SHE GLANCED DOWN AT THE NOTES ON THE 10-7 PROFILE AND SIMPLY MISREAD 'V2+20' AS '220.' BECAUSE SHE WAS QUICK IN MOVING THE FLAP HANDLE TO 5 DEGS; WE BOTH FELT WE HAD NOT CAUSED AN EXCEEDANCE; BUT AGREED IT WAS PRUDENT TO LOG A WRITE-UP OF A POSSIBLE OVERSPD OF 1-2 KTS; AND SENT AN ACARS TO MAINT TO THAT EFFECT. I HAVE NOT HAD AN INCIDENT OF THIS TYPE IN QUITE SOME TIME; BUT IT WAS GOOD REMINDER TO BE MORE DILIGENT OF ALL PARAMETERS WHEN THE AUTOPLT IS ON; TO BETTER MONITOR THE FO'S ACTIONS; AND VERY IMPORTANTLY; TO IDENT THE CAUSE OF ANY ABNORMAL INDICATIONS SUCH AS UNUSUAL SOUNDS AND VIBRATIONS.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.