RUSHED FLT CREW OF CRJ FAIL TO NOTE FLAPS NOT SET TO TKOF POS. REJECT TKOF WHEN CONFIGN WARNING RESULTS.

Date: 2006-09 · Aircraft: Regional Jet CL65; Undifferentiated or Other Model · Phase: takeoff

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

Synopsis

RUSHED FLT CREW OF CRJ FAIL TO NOTE FLAPS NOT SET TO TKOF POS. REJECT TKOF WHEN CONFIGN WARNING RESULTS.

Narrative

ALTHOUGH THE MORNING FLT WAS SCHEDULED TO DEPART AT XA00 EDT WE WERE NOT ABLE TO DUTY ON UNTIL XD37 EDT. I NOTED THAT DESPITE HAVING MINIMUM REDUCED REST OF 8 HRS I WAS NOT FEELING FATIGUED. I ALSO REALIZED THAT WITH THE FLT BLOCKED FOR 2 HRS WE WOULD LIKELY NOT ARRIVE IN XXX IN TIME FOR ME TO MAKE MY DEADHEAD FROM XXX TO YYY AT XG25 EDT. RATHER THAN ACCEPT THIS FACT I DECIDED TO TRY MY BEST TO MAKE IT IN TIME. THE FO DID NOT HAVE THIS SAME PREDICAMENT; BUT HAVING BEEN JUNIOR ASSIGNED ON HIS DAY OFF; HE HAD HIS OWN MOTIVATION FOR WANTING TO GET HOME. WE COMPLETED OUR PREFLT ACTIVITIES IN WHAT I FELT WAS NORMAL FASHION AND DEPARTED THE GATE AT XE05 EDT. PROC CALLS FOR THE FLAPS TO BE SET TO TKOF CONFIGN AT THE GATE AND INSPECTED AS PART OF THE PREFLT WALKAROUND. IT WAS NOT NOTICED AT THIS POINT THAT THE FLAPS WERE SET TO ZERO. DURING TAXI WE COMPLETED THE BEFORE TKOF CHKLIST DURING WHICH THE FO IS TO CHK THE FLAP POS AND THE CAPT IS TO VERIFY THE FLAP POS. WE ACCOMPLISHED THIS CHK; BUT WE BOTH MISSED THE FACT THAT THE FLAPS WERE SET TO ZERO. AFTER WE WERE CLRED FOR TKOF WE COMPLETED THE 'BELOW THE LINE' PORTION OF THE BEFORE TKOF CHKLIST IN WHICH THE FO IS TO NOTE THE 'TKOF CONFIGN OK' MESSAGE ON EICAS. AGAIN; WE MISSED THIS INDICATION OF THE INCORRECT FLAP SETTING. UPON ADVANCING THE THRUST LEVERS WE IMMEDIATELY RECEIVED AN EICAS WARNING OF 'CONFIGN FLAPS.' I RETARDED THE THRUST LEVERS TO IDLE AND ASKED THE FO TO INFORM THE TWR THAT WE NEEDED TO EXIT THE RWY. AFTER EXITING THE RWY WE SET THE FLAPS TO THE CORRECT POS. I NOTED THAT PER COMPANY POLICY IT WOULD BE NECESSARY TO SUBMIT AN OCCURRENCE RPT DESCRIBING THE INCIDENT; WHICH WAS COMPLETED LATER THAT DAY. I ALSO CONSIDERED MAKING AN ENTRY IN THE AFML AS IS REQUIRED FOR ANY ABORTED TKOF. HOWEVER FOR 3 REASONS I DID NOT ACCOMPLISH THIS ENTRY. FIRST; I FELT THAT THE TIME REQUIRED TO ACCOMPLISH THIS WOULD ENSURE THAT I WOULD MISS THE DEADHEAD AND THEREFORE MY TWO ADDITIONAL SCHEDULED FLTS LATER THAT DAY. SECOND; I RATIONALIZED THAT BECAUSE WE NEVER ACCELERATED THAT IT WAS NOT IN FACT AN ABORTED TKOF. THIRD; I CONVINCED MYSELF THAT BECAUSE IT WAS PLT ERROR RATHER THAN ACFT MALFUNCTION IT WASN'T NECESSARY TO RPT AS A DISCREPANCY AND THAT THE OCCURRENCE RPT WOULD SUFFICE. THIS INCIDENT WOULD NOT HAVE OCCURRED IF WE HAD FOLLOWED CORRECT PROCS INVOLVING CHKLISTS AND RPTING. I BELIEVE THAT THERE WERE 3 FACTORS INVOLVED WHICH LED TO DEP FROM PROC. FIRST; ALTHOUGH I NOTED THAT I WAS NOT 'FEELING' FATIGUED MY POOR DECISION MAKING PERFORMANCE INDICATED OTHERWISE. SECOND; MY ATTEMPT TO ARRIVE IN TIME FOR MY DEADHEAD EXHIBITED POOR JUDGEMENT DESPITE MY BETTER INTENTIONS OF SALVAGING THE SCHEDULE. THIRD; WAS POOR CRM; I WAS LULLED INTO COMPLACENCY BY THE FACT THAT I HAD A VERY EXPERIENCED FO AND DID NOT FEEL THE NEED TO XCHK HIM. IN RETROSPECT I HAVE LEARNED 3 VALUABLE LESSONS WHICH I HOPE WILL MAKE THIS UNFORTUNATE INCIDENT A LEARNING EXPERIENCE.

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