2011-07 · NASA ASRS report 963179
B757/767 flight crew describes a departure delay to study new manuals and checklists which had not been previously issued and for which only online training had been received.
Last week I was assigned to fly a segment in a Boeing 767 aircraft. Upon reaching the cockpit to begin my preflight duties; I noted that the Quick Reference Checklist had been replaced. In the chart holder next to my seat there was a large laminated; bound volume labeled 'Quick Reference Handbook.' I had never seen this document before. Upon investigation; it appeared to contain a number of emergency and irregular checklists organized by component (i.e. Engines; Hydraulics; Pneumatics; etc.). During the previous month; we had been instructed by the company to watch a computer based video; which was of very poor quality and contained very little useful information; which ostensibly was our training for the use of this document. Over my aviation career; it has been standard practice; when confronted by a change of this magnitude; that the company would spend an inordinate amount of time and energy preparing us for the change. In this case; the change of an entire new set of checklists and procedures for any emergency encountered; was haphazardly presented in a video that was difficult to navigate and materials which in no way represented the type of change this new document contained. During preflight we encountered a mechanical and I had approximately one hour to familiarize myself with this document. I have never; in 16 years of flying been presented such a massive change to the standard or emergency procedures under which we operate with so little preparation. Equally disturbing was my flight two days later in a Boeing 757 aircraft. Fifteen minutes prior to departure we discovered the new Quick Reference Handbook and massive Flight Manual changes in our flight bags. The Captain advised me that he had not flown with these changes and needed to take some time to familiarize himself with this new material. We encountered a delay until the Captain could be assured that he could operate the flight safely. I cannot speak for the Captain of this flight; but I immediately felt that CSR Supervisors and the assistant Chief Pilot began pressuring my Captain; the next day my Captain continued to receive messages from Flight Managers trying to make him feel guilty for the disruption this caused. He was then taken off his next trip and was advised he needed to make a special trip into the Flight Office. I believe this management's behavior is simply to intimidate pilots to follow their agenda no matter what the cost.
A delay was taken prior to brake release for the following SAFETY concerns and issues. 1. The new Flight Manual; FOM; Checklist Cards; QRH; and ship sets were onboard. 2. We (the First Officer and I) proceeded to review the new changes and realized that the changes entailed numerous items that were not evident in the required and completed Phase One training. 3. I notified the flight attendants; Operations; Customer Service; and the passengers that once a safe review of the required items was complete that we would precede. 4. While reviewing the materials; I was available to any passenger; Customer Service agent; supervisor that had a question or concern. I answered several inquiries from Customer Service; Zone; passengers; Zone/Ramp supervisor; and a phone call from a Chief Pilot regarding the delay. These all lengthened the time needed to complete my review. 5. We also had an inoperative; deferred; APU which required extra coordination with ramp to maintain external power; AC; and air start cart. [I] also contacted ATC to keep our flight plan/PDC valid. 6. Reviewed: Non-Normals QRH and Flight Manual to clarify indexing and format; new 'Memory Items'; FOM Revision Summary. Many of these items are interrelated and the changes reflect differences across various manuals that affect the safe operation of the aircraft in a multitude of ways. 7. Noted that with all the revisions 'change bars' that previously highlighted changes; may or may not be present during these changes. 8. With the review complete; and the First Officer and myself confident with our compliance with the required material; we coordinated for departure. We then proceeded with 'APU inoperative' engine start at the gate; pushback; cross-bleed start; taxi; and takeoff. The extensive changes that make up 'Phase One' need to be trained taught and reviewed as a complete package that was not adequately addressed in the 'Phase One' video. In compliance with [my Air Carrier's] focus that safety is always our first priority; and my FAA requirement not to release the brakes until I am in compliance with all FM changes; FOM changes; Bulletins; as well as my legal and moral responsibility to operate the flight SAFELY? This delay could have been prevented by properly training and equipping the crews with all the needed materials and knowledge PRIOR to implementing the 'Phase One' and subsequent changes.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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