Following is another high-speed rejected takeoff (NASA ASRS #1758495)
During takeoff roll, after 80 knots, Master Caution illuminated briefly. FO (First Officer) didn’t say anything at first. Then he said “over temp”. I looked at the speed and it was 125 knots. I looked down at the engine instruments and the #2 engine N1 numerical presentation was displayed in red with a red box around it. I looked back at the speed and it was 131 kts. V1 was 134 kts. I immediately applied the Phase One and rejected. FO did not call Tower to advise our reject. After taxiing clear, I noticed a Level One ENG 2 EXCEEDANCE. Ran appropriate checklists and taxied back to the gate. This was the second time in the same day that this aircraft rejected for the same thing. Maintenance ended up replacing the engine fan speed sensor.
Poor analysis, troubleshooting and resolution of the same issue earlier that morning.
The maintenance sign off of the morning’s reject before I got the airplane was a joke. Both rejects in this aircraft that day are extremely serious in nature and the first of the two wasn’t treated as such. … It’s an understatement to say rejecting 3 knots before V1 is highly dangerous. Further, I would have rejected at a much lower speed had my FO been doing his job correctly. I don’t think he was looking at the engine instruments during the takeoff roll as he should have been. When the Master Caution came on, I doubt he wasn’t [sic] looking where he should have been to notice the alert. And when he finally did notice the alert, he said the wrong problem. He said “over temp”. There was no over temp it was pretty clearly spelled out in amber “ENG 2 EXCEEDANCE” Is this the result of him not bringing his A-Game to work that day? Is this the result of poor training? Is this the result of hiring low hour [type aircraft] pilots directly to the right seat of a heavy? Whatever the case, I was on my own during this one.
Questions for analysis:
- The Captain voices clear frustration with maintenance clearing the previous rejected takeoff event and the FO not making appropriate callouts. The Captain doesn’t share what they briefed prior to takeoff. Given prior knowledge of the previous rejected takeoff event, what briefing points would be appropriate to cover during the Captain’s briefing?
- The FO failed to advise Tower of the rejected takeoff. What does this imply about the FO’s mindset during the RTO?
- What evidence implies startle and surprise behaviors in the FO’s performance?
- The FO made the incorrect callout during the event. How did this affect the Captain’s reject decision?
- The Captain reported that the maintenance sign-off from the earlier event “was a joke”. Does this imply hindsight bias? If the Captain thought it was an invalid sign-off, what steps should the Captain have taken before accepting the aircraft?
- The Captain reports several assumptions about where the FO wasn’t looking and should have been looking during takeoff. This implies that the crew didn’t effectively debrief the event. What debrief topics should have been covered?
Questions for analysis:
- The Captain voices clear frustration with maintenance clearing the previous rejected takeoff event and the FO not making appropriate callouts. The Captain doesn’t share what they briefed prior to takeoff. Given prior knowledge of the previous rejected takeoff event, what briefing points would be appropriate to cover during the Captain’s briefing?
Anytime we receive an aircraft that documents a serious event, like a high-speed reject for an engine indication, we should evaluate the write-up and the maintenance resolution very carefully. If the resolution was something like, “Performed engine run. No faults or problems noted”, we should exercise heightened caution. Perhaps, we would call our Maintenance Control supervisor to hear their thoughts. If they don’t allay our fears, we might consider a range of options from rejecting the aircraft to continuing, but with heightened caution. On the other hand, if the resolution documented a malfunctioning engine sensor with proper replacement, we might feel more optimistic that the problem had been resolved.
In any case, we should view the previous takeoff rejection and maintenance action as a warning flag that mandates additional due diligence on our part. If the previous crew is available for direct contact, we should discuss their experience. What did they see and when did they see it? Were there any associated indications or experiences that were not documented in the writeup? What surprised them about the event?
Given the information that we gather, we should perform a detailed crew discussion. As Captains, we would reiterate FO duties during the takeoff – what they should monitor – possible malfunction indications they might expect to see – what callouts to make, etc.
A Master Pilot Captain strategy would be to give the takeoff to the FO and assume PM duties during the takeoff. This would assign the familiar tasks and duties to the FO and transfer the unfamiliar tasks and duties to the most experienced pilot – the Captain. As the Captain, we could closely watch the engine indications and speeds. We would immediately detect unfavorable indications, select the proper course of action, and quickly assume aircraft control for an RTO.
- The FO failed to advise Tower of the rejected takeoff. What does this imply about the FO’s mindset during the RTO?
This implies a level of startle and surprise – and possibly a lack of proficiency with executing trained procedures. A detailed crew briefing while at the gate and again before taking the runway for takeoff would have improved the quality of their actions and results.
- What evidence implies startle and surprise behaviors in the FO’s performance?
First, there was a delay between the first indication of engine anomaly and the FO’s first callout. Either they didn’t see the indication, saw it and didn’t know what it meant, or understood it and didn’t know what to say. All of these would have been improved by a better crew briefing.
The FO made the wrong callout and then failed to perform trained post-RTO tasks and duties – all of which imply startle and surprise.
- The FO made the incorrect callout during the event. How did this affect the Captain’s reject decision?
We sense that the Captain expanded their PF duties to assume the PM’s indication detection and identification duties – essentially assuming both flightdeck roles. While this is not how our procedures are designed, it is realistic in the fast-paced real world. Captains remain responsible for deciding when to reject the takeoff – regardless of how their FOs perform their PM duties. It appears that this Captain was on their A-game and handled both roles effectively. Imagine if they weren’t. Imagine if they became startled or surprised and allowed their own PF duties to suffer while they tried to compensate for their FO’s shortfalls.
- The Captain reported that the maintenance sign-off from the earlier event “was a joke”. Does this imply hindsight bias? If the Captain thought it was an invalid sign-off, what steps should the Captain have taken before accepting the aircraft?
Yes, it implies hindsight bias. If the sign-off was really a “joke”, why did they accept the aircraft? We don’t know what measures they took to investigate the sign-off, but it appears that they accepted the aircraft and then failed to exercise heightened diligence in briefing and preparation.
- The Captain reports several assumptions about where the FO wasn’t looking and should have been looking during takeoff. This implies that the crew didn’t effectively debrief the event. What debrief topics should have been covered?
Had they performed a detailed event debrief, the Captain would know exactly what the FO saw and failed to see. They would probably have documented the exact errors and misconceptions that the FO made instead of the list of questions that they wrote in their report.
In the end, this appears to be a situation with clear warning flags about a likely engine anomaly during takeoff. Master Class actions include making a call to Maintenance Control to verify the airworthiness of the aircraft and performing detailed briefings of roles and duties expected during takeoff – including likely malfunction indications, the callouts to make, and tasks/duties during and following a high-speed reject. Finally, Master Class pilots conduct detailed debriefings following events like this to understand what happened and to promote learning.
