B737-800
Flight Crew Air Transport Pilot (ATP)
Training / Qualification; Situational Awareness; Distraction; Communication Breakdown; Workload
Deviation - Speed All Types; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Flight Crew Became Reoriented; Flight Crew FLC complied w / Automation / Advisory
Human Factors; Procedure
As Pilot Flying (PF) I was to fly the Departure. Performance [program] had generated flaps 25; engine bleeds off; takeoff for us. We had briefed in detail both the departure procedure; which as published showed 'Assigned headings 360 degrees clockwise through 080 degrees climbing right turn to 2400 feet; heading 100 degrees before proceeding on course;' the call outs we were going to expect; and paid particular attention to how challenging the multiple heading; altitude; and configuration changes were going to be given our heavily loaded -800 aircraft and the short runway. We both missed the fact that our takeoff was supposed to be an 'Engine Bleeds Off' takeoff until we were taxiing to the runway and called Tower to let them know we would need a moment at the end of the taxiway to configure and call them when we were ready for departure. I mentioned to the Captain that other than in the simulator I had never done an engine bleeds off takeoff. The Captain configured the bleed panel for departure and said; 'Don't worry about the bleeds; just fly the aircraft and I'll reconfigure them once we are cleaned up.' At that point in the event I was solidly 'in the Yellow' and probably getting 'into the Red' on our CRM model.We reconfirmed the configuration of the bleeds panel; completed our departure plan and Before Takeoff Checklist then called for takeoff. Tower cleared us for takeoff; 'on departure turn left heading 250; cleared for takeoff.' The Captain transferred the controls to me and we both acknowledged that it was going to be even more complicated by an initial right turn to 100 degrees and at 2400 feet; a climbing left turn to heading 250 while leveling at 3000 feet and cleaning up the flaps. I advanced the throttles and set takeoff thrust. The takeoff roll and call outs were normal and we got airborne. At 400 feet I called for Heading Select and started my right turn. As we approached the minimum cleanup altitude; the Captain said 'watch your speed' and I assumed he was afraid that I would overspeed the flaps so instead of calling 'Set Speed' in the ensuing confusion I called 'Flaps 15' and began a gentle nose over to catch the expected climb profile. Because the Speed bug had not been moved to the 'UP' position; the autothrottles pulled back to mid-range thrust as designed to maintain the initial speed setting. We were just under 2000 feet MSL and we started our left-hand turn to the assigned heading of 250 with the aircraft at flaps 15. I was aware that something was wrong and focused on the flight director and attempting to fly the aircraft when I noticed the red light indicating the autothrottles were off. The Captain said something to the effect of 'there's something wrong with the autothrottles' and then said he was re-engaging them. I found out later that he had disengaged them; pushed them forward to get more speed; and then re-engaged them thinking that he had corrected the problem. We were turning north at under 2000 feet MSL in a left hand turn at about 160 knots. The handling of the aircraft seemed very sluggish and the Captain and I were very confused as evidenced by our lack of communication. What little we did say was focused on getting airspeed. Finally; when we got the Gear warning horn; 'Don't Sink'; and 'Pull Up'; I disengaged the autothrottles and moved them forward; rolled partially wings level and got the nose above the horizon on a climbing profile and cleaned up the flaps. It was at that point that we realized our error in failing to set the Speed bug appropriately.
We conducted a full Departure Briefing to include a heavy takeoff and the initial departure procedures. Due to some confusion at the gate during pushback; we failed to run a Pushback Checklist. After pushback was complete; I realized this; and we conducted the briefing. We caught the engine bleeds-off takeoff requirement late and configured the aircraft. It was a max thrust takeoff on Runway XXR with an assigned heading 'left turn to 250'. After takeoff; we started our initial turn in accordance with the SID to 100 degrees. I became focused on the VMO/MMO and minimum maneuver speed tapes- given our heavy weight. At our cleanup altitude I don't remember the Pilot Flying call for 'Set speed; flaps 15; climb thrust'; and I failed to monitor for the calls as I was still focused on the speed tapes. I do remember bringing the flaps to 15 as the autothrottles retarded the thrust levers. I disengaged to autothrottles and advanced the thrust levers. The First Officer appeared focused on following the flight directors and flying the SID; turning left to the assigned heading. After the airspeed started to increase I re-engaged the autothrottles; but was slow to set climb speed; and the throttles again retarded. Simultaneously as I again disengaged the autothrottles and manually advanced the thrust levers; we received a momentary 'Don't Sink' and a 'Pull UP' warning. As the thrust lever advanced the aural alerts ceased. The FO (First Officer) continued to fly the flight director and now with the thrust levers advanced and airspeed increasing we continued the departure and cleaning up on schedule.I cannot tell you how many times I have replayed this event in my mind. I can't remember ever having lost situational awareness so fast. Had I called/queried Set speed; flaps 15; climb thrust we could have properly executed the departure. When I dig down deep into my errors; I first failed to timely conduct checklists. Second; I became singularly focused on the airspeed tapes and failed to properly monitor automation (autothrottles) and the minimum cleanup attitude call outs. I also failed to properly communicate changes in automation and flap settings. We also failed to properly respond to the aural warning. As a crew we became laser-focused on separate indications and failed to properly communicate our individual loss of situational awareness; we were both in the Red. I have done many uneventful flaps 25; -800 takeoffs from ZZZ as both the Pilot Flying and Pilot Monitoring. Although there were a few distractions prior to takeoff; the only other differences were my focus on our airspeed; and on the large left turn requirement. As this event is now indelibly embedded in my mind; in the future I will slow down and fully review checklists and aircraft configuration impact on departure procedures. I will also guard against tunnel vision and adhere to assigned duties.
B737-800 flight crew reported that autoflight mismanagement led to a 'Don't sink. Pull up' warning on departure.