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|
Attributes | |
ACN | 1180431 |
Time | |
Date | 201406 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.ARTCC |
State Reference | US |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Make Model Name | Light Transport Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | Cruise |
Flight Plan | IFR |
Person 1 | |
Function | Dispatcher |
Qualification | Dispatch Dispatcher |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Inflight Event / Encounter Weather / Turbulence Inflight Event / Encounter Fuel Issue |
Narrative:
Flight pushed with 9;000 pounds of fuel on board for okc. Lift off occurred [almost an hour later]. The planned route was to depart on course southbound to okc at FL300. The first time I realized there was a problem was when the pilot called me after departure on the ground maintenance radio. He stated that he was approximately 80 [NM] northwest on the west side of a solid line of thunderstorms and that ATC had vectored him up there. He requested an assessment of his proposed route and the fuel required to fly down the west side of the solid line of thunderstorms and crossing that line near the nebraska/kansas border then direct okc. I told him that I would look at it and get back to him.following is a series of ACARS messages that continued the conversation: your current route will take you through thunderstorms over nebraska about 200 [NM] south of where you are now. I don't like it; so let's figure out how to go around it via pnh near amarillo. I'll get back to you on fuel quickly. After calculating the required fuel and consulting with the duty manager; I sent the following ACARS: you do not have enough fuel to go around the south. You may be able to find a hole abeam fsd and go east to FOD. After making a brief attempt to get through; the pilot sent me the following ACARS: okay...heres the plan since were stuck on the west of the weather... We are planning prsnt position dir onl obh dir okc... May have to go west of obh a bit for weather. After reviewing his plan I sent the following: I see your plan but the tops along your route between obh and okc are FL500 to FL600. You will probably have to go via lbl to get around the south end. Do you have fuel for that? The pilot then replied: we are going around the weather over obh and planning dir okc from there. I consulted again with duty manager and sent the following: currently there are no visible holes between obh and okc. Cell tops are currently fl 450 to FL600. You will probably have to continue southwest to lbl then dirct okc. Do you have enough fuel to go via lbl if you cannot get through the cells from your present position? The pilot then replied: currently it is mostly smooth...we are direct okc and are planning on deviating to the west of sln then back dir okc efoa 1.7 it was now apparent that the crew was not accepting reality. Their position at this time was just north of abeam den. I sent the following: ok. What is your current fob? 3.3 copy. I recommended to the duty manager that we consider diverting the flight immediately to den or cos. Shortly after this last ACARS; the pilot contacted me via radio. He admitted that he would have to go to okc via lbl and estimated that he would arrive at okc with minimum fuel of 800 to 1000 pounds. I suggested diverting to den or cos but the connection was soon lost. I sent the following: does direct cos work for fuel? It is also closer than okc via lbl. They were now approximately 210 NM directly east of cos and 320 NM from okc via lbl. The operator was still on the line with me and there was no response so I sent the following directive: go direct cos. Repeat go direct cos. Please confirm. Still no response on either the radio or ACARS so the operator suggested that I send the following: pl[ease] switch frequency. The pilot then replied: we are now going dir lib dir okc we are min fuel. It was now obvious that the pilot was making decisions by ignoring input from me. It was also obvious that I had completely lost operational control of the flight. I resigned myself to change to a supporting role exclusively in an attempt to prevent harm to the passengers on board. I also discussed with duty manager the possibility of declaring an emergency for him. I called okc tower and advised that the flight was approximately 100 to the northwest with a very low fuel situation. I requested that he expeditiously clear them for a straight-in for the most suitable runway; no unnecessary turns. I also asked him to inform TRACON and center of the situation. I then sent the following: what is your current fob? 2.2 estimated 1.2 on arrival to okc. We have the speed pulled back to .60 copy. Sounds like a good move to conserve fuel. Thank you.I confirmed with okc operations today that early this morning they pumped 1;306 gallons of jet fuel at 6.7 pounds per gallon into the aircraft before departure for a 9;800 pound fuel load. This means that the flight blocked in with approximately 1;050 pounds of fuel; no more than 21 minutes to flame-out. The captain; called me after arriving at okc. He was audibly shook up. I asked him to tell me about the flight. He admitted that he allowed ATC to vector him the wrong way to the northwest because he couldn't get a word in edgewise. He also said he decided against cos because when he plugged it into his FMS; it showed him landing with no fuel as opposed to okc with about 800 to 1;000. This makes no sense because he was over 100 NM closer to direct cos than okc via lbl at the time I gave him the directive to go direct cos. I chose not to press [the captain] on why he was so unresponsive to me during the flight. The passengers probably view the crew as heroes. After all; they flew them to okc safely as they see it. However; the passengers are completely unaware of the mortal danger that the crew put them in. I am grateful that no-one died. It became apparent that the crew was not accepting my input or directives resulting in a complete loss of operational control. 1. The crew failed to assert their priorities with TRACON and haplessly ended up 80 NM in the wrong direction and on the wrong side of the thunderstorm line. 2. The crew failed to come to grips with the reality I was telling them early on about having to go around the south end of the thunderstorms. 3. Operations failed to open a station along the flight's route on the west side of the storms to drop in for a gas-and-go.4. The crew failed to follow my directive to divert to cos. Had they followed my directive; they probably would have landed with just under 2;000 lbs of fuel. A much larger margin for error. I kept the duty manager in the loop as well as eliciting input from them about the events and decisions being made. Change the flight operations and operations culture so that the company safety management system (sms) is an integral part of everything we do. It should be seamlessly and invisibly systemic in everything we do. Right now; it is the 'other'; something we need to remember to read and do or integrate on an individual basis. It is not yet systemic. Further; choices of safe behavior should be prominently rewarded.
Original NASA ASRS Text
Title: CRJ-200 Dispatcher describes a flight he is controlling that is vectored away from the planned destination (OKC); and winds up on the west side of a line of thunderstorms in a low fuel situation. Despite his best efforts to get the Captain to divert for fuel the flight continues to destination; landing with just 21 minutes of fuel on board.
Narrative: Flight pushed with 9;000 pounds of fuel on board for OKC. Lift off occurred [almost an hour later]. The planned route was to depart on course southbound to OKC at FL300. The first time I realized there was a problem was when the pilot called me after departure on the ground Maintenance radio. He stated that he was approximately 80 [NM] northwest on the west side of a solid line of thunderstorms and that ATC had vectored him up there. He requested an assessment of his proposed route and the fuel required to fly down the west side of the solid line of thunderstorms and crossing that line near the Nebraska/Kansas border then direct OKC. I told him that I would look at it and get back to him.Following is a series of ACARS messages that continued the conversation: Your current route will take you through thunderstorms over Nebraska about 200 [NM] south of where you are now. I don't like it; so let's figure out how to go around it via PNH near Amarillo. I'll get back to you on fuel quickly. After calculating the required fuel and consulting with the Duty Manager; I sent the following ACARS: YOU DO NOT HAVE ENOUGH FUEL TO GO AROUND THE SOUTH. YOU MAY BE ABLE TO FIND A HOLE ABEAM FSD AND GO EAST TO FOD. After making a brief attempt to get through; the pilot sent me the following ACARS: OKAY...HERES THE PLAN SINCE WERE STUCK ON THE WEST OF THE WEATHER... WE ARE PLANNING PRSNT POS DIR ONL OBH DIR OKC... MAY HAVE TO GO WEST OF OBH A BIT FOR WEATHER. After reviewing his plan I sent the following: I SEE YOUR PLAN BUT THE TOPS ALONG YOUR ROUTE BETWEEN OBH AND OKC ARE FL500 TO FL600. YOU WILL PROBABLY HAVE TO GO VIA LBL TO GET AROUND THE SOUTH END. DO YOU HAVE FUEL FOR THAT? The pilot then replied: WE ARE GOING AROUND THE WEATHER OVER OBH AND PLANNING DIR OKC FROM THERE. I consulted again with Duty Manager and sent the following: CURRENTLY THERE ARE NO VISIBLE HOLES BETWEEN OBH AND OKC. CELL TOPS ARE CURRENTLY FL 450 TO FL600. YOU WILL PROBABLY HAVE TO CONTINUE SW TO LBL THEN DIRCT OKC. DO YOU HAVE ENOUGH FUEL TO GO VIA LBL IF YOU CANNOT GET THROUGH THE CELLS FROM YOUR PRESENT POSITION? The pilot then replied: CURRENTLY IT IS MOSTLY SMOOTH...WE ARE DIRECT OKC AND ARE PLANNING ON DEVIATING TO THE WEST OF SLN THEN BACK DIR OKC EFOA 1.7 It was now apparent that the crew was not accepting reality. Their position at this time was just north of abeam DEN. I sent the following: OK. WHAT IS YOUR CURRENT FOB? 3.3 COPY. I recommended to the Duty Manager that we consider diverting the flight immediately to DEN or COS. Shortly after this last ACARS; the pilot contacted me via radio. He admitted that he would have to go to OKC via LBL and estimated that he would arrive at OKC with minimum fuel of 800 to 1000 pounds. I suggested diverting to DEN or COS but the connection was soon lost. I sent the following: DOES DIRECT COS WORK FOR FUEL? IT IS ALSO CLOSER THAN OKC VIA LBL. They were now approximately 210 NM directly east of COS and 320 NM from OKC via LBL. The operator was still on the line with me and there was no response so I sent the following directive: GO DIRECT COS. REPEAT GO DIRECT COS. PLEASE CONFIRM. Still no response on either the radio or ACARS so the operator suggested that I send the following: PL[EASE] SWITCH FREQUENCY. The pilot then replied: WE ARE NOW GOING DIR LIB DIR OKC WE ARE MIN FUEL. It was now obvious that the pilot was making decisions by ignoring input from me. It was also obvious that I had completely lost operational control of the flight. I resigned myself to change to a supporting role exclusively in an attempt to prevent harm to the passengers on board. I also discussed with Duty Manager the possibility of declaring an emergency for him. I called OKC Tower and advised that the flight was approximately 100 to the northwest with a very low fuel situation. I requested that he expeditiously clear them for a straight-in for the most suitable runway; no unnecessary turns. I also asked him to inform TRACON and Center of the situation. I then sent the following: What is your current FOB? 2.2 ESTIMATED 1.2 ON ARRIVAL TO OKC. WE HAVE THE SPEED PULLED BACK TO .60 Copy. Sounds like a good move to conserve fuel. Thank you.I confirmed with OKC Operations today that early this morning they pumped 1;306 gallons of jet fuel at 6.7 pounds per gallon into the aircraft before departure for a 9;800 pound fuel load. This means that the flight blocked in with approximately 1;050 pounds of fuel; no more than 21 minutes to flame-out. The Captain; called me after arriving at OKC. He was audibly shook up. I asked him to tell me about the flight. He admitted that he allowed ATC to vector him the wrong way to the northwest because he couldn't get a word in edgewise. He also said he decided against COS because when he plugged it into his FMS; it showed him landing with no fuel as opposed to OKC with about 800 to 1;000. This makes no sense because he was over 100 NM closer to direct COS than OKC via LBL at the time I gave him the directive to go direct COS. I chose not to press [the Captain] on why he was so unresponsive to me during the flight. The passengers probably view the crew as heroes. After all; they flew them to OKC safely as they see it. However; the passengers are completely unaware of the mortal danger that the crew put them in. I am grateful that no-one died. It became apparent that the crew was not accepting my input or directives resulting in a complete loss of operational control. 1. The crew failed to assert their priorities with TRACON and haplessly ended up 80 NM in the wrong direction and on the wrong side of the thunderstorm line. 2. The crew failed to come to grips with the reality I was telling them early on about having to go around the south end of the thunderstorms. 3. Operations failed to open a station along the flight's route on the west side of the storms to drop in for a gas-and-go.4. The crew failed to follow my directive to divert to COS. Had they followed my directive; they probably would have landed with just under 2;000 lbs of fuel. A much larger margin for error. I kept the Duty Manager in the loop as well as eliciting input from them about the events and decisions being made. Change the flight operations and Operations culture so that the Company Safety Management System (SMS) is an integral part of everything we do. It should be seamlessly and invisibly systemic in everything we do. Right now; it is the 'other'; something we need to remember to read and do or integrate on an individual basis. It is not yet systemic. Further; choices of safe behavior should be prominently rewarded.
Data retrieved from NASA's ASRS site and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.