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|
Attributes | |
ACN | 131215 |
Time | |
Date | 198912 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : cvg |
State Reference | OH |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 15000 flight time type : 2100 |
ASRS Report | 131215 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 140 flight time total : 4100 flight time type : 750 |
ASRS Report | 131425 |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The entire 3-MAN flight deck crew boarded the aircraft at XA25 EST for an XB02 EST departure. As the before starting engine checklist was being read/accomplished it was discovered that the fuel gauges did not test properly. Mechanic was called and when he showed up gauges tested normally. At about same time, fuel slip was delivered to aircraft showing a total of 51,000 pounds of fuel on board. Both second officer and I checked, but misadded actual tank fuel by a total of 10,000 pounds (although we did not discover our error until much later when the aircraft was approximately :40 minutes into a 3:43 flight). When discovered, immediate action was taken involving the dispatcher, and after evaluating the situation as thoroughly as possible, it was determined that we could proceed to our destination and still have safe and minimum required fuel on board. WX en route and at numerous airports en route, as well as destination, was excellent so we continued, keeping a very close watch on fuel status and contact with our dispatcher. We logged many anxious moments (in fact, all of them) while proceeding to our destination. We made it with sufficient fuel (6,500 pounds) to satisfy minimum requirements, but much less than was called for on the flight plan and/or was comfortable. Additionally, our weight was 10,000 pounds less than projected (that helped after the mistake was discovered). Why did it occur? It was our first time with new checklist, and we were paying close attention to performing/responding, quite possibly to the point of seeing/responding to what we wanted to see as opposed to what actually existed regards the fuel. While it's no excuse, a 10,000 pound error can be made, and obviously we made it. Also the sheer number of actions taking place at this time (at 5 minutes prior to push/departure) can create diversions if one is not guarding against them. Suggested corrective actions would most obviously include all crew members devoting more intense attention to the details. We did not discover the error until well into the flight, but I can say that after the discovery, the crew and dispatcher molded together, with a common goal, that being to safely accomplish completing the flight either to destination or suitable diversion airport, and considering the seriousness of the situation, displayed outstanding professionalism. We did complete the flight to destination safely. I don't ever again want to be involved in a situation that serious, and you can believe that I will take every reasonable step possible to prevent it.
Original NASA ASRS Text
Title: ACR LGT DEPARTED WITH 10,000 POUNDS LESS FUEL THAN PLANNED.
Narrative: THE ENTIRE 3-MAN FLT DECK CREW BOARDED THE ACFT AT XA25 EST FOR AN XB02 EST DEP. AS THE BEFORE STARTING ENGINE CHECKLIST WAS BEING READ/ACCOMPLISHED IT WAS DISCOVERED THAT THE FUEL GAUGES DID NOT TEST PROPERLY. MECHANIC WAS CALLED AND WHEN HE SHOWED UP GAUGES TESTED NORMALLY. AT ABOUT SAME TIME, FUEL SLIP WAS DELIVERED TO ACFT SHOWING A TOTAL OF 51,000 LBS OF FUEL ON BOARD. BOTH S/O AND I CHECKED, BUT MISADDED ACTUAL TANK FUEL BY A TOTAL OF 10,000 LBS (ALTHOUGH WE DID NOT DISCOVER OUR ERROR UNTIL MUCH LATER WHEN THE ACFT WAS APPROX :40 MINUTES INTO A 3:43 FLT). WHEN DISCOVERED, IMMEDIATE ACTION WAS TAKEN INVOLVING THE DISPATCHER, AND AFTER EVALUATING THE SITUATION AS THOROUGHLY AS POSSIBLE, IT WAS DETERMINED THAT WE COULD PROCEED TO OUR DEST AND STILL HAVE SAFE AND MINIMUM REQUIRED FUEL ON BOARD. WX ENRTE AND AT NUMEROUS ARPTS ENRTE, AS WELL AS DEST, WAS EXCELLENT SO WE CONTINUED, KEEPING A VERY CLOSE WATCH ON FUEL STATUS AND CONTACT WITH OUR DISPATCHER. WE LOGGED MANY ANXIOUS MOMENTS (IN FACT, ALL OF THEM) WHILE PROCEEDING TO OUR DEST. WE MADE IT WITH SUFFICIENT FUEL (6,500 LBS) TO SATISFY MINIMUM REQUIREMENTS, BUT MUCH LESS THAN WAS CALLED FOR ON THE FLT PLAN AND/OR WAS COMFORTABLE. ADDITIONALLY, OUR WEIGHT WAS 10,000 LBS LESS THAN PROJECTED (THAT HELPED AFTER THE MISTAKE WAS DISCOVERED). WHY DID IT OCCUR? IT WAS OUR FIRST TIME WITH NEW CHECKLIST, AND WE WERE PAYING CLOSE ATTN TO PERFORMING/RESPONDING, QUITE POSSIBLY TO THE POINT OF SEEING/RESPONDING TO WHAT WE WANTED TO SEE AS OPPOSED TO WHAT ACTUALLY EXISTED REGARDS THE FUEL. WHILE IT'S NO EXCUSE, A 10,000 LB ERROR CAN BE MADE, AND OBVIOUSLY WE MADE IT. ALSO THE SHEER NUMBER OF ACTIONS TAKING PLACE AT THIS TIME (AT 5 MINUTES PRIOR TO PUSH/DEP) CAN CREATE DIVERSIONS IF ONE IS NOT GUARDING AGAINST THEM. SUGGESTED CORRECTIVE ACTIONS WOULD MOST OBVIOUSLY INCLUDE ALL CREW MEMBERS DEVOTING MORE INTENSE ATTN TO THE DETAILS. WE DID NOT DISCOVER THE ERROR UNTIL WELL INTO THE FLT, BUT I CAN SAY THAT AFTER THE DISCOVERY, THE CREW AND DISPATCHER MOLDED TOGETHER, WITH A COMMON GOAL, THAT BEING TO SAFELY ACCOMPLISH COMPLETING THE FLT EITHER TO DEST OR SUITABLE DIVERSION ARPT, AND CONSIDERING THE SERIOUSNESS OF THE SITUATION, DISPLAYED OUTSTANDING PROFESSIONALISM. WE DID COMPLETE THE FLT TO DEST SAFELY. I DON'T EVER AGAIN WANT TO BE INVOLVED IN A SITUATION THAT SERIOUS, AND YOU CAN BELIEVE THAT I WILL TAKE EVERY REASONABLE STEP POSSIBLE TO PREVENT IT.
Data retrieved from NASA's ASRS site as of August 2007 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.