Narrative:

After performing a special noise abatement departure from ontario (ont) airport, we observed the #1 oil quantity gauge fluctuating. While discussing this with the flight engineer, I noticed that all 3 oil temperature indicators were in the yellow band. At first I thought they were reacting to the additional time period at takeoff thrust for the departure, but when they didn't decrease I asked the flight engineer to accomplish the appropriate procedure in our book, while at the same time I asked ATC for a level off to see if pulling the throttles back would lower the temperatures. Shortly after we leveled off, the flight engineer reported that the procedure had not corrected the problem and asked if I wanted to go over it with him. I told him I was going to return to ont due to the :15 time limit on the oil temperatures, and asked him to go over the procedure again by himself until I could get back with him. I asked ATC for return and elected to declare an emergency. The first officer and I got the WX, called the company for gate assignment, and prepared radios and approach plates as we were vectored for a quick return. During the second time through the procedure the flight engineer realized that he had left all 3 fuel heat switches on during his preflight, and immediately turned them off. Since by then I knew we would exceed the :15 limit and already had exceeded the 1 min limit on fuel heat use, I of course chose to continue with a precautionary landing, but cancelled the emergency. After informing maintenance of the occurrence, they performed checks and run-ups on all engines and released us for flight with no further problems. I believe this situation occurred due to a series of human factors-induced errors. During his panel preflight, the flight engineer had allowed himself to be interrupted by maintenance and returned to his flow at a different point, unintentionally leaving the fuel heat switches on. Moral there -- never allow yourself to be interrupted in a flow pattern, and if you are, leave a hand on the switch and come back where you left off. Next factor was that the flight engineer missed it on the before takeoff checklist. Moral there -- look at what you're responding to. Don't just say it. Also, some of our aircraft have lights on when fuel heat is on, but this one didn't. A differences problem. Next, I had a chance to catch it before takeoff during my habitual last look back at the panel, but again, when seeing no lights on, I did not 'see' the position of the switches I was looking at. The lesson here -- look and see, don't just point your eyes! Then, in troubleshooting, none of us considered fuel heat as the likely culprit of high oil temperatures though it should have been obvious. It was warm out and there was no reason to have had it on, but I/we should have looked at it anyway. Also, had the flight engineer followed the procedure in the book the first time through, he would have caught it then. And finally, I should have made time to work with the flight engineer on the procedure, and we would have found the problem sooner. Also, I could have asked the first officer to work with the flight engineer on it. Another major contributing factor, I now realize, was fatigue. We had reported for our assigned trip initially at xxpm, only to be rescheduled for the same flight, after a legal 10 hour 45 min 'rest' period, for a XX45 am departure. Having showed fully rested for the original trip, however, it was impossible to fall asleep again until shortly before having to depart for the airport for the second time. Thus, when we taxied out, we had each had about 2 hours sleep in the last 20 to 21 hours. (Not unusual for reserve pilots at this company.) we thought we felt alert but were apparently more tired than we realized. And finally, I must mention that I experienced undue intimidation by the company over this situation. First, after returning to ont, I called flight control to inform them of our problem. I was verbally reprimanded by the dispatcher for not calling him in flight during our air-turn-back thought I had declared an emergency. He continued to speak to me in a very accusatory tone, concluding with the demand that I come in to see him upon arriving at sdf. Then, I received 2 en route ACARS messages from the companytelling me to see my supervisor's boss when arriving at sdf. And finally, during our in-range radio call to the company, we were told that all 3 of us were to report to the above mentioned manager when arriving. I might add that we had no freight on board, as this was a ferry flight only. Among other things, during the meeting with this manager, we were told that we were going to have to cope with the lack of rest which our reserve system causes because it wasn't going to change, and that we should compensate by increasing our scan speeds and to 'be glad that reserve doesn't last forever'. Pilots on reserve here, unfortunately, feel a constant need to refuse trips (thought they seldom do), on the basis of a lack of sleep. This is made all the more difficult in the face of this company pressure and insistence that our fatigue is simply the nature of our jobs, and that we just have to concentrate harder to overcome it. I realize that what happened to me and my crew is only 1 of many 'gotchas' awaiting those of us who must fly with less sleep, and in the middle of the night, not to mention on a constantly changing sleep/wake cycle. I know that I must be especially vigilant under these circumstances, and just as importantly, I have to be willing to say, 'I can't do it' when I know I'm not sufficiently rested -- even if it's often and my job is in jeopardy. Moreover, I am working with my fellow pilots to convince our company that it is in everyone's best interest that we not be expected to be super human by having to be 'ready' for a 16 hour duty day every hour for 24 hours, 6 days a week. Many lessons to be learned here.

Related reports:

Google
 

Original NASA ASRS Text

Title: ACR LGT RETURN LAND DUE HIGH OIL TEMP ALL 3 ENGS.

Narrative: AFTER PERFORMING A SPECIAL NOISE ABATEMENT DEP FROM ONTARIO (ONT) ARPT, WE OBSERVED THE #1 OIL QUANTITY GAUGE FLUCTUATING. WHILE DISCUSSING THIS WITH THE FE, I NOTICED THAT ALL 3 OIL TEMP INDICATORS WERE IN THE YELLOW BAND. AT FIRST I THOUGHT THEY WERE REACTING TO THE ADDITIONAL TIME PERIOD AT TKOF THRUST FOR THE DEP, BUT WHEN THEY DIDN'T DECREASE I ASKED THE FE TO ACCOMPLISH THE APPROPRIATE PROC IN OUR BOOK, WHILE AT THE SAME TIME I ASKED ATC FOR A LEVEL OFF TO SEE IF PULLING THE THROTTLES BACK WOULD LOWER THE TEMPS. SHORTLY AFTER WE LEVELED OFF, THE FE RPTED THAT THE PROC HAD NOT CORRECTED THE PROBLEM AND ASKED IF I WANTED TO GO OVER IT WITH HIM. I TOLD HIM I WAS GOING TO RETURN TO ONT DUE TO THE :15 TIME LIMIT ON THE OIL TEMPS, AND ASKED HIM TO GO OVER THE PROC AGAIN BY HIMSELF UNTIL I COULD GET BACK WITH HIM. I ASKED ATC FOR RETURN AND ELECTED TO DECLARE AN EMER. THE FO AND I GOT THE WX, CALLED THE COMPANY FOR GATE ASSIGNMENT, AND PREPARED RADIOS AND APCH PLATES AS WE WERE VECTORED FOR A QUICK RETURN. DURING THE SECOND TIME THROUGH THE PROC THE FE REALIZED THAT HE HAD LEFT ALL 3 FUEL HEAT SWITCHES ON DURING HIS PREFLT, AND IMMEDIATELY TURNED THEM OFF. SINCE BY THEN I KNEW WE WOULD EXCEED THE :15 LIMIT AND ALREADY HAD EXCEEDED THE 1 MIN LIMIT ON FUEL HEAT USE, I OF COURSE CHOSE TO CONTINUE WITH A PRECAUTIONARY LNDG, BUT CANCELLED THE EMER. AFTER INFORMING MAINT OF THE OCCURRENCE, THEY PERFORMED CHKS AND RUN-UPS ON ALL ENGS AND RELEASED US FOR FLT WITH NO FURTHER PROBLEMS. I BELIEVE THIS SITUATION OCCURRED DUE TO A SERIES OF HUMAN FACTORS-INDUCED ERRORS. DURING HIS PANEL PREFLT, THE FE HAD ALLOWED HIMSELF TO BE INTERRUPTED BY MAINT AND RETURNED TO HIS FLOW AT A DIFFERENT POINT, UNINTENTIONALLY LEAVING THE FUEL HEAT SWITCHES ON. MORAL THERE -- NEVER ALLOW YOURSELF TO BE INTERRUPTED IN A FLOW PATTERN, AND IF YOU ARE, LEAVE A HAND ON THE SWITCH AND COME BACK WHERE YOU LEFT OFF. NEXT FACTOR WAS THAT THE FE MISSED IT ON THE BEFORE TKOF CHKLIST. MORAL THERE -- LOOK AT WHAT YOU'RE RESPONDING TO. DON'T JUST SAY IT. ALSO, SOME OF OUR ACFT HAVE LIGHTS ON WHEN FUEL HEAT IS ON, BUT THIS ONE DIDN'T. A DIFFERENCES PROBLEM. NEXT, I HAD A CHANCE TO CATCH IT BEFORE TKOF DURING MY HABITUAL LAST LOOK BACK AT THE PANEL, BUT AGAIN, WHEN SEEING NO LIGHTS ON, I DID NOT 'SEE' THE POS OF THE SWITCHES I WAS LOOKING AT. THE LESSON HERE -- LOOK AND SEE, DON'T JUST POINT YOUR EYES! THEN, IN TROUBLESHOOTING, NONE OF US CONSIDERED FUEL HEAT AS THE LIKELY CULPRIT OF HIGH OIL TEMPS THOUGH IT SHOULD HAVE BEEN OBVIOUS. IT WAS WARM OUT AND THERE WAS NO REASON TO HAVE HAD IT ON, BUT I/WE SHOULD HAVE LOOKED AT IT ANYWAY. ALSO, HAD THE FE FOLLOWED THE PROC IN THE BOOK THE FIRST TIME THROUGH, HE WOULD HAVE CAUGHT IT THEN. AND FINALLY, I SHOULD HAVE MADE TIME TO WORK WITH THE FE ON THE PROC, AND WE WOULD HAVE FOUND THE PROBLEM SOONER. ALSO, I COULD HAVE ASKED THE FO TO WORK WITH THE FE ON IT. ANOTHER MAJOR CONTRIBUTING FACTOR, I NOW REALIZE, WAS FATIGUE. WE HAD RPTED FOR OUR ASSIGNED TRIP INITIALLY AT XXPM, ONLY TO BE RESCHEDULED FOR THE SAME FLT, AFTER A LEGAL 10 HR 45 MIN 'REST' PERIOD, FOR A XX45 AM DEP. HAVING SHOWED FULLY RESTED FOR THE ORIGINAL TRIP, HOWEVER, IT WAS IMPOSSIBLE TO FALL ASLEEP AGAIN UNTIL SHORTLY BEFORE HAVING TO DEPART FOR THE ARPT FOR THE SECOND TIME. THUS, WHEN WE TAXIED OUT, WE HAD EACH HAD ABOUT 2 HRS SLEEP IN THE LAST 20 TO 21 HRS. (NOT UNUSUAL FOR RESERVE PLTS AT THIS COMPANY.) WE THOUGHT WE FELT ALERT BUT WERE APPARENTLY MORE TIRED THAN WE REALIZED. AND FINALLY, I MUST MENTION THAT I EXPERIENCED UNDUE INTIMIDATION BY THE COMPANY OVER THIS SITUATION. FIRST, AFTER RETURNING TO ONT, I CALLED FLT CTL TO INFORM THEM OF OUR PROBLEM. I WAS VERBALLY REPRIMANDED BY THE DISPATCHER FOR NOT CALLING HIM IN FLT DURING OUR AIR-TURN-BACK THOUGHT I HAD DECLARED AN EMER. HE CONTINUED TO SPEAK TO ME IN A VERY ACCUSATORY TONE, CONCLUDING WITH THE DEMAND THAT I COME IN TO SEE HIM UPON ARRIVING AT SDF. THEN, I RECEIVED 2 ENRTE ACARS MESSAGES FROM THE COMPANYTELLING ME TO SEE MY SUPVR'S BOSS WHEN ARRIVING AT SDF. AND FINALLY, DURING OUR IN-RANGE RADIO CALL TO THE COMPANY, WE WERE TOLD THAT ALL 3 OF US WERE TO RPT TO THE ABOVE MENTIONED MGR WHEN ARRIVING. I MIGHT ADD THAT WE HAD NO FREIGHT ON BOARD, AS THIS WAS A FERRY FLT ONLY. AMONG OTHER THINGS, DURING THE MEETING WITH THIS MGR, WE WERE TOLD THAT WE WERE GOING TO HAVE TO COPE WITH THE LACK OF REST WHICH OUR RESERVE SYS CAUSES BECAUSE IT WASN'T GOING TO CHANGE, AND THAT WE SHOULD COMPENSATE BY INCREASING OUR SCAN SPDS AND TO 'BE GLAD THAT RESERVE DOESN'T LAST FOREVER'. PLTS ON RESERVE HERE, UNFORTUNATELY, FEEL A CONSTANT NEED TO REFUSE TRIPS (THOUGHT THEY SELDOM DO), ON THE BASIS OF A LACK OF SLEEP. THIS IS MADE ALL THE MORE DIFFICULT IN THE FACE OF THIS COMPANY PRESSURE AND INSISTENCE THAT OUR FATIGUE IS SIMPLY THE NATURE OF OUR JOBS, AND THAT WE JUST HAVE TO CONCENTRATE HARDER TO OVERCOME IT. I REALIZE THAT WHAT HAPPENED TO ME AND MY CREW IS ONLY 1 OF MANY 'GOTCHAS' AWAITING THOSE OF US WHO MUST FLY WITH LESS SLEEP, AND IN THE MIDDLE OF THE NIGHT, NOT TO MENTION ON A CONSTANTLY CHANGING SLEEP/WAKE CYCLE. I KNOW THAT I MUST BE ESPECIALLY VIGILANT UNDER THESE CIRCUMSTANCES, AND JUST AS IMPORTANTLY, I HAVE TO BE WILLING TO SAY, 'I CAN'T DO IT' WHEN I KNOW I'M NOT SUFFICIENTLY RESTED -- EVEN IF IT'S OFTEN AND MY JOB IS IN JEOPARDY. MOREOVER, I AM WORKING WITH MY FELLOW PLTS TO CONVINCE OUR COMPANY THAT IT IS IN EVERYONE'S BEST INTEREST THAT WE NOT BE EXPECTED TO BE SUPER HUMAN BY HAVING TO BE 'READY' FOR A 16 HR DUTY DAY EVERY HR FOR 24 HRS, 6 DAYS A WK. MANY LESSONS TO BE LEARNED HERE.

Data retrieved from NASA's ASRS site as of July 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.