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|
Attributes | |
ACN | 194436 |
Time | |
Date | 199111 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : abq |
State Reference | NM |
Altitude | msl bound lower : 33000 msl bound upper : 33000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zab |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 7500 flight time type : 2400 |
ASRS Report | 194436 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During the flight little or no fuel was used from the center tank. Most of the fuel was used from the wing tanks (1500 pounds remained in each wing tank at shut down). This fuel imbal could have resulted in a structural problem but did not in this case. The major concern is that center tank fuel cannot be used of both center tank pumps fail. There is a procedure for checking center tank fuel usage throughout the flight but this procedure was not followed by either pilot (for some unknown reason). Both pilots regularly follow this procedure. Contributing factors. Fuel usage (center tank) cannot always be checked right away after takeoff because with full center sometimes it appears that the center is not feeding. However, usually by the first fix usage can be determined. The first fix for us was las, new mexico, but at this point we were asked by ATC if we could reach 330 in the next 20 mi. My attention was diverted for the next 20 mi. At the next 2 fixes gck and sln we accomplished a company position report (which includes fuel remaining). I just looked at the totalizer! I can't believe it but I did, just the totalizer. When it appeared there might be delays into ord I pulled up the alternate WX (msp) and checked the fuel again, but just the totalizer. When we parked at the gate at ord we discovered the problem. I cannot remember if all pumps were on at shutdown but my habit is to always turn on all fuel pumps during start, even when there is no center tank fuel. We then checked each center tank pump twice and they both worked. That I missed this fuel problem is inconceivable to me. It is humbling, disappointing, and disturbing. Yes there was bad WX at abq and ord and yes there were some distrs but en route WX was good and in this case distrs don't seem very meaningful. My procedures for checking fuel must be reviewed and changed. Evidently I became lax because I had never before had a problem.
Original NASA ASRS Text
Title: ACR MLG FUEL MGMNT INCORRECT.
Narrative: DURING THE FLT LITTLE OR NO FUEL WAS USED FROM THE CENTER TANK. MOST OF THE FUEL WAS USED FROM THE WING TANKS (1500 POUNDS REMAINED IN EACH WING TANK AT SHUT DOWN). THIS FUEL IMBAL COULD HAVE RESULTED IN A STRUCTURAL PROBLEM BUT DID NOT IN THIS CASE. THE MAJOR CONCERN IS THAT CENTER TANK FUEL CANNOT BE USED OF BOTH CENTER TANK PUMPS FAIL. THERE IS A PROC FOR CHKING CENTER TANK FUEL USAGE THROUGHOUT THE FLT BUT THIS PROC WAS NOT FOLLOWED BY EITHER PLT (FOR SOME UNKNOWN REASON). BOTH PLTS REGULARLY FOLLOW THIS PROC. CONTRIBUTING FACTORS. FUEL USAGE (CENTER TANK) CANNOT ALWAYS BE CHKED RIGHT AWAY AFTER TKOF BECAUSE WITH FULL CENTER SOMETIMES IT APPEARS THAT THE CENTER IS NOT FEEDING. HOWEVER, USUALLY BY THE FIRST FIX USAGE CAN BE DETERMINED. THE FIRST FIX FOR US WAS LAS, NEW MEXICO, BUT AT THIS POINT WE WERE ASKED BY ATC IF WE COULD REACH 330 IN THE NEXT 20 MI. MY ATTN WAS DIVERTED FOR THE NEXT 20 MI. AT THE NEXT 2 FIXES GCK AND SLN WE ACCOMPLISHED A COMPANY POS RPT (WHICH INCLUDES FUEL REMAINING). I JUST LOOKED AT THE TOTALIZER! I CAN'T BELIEVE IT BUT I DID, JUST THE TOTALIZER. WHEN IT APPEARED THERE MIGHT BE DELAYS INTO ORD I PULLED UP THE ALTERNATE WX (MSP) AND CHKED THE FUEL AGAIN, BUT JUST THE TOTALIZER. WHEN WE PARKED AT THE GATE AT ORD WE DISCOVERED THE PROBLEM. I CANNOT REMEMBER IF ALL PUMPS WERE ON AT SHUTDOWN BUT MY HABIT IS TO ALWAYS TURN ON ALL FUEL PUMPS DURING START, EVEN WHEN THERE IS NO CENTER TANK FUEL. WE THEN CHKED EACH CENTER TANK PUMP TWICE AND THEY BOTH WORKED. THAT I MISSED THIS FUEL PROBLEM IS INCONCEIVABLE TO ME. IT IS HUMBLING, DISAPPOINTING, AND DISTURBING. YES THERE WAS BAD WX AT ABQ AND ORD AND YES THERE WERE SOME DISTRS BUT ENRTE WX WAS GOOD AND IN THIS CASE DISTRS DON'T SEEM VERY MEANINGFUL. MY PROCS FOR CHKING FUEL MUST BE REVIEWED AND CHANGED. EVIDENTLY I BECAME LAX BECAUSE I HAD NEVER BEFORE HAD A PROBLEM.
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.