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|
Attributes | |
ACN | 195665 |
Time | |
Date | 199111 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : iad |
State Reference | VA |
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 | Widebody, Low Wing, 3 Turbojet Eng |
Flight Phase | ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 17000 flight time type : 1500 |
ASRS Report | 195665 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 14000 |
ASRS Report | 195787 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
The widebody transport aircraft had an inoperative fuel gauge. The tank was determined (by drip stick) to be full. After takeoff, the aircraft banked sharply to the right. Left rudder and aileron correction were required. It was decided to return to iad airport. On approach the fuel tank low quantity light and pump low light came on. A normal landing was made. The tank for the inoperative fuel gauge was rechked by drip stick and found to be empty. The tank was then fueled properly as the total fuel load was 'topped off' for another takeoff. Now the gauge was indicating properly. The takeoff and flight to destination were routine. Sequence of events from my viewpoint: (on preflight). The flight engineer told me the 2L quantity fuel gauge was inoperative. I told him to check the MEL (min equipment list). It is required that the tank be checked by the dripless measuring sticks. 2 people must observe the readings. Then maintenance personnel are to sign off the fuel loading slip certifying that 2 individuals observed the stick readings. This was all done, at least the form was signed. After the fueling was completed, the 2L fuel quantity gauges read low (about 2300 pounds), almost 25000 pounds in that tank was the required load. Also, the totalizer quantity gauge read considerably low! An inoperative gauge would not affect the totalizer (total fuel on board) gauge. I inquired about this and the mechanic told us it was because of a faulty fuel condition signal. I instructed the flight engineer to put this in the 'logbook' and to check the MEL list again. The totalizer was 'placarded' as inoperative and we were still completely legal to depart. What I think happened: both fuel gauges were reading accurately as we determined after the next takeoff. The person that initially fueled the aircraft did not check his required readings accurately. He is required to record figures of tank quantities before fueling, determine how much fuel is required to be added. Then the fuel that is actually added must be correct within a determined tolerance. The fuel added was exactly the predetermined amount. There was notolerance! This was clearly not correct. The 2 people who checked the 'dripsticks' were checking for a full tank (25000 pounds). I understand that these sticks read the same whether they are empty or full! Only 'in between' loads can be determined accurately! So, what they saw was a full tank when in fact it was nearly empty. Supplemental information from acn 195667: informed by maintenance that a fuel gauge was not operating properly and would probably need to be written in the logbook and deferred. The fuel gauge seemed to be sticking at 2300 pounds, so a logbook write up was made and later deferred. After fueling was complete the mechanic came back into the cockpit and told us that the fuel gauge would be inoperative. Fuel was supposed to be loaded to 103800 pounds, the gauges showed 79650 pounds. We were told by means of a fuel slip and service record that there was 25000 pounds in the fuel tank in question, this was determined by means of drip sticks. Company policy requires 2 authorized personnel to verify the stick readings, this was done by 2 aircraft mechanics with 25 years of experience between the 2. We also noticed that the fuel totalizer was also reading 80000 pounds and asked the mechanic why. He explained that the totalizer was receiving the same erroneous information as the fuel gauge. I suggested that we also write up the totalizer which we did, and was also deferred. We made a normal landing and taxied to the gate. After speaking to a mechanic involved in the fueling we found out that this tank was reading correctly and was now nearly empty. He also told us that we had a brand new fueler (contractor) who thought he had filled that tank and also that there was a disagreement between the 2 mechanics who sticked the tanks, that was not resolved. We therefore takeoff with 23000 pounds of fuel less and an obvious balance problem. I feel that the liberal use of deferring items without thoroughly determining the problem, and on 2 items in the same system, and the rush to get the aircraft out on schedule (which was unnecessary since the acftwas on the ground for at least 12 hours) caused this incident.
Original NASA ASRS Text
Title: WDB FLC TKOF FROM REFUELING STOP. HAD ACFT IMBAL AND CTL PROBLEM. RETURNED AND LANDED. L WING TANK EMPTY.
Narrative: THE WDB ACFT HAD AN INOP FUEL GAUGE. THE TANK WAS DETERMINED (BY DRIP STICK) TO BE FULL. AFTER TKOF, THE ACFT BANKED SHARPLY TO THE R. L RUDDER AND AILERON CORRECTION WERE REQUIRED. IT WAS DECIDED TO RETURN TO IAD ARPT. ON APCH THE FUEL TANK LOW QUANTITY LIGHT AND PUMP LOW LIGHT CAME ON. A NORMAL LNDG WAS MADE. THE TANK FOR THE INOP FUEL GAUGE WAS RECHKED BY DRIP STICK AND FOUND TO BE EMPTY. THE TANK WAS THEN FUELED PROPERLY AS THE TOTAL FUEL LOAD WAS 'TOPPED OFF' FOR ANOTHER TKOF. NOW THE GAUGE WAS INDICATING PROPERLY. THE TKOF AND FLT TO DEST WERE ROUTINE. SEQUENCE OF EVENTS FROM MY VIEWPOINT: (ON PREFLT). THE FLT ENGINEER TOLD ME THE 2L QUANTITY FUEL GAUGE WAS INOP. I TOLD HIM TO CHK THE MEL (MIN EQUIP LIST). IT IS REQUIRED THAT THE TANK BE CHKED BY THE DRIPLESS MEASURING STICKS. 2 PEOPLE MUST OBSERVE THE READINGS. THEN MAINT PERSONNEL ARE TO SIGN OFF THE FUEL LOADING SLIP CERTIFYING THAT 2 INDIVIDUALS OBSERVED THE STICK READINGS. THIS WAS ALL DONE, AT LEAST THE FORM WAS SIGNED. AFTER THE FUELING WAS COMPLETED, THE 2L FUEL QUANTITY GAUGES READ LOW (ABOUT 2300 POUNDS), ALMOST 25000 POUNDS IN THAT TANK WAS THE REQUIRED LOAD. ALSO, THE TOTALIZER QUANTITY GAUGE READ CONSIDERABLY LOW! AN INOP GAUGE WOULD NOT AFFECT THE TOTALIZER (TOTAL FUEL ON BOARD) GAUGE. I INQUIRED ABOUT THIS AND THE MECH TOLD US IT WAS BECAUSE OF A FAULTY FUEL CONDITION SIGNAL. I INSTRUCTED THE FLT ENGINEER TO PUT THIS IN THE 'LOGBOOK' AND TO CHK THE MEL LIST AGAIN. THE TOTALIZER WAS 'PLACARDED' AS INOP AND WE WERE STILL COMPLETELY LEGAL TO DEPART. WHAT I THINK HAPPENED: BOTH FUEL GAUGES WERE READING ACCURATELY AS WE DETERMINED AFTER THE NEXT TKOF. THE PERSON THAT INITIALLY FUELED THE ACFT DID NOT CHK HIS REQUIRED READINGS ACCURATELY. HE IS REQUIRED TO RECORD FIGURES OF TANK QUANTITIES BEFORE FUELING, DETERMINE HOW MUCH FUEL IS REQUIRED TO BE ADDED. THEN THE FUEL THAT IS ACTUALLY ADDED MUST BE CORRECT WITHIN A DETERMINED TOLERANCE. THE FUEL ADDED WAS EXACTLY THE PREDETERMINED AMOUNT. THERE WAS NOTOLERANCE! THIS WAS CLRLY NOT CORRECT. THE 2 PEOPLE WHO CHKED THE 'DRIPSTICKS' WERE CHKING FOR A FULL TANK (25000 POUNDS). I UNDERSTAND THAT THESE STICKS READ THE SAME WHETHER THEY ARE EMPTY OR FULL! ONLY 'IN BTWN' LOADS CAN BE DETERMINED ACCURATELY! SO, WHAT THEY SAW WAS A FULL TANK WHEN IN FACT IT WAS NEARLY EMPTY. SUPPLEMENTAL INFO FROM ACN 195667: INFORMED BY MAINT THAT A FUEL GAUGE WAS NOT OPERATING PROPERLY AND WOULD PROBABLY NEED TO BE WRITTEN IN THE LOGBOOK AND DEFERRED. THE FUEL GAUGE SEEMED TO BE STICKING AT 2300 POUNDS, SO A LOGBOOK WRITE UP WAS MADE AND LATER DEFERRED. AFTER FUELING WAS COMPLETE THE MECH CAME BACK INTO THE COCKPIT AND TOLD US THAT THE FUEL GAUGE WOULD BE INOP. FUEL WAS SUPPOSED TO BE LOADED TO 103800 POUNDS, THE GAUGES SHOWED 79650 POUNDS. WE WERE TOLD BY MEANS OF A FUEL SLIP AND SVC RECORD THAT THERE WAS 25000 POUNDS IN THE FUEL TANK IN QUESTION, THIS WAS DETERMINED BY MEANS OF DRIP STICKS. COMPANY POLICY REQUIRES 2 AUTHORIZED PERSONNEL TO VERIFY THE STICK READINGS, THIS WAS DONE BY 2 ACFT MECHS WITH 25 YEARS OF EXPERIENCE BTWN THE 2. WE ALSO NOTICED THAT THE FUEL TOTALIZER WAS ALSO READING 80000 POUNDS AND ASKED THE MECH WHY. HE EXPLAINED THAT THE TOTALIZER WAS RECEIVING THE SAME ERRONEOUS INFO AS THE FUEL GAUGE. I SUGGESTED THAT WE ALSO WRITE UP THE TOTALIZER WHICH WE DID, AND WAS ALSO DEFERRED. WE MADE A NORMAL LNDG AND TAXIED TO THE GATE. AFTER SPEAKING TO A MECH INVOLVED IN THE FUELING WE FOUND OUT THAT THIS TANK WAS READING CORRECTLY AND WAS NOW NEARLY EMPTY. HE ALSO TOLD US THAT WE HAD A BRAND NEW FUELER (CONTRACTOR) WHO THOUGHT HE HAD FILLED THAT TANK AND ALSO THAT THERE WAS A DISAGREEMENT BTWN THE 2 MECHS WHO STICKED THE TANKS, THAT WAS NOT RESOLVED. WE THEREFORE TKOF WITH 23000 POUNDS OF FUEL LESS AND AN OBVIOUS BAL PROBLEM. I FEEL THAT THE LIBERAL USE OF DEFERRING ITEMS WITHOUT THOROUGHLY DETERMINING THE PROBLEM, AND ON 2 ITEMS IN THE SAME SYS, AND THE RUSH TO GET THE ACFT OUT ON SCHEDULE (WHICH WAS UNNECESSARY SINCE THE ACFTWAS ON THE GND FOR AT LEAST 12 HRS) CAUSED THIS INCIDENT.
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.