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|
Attributes | |
ACN | 209368 |
Time | |
Date | 199204 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phx |
State Reference | AZ |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 400 flight time total : 11500 flight time type : 5000 |
ASRS Report | 209368 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 117 flight time total : 8100 flight time type : 272 |
ASRS Report | 209371 |
Events | |
Anomaly | non adherence : far non adherence : published procedure |
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 other |
Narrative:
It was the first flight of the day and I was met at the airplane by an FAA inspector. He was courteous and every bit the professional, however he was an agent of a hostile organization and I was on guard. I normally operate as if an inspector is sitting on my jumpseat so everything proceeded normally until it came time for the trim sheet. At that time the loadmaster informed me that the computer was down and they would have to do a manual trim sheet. I now knew that the possibility for an error had increased significantly. When the trim sheet arrived I checked it over in detail and, bingo, I found the error that I was looking for. The preparer had listed 1901 for the fuel load when actually I only had 17000. I looked on the fuel load table and found 1901, backed up to 1701 and confirmed that the trim units were correct (the last 2 digits of a weight are trim units, not pounds) changed the 9 to a 7, told the loadmaster to make the correction on the company copy (which was not in the loadmaster's possession), asked the FAA inspector if he had any problem with what I had done, he replied 'no,' so we were on our way. The first officer opened the speed book to 84000 pounds (the flight release had us planned at 98.9 thousand). He computed a power reduction, since we could not take one since we were so light. We adjusted our speed bugs and pushed. I remember having an uneasy feeling as if something was wrong but I couldn't put a finger on it. I even glanced at the trim sheet when we were waiting for takeoff and still didn't see the error. The acceleration felt slow but it was a hot day in phx (99 degrees F) and this was an X, and I had been flying mostly Y's, so I didn't think too much of it. The rotation was normal, however, at about 10 degrees pitch the aircraft had not left the ground and obviously had no intention of doing so. I stopped the rotation (the tail strikes at about 13 degrees) and allowed the aircraft to accelerate. She eventually staggered into the air. That uneasy feeling returned. About 5 mins after takeoff, still trying to figure out what was wrong and having a gut feeling that I has hvyier than I thought I was, my eyes fell on the tat/EPR gauge and it hit me like a thunderbolt. The trim sheet had 1700 pounds of fuel listed when actually there was 17000 pounds on board! We had rotated 11 KTS early with reduced power! Conclusion: 1) there is very little doubt in my mind that this error would have been discovered were it not for the presence of an FAA inspector. Even the first officer expressed amazement that he did not notice that the takeoff weight was only 2000 pounds more than the 0 fuel weight. However, I can do nothing about the hostility of government organizations or my perceptions of them. That must come from them and it will take many yrs. 2) my company adheres to the philosophy of xutilization of its ground personnel. So I know these errors are going to continue and the situation will never improve. Our ground personnel are 'jacks of all trades, masters of none.' 3) I became so focused on 1 expected error that I missed an ever greater one. I now physically do a gross error check of my own rather than just check over numbers that have been supplied to me.
Original NASA ASRS Text
Title: AN ACR MLG WITH AN ACR INSPECTOR ON BOARD TOOK OFF WITH A 10000 POUND FUEL ERROR. COMPANY GND PERSONNEL AND THE FLC MADE THE ERROR INITIALLY AND THE FLC DID NOT FIND IT.
Narrative: IT WAS THE FIRST FLT OF THE DAY AND I WAS MET AT THE AIRPLANE BY AN FAA INSPECTOR. HE WAS COURTEOUS AND EVERY BIT THE PROFESSIONAL, HOWEVER HE WAS AN AGENT OF A HOSTILE ORGANIZATION AND I WAS ON GUARD. I NORMALLY OPERATE AS IF AN INSPECTOR IS SITTING ON MY JUMPSEAT SO EVERYTHING PROCEEDED NORMALLY UNTIL IT CAME TIME FOR THE TRIM SHEET. AT THAT TIME THE LOADMASTER INFORMED ME THAT THE COMPUTER WAS DOWN AND THEY WOULD HAVE TO DO A MANUAL TRIM SHEET. I NOW KNEW THAT THE POSSIBILITY FOR AN ERROR HAD INCREASED SIGNIFICANTLY. WHEN THE TRIM SHEET ARRIVED I CHKED IT OVER IN DETAIL AND, BINGO, I FOUND THE ERROR THAT I WAS LOOKING FOR. THE PREPARER HAD LISTED 1901 FOR THE FUEL LOAD WHEN ACTUALLY I ONLY HAD 17000. I LOOKED ON THE FUEL LOAD TABLE AND FOUND 1901, BACKED UP TO 1701 AND CONFIRMED THAT THE TRIM UNITS WERE CORRECT (THE LAST 2 DIGITS OF A WT ARE TRIM UNITS, NOT POUNDS) CHANGED THE 9 TO A 7, TOLD THE LOADMASTER TO MAKE THE CORRECTION ON THE COMPANY COPY (WHICH WAS NOT IN THE LOADMASTER'S POSSESSION), ASKED THE FAA INSPECTOR IF HE HAD ANY PROBLEM WITH WHAT I HAD DONE, HE REPLIED 'NO,' SO WE WERE ON OUR WAY. THE FO OPENED THE SPD BOOK TO 84000 POUNDS (THE FLT RELEASE HAD US PLANNED AT 98.9 THOUSAND). HE COMPUTED A PWR REDUCTION, SINCE WE COULD NOT TAKE ONE SINCE WE WERE SO LIGHT. WE ADJUSTED OUR SPD BUGS AND PUSHED. I REMEMBER HAVING AN UNEASY FEELING AS IF SOMETHING WAS WRONG BUT I COULDN'T PUT A FINGER ON IT. I EVEN GLANCED AT THE TRIM SHEET WHEN WE WERE WAITING FOR TKOF AND STILL DIDN'T SEE THE ERROR. THE ACCELERATION FELT SLOW BUT IT WAS A HOT DAY IN PHX (99 DEGS F) AND THIS WAS AN X, AND I HAD BEEN FLYING MOSTLY Y'S, SO I DIDN'T THINK TOO MUCH OF IT. THE ROTATION WAS NORMAL, HOWEVER, AT ABOUT 10 DEGS PITCH THE ACFT HAD NOT LEFT THE GND AND OBVIOUSLY HAD NO INTENTION OF DOING SO. I STOPPED THE ROTATION (THE TAIL STRIKES AT ABOUT 13 DEGS) AND ALLOWED THE ACFT TO ACCELERATE. SHE EVENTUALLY STAGGERED INTO THE AIR. THAT UNEASY FEELING RETURNED. ABOUT 5 MINS AFTER TKOF, STILL TRYING TO FIGURE OUT WHAT WAS WRONG AND HAVING A GUT FEELING THAT I HAS HVYIER THAN I THOUGHT I WAS, MY EYES FELL ON THE TAT/EPR GAUGE AND IT HIT ME LIKE A THUNDERBOLT. THE TRIM SHEET HAD 1700 POUNDS OF FUEL LISTED WHEN ACTUALLY THERE WAS 17000 POUNDS ON BOARD! WE HAD ROTATED 11 KTS EARLY WITH REDUCED PWR! CONCLUSION: 1) THERE IS VERY LITTLE DOUBT IN MY MIND THAT THIS ERROR WOULD HAVE BEEN DISCOVERED WERE IT NOT FOR THE PRESENCE OF AN FAA INSPECTOR. EVEN THE FO EXPRESSED AMAZEMENT THAT HE DID NOT NOTICE THAT THE TKOF WT WAS ONLY 2000 POUNDS MORE THAN THE 0 FUEL WT. HOWEVER, I CAN DO NOTHING ABOUT THE HOSTILITY OF GOV ORGANIZATIONS OR MY PERCEPTIONS OF THEM. THAT MUST COME FROM THEM AND IT WILL TAKE MANY YRS. 2) MY COMPANY ADHERES TO THE PHILOSOPHY OF XUTILIZATION OF ITS GND PERSONNEL. SO I KNOW THESE ERRORS ARE GOING TO CONTINUE AND THE SITUATION WILL NEVER IMPROVE. OUR GND PERSONNEL ARE 'JACKS OF ALL TRADES, MASTERS OF NONE.' 3) I BECAME SO FOCUSED ON 1 EXPECTED ERROR THAT I MISSED AN EVER GREATER ONE. I NOW PHYSICALLY DO A GROSS ERROR CHK OF MY OWN RATHER THAN JUST CHK OVER NUMBERS THAT HAVE BEEN SUPPLIED TO ME.
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.