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|
Attributes | |
ACN | 256627 |
Time | |
Date | 199311 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ths |
State Reference | PA |
Altitude | msl bound lower : 14000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute airway : zny |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 4600 flight time type : 1400 |
ASRS Report | 256627 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial |
Experience | flight time last 90 days : 190 flight time total : 11544 flight time type : 1427 |
ASRS Report | 256621 |
Events | |
Anomaly | other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On arrival in rdg, the passenger were deplaned and we left the airplane to go into the operation area. While walking to operations, a gate agent asked for our inbound times and fuel. We told the agent what the times were and that we would need 2600 pounds of fuel to return to pit. At that point, the captain was stopped by 2 officials of the rdg airport and he began to talk with them. The flight attendant and I continued to operations to get WX, a release, and some ice. The captain came into operations a few mins later. He stayed for a few mins and then left for the airplane before us. The flight attendant and I then returned to the airplane and found the captain standing by it talking with the 2 rdg officials again. I did a walkaround inspection of the aircraft and climbed into the cockpit to begin my preflight duties. I was getting the ATIS and clearance when passenger boarding began, about half way through boarding, the captain came to the cockpit. At this time we then performed the 'before starting engines' checklist. After the boarding process was completed, the flight attendant advised that she was ready, and we proceeded with the 'starting engines' checklist. For the return to pit the captain was the PF and I was the PNF. Once the engines were operating we obtained a taxi clearance and began the 'taxi' checklist. At the end of the runway, ATC cleared us for departure, so we completed the 'line-up' checklist and had a normal departure. During the climb, the 'climb' checklist was performed, but I was holding on calling operations with our times until we were on course and had climbed to a higher altitude. Approximately 15-20 mins into the flight, I called the time back to rdg, and at that time I discovered that we had not been fueled there. I advised captain of the situation and we began a discussion of our alternatives. At the time, we were in the vicinity of the ths (st. Thomas) VOR. It was decided that our best option was to divert to hgr and get more fuel. We informed ATC, and proceeded to land at hgr without incident. Once on the ground, flight control was notified that we had diverted due to maintenance, but after further discussion between myself and the captain, we decided to call the director of operations and advise him of the situation. At that time we were given a new release and departed for pit. The flight to pit was without incident. When we arrived in pit, we contacted the company again and talked with both the director of operations and the chief pilot, at which time we were placed on administrative suspension. I feel that this event occurred due to a number of reasons. The most prevalent reason is complacency. We usually fly 5-7 legs per day, 17-20 days a month. I am normally on duty for 12-14 hours, with reduced rest the night before being the norm. Every time we run the checklist the responses are always the same, so after a while, you make a response to a certain item without actually checking it. That is the complacency setting in. One of the problems with our company's checklist is that the response to fuel quantity is 'set/checked.' this makes it too easy to just say 'set' and forget to verify it. A better response would be '...pounds/checked.' this would force the crew to state the amount of fuel on board versus only saying 'set.' another possible problem is the fact that checking the fuel quantity only appears on the 'before starting engines' checklist. If it also appeared on the 'taxi' checklist, this type of problem could be caught on the ground. The aircraft has numerous warnings, both visually and aural, to warn you if something critical was missed on a checklist, except for fuel. For this reason, having it twice on the checklist would be appropriate. Supplemental information from acn 256621: we were the first aircraft type into a new city that we started to serve that day.
Original NASA ASRS Text
Title: DEPARTED WITHOUT FUEL SVC.
Narrative: ON ARR IN RDG, THE PAX WERE DEPLANED AND WE LEFT THE AIRPLANE TO GO INTO THE OP AREA. WHILE WALKING TO OPS, A GATE AGENT ASKED FOR OUR INBOUND TIMES AND FUEL. WE TOLD THE AGENT WHAT THE TIMES WERE AND THAT WE WOULD NEED 2600 LBS OF FUEL TO RETURN TO PIT. AT THAT POINT, THE CAPT WAS STOPPED BY 2 OFFICIALS OF THE RDG ARPT AND HE BEGAN TO TALK WITH THEM. THE FLT ATTENDANT AND I CONTINUED TO OPS TO GET WX, A RELEASE, AND SOME ICE. THE CAPT CAME INTO OPS A FEW MINS LATER. HE STAYED FOR A FEW MINS AND THEN LEFT FOR THE AIRPLANE BEFORE US. THE FLT ATTENDANT AND I THEN RETURNED TO THE AIRPLANE AND FOUND THE CAPT STANDING BY IT TALKING WITH THE 2 RDG OFFICIALS AGAIN. I DID A WALKAROUND INSPECTION OF THE ACFT AND CLBED INTO THE COCKPIT TO BEGIN MY PREFLT DUTIES. I WAS GETTING THE ATIS AND CLRNC WHEN PAX BOARDING BEGAN, ABOUT HALF WAY THROUGH BOARDING, THE CAPT CAME TO THE COCKPIT. AT THIS TIME WE THEN PERFORMED THE 'BEFORE STARTING ENGS' CHKLIST. AFTER THE BOARDING PROCESS WAS COMPLETED, THE FLT ATTENDANT ADVISED THAT SHE WAS READY, AND WE PROCEEDED WITH THE 'STARTING ENGS' CHKLIST. FOR THE RETURN TO PIT THE CAPT WAS THE PF AND I WAS THE PNF. ONCE THE ENGS WERE OPERATING WE OBTAINED A TAXI CLRNC AND BEGAN THE 'TAXI' CHKLIST. AT THE END OF THE RWY, ATC CLRED US FOR DEP, SO WE COMPLETED THE 'LINE-UP' CHKLIST AND HAD A NORMAL DEP. DURING THE CLB, THE 'CLB' CHKLIST WAS PERFORMED, BUT I WAS HOLDING ON CALLING OPS WITH OUR TIMES UNTIL WE WERE ON COURSE AND HAD CLBED TO A HIGHER ALT. APPROX 15-20 MINS INTO THE FLT, I CALLED THE TIME BACK TO RDG, AND AT THAT TIME I DISCOVERED THAT WE HAD NOT BEEN FUELED THERE. I ADVISED CAPT OF THE SIT AND WE BEGAN A DISCUSSION OF OUR ALTERNATIVES. AT THE TIME, WE WERE IN THE VICINITY OF THE THS (ST. THOMAS) VOR. IT WAS DECIDED THAT OUR BEST OPTION WAS TO DIVERT TO HGR AND GET MORE FUEL. WE INFORMED ATC, AND PROCEEDED TO LAND AT HGR WITHOUT INCIDENT. ONCE ON THE GND, FLT CTL WAS NOTIFIED THAT WE HAD DIVERTED DUE TO MAINT, BUT AFTER FURTHER DISCUSSION BTWN MYSELF AND THE CAPT, WE DECIDED TO CALL THE DIRECTOR OF OPS AND ADVISE HIM OF THE SIT. AT THAT TIME WE WERE GIVEN A NEW RELEASE AND DEPARTED FOR PIT. THE FLT TO PIT WAS WITHOUT INCIDENT. WHEN WE ARRIVED IN PIT, WE CONTACTED THE COMPANY AGAIN AND TALKED WITH BOTH THE DIRECTOR OF OPS AND THE CHIEF PLT, AT WHICH TIME WE WERE PLACED ON ADMINISTRATIVE SUSPENSION. I FEEL THAT THIS EVENT OCCURRED DUE TO A NUMBER OF REASONS. THE MOST PREVALENT REASON IS COMPLACENCY. WE USUALLY FLY 5-7 LEGS PER DAY, 17-20 DAYS A MONTH. I AM NORMALLY ON DUTY FOR 12-14 HRS, WITH REDUCED REST THE NIGHT BEFORE BEING THE NORM. EVERY TIME WE RUN THE CHKLIST THE RESPONSES ARE ALWAYS THE SAME, SO AFTER A WHILE, YOU MAKE A RESPONSE TO A CERTAIN ITEM WITHOUT ACTUALLY CHKING IT. THAT IS THE COMPLACENCY SETTING IN. ONE OF THE PROBS WITH OUR COMPANY'S CHKLIST IS THAT THE RESPONSE TO FUEL QUANTITY IS 'SET/CHKED.' THIS MAKES IT TOO EASY TO JUST SAY 'SET' AND FORGET TO VERIFY IT. A BETTER RESPONSE WOULD BE '...LBS/CHKED.' THIS WOULD FORCE THE CREW TO STATE THE AMOUNT OF FUEL ON BOARD VERSUS ONLY SAYING 'SET.' ANOTHER POSSIBLE PROB IS THE FACT THAT CHKING THE FUEL QUANTITY ONLY APPEARS ON THE 'BEFORE STARTING ENGS' CHKLIST. IF IT ALSO APPEARED ON THE 'TAXI' CHKLIST, THIS TYPE OF PROB COULD BE CAUGHT ON THE GND. THE ACFT HAS NUMEROUS WARNINGS, BOTH VISUALLY AND AURAL, TO WARN YOU IF SOMETHING CRITICAL WAS MISSED ON A CHKLIST, EXCEPT FOR FUEL. FOR THIS REASON, HAVING IT TWICE ON THE CHKLIST WOULD BE APPROPRIATE. SUPPLEMENTAL INFORMATION FROM ACN 256621: WE WERE THE FIRST ACFT TYPE INTO A NEW CITY THAT WE STARTED TO SERVE THAT DAY.
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.