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|
Attributes | |
ACN | 257391 |
Time | |
Date | 199311 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : roc |
State Reference | NY |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 250 flight time total : 10000 flight time type : 6000 |
ASRS Report | 257391 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 6000 flight time type : 3300 |
ASRS Report | 257816 |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The following is a brief description of events concerning flight (roc-yyz) this date. I arrived in roc at XX20 local with approximately 9000 pounds showing on the fuel totalizer. Shortly after XY00 local, I noticed that we had not been fueled as the totalizer was now reading about 8000. I waked down to operations to inform them of this. As I entered, I saw the fuel slip for our flight on the table and overheard one of the agents talking with the fueler over the radio. I assumed they were aware of the fact that flight had not been fueled, so I said nothing and remained downstairs to call scheduling to resolve a conflict concerning next month. I returned to the aircraft about XZ15 local. There was a problem with boarding which was leading to a slight delay in our departure, and as soon as the agent closed the door, we quickly ran the before start check. I remember the fuel totalizer reading 7500, which I mistook for 17500 pounds, the minimum release fuel load. As I turned out of the gate area I found myself very close to a company mdt that was also taxiing for takeoff. This was more than a little distraction as I had not expected to see him there. We competed the after start and before takeoff checks down to the line as I taxied to the runway. When I was cleared into position for takeoff, (I have a personal habit of running a fuel, oil, hydraulic quantities, slats and flaps check as we start the below the line items of the before takeoff check), I noticed the fuel totalizer reading about 6600 pounds. About this same time, the first officer advised me that we had just received an ACARS message to call operations. Operations confirmed that we had not been fueled, so I advised the tower that the company had requested us to return to the gate. As I taxied to the gate, the fuel totalizer again read 7500. I'm sure you will agree it is not uncommon for that gauge to change indications as you taxi. I would like to point out that even though we ran all the checklists, we both missed the fuel gauge not reading 17500, it was a human error that could, and most likely will, happen to someone else under our present operating procedures. The mistake on my part may have possibly been caused by the totalizer reading 7500, when combined with the fact that I had been in operations to check on the fueling status, which I though was taken care of, I saw what I expected to and not what was really on the gauge. I truly believe that one little slip of paper from the fueler to the cockpit, or a query from the agent such as 'is fueling completed?' or 'is it ok to close the door?' would have averted the entire problem. Keep in mind also that this was not an isolated incident. In the course of just this 4 day trip, no less than 3 other times did we have to remind operations that we were close to departure without having been fueled. One flight took a delay because no one was aware of this fact until we advised them of it.
Original NASA ASRS Text
Title: MLG TAXIES FOR DEP WITHOUT HAVING BEEN REFUELED.
Narrative: THE FOLLOWING IS A BRIEF DESCRIPTION OF EVENTS CONCERNING FLT (ROC-YYZ) THIS DATE. I ARRIVED IN ROC AT XX20 LCL WITH APPROX 9000 LBS SHOWING ON THE FUEL TOTALIZER. SHORTLY AFTER XY00 LCL, I NOTICED THAT WE HAD NOT BEEN FUELED AS THE TOTALIZER WAS NOW READING ABOUT 8000. I WAKED DOWN TO OPS TO INFORM THEM OF THIS. AS I ENTERED, I SAW THE FUEL SLIP FOR OUR FLT ON THE TABLE AND OVERHEARD ONE OF THE AGENTS TALKING WITH THE FUELER OVER THE RADIO. I ASSUMED THEY WERE AWARE OF THE FACT THAT FLT HAD NOT BEEN FUELED, SO I SAID NOTHING AND REMAINED DOWNSTAIRS TO CALL SCHEDULING TO RESOLVE A CONFLICT CONCERNING NEXT MONTH. I RETURNED TO THE ACFT ABOUT XZ15 LCL. THERE WAS A PROB WITH BOARDING WHICH WAS LEADING TO A SLIGHT DELAY IN OUR DEP, AND AS SOON AS THE AGENT CLOSED THE DOOR, WE QUICKLY RAN THE BEFORE START CHK. I REMEMBER THE FUEL TOTALIZER READING 7500, WHICH I MISTOOK FOR 17500 LBS, THE MINIMUM RELEASE FUEL LOAD. AS I TURNED OUT OF THE GATE AREA I FOUND MYSELF VERY CLOSE TO A COMPANY MDT THAT WAS ALSO TAXIING FOR TKOF. THIS WAS MORE THAN A LITTLE DISTR AS I HAD NOT EXPECTED TO SEE HIM THERE. WE COMPETED THE AFTER START AND BEFORE TKOF CHKS DOWN TO THE LINE AS I TAXIED TO THE RWY. WHEN I WAS CLRED INTO POS FOR TKOF, (I HAVE A PERSONAL HABIT OF RUNNING A FUEL, OIL, HYD QUANTITIES, SLATS AND FLAPS CHK AS WE START THE BELOW THE LINE ITEMS OF THE BEFORE TKOF CHK), I NOTICED THE FUEL TOTALIZER READING ABOUT 6600 LBS. ABOUT THIS SAME TIME, THE FO ADVISED ME THAT WE HAD JUST RECEIVED AN ACARS MESSAGE TO CALL OPS. OPS CONFIRMED THAT WE HAD NOT BEEN FUELED, SO I ADVISED THE TWR THAT THE COMPANY HAD REQUESTED US TO RETURN TO THE GATE. AS I TAXIED TO THE GATE, THE FUEL TOTALIZER AGAIN READ 7500. I'M SURE YOU WILL AGREE IT IS NOT UNCOMMON FOR THAT GAUGE TO CHANGE INDICATIONS AS YOU TAXI. I WOULD LIKE TO POINT OUT THAT EVEN THOUGH WE RAN ALL THE CHKLISTS, WE BOTH MISSED THE FUEL GAUGE NOT READING 17500, IT WAS A HUMAN ERROR THAT COULD, AND MOST LIKELY WILL, HAPPEN TO SOMEONE ELSE UNDER OUR PRESENT OPERATING PROCS. THE MISTAKE ON MY PART MAY HAVE POSSIBLY BEEN CAUSED BY THE TOTALIZER READING 7500, WHEN COMBINED WITH THE FACT THAT I HAD BEEN IN OPS TO CHK ON THE FUELING STATUS, WHICH I THOUGH WAS TAKEN CARE OF, I SAW WHAT I EXPECTED TO AND NOT WHAT WAS REALLY ON THE GAUGE. I TRULY BELIEVE THAT ONE LITTLE SLIP OF PAPER FROM THE FUELER TO THE COCKPIT, OR A QUERY FROM THE AGENT SUCH AS 'IS FUELING COMPLETED?' OR 'IS IT OK TO CLOSE THE DOOR?' WOULD HAVE AVERTED THE ENTIRE PROB. KEEP IN MIND ALSO THAT THIS WAS NOT AN ISOLATED INCIDENT. IN THE COURSE OF JUST THIS 4 DAY TRIP, NO LESS THAN 3 OTHER TIMES DID WE HAVE TO REMIND OPS THAT WE WERE CLOSE TO DEP WITHOUT HAVING BEEN FUELED. ONE FLT TOOK A DELAY BECAUSE NO ONE WAS AWARE OF THIS FACT UNTIL WE ADVISED THEM OF IT.
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.