An air carrier B747 crew lost fuel pressure to its #4 engine.

Attributes
ACN	268440
Time
Date	199404
Day	Sat
Local Time Of Day	0601 To 1200
Place
Locale Reference	atc facility : stu
State Reference	FO
Altitude	msl bound lower : 28000 msl bound upper : 28000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : egtt tower : stl
Operator	common carrier : air carrier
Make Model Name	B747-100
Operating Under FAR Part	Part 121
Navigation In Use	Other
Flight Phase	cruise other
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 140 flight time total : 18000 flight time type : 600
ASRS Report	268440
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp pilot : cfi
Experience	flight time last 90 days : 180 flight time total : 24000 flight time type : 700
ASRS Report	268444
Events
Anomaly	inflight encounter other non adherence : published procedure other anomaly other
Independent Detector	aircraft equipment other aircraft equipment : unspecified other flight crewa
Resolutory Action	flight crew : became reoriented other
Consequence	faa : investigated faa : assigned or threatened penalties
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Use the proper checklist. We fly 4 different models of this aircraft, with the corresponding different checklists for fuel management. The flight engineer inadvertently skipped from 1 model airplane to another while configuring his fuel panel for fuel transfer. As a result, fuel pressure was momentarily lost to #4 engine. No loss of power, but a fluctuation of EPR was noticed and the fuel panel immediately configured properly. This was followed up by a thorough discussion of fuel management and proper checklists identify. As an aside to this report, an FAA aci on this flight made the comment that pilots should not file NASA ASRS reports as this hides information from the FAA. I found this commentary outrageous. Callback conversation with reporter revealed the following information: the reporting captain flies the B-747 for a major united states air carrier. The crews fly several different dash models of the 747, each with slightly different procedures in several areas of operation. The so on this trip had been off duty for about 2 months and had the fuel transfer pages for all of the different aircraft on his desk. He got mixed up, and used the 747-sp procedure vice the -100. No engine flamed out, there was just a momentary fluctuation of the EPR. The aci that witnessed this discussed the problem halfway across the atlantic. When the ASRS report was mentioned, the aci said that no report was necessary, as this prevented the FAA from finding out the facts. The captain said that he was so angry over this point of view that he didn't dare continue the discussion further. The captain has heard nothing from the FAA on this yet. Supplemental information from acn 268444: it is interesting and disturbing to me that during the debriefing with the FAA inspector, he discouraged us from filing a NASA report, although he said he would write a report to his superior, the poi. He said a NASA report 'does not allow us to get to the bottom of problems.'

Original NASA ASRS Text

Title: AN ACR B747 CREW LOST FUEL PRESSURE TO ITS #4 ENG.

Narrative: USE THE PROPER CHKLIST. WE FLY 4 DIFFERENT MODELS OF THIS ACFT, WITH THE CORRESPONDING DIFFERENT CHKLISTS FOR FUEL MGMNT. THE FE INADVERTENTLY SKIPPED FROM 1 MODEL AIRPLANE TO ANOTHER WHILE CONFIGURING HIS FUEL PANEL FOR FUEL TRANSFER. AS A RESULT, FUEL PRESSURE WAS MOMENTARILY LOST TO #4 ENG. NO LOSS OF PWR, BUT A FLUCTUATION OF EPR WAS NOTICED AND THE FUEL PANEL IMMEDIATELY CONFIGURED PROPERLY. THIS WAS FOLLOWED UP BY A THOROUGH DISCUSSION OF FUEL MGMNT AND PROPER CHKLISTS IDENT. AS AN ASIDE TO THIS RPT, AN FAA ACI ON THIS FLT MADE THE COMMENT THAT PLTS SHOULD NOT FILE NASA ASRS RPTS AS THIS HIDES INFO FROM THE FAA. I FOUND THIS COMMENTARY OUTRAGEOUS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTING CAPT FLIES THE B-747 FOR A MAJOR UNITED STATES ACR. THE CREWS FLY SEVERAL DIFFERENT DASH MODELS OF THE 747, EACH WITH SLIGHTLY DIFFERENT PROCS IN SEVERAL AREAS OF OP. THE SO ON THIS TRIP HAD BEEN OFF DUTY FOR ABOUT 2 MONTHS AND HAD THE FUEL TRANSFER PAGES FOR ALL OF THE DIFFERENT ACFT ON HIS DESK. HE GOT MIXED UP, AND USED THE 747-SP PROC VICE THE -100. NO ENG FLAMED OUT, THERE WAS JUST A MOMENTARY FLUCTUATION OF THE EPR. THE ACI THAT WITNESSED THIS DISCUSSED THE PROB HALFWAY ACROSS THE ATLANTIC. WHEN THE ASRS RPT WAS MENTIONED, THE ACI SAID THAT NO RPT WAS NECESSARY, AS THIS PREVENTED THE FAA FROM FINDING OUT THE FACTS. THE CAPT SAID THAT HE WAS SO ANGRY OVER THIS POINT OF VIEW THAT HE DIDN'T DARE CONTINUE THE DISCUSSION FURTHER. THE CAPT HAS HEARD NOTHING FROM THE FAA ON THIS YET. SUPPLEMENTAL INFO FROM ACN 268444: IT IS INTERESTING AND DISTURBING TO ME THAT DURING THE DEBRIEFING WITH THE FAA INSPECTOR, HE DISCOURAGED US FROM FILING A NASA RPT, ALTHOUGH HE SAID HE WOULD WRITE A RPT TO HIS SUPERIOR, THE POI. HE SAID A NASA RPT 'DOES NOT ALLOW US TO GET TO THE BOTTOM OF PROBS.'

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.