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|
Attributes | |
ACN | 274833 |
Time | |
Date | 199406 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : syr |
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 | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
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 |
Experience | flight time last 90 days : 120 flight time total : 11000 flight time type : 3768 |
ASRS Report | 274833 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 6000 flight time type : 5000 |
ASRS Report | 275366 |
Events | |
Anomaly | non adherence : far 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:
Departed the gate with insufficient fuel for flight to new york's laguardia airport. This happened because of human factors. A rushed departure preflight in an attempt to get back on schedule. Noticed the shortage during taxi prior to takeoff and returned to the gate for fuel. The flight arrived in syracuse approximately 1 hour late due to a maintenance problem at its previous station. A stuck microphone was causing ATC communication problems and a mechanic was in the copilot's seat working on that problem. As captain, I was getting the clearance, checking ATIS and loading ACARS and pre departure clearance's while the mechanic was finishing up. As soon as we were boarded, the forward door was closed (mechanic had left) and the start signal was given. It was rushed, but the engine start was normal (I don't remember if we ran the before start checklist, I don't think so). On taxi out, the #2 engine was started and at that point I noticed we had only about 8500 pounds of fuel (our dispatch release was 12300 pounds). Immediately I asked syracuse ground control if we could return to the gate. Receiving an affirmative response, we taxied back and told operations we needed more fuel. He asked, 'did you not get enough from the fueler, or did he not fuel you at all?' I replied that it looked like we never got fuel from him in the first place. We were then pumped up to our release fuel weight of 12300 pounds and flew uneventfully to new york's lga. The reason this happened was human factors -- plain and simple. Had the fueler refueled us in the first place, it wouldn't have happened. Had the mechanic not been in the cockpit, it wouldn't have happened. Had I properly followed established company procedures in a timely manner, it wouldn't have happened. Had we not been in such a hurry-up mode of operation, it wouldn't have happened. But the fact is, it did happen, as PIC it was my responsibility to make sure it never happens. Established company procedures and published checklists, if followed every time, would keep this sort of thing from happening ever. The old saying, 'there's never time to do it right but always time to do it over' applies here. Rushing through checklists or procedures may save a few seconds, but could ultimately cost a lot more than that. It did in this case. I thought I was professional enough to learn from everyone else's problems rather than from experience, but my normal excellent flow pattern was disrupted by all the 'little' things that were happening around us. We had been 'in the seat' (with 25 mins or less at the gate) for 5 hours and 3 flts. XA30 wakeup, no breakfast, on the go, maintenance problems, behind schedule, getting my own release, busy, busy, busy. It all added up to a 'gotcha' which could have been very serious. Thank god we did not take off with insufficient fuel, but noticed it on taxi out!
Original NASA ASRS Text
Title: AFTER ACFT LEAVES GATE TO TAXI FOR DEP, FLC NOTICES THEY HAVE INADEQUATE FUEL FOR FLT. FLC FEELS RUSHED GND TIME MADE THEM FORGET TO ACCOMPLISH 'BEFORE START CHKLIST.'
Narrative: DEPARTED THE GATE WITH INSUFFICIENT FUEL FOR FLT TO NEW YORK'S LAGUARDIA ARPT. THIS HAPPENED BECAUSE OF HUMAN FACTORS. A RUSHED DEP PREFLT IN AN ATTEMPT TO GET BACK ON SCHEDULE. NOTICED THE SHORTAGE DURING TAXI PRIOR TO TKOF AND RETURNED TO THE GATE FOR FUEL. THE FLT ARRIVED IN SYRACUSE APPROX 1 HR LATE DUE TO A MAINT PROB AT ITS PREVIOUS STATION. A STUCK MIKE WAS CAUSING ATC COM PROBS AND A MECH WAS IN THE COPLT'S SEAT WORKING ON THAT PROB. AS CAPT, I WAS GETTING THE CLRNC, CHKING ATIS AND LOADING ACARS AND PDC'S WHILE THE MECH WAS FINISHING UP. AS SOON AS WE WERE BOARDED, THE FORWARD DOOR WAS CLOSED (MECH HAD LEFT) AND THE START SIGNAL WAS GIVEN. IT WAS RUSHED, BUT THE ENG START WAS NORMAL (I DON'T REMEMBER IF WE RAN THE BEFORE START CHKLIST, I DON'T THINK SO). ON TAXI OUT, THE #2 ENG WAS STARTED AND AT THAT POINT I NOTICED WE HAD ONLY ABOUT 8500 LBS OF FUEL (OUR DISPATCH RELEASE WAS 12300 LBS). IMMEDIATELY I ASKED SYRACUSE GND CTL IF WE COULD RETURN TO THE GATE. RECEIVING AN AFFIRMATIVE RESPONSE, WE TAXIED BACK AND TOLD OPS WE NEEDED MORE FUEL. HE ASKED, 'DID YOU NOT GET ENOUGH FROM THE FUELER, OR DID HE NOT FUEL YOU AT ALL?' I REPLIED THAT IT LOOKED LIKE WE NEVER GOT FUEL FROM HIM IN THE FIRST PLACE. WE WERE THEN PUMPED UP TO OUR RELEASE FUEL WT OF 12300 LBS AND FLEW UNEVENTFULLY TO NEW YORK'S LGA. THE REASON THIS HAPPENED WAS HUMAN FACTORS -- PLAIN AND SIMPLE. HAD THE FUELER REFUELED US IN THE FIRST PLACE, IT WOULDN'T HAVE HAPPENED. HAD THE MECH NOT BEEN IN THE COCKPIT, IT WOULDN'T HAVE HAPPENED. HAD I PROPERLY FOLLOWED ESTABLISHED COMPANY PROCS IN A TIMELY MANNER, IT WOULDN'T HAVE HAPPENED. HAD WE NOT BEEN IN SUCH A HURRY-UP MODE OF OP, IT WOULDN'T HAVE HAPPENED. BUT THE FACT IS, IT DID HAPPEN, AS PIC IT WAS MY RESPONSIBILITY TO MAKE SURE IT NEVER HAPPENS. ESTABLISHED COMPANY PROCS AND PUBLISHED CHKLISTS, IF FOLLOWED EVERY TIME, WOULD KEEP THIS SORT OF THING FROM HAPPENING EVER. THE OLD SAYING, 'THERE'S NEVER TIME TO DO IT RIGHT BUT ALWAYS TIME TO DO IT OVER' APPLIES HERE. RUSHING THROUGH CHKLISTS OR PROCS MAY SAVE A FEW SECONDS, BUT COULD ULTIMATELY COST A LOT MORE THAN THAT. IT DID IN THIS CASE. I THOUGHT I WAS PROFESSIONAL ENOUGH TO LEARN FROM EVERYONE ELSE'S PROBS RATHER THAN FROM EXPERIENCE, BUT MY NORMAL EXCELLENT FLOW PATTERN WAS DISRUPTED BY ALL THE 'LITTLE' THINGS THAT WERE HAPPENING AROUND US. WE HAD BEEN 'IN THE SEAT' (WITH 25 MINS OR LESS AT THE GATE) FOR 5 HRS AND 3 FLTS. XA30 WAKEUP, NO BREAKFAST, ON THE GO, MAINT PROBS, BEHIND SCHEDULE, GETTING MY OWN RELEASE, BUSY, BUSY, BUSY. IT ALL ADDED UP TO A 'GOTCHA' WHICH COULD HAVE BEEN VERY SERIOUS. THANK GOD WE DID NOT TAKE OFF WITH INSUFFICIENT FUEL, BUT NOTICED IT ON TAXI OUT!
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.