37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 288814 |
Time | |
Date | 199411 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bdl |
State Reference | CT |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-8 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 70 flight time total : 2350 flight time type : 70 |
ASRS Report | 288814 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : atp pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 105 flight time total : 5850 flight time type : 2468 |
ASRS Report | 288817 |
Events | |
Anomaly | non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In an effort to help the captain make a on-time departure the first officer started the before-start checklist without the captain present. I was the so. I thought it was unusual and was uncomfortable but I did not voice my concern. The captain was in and out of the cockpit trying to find approach plates for a new alternate on the flight plan. They were not in the issued pubs and he needed to go inside to the facsimile machine to get a company copy. He had the flight plan with the dispatched fuel on it. With less than 2 mins left to get rolling the first officer and I did the checklist down to 'takeoff fuel.' my response is the fuel on-board in this case 44.9K. First officer response (supposed to be the captain, but he's inside with flight plan) was 'plenty.' first officer, very senior and had done route multiple times. Unfortunately the alternate was different and required additional fuel. He was reading the checklist and should have held it there, he didn't. I should have asked for it to be held, I didn't either. Captain entered the cockpit and was told that before start checklist was complete 'down to the line.' the first officer asked the captain if he wanted to redo the checklist. He said no. Engines started and away we went. About 3-5 mins into the climb first officer says to me to refigure my fuel since it did not agree with his how- goes-it. I did and told him that what I told him earlier on the checklist was correct. He then told the captain about the problem an we then discussed WX of destination, changing alternates and getting an artr (amended release with lower fuel and usual alternate). WX was good and not a concern at new alternate, original alternate, or destination. Captain decided not to get an artr because he thought it was too late to. We continued on to destination and landed safely with plenty of fuel to proceed to out flight plan alternate. Lessons learned: do not deviate from procedure despite good intentions. Helping 'speed things up' doesn't. If uncomfortable with situation say something no matter how junior. The old salt experienced crewmember is important but not fail-safe. The captain must not allow shortcuts. Supplemental information from acn 288817: a new clerk at kbdl gateway had misread the time 04.43 (hours 55300 pounds total fuel would give) as the required total fuel for this flight. He put that number down on the fuel slip and the mechanic fueled the aircraft to 44300 pounds. In addition, the weight and balance had fuel figures that ran from 42.8-47.3 which allowed the flight engineer and the captain both to 'buy' fuel at 43.9. Corrective actions: simply follow established procedures to the letter! If the checklist would have been done as required by company procedures, this error would have been caught. Human performance considerations: this company places an unusually large amount of pressure on flcs to depart on schedule. Disciplinary action and/or implied threats of dismissal are often the result of any infraction of company procedures and/or policies. The captain (a manager at the company) and I both have been here since the airline was started, and I feel that pressure for 'on time departures' lead me to run the checklist without the captain and for him to not run the checklist 'from the top' as is done when either pilot leaves his seat.
Original NASA ASRS Text
Title: HVT FREIGHTER TAKES OFF WITH LESS THAN CLRED FUEL ABOARD.
Narrative: IN AN EFFORT TO HELP THE CAPT MAKE A ON-TIME DEP THE FO STARTED THE BEFORE-START CHKLIST WITHOUT THE CAPT PRESENT. I WAS THE SO. I THOUGHT IT WAS UNUSUAL AND WAS UNCOMFORTABLE BUT I DID NOT VOICE MY CONCERN. THE CAPT WAS IN AND OUT OF THE COCKPIT TRYING TO FIND APCH PLATES FOR A NEW ALTERNATE ON THE FLT PLAN. THEY WERE NOT IN THE ISSUED PUBS AND HE NEEDED TO GO INSIDE TO THE FAX MACHINE TO GET A COMPANY COPY. HE HAD THE FLT PLAN WITH THE DISPATCHED FUEL ON IT. WITH LESS THAN 2 MINS LEFT TO GET ROLLING THE FO AND I DID THE CHKLIST DOWN TO 'TKOF FUEL.' MY RESPONSE IS THE FUEL ON-BOARD IN THIS CASE 44.9K. FO RESPONSE (SUPPOSED TO BE THE CAPT, BUT HE'S INSIDE WITH FLT PLAN) WAS 'PLENTY.' FO, VERY SENIOR AND HAD DONE RTE MULTIPLE TIMES. UNFORTUNATELY THE ALTERNATE WAS DIFFERENT AND REQUIRED ADDITIONAL FUEL. HE WAS READING THE CHKLIST AND SHOULD HAVE HELD IT THERE, HE DIDN'T. I SHOULD HAVE ASKED FOR IT TO BE HELD, I DIDN'T EITHER. CAPT ENTERED THE COCKPIT AND WAS TOLD THAT BEFORE START CHKLIST WAS COMPLETE 'DOWN TO THE LINE.' THE FO ASKED THE CAPT IF HE WANTED TO REDO THE CHKLIST. HE SAID NO. ENGS STARTED AND AWAY WE WENT. ABOUT 3-5 MINS INTO THE CLB FO SAYS TO ME TO REFIGURE MY FUEL SINCE IT DID NOT AGREE WITH HIS HOW- GOES-IT. I DID AND TOLD HIM THAT WHAT I TOLD HIM EARLIER ON THE CHKLIST WAS CORRECT. HE THEN TOLD THE CAPT ABOUT THE PROB AN WE THEN DISCUSSED WX OF DEST, CHANGING ALTERNATES AND GETTING AN ARTR (AMENDED RELEASE WITH LOWER FUEL AND USUAL ALTERNATE). WX WAS GOOD AND NOT A CONCERN AT NEW ALTERNATE, ORIGINAL ALTERNATE, OR DEST. CAPT DECIDED NOT TO GET AN ARTR BECAUSE HE THOUGHT IT WAS TOO LATE TO. WE CONTINUED ON TO DEST AND LANDED SAFELY WITH PLENTY OF FUEL TO PROCEED TO OUT FLT PLAN ALTERNATE. LESSONS LEARNED: DO NOT DEVIATE FROM PROC DESPITE GOOD INTENTIONS. HELPING 'SPD THINGS UP' DOESN'T. IF UNCOMFORTABLE WITH SIT SAY SOMETHING NO MATTER HOW JUNIOR. THE OLD SALT EXPERIENCED CREWMEMBER IS IMPORTANT BUT NOT FAIL-SAFE. THE CAPT MUST NOT ALLOW SHORTCUTS. SUPPLEMENTAL INFO FROM ACN 288817: A NEW CLERK AT KBDL GATEWAY HAD MISREAD THE TIME 04.43 (HRS 55300 LBS TOTAL FUEL WOULD GIVE) AS THE REQUIRED TOTAL FUEL FOR THIS FLT. HE PUT THAT NUMBER DOWN ON THE FUEL SLIP AND THE MECH FUELED THE ACFT TO 44300 LBS. IN ADDITION, THE WT AND BAL HAD FUEL FIGURES THAT RAN FROM 42.8-47.3 WHICH ALLOWED THE FE AND THE CAPT BOTH TO 'BUY' FUEL AT 43.9. CORRECTIVE ACTIONS: SIMPLY FOLLOW ESTABLISHED PROCS TO THE LETTER! IF THE CHKLIST WOULD HAVE BEEN DONE AS REQUIRED BY COMPANY PROCS, THIS ERROR WOULD HAVE BEEN CAUGHT. HUMAN PERFORMANCE CONSIDERATIONS: THIS COMPANY PLACES AN UNUSUALLY LARGE AMOUNT OF PRESSURE ON FLCS TO DEPART ON SCHEDULE. DISCIPLINARY ACTION AND/OR IMPLIED THREATS OF DISMISSAL ARE OFTEN THE RESULT OF ANY INFRACTION OF COMPANY PROCS AND/OR POLICIES. THE CAPT (A MGR AT THE COMPANY) AND I BOTH HAVE BEEN HERE SINCE THE AIRLINE WAS STARTED, AND I FEEL THAT PRESSURE FOR 'ON TIME DEPS' LEAD ME TO RUN THE CHKLIST WITHOUT THE CAPT AND FOR HIM TO NOT RUN THE CHKLIST 'FROM THE TOP' AS IS DONE WHEN EITHER PLT LEAVES HIS SEAT.
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.